What are the recommended treatments for xerostomia (dry mouth)?

Treatment for Dry Mouth (Xerostomia)

The recommended treatment for xerostomia follows a severity-based algorithm: first measure salivary flow rates objectively, then use sugar-free gum or xylitol lozenges for mild dysfunction, prescribe pilocarpine 5 mg four times daily for moderate dysfunction, and employ saliva substitutes for severe dysfunction, while implementing supportive measures at all levels. 1

Mandatory First Step: Objective Assessment

Before initiating any treatment, measure whole salivary flow rates to objectively determine glandular function, as the subjective sensation of dry mouth does not correlate with actual salivary output. 1 Do not rely solely on patient-reported symptoms to guide treatment selection, as this leads to inappropriate therapy choices. 1

Treatment Algorithm Based on Severity

Mild Glandular Dysfunction

• Use non-pharmacological salivary stimulation as first-line therapy, with sugar-free chewing gum as the preferred mechanical stimulant. 1
• Sugar-free acidic candies or lozenges containing xylitol provide gustatory stimulation and protection against dental caries. 1

Moderate Glandular Dysfunction

• Prescribe pilocarpine 5 mg orally four times daily as the preferred pharmacological stimulant. 1, 2
• The dose may be increased up to 30 mg/day (7.5 mg four times daily) if needed for improved efficacy. 2
• After 6 weeks of treatment at 5 mg four times daily, statistically significant global improvement of dry mouth occurs compared to placebo. 2
• The 2.5 mg four times daily dose (10 mg/day total) is not significantly different from placebo and should not be used. 2
• The most common adverse events are sweating, nausea, rhinitis, diarrhea, chills, flushing, urinary frequency, dizziness, and asthenia, with sweating being the most common reason for treatment withdrawal (12% at 10 mg three times daily). 2

Severe Glandular Dysfunction

• Use saliva substitutes as the primary therapeutic approach, selecting products with neutral pH containing fluoride and electrolytes to mimic natural saliva. 1

Essential Supportive Measures (All Severity Levels)

Dietary and Lifestyle Modifications

• Use alcohol-free mouth rinses exclusively. 3
• Consume a low-sucrose diet and avoid caffeine, spicy and highly acidic foods, and tobacco. 3
• Avoid crunchy, hot foods, alcohol (including mouthwash containing alcohol), sugar-containing chewing gum or sugary soft drinks, and acidic or citric liquids. 3
• Increase water intake throughout the day with frequent small amounts rather than large volumes at once. 1

Hydration Strategy

• Encourage drinking fluoridated tap water to avoid dehydration, but explain that water consumption alone will not eliminate xerostomia. 3

Critical Dental Complications Prevention

Caries Prevention

• Prescribe 1.1% sodium fluoride toothpaste as a dentifrice or in customized delivery trays for all dentate patients. 3
• Counsel patients on dental prophylaxis, including brushing with remineralizing toothpaste and the use of dental floss. 3
• Minimize intake of sticky and/or sugar-containing food and drink to reduce caries risk. 3

Dental Surveillance

• Counsel patients to maintain close follow-up with a dental professional, as proper preventive care reduces caries and gingival disease. 3
• Refer to a dental professional specializing in oncology patients if xerostomia is treatment-related. 3
• Seek immediate attention to any intraoral changes that may occur. 3

When to Escalate Care

• Refer for specialty consultation when symptoms are severe and persistent despite management strategies, or when dry mouth significantly affects quality of life. 1
• Refer when signs of dental complications appear, such as caries, periodontal disease, or infections. 1
• Consider rheumatology referral when features suggesting Sjögren's syndrome or other autoimmune conditions develop. 1

Common Pitfalls to Avoid

• Do not assume subjective complaints correlate with actual salivary dysfunction—always measure flow rates first. 1 This prevents inappropriate treatment selection and ensures therapy matches the actual severity of glandular dysfunction.
• Do not use pilocarpine at 2.5 mg four times daily, as this dose is no more effective than placebo. 2
• Do not overlook medication review, as drugs are the most common cause of xerostomia in elderly populations. 4, 5
• Do not neglect fluoride supplementation in dentate patients, as untreated severe dry mouth leads to dental caries and tooth loss. 1