The goals of treating xerostomia include identifying the possible cause(s), relieving discomfort, and preventing complications, e.g., dental caries and periodontal infections.4
Identification
Patients with complaints of dry mouth should have a detailed health history (medical and dental) performed to help with early detection and identification of potential underlying causes.1, 2, 9 In patients with xerostomia or salivary gland hypofunction, oral examination may reveal dry and friable oral mucosa and the tongue may appear dry and fissured.1, 2, 5 Patients may commonly have dental caries (especially root, cervical, or incisal/cuspal tips), plaque accumulation, gingivitis, and/or periodontitis.1, 2, 5, 20 Infections (e.g., oral candidiasis) and enlargement of salivary glands from sialadenitis may also be present.1, 2, 5, 9, 20 Other oral manifestations evident on examination may include angular cheilitis, mucositis, traumatic oral lesions, and/or difficulty in wearing/retaining oral prostheses.5, 9, 20
A thorough head and neck examination, including an intraoral evaluation to identify the presence or absence of salivary pooling on the floor of the mouth, can help a dentist identify who will benefit from further diagnostic evaluations, such as salivary flow rate measurement, minor salivary gland biopsy, or blood and microbial tests.1, 2 A patient is considered to have reduced salivary flow if the unstimulated salivary flow is 0.1 mL/min or less (measured for 5 to 15 minutes) or if the chewing-stimulated salivary flow is 0.7 mL/min or less (measured for 5 minutes).5, 20
General Palliative/Preventive Interventions
Management of xerostomia and hyposalivation should emphasize patient education and lifestyle modifications.1, 2 Various palliative and preventive measures, including pharmacologic treatment with salivary stimulants, topical fluoride, saliva substitutes, and use of sugar-free gum/mints may alleviate some symptoms of dry mouth and may improve a patient’s quality of life.1, 2, 5
Patients should be counseled on lifestyle tips for relieving dry mouth; these include:9, 12
- sipping water or sugarless, caffeine-free drinks
- sucking on ice chips
- using lip lubricants frequently (e.g., every 2 hours)
- chewing sugar-free gum or sucking on sugar-free candy9
- avoiding salty or spicy food or dry, hard-to-chew foods9
- avoiding sticky, sugary foods
- avoiding irritants such as alcohol (including alcohol-containing mouth rinses5), tobacco, and caffeine
- drinking fluids while eating carefully6, 9
- using a humidifier at night9
Dental and oral health-specific recommendations from the National Institute for Dental and Craniofacial Research3 and others5, 9, 13 include the following for patients with dry mouth:
- brush teeth gently at least twice a day with fluoridated toothpaste
- floss teeth every day
- schedule dental visits at least twice a year (with yearly bitewing radiographs)
- use of a prescription-strength fluoride gel (0.4% stannous fluoride, 1.0% sodium fluoride) daily to help prevent dental decay
- prompt treatment of oral fungal or bacterial infections
- application of 0.5% fluoride varnish to teeth
- dental soft- and hard-tissue relines of poorly fitting prostheses and use of denture adhesives
Salivary Stimulants. Salivary stimulants should be considered in patients with residual salivary gland function.9, 12 Sugar-free chewing gum, candies, and mints can be used to stimulate salivary output.9 The FDA has approved the oral secretagogues pilocarpine (Salagen®, Eisai and generics)21 and cevimeline hydrochloride (Evoxac® capsules, Daiichi-Sankyo and generics)22 to treat symptoms of dry mouth.10, 13 Pilocarpine is typically administered at a dose of 5 mg three times a day for at least 3 months and cevimeline is prescribed at a dose of 30 mg three times a day for at least 3 months.10 Adverse effects include sweating, cutaneous vasodilation, nausea and vomiting, diarrhea, hiccup, hypotension and bradycardia, increased urinary frequency, bronchoconstriction, and vision problems.10
Artificial Saliva/Saliva Substitutes/Oral Moisturizers. Artificial saliva products are available with or without prescription. They typically contain a combination of carboxymethylcellulose and glycerin to increase viscosity, as well as buffering and flavoring agents (e.g., sorbitol, xylitol), and calcium and phosphate ions;4, 23 however, they do not contain the digestive and antibacterial enzymes or other proteins and minerals of biologic saliva.23 Some products also contain fluoride.4 A prescription-only product, NeutraSal® (OraPharma, Inc.), is a supersaturated calcium phosphate rinse available as powder for reconstitution.24
The ADA Seal of Acceptance category for products for temporary relief of dry mouth means that the product is safe and has shown efficacy in temporarily relieving dry mouth symptoms, when used as directed.
Saliva substitutes are used as often as needed and although they do not cure dry mouth, they can provide temporary relief of symptoms.4, 23 Alcohol-free mouth rinses, lozenges, and moisturizing oral sprays and gels are marketed as OTC oral care options for patients with dry mouth.4, 6, 9 There are also toothpastes specifically formulated for use in patients with dry mouth.4, 6
A 2011 Cochrane Review25, 26 found “no strong evidence” that any specific topical therapy (e.g., sprays, lozenges, mouth rinses, gels, oils, chewing gum, or toothpastes) was effective for relieving the symptoms of dry mouth. Although chewing gum was shown to increase saliva production, there was no strong evidence that dry mouth symptoms were improved. The authors noted that “patient preference is an important consideration, together with consideration of the potential adverse effects.” The review concluded that, “Well designed, adequately powered randomised controlled trials of topical interventions for dry mouth, which are designed and reported according to CONSORT guidelines, are required to provide evidence to guide clinical care.”