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Management of Xerostomia (Dry Mouth)

last modified on: Mon, 10/28/2024 - 16:06

see also: Pilocarpine / Salagen® and Cevimeline / Evoxac® for Dry Mouth (Xerostomia); Xerostomia (dry mouth) and Salivary Swelling after Irradiation Prevention and Treatment; Handout: Homeopathic Throat Soothers

see also: I131 sialadenitis (Radioiodine Sialadenitis); Radioiodine Sialadenitis RAI and Sialendoscopy Lecture 2016

Xerostomia (Dry Mouth) Patient Handout

Cindy L. Marek, PharmD, FACA, Associate Professor (Clinical)

Department of Oral Pathology, Radiology and Medicine

The University of Iowa Colleges of Dentistry and Pharmacy

January 2019

DEFINITION & CAUSES

Xerostomia (pronounced “zero-sto¢me-ah”) is the medical word for the sensation of dry mouth often due to decreased or absent saliva. Saliva is important for hydration, lubrication and cleansing in the oral cavity. The components of saliva aid in digestion, maintain the health of the oral mucosa and help prevent tooth decay.

Dry mouth is a common problem and is caused by a variety of medical conditions and medications. Many drugs, including antihistamines, antidepressants, blood pressure medications and opioid analgesics are known to cause xerostomia. Dry mouth can also be caused by head and neck radiation, depression, anxiety and some autoimmune diseases.

update (HH 05182024): Aging - defined as the 'gradual decline in body function' - with several studies suggesting xerostomia associated with aging also associated with a decrease in the volume of salivary gland acini with an increase in fibrotic tissue and 'lipid droplet infiltation" (Toan and Ahn 2021). These investigators additionally identify a decrease in salivary receptors that my reduce the intensity of stimulation to the salivary glands.

HELPFUL SUGGESTIONS

The lifestyle modifications listed below can help relieve dry mouth symptoms.

Avoid the following:

  1. Caffeine
  • Daily high doses of caffeine can contribute to dry mouth. Make sure all of your beverages (coffee, tea, etc.) are caffeine free.
  1. Alcohol and alcohol containing mouthwashes (read labels carefully)
  • Many commercial mouthwashes contain alcohol which has a drying effect and can irritate the tissue.
  • Biotène® and Oasis® make mouth rinses specifically for dry mouth. ACT® Total Care Dry Mouth rinse contains fluoride.
  1. Acidic beverages and foods
  • Carbonated beverages, vitamin waters, energy and sports drinks are very acidic. Without the neutralizing ability of saliva, these drinks erode the teeth and can make your mouth sore. Constant sipping of acidic beverages is especially problematic.
  • Foods and candies high in acid content (citrus fruits, tomatoes, lemon drops, etc.) cause dental decay and may irritate the soft tissue of your mouth.
  1. Gum, candy, cough drops and beverages that contain sugar
  • Sugar, especially in retentive (sticky) form is very damaging to the teeth. Sucrose feeds bacteria that cause cavities.
  • Look for products that contain xylitol (a sweetener that does not cause cavities).  Xylitol gums (Spry®, Xyloburst®) when chewed frequently, may inhibit cavity causing bacteria.
  • Avoid gums, candies and oral care products that contain cinnamon as it is a common irritant.
  1. Toothpastes with harsh chemicals or strong flavoring agents
  • Many toothpastes advertised for tartar control, whitening etc. contain pyrophosphates and other chemicals that can damage dry oral tissues. 
  • Sodium lauryl sulfate (SLS) is a foaming agent/detergent that is found in most toothpastes. This detergent is well-recognized as a cause of intraoral tenderness and ulceration. We recommend toothpastes that are SLS-free and contain no pyrophosphates (Squiggle Enamel Saver Toothpaste – may be purchased from Dental Pharmacy or online)

Try the following:

      a. Hydration - inadequate hydration can be an important factor in having dry mouth symptoms

  • Remain well hydrated, but avoid sipping water throughout the day as it displaces your natural saliva. (in contrast, some feel that frequent sipping of water through the day may be helpful)
  • Many people don’t drink enough fluids and this will contribute to a dry mouth.
  • Constant, daily hydration is very important
  1. Try drinking whole or 2% milk with meals.
  • Milk containing fat has moisturizing properties that can aid in swallowing.
  • Patients who cannot drink cow’s milk may find similar benefit in almond or soy milk
  1. Use a cool air humidifier in the bedroom – clean and change water daily
  • Start the humidifier 1-2 hours before bedtime and run continuously throughout the night. The extra humidity can help keep your mouth more comfortable and allow you to sleep through the night. This is of benefit even if you have a humidifier attached to your furnace.
  1. For dry lips, highly purified lanolin products (Lansinoh®) are good lip moisturizers.
  • Chronic use of petrolatum type products on dry lips can be counterproductive.
  • Moisturizing lip balms we recommend include Blistex Herbal Answer®, Blistex Complete Moisture or Banana Boat with Aloe Vera and Vitamin E®. 
  • Many dry lip products contain chemicals that can cause irritation or dryness. The need to frequently reapply lip balm is a good indicator that the product is not helpful.
  1. If possible, sleep on your side to reduce mouth breathing.
  2. See your dental practitioner frequently.
  • People with dry mouth are much more prone to oral health problems including oral yeast infections and tooth decay. Excellent oral hygiene is necessary to prevent cavities and gum disease.
  • Your dentist may use tooth sealants, prescription fluoride toothpastes and other interventions that will help prevent oral health problems.
  • Report any unusual oral soreness or burning sensations to your dentist.

      g. At least one patient (an RN) identifies the most effective approach to addressing her radiation induced dry mouth is to suck on 'generic altoids' for an hour to an hour and 1/2 for up to 5 times a day (using in place of water if in situations where water bottle not with her)

COMMERCIAL SALIVA SUBSTITUES, STIMULANTS AND MOISTURIZING GELS

The products listed below are available without a prescription and can be found or ordered from many pharmacies. These products are often helpful in alleviating the discomfort of dry mouth. They can be used as often as needed and do not interfere or react with other medications. Here are a few examples of products we recommend:

  1. SalivaSure™ Tablets (Scandanavian Formulas, Inc) – 90 ct. bottle
  • To stimulate natural saliva flow, dissolve one tablet slowly under tongue up to every hour as needed.
  • Highly recommended, will not cause cavities or sore mouth. Easy to carry, no drug interactions.
  • This product is available at the Dental Pharmacy and does not require a prescription.
  1. Biotèn ® Products (GlaxoSmithKline)
  • Oralbalance® Gel – 1.5 oz tube – has a soothing effect on oral tissue, can be used under dentures to improve comfort. Rinse mouth with water, then spread thin film over affected tissues. Can be used as often as needed. 
  • Biotène ® Moisturizing Mouth Spray – 1.5 oz. spray bottle. Shake well and spray directly into mouth as needed. 
  • Oralbalance® Dry Mouth Moisturizing Liquid – 1.5 oz squeeze bottle. Squeeze several drops directly into mouth as needed.

COMMERCIAL OVER THE COUNTER (OTC) TOOTHPASTES

Avoid toothpastes that make claims on whitening or tartar control as they often contain ingredients that are irritating to the oral mucosa. Most OTC toothpastes contain detergents (sodium lauryl sulfate (SLS), cocamidopropyl betaine etc.) that irritate oral mucosa as mentioned above. We recommend mild detergent toothpastes:

  • Squigle Enamel Saver Toothpaste –contains xylitol and fluoride, detergent is mild poloxymer

PROFESSIONALLY DISPENSED OR RX PRODUCTS

Products a and b are only available at the Dental Pharmacy (319) 335-7435 and can be mailed out:

a. GC Dry Mouth Gel (GC America) – 40 g. tube. Rinse mouth with water, then spread thin film on affected tissue as needed. Similar to Oralbalance® gel. Available in 5 mild flavors.

b. MI Paste™ and MI Paste Plus™ - 40 g. tube. Rinse mouth with water, then spread pea-sized amount over teeth and tissue. (This product requires a prescription from your dentist or physician)
These products were developed to help rebuild tooth structure, but have the additional effect of soothing dry intraoral tissue. Cannot be used by people with casein (milk protein) allergies. Especially useful at bedtime. Probably the best product we have to provide oral comfort.    

c. 3M Xerostmia Spray -10 ml cannisters. Lipid based solution contains oxidized glycerol triesters (TGO) which have proven, consistent relief for dry mouth. May be obtained via Rx through specialty pharmacy that will bill your insurance, otherwise $35 per canister.

CLINICAL TRIALS

Excellent search engine for clinical trials - "ClinicalTrials.gov" - in "condition or disease" type in xerostomia or other relevant disorders such as Sjogren's  

https://clinicaltrials.gov/ct2/home

updated 2-16-2022

References

Brito-Zerón P, Retamozo S, Kostov B, Baldini C, Bootsma H, De Vita S, Dörner T, Gottenberg JE, Kruize AA, Mandl T, Ng WF, Seror R, Tzioufas AG, Vitali C, Bowman S, Mariette X, Ramos-Casals M. Efficacy and safety of topical and systemic medications: a systematic literature review informing the EULAR recommendations for the management of Sjögren's syndrome. RMD Open. 2019 Oct 28;5(2):e001064. doi: 10.1136/rmdopen-2019-001064. PMID: 31749986; PMCID: PMC6827762.

(abstract from poster): Supersaturated Calcium Phosphate Rinse on Oral Mucositis in Head and Neck Patiens Receiving Radiation and/or Chemoterehapy J  Hamker; Cleveland Clinic Foundation, Cleveland OH  cited in

Hamker J: Supersaturated Calcium Phosphate Rinse on Oral Mucositis in Head and Neck Patients Receiving Radiation and/or Chemotherapy  RSS  International Journal of Radiation Oncology, Biology, Physics, 2013-10-01, Volume 87, Issue 2, Pages S429-S429, Copyright © 2013

Wolff A, Joshi RK, Ekström J, Aframian D, Pedersen AM, Proctor G, Narayana N, Villa A, Sia YW, Aliko A, McGowan R, Kerr AR, Jensen SB, Vissink A, Dawes C. A Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective Sialorrhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI. Drugs R D. 2017 Mar;17(1):1-28. doi: 10.1007/s40268-016-0153-9. PMID: 27853957; PMCID: PMC5318321.

Fortuna G, Whitmire S, Sullivan K, Alajbeg I, Andabak-Rogulj A, Pedersen AML, Vissink A, di Fede O, Aria M, Jager DJ, Noll J, Jensen SB, Wolff A, Brennan MT. Impact of medications on salivary flow rate in patients with xerostomia: a retrospective study by the Xeromeds Consortium. Clin Oral Investig. 2023 Jan;27(1):235-248. doi: 10.1007/s00784-022-04717-1. Epub 2022 Oct 21. PMID: 36269468.

Wolff A, Joshi RK, Ekström J, Aframian D, Pedersen AM, Proctor G, Narayana N, Villa A, Sia YW, Aliko A, McGowan R, Kerr AR, Jensen SB, Vissink A, Dawes C (2017) A guide to medications inducing salivary gland dysfunction, xerostomia, and subjective sialorrhea: a systematic review sponsored by the World Workshop on Oral Medicine VI. Drugs R D 17(1):1–28. https://doi.org/10.1007/s40268 016-0153-9

Toan NK, Ahn SG. Aging-Related Metabolic Dysfunction in the Salivary Gland: A Review of the Literature. Int J Mol Sci. 2021 May 29;22(11):5835. doi: 10.3390/ijms22115835. PMID: 34072470; PMCID: PMC8198609.

May 5 2023 Lecture "File Saliva - Xerostomia, Hyposalivation, Hypersalivation" at Massachusetts Eye and Ear Infirmary, Boston Mass