Clinical Guidelines for Managing Patients with Chronic Dry Mouth

A professional dental team can assist in developing a comprehensive oral hygiene plan to address a patient’s dry mouth needs. A preventive program for dry mouth will often include the following components:

  1. Dental Caries Risk – An important assessment that is derived from the severity of past dental changes, measurement of saliva flow rate, and estimation of caries-producing organisms in the saliva.23
  2. Diet – A patient needs to be educated about the role of dietary sugars in the development of dental caries. Sugar intake needs to be confined to meals and no sugar should be consumed in between meals. Recommend sugar-free beverages, gums, lozenges that contain non-cariogenic sweetening agents like xylitol, recaldent, sorbitol, aspartame, and sucralose.23
  3. Oral Hygiene – Each patient needs to be given appropriate oral hygiene instructions that are individualized for the patient’s specific needs. The objective of home care instruction is to teach the patient to reduce the total bacterial count in the oral cavity on a daily basis. Instructions may include toothbrushing, interdental brushes or dental floss, oral irrigation with an antimicrobial agent like alcohol free chlorhexidine, tongue brushing, oral mouthrinsing with an appropriate antibacterial mouthrinse, and the use of disclosing agents to stain biofilms in situ.
  4. Topical Fluoride – Patients will benefit from professionally applied topical fluorides like a 2.25% fluoride varnish. The daily use of topical fluoride will assist in the prevention of root caries. Self-applied home topical fluoride is the single most important preventive measure a person can take to prevent the devastating effects of root caries. Make sure you discuss with patients the different types of home fluoride and select a product that is customized for the patient̻s individual needs. For example, if a patient has many ‘tooth-colored’ fillings, certain types of fluoride will cause staining of these fillings. Other products like an over-the-counter toothpaste or mouthrinse with fluoride will probably not contain enough fluoride to be of any benefit. Patients should be given names of prescription fluoride products, and you can assist in selecting the right one for the patient. If a patient is suffering from dry mouth, a neutral pH fluoride prescription product is usually preferable to other types of fluoride.
  5. Dental caries detection kits that permit the culture and estimation of Streptococcus mutans in a dental office are commercially available. If the amount of salivary S. mutans exceeds 1 X 106, colony forming units/ml of whole saliva, consider prescribing a 1-minute twice-daily rinse with 0.12% alcohol free chlorhexidine for two weeks.23
  6. Remineralization strategies may also include calcium phosphate-based remineralization technology like casein phosphopeptides-amorphous calcium phosphate, also known as CPP-ACP. Research shows that CPP-ACP binds well to plaque biofilm and provides a large calcium phosphate reservoir within plaque biofilm that will likely restrict mineral loss during a cariogenic episode, and provide a source of calcium for subsequent remineralization.24
  7. Stimulating Salivary Secretion – Medical and dental teams can help patients determine what is causing dry mouth. If a patient’s dry mouth is caused by medication, the patient’s physician can sometimes change it or lower the dose. If the patient’s salivary glands have ceased working but can still produce saliva, the attending physician or dentist can prescribe medication that stimulates saliva secretion from salivary glands. Salagen (pilocarpine hydrochloride, a cholinergic agonist) is one such prescription medication that increases saliva production. Another medication that is used for Sjögren’s syndrome is Exovac (another cholinergic agonist), which causes glands in the mouth to produce saliva. Both of these medications have side effects so it is important to get detailed product information from the physician/dentist and pharmacist. The effects of these products last for a few hours and are taken three to four times a day. In addition to prescription medicines for dry mouth, artificial saliva is available for those individuals who produce very little saliva. Certain brands of artificial saliva come in a spray form. Artificial saliva works only for a limited period (about two hours) and eventually swallowed.
  8. OGT Spray – A Cochrane systematic review (SR) from 2011 indicates there is no strong evidence that any topical therapy is effective for relieving dry mouth symptoms; however, Oxygenated glycerol triester (OGT) spray appears to be more effective than an aqueous electrolyte (SMD) spray. Chewing gums appear to increase saliva production in those with residual secretory capacity but there is no evidence that gum is more effective than saliva substitutes.28
  9. Non-drug treatments used to stimulate saliva production for the relief of dry mouth – Another Cochrane systematic review (2013) assessed the effects of non-drug treatments used to stimulate saliva production for the relief of xerostomia symptoms. Non-drug treatments like acupuncture, mild electrical stimulation, lasers, tooth brushing and other stimulation techniques are used to improve dry mouth symptoms. Studies were of poor quality and none of the non-drug treatments made a difference in dry mouth symptoms. 29

Here is a list of other suggestions to make a patient’s mouth more comfortable and protected against foreign invaders like bacteria, viruses, and fungi. Patients should:

  • Sip room-temperature water throughout the day and carry a water bottle at all times. Avoid drinking lots of water at an extreme water temperature (very hot or very cold).
  • Only drink sugar-free drinks and avoid carbonated beverages.
  • Avoid drinks with caffeine because caffeine can dry out the mouth. Drinking coffee, tea, or a diet soda occasionally is OK but do not overdo it.
  • While eating a meal, make sure you include a beverage like bottled water. Drink water before, during, and after the meal.
  • If there is remaining salivary tissue, the regular use of sugarless gum, mints, candies, lozenges and sprays can help stimulate salivary flow and they should be allowed to dissolve slowly in the mouth.
  • Try to select sugarless products that contain xylitol. (As a sweetening agent, xylitol aids in stimulating the flow of saliva and also helps to control S. mutans.) Xylitol is a natural sweetener product that differs chemically from other sweeteners like sorbitol, fructose or glucose. It actually interferes with the growth of bacteria associated with tooth decay and it is approved as a therapeutic sweetener by the Food and Drug Administration (FDA)
  • If you smoke or drink alcohol, do not! Both alcoholic beverages and smoking dries out the mouth and makes you more susceptible to gingival and periodontal diseases and oral cancer.
  • Select an alcohol-free over-the-counter mouthrinse if you are in the habit of using one. Read the label and make sure alcohol is not listed as an active ingredient.
  • Check the pharmacy shelves for other over-the-counter dry mouth products. There are several moisture gel products that many people like to use, especially before bedtime. Apply the moisture gel liberally over the tongue, palate, and inside cheeks immediately before falling asleep and be sure to follow the manufacturer’s instructions.
  • Tell a healthcare provider about dry mouth symptoms. Healthcare professionals will not always be able to detect it. The erythematous form of oral candidiasis may go undetected and should be evaluated and managed.
  • Drink fluids with meals to aid in swallowing.
  • Eat foods with a high fluid content, like sugar-free pudding.
  • Avoid excessively dry foods like crackers, salty pretzels, and chips. Avoid pre-prepared meals or soups that have high sodium content.
  • Protect dry lips, which are annoying, and another form of discomfort. The regular use of topically applied oil-based balms or lipsticks are helpful, including use of vitamin E-containing balm. These products must be re-applied on a regular basis to ensure effectiveness.
  • Use a humidifier, particularly at night.
  • Try using a saliva substitute instead of drinking water before bedtime in order to reduce the need go to the bathroom during the night.