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Treatment of Xerostomia

Xerostomia, a subjective feeling of dry mouth, affects an estimated 21% of men and 27% of women, mostly older adults. 

Causes may be iatrogenic — that is, as a consequence of medical treatment — or immunogenic. 

The most frequent iatrogenic source is xerogenic medications, with more than 500 drugs listing dry mouth as a possible side effect.

Other sources in this category include radiothera- py for the treatment of head and neck cancer, bone marrow transplantation, and graft versus host disease.

Common immunogenic sources include patients with Sjörgren’s syndrome, a chronic autoimmune disease that progressively destroys salivary gland tissue, and sialosis, chronic non-inflammatory swelling of the salivary glands.

Oral Health and Treatment of Xerostomia

Xerostomia can result in serious oral disease (e.g., root caries), which in turn may have a negative effect on patients’ health, diet, and quality of life.

It is important to treat xerostomia to ensure good oral health.  Treatment strategy is customized to the individual patient and is recommended to include patient education, management of the underlying systemic condition, preventive oral care measures, and pharmacological treatment with sali- vary stimulants.

Pilocarpine for the Treatment of Xerostomia

The only two medications approved by the FDA for the treatment of xerostomia due to head and neck cancer or Sjörgren’s syndrome are pilocarpine hydrochloride and cevimeline, both non-selective muscarinic receptor agonists. 

Pilocarpine has been the focus of recent research.  

Based on six randomized clinical trials (RCTs) investigating oral pilocarpine for the treatment of radiation induced xerostomia, a consistent observation of a 45% response rate to 5 to 10 mg pilocarpine compared to 25% for placebo was reported.3 However, regarding the prevention of radiation therapy-induced xerostomia among patients treated for head and neck cancer, pilocarpine seems to be ineffective; only two out of five published trials reported an improvement of xerostomia symptoms when pilocarpine was used prophylactically.

In addition to pilocarpine’s two FDA- approved indications, it may also be beneficial for the treatment of xerostomia manifesting as a side effect of xerogenic drugs. 

A comparative study of 45 patients suffering from xerostomia (13 due to irradiation, 13 due to Sjörgren’s syndrome, 19 due to sialosis and/or xerogenic medication) reported that pilocarpine hydrochloride had the most significant effect on the sialosis/xerogenic medication group followed by the Sjörgren’s syn- drome group, with only modest effects in the irradiationgroup.

However,muscarinicreceptors are not exclusively located in salivary glands, therefore adverse side effects can be observed.

Urinary frequency, dizziness, and sweating were observed; in large RCTs, sweating was persistently elevated and dose-dependent.

Further, pilocarpine is contraindicated in patients with uncontrolled asthma, known hypersensitivity reactions, acute iritis, and narrow-angle glaucoma.

Benefits of Topical Pilocarpine

A meta-analysis, including eight prospective controlled studies evaluating pilocarpine hydrochloride and two additional treatment options (salivary substitutes or acupuncture) for radiation-induced xerostomia in patients with head and neck cancer, indicated that all treatments showed improvements compared to placebo, with topical pilocarpine being the most effective.

Moreover, there have been studies conducted to manage xerostomia with topical application of pilocarpine via a mouthwash, gum, or spray to increase minor salivary gland secretion without inducing adverse effects.

A double-blind RCT determined that 0.1% pilocarpine mouthwash induced a greater increase in minor salivary gland secretion and unstimulated whole saliva compared to control (i.e.,0.9%saline).

However, there was no significant decrease in the severity of oral dryness, suggesting additional research is required to identify the minimum effective pilocarpine concentration that relieves oral dryness with no occurrence of side effects.

Conclusion

The effective treatment of xerostomia requires a systematic approach involving collaboration between dental professionals and physicians to identify whether systemic conditions or medication use is the cause. 

It also requires patient education and lifestyle changes to ensure optimal oral hygiene. OC

References

1. Visvanathan V, Nix P. Managing the patient presenting with xerostomia: a review. Int J Clin Pract 2010;64(3):404-7.2. Aframian DJ, Helcer M, Livni D, Robinson SD, Markitziu A, Nadler C. Pilocarpine treat- ment in a mixed cohort of xerostomic patients. Oral Dis 2007;13(1):88-92.3. Berk L. Systemic pilocarpine for treatment of xerostomia. Expert Opin Drug Metab Toxicol 2008;4(10):1333-40.4. Kim JH, Ahn HJ, Choi JH, Jung DW, Kwon JS. Effect of 0.1% pilocarpine mouthwash on xerostomia: double-blind, randomised controlled trial. J Oral Rehabil 2014;41(3):226- 35.5. Plemons JM, Al-Hashimi I, Marek CL. Managing xerostomia and salivary gland hypo- function: Executive summary of a report from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2014;145(8):867-73.6. Lovelace TL, Fox NF, Sood AJ, Nguyen SA, Day TA. Management of radiotherapy- induced salivary hypofunction and conse- quent xerostomia in patients with oral or head and neck cancer: meta-analysis and litera- ture review. Oral Surg Oral Med Oral Pathol Oral Radiol 2014;117(5):5