January 2019

C O N T I N U I N G
eBOOK
E D U C A T I O N • 2 C E U

X E R O S T O M I A T R E AT M E N T

A Systematic Approach to Xerostomia

Diagnosis and Management
Mark Donaldson, ACPR, PHARMD; and Jason H. Goodchild, DMD

SUPPORTED BY AN UNRESTRICTED GRANT FROM PREMIER DENTAL PRODUCTS CO. • Published by AEGIS Publications LLC 2019
 C O N T I N U I N G E D U C A T I O N • 2 C E U

A Systematic Approach to Xerostomia

Diagnosis and Management
Mark Donaldson, ACPR, PHARMD; and Jason H. Goodchild, DMD

ABSTRACT
Dry mouth is a pervasive oral health problem, with 5% to 46% of the population experiencing this condition. Patient factors such as age, gender, systemic diseases, and
medication use play significant roles in correctly diagnosing this presentation. The subjective feeling of dry mouth is often referred to as xerostomia but may be more
correctly diagnosed as salivary gland dysfunction: a reduced volume of saliva secretion or a change in salivary composition. Symptoms of dry mouth may range from
mild oral discomfort to significant oral disease that can negatively impact patients’ health, dietary intake, and quality of life. Despite the significant prevalence of xero-
stomia in the general population, however, no standard treatment guidelines exist. Successful treatments are typically individualized for the specific patient and should
be targeted at the underlying pathophysiology of the disease. For these reasons, an accurate diagnosis of xerostomia is paramount so that patients may be offered the
best treatment possible, and this treatment often involves a multimodal approach.

LEARNING OBJECTIVES
Explain why xerostomia is not simply a
problem of “dry mouth,” and describe the
underlying pathophysiology
Identify commonly used medications
associated with causing xerostomia, and
discuss current treatment strategies
Describe a systematic approach to xerostomia
management that includes reviewing systemic
conditions and medication use and emphasizes
patient education, lifestyle modifications, and
palliative and preventive measures

M
any patients report the subjective feeling of dry mouth, which
oral healthcare practitioners (OHCPs) often refer to as xe-
rostomia.1,2 In reality, though a disruption in the amount or
quality of saliva being produced is related to patient-reported
xerostomia, from a pathophysiological standpoint it may be
more correctly diagnosed as salivary gland dysfunction. Salivary gland
dysfunction routinely manifests as salivary gland hypofunction (a reduced
volume of saliva secretion) or a change in salivary composition.3 The
objective presentation of salivary gland hypofunction, however, is not an
absolute indicator of the subjective reporting of xerostomia.4,5
The clinical method most often employed to diagnose salivary dysfunction
is a sialometry test, and a definitive diagnosis of hyposalivation is made when
unstimulated salivary flow rates are less than 0.1 mL/minute or 0.7 mL/minute
under stimulation.6 Although xerostomia, defined as the subjective report of a
dry mouth, is often associated with hyposalivation, many cases of xerostomia
have been described in patients with a normala salivary flow.7-9 Xerostomia,
therefore, is the subjective sensation of dry mouth, whereas hyposalivation is
a pathological condition in which there is insufficient or decreased production
of saliva. In many though not necessarily all cases, the subjective report of
xerostomia may correlate with a decrease in the amount of saliva, while there
may be instances where patients report xerostomia without hyposalivation,
which could be because of alterations in salivary composition.2,4
Symptoms of dry mouth may range from mild oral discomfort to significant
oral disease that can negatively impact a patient’s health, dietary intake, and qual-
ity of life.10-14 Five percent to 46% of the population experiences xerostomia, and
factors such as age, gender, systemic diseases, and medications play significant
roles in correctly diagnosing this presentation.15-18 Identifying and treating the
underlying causes of dry mouth are paramount to providing optimal, targeted
oral healthcare. Effective prevention, early detection, and treatment of the oral
sequelae associated with dry mouth require aggressive management by both den-
tist and patient along with interdisciplinary care. While symptom relief and sal-
ivary stimulation comprise most of the contemporary treatment options, newer

DISCLOSURE: Dr. Donaldson is Associate Principal for Vizient Pharmacy Advisory Solutions, and Dr. Goodchild is Director of Clinical Affairs for Premier Dental
Products Co. The views expressed in this article are those of the authors and do not necessarily reflect those of Vizient, Premier, Creighton University School of
Dentistry, or Rutgers School of Dental Medicine.
Supported by an unrestricted grant from Premier Dental Products Co.
2 COMPENDIUM EBOOK JANUARY 2019
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products and strategies are being investigated such as transcutaneous electrical
nerve stimulation and acupuncture as alternative strategies with mixed results.3,19-24
This article presents a comprehensive, practical, and evidence-based ap-
proach to the current management of xerostomia for the practicing oral health-
care professional.
NORMAL SALIVARY FUNCTION
Saliva not only aids in digestion by facilitating oral processing and swallow-
ing of food, but it also has protective functions that include cleansing the oral
cavity, maintaining a neutral pH, preventing tooth demineralization, and pro-
tecting oral tissue against microbial and physical insults (Table 1). The vari-
ous immune and non-immune salivary proteins that inhibit the adherence and
growth of viruses and bacteria confer the antimicrobial properties of saliva,25
while the mucins and salivary proteins contribute to the lubrication and coating
of oral tissues. These agents protect the oral mucosa and teeth from physical,
chemical, and microbial damage. Saliva facilitates speech and taste through
lubrication and moisture, and the dissolution of materials in saliva stimulates
taste receptors on the tongue. Salivary gland hypofunction often results in
dysgeusia (altered taste sensation) and dysphagia (difficulty swallowing).26,27
PHYSICAL ASSESSMENT AND DIAGNOSIS OF XEROSTOMIA
Disease-Induced Xerostomia
A thorough medical history is the cornerstone of a correct diagnosis and,
subsequently, appropriate treatment of the underlying cause of xerostomia.
The presence or history of particular diseases may put patients at risk for the
development of dry mouth, or, much more commonly, xerostomia may be
medication-induced (licit or illicit). Table 2 lists the most common medical
conditions associated with xerostomia.18,28,29
Given that Sjögren’s disease (Sicca) is the second most common autoim-
mune disorder, affecting from 0.06% to 4.8% of the population, OHCPs are
particularly sensitive to this autoimmune illness given its propensity to cause
decreased saliva production, dry mouth, and dry eyes (xerophthalmia).22,30
Moutsopoulos et al from the National Institutes of Health developed a con-
cise, chairside questionnaire to help identify these patients more easily (Ta-
ble 3).15,31 While the results of this survey confirm a differential diagnosis of
xerostomia likely due to Sjögren’s disease, dehydration, obstruction to saliva
flow (stone, tumor, etc), or a drug effect or infection, further objective criteria
for the diagnosis of xerostomia would then include at least two of the follow-
ing: (1) reduced unstimulated salivary flow, with ≤1.5 mL saliva collected in
15 minutes; (2) lymphoplasmocytic infiltrate in an adequate biopsy of labial
salivary glands (sialoadenitis); (3) abnormal salivary gland imaging studies
(scintigraphy) demonstrating decreased uptake, decreased spontaneous secre-
tion, and/or decreased secretion after citrus stimulation.
Other systemic diseases and comorbidities leading to xerostomia are di-
verse. They include Parkinson’s disease, anxiety and depression, rheumatoid
arthritis, scleroderma, and treatment for head and neck cancers.3,32-34
Iatrogenic Causes of Xerostomia
Hyposalivation and salivary gland damage most often are the result of medical
treatment, whether it be interventional or pharmacological.15,35-38 Regarding
radiation therapy for head and neck cancer, salivary flow decreases rapidly
during the first week of treatment. The ensuing fibrosis of the salivary glands
and permanent loss of secretory capacity may dramatically diminish the pa-
tient’s overall quality of life.19,38,39 The degree of damage is dependent on the
volume of tissue irradiated and the total dose of radiation. Patients undergoing
chemotherapy may also experience transient xerostomia.40,41
Systemic medication use is one of the most frequently reported causes of
hyposalivation and xerostomia.4,28,42,43 More than 500 drugs are known to cause
dry mouth, including many of the most common over-the-counter (OTC) and
prescribed classes of medications (Table 4).3,27 Unfortunately, this effect is
not just limited to licit medications, as many illicit drugs produce this conse-
quence as well.44-49 Patients receiving multiple xerostomic medications tend

TABLE 1

Structure and Function of Normal Saliva

PROPERTY SALIVARY COMPONENT FUNCTION
Maintain tissue integrity Mucins (glycoproteins) Lubricate mucous membranes; protect tissues from
injury and ulceration during eating, speaking, oral
hygiene, wearing appliances/prosthetics

Protection Mucins Prevent penetration of carcinogens, toxins, viruses, and

irritants; encourage soft-tissue repair
Microbial balance Immunologic processes, Prevent microbial colonization and reduce bacterial
nonimmunologic adherence to teeth and oral tissues; antibacterial,
processes, antimicrobial antifungal, and antiviral mechanisms protect oral cavity
properties, salivary from infections
enzymes
Physiologic buffer Sodium bicarbonate, Regulate oral pH
phosphate
Maintain/restore Salivary pellicle, Promote remineralization of enamel
structural integrity of electrolytes, calcium and
teeth phosphorus
Digestion α-amylases (salivary Break down starches and aid in overall digestive
proteins) function; saliva is first digestive enzyme of
gastrointestinal tract
Cleansing Fluid components Assist with clearing of food and swallowing
Taste Fluid components Facilitate taste perception

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 C O N T I N U I N G E D U C A T I O N
to have more severe dry mouth symptoms, and patients with salivary gland
hypofunction are more susceptible to the xerogenic side effects of medica-
tions than patients with normal salivary gland function.6-9
Most xerostomic medications do not damage salivary glands, but they do
decrease unstimulated salivary flow rates typically because of their anticho-
linergic side effects. Some studies have shown differences in the prevalence
of xerostomia between the sexes (occurring more so in females than males)
and with increasing age.15,42,50 One possible explanation for the latter is that
older individuals take many more xerogenic medications for chronic ailments
than younger individuals, which may lead to an overall reduction of the un-
stimulated salivary flow rate.15,51
Mouth breathing, dehydration, and psychological or neurological disor-
ders can add to the perception of xerostomia. Mood disorders may affect the
sympathetic nervous system (fight or flight reaction), and such patients may
experience oral dryness.52-55
XEROSTOMIA MANAGEMENT
Identifying and treating the underlying cause(s) of dry mouth are paramount
to providing optimal, targeted oral healthcare.15 In addition, management of
xerostomic side effects may also require attention. Patients with dry mouth
often have erythematous and atrophic oral mucosa, loss of tongue papillae,
angular cheilitis, and peeling or cracked lips. Traumatic lesions may even be
visible on the lateral borders and buccal mucosa of the tongue. Removable
dentures may become loose, which could lead to painful ulcerations. Patients
often describe a constant need to sip fluids, especially when eating or immedi-
ately upon awaking from sleep. Root surface or cervical caries and candidiasis
are common in patients with xerostomia; these patients may have enlarged
salivary glands and possibly salivary gland infection. Treatment for xerosto-
mia should be patient-specific and often requires a multimodal approach that
goes beyond patient education and includes frequent consultation with the
patient’s physician, oncologist, or other healthcare providers.
Prevention
In patients at risk for xerostomia or hyposalivation, frequent visits to their
OHCP (usually every 3 to 6 months) is critical for treatment compliance and
TABLE 2
Medical Conditions
Associated With Xerostomia
Autoimmune and inflammatory conditions
(eg, Sjögren’s disease, primary biliary
cirrhosis)
Graft-versus-host disease
Immunoglobulin G4-related
sclerosing disease
Degenerative disease (eg, amyloidosis)
Granulomatous disease (eg, sarcoidosis)
Infections: human immunodeficiency
virus/acquired immune deficiency
syndrome (HIV/AIDS), hepatitis C
Salivary gland aplasia or agenesis
Lymphoma
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success.56,57 In addition, although evidence is lacking, patients using medica-
tions known to induce salivary gland hypofunction could consider taking less
xerostomic medications or decreasing the dosage of their medications if an
alternative is unavailable.58,59 Of course, any suggested change to a patient’s
medication should be discussed with the primary prescriber.
Smoking, including vaping and use of e-cigarettes, has a strong associa-
tion with dry mouth and should be minimized or discontinued altogether.44,60
For patients who smoke, integrating smoking-cessation counseling and asso-
ciated medication treatment is the cornerstone of successful xerostomia man-
agement.61 Other lifestyle modifications to help address oral dryness include
adequate hydration maintenance by frequently sipping water, sucking on ice,
or using a humidifier at night.15,62 Moreover, it is important to educate xerosto-
mia patients regarding intake of sugar and other fermentable carbohydrates,
which can increase caries risk, as well as other dietary issues such as limiting
alcohol and caffeine consumption.56,57 An effective multimodal approach to
managing xerostomia combines these important lifestyle changes with phar-
macological interventions.
OTC Treatment Options
The high prevalence of xerostomia has produced a market for numerous OTC
products for dry mouth. These include toothpastes, rinses, lozenges, sprays,
gels, oral patches, and chewing gums. Despite the wide selection of OTC for-
mulations, however, a recent systematic review and meta-analysis and a 2011
Cochrane review concluded that, “the use of these agents cannot be supported
on the basis of current evidence.”19,63 Regardless, some patients do find these
products to be effective, and when used in conjunction with proven, prescrip-
tion therapies the benefits may be additive.
Toothpastes-A bevy of toothpastes are marketed for dry mouth. OTC exam-
ples include: Biotène® Fresh Mint Original Fluoride Toothpaste (GlaxoSmith-
Kline, gsk.com), ACT® Dry Mouth Toothpaste (Sanofi, sanofi.com), Hydris™
Dry Mouth Hydrating Toothpaste (Colgate, colgate.com), and Enamelon®
Preventive Treatment Gel (Premier, premusa.com). Even more products are
available via prescription, such as PreviDent® 5000 Dry Mouth (Colgate) and
MI Paste® ONE (GC America, gcamerica.com). Commonalities of toothpastes
designed for the relief of dry mouth are that they contain fluoride and may
TABLE 3
Chairside Questionnaire for
Screening Patients for Xerostomia
1. Do you drink lots of fluids with
your meals?
2. Does food stick in your mouth or throat?
3. Can you eat a dry cracker without water?
4. Has your taste sensation decreased?
5. Do you keep a glass of water at your
bedside at night?
6. Do you awake at night to drink water?
7. Do you carry a bottle of water with you?
8. Does your mouth feel dry?
9. Do you have excessive dental cavities?
A “no” response = 0 points, a “yes” response = 1 point.
Xerostomia is present if the score is 5 or more.
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contain a sugar alcohol such as xylitol, they do not contain sodium lauryl sul-
fate (SLS), they are designed to soothe and moisturize oral tissues, and they
are intended to be non-irritating.15,64
In 2003 Rantanen et al completed a crossover trial comparing three types of
toothpaste: 1% SLS, a formulation containing 4% betaine (BET), and a third
product containing both 1% SLS and 4% BET. The researchers found a statis-
tically significant difference in mouth dryness relief in 44% of the BET tooth-
paste group compared to relief of symptoms in 22% and 18% of BET + SLS
and SLS toothpaste groups, respectively.64 More recently, Jose et al evaluated
the results from two randomized studies comparing the oral tolerance of three
fluoride toothpaste formulations in a dry mouth population and found all for-
mulations to offer potential alternatives to individuals with dry mouth equally
compelling.65 Once again, there was no clear benefit of one product over anoth-
er, but the authors reaffirmed the need for fluoride in a dry mouth toothpaste.
Similarly, a comparative study between a new preventive treatment gel
containing 0.4% stannous fluoride compared to a marketed OTC artificial sa-
liva gel product to relieve subject-perceived dry mouth symptoms in a self-re-
ported dry mouth population showed each product performed equally well.66
Based on inter-patient variability and individual patient preferences the study
generally recommended that patients should evaluate multiple products to de-
termine which can provide favorable results.
Saliva substitutes-Saliva substitutes can be administered either as sprays, gels,
or lozenges. No type of product has shown superiority over another in compari-
sons between formulations or in comparative trials to placebo.63 Products such
as mucin sprays, mucoadhesive discs, mucin lozenges, carboxymethylcellulose
sprays, xanthum gum-containing sprays, carbopol sprays, and even buffered pro-
phylin gel have all failed to show clear superiority. While this reinforces the Co-
chrane database finding that, “the use of these agents cannot be supported on the
basis of current evidence,”63 it does not necessarily rule out the benefit of these
products in combination or in a multimodal approach to xerostomia treatment,
TABLE 4
Therapeutic Categories and Drugs Associated With Xerostomia*
THERAPEUTIC CATEGORY
Anticholinergic agents
Antidepressant and antipsychotic agents
Selective serotonin-reuptake inhibitors (SSRIs)
Tricyclic antidepressants (TCAs)
Heterocyclic antidepressants
Monoamine oxidase inhibitors (MAOIs)
Atypical antidepressants
Diuretic agents
Antihypertensive agents
Sedative and anxiolytic agents
Muscle relaxant agents
Analgesic agents
Central nervous system/opioids
Nonsteroidal anti-inflammatory agents (NSAIDs)
Antihistamines
*Drugs listed have been reported to have a xerostomia incidence of 10% or more.
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especially when combined with prescription treatment options.
Saliva stimulants-The production of saliva is stimulated by the act of masti-
cation. Therefore, sugar-free chewing gum, usually containing a sugar alcohol
like xylitol, for patients with residual salivary function may be more helpful
than salivary substitutes described above. There is still, however, insufficient
evidence to substantiate that chewing gum is superior to other interventions in
assuaging dry mouth symptoms.67 Other saliva stimulants in the form of lozeng-
es, which are easy to administer, offer prolonged contact with the oral mucosa
and may be gentler on the sensitive mouth in patients following recent radio-
therapy.68 Lozenges also have the benefit of mechanical stimulation of saliva.69
Topical oral gels have also been formulated with the same endpoint in mind. In
all of these cases, however, there is insufficient evidence to definitively confirm
whether lozenges or oral gel formulations are effective treatments for dry mouth.
Prescription Treatment Options
Mercadante et al recently reviewed currently available interventions for the
management of radiotherapy-induced xerostomia and hyposalivation.19 As
mentioned earlier, this systematic review and meta-analysis concurred with
prior reviews on the lack of efficacy of OTC treatment strategies for xero-
stomia.70 Based on their results from 20 randomized, controlled clinical trials
involving 1732 participants, however, the prescription sialagogue medica-
tions pilocarpine and cevimeline were found to consistently reduce dry mouth
symptoms and increase salivary flow.
Pilocarpine and cevimeline are the only two systemic sialagogues approved
by the US Food and Drug Administration for the treatment of dry mouth. Their
mechanism of action is dependent on the presence of functional salivary gland
tissue, with oral pilocarpine acting as a parasympathomimetic with musca-
rinic action and cevimeline acting as a salivary gland stimulant with stronger
affinity for M3 muscarinic receptors.15,71-74 Both pilocarpine and cevimeline
offer similar benefits in patients with dry mouth.75 The choice between the
GENERIC DRUG NAME
atropine, belladonna, benztropine, oxybutynin, scopolamine,
trihexyphenidyl
amitriptyline, bupropion, citalopram, desipramine, fluoxetine,
haloperidol, imipramine, mirtazapine, nefazodone,
olanzapine, paroxetine, phenelzine, pimozide, sertraline,
venlafaxine
chlorothiazide, furosemide, hydrochlorothiazide, triamterene
captopril, chlorthalidone, clonidine, enalapril, guanfacine,
lisinopril, methyldopa
alprazolam, diazepam, flurazepam, temazepam, triazolam
cyclobenzaprine, orphenadrine, tizanidine
codeine, diflunisal, ibuprofen, meperidine, methadone,
naproxen, pentazocine, piroxicam, propoxyphene, tramadol
astemizole, brompheniramine, chlorpheniramine,
diphenhydramine, loratadine, meclizine
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two medications is largely determined by individual patient factors, includ-
ing cost to the patient, individual clinical response, convenience, and regula-
tory or insurance limitations on drug availability. The following summaries
differentiate these drugs further.
Pilocarpine-As a parasympathomimetic, pilocarpine directly stimulates
cholinergic receptors causing secretions of the exocrine glands, including an
increase in salivary flow.75,76 It is available in 5-mg and 7.5-mg tablets and
is initially dosed as 5 mg four times daily. The dosage may be titrated up to
7.5 mg four times daily, if needed, but the lowest effective maintenance dose
should be used. A reduced dose of 2.5 mg to 3.75 mg three times daily or even
5 mg twice daily may still provide benefit.77,78
Adverse reactions seen with orally administered pilocarpine are an exag-
geration of its parasympathetic effect. Hyperhidrosis (sweating) is a frequent
adverse effect reported in 29% to 68% of patients. Other common adverse
effects include chills (3% to 15%), edema (≤5%), flushing (8% to 13%), ep-
istaxis (1% to 2%), and pruritus (1% to 2%).79 Pilocarpine (and cevimeline)
are contraindicated in patients with hypersensitivity, narrow-angle glauco-
ma, and uncontrolled asthma, and these agents should be used cautiously in
patients taking beta-blockers. Patients using pilocarpine typically experience
a brief spurt of saliva due to the relatively short serum half-life of this drug
compared to cevimeline, given the higher frequency of administration, but
pilocarpine typically is at least half the price of cevimeline.
During a shortage of pilocarpine tablets in 1990, many patients were switched
to pilocarpine eye drops to be taken orally, as the eye drops were also used be-
fore the availability of the tablets.78,80 The gastrointestinal absorption of the oph-
thalmic solution appears to be similar to that of the tablets, and the medication
appears to be equiefficacious when administered by this route. The cost can be
significantly less as shown in at least one study where patients used four drops
of 2% pilocarpine solution, swish and swallow, three times daily. In this study
by Rhodus and Schuh, pilocarpine stimulated saliva production in more than
75% of patients.78 The volume of each dose depends on the concentration of the
solution used. Because the usual dose is 5 mg four times per day, the amount of
solution used should reflect this same dose. For example, there is 5 mg in each
mL of a 0.5% solution. The cost savings will be greater if more concentrated
pilocarpine solutions are used since there is 20 mg in each mL of a 2% solution;
thus, only 0.25 mL, or about five drops, is required for each dose.
In one clinical trial pilocarpine oral rinse was also shown to increase sali-
vary flow and relieve dry mouth symptoms with less side effects when com-
pared to oral tablets.81 The oral solution was compounded by dissolving three
5-mg tablets in 150 mL of water. Patients held the rinse in their mouth for
2 minutes before expectorating it and were allowed to use up to 150 mL of
the rinse per day. This may be an option for patients who wish to easily titrate the
dose of pilocarpine and avoid the systemic side effects of oral pilocarpine tablets.
Cevimeline-Cevimeline is a muscarinic receptor agonist and has a specif-
ically high binding affinity for muscarinic M3 receptors on lacrimal and sali-
vary gland epithelium. As a muscarinic receptor agonist, cevimeline increases
secretion of exocrine glands, such as salivary and sweat glands, and increases
tone of the smooth muscle in the gastrointestinal tract and urinary tract sim-
ilar to pilocarpine. Cevimeline is prescribed at a dose of 30 mg three times
per day taken about a half-hour before meals. There is insufficient safety and
efficacy information to support doses of more than 90 mg/day.82
Adverse effects of cevimeline are similar to those of pilocarpine and in-
clude excessive sweating, cutaneous vasodilation, emesis, nausea, diarrhea,
and, in some patients, persistent hiccups. It has a longer half-life and receptor
occupancy time than pilocarpine and requires dosing only three times daily
rather than four, which may further improve patient compliance. Some stud-
ies have reported cevimeline is better tolerated than pilocarpine since it does
cause less diaphoresis (flushing), but other studies have found that it causes
gastrointestinal side effects (eg, nausea, diarrhea) more often.83,84
The dose of pilocarpine or cevimeline should be increased gradually when
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initiating therapy, starting with one dose daily for a week, which helps to pre-
vent a sudden onset of sweating. Taking these medications with food to avoid
dyspepsia and gastric bloating is also advantageous. Typically, a trial of at least
3 months’ duration is necessary to see if these medications are tolerated be-
cause the response is frequently delayed. Cevimeline can be taken in a fourth
dose at bedtime if needed for nocturnal dryness. Similar to pilocarpine, the
effective use of lower doses of cevimeline in patients with poor tolerance of
the full dose has been reported.76 A lower dose can be prepared by dissolving
the desired fraction of a 30-mg capsule’s contents in water. The desired frac-
tion can be taken to achieve the preferred reduced dose, or the solution can
be used in a “rinse-and-spit” regimen to minimize systemic absorption.76,85
CONCLUSIONS
Despite the significant prevalence of xerostomia in the general population,
no standard treatment guidelines exist. Successful treatments are typically in-
dividualized for the specific patient and should target the underlying patho-
physiology of the disease. Therefore, an accurate diagnosis of xerostomia
causality is paramount in order to offer patients the best treatment possible.
While many treatment options exist for the management of xerostomia and
hyposalivation, ranging from the removal or reduction in dose of xerostomic
agents to lifestyle changes that include smoking cessation, the recommenda-
tion of nonprescription, topical agents cannot be routinely made on the basis
of current evidence. Only the prescription sialagogue medications pilocarpine
and cevimeline have been found to consistently reduce dry mouth symptoms
and increase salivary flow, although some patients may prefer a multimod-
al approach that combines the use of these agents with a topical treatment.
ABOUT THE AUTHORS
Mark Donaldson ACPR, PHARMD
Associate Principal, Vizient Pharmacy Advisory Solutions, Irving, Texas;
Clinical Professor, School of Pharmacy, University of Montana, Missou-
la, Montana; Clinical Assistant Professor, School of Dentistry, Oregon
Health & Sciences University, Portland, Oregon; Adjunct Professor,
Faculty of Dentistry, University of British Columbia, Vancouver, British
Columbia; Fellow, American Society of Hospital Pharmacists; Fellow,
American College of Healthcare Executives
Jason H. Goodchild, DMD
Director of Clinical Affairs, Premier Dental Products Co., Plymouth Meet-
ing, Pennsylvania; Associate Clinical Professor, Department of Diagnostic
Sciences, Creighton University School of Dentistry, Omaha, Nebraska;
Adjunct Assistant Professor, Division of Oral Diagnosis, Department of Di-
agnostic Sciences, Rutgers School of Dental Medicine, Newark, New Jersey
Queries to the author regarding this course may be submitted to
authorqueries@aegiscomm.com.
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JANUARY 2019
 CONTINUING EDUCATION QUIZ 2 Hours CE Credit

A Systematic Approach to Xerostomia Diagnosis and Management

Mark Donaldson, ACPR, PHARMD; and Jason H. Goodchild, DMD

TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/ccedxerotreatment

ENTER PROMO CODE: CCEDXERO1

1. The clinical method most often employed to diagnose 6. One of the most frequently reported causes of
salivary dysfunction is a: hyposalivation and xerostomia is:
A. salivary biomarker test. A. psychological treatment.
B. sialometry test. B. use of xylitol chewing gum.
C. salivametry test. C. illicit drug use.
D. sialvometry test. D. systemic medication use.

2. 
A definitive diagnosis of hyposalivation is made when 7. 
Most xerostomic medications:
unstimulated salivary flow rates are less than: A. increase unstimulated salivary flow rates.
A. 0.1 mL/minute. B. destroy salivary glands.
B. 0.4 mL/minute. C. do not damage salivary glands.
C. 0.7 mL/minute. D. cause neurological disorders.
D. 1.0 mL/minute.
8. 
Which of the following is/are common in patients with
3. 
Protective functions of saliva include: xerostomia?
A. cleansing the oral cavity. A. c
 andidiasis
B. maintaining a basic pH. B. increased tongue papillae
C. causing tooth demineralization. C. peri-implantitis
D. All of the above D. well-fitting dentures

4. Salivary gland hypofunction often results in altered taste 9. Commonalities of toothpastes designed for the relief of dry
sensation, also known as: mouth are that they:
A. dyspepsia.  A. contain fluoride.
B. dysgeusia. B. may contain a sugar alcohol such as xylitol.
C. dyspeusia. C. do not contain sodium lauryl sulfate.
D. xerophthalmia. D. All of the above

5. Sjögren’s disease is an autoimmune illness with a 10. Cevimeline is prescribed at a dose of 30 mg:
propensity to cause: A. diluted in 150 mL of water.
A. tooth decay. B. three times per day taken a half-hour before meals.
B. decreased saliva production. C. four times per day, including when waking up.
C. excessive moisture in the mouth. D. daily.
D. dental erosion.

Course is valid from 1/1/2019 to 1/31/2022. Participants must attain

a score of 70% on each quiz to receive credit. Participants receiving
a failing grade on any exam will be notified and permitted to take one AEGIS Publications, LLC, is an ADA CERP Recognized Provider. ADA CERP is a service
of the American Dental Association to assist dental professionals in identifying quality
Approval does not imply acceptance
re-examination. Participants will receive an annual report documenting providers of continuing dental education. ADA CERP does not approve or endorse
by a state or provisional board of
individual courses or instructors, nor does it imply acceptance of credit hours by boards
their accumulated credits, and are urged to contact their own state of dentistry. Concerns or complaints about a CE provider may be directed to the provider dentistry or AGD endorsement. The
or to ADA CERP at www.ada.org/cerp. current term of approval extends from
registry boards for special CE requirements.
1/1/2017 to 12/31/2022.
Provider #: 209722.

9 COMPENDIUM EBOOK JANUARY 2019

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