Management of Xerostomia in Older Adults:

A Systematic Review
BETTY DANIELS, MARY MCNALLY, DEBORA MATTHEWS, INGRID SKETRIS,
JILL A HAYDEN

Background: Xerostomia (dry mouth) is a common adverse effect of many medications and can severely
diminish quality of life for older adults.
Objective: To assess the effectiveness of 3 categories of interventions used to manage drug-induced
xerostomia and xerostomia secondary to Sjögren syndrome and radiation treatment for head and neck
cancer in older adults: saliva substitutes, saliva stimulants, and topical fluoride.
Data Sources: The Cochrane Library, PubMed, EMBASE (to July 2009) and CINAHL (to February 2010) were
searched for randomized or quasi-randomized studies involving older adults with drug- or radiation-
induced xerostomia or Sjögren syndrome.
Study Selection and Data Extraction: An updating search focusing on systematic reviews (to June 2012) was
conducted prior to publication. Outcomes included perceived dryness of the mouth, reduced sialometry, or
increased root caries. Duplicate study selection and data extraction were conducted. Risk of bias was
assessed. A random effects meta-analysis was employed.
Data Synthesis: Four studies of saliva substitutes (N = 116), 3 studies of saliva stimulants (N = 361), and 1 of
fluoride treatment (N = 334) met selection criteria. Saliva substitutes were more effective than other treatments at
improving perceived dryness of the mouth as determined on a 10-point visual analog scale (weighted mean
difference [WMD] –1.91 [95% CI –2.54 to –1.29]) but less effective than placebo (WMD 0.26 [95% CI 0.51-1.02]).
Parasympathetic stimulants were more effective than placebo in improving oral dryness (OR = 0.37 [95% CI 0.19-
0.72]). Due to lack of data, quantitative synthesis of results for topical fluoride was not possible.
Conclusions: There is evidence to suggest that saliva substitutes improve symptoms but the clinical significance
is minimal. The evidence more strongly supports the effect of saliva stimulants, although the quality of evidence
is poor and adverse effects from these medications cannot be overlooked. Evidence demonstrating efficacy of
topical fluoride in disease prevention was inconclusive. Addressing underlying causes of xerostomia, including
drug choices, may help mitigate the burden of illness and effects on quality of life.
J Pharm Technol 2013;29:13-22.

Reduced salivary flow and subsequent xerostomia (per-
ceived dryness of the mouth) is a significant risk factor
for dental disease and can adversely affect swallowing
and chewing efficiency.1 Approximately 30% of the pop-
ulation aged 65 years and older experiences some de-
gree of dry mouth. The rate is reported to be as high as
45-50% for elders living in residential care.2 Xerostomia
is most commonly attributed to polypharmacy, in
which it is a known adverse effect of more than 500
medications.3-6 Xerostomia can also be caused by sali-
vary gland dysfunction related to autoimmune ex-
ocrinopathies (eg, Sjögren syndrome), radiation-in-

BETTY DANIELS MAHR, Administrator, Orchard View Long Term Care, Gagetown, New Brunswick, Canada; MARY MCNALLY
MSc DDS MA, Associate Professor, Faculties of Dentistry and Medicine, Research Associate, Atlantic Health Promotion Research
Centre, Dalhousie University, Halifax, Nova Scotia, Canada; DEBORA MATTHEWS DDS Dip Perio MSc, Professor and Chair, De-
partment of Dental Clinical Sciences, Faculty of Dentistry, Dalhousie University; INGRID SKETRIS PharmD MPA (HSA), Professor and
Associate Director, Research, College of Pharmacy, Dalhousie University; JILL A HAYDEN DC PhD, Assistant Professor, Community
Health and Epidemiology, Faculty of Medicine, Dalhousie University. Correspondence: Dr. McNally, mary.mcnally@dal.ca
Reprints/Online Access: https://www.hwbooks.com/jpt/abstracts/volume29/january-february/order_article.html
Conflict of interest: Authors reported none
© 1985-2013 Harvey Whitney Books Co. All rights reserved. No part of this document may be reproduced or transmitted in any
form or by any means without prior written permission of Harvey Whitney Books Co. For reprints of any article appearing in the
journal of Pharmacy Technology, please contact 415sales@hwbooks.com

JPHARMTECHNOL.COM JANUARY/FEBRUARY 2013 I VOLUME 29 I J PHARM TECHNOL 13

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duced salivary gland dysfunction, dehydration, or sali-
vary gland trauma.7
Saliva is essential to good oral health and protects the
oral cavity and contiguous gastrointestinal epithelium in
a variety of ways. Salivary secretions function to cleanse
and lubricate the oral soft and hard tissues, facilitate
taste perception, mastication, and speech and retain re-
movable dental prostheses.3 Saliva also protects the teeth
from dental caries (decay).8 Bicarbonate and other
buffers in saliva function to maintain physiologic pH
balance, protecting tooth enamel from acid dissolution.
Calcium and phosphate present in saliva decrease the
solubility of hydroxyapatite (the mineral component of
tooth enamel)9-11 and function to restore loss of tooth
enamel.12 Reduced salivary flow limits the availability of
salivary calcium and phosphate ions and reduces buffer-
ing capacity essential for maintaining a healthy tooth
surface. Decreased saliva production and concomitant
reduction of the antimicrobial potential of saliva also
contributes to increased risk for mucosal infections such
as candidiasis.8
The incidence and severity of xerostomia is correlated
with both the number and type of drugs taken.13 Many
medications, including anticholinergics, antidepressants,
antipsychotics, antihypertensives, diuretics, laxatives, and
antihistamines, produce xerostomia as a known adverse ef-
fect. Among the most common antisialogogues are anti-
cholinergic drugs that block the release of acetylcholine at
the parasympathetic neuro-effector junction and neuro-
transmitter inhibitors that interfere with salivary gland ion
transport pathways output.14
Managing xerostomia can be challenging, especially if
decreasing dosages or substitution of medications is not
feasible or there is no available treatment for underlying
diseases. A variety of strategies being used to address xe-
rostomia include relief of symptoms (ie, saliva substitutes,
saliva stimulants) and prevention of the sequelae of sali-
vary gland hypofunction, such as dental disease (ie, topical
fluoride).7 Saliva substitutes and artificial saliva products
are applied directly in the mouth to replace natural saliva.
They serve as palliative and coadjutant treatments. Artifi-
cial saliva humidifies and lubricates the dehydrated oral
mucosa and protects the oral cavity against irritation.15,16
Saliva stimulants increase the volume of saliva produced
and secreted by the salivary glands through either physical
stimulation or pharmacotherapeutic effect. Saliva stimu-
lants increase secretion of normal saliva and ameliorate
both xerostomia and other complications of hyposaliva-
tion. The 2 categories of saliva stimulants are
gustatory/mechanical stimulants and parasympathetic
stimulants. For mild xerostomia, a mechanical or gustatory
stimulation of the salivary glands may be effective.17 Topi-
cal fluoride does not stimulate or mimic the functions of
saliva. Given the significantly higher rate of active dental
caries in the presence of xerostomia, fluoride is an impor-
tant adjunct treatment for clinicians managing sequelae of
xerostomia, particularly dental decay.18
14 J PHARM TECHNOL I VOLUME 29 I JANUARY/FEBRUARY 2013
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The purpose of this research was to conduct a system-
atic review to address the following clinical question: In
older adults taking xerostomic drugs, do saliva substi-
tutes, saliva stimulants, or topical fluoride gels relieve
symptoms, improve quality of life, and/or prevent den-
tal caries?
Methods
INCLUSION CRITERIA
Types of Studies
Randomized controlled trials (RCTs) or quasi-ran-
domized controlled trials were included in the review.
Trials that used blind outcome assessment in which inter-
ventions were compared concurrently to an alternative
treatment or placebo or to no intervention were included.
Patient Population
The target population of this study was older adults
with symptoms of drug-induced xerostomia. Xerostomia
was based on: (1) a subjective perception of dry mouth
(ie, a burning sensation in the mouth or difficulty chew-
ing, swallowing, or speaking), with or without clinically
measured reduced salivary flow (hyposalivation), mea-
sured using a visual analog scale (VAS) in which re-
sponses to at least 1 of 8 VAS questions related to dry
mouth was 3 cm or greater on a 10-cm scale or (2) a sali-
va flow rate less than 0.1-0.2 mL/min (resting whole sali-
va) or 0.7 mL/min (stimulated whole saliva) using
sialometry.8 The original protocol focused only on indi-
viduals over the age of 65 with drug-induced xerostomia.
However, there were few studies available specific to this
defined population. We expanded our criteria to include
individuals with Sjögren syndrome, those who received
radiation treatment for head and neck cancer, as well as
any participants over the age of 60.
Interventions
Interventions included saliva substitutes, saliva stimu-
lants, and topical fluoride treatment.
Comparisons
Trials in which interventions (saliva stimulants, saliva
substitutes, and topical fluoride) were compared concur-
rently to an alternative treatment or placebo or to no in-
tervention were included.
Outcomes
The primary outcome was a reduction in the degree of
the patient’s perceived dryness of the mouth as measured
using a 10-cm VAS.2 To compensate for the limited infor-
JPHARMTECHNOL.COM

mation from VAS results, a dichotomous variable was cre-
ated to reflect improvement in overall perceived symptoms
of xerostomia compared with no improvement. Secondary
outcome measures were changes in unstimulated salivary
flow rates from baseline to the end of the first intervention
phase (measured in mL/min), proportion of subjects who
reported improvement in oral dryness (compared with no
change or increase in symptoms), changes in taste and abil-
ity to swallow (determined with VAS), and a reduction in
root caries. The latter was measured by a change from
baseline using the Root Caries Index (RCI) instrument (ra-
tio of the number of decayed and filled surfaces to the
number of exposed tooth surfaces).19
EXCLUSION CRITERIA
Studies without control groups, populations other
than the targeted population, and interventions inconsis-
tent with this review were excluded.
SEARCH STRATEGY
The following databases were searched: the Cochrane
Library (Issue 7, 2009), PubMed (1950-July 2009), EM-
BASE (1980- July 2009), and Cumulative Index to Nurs-
ing and Allied Health Literature (CINAHL) (1982-Febru-
ary 2010). The search strategies are found in Appendix I.
An updating search focusing on systematic reviews (the
Cochrane Library and PubMed) was conducted for the
period up to June 2012. Only articles in English were in-
cluded. Attempts were made to contact authors of the in-
cluded studies for missing data where required. Studies
were reviewed by 2 of the authors (BD, DM), with dis-
agreements resolved by a third reviewer (MM).
L but no additional relevant studies were identified.21
Interventions included saliva
substitutes, saliva stimulants, and
topical fluoride treatment.
M Four studies investigated saliva substitutes (N =
RISK OF BIAS
The Cochrane Collaboration’s tool for assessing risk of
bias was used.20 Assessment of the internal validity of the
included studies was based on appropriate sequence
generation, concealment allocation, blinding, and incom-
plete reporting of outcome data. Risk of bias was as-
sessed by 2 of the authors (BD, DM), with disagreements
resolved by a third reviewer (JH).
JPHARMTECHNOL.COM
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MANAGEMENT OF XEROSTOMIA IN OLDER ADULTS
DATA ANALYSIS
Data from the included studies were synthesized based
on sufficient similarity in the category of intervention (eg,
saliva substitutes), the etiology of the condition, the study
design (eg, crossover, parallel comparisons), methodologic
quality, and outcomes measured. Data extracted from in-
cluded studies were reported on standardized data extrac-
tion forms and entered into RevMan (V. 5.0) software pro-
gram for analysis. Meta-analyses were conducted if a
minimum of 2 studies in an intervention category provided
sufficient data. For continuous outcome measures, a
weighted mean difference (WMD) with a random effects
model was used.
For studies reporting percentage of patients improved
in terms of perceived oral dryness, treatment effects were
estimated using study odds ratio and pooled using a ran-
dom effects model. Overall treatment effects and 95%
confidence intervals (CIs) were calculated.
Statistical heterogeneity was determined using the I2
statistic.
Results
SEARCH RESULTS
Search results are summarized in the flow chart in Fig-
ure 1. Of 68 papers retrieved for full evaluation, 52 were
excluded. Of studies that were excluded, 14 had no con-
trol group, 21 had populations that failed to meet the re-
view inclusion criteria, 4 measured no compatible out-
comes, 5 used interventions that failed to meet inclusion
criteria, 5 were case reports, and 3 were excluded for oth-
er reasons (eg, incomplete data). Of the 16 papers that
met the inclusion criteria, there were insufficient data in a
further 8 studies to include in a meta-analysis. One sys-
tematic review was found through the updating search
DESCRIPTION OF INCLUDED STUDIES
A summary of characteristics of the included studies
is in Table 1. Of the 8 studies, 4 included populations in
which xerostomia was drug-induced. Four included pa-
tients with radiation-induced xerostomia.5,18,22,23
116).5,22,24,25 Saliva substitutes were either biopolymer
based (carboxymethylcellulose spray25 and xanthan
gum24), salivary enzyme based (latoperoxidase, ly-
zozyme and glucose oxidised gel and spray),25 or other
(lubricant-compound oxygenated glycerol trimester and
aqueous electrolyte solution).5
Three studies (N = 361) investigated the effectiveness
of saliva stimulants from the parasympathetic stimulant
category.23,26,27 One study (N = 334) investigated fluoride
as a preventive intervention for root decay in individu-
als with xerostomia.18 Five studies evaluating saliva sub-
JANUARY/FEBRUARY 2013 I VOLUME 29 I J PHARM TECHNOL 15
stitutes measured patient-perceived xerostomia using a
VAS.5,22,24,27 Changes in unstimulated salivary flow rates
(measured in mL/min) from baseline to the end of the
first intervention phase were assessed in 4 studies.22,25-27
The period from the beginning of the intervention to
the conclusion of the first phase of the study ranged from
3 weeks to 12 weeks for the parasympathetic stimulant
category.23,27 In terms of secondary outcomes, changes in
taste sensation and ability to swallow were measured
with a 10-cm VAS in 2 studies.5,22
Only 1 study of topical fluoride used root caries re-
duction18 as an outcome measure.
QUALITY OF INCLUDED STUDIES
The most common flaw identified in determining risk
of bias was inadequate concealment of treatment alloca-
tion (Table 2). Additionally, while the majority of studies
indicated that randomization was implemented in sam-
ple selection, many failed to provide clear details of ran-
domization in the published article. Only 3 of the trials
were rated as low risk of bias. Additionally, many of the
studies lacked information to assess the clinical relevance
Figure 1. Screening of Articles.
16 J PHARM TECHNOL I VOLUME 29 I JANUARY/FEBRUARY 2013
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of the treatments presented.
EFFECTS OF INTERVENTIONS
Saliva Substitutes
Effectiveness of saliva substitutes for the overall im-
provement outcome is summarized in Figure 2. The prima-
ry outcome of interest for saliva substitutes was the partici-
pant’s perceived sense of dryness of the mouth, measured
with a 10-cm VAS. Four studies provided the mean (SD)
values for the VAS after the first intervention phase (short-
term follow-up in a range of 1 to 5 weeks).5,22,24,25 A placebo
comparison was used in studies by Gil-Montoya et al.22
and Jellema et al.24 The treatment effect favored the place-
bo: WMD = 0.26 (95% CI –0.51 to 1.02). The I2 test for het-
erogeneity was 0%. Mouly et al.5 and Nagy et al.25 com-
pared an experimental treatment with another saliva
substitute. The treatment effect favored the experimental
therapy: WMD –1.91 (95% CI –2.54 to –1.29). The I2 test for
heterogeneity was also 0%. The pooled effect favored the
experimental therapy: WMD –0.89 (–2.13 to 0.36; 95% CI),
with significant heterogeneity (I2 84%).
JPHARMTECHNOL.COM
 MANAGEMENT OF XEROSTOMIA IN OLDER ADULTS

Saliva Stimulants cal/gustatory category provided mean (SD) values27; there-

The effectiveness of saliva stimulants for the overall
improvement outcome (proportion of subjects who per-
ceived their symptoms to be improved) is detailed in Fig-
ure 3. A meta-analysis of the primary outcome was not
possible with the information available in the subcategory
of gustatory saliva stimulants due to lack of data. In the
subcategory of parasympathetic saliva substitutes, the
overall improvement outcome suggests slightly greater
improvement in favor of the experimental parasympa-
thetic products tested (OR 0.037 [95% CI 0.19-0.72]).
Sialometry values were provided for a limited number
of the studies in this review. Many of the researchers pro-
vided only the baseline values as evidence of hypo-
salivation and participant suitability for inclusion in the
study. Only 1 saliva stimulant study from the mechani-
fore, meta-analysis was not possible.
Fluorides
With respect to improvement in root caries remineral-
ization, a single study examining effects of topical fluo-
ride did not allow for data synthesis. Papas et al.18 com-
pared 2 topical fluorides and found that 29 of the 134
(22%) of soft or leathery root caries remineralized to hard
lesions in response to stannous fluoride and 38 of the 145
(26%) remineralized in response to sodium fluoride.
SECONDARY OUTCOMES
Two studies5,24 compared salivary substitutes using
changes in VAS scores for a perceived change in degree of

Table 1. Summary of Characteristics of Included Studies

MEAN
PTS., AGE OUTCOME
REFERENCE POPULATION N (YEARS) INTERVENTION CONTROL DURATION MEASURE DESIGN

Saliva Substitutes
Gil-Montoya Drug-induced 20 81.3 Biotinea mouth rinse Oral Balance Biotene gel 4 weeks VAS, sialometry Crossover
(2008)22 (lactoperoxicase, (lactoperoxidase
lysozyme, glucose lysozyme, glucose
oxidase, and oxidase, lactoferrin);
lactoferrin, xylitol); 3 times daily
3 times daily
Mouly Drug-induced 41 84 OGT (oxygenated Saliveze (aqueous electro- 2 weeks VAS Parallel
(2007)5 glycerol triester lyte solution: calcium
lubricant compound chloride, magnesium
(94.4%), silicon chloride, sodium chloride,
dioxide (1.5%)); at potassium chloride,
least 5 times per day sodium phosphate, and
sorbitol); at least 5 times
per day
Jellema Radiation- 30 59 Xialineb rinse (xanthan Placebo rinse at least 4 1 week VAS Crossover
(2001)24 induced gum-based polymer, times daily
sodium fluoride); at
least 4 times daily
Nagy Radiation- 30 58.2 Biotine rinse CMC (carboxymethyl- 4 weeks VAS, sialometry Parallel
(2007)25 induced cellulose) gel
Saliva Stimulants
Davies Drug-induced 43 66 Pilocarpine 5 mg 3 times Saliva Orthanac spray 2 weeks % improved Crossover
(1998)23 daily (3.5% mucin, 2% xylitol,
methyl hydroxybenzo-
nate, chloride, disodium
edentate); 2-3 times daily
Frydrych Radiation- 23 62 Pilocarpine mouth spray Placebo mouth spray for 8 weeks % improved, Parallel
(2002)26 induced for symptom relief symptom relief sialometry
Reike Radiation- 369 59.4 Pilocarpine, fixed dose Placebo 12 weeks VAS, % Parallel
(1995)27 induced (5 or 10 mg 3 times improved
daily); titrated
Fluorides
Papas Drug-induced 440 65.9 0.454% stannous Control dentrifice twice 2 years Root caries Parallel
(2007)18 fluoride/sodium daily remineralization
hexametaphosphate
dentifrice; twice daily

VAS = visual analog scale.

a
Glaxo-SmithKline, Inc., Brentford, Middlesex, UK.
b
Pharma, Netherlands.
c
AS Pharma, Andover, Hampshire, UK.

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difficulty speaking and a perceived change in degree of dif- VAS outcome measures as well as the more objective
ficulty swallowing (Figure 4). Salivary substitutes reduced sialometry measures of unstimulated and stimulated sali-
subjects’ difficulty in speaking (WMD –0.68 [95% CI –0.89 vary flow rates with mean (SD) values would have
to –0.46]). The test for change in difficulty swallowing was strengthened the evidence arising from the meta-analysis.
not statistically significant (WMD –0.83 [95% CI –2.60 to
0.94]).
L
Discussion
The overall outcome for
The primary outcome (overall degree of dryness of the
mouth measured with VAS) for 4 studies indicated im-
parasympathetic saliva stimulants
provement in the degree of dryness of the mouth, although suggests slightly more
the evidence is conflicting. As noted, the WMD for the
studies comparing the experimental treatment to a placebo improvement in favor of
favored the placebo, whereas studies comparing the exper-
imental treatment to another saliva substitute favored the experimental parasympathetic
experimental therapy. This finding is contrary to the expec-
tation that the experimental treatment should show a products tested when compared
greater improvement than placebo and demonstrates the
importance of considering risk of bias. Both studies in
with the improvement observed
which experimental treatment was compared with another for saliva substitutes (compared
treatment subcategory were of high or unclear risk of
bias.5,25 The 2 studies comparing the experimental treat- with placebo).
ment with a placebo were of low risk of bias.22,24 The stud-
ies with a higher risk of bias may have inflated results in fa-
vor of the experimental treatment. M
The overall outcome for parasympathetic saliva stimu-
lants suggests slightly more improvement in favor of ex- Fluoride was demonstrated to promote remineraliza-
perimental parasympathetic products tested when com- tion of existing carious lesions in the presence of xerosto-
pared with the improvement observed for saliva mia.18 Although this is consistent with fluoride’s known
substitutes (compared with placebo). This must be viewed benefits in promoting tooth mineralization, there is also
with caution, however, as studies by both Reike et al.27 and evidence to suggest that oral dryness may diminish the
Davies et al.23 were evaluated as having high risk of bias. solubility and overall efficacy of fluoride gel.28
Although saliva stimulants are intended to improve
salivary flow, sialometry values were not provided consis- LIMITATIONS
tently in the studies reviewed and were often presented
only as baseline values to demonstrate hyposalivation and There are a number of biases in existing literature re-
participant suitability for inclusion in the study. Standard garding management of xerostomia. It was not possible to

Table 2. Risk of Bias of Included Studies

INCOMPLETE
ALLOCATION OUTCOME RISK OF
REFERENCE RANDOMIZED CONCEALED BLINDED REPORTING BIAS

Saliva Substitutes
Gil-Montoya (2008)22 Yes Yes Yes Yes Low
Mouly (2007)5 Unclear No No (examiner only) Yes Unclear
Jellema (2001)24 Yes Yes Yes Yes Low
Nagy (2007)25 Unclear No Unclear Yes Unclear
Saliva Stimulants
Davies (1998)23 Unclear No No Yes Unclear
Frydrych (2002)26 Unclear Unclear Yes Yes Unclear
Reike (1995)27 Unclear Unclear Yes Yes Unclear
Fluorides
Papas (2007)18 Yes Yes Yes Yes Low

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Figure 2. Effectiveness of saliva substitutes for the overall improvement outcome (10-cm visual analog scale).

Figure 3. Effectiveness of saliva stimulants for the overall improvement outcome (improved or not).

Figure 4. Analysis testing the effectiveness of saliva substitutes for improvement in speaking and swallowing.

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conduct sensitivity analyses in this review. Additional tests
should determine whether removal of high risk of bias
studies would alter the results. However, this was not pos-
sible due to the small number of included studies. No at-
tempt was made to assess the possibility of publication
bias.
Study design also presented inconsistencies. Three of
the studies used a crossover design22,23,24 and 5 used a
parallel design.5,18,25-27 Caution is recommended when
combining studies in which both crossover and parallel
designs have been used because of the potential of a car-
ryover effect with the crossover design. Two separate cat-
egories should be established when conducting meta-
analysis.29 For this review, the decision was made to use
only data following the first intervention to mitigate this
potential problem. Overall, the strength of evidence is
limited, which is a clear indication that future studies
will require an increased effort on the part of investiga-
tors to adhere to best practices for study design.
This review revealed that there are few clinical trials that
examine the efficacy of interventions specific to polyphar-
macy-induced dry mouth in older adults. However, when
the study criteria were expanded to include clinical investi-
gations focused on radiation-induced salivary hypofunc-
tion or Sjögren syndrome, we were able to provide evi-
dence that topical dry mouth products are effective in
improving symptoms of dry mouth for some people affect-
ed by xerostomia.
CLINICAL CONSIDERATIONS
This review has implications for older adults and their
families, practicing clinicians, researchers as well as prima-
ry care physicians, long-term care, and hospital formulary
system administrators. Health care providers and decision
makers who directly impact the care of older adults,
particularly those in long-term care, should be aware of
xerostomia’s debilitating impact on quality of life and
risk for dental disease. Increasing age expectancies will be
accompanied by a greater number of older adults living
with chronic conditions. The need for multiple medications
to manage chronic conditions will accompany this trend
and contribute to the likelihood that the incidence and
prevalence of drug-induced xerostomia will also continue
to increase.30 Clinicians who prescribe and dispense medi-
cations may wish to consider choices that minimize risk for
xerostomia as an adverse effect. When those choices are not
available, this study supports the recommendation that
saliva substitutes and gustatory/mechanical stimulants
provide symptomatic relief for some people. Saliva substi-
tutes have the advantage of few adverse effects and, there-
fore, minimal risk. Although a higher degree of improve-
ment is indicated with the parasympathetic saliva
stimulants, recommending these products must be bal-
anced against the risk of adverse effects such as sweating,
dizziness, and nausea. Because reduced saliva is a known
risk factor for dental caries, this study also supports topical
fluorides as a useful adjunct for disease prevention.
20 J PHARM TECHNOL I VOLUME 29 I JANUARY/FEBRUARY 2013
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Summary
Xerostomia, no matter what the cause, has the poten-
tial to create a burden of illness and significant impact on
quality of life. Unlike the permanent affects that Sjögren
syndrome and radiation have on salivary gland function-
ing, drug-induced xerostomia has the potential to be mini-
mized through careful consideration of pharmaceutical
choices. Despite weak evidence and given the significant
impact of xerostomia on oral discomfort, speaking, and
swallowing, even a small amount of relief may make an
important difference in the quality of life for an individual.
In order to strengthen the evidence base for managing xe-
rostomia, a number of research priorities are apparent from
this review. More intervention research is required to exam-
ine the impact, costs, and uptake of both novel and existing
therapies. To be useful, intervention studies must also in-
clude standard outcome measures, determine clinically rel-
evant improvement in outcome measures such as VAS
scores, and employ strategies to reduce bias.
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Appendix I. Search Strategies
Cumulative Index to Nursing and Allied Health Literature (CINAHL) Search Strategy
#21 Search #7 and #19 Limits: Humans, English, Aged: 65+ years, 80 and over: 80+ years
#20 Search #7 and #19
#19 Search #17 or #18
#18 Search “saliva stimulant” or “saliva stimulants” or “saliva substitute” or “saliva substitutes” or fluoride or xylitol*
#17 Search (“Saliva, Artificial”[ CINAHL heading] OR “Fluorides”[ CINAHL heading]) OR “Xylitol”[ CINAHL heading]
#7 Search #5 or #6
#6 Search xerostomi* or “dry mouth” or hyposalivation
#5 Search “Xerostomia”[ CINAHL heading:NoExp]
PubMed Search Strategy
Search (#21) AND ((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] OR clinical trial[Publication Type] OR
random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading]) Limits: Humans, English, Aged: 65+ years,
80 and over: 80+ years
Search #7 and #19 Limits: Humans, English, Aged: 65+ years, 80 and over: 80+ years
Search #7 and #19
Search #17 or #18
Search “saliva stimulant” or “saliva stimulants” or “saliva substitute” or “saliva substitutes” or fluoride or xylitol*
Search (“Saliva, Artificial”[Mesh] OR “Fluorides”[Mesh]) OR “Xylitol”[Mesh]
Search #5 or #6
Search xerostomi* or “dry mouth” or hyposalivation
Search “Xerostomia”[Mesh:NoExp]
Search “Xerostomia”[Mesh]
Cochrane Database Search Strategy
#1 (xerostomi* or “dry mouth” or hyposalivation):ti,ab,kw
#2 MeSH descriptor Saliva, Artificial explode all trees 7
#3 MeSH descriptor Xerostomia, this term only
#4 MeSH descriptor Fluorides explode all trees
#5 MeSH descriptor Xylitol explode all trees
#6 “saliva stimulant” or “saliva stimulants” or “saliva substitute” or “saliva substitutes” or fluoride or xylitol*:ti,ab,kw
#7 (#3 OR #1)
#8 (#2 OR #4 OR #5 OR #6)
#9 (#7 AND #8)
EMBASE Search Strategy
#10 #8 NOT #9
#9 ‘Sjögren Syndrome’/exp
#8 #3 AND #6 AND [English]/lim AND [humans]/lim AND [aged]/lim
#7 #3 AND #6
#6 #4 OR #5
#5 ‘saliva stimulant’ OR ‘saliva stimulants’ OR (‘saliva substitute’/exp OR ‘saliva substitute’) OR ‘saliva substitutes’ OR (‘fluoride’/exp OR ‘fluoride’) OR
xylitol*
#4 ‘saliva substitute’/exp OR ‘fluoride’/exp OR ‘xylitol’/exp
#3 #1 OR #21
#2 xerostomi* OR (‘dry mouth’/exp OR ‘dry mouth’) OR (‘hyposalivation’/exp OR ‘hyposalivation’)
#1 ‘xerostomia’/exp

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