Xerostomia, or chronic dry mouth, is a prevalent and often debilitating condition with significant implications for oral health, nutrition, and overall quality of life. It is commonly encountered in patients with Sjögren’s syndrome, those undergoing head and neck radiation therapy, individuals taking xerogenic medications, CPAP machine use, and increased marijuana consumption.1,2 The management of xerostomia is multifaceted, involving lifestyle modifications, pharmacological agents, and topical therapies, with the choice of intervention guided by symptom severity, underlying etiology, and patient-specific factors.
Screening Protocols and Early Detection
The rising prevalence of xerostomia—now affecting one in four individuals—has transformed it into a “silent pandemic” with systemic implications. Early identification is critical to mitigate complications like dental caries, infections, and malnutrition.1 Traditional screening tools, such as the Clinical Oral Dryness Score (CODS) and Xerostomia Inventory, enable clinicians to assess symptom severity through visual oral examinations and patient-reported outcomes.3,4 These tools categorize dryness into mild, moderate, or severe grades, guiding initial interventions.
However, the implementation of systematic xerostomia screening protocols has important implications for dental practice workflow. Incorporating these assessments into routine care can increase chair time, as clinicians must allocate additional minutes to administer questionnaires, perform oral evaluations, and discuss findings with patients.3 This time investment is necessary to ensure accurate diagnosis and effective management, but it may impact scheduling and overall practice efficiency if not properly integrated.
Furthermore, the effectiveness of screening depends heavily on the training and confidence of dental professionals. Studies indicate that many practitioners feel underprepared to diagnose and manage xerostomia, often due to limited exposure to effective screening and treatment options.1,3 Comprehensive training in the use of screening tools and in the recognition of both clinical and subjective signs of xerostomia, and knowledge of the possible treatment options, is essential to maximizing the benefits of early detection and to ensure that dental teams can provide high-quality, patient-centered care.3,5
Recently, I had the privilege of advancing xerostomia screening by creating the Personalized Xerostomia Protocol (PXP), in collaboration with K Pharmaceuticals. Designed for use at every dental appointment, the PXP standardizes screening, patient education, and treatment adaptation.5,7 Importantly, the protocol streamlines the screening process by providing a straightforward, efficient tool that can be seamlessly integrated into routine visits, minimizing additional chair time while ensuring comprehensive assessment. It emphasizes routine evaluation of dry mouth symptoms—even in asymptomatic patients—and incorporates protocol-driven treatment options into management plans when first-line measures such as water-based substitutes and sugar-free gum fail.6,7 By bridging gaps in global guidelines, the PXP aims to reduce underdiagnosis and preventable systemic sequelae while enhancing clinical workflow efficiency and patient engagement.
Current Treatment Protocols
Modern xerostomia management prioritizes a tiered strategy, beginning with lifestyle modifications such as hydration, sugar-free gum, and avoidance of caffeine or alcohol, as outlined by the Mayo Clinic and StatPearls guidelines.8,9 For moderate to severe cases, systemic sialagogues like pilocarpine and cevimeline are recommended by the American Society of Clinical Oncology (ASCO) and Johns Hopkins Sjögren’s Center.8,10 These muscarinic agonists stimulate residual salivary gland function but require careful titration to manage side effects, such as sweating and gastrointestinal distress.
Radiation-induced xerostomia benefits from prophylactic measures, including intensity modulated radiation therapy (IMRT), which reduces salivary gland damage.8,11 Cytoprotective agents like amifostine remain controversial due to transient efficacy and adverse effects, though their use persists in high-risk radiotherapy patients.10 Topical therapies, particularly saliva substitutes, are widely endorsed. Lipid-based formulations (e.g., Aquoral) are prioritized in severe cases for their mucosal barrier properties, yet they remain absent from protocols such as the American Dental Association (ADA) guidelines, which focus disproportionately on water-based products.11,2
Clinical Implications: Escalation and Preventive Care
Tailored escalation of care is critical. The Sjögren’s Foundation advises initiating low-dose sialogogues and adjusting based on tolerance, particularly for autoimmune-related cases.5 Delayed escalation to lipid-based substitutes in persistent xerostomia correlates with preventable complications like dental caries.10,11 For example, BC Cancer guidelines recommend lipid-based sprays when basic interventions fail, yet protocol heterogeneity persists—Mayo Clinic prioritizes lifestyle adjustments, while Johns Hopkins offers gland suctioning for refractory cases.10,11
Preventive strategies must evolve. While the ADA emphasizes fluoride treatments, moisture retention via lipid-based products is equally vital in severe cases to prevent enamel demineralization.11 Multidisciplinary coordination ensures holistic management; for instance, integrating IMRT with post-radiation lipid-based substitutes can mitigate long-term dryness.11
Legal Considerations
Negligence claims often stem from inadequate screening or failure to escalate therapy. Clinicians relying on outdated substitutes (e.g., water-based gels) instead of lipid-based alternatives in severe cases may breach standards of care, particularly if preventable dental damage occurs.12 Informed consent mandates transparency about all options, including emerging therapies like the PXP protocol. Withholding information about lipid-based substitutes or sialogogues invalidates consent and risks liability.10,12
Guideline Gaps and Future Directions
Major guidelines, including ASCO (2021) and EULAR (2020), lack references to lipid-based substitutes, while the ADA underprioritizes moisture retention.8,11 The PXP protocol highlights these disparities, advocating for global standardization.6,7 Future updates must integrate multidisciplinary insights, particularly for irreversible salivary gland damage, and validate emerging therapies like electrostimulation devices.
Conclusion
Contemporary xerostomia protocols emphasize personalized, escalating strategies but face challenges in standardization and adoption of lipid-based therapies. The PXP protocol represents a paradigm shift in screening and management, yet guideline bodies must accelerate updates to reflect current evidence. Clinicians must balance evidence-based interventions with legal obligations to informed consent, ensuring patients receive comprehensive, proactive care.
Melissa Turner, BASDH, RDHEP, EFDA
Chief Hygiene Officer, Cellerant Consulting Group
Cofounder, The Denobi Awards, the National Mobile & Teledentistry Conference, and the I Heart Dentistry Network
www.MelissaKTurner.com
Figures and Images
Melissa Turner, BASDH, RDHEP, EFDA
