When dry mouth (xerostomia) is a patient's only symptom and the patient doesn't have associated disease, should a medication be prescribed?

Response from Robert I. Fox, MD, PhD
Professor and Member, Scripps Memorial Hospital and Research Foundation; Rheumatologist, Scripps Memorial Hospital, La Jolla, California

At our clinic, we see many patients who present with the complaint of dry or painful mouth. Presentations range from abnormal salivary secretion to complaints of dry mouth for other reasons. Normal aging, Alzheimer's disease,[1] and multiple sclerosis[2] can all produce significant dryness. In patients with multiple sclerosis, outflow of cholinergic tracts at the subcortical level has been proposed as the cause. Dryness is also a common component in depression[3] and in fibromyalgia,[4] where it is difficult to demonstrate objective abnormalities in salivary flow.

The initial evaluation of these patients should focus on identifying treatable causes of the dryness, such as certain medications (eg, tricyclics and antihistamines) or herbal supplements that can have anticholinergic side effects. Low-grade oral yeast infection may also be reported by patients as a "dry" or "painful" mouth.[5]

Two oral agents have been approved by the US Food and Drug Administration for treatment of dry mouth: pilocarpine[6] and cevimeline.[7] Both drugs are significantly effective in treating dry mouth and act as cholinergic agonists that stimulate the muscarinic M3 receptor on the salivary glands.