Guideline sources The following summarized guidelines for the management of xerostomia are prepared by our editorial team based on guidelines from the Multinational Association of Supportive Care in Cancer (MASCC/ISOO/ASCO 2021) and the Sj gren's Syndrome Foundation (SSF 2016). 1 2 Guidelines 1. Medical management Caries prophylaxis: offer topical fluoride in patients with Sj gren's disease with dry mouth. A Show 2 more Muscarinic agonists: As per ASCO 2021 guidelines, consider offering oral pilocarpine, and cevimeline if available, in patients with head and neck cancer after radiotherapy for transitory improvement of xerostomia and salivary gland hypofunction by stimulating residual capacity of salivary gland tissue. B As per SSF 2016 guidelines, offer pilocarpine and cevimeline in patients with Sj gren's disease and dry mouth to increase saliva. B Biologic agents: Consider initiating rituximab as a therapeutic option for xerostomia in patients with primary Sj gren's disease with some evidence of residual salivary production, significant evidence of https://web.pathway.md/diseases/recBkeBz17oH6BXQt 1/3 6/29/23, 3:12 AM Xerostomia Pathway oral damage, and for whom conventional therapies, including topical moisturizers and secretagogues, have been insufficient. C Do not use TNF-alpha inhibitors for the treatment of sicca symptoms in patients with primary Sj gren's disease. D 2. Nonpharmacologic interventions Salivary substitutes: as per ASCO 2021 guidelines, consider offering topical mucosal lubricants or saliva substitutes (agents directed at ameliorating xerostomia and other salivary gland hypofunction-related symptoms) to improve xerostomia induced by nonsurgical cancer therapies. B Salivary stimulants: As per ASCO 2021 guidelines, consider offering gustatory and masticatory salivary reflex stimulation by sugar-free lozenges, acidic (nonerosive and sugar-free special preparation if dentate patients) candies, or sugar-free, nonacidic chewing gum to produce transitory increased saliva flow rate and transitory relief from xerostomia by stimulating residual capacity of salivary gland tissue. C As per SSF 2016 guidelines, offer patients with Sj gren's disease and dry mouth to increase saliva through gustatory, masticatory stimulation, such as sugar-free lozenges and/or chewing gum, xylitol and mannitol. B Acupuncture: offer acupuncture after radiotherapy in patients with head and neck cancer for improvement of xerostomia. B 3. Preventative measures Prevention of radiation-induced xerostomia: use intensity-modulated radiotherapy to spare major and minor salivary glands from a higher dose of radiation to reduce the risk of salivary gland hypofunction and xerostomia in patients with head and neck cancer. A Show 7 more Clinical findings Symptoms Past medical history Cracked lips Radiation therapy to the neck area Dry mouth Sj gren's disease Dysphagia Halitosis Head and neck exam Xerostomia Angular cheilitis Vascular exam Tongue furrows Dry tongue Dental exam https://web.pathway.md/diseases/recBkeBz17oH6BXQt 2/3 6/29/23, 3:12 AM Xerostomia Pathway Dental caries References 1. Valeria Mercadante, Siri Beier Jensen, Derek K Smith et al. Salivary Gland Hypofunction and/or Xerostomia Induced by Nonsurgical Cancer Therapies: ISOO/MASCC/ASCO Guideline. J Clin Oncol. 2021 Sep 1;39 25 2825 2843. Open 2. Vivino FB, Carsons SE, Foulks G et al. New Treatment Guidelines for Sj gren's Disease. Rheum Dis Clin North Am. 2016 Aug;42 3 531 51. Open https://web.pathway.md/diseases/recBkeBz17oH6BXQt 3/3