Patients with clinical depression, anxiety, neuropathy, Alzheimer’s disease (even in the presence of drooling), and multiple sclerosis frequently have complaints of dryness [14, 15]. This indicates the importance of cortical influence and cholinergic white matter (cholinergic) outflow tracts.

The first line of treatment for dry mouth includes topical agents to lubricate and facilitate swallowing and talking, as well as lip balms to moisturize and soothe the lips. In addition, over the past 20 years, a variety of mechanical and electrical devices placed in the mouth have been shown to stimulate basal saliva flow [16, 17]. For the past 20 years, a variety of electrical devices (such as the Salitron) have been approved by FDA but have not proven cost-effective [18]. However, these devices do establish the role of mechanical stimulation in stimulation of saliva. As such, patients need to recognize the importance of mechanical stimulation in saliva stimulation and the importance of brushing their tongue and buccal mucosa when brushing their teeth, as well as frequent use of sugar-free lozenges.

In addition, other sicca symptoms include dryness of the skin (xerosis), nasal dryness, and vaginal dryness [19]. The need to keep the nasal passages clear and moist will prevent mouth breathing, particularly at night, when the basal secretory rate is diminished. The role of smell is closely linked to gustatory stimulation [20].

36.2General Approach to Dry Mouth

36.2.1Oral Hygiene and Self-Care by the Patient

Approaches to clinical management of oral sicca symptoms are generally the same for primary or secondary SjS. The quality of information available from resources on the Internet or from patient support groups varies widely.

Current recommendations by the American Dental Association [21–23] include:

•Use of dental floss after EACH meal, AND fluoride – either as toothpaste or a mouth rinse daily.

–Carrying portable toothbrush and fluoride toothpaste is a very worthwhile practice for patients with SjS.

•Avoidance of sucrose, carbonated beverages, juices, and water with “sweetener” additives.

•Avoidance of oral irritants (e.g., coffee, alcohol, and nicotine).

•Maintenance of good hydration by taking regular sips of water and drinking sugar-free liquids (see “Fluids” below).

•Use of toothpastes specifically designed for dry mouth, which lack detergents (such as sodium laurel sulfate, which is the foaming agent in most toothpastes). These substances, present in many types of toothpaste, can irritate dry mouths.

Some fluoride-containing toothpastes may lead to brown discoloration of the teeth. Many of these “dry mouth” toothpastes are widely advertised, but have not been carefully studied in terms of their outcome for dental caries or tooth loss.

•One commercially available toothpaste (Biotene®) was found to give improved symptomatic relief in SjS patients, although no change in the microbacterial composition of the biofilm was noted [24, 25].

We strongly encourage our patients to use toothbrushes with features that improve effectiveness, such as interdental brushes (for cleaning between teeth) and electric toothbrushes. Table 3 includes suggestions for dental hygiene and suggestions that are helpful to patients with SjS.

A number of basic measures are used to prevent as well as treat dry mouth in those with SjS. The published evidence supporting these measures consists largely of clinical experience and small case series [25]. Several older double-blind studies in SjS patients demonstrated that the addition of mucins or lactoperoxidase to carboxymethylcellulose (CMC) was superior to CMC alone [24, 26]. A small singleblinded study using a commercially available product (Oral Balance®) also showed symptomatic benefit [24].

The following measures for prevention of dryness, stimulation of secretions, dental prophylaxis, and attention to complications should be used in all patients with dry mouth due to SjS, regardless of symptom severity:

1. Avoidance of drying medications that may worsen oral dryness, especially those with anticholinergic side effects. These include over-the-counter antihistamines, cold and sleep remedies.

2. Avoidance of smoking and alcohol.

3. Maintenance of open nasal passages to avoid mouth breathing (see ‘Nasal Dryness’ below).

4.Use of room cold humidifiers, particularly at night, in areas that are dry or windy.

5. Stimulation of salivary secretions, using sugar-free salivary stimulants (e.g., chewing gums and lozenges).

6. Careful chewing of food before swallowing (see ‘Topical Stimulation of Salivary Flow’ below).

7. Meticulous oral hygiene and regular dental care, and avoidance of pre-processed “soft” foods that may be high in sugar content (see ‘Basic Dental Care’ below and ‘Prevention of Dental Caries’ below).

8. Recognition of oral candidiasis that may mimic or exacerbate dry mouth symptoms (see ‘Oral Candidiasis’ below).

Various solutions – ranging from water to forms of artificial saliva – can be used to replace oral secretions. We suggest frequent sips of water, because of convenience, low cost, and efficacy. The water does not have to be swallowed, but can be rinsed around the mouth and expectorated. Although water provides temporary