Prevention of Xerostomia and salivary gland hypofunction induced by nonsurgical cancer therapies: Updated guidelines

Key recommendations include:

• Intensity-modulated radiation therapy should be used 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.
• Other radiation modalities that limit cumulative dose to and irradiated volume of major and minor salivary glands as or more effectively than intensity-modulated radiation therapy may be offered to reduce salivary gland hypofunction and xerostomia.
• Acupuncture may be offered during radiation therapy for head and neck cancer to reduce the risk of developing xerostomia.
• Systemic administration of the sialogogue bethanechol may be offered during radiation therapy for head and neck cancer to reduce the risk of salivary gland hypofunction and xerostomia.
• Vitamin E or other antioxidants should not be used to reduce the risk of radiation-induced salivary gland hypofunction and xerostomia because of the potential adverse impact on cancer-related outcomes and the lack of evidence of benefit.
• Evidence remains insufficient for a recommendation for or against the use of submandibular gland transfer administered before head and neck cancer treatment to reduce the risk of salivary gland hypofunction and xerostomia because of insufficient evidence with contemporary radiation modalities.
• Evidence remains insufficient for a recommendation for or against the use of the following interventions during radiation therapy for head and neck cancer: Oral pilocarpine, amifostine (with contemporary radiation modalities), or low-level laser therapy.
• Evidence remains insufficient for a recommendation for or against the use of the following interventions to reduce the risk of salivary gland hypofunction or xerostomia in patients with head and neck cancer: n-acetylcysteine oral rinse, traditional Chinese medicine–based herbal mouthwash, local clonidine, concurrent chemotherapy with nedaplatin, boost radiation therapy, hyperfractionated or hypofractionated radiation therapy, intra-arterial chemoradiation, minocycline, melatonin, nimotuzumab, zinc sulfate, propolis, viscosity-reducing mouth spray, transcutaneous electrical nerve stimulation (TENS), parotid gland massage, thyme honey, and human epidermal growth factor.
• Topical mucosal lubricants or saliva substitutes (agents directed at ameliorating xerostomia and other salivary gland hypofunction-related symptoms) may be offered to improve xerostomia induced by nonsurgical cancer therapies.
• 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 may be offered to produce transitory increased saliva flow rate and transitory relief from xerostomia by stimulating residual capacity of salivary gland tissue.
• Oral pilocarpine, and cevimeline where available, may be offered after radiation therapy in patients with head and neck cancer for transitory improvement of xerostomia and salivary gland hypofunction by stimulating residual capacity of salivary gland tissue. However, improvement of salivary gland hypofunction may be limited.
• Acupuncture may be offered after radiation therapy in patients with head and neck cancer for improvement of xerostomia.
• Transcutaneous electrostimulation or acupuncture-like transcutaneous electrostimulation of the salivary glands may be offered after radiation therapy in patients with head and neck cancer for improvement of salivary gland hypofunction and xerostomia.
• Evidence remains insufficient for a recommendation for or against the use of the following interventions for improvement of salivary gland hypofunction and xerostomia: Extract of ginger and mesenchymal stem cell therapy.