Specific saliva substitutes

For detailed information about individual saliva substitutes, including which are prescribable, see our page:

Dry mouth

Dry mouth, or xerostomia, is the feeling of oral dryness. It may be linked to impaired function of the salivary glands, which produce less saliva when damaged.

Salivary glands may be damaged by chemotherapy, radiotherapy, neurological conditions and autoimmune diseases such as Sjögren’s syndrome.

A common cause of dry mouth is as a side effect of certain medications. Frequently involved medications include anticholinergic drugs (such as tolterodine and oxybutynin), antidepressants (such as amitriptyline and citalopram) and opioids (such as codeine and morphine).

People with chronic dry mouth are at higher risk of tooth decay, gum disease, oral infections and oral thrush.

Symptoms range from mild oral discomfort to a significant oral disease that can compromise the individual’s health, dietary intake, and quality of life.

Self-help

When treating dry mouth, first consider non-pharmaceutical measures. Options include frequent sips of cool drinks or sucking pieces of ice or sugar-free fruit pastilles. Sugar-free chewing gum stimulates salivation in patients with residual salivary function.

Artificial saliva products

These do not restore salivary gland function but can help relieve dry mouth symptoms.

There are two main categories, but no strong evidence that any one product or formulation is more effective than another:

• artificial saliva replacements: available as gels, sprays, and mouth rinses.
• salivary stimulants: available as pastilles and tablets that encourage natural saliva production, these can be considered in individuals who still have some salivary gland function

Frequency and duration of use

The effects of both types of artificial saliva products are short-lived, generally lasting no more than a few hours, which makes frequent use necessary. They should be used as often as needed, including before and during meals.

The duration of use depends on the duration of need. If medications that cause dry mouth are stopped, or if Sjögren’s disease enters remission, saliva substitutes may no longer be necessary. Chemotherapy or radiotherapy may result in permanent loss of salivary gland function, requiring lifelong use of saliva substitutes.

Key properties of artificial saliva

Saliva serves several important functions in the mouth, including:

• helping with speech and swallowing
• protecting teeth and oral tissue from injury and infection
• promoting remineralisation of teeth

Natural saliva is a complex mixture of fluids and contains electrolytes (sodium, potassium, calcium, bicarbonate, phosphate) and organic components (such as immunoglobulins, enzymes and mucin). It maintains a neutral pH in the mouth.
For optimal benefit and to avoid potentially causing or worsening oral health problems, artificial saliva products should mimic natural saliva as closely as possible.

When choosing an artificial saliva product to prescribe or recommend, consider:

Acidity

The pH of artificial saliva differs between products. Ideally, products should have a neutral pH (around 7).

Do not recommend or prescribe acidic products (those with a pH lower than 7) for people with their own teeth. Acidic pH can increase tooth demineralisation and the risk of tooth decay, especially with long-term use.

Fluoride content

Some artificial saliva products contain fluoride to promote remineralisation and protect against tooth decay.

Recommend or prescribe fluoride-containing products for people with their own teeth.

Sugar content and sweeteners

Most artificial saliva products are sugar-free, instead containing various sweeteners.

Some products contain the enzyme glucose oxidase, which inhibits bacterial growth. The enzyme uses glucose during its activation process, so these products may contain tiny amounts of sugar. This sugar is ‘consumed’ by the enzyme and so does not cause tooth decay.

Dietary preferences or requirements

Artificial saliva products may contain ingredients that some people may wish to avoid for health, religious or lifestyle reasons.

Some people may need to avoid certain sweeteners. For example, aspartame is unsuitable for people with phenylketonuria.

Gluten can be present in some products, making them unsuitable for people with coeliac disease.

Some artificial saliva products contain ingredients derived from animal products. These may not be suitable for vegans or individuals with specific dietary restrictions related to their religious or lifestyle requirements.

Our article on understanding excipient in medicines offers guidance and suggested resources to support situations where certain excipients must be avoided.

Product formulation

Artificial saliva replacements and salivary stimulants are available in different formulations. These include gels, sprays, mouthrinses, pastilles, lozenges and toothpastes. The choice of formulation should be guided by individual preference.

Dental prescribing and supply

In England, dentists in primary care use yellow prescription form FP10D. In secondary care, dentists may use FP10D or the appropriate hospital prescription.

Prescribing on FP10D

When prescribing on FP10D prescription forms, dentists are restricted to items in the Dental Practitioners’ Formulary (DPF).

Dentists can write prescriptions for artificial saliva products using generic names as listed in the DPF. The BNF section of artificial saliva products lists generic names corresponding to prescribable branded products. The dispensing pharmacy will supply an allowed product.

Prescribing restrictions

Certain artificial saliva products are considered ‘borderline substances’ by the government’s Advisory Committee on Borderline Substances (ACBS). This means they can only be prescribed for specific indications.

In dentistry, the ACBS advise that certain artificial saliva products can only be prescribed for xerostomia resulting from radiotherapy or sicca syndrome.

These products are listed in Part XV of the Drug Tariff.

Prescribers should endorse these prescriptions as “ACBS” to comply with the ACBS recommendations. This endorsement will also help ensure that the dispensing pharmacy is properly reimbursed.

Private prescriptions

A dentist may prescribe any appropriate product they are competent to prescribe on a private prescription.

Retail sale

Artificial saliva products are not medicines and so are not regulated by the Human Medicines Regulations 2012 or NHS dental contracts. The products can be sold from retail outlets or directly by dental practices.

Retail purchase may be cheaper than the NHS prescription charge.