Xerostomia and hyposalivation

Molecular cues for development and regeneration of salivary glands

The hypofunction of salivary glands caused by Sjögren's Syndrome or radiotherapy for head and neck cancer significantly compromises the quality of life of millions patients. Currently no curative treatment is available for the irreversible hyposalivation, whereas regenerative strategies targeting salivary stem/progenitor cells are promising. However, the success of these strategies is constrained by the lack of insights on the molecular cues of salivary gland regeneration. Recent advances in the molecular controls of salivary gland morphogenesis provided valuable clues for identifying potential regenerative cues. A complicated network of signaling molecules between epithelia, mesenchyme, endothelia, extracellular matrix and innervating nerves orchestrate the salivary gland organogenesis. Here we discuss the roles of several cross-talking intercellular signaling pathways, i.e., FGF, Wnt, Hedgehog, Eda, Notch, Chrm1/HB-EGF and Laminin/Integrin pathways, in the development of salivary glands and their potentials to promote salivary regeneration.

Endocannabinoids mediate hyposalivation induced by inflammogens in the submandibular glands and hypothalamus

OBJECTIVE

The aim of this study was to investigate the factors that could participate on salivary glands hypofunction during inflammation and the participation of endocannabinoids in hyposalivation induced by the presence of inflammogens in the submandibular gland (SMG) or in the brain.

DESIGN

Salivary secretion was assessed in the presence of inflammogens and/or the cannabinoid receptor antagonist AM251 in the SMG or in the brain of rats. At the end of the experiments, some systemic and glandular inflammatory markers were measured and histopathological analysis was performed.

RESULTS

The inhibitory effect observed 1h after lipopolysaccharide (LPS, 50μg/50μl) injection into the SMG (ig) was completely prevented by the injection of AM251 (5μg/50μl) by the same route (P<0.05). The LPS (ig)-induced increase in PGE2 content was not altered by AM251 (ig), while the glandular production of TNFα induced by the endotoxin (P<0.001) was partially blocked by it. Also, LPS injection produced no significant changes in the wet weight of the SMG neither damage to lipid membranes of its cells, nor significant microscopic changes in them, after hispopathological analysis, compared to controls. Finally, TNFα (100ng/5μl) injected intracerebro-ventricularly (icv) inhibited methacholine-induced salivary secretion evaluated 30min after (P<0.01), but the previous injection of AM251 (500ng/5μl, icv) prevented completely that effect.

CONCLUSION

We conclude that endocannabinoids mediate the hyposialia induced by inflammogens in the SMG and in the brain. The hypofunction would be due to changes on signalling pathway produced by inflammatory compounds since anatomical changes were not observed.

Unstimulated whole saliva 25-hydroxycholecalciferol in patients with xerostomia in menopausal women

BACKGROUND AND AIM

The aim of this study was to compare unstimulated whole saliva 25-hydroxycholecalciferol (25(OH)D) in menopausal women with and without oral dryness (OD) feeling, and evaluate the relationship between saliva 25(OH)D and severity of OD feeling.

METHODS

A case-control study was carried out on 70 selected menopausal women aged 41-77 years with or without OD feeling (35 as case and 35 as control) conducted at the Clinic of Oral Medicine, Tehran University of Medical Sciences. Unstimulated saliva samples were obtained by expectoration. Xerostomia inventory (XI) score was used as an index of OD feeling severity. The saliva 25(OH)D concentration was measured by ELISA. Statistical analysis of Student's t test and Spearman correlation was used.

RESULTS

The mean saliva 25(OH)D level was significantly higher in the case group (897.1 ± 128.9 pg/ml), compared with control (156.7 ± 43.4 pg/ml; P < 0.05). XI score correlated significantly with saliva 25(OH)D concentration (r = 0.457, P < 0.001).

CONCLUSIONS

It seems that the level of salivary 25(OH)D concentration may be higher in menopausal women with OD feeling than in the control group, and there is a positive correlation between OD feeling severity and unstimulated whole saliva 25(OH)D.

Characterization of oral bacterial diversity of irradiated patients by high-throughput sequencing

The objective of this study was to investigate the compositional profiles and microbial shifts of oral microbiota during head-and-neck radiotherapy. Bioinformatic analysis based on 16S rRNA gene pyrosequencing was performed to assess the diversity and variation of oral microbiota of irradiated patients. Eight patients with head and neck cancers were involved in this study. For each patient, supragingival plaque samples were collected at seven time points before and during radiotherapy. A total of 147 232 qualified sequences were obtained through pyrosequencing and bioinformatic analysis, representing 3 460 species level operational taxonomic units (OTUs) and 140 genus level taxa. Temporal variations were observed across different time points and supported by cluster analysis based on weighted UniFrac metrics. Moreover, the low evenness of oral microbial communities in relative abundance was revealed by Lorenz curves. This study contributed to a better understanding of the detailed characterization of oral bacterial diversity of irradiated patients.

Xerostomia in hereditary gelsolin amyloidosis

Hereditary gelsolin amyloidosis (AGel amyloidosis) is a rare, dominantly inherited systemic disease with worldwide distribution, caused by c.654G > A or c.654G > T gelsolin gene mutation. The disease mainly manifests with late-onset dystrophy of the cornea, laxity of the skin and dysfunction of the cranial nerves whereas the oral manifestations have remained less-studied. To examine if AGel amyloidosis also affects salivary gland function, we studied 27 patients. In a questionnaire, 89% of them reported oral dryness, and 74% oral and ocular dryness. Unstimulated (UWS) and stimulated whole salivary flow (SWS) rates were measured, and salivary proteins were analyzed in the patients and controls. Hyposalivation according to UWS was detected in 67% of the patients, while decreased SWS occurred in 63% of the patients and 19% of the controls (p = 0.001). The secretion rates of salivary total protein and IgA were significantly lower in patients than controls. Histopathological analyses of labial salivary gland biopsies showed deposition of gelsolin amyloid, atrophy and inflammation. This study showed that AGel amyloidosis belongs to the differential diagnostic choices to be kept in mind in the patients presenting with xerostomia, low secretion rates of salivary total protein and IgA and/or deposition of amyloid in the minor salivary glands. AGel amyloidosis patients should be advised for efficient dental care.

Exploring the dynamic core microbiome of plaque microbiota during head-and-neck radiotherapy using pyrosequencing

Radiotherapy is the primary treatment modality used for patients with head-and-neck cancers, but inevitably causes microorganism-related oral complications. This study aims to explore the dynamic core microbiome of oral microbiota in supragingival plaque during the course of head-and-neck radiotherapy. Eight subjects aged 26 to 70 were recruited. Dental plaque samples were collected (over seven sampling time points for each patient) before and during radiotherapy. The V1–V3 hypervariable regions of bacterial 16S rRNA genes were amplified, and the high-throughput pyrosequencing was performed. A total of 140 genera belonging to 13 phyla were found. Four phyla (Actinobacteria, Bacteroidetes, Firmicutes, and Proteobacteria) and 11 genera (Streptococcus, Actinomyces, Veillonella, Capnocytophaga, Derxia, Neisseria, Rothia, Prevotella, Granulicatella, Luteococcus, and Gemella) were found in all subjects, supporting the concept of a core microbiome. Temporal variation of these major cores in relative abundance were observed, as well as a negative correlation between the number of OTUs and radiation dose. Moreover, an optimized conceptual framework was proposed for defining a dynamic core microbiome in extreme conditions such as radiotherapy. This study presents a theoretical foundation for exploring a core microbiome of communities from time series data, and may help predict community responses to perturbation as caused by exposure to ionizing radiation.

Impact of xerostomia on oral health and quality of life among adults infected with HIV-1

The study investigated the impact of xerostomia on oral health and quality of life (QoL) among patients infected with human immunodeficiency virus (HIV) who were attending for routine HIV monitoring in Australia. This cross-sectional, self-administered questionnaire survey and oral screening (OS) included 100 subjects who were HIV positive. The OS was conducted by a dentist blinded to the subject's survey responses. Xerostomia was determined by asking the subjects a single question. Subjects with xerostomia were found to have increased caries activity and poorer QoL, especially in the psychological dimensions of the oral health impact profile. Age and duration of HIV infection were associated with xerostomia. Early diagnosis of xerostomia and intervention with preventive dental care would potentially reduce caries and improve QoL among patients infected with HIV-1. Ongoing chronic inflammation of salivary glands despite the beneficial effects of antiretroviral therapy may play a role in the etiology of xerostomia in patients infected with HIV and requires further study.

A systematic review of methods to diagnose oral dryness and salivary gland function

Background

The most advocated clinical method for diagnosing salivary dysfunction is to quantitate unstimulated and stimulated whole saliva (sialometry). Since there is an expected and wide variation in salivary flow rates among individuals, the assessment of dysfunction can be difficult. The aim of this systematic review is to evaluate the quality of the evidence for the efficacy of diagnostic methods used to identify oral dryness.

Methods

A literature search, with specific indexing terms and a hand search, was conducted for publications that described a method to diagnose oral dryness. The electronic databases of PubMed, Cochrane Library, and Web of Science were used as data sources. Four reviewers selected publications on the basis of predetermined inclusion and exclusion criteria. Data were extracted from the selected publications using a protocol. Original studies were interpreted with the aid of Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool.

Results

The database searches resulted in 224 titles and abstracts. Of these abstracts, 80 publications were judged to meet the inclusion criteria and read in full. A total of 18 original studies were judged relevant and interpreted for this review. In all studies, the results of the test method were compared to those of a reference method.

Based on the interpretation (with the aid of the QUADAS tool) it can be reported that the patient selection criteria were not clearly described and the test or reference methods were not described in sufficient detail for it to be reproduced. None of the included studies reported information on uninterpretable/intermediate results nor data on observer or instrument variation. Seven of the studies presented their results as a percentage of correct diagnoses.

Conclusions

The evidence for the efficacy of clinical methods to assess oral dryness is sparse and it can be stated that improved standards for the reporting of diagnostic accuracy are needed in order to assure the methodological quality of studies. There is need for effective diagnostic criteria and functional tests in order to detect those individuals with oral dryness who may require oral treatment, such as alleviation of discomfort and/or prevention of diseases.

A comparison of two clinical methods for measuring saliva in patients with Sjögren's syndrome

OBJECTIVE

The aim of the present study was to evaluate two different ways of measuring unstimulated and stimulated whole salivary output in the dental clinic, namely by volume (mL/min) and by weight (g/min).

MATERIALS AND METHODS

Thirty-one patients diagnosed with Secondary Sjögren's syndrome (SSS) participated in the study.

RESULTS

The results showed a large discrepancy between the measurements performed by volume and by weight (p < 0.001) and additionally when taking into account density calculation, especially in individuals with low salivary secretion rate.

CONCLUSION

It is suggested that weight measurement of saliva should be more routinely implemented, especially in patients with reduced salivary secretion.

Unstimulated saliva 17β-estradiol and xerostomia in menopause

One of the most common oral manifestations of menopause is xerostomia. As gingival tissue is sensitive to changes in the female sex steroids; the aim of this study was to evaluate the relationship between saliva 17β-estradiol and severity of xerostomia. A case-control study was carried out in 64 selected menopausal women aged 42-75 years with or without xerostomia (32 as case and 32 as control) conducted at the Clinic of Oral Medicine, Tehran university of medical sciences. Xerostomia inventory (XI) score was used as an index of xerostomia severity. The saliva 17β-estradiol was measured by an enzyme immunoassay kit. The mean unstimulated saliva flow rate and concentration of 17β-estradiol were significantly lower in case than control. There were significant negative correlation between XI score and unstimulated whole saliva flow rate and also concentration of 17β-estradiol in menopausal women. It seems that there is a negative correlation between xerostomia severity and saliva 17β-estradiol in menopausal women.

Correlation of serum oestrogen with salivary calcium in post-menopausal women with and without oral dryness feeling

OBJECTIVE

The aim of this study was to verify the association between salivary calcium and serum oestrogen levels with oral dryness in post-menopausal women. Also, the correlation between these variables was evaluated.

METHODS

A case-control study was carried out on 60 selected menopausal women with and without oral dryness feeling (30 as case and 30 as control) conducted in the Department of Oral Medicine and Radiology, Maharishi Markandeshar University, Mullana, India. Paraffin-stimulated saliva samples were obtained by expectoration. Salivary calcium concentrations were assessed colorimetrically using Arsenazo III reaction. The serum oestrogen concentration was measured using ELISA. Statistical analysis of Student's t-test and Pearson correlation was used.

RESULTS

There was significant difference in mean values of both salivary calcium concentration and serum oestrogen between case and control groups. The result obtained also showed that an inverse correlation was found between salivary calcium concentration and serum oestrogen levels in both the groups and in total sample size.

CONCLUSION

Oral dryness in post-menopausal women is associated with high levels of salivary calcium and low levels of serum oestrogen. The concentrations of salivary calcium and serum oestrogen are inversely correlated in post-menopausal women, regardless of the presence or absence of oral dryness.

XyliMelts time-release adhering discs for night-time oral dryness

Dry mouth can be caused by medication, CPAP use, radiation treatment and a variety of connective tissue diseases, with the prevalence increasing with age. In most individuals, daytime dryness is easily managed. However, except for a new product tested in this study, there is no product lasting longer than an hour that can be used at night to reduce the perception of oral dryness while sleeping. The purpose of this study was to assess whether a self-adhering, slowly dissolving disc that time-releases 500 mg of xylitol, cellulose gum (lubricant and humectant) and mild mint flavour (XyliMelts for Dry Mouth, OraHealth Corp.) used during sleep would reduce perceived morning oral dryness and discomfort. Fifteen subjects self-identified as having morning oral dryness were evaluated first without treatment and again with the use of XyliMelts for Dry Mouth. Measures of initial morning discomfort and perceived wetness demonstrated significant improvement. Perceived oral wetness scores increased more than threefold with the use of XyliMelts for Dry Mouth while sleeping. These findings suggest that XyliMelts for Dry Mouth may be an effective strategy for managing oral dryness that occurs at night.

Oral health status, salivary factors and microbial analysis in patients with active gastro-oesophageal reflux disease

AIM

To present a complex oral health status including salivary factors, microbial analysis and periodontal and hygiene indices in patients with active gastro-oesophageal reflux disease (GORD). Return of stomach contents is quite common in cases of gastro-oesophageal reflux. Pathological acid movement from the stomach into the oesophagus and oral cavity may lead to a development of dental erosion. Long-lasting untreated GORD may damage hard dental and periodontal tissues and alter the oral microbial environment. The quality and amount of the saliva play an important role in hard and soft oral tissues changes.

METHOD

Fifty patients with diagnosed GORD using 24-hour pH manometry underwent dental examination; 24 patients had active GORD and had been waiting for surgical therapy. In this patient group oral health status and salivary analysis were evaluated.

RESULTS

Indicated low salivary flow rates and buffering capacity with a low caries risk but a high risk for dental erosion progression.

Oral health status, salivary flow rate and salivary quality in children, adolescents and young adults with ADHD

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a childhood neurological disorder that presents in 3-7% of school-age children. Studies have shown that children, adolescents and young adults with ADHD are more prone to caries than those without.

AIM

The study investigated a possible relationship between the oral health status of children, adolescents and young adults diagnosed with ADHD, both with and without pharmacological intervention, and the following: salivary flow rate, oral mucosal pH, plaque index (PI), oral hygiene and dietary behaviour.

STUDY DESIGN

DMFT/dmft index (D;d-Decay, M;m-Missing; F;f-Filled,T;t-teeth), plaque index, oral mucosal pH and unstimulated whole salivary flow (USF) were examined in three groups of children, adolescents and young adults: those diagnosed with ADHD with no pharmacological intervention (N=31), those treated with medications for ADHD (N=30), and a healthy control group (N=30). Diet and oral health habits were assessed by means of questionnaires completed by parents.

RESULTS

Mean USF values were 0.72, 0.85 and 1.13 ml/min for participants with ADHD and without medication, with ADHD and with medication, and without ADHD, respectively (p=0.016). There were no differences in the DMFT/dmft index and in parent reported diet and oral health behaviour between the three groups. Children with ADHD demonstrated a statistically significant higher plaque index (p<0.05).

CONCLUSIONS

The ADHD group, with or without pharmacological intervention, showed higher plaque index and lower USF, but no difference in DMFT/dmft. The ADHD group did not differ from the non-ADHD group in their diet or oral health behaviour as assessed by parent reports.

Evaluation of saliva flow rates, Candida colonization and susceptibility of Candida strains after head and neck radiation

Hyposalivation is a long-term effect in patients receiving head and neck radiation. Radiotherapy can predispose oral colonization by Candida species of the mucosa. This study aims to evaluate the correlation between hyposalivation, measured by unstimulated saliva flow rates (SFR) and fungal colonization of the oral cavity, and also the resistance of isolated Candida strains to antimicrobial therapy. Fifty-three consecutive patients with radiotherapy were examined for late radiation damage on dental hard tissue and the salivary glands (SFR over a period of 5 min). The SFR were divided into three different values of hyposalivation: grade I (SFR 0.1-0.25 ml/min), grade II (SFR ≤0.1 ml/min), and grade III (SFR = 0.0 ml/min). Candidal colonization was defined using Sabouraud agar and identified using API 20C AUX (biomerieux) in the patients' rinsing water. Susceptibility was tested with Etest (amphotericin B, ketoconacole, voriconacole, and fluconacole). Hyposalivation grade I was detected in 23% (9.1 × 10(1) colony forming units (cfu); range, 200-5,900 cfu), hyposalivation grade II in 26% (4.3 × 10(1) cfu; range, 110-3,300 cfu), and hyposalivation grade III in 51% (2.0 × 10(3) cfu; range, 300-19,475 cfu) of patients. A significant correlation between the SFR and candidal colonization and clinical presentation (European Organization for Research and Treatment of Cancer (EORTC) score) was detected (Mann-Whitney test, p = 0.031). Twenty Candida albicans and 27 non-albicans species were identified. The resistance of C. albicans was higher than that of non-albicans strains against antimicrobial agents. By comparison, amphotericin B showed the greatest and fluconazole the least effect. A higher value of hyposalivation correlates with a higher risk of candidal colonization in patients who have received radiotherapy and also with a higher EORTC score. The spectrum of Candida is wide and susceptibility against antifungal therapy differs. In long-term examinations of patients with xerostomia after radiotherapy, the EORTC score can be used to measure hyposalivation. Reduced susceptibility of C. albicans might introduce complications to therapy. Findings of more non-albicans strains show a change in colonization which should be examined in further studies.

Preference for dentist's home visits among older people

OBJECTIVES

To investigate factors associated with older people's preference for a dentist's home visit.

METHODS

This is a report on 321 home-dwelling participants (mean age 81.6) in the population-based Geriatric Multidisciplinary Strategy for Good Care of the Elderly (GeMS) study, conducted in 2004-2005 in the city of Kuopio in eastern Finland. The information about sociodemographic and general health-related factors and the use of social and health services was collected by two study nurses using a structured interview. Each study subject was given a clinical oral examination and an interview about oral health and the use of dental health care services by one of two dentists. Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Of the study subjects, 25.9% preferred a dentist's home visit. The preference for choosing a dentist's home visit was associated with a low score (≤24) in the Mini-Mental State Examination, OR 6.1 (CI: 2.9-13.6), and a low score (<8) on the scale of Instrumental Activities of Daily Living, OR 8.0 (CI: 3.6-18.6). It was also associated with living alone, OR 5.9 (CI: 2.7-13.0), and high use of home care services, OR 9.3 (CI: 4.6-19.0).

CONCLUSIONS

The findings of this study emphasize the need to organize dentists' home visits in order to increase equality in the use of dental health care services among the older people with disabilities.

Unstimulated whole saliva parathyroid hormone in postmenopausal women with xerostomia

OBJECTIVE

The aim of this study was to evaluate the correlation of xerostomia severity with unstimulated saliva parathyroid hormone (PTH) and to compare unstimulated whole saliva PTH between postmenopausal women with/without xerostomia.

METHODS

A case-control study was carried out in 60 (30 as case and 30 as control) selected postmenopausal women with/ without xerostomia conducted at the Clinic of Oral Medicine, Tehran University of Medical Sciences. Xerostomia inventory (XI) score was also used as an index of xerostomia severity. PTH concentration was analyzed by enzyme-linked immunosorbent assay (ELISA). Statistical analysis of Student's t-test and Spearman correlation was used.

RESULTS

The mean unstimulated saliva PTH concentration was significantly higher but flow rate was lower in the case group compared with control. XI score correlated significantly with saliva PTH (r = 0.688, p = 0.001) and flow rate (r = - 0.529, p = 0.001).

CONCLUSION

Xerostomia severity correlated positively with unstimulated whole saliva PTH and negatively with saliva flow rate in this group of postmenopausal women. Thus, salivary flow rate and PTH levels appear associated with xerostomia and menopause.

CLINICAL SIGNIFICANCE

Salivary PTH level appears to be associated with xerostomia and menopause.

Effects of intensity-modulated radiotherapy on human oral microflora

This study aimed to evaluate changes in the biodiversity of the oral microflora of patients with head and neck cancer treated with postoperative intensity-modulated radiotherapy (IMRT) or conventional radiotherapy (CRT). Pooled dental plaque samples were collected during the radiation treatment from patients receiving IMRT (n = 13) and CRT (n = 12). Denaturing gradient gel electrophoresis (DGGE) was used to analyze the temporal variation of these plaque samples. The stimulated and unstimulated salivary flow rates were also compared between IMRT and CRT patients. Reductions in the severity of hyposalivation were observed in IMRT patients compared with CRT patients. We also observed that the temporal stability of the oral ecosystem was significantly higher in the IMRT group (69.96 ± 7.82%) than in the CRT group (51.98 ± 10.45%) (P < 0.05). The findings of the present study suggest that IMRT is more conducive to maintaining the relative stability of the oral ecosystem than CRT.

Associations between oral and ocular dryness, labial and whole salivary flow rates, systemic diseases and medications in a sample of older people

OBJECTIVE

To investigate the associations between age, gender, systemic diseases, medications, labial and whole salivary flow rates and oral and ocular dryness in older people.

METHODS

Symptoms of oral and ocular dryness, systemic diseases, medications (coded according to the Anatomical therapeutic chemical (ATC) classification system), tobacco and alcohol consumption were registered, and unstimulated labial (LS) and unstimulated (UWS) and chewing-stimulated (SWS) whole salivary flow rates were measured in 668 randomly selected community-dwelling elderly aged 65-95.

RESULTS

Presence of oral (12%) and ocular (11%) dryness was positively correlated. Oral dryness was associated with low UWS, SWS and LS, and ocular dryness with low UWS and SWS. Oral and ocular dryness was related to female gender, but not to age. Only four persons in the healthy and nonmedicated subgroups reported oral and ocular dryness. The numbers of diseases and medications were higher in the older age groups and associated with oral and ocular dryness, low UWS, SWS and LS. On average, women were slightly older, reported more oral and ocular dryness and had lower UWS, SWS, LS and higher numbers of diseases and medications. High prevalence and odds ratios for oral dryness were associated with metabolic, respiratory and neurological diseases and intake of thyroid hormones, respiratory agents (primarily glucocorticoids), psycholeptics and/or psychoanaleptics, antineoplastics, proton pump inhibitors, antidiabetics, loop diuretics, antispasmodics, quinine and bisphosphonates. Ocular dryness was especially associated with neurological diseases and intake of psycholeptics and/or psychoanaleptics. Intake of magnesium hydroxide, antithrombotics, cardiac agents, thiazides, beta-blockers, calcium channel blockers, ACE inhibitors/angiotensin II antagonists, statins, glucosamine, paracetamol/opioids, ophthalmologicals and certain combination therapies was related to oral and ocular dryness.

CONCLUSIONS

In older people, oral and ocular dryness are associated with low salivary flow rates, specific as well as high number of diseases and medications, but neither with age and gender per se nor with tobacco and alcohol consumption. New detailed information concerning associations between medications and oral and ocular dryness has been obtained using the ATC classification system.

Clinical effectiveness and safety of acupuncture in the treatment of irradiation-induced xerostomia in patients with head and neck cancer: a systematic review

BACKGROUND

Irradiation-induced xerostomia seriously reduces quality of life for patients with head and neck cancer (HNC). Anecdotal evidence suggests that acupuncture may be beneficial.

OBJECTIVE

To systematically review evidence on clinical effectiveness and safety of acupuncture in irradiation-induced xerostomia in patients with HNC.

METHODS

A detailed search was performed to identify randomised controlled trials (RCTs) and systematic reviews of RCTs on acupuncture in irradiation-induced xerostomia, using AMED, BNIA, CINAHL, Cochrane, Embase, HPSI, PsycInfo and Medline. Grey literature was explored and 11 journals hand searched. Search terms included: acupuncture, xerostomia, salivary hypofunction, hyposalivation, dry mouth, radiotherapy, irradiation, brachytherapy, external beam. Two authors independently extracted data for analysis using predefined selection criteria and quality indicators.

RESULTS

43 of the 61 articles identified were excluded on title/abstract. 18 articles underwent full-text review; three were deemed eligible for inclusion. Two trials had moderate risk of bias; one had high risk. Two trials compared acupuncture with sham acupuncture; one control arm received 'usual care'. Outcome measurements included salivary flow rates (SFRs) in two trials and subjective questionnaires in three. All three trials reported significant reduction in xerostomia versus baseline SFR (p<0.05); one reported greater effect in the intervention group for stimulated SFR (p<0.01). Subjective assessment reported significant differences between real acupuncture and control in two trials (p<0.02-0.05). Insufficient evidence was presented to undertake risk/benefit assessment.

CONCLUSIONS

Limited evidence suggests that acupuncture is beneficial for irradiation-induced xerostomia. Although current evidence is insufficient to recommend this intervention, it is sufficient to justify further studies. Highlighted methodological limitations must be dealt with.

Wnt/β-catenin signaling regulates postnatal development and regeneration of the salivary gland

Regenerative therapy of the salivary gland (SG) is a promising therapeutic approach for irreversible hyposalivation in patients with head and neck cancer treated by radiotherapy. However, little is known about the molecular regulators of stem/progenitor cell activity and regenerative processes in the SG. Wnt/β-catenin signaling regulates the function of many adult stem cell populations, but its role in SG development and regeneration is unknown. Using BAT-gal Wnt reporter transgenic mice, we demonstrate that in the submandibular glands (SMGs) of newborn mice Wnt/β-catenin signaling is active in a few cells at the basal layer of intercalated ducts, the putative location of salivary gland stem/progenitor cells (SGPCs). Wnt activity decreases as mice age, but is markedly enhanced in SG ducts during regeneration of adult SMG after ligation of the main secretory duct. The Hedgehog (Hh) pathway is also activated after duct ligation. Inhibition of epithelial β-catenin signaling in young Keratin5-rtTA/tetO-Dkk1 mice impairs the postnatal development of SMG, particularly affecting maturation of granular convoluted tubules. Conversely, forced activation of epithelial β-catenin signaling in adult Keratin5-rtTA/tetO-Cre/Ctnnb1((Ex3)fl) mice promotes proliferation of ductal cells, expansion of the SGPC compartment, and ectopic activation of Hh signaling. Taken together, these results indicate that Wnt/β-catenin signaling regulates the activity of SGPCs during postnatal development and regeneration upstream of the Hh pathway, and suggest the potential of modulating Wnt/β-catenin and/or Hh pathways for functional restoration of SGs after irradiation.

Stimulated and unstimulated saliva progesterone in menopausal women with oral dryness feeling

The aim of this study was to investigate the stimulated and unstimulated salivary progesterone in menopausal women with oral dryness (OD) feeling. A case-control study was carried out on 70 selected menopausal women aged 42-78 years with or without OD feeling (35 as cases with xerostomia and 35 as control without xerostomia), conducted at the Clinic of Oral Medicine, Tehran University of Medical Sciences (TUMS). Unstimulated and paraffin-stimulated saliva samples were obtained by expectoration. The salivary concentration of progesterone was determined with an enzyme immunoassay kit. Statistical analysis of the Student's t test was used. The mean stimulated and unstimulated whole saliva progesterone concentrations and unstimulated saliva flow, but not stimulated saliva flow rate, was significantly lower in the case than in the control. The results showed that subjects with dry mouth had decreased unstimulated saliva flow and salivary progesterone compared with those without dry mouth. Thus, salivary progesterone level appears associated with OD feeling in menopause.

Medication in elderly people: its influence on salivary pattern, signs and symptoms of dry mouth

OBJECTIVE

To compare stimulated and non-stimulated salivary flow, pH, buffering capacity and presence of signs and symptoms of hyposialie and xerostomia in elderly patients, with senile dementia using medication and healthy elderly subjects not using medication.

METHODS

Forty individuals (mean age: 68.5 years) were divided into two groups, according to the use (G1) or non-use (G2) of medication and the presence (G1) or absence (G2) of senile dementia. Data with reference to the general health condition, use of medication and the patient's complaints were collected during anamnesis. Clinical examination identified signs associated with hyposialie and xerostomia. Stimulated and non-stimulated saliva flow, pH and buffering capacity were verified.

RESULTS

The stimulated saliva flow in both groups was below normal parameters. The drugs used by individuals in G1 showed xerostomic potential. Individuals with a higher consumption of xerostomic medication presented with dry and cracked lips. A significant negative relationship was found between drugs consumption and the buffering capacity (p < 0.001), and the resting saliva flow rate (p = 0.002).

CONCLUSION

The use of medication increases the chance that an elderly person may present signs related to xerostomia and alterations in stimulated saliva flow and buffering capacity.

Oral complaints and stimulated salivary flow rate in 1188 adults

BACKGROUND

Recently, oral sensory complaints (OSC) were proposed as a disease entity to represent idiopathic sensory disturbances of dry mouth, burning mouth, and taste disturbance, even though neither the status of OSC in the general population nor its underlying mechanism has yet been elucidated. Moreover, these three OSC-related complaints have not been assessed in combination by means of a visual analog scale (VAS) in a large-scale, community-dwelling population of a broad age range.

METHODS

In a 1188-member community-dwelling adult population, comprised of 373 males and 815 females, aged 20-90 years, the three OSC-related complaints and stimulated salivary flow rate (SSFR) were assessed by means of a VAS and modified Saxon test, respectively. Association of each complaint with age, gender, SSFR, and other complaints was analyzed.

RESULTS

Increases in both prevalence and intensity of subjective dry mouth and burning mouth were associated closely with decreasing SSFR. Even for taste disturbance, which may be affected less significantly by salivation status than the other two complaints, a significant association was suggested between decreasing SSFR and especially severe taste disturbance. However, these oral complaints were found in considerable prevalence even in the individuals with high SSFR. Often overlapping presentation of these complaints and a close association in intensity between the complaints to each other were also found.

CONCLUSIONS

Hyposalivation may be a significant and common etiology for the three oral complaints, although the considerable prevalence of complaints without hyposalivation suggests other etiologies, including those related to the OSC.

A simplified quantitative test--adapted Checkbuf test--for resting saliva buffering capacity compared with a standard test

OBJECTIVE

The aim of this study was to adapt a quantitative test for stimulated saliva, known as the Checkbuf test, to measure the buffering capacity of resting saliva and to evaluate its correlation with the Ericsson test for resting saliva.

STUDY DESIGN

Resting saliva was collected from 112 patients. Buffering capacity was assessed with the adapted Checkbuf test and 4 other methods: Ericsson test for resting saliva, Checkbuf test, and commercially available paper and liquid colorimetric tests for stimulated saliva. Data were analyzed by Cohen kappa coefficient to evaluate the agreement between the Ericsson test and the other tests.

RESULTS

There was a significant positive agreement between the Ericsson test for resting saliva and adapted Checkbuf test (kappa = 0.708). However, there were no agreements between the Ericsson test and the 3 other tests.

CONCLUSIONS

This study demonstrated that the adapted Checkbuf test is useful for measuring resting saliva buffering capacity, even for subjects with low salivary flow rates.

Salivary levels of hyaluronic acid in female patients with dry mouth compared with age-matched controls: a pilot study

Little is known regarding the association between the level of hyaluronic acid (HA) in saliva and dry mouth status. The aim of this study was to evaluate the salivary levels of HA in female patients with dry mouth (perceived xerostomia and hyposalivation) and compare them with age-matched controls. We studied 46 females, and classified them into two groups based on perceived xerostomia and salivary flow rate, as well as a control group without symptoms. HA concentrations in unstimulated whole saliva were determined and a significant difference was found between the groups. The statistical association was stronger in patients (perceived xerostomia, normosalivation) administrated xerogenic drugs, while the HA levels in that group were significantly lower than those in the controls when converted to absolute amount of saliva per min. Within the limitations of the present study, patients with dry mouth had lower HA levels in saliva, which may serve as a marker of local dryness or oral mucosa lubrication.

Path generator control system and virtual compliance calculator for maxillofacial massage robots

PURPOSE

Oral disorders such as temporomandibular joint disorders (TMD) and dry mouth are common and often require treatment. Maxillofacial massage is used as a complementary and alternative therapy for these disorders. We developed an oral rehabilitation robot that massages the maxillofacial tissues for this purpose. In this paper, we propose a control system for oral rehabilitation robots.

METHOD

The control system consists of a massage path generator, virtual compliance calculator, and inverse kinematics calculator. The massage path generator computes a target massage path based on a human head model obtained from a reference MRI image of an adult male. The head model includes the shape and elastic modulus of each component, all of which were obtained experimentally. Virtual compliance control is used to control manipulators with position servo actuators. The manipulators, which have a force sensor at their end-effectors, move actively in the direction of the external force applied to their sensors via virtual compliance control. We implemented this control in WAO-1, our first prototype oral rehabilitation robot.

RESULTS

WAO-1 provided massage to three adult male subjects with and without virtual compliance control. One of the subjects was the adult male whose MRI image was used to synthesize the head model in the massage path generator. Without virtual compliance control, the actual massage force was greater than the target massage force, while that with virtual compliance control was less than the target massage force. Furthermore, with virtual compliance control, the massage paths conformed to the head shape of each patient.

CONCLUSION

Implementation of virtual compliance control in the WAO-1 massage robot is feasible and useful for implementation of safe and potentially effective maxillofacial massage therapy.

Development and Experimental Evaluation of Oral Rehabilitation Robot that Provides Maxillofacial Massage to Patients with Oral Disorders

We have developed an oral-rehabilitation robot WAO-1 (Waseda Asahi Oral-rehabilitation robot No. 1) for use in cases of oral disorders such as temperomandibular joint (TMJ) disorder and dry mouth. WAO-1 is the first robot designed to provide massage to the facial tissues of a patient with oral disorders. This robot provides massage to the masseter and temporal muscles and to the parotid gland and duct with simple operation. It consists of two six-degree-of-freedom arms with plungers, a body with headrest, a control box, a PC, and an automatic massage trajectory generation system with virtual compliance control. Two evaluation experiments were performed to verify the effectiveness of the oral massages of WAO-1 compared with the massages given by doctors. In the experiments, the massage to the parotid gland and duct by WAO-1 increased the amount of saliva in the subjects, and the massage to the masseter muscle by WAO-1 increased facial skin temperature and width of the masseter muscle in the subjects. We consider that these results indicate that massage by WAO-1 can be effective for patients with oral disorders.

Serum and stimulated whole saliva parathyroid hormone in menopausal women with oral dry feeling

OBJECTIVE

The aim of this study was to evaluate the correlation of severity of oral dryness (OD) with serum and saliva parathyroid hormone (PTH) and calcium levels, and to compare serum and stimulated whole saliva PTH and calcium between menopausal women with/without OD.

METHODS

A case-control study was carried out in 76 (38 as case and 38 as control) selected menopausal women with/without OD conducted at the Clinic of Oral Medicine, Tehran University of Medical Sciences (TUMS). Xerostomia Inventory (XI) score was also used as an index of OD severity. Serum and saliva Ca(+2) concentrations were assessed colorimetrically by Arsenazo reaction. PTH concentration was analyzed by enzyme-linked immunosorbent assay (ELISA). Statistical analysis of Student t test and Spearman correlation was used.

RESULTS

The mean saliva calcium and PTH concentrations and outputs, and serum PTH were significantly higher in the case group, compared with control. However, there were no significant differences in serum calcium concentration and stimulated saliva flow rate between groups. XI score correlated significantly with serum PTH (r = 0.387, P = .004), saliva concentration (r = 0.382, P = .002) and output (r = 0.346, P = .007) of PTH; and also with saliva concentration (r = 0.326, P = .013) and output (r = 0.315, P = .018) of calcium; but not with serum calcium and saliva flow rate.

CONCLUSION

OD severity correlated positively with serum and stimulated whole saliva PTH, and with saliva calcium levels in this group of menopausal women. Thus, salivary calcium and PTH levels appear associated with OD and menopause.

Relationship of stimulated saliva 17beta-estradiol and oral dryness feeling in menopause

OBJECTIVES

The aim of this study was to compare stimulated whole saliva 17beta-estradiol of menopausal women with/without oral dryness (OD) feeling, and evaluate the relationship between saliva 17beta-estradiol and severity of OD feeling.

METHODS

A case-control study was carried out in 76 selected menopausal women aged 41-77 years with or without OD feeling (38 as case and 38 as control) conducted at the Clinic of Oral Medicine, Tehran university of medical sciences. Paraffin-stimulated saliva samples were obtained by expectoration. Xerostomia inventory (XI) score was used as an index of OD feeling severity. The saliva 17beta-estradiol concentration was measured by ELISA. Statistical analysis of Student's t-test and Spearman correlation was used.

RESULTS

No significant difference was found in stimulated whole saliva flow rate between the two groups, but the mean concentration and output of saliva 17beta-estradiol were significantly lower in case than control. There was significant negative correlation between XI score and stimulated whole saliva concentration (r=-0.391, P=0.004) and output (r=-0.302, P=0.002) of 17beta-estradiol in menopausal women.

CONCLUSIONS

It seems that there is a negative correlation between OD feeling severity and stimulated whole saliva 17beta-estradiol in menopausal women.

Measuring salivary flow: challenges and opportunities

BACKGROUND

Saliva is being studied extensively and is being used for risk assessment, diagnosis and monitoring high-risk behavior and disease progression. A variety of medical conditions and medications are associated with salivary gland hypofunction. The major disadvantage in the use of saliva for health-related purposes is the lack of standardization in saliva collection methods.

METHODS

The authors provide a brief overview of different methods of saliva collection and the advantages and disadvantages associated with each method, as well as of how to assess the salivary flow rate.

RESULTS

The authors present the complete set up and step-by-step guidelines for the collection of unstimulated and stimulated whole saliva.

CONCLUSIONS

The life expectancy of people will continue to increase with advances in medicine and therapeutic modalities, and the prevalence of salivary gland hypofunction in the elderly population will increase owing to their longevity. The assessment of salivary gland hypo-function will need to be incorporated into everyday clinical practice.

CLINICAL IMPLICATIONS

The saliva collection methods outlined in this article can be used by dentists to assess patients at risk of developing diseases and by scientists for scholarly activities.

Salivary levels of cortisol and chromogranin A in patients with dry mouth compared with age-matched controls

OBJECTIVE

To evaluate the salivary levels of cortisol and chromogranin A (CgA) in patients with dry mouth (perceived xerostomia and hyposalivation) compared with age-matched controls.

STUDY DESIGN

We studied 174 subjects, including those with dry mouth, classified into 2 subgroups based on perceived xerostomia and salivation, and those without (control subjects). The control subjects were patients at the same hospital and healthy volunteers. Cortisol and CgA levels in stimulated whole saliva were measured using ELISA kits.

RESULTS

All subjects with dry mouth had significantly higher cortisol and CgA levels than the control subjects. The statistical associations remained significant when they were divided into the 2 subgroups, although somewhat weaker associations were observed. The influences of xerogenic drugs were found to be minimal on salivary flow rate and levels of cortisol and CgA.

CONCLUSIONS

We found significant associations between salivary cortisol and CgA levels and symptoms of oral dryness and reduced salivary flow.

Stimulated whole salivary flow rate and composition in menopausal women with oral dryness feeling

The aim of this study was to compare stimulated whole saliva flow rate and composition of menopausal women with/without oral dryness (OD) feeling. A case-control study was carried out in 42 selected menopausal women aged 52-73 years with or without OD feeling (21 as case and 21 as control) conducted at the Clinic of Oral Medicine, Tehran University of Medical Sciences. Paraffin-stimulated saliva samples were obtained by expectoration. The stimulated whole saliva composition was measured by a spectrophotometer [magnesium (Mg(+2)), calcium (Ca(+2)), chloride (Cl(-)), inorganic phosphate (Pi) and total protein], flame-photometry [sodium (Na(+))] and ion selective electrode (ISE) [potassium (K(+))] methods. No significant differences were found in stimulated whole saliva flow rate, Mg(+2), Cl(-), Pi, Na(+), K(+) and total protein concentrations between the two groups, but the mean calcium concentration was significantly higher in cases than in controls (P = 0.003). It seems that the level of salivary calcium concentration may be higher in menopausal women with OD feeling than in the control group.