Efficacy and safety of an intraoral electrostimulation device for xerostomia relief: a multicenter, randomized trial

Effect of Electrical Stimulation of Lingual Nerve on Xerostomia: A Randomized Controlled Trial

INTRODUCTION

Xerostomia is a subjective sensation of dry mouth affecting millions of people worldwide. Current management has limitations, often causing side effects. This study aims to investigate whether electrical stimulation of the lingual nerve could offer effective relief for xerostomia sufferers.

METHODS

Eligible participants were randomly assigned (1:1) to either the experimental or sham group, receiving electrical stimulation of the lingual nerve (n = 24) or sham stimulation (n = 23) for 12 wk. The primary outcome is the changes in xerostomia score using a 100-mm visual analog scale throughout the therapy. Participants assessed their dryness and assigned corresponding scores, with lower scores indicating more severe dry mouth. Secondary outcomes included remission rate in dry mouth frequency, changes in stimulated/unstimulated salivary flow rate (SSFR/USFR), and changes in Oral Health Impact Profile-14 (OHIP-14) questionnaire scores, where higher scores indicate greater impact on oral quality of life.

RESULTS

At week 12, the electrical stimulation group showed greater improvement in xerostomia score compared to the sham group, with a mean between-group difference of 13.8 (95% confidence interval [CI], 10.0-17.6). The therapeutic effect of electrical stimulation was also confirmed by secondary outcomes. The remission rate of dry mouth was higher at 12 wk in the electrical stimulation group (61.9% [95% CI, 40.9%-79.3%] vs. 28.6% [95% CI, 13.8%-50.0%]). Participants in the electrical stimulation group also experienced a greater increase in USFR, with a mean difference of 14.5 (6.1-23.0) μL/min. Moreover, they exhibited significant improvement in OHIP-14 score after 12 wk of therapy, with a mean between-group difference of -10.0 (-13.9 to -6.2). No significant difference was observed between the 2 groups for SSFR (P = 0.702).

CONCLUSIONS

Electric stimulation offers promise as a noninvasive, nonpharmacological strategy for the management of xerostomia. Further research is needed to understand its long-term effectiveness, optimal parameters, and underlying mechanisms.

KNOWLEDGE TRANSFER STATEMENT

The study confirmed that electrical stimulation of the lingual nerve is a promising noninvasive and nonpharmacological modality for relief of xerostomia.

A cross-sectional study on activity impairment in primary Sjogren's syndrome

OBJECTIVE

The aim of this cross-sectional study was to show relations between activity impairment and salivary gland involvement for patient empowerment in primary Sjogren's syndrome (pSS).

METHODS

In the study, 86 patients with pSS were included. The data were collected through clinical examinations and a questionnaire regarding Work Productivity and Activity Impairment (WPAI), EULAR Sjogren's syndrome patient-reported index (ESSPRI) and Oral Health Impact Profile-14 (OHIP-14). Relations were analysed by using mediation and moderation analyses. In simple mediation analysis, an independent variable (X) influences outcome variable (Y) through a mediator variable (M) whereas a moderator variable (W) affects the direction of the relationship between the dependent (Y) and independent variables (X).

RESULTS

Increases in ESSPRI-Dryness score (X) (p = 0.0189) and OHIP-14 score (M) (p = 0.0004) were associated with the poor WPAI activity impairment score (Y) in the first mediation analysis. The WPAI activity impairment score was mediated by the elevated ESSPRI-Fatigue score (X) (p = 0.03641) and low U-SFR (M) (p = 0.0000) in the second mediation analysis. In addition, ESSPRI-Pain score (W) was the significant moderator for WPAI activity impairment (Y) in patients without hyposalivation in the moderation analysis (p = 0.0010).

CONCLUSION

WPAI activity impairment was affected by both ESSPRI-Dryness with OHRQoL and ESSPRI-Fatigue with SFR in glandular involvement.

Salivary Electrostimulation in the Treatment of Radiation Therapy-Induced Xerostomia (LEONIDAS-2): A Multicenter, Randomized, Double-Masked, Sham-Controlled, Phase 3 Trial

PURPOSE

Radiation therapy-induced xerostomia significantly affects quality of life in head and neck cancer survivors. Neuro-electrostimulation of the salivary glands may safely increase natural salivation and reduce dry mouth symptoms.

METHODS AND MATERIALS

This multicenter, double-masked, randomized, sham-controlled clinical trial assessed the long-term effects of a commercially available intraoral neuro-electrostimulating device in lessening xerostomia symptoms, increasing salivary flow, and improving quality of life in individuals with radiation therapy-induced xerostomia. Using a computer-generated randomization list, participants were assigned (1:1) to an active intraoral custom-made removable electrostimulating device or a sham device to be used for 12 months. The primary outcome was the proportion of patients reporting a 30% improvement on the xerostomia visual analog scale at 12 months. A number of secondary and exploratory outcomes were also assessed through validated measurements (sialometry and visual analog scale) and quality-of-life questionnaires (EORTC QLQ-H&N35, OH-QoL16, and SF-36).

RESULTS

As per protocol, 86 participants were recruited. Intention-to-treat analyses showed no statistical evidence of a difference between the study groups with respect to the primary outcome or for any of the secondary clinical or quality-of-life outcomes. Exploratory analyses showed a statistically significant difference in the changes over time of the dry mouth subscale score of the EORTC QLQ-H&N35 in favor of the active intervention.

CONCLUSIONS

LEONIDAS-2 did not meet the primary and secondary outcomes.

Evaluation and management of dry mouth and its complications in rheumatology practice

INTRODUCTION

The symptom of dry mouth has multiple potential etiologies and can be a diagnostic clue to the presence of common systemic diseases encountered in rheumatology practice. The presence of decreased saliva flow (i.e. salivary hypofunction) defines a subset of dry mouth patients in whom there may be reversible drug effects, an iatrogenic insult such as head and neck irradiation, or a disease that directly involves the salivary glands (e.g. Sjögren's disease). The assessment of salivary hypofunction includes sialometry, salivary gland imaging, salivary gland biopsy, and an assessment for relevant systemic diseases. Optimal management of dry mouth requires accurate definition of its cause, followed by general measures that serve to alleviate its symptoms and prevent its complications.

AREAS COVERED

Through a literature search on xerostomia and salivary hypofunction, we provide an overview of the causes of dry mouth, highlight the potential impact of salivary hypofunction on oral and systemic health, detail routine evaluation methods and treatment strategies, and emphasize the importance of collaboration with oral health care providers.

EXPERT OPINION

Our Expert Opinion is provided on unmet needs in the management of dry mouth and relevant research progress in the field.

Long-term effectiveness of a novel intra-oral electro-stimulator for the treatment of dry mouth in patients with Sjogren's syndrome: A randomised sham-controlled feasibility study (LEONIDAS-1)

BACKGROUND

Effective treatments for dry mouth of Sjogren's syndrome are limited and hampered by adverse effects. The aim of LEONIDAS-1 was to explore the feasibility of salivary electrostimulation in individuals with primary Sjogren's syndrome, as well as parameters required to inform the design of a future phase III trial.

METHODS

Multicentre, parallel-group, double-blind, randomised sham-controlled trial in two UK centres. Participants were randomised (1:1, computer-generated) to active or sham electrostimulation. The feasibility outcomes included screening/eligibility ratio, consent, and recruitment and drop-out rates. Preliminary efficacy outcome included dry mouth visual analogue scale, Xerostomia Inventory, the EULAR Sjögren's syndrome patient reported index-Q1, and unstimulated sialometry.

RESULTS

Forty-two individuals were screened, of whom 30 (71.4%) met the eligibility criteria. All eligible individuals consented to recruitment. Out of the 30 randomised participants (active n = 15, sham n = 15), 4 dropped out and 26 (13 vs. 13) completed all study visits as per protocol. Recruitment rate was 2.73 participants/month. At 6-month post-randomisation the difference in mean reduction in visual analogue scale, xerostomia inventory and EULAR Sjögren's syndrome patient reported index-Q1 scores between groups were 0.36 (95% CI: -0.84, 1.56), 3.31 (0.43, 6.18), and 0.23 (-1.17, 1.63), respectively; unstimulated salivary flow increased by a mean of 0.98 mL/15 min, all in favour of the active group. No adverse events were reported.

CONCLUSION

LEONIDAS-1 results support progression to a phase III definitive randomised controlled trial of salivary electrostimulation in individuals with Sjogren's syndrome. Xerostomia inventory could be considered the primary patient-centred outcome measure and the corresponding observed treatment effect could inform the sample size of a future trial.

World Workshop on Oral Medicine VIII: Development of a Core Outcome Set for Dry Mouth: A Systematic Review of Outcome Domains for Xerostomia

OBJECTIVE

The purpose of this study was to identify all outcome domains used in clinical studies of xerostomia, that is, subjective sensation of dry mouth. This study is part of the extended project "World Workshop on Oral Medicine Outcomes Initiative for the Direction of Research" to develop a core outcome set for dry mouth.

STUDY DESIGN

A systematic review was performed on MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials databases. All clinical and observational studies that assessed xerostomia in human participants from 2001 to 2021 were included. Information on outcome domains was extracted and mapped to the Core Outcome Measures in Effectiveness Trials taxonomy. Corresponding outcome measures were summarized.

RESULTS

From a total of 34,922 records retrieved, 688 articles involving 122,151 persons with xerostomia were included. There were 16 unique outcome domains and 166 outcome measures extracted. None of these domains or measures were consistently used across all the studies. The severity of xerostomia and physical functioning were the 2 most frequently assessed domains.

CONCLUSION

There is considerable heterogeneity in outcome domains and measures reported in clinical studies of xerostomia. This highlights the need for harmonization of dry mouth assessment to enhance comparability across studies and facilitate the synthesis of robust evidence for managing patients with xerostomia.

A Stimulator of the Salivary Excretion Based on Physical Vibration of the Parotid Glands

Oral dryness causes significant health problems both functional (difficulty speaking, chewing and swallowing) and structural in teeth (increased number of infections) and oral mucosa. The main objective of this study is to show an alternative treatment to help stimulate the salivary secretion thus improving the quality of life of the patient. In this study, a salivary stimulation equipment using vibrotactile stimuli is shown. The system has been placed bilaterally in the parotid glands and assessed the efficacy of the salivary secretion by sialometry before and after the stimulation. The new proposal is capable of stimulating salivary secretion, in a significative way after 7 minutes of use, at least in the cases analyzed, and fulfills low-cost, easy-to-use, and safe technical restrictions. In this setting, this paper suggests the performance of a deep clinical trial to measure the exact efficacy of the prototype and the times and frequencies needed to state the optimal treatment depending in each case.

Oral Immune-Related Adverse Events - Current Concepts and their Management

Recent advent of immune checkpoint inhibitors (ICIs) have made significant improvement in the treatment outcome of cancer patients. They are also known to increase the overall survival in many malignancies. They target key immune checkpoints, acting on the cytotoxic T-lymphocyte antigen-4, programmed death-1 (PD-1), and PD-1 ligand 1 pathways. ICIs are effective in cancer therapy, but also possess various adverse effects that are termed together as immune-related adverse events (irAEs). Information focusing only on the oral reactions of irAEs is scanty in the literature. Therefore, we performed a computerized database search in PubMed and Google Scholar to identify and collect data regarding the oral adverse effects of ICIs. The early recognition of oral irAEs and appropriative intervention may help in improving the quality of life in patients. This paper presents a brief review of oral irAEs and their management.

Therapeutic Strategies for Dry Mouth Management with Emphasis on Electrostimulation as a Treatment Option

OBJECTIVES

Xerostomia is a subjective sensation of dry mouth. It is commonly associated with salivary gland hypofunction. Both changes in the composition of the saliva and a reduction in the quantity secreted may be an objective finding of dry mouth. Although there are no currently available cures for the conditions resulting in dry mouth, there are several treatment options that give hope for patients who suffer from xerostomia. Individuals with some residual salivary gland function, which are contraindicated to pharmacological therapies, would benefit the most from identifying novel, alternative effective methods for stimulating production of saliva. The aim of this study was to give an overview of the latest and most relevant data related to treatment modalities for the management of dry mouth conditions. Data Resources and Study Selection. The present review was prepared by searching the National Library of Medicine database using the relevant medical terms and their combinations. A total of thirty-three studies met the inclusion criteria. Data were extracted by one author and verified by another.

CONCLUSION

A number of patients showed positive treatment outcomes, and the adverse effects of both electrical stimulation (ES) and acupuncture have been reported as mild and transient. In patients who have undergone radiotherapy, acupuncture is shown to increase salivation. However, in patients with Sjogren's syndrome, the effects of ES devices seem to be elusive. Moreover, due to the instability of the findings in relation to longevity of clinical effect, patient satisfaction, quality of life, and clinical effectiveness of such treatments, the results remain vague.

Oil pulling to relieve medication-induced xerostomia: A randomized, single-blind, crossover trial

OBJECTIVES

To determine the subjective effectiveness of oilpulling on medication-induced xerostomia with regard to symptom relief, quality of life, taste, mucosal moisture and oral parameters.

MATERIALS AND METHODS

In a randomized, single-blind, crossover trial in participants with medication-induced xerostomia (n = 26; mean age 64.71 (standard deviation (SD) 15.60) years), we investigated oilpulling efficacy (sunflower oil) versus mineral water after one-week use. Xerostomic burden (visual analogue scale, VAS), symptom relief and oral examinations (gingivitis index, plaque index, whole stimulated and unstimulated salivation rates) were investigated at baseline and the end of the follow-up.

RESULTS

Oilpulling reduced the xerostomic burden (baseline value 6.46 (SD 1.80), decreasing to 4.93 (SD 2.97)) (p = .003), without difference between oil versus water (p = .067). Baseline values for water were 6.08 (SD 2.17) decreasing to 5.72 (SD 2.17) (p = .124). Compared to water, oil made swallowing easier (p = .031), caused a pleasant mouthfeel (p = .031) and caused less waking up at night (p = .031). Effectiveness (p = .002) and duration (p = .007) of symptom relief showed differences between products in favour of oil.

CONCLUSIONS

Oil pulling alleviated the overall xerostomic burden. In the comparison between oil and water, no difference regarding symptom relief could be shown. Patients should be informed of possibilities and limitations of oilpulling as inexpensive and easy-to-obtain alternative to commercially available products for short-term symptom relief.

Effectiveness of an intraoral thermoformed splint with magnet device in patients with xerostomia and hyposalivation: A pilot study

AIM

The aim of the study was to examine the effectiveness of intraoral thermoformed splint with a magnet device over a period of 3 months, that is, to assess acceptability of this method of treatment using both objective and self-reported measures.

MATERIALS AND METHODS

This study was designed as a prospective clinical pilot trial. 22 patients with xerostomia and hyposalivation were included. Xerostomia was assessed using a 4-question xerostomia questionnaire score and a test for unstimulated salivary flow rates. Evaluations were performed before the treatment and 3 months after the treatment using a thermoformed splint with a magnet device.

RESULTS

There was a significant reduction in subjective symptoms after using a thermoformed splint with a magnet device for 3 months. For all 4 scored items, there was a statistically significant difference (P < .001) in median VAS scores before and 3 months after treatment. There was also a statistically significant difference in USFR before (0,15 ± 0,04 ml/min) and after treatment (0,24 ± 0,03 mL/min).

CONCLUSION

Our findings indicate that the use of this device alleviated oral dryness and stimulated the function of the submandibular salivary gland. An intraoral thermoformed splint with a magnet device is safe, physiologically indifferent, useful, and effective in treating xerostomia and hyposalivation.

Short-term and long-term unstimulated saliva flow following unilateral vs bilateral radiotherapy for oropharyngeal carcinoma

BACKGROUND

We aimed to compare unstimulated saliva flow using 3-minute modified Schirmer test (MST) following bilateral vs unilateral radiotherapy (RT) in oropharyngeal carcinoma (OPC).

METHODS

We reviewed OPC patients treated with definitive intensity-modulated radiation therapy (IMRT) between 2011 and 2017. MST was measured at baseline, 1-/6-/12-/24-month post-RT. MST values were compared between bilateral-RT vs unilateral-RT groups. Multivariable logistic regression analysis (MVA) identified predictors of hyposalivation (MST < 25 mm).

RESULTS

Total 498 bilateral-RT and 36 unilateral-RT patients were eligible. The MST values at 1-/6-/12-/24-month post-RT were all significantly reduced from baseline for the entire cohort. Baseline unilateral-RT and bilateral-RT MST values (in mm) were similar (P = .2), but much higher for unilateral-RT 1-month (mean: 19.1 vs 13.0, P = .03), 6-month (20.5 vs 9.3, P < .001), 12-month (20.1 vs 11.9, P < .01), and 24-month post-RT (22.2 vs 13.9, P = .04). MVA confirmed that unilateral RT reduced the likelihood of hyposalivation vs bilateral RT (OR 2.36, P = .006).

CONCLUSION

Unilateral RT reduces unstimulated salivary flow in OPC patients.

Salivary Gland Hypofunction and Xerostomia in Head and Neck Radiation Patients

BACKGROUND

The most manifest long-term consequences of radiation therapy in the head and neck cancer patient are salivary gland hypofunction and a sensation of oral dryness (xerostomia).

METHODS

This critical review addresses the consequences of radiation injury to salivary gland tissue, the clinical management of salivary gland hypofunction and xerostomia, and current and potential strategies to prevent or reduce radiation injury to salivary gland tissue or restore the function of radiation-injured salivary gland tissue.

RESULTS

Salivary gland hypofunction and xerostomia have severe implications for oral functioning, maintenance of oral and general health, and quality of life. Significant progress has been made to spare salivary gland function chiefly due to advances in radiation techniques. Other strategies have also been developed, e.g., radioprotectors, identification and preservation/expansion of salivary stem cells by stimulation with cholinergic muscarinic agonists, and application of new lubricating or stimulatory agents, surgical transfer of submandibular glands, and acupuncture.

CONCLUSION

Many advances to manage salivary gland hypofunction and xerostomia induced by radiation therapy still only offer partial protection since they are often of short duration, lack the protective effects of saliva, or potentially have significant adverse effects. Intensity-modulated radiation therapy (IMRT), and its next step, proton therapy, have the greatest potential as a management strategy for permanently preserving salivary gland function in head and neck cancer patients.Presently, gene transfer to supplement fluid formation and stem cell transfer to increase the regenerative potential in radiation-damaged salivary glands are promising approaches for regaining function and/or regeneration of radiation-damaged salivary gland tissue.

Efficacy and safety of topical and systemic medications: a systematic literature review informing the EULAR recommendations for the management of Sjögren's syndrome

Objective

To evaluate current evidence on the efficacy and safety of topical and systemic medications in patients with primary Sjögren syndrome (SjS) to inform European League Against Rheumatism treatment recommendations.

Methods

The MEDLINE, EMBASE and Cochrane databases were searched for case-control/prospective cohort studies, randomised controlled trials (RCTs) and systematic reviews.

Results

Current evidence in primary SjS patients fulfilling the 2002 criteria is based on the data from 9 RCTs, 18 prospective cohort studies and 5 case-control studies. Two Cochrane systematic literature reviews (SLRs) have reported that topical treatments for dry mouth and dry eye are safe and effective. Ocular cyclosporine A was safe and effective in two RCTs including 1039 patients with dry eye syndrome. Two Cochrane SLRs on serum tear drops and plugs showed inconsistency in possible benefits, both for symptoms and objective measures. Five RCTs reported significant improvements in oral dryness and salivary flow rates for pilocarpine and cevimeline. An RCT showed no significant placebo-differences for hydroxychloroquine 400 mg/day for the primary outcome (visual analogue scale (VAS) composite of dryness, fatigue and pain). We identified seven RCTs carried out in primary SjS patients. RCTs using infliximab, anakinra and baminercept found no placebo-differences for the primary outcomes. The two largest RCTs randomised 255 patients to receive rituximab or placebo and reported no significant results in the primary outcome (VAS composite), while prospective studies suggested efficacy in systemic disease.

Conclusion

The current evidence supporting the use of the main topical therapeutic options of primary SjS is solid, while limited data from RCTs are available to guide systemic therapies.

Artificial Saliva: Challenges and Future Perspectives for the Treatment of Xerostomia

The chronic sensation of a dry mouth is a disease condition called xerostomia and affects a large part of the population. Xerostomia is associated with decreased secretion, or more often, qualitative changes in saliva proteins and immunoglobulin concentrations that develop as a result of salivary gland dysfunction. Several reasons causing dry mouth were described, and usually, they include taking medications, diseases or radiotherapy. In some situations, when it is difficult to use salivary stimulants or salivary gland damage is irreversible, the only option might seem to be saliva substitutes. The paper presents the most important aspects considering saliva preparations. The rheological and lubricating properties and the reconstruction of the complex saliva structure has been the main purpose of research. The biological properties of saliva preparations were also widely discussed. As part of the work, the antimicrobial effect of three commercial saliva preparations was tested. Finally, inadequate antimicrobial properties against the strains isolated from the oral cavity were demonstrated. The development of salivary substitutes, in particular, the improvement of antimicrobial properties, can be achieved using nanotechnology, including drug delivery systems containing nanocarriers.

Efficacy of a newly developed mouth gel for xerostomia relief-A randomized double-blind trial

OBJECTIVES

To determine the efficacy of a new symptom-relieving mouth gel vs. a widely used control gel on xerostomic burden.

MATERIALS AND METHODS

This randomized, double-blind, crossover trial investigated the efficacy of the test gel (Dr. Wolff Gel) vs. control (Biotene) in participants with xerostomia (n = 32; mean age 60 years). Oral examinations were taken at baseline, and xerostomic visual analogue scales (xVAS), after-use questionnaires and willingness to pay were investigated before and after use.

RESULTS

Neither gel reduced xerostomic burden (xVAS) after 7-day application. There was some preference for the test gel regarding taste and healthy gum feeling. After 1-time application, there were differences favouring the test gel for symptom-relieving effects between test gel and water (p < 0.001), mucosal adhesion (p < 0.001) and taste persistence (p < 0.001). Overall symptomatic relief with the test gel lasted around 2 hr.

CONCLUSIONS

No mouth gel alleviated the overall xerostomic burden. Nevertheless, the test gel led to short-term perceived symptomatic relief and improved patient-centred outcomes as taste and perceived gum health. The gel will probably mainly be effective at moments that patients mostly suffer from xerostomia. Selection of a product will be based on perceived subjective differences and their value in the context of the overall xerostomic burden.

Medication-Induced Xerostomia and Hyposalivation in the Elderly: Culprits, Complications, and Management

Medication-induced xerostomia and hyposalivation will increasingly become oral health issues for older and geriatric patients because of the likely high prevalence of medication intake and polypharmacy, with a complex negative impact on other symptoms such as dysphagia, caries incidence, malnutrition, and quality of life. All healthcare professionals are encouraged to investigate dry mouth symptoms among their patients, since diagnosis can easily be performed within daily clinical practice. This practical article also provides a review of available treatment options, which include medication changes towards products with fewer xerogenic side effects or dose reductions, if possible, as well as multidisciplinary, preventive care-oriented approaches that consider all influencing factors and treatment of the oral symptoms. In addition, several topical agents and saliva substitutes are discussed that may provide symptomatic relief but need to be carefully adapted to each patient's situation in terms of usability and practicability and in the knowledge that therapeutic success varies with each individual. Innovative methods such as intraoral electrostimulation or topical application of anticholinesterase on the oral mucosa are also discussed. The most commonly prescribed pharmaceutical treatment options for dry mouth are pilocarpine (a parasympathomimetic agent with potent muscarinic, cholinergic salivation-stimulating properties) and cevimeline (a quinuclidine analogue with therapeutic and side effects similar to those of pilocarpine). These pharmaceutic treatment options are described in the context of older patients, where the highly prevalent cholinergic side effects, which include nausea, emesis, bronchoconstriction, among others, need to be thoroughly supervised by the healthcare professionals involved. Providing these therapeutic options to patients with medication-induced dry mouth will help improve their oral health and therefore maintain a better quality of life, general health, and well-being.

Electrostimulation of the lingual nerve by an intraoral device may lead to salivary gland regeneration: A case series study

Background

Salivary gland function is controlled by the salivary reflex, whose efferent arm is composed by the parasympathetic and the sympathetic divisions of the autonomic nervous system. Parenchymal injury is the main salivary gland involvement of Sjögren’s syndrome and head and neck radiotherapy, but neural damage has been reported as well. Recently an intraoral device for electrostimulation of the lingual nerve in vicinity to the lower third molar has been introduced. At this point this nerve carries efferent fibers for the innervation of the submandibular, sublingual and several minor salivary glands and afferent fibers of the salivary reflex. Therefore, excitation of these fibers potentially leads to increased secretion of all salivary glands. Thus, the study objective was to assess whether comprehensive neural activation by electrostimulation of the lingual nerve carries the potential to induce the regeneration of damaged salivary glands.

Material and Methods

The device was tested on three patients with no collectable resting and stimulated secretion of saliva during a double blind, sham controlled period of two months and nine open-label months.

Results

All three subjects developed the capacity to spit saliva, not only in direct response to the electrostimulation but also after free intervals without electrostimulation. In addition, their symptoms of dry mouth severity and frequency improved.

Conclusions

This recovery is probably due to the combined effect of increase in secretory functional gland mass and regain of nervous control of the secretory elements and blood vessels. Both are phenomena that would contribute to gland regeneration.

Key words:Xerostomia, dry mouth, saliva, electrostimulation, regeneration.

Management of primary Sjögren's syndrome: recent developments and new classification criteria

For many years primary Sjögren's syndrome (pSS) has been considered an orphan disease, since no specific therapies were recognized as being capable of contrasting the development and progression of this disorder. The treatment of oral and ocular features, as well as of the systemic organ involvement, has been entrusted to the joint management of different subspecialty physicians, like ophthalmologists, otolaryngologists, dentists and rheumatologists. These latter subspecialty doctors are usually more involved in the treatment of systemic extraglandular involvement and, to do it, they have long been using the conventional therapies borrowed by the treatment schedules adopted in other systemic autoimmune diseases. The increasing knowledge of the biological pathways that are operative in patients with pSS, and the parallel development of molecular biology technology, have allowed the production and availability of a number of biological agents able to positively act on different disease mechanisms, and thus are candidates for testing in therapeutic trials. Meanwhile, the scientific community has made a great effort to develop new accurate and validated classification criteria and outcome measures to be applied in the selection of patients to be included and monitored in therapeutic studies. Some of the new-generation biotechnological agents have been tested in a number of open-label and randomized controlled trials that have produced in many cases inconclusive or contradictory results. Behind the differences in trial protocols, adopted outcome measures and predefined endpoints, reasons for such unsatisfactory results can be found in the large heterogeneity of clinical subtypes in the examined cohorts. The future challenge for a substantial advancement in the therapeutic approach to pSS could be to identify the pathologic mechanisms, outcome tools and biomarkers that characterize the different subsets of the disease in order to test carefully selected target therapies with the highest probability of success in each different clinical phenotype.

Electrical nerve stimulation for xerostomia: A meta-analysis of randomised controlled trials

BACKGROUND

Xerostomia leads to caries, infection and overall psychological discomfort. Salivary substitutes and pharmacological agents have been tried only with temporary relief. The use of transcutaneous electrical nerve stimulation (TENS) has been contemplated on by various researchers for treatment of xerostomia. We carried out the present review as a systematic compilation and quantitative synthesis of the existing evidence related to the utility of TENS in patients with xerostomia.

METHODOLOGY

Six randomized controlled trials were identified from databases for inclusion and analysed using non-Cochrane mode in RevMan 5.0 software. The heterogeneity between the studies were assessed using Forest plot, I² statistics wherein more than 50% was considered to have moderate to severe heterogeneity and Chi-square test with a statistical P-value of less than 0.10 to indicate statistical significance.

RESULTS

Results show that the effect of TENS on salivary flow rate in 369 participants with SMD [95% CI] was 0.63 [-0.03, 1.29] and was not statistically significant.

CONCLUSION

To conclude, the current evidence does not support the use of TENS in patients with xerostomia and may be considered as a salivary substitute for symptomatic improvement. However the type, frequency and amplitude of current used needs to be studied in detail. High quality randomized controlled trials with adequate power are required, either to support or refute the use of TENS in xerostomia.

Orofacial manifestations in patients with inflammatory rheumatic diseases

The main orofacial manifestation of the inflammatory rheumatic diseases is that of Sjögren's syndrome. In addition, there is a constellation of orofacial manifestations of the inflammatory rheumatic diseases, many of which are extra-articular with some constituting presenting signs of the underlying rheumatic disease. This review will discuss the orofacial manifestations in a variety of connective tissue diseases and will also allude to the oral adverse drug reactions that may occur as a consequence of therapy.

What rheumatologists should know about orofacial manifestations of autoimmune rheumatic diseases

Orofacial manifestations occur frequently in rheumatic diseases and usually represent early signs of disease or of its activity that are still neglected in clinical practice. Among the autoimmune rheumatic diseases with potential for oral manifestations, rheumatoid arthritis (RA), inflammatory myopathies (IM), systemic sclerosis (SSc), systemic lupus erythematosus (SLE), relapsing polychondritis (RP) and Sjögren's syndrome (SS) can be cited. Signs and symptoms such as oral hyposalivation, xerostomia, temporomandibular joint disorders, lesions of the oral mucosa, periodontal disease, dysphagia, and dysphonia may be the first expression of these rheumatic diseases. This article reviews the main orofacial manifestations of rheumatic diseases that may be of interest to the rheumatologist for diagnosis and monitoring of autoimmune rheumatic diseases.

Treatment of primary Sjögren syndrome

Primary Sjögren syndrome (pSS) is a progressive autoimmune disease characterized by sicca and systemic manifestations. In this Review, we summarize the available data on topical and systemic medications, according to clinical signs and disease activity, and we describe the ongoing studies using biologic drugs in the treatment of pSS. Expanding knowledge about the epidemiology, classification criteria, systemic activity scoring (ESSDAI) and patient-reported outcomes (ESSPRI) is driving active research. Treatment decisions are based on the evaluation of symptoms and extraglandular manifestations. Symptomatic treatment is usually appropriate, whereas systemic treatment is reserved for systemic manifestations. Sicca is managed by education, environment modification, elimination of contingent offending drugs, artificial tears, secretagogues and treatments for complications. Mild systemic signs such as fatigue are treated by exercise. Pain can require short-term moderate-dose glucocorticoid therapy and, in some cases, disease-modifying drugs. Severe and acute systemic manifestations indicate treatment with glucocorticoids and/or immunosuppressant drugs. The role for biologic agents is promising, but no double-blind randomized controlled trials (RCTs) proving the efficacy of these drugs are available. Targets for new treatments directed against the immunopathological mechanisms of pSS include epithelial cells, T cells, B-cell overactivity, the interferon signature, proinflammatory cytokines, ectopic germinal centre formation, chemokines involved in lymphoid cell homing, and epigenetic modifications.

Treatment of xerostomia and hyposalivation in the elderly: A systematic review

BACKGROUND

Therapeutic strategies for xerostomia, regardless of etiology, have so far not had definitive or clearly effective results.

OBJECTIVES

To systematically revise the latest scientific evidence available regarding the treatment of dry mouth, regardless of the cause of the problem.

MATERIAL AND METHODS

The literature search was conducted in March 2015, using the Medline and Embase databases. The "Clinical Trial", from 2006 to March 2015, was carried out in English and only on human cases. The draft of the systematic review and assessment of the methodological quality of the trials was carried out following the criteria of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and the "Oxford Quality Scale".

RESULTS

Finally, a total of 26 trials were identified that met the previously defined selection and quality criteria; 14 related to drug treatments for dry mouth, 10 with non-pharmacological treatment and 2 with alternative treatments.

CONCLUSIONS

Pilocarpine continues to be the best performing sialogogue drug for subjects with xerostomia due to radiation on head and neck cancer or diseases such as Sjogren's Syndrome. For patients with dry mouth caused solely by medication, there are some positive indications from the use of malic acid, along with other elements that counteract the harmful effect on dental enamel. In general, lubrication of oral mucous membrane reduces the symptoms, although the effects are short-lived.

Enhanced salivary secretion by interferential current stimulation in patients with dry mouth: a pilot study

OBJECTIVE

This pilot study tested the effects of submandibular and sublingual gland stimulation by interferential current stimulation (IFCS), a noninvasive mode of electrical stimulation.

STUDY DESIGN

Three groups were enrolled in this study: 20 young adults, 19 older adults, and 21 patients with dry mouth. Four electrodes were attached to the submandibular area, and the secreted saliva was collected by using Salivette cotton rolls (Sarstedt K. K., Tokyo, Japan) for 15 minutes, either with or without IFCS. Patients were randomly chosen to receive IFCS. Each subject rated pain and discomfort on the Visual Analogue Scale (VAS) after each experiment. Saliva chromogranin A levels were measured as a stress marker. To compare data between conditions with and without IFCS, a two-sample Student t test analysis was performed.

RESULTS

Saliva flow was slightly increased in those in the dry mouth group receiving IFCS compared with those who did not receive IFCS (approximately 130%). However, no such difference was found in the young and older adult groups. There was no significant difference in the VAS values of pain and discomfort or in the stress marker levels between patients who received or did not receive IFCS in the three groups.

CONCLUSIONS

IFCS delivered to submandibular and sublingual glands may promote saliva secretion in persons who suffer from dry mouth in a manner that does not induce pain or physical stress.

What rheumatologists should know about orofacial manifestations of autoimmune rheumatic diseases

Orofacial manifestations occur frequently in rheumatic diseases and usually represent early signs of disease or of its activity that are still neglected in clinical practice. Among the autoimmune rheumatic diseases with potential for oral manifestations, rheumatoid arthritis (RA), inflammatory myopathies (IM), systemic sclerosis (SSc), systemic lupus erythematosus (SLE), relapsing polychondritis (RP) and Sjögren's syndrome (SS) can be cited. Signs and symptoms such as oral hyposalivation, xerostomia, temporomandibular joint disorders, lesions of the oral mucosa, periodontal disease, dysphagia, and dysphonia may be the first expression of these rheumatic diseases. This article reviews the main orofacial manifestations of rheumatic diseases that may be of interest to the rheumatologist for diagnosis and monitoring of autoimmune rheumatic diseases.

The Quality of Life Burden Associated With Voice Disorders in Sjögren's Syndrome

OBJECTIVES

This study examined quality of life burden of voice disorders in Sjögren's syndrome (SS).

METHODS

Patients with SS (n = 101) completed interviews involving patient-reported histories of voice disorders, specific voice symptoms, SS disease severity, the Voice-Related Quality of Life (V-RQOL), and the general health-related quality of life Short Form 36 (SF-36) questionnaires. Relationships among voice symptoms, disease severity, and quality-of-life measures were examined and compared with patient-reported voice disorders.

RESULTS

Significant correlations were observed among voice symptoms, disease severity, V-RQOL, SF-36, and patient-reported voice disorders (P < .05). Patients with SS who reported a voice disorder experienced a greater burden on general quality of life as compared with those without voice disorders. Specific voice symptoms significantly correlated with reduced SF-36 scores included frequent throat-clearing, throat soreness, difficulty projecting, and vocal discomfort. Despite the added burden of a voice disorder on quality of life in SS, voice-related treatment seeking was low (15.8%). However, the majority of patients who received voice treatment reported voice improvement.

CONCLUSIONS

Individuals with SS frequently experience voice disorders and specific voice-related symptoms that are associated with reduced quality of life. These findings have important implications for voice referral practices and voice disorder symptom management in this population.

Basic oral care for hematology-oncology patients and hematopoietic stem cell transplantation recipients: a position paper from the joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT)

PURPOSE

Hematology-oncology patients undergoing chemotherapy and hematopoietic stem cell transplantation (HSCT) recipients are at risk for oral complications which may cause significant morbidity and a potential risk of mortality. This emphasizes the importance of basic oral care prior to, during and following chemotherapy/HSCT. While scientific evidence is available to support some of the clinical practices used to manage the oral complications, expert opinion is needed to shape the current optimal protocols.

METHODS

This position paper was developed by members of the Oral Care Study Group, Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT) in attempt to provide guidance to the health care providers managing these patient populations.

RESULTS

The protocol on basic oral care outlined in this position paper is presented based on the following principles: prevention of infections, pain control, maintaining oral function, the interplay with managing oral complications of cancer treatment and improving quality of life.

CONCLUSION

Using these fundamental elements, we developed a protocol to assist the health care provider and present a practical approach for basic oral care. Research is warranted to provide robust scientific evidence and to enhance this clinical protocol.

Diagnosis and management of xerostomia and hyposalivation

Xerostomia, the subjective complaint of dry mouth, and hyposalivation remain a significant burden for many individuals. Diagnosis of xerostomia and salivary gland hypofunction is dependent upon a careful and detailed history and thorough oral examination. There exist many options for treatment and symptom management: salivary stimulants, topical agents, saliva substitutes, and systemic sialogogues. The aim of this review is to investigate the current state of knowledge on management and treatment of patients affected by xerostomia and/or hyposalivation.

Management of xerostomia and other complications of Sjögren's syndrome

This article provides an overview of the published literature in English in the past 63 years involving the management of xerostomia and other oral complications of Sjögren's syndrome. The evidence supporting studied interventions was evaluated using published criteria.

Safety and efficacy of an intra-oral electrostimulator for the relief of dry mouth in patients with chronic graft versus host disease: Case series

Objectives: Patients with chronic graft-versus-host disease (cGVHD) often suffer from dry mouth and oral mucosal lesions. The primary objective of this study was to investigate the safety of an intra-oral electrostimulator (GenNarino) in symptomatic cGVHD patients. The secondary objective was to study the impact on the salivary gland involvement of cGVHD patients. Study Design: This paper presents a case series. The study included patients treated for 4 weeks, randomly assigned to the active device and then crossed-over to a sham-device or vice versa. The patients and clinicians were blind to the treatment delivered. Data regarding oral mucosal and salivary gland involvement were collected. Results: Six patients were included in this series. Most of the intraoral areas with manifestations of cGVHD were not in contact with the GenNarino device. Two patients developed mild mucosal lesions in areas in contact with the GenNarino during the study. However, only one of them had a change in the National Institutes of Health (NIH) score for oral cGVHD. The unstimulated and stimulated salivary flow rate increased in 4 out of the 5 patients included in this analysis. Symptoms of dry mouth and general oral comfort improved. Conclusion: This study suggests that GenNarino is safe in cGVHD patients with respect to oral tissues. Furthermore the use of GenNarino resulted in subjective and objective improvements in dry mouth symptoms. A large scale study is needed to confirm the impact and safety of GenNarino on systemic cGVHD.

Key words:Dry mouth, graft versus host disease, electrostimulation, oral mucosa, hematopoietic stem cell transplantation.

Relative Efficacy of Swallowing versus Non-swallowing Tasks in Dysphagia Rehabilitation: Current Evidence and Future Directions

Clinical trials published in 2012 and the first six months of 2013 were reviewed. These involved either traditional dysphagia therapy, indirect methods not involving dysphagia therapy or a combination of direct and indirect methods. Of 27 studies, 7 were RCTs, 5 were controlled clinical trials and the remainder were uncontrolled case series. Sixteen studies combined an indirect treatment with traditional dysphagia therapy; only one study examined one technique for direct swallowing therapy. Effect sizes were computed and contrasted for each trial. Traditional dysphagia therapy had small to moderate effect sizes (between 0.3 and 0.6) while spontaneous recovery in acute stroke had effect sizes of 1.2. Placebo effects on patient ratings of degree of improvement on swallowing were estimated as small to moderate. To improve effect sizes, adaptive research designs are needed to develop the optimal methods and dosages of therapy before future clinical trials.

Interventions for the management of dry mouth: non-pharmacological interventions

BACKGROUND

Xerostomia is the subjective sensation of dry mouth. Common causes of xerostomia include adverse effects of many commonly prescribed medications, disease (e.g. Sjogren's Syndrome) and radiotherapy treatment for head and neck cancers. Non-pharmacological techniques such as acupuncture or mild electrostimulation may be used to improve symptoms.

OBJECTIVES

To assess the effects of non-pharmacological interventions administered to stimulate saliva production for the relief of dry mouth.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 16th April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 3), MEDLINE via OVID (1948 to 16th April 2013), EMBASE via OVID (1980 to 16th April 2013), AMED via OVID (1985 to 16th April 2013), CINAHL via EBSCO (1981 to 16th April 2013), and CANCERLIT via PubMed (1950 to 16th April 2013). The metaRegister of Controlled Clinical Trials (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov) were also searched to identify ongoing and completed trials. References lists of included studies and relevant reviews were also searched. There were no restrictions on the language of publication or publication status.

SELECTION CRITERIA

We included parallel group randomised controlled trials of non-pharmacological interventions to treat dry mouth, where participants had dry mouth symptoms at baseline.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed each of the included studies to confirm eligibility, assess risk of bias and extract data using a piloted data extraction form. We calculated mean difference (MD) and 95% confidence intervals (CI) for continuous outcomes or where different scales were used to assess an outcome, we calculated standardised mean differences (SMD) together with 95% CIs. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information.

MAIN RESULTS

There were nine studies (total 366 participants randomised) included in this review of non-pharmacological interventions for dry mouth which were divided into three comparisons. Eight studies were assessed at high risk of bias in at least one domain and the remaining study was at unclear risk of bias.Five small studies (total 153 participants, with dry mouth following radiotherapy treatment) compared acupuncture with placebo. Four were assessed at high risk and one at unclear risk of bias. Two trials reported outcome data for dry mouth in a form suitable for meta-analysis. The pooled estimate of these two trials (70 participants, low quality evidence) showed no difference between acupuncture and control in dry mouth symptoms (SMD -0.34, 95% CI -0.81 to 0.14, P value 0.17, I(2) = 39%) with the confidence intervals including both a possible reduction or a possible increase in dry mouth symptoms. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). There was a very small increase in unstimulated whole saliva (UWS) at the end of 4 to 6 weeks of treatment (three trials, 71 participants, low quality evidence) (MD 0.02 ml/minute, 95% CI 0 to 0.04, P value 0.04, I(2) = 57%), and this benefit persisted at the 12-month follow-up evaluation (two trials, 54 participants, low quality evidence) (UWS, MD 0.06 ml/minute, 95% CI 0.01 to 0.11, P value 0.03, I(2) = 10%). For the outcome of stimulated whole saliva (SWS, three trials, 71 participants, low quality evidence) there was a benefit favouring acupuncture (MD 0.19 ml/minute, 95% CI 0.07 to 0.31, P value 0.002, I(2) = 1%) an effect which also persisted at the 12-month follow-up evaluation (SWS MD 0.28 ml/minute, 95% CI 0.09 to 0.47, P value 0.004, I(2) = 0%) (two trials, 54 participants, low quality evidence).Two small studies, both at high risk of bias, compared the use of an electrostimulation device with a placebo device in participants with Sjögren's Syndrome (total 101 participants). A further study, also at high risk of bias, compared acupuncture-like electrostimulation of different sets of points in participants who had previously been treated with radiotherapy. None of these studies reported the outcome of dry mouth. There was no difference between electrostimulation and placebo in the outcomes of UWS or SWS at the end of the 4-week treatment period in the one study (very low that provided data for these outcomes. No adverse effects were reported.A single study at high risk of bias, compared the stimulatory effect of powered versus manual toothbrushing and found no difference for the outcomes of UWS or SWS.

AUTHORS' CONCLUSIONS

There is low quality evidence that acupuncture is no different from placebo acupuncture with regard to dry mouth symptoms, which is the most important outcome. This may be because there were insufficient participants included in the two trials to show a possible effect or it may be that there was some benefit due to 'placebo' acupuncture which could have biased the effect to the null. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms. It is well known that dry mouth symptoms may be problematic even when saliva production is increased, yet only two of the trials that evaluated acupuncture reported dry mouth symptoms, a worrying reporting bias. There is some low quality evidence that acupuncture results in a small increase in saliva production in patients with dry mouth following radiotherapy.There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms or saliva production in patients with Sjögren's Syndrome. Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation.

Interventions for the management of dry mouth: non-pharmacological interventions

BACKGROUND

Xerostomia is the subjective sensation of dry mouth. Common causes of xerostomia include adverse effects of many commonly prescribed medications, disease (e.g. Sjogren's Syndrome) and radiotherapy treatment for head and neck cancers. Non-pharmacological techniques such as acupuncture or mild electrostimulation may be used to improve symptoms.

OBJECTIVES

To assess the effects of non-pharmacological interventions administered to stimulate saliva production for the relief of dry mouth.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 16th April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 3), MEDLINE via OVID (1948 to 16th April 2013), EMBASE via OVID (1980 to 16th April 2013), AMED via OVID (1985 to 16th April 2013), CINAHL via EBSCO (1981 to 16th April 2013), and CANCERLIT via PubMed (1950 to 16th April 2013). The metaRegister of Controlled Clinical Trials (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov) were also searched to identify ongoing and completed trials. References lists of included studies and relevant reviews were also searched. There were no restrictions on the language of publication or publication status.

SELECTION CRITERIA

We included parallel group randomised controlled trials of non-pharmacological interventions to treat dry mouth, where participants had dry mouth symptoms at baseline.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed each of the included studies to confirm eligibility, assess risk of bias and extract data using a piloted data extraction form. We calculated mean difference (MD) and 95% confidence intervals (CI) for continuous outcomes or where different scales were used to assess an outcome, we calculated standardised mean differences (SMD) together with 95% CIs. We attempted to extract data on adverse effects of interventions. Where data were missing or unclear we attempted to contact study authors to obtain further information.

MAIN RESULTS

There were nine studies (total 366 participants randomised) included in this review of non-pharmacological interventions for dry mouth which were divided into three comparisons. Eight studies were assessed at high risk of bias in at least one domain and the remaining study was at unclear risk of bias.Five small studies (total 153 participants, with dry mouth following radiotherapy treatment) compared acupuncture with placebo. Four were assessed at high risk and one at unclear risk of bias. Two trials reported outcome data for dry mouth in a form suitable for meta-analysis. The pooled estimate of these two trials (70 participants, low quality evidence) showed no difference between acupuncture and control in dry mouth symptoms (SMD -0.34, 95% CI -0.81 to 0.14, P value 0.17, I(2) = 39%) with the confidence intervals including both a possible reduction or a possible increase in dry mouth symptoms. Acupuncture was associated with more adverse effects (tiny bruises and tiredness which were mild and temporary). There was a very small increase in unstimulated whole saliva (UWS) at the end of 4 to 6 weeks of treatment (three trials, 71 participants, low quality evidence) (MD 0.02 ml/minute, 95% CI 0 to 0.04, P value 0.04, I(2) = 57%), and this benefit persisted at the 12-month follow-up evaluation (two trials, 54 participants, low quality evidence) (UWS, MD 0.06 ml/minute, 95% CI 0.01 to 0.11, P value 0.03, I(2) = 10%). For the outcome of stimulated whole saliva (SWS, three trials, 71 participants, low quality evidence) there was a benefit favouring acupuncture (MD 0.19 ml/minute, 95% CI 0.07 to 0.31, P value 0.002, I(2) = 1%) an effect which also persisted at the 12-month follow-up evaluation (SWS MD 0.28 ml/minute, 95% CI 0.09 to 0.47, P value 0.004, I(2) = 0%) (two trials, 54 participants, low quality evidence).Two small studies, both at high risk of bias, compared the use of an electrostimulation device with a placebo device in participants with Sjögren's Syndrome (total 101 participants). A further study, also at high risk of bias, compared acupuncture-like electrostimulation of different sets of points in participants who had previously been treated with radiotherapy. None of these studies reported the outcome of dry mouth. There was no difference between electrostimulation and placebo in the outcomes of UWS or SWS at the end of the 4-week treatment period in the one study (very low that provided data for these outcomes. No adverse effects were reported.A single study at high risk of bias, compared the stimulatory effect of powered versus manual toothbrushing and found no difference for the outcomes of UWS or SWS.

AUTHORS' CONCLUSIONS

There is low quality evidence that acupuncture is no different from placebo acupuncture with regard to dry mouth symptoms, which is the most important outcome. This may be because there were insufficient participants included in the two trials to show a possible effect or it may be that there was some benefit due to 'placebo' acupuncture which could have biased the effect to the null. There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms. It is well known that dry mouth symptoms may be problematic even when saliva production is increased, yet only two of the trials that evaluated acupuncture reported dry mouth symptoms, a worrying reporting bias. There is some low quality evidence that acupuncture results in a small increase in saliva production in patients with dry mouth following radiotherapy.There is insufficient evidence to determine the effects of electrostimulation devices on dry mouth symptoms or saliva production in patients with Sjögren's Syndrome. Reported adverse effects of acupuncture are mild and of short duration, and there were no reported adverse effects from electrostimulation.

[Prognosis and treatment of dry mouth. Systematic review]

There are no clearly established protocols for the treatment of dry mouth. The aim of this paper is a systematic review of the literature of the past 10 years using the words « dry mouth », « prognosis », « treatment » and « dentistry ». The initial search found 1,450 entries and within the restriction « clinical trials OR randomized controlled trial OR systemic reviews » it has been reduced to 522, which 145 were meta-analysis and systematic reviews. Papers not relevant to the issue were removed reducing the entries to 53. Twenty-four were dismissed (8 irrelevant, 7 reviews without adequate information and 9 personal opinions). Of the 29 items tested, 15 were controlled trials, 2 uncontrolled trials, 4 observational studies, 2 systematic reviews and 5 non systematic reviews. The most studied patients were Sjögren's syndrome and the irradiated patients. Treatments are focused on the etiology, prevention, symptomatic, local salivary stimulation and systemic treatments. It can be concluded that treatment must be individualized, salivary substitutes and mechanical stimulation techniques can be applied.

Intraoral electrostimulator for xerostomia relief: a long-term, multicenter, open-label, uncontrolled, clinical trial

OBJECTIVE

A previous sham-controlled multinational study demonstrated the short-term efficacy and safety for xerostomia treatment of an intraoral device that delivers electrostimulation to the lingual nerve. The objective of this study was to test the hypothesis that those beneficial effects would be sustained over an 11-month period.

STUDY DESIGN

The device was tested on a mixed sample of 94 patients with xerostomia in an open-label, uncontrolled, prospective multicenter trial. Statutory outcome assessments were done at 5th, 8th, and 11th months and analyzed by multiple comparisons.

RESULTS

Improvements achieved at month 5 from baseline were sustained throughout the follow-up period for the primary outcome, xerostomia severity, and the secondary outcomes resting whole salivary flow rate, xerostomia frequency, oral discomfort, and difficulties in speech, swallowing, and sleeping. No significant side effects were detected.

CONCLUSIONS

The beneficial effects of a removable intraoral electrostimulating device were sustained for an 11-month period.

Sjögren's syndrome, the old and the new

Sjögren's syndrome is a chronic autoimmune disease characterised by progressive injury to exocrine glands accompanied by diverse extra-glandular manifestations. The spectrum of Sjögren's manifestations expanded in recent years to include new symptoms and signs such as small fibre neuropathy, and also well-defined activity and prognostic indexes. Similar to other non-organ-specific autoimmune diseases, a mosaic of factors have been linked with the development and appearances of Sjögren's syndrome. Progress has been made unravelling those factors, including susceptibility genes, immunological parameters and various environmental factors in the last decade, some of which may enable targeted therapies, biological and non-biological ones, for patients suffering from this disease. Thus, herein we review the postulated aetiologies, pathogenesis and new insights related to Sjögren's syndrome.

Topical and systemic medications for the treatment of primary Sjögren's syndrome

The treatment of primary Sjögren's syndrome (SS) is based principally on the management of sicca features and systemic manifestations. Sicca manifestations are treated symptomatically through administration of topical therapies, such as saliva substitutes and artificial tears; in patients with residual salivary gland function, stimulation of salivary flow with a sialogogue is the therapy of choice. The management of extraglandular features must be tailored to the specific organ or organs involved; however, limited data have been obtained from controlled trials in SS to guide the treatment of systemic symptoms using therapies including antimalarials, glucocorticoids, immunosuppressive drugs and biologic agents. Nevertheless, randomised controlled trials of biologic agents that target molecules and receptors involved in the aetiopathogenesis of primary SS have initiated a new era in the therapeutic management of the disease, although the potential risks and benefits of these agents must be carefully considered. In this Review, we analyse the evidence regarding the efficacy of the therapeutic agents currently available to treat the manifestations of SS. On the basis of this evidence, we provide guidance on the use of these agents in different clinical scenarios.

Vasoactive intestinal peptide/vasoactive intestinal peptide receptor relative expression in salivary glands as one endogenous modulator of acinar cell apoptosis in a murine model of Sjögren's syndrome

Sjögren's syndrome (SS) is a chronic autoimmune disease characterized by a progressive oral and ocular dryness that correlates poorly with the autoimmune damage of the glands. It has been proposed that a loss of homeostatic equilibrium in the glands is partly responsible for salivary dysfunction with acinar cells involved actively in the pathogenesis of SS. The non-obese diabetic (NOD) mouse model of Sjögren's syndrome develops secretory dysfunction and early loss of glandular homeostatic mechanisms, with mild infiltration of the glands. Based on the vasodilator, prosecretory and trophic effects of the vasoactive intestinal peptide (VIP) on acini as well as its anti-inflammatory properties we hypothesized that the local expression of VIP/vasoactive intestinal peptide receptor (VPAC) system in salivary glands could have a role in acinar cell apoptosis and macrophage function thus influencing gland homeostasis. Here we show a progressive decline of VIP expression in submandibular glands of NOD mice with no changes in VPAC receptor expression compared with normal mice. The deep loss of endogenous VIP was associated with a loss of acinar cells through apoptotic mechanisms that could be induced further by tumour necrosis factor (TNF)-α and reversed by VIP through a cyclic adenosine-5'-monophosphate (cAMP)/protein kinase A (PKA)-mediated pathway. The clearance of apoptotic acinar cells by macrophages was impaired for NOD macrophages but a shift from inflammatory to regulatory phenotype was induced in macrophages during phagocytosis of apoptotic acinar cells. These results support that the decline in endogenous VIP/VPAC local levels might influence the survival/apoptosis intracellular set point in NOD acinar cells and their clearance, thus contributing to gland homeostasis loss.