Different saliva substitutes for treatment of xerostomia following radiotherapy. A prospective crossover study

Efficacy of natural enzymes mouthwash: a randomised controlled trial

OBJECTIVES

Natural enzymes mouthwash has been proposed as salivary substitutes to treat xerostomia. This study aims to evaluate the efficacy of the mouthwash to treat xerostomia.

MATERIALS AND METHODS

A double-blind, parallel group randomised control clinical trial involving N = 49 adult participants with xerostomia was carried out. Intervention group received natural enzymes moisturising mouthwash (with active ingredients lactoferrin, lysozyme, lactoperoxidase and glucose oxidase); while control group received benzydamine mouthwash. Mouthwashes were repacked, labelled with specific code, and were given to participants by third-party. Subjects were instructed to rinse with the mouthwash 4 times per day at a specific period, for 2 weeks. Symptoms of xerostomia were assessed using Xerostomia Inventory at day 0 and 14; together with the assessment of Clinical Oral Dryness Score (CODS), and measurement of resting and stimulated salivary flow rate.

RESULTS

48 participants completed the clinical follow-up, and n = 1 had lost of follow-up. From the 48 participants, n = 23 received natural enzymes mouthwash, while n = 25 received benzydamine mouthwash. Intervention group achieved reduction in symptoms of xerostomia from baseline. Intervention group also showed significantly better improvements in the cognitive perception of dry mouth and oromotor function such as chewing, swallowing and speech of the participants; and reduction in waking up at night to drink water (p < 0.05). The CODS and resting salivary flow rate were also significantly improved in intervention group (p < 0.05).

CONCLUSION

Use of natural enzymes mouthwash improved signs and symptoms of xerostomia.

CLINICAL RELEVANCE

Natural enzymes mouthwash is potentially effective to treat xerostomia, well-tolerated and safe to be used by xerostomia patients.

CLINICAL TRIAL REGISTRATION NUMBER

This study was retrospectively registered in ClinicalTrials.gov ID NCT05640362 on 7 December 2022.

Xerostomia and prevention of dryness with a Pycnogenol® mouth spray: a pilot study

BACKGROUND

The aim of this pilot, supplement study was the evaluation of primary, idiopathic mucosal mouth dryness (xerostomia or dry mouth) in subjects without systemic diseases.

METHODS

Subjects with xerostomia were managed either with standard management (SM) or with SM and a Pycnogenol® mouth spray (Hankintatukku Oy, Karkkila, Finland), at the dosage of 60 mg/day in 30 spurts, for 2 weeks.

RESULTS

A total of 50 subjects were included in the study: 25 controls using only standard management (SM) and 25 subjects using the Pycnogenol® mouth spray. No side effects and no tolerability problems were observed with the Pycnogenol® mouth spray. The groups were comparable for characteristics and symptoms at baseline. These otherwise healthy subjects had a BMI<26. After 2 weeks, salivary flow and salivary oxidative stress (in Carr Units) were improved significantly with Pycnogenol® mouth spray as compared to controls (P<0.05), whereas minimal improvements in salivary flow were seen with SM. The subjective symptomatic dry mouth score and the number of mucosal breaks and ulcerations (all minimal, <1 mm in length or diameter) were significantly decreased with the Pycnogenol® mouth spray supplement compared to SM controls (P<0.05). The Pycnogenol® mouth spray led to significant improvement in salivary lysozyme levels, compared to controls (P<0.05).

CONCLUSIONS

Based on these preliminary results, Pycnogenol® mouth spray could be a new supplementary option for the management of primary xerostomia.

Efficacy of bethanechol chloride in the treatment of radiation-induced xerostomia in patients with head and neck cancer: A systematic review and meta-analysis

BACKGROUND AND PORPUSE

Salivary glands sustain collateral damage following radiotherapy (RT) to treat cancers of the head and neck, leading to complications, including xerostomia and hyposalivation. This systematic review (SR) with meta-analysis was performed to determine the effectiveness of bethanechol chloride in preventing salivary gland dysfunction in this context.

MATERIALS AND METHODS

Medline/Pubmed, Embase, Scopus, LILACS via Portal Regional BVS and Web of Science were searched electronically in accordance with the Cochrane manual and reported PRISMA guidelines.

RESULTS

170 patients from three studies were included. Results from the meta-analysis suggest that bethanechol chloride is associated with increases in: whole stimulating saliva (WSS) after RT (Std. MD 0.66, 95% CI 0.28 to 1.03, P < 0.001); whole resting saliva (WRS) during RT (Std. MD 0.4, 95% CI 0.04 to 0.76, P = 0.03); and WRS after RT (Std. MD 0.45, 95% CI 0.04 to 0.86, P = 0.03).

CONCLUSION

The present study suggests that bethanechol chloride therapy may be effective in patients with xerostomia and hyposalivation.

A Comparison of the Wetting Ability of Three Artificial Saliva Substitutes on Heat-Cured Denture Base Resin - An In vitro Study

Introduction

Salivary substitutes are gaining popularity these days because of the increase in patients with dry mouth. These substitutes must satisfy certain criteria to fulfill the patient's needs. One of these is wettability.

Materials and Methods

One hundred fifty rectangular specimens of heat-cured denture base acrylic resin were prepared. A drop of test liquids (human saliva, distilled water, aqwet, saleva, and wet mouth) was placed over the test specimen and right and left contact angles were measured using optical contact angle machine.

Results

All test liquids performed better than distilled water. Human saliva has the least contact angle followed by aqwet.

Conclusion

Carboxymethyl cellulose base aqwet saliva substitute was found to be best having similar contact angle values to human saliva.

Efficacy of a 1% malic acid spray for xerostomia treatment: A systematic review and meta-analysis

OBJECTIVES

To assess the efficacy of topical sialogogue spray containing malic acid 1% for treating xerostomia.

METHODS

We searched PubMed, Cochrane Library, Embase, ClinicalTrials.gov and Web of Science databases. Literature search, screening, study selection, data collection, data extraction and assessment of bias risk were independently conducted by two reviewers. The study appraisal was performed by Cochrane Collaboration's tool for assessing bias risk. The systematic review registration number was PROSPERO-CRD42021241322. All statistical analyses were performed using Review Manager version 5.4.

RESULTS

Five original articles involving 244 patients with xerostomia who received topical sialogogue spray (malic acid 1%) or placebo for two weeks were included in this review. Based on the questionnaire survey, the topical sialogogue spray (malic acid 1%) improved the symptoms of dry mouth significantly better than the placebo, which was reflected in the Dry Mouth Questionnaire (DMQ), Xerostomia Inventory (XI) and Visual Analogue Scale (VAS) scores. Regarding the increase in unstimulated and stimulated saliva flow rates, the intervention group was also better than the placebo group after a two-week course of treatment.

CONCLUSIONS

Although the included studies are limited, our results show that topical sialogogue spray (malic acid 1%) is an effective method for the treatment of xerostomia. Additional randomised controlled trials in the future are needed to provide high-quality evidence of this therapy and to improve clinical practice guidelines.

A Review on Xerostomia and Its Various Management Strategies: The Role of Advanced Polymeric Materials in the Treatment Approaches

The medical term xerostomia refers to the subjective sensation of oral dryness. The etiology seems to be multifactorial with the most frequently reported causes being the use of xerostomic medications, neck and head radiation, and systematic diseases (such as Sjögren’s syndrome). Xerostomia is associated with an increased incidence of dental caries, oral fungal infections, and difficulties in speaking and chewing/swallowing, which ultimately affect the oral health-related quality of life. The development of successful management schemes is regarded as a highly challenging project due to the complexity of saliva. This is why, in spite of the fact that there are therapeutic options aiming to improve salivary function, most management approaches are alleviation-oriented. In any case, polymers are an integral part of the various formulations used in every current treatment approach, especially in the saliva substitutes, due to their function as thickening and lubricating agents or, in the case of mucoadhesive polymers, their ability to prolong the treatment effect. In this context, the present review aims to scrutinize the literature and presents an overview of the role of various polymers (or copolymers) on either already commercially available formulations or novel drug delivery systems currently under research and development.

Efficacy and safety of two artificial saliva-based polymers containing 0.1% pilocarpine for treatment of xerostomia: A randomized clinical pilot trial

Background

Topical agents are the mainstay in the treatment of xerostomia, a common complaint most frequently associated with salivary dysfunction. This study aimed to compared the efficacy and safety for xerostomia treatment of 2 artificial saliva preparations containing 0.1% pilocarpine, and, either sodium carboxymethylcellulose (SCMC), or, sodium polyacrylate (SPA).

Material and Methods

Thirty-one xerostomia patients were randomly allocated into either a SCMC-treated group (15 patients), or, a SPA-treated group (16 patients). The formulations were taken 0.5 ml, 4 times daily for 6 weeks and double-blinded assessed before and after treatments using Xerostomia Inventory (XI) and Clinical Oral Dryness Score (CODs). Unstimulated and stimulated whole salivary flow rates were measured.

Results

After treatment, the SCMC-treated group had significantly lower CODs and higher unstimulated and stimulated whole salivary flow rates (p<0.001, p=0.035, and p=0.013, respectively), while the SPA-treated group showed significantly lower CODs only (p=0.004). In contrast, SCMC-treated and SPA-treated groups at the 6th week after treatments showed non-significant differences in all assessments (p>0.05, all). Some adverse events (AEs) were reported, e.g., burning tongue, dizziness and watery eyes, but no severe AEs.

Conclusions

This randomized controlled pilot trial demonstrated superior efficacy of SCMC-formula over a SPA-formula after 6 weeks of xerostomia treatment. These formulations with topical pilocarpine proved safe in clinical use with minimal reported AE.

Key words:Xerostomia, artificial saliva, sodium carboxymethylcellulose, sodium polyacrylate, pilocarpine.

Salivary Gland Hypofunction and/or Xerostomia Induced by Nonsurgical Cancer Therapies: ISOO/MASCC/ASCO Guideline

PURPOSE

To provide evidence-based recommendations for prevention and management of salivary gland hypofunction and xerostomia induced by nonsurgical cancer therapies.

METHODS

Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library were searched for randomized controlled trials published between January 2009 and June 2020. The guideline also incorporated two previous systematic reviews conducted by MASCC/ISOO, which included studies published from 1990 through 2008.

RESULTS

A total of 58 publications were identified: 46 addressed preventive interventions and 12 addressed therapeutic interventions. A majority of the evidence focused on the setting of radiation therapy for head and neck cancer. For the prevention of salivary gland hypofunction and/or xerostomia in patients with head and neck cancer, there is high-quality evidence for tissue-sparing radiation modalities. Evidence is weaker or insufficient for other interventions. For the management of salivary gland hypofunction and/or xerostomia, intermediate-quality evidence supports the use of topical mucosal lubricants, saliva substitutes, and agents that stimulate the salivary reflex.

RECOMMENDATIONS

For patients who receive radiation therapy for head and neck cancer, tissue-sparing radiation modalities should be used when possible to reduce the risk of salivary gland hypofunction and xerostomia. Other risk-reducing interventions that may be offered during radiation therapy for head and neck cancer include bethanechol and acupuncture. For patients who develop salivary gland hypofunction and/or xerostomia, interventions include topical mucosal lubricants, saliva substitutes, and sugar-free lozenges or chewing gum. For patients with head and neck cancer, oral pilocarpine and oral cevimeline, acupuncture, or transcutaneous electrostimulation may be offered after radiation therapy.Additional information can be found at www.asco.org/supportive-care-guidelines.

A Randomized, Double-Blind, Placebo-Controlled, Cross-Over Study to Evaluate the Efficacy of AqualiefTM Mucoadhesive Tablets in Head and Neck Cancer Patients Who Developed Radiation-Induced Xerostomia

Xerostomia, the subjective complaint of dry mouth, is caused by therapeutic interventions or diseases. Nowadays, radiotherapy (RT) in patients with head and neck cancer (HNC) stands out as one of the most important causes of xerostomia. Currently available therapies for the treatment of xerostomia are still less than optimal and xerostomia still represents an unmet clinical need. In this article, we present the results of a prospective clinical study with a new product, Aqualief^TM, in patients treated with curative RT with or without chemotherapy for HNC. Aqualief^TM is based on two main ingredients, carnosine and karkadé, which have acid buffering and antioxidant properties. The study was performed on 30 patients, with 4 of the patients being lost during the study period. Each patient received randomly one of the two treatments, Aqualief^TM or placebo, for 8 days. After a 10-day wash-out period, each patient received the other treatment for a further 8 days. The results show that Aqualief^TM stimulated salivation in these patients and reduced the pH drop that was observed in an equivalent placebo-treated population of patients. Moreover, no serious, treatment-related adverse events were observed. Aqualief^TM has shown positive results, although with limitations due to unsuccessful trial accrual. Therefore, it may be further investigated as a tool for the treatment of RT-related xerostomia.

Could the use of saliva substitutes improve food oral processing in individuals with xerostomia? A systematic review

Xersotomia is associated with food avoidance and low nutritional assessment. This review seeks to document whether products called "saliva substitutes" or "artificial saliva" can really replace saliva in food oral processing. Pubmed and Science Direct were searched for articles using the keywords "saliva substitutes" and "artificial saliva." An advanced search was applied using the terms "xerostomia" and/or "food oral processing" and/or "eating" and/or "mastication" and/or "chewing" and/or "swallowing." The analysis methods and the inclusion criteria were documented in a protocol published in the International prospective register of systematic reviews (PROSPERO with the registration number CRD42019124585). The search included 43 articles, published between 1979 and 2017. Among the included studies, 17 were observational studies, 5 were pilot studies, 21 were crossover studies, and 14 of these studies were blinded. The Strobe score for the included articles varied from 7.5 to 20. The possible effects of the use of saliva substitutes on the ingestion function were poorly investigated. No evidence was based on physiological studies. It is unknown whether using a saliva substitute has an effect on the composition and rheological properties of the food bolus, on the lubrication of the oral and laryngeal mucosa or on both phenomena. Moreover, saliva substitutes were not formulated to improve food oral processing and most of them are flavored. New saliva substitutes and artificial saliva should be designed and formulated to improve food oral processing.

Radiation therapy in head and neck cancer

This review summarizes the beginning of radiotherapy, techniques of modern radiation therapy with different types, toxicities induced by radiotherapy and their management. Head and neck radiation therapy is still improving for the better management and control of the cancer and induced radiotherapy toxicities.

Photoinactivation of Staphylococci with 405 nm Light in a Trachea Model with Saliva Substitute at 37 °C

The globally observed rise in bacterial resistance against antibiotics has increased the need for alternatives to antibiotic treatments. The most prominent and important pathogen bacteria are the ESKAPE pathogens, which include among others Staphylococcus aureus, Klebsiella pneumoniae and Acinetobacter baumannii. These species cause ventilator-associated pneumonia (VAP), which accounts for 24% of all nosocomial infections. In this study we tested the efficacy of photoinactivation with 405 nm violet light under conditions comparable to an intubated patient with artificial saliva for bacterial suspension at 37 °C. A technical trachea model was developed to investigate the visible light photoinactivation of Staphylococcus carnosus as a non-pathogen surrogate of the ESKAPE pathogen S. aureus (MRSA). The violet light was coupled into the tube with a fiber optic setup. The performed tests proved, that photoinactivation at 37 °C is more effective with a reduction of almost 3 log levels (99.8%) compared to 25 °C with a reduction of 1.2 log levels. The substitution of phosphate buffered saline (PBS) by artificial saliva solution slightly increased the efficiency during the experimental course. The increased efficiency might be caused by a less favorable environment for bacteria due to for example the ionic composition.

Investigation of Changes in Saliva in Radiotherapy-Induced Head Neck Cancer Patients

The intact function of the salivary glands is of utmost importance for oral health. During radiotherapy in patients with head and neck tumors, the salivary glands can be damaged, causing the composition of saliva to change. This leads to xerostomia, which is a primary contributor to oral mucositis. Medications used for protective or palliative treatment often show poor efficacy as radiation-induced changes in the physico-chemical properties of saliva are not well understood. To improve treatment options, this study aimed to carefully examine unstimulated whole saliva of patients receiving radiation therapy and compare it with healthy unstimulated whole saliva. To this end, the pH, osmolality, electrical conductivity, buffer capacity, the whole protein and mucin concentrations, and the viscoelastic and adhesive properties were investigated. Moreover, hyaluronic acid was examined as a potential candidate for a saliva replacement fluid. The results showed that the pH of radiation-induced saliva shifted from neutral to acidic, the osmolality increased and the viscoelastic properties changed due to a disruption of the mucin network and a change in water secretion from the salivary glands. By adopting an aqueous 0.25% hyaluronic acid formulation regarding the lost properties, similar adhesion characteristics as in healthy, unstimulated saliva could be achieved.

Saliva substitute mouthwash in nasopharyngeal cancer survivors with xerostomia: a randomized controlled trial

Objectives

Xerostomia is a prevalent sequelae among nasopharyngeal cancer (NPC) survivors; yet, effective treatment protocols have been elusive. This study was a prospective randomized clinical trial to compare the effects of saliva substitute mouthwash in nasopharyngeal cancer survivors with xerostomia, between two treatment arms, conducted in a tertiary center.

Materials and methods

This study measured the effects within 4 weeks in relation to summated xerostomia inventory (SXI) and unstimulated whole saliva (UWS). Patients randomized into the interventional arm were prescribed an immunologically active saliva substitute (IASS), while patients in the control arm were prescribed a non-immunologically active mouthwash as placebo.

Results

The study population consisted of 94 patients. There was a significant difference in SXI difference (p < 0.0001) and UWS difference (p < 0.0001) between control and interventional arms. No harmful side effects associated with the use of either mouthwash encountered throughout the study duration.

Conclusion

IASS mouthwash significantly reduces subjective xerostomia scores measured using SXI and improves objective measurement of salivary flow using UWS among nasopharyngeal cancer survivors with xerostomia.

Clinical relevance

IASS is significantly more effective in improving subjective and objective xerostomia measurements compared to non-immunologically active mouthwash. Additionally, this treatment is very safe, with superior side effect profiles.

Trial registration

ClinicalTrials.gov Identifier: NCT04491435

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.

Taste and smell disturbances in cancer patients: a scoping review of available treatments

PURPOSE

Taste and smell disturbances in patients affected by cancer are very common, but often under-recognized symptoms. If not addressed properly, they may impact nutritional status, food enjoyment, and quality of life. Treatment tools available for clinicians to manage chemosensory alterations are limited and are often based on personal clinical experiences. The aim of this study was to assess current oncological and palliative care literature through a scoping review, in order to identify available treatments for taste and smell alterations in cancer patients.

METHODS

Medline, Embase, CINAHL, ProQuest Dissertations and Theses, and Google Scholar were searched from inception until January 2020, with subject headings relevant to the domains of chemosensory alterations, palliative, and cancer care. A total of 10,718 English and French language publications were reviewed, yielding 43 articles on the researched topic.

RESULTS

The heterogeneity of selected articles led to difficulties in interpretation and analysis of the available evidence. Included publications differed in study design, population sample, anticancer treatments, and measures of assessment for taste and smell disturbances. A broad variety of treatment options were described including zinc and polaprezinc, radio-protectors, vitamins and supplements, anti-xerostomia agents, active swallowing exercises, nutritional interventions, delta-9-tetrahydrocannabinol, and photobiomodulation.

CONCLUSION

This scoping review identifies the current state of knowledge regarding chemosensory alterations within supportive cancer care. Despite not reaching firm conclusions, this article offers therapeutic venues to further explore in larger and more methodologically sound studies.

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.

Artificial Saliva in Diabetic Xerostomia (ASDIX): Double Blind Trial of Aldiamed® Versus Placebo

Xerostomia is a symptom frequently present in patients with type 1 (T1DM) and type 2 diabetes mellitus (T2DM). In the present trial, the activity of an artificial saliva (aldiamed^® spray) in comparison to a placebo spray were used to evaluate the xerostomia and the saliva antioxidant capacity (SAT). Sixty patients of both genders with T1DM or T2DM were randomized into two groups of 30 subjects each. The experiment was a double-blind study approved by the Ethics Committee of the “G. d’Annunzio University” of Chieti and Pescara. Moreover, measurements of the stimulated saliva flow rate and the ultrasonography of the submandibular and parotid glands were performed at both the study time points. The results demonstrated statistically significant differences between the treatments in terms of the xerostomia average score. Specifically, the values were at baseline and after 30 days 2.9 ± 1.31 and 3.0 ± 1.44 and 1.4 ± 1.48 and 2.4 ± 0.99 for aldiamed^® spray and the placebo, respectively. Meanwhile, no statistically significant differences were shown between the two groups for the other variables, such as the salivary flow rate, the antioxidant capacity of the saliva, and the ultrasonography of the major salivary glands.

Acupuncture for Radiation-Induced Xerostomia in Cancer Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Radiation-induced xerostomia is one of the most common symptoms experienced by cancer patients. The aim of our study is to evaluate the preventive and therapeutic effect of acupuncture for radiation-induced xerostomia in cancer patients.

METHODS

Eight databases were searched for all published randomized clinical trials (RCTs) on acupuncture for radiation-induced xerostomia in cancer patients up to December 31, 2019. Manual searching included other conference abstracts and reference lists. Meta-analysis was conducted using Revman V.5.3, and risks of bias for included studies was assessed following the Cochrane Handbook.

RESULTS

Eight clinical trials (725 participants) were analyzed, and 3 were included in a meta-analysis. All included trials had a high risk of bias, such as selection, performance, and detection bias. Analysis indicated favorable effects of acupuncture regarding the improvement of xerostomia symptoms (MD -3.05, P = 0.02, 95% CI -5.58 to -0.52), compared with sham acupuncture. There were no significant differences between real acupuncture and sham acupuncture regarding the stimulated salivary flow rate (MD 0.37, P = 0.08, 95% CI -0.05 to 0.79) and unstimulated salivary flow rate (MD 0.09, P = 0.12, 95% CI -0.02 to 0.21), which were whole salivary flow rate. Compared with no acupuncture (standard oral care, usual care, or no treatment), acupuncture produced a significant improvement in patient-reported xerostomia, without causing serious adverse effects. However, a Grading of Recommended Assessments analysis revealed that the quality of all acupuncture outcome measures was low.

CONCLUSION

The present meta-analysis and systematic review suggests that acupuncture is effective at improving xerostomia symptoms in cancer patients but not at objective salivary flow measurements. The evidence is still limited due to the low quality of the published studies.

Acupuncture for patients with cancer-induced xerostomia: a systematic review protocol

INTRODUCTION

Xerostomia is a common symptom in patients with cancer. Currently available methods to manage xerostomia include stringent oral hygiene using fluoride agents and antimicrobials, saliva substitutes and sialagogic agents, but side effects such as headache, dizziness and sweating can occur with these therapies. Clinical trials have shown that acupuncture may be effective in treating xerostomia. The objective of this systematic review is to assess the effectiveness and safety of acupuncture treatment for xerostomia caused by cancer.

METHODS AND ANALYSIS

This systematic review will incorporate articles identified by electronically searching the following databases: PubMed, MEDLINE, the Cochrane Library, AMED, EMbase, WorldSciNet, Nature, Science Online, China National Knowledge Infrastructure, the Chongqing VIP Chinese Science and Technology Periodical Database, the Wanfang Database and China Biology Medicine Disc from inception to 1 December 2019. Other sources including conference proceedings and reference lists of identified publications and existing systematic reviews will also be searched. Two reviewers will independently search the databases, perform data extraction and assess the quality of studies. Data will be synthesised using either a fixed-effects model or a random-effects model, according to heterogeneity testing. Patient-reported change in the Visual Analogue Scale or the Xerostomia Inventory will be assessed as the primary outcome. Saliva collection, whole saliva production and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 will be evaluated as secondary outcomes. RevMan V. 5.3 will be employed for data analysis. The results will be expressed as risk ratios for dichotomous data and mean differences for continuous data.

ETHICS AND DISSEMINATION

This protocol will not evaluate individual patient information or affect patient rights and therefore does not require ethical approval. Results from this review will be disseminated through peer-reviewed journals and conference reports.

TRIAL REGISTRATION NUMBER

CRD42019129069.

Xerostomia: prevention with Pycnogenol® supplementation: a pilot study

BACKGROUND

The aim of this pilot study was the evaluation of primary, idiopathic mucosal dryness (xerostomia or dry mouth) in subjects without cancer.

METHODS

A group of non-diabetic subjects and a group of diabetics were managed with standard management (SM) or with SM+Pycnogenol® (150 mg/day) for 2 weeks.

RESULTS

In total, 48 subjects were included in the study; 24 diabetics and 24 non-diabetics. 12 diabetics and 12 non-diabetics took Pycnogenol® and 12 diabetics and 12 non-diabetics were followed up with standard management only and served as controls. No side effects and no tolerability problems were observed with Pycnogenol®. The registry groups were comparable for characteristics and symptoms at baseline. All otherwise healthy subjects had a BMI<26 kg/m2. In 2 weeks, salivary flow and oxidative stress improved significantly in both groups of subjects (non-diabetics and diabetics) with 150 mg/day Pycnogenol® (P<0.05), while minimal improvements in salivary flow were seen with SM. The subjective score and the number of mucosal breaks and ulcerations, all minimal (<1 mm in length or diameter), were significantly decreased with Pycnogenol® supplementation (P<0.05) with minimal variations in the SM controls. Finally, the mean lysozyme level in parotid saliva samples was significantly increased in the Pycnogenol® group (P<0.05) both in diabetics and non-diabetics.

CONCLUSIONS

Based on these preliminary results, Pycnogenol® could be a new, valid option for the treatment of xerostomia.

Comprehensive investigation of saliva replacement liquids for the treatment of xerostomia

The sensation of dry mouth also referred to as xerostomia is becoming increasingly common worldwide. Current treatment strategies include topical agents, sialagogues and saliva substitutes. The latter have been reported to be ineffective as special physicochemical features of natural saliva have so far been ignored (e.g., buffer capacity, osmolality, etc.). The aim of this study was to comprehensively investigate the most relevant physicochemical properties of three products frequently used in the clinics and compare them to unstimulated whole saliva (UWS). Sialin-Sigma®, Glandomed® and Xylitol CVS Health^TM Dry Mouth Spray were characterized regarding their pH, osmolality, electrical conductivity, buffer capacity, rheological behaviour, microstructure, surface tension and wettability and compared to UWS. The influence of residual saliva was examined under consideration of the conditions of xerostomia to assess whether the quantity given in the instruction for use is appropriate. All three products showed significant differences to UWS regarding the values received. Only Xylitol CVS Health^TM Dry Mouth Spray showed a comparable wettability. It could be further determined that the recommended doses were too low. These data can not only be used for an improved understanding of saliva, but also for the development of a replacement fluid to successfully alleviate xerostomia.

Sialadenitis May Be Associated With an Increased Risk for Osteoradionecrosis: A Nationwide Population-Based Cohort Study

PURPOSE

The impact of sialadenitis on osteoradionecrosis (ORN) is controversial. The aim of this study was to determine the association between sialadenitis and ORN.

MATERIALS AND METHODS

Participants were derived from the Taiwanese Longitudinal Health Insurance Database. From January 1, 2000 to December 31, 2008, cases of sialadenitis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 527.2, 527.3, 527.5 to 527.7, 527.9, and 710.2) and ORN (ICD-9-CM codes 526.89, 526.5, 730.0, and 730.1) were identified. Different treatment modalities, including surgery versus medicine, were used to distinguish the severity of sialadenitis. The primary predictor variable was sialadenitis. The secondary predictor variable was severity of sialadenitis. The primary outcome variable was time to developing ORN. Other study variables were grouped for age, gender, risk factor, and medical treatment. Cox proportional hazard regression was used to investigate the associations between sialadenitis and ORN after adjusting for statistical confounders.

RESULTS

The sample was composed of 47,385 patients with a mean age of 46.6 years (standard deviation, 19.9 yr) and 37.2% were men. Twenty percent had a diagnosis of sialadenitis and 1.13% had a diagnosis of ORN. Sialadenitis was associated with an increased risk of ORN (hazard ratio [HR] = 1.93; 95% confidence interval [CI], 1.61-2.31; P < .0001). After adjustment for confounders, sialadenitis was associated with ORN (multivariable HR = 1.83; 95% CI, 1.52-2.19; P < .0001). Severity of sialadenitis was associated with an increased risk of ORN; risks for ORN were 1.79 (95% CI, 1.49-2.16; P < .0001) and 3.52 (95% CI, 1.67-7.44; P < .001) in patients with mild and serious sialadenitis, respectively, compared with the no-sialadenitis cohort. For the joint effect of ORN between sialadenitis and malignancy type, patients with sialadenitis had 11.6-fold risk for ORN (95% CI, 5.58-23.9) compared with patients without malignancy.

CONCLUSIONS

Sialadenitis markedly increased the risk to develop ORN. The severity of sialadenitis was positively correlated with the incidence of ORN.

Extensional and shear rheology of okra polysaccharides in the presence of artificial saliva

Extensional and shear viscosities were studied for mixtures comprising artificial saliva and okra mucilage, the latter acting as a model thick-liquid food. These experiments aimed to obtain information on the flow-behavior information of the systems, underpinning the texture sensation of foods as perceived by dysphagic and xerostomic populations. Mixing okra mucilage with artificial saliva dramatically increases the shear viscosity of artificial saliva throughout the studied ranges of concentrations and deformation rates. Particle tracking does not suggest direct interactions between the components of artificial saliva and of okra mucilage. The rheology of the okra polymer (OP)–artificial saliva (AS) mixture is dominated by its extensional viscosity: Trouton ratios are in the order of tens to hundreds, while they decrease with increasing okra-mucilage concentration; this highlighs the dominance of the extensional rheology and the increasing importance of the shear mechanics with increasing okra content. The relaxation times and extensional moduli are also reported for the systems under study. Extensional and shear flows are of equal importance concerning the elastic behavior.

Artificial saliva is usually formulated to help people with dysphagia or xerostomia. Their mouth feels of food textures are largely dependent on the flow behaviors of the food–artificial saliva mixtures. Christos Ritzoulis and coworkers from Zhejiang Gongshang University now studied the rheological and structural properties of artificial saliva when mixed with okra mucilage. They found the shear viscosity and storage modulus of the artificial saliva were much higher in the presence of okra polysaccharide, suggesting the formation of a macromolecular-interacting network. Moreover, it was found the overall rheological behaviors of the mixtures were always dominated by the extensional viscosity, though the shear behavior became more and more obvious with the increasing amount of okra polymer. Together with the data obtained with real saliva, these on artificial saliva could guide the future formulation of artificial saliva.

Wettability of 3 different artificial saliva substitutes on heat-polymerized acrylic resin

STATEMENT OF PROBLEM

The prosthodontic problems faced by a patient with xerostomia are of great concern. To aid in retention, artificial saliva substitutes should exhibit good wettability on the denture base.

PURPOSE

The purpose of this in vitro study was to evaluate the wettability of 3 different artificial saliva substitutes on heat-polymerized acrylic resin and to compare these properties with natural saliva and distilled water.

MATERIAL AND METHODS

A total of 150 heat-polymerized acrylic resin specimens were prepared with 25×15×2 mm dimensions. The specimens were divided into 5 groups (n=30): human saliva, distilled water, Aqwet, Mouth Kote, and Stoppers 4. The advancing and receding contact angle values were measured by using a goniometer, and the contact angle hysteresis and equilibrium angle were calculated. One-way ANOVA and the Bonferroni multiple comparisons test were performed to determine the difference between contact angle values among the groups (α=.05).

RESULTS

The means of the 5 groups differed significantly (P<.05). The comparison between human saliva and Aqwet showed no significant difference for advancing contact angle, receding contact angle, contact angle hysteresis, or equilibrium contact angle, while comparison between the remaining groups indicated statistically significant (P<.05) results. All 3 saliva substitutes used in this study (Aqwet, Mouth Kote, and Stoppers 4) had significantly better wetting properties than distilled water.

CONCLUSIONS

Human saliva had the lowest advancing, receding, and equilibrium contact angle values and the highest angle of hysteresis on heat-polymerized acrylic resin. Aqwet had better wetting ability than the other artificial salivary substitutes tested and was comparable to the human saliva on heat-polymerized acrylic resin. All saliva substitutes have better wetting properties than distilled water.

Preliminary Comparative Study of Oral7® Versus Salt-Soda Mouthwash on Oral Health Related Problems and Quality of Life among Head and Neck Cancer Patients Undergoing Radiotherapy

Background

This quasi-clinical trial compared the effects of Oral7^® and salt-soda mouthwash on the development of dental caries, salivary gland function, radiation mucositis, xerostomia and EORTC QLQ H&N C35 scores in head and neck cancer patients who underwent radiotherapy.

Methods

We included patients with histopathologically diagnosed head and neck cancers who had received radiation, with an Eastern Cooperative Oncology Group (ECOG) performance status 0–1 and age range of 15–60 years. Patients with prior radiotherapy and chemotherapy, edentulous status, total parotidectomy, sicca syndrome or on xerosis-induced medications were excluded. We assigned 15 patients each to the Oral7^® and salt-soda groups.

Results

There was no significant difference in the mean Decayed, Missing and Filling Teeth (DMFT) score between groups. Head and neck cancer patients who were on Oral7^® had a significantly better quality of life than those on salt-soda in relation to the swallowing problems, social eating, mouth opening, xerostomia and illness scales. Patients who were on Oral7^® had a significantly lower xerostomia score than patients on salt-soda mouthwash. Patients on Oral7^® had a significantly lower mucositis score in week 5–7 compared to patients in the salt-soda group.

Conclusion

Oral7^® showed advantages over salt-soda solution in relation to reducing xerostomia, easing radiation-induced mucositis, and improving quality of life, despite the non-significant difference in the dental caries assessment.

Effect of NaF, AmF, KF gels and NaF toothpaste combined with a saliva substitute on dentin lesions in vitro

OBJECTIVE

The aim of the present in vitro study was to evaluate the remineralizing effects of NaF, AmF, KF gels and NaF toothpaste in combination with a potentially demineralizing saliva substitute (Glandosane; pH = 5.1) being widely used in Germany.

METHODS

In each of 120 dentin specimens, three artificial lesions were created. One lesion was covered for analysis of pre-demineralization (ΔZ_B). Treatments during pH cycling (3 × 1 h demineralization/day [pH = 5.0] and 3 × 3 h Glandosane/day; 12 h 100%humidity) were as follows: no treatment (NT), application (5 min,2×/day) of 12.500 ppm F^- [pH = 6.04] (NaF-gel₁), 12.500 ppm F^- [pH = 7.34] (NaF-gel₂), 12.500 ppm F^- [pH = 5.82] (AmF-gel), 1450 ppm F^- [pH = 7.35] (KF-gel), and 5000 ppm F^- [pH = 8.14]; (NaF-TP) for 7 days (E1). Subsequently, from each specimen, one lesion was covered, while the remaining lesion was cycled for another 7 days (E2). Differences in integrated mineral loss (ΔΔZ_E1/ΔΔZ_E2) were calculated between values before and after pH cycling.

RESULTS

Mean (95%CI) ΔZ_B was 3851 (3762;3939) vol% × μm. Except for NaF-gel₂ and NaF-TP, specimens of all other groups further demineralized. Only NaF-gel₂ induced a significant gain in mineral content (p ≤ 0.004; paired t test). Significant differences in the change of mineral loss were found between NT and all fluoride groups for both ΔΔZ_E1 and for ΔΔZ_E2 (p < 0.05, Bonferroni post hoc test). However, only NaF-gel₂ and NaF-TP induced remineralization.

CONCLUSION

Under the in vitro conditions chosen, all fluoride agents could significantly hamper the adverse effects of a demineralizing saliva substitute.

CLINICAL SIGNIFICANCE

In combination with a demineralizing saliva substitute, slight mineral gain was only observed for neutral NaF-gel₂ and 5000 ppm F^- toothpaste.

Effects of molecular weight of hyaluronic acid on its viscosity and enzymatic activities of lysozyme and peroxidase

OBJECTIVES

To investigate the effects of the molecular weight of hyaluronic acid on its viscosity and enzymatic activities of lysozyme and peroxidase in solution and on the hydroxyapatite surface.

DESIGN

Hyaluronic acids of four different molecular weights (10 kDa, 100 kDa, 1 MDa, and 2 MDa), hen egg-white lysozyme, bovine lactoperoxidase, and human whole saliva were used. Viscosity values of hyaluronic acids were measured using a cone-and-plate viscometer at six different concentrations (0.1-5.0 mg/mL). Enzymatic activities of lysozyme and peroxidase were examined by hydrolysis of fluorescein-labeled Micrococcus lysodeikticus and oxidation of fluorogenic 2',7'-dichlorofluorescein to fluorescing 2',7'-dichlorofluorescein, respectively.

RESULTS

In solution assays, only 2 MDa-hyaluronic acid significantly inhibited lysozyme activities in saliva. In surface assays, hyaluronic acids inhibited lysozyme and peroxidase activities; the inhibitory activities were more apparent with high-molecular-weight ones in saliva than in purified enzymes. The 100 kDa-hyaluronic acid at 5.0 mg/mL, 1 MDa-one at 0.5 mg/mL, and 2 MDa-one at 0.2 mg/mL showed viscosity values similar to those of human whole saliva at a shear rate range required for normal oral functions. The differences among the influences of the three conditions on the enzymatic activities were not statistically significant.

CONCLUSIONS

High-molecular-weight hyaluronic acids at low concentration and low-molecular-weight ones at high concentration showed viscosity values similar to those of human whole saliva. Inhibitory effects of hyaluronic acids on lysozyme and peroxidase activities were more significant with high-molecular-weight ones on the surface and in saliva compared with in solution and on purified enzymes.

A Pilot Study of Perceived Mouth Dryness, Perceived Swallowing Effort, and Saliva Substitute Effects in Healthy Adults Across the Age Range

Xerostomia, or perceived mouth dryness, increases with advancing age, but its influence on swallowing effort is unknown. This study: (1) quantified relationships among age, perceived sense of swallowing effort, and ratings of perceived mouth dryness, and (2) examined changes in swallowing effort following application of a gel-based saliva substitute in healthy participants. This was a cross-sectional observational study and data were collected from attendees of a community healthy aging fair. Forty-two healthy participants (mean age = 65 years; 20 female) were enrolled. Each participant rated perceived effort with swallowing and perceived mouth dryness on a 10-cm horizontal, undifferentiated line. After participants applied a gel-based saliva substitute (Biotene^® Oral Balance) to their tongue and oral mucosa, they rated perceived effort with swallowing again. Age was associated with greater perceived mouth dryness (r = 0.37, p < 0.03) but not with perceived swallowing effort (r = 0.16, p = 0.32). Perceived mouth dryness was associated with greater perceived swallowing effort (r = 0.62, p < 0.001). Perceived swallowing effort declined following application of the salivary substitute (mean difference = 9.39 mm, p < 0.002). Age was found to be a significant predictor of perceived mouth dryness (p < .02); and perceived mouth dryness was found to significantly predict perceived swallow effort (p < .001). Perceived mouth dryness increased with advancing age, but perceived swallowing effort did not. Regardless of age, participants with higher levels of perceived mouth dryness also reported more perceived effort with swallowing suggesting a role for adequate oral lubrication in this perception. Even in healthy participants, use of a gel-based saliva substitute lowered perceived swallowing effort.

Treatment of late sequelae after radiotherapy for head and neck cancer

Radiotherapy (RT) is used to treat approximately 80% of patients with cancer of the head and neck. Despite enormous advances in RT planning and delivery, a significant number of patients will experience radiation-associated toxicities, especially those treated with concurrent systemic agents. Many effective management options are available for acute RT-associated toxicities, but treatment options are much more limited and of variable benefit among patients who develop late sequelae after RT. The adverse impact of developing late tissue damage in irradiated patients may range from bothersome symptoms that negatively affect their quality of life to severe life-threatening complications. In the region of the head and neck, among the most problematic late effects are impaired function of the salivary glands and swallowing apparatus. Other tissues and structures in the region may be at risk, depending mainly on the location of the irradiated tumor relative to the mandible and hearing apparatus. Here, we review the available evidence on the use of different therapeutic strategies to alleviate common late sequelae of RT in head and neck cancer patients, with a focus on the critical assessment of the treatment options for xerostomia, dysphagia, mandibular osteoradionecrosis, trismus, and hearing loss.

Facilitated saliva secretion and reduced oral inflammation by a novel artificial saliva system in the treatment of salivary hypofunction

Saliva substitutes and/or lubricants are commonly employed to lessen dry mouth symptoms by stimulating and/or substituting for the secretion of saliva. In this study, a novel artificial saliva containing inorganic salts, including sodium chloride and potassium chloride, and bactericidal agents, including potassium thiocyanate and lactoperoxidase, was formulated in the form of a solution (DM-sol) or gel (DM-gel). Those in vivo therapeutic efficacies were assessed in terms of saliva secretion and anti-inflammatory activity in rats and mice, respectively. Salivary secretion was promoted by mucosal application of DM-formulations in normal rats. In particular, DM-gel resulted in 2.5- and 1.9-fold greater salivary flow rates compared to normal saline and DM-sol, respectively. In an in vivo efficacy evaluation in diabetic mice with salivary hypofunction, repeated application of DM-formulations alleviated histopathological changes in the buccal mucosa in terms of atrophy and thinning of the epithelium, compared to vehicle, after 4 weeks. Moreover, the DM-sol and DM-gel were comparably effective for relieving periodontal gingivitis, reducing infiltration of inflammatory cells, and normalizing the neutrophil level in the gingival gingiva, after 4 weeks. Therefore, the novel artificial saliva is expected to facilitate salivary secretion and restore physiological conditions in the mouth of patients with salivary hypofunction.

Interventions for the management of radiotherapy-induced xerostomia and hyposalivation: A systematic review and meta-analysis

INTRODUCTION

Salivary gland hypofunction is a common and permanent adverse effect of radiotherapy to the head and neck. Randomised trials of available treatment modalities have produced unclear results and offer little reliable guidance for clinicians to inform evidence-based therapy. We have undertaken this systematic review and meta-analysis to estimate the effectiveness of available interventions for radiotherapy-induced xerostomia and hyposalivation.

METHODS

We searched MEDLINE, Cochrane Central, EMBASE, AMED, and CINAHL database through July 2016 for randomised controlled trials comparing any topical or systemic intervention to active and/or non-active controls for the treatment of radiotherapy-induced xerostomia. The results of clinically and statistically homogenous studies were pooled and meta-analyzed.

RESULTS

1732 patients from twenty studies were included in the systematic review. Interventions included systemic or topical pilocarpine, systemic cevimeline, saliva substitutes/mouthcare systems, hyperthermic humidification, acupuncture, acupuncture-like transcutaneous electrical nerve stimulation, low-level laser therapy and herbal medicine. Results from the meta-analysis, which included six studies, suggest that both cevimeline and pilocarpine can reduce xerostomia symptoms and increase salivary flow compared to placebo, although some aspects of the relevant effect size, duration of the benefit, and clinical meaningfulness remain unclear. With regard to interventions not included in the meta-analysis, we found no evidence, or very weak evidence, that they can reduce xerostomia symptoms or increase salivary flow in this population.

CONCLUSIONS

Pilocarpine and cevimeline should represent the first line of therapy in head and neck cancer survivors with radiotherapy-induced xerostomia and hyposalivation. The use of other treatment modalities cannot be supported on the basis of current evidence.

Using mid infrared technology as new method for the determination of the dwell time of salivary substitutes on three dimensional gingiva models

Background

Many people suffer from dry mouth (xerostomia) due to radiotherapy treatment of head and neck cancer, diseases like Sjogren’s syndrome or as adverse effects to prescribed medications. Salivary substitute products like gels or sprays are often used for treatment. Efficacy of those oral care products are regularly assessed by validated or even not validated questionnaires. To determine the adhesion effect over time more objectively a new and sensitive method was established. The following study was designed to assess the dwell time of different oral care products in vitro.

Method

Two different types of surfaces were covered with oral care products and washed using a definite protocol with artificial saliva salt solution. First, oral care gels or oral care sprays were spread to a polystyrene surface of 2.25 cm², then onto cell based three-dimensional gingiva models. The surfaces were washed ten times with artificial saliva salt solution. The resulting washing solutions were examined using mid infrared spectroscopy in order to detect ingredients of the oral care products.

Results

All assessed oral care gels or oral care sprays and their components were detected very sensitive. Even traces of the products were detected in the eluent and thus enabled to differentiate the dwell times of the different products. In general, the dwell time of oral care gels on polystyrene or gingiva models was longer than that of oral care sprays. The use of gingiva models improved the differentiation between different products.

Conclusions

MIR spectroscopy turned out to be a sensitive method to detect salivary substitutes. Differences between single components and different products can be detected. The described method is a simple, reliable and easy process to evaluate the dwell time of oral care products in vitro and thus a useful tool to design optimised salivary substitute products.

Ethics

This is an in vitro study. No ethics or consent was required for this study.

Oral toxicity management in head and neck cancer patients treated with chemotherapy and radiation: Xerostomia and trismus (Part 2). Literature review and consensus statement

Radiotherapy alone or in combination with chemotherapy and/or surgery is a well-known radical treatment for head and neck cancer patients. Nevertheless acute side effects (such as moist desquamation, skin erythema, loss of taste, mucositis etc.) and in particular late toxicities (osteoradionecrosis, xerostomia, trismus, radiation caries etc.) are often debilitating and underestimated. A multidisciplinary group of head and neck cancer specialists from Italy met in Milan with the aim of reaching a consensus on a clinical definition and management of these toxicities. The Delphi Appropriateness method was used for this consensus and external experts evaluated the conclusions. The paper contains 20 clusters of statements about the clinical definition and management of stomatological issues that reached consensus, and offers a review of the literature about these topics. The review was split into two parts: the first part dealt with dental pathologies and osteo-radionecrosis (10 clusters of statements), whereas this second part deals with trismus and xerostomia (10 clusters of statements).

Xerostomia induced by radiotherapy: an overview of the physiopathology, clinical evidence, and management of the oral damage

BACKGROUND

The irradiation of head and neck cancer (HNC) often causes damage to the salivary glands. The resulting salivary gland hypofunction and xerostomia seriously reduce the patient's quality of life.

PURPOSE

To analyze the literature of actual management strategies for radiation-induced hypofunction and xerostomia in HNC patients.

METHODS

MEDLINE/PubMed and the Cochrane Library databases were electronically evaluated for articles published from January 1, 1970, to June 30, 2013. Two reviewers independently screened and included papers according to the predefined selection criteria.

RESULTS

Sixty-one articles met the inclusion criteria. The systematic review of the literature suggests that the most suitable methods for managing the clinical and pathophysiological consequences of HNC radiotherapy might be the pharmacological approach, for example, through the use of cholinergic agonists when residual secretory capacity is still present, and the use of salivary substitutes. In addition, a modified diet and the patient's motivation to enhance oral hygiene can lead to a significant improvement.

CONCLUSION

Radiation-induced xerostomia could be considered a multifactorial disease. It could depend on the type of cancer treatment and the cumulative radiation dose to the gland tissue. A preventive approach and the correct treatment of the particular radiotherapeutic patient can help to improve the condition of xerostomia.

Xerostomia due to systemic disease: a review of 20 conditions and mechanisms

Xerostomia is a common complaint of nearly half of the elderly population and about one-fifth of younger adults. It causes several signs and symptoms, and compromise oral functions and health-related quality-of-life. Multiple reasons are proposed to describe the etiology of xerostomia such as local factors, psychogenic factors, and systemic diseases. In order to manage xerostomia effectively, identification of the main causality is mandatory. The aim of this review was to present systemic diseases leading to xerostomia with their mechanisms of action. We used various general search engines and specialized databases such as Google, Google Scholar, Yahoo, PubMed, PubMed Central, MedLine Plus, Medknow, EBSCO, ScienceDirect, Scopus, WebMD, EMBASE, and authorized textbooks to find relevant topics by means of Medical Subject Headings keywords such as "xerostomia," "hyposalivations," "mouth dryness," "disease," and "systemic." We appraised 97 English-language articles published over the last 40 years in both medical and dental journals including reviews, meta-analysis, original papers, and case reports. Upon compilation of relevant data, it was concluded that autoimmune diseases most frequently involve salivary glands and cause xerostomia followed by diabetes mellitus, renal failure, and graft-versus-host disease. Moreover, the underlying mechanisms of systemic disease-related xerostomia are: autoimmunity, infiltration of immunocompetent cells, granuloma formation, fibrosis and dehydration, deposition of proteinaceous substances, bacterial infection, and side-effects of medications.

Saliva substitutes in combination with high-fluoride gel on dentin remineralization

OBJECTIVE

This study aimed to determine whether the application of a high-fluoride gel could increase the remineralization of subsurface dentin lesions stored in saliva substitutes.

MATERIALS AND METHODS

Demineralized bovine dentin specimens were stored in mineral water (W), Glandosane (G), or modified Saliva natura (SN). Different treatments were applied twice daily: no treatment, Elmex sensitive mouth rinse (E), ProSchmelz gel (P), Duraphat toothpaste (D), ED, PD, and EPD. Differences in mineral loss were evaluated by transversal microradiography after 2 and 5 weeks.

RESULTS

The treatments with E, D, and ED inhibited the mineral loss induced by G and enabled some mineral gain. ProSchmelz was not able to inhibit the demineralizing effect of G. This high-fluoride gel induced an erosive mineral loss in combination with G. The use of ProSchmelz in combination or not with other fluoride products did not increase remineralization of specimens stored in SN or W (p > 0.05). ProSchmelz resulted in an erosion of the specimens stored in W and revealed a lower mineralized surface layer of specimens stored in SN.

CONCLUSION

Topical application of high-fluoride gel reduced the mineral loss induced by G but resulted in an erosion of specimens' surface. In addition, ProSchmelz did not demonstrate beneficial effects in combination with SN on subsurface dentin lesion remineralization.

CLINICAL RELEVANCE

Within the limitations of an in vitro study, it was concluded that the application of a high-fluoride gel did not promote additional effects on remineralization of subsurface dentin lesions in combination with saliva substitutes when compared to products with lower fluoride concentration.

Root caries: a periodontal perspective

BACKGROUND AND OBJECTIVE

A prevailing dental problem in the periodontal patient is root caries. Specifically, periodontal involvement often results in root surfaces becoming exposed and at risk for this condition. Periodontal therapy often leads to increased gingival recession as well, and the associated increased root caries risk may compromise the long-term success and survival of periodontally treated teeth.This narrative review will address the topic of root caries in the periodontal patient, focusing on unmet research needs.

MATERIAL AND METHODS

The Medline database was searched to identify items dealing with root caries, in terms of clinical features, diagnosis, pathogenic mechanisms and histopathology, as well as epidemiology, focusing then on the relationship between root caries and periodontal disorders.

RESULTS

Although there is extensive literature on root caries, consensus is lacking regarding certain aspects, such as diagnostic criteria, prevalence within populations and indisputable risk factors. Advancing age could be an aggravating factor in susceptibility to root caries for the periodontal patient; however, definitive evidence in this regard is still missing. Similarly, full awareness of the increased risk of root caries in patients with periodontal disease or long-term periodontal treatment appears to be still lacking.

CONCLUSION

Research regarding root caries in age-specific (elderly) periodontal patients is needed. Improved oral hygiene practices, locally applied preventive measures, good dietary habits and regular dental check-ups are crucial approaches to prevent both periodontal disease progression and root caries. Periodontal patients with root exposure should follow a strict root caries prevention protocol, as an integral component of their periodontal maintenance therapy.

Drug induced xerostomia in elderly individuals: An institutional study

Introduction:

With better health care facilities and nutritional levels the average life expectancy of Indian population has been on the rise over the years. Most of the geriatric population is under long-term medication.

Aim:

The aim of this study was to evaluate the synergistic effect of multiple xerostomia drugs.

Materials and Methods:

Unstimulated saliva was measured in 60 geriatric patients, and xerostomia questionnaire and quality-of-life scale were also administered.

Results:

There was a very highly significant reduction in the salivary flow rates of patients under multiple xerostomia-inducing drugs.

Conclusion:

The synergistic effect of the xerostomia inducing medication could be the possible factor responsible for reduced salivary flow in elderly individuals using such drugs

The Preventive and Therapeutic Effect of Acupuncture for Radiation-Induced Xerostomia in Patients With Head and Neck Cancer

Background. Methods currently available to prevent and manage xerostomia which caused by radiotherapy in patients with head and neck caner have limited efficacy. Some studies suggest that acupuncture may be beneficial. Objectives. The authors evaluated the preventive and therapeutic effect of acupuncture for radiation-induced xerostomia among patients with head and neck cancer. Methods. PUBMED, EMBASE, Cochrane Library, CBM, CAJD, Wan Fang database, and VIP Database for Chinese Technical Periodicals were electronically searched, in conjunction with further manual search for relevant articles. Studies that met the inclusion criteria were systematically evaluated. Results. Three randomized controlled trials (RCTs) investigating the therapeutic effect of acupuncture were included. One RCT on the preventive effect of acupuncture was found. Because of the considerable variation among included studies, meta-analysis was not possible. Two included RCTs used placebo controls, and both observed significant improvement in the salivary flow rates between acupuncture and control groups. However, no significant differences were found. Three included RCTs suggested that acupuncture for radiation-induced xerostomia can improve patients’ subjective symptoms. The only study evaluating the preventive effect of acupuncture for radiation-induced xerostomia showed positive changes in salivary flow rates (both unstimulated and stimulated) and dry mouth -related symptoms. Acupuncture treatment was well tolerated by all patients and no severe adverse effects were seen. Conclusions. Insufficient evidence is available to judge whether acupuncture is safe and whether it is effective in preventing or treating radiation-induced xerostomia. Significant research remains to be done before acupuncture can be recommended for routine use in radiation-induced xerostomia.

Evaluation of a moisturising micro-gel spray for prevention of cell dryness in oral mucosal cells: an in vitro study and evaluation in a clinical setting

A moisturising micro-gel spray for prevention of dryness was compared with commercial products and artificial saliva in vitro and in a clinical setting in patients with cancer. Survival of cultured human gingival epithelial cells was evaluated after treatment with each product for 15 min. A dry test was performed for products giving a 50% survival rate, in which cell survival was measured after drying of cells treated with each product. The survival rates of cells treated with the micro-gel spray and artificial saliva were significantly higher than those of control cells. The micro-gel spray was then evaluated for 1 week in patients with symptoms of dry mouth caused by cancer treatment. There was significant improvement of these symptoms at night and on awakening and of subjective symptoms of decreased salivary volume (P < 0.05). Mean visual analogue scale scores also significantly decreased (P < 0.01). These data suggest that evaluation of moisturising products for dryness prevention can be performed in cultured cells, since products that performed well in vitro also showed good efficacy for symptoms of dry mouth. The micro-gel spray was particularly effective for relieving symptoms of dry mouth in patients with cancer.

Evaluation of the efficacy of two mouthrinses formulated for the relief of xerostomia of diverse origin in adult subjects

OBJECTIVE

To evaluate the efficacy of two new mouthrinses in the reduction of xerostomía-associated symptomatology.

BACKGROUND

Xerostomia is a common chronic health condition that affects a great number of adults and significantly deteriorates quality of life, such that treatment is necessary.

MATERIALS AND METHODS

Sixty-seven adult subjects of both sexes presenting xerostomia of diverse origin were selected. Mouthrinses were tested using a double-blind, randomized, cross-over clinical trial with an intervining wash out period.

RESULTS

The 100% of subjects presented sensation of dry mouth, and 86% stated sensation of thick saliva. Burning tongue sensation, need to drink liquids to swallow and the sensation of swallowing difficulty were recorded in more than 50% of the patients. The most frequent pathologies in the sample were depression, arthritis, and arterial hypertension. Results of the clinical tests showed that mouthrinse 1 relieves sensation of dry mouth, need to drink liquids, and swallowing difficulty. In contrast, mouthrinse 2 relieves only latter two symptoms. Both rinses were more effective in relieving xerostomía-associated symptomatology in patients taking 3 or more medicines simultaneously.

CONCLUSION

Both mouthrinses were effective in relieving various xerostomia symptoms, could be distributed at a low cost, thereby improving the quality of life of population affected.