Sensory stimulation (acupuncture) increases the release of vasoactive intestinal polypeptide in the saliva of xerostomia sufferers

Acupuncture: An Overview on Its Functions, Meridian Pathways and Molecular Mechanisms

Recent research has extensively explored the intricate mechanisms that underlie the effectiveness of acupuncture, highlighting the importance of stimulating acupoints, the role of acupuncture techniques in managing diseases, and the interaction between meridian pathways and molecular processes. Studies have underscored the crucial role of acupuncture in activating neurons, modulating the immune system, and influencing vascular activity, all of which contribute significantly to its therapeutic benefits across a wide range of symptoms and conditions. Utilization of imaging modalities enables the identification of changes in cerebral blood flow, brain function, and regional glucose metabolism following acupuncture sessions. The interstitial fluid circulation network within meridians adheres to specific laws that facilitate the transportation of materials. Acupuncture initiates the release of neurotransmitters, neuropeptides, and immune factors, impacting pain perception, inflammation, and physiological functions. It influences the complex neuro-endocrine-immune network by activating pathways involving the nervous system, the hypothalamic-pituitary-adrenal axis, and immune responses. Moreover, acupuncture induces molecular modifications such as phosphorylation, methylation, and histone modification, leading to key molecular changes that ultimately result in anti-inflammatory effects and the regulation of immune responses.

Acupuncture for Chronic Radiation-Induced Xerostomia in Head and Neck Cancer: A Multicenter Randomized Clinical Trial

Importance

Patients with head and neck cancer who undergo radiotherapy can develop chronic radiation-induced xerostomia. Prior acupuncture studies were single center and rated as having high risk of bias, making it difficult to know the benefits of acupuncture for treating radiation-induced xerostomia.

Objective

To compare true acupuncture (TA), sham acupuncture (SA), and standard oral hygiene (SOH) for treating radiation-induced xerostomia.

Design, Setting, and Participants

A randomized, blinded, 3-arm, placebo-controlled trial was conducted between July 29, 2013, and June 9, 2021. Data analysis was performed from March 9, 2022, through May 17, 2023. Patients reporting grade 2 or 3 radiation-induced xerostomia 12 months or more postradiotherapy for head and neck cancer were recruited from community-based cancer centers across the US that were part of the Wake Forest National Cancer Institute Community Oncology Research Program Research Base. Participants had received bilateral radiotherapy with no history of xerostomia.

Interventions

Participants received SOH and were randomized to TA, SA, or SOH only. Participants in the TA and SA cohorts were treated 2 times per week for 4 weeks. Those experiencing a minor response received another 4 weeks of treatment.

Main Outcomes and Measures

Patient-reported outcomes for xerostomia (Xerostomia Questionnaire, primary outcome) and quality of life (Functional Assessment of Cancer Therapy-General) were collected at baseline, 4 (primary time point), 8, 12, and 26 weeks. All analyses were intention to treat.

Results

A total of 258 patients (201 men [77.9%]; mean [SD] age, 65.0 [9.16] years), participated from 33 sites across 13 states. Overall, 86 patients were assigned to each study arm. Mean (SD) years from diagnosis was 4.21 (3.74) years, 67.1% (n = 173) had stage IV disease. At week 4, Xerostomia Questionnaire scores revealed significant between-group differences, with lower Xerostomia Questionnaire scores with TA vs SOH (TA: 50.6; SOH: 57.3; difference, -6.67; 95% CI, -11.08 to -2.27; P = .003), and differences between TA and SA (TA: 50.6; SA: 55.0; difference, -4.41; 95% CI, -8.62 to -0.19; P = .04) yet did not reach statistical significance after adjustment for multiple comparisons. There was no significant difference between SA and SOH. Group differences in Functional Assessment of Cancer Therapy-General scores revealed statistically significant group differences at week 4, with higher scores with TA vs SOH (TA: 101.6; SOH: 97.7; difference, 3.91; 95% CI, 1.43-6.38; P = .002) and at week 12, with higher scores with TA vs SA (TA: 102.1; SA: 98.4; difference, 3.64; 95% CI, 1.10-6.18; P = .005) and TA vs SOH (TA: 102.1; SOH: 97.4; difference, 4.61; 95% CI, 1.99-7.23; P = .001).

Conclusions and Relevance

The findings of this trial suggest that TA was more effective in treating chronic radiation-induced xerostomia 1 or more years after the end of radiotherapy than SA or SOH.

Trial Registration

ClinicalTrials.gov Identifier: NCT02589938.

Umbrella review: Summary of findings for acupuncture as treatment for radiation-induced xerostomia

Acupuncture is a common part of complementary medicine. However, traditional Chinese acupuncture has been built on concepts which are not in accordance with science-based medicine. Our aim was to critically assess the evidence presented in systematic reviews (SRs) and meta-analyses (MAs) about the effectiveness of acupuncture on radiotherapy induced xerostomia. A systematic search was conducted in February 2022. We evaluated all SRs/MAs using the AMSTAR-2 instrument. Eight SRs, with 12 controlled studies were included. All SRs summarize that the methodological drawbacks do not allow to give a clear statement about the effectiveness of acupuncture. While objective assessments in most SRs/MAs reported no difference between real and sham acupuncture, some favorable effects on subjective xerostomia symptoms are found. No clinical meaningful effectiveness of acupuncture on xerostomia has been proven so far, but positive subjective findings need to be explored more. While most SRs recommend further studies, studies involving patients with a serious cancer diagnosis are ethically questionable.

Research status and prospects of acupuncture for prevention and treatment of chemo- and radiotherapy-induced salivary gland dysfunction in head and neck cancer

Salivary gland dysfunction (SGD) induced by chemo- and radiotherapy for head and neck cancer (HNC) has always been a difficult problem in modern medicine. The quality of life of a large number of HNC patients is severely impaired by SGD such as xerostomia and dysphagia. In recent years, several studies have found that acupuncture can improve patients' salivary secretion, but it has not yet been approved as an alternative therapy for SGD. For this reason, we collected the clinical study reports on acupuncture in the treatment of SGD induced by chemo- and radiotherapy in HNC patients in the past 20 years, and analyzed and discussed the advantages and disadvantages of these studies with respect to tumor types, group setting, intervention modality, acupoints selection, outcome evaluation, and safety. We believed that acupuncture is beneficial for SGD, but the existing objective evidence is insufficient to support its effectiveness. Therefore, improving the Standards for Reporting Interventions in Clinical Trials of Acupuncture, selecting the optimal combination of acupoints through scientific and rigorous study design, and exploring the potential mechanism of acupuncture in the treatment of diseases combined with the meridian theory may be effective ways to promote the acceptance of acupuncture as an alternative therapy for SGD in future. The significance of this review is to provide a reference for researchers to carry out high-quality clinical trials of acupuncture in the treatment of SGD in future from the perspective of the combination of modern medicine and traditional Chinese medicine.

Veterinary acutherapy in management of musculoskeletal disorders: An eye-opener to the developing countries' veterinarians

Traditional Chinese medicine practitioners believed that the maintenance of the health status of any individual or animal is by the harmonious flow of Chi (life force) along a pathway known as the meridian. Interruption or blockage of Chi brings about disorders, pain, and diseases. Acutherapy, therefore, aims at correcting the interruption or blockage of the harmonious flow of Chi along the meridian to restore the healthy condition of the body system. This correction could be accomplished by either acupuncture or acupressure, and are both collectively referred to as acutherapy. This form of therapy has been used in both humans and animals for several decades. It is, however, just gaining popularity in the treatment of humans and is still not yet in practice among veterinarians for animal patients in most developing countries like Nigeria. This review, therefore, is aimed at exposing veterinarians from the developing countries to the general application of acutherapy with emphasis on the musculoskeletal system and associated pain where it is most applied. It is highly recommended that the universities, where Veterinary Medicine is studied in developing countries, should endeavor to train their veterinary surgeons in this area and see to how acutherapy can be included in the curriculum.

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.

Spotlight on acupuncture in laboratory animal medicine

Acupuncture has been practiced for thousands of years, although it is only in the past century that science has worked to unravel the mechanisms behind its use. Literature supporting the efficacious use of acupuncture to treat a variety of conditions has been and continues to be published, including the randomized controlled studies we all appreciate when practicing evidence-based medicine. The use of acupuncture in veterinary medicine has paralleled the trends observed in people, with an increasingly common use to remedy specific medical conditions. These conditions are commonly related to neurological dysfunction or orthopedic pain. Although pain relief is the most common use of acupuncture, numerous other conditions have been shown to improve with this therapy. Laboratory animals are also benefiting from acupuncture. Its use is starting to be incorporated into research settings, although there is still further progress to be made in this field. Acupuncture has been shown to improve clinical conditions and quality of life in laboratory animals, and should be considered as a tool to treat laboratory animals with conditions known to benefit from therapy. Here we review the history, mechanisms of action, and use of acupuncture to treat veterinary patients and laboratory animals.

The standardization of acupuncture treatment for radiation-induced xerostomia: A literature review

OBJECTIVE

To assess the relative standardization of acupuncture protocols for radiation-induced xerostomia.

METHODS

A literature search was carried out up to November 10, 2012 in the databases PubMed/MEDLINE, EMBASE and China National Knowledge Infrastruction with the terms: radiation-induced xerostomia, acupuncture, acupuncture treatment, and acupuncture therapy. Five ancient Chinese classic acupuncture works were also reviewed with the keywords "dry mouth, thirst, dry tongue, dry eyes and dry lips" to search the effective acupuncture points for dry mouth-associated symptoms in ancient China.

RESULTS

Twenty-two full-text articles relevant to acupuncture treatment for radiation-induced xerostomia were included and a total of 48 acupuncture points were searched in the 5 ancient Chinese classic acupuncture works, in which the most commonly used points were Chengjiang (CV24), Shuigou (GV 26), Duiduan (GV 27), Jinjin (EX-HN 12), and Yuye (EX-HN 13) on head and neck, Sanjian (LI 3), Shangyang (LI 1), Shaoshang (LU 11), Shaoze (SI 1), Xialian (LI 8) on hand, Fuliu (KI 7), Dazhong (KI 4), Zuqiaoyin (GB 44), Taichong (LR 3), Zhaohai (KI 6) on foot, Burong (ST 19), Zhangmen (LR 13), Tiantu (CV 22), Qimen (LR 14) on abdomen, Feishu (BL 13), Danshu (BL 19), Xiaochaogshu (BL 27), Ganshu (BL 18) on back, Shenmen (TF 4), Shen (CO10, Kidney), Yidan (CO11, Pancreas) and Pi (CO13, Spleen) on ear.

CONCLUSION

There were considerable heterogeneities in the current acupuncture treatment protocols for radiation-induced xerostomia. Based on the results of the review and the personal perspectives, the authors provide a recommendation for manual acupuncture protocols in treating radiationinduced xerostomia patients with head and neck cancer.

Salivary Secretory Disorders, Inducing Drugs, and Clinical Management

BACKGROUND

Salivary secretory disorders can be the result of a wide range of factors. Their prevalence and negative effects on the patient's quality of life oblige the clinician to confront the issue.

AIM

To review the salivary secretory disorders, inducing drugs and their clinical management.

METHODS

In this article, a literature search of these dysfunctions was conducted with the assistance of a research librarian in the MEDLINE/PubMed Database.

RESULTS

Xerostomia, or dry mouth syndrome, can be caused by medication, systemic diseases such as Sjögren's Syndrome, glandular pathologies, and radiotherapy of the head and neck. Treatment of dry mouth is aimed at both minimizing its symptoms and preventing oral complications with the employment of sialogogues and topical acting substances. Sialorrhea and drooling, are mainly due to medication or neurological systemic disease. There are various therapeutic, pharmacologic, and surgical alternatives for its management. The pharmacology of most of the substances employed for the treatment of salivary disorders is well-known. Nevertheless, in some cases a significant improvement in salivary function has not been observed after their administration.

CONCLUSION

At present, there are numerous frequently prescribed drugs whose unwanted effects include some kind of salivary disorder. In addition, the differing pathologic mechanisms, and the great variety of existing treatments hinder the clinical management of these patients. The authors have designed an algorithm to facilitate the decision making process when physicians, oral surgeons, or dentists face these salivary dysfunctions.

Salivary VIP concentrations are elevated in humans after acute stress

Salivary (s)-cortisol, s-amylase, s-DHEA are used extensively in stress research. Vasoactive Intestinal Peptide (VIP) is also detectable in saliva using a standard RIA kit. VIP is a 28 amino acid neuropeptide that belongs to the secretin/glucagon family of peptides and acts as a neurotransmitter/neuromodulator. VIP has also been detected in the parasympathetic nerves enervating the salivary glands. Here we measured the level of s-cortisol, s-DHEA, s-amylase and s-VIP in three different stress exercises of different duration and intensity. The results indicate that a brief intense exercise lasting minutes elicited a stress response with significant increases in s-cortisol, s-DHEA, s-amylase and s-VIP. A less rigorous exercise did not elicit a stress response with no significant increases in s-cortisol, s-DHEA, s-amylase and s-VIP. A longer intense exercise lasting hours elicited a stress response with significant increases only in s-cortisol.

[Changes in the innervation of the taste buds in diabetic rats]

INTRODUCTION

Abnormal sensations such as pain and impairment of taste are symptoms of approximately 10% of patients having diabetes mellitus.

AIM

The aim of the study was to investigate and quantify the different neuropeptide containing nerve fibres in the vallate papilla of the diabetic rat.

METHODS

Immunohistochemical methods were used to study the changes of the number of different neuropeptide containing nerve terminals located in the vallate papillae in diabetic rats. Diabetes was induced in the rats with streptozotocin.

RESULTS

Two weeks after streptozotocin treatment the number of the substance P, galanin, vasoactive intestinal polypeptide and neuropeptide Y immunoreactive nerve terminals was significantly increased (p<0.05) in the tunica mucosa of the tongue. The number of the lymphocytes and mast cells was also increased significantly. Some of the immunoreactive nerve terminals were located in the lingual epithelium both intragemmally and extragemmally and were seen to comprise dense bundles in the lamina propria just beneath the epithelium. No taste cells were immunoreactive for any of the investigated peptides. Vasoactive intestinal polypeptide and neuropeptide Y immunoreactive nerve fibres were not detected in the taste buds. For weeks after streptozotocin administration the number of the substance P, calcitonin gene related peptide and galanin immunoreactive nerve terminals was decreased both intragemmally and intergemmally. In case of immediate insulin treatment, the number of the immunoreactive nerve terminals was similar to that of the controls, however, insulin treatment given 1 week later to diabetic rats produced a decreased number of nerve fibers. Morphometry revealed no significant difference in papilla size between the control and diabetic groups, but there were fewer taste buds (per papilla).

CONCLUSIONS

Increased number of immunoreactive nerve terminals and mast cells 2 weeks after the development of diabetes was the consequence of neurogenic inflammation which might cause vasoconstriction and lesions of the oral mucosa. Taste impairment, which developed 4 weeks after streptozotocin treatment could be caused by neuropathic defects and degeneration or morphological changes in the taste buds and nerve fibres.

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.

Sham-controlled, randomised, feasibility trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma

BACKGROUND

Xerostomia (dry mouth) after head/neck radiation is a common problem among cancer patients. Quality of life (QOL) is impaired, and available treatments are of little benefit. This trial determined the feasibility of conducting a sham-controlled trial of acupuncture and whether acupuncture could prevent xerostomia among head/neck patients undergoing radiotherapy.

METHODS

A sham controlled, feasibility trial was conducted at Fudan University Shanghai Cancer Center, Shanghai, China among patients with nasopharyngeal carcinoma undergoing radiotherapy. To determine feasibility of a sham procedure, 23 patients were randomised to real acupuncture (N=11) or to sham acupuncture (N=12). Patients were treated three times/week during the course of radiotherapy. Subjective measures were the Xerostomia Questionnaire (XQ) and MD Anderson Symptom Inventory for Head and Neck Cancer (MDASI-HN). Objective measures were unstimulated whole salivary flow rates (UWSFR) and stimulated salivary flow rates (SSFR). Patients were followed for 1 month after radiotherapy.

RESULTS

XQ scores for acupuncture were significantly lower than sham controls starting in week 3 and lasted through the 1-month follow-up (all P's <0.001 except for week 3, which was 0.006), with clinically significant differences as follows: week 6 - RR 0.28 [95% confidence interval, 0.10, 0.79]; week 11 - RR 0.17 [95%CI, 0.03, 1.07]. Similar findings were seen for MDASI-HN scores and MDASI-Intrusion scores. Group differences for UWSFR and SSFR were not found.

CONCLUSIONS

In this small pilot study, true acupuncture given concurrently with radiotherapy significantly reduced xerostomia symptoms and improved QOL when compared with sham acupuncture. Large-scale, multi-centre, randomised and placebo-controlled trials are now needed.

Phase 2 results from Radiation Therapy Oncology Group Study 0537: a phase 2/3 study comparing acupuncture-like transcutaneous electrical nerve stimulation versus pilocarpine in treating early radiation-induced xerostomia

BACKGROUND

In this phase 2 component of a multi-institutional, phase 2/3, randomized trial, the authors assessed the feasibility and preliminary efficacy of acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) in reducing radiation-induced xerostomia.

METHODS

Patients with cancer of the head and neck who were 3 to 24 months from completing radiotherapy with or without chemotherapy (RT ± C) and who were experiencing xerostomia symptoms with basal whole saliva production ≥0.1 mL per minute and were without recurrence were eligible. Patients received twice weekly ALTENS sessions (24 sessions over 12 weeks) using a proprietary electrical stimulation unit. The primary study objective was to assess the feasibility of ALTENS treatment. Patients were considered compliant if 19 of 24 ALTENS sessions were delivered, and the targeted compliance rate was 85%. Secondary objectives measured treatment-related toxicities and the effect of ALTENS on overall radiation-induced xerostomia burden using the University of Michigan Xerostomia-Related Quality of Life Scale (XeQOLS).

RESULTS

Of 48 accrued patients, 47 were evaluable. The median age was 60 years, 84% of patients were men, 70% completed RT ± C for >12 months, and 21% had previously received pilocarpine. Thirty-four patients completed all 24 ALTENS sessions, 9 patients completed 20 to 23 sessions, and 1 patient completed 19 sessions, representing a 94% total compliance rate. Six-month XeQOLS scores were available for 35 patients and indicated that 30 patients (86%) achieved a positive treatment response with a mean ± standard deviation reduction of 35.9% ± 36.1%. Five patients developed grade 1 or 2 gastrointestinal toxicity, and 1 had a grade 1 pain event.

CONCLUSIONS

The current results indicated that ALTENS treatment for radiation-induced xerostomia can be delivered uniformly in a cooperative, multicenter setting and produces possible beneficial treatment response. Given these results, the phase 3 component of this study was initiated.

Randomized controlled trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma

BACKGROUND

Xerostomia (dry mouth) after head/neck radiation is a common problem among cancer patients, and available treatments are of little benefit. The objective of this trial was to determine whether acupuncture can prevent xerostomia among head/neck patients undergoing radiotherapy.

METHODS

A randomized, controlled trial among patients with nasopharyngeal carcinoma was conducted comparing acupuncture to standard care. Participants were treated at Fudan University Shanghai Cancer Center, Shanghai, China. Forty patients were randomized to acupuncture treatment and 46 to standard care. Patients were treated 3×/wk on the same days they received radiotherapy. Subjective measures included the Xerostomia Questionnaire and MD Anderson Symptom Inventory-Head and Neck (MDASI-HN). Objective measures were unstimulated and stimulated whole salivary flow rates. Patients were followed for 6 months after the end of radiotherapy.

RESULTS

Xerostomia Questionnaire scores for acupuncture were statistically significantly lower than for controls starting in week 3 through the 6 months (P = .003 at week 3, all other P < .0001), with clinically significant differences as follows: week 11, relative risk (RR) 0.63 (95% confidence interval [CI], 0.45-0.87); 6 months, RR 0.38 (95% CI, 0.19-0.76). Similar findings were seen for MDASI-HN scores. Group differences emerged as early as 3 weeks into treatment for saliva (unstimulated whole salivary flow rate, P = .0004), with greater saliva flow in the acupuncture group at week 7 (unstimulated whole salivary flow rate, P < .0001; stimulated whole salivary flow rate, P = .002) and 11 (unstimulated whole salivary flow rate, P < .02; stimulated whole salivary flow rate, P < .03) and at 6 months (stimulated whole salivary flow rate, P < .003).

CONCLUSIONS

Acupuncture given concurrently with radiotherapy significantly reduced xerostomia and improved quality of life.

Group acupuncture to relieve radiation induced xerostomia: a feasibility study

BACKGROUND

a distressing complication of radiotherapy treatment for head and neck cancer is xerostomia (chronic oral dryness). Xerostomia is difficult to treat conventionally but there are reports that acupuncture can help. We conducted a feasibility study to examine the acceptability of a standardised group acupuncture technique and adherence to group sessions, together with acceptability of the objective and subjective measurements of xerostomia.

METHODS

12 males with established radiation induced xerostomia were treated in three groups of four. Each received eight weekly sessions of acupuncture using four bilateral acupuncture points (Salivary Gland 2; Modified Point Zero; Shen Men and one point in the distal radial aspect of each index finger (LI1)). Sialometry and quality of life assessments were performed at baseline and at the end of treatment. A semi-structured interview was conducted a week after completing the intervention.

RESULTS

adherence to and acceptability of the treatment and assessments was 100%. There were objective increases in the amounts of saliva produced for 6/12 patients post intervention and the majority also reported subjective improvements. Mean quality of life scores for domains related to salivation and xerostomia also showed improvement. At baseline 92% (11/12) patients reported experiencing a dry mouth "quite a bit/very much" as compared to 42% (5/12) after the treatment. Qualitative data revealed that the patients enjoyed the sessions.

CONCLUSION

the pilot study shows that a standardised group technique is deliverable and effective. The tools for objective and subjective assessment are appropriate and acceptable. Further examination in a randomised trial is now warranted.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acupuncture for radiation-induced xerostomia in patients with cancer: a pilot study

BACKGROUND

This pilot study evaluated if acupuncture can alleviate radiation-induced xerostomia among patients with cancer. Secondary objectives were to assess the effects of acupuncture on salivary flow and quality of life (QOL).

METHODS

Nineteen patients received acupuncture twice a week for 4 weeks.

RESULTS

Xerostomia inventory (XI) and patient benefit questionnaire (PBQ) scores were significantly better after acupuncture on weeks 4 and 8 than at baseline (XI: p = .0004 and .0001; PBQ: p = .0004 and .0011, respectively). For QOL at weeks 4 and 8, there was a significant difference for questions related to head/neck cancer (p = .04 and .006, respectively). At week 8, there was a significant difference in physical well-being (p = .04). At weeks 5 and 8, there were significant differences in the total score (p = .04 and .03, respectively).

CONCLUSIONS

Acupuncture was effective for radiation-induced xerostomia in this small pilot study. Further research is needed.

Acupuncture for preconditioning of expectancy and/or Pavlovian extinction

Both specific and non-specific factors, as well as the therapist, may play a role in acupuncture therapy. Recent results suggest that verum acupuncture has specific physiological effects and that patients expectations and belief regarding a potentially beneficial treatment modulate activity in the reward and self-appraisal systems in the brain. We suggest that acupuncture treatment may partly be regarded and used as an intervention that preconditions expectancy, which results in both conditional reflexes and conditioning of expected reward and self-appraisal. If so, acupuncture should preferably be applied before the start of the specific treatment (drug or behavioural intervention which is given with the intention of achieving a specific outcome) to enhance the specific and non-specific effects. This hypothesis is further supported by the suggestions that acupuncture may be viewed as a neural stimulus that triggers Pavlovian extinction. If this is the case, acupuncture should preferably be applied repeatedly (ie in a learning process) before the start of the specific treatment to initiate the extinction of previous unpleasant associations like pain or anxiety. Our clinical data suggest that acupuncture may precondition expectancy and conditional reflexes as well as induce Pavlovian extinction. Based on the above we suggest that acupuncture should be tried (as an adjunct) before any specific therapy.

Acupuncture as an optional treatment for hospice patients with xerostomia: an intervention study

More than 70% of seriously ill patients with cancer suffer from xerostomia and the associated problems of swallowing, chewing and speaking. This study aims to investigate whether treatment with acupuncture is a viable option for hospice patients with xerostomia. During a 2-year period, 117 patients were assessed for xerostomia. Eighty-two patients were found to have moderate xerostomia. Sixty-seven fulfilled the criteria for inclusion. Of these, 14 were included but only eight completed the study. Ten acupuncture treatments were given during a 5-week period. The effect of acupuncture was measured using a visual analogue scale, and by measuring the saliva production before and after the series of treatment. The results show that all the patients experienced alleviation of dryness of the mouth and the associated symptoms, and thus benefited from the acupuncture treatment. However, conducting a 5-week acupuncture intervention study is not feasible at an inpatient hospice due to the patients being too close to death.

Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs

OBJECTIVE

To evaluate use of electroacupuncture combined with standard Western medical treatment versus Western medical treatment alone for treatment of thoracolumbar intervertebral disk disease in dogs.

DESIGN

Prospective controlled study.

ANIMALS

50 dogs with signs of thoracolumbar intervertebral disk disease.

PROCEDURES

Dogs were randomly allocated to 1 of 2 treatment groups and classified as having grade 1 to 5 neurologic dysfunction. Dogs in group 1 received electroacupuncture stimulation combined with standard Western medical treatment; those in group 2 received only standard Western medical treatment. A numeric score for neurologic function was evaluated at 4 time points to evaluate effects of treatments.

RESULTS

Time (mean +/- SD) to recover ambulation in dogs with grade 3 and 4 dysfunction in group 1 (10.10 +/- 6.49 days) was significantly lower than in group 2 (20.83 +/- 11.99 days). Success (able to walk without assistance) rate for dogs with grade 3 and 4 dysfunction in group 1 (10/10 dogs) was significantly higher than that of similarly affected dogs in group 2 (6/9 dogs). Dogs without deep pain perception (grade 5 dysfunction) had a success (recovery of pain sensation) rate of 3 of 6 and 1 of 8 in groups 1 and 2, respectively, but the difference was not significant. Overall success rate (all dysfunction grades) for group 1 (23/26; 88.5%) was significantly higher than for group 2 (14/24; 58.3%).

CONCLUSIONS AND CLINICAL RELEVANCE

Electroacupuncture combined with standard Western medical treatment was effective and resulted in shorter time to recover ambulation and deep pain perception than did use of Western treatment alone in dogs with signs of thoracolumbar intervertebral disk disease.

Acupuncture stimulation to the sacral segment affects state of vigilance in rats

The effects of acupuncture stimulation to the sacral segment on electroencephalograms (EEGs) and activity of locus coeruleus (LC) neurons were examined in urethane-anesthetized rats. In 71 of 112 trials, when EEGs displayed small amplitude and high frequency, stimulation to the sacral segment-induced large amplitude and slow EEGs with a latency of <450s and duration ranged from 32s to >42 min. Stimulus-induced EEGs comprised significant increases in delta power and significant decreases in theta and beta powers. After intraperitoneal administration of bicuculline, stimulation to the sacral segment failed to induce changes in EEG pattern. Firing rate of noradrenergic LC neurons decreased significantly from 2.9+/-1.5 to 1.1+/-0.8 Hz (n=11, p<0.001). Decreased neuronal activity exhibited close relationships with increased EEG amplitude. These results suggest that acupuncture stimulation to the sacral segment changes the state of animals from light anesthesia to deep anesthesia, and that this change is mediated by GABAergic systems suppressing the activity of noradrenergic LC neurons.

Specific acupuncture sensation correlates with EEGs and autonomic changes in human subjects

Sympathetic overactivation is suggested to be associated with chronic pain syndrome, and acupuncture is frequently applied in therapy for this syndrome. Furthermore, the forebrain including the various cerebral cortices has been implicated in inhibitory and facilitatory control of pain as well as autonomic functions. We investigated relationships among specific sensations induced by acupuncture manipulation, effects on sympathetic and parasympathetic autonomic functions, and EEG changes. An acupuncture needle was inserted into the right trapezius muscle of the subjects, and acupuncture manipulation was repeated to induce specific acupuncture sensation repeatedly while the needle was left in the muscle. Acupuncture manipulation significantly decreased heart rate (HR), and increased systolic blood pressure (SBP). Spectral analysis indicated that acupuncture manipulation significantly decreased low frequency components (LF) of both HR variability (HRV) and SBP variability (SBPV), and significantly reduced ratio of LF to high frequency component (HF) of HRV (LF/HF, index of sympathetic activity). Furthermore, there was a significant negative correlation between changes in LF/HF ratio of HRV and the number of specific acupuncture sensations reported, and a significant positive correlation between HF of HRV and the number of acupuncture sensations. Analyses of EEG data indicated that acupuncture manipulation non-specifically increased power of all spectral bands except the gamma band. Furthermore, changes in HF (index of parasympathetic activity) and total power (overall activity of the autonomic nervous system) of HRV were positively correlated with changes in theta, alpha, and gamma power, while changes in LF of SBPV and LF/HF of HRV were negatively correlated with changes in power of all spectral bands. These results are consistent with the suggestion that autonomic changes induced by manipulation inducing specific acupuncture sensations might be mediated through the central nervous system, especially through the forebrain as shown in EEG changes, and are beneficial to relieve chronic pain by inhibiting sympathetic nervous activity.

Acupuncture treatment in patients with keratoconjunctivitis sicca: a pilot study

AIM

To evaluate the effects of acupuncture in patients with keratoconjunctivitis sicca (KCS).

MATERIAL AND METHODS

Twenty-five patients (20 women, five men) with KCS were randomly assigned to an acupuncture treatment group or a control group. The effects of acupuncture were evaluated by a questionnaire on symptoms, visual analogue scale recordings, registration of drop frequency, and dry eye tests. Ten acupuncture sessions were given. Follow-up was carried out after 2-3 weeks and again after a mean period of 8 months.

RESULTS

Patients receiving acupuncture felt better at the first follow-up compared with the control group (p = 0.036). However, no statistical significance could be found concerning any change, or difference, in the total number of subjective symptoms, dosage frequency or, as indicated by the dry eye tests, tear quality, tear secretion and ocular surface disease.

CONCLUSION

The results indicate that acupuncture has subjective beneficial effects in patients with KCS and could therefore be tried as a complement to ordinary treatment.

Salivary Enhancement Therapies

When salivary output is reduced chronically to a significant extent, there is a marked increase in dental caries. As the role of saliva in protection of the oral hard tissue is well recognized, there have long been efforts to enhance salivary function in conditions with associated secretory hypofunction. The rationale is that by stimulating salivary output, caries and other oral complications will be reduced or eliminated. The most widely used method for increasing salivary function is a combination of masticatory and gustatory stimulation. A large number of systemic agents have also been proposed as secretagogues, but only a few have shown consistent salivary enhancing properties in well-designed, controlled trials. Pilocarpine has been shown to improve symptoms of oral dryness and to increase salivary output in patients with Sjögren's syndrome and postradiation xerostomia. Recently, cevimeline has shown significant salivary enhancement in Sjögren's syndrome. Pilocarpine and cevimeline have a similar mechanism of action, side effect profile and duration of activity. No secretagogues have been linked directly in clinical trials to either caries prevention or a reduction in the existing caries rate of salivary dysfunction patients. Improved secretagogues are needed, with fewer side effects, increased duration of activity and greater potency. Future research directions include gene therapeutic approaches to direct salivary growth and differentiation or modify remaining tissues to promote secretion, creation of a biocompatible artificial salivary gland and salivary transplantation. With improved secretagogues, the effects of conditions that result in reduced salivary function and increased caries will be ameliorated.

A Phase I-II study in the use of acupuncture-like transcutaneous nerve stimulation in the treatment of radiation-induced xerostomia in head-and-neck cancer patients treated with radical radiotherapy

PURPOSE

Recent studies have suggested that acupuncture may improve radiation-induced xerostomia with an increase in the median salivary flow rate and sustained symptom relief. An acupuncture-like transcutaneous nerve stimulation method (Codetron) without invasive needles was developed to mimic acupuncture treatment. This Phase I-II study examined the effectiveness of Codetron in treating radiation-induced xerostomia.

METHODS AND MATERIALS

Patients with symptomatic xerostomia after radical radiotherapy for head-and-neck cancer but with evidence of residual salivary function were recruited into the study. Two 6-week courses of Codetron treatment of acupuncture points preselected according to traditional Chinese medicine principles were given with a 2-week break between each course. Basal and citric acid-primed whole saliva production were measured at baseline and up to 1 year after treatment completion. Xerostomia symptoms were assessed by a five-item xerostomia symptom questionnaire with a visual analog scale and quality of life was evaluated using the Head and Neck Radiotherapy Questionnaire.

RESULTS

We enrolled 46 patients in the study. All patients had received radiotherapy doses of >or=50 Gy to bilateral head-and-neck fields, including the parotid glands. Of the 46 patients, 37 completed the follow-up assessments at 3 and 6 months after treatment completion. No Codetron treatment-related complications occurred. Improvement in xerostomia symptoms was noted, with a mean increase in the visual analog scale score of 86 (p < 0.0005) and 77 (p < 0.0001) at 3 and 6 months after treatment completion, respectively. For all patients, the increase in the mean basal and citric acid-primed whole saliva production at 3 and 6 months after treatment completion was also statistically significant (p < 0.001 and p < 0.0001, respectively). No statistically significant change in the quality-of-life evaluation compared with baseline was observed.

CONCLUSION

The results suggest that Codetron treatment improves whole saliva production and related symptoms in patients with radiation-induced xerostomia. The treatment effects were sustained for at least 6 months after Codetron treatment completion. A prospective randomized Phase III trial with appropriate controls is being planned.

Xerostomia: etiology, recognition and treatment

BACKGROUND

Clinicians may encounter symptoms of xerostomia, commonly called "dry mouth," among patients who take medications, have certain connective tissue or immunological disorders or have been treated with radiation therapy. When xerostomia is the result of a reduction in salivary flow, significant oral complications can occur.

TYPES OF STUDIES REVIEWED

The authors conducted an Index Medicus--generated review of clinical and scientific reports of xerostomia in the dental and medical literature during the past 20 years. The literature pertaining to xerostomia represented the disciplines of oral medicine, pathology, pharmacology, epidemiology, gerodontology, dental oncology, immunology and rheumatology. Additional topics included the physiology of salivary function and the management of xerostomia and its complications.

RESULTS

Xerostomia often develops when the amount of saliva that bathes the oral mucous membranes is reduced. However, symptoms may occur without a measurable reduction in salivary gland output. The most frequently reported cause of xerostomia is the use of xerostomic medications. A number of commonly prescribed drugs with a variety of pharmacological activities have been found to produce xerostomia as a side effect. Additionally, xerostomia often is associated with Sjögren's syndrome, a condition that involves dry mouth and dry eyes and that may be accompanied by rheumatoid arthritis or a related connective tissue disease. Xerostomia also is a frequent complication of radiation therapy.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Xerostomia is an uncomfortable condition and a common oral complaint for which patients may seek relief from dental practitioners. Complications of xerostomia include dental caries, candidiasis or difficulty with the use of dentures. The clinician needs to identify the possible cause(s) and provide the patient with appropriate treatment. Remedies for xerostomia usually are palliative but may offer some protection from the condition's more significant complications.

Acupuncture mechanisms for clinically relevant long-term effects--reconsideration and a hypothesis

From the author's direct involvement in clinical research, the conclusion has been drawn that clinically relevant long-term pain relieving effects of acupuncture (>6 months) can be seen in a proportion of patients with nociceptive pain. The mechanisms behind such effects are considered in this paper. From the existing experimental data some important conclusions can be drawn: 1. Much of the animal research only represents short-term hypoalgesia probably induced by the mechanisms behind stress-induced analgesia (SIA) and the activation of diffuse noxious inhibitory control (DNIC). 2. Almost all experimental acupuncture research has been performed with electro-acupuncture (EA) even though therapeutic acupuncture is mostly gentle manual acupuncture (MA). 3. Most of the experimental human acupuncture pain threshold (PT) research shows only fast and very short-term hypoalgesia, and, importantly, PT elevation in humans does not predict the clinical outcome. 4. The effects of acupuncture may be divided into two main components--acupuncture analgesia and therapeutic acupuncture. A hypothesis on the mechanisms of therapeutic acupuncture will include: 1. Peripheral events that might improve tissue healing and give rise to local pain relief through axon reflexes, the release of neuropeptides with trophic effects, dichotomising nerve fibres and local endorphins. 2. Spinal mechanisms, for example, gate-control, long-term depression, propriospinal inhibition and the balance between long-term depression and long-term potentiation. 3. Supraspinal mechanisms through the descending pain inhibitory system, DNIC, the sympathetic nervous system and the HPA-axis. Is oxytocin also involved in the long-term effects? 4. Cortical, psychological, "placebo" mechanisms from counselling, reassurance and anxiety reduction.

Salivary gland dysfunction: a review of systemic therapies

Xerostomia may result from salivary dysfunction secondary to a variety of conditions, including medications, autoimmune disease, and tumoricidal therapy. As the geriatric population increases, the incidence of xerostomia will increase and the oral manifestations will continue to be a challenge to the clinician. Common oral manifestations resulting from decreased salivary flow include increased dental caries, fungal infections, and dysphagia. Treatment for salivary gland dysfunction is currently limited because of a lack of controlled clinical trials. Medications that have been studied in clinical trials are emphasized in this article. The aim of this article is to briefly review salivary gland physiology and to summarize the suggested systemic treatment modalities for xerostomia that emphasize controlled clinical trials.

Long-term follow-up of patients treated with acupuncture for xerostomia and the influence of additional treatment

OBJECTIVE

To determine the long-term effects of acupuncture in patients with xerostomia of different etiologies and the influence of additional treatment.

DESIGN

Retrospective study.

SUBJECTS

Seventy patients, between the ages of 33 and 82, with xerostomia due to primary and secondary Sjögren's syndrome, irradiation and other causes were included. The median duration of xerostomia was 32 months.

METHODS

Salivary flow rates (SFR) for whole unstimulated and stimulated saliva were used as indicators of effects of treatment. Data from 67/70 patients were analyzed 6 months following a baseline course of 24 acupuncture treatments using two-way ANOVA. Patients data up to 3 years were also compared by those who chose to receive additional acupuncture treatment vs those who did not. These data were analyzed descriptively.

RESULTS

Statistically significant differences in unstimulated and stimulated salivary flow rates (P < 0.01) were found in all etiological groups after 24 acupuncture treatments and up to 6 months follow-up compared to baseline. Three years observation of these patients showed that patients receiving additional acupuncture treatment had a consistently higher median SFR in both unstimulated and stimulated saliva compared to patients who chose not to continue acupuncture. The upper limits of the interquartile range were also higher.

CONCLUSIONS

This study shows that acupuncture treatment results in statistically significant improvements in SFR in patients with xerostomia up to 6 months. It suggests that additional acupuncture therapy can maintain this improvement in SFR for up to 3 years.

Sensory stimulation (acupuncture) increases the release of calcitonin gene-related peptide in the saliva of xerostomia sufferers

Over the last decade, several patients afflicted with xerostomia have been treated with acupuncture. Their salivary flow rates increased significantly and the improvement lasted during a long observation period. We also found that the release of several neuropeptides in the saliva of healthy subjects can be increased by acupuncture stimulation. The concentration of vasoactive intestinal polypeptide increased significantly in the saliva of xerostomic patients after acupuncture treatment. The release of the neuropeptide calcitonin gene-related peptide (CGRP) was investigated in the saliva of xerostomic patients in order to elucidate further the mechanisms of the effect of sensory stimulation (acupuncture) on the salivary secretion. CGRP-like immunoreactivity was measured with radioimmunoassay (RIA) before and after a double series of acupuncture treatment, in stimulated saliva of 14 patients who suffered from xerostomia. The results showed that the concentration of CGRP increased significantly (P<0.001) in the saliva of these patients after the end of acupuncture treatment as compared to base-line levels. Taking into consideration the influence of CGRP on the salivary flow, as well as its trophic effect, we concluded that the increased release of CGRP could be one of the factors that affect positively the salivary flow rates of xerostomic patients who were treated with acupuncture.