Salivary Gland Dysfunction

Development and accuracy validation of a fat fraction imaging biomarker for sialadenitis in the parotid gland

BACKGROUND

The diagnosis of sialadenitis, the most frequent disease of the salivary glands, is challenging when the symptoms are mild. In such cases, biomarkers can be used as definitive diagnostic indicators. Recently, biomarkers have been developed by extracting and analyzing pathological and morphological features from medical imaging. This study aimed to establish a diagnostic reference for sialadenitis based on the quantitative magnetic resonance imaging (MRI) biomarker IDEAL-IQ and assess its accuracy.

METHODS

Patients with sialadenitis (n = 46) and control subjects (n = 90) that underwent MRI were selected. Considering that the IDEAL-IQ value is a sensitive fat fractional marker to the body mass index (BMI), all subjects were also categorized as under-, normal-, and overweight. The fat fraction of parotid gland in the control and sialadenitis groups were obtained using IDEAL-IQ map. The values from the subjects in the control and sialadenitis groups were compared in each BMI category. For comparison, t-tests and receiver operating characteristic (ROC) curve analyses were performed.

RESULTS

The IDEAL-IQ fat faction of the control and sialadenitis glands were 38.57% and 23.69%, respectively, and the differences were significant. The values were significantly lower in the sialadenitis group (P), regardless of the BMI types. The area under the ROC curve (AUC) was 0.83 (cut-off value: 28.72) in patients with sialadenitis. The AUC for under-, normal-, and overweight individuals were 0.78, 0.81, and 0.92, respectively.

CONCLUSIONS

The fat fraction marker based on the IDEAL-IQ method was useful as an objective indicator for diagnosing sialadenitis. This marker would aid less-experienced clinicians in diagnosing sialadenitis.

Impact of physiological parameters on the parotid gland fat fraction in a normal population

Quantifying physiological fat tissue in the organs is important to further assess the organ's pathologic status. This study aimed to investigate the impact of body mass index (BMI), age, and sex on the fat fraction of normal parotid glands. Patients undergoing magnetic resonance imaging (MRI) of iterative decomposition of water and fat with echo asymmetry and least squares estimation (IDEAL-IQ) due to non-salivary gland-related disease were reviewed. Clinical information of individual patients was categorized into groups based on BMI (under/normal/overweight), age (age I/age II/age III), and sex (female/male) and an inter-group comparison of the fat fraction values of both parotid glands was conducted. Overall, in the 626 parotid glands analyzed, the fat fraction of the gland was 35.80%. The mean fat fraction value increased with BMI (30.23%, 35.74%, and 46.61% in the underweight, normal and overweight groups, respectively [p < 0.01]) and age (32.42%, 36.20%, and 41.94% in the age I, II, and III groups, respectively [p < 0.01]). The fat content of normal parotid glands varies significantly depending on the body mass and age regardless of sex. Therefore, the patient's age and body mass should be considered when evaluating fatty change in the parotid glands in imaging results.

Association of Hyper-Low-Density Lipoprotein and Hypo-High-Density Lipoprotein Cholesterolemia with Low Saliva Flow Rates in Japanese Community-Dwelling Elders

Introduction  The associations of low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein (HDL-C) with reduced saliva flow rates have not been previously reported. Objective  The present study aimed to assess the association of cholesterolemia with reduced saliva flow rates in community-dwelling elderly subjects. Methods  The present study analyzed 342 participants (170 males and 172 females aged between 78 and 79 years old). Unstimulated salivary flow rate (USFR) was assessed using a cotton roll method. Low-USFR was defined as 0.10 g/30 seconds. Stimulated salivary flow rate (SSFR) was assessed by having the participants chew tasteless gum for 3 minutes. Low-SSFR was defined as 1.0 mL/minute. Blood samples were collected for the measurement of LDL-C, HDL-C, rheumatoid factor, hemoglobin A1c, and creatinine. To assess depression, the General Health Questionnaire 30 was used. A standardized questionnaire was completed, covering the current and previous medications of the participants and smoking status. We stratified the serum LDL-C levels of the participants as normal, moderate or severe hyper-LDL cholesterolemia and serum HDL-C levels as normal or hypo-HDL cholesterolemia. Multivariate logistic regression models were established and low-USFR or low-SSFR were set as dependent variables in the aforementioned models. Results  After controlling for the effects of the other variables, the odds ratios (ORs) (95% confidence intervals [CIs]) for low-USFR were 2.25 (1.10-4.61) for moderate and 5.69 (1.55-20.8) for severe hyper-LDL cholesterolemia, while that of hypo-HDL cholesterolemia was 3.40 (1.33-8.69). Severe hyper-LDL cholesterolemia was also associated with low-SSFR with an OR of 3.89 (1.39-10.88). Conclusion  Elderly patients with cholesterolemia have a risk of reduced salivary flow rate.

Thirst sensation and oral dryness following alcohol intake

Substantial acute and chronic intakes of alcohol or ethanol (EtOH) severely influence oral sensations, such as thirst and oral dryness (dry mouth, xerostomia). Thirst sensation and oral dryness are primarily caused by the activation of neurons in brain regions, including the circumventricular organs and hypothalamus, which are referred to as the dipsogenic center, and by a decrease in salivary secretion, respectively. The sensation of thirst experienced after heavy-alcohol drinking is widely regarded as a consequence of EtOH-induced diuresis; however, EtOH in high doses induces anti-diuresis. Recently, it has been proposed that the ethanol metabolite acetaldehyde induces thirst via two distinct processes in the central nervous system from EtOH-induced diuresis, based on the results of animal experiments. The present review describes new insights regarding the induction mechanism of thirst sensation and oral dryness after drinking alcohol.

Antipsychotic medications and dental caries in newly diagnosed schizophrenia: A nationwide cohort study

We investigated the association between antipsychotic medications and the risk of dental caries in patients with schizophrenia. We enroled a nationwide cohort of patients with newly diagnosed schizophrenia within 1 year of dental caries development. Exposure to antipsychotics and other medications was categorised according to their type and duration, and the association between exposure and dental caries was assessed through logistic regressions. Of the 3610 patients with newly diagnosed schizophrenia, 2149 (59.5%) exhibited an incidence of treated dental caries. Logistic regression analysis identified a younger age, female sex, high income, a 2-year history of dental caries, and exposure to first-generation antipsychotics, and antihypertensives as independent risk factors for treated dental caries in patients with schizophrenia. Hyposalivation, the adverse effect of first-generation antipsychotics and antihypertensives, was associated with an increased risk of treated dental caries. However, hypersalivation from first-generation antipsychotics for dental caries was associated with a protective factor. These findings suggest that clinicians should pay attention to the aforementioned risk factors for dental caries in patients with schizophrenia, particularly while prescribing first-generation antipsychotics and antihypertensives to such patients.

Meal Patterns of Older Adults in Rural Communities: Life Course Analysis and Implications for Undernutrition

Mealfrequency and composition data were collected in home interviews from a random sample of 556 adults age 55 to 96 years from two rural Kentucky counties Only 65% consumed three meals every day, and less than one third regularly snacked. Factor analysis distinguished patterns of hot, cooked meals from cold, uncooked meals at each meal; patterns varied by sociodemographic characteristics. Qualitative data from in-depth interviews with key infor mants provide context for understanding the influence of life course experiences These data show both continutty of local rural meal patterns and changes informants attribute to life course transitions—the most salient related to family, work, and health status. Knowledge of how meals are patterned and how patterns are distributed can inform efforts to correct or prevent nutritional problems, particularly undernutrition. We suggest ways in which these findings can be applied in programs to improve the nutritional status of elders.

Meaning and Management of Food Security Among Rural Elders

Food insecurity is the limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire acceptable foods in socially acceptable ways. This study uses fixed response and textual data obtained through in-depth interviews with adults 70 years and older from a multiethnic population in rural North Carolina to examine the incidence of food insecurity and how older adults experience food insecurity and maintain food security. We interviewed 145 elders up to five times over the course of 1 year. Responses to standard food insecurity questions indicate that only 12% of older adults experience food insecurity. However, analysis of textual data reveals common themes concerning food insecurity that suggest that these questions may underestimate the number of rural elders who are food insecure and not tap the potential vulnerability of others who are dependent on precarious nutritional self-management strategies to meet their needs.

The effect of basic fibroblast growth factor on regeneration in a surgical wound model of rat submandibular glands

This study developed an animal model of surgically wounded submandibular glands (SMGs) and investigated the effects of collagen gel with basic fibroblast growth factor (bFGF) on tissue regeneration of surgically wounded SMGs in vivo. The animal model was produced by creating a surgical wound using a 3-mm diameter biopsy punch in SMGs. The wound was filled with collagen gel with bFGF (bFGF group) or without bFGF (control group). In the animal model of surgically wounded SMGs, salivary glands without scar tissue around the wound area were observed with smaller areas of collagen gel. Small round and spindle-shape cells invaded the collagen gel in both groups after operation day (AOD) 5, and this invasion dramatically increased at AOD 7. Host tissue completely replaced the collagen gel at AOD 21. The invading immune cells in the group treated with collagen gel with bFGF were positive for vimentin, α-smooth muscle actin (αSMA), CD49f, c-kit and AQP5 at AOD 7. Similarly, the mRNA expression of vimentin, αSMA, CD49f, keratin19 and AQP5 was also increased. This study suggests that the use of collagen gels with bFGF improves salivary gland regeneration.

P2Y2 nucleotide receptor activation enhances the aggregation and self-organization of dispersed salivary epithelial cells

Hyposalivation resulting from salivary gland dysfunction leads to poor oral health and greatly reduces the quality of life of patients. Current treatments for hyposalivation are limited. However, regenerative medicine to replace dysfunctional salivary glands represents a revolutionary approach. The ability of dispersed salivary epithelial cells or salivary gland-derived progenitor cells to self-organize into acinar-like spheres or branching structures that mimic the native tissue holds promise for cell-based reconstitution of a functional salivary gland. However, the mechanisms involved in salivary epithelial cell aggregation and tissue reconstitution are not fully understood. This study investigated the role of the P2Y2 nucleotide receptor (P2Y2R), a G protein-coupled receptor that is upregulated following salivary gland damage and disease, in salivary gland reconstitution. In vitro results with the rat parotid acinar Par-C10 cell line indicate that P2Y2R activation with the selective agonist UTP enhances the self-organization of dispersed salivary epithelial cells into acinar-like spheres. Other results indicate that the P2Y2R-mediated response is dependent on epidermal growth factor receptor activation via the metalloproteases ADAM10/ADAM17 or the α5β1 integrin/Cdc42 signaling pathway, which leads to activation of the MAPKs JNK and ERK1/2. Ex vivo data using primary submandibular gland cells from wild-type and P2Y2R(-/-) mice confirmed that UTP-induced migratory responses required for acinar cell self-organization are mediated by the P2Y2R. Overall, this study suggests that the P2Y2R is a promising target for salivary gland reconstitution and identifies the involvement of two novel components of the P2Y2R signaling cascade in salivary epithelial cells, the α5β1 integrin and the Rho GTPase Cdc42.

Functional transplantation of salivary gland cells differentiated from mouse early ES cells in vitro

Atrophy or hypofunction of the salivary gland because of aging or disease causes hyposalivation and has an effect on the quality of life of patients, for example not only dry mouth but deterioration in mastication/deglutition disorder and the status of oral hygiene. Currently conducted therapies for atrophy or hypofunction of the salivary gland in clinical practice are only symptomatic treatments with drugs and artificial saliva, and therefore it is preferable to establish a radical therapy. At this time, as a fundamental investigation, by co-culturing mouse early ES (mEES-6) cells with human salivary gland-derived fibroblasts (hSG-fibro), differentiation of mEES-6 cells to salivary gland cells has been attempted. Also, the possibility of cell engraftment was examined. After identifying the cells which were co-cultured with GFP-transfected mEES-6 cells and hSG-fibro, the cells were transplanted into the submandibular gland of SCID mice, and the degree of differentiation into tissues was examined. The possibility of tissue functional reconstitution from co-cultured cells in a three-dimensional culture system was examined. Our results confirmed that the co-cultured cells expressed salivary gland-related markers and had an ability to generate neo-tissues by transplantation in vivo. Moreover, the cells could reconstitute gland structures in a three-dimensional culture system. By co-culture with hSG-fibro, mEES-6 cells were successfully differentiated into salivary gland cells which were transplantable and have tissue neogenetic ability.

DNA demethylating agent decitabine increases AQP5 expression and restores salivary function

Xerostomia is the symptom of oral dryness resulting most frequently, but not exclusively, from salivary gland hypofunction. Because the prevalence of xerostomia may increase with age, it has multiple oral health consequences in aging populations. In the present study, we demonstrate that the in vivo administration of 5-aza-2'-deoxycytidine (5-Aza-CdR; decitabine), a DNA demethylating agent, to the murine aging model C57BL/6CrSlc mice (24 wks old) increased the volumes of salivary flow compared with those of control mice. Western blot analysis and immunohistochemical staining demonstrated the augmented expression of AQP5 protein in the salivary glands of 5-Aza-CdR-treated mice compared with those of control mice. In addition, AQP5 protein expression levels in 5-Aza-CdR-treated old mice (27 wks old) were much higher than those in untreated and young mice (6 wks old). Global methylation levels in the salivary glands were significantly lower in the 5-Aza-CdR-treated mice than in the untreated mice. Moreover, the induction of demethylation in the AQP5 promoter of 5-Aza-CdR-treated mice was stronger than in the control mice. Analysis of our data therefore suggests that a DNA demethylating agent may be a useful drug for restoring hyposalivation in elderly individuals, thereby leading to the resolution of xerostomia.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Oral symptoms and functional outcome related to oral and oropharyngeal cancer

Purpose

This study aimed to assess: (1) oral symptoms of patients treated for oral or oropharyngeal cancer; (2) how patients rank the burden of oral symptoms; (3) the impact of the tumor, the treatment, and oral symptoms on functional outcome.

Methods

Eighty-nine patients treated for oral or oropharyngeal cancer were asked about their oral symptoms related to mouth opening, dental status, oral sensory function, tongue mobility, salivary function, and pain. They were asked to rank these oral symptoms according to the degree of burden experienced. The Mandibular Function Impairment Questionnaire (MFIQ) was used to assess functional outcome. In a multivariate linear regression analyses, variables related to MFIQ scores (p ≤ 0.10) were entered as predictors with MFIQ score as the outcome.

Results

Lack of saliva (52%), restricted mouth opening (48%), and restricted tongue mobility (46%) were the most frequently reported oral symptoms. Lack of saliva was most frequently (32%) ranked as the most burdensome oral symptom.

For radiated patients, an inability to wear a dental prosthesis, a T3 or T4 stage, and a higher age were predictive of MFIQ scores. For non-radiated patients, a restricted mouth opening, an inability to wear a dental prosthesis, restricted tongue mobility, and surgery of the mandible were predictive of MFIQ scores.

Conclusions

Lack of saliva was not only the most frequently reported oral symptom after treatment for oral or oropharyngeal cancer, but also the most burdensome. Functional outcome is strongly influenced by an inability to wear a dental prosthesis in both radiated and non-radiated patients.

The effects of high frequency, low intensity ultrasound therapy on parotid flow rates

OBJECTIVES

Saliva plays a critical role in maintaining oral health and comfort. Development of a single device capable of simulating salivary flow with no taste or adverse side effects is desirable.

STUDY DESIGN

This clinical investigation on 23 healthy volunteers with no dry mouth complaints evaluated the effectiveness of ultrasonic therapy in mechanical stimulation of the parotid gland to increase saliva flow. Stimulated and unstimulated parotid saliva was collected. Differences in mean salivary flow rates and affects of age and ethnicity were measured.

RESULTS

The mean difference between stimulated and unstimulated saliva flow rates was 0.009 mL/min +/- SD = 0.042, t (df = 22) = 1.27 with P = .31. There were no significant differences of age (P = .26), gender (P = .38), or race/ethnicity (P = .58) for the difference of stimulated and unstimulated conditions.

CONCLUSIONS

Results indicate that high-frequency low-intensity ultrasound therapy is not effective in stimulating salivary flow rates.

Restoring the function of salivary glands

Salivary gland destruction occurs as a result of various pathological conditions such as radiation therapy for head and neck cancer and Sjögren's syndrome. As saliva possesses self-cleaning and antibacterial capability, hyposalivation is known to deteriorate dental caries and periodontal disease. Furthermore, hyposalivation causes mastication and swallowing problems, burning sensation of the mouth and dysgeusia. Currently available treatments for dry mouth are prescription for artificial saliva, moisturizers and medications which induce salivation from the residual tissue. Unfortunately, these treatments cannot restore the acini functions. This review focuses on various efforts to restore the function of damaged salivary gland. First, the possibility of salivary gland regeneration and tissue engineering is discussed with reference to stem cells, growth factors and scaffold materials. Second, the current status of gene transfer to salivary glands is discussed.

Management of patients who have undergone head and neck cancer therapy

Patients who undergo treatment for head and neck cancers often suffer from acute or late reactions to therapy. Severity of these oral complications may be based on the location and extent of tumor, as well as the type and extent of treatment. Some complications are transient, whereas others require a lifetime of management secondary to damage that results in permanent dysfunction. Patients who have a history of head and neck cancers are also at an increased risk for recurrences or second malignancies, and therefore require close follow-up. Dental professionals should provide preventive and supportive care, including education and symptom management, for patients experiencing oral complications related to cancer therapy, and should closely monitor patients' level of distress, ability to cope, and treatment response.

Salivary secretion, taste and hyposalivation

Saliva has many essential functions. As the first digestive fluid in the alimentary canal, saliva is secreted in response to food, assisting intake and initiating the digestion of starch and lipids. During this process, saliva acts as a solvent of taste substances and affects taste sensitivity. Clinically, a more important role is in the maintenance of oral health, including the protection of teeth and mucosa from infections, maintenance of the milieu of taste receptors, and communication ability through speech. Variations in salivary flow can be affected, reversibly or irreversibly, by numerous physiological and pathological factors. Decreased salivary flow results in clinically significant oral discomfort that may manifest as increased caries, susceptibility to oral candidiasis, altered taste sensation or as a host of other problems. Hyposalivation is a condition that is frequently encountered in dental practice. The most common cause is the use of certain systemic medications, which put the elderly at greater risk because they are usually more medicated. Other causes include high doses of radiation and certain diseases such as Sjögren's syndrome. This article reviews the mechanism of salivary secretion, effect of saliva on taste, importance of saliva in oral health, and hyposalivation in relation to ageing, medicine and/or disease and management of hyposalivation.

Acupuncture in xerostomia--a systematic review

The aim of this systematic review was to assess the efficacy of acupuncture in the management of xerostomia. Assessing quality of studies aim to efficiently integrate valid information and provide a basis for sound decision making based on the best available evidence. Articles of controlled clinical trials evaluating the efficacy of acupuncture in the management of xerostomia were obtained by searching through the databases MEDLINE and Cochrane Central Register of Controlled Trials to September 2003. Three articles met the criteria for inclusion and a criteria list was used to assess the quality of these studies. The studies were considered to be of high quality or low quality in accordance with the criteria list utilized. The results of the trials were considered positive, negative or indifferent based on statistically significant between group differences. The criteria list utilized indicate that one of the three studies was of high quality and it presents indifferent results. One of the two studies of low quality presents positive results and one presents indifferent results. An analysis of the results degree of evidence resulted in no evidence for the efficacy of acupuncture in the management of xerostomia. This systematic review shows that there is no evidence for the efficacy of acupuncture in the management of xerostomia. There is a need for future high quality randomized controlled trials.

Influence of the time of measurement of unstimulated human whole saliva on the diagnosis of hyposalivation

OBJECTIVE

An unstimulated whole saliva flow rate (UWSFR) of less than 0.1 mL/min is often related to symptoms of dry mouth. It is also used as a diagnostic criterion for Sjogren's syndrome, and for assessment of hyposalivation as a caries risk factor. The main hypothesis was that the circadian rhythm of salivary flow affects this diagnosis if saliva is collected at different morning time-points.

DESIGN

UWSFR was tested at 7:30 and 11:30 a.m. in 108 individuals, age 15-46 years (mean 33+/-9). The participants were allocated to one of three groups (very low< or =0. 1/min, low 0.1-0.2 mL/min and normal>0.2 mL/min) based on the UWSFR at 7:30 a.m. Different aspects of the perception of oral dryness were rated using Visual Analog Scales.

RESULTS

All three groups displayed a statistically significant increase in UWSFR at 11:30 a.m. compared with 7:30 a.m., all of similar magnitude (0.08-0.09 mL/min). In the group with very low UWSFR, 70% at 11:30 a.m. exceeded the 0.1 mL/min limit. There were significant difference in perception of oral dryness between the normal group and both the low and the very low groups. Only the subjects in the groups with a low or very low UWSFR perceived an increase in oral wetness at 11:30 a.m.

CONCLUSIONS

It was concluded that the time of measurement strongly influences the diagnosis of hyposalivation. To control the influence of variations in the time of saliva collection, we suggest that unstimulated whole saliva tests are performed at a fixed time-point or in a limited time interval early in the morning.

Xerostomia: clinical aspects and treatment

Xerostomia or dry mouth is a condition that is frequently encountered in dental practice. The most common cause is the use of certain systemic medications, which make the elderly at greater risk because they are usually more medicated. Other causes include high doses of radiation and certain diseases such as Sjogren's syndrome. Xerostomia is associated with difficulties in chewing, swallowing, tasting or speaking. This results in poor diet, malnutrition and decreased social interaction. Xerostomia can cause oral discomfort, especially for denture wearers. Patients are at increased risk of developing dental caries. A thorough intraoral and extra-oral clinical examination is important for diagnosis. Treatment may include the use of salivary substitutes (Biotene), salivary stimulants such as pilocarpine, ongoing dental care, caries prevention, a review of the current prescription drug regimen and possible elimination of drugs having anticholinergic effects. Because of the ageing population, and the concomitant increase in medicated individuals, dentists can expect to be presented with xerostomia in an increasing number of patients in the coming years and therefore should be familiar with its diagnosis and treatment. Therefore, the purpose of this review is to outline for clinicians the common aetiologies, clinical identification, and routine therapeutic modalities available for individuals with xerostomia.

Autoimmunity and geriatrics: clinical significance of autoimmune manifestations in the elderly

The immune system undergoes continuous morphologic and functional changes throughout the years, and it is now believed that the immune response has its peak function in puberty and gradually decreases with age (immunosenescence). Recent studies in healthy octogenarian patients suggest that the immune system, instead of suffering a generalized deterioration, undergoes a remodelling/readjustment of its major functions. Increase in two contrasting phenomena coexist in immunosenescence: on the one hand, a decrease in the capacity of the immune response and, on the other hand autoantibody production. The possible consequences of this progressive 'ageing' of the immune system are the increase in autoimmune phenomena, incidence of neoplasia and predisposition to infections. The study of autoimmune manifestations in elderly populations should be considered a priority for future medical research because of increasing life expectancy, especially in developed countries. This review analyses the main immune disorders associated with immunosenescence, the prevalence and clinical significance of autoantibodies in the elderly and the clinical expression of the main autoimmune diseases in older patients.

Fungal load and candidiasis in Sjögren's syndrome

OBJECTIVE

We sought to investigate the prevalence of Candida carriage and the relationships between salivary flow rates and oral Candida load in patients with Sjögren's syndrome (SS).

METHODS

The oral Candida load of patients with SS was evaluated by culturing oral rinse (swish and spit) samples. Culture, Gram stain, and wet-mount test results were reported.

RESULTS

One hundred three patients (96 women) met European criteria for SS (91 with primary SS and 12 with secondary SS). The mean age (95% confidence interval) was 55 years (range, 51-57 years). Oral rinse cultures were positive in 77% of subjects. The total stimulated salivary flow rate was inversely correlated with oral Candida load (r = -0.47; P </=.0001). The oral rinse samples yielded gram-positive results in 38% of patients with SS, and the Fungi-Fluor assay (wet mount) results were positive in 49%.

CONCLUSIONS

The prevalence of Candida carriage varies according to the methods used to determine the presence of the organism and is similar to that reported in the literature. A low stimulated salivary flow rate-not a low unstimulated flow rate-was associated with Candida carriage.

Periodontitis, caries and salivary factors in Sjögren's syndrome patients compared to sex- and age-matched controls

The aims of this investigation were: (i) to study a group of dry mouth Sjögren's syndrome (SS) patients comprising individuals with pathological and non-pathological amounts of rest saliva and (ii) to compare these two categories of SS patients with a sex- and age-matched control group with respect to their periodontal and dental status. Thirty-three dry mouth patients and 33 sex- and age-matched patients, referred to the same private dental clinic in southern Norway, were examined for rest and stimulated saliva, as well as their dental and periodontal status. All patients were referred to the local hospital for blood and urine examinations. The dry mouth SS patients were all of the secondary type. Volumes of rest and stimulated saliva were significantly lower in the low saliva SS group compared with the high saliva SS group; the values for immunoglobulin G (IgG) and IgA were similarly lower for the low saliva group, but not for IgM which was significantly higher. The two SS subgroups and their controls were compared for the volume of rest and stimulated saliva, which showed a statistically significant lower volumes for the low saliva SS group compared with the control group. None of the subgroups and their controls differed concerning filled or missing teeth, but the total SS group revealed significantly higher number of missing teeth. The periodontal and dental status did not show any statistically significant differences except for a few scattered higher periodontal level losses of attachment in the SS subgroups. The blood and urine analyses showed statistically significant higher values for sedimentation rate, white blood cell count and haemoglobin in the SS low saliva group compared with the control group while anti-streptolysin was lower. In the high saliva SS group only sedimentation rate and white cell count were higher compared with the control. The conclusions is SS patients do not have an increased risk for developing periodontitis.

Antidepressant use in psychiatry and medicine: importance for dental practice

BACKGROUND

Many dental patients receive antidepressant therapy. However, antidepressants taken with other drugs may increase the risk of complications that require special dental precautions and care.

METHODS

The authors conducted a retrospective study of 1,800 randomly selected patient records and evaluated the prevalence of using antidepressants and other medications concurrently. They analyzed antidepressant intake relative to drug classification and mechanism of action, age, sex and associated potential for clinical complications such as xerostomia, orthostatic hypotension and interaction with vasoconstrictors. The potential for additive adverse effects between antidepressants and other medications also was analyzed.

RESULTS

Three hundred eighty-one (21 percent) of the 1,800 patient records indicated that patients were being treated with 412 antidepressants. Female subjects out-numbered male subjects by an approximate 2.3:1 ratio. Selective serotonin reuptake inhibitors were most commonly prescribed, followed by tricyclic antidepressants, atypical and third-generation antidepressants, and monoamine oxidase inhibitors. Based on reported medication intake, almost 58 percent of subjects in the antidepressant group were receiving treatment with two or more medications that had the potential for producing xerostomia. Two hundred fifty-seven (67 percent) of the 381 records documented intake of an antidepressant or other medication with orthostatic hypotension potential.

CONCLUSIONS

Three hundred eighty-one patients reported that they were receiving antidepressant therapy for psychiatric and other medical reasons. Potential adverse effects and interactions with other medications have direct implications for dental treatment.

CLINICAL IMPLICATIONS

Patients receiving antidepressant therapy are at risk of developing xerostomia and orthostatic hypotension, as well as experiencing the adverse effects of interaction with vasoconstrictors. Dentists must take appropriate precautions in treating these patients.

Geriatric pharmacology

With the dramatic demographic change that has resulted in the "graying of the population" has come a compelling interest in the health and health concerns of older adults. The increasing incidence and prevalence of systemic diseases, especially chronic diseases, among older adults, and the concomitant increase in medication use, have provided impetus for the subspecialty of geriatric pharmacology. This article reviews the physiologic changes, nonphysiologic aspects, and pharmacologic changes associated with aging and their implications for dental practice.

Treatment of xerostomia: a systematic review of therapeutic trials

The results of the present systematic review of randomized controlled trials published in peer-reviewed journals demonstrate the presence of a wide variety of biases and the weakness of the existing literature of xerostomia treatment. The report of statistically significant efficacy on an outcome measure is only meaningful in the setting of a well-controlled, appropriately designed clinical trial. This points to the importance of evaluating the quality of the clinical trial closely when deciding if study results are applicable to a specific patient population. Future studies in the management of xerostomia will require an increased effort on the part of investigators to eliminate easily recognized flaws during the planning stages of a clinical trial. Minimizing bias in clinical studies will allow for easier interpretation and comparisons of different studies. Better clinical trial design is vital to provide maximal confidence in the efficacy of xerostomia interventions.

The impact of saliva on patient care: A literature review

Decreased salivary flow results in a clinically significant oral imbalance that may manifest as increased caries, susceptibility to oral candidosis, altered taste sensation, or a host of other problems. This article reviews the role of saliva in oral health, highlights the causes and consequences of xerostomia, and outlines treatment modalities for patients with xerostomia. Journal articles were investigated through Medline, and relevant textbooks and handbooks were consulted. A summary of the literature pertinent to clinical prosthodontics is presented.

Elevated blood pressure is not related to saliva flow in patients with Sjögren's syndrome

OBJECTIVE

The purpose of this study was to determine whether systolic and diastolic blood pressures are associated with salivary flow, dry mouth, or dry eye symptoms in patients with primary Sjögren's syndrome as compared with xerostomic control subjects.

STUDY DESIGN

One hundred forty consecutive patients seen at the Sjögren's Syndrome Clinic were categorized retrospectively with various classification schemes: (1) subjective dry mouth; (2) subjective dry eye; (3) European criteria; and (4) international criteria. Data collection included age, gender, systolic blood pressure, diastolic blood pressure, salivary flow rate, focus score, Schirmer's test, and laboratory findings, including antinuclear antibodies, anti-SSA, anti-SSB, IgG, IgA, IgM, erythrocyte sedimentation rate, and rheumatoid factor.

RESULTS

No meaningful associations of salivary flow rates with systolic or diastolic blood pressures were found in patients with Sjögren's syndrome or in xerostomic control subjects. An inverse correlation was seen between salivary flow and elevated diastolic blood pressure in xerostomic control subjects only.

CONCLUSION

Elevated blood pressure was not related to saliva flow in patients with Sjögren's syndrome.

Quality of diets consumed by older rural adults

Older adults residing in rural communities are at risk for low dietary quality because of a variety of social, physical and environmental circumstances. Minority elders are at additional risk because of poorer health status and lower socioeconomic status. This study evaluated the food group intake of 130 older (>70 years) African American (34%), European American (36%), and Native American (30%) residents of two rural communities in central North Carolina. An interviewer-administered food frequency questionnaire was used to measure dietary intake. Food items were classified into food groups similar to the United States Department of Agriculture (USDA) Food Guide Pyramid and the National Cancer Institutes 5 A Day for Better Health program. None of the survey participants met minimum intake recommendations and most over-consumed fats, oils, sweets and snacks. African Americans and Native Americans consumed fewer servings of meats,fruits and vegetables, and fats, oils, sweets and snacks than European Americans. African American men consumed the fewest servings of fruits and vegetables of all gender/ethnic groups. Consumption of fats, oils and sweets was greatest among those 85 years and older and was more common among denture users. National strategies to educate the public about the importance of consuming a varied diet based on the recommendations presented in national nutrition education campaigns may not be reaching older adults in rural communities, particularly minority group members.

The relationship between MMPs and pH in whole saliva of radiated head and neck cancer patients

BACKGROUND

Radiation therapy for head and neck tumour patients may lead to decreased salivary flow, oral mucosal lesions and increased caries experience. Salivary matrix metalloproteinases (MMPs) may participate in the pathogenesis of mucosal lesions and dentinal caries. The aims of this study were: (i) to assay the presence, molecular forms and proteolytic activity of MMP-8 (collagenase-2) and MMP-9 (gelatinase B) in the whole saliva of head and neck cancer patients having radiation therapy; (ii) to see whether salivary pH affects the activity of MMP-8 and MMP-9; and (iii) to find out the possible connection between MMP-8 and MMP-9 with the eruption of oral mucosal lesions during radiation therapy.

METHODS

The whole saliva samples of 39 head and neck cancer patients having radiation therapy were collected before, during and after radiation therapy, and saliva flow rate, pH, buffer capacity, Streptococcus mutans, Lactobacillus and Candida albicans were measured. Any oral mucosal lesions were examined during each visit. The levels of MMP-8 were measured by immunofluorometric assay (IFMA) and the presence of different MMP-8 forms was analysed using Western immunoblotting. The presence and molecular forms of MMP-9 were analyzed by gelatin zymography. MMP-9 capture activity assay was used to determine the APMA-activated MMP-9 activity (total) and the endogenously active MMP-9 (free activity).

RESULTS

Salivary flow rate, buffer capacity and pH decreased, and the levels of Lactobacilli increased significantly, during the first half of the radiation therapy. The endogenously activated salivary MMP-9 correlated with low salivary pH (P = 0.013). No connection was found between the oral mucosal lesions and salivary MMP-8 or MMP-9.

CONCLUSIONS

In this study, salivary MMP-8 or MMP-9 did not correlate with the presence of radiation induced oral mucosal lesions, but the activation of MMP-9 may be dependent on pH.

Saliva and gastrointestinal functions of taste, mastication, swallowing and digestion

Saliva has multiple essential functions in relation to the digestive process taking place in the upper parts of the gastrointestinal (GI) tract. This paper reviews the role of human saliva and its compositional elements in relation to the GI functions of taste, mastication, bolus formation, enzymatic digestion, and swallowing. The indirect function of saliva in the digestive process that includes maintenance of an intact dentition and mucosa is also reviewed. Finally, pathophysiological considerations of salivary dysfunction in relation to some GI functions are considered.

Sickle cell anemia and dental caries: a literature review and pilot study

The purpose of this cohort study was to determine whether individuals with sickle cell anemia (SCA) were more susceptible to dental caries than non-sickle-cell control subjects. A review of the literature suggests several reasons why individuals with SCA may be at increased risk. Thirty-five cases of SCA aged 6 years and older were identified from a screening of 15,900 current patient files at the Howard University College of Dentistry Dental Clinic. A total of 140 non-SCA control subjects (four per case), frequency-matched on enrollment period (+/- 5 yrs) and age (+/- 2 yrs if under age 21, or +/- 5 yrs if 21 or over), was selected by a nonbiased method from the same dental clinic files. SCA cases and controls were identical on mean age (30.4 +/- 19 yrs, ranging from 5 to 92 yrs) and were similar in sex distribution (males: 34% of SCA cases, 40% of controls). The mean number of permanent teeth present was very similar for SCA cases and controls (23.4 +/- 6.4 vs. 24.2 +/- 6.4). The mean DMFT was 21% higher in the SCA cases (12.0 +/- 8.4 vs. 9.9 +/- 6.9), and the mean DMFS was 26% higher in the SCA cases (33.0 +/- 32.3 vs. 26.2 +/- 27.7). While there was virtually no difference in DMFS between SCA cases and controls for 6- to 19-year-olds, for subjects aged 20 and older, the DMFS was 30.4% higher in the SCD cases. For all ages, the M component for SCA cases was 40.7% higher, and the D component was 20.0% higher, while the F component was only 3.5% higher than for controls. Untreated decay (the D/D+F surfaces ratio) was 24.4% higher in the SCA cases. The findings from this pilot study suggest that SCA cases have a higher susceptibility to dental caries and/or that SCA patients may have different treatment pathways once caries is detected. While none of the observed differences was statistically significant, these findings were of clinical interest and should be pursued in future large-scale studies.

Xerostomia and the geriatric patient

Saliva is essential for the preservation of oral-pharyngeal health, and disorders of salivary physiology are associated with numerous oral and pharyngeal problems, particularly in older people. Although salivary function is remarkably intact in healthy aging, medical problems, medications, and head and neck radiotherapy can cause salivary dysfunction and complaints of xerostomia among older people. Sjögren's syndrome, an autoimmune exocrinopathy, is the most common medical disease associated with salivary dysfunction. Medications with anticholinergic side effects will impair salivary output, and head and neck radiotherapy for cancer will cause permanent destruction of salivary glands. Treatments for salivary problems are based upon establishing a diagnosis, protecting oral and pharyngeal health, stimulating remaining glands, and replacing lost salivary fluids.

Use of muscarinic agonists in the treatment of Sjögren's syndrome

Two muscarinic agonists (pilocarpine and cevimeline) have recently been approved for the treatment of symptoms of xerostomia in Sjögren's syndrome (SS). These agents stimulate the M1 and M3 receptors present on salivary glands, leading to increased secretory function. The use of these agents emphasizes the importance of neuroendocrine mechanisms in SS, which is considered an autoimmune disorder. We review recent studies on the release of cytokines and metalloproteinases in SS-affected glands and their influence on the release of and response to neurotransmitters. Also, we review the structure and function of muscarinic receptors as they may relate to SS and the potential use of novel muscarinic agonists in SS.

Xerostomic complaints induced by an anti-sialogogue in healthy young vs. older adults

Complaints of xerostomia and salivary hypofunction are common in older adults. However, recent studies reported that dehydration-induced salivary hypofunction caused fewer xerostomic complaints in older compared with young adults. This may predispose older adults to developing oral problems that will subsequently not receive attention from health care providers. Since many medications are known to inhibit salivation, this study attempted to determine if an anticholinergic drug (glycopyrrolate) had a differential effect on xerostomic complaints in young vs. older adults. Eighteen young (age 20-38 yrs) and 18 older (age 60-77 yrs) healthy adults were given a 4.0 micrograms/kg dose of i.v. glycopyrrolate. For 6 hrs after drug administration, stimulated parotid salivary flow was collected, and an eight-item Visual Analogue Scale (VAS) subjective xerostomia test was given. At several time points post-i.v. glycopyrrolate, salivary flow rates were consistently lower in older compared with young adults. For some measures of xerostomic complaint (time to first complaint; time to maximum complaint; mean maximum complaint), there were no age-related differences for all VAS items. However, a trend for increased xerostomic complaints in older adults was demonstrated (time to recovery; total duration of complaint; number xerostomic at 6 hrs). These findings suggest that, given equal doses of an anti-sialogogue, salivary hypofunction is greater in healthy older adults, while increased complaints of xerostomia are not as consistent.

Partial irradiation of the parotid gland

Recent efforts to reduce xerostomia associated with irradiation (RT) of head and neck cancer include the use of conformal and intensity-modulated RT (IMRT) to partly spare the major salivary glands, notably the parotid glands, from a high radiation dose while treating adequately all the targets at risk of disease. Knowledge of the dose-volume-response relationships in the salivary glands would determine treatment planning goals and facilitate optimization of the RT plans. Recent prospective studies of salivary flows following inhomogeneous irradiation of the parotid glands have utilized dose-volume histograms (DVHs) and various models to assess these relationships. These studies found that the mean dose to the gland is correlated with the reduction of the salivary output. This is consistent with a pure parallel architecture of the functional subunits (FSUs) of the salivary glands. The range of the mean doses, which have been found in these studies to cause significant salivary flow reduction is 26 to 39 Gy.

Environmental illness: evaluation of salivary flow, symptoms, diseases, medications, and psychological factors

Patients with symptoms allegedly caused by abnormal sensitivity to dental fillings and/or to electromagnetic fields and other environmental factors frequently report oral complaints. Forty-four consecutive patients with these symptoms were studied. The aim was to investigate whether unstimulated salivary flow rate was associated with Candida, symptoms, disease, medication, age, sex, anxiety, depression, and stress. Furthermore, the aim was to compare the level of anxiety, depression, and stress in these patients with an age- and sex-matched control group. Fifty percent had no or low flow rate from the minor salivary glands. Candida pseudohyphae were found in 50% of the patients. Hypothyroidism and/or intake of thyroid hormones, headache, fatigue, and age were negatively associated with unstimulated salivary flow rate, and dizziness was positively associated. Unstimulated salivary flow rate was positively associated with stimulated salivary flow rate and flow rate from the minor salivary glands. Burning mouth and subjective oral dryness were reported by 48%, and 46%, respectively. The patients were more anxious, stressed, and especially more depressed than the control group. Unstimulated salivary flow rate was negatively associated with state anxiety. Measurement of salivary flow rate is important in patients with environmental illness and can be used in combination with other measurements as a diagnostic tool.

Prospects for re-engineering salivary glands

In the last decade, two areas of biomedical research--gene therapy and tissue engineering--have especially captured the imagination of the public. Both areas offer the potential for the treatment of clinical conditions that now are considered impossible or extremely difficult to manage by conventional therapeutic measures. Gene therapy has made remarkable scientific progress in the laboratory, but has yet to realize its enormous clinical promise. Tissue engineering studies have led to some tangible clinical breakthroughs, but the routine replacement of whole internal organs is still well into the future. This report will examine the applications of gene therapy and tissue engineering to salivary glands, with a focus on the repair of irreversible gland damage.