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

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.

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.

Efficacy of Acupuncture at the Sphenopalatine Ganglion in the Treatment of Persistent Allergic Rhinitis

Objective: The aim of this research was to explore the hypothesis that acupuncture at the sphenopalatine ganglion (SPG), a new a new method of acupuncture, would be more efficacious and safe than traditional acupuncture in the treatment of persistent allergic rhinitis (PAR). Materials and Methods: For this study, 120 patients with PAR were randomly assigned to SPG acupuncture, traditional acupuncture (Yingxiang [LI 20], Hegu [LI 4], and Yintang [Ex-HN 3]), or drug treatment (budesonide nasal spray). Efficacy was assessed by using single symptoms, including sneezing, rhinorrhea, nasal obstruction and nasal itch, a total nasal symptoms score (TNSS), and a Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) before treatment, the day treatment ended, and 4-, 8-, 12-weeks later, respectively. Results: Four weeks after treatment ended, the effectiveness rate in the SPG-acupuncture group was superior to that of the traditional-acupuncture group (P = 0.033) but was still lower than that of the drug-treatment group (P = 0.039), with mean effectiveness rates of 69.70%, 44.44%, and 71.43%, respectively. However, these rates gradually decreased in each group during weeks 8 through 16. Moreover, statistically significant improvements in TNSS', and reductions in nasal congestion and sneezing symptoms were observed in the SPG-acupuncture group, compared with those in the traditional-acupuncture group as early as the day treatment ended and this continued throughout the observation period (P < 0.05). However, the improvement did not continue for sneezing, during weeks 8 through weeks 12 after treatment ended. The RQLQ of the SPG-acupuncture group was lower than that of the traditional-acupuncture group at week 12; however, there were no differences at weeks 8 and 16. Conclusions: The data generated by this study confirmed that acupuncture at the SPG alleviated the symptoms of PAR rapidly and safely, especially nasal obstruction, and improved the patients' life quality. These results were worthy of clinical promotion.

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.

The Evidence on Acupuncture for Knee Osteoarthritis – Editorial Summary on the Implications for Health Policy

Decisions on whether a health service should provide a particular treatment are based on the evidence on three questions: 1) whether the treatment can work, ie it is biologically active; 2) whether the treatment is safe and effective in daily practice; and 3) whether it is economically worthwhile. Evidence presented at the Kyoto conference shows that acupuncture for osteoarthritis of the knee has a biological effect, has a large clinical effect in practice, has negligible risk, and has a cost effectiveness which is well within the usual acceptable limit. On the present evidence, acupuncture is likely to offer an alternative to treatment with non-steroidal anti-inflammatory drugs (NSAIDs).

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.

Acupuncture: could it become everyday practice in oncology?

Acupuncture is a complementary and alternative medical treatment (CAM) which is increasingly used in the care of cancer patients. Traditionally derived from Chinese medicine, nowadays it is becoming a part of evidence-based oncology. The use of acupuncture in these patients has been recommended by the American Cancer Society (ACS) for the treatment of side effects associated with conventional cancer therapy and cancer-related ailments. A growing body of evidence supports the use of acupuncture in the treatment of cancer-induced pain and chemotherapy-related nausea and vomiting. Also other indications, such as xerostomia, fatigue, hot flashes, anxiety and peripheral neuropathy, are being constantly evaluated. This article summarizes the most important discoveries related to the possible usefulness of this method in contemporary oncology. Emphasis is placed on the results of randomized controlled trials with an adequate level of evidence. However, explanation of the mechanisms responsible for these effects requires confirmation in further studies with an adequate level of evidence. In future, acupuncture may become an interesting and valuable addition to conventional medicine.

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.

Clinical practice guideline: Allergic rhinitis

OBJECTIVE

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.

PURPOSE

The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.

ACTION STATEMENTS

The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

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.

Palliative dental care- a boon for debilitating

World Health Organization defines "palliative care" as the active total care of patients whose disease is not responding to curative treatment. Palliative care actually deals with patients at the terminal end stage of the disease. We always face a question why a dentist should be in a palliative team? What is the exact role of dentist? Dental treatment may not always be strenuous and curative, but also can focus on improving quality of life of the patient. Hence forth the present paper enlightens the importance of dentist role in palliative team.

Acupuncture for analgesia in veterinary medicine

Acupuncture for analgesia is growing rapidly in popularity with veterinarians and pet owners. This article summarizes the mechanisms of analgesia derived from acupuncture and reviews current literature on the topic. Areas covered include the local effects at area of needle insertion, systemic effects secondary to circulating neurotransmitters and changes in cell signaling, central nervous system effects including the brain and spinal cord, and myofascial trigger point and pathology treatment. Clinical applications are discussed and suggested in each section. When used by appropriately trained professionals, acupuncture offers a compelling and safe method for pain management in our veterinary patients and should be strongly considered as a part of multimodal pain management plans.

Yukmijihwang-tang for the treatment of xerostomia in the elderly: study protocol for a randomized, double-blind, placebo-controlled, two-center trial

BACKGROUND

Xerostomia, a subjective sense of dry mouth, is not generally regarded a disease despite its high prevalence among the elderly, and therefore continues to impair affected patients' quality of life. In traditional Korean medicine, 'Yin-Deficiency' has been implicated in the pathogenesis of xerostomia among the elderly. Yukmijihwang-tang is a famous herbal prescription used to relieve 'Yin-Deficiency', and reportedly has antioxidant effects; therefore, it is postulated that Yukmijihwang-tang can be used to treat xerostomia in the elderly. However, to our knowledge, no clinical trial has been conducted on the effects of Yukmijihwang-tang on xerostomia. Thus, we designed a randomized clinical trial to investigate the effects and safety of Yukmijihwang-tang on xerostomia in the elderly. In addition, we will clarify the aforementioned assumption that 'Yin-Deficiency' is the major cause of xerostomia in the elderly by identifying a correlation between xerostomia and 'Yin-Deficiency'.

METHODS/DESIGN

This randomized, double-blind, placebo-controlled trial will be carried out at two centers: Kyung Hee University Korean Medicine Hospital and Kyung Hee University Hospital at Gangdong. We will recruit 96 subjects aged 60-80 years who have experienced xerostomia for 3 months prior to participation. Subjects who present with score >40 on the visual analogue scale for xerostomia and unstimulated salivary flow rate under 0.3mL/min will be included and the randomization will be carried out by an independent statistician by using a random number creation program. The subjects and all researchers except the statistician will be blinded to the group assignment. Yukmijihwang-tang or placebo will be administered to each group for 8 weeks. The primary outcome is change in the scores for the visual analogue scale for xerostomia and the dry mouth symptom questionnaire from 0 to 8 weeks.

DISCUSSION

It will be assessed whether Yukmijihwang-tang can be used as a new herbal treatment for xerostomia in the elderly by demonstrating its therapeutic effects in a well-designed clinical trial.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01579877.

S100β Levels in CSF of Nonambulatory Dogs with Intervertebral Disk Disease Treated with Electroacupuncture

The aim of the study was to investigate S100β levels in the cerebrospinal fluid of nonambulatory dogs with intervertebral disk disease treated with electroacupuncture: 10 dogs with thoracolumbar disk extrusion graded 3 to 5 (EA group) and 7 dogs without neurologic dysfunction (control group). All dogs regained ambulation. S100β was detected by Western blot analysis where EA group dogs were evaluated at two time points (M1 = before EA and M2 = when the dogs return ambulation) and at one time point from control group. In EA group dogs M1-S100β levels were significantly higher than in control group. EA group dogs were divided into subgroups A (n = 7-early motor recovery; 6.7 ± 7.8 days) and B (n = 3-late motor recovery; 76 ± 17.0 days). M1-S100β levels were similar between subgroups A and B. However, M2-S100β levels were significantly higher in subgroup B than in subgroup A. An elevated S100β levels were observed in dogs with late motor recovery. S100β may be associated with neuroplasticity following spinal cord injuries with intervertebral disk extrusion. Further studies with larger numbers of subjects and control group with affected dogs are necessary to investigate the relationship between neurotrophic factors and electroacupuncture stimulation.

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.

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.

Effect of Acupuncture on Salivary Immunoglobulin a after a Bout of Intense Exercise

In the field of athletics, acupuncture has been used for treatment of injury, reduction of fatigue and management of physical condition. However, there is little information on the effect of acupuncture on the immune function in response to exercise.

Purpose

The aim of this study was to examine the effect of acupuncture treatment on the mucosal immune function after a single period of intense exercise by measuring salivary immunoglobulin A (SIgA).

Methods

12 healthy men (23.6±SEv 0.3 years) participated in this study with a crossover design. The subjects exercised on a bicycle equipped with an ergometer at 75% VO2max for 60 min. Acupuncture treatment was applied at LU6, LI4, ST36 and ST6, for 30 min after the exercise. The control treatment was rest without acupuncture and that the order of the treatment was randomised. We measured parameters including saliva flow rate, SIgA concentration, SIgA secretion rate, heart rate and plasma catecholamine concentration all before the exercise and at 1 h, 2 h, 3 h, 4 h and 24 h after the exercise. The visual analogue scale for self-perceived tiredness and the profile of mood states questionnaires were recorded before the exercise and at 24 h after the exercise.

Result

Intense exercise-induced decrease of SIgA levels was attenuated by the acupuncture treatment. In contrast, the subjective fatigue score and psychological measurement were not affected by the acupuncture.

Conclusion

Acupuncture treatment may attenuate the decrease in SIgA level induced by intense exercise.

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.

Acupuncture for persistent allergic rhinitis: a randomised, sham-controlled trial

OBJECTIVE

To investigate the effectiveness and safety of acupuncture in persistent allergic rhinitis (PAR) DESIGN: Randomised, single-blind, sham-controlled trial conducted from May 2004 to February 2005.

PARTICIPANTS AND INTERVENTION

80 patients with PAR (age, 16-70 years) were randomly assigned to receive real or sham acupuncture. After a 1-week baseline period, participants were treated twice weekly for 8 weeks and followed up for another 12 weeks.

MAIN OUTCOME MEASURES

Nasal obstruction, sneezing, rhinorrhoea and nasal itch were each self-assessed daily on a 5-point scale, and scores were aggregated weekly. The sum of the symptom scores (total nasal symptom score, TNSS) was also determined. A secondary outcome was use of PAR relief medication.

RESULTS

After 8 weeks' treatment, the weekly mean difference in TNSS from baseline was greater with real (-17.2; 95% CI, -24.6 to -9.8) than with sham acupuncture (-4.2; 95% CI, -11.0 to 2.7) (P = 0.01). The decrease in individual symptom score was also greater with real acupuncture for rhinorrhoea (P < 0.01) but not the other symptoms. At the end of follow-up, the greater difference in TNSS from baseline in the real acupuncture group was still apparent: real, -21.0 (95% CI, -29.1 to -12.9) versus sham, - 2.3 (95% CI, -10.2 to 5.6) (P = 0.001). Moreover, the differences from baseline in all four individual symptom scores were greater for the real than for the sham group (P < 0.05). Real and sham acupuncture were both well tolerated.

CONCLUSION

Our findings suggest that acupuncture is effective in the symptomatic treatment of PAR.

TRIAL REGISTRATION

Australian Government Therapeutic Goods Administration CTN 034/2004.

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.

Electro-acupuncture and Chinese herbs for treatment of cervical intervertebral disk disease in a dog

A non-ambulatory dog with tetraparesis following a pain episode that had evolved over 2 months was submitted for medical treatment and diagnosed with intervertebral disk disease at C3-C4 and dorsal extradural compression at C1-C2 and C3-C4 using myelography and computed tomography. The dog experienced ambulation recovery after 15 days of treatment with only electroacupuncture and Chinese herbal medicine, with marked improvement occurring after only 10 treatments. Six months of follow-up demonstrated that the dog was stable and had no recurrence of symptoms. Therefore, it was concluded that the combination of electroacupuncture and Chinese herbal medicine was responsible for motor rehabilitation.

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 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.

Complementary medicine in chronic cancer care

Although advancements in cancer care have led to increased cure rates and survival times, those coping with the long-term sequelae of a cancer diagnosis often report high levels of distress, poor health-related quality of life, and unmet psychosocial needs. The shortcomings of the conventional biomedical system at sufficiently addressing these chronic illness issues are a primary reason that many patients turn to complementary and alternative medicine (CAM). Although patients usually use such treatments in addition to conventional care, they often do not discuss doing so with their conventional physicians, who are perceived as being unreceptive to the topic. Physicians may feel uninformed about CAM treatments, especially given the relatively small amount of data on the topic available in the medical literature. This article reviews a few CAM modalities commonly used by cancer survivors and those with chronic cancer illness, with a particular focus on familiarizing physicians with treatments that may potentially complement regular oncologic care by decreasing stress and enhancing health-related quality of life.

Different patterns of blood flow response in the trapezius muscle following needle stimulation (acupuncture) between healthy subjects and patients with fibromyalgia and work-related trapezius myalgia

Needle stimulation (acupuncture) has recently been shown to increase blood flow in the tibialis anterior muscle and overlying skin in healthy subjects (HS) and patients with fibromyalgia (FM). The aim of the present study was to examine the effect of needle stimulation on local blood flow in the trapezius muscle and overlying skin in HS and two groups of patients suffering from chronic pain in the trapezius muscle, i.e., FM and work-related trapezius myalgia (TM) patients. Two modes of needling, deep muscle stimulation (Deep) and subcutaneous needle insertion (SC), were performed at the upper part of the shoulder and blood flow was monitored for 60 min post-stimulation. Blood flow changes were measured non-invasively by using a new application of photoplethysmography. Increased blood flow in the trapezius muscle and overlying skin was found in all three groups following both Deep and SC. In HS, Deep was superior to SC in increasing skin and muscle blood flow, whereas in FM, SC was as effective as, or even more effective, than Deep. In the severely affected TM patients, no differences were found between the stimuli, and generally, a lesser blood flow response to the stimuli was found. At Deep, the muscle blood flow increase was significantly larger in HS, compared to the two patient groups. Positive correlations were found between muscle blood flow at Deep and pressure pain threshold in the trapezius muscle, neck movement and pain experienced at the stimulation, and negative correlations were found with spontaneous pain-related variables, symptom duration and age, pointing to less favorable results with worsening of symptoms, and to the importance of nociceptor activation in blood flow increase. It was hypothesized that the different patterns of muscle blood flow response to the needling may mirror a state of increased sympathetic activity and a generalized hypersensitivity in the patients. The intensity of stimulation should be taken into consideration when applying local needle stimulation (acupuncture) in order to increase the trapezius muscle blood flow in chronic pain conditions.

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.

The Use of Acupuncture in Implant Dentistry

This article aims to review how acupuncture can provide complimentary treatments to patients through implant rehabilitation. The following topics are discussed: control of gagging reflex, control of postoperative vomiting, control of postoperative pain, enhance anesthetic effects, control of anxiety, increase saliva production, enhance immune responses, management of temporomandibular dysfunction, smoking cessation, control diabetic mellitus, stimulation of peripheral nerve regeneration, and adverse effects.

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.