Xerostomia and associated factors in a community-dwelling adult population

Metabolomic insights into idiopathic xerostomia: The central role of caffeine metabolism in salivary biochemistry

OBJECTIVE

This study aims to delineate the salivary metabolomic profile of patients with idiopathic xerostomia using untargeted metabolomics techniques, with the goal of addressing the lack of clear diagnostic markers and providing insights into the pathophysiological mechanisms of the condition.

DESIGN

In this observational, cross-sectional study, saliva samples from 33 patients with idiopathic xerostomia and 34 healthy controls were analyzed using Ultra Performance Liquid Chromatography Quadrupole Time of Flight Mass Spectrometry (UPLC-QTOF MS). Metabolomic profiling was complemented by multivariate statistical analysis to differentiate between affected individuals and controls.

RESULTS

Metabolomic analysis delineated a pronounced differentiation between patients with idiopathic xerostomia and healthy controls. A total of 195 metabolites displayed significant differential expression, each with a variable importance in projection (VIP) greater than 1 and a P-value less than 0.05. Pathway enrichment analysis, according to the Kyoto Encyclopedia of Genes and Genomes (KEGG), identified 22 metabolites that participated in 18 distinct metabolic pathways. Among these, the caffeine metabolism pathway, characterized by notable alterations in impact values (VIP, P-value, Log2-fold change, Rich factor), emerged as the most significantly disrupted, underscoring its potential role in the pathophysiology of idiopathic xerostomia (P = 0.0000395).

CONCLUSIONS

The salivary metabolomic profiling revealed distinct alterations in idiopathic xerostomia, with a significant reduction in caffeine metabolism pathways, underscoring potential neuropathic involvement. This study advances our understanding of the metabolic alterations in xerostomia, suggesting that salivary metabolomics may offer viable biomarkers for diagnosing and understanding the etiology of idiopathic xerostomia. Future research should focus on therapeutic targeting of these metabolic disturbances and evaluating their reversibility with treatment.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Anticholinergic burden of medications is associated with dry mouth and reflected in minor labial gland secretion

OBJECTIVE

Medications with anticholinergic potential inhibit saliva secretion. Polypharmacy potentiates anticholinergic burden, causing dry mouth symptoms and chronic deterioration of oral health. Patients of any age can be affected by anticholinergic medication-triggered hyposalivation (the objective measure of dry mouth); therefore, seeking predictions of hyposalivation to screen dry mouth is needed.

DESIGN

In our prospective, cross-sectional clinical study, 55 middle-aged adult patients participated. We examined whether the anticholinergic burden calculated from anticholinergic medications (anticholinergic drug score; ADS) and blood serum anticholinergic activity (SAA; the gold standard measure of anticholinergic burden) is associated with hyposalivation. As no prior studies measured minor salivary glands regarding the quantifiable anticholinergic burden, we assessed hyposalivation by the minor saliva flow (MSF) and unstimulated whole saliva (UWS) secretion.

RESULTS

Our data showed a negative linear relationship between SAA and UWS (p < 0.05); when SAA increases by one pmol/ml unit, the saliva flow decreases by 0.058 ml/min. MSF showed a linear correlation (p < 0.005) with UWS. In a multivariate logistic regression model (including age, gender, race, smoking status, xerostomia severity, ADS, and BMI), we identified SAA and age as predictors of hyposalivation (p < 0.05).

CONCLUSIONS

We provide evidence for the significant relationship between measurable anticholinergic burden and saliva flow. The correlation between UWS and MSF suggests that both saliva flow rate measurement methods could reflect anticholinergics-induced changes in salivary health.

E-cigarette, cannabis and combustible tobacco use: associations with xerostomia among California adolescents

OBJECTIVE

Xerostomia (subjective experience of dry mouth), while less common in younger populations, can contribute to caries and oral discomfort. Use of e-cigarettes and cannabis among adolescents is increasing and may be a xerostomia risk factor. This study evaluates xerostomia prevalence in an adolescent population, overall and by e-cigarette, cannabis and combustible tobacco use.

METHODS

Cross-sectional analyses of 12-month follow-up data (N=976; collected 2020-2021) from a cohort of adolescents recruited from public high schools in Northern California (USA) compared self-reported past 30-day e-cigarette, cannabis and other tobacco use and dry mouth (overall dry mouth experience; shortened xerostomia inventory, SXI). Dry mouth experience (never, occasionally, frequently/always) was modelled using ordered logistic regression with school-level clustering and adjustment for gender, race/ethnicity, alcohol use, asthma, physical activity and mutually for e-cigarette, cannabis and tobacco use.

RESULTS

Past 30-day use prevalence was 12% for e-cigarettes, 16% for cannabis and 3% for combustible tobacco. Occasional dry mouth experience (54%) was more common than frequent/always experience (5%). Frequent/always dry mouth was more prevalent among frequent (>5 days/month) e-cigarette (14%) and cannabis (19%) users and combustible tobacco users (19%) than non-users of those respective products (all comparisons p < 0.001). In covariable-adjusted models, frequent e-cigarette use was no longer significantly associated with dry mouth experience (OR: 1.40; 95% CI: 0.69, 2.84), while frequent cannabis use (OR: 3.17; 95% CI: 1.47, 6.82) and combustible tobacco use (OR: 1.92; 95% CI: 1.38, 2.68) were associated with greater odds of reporting more frequent dry mouth. Findings were qualitatively similar using the SXI.

CONCLUSIONS

In this study, xerostomia was not independently associated with e-cigarette use but was one potential health concern of adolescent cannabis and combustible tobacco use.

Saliva secretion is reduced in mild reflux esophagitis patients

BACKGROUND

Salivary secretion in patients with mild reflux esophagitis has not been examined. In this study, saliva secretion and salivary epidermal growth factor (EGF) in patients with mild reflux esophagitis were investigated.

METHODS

Thirty-eight mild reflux esophagitis patients and 38 control subjects were recruited for this case-control study. Saliva secretion testing was performed. Saliva secretion was assessed as follows: each patient chewed sugar-free gum for 3 min prior to endoscopy, and the volume and pH of saliva before and after acid loading as an index of the acid-buffering capacity were measured. The salivary EGF concentration was assessed by ELISA.

RESULTS

The volume of saliva secreted was significantly (p = 0.0412) lower in the mild reflux esophagitis group than in the control group, with medians (25th-75th percentile) of 4.2 mL/3 min [2.6-6.2] and 6.0 [3.9-8.0], respectively. No significant differences were observed in salivary pH (the mild reflux esophagitis group: 7.1 [6.9-7.2], the control group 7.2 [7.1-7.3]). Salivary pH after acid loading was significantly (p = 0.0009) lower in the mild reflux esophagitis group (5.9 [5.5-6.3]) than in the control group (6.3 [6.2-6.5]). No significant differences were noted in salivary EGF concentrations (the mild reflux esophagitis group: 1739.0 pg/mL [1142.3-3329.0], the control group: 1678.0 [1091.8-2122.5].

CONCLUSION

The secretion volume and acid-buffering capacity of stimulated saliva were reduced in patients with mild reflux esophagitis.

Protease inhibitor concentrations in the saliva of individuals experiencing oral dryness

Background

Oral dryness is a common symptom that may interfere with swallowing, chewing, and taste. The most common reason for oral dryness is hyposalivation. Some individuals experiencing oral dryness do not have hyposalivation, however, and the reverse is also true. Here, we focused on healthy individuals with a lower salivary flow rate and evaluated the relationship between the perception of oral dryness and salivary parameters to clarify the cause underlying the perception of oral dryness.

Methods

A total of 59 participants were divided into 2 groups with a lower or higher salivary flow rate according to the median salivary flow rate. In participants with a lower salivary flow rate, we assessed salivary bacterial counts, protease activities, protein concentrations, oral parameters, and the subjective perception of oral dryness.

Results

Protease activities and concentrations of protease inhibitors such as cystatin-D and cystatin-SA in the saliva of participants experiencing oral dryness were significantly higher and lower, respectively, than in those not experiencing oral dryness, even though no difference in the salivary flow rate was detected. Salivary cystatin-D and cystatin-SA concentrations correlated negatively with salivary protease activities.

Conclusions

The composition of salivary protease inhibitors and increased protease activities affect the subjective perception of oral dryness.

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

OBJECTIVES

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

CONCLUSION

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

Anticholinergic medication: Related dry mouth and effects on the salivary glands

OBJECTIVE

Salivary glands are among the most sensitive target organs of medications with anticholinergic (AC) properties, interrupting the neural stimulation of saliva secretion and reducing saliva flow. Hyposalivation results in dry mouth, leading to dental caries, intraoral infection, orofacial pain, problems with speaking and swallowing, and diminished oral health--related quality of life. Current understanding of the pharmacokinetics of AC medications and their effect on muscarinic receptors in the salivary glands were reviewed to assist clinicians in predicting salivary damage in patients with AC medication-induced dry mouth.

STUDY DESIGN

We summarized the literature related to the mechanisms and properties of AC medications, anticholinergic adverse effects, and their effect on salivary function and management strategies to prevent oral health damage.

RESULTS

Although a large number of studies reported on the frequencies of medication-induced dry mouth, we found very limited data on predicting individual susceptibility to AC medication--caused hyposalivation and no prospective clinical studies addressing this issue.

CONCLUSION

Dry mouth is most frequently caused by medications with AC properties, which interrupt the neural stimulation of saliva secretion. Interdisciplinary care should guide pharmacotherapeutics and dental interventions should aim in preventing AC salivary adverse effects and reducing the oral health burden from AC medication-induced dry mouth.

Oral health-related quality of life and associated factors in patients with xerostomia

OBJECTIVE

This study aimed to investigate clinical and demographic factors associated with oral health-related quality of life (OHRQoL) in patients with xerostomia.

METHODS

Forty-one patients (55.2 ± 13.8 years) with xerostomia as a chief complaint participated in the study. Comprehensive information about clinical and demographic characteristics of the patients with xerostomia, xerostomia-related symptoms and behaviours, and xerostomia-associated complaints was investigated using a xerostomia questionnaire. Flow rates of unstimulated and stimulated whole saliva were measured. The Oral Health Impact Profile-14 (OHIP-14) score was used to assess the OHRQoL of patients. The relationships between various factors and the OHIP-14 score were assessed by simple and multiple linear regression analyses.

RESULTS

The OHIP-14 score of patients with xerostomia was high (44.3 ± 13.2). Characteristics of the patients with xerostomia associated with high OHIP-14 score were the intensity of xerostomia-related symptoms, frequency of xerostomia-related behaviours and the presence of speaking difficulty. Results from multiple linear regressions found that self-reported amount of saliva in usual, everyday life (β = 0.622, p = 0.012) and the presence of a speaking difficulty (β = 0.348, p = 0.014) had significant adversely affected the OHRQoL in patients with xerostomia.

CONCLUSIONS

Subjective perceptions of the amount of saliva in the mouth and the experience of speaking difficulty affected the OHRQoL in patients with xerostomia.

Effects of Domiciliary Professional Oral Care for Care-Dependent Elderly in Nursing Homes - Oral Hygiene, Gingival Bleeding, Root Caries and Nursing Staff's Oral Health Knowledge and Attitudes

Purpose

The primary aim was to describe the effects for nursing home residents of monthly professional cleaning and individual oral hygiene instruction provided by registered dental hygienists (RDHs), in comparison with daily oral care as usual. The secondary aim was to study the knowledge and attitudes among nursing staff regarding oral health care and needs.

Patients and Methods

In this randomised controlled trial (RCT), 146 residents were recruited from nine nursing homes in Regions of Stockholm and Sörmland and were randomly assigned (on nursing home level) to either intervention group (I; n=72) or control group (C; n=74). Group I received monthly professional cleaning, individual oral hygiene instructions and information given by an RDH. Group C proceeded with daily oral care as usual (self-performed or nursing staff-assisted). Oral health-related data was registered with the mucosal-plaque score index (MPS), the modified sulcus bleeding index (MSB), and root caries. The nursing staff’s attitudes and knowledge were analysed at baseline and at six-month follow-up. Statistical analysis was performed by Fisher’s exact test and two-way variance analysis (ANOVA).

Results

Improvements were seen in both Group I and Group C concerning MPS, MSB and active root caries. The nursing staff working with participants in Group I showed significant improvements regarding the Nursing Dental Coping Beliefs Scale (DCBS) in two of four dimensions, oral health care beliefs (p=0.0331) and external locus of control (p=0.0017) compared with those working with Group C. The knowledge-based questionnaire showed improvement (p=0.05) in Group I compared with Group C.

Conclusion

Monthly professional oral care, combined with individual oral health care instructions, seems to improve oral hygiene and may reduce root caries among nursing home residents. This may also contribute to a more positive attitude regarding oral hygiene measures among nursing home staff, as compared with daily oral care as usual.

Bone turnover markers in serum but not in saliva correlate with bone mineral density

Saliva was proposed as a diagnostic tool for systemic diseases. Here we determined the correlation of bone turnover markers in saliva, bone turnover markers in serum and bone mineral density in postmenopausal osteoporotic and healthy women. Forty postmenopausal osteoporotic and 40 age-matched healthy non-osteoporotic females were recruited for this case–control study. Serum and stimulated saliva levels of osteocalcin, N-terminal propeptide of type I collagen, bone-specific alkaline phosphatase and cross-linked-C-telopeptide of type I collagen were determined. Bone mineral density of the lumbar spine, proximal femur, and total hip were obtained. We show that osteocalcin and cross-linked-C-telopeptide of type I collagen (CTX) reached detectable levels in saliva while N-terminal propeptide of type I collagen and alkaline phosphatase were close or below the detection limit. Serum levels of bone turnover markers were significantly higher than saliva levels. Correlation analysis revealed a strong correlation of serum osteocalcin and, to a lesser extent, also serum CTX values with bone mineral density in lumbar spine, femoral neck, or total hip, respectively. There was, however, no significant correlation of bone mineral density with the respective bone turnover markers in saliva. There was a trend that saliva osteocalcin correlates with femoral neck (p = 0.16) or total hip (p = 0.06). There was also no association between serum and saliva bone turnover markers. This study reveals that saliva cannot replace the withdrawal of serum to evaluate bone metabolism.

Prevalence of Dental Caries among Smoking and Smokeless Tobacco Users Attending Dental Hospital in Eastern Region of Uttar Pradesh

Introduction:

The relationship of tobacco use to dental caries is still unclear. The aim of this study is to assess the relationship between smoking and smokeless tobacco usage and prevalence of dental caries and its pattern in the Varanasi population.

Materials and Methods:

In this study, 472 elderly dentate and consenting individuals were included. Individuals were examined with the aid of mouth mirror, No. 23 explorer, and cotton rolls. The age of the study group ranged from 16 years to 75 years. Individuals were categorized as smoking tobacco users, smokeless tobacco users, and the combination of these two. Frequency and dosage of tobacco usage was recorded. Dental caries was measured using decayed, missing, and filled teeth (DMFT) index. Oral hygiene practices such as mode, material, and frequency of brushing were also recorded. Data were assessed using SPSS 17.0 using Chi-square, t-test, ANOVA test, and binary regression.

Results:

Caries rate was similar in both males and females (2.57 and 2.70), and the difference was not statistically significant. Caries was higher in individuals with habits when compared to those who were not having habits. There was no statistically significant association between individuals who were smokers, using smokeless tobacco, frequency, mode, and material of brushing with caries pattern. Among smokers, DMFT increased with frequency and duration of smoking, and it was statistically significant; however, in smokeless tobacco users, this was not the case. There was a positive correlation with DMFT and frequency of smoking.

Conclusion:

The study has shown that tobacco habit is a risk factor for increased caries activity, and it is higher in smokers as compared to smokeless tobacco chewers.

Toward better outcomes in Sjögren's syndrome: The promise of a stratified medicine approach

Sjögren's syndrome is a systemic autoimmune disease defined by its targeted inflammation of the salivary and lacrimal glands, resulting in dry mouth and eyes in the majority and persistent or recurrent salivary gland enlargement in a minority of those affected. Involvement of major organs, an increased risk of lymphoma, and autoantibodies against ubiquitous cellular ribonucleoproteins define some of its systemic features. Those affected have a high symptom burden and the development of disease-modifying therapies is thus an urgent need. A stratified medicine approach offers promise as a means of targeting specific therapies to patients for whom the mechanism of action is most relevant. Implementation of this approach will require an understanding of the pathophysiological processes underlying different patient subsets, and then identifying or developing a drug that targets this pathway. Such therapies would be most effective if implemented early in the disease course before the advent of adverse outcomes or glandular damage. This review will provide a disease overview followed by an analysis of the feasibility of a stratified medicine approach, focusing on the disease heterogeneity, predictors of disease progression and adverse outcomes, and recent advances in the development of relevant outcome measures and new therapies.

Investigation of the relationship between sleep disorders and xerostomia

OBJECTIVES

To investigate the relationship between sleep disorders, morning hyposalivation, and subjective feeling of dry mouth.

MATERIALS AND METHODS

A cross-sectional, observational, clinical study was carried out in a homogenous population sample which consists of Greek male soldiers without any medical history. After the application of oral modified Schirmer test, the sample was divided into a study group (n = 63) (MST < 25 mm/3 min) and a control group (n = 110) (MST ≥ 25 mm/3 min). In order to assess daytime sleepiness, risk of obstructive sleep apnea (OSA), sleep quality, sleep bruxism (SB), and subjective feeling of dry mouth, all the participants filled in the following scales in Greek version: Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Berlin Questionnaire (BQ), a SB questionnaire, and Xerostomia Inventory (XI) respectively. In every subgroup that came of ESS, PSQI, BQ, and SB questionnaire scoring, subjective feeling of dry mouth was evaluated, based on XI values.

RESULTS

Statistically significant difference (p < 0.001) through PSQI scores was found between the study and control group. In contrast, a statistically significant difference was not obtained for the scores of ESS (p = 0.293), BQ (p = 0.089), and SB questionnaire (p = 0.730). XI scores introduced statistically significant difference between the subgroups of PSQI (p < 0.001), BQ (p = 0.001), SB questionnaire (p = 0.004)  and statistically weak between the subgroups of ESS (p = 0.049).

CONCLUSIONS

This is the first research study so far suggesting that patients with morning hyposalivation exhibit poor sleep quality using an objective method. The present results have, also, shown that subjective feeling of dry mouth is related to excessive daytime sleepiness, poor sleep quality, high risk of obstructive sleep apnea, and sleep bruxism, but larger-scale studies are still needed.

CLINICAL RELEVANCE

These findings should keep dentists aware of a possible association between xerostomia and sleep disorders and support larger-scale studies.

Update on Sjögren Syndrome and Other Causes of Sicca in Older Adults

Dry eye and dry mouth symptoms are each reported by up to 30% of persons more than 65 years of age, particularly in women. Medication side effects are the most common contributing factors. The evaluation of these symptoms requires measures of ocular and oral dryness. Sjögren syndrome is the prototypical disease associated with dryness of the eyes and mouth and predominantly affects women in their perimenopausal and postmenopausal years. In addition to topical treatment of the mucosal dryness, patients with Sjögren syndrome may require treatment with systemic immunomodulatory and immunosuppressive agents to manage a variety of extraglandular manifestations.

Sjögren Syndrome and Other Causes of Sicca in Older Adults

Dry eye and dry mouth symptoms are each reported by up to 30% of persons more than 65 years of age, particularly in women. Medication side effects are the most common contributing factors. The evaluation of these symptoms requires measures of ocular and oral dryness. Sjögren syndrome is the prototypic disease associated with dryness of the eyes and mouth and predominantly affects women in their perimenopausal and postmenopausal years. In addition to topical treatment of the mucosal dryness, patients with Sjögren syndrome may require treatment with systemic immunomodulatory and immunosuppressive agents to manage a variety of extraglandular manifestations.

Diagnostic performance of MR imaging of three major salivary glands for Sjögren's syndrome

OBJECTIVE

We analyzed the diagnostic performance of the MR imaging findings of the parotid, submandibular, and sublingual glands to discriminate between patients with and without Sjögren's syndrome.

METHODS

We retrospectively analyzed the correlation between the MR imaging and histopathological findings obtained from 69 patients with clinically suspected Sjögren's syndrome. We evaluated the heterogeneous signal intensity distribution on T1- and T2-weighted images, the multiple high-signal-intensity spots on MR sialograms, and the volume of the parotid, submandibular, and sublingual salivary glands.

RESULTS

The multiple high-signal-intensity spots in the parotid gland showed the highest sensitivity and diagnostic accuracy (82% and 83%, respectively). In addition, the multiple high-signal-intensity spots and the heterogeneous signal intensity distribution in the submandibular gland showed high specificity (100% and 88%, respectively). The volume of the submandibular gland, but not that of the parotid or sublingual gland, was smaller in patients with Sjögren's syndrome.

CONCLUSIONS

The presence of multiple high-signal-intensity spots on an MR sialogram in the parotid gland should be considered the best diagnostic indicator for Sjögren's syndrome. The presence of spots, heterogeneity, and the change to smaller volumes in the submandibular gland were also helpful because of their high specificity, particularly in advanced cases.

The Differential Diagnosis of Dry Eyes, Dry Mouth, and Parotidomegaly: A Comprehensive Review

Primary Sjögren's syndrome (pSS) is a frequent autoimmune systemic disease, clinically characterized by eyes and mouth dryness in all patients, salivary gland swelling or extraglandular systemic manifestations in half of the patients, and development of lymphoma in 5 to 10 % of the patients. However, patients presenting with sicca symptoms or salivary gland swelling may have a variety of conditions that may require very different investigations, treatments, or follow-up. Eye and/or mouth dryness is a frequent complaint in clinical setting, and its frequency increases with age. When evaluating a patient with suspected pSS, the first step is to rule out its differential diagnoses, before looking for positive arguments for the disease. Knowledge of normal and abnormal lachrymal and salivary gland physiology allows the clinician to prescribe the most adapted procedures for evaluating their function and structure. New tests have been developed in recent years for evaluating these patients, notably new ocular surface staining scores or salivary gland ultrasonography. We describe the different diagnoses performed in our monocentric cohort of 240 patients with suspected pSS. The most frequent diagnoses are pSS, other systemic autoimmune diseases, idiopathic sicca syndrome and drug-induced sicca syndrome. However, other diseases are important to rule out due to their specific management, such as sarcoidosis, granulomatosis with polyangeitis, IgG4-related disease, chronic hepatitis C virus or human immunodeficiency virus infections, graft-versus-host disease, and head and neck radiation therapy. At the light of these data, we propose a core of minimal investigations to be performed when evaluating a patient with suspected pSS.

Effects of Change in Tongue Pressure and Salivary Flow Rate on Swallow Efficiency Following Chemoradiation Treatment for Head and Neck Cancer

Patients treated with chemoradiation for head and neck cancer frequently develop dysphagia. Tissue damage to the oral tongue causing weakness along with decreases in saliva production may contribute to dysphagia. Yet, effects of these variables on swallowing-related measures are unclear. The purpose of this study was (1) to determine effects of chemoradiation on tongue pressures, as a surrogate for strength, and salivary flow rates and (2) to elucidate relationships among tongue pressures, saliva production, and swallowing efficiency by bolus type. Twenty-one patients with head and neck cancer treated with chemoradiation were assessed before and after treatment and matched with 21 healthy control participants who did not receive chemoradiation. Each participant was given a questionnaire to rate dysphagia symptoms. Videofluoroscopic Evaluation of Swallowing (VFES) was used to determine swallowing efficiency; the Saxon test measured salivary flow rate; and the Iowa Oral Performance Instrument (IOPI) was used for oral tongue maximum and endurance measures. Results revealed significantly lower tongue endurance measures for patients post-treatment as compared to controls (p = .012). Salivary flow rates also were lower compared to pre-treatment (p = .000) and controls (p = .000). Simple linear regression analyses showed that change in salivary flow rate was predictive of change in swallow efficiency measures from pre- to post-treatment for 1 mL thin liquid (p = .017), 3 mL nectar-thick liquid (p = .026), and 3 mL standard barium pudding (p = .011) boluses. Based on these findings, it appears that chemoradiation treatment affects tongue endurance and salivary flow rate, and these changes may impact swallow efficiency. These factors should be considered when planning treatment for dysphagia.

Xerostomia among older home care clients

OBJECTIVES

The purpose of this study was to examine drug use and other factors associated with xerostomia in home care clients aged 75 years or older.

METHODS

The study sample included 270 home care clients aged ≥75 years living in Eastern and Central Finland. The home care clients underwent in-home interviews carried out by trained home care nurses, nutritionists, dental hygienists and pharmacists. The collected data contained information on sociodemographic factors, health and oral health status, drug use, depressive symptoms (GDS-15), cognitive functioning (MMSE), functional ability (Barthel Index, IADL) and nutrition (MNA). The primary outcome was xerostomia status (never, occasionally or continuously).

RESULTS

Among the home care clients, 56% (n = 150) suffered from xerostomia. Persons with continuous xerostomia used more drugs and had more depressive symptoms and a higher number of comorbidities than other home care clients. In multivariate analyses, excessive polypharmacy (OR = 1.83, 95% Cl 1.08-3.10) and depressive symptoms (OR = 1.12, 95% Cl 1.03-1.22) were associated with xerostomia.

CONCLUSIONS

Xerostomia is a common problem among old home care clients. Excessive polypharmacy, use of particular drug groups and depressive symptoms were associated with xerostomia. The findings support the importance of a multidisciplinary approach in the care of older home care clients.

Xerostomia in geriatric patients: a burgeoning global concern

Saliva plays a key role in maintaining oral homeostasis, function, and health. The prevalence of xerostomia and its consequences are rising due to the increasing aging population, the effects of some systemic diseases, medical management, and commonly-prescribed medications that reduce saliva production. When salivary function is diminished, patients are at a greater risk of developing caries, discomfort in wearing dentures, and opportunistic diseases, such as candidiasis. The psychosocial aspects of xerostomia can range from a mild effect on self-rated oral health to frustration, embarrassment, unhappiness, or substantial disruptions in quality of life. This article reviews the clinical features, diagnosis, and prevalence of dry mouth, as well as its treatment strategies.

Role of oral glutamine in alleviation and prevention of radiation-induced oral mucositis: A prospective randomized study

Background:

Oral mucositis is the most frequently occurring painful and dose-limiting side-effect of radiation of the head and neck region. Few studies demonstrated that oral glutamine suspension may significantly reduce the duration and severity of objective oral mucositis during radiotherapy.

Materials and Methods:

A randomized, prospective single institutional case control study was performed between April 2012 and November 2012 comparing the influence of oral glutamine on radiation induced mucositis in head and neck malignancy patients. Seventy biopsy proven patients with head and neck cancer receiving primary or adjuvant radiation therapy were randomized to receive either oral glutamine suspension daily 2h before radiation in the study arm (10 g in 1000 ml of water) (n = 35) or nothing before radiation; control arm (n = 35).

Results and Analysis:

Total 32 patients (91.43%) in the glutamine arm and total 34 patients (97.15%) developed mucositis. Grade 3 mucositis (14.29%) and grade 4 mucositis (2.86%) in the study arm (who received oral glutamine) were significantly less (P = 0.02 and P = 0.04, respectively) in the glutamine arm. The mean duration of grade 3 or worse mucositis (grade 3 and grade 4) was significantly less (6.6 days vs. 9.2 days) in study arm with P < 0.001. Mean time of onset of mucositis was significantly delayed in patients who took glutamine in comparison to control arm with P < 0.001.

Conclusion:

Glutamine delays oral mucositis in the head neck cancer patients. Moreover, it reduces the frequency and duration of grade 3 and grade 4 mucositis.

Findings from the oral health study of the Danish Health Examination Survey 2007-2008

OBJECTIVE

The aims of the oral part of the Danish Health Examination Survey (DANHES 2007-2008) were (1) to establish an oral health database for adult Danes and (2) to explore the influence of general diseases and lifestyle on oral health. This paper presents the study population, examination methods, questionnaire and baseline results.

MATERIALS AND METHODS

The study population comprised 4402 subjects, aged 18-96, consecutively enrolled from 18 065 DANHES participants from 13 municipalities in Denmark. The oral part consisted of a validated questionnaire and a clinical examination, carried out in mobile units by three trained and calibrated dental hygienists. The data were processed with descriptive statistics and mono- and bivariate analyses.

RESULTS

The mean age was 54.1 years and 60% were women. The mean number of natural teeth was 26.6; the mean DMFT/DMFS values were 18.9 and 61.0, and varied with age (DMFT 8.7-24.3). A higher proportion of females suffered from dental erosion in the younger age groups. Forty per cent of all subjects had a mean clinical attachment loss ≥ 3 mm, varying from 4% among those aged 18-34 to 80% in those over 75. A sub-optimal saliva secretion rate was more common among females than males (17.7% vs 10.4%) and this was reflected by the reported frequency of dry mouth.

CONCLUSION

This extensive cross-sectional study provides a platform for obtaining future knowledge of the impact of health- and lifestyle-related factors on oral diseases. The validated questionnaire and the clinical characteristics enable robust analyses, although the conclusions may be hampered by limited external validity.

Prevalence of Candida spp., xerostomia, and hyposalivation in oral lichen planus--a controlled study

OBJECTIVE

To determine the frequency of Candida spp., xerostomia, and salivary flow rate (SFR) in three different groups: patients with OLP (OLP group), patients with oral mucosal lesions other than OLP (non-OLP group), and subjects without oral mucosal lesions (control group).

MATERIAL AND METHODS

Xerostomia as well as SFR was investigated in the three groups. Samples for isolation of Candida spp. were collected from OLP lesions (38 patients), non-OLP lesions (28 patients), and healthy subjects (32 subjects).

RESULTS

There was no statistically significant difference regarding the frequency of xerostomia and hyposalivation among the three groups (P > 0.05). A higher prevalence for colonization by Candida spp. was found in the healthy subject as compared to that of patients with OLP (P = 0.03) and non-OLP (P = 0.02) groups. Low SFR was not a factor for colonization by Candida spp.

CONCLUSIONS

Xerostomia and hyposalivation occur with similar frequency in subjects with and without oral lesions; also, the presence of oral lesions does not increase the susceptibility to colonization by Candida spp. It seems that any study implicating Candida spp. in the malignant transformation of oral lesions should be carried out mostly on a biochemical basis, that is, by testing the capability of Candida spp. to produce carcinogenic enzyme.

Tobacco and dental caries: a systematic review

OBJECTIVE

Despite the abundance of evidence linking tobacco consumption to many oral conditions, no systematic review of the relationship with dental caries is available. The main aim of this systematic review was, therefore, to evaluate the effect of tobacco smoking on dental caries in adult smokers.

MATERIALS AND METHODS

According to the PRISMA checklist, observational studies published from January 1991 to June 2011 were reviewed. The quality of evidence for each finding was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

Five studies, four related to dental caries and one on oral bacteria activity, were finally included in a qualitative analysis; they were all cross-sectional studies. As a result, the overall quality of evidence was poor, with two articles given a score of very low and three a score of low according to GRADE.

CONCLUSIONS

Tobacco smoking was found to be associated with an increased risk of dental caries. However, the overall poor quality of studies produced no validation for such an association. Further, more extensive research on this topic and prospective studies are needed.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Xerostomia in complete denture wearers: prevalence, clinical findings and impact on oral functions

OBJECTIVES

To investigate the prevalence of dry mouth in a select sample of edentulous Jordanian older population wearing complete dentures and to evaluate its impact on oral functions.

BACKGROUND

The prevalence and impact of Xerostomia as a cofactor in causing denture problems in Jordanians have not been previously investigated.

MATERIALS AND METHODS

This study included 455 participants (253 men and 202 women). Perception of dry mouth was measured by a pilot-tested questionnaire. Xerostomic status was confirmed clinically. Complete denture function was also assessed.

RESULTS

One hundred and thirty six subjects (29.9%) had reported a subjective feeling of dry mouth with a prevalence of 24.9% in men (n = 63) and 36.1% in women (n = 73) (p < 0.01). 136 of the 145 subjects with satisfactory dentures showed one or more signs suggestive of Xerostomia. The majority of xerostomic participants with different sets of complete dentures were dissatisfied with oral functions (p < 0.05). There was a significant association between dry mouth and increasing age, female gender and smoking status (p < 0.05).

CONCLUSION

Among complete denture wearers, Xerostomia is significantly more prevalent in women and associated with increased age and smoking. Xerostomia adversely affects oral functions and overall satisfaction with dentures.

A systematic review of methods to diagnose oral dryness and salivary gland function

Background

The most advocated clinical method for diagnosing salivary dysfunction is to quantitate unstimulated and stimulated whole saliva (sialometry). Since there is an expected and wide variation in salivary flow rates among individuals, the assessment of dysfunction can be difficult. The aim of this systematic review is to evaluate the quality of the evidence for the efficacy of diagnostic methods used to identify oral dryness.

Methods

A literature search, with specific indexing terms and a hand search, was conducted for publications that described a method to diagnose oral dryness. The electronic databases of PubMed, Cochrane Library, and Web of Science were used as data sources. Four reviewers selected publications on the basis of predetermined inclusion and exclusion criteria. Data were extracted from the selected publications using a protocol. Original studies were interpreted with the aid of Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool.

Results

The database searches resulted in 224 titles and abstracts. Of these abstracts, 80 publications were judged to meet the inclusion criteria and read in full. A total of 18 original studies were judged relevant and interpreted for this review. In all studies, the results of the test method were compared to those of a reference method.

Based on the interpretation (with the aid of the QUADAS tool) it can be reported that the patient selection criteria were not clearly described and the test or reference methods were not described in sufficient detail for it to be reproduced. None of the included studies reported information on uninterpretable/intermediate results nor data on observer or instrument variation. Seven of the studies presented their results as a percentage of correct diagnoses.

Conclusions

The evidence for the efficacy of clinical methods to assess oral dryness is sparse and it can be stated that improved standards for the reporting of diagnostic accuracy are needed in order to assure the methodological quality of studies. There is need for effective diagnostic criteria and functional tests in order to detect those individuals with oral dryness who may require oral treatment, such as alleviation of discomfort and/or prevention of diseases.

Factors associated with dry mouth in dependent Japanese elderly

OBJECTIVES

To identify factors associated with dry mouth.

BACKGROUND

Dry mouth adversely affects oropharyngeal health, particularly in elderly, and can lead to pneumonia. A better understanding of the epidemiology of dry mouth is therefore important in improving treatment strategies and oral health in high-risk elderly patients.

METHODS

We conducted a cross-sectional study involving 383 dependent Japanese elderly individuals (65-84 [n = 167] and ≥85 [n = 216] years) at eight long-term care facilities and hospitals. Thirty-four potential factors associated with dry mouth were examined by multiple logistic regression analysis. The primary outcome was dry mouth, as diagnosed by tongue dorsum moisture.

RESULTS

We identified that body mass index and severity of physical disability were identified as a potential factors associated with dry mouth in the super-elderly (≥85 years) group, whereas severity of physical disability, outcome measurement time, high daily water consumption, mouth breathing, use of antidepressants and diuretics, and high frequency of daily brushing (≥2 times per day; Odds ratio: 5.56; 95% Confidence Interval: 1.52-20.00) were associated with dry mouth in the 65- to 84-year-old group.

CONCLUSION

To our knowledge, this is the first study to identify a link between frequency of daily brushing and dry mouth and suggests that tooth brushing should be encouraged in high-risk dependent Japanese elderly (65-84 years), particularly those taking antidepressants and/or diuretics.

Xerostomia and salivary hypofunction in vulnerable elders: prevalence and etiology

OBJECTIVE

The goal of this article is to review existing research on the prevalence and etiology of dry mouth in the vulnerable elders and identify knowledge gaps.

STUDY DESIGN

Vulnerable elders (VE) are persons aged >65 years who have any or all of the following: limited mobility, limited resources, or complex health status. A systematic search was conducted of PubMed sources from 1989 to May 2010. Evidence was evaluated on the prevalence and etiology of xerostomia and salivary gland hypofunction (SGH) in VE.

RESULTS

The search identified 1,422 publications. The inclusion/exclusion criteria yielded 348 articles, 80 of which are cited herein.

CONCLUSIONS

Research has showed a high prevalence of xerostomia and SGH in VE. Common etiologies include medications, poor general health, female gender, and age. Gaps still exist in the evaluation of dry mouth in VE. Nonetheless, oral dryness will remain an important health issue as life expectancy increases.

Relationship between hyposalivation and acute respiratory infection in dental outpatients

BACKGROUND

Hyposalivation may affect respiratory disease because the mouth serves as the entrance to the respiratory apparatus, as well as to the digestive tract. Patients with acute respiratory infection generally have a favorable prognosis and a short natural course. However, in cases in which the host has lowered resistance, such as in elderly patients, the infection may develop into pneumonia.

OBJECTIVES

A prospective study was performed to examine the relationship between hyposalivation, which is common in elderly patients, and acute respiratory infection, which tends to become severe in elderly patients.

METHODS

The subjects were 323 male and female patients ≥40 years old who lived in Utsunomiya City and surrounding areas and regularly visited the Department of Dentistry and Oral Surgery, Tochigi National Hospital. A 6-month follow-up survey was performed to examine development of acute respiratory infection. Age, sex, and known risk factors were also investigated. Hyposalivation was defined as a saliva production (saliva secretion rate) of ≤0.6 ml/min. Multivariate analysis adjusted for age and sex was performed to examine potential risk factors associated with the development of acute respiratory infection.

RESULTS

Data were analyzed for 278 subjects who completed the follow-up survey. The incidence of acute respiratory infection was 60.4%, while hyposalivation was present in 96 subjects (35.5%). Multivariate analysis showed that the incidence of acute respiratory infection was higher in subjects with hyposalivation than in those without hyposalivation (adjusted odds ratio 1.761, p = 0.048).

CONCLUSION

The results of this study suggest that hyposalivation may be a risk factor for acute respiratory infection. This also suggests that improvement of hyposalivation might prevent acute respiratory infection.

Relationships between the amount of saliva and medications in elderly individuals

OBJECTIVE

To investigate medications that are related to volume of saliva in the elderly.

BACKGROUND DATA

In the elderly, many cases of mouth dryness may represent side effects of medication.

MATERIALS AND METHODS

The volume of unstimulated saliva was measured for 30 s (cotton roll test), and with stimulation for 3 min (gum test) in 368 subjects 79-80 years old (177 men, 191 women). Medications were investigated using subject's medication notebooks.

RESULTS

Mean volumes of unstimulated and stimulated saliva were 0.14±0.13 and 4.30±2.54 ml respectively. Significant differences were seen between gender and mean volume of saliva. The volume of unstimulated saliva was 0.16±0.15 ml for men and 0.11±0.10 ml for women. The volume of stimulated saliva was 4.99±2.67 ml for men and 3.67±2.25 ml for women. The percentage of subjects taking medication was 64.7% (238/368). Mean number of medications was 2.08±2.26, with no significant difference with gender (2.01±2.37 for men, 2.16±2.16 for women). In a stepwise multiple regression analysis with volume of saliva as the objective variable and number of drugs by category as explanatory variables, significant explanatory variables in addition to gender and number of medications were blood-coagulating agents, Ca antagonists and peptic ulcer drugs for volume of unstimulated saliva, and diabetes medications and peptic ulcer drugs for volume of stimulated saliva.

CONCLUSION

These findings suggest that differences exist between gender in volume of saliva for elderly individuals, and that the volume of saliva is affected by the number and type of medications.

Poor chewing ability is associated with lower mucosal moisture in elderly individuals

Oral dryness is common among aging individuals and its objective evaluation is an important issue for improving their oral health. In the present study, we measured the objective mucosal moisture in elderly individuals with a moisture checker and evaluated its relation with laboratory findings and subjective oral status. The subjects were 502 adults (244 men and 258 women), with a mean age of 72.3 +/- 6.7 years, who participated in a regular medical screening program in Nagasaki Prefecture, Japan. We evaluated the moisture of the oral mucosa by measuring the weight percentage of water content in the oral epithelium, subjective oral dryness, self-assessed chewing ability ["good" ("able to chew all foods") or "poor" ("able to chew soft foods only" and "unable to chew any foods")], and laboratory findings. The values obtained with a moisture checker, which represent objective oral mucosal moisture, were significantly lower in women with poor chewing ability than those with good chewing ability (28.2 +/- 2.4% vs. 29.2 +/- 2.0%, p = 0.004) and in all subjects (28.4 +/- 2.4% vs. 29.1 +/- 2.0%, p = 0.004), but not in men (28.6 +/- 2.5% vs. 29.0 +/- 2.0%, p = 0.27). When multiple logistic regression analysis was performed on confounding factors, older age (OR: 1.24, p = 0.015), women (OR: 1.70, p = 0.016), and anemia (OR: 1.96, p = 0.030) were significantly associated with self-assessed chewing ability. Our current study indicates that poor chewing ability is associated with lower mucosal moisture in elderly individuals.

Oral complaints and stimulated salivary flow rate in 1188 adults

BACKGROUND

Recently, oral sensory complaints (OSC) were proposed as a disease entity to represent idiopathic sensory disturbances of dry mouth, burning mouth, and taste disturbance, even though neither the status of OSC in the general population nor its underlying mechanism has yet been elucidated. Moreover, these three OSC-related complaints have not been assessed in combination by means of a visual analog scale (VAS) in a large-scale, community-dwelling population of a broad age range.

METHODS

In a 1188-member community-dwelling adult population, comprised of 373 males and 815 females, aged 20-90 years, the three OSC-related complaints and stimulated salivary flow rate (SSFR) were assessed by means of a VAS and modified Saxon test, respectively. Association of each complaint with age, gender, SSFR, and other complaints was analyzed.

RESULTS

Increases in both prevalence and intensity of subjective dry mouth and burning mouth were associated closely with decreasing SSFR. Even for taste disturbance, which may be affected less significantly by salivation status than the other two complaints, a significant association was suggested between decreasing SSFR and especially severe taste disturbance. However, these oral complaints were found in considerable prevalence even in the individuals with high SSFR. Often overlapping presentation of these complaints and a close association in intensity between the complaints to each other were also found.

CONCLUSIONS

Hyposalivation may be a significant and common etiology for the three oral complaints, although the considerable prevalence of complaints without hyposalivation suggests other etiologies, including those related to the OSC.

Path generator control system and virtual compliance calculator for maxillofacial massage robots

PURPOSE

Oral disorders such as temporomandibular joint disorders (TMD) and dry mouth are common and often require treatment. Maxillofacial massage is used as a complementary and alternative therapy for these disorders. We developed an oral rehabilitation robot that massages the maxillofacial tissues for this purpose. In this paper, we propose a control system for oral rehabilitation robots.

METHOD

The control system consists of a massage path generator, virtual compliance calculator, and inverse kinematics calculator. The massage path generator computes a target massage path based on a human head model obtained from a reference MRI image of an adult male. The head model includes the shape and elastic modulus of each component, all of which were obtained experimentally. Virtual compliance control is used to control manipulators with position servo actuators. The manipulators, which have a force sensor at their end-effectors, move actively in the direction of the external force applied to their sensors via virtual compliance control. We implemented this control in WAO-1, our first prototype oral rehabilitation robot.

RESULTS

WAO-1 provided massage to three adult male subjects with and without virtual compliance control. One of the subjects was the adult male whose MRI image was used to synthesize the head model in the massage path generator. Without virtual compliance control, the actual massage force was greater than the target massage force, while that with virtual compliance control was less than the target massage force. Furthermore, with virtual compliance control, the massage paths conformed to the head shape of each patient.

CONCLUSION

Implementation of virtual compliance control in the WAO-1 massage robot is feasible and useful for implementation of safe and potentially effective maxillofacial massage therapy.

Development and Experimental Evaluation of Oral Rehabilitation Robot that Provides Maxillofacial Massage to Patients with Oral Disorders

We have developed an oral-rehabilitation robot WAO-1 (Waseda Asahi Oral-rehabilitation robot No. 1) for use in cases of oral disorders such as temperomandibular joint (TMJ) disorder and dry mouth. WAO-1 is the first robot designed to provide massage to the facial tissues of a patient with oral disorders. This robot provides massage to the masseter and temporal muscles and to the parotid gland and duct with simple operation. It consists of two six-degree-of-freedom arms with plungers, a body with headrest, a control box, a PC, and an automatic massage trajectory generation system with virtual compliance control. Two evaluation experiments were performed to verify the effectiveness of the oral massages of WAO-1 compared with the massages given by doctors. In the experiments, the massage to the parotid gland and duct by WAO-1 increased the amount of saliva in the subjects, and the massage to the masseter muscle by WAO-1 increased facial skin temperature and width of the masseter muscle in the subjects. We consider that these results indicate that massage by WAO-1 can be effective for patients with oral disorders.