World Workshop on Oral Medicine VI: a systematic review of medication-induced salivary gland dysfunction

Efficacy of natural enzymes mouthwash: a randomised controlled trial

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

CLINICAL TRIAL REGISTRATION NUMBER

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

Current developments and opportunities of pluripotent stem cells-based therapies for salivary gland hypofunction

Salivary gland hypofunction (SGH) caused by systemic disease, drugs, aging, and radiotherapy for head and neck cancer can cause dry mouth, which increases the risk of disorders such as periodontitis, taste disorders, pain and burning sensations in the mouth, dental caries, and dramatically reduces the quality of life of patients. To date, the treatment of SGH is still aimed at relieving patients' clinical symptoms and improving their quality of life, and is not able to repair and regenerate the damaged salivary glands. Pluripotent stem cells (PSCs), including embryonic stem cells (ESCs), induced pluripotent stem cells (iPSCs), and extended pluripotent stem cells (EPSCs), are an emerging source of cellular therapies that are capable of unlimited proliferation and differentiation into cells of all three germ layers. In recent years, the immunomodulatory and tissue regenerative effects of PSCs, their derived cells, and paracrine products of these cells have received increasing attention and have demonstrated promising therapeutic effects in some preclinical studies targeting SGH. This review outlined the etiologies and available treatments for SGH. The existing efficacy and potential role of PSCs, their derived cells and paracrine products of these cells for SGH are summarized, with a focus on PSC-derived salivary gland stem/progenitor cells (SGS/PCs) and PSC-derived mesenchymal stem cells (MSCs). In this Review, we provide a conceptual outline of our current understanding of PSCs-based therapy and its importance in SGH treatment, which may inform and serve the design of future studies.

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.

Factors influencing xerostomia and oral health-related quality of life in polymedicated patients

OBJECTIVES

To evaluate whether the severity of xerostomia in older polymedicated patients impacts oral health-related quality of life (OHRQoL).

BACKGROUND

Medication-associated xerostomia is common in older people. Xerostomia may impair OHRQoL.

MATERIALS AND METHODS

This cross-sectional study included older hypertensive patients from two health centres. We assessed the severity of xerostomia and OHRQoL using the Xerostomia Inventory (XI) tool, and the Oral Health Impact Profile-14 (OHIP-14) instrument, respectively. We measured unstimulated (UWS) and stimulated (SWS) salivary flows. Univariate and multiple linear regression analyses evaluated the associations of XI and OHIP-14 and different explanatory variables.

RESULTS

Of the 218 patients enrolled, 51.8% had xerostomia, and 38.1% and 27.5% suffered from UWS and SWS hyposalivation, respectively. Patients with xerostomia, UWS, and SWS hyposalivation scored significantly higher on the XI. However, only those with xerostomia or UWS hyposalivation had significantly higher OHIP-14 scores. A moderate correlation was observed between XI and OHIP-14 scores. The multiple regression model showed that factors with the greatest impact on XI were the patient's complaint of xerostomia, UWS flow rate, age and sex. However, only the XI score was significantly associated with the OHIP-14 score.

CONCLUSION

Xerostomia has a negative impact on OHRQoL in older polymedicated patients, but this impact is less than in other types of xerostomia. Longitudinal studies are needed to determine whether changes in the detected explanatory variables influence XI and OHIP scores in these patients.

Anticholinergic Burden and Xerostomia in Critical Care Settings

BACKGROUND

Although previous studies have established the association of medications with anticholinergic adverse effects and xerostomia, anticholinergic burden and xerostomia in critical care settings are poorly characterized. The objective of this study was to determine the impact of medication burdens associated with anticholinergic adverse effects, particularly the occurrence of xerostomia (dry mouth) in a critical care setting. In addition, this study explored the correlation between the timing of the first instance of xerostomia and the administration timing of medication known to have anticholinergic adverse effects.

METHODS

A retrospective case-control study was used with the MIMIC (Medical Information Mart for Intensive Care) III database. The MIMIC-III clinical database is a publicly available, deidentified, health-related database with more than 40 000 patients in critical care units from 2001 to 2012. Cases of xerostomia (n = 1344) were selected from clinical notes reporting "dry mouth," "xerostomia," or evidence of pharmacological treatment for xerostomia; control (n = 4032) was selected using the propensity analysis with 1:3 matching on covariates (eg, age, sex, race, ethnicity, and length of stay). The anticholinergic burden was quantified as the cumulative effect of anticholinergic activities using the Anticholinergic Burden Scale.

RESULTS

Anticholinergic burden significantly differed between xerostomia patients and control subjects (P = .04). The length of stay was a statistically significant factor in xerostomia. The probability of developing the symptom of xerostomia within 24 hours was .95 (95%) for patients of xerostomia.

CONCLUSIONS

Anticholinergic Burden Scale is associated with xerostomia in the critical care setting, particularly within 24 hours after admission. It is crucial to carefully evaluate alternative options for medications that may have potential anticholinergic adverse effects. This evaluation should include assessing the balance between the benefits and harms, considering the probability of withdrawal reactions, and prioritizing deprescribing whenever feasible within the initial 24-hour period.

Immunoassay Detects Salivary Anti-SSA/Ro-52 Autoantibodies in Seronegative Patients with Primary Sjögren's Syndrome

The diagnostic work-up for Sjögren's syndrome is challenging and complex, including testing for serum autoantibodies to SSA/Ro and a labial salivary gland biopsy. Furthermore, the diagnosis is often delayed. In this study, we tested the hypothesis that anti-SSA/Ro autoantibodies are detectable in the saliva of patients with primary Sjögren's syndrome (pSS) because the disease affects the salivary glands, and these autoantibodies display greater discriminatory performance in saliva than in serum. SSA/Ro-52 Ags were used to develop what is, to our knowledge, a novel quantitative electrochemical-based immunoassay: the electric field-induced release and measurement (EFIRM) platform. The clinical utility was determined by measuring salivary anti-SSA/Ro-52 autoantibodies in patients with pSS and sicca (n = 34), patients without pSS with sicca (n = 35), and healthy subjects (n = 41). The statistical analysis of discrimination included the area under the receiver operating characteristic curve. Salivary anti-SSA/Ro-52 autoantibodies were measured in 94% (32 of 34) of patients with pSS with 85% (29 of 34) seropositivity. Four of the five seronegative patients with pSS had EFIRM-measurable anti-SSA/Ro-52 autoantibodies in saliva. Additionally, 60% (21 of 35) of the seronegative patients without pSS who had sicca had EFIRM-detectable SSA/Ro-52 autoantibodies in saliva, indicating the onset of autoimmune disease. Two of the 41 healthy control subjects had EFIRM-detectable SSA/Ro-52 autoantibodies in their saliva. Salivary SSA/Ro-52 autoantibodies significantly discriminated patients with pSS or patients with the initial stage of autoimmune disease from healthy subjects with an area under the receiver operating characteristic curve of 0.91. Our findings suggest that the proposed saliva SSA/Ro-52 immunoassay improves early and accurate diagnosis of seronegative patients with pSS and patients with early-onset autoimmune disease.

Dental status and its correlation with polypharmacy and multimorbidity in a Swiss nursing home population: a cross-sectional study

OBJECTIVE

To assess the correlation between oral health status in terms of present teeth, implants, removable prostheses, and polypharmacy and/or multimorbidity in three Swiss nursing homes with affiliated or integrated dental care.

METHODS

A cross-sectional study was conducted in three Swiss geriatric nursing homes with integrated dental care. Dental information consisted of the number of teeth, root remnants, implants, and presence of removable dental prostheses. Furthermore, the medical history was assessed in terms of diagnosed medical conditions and prescribed medication. Age, dental status, polypharmacy, and multimorbidity were compared and correlated using t-tests and Pearson correlation coefficients.

RESULTS

One hundred eighty patients with a mean age of 85.5 ± 7.4 years were included of which a portion of 62% presented with multimorbidity and 92% with polypharmacy. The mean number of remaining teeth and remnant roots were 14.1 ± 9.9 and 1.0 ± 3.1, respectively. Edentulous individuals comprised 14%, and over 75% of the population did not have implants. Over 50% of the included patients wore removable dental prostheses. A negative correlation with statistical significance (p = 0.001) between age and tooth loss (r = - 0.27) was observed. Finally, there was a non-statistically correlation between a higher number of remnant roots and specific medications linked to salivary dysfunction; specifically antihypertensive medication and central nervous system stimulants.

CONCLUSION

The presence of a poor oral health status was associated with polypharmacy and multimorbidity among the study population.

CLINICAL RELEVANCE

Identifying elderly patients in need of oral healthcare in nursing homes is a challenge. In Switzerland, the collaboration of dentists and nursing staff is still improvable, but is urgently needed due to the demographic changes and raising treatment demand of the oldest portion of the population.

Risk factors associated with xerostomia and reduced salivary flow in hypertensive patients

OBJECTIVE

The aim of this study was to evaluate the risk factors associated with xerostomia and hyposalivation in a group of hypertensive patients.

SUBJECTS AND METHODS

A cross-sectional study was conducted. Hypertensive patients belonged to two healthcare centers were included. Xerostomia was assessed by asking a question and using the Xerostomia Inventory. Unstimulated salivary flow was collected. Different epidemiological variables were analyzed such as age, sex, habits, diseases, drugs, and blood pressure.

RESULTS

221 individuals were included. Xerostomia was reported in 51.13% of patients. Patients with xerostomia suffered more from osteoarthritis and diaphragmatic hernia. These patients took more anticoagulants (acenocoumarol), antiarrhythmics (amiodarone), analgesics (paracetamol) and epilepsy drugs (pregabalin) and less platelet aggregation inhibitors and angiotensin II receptor blockers (losartan). Unstimulated flow was reduced in 37.56% of patients. Patients suffering hyposalivation presented more diseases such as anxiety, infectious or parasitic diseases, hepatitis C, diaphragmatic hernia, and osteoarthritis. These patients took more repaglinide, thiazides, anti-inflammatories, anti-rheumatics, glucosamine, diazepam, and selective beta-2-adrenoreceptor agonists and less combinations of candesartan and diuretics.

CONCLUSIONS

Xerostomia and hyposalivation are frequent in hypertensive patients. It is advisable to take into consideration the comorbidities and the drugs they receive, since they can increase the risk of these salivary disorders.

Treatment of Clozapine-Associated Sialorrhea: The Role of Benzamide Derivatives

PURPOSE

Hypersalivation is one of the most prevalent and distressing adverse effects associated with clozapine treatment. Currently, there is no standard therapeutic approach toward how to overcome it. Clinicians use various medications for managing this adverse effect. However, some of the agents are not effective enough, whereas others can induce other adverse effects. Recently, several reviews have been published on the treatment of clozapine-associated hypersalivation, in which the focus was on drugs from various pharmacological groups, and little attention was paid to drugs from the group of substituted benzamides. The intention of this brief narrative review is to draw the attention of clinicians to the use of the benzamide group for the treatment of this unpleasant adverse effect.

METHODS

A MEDLINE search was conducted to identify published treatment studies and case reports in the literature from 2000 to September 2021, concerning a treatment of clozapine-associated hypersalivation, mainly substituted benzamides.

RESULTS

Accumulating evidence during the last 2 decades indicates that agents derived from the benzamide group may be effective and safe agents for treatment of clozapine-associated hypersalivation. Whether with a psychotropic effect or without, medications from this group may produce a beneficial response.

CONCLUSIONS

Substitute benzamide derivatives have emerged as effective and well-tolerated agents for treatment clozapine-associated hypersalivation.

Salivation in Parkinson's disease: A scoping review

OBJECTIVES

We aimed to provide an overview of the available literature that includes both objective assessments (namely hypersalivation and hyposalivation) and the subjective experience (namely xerostomia and drooling) of salivary problems in patients with Parkinson's disease.

BACKGROUND

In patients with Parkinson's disease, there may be complaints of salivary problems such as xerostomia or drooling. This can have consequences for their oral health and quality of life. To date, systematic reviews have focused on drooling only.

MATERIALS AND METHODS

A literature search in 4 databases was performed up to 12 February 2021. Two researchers independently assessed studies for eligibility.

RESULTS

In total, 63 studies were included. The prevalence of self-reported xerostomia ranged from 49% to 77%, and that of self-reported drooling ranged from 5% to 80%. Ten articles reported a significantly lower mean salivary flow in patients with Parkinson's disease than in controls. None of the articles with both a control group and a patient group reported a significantly higher salivary flow in patients with Parkinson's disease. When questioned about subjective salivary problems, a significantly higher prevalence of both xerostomia (7 studies) and drooling (14 studies) was found in patients with Parkinson's disease than in controls. Patients with Parkinson's disease have a lower salivary flow rate and higher prevalence of both xerostomia and drooling than controls.

CONCLUSION

The complexity of salivary problems present in patients with Parkinson's disease necessitates a multidisciplinary approach in order to avoid mutually counteracting treatments from different healthcare professionals.

Oral frailty indicators to target major adverse health-related outcomes in older age: a systematic review

A well-preserved oral function is key to accomplishing essential daily tasks. However, in geriatric medicine and gerodontology, as age-related physiological decline disrupts several biological systems pathways, achieving this objective may pose a challenge. We aimed to make a systematic review of the existing literature on the relationships between poor oral health indicators contributing to the oral frailty phenotype, defined as an age-related gradual loss of oral function together with a decline in cognitive and physical functions, and a cluster of major adverse health-related outcomes in older age, including mortality, physical frailty, functional disability, quality of life, hospitalization, and falls. Six different electronic databases were consulted by two independent researchers, who found 68 eligible studies published from database inception to September 10, 2022. The risk of bias was evaluated using the National Institutes of Health Quality Assessment Toolkits for Observational Cohort and Cross-Sectional Studies. The study is registered on PROSPERO (CRD42021241075). Eleven different indicators of oral health were found to be related to adverse outcomes, which we grouped into four different categories: oral health status deterioration; decline in oral motor skills; chewing, swallowing, and saliva disorders; and oral pain. Oral health status deterioration, mostly number of teeth, was most frequently associated with all six adverse health-related outcomes, followed by chewing, swallowing, and saliva disorders associated with mortality, physical frailty, functional disability, hospitalization, and falls, then decline in oral motor skills associated with mortality, physical frailty, functional disability, hospitalization, and quality of life, and finally oral pain was associated only with physical frailty. The present findings could help to assess the contribution of each oral health indicator to the development of major adverse health-related outcomes in older age. These have important implications for prevention, given the potential reversibility of all these factors.

Evidence of pharmacogenetics-based fluvoxamine use as an add-on to clozapine treatment in psychiatry

Pharmacological treatments used for psychiatric disorders, such as clozapine, demonstrate large interindividual variability in terms of possible adverse effects and therapeutic benefit. This variability can be explained by multiple factors, including pharmacogenetic factors. Clozapine efficacy can be impacted by CYP polymorphisms. A growing body of literature on pharmacogenetics suggests the clinical benefit of concomitant use of clozapine and fluvoxamine to improve global pharmacotherapeutic management. This article reviews and discusses available clinical and pharmacological data and limitations of clozapine augmentation with fluvoxamine based on pharmacogenetic rationale and clinical experience. The aim is to provide an updated approach on how to use the pharmacological and pharmacogenetic profile to improve clozapine efficacy and tolerance in severely ill patients.

Oral health status among 60-year-old individuals born in 1941-1943 and 1954-1955 and 81-year-old individuals born in 1922-1924 and 1933-1934, respectively: a cross-sectional study

OBJECTIVE

This study aimed to analyze the oral health status of four different birth cohorts: two cohorts of 60-year-olds born in 1941-1943 and 1954-1955 and 2 cohorts of 81-year-olds born in 1920-1922 and 1933-1934.

MATERIAL AND METHODS

The study was based on data from an ongoing longitudinal population project, The Swedish National Study on Aging and Care (SNAC). Oral health status was repeatedly examined clinically and radiographically in 2001-2003 and 2014-2015, including 60- and 81-year-olds, in total 412 individuals. Statistical analyses were performed using independent-samples t test and Pearson's χ² test.

RESULTS

More individuals were dentate in 2014-2015 compared to 2001-2003 in the two age groups: 60 and 81 years (p < 0.001 for both). The mean number of teeth increased in the 60-year-olds from 24.2 to 27.0 and in the 81-year-olds from 14.3 to 20.2. The numbers of at least one intact tooth increased for both age groups (p < 0.001 and p < 0.004, respectively). In the age groups 81 years, there was an increase in having at least one PPD ≥ 6 mm (p < 0.016) and bone loss ≥ 5 mm (p < 0.029) between the two examinations. No such differences were found in the age groups of 60 years.

CONCLUSION

Over 13 years, oral health improved for both 60- and 81-year-old age groups. The most significant changes were in the 81-year-olds where oral health had improved except for periodontal status.

CLINICAL RELEVANCE

More natural teeth and impaired periodontal status potentially impact oral health and should increase focus on preventive and supportive dental care in older individuals.

Microbial Poly-γ-Glutamic Acid (γ-PGA) as an Effective Tooth Enamel Protectant

Poly-γ-glutamic acid (γ-PGA) is a bio-derived water-soluble, edible, non-immunogenic nylon-like polymer with the biochemical characteristics of a polypeptide. This Bacillus-derived material has great potential for a wide range of applications, from bioremediation to tunable drug delivery systems. In the context of oral care, γ-PGA holds great promise in enamel demineralisation prevention. The salivary protein statherin has previously been shown to protect tooth enamel from acid dissolution and act as a reservoir for free calcium ions within oral cavities. Its superb enamel-binding capacity is attributed to the L-glutamic acid residues of this 5380 Da protein. In this study, γ-PGA was successfully synthesised from Bacillus subtilis natto cultivated on supplemented algae media and standard commercial media. The polymers obtained were tested for their potential to inhibit demineralisation of hydroxyapatite (HAp) when exposed to caries simulating acidic conditions. Formulations presenting 0.1, 0.25, 0.5, 0.75, 1, 2, 3 and 4% (w/v) γ-PGA concentration were assessed to determine the optimal conditions. Our data suggests that both the concentration and the molar mass of the γ-PGA were significant in enamel protection (p = 0.028 and p < 0.01 respectively). Ion Selective Electrode, combined with Fourier Transform Infra-Red studies, were employed to quantify enamel protection capacity of γ-PGA. All concentrations tested showed an inhibitory effect on the dissolution rate of calcium ions from hydroxyapatite, with 1% (wt) and 2% (wt) concentrations being the most effective. The impact of the average molar mass (M) on enamel dissolution was also investigated by employing commercial 66 kDa, 166 kDa, 440 kDa and 520 kDa γ-PGA fractions. All γ-PGA solutions adhered to the surface of HAp with evidence that this remained after 60 min of continuous acidic challenge. Inductively Coupled Plasma analysis showed a significant abundance of calcium ions associated with γ-PGA, which suggests that this material could also act as a responsive calcium delivery system. We have concluded that all γ-PGA samples tested (commercial and algae derived) display enamel protection capacity regardless of their concentration or average molar mass. However, we believe that γ-PGA D/L ratios might affect the binding more than its molar mass.

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

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

Prevalence of dry mouth in adult patients in primary health care

OBJECTIVES

To determine the prevalence and severity of dry mouth by age, gender, presence of disease, and medication intake for patients aged 18 years and over, seeking primary health care on the west coast of Sweden (Region of Västra Götaland, VGR).

MATERIALS AND METHODS

Cross-sectional study conducted among patients (n = 374, age ≥ 18) visiting primary health care providers (n = 4) in VGR for any medical reasons. Patients were invited to participate by answering a single-item question, 'Have you experienced dry mouth in the last six months?' Patients giving positive answers (n = 163) were asked to fill in the 11-item Xerostomia Inventory (XI) questionnaire to determine the variability and severity of xerostomia. Patients replying 'No' (n = 211) to the single-item question were considered not to have xerostomia and included in the non-xerostomia group.

RESULTS

The overall prevalence of xerostomia was 43.6% with a female dominance (61.2%). The prevalence in different age groups among females and males was similar. The number of medications and/or diseases are positively associated with xerostomia. Medication was a significant predictor of the prevalence of xerostomia, regardless of age and gender (p < .001). Patients with five or more medications had the highest prevalence of xerostomia (71.2%).

CONCLUSION

Patients seeking primary care on the west coast of Sweden have a high prevalence of xerostomia. Factors associated with xerostomia were female gender and medications and/or diseases. Awareness is required to manage patients with xerostomia in medical and dental care.

Parkinson's disease, temporomandibular disorder pain and bruxism and its clinical consequences: a protocol of a single-centre observational outpatient study

INTRODUCTION

A recent questionnaire-based study suggested that bruxism and painful temporomandibular disorders (TMD pain) may be more prevalent in patients with Parkinson's disease (PD) compared with controls. The presence of both bruxism and TMD pain may negatively influence patients' quality of life. The present study is designed to clinically and more objectively investigate the presence of bruxism and TMD pain in patients with PD. The secondary aim of the study is to identify factors associated with bruxism and TMD pain in patients with PD, such as disease severity and dopaminergic medication usage. Furthermore, the presence of tooth wear in patients with PD will be studied as this can be a major consequence of bruxism. Finally, deviations in saliva composition that may contribute to tooth wear will be studied.

METHODS AND ANALYSIS

This is a single-centre observational outpatient study at the Amsterdam University Medical Centres, location VUmc. All patients with a clinical diagnosis of PD will be eligible for inclusion. Participants will fill in a set of questionnaires. Subsequently, patients will be examined clinically for, among others, TMD pain, presence and severity of tooth wear, and deviations in saliva composition. Sleep-time registrations will take place for 5 nights with the GrindCare GC4 (ie, a portable, single-channel electromyographic recorder) to assess sleep bruxism and simultaneously by the use of the BruxApp for 5 days to assess awake bruxism. We will partly use data collected during standard clinical care to minimise patient burden.

ETHICS AND DISSEMINATION

The scientific and ethical aspects of this study protocol have been approved by the Medical Ethics Review Committee of the Amsterdam UMC, location VUmc; NL. 2019.143. Informed consent will be obtained from all participants. The results will be published in a peer-reviewed journal, if relevant presented at conferences, and published as part of a PhD thesis.

TRIAL REGISTRATION NUMBER

NL8307.

Prediction of xerostomia in a 75-year-old population: A 25-year longitudinal study

OBJECTIVES

To follow the same individuals from age 50 up to 75 years to report on prevalence, persistence, progression, remission, incidence and predictors for xerostomia.

METHODS

A questionnaire was distributed to all 50-years-olds (1992) in two Swedish counties (N=8888) and repeated at the age of 65 (2007) and 75 years (2017). 3060 individuals responded on all three occasions (response rate 42.5%). Xerostomia was assessed with two questions. Additional questions addressed inter alia general/oral health and oral function.

RESULTS

Reported prevalence of daytime xerostomia were 23.3% and 14.7%, and 39.5% and 27.5% in women and men, age 50 and 75, respectively. Night-time prevalence was higher. At age 50, 27.4% women and 24.0% men reported having dry mouth, and at age 75, 61.0% and 53.8%, respectively. At all time points, women reported significantly more xerostomia than men. Progression (deterioration) was common, and persistence (continuing presence) was high, while 25-year incidence for daytime xerostomia was 16.2% and 12.8%, and 33.6% and 29.8% at night-time, for women and men, respectively. Based on reports at age 50, regression analyses showed that prediction for developing xerostomia during the observation period, and reporting xerostomia at age 75 years, were female gender, impaired general health, chewing, jaw opening and intraoral problems, dissatisfaction with dental appearance, low education and having white/plastic filling.

CONCLUSIONS

Xerostomia is common in older people, especially at night and in women. It can be predicted by diverse factors reported earlier in life.

CLINICAL SIGNIFICANCE

Clinicians need to be made aware of that elderly often suffers from dry mouth so that they can recommend effective measures to eliminate or ease the patients accompanying symptoms and also exclude or lessen possible negative impact on oral health related to xerostomia.

Lectin-Functionalized Polyethylene Glycol for Relief of Mucosal Dryness

The importance of lubrication between oral surfaces provided by the salivary film is most acutely apparent when it is disrupted, a prevalent consequence of salivary gland hypofunction experienced with aging, a symptom of certain diseases, or a side effect of some medical interventions. Sufferers report difficulty with speech and oral food processing and collectively is detrimental to quality of life. Polyethylene glycol (PEG) is widely employed as a successful biocompatible boundary lubricant in engineering and biomedical applications. It is hypothesized that the immobilization of PEG to biological materials such as oral epithelial cells and tissue can mimic the salivary film and provide durable relief from the symptoms of mucosal dryness. To do so, PEG is functionalized with a sugar binding lectin (wheat germ agglutinin) to enhance epithelial adhesion through lectin-sugar interactions. Retention and lubricity are characterized on an ex vivo oral tissue tribology rig. WGA-PEG coats and retains on mucin films, oral epithelial cells, and porcine tongue tissue, and offers sustained reduction in coefficient of friction (COF). WGA-PEG could be developed into a useful topical treatment for reducing oral friction and the perception of dry mouth.

A Clinical Study on the Efficacy and Tolerability of a New Topical Gel and Toothpaste in Patients with Xerostomia: A Randomized Controlled Trial

OBJECTIVE

xerostomia is a very common problem in the general population. The objective of this study was to determine the efficacy of a new gel and toothpaste in patients with xerostomia, analyze the role of salivary cytokines as biomarkers of xerostomia and assess the possible changes in salivary cytokines following treatment.

MATERIALS AND METHODS

A randomized, controlled double-blind clinical study was carried out in 73 patients with xerostomia divided into two groups: placebo and active treatment (cymenol; tocopheryl acetate; D-panthenol; Aloe barbadensis; citrate tribasic dihydrate; fluoride) with oral gel and toothpaste three times a day for four consecutive weeks. The Thomson Xerostomia Inventory was applied, with the assessment of oral quality of life (OHIP-14) at baseline and after four weeks of application of the product. Sialometry was also performed in both groups, with analysis of the IL-1b, IL-6, IL-8 and TNFa levels in saliva.

RESULTS

In the active treatment group, the xerostomia scores decreased significantly at the end of the study versus baseline, from 33.47 to 27.93 (p < 0.001). No significant decrease was recorded in the placebo group (34.5 to 32.75; p = 0.190). There were no adverse effects in either group. Regarding the saliva samples, the active treatment group showed significant differences in IL-6 concentration versus the control group (18.55 pg/mL (8-38.28) and 5.83 pg/mL (1.19-12.04), respectively; p = 0.002). No significant differences in salivary cytokines were observed in either the treatment group or the control group.

CONCLUSIONS

The use of a new toothpaste and gel developed for patients with xerostomia proved effective, with greater symptom relief than in the placebo group. Further clinical studies involving longer time periods and larger samples are advisable in order to confirm the benefits of the described treatment.

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 Complications of Head and Neck Cancer Therapy

Current therapies for Head and Neck cancer treatment are extremely advanced. Though, they cause oral complications which have deleterious effects on basic life functions, affect oral and overall health, may lead to significant morbidity and treatment discontinuation and have an impact on survivorship and quality of life. As new therapies are introduced, a new spectrum of oral complications is rising, compromising the mucosal integrity and the salivary function, that may not be recognized, reported and treated properly. Oral complications, often permanent and extremely painful, may include mucositis, xerostomia, dysgeusia, infections, trismus and fibrosis, risk of dental disease and necrosis of the jaw, neurosensory disorders and when targeted therapies and immunotherapy are involved, aphthoid and lichenoid lesions can also be reported. Increased awareness is required for the prevention and management of these complications, which can be best provided by a multidisciplinary team.

Polypharmacy and saliva volumes in the northeast of Germany - The Study of Health in Pomerania

OBJECTIVES

Associations between saliva volumes or salivary flow rates and potentially xerogenic medication are rarely evaluated in cohorts with a wide age range. This cross-sectional cohort study investigated possible relationships between the regular consumption of potentially xerogenic medication and stimulated saliva volumes.

METHODS

Data from the German Studies of Health in Pomerania (SHIP-2 and SHIP-Trend-0) were pooled. Potentially xerogenic medications were identified using the Workshop on Oral Medicine VI criteria. Stimulated saliva was sampled using Salivette®, and saliva volumes expressed as μl/min were determined. Applying linear mixed models with adjustment for time point of saliva collection, associations of (a) age and sex with regularly consumed medication, (b) age and sex with saliva volumes, and (c) the number of regularly consumed xerogenic medications with saliva volumes were evaluated.

RESULTS

Six thousand seven hundred and fifty-three participants aged 20-83 years (mean 53.4 ± 14.9) were included. The average number of medications did not differ markedly between females (2.21 ± 2.46) and males (2.24 ± 2.83). Males took more potentially xerogenic medication (1.0 ± 1.3) than did females (0.9 ± 1.3). Also, males took more potentially xerogenic cardiovascular medications than did females (0.9 ± 1.2 versus 0.7 ± 1.1), while females were prescribed a higher number of potentially xerogenic medications affecting the nervous system (0.2 ± 0.5 versus 0.1 ± 0.4). The average stimulated saliva volume was 967.0 ± 433.3 µL/min. Regularly consumed and potentially xerogenic medications were associated with lower saliva volumes. Older age correlated not only with a higher number of total medications and a higher number of xerogenic medications affecting either the cardiovascular (in males) or the nervous system (in females), but also with lower saliva volumes.

CONCLUSIONS

Ageing was associated with polypharmacy, especially with the intake of potentially xerogenic medication, and lower average saliva volumes. With regard to complications of dry mouth, anamnesis of medication consumption is of high importance.

Effects of photobiomodulation in salivary glands of chronic kidney disease patients on hemodialysis

This randomized placebo-controlled trial evaluates the impact of photobiomodulation (PBMT) on the salivary flow and biochemistry of patients with chronic kidney disease (CKD) on hemodialysis. Forty-four patients on hemodialysis self-responded two questionnaires for oral health and salivary gland function perception. The subjects were evaluated for function of salivary glands and randomly allocated to two groups: PBMT group (three irradiations at 808 nm, 100 mW, 142 J/cm², and 4 J per site); and placebo group. Patients were submitted to non-stimulated and stimulated sialometry and after the treatment at baseline and 14 days. Salivary volume and biochemical of the saliva were analyzed. At baseline, most subjects had self-perception of poor oral health (52.6%) and salivary dysfunction (63.1%). Clinical exam revealed that 47.3% of subjects presented dry mucosa. PBMT promoted increase of the non-stimulated (p = 0.027) and stimulated saliva (p = 0.014) and decrease of urea levels in both non-stimulated (p = 0.0001) and stimulated saliva (p = 0.0001). No alteration was detected in total proteins and calcium analysis. Patients with kidney disease can present alteration in flow, concentrations, and composition of saliva, affecting oral health, but our findings suggest that PBMT is effective to improve hyposalivation and urea levels in saliva of patients with CKD.

Impact of Oral and Swallowing Function on the Feeding Status of Older Adults in Nursing Homes

BACKGROUND

To date, there have been few guidelines proposed for adjustment of the food consistency, particularly to match the oral function of older adults, which will guide clinicians and caregivers in appropriately modifying food.

OBJECTIVE

We investigated how oral, swallowing, and cognitive conditions of older adults who required daily nursing care in a nursing home were associated with different dietary food consistencies.

METHODS

Clinical examinations to record dentition status, swallowing, and cognitive functions were performed, and the feeding status, including the food consistencies and need for assistance at lunchtime, was evaluated in 37 older residents in nursing homes. The swallowing function was assessed by performing a modified water-swallowing test, and food swallowing was tested using pudding and rice crackers. The χ2 test was used to determine the relationships among the parameters.

RESULTS

No participants were able to take cooked rice, nor regular and soft side dishes. There was no significant relationship between dentition status and feeding status. Of the participants, 95% ate pudding without any problems and 49% ate rice crackers without any signs of swallowing difficulty such as coughing or stopping chewing. There was a significant relationship between the food test score using a rice cracker and the level of food consistencies, and between the same test score and the level of mealtime assistance, whereby the better the score of the food test using a rice cracker, the better was the level of food consistencies including use of a thickening agent and the better was the level of mealtime assistance.

CONCLUSION

The results strongly suggest that the food test using a rice cracker was associated with the level of food consistency and mealtime assistance for older adults in nursing homes.

Oral Health and Nutritional Characteristics of Adults With Morbid Obesity: A Multivariate Analysis

The relationship between oral health and nutritional aspects are complex, especially in individuals with chronic diseases and comorbidities, such as morbid obesity. Thus, the aim of the present study was to identify oral health and nutritional-related patterns in 113 individuals, aged 19–68 years (92 females), seeking treatment for morbid obesity. Sociodemographic variables and medical records were examined, in addition to the consumption of fruit, vegetables, candies, and processed foods. Measures of body mass index, neck, waist and hip, caries experience (DMFT index), Community Periodontal Index (CPI index), and salivary physicochemical aspects were gathered. Aspects of oral health-related quality of life and symptoms of dry mouth were evaluated by means of Oral Health Impact Profile (OHIP-14) and Xerostomia Inventory-XI questionnaires. K-means cluster analysis and, subsequently, comparisons between clusters (one-way ANOVA) were performed (α = 5%). Three clusters were generated: Cluster 1 (labeled “Young”; n = 77) was characterized by younger participants with higher BMI, who reported the use of distractors while eating, the smallest number of meals/day, and who consumed sweetened drinks and processed food the day before. Cluster 2 (labeled “Diabetic individuals”; n = 12) was characterized by older participants with the highest proportion of diabetic participants (100% were diabetic; 73% insulin users), lower BMI, higher DMFT index and OHIP-14 and xerostomia scores, and who reported having consumed fruit and vegetables the day before. Finally, Cluster 3 (labeled “Poor periodontal health”; n = 24) was characterized by participants with the worse periodontal condition (higher CPI), and lower salivary flow, pH, and buffer capacity. Cluster 1 and 2 were the groups that showed higher demand for nutritional and dietetic counseling, because of the poor eating behavior and higher serum glucose levels, respectively. On the other hand, Cluster 2 and 3 showed the higher demand for oral rehabilitation and dental treatment because of the loss of teeth and worse periodontal condition, respectively, besides the need for dietetic counseling. This sample of individuals with morbid obesity showed very unique oral-health and nutritional characteristics and special needs patterns that should be identified to adjust or change unhealthy habits, thus improving the assistance of this condition.

Relationship between polypharmacy, xerostomia, gustatory sensitivity, and swallowing complaints in the elderly: A multidisciplinary approach

Oral dysfunctions are common in the elderly but the literature lacks a multidisciplinary approach on the relationship between polypharmacy, saliva flow, xerostomia, taste, and swallowing complaints. This cross-sectional study included 204 non-institutionalized elderly (>60 years; 123 women/81 men), free of severe disabilities and non-alcohol/tobacco consumers, from whom specific pharmacological therapies were evaluated, as well xerostomia (Xerostomia Inventory-XI) and swallowing complaints (EAT-10 questionnaire), salivary flow rate and gustatory sensitivity. Statistical analysis included Chi-square, Mann-Whitney, Two-way ANCOVA, and linear multiple regression. Polypharmacy (≥5 drugs daily), hyposalivation, and severe taste dysfunction were found in 18, 46, and 10% of the participants, respectively. Polypharmacy was related with xerostomia (p = .041) and swallowing complaints (p < .001; power = 94%), but not with taste dysfunction. Dry mouth complaint and higher risk of swallowing disorders were found in 50 and 12% of the elderly, respectively, and angiotensin-converting enzyme (ACE) inhibitors users (n = 36) showed higher EAT-10 scores (p = .038). Regression models showed that stimulated salivary flow rate was dependent on gender and diuretic use, while xerostomia scores were dependent on the number of medications and unstimulated saliva flow (p < .001). In conclusion, the results draw attention to the high frequency of oral and maxillofacial dysfunctions found in non-institutionalized elderly, especially polypharmacy, xerostomia and swallowing complaints, and the side effects of drugs that can disturb the oral functions, the acceptance of food, and the adherence to oral therapies.

Self-reported dry mouth in 50- to 80-year-old Swedes: Longitudinal and cross-sectional population studies

Xerostomia is a common condition among elderly. The objectives were to examine prevalence, persistence, progression, yearly incidence of xerostomia, associated background factors and its influence on oral impacts on daily performances (OIDP) in 50- to 80-year-old people. In 1992, a questionnaire was sent to all 50-year-old (n = 8888) and in 2007 to all 75-year-old persons (n = 5195) living in two Swedish counties. In 2012, the same questionnaire was sent to both age cohorts, now 70- and 80-year-old. Response rate was for the 50-, 70- 75- and 80-year-old groups 71.4%, 72.2%, 71.9% and 66.4%, respectively. In the 50- to 70-year-old sample, 40.3% of the participants answered all five examinations and in the 75-80 group 49.5% (intact samples). In all age groups, xerostomia was significantly more prevalent in women than in men. At age 80, "often mouth dryness at night" was reported by 24.3% and 16.2% of women and men, respectively. Prevalence increased with age and was more frequent at night-time. Persistence of xerostomia was reported by 61.4%-77.5%, progression by 11.5%-33.0% and remission by 5.7%-11.3%. Average yearly incidence was 0.99%-3.28%. Xerostomia was more prevalent in those who reported a negative impact on OIDP. Highest odd ratios for xerostomia were burning mouth (OR 12.0), not feeling healthy (OR 5.1) and medicine usage (OR 3.9). Xerostomia is common in older age, persistence is high and progression common. The comorbidity between xerostomia, oral health problems and impaired general health needs to be taken into consideration when providing dental care to elderly patients.

Losartan and isoproterenol promote alterations in the local renin-angiotensin system of rat salivary glands

Renin-angiotensin system (RAS) systemically or locally collaborates with tissue homeostasis, growth and development, which has been extensively studied for its pharmacological implications. This study was primarily aimed at finding and characterizing local RAS in rat parotid, sublingual and submandibular glands. It was also hypothesized that vasoactive drugs could affect the expression of RAS targets, as well as saliva flow and its composition. Therefore, another objective of this study was to compare the effects of losartan (angiotensin II receptor blocker) and isoproterenol (β-adrenergic receptor agonist). Forty-one Wistar rats were divided into three groups and administered a daily intraperitoneal dose of saline, losartan or isoproterenol solutions for one week. The following RAS targets were studied using qPCR: renin (REN), angiotensinogen (AGT), angiotensin converting enzyme (ACE), ACE-2, elastase-2 (ELA-2), AT1-a and MAS receptors, using RPL-13 as a reference gene. Morphology of glands was analyzed by immunohistochemistry using REN, ACE, ACE-2, AT1, AT2 and MAS antibodies. The volume and total protein content of saliva were measured. Our results revealed that ACE, ACE-2, AT1-a, AT2 and MAS receptors were expressed in all salivary gland samples, but REN and ELA-2 were absent. Losartan decreased mRNA expression of RAS targets in parotid (MAS) and submandibular glands (ACE and both AT receptors), without affecting morphological alterations, and significantly decreased saliva and total protein secretions. Isoproterenol treatment affected gene expression profiles in parotid (ACE, ACE-2, AT1-a, MAS, AGT), and submandibular (ACE, AT2, AGT) glands, thus promoting acinar hypertrophy in serous acini, without significant changes in salivary flow or total protein content. These drugs affected mainly acini, followed by duct systems and myoepithelial cells, whereas blood vessels were not affected. In conclusion, there is a local RAS in major rat salivary glands and losartan, an angiotensin II receptor blocker, affected not only the RAS-target gene expression but also decreased salivary flow and total protein content.

Anticholinergic Burden and Dry Mouth in Middle-Aged People

INTRODUCTION

Anticholinergic burden refers to the cumulative effect of taking 1 or more drugs with anticholinergic properties. At the moment, little is known about the association between the anticholinergic burden and dry mouth.

OBJECTIVES

The objective of this article was to study, whether an anticholinergic burden is associated with dry mouth among middle-aged people.

METHODS

The study population included 1,345 people aged 46 y from the Northern Finland Birth Cohort 1966 (NFBC1966) study, who took part in a clinical medical and dental examination during 2012-2013. Medication data comprised both self-reported drug use and information obtained from the national register. Anticholinergic burden was measured using 10 different anticholinergic scales. Dry mouth was defined on the basis of having either a subjective feeling of dry mouth (xerostomia) or objectively measured low unstimulated or stimulated whole salivary flow rates (hyposalivation). Poisson regression models with robust error variance were used to estimate relative risk (RR). Regression models were adjusted for sex, smoking, diabetes, rheumatoid diseases, depressive symptoms, anxiety, total number of drugs, and antihypertensive drugs.

RESULTS

Approximately 14% of the participants reported having xerostomia and about 2% had hyposalivation. The RRs of different anticholinergic scales for xerostomia varied from 1.05 to 1.68. The scales' RRs were between 0.89 and 2.03 for low unstimulated whole salivary flow (<0.1 mL/min) and between 0.59 and 1.80 for low stimulated whole salivary flow (<0.7 mL/min). Seven of 10 studied anticholinergic scales associated statistically significantly with dry mouth, either with xerostomia or hyposalivation.

CONCLUSION

Most of the anticholinergic scales were associated with dry mouth, either with xerostomia or hyposalivation. There was considerable variation in the strength of the associations between anticholinergic scales and dry mouth.

KNOWLEDGE TRANSFER STATEMENT

The findings of this study suggest that dentists should take notice of the use of drugs with anticholinergic properties and their harmful effects among middle-aged people. Dentists should provide these patients with necessary guidance on how to cope with dry mouth and give them prophylactic measures against oral diseases associated with dry mouth.

Treatment Strategies for Clozapine-Induced Sialorrhea: A Systematic Review and Meta-analysis

BACKGROUND

Clozapine is the most effective medication for treatment-refractory schizophrenia. However, it has a high burden of adverse events, including common adverse events such as sialorrhea. Sialorrhea can lead to severe physical complications such as aspiration pneumonia, as well as psychological complications including embarrassment and low self-esteem. Compromised adherence and treatment discontinuation can occur due to intolerability. There have been no meta-analyses examining strategies to mitigate clozapine-induced sialorrhea.

METHODS

We systematically searched Chinese and Western research databases for randomised controlled trials examining agents for clozapine-induced sialorrhea. No limit to language or date were applied to the search. Where sufficient data for individual agents was available, pairwise meta-analyses were conducted. Results were provided as risk ratios and number needed to treat. Sensitivity analysis was conducted by study quality. Adverse events were provided as number needed to harm.

RESULTS

19 studies provided data for use in the meta-analysis. Improvement in clozapine-induced sialorrhea was seen in meta-analyses of propantheline (studies = 6, risk ratio [RR] 2.38, 95% confidence interval [CI] 1.52-3.73; number needed to treat [NNT] 3, 95% CI 1.9-2.7), diphenhydramine (studies = 5, RR 3.09, 95% CI 2.36-4.03; NNT 2, 95% CI 1.5-2.0), chlorpheniramine (studies = 2, RR 2.37, 95% CI 1.59-3.55; NNT 3, 95% CI 1.6-3.5), and benzamide derivatives (odds ratio [OR] 6.93, 95% CI 3.03-15.86). When meta-analyses were limited to high-quality studies, all these results remained significant. Single studies of benzhexol, cyproheptadine, doxepin and Kongyan Tang showed promise. Propantheline increased rates of constipation with a number needed to harm (NNH) of 9 (95% CI 4.2-204.1).

CONCLUSION

Clozapine-induced sialorrhea is a potentially serious adverse event. Included studies in this meta-analysis were limited by poor study quality. Diphenhydramine, chlorpheniramine and benzamide derivatives appear to have the best supporting evidence and lowest reported adverse events. Caution should be exercised when using propantheline given its increased risk of constipation.

Electrostimulation of the lingual nerve by an intraoral device may lead to salivary gland regeneration: A case series study

Background

Salivary gland function is controlled by the salivary reflex, whose efferent arm is composed by the parasympathetic and the sympathetic divisions of the autonomic nervous system. Parenchymal injury is the main salivary gland involvement of Sjögren’s syndrome and head and neck radiotherapy, but neural damage has been reported as well. Recently an intraoral device for electrostimulation of the lingual nerve in vicinity to the lower third molar has been introduced. At this point this nerve carries efferent fibers for the innervation of the submandibular, sublingual and several minor salivary glands and afferent fibers of the salivary reflex. Therefore, excitation of these fibers potentially leads to increased secretion of all salivary glands. Thus, the study objective was to assess whether comprehensive neural activation by electrostimulation of the lingual nerve carries the potential to induce the regeneration of damaged salivary glands.

Material and Methods

The device was tested on three patients with no collectable resting and stimulated secretion of saliva during a double blind, sham controlled period of two months and nine open-label months.

Results

All three subjects developed the capacity to spit saliva, not only in direct response to the electrostimulation but also after free intervals without electrostimulation. In addition, their symptoms of dry mouth severity and frequency improved.

Conclusions

This recovery is probably due to the combined effect of increase in secretory functional gland mass and regain of nervous control of the secretory elements and blood vessels. Both are phenomena that would contribute to gland regeneration.

Key words:Xerostomia, dry mouth, saliva, electrostimulation, regeneration.

Salivary adiponectin, but not adenosine deaminase, correlates with clinical signs in women with Sjögren's syndrome: a pilot study

OBJECTIVES

To evaluate salivary adiponectin and adenosine deaminase (ADA) in women suffering from Sjögren's syndrome (SS).

METHODS

Salivary adiponectin and ADA were measured in patients with SS (n = 17) and compared to their values in healthy controls (n = 13) and patients suffering from drug-induced xerostomia (non-SS sicca group; n = 19). A clinical history was made for each patient, patients were examined clinically, and xerostomia inventory (XI) was performed.

RESULTS

Salivary adiponectin corrected by total protein was higher in patients with SS than in healthy individuals (P < 0.05) or patients with non-SS sicca (P < 0.01) and correlated with XI (r = 0.555; P < 0.05). Salivary ADA was higher in patients with SS and non-SS sicca compared to controls (P < 0.05 in both cases).

CONCLUSION

The results of the present study indicate that adiponectin and ADA are increased in the saliva of patients with SS.

CLINICAL RELEVANCE

Salivary adiponectin corrected by total protein can be a potential biomarker of SS.

TRIAL REGISTRATION

NCT03156569.

Salivary secretion in health and disease

Saliva is a complex fluid produced by 3 pairs of major salivary glands and by hundreds of minor salivary glands. It comprises a large variety of constituents and physicochemical properties, which are important for the maintenance of oral health. Saliva not only protects the teeth and the oropharyngeal mucosa, it also facilitates articulation of speech, and is imperative for mastication and swallowing. Furthermore, saliva plays an important role in maintaining a balanced microbiota. Thus, the multiple functions provided by saliva are essential for proper protection and functioning of the body as a whole and for the general health. A large number of diseases and medications can affect salivary secretion through different mechanisms, leading to salivary gland dysfunction and associated oral problems, including xerostomia, dental caries and fungal infections. The first part of this review article provides an updated insight into our understanding of salivary gland structure, the neural regulation of salivary gland secretion, the mechanisms underlying the formation of saliva, the various functions of saliva and factors that influence salivary secretion under normal physiological conditions. The second part focuses on how various diseases and medical treatment including commonly prescribed medications and cancer therapies can affect salivary gland structure and function. We also provide a brief insight into how to diagnose salivary gland dysfunction.

Salivary fingerprint of simple obesity

BACKGROUND

The nature of a link between poor oral health and obesity is not fully understood. It is also unclear if saliva contributes to it and whether the properties of saliva change as a result of an increase in body mass or rather as a consequence of obesity-associated comorbidities. This pilot study was undertaken in an attempt to determine if salivary biomarkers can identify obesity per se.

METHODS

Whole mixed saliva was analysed for 16 soluble parameters covering 4 categories (inflammation, oxidative stress, endothelial dysfunction, adipokines). In the discovery group, 19 obese and 25 non-obese women matched for age, with similar hygiene habits, with no comorbidities and not taking any medication known to affect saliva secretion were analysed. In the validation group, a cohort of no-preselected 81 individuals (34 obese) were analysed.

RESULTS

Individuals with obesity had significantly higher salivary concentrations of several cytokines and adipokines, of which TNF-R1, serpin A12 and PAI-1 were identified as parameters discriminating between obese and non-obese subjects with the highest sensitivity and specificity.

CONCLUSIONS

Obesity per se leads to distinct changes in the concentration of several parameters in saliva. These findings may have diagnostic implications for distinguishing the effects of obesity and obesity-linked comorbidities on oral health.

Salivary flow and xerostomia in patients with type 2 diabetes

BACKGROUND

Saliva is secreted by the major and minor salivary glands. There are a number of physiological factors that can reduce this secretion such as age, sex, body weight, number of teeth present in the mouth or time of day. This decrease may also be caused by the use of certain drugs, radiotherapy for head and neck cancer, chronic rheumatic diseases such as Sjögren's syndrome and other systemic disorders such as diabetes mellitus (DM). Objective of this study was to investigate the effect of type 2 DM on salivary secretion and its relation to the sensation of xerostomia.

METHODS

Forty-seven patients with type 2 DM and 46 healthy individuals, aged 40-80, participated in the study. Samples of saliva were collected, at rest and after stimulation, at baseline and after the administration of a meal. A questionnaire of 10 items was used to define the patients' sensations of xerostomia. For statistical analysis, the Mann-Whitney test was used to assess the difference in salivary flow between the two groups and the relationship between the response to each of the questions and salivary flow levels. The degree of the patients' sensation of xerostomia was analysed by the Fisher test.

RESULTS AND CONCLUSIONS

There was a significant decrease in total saliva levels at rest in patients with type 2 DM compared to the control group. The study group also experienced higher levels of dryness at night and on waking as well as a greater sensation of lingual burning compared to the control group.

Relationship among perceived stress, xerostomia, and salivary flow rate in patients visiting a saliva clinic

OBJECTIVE

This aimed to assess the potential role of chronic stress in saliva secretion, xerostomia, and oral health in a population attending a saliva clinic.

MATERIALS AND METHODS

Data of 114 patients who met the inclusion criteria and completed all questionnaires were analyzed in this study. Participants completed several validated questionnaires, including the Perceived Stress Scale, the Oral Health Impact Profile (OHIP-14), Xerostomia Inventory (XI), and Bother xerostomia Index (BI). Subsequently, the unstimulated, chewing-stimulated, and citric acid-stimulated saliva secretion rates were determined gravimetrically. Data were evaluated using Spearman's correlation analysis and the Mann-Whitney U test.

RESULTS

A significant correlation was observed between perceived stress and XI score (r = 0.312, p = 0.001), as well as between perceived stress and BI score (r = 0.334, p = 0.001). Stress levels also were significantly associated with OHIP-14 scores (r = 0.420, p < 0.001), but an association between experienced stress and salivary flow rate could not be established.

CONCLUSION

In this population, perceived chronic stress seems to be related to several aspects of dry mouth, including the perception of dry mouth, suffering from dry mouth, and the impact on quality of life. These effects were independent of the use of psychotropic medication. No actual reduction in salivary flow was found. Further studies to explore the causal linkage of stress with xerostomia seem warranted.

CLINICAL RELEVANCE

Perceived chronic stress seems to be related with several aspects of dry mouth. This finding might be relevant in future prevention and treatment of xerostomia.

Does poor oral health status increase the risk of falls?: The JAGES Project Longitudinal Study

We sought to examine if self-reported oral health conditions regarding difficulty eating tough foods, dry mouth, choking, number of teeth and denture use are associated with incident falls. Our study was based on panel data from the Japan Gerontological Evaluation Study conducted in 2010 and 2013 using self-administered questionnaires. Data from 19,995 male and 20,858 female community-dwelling older people aged ≥65 years without a history of falls within the previous year in 2010 were analyzed. Multilevel logistic regression models were used to determine the association between poor oral health in 2010 and multiple incident falls in 2013 after adjusting for possible confounders and considering differences in municipalities. The percentage of males and females who reported falls in 2013 were 2.4% and 2.1%, respectively. After adjusting for age, educational attainment, equivalized income, depression, self-rated health, instrumental activities of daily living, body mass index, present illness related to falls, social participation, walking in min/day, alcohol drinking status, and municipality population density, dry mouth in males (odds ratio [OR] = 1.41; 95% confidence interval [CI]: 1.12–1.77) and choking in females (OR = 1.64; 95% CI: 1.27–2.11) were significantly associated with incident falls. Difficulty eating tough foods in both sexes and choking in males were marginally associated with incident falls (p<0.1). Females having 10–19 teeth without dentures (OR = 1.63; 95% CI: 1.14–2.31), ≤9 teeth with dentures (OR = 1.36; 95% CI: 1.03–1.80), and ≤9 without dentures (OR = 1.46; 95% CI: 1.02–2.08) were significantly associated with incident falls compared with those having ≥20 teeth, respectively. These findings suggest that poor oral function, having fewer teeth, and not using dentures are predictors of incident falls. Further studies are needed to determine whether improving oral health can reduce the risk of falls.

Can clusters based on caries experience and medical status explain the distribution of overhanging dental restorations and recurrent caries? A cross-sectional study in Madinah - Saudi Arabia

BACKGROUND

Overhanging dental restorations (ODRs) and secondary caries lesions (SCLs) are of high prevalence and jeopardize the fate of the restoration.

OBJECTIVES

To assess the relationship between ODRs, SCLs and certain caries contributory factors.

METHODS

A total of 502 radiographic records of dental patients with proximal fillings (mean age 38 ± 13 years, 50% females) were screened for ODRs and SCLs. Descriptive and inferential statistics were used. In addition, two-step cluster analysis was performed in an attempt to explain trends in ODR and SCL distribution. A p value of ≤ 0.05 was considered statistically significant.

RESULTS

More than 30% of the individuals had ODRs and SCLs. No differences between genders were observed (p > 0.05). Individuals with medical conditions had more ODRs than those without (49% vs. 34%, p ≤ 0.05), while those with high caries experience had more SCLs (49%, p ≤ 0.05). The cluster analysis grouped the participants in five clusters, with the cluster involving individuals with no medical conditions and low caries experience demonstrating the lowest prevalence of ODRs and SCLs.

CONCLUSIONS

Within the study limits, more than one third of the sample of dental patients had ODRs and SCLs. The medical condition was associated with ODRs, while the past caries experience was associated with SCLs.

Oral symptoms and salivary findings in oral lichen planus, oral lichenoid lesions and stomatitis

Background

To examine if patients with oral lichen planus, oral lichenoid lesions and generalised stomatitis and concomitant contact allergy have more frequent and severe xerostomia, lower unstimulated and chewing-stimulated saliva and citric-acid-stimulated parotid saliva flow rates, and higher salivary concentration of total protein and sIgA than cases without contact allergy and healthy controls.

Methods

Forty-nine patients (42 women, aged 61.0 ± 10.3 years) and 29 healthy age- and gender-matched subjects underwent a standardised questionnaire on general and oral health, assessment of xerostomia, clinical examination, sialometry, mucosal biopsy and contact allergy testing.

Results

Nineteen patients had oral lichen planus, 19 patients had oral lichenoid lesions and 11 patients had generalised stomatitis. 38.8% had contact allergy. Xerostomia was significantly more common and severe in patients (46.9%) than in healthy controls, whereas the saliva flow rates did not differ. The patients had higher sIgA levels in unstimulated and chewing-stimulated saliva than the healthy controls. The total protein concentration in saliva was lower in the unstimulated saliva samples whereas it was higher in the chewing stimulated saliva samples from patients when compared to healthy controls. The differences were not significant and they were irrespective of the presence of contact allergy.

Conclusion

Xerostomia is prevalent in patients with oral lichen planus, lichenoid lesions and generalised stomatitis, but not associated with salivary gland hypofunction, numbers of systemic diseases or medications, contact allergy, age, or gender. Salivary sIgA levels were higher in patients than in healthy controls, but did not differ between patient groups. The total salivary protein concentration was lower in unstimulated saliva samples and higher in chewing-stimulated saliva samples in patients than in healthy controls, but did not differ between patient groups. Our findings do not aid in the discrimination between OLP and OLL and these conditions with or without contact allergic reactions.

A Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective Sialorrhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI

BACKGROUND

Medication-induced salivary gland dysfunction (MISGD), xerostomia (sensation of oral dryness), and subjective sialorrhea cause significant morbidity and impair quality of life. However, no evidence-based lists of the medications that cause these disorders exist.

OBJECTIVE

Our objective was to compile a list of medications affecting salivary gland function and inducing xerostomia or subjective sialorrhea.

DATA SOURCES

Electronic databases were searched for relevant articles published until June 2013. Of 3867 screened records, 269 had an acceptable degree of relevance, quality of methodology, and strength of evidence. We found 56 chemical substances with a higher level of evidence and 50 with a moderate level of evidence of causing the above-mentioned disorders. At the first level of the Anatomical Therapeutic Chemical (ATC) classification system, 9 of 14 anatomical groups were represented, mainly the alimentary, cardiovascular, genitourinary, nervous, and respiratory systems. Management strategies include substitution or discontinuation of medications whenever possible, oral or systemic therapy with sialogogues, administration of saliva substitutes, and use of electro-stimulating devices.

LIMITATIONS

While xerostomia was a commonly reported outcome, objectively measured salivary flow rate was rarely reported. Moreover, xerostomia was mostly assessed as an adverse effect rather than the primary outcome of medication use. This study may not include some medications that could cause xerostomia when administered in conjunction with others or for which xerostomia as an adverse reaction has not been reported in the literature or was not detected in our search.

CONCLUSIONS

We compiled a comprehensive list of medications with documented effects on salivary gland function or symptoms that may assist practitioners in assessing patients who complain of dry mouth while taking medications. The list may also prove useful in helping practitioners anticipate adverse effects and consider alternative medications.