Investigation of xerostomia in patients with rheumatoid arthritis

Oral health-related quality of life and dental caries in rheumatoid arthritis patients: a cross-sectional observational study

Rheumatoid arthritis (RA) is a systemic, chronic, and inflammatory joint disease with oral complications. This research aimed to compare the oral health-related quality of life and decayed, missing and filled teeth (DMFT) index in rheumatoid arthritis patients over 18 years with healthy individuals. In this study, 45 rheumatoid arthritis cases were assigned to the experimental group, and 45 healthy individuals were assigned to the control group. After completing biography forms, the participants filled out two questionnaires. These questionnaires included the Oral Health Impact Profile-14 (OHIP-14) and the Oral Health Assessment Index (GOHAI). Next, their teeth were clinically examined to check for caries. Finally, the data were analyzed statistically. RA and control groups were similar in gender, marital status, age, occupation, and level of education. However, a significant difference was observed between the two groups concerning DMFT (P<0.001) and total OHIP-14 score (P<0.001). Moreover, no significant difference was observed between the groups concerning the total GOHAI score (P=0.526). The oral health-related quality of life in rheumatoid arthritis patients was lower than that in the general population, with the rate of dental caries being higher in these patients.

The Effect of N-Acetylcysteine on Respiratory Enzymes, ADP/ATP Ratio, Glutathione Metabolism, and Nitrosative Stress in the Salivary Gland Mitochondria of Insulin Resistant Rats

This is the first study to assess the effect of N-acetylcysteine (NAC) on the mitochondrial respiratory system, as well as free radical production, glutathione metabolism, nitrosative stress, and apoptosis in the salivary gland mitochondria of rats with high-fat diet (HFD)-induced insulin resistance (IR). The study was conducted on male Wistar rats divided into four groups of 10 animals each: C (control, rats fed a standard diet containing 10.3% fat), C + NAC (rats fed a standard diet, receiving NAC intragastrically), HFD (rats fed a high-fat diet containing 59.8% fat), and HFD + NAC (rats fed HFD diet, receiving NAC intragastrically). We confirmed that 8 weeks of HFD induces systemic IR as well as disturbances in mitochondrial complexes of the parotid and submandibular glands of rats. NAC supplementation leads to a significant increase in the activity of complex I, II + III and cytochrome c oxidase (COX), and also reduces the ADP/ATP ratio compared to HFD rats. Furthermore, NAC reduces the hydrogen peroxide production/activity of pro-oxidant enzymes, increases the pool of mitochondrial glutathione, and prevents cytokine formation, apoptosis, and nitrosative damage to the mitochondria in both aforementioned salivary glands of HFD rats. To sum up, NAC supplementation enhances energy metabolism in the salivary glands of IR rats, and prevents inflammation, apoptosis, and nitrosative stress.

Salivary gland performance in autoimmune diseases: review and meta-analysis

Objectives: Autoimmune diseases include a spectrum of disorders in which immune response to the autoantigens leads to tissue damage or dysfunction. Xerostomia, salivary gland dysfunction and lack of saliva are some common symptoms associated with many autoimmune diseases.Methods: In this review study, the meta-analysis technique is used to objectively review the relationship between autoimmune diseases and salivary gland dysfunction. We have searched Medline and Embase and Google Scholar. By Revman 5.3, meta-analysis was performed to investigate the salivary flow rate in both stimulatory and non-stimulatory saliva. The sample size obtained from these studies was 130 people with autoimmune diseases and 100 healthy individuals.Results: The results showed a significant decrease in the level of non-stimulatory saliva in people with autoimmune diseases.Conclusions: A complete and comprehensive understanding of the clinical manifestation of systemic diseases is crucial in early diagnosis of diseases and identifying the mechanisms that develop the disease. Other than xerostomia, there is a significant reduction in salivary flow rate in patients with autoimmune diseases. As saliva plays a very important role in oral health and has significant functions, more attention is needed for monitoring and managing of hyposalivation in autoimmune patients.

"Assessment of relationship between xerostomia and oral health-related quality of life in patients with rheumatoid arthritis"

OBJECTIVE

To determine the relationship between xerostomia and oral health-related quality of life in patients with rheumatoid arthritis.

MATERIALS AND METHOD

Two hundred patients with rheumatoid arthritis were assessed using Fox and OHIP-14 questionnaires concerning xerostomia and oral health-related quality of life, respectively. The sum of decayed, missing, and filled teeth (DMFT) was determined via an intra-oral examination. In addition, intergroup comparisons were evaluated using t test, chi-square, regression, and Tukey analysis.

RESULT

Among rheumatoid arthritis patients, 51% had been afflicted with xerostomia. We found a statistically significant relationship between xerostomia and oral health-related quality of life (p-value=.004), as xerostomia cases have significantly worse oral health-related quality of life. Also, there was a statistically significant association between oral health-related quality of life and gender as well as DMFT.

CONCLUSION

Because there seem to be a high prevalence of xerostomia in patients with rheumatoid arthritis, screening in such population is highly recommended. Therefore, educational programs and/or workshops should be encouraged among healthcare providers to prevent worsening of oral health-related quality of life.

What rheumatologists should know about orofacial manifestations of autoimmune rheumatic diseases

Orofacial manifestations occur frequently in rheumatic diseases and usually represent early signs of disease or of its activity that are still neglected in clinical practice. Among the autoimmune rheumatic diseases with potential for oral manifestations, rheumatoid arthritis (RA), inflammatory myopathies (IM), systemic sclerosis (SSc), systemic lupus erythematosus (SLE), relapsing polychondritis (RP) and Sjögren's syndrome (SS) can be cited. Signs and symptoms such as oral hyposalivation, xerostomia, temporomandibular joint disorders, lesions of the oral mucosa, periodontal disease, dysphagia, and dysphonia may be the first expression of these rheumatic diseases. This article reviews the main orofacial manifestations of rheumatic diseases that may be of interest to the rheumatologist for diagnosis and monitoring of autoimmune rheumatic diseases.

Associations between xerostomia and health status indicators in the elderly

Aims: This study investigated the associations between xerostomia (dry mouth) (low, moderate and high) with other categorical variables (e.g. demographic and health status indicators). This paper aims to report on the severity of xerostomia in the elderly population and investigate the relationship with other aspects of perceived health.

Method: Data were obtained from a cross-sectional survey of 225 elderly people from a large multilevel geriatric care centre. The centre consists of three levels of care: an apartment building in which residents live more or less independently, a home for the aged, and a chronic care hospital. Participants in the study were recruited when they attended the dental care facility. Data were collected by means of a personal interview conducted either at the dental care facility or the participant’s residence.

Results: The mean age was 83 years. Most were females (72%) and almost all (99%) reported one or more chronic medical conditions; 88% had physical disabilities. Xerostomia was recorded on a seven-point scale. Scores were categorised as low, medium or high and the proportions were 49.3%, 30.3% and 20.4% respectively. Bivariate analysis showed no association between dry mouth and sex, age, general health change or life satisfaction. However, when the high xerostomia group was separated out and odds ratios calculated they were 2.3 to 4.9 times more likely to experience a negative impact on health than the low group. Xerostomia did not have a significant impact on chewing capacity, morale or stress, although it contributed to the variability of the oral health-related quality of life measures. It was the only variable with a significant effect (OR 2.55) for the Oral Health Impact Profile-14 and displayed a higher odds ratio (2.76) for the Geriatric Oral Health Assessment Index. Selfreported xerostomia in the elderly population can be categorised into a severity scale. Those suffering most from xerostomia are more likely to experience a negative impact on general health.

Conclusion: The key finding in this study is that xerostomia has a significant and negative impact on the quality of life of elderly individuals, though oral function may be less affected.

Oral manifestations of rheumatoid arthritis. A cross-sectional study of 73 patients

OBJECTIVE

A study is made of the main oral manifestations of patients with rheumatoid arthritis (RA), particularly salivary flow, and of its possible association to periodontal disease.

MATERIAL AND METHODS

A prospective comparative study was made of 146 patients (73 with RA and 73 controls), recording pocket depth, clinical attachment loss, bleeding index, plaque index, and the DMFT index to assess periodontal and dental alterations. Sialometric measurements were also made to determine resting, stimulated, and parotid salivary flow.

RESULTS

The patients with RA had greater periodontal pocket depths (with moderate depths in most cases), as well as greater attachment loss and more bacterial plaque. The resting whole saliva and stimulated parotid saliva rates were also clearly decreased in the RA group compared with the controls.

CONCLUSIONS

Patients with RA are more likely to present periodontal disease, poorer oral hygiene manifesting as an increased accumulation of bacterial plaque, and decreased salivary flow rates.

CLINICAL RELEVANCE

Vulnerability to periodontitis is confirmed in one of the largest samples ever studied of patients with rheumatoid arthritis (RA). Also, there is evidence of hyposialia (decrease in salivary rate) in RA patients without Sjögren's syndrome.

What rheumatologists should know about orofacial manifestations of autoimmune rheumatic diseases

Orofacial manifestations occur frequently in rheumatic diseases and usually represent early signs of disease or of its activity that are still neglected in clinical practice. Among the autoimmune rheumatic diseases with potential for oral manifestations, rheumatoid arthritis (RA), inflammatory myopathies (IM), systemic sclerosis (SSc), systemic lupus erythematosus (SLE), relapsing polychondritis (RP) and Sjögren's syndrome (SS) can be cited. Signs and symptoms such as oral hyposalivation, xerostomia, temporomandibular joint disorders, lesions of the oral mucosa, periodontal disease, dysphagia, and dysphonia may be the first expression of these rheumatic diseases. This article reviews the main orofacial manifestations of rheumatic diseases that may be of interest to the rheumatologist for diagnosis and monitoring of autoimmune rheumatic diseases.

Salivary flow rates among women diagnosed with benign and malignant tumors

The purpose of this study was to compare salivary flow rates (SWS) among patients diagnosed with benign and varying malignant solid tumors with the comparison group, prior to the initiation of any treatment. An evaluation of the results found that mean baseline SWS flow rates were higher for healthy patients (1.55 ml/min) when compared to patients diagnosed with benign tumors (1.13 ml/min), breast cancer (1.09 ml/min), and reproductive carcinomas (0.94 ml/min). The overall model (F = 7.76; p < .001) and the Dunnett's post hoc analyses were statistically significant at the p < .001 level. Additionally, medications, race, and season of the year had significant effects on mean SWS flow rates. The results suggest that salivary secretion is lower among both benign and malignant tumor subjects prior to the initiation of treatment. Salivary evaluations of subjects prior to treatment may be useful in identifying individuals at risk for oral complications during chemotherapy.

Interventions for the management of dry mouth: topical therapies

BACKGROUND

Xerostomia (the feeling of dry mouth) is a common symptom especially in older adults. Causes of dry mouth include medications, autoimmune disease (Sjögren's Syndrome), radiotherapy or chemotherapy for cancer, hormone disorders and infections.

OBJECTIVES

To determine which topical treatments for dry mouth are effective in reducing this symptom.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (28 October 2011), The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4 2011), MEDLINE via OVID (1950 to 28 October 2011), EMBASE via OVID (1980 to 28 October 2011), CINAHL via EBSCO (1980 to 28 October 2011), AMED via OVID (1985 to 28 October 2011), CANCERLIT via PubMed (1950 to 28 October 2011).

SELECTION CRITERIA

We included randomised controlled trials of topical interventions such as lozenges, sprays, mouthrinses, gels, oils, chewing gum or toothpastes for the treatment of dry mouth symptom. We classified interventions into two broad categories, saliva stimulants and saliva substitutes, and these were compared with either placebo or another intervention. We included both parallel group and crossover trials.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently carried out data extraction and assessed risk of bias. Trial authors were contacted for additional information as required.

MAIN RESULTS

Thirty-six randomised controlled trials involving 1597 participants met the inclusion criteria. Two trials compared saliva stimulants to placebo, nine trials compared saliva substitutes to placebo, five trials compared saliva stimulants directly with saliva substitutes, 18 trials directly compared two or more saliva substitutes, and two trials directly compared two or more saliva stimulants. Only one trial was at low risk of bias and 17 were at high risk of bias. Due to the range of interventions, comparisons and outcome measures in the trials, meta-analysis was possible for only a few comparisons. Oxygenated glycerol triester (OGT) saliva substitute spray shows evidence of effectiveness compared to an electrolyte spray (standardised mean difference (SMD) 0.77, 95% confidence interval (CI) 0.38 to 1.15) which corresponds to approximately a mean difference of 2 points on a 10-point visual analogue scale (VAS) for mouth dryness. Both integrated mouthcare systems (toothpaste + gel + mouthwash) and oral reservoir devices show promising results but there is insufficient evidence at present to recommend their use. Although chewing gum is associated with increased saliva production in the majority of those with residual capacity, there is no evidence that gum is more or less effective than saliva substitutes.

AUTHORS' CONCLUSIONS

There is no strong evidence from this review that any topical therapy is effective for relieving the symptom of dry mouth. OGT spray is more effective than an aqueous electrolyte spray (SMD 0.77, 95% CI 0.38 to 1.15) which is approximately equivalent to a mean difference of 2 points on a 10-point VAS scale for mouth dryness. Chewing gums appear to increase saliva production in those with residual secretory capacity and may be preferred by patients, but there is no evidence that gum is better or worse than saliva substitutes. Integrated mouthcare systems and oral reservoir devices may be helpful but further research is required to confirm this. Well designed, adequately powered randomised controlled trials of topical interventions for dry mouth, which are designed and reported according to CONSORT guidelines, are required to provide evidence to guide clinical care. For many people the symptom of dry mouth is a chronic problem and trials should evaluate whether treatments are palatable, effective in reducing xerostomia, as well as the long-term effects of treatments on quality of life of those with chronic dry mouth symptoms.

Oral events related to low-dose methotrexate in rheumatoid arthritis patients

Low-dose methotrexate (MTX) is frequently used for patients with rheumatoid arthritis (RA). High doses of MTX frequently produce side effects. The aim of this study was to explore oral complications of low-dose MTX therapy in a population of RA patients. This is a cross-sectional study in which oral examination was performed on a population of RA patients. Patients undergoing MTX therapy (5-20 mg weekly) for at least six months were included in the study group, and RA patients being treated under another regimen were used as controls. The frequency of oral lesions was compared between groups. The chi-square test was used to compare frequencies. Relative risk (RR) and its confidence interval (CI) were established. Significance level was set at 0.05. Twenty-eight RA patients on a low-dose MTX regimen and 21 controls were enrolled in the study. Oral lesions were found in 22 patients (78.6%) undergoing MTX therapy, and in 5 patients (23.8%) undergoing other therapies (p < 0.001). There were no significant differences regarding age, gender or dosage. The most common oral events observed in patients in the MTX group were ulcerative/erosive lesions (60.7%) and candidiasis (10.7%). Patients in the control group presented lower prevalence of the same lesions (p < 0.001). The RR for developing oral lesions was 11.73 (CI 2.57 - 58.98), with low-dose MTX therapy. In conclusion, the prevalence of oral mucosa lesions in RA patients receiving low doses of MTX therapy is higher than in RA patients not receiving the drug.

Views of xerostomia among health care professionals: a qualitative study

AIM

To explore and describe views of xerostomia among health care professionals.

BACKGROUND

Xerostomia (dry mouth) is caused by changes in quality and quantity of saliva due to poor health, certain drugs and radiation therapy. It is a common symptom, particularly among older people and has devastating consequences with regard to oral health and general well-being.

METHODS

Data were obtained and categorised by interviewing 16 health care professionals. Qualitative content analysis was chosen as the method of analysis.

DESIGN

Qualitative.

RESULTS

The latent content was formulated into a theme: xerostomia is a well-known problem, yet there is inadequate management of patients with xerostomia. The findings identified three categories expressing the manifest content: awareness of xerostomia, indifferent attitude and insufficient support.

CONCLUSIONS

Although xerostomia was recognised as commonly occurring, it was considered to be an underestimated and an ignored problem. Proper attention to conditions of xerostomia and subsequent patient management were viewed as fragmentary and inadequate. Additional qualitative studies among patients with xerostomia would be desirable to gain further understanding of the problems with xerostomia, its professional recognition and management.

RELEVANCE TO CLINICAL PRACTICE

A holistic view, positive professional attitudes and enhanced knowledge of xerostomia seem essential to augment collaboration among health care professionals and to improve compassion for and support of patients with xerostomia.

Oral manifestations of Sjögren's syndrome

Sjögren's syndrome is a common autoimmune rheumatic disease. The most common symptoms of Sjögren's syndrome are extreme tiredness, along with dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). Saliva plays an essential role in numerous functions of the mouth. Xerostomia can be caused by medications, chronic diseases like Sjögren's syndrome, and medical treatments, such as radiation therapy and bone marrow transplant. Xerostomia can eventually lead to difficulty in swallowing, severe and progressive tooth decay, or oral infections. Despite having excellent oral hygiene, individuals with Sjögren's syndrome have elevated levels of dental caries, along with the loss of many teeth, early in the disease. Sjögren's syndrome alters the protein profile and brings about a change in the composition of saliva. There is an increase in the levels of lactoferrin, beta(2)-microglobulin, sodium, lysozyme C, and cystatin C, and a decrease in salivary amylase and carbonic anhydrase. Up to 90% of individuals with Sjögren's syndrome have antibodies targeting the Ro 60 and La autoantigens. Natural aging, regardless of Sjögren's syndrome, is also another factor that brings about a significant change in the composition of saliva. The most prevailing cause of xerostomia in elderly persons is the use of anticholinergic medications. Currently, there is no cure for Sjögren's syndrome, and treatment is mainly palliative.

Videofluoroscopy and swallowing studies for neurologic disease: a primer

Many patients with neurologic impairment due to stroke, multiple sclerosis, trauma, bulbar palsy, and other disorders have difficulty swallowing. Videofluoroscopy can provide important information on patterns of impairment of the swallowing mechanism, allowing important changes in patient treatment. The detailed videofluoroscopic evaluation required to provide this information is now seldom taught and is practiced by relatively few radiologists. The aim of this article is to (a) describe the indications for videofluoroscopic swallowing studies in the evaluation of patients with neurologic conditions affecting swallowing, (b) describe the techniques for evaluating the swallow mechanism with videofluoroscopy in a standardized manner, and (c) use cine videofluoroscopy to illustrate the range of abnormalities that can be demonstrated for some of these conditions and discuss the effect of patient treatment.

Xerostomia: clinical aspects and treatment

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

Salivary proteins in rheumatoid arthritis and Sjögren's syndrome: one-dimensional and two-dimensional electrophoretic studies

Parotid saliva from patients with rheumatoid arthritis and Sjögren's syndrome contains elevated levels of multiple anionic proteins of pI approximately 3.75-4.75 and Mr approximately 32,000. Further studies on these components involving narrow range pH 3.5-5.0 immobilized pH gradients (IPGs) and two-dimensional (2D) electrophoresis with narrow- or broad-range IPGs in the first dimension have confirmed their association with these disorders. Immunoblotting showed that these proteins include multiple forms of tissue kallikrein. Treatment with neuraminidase results in removal of these anionic substances from the pH 3.75-4.75 region of gels, thereby indicating that heterogeneity arises from differences in sialation of the carbohydrate residues. The results of treatment with endo-beta-N-acetylglucosaminidase (Endo F) or peptide N-glycosidase (PNGase F) and comparison of the results with studies on human urinary kallikrein suggest that proteins other than kallikrein may also comigrate in the anionic region of gels and that deglycosylation of kallikrien is incomplete in the experimental conditions used, probably because of inadequate denaturation. The paper also reviews the limitations of current criteria used in the investigation of salivary gland function associated with connective tissue disorders and the diagnosis of these. It assesses the potential of electrophoresis in forming the basis of new diagnostic techniques and furthering the understanding of the nature of these diseases. The findings presented in this paper could make a key contribution to this.