Xerostomia: diagnosis and treatment

Transdermal pilocarpine on the skin over salivary glands to increase salivation: an in vivo study

BACKGROUND

Hyposalivation is treated using oral cholinergic drugs; however, systemic side effects occasionally lead to discontinuation of treatment. We aimed to investigate the effects of transdermal pilocarpine on the salivary gland skin on saliva secretion and safety in rats.

METHODS

Pilocarpine was administered to rats orally (0.5 mg/kg) or topically on the salivary gland skin (5 mg/body). Saliva volume, the number of sweat dots, and fecal weight were measured along with pilocarpine concentration in plasma and submandibular gland tissues.

RESULTS

Saliva volume significantly increased 0.5 h after oral administration and 0.5, 3, and 12 h after topical administration. Fecal weight and sweat dots increased significantly 1 h after oral administration; however, no changes were observed after topical application. The pilocarpine concentration in the submandibular gland tissues of the topical group was higher than that in the oral group at 0.5, 3, and 12 h of administration.

CONCLUSIONS

Pilocarpine application to salivary gland skin persistently increased salivary volume in rats without inducing sweating or diarrhea. Transdermal pilocarpine applied to the skin over the salivary glands may be an effective and safe treatment option for hyposalivation.

Characteristics of medication-induced xerostomia and effect of treatment

OBJECTIVE

Side-effects of medications cause xerostomia. There have been cases where a medication has been discontinued owing to its severe side-effects. Therefore, the xerostomia must be treated to ensure that the primary disease is managed effectively. This study analyzed the actual status of patients with medication-induced xerostomia and investigates factors associated with its improvement.

METHODS

This study assessed 490 patients diagnosed with medication-induced xerostomia who had an unstimulated salivary flow of ≤0.1 mL/min and received treatment for xerostomia at a xerostomia clinic. Patient age, sex, medical history, medications used, disease duration of xerostomia, and psychological disorders were recorded. The anticholinergic burden was assessed using the Anticholinergic Cognitive Burden scale. The unstimulated salivary flow was measured by the spitting method. According to their symptoms and diagnoses, the patients were introduced to oral lubricants, instructed on how to perform massage, and prescribed Japanese herbal medicines, and sialogogues. Factors associated with the subjective improvement of xerostomia and objective changes in the salivary flow rate were recorded at six months.

RESULTS

Xerostomia improved in 338 patients (75.3%). The improvement rate was significantly lower in patients with psychiatric disorders (63.6%) (P = 0.009). The improvement rate decreased as more anticholinergics were used (P = 0.018). However, xerostomia improved in approximately 60% of patients receiving three or more anticholinergics. The unstimulated salivary flow increased significantly more in patients who reported an improvement of xerostomia (0.033±0.053 mL/min) than in those who reported no improvement (0.013±0.02 mL/min) (P = 0.025).

CONCLUSION

Xerostomia treatment improved oral dryness in 75.3% of patients receiving xerogenic medications in this study. If xerostomia due to side-effects of medications can be improved by treatment, it will greatly contribute to the quality of life of patients with xerogenic medications and may reduce the number of patients who discontinue medications.

A Review on Xerostomia and Its Various Management Strategies: The Role of Advanced Polymeric Materials in the Treatment Approaches

The medical term xerostomia refers to the subjective sensation of oral dryness. The etiology seems to be multifactorial with the most frequently reported causes being the use of xerostomic medications, neck and head radiation, and systematic diseases (such as Sjögren’s syndrome). Xerostomia is associated with an increased incidence of dental caries, oral fungal infections, and difficulties in speaking and chewing/swallowing, which ultimately affect the oral health-related quality of life. The development of successful management schemes is regarded as a highly challenging project due to the complexity of saliva. This is why, in spite of the fact that there are therapeutic options aiming to improve salivary function, most management approaches are alleviation-oriented. In any case, polymers are an integral part of the various formulations used in every current treatment approach, especially in the saliva substitutes, due to their function as thickening and lubricating agents or, in the case of mucoadhesive polymers, their ability to prolong the treatment effect. In this context, the present review aims to scrutinize the literature and presents an overview of the role of various polymers (or copolymers) on either already commercially available formulations or novel drug delivery systems currently under research and development.

Factors associated with xerostomia in perimenopausal women

OBJECTIVES

Various oral symptoms, including xerostomia and burning mouth syndrome, may occur in menopausal women. These symptoms reduce quality of life (QOL). However, the actual condition of xerostomia after menopause is not clear. The purpose of this study was to reveal the factors associated with xerostomia in perimenopausal women.

METHODS

Participants included 118 outpatients (mean age, 49.9 ± 3.2 years; range, 45-55 years) at a department of gynecology in Japan. Information was collected concerning age, medical history, medications, menstrual status, and history of treatment for climacteric symptoms. Oral symptoms, including xerostomia were evaluated with a 3-point scale. The climacteric symptom checklist for Japanese women and 36-Item Short-Form Health were used to evaluate climacteric symptoms and QOL, respectively. In addition, the volume of unstimulated saliva, oral moisture, salivary α-amylase, chromogranin A, and 17-β estradiol were measured.

RESULTS

Higher age, the total number of medications, psychotropic drug, hormone replacement therapy, treatment for climacteric symptoms, sticky mouth, burning sensation of tongue, dryness of nose and 14 of the 21 climacteric symptoms significantly affected xerostomia. In addition, treatment for climacteric symptoms, fall asleep but often awake at night, headaches and dryness of nose were significantly associated with xerostomia. In conclusion, xerostomia is closely associated to factors such as treatment for climacteric symptoms and certain menopausal symptoms, and it may be related to QOL in perimenopausal women.

The use of Schirmer strips to measure salivary and lacrimal flow in non-Sjögren patients

Introduction

Oral and ocular dryness are the most common symptoms reported during ophthalmological and dental examinations. It is becoming a serious and growing problem due to the huge variety of affecting factors and with population aging.

Objectives

The purpose was to demonstrate an application of the Schirmer test for xerostomia. Subsequently, to compare and correlate the results achieved from the lacrimal Schirmer test and salivary Schirmer test in non-Sjögren patients.

Methods

Study group consisted of 642 patients with/without subjective or/and objective symptoms of dry eye or mouth who did not fulfill the criteria for diagnosis of Sjögren syndrome. The lacrimal Schirmer test (lST) and the salivary Schirmer tests (sST) were performed (sSTm was put on the floor of the mouth, sSTp in front of the parotid gland duct). The results were recorded after 1 min (sSTm), 3 min (sSTp), and 5 min (lST).

Results

The lST and sST test scores were considerably higher in the healthy group than in others, p < 0.001. The results of sST1 and sST2 decreased with the appearance of subjective and objective symptoms, p < 0.001. There were positive correlations between lST and sSTm outcomes between the groups, p < 0.001.

Conclusions

We present the Schirmer test adapted to measure salivary gland hypofunction that is a time-saving tool in our daily practice. Results of this study reveal an excellent correlation between the eye Schirmer test and the salivary Schirmer tests.

Clinical relevance

The salivary Schirmer tests seem to be rapid, convenient, and reliable objective screening tools for salivary gland hypofunction in non-Sjögren patients.

Management of Pain Associated with Selected Conditions in Dermatology

Dermatologists face a wide range of pain control challenges in daily practice, from the transient pain of dermatologic surgery to the persistent pain that plagues some chronic dermatologic conditions. Although the pathophysiology of pain is well described and the profound impact of dermatological pain on patients' quality of life is well appreciated, there is an identified need for clear therapeutic plans for providing symptomatic pain relief of common painful dermatoses. In this paper, we will review and clearly outline approaches to pain management of a number of common painful dermatoses such as herpes zoster and post-herpetic neuralgia, ulcers, oral dermatoses, dysesthesias, and many others.

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

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

Review of the Pharmacological Properties and Clinical Usefulness of Muscarinic Agonists for Xerostomia in Patients with Sjögren's Syndrome

The anti-xerostomia effects of muscarinic agonists (cholinomimetics) are reviewed. Cevimeline (cevimeline monohydrochloride hemihydrate) is a novel muscarinic agonist that stimulates salivary secretion in animals and humans both with normal salivary gland function and with impaired salivary secretion (xerostomia or oral dryness) as effectively as pilocarpine. Other classic and nonselective muscarinic agonists, such as arecoline, carbachol, muscarine and oxotremorine, as well as acetylcholine, failed to exhibit a sufficient salivation effect even at sublethal doses in animals.Oral administration of cevimeline 30mg to humans induces a moderate and lasting increase in salivary flow, and the effect is maintained for at least 4 to 6 hours, longer than with pilocarpine. Mean increases in salivary flow rates after cevimeline treatment were 2-fold higher than after placebo, and no evidence of tolerance of the pharmacological effect has been observed during prolonged administration for up to 12 months.The clinical efficacy of cevimeline in relieving symptoms of xerostomia, including oral dryness and difficulties in chewing, swallowing and speaking, has been demonstrated by placebo-controlled, double-blind, randomised clinical trials in the USA and Japan. In these studies, cevimeline 30mg three times daily increased salivary flow and improved the symptoms of xerostomia in a significantly higher percentage of patients compared with placebo. Some patients receiving cevimeline therapy for xerostomia experienced adverse events such as sweating, gastrointestinal symptoms (nausea, diarrhoea, abdominal pain and vomiting), dizziness and rigors; these effects were related to muscarinic activity and were generally mild and tolerable in comparison with those of pilocarpine.These findings suggest that muscarinic M3 agonists are suitable for the treatment of xerostomia. Cevimeline in particular has a long-lasting salivation effect with fewer adverse events than pilocarpine, and so is expected to be more useful for the treatment of xerostomia in patients with Sjögren's syndrome, reducing symptom severity and improving their quality of life.

Effects of reduced saliva production on swallowing in patients with Sjogren's syndrome

This study aimed to further characterize the nature of swallowing dysfunction in patients with Sjogren's syndrome (SS). Subjects filled out a perception of swallow function form. Measures of stimulated salivary flow rate were also taken, and videofluoroscopic evaluation of swallowing was completed. The amount of saliva produced by patients with SS was significantly less than that produced by normal age-matched controls, and these patients perceived their swallowing to be impaired. Few statistically significant differences were found between the SS group and normal age-matched controls on temporal measures of swallowing, and 96% of swallows in the SS group were judged to be functional. There was no correlation between perception of swallowing and amount of saliva produced. No strong correlations were found between temporal measures of swallowing and salivary flow rate. Results indicated that patients with SS tend to perceive their swallowing to be worse than physiologic swallowing measures indicate. The decreased saliva production in these patients does not appear to be the cause of their perceived swallowing difficulty but may affect their sensory judgment of swallow function. Future studies will focus on how quality of saliva affects swallowing in these patients.

Chemotherapy-induced and/or radiation therapy-induced oral mucositis--complicating the treatment of cancer

The term mucositis is coined to describe the adverse effects of radiation and chemotherapy treatments. Mucositis is one of the most common adverse reactions encountered in radiation therapy for head and neck cancers, as well as in chemotherapy, in particular with drugs affecting DNA synthesis (S-phase-specific agents such as fluorouracil, methotrexate, and cytarabine). Mucositis may limit the patient's ability to tolerate chemotherapy or radiation therapy, and nutritional status is compromised. It may drastically affect cancer treatment as well as the patient's quality of life. The incidence and severity of mucositis will vary from patient to patient. It will also vary from treatment to treatment. It is estimated that there is 40% incidence of mucositis in patients treated with standard chemotherapy and this will not only increase with the number of treatment cycles but also with previous episodes. Similarly, patients who undergo bone marrow transplantation and who receive high doses of chemotherapy have a 76% chance of getting mucositis. Patients receiving radiation, in particular to head and neck cancers, have a 30% to 60% chance. The exact pathophysiology of development is not known, but it is thought to be divided into direct and indirect mucositis. Chemotherapy and/or radiation therapy will interfere with the normal turnover of epithelial, cells leading to mucosal injury; subsequently, it can also occur due to indirect invasion of Gram-negative bacteria and fungal species because most of the cancer drugs will cause changes in blood counts. With the advancement in cytology, a more precise mechanism has been established. With this understanding, we can select and target particular mediators responsible for the mucositis. Risk factors such as age, nutritional status, type of malignancy, and oral care during treatment will play important roles in the development of mucositis. Many treatment options are available to prevent and treat this condition, but none of them can completely prevent or treat mucositis. More and more pathological methods are being developed to understand this condition so that better therapeutic regimens can be selected. Emphasis also should be made in assessing the patient's psychologic condition, particular depressive disorders. This is important because treatment with antidepressants will not only contribute in lifting depression but also reduces pain somatization. Although mucositis is rarely life-threatening, it will interfere with treatment of cancer to a great extent.

Lowered susceptibility of muscarinic receptor involved in salivary secretion of streptozotocin-induced diabetic rats

We investigated the responses of salivary secretion and the susceptibility of the muscarinic receptors in the salivary glands of the streptozotocin (STZ)-induced diabetic rats (STZ rats). Giving water ad libitum, the amount of whole saliva with no stimulation was similar in the STZ and the control rats. Pilocarpine increased salivary secretion in both groups, although the effect in the STZ rats was two to three fold less than in the control rats. If the animals were restricted from taking water for 6 h, salivary secretion was not slightly changed in the STZ rats in spite of a remarkable increase in the control. An obvious decrease in salivary secretion of the STZ rats was negatively correlated with an increase in urination. Furthermore, salivary secretion from the parotid gland was increased in a dose-dependent manner with pilocarpine in the control rats, but not in the STZ rats. In the [3H]quinuclidinyl benzilate (QNB) binding studies for muscarinic receptor of the STZ rats, Bmax was decreased in the parotid gland and Kd was increased in the submandibular gland. Competitive inhibition of [3H]QNB binding to both glands showed an increase in IC50 of pilocarpine and carbachol. These results suggest that a decrease in salivary secretion of STZ rats is not only induced by a water loss, but also closely associated with the lowered susceptibility of the muscarinic receptors.

Double blind clinical trial of a remineralizing dentifrice in the prevention of caries in a radiation therapy population

OBJECTIVES

The purpose of this study is to determine the efficacy and safety of a specially formulated remineralizing toothpaste in controlling caries in a group of high risk, head and neck radiation patients.

DESIGN

The study compares the performance of the remineralizing toothpaste with a leading conventional fluoride dentifrice using double-blind randomization. TEST PRODUCTS: The products compared both contain equivalent quantities of fluoride (1150 ppm). The remineralizing toothpaste also delivers soluble calcium and phosphate ions, the essential components of teeth.

SUBJECTS

On completion, 50 subjects who received > 50 Gy of radiation to the head and neck.

MEASUREMENTS

Examinations include coronal and root caries using the Pitts Diagnostic Criteria, salivary flow rate, plaque and gingival indices and microbiological counts over one year.

RESULTS

At this point subjects are enrolled in the study at various phases. However, the current average for the net increment per month per subject is -0.12 (+/- 1.30) for coronal caries and 0.06 (+/- 0.73) for root caries in subjects using the remineralizing toothpaste and 0.53 (+/- 1.62) for coronal caries and 0.45 (+/- 0.98) for root caries in subjects using the conventional fluoride dentifrice. Non-parametric analysis of rank scores for net root surface increments/month was statistically significant (p = 0.02), suggesting lower net root surface increment/month for the remineralizing toothpaste relative to the conventional toothpaste. No significant differences were noted on coronal surfaces.

CONCLUSIONS

The results to date indicate that the remineralizing toothpaste is significantly superior to the conventional fluoride dentifrice in preventing root caries in high risk patients.

Identifying and treating xerostomia in restorative patients

Inadequate saliva can have devastating consequences for a patient, including oral discomfort, rampant caries, increased candida infections, and desiccation of restorative and esthetic dental treatment. Diagnosis of the cause of xerostomia is imperative to treating the condition, and multiple causes should be considered. Treatment options for xerostomia consists of treatment for hyposalivation, palliative and preventive care to combat the results of long-term dry mouth. Treatment of xerostomia should be based on the etiologic factors of the disease, with prevention of further oral destruction and comfort being the primary goals of treatment.

Risk factors associated with mucositis in cancer patients receiving 5-fluorouracil

Oral mucositis is a dose-limiting toxicity of 5-fluorouracil (5-FU). This prospective cohort study investigated factors associated with mucositis in patients receiving 5-FU for cancer of the digestive tract. Sixty-three patients (mean age 65 years) completed self-administered questionnaires and had interviews, oral examinations and unstimulated whole salivary flow measurements at baseline and follow-up appointments. The duration of follow-up was 2 months. Predictor variables included sociodemographic data, body surface area, diabetes, smoking, alcohol consumption, salivary flow, oral hygiene, presence of prostheses, performance status, regimen of cytotoxic drugs, hematological data, and herpes simplex virus antibody titer. Forty-six per cent of patients developed at least one episode of oral mucositis during cytotoxic treatment. Pearson's chi-square analysis showed that mucositis was significantly associated with xerostomia at baseline, xerostomia during chemotherapy, and lower baseline neutrophil counts (P < or = 0.05). Multiple logistic regression analysis indicated that xerostomia at baseline (odds ratio, OR = 10.0), or baseline neutrophil level under 4000 cells/mm3 (OR = 3.9) were significant predictors of mucositis. Taking into account the effect of neutrophil level at baseline, xerostomia during chemotherapy (OR = 4.5) was also a significant predictor of mucositis. The results showed that xerostomia and lower baseline neutrophil levels are significantly associated with oral mucositis. These variables should be taken into consideration in the design of intervention studies to reduce the frequency and severity of mucositis. More research is required to investigate the role of saliva and neutrophils in the pathogenesis of chemotherapy-induced mucositis.

Relationship among stimulated whole, glandular salivary flow rates, and root caries prevalence in an elderly population: a preliminary study

A comparison of salivary flow rates was made between two groups of healthy, unmedicated, elderly, Caucasian men and women ranging in age from 60 to 90 years. One group was a control group, while the other group had both active and restored root caries. The control group consisted of 69 individuals with a mean age of 73 years. The root caries group consisted of 39 individuals with a mean age of 71 years. The groups were evaluated for unstimulated (UPAR) and stimulated parotid gland flow rates (SPAR), unstimulated (USUB) and stimulated submandibular/sublingual gland flow rates (SSUB), and stimulated whole saliva flow rates (SWhole). Parotid flow rates were determined with the use of a Carlson-Crittenden cup, while submandibular/sublingual flow rates were determined by means of the NIDR collector. A 2% citrate solution was used for stimulation in glandular collections. Subjects chewed a 1-cm3 cube of paraffin to stimulate whole saliva. The results showed that the control group had higher UPAR, SPAR, USUB, SSUB, and SWhole than the root caries group.

Promoting oral health in institutionalised older adults: a nursing perspective

Current demographic trends necessitate that increased attention be paid to problems arising in the older population. One such area relates to the oral cavity, which may be affected by both the effects of aging and the effects of disease and illness. Yet the evidence shows a significant lack of adequate oral care, which may create major problems for affected individuals, causing oral and dental problems that may, in turn, predispose to nutritional deficiencies, communication difficulties and devastating dental disease (Ogle, 1982). This paper reviews the literature pertaining to this complex subject, concluding that although nurses have an important role in providing effective oral care for the institutionalised patient, it is difficult to identify appropriate techniques, agents and tools with which to provide such care. Further research in this field is undoubtedly needed.

A possible role for saliva as a diagnostic fluid in patients with chronic pain

OBJECTIVES

The focus of this review was on proteins and peptides found in saliva. Of greatest interest were those neuropeptides relevant to nociception and to the pathogenesis of chronic pain syndromes. An additional goal was to develop a standardized protocol to collect saliva for laboratory assessment.

METHODS

Data were obtained through discussion with experts at the medical schools in San Antonio and Heidelberg and a Medline literature search involving all relevant studies from 1966 to 1997. The literature search was based on the following key terms: saliva, serotonin, neuropeptide, substance P (SP), calcitonin gene-related peptide (CGRP), and nerve growth factor (NGF).

RESULTS

The mean concentration of SP in the saliva of healthy normal controls ranged from 9.6 to 220 pg/mL. Generally, the concentration of SP was approximately three times higher in saliva than in plasma. In a number of painful conditions, particularly tension headache, substantial elevations of salivary SP were found. Mean values for salivary CGRP in healthy controls were approximately 22 pmol/L and were significantly elevated in patients with migraine attacks or cluster headache. There were no data to indicate prior quantitative determination of NGF in human saliva.

CONCLUSIONS

After sampling and processing techniques have been standardized, measurement of neuropeptides in human saliva could provide a valuable tool for study of patients with chronic painful disorders such as rheumatoid arthritis, osteoarthritis, and even fibromyalgia syndrome.

Salivary sIgA concentrations and stimulated whole saliva flow rates among women undergoing chemotherapy for breast cancer: an exploratory study

A study was conducted to evaluate the secretion of stimulated whole saliva (SWS) and secretory IgA (sIgA) among three groups of women. One group was a healthy control group, the second group consisted of women diagnosed with metastatic breast cancer before being placed on chemotherapy, while the third group consisted of women on chemotherapy taking CMF (cyclophosphamide, methotrexate, and fluorouracil) for at least one month. There were seven patients in each group. SWS was collected. Salivary sIgA concentrations were determined by enzyme-linked immunoabsorbant assay. The results of the study showed that the mean SWS flow rate for the chemotherapy group (x = 0.96 mL/min) was significantly lower (p > 0.03) than that of the control group (x = 2.33 mL/min) and lower than that of the group with cancer (x = 1.81 mL/min). Additionally, the results showed that the mean sIgA concentrations for the chemotherapy group (x = 10.9 ng/mg of protein) were slightly lower than those of the control group (x = 13.7 ng/mg of protein) and lower than those of the group with cancer (x = 12.6 ng/mg of protein). The results of this study suggest that women placed on CMF for treatment of carcinoma of the breast may have reduced stimulated salivary production.

Oral problems in advanced cancer

Despite the unquestionable relevance of ensuring effective oral care for patients with advanced cancer, inadequate research activity has been directed towards developing and evaluating specific mouth care regimes for this group of seriously ill patients. The prevalence of the problems experienced by these individuals is well known and ensures that we have a clear picture of the areas where practice development is urgently needed. This paper presents a critique of research-based oral care interventions through a consideration of the management of the following problems: coated mouth and tongue; dry mouth; infection (fungal, viral, bacterial); pain; altered taste. Where possible, research findings are presented, but for many of the areas of care it is possible only to offer guidelines based upon an understanding of the normal structure and function of the oral cavity, the agents and tools currently in use, and practice-based evidence. There is an urgent need for a coordinated body of research activity within this field.

An epidemiologic perspective of saliva flow rates as indicators of susceptibility to oral disease

Catastrophic hyposalivation significantly increases susceptibility to dental caries in dentate individuals and may cause the expression or exacerbation of other oral diseases/disorders as well. The effect of subcatastrophic hyposalivation on susceptibility to caries or other diseases/disorders is less well understood. The aim of this study (part of a larger study on the prevalence of hyposalivation) was to determine the prevalence and to measure the association of oral pathologic conditions with unstimulated and stimulated whole saliva flow rates. Only 6.3% of all study participants had significantly diminished unstimulated (< 0.05 ml/min) and stimulated (< 0.50 ml/min) saliva flow rates. A total of 15 individuals were encountered with oral pathologic lesions and none of these lesions were associated with hyposalivation. Although the prevalence of coronal caries, root surface caries, abrasion, and erosion tended to increase as salivary flow decreased, when the effect of age was considered no significant differences were present. These data suggest that low saliva flow rates alone, at least from an epidemiologic perspective, do not have a clinically relevant effect on susceptibility to oral diseases/disorders.

Pilocarpine and other cholinergic drugs in the management of salivary gland dysfunction

Sialagogues constitute an important component in the management of salivary gland dysfunction. Of the pharmacologic agents available, pilocarpine has been used extensively over the last century. Many clinical trials have documented the efficacy of this alkaloid, with doses that range from 1 to 15 mg normally taken four times a day. There is considerable individual variation in response although it is usually possible, in the presence of sufficient responsive exocrine tissue, to establish a therapeutic regimen that promotes increased salivation without significant side effects.

The condition of the oral mucosa in institutionalized elderly patients before and after using a mucin-containing saliva substitute

The purpose of this investigation was to evaluate whether the condition of the oral mucous membrane and the mouth comfort of the elderly could improve using a mucin-containing saliva substitute. In total, 52 patients were examined before and after a 60-day treatment period, with mucin-containing saliva substitute given three times a day before meals. The patients were examined with regard to weight, oral mucosa condition, the duration of meals, eating and swallowing. Before the treatment period the prevalence of stomatitis was 90.4% and oral candidosis was 80.8% compared to 15.4% and 5.8% respectively after the treatment period. The pH increased significantly. Artificial mucin-containing saliva substitute seems to be an adequate treatment of stomatitis and oral candidosis in elderly patients.

Clinical criteria for the diagnosis of salivary gland hypofunction

There is considerable difficulty in the making of initial clinical decisions as to whether a given patient has salivary gland hypofunction, and hence requires additional salivary gland evaluation. This study identified a set of four clinical measures that, together, successfully predicted the presence or absence of salivary gland hypofunction. The four measures were: dryness of lips, dryness of buccal mucosa, absence of saliva produced by gland palpation, and total DMFT; they were derived from discriminant analysis of data collected from 71 individuals with normal and low salivary flow rates. These measures are proposed as criteria for clinical decision-making, as well as for classification of patients in studies of salivary gland dysfunction syndromes. This study also identified unstimulated whole salivary flow rates of 0.12-0.16 mL/min as the critical range separating individuals with salivary gland hypofunction from those with normal gland function.

The oral complications of specific anticancer therapy

Oral complications commonly affect cancer patients undergoing active treatment. These include oral infection, gingival bleeding, stomatitis/mucositis, xerostomia, dental caries and periodontal disease. The oral cavity also acts as an entry site for systemic infection, particularly in those who are myelosuppressed. This paper reviews the structure and function of the oral cavity and how this may be affected by anticancer therapy. Oral care procedures are discussed and controversial areas highlighted showing that, although it is generally agreed that oral care is essential in preventing/minimizing complications and maintaining general comfort, there is no general agreement about the frequency with which care is required or about the tools and agents to be employed. Areas for future research are highlighted.

Outcome of renal replacement treatment in patients with diabetes mellitus

OBJECTIVE

To compare the outcome of renal replacement treatment in patients with diabetes mellitus and in non-diabetic patients with end stage renal failure.

DESIGN

Retrospective comparison of cases and matched controls.

SETTING

Renal unit, Western Infirmary, Glasgow, providing both dialysis and renal transplantation.

PATIENTS

82 Diabetic patients starting renal replacement treatment between 1979 and 1988, compared with 82 matched non-diabetic controls with renal failure and 39 different matched controls undergoing renal transplantation.

MAIN OUTCOME MEASURES

Patient characteristics, history of smoking, prevalence of left ventricular hypertrophy and myocardial ischaemia at start of renal replacement treatment; survival of patients with renal replacement treatment and of patients and allografts with renal transplantation.

RESULTS

The overall survival of the diabetic patients during the treatment was 83%, 59%, and 50% at one, three, and five years. Survival was significantly poorer in the diabetic patients than the controls (p less than 0.001). Particularly adverse features for outcome at the start of treatment were increasing age (p less than 0.01) and current cigarette smoking (relative risk (95% confidence interval) 2.28 (0.93 to 4.84), p less than 0.05). Deaths were mainly from cardiac and vascular causes. The incidence of peritonitis in patients on continuous ambulatory peritoneal dialysis was the same in diabetic patients and controls (49% in each group remained free of peritonitis after one year), and the survival of renal allografts was not significantly worse in diabetic patients (p less than 0.5).

CONCLUSIONS

Renal replacement treatment may give good results in diabetic patients, although the outlook remains less favourable than for non-diabetic patients because of coexistent, progressive vascular disease, which is more severe in older patients.

The effect of chronic propranolol treatment on salivary composition and caries in the rat

Many drugs are known to affect salivary secretion. The purpose of this study was to explore the chronic effects of a commonly used beta-adrenergic blocker, propranolol. Adult rats were desalivated or treated for 28 days with propranolol HCl (10 or 20 mg/kg, daily) or sterile buffer (sham-operated control) using osmotic pumps for delivery. The parotid and submandibular glands of each rat were cannulated and secretion elicited by pilocarpine (10 mg/kg, intravenous). There were no statistical differences in salivary protein content (Lowry) or output among the groups (ANOVA, p greater than 0.05). Analysis of salivary proteins by SDS-PAGE revealed a constant profile for submandibular secretions, but peak A and SP-3 proline-rich proteins were not detectable in parotid saliva of animals treated with propranolol for the entire experiment. Significantly increased smooth-surface (p = 0.0003) and sulcal (p = 0.0011) caries scores were found within these propranolol groups (ANOVA). The findings provide further evidence that chronic administration of propranolol alters salivary composition by decreasing proline-rich proteins and concurrently enhances susceptibility to caries.

Objective measures of swallowing in patients with primary Sjogren's syndrome

Primary Sjogren's syndrome (SS) is an autoimmune disorder primarily affecting salivary and lacrimal glands. Durational measures of the oral phase of swallowing were obtained on 34 patients with primary SS and 34 age-matched controls from analyses of ultrasound scans. Two conditions were examined: a basal (BA) swallow (only endogeneous secretions present in the subjects' mouths) and a 10 ml water bolus (WB) swallow. The patients with SS produced swallowing durations significantly longer (p less than 0.05) than those of the controls for each of the two conditions. Moreover, unlike normals, over 40% of the patients with SS produced WB swallows that were longer than their BA swallows. For further analyses, patients with SS were classified into two groups based on the difference in duration between their BA and WB swallows. These two groups differed from each other on clinical evaluations of oral motor function and presenting complaints. No significant differences were found between these two groups for salivary function or immunologic profile. These findings support the hypothesis that dysphagia can result from conditions leading to salivary gland dysfunction and document the need for the assessment of swallowing function in patients with Sjogren's syndrome.

Hyposalivatory drug use, whole stimulated salivary flow, and mouth dryness in older, long-term care residents

Drug-induced hyposalivation has only been anecdotally related to various subjective and objective oral problems. The study described here of 157 residents of a long-term care facility reports data on whole masticatory-stimulated salivary flow rates, use of medications, and perceptions of symptoms associated with hyposalivation, including mouth and eye dryness, tooth sensitivity, chewing satisfaction, and taste and smell acuity. One hundred and twelve residents (71%) were taking one or more drugs that induced hyposalivation. Salivary flow rates were lower in persons who were taking such drugs, and lowest in persons who were taking such drugs for a protracted period. Flow was also lower in females than males, and lower in persons institutionalized for long periods than in persons institutionalized for short periods. Persons who were taking drugs that induce hyposalivation were institutionalized longer, used more medications, had more health problems, were dissatisfied with chewing, and had fewer teeth than persons who were not taking such drugs. Persons who reported having mouth dryness also reported eye dryness and were dissatisfied with their chewing ability. Perceived mouth dryness was not related to salivary flow.

Sjögren's syndrome: clinical and laboratory features, immunopathogenesis, and management

Sjögren's syndrome may be accompanied by local oral problems such as dry mouth, rampant caries, candidosis, or sialadenitis, but it is a systemic autoimmune disorder with wide repercussions, including a small premalignant potential. This article reviews the clinical and immunopathogenic features, as well as the etiology, of Sjögren's syndrome and discusses the diagnosis and management of oral complications.

Xerostomia: evaluation of a symptom with increasing significance

Xerostomia is the subjective sensation of oral dryness. Although it is most commonly associated with salivary gland dysfunction, it may also occur with normal gland activity. Xerostomia may be an early symptom of several morbid systemic conditions with important implications for the medical and dental management of patients. Oral dryness also has negative effects on an individual's emotional well-being and quality of life. The complaint of xerostomia necessitates a complete evaluation of a patient's general health, salivary gland function, and oral motor and sensory abilities. The salivary gland assessment includes symptom review, analysis of glandular secretions, scintiscanning, and minor labial gland biopsy. No single component is sufficient to adequately diagnose the presence, extent, or cause of salivary dysfunction. Treatment of a dry mouth, to date, is mainly palliative in nature, with the intent of preserving oral structures and functions. Better therapies are essential in the management of xerostomia, whatever the cause. The importance of xerostomia as a symptom is increasingly recognized in medicine and dentistry. The dentist is commonly the first health professional to hear this complaint and may be critical in directing a full and appropriate evaluation.