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

Xerostomia and oral health-related quality of life in peri- and postmenopausal women

OBJECTIVE

The menopausal transition triggers hormonal changes that can manifest in oral symptoms such as xerostomia, which can substantially impact women's quality of life. Our study examined the prevalence and severity of xerostomia and its association with menopausal status. Furthermore, we evaluated the impact of xerostomia on oral health-related quality of life in peri- and postmenopausal women.

METHODS

This study was a cross-sectional investigation based on the results of a REDCap survey, involving 3211 women aged between 40 and 90 years. The survey recorded age, menopause status, age at menopause, smoking status, and being treated with xerogenic drugs and included two instruments: the Xerostomia Inventory, used to evaluate the oral symptoms; and the Oral Health Impact Profile-14 (OHIP-14), used to assess the related quality of life. Student's t-test, the chi-squared test, Pearson's correlation coefficient, and multivariable logistic and linear regressions were performed for data analysis. Odds ratio (OR), beta coefficient (β), and their 95 % confidence intervals (CIs) were applied to assess associations.

RESULTS

The global prevalence of xerostomia was 71.2 %. The Xerostomia Inventory score correlated with the OHIP-14 score (r = 0.686; p = 0.000). Smoking was significantly associated with the probability of xerostomia (OR = 1.36; 95 % CI = 1.02-1.82), as were the following OHIP-14 domains: functional limitation (OR = 1.43; 95 % CI = 1.30-1.50), physical pain (OR = 1.17; 95 % CI = 1.06-1.29), psychological discomfort (OR = 1.21; 95 % CI = 1.13-1.29), physical disability (OR = 1.11; 95 % CI = 1.02-1.20), psychological disability (OR = 1.18; 95 % CI = 1.09-1.29), and social disability (OR = 1.15; 95 % CI = 1.01-1.32). There were no significant differences in the probability of xerostomia according to the menopausal status. In women with xerostomia the OHIP-14 score was higher than in women without xerostomia (β = 5.50; 95 % CI = 4.69-6.31).

CONCLUSIONS

Peri- and postmenopausal women have a high prevalence of xerostomia. There were no differences in the probability of xerostomia between peri- and postmenopausal women. There was a strong association between xerostomia symptoms and poor oral health-related quality of life.

Quantitative evaluation of parotid gland dysfunction in patients with hyposalivation using magnetic resonance imaging mapping technique : Quantification of Parotid gland function using MRI

OBJECTIVE

This study aimed to assess the feasibility of quantitative magnetic resonance imaging (MRI) employing the multi-dynamic multi-echo (MDME) technique as a diagnostic modality for evaluating glandular dysfunction in patients with hyposalivation.

METHODS

The MDME technique generated T1, T2, and proton density (PD) maps of the parotid gland, allowing for the simultaneous acquisition of values from the respective mappings. The Mann-Whitney U-test was used to compare the hyposalivation and control groups, and receiver operating characteristic (ROC) curve analysis was performed.

RESULTS

A total of 71 patients who underwent MDME MRI were reviewed and categorized into hyposalivation patients (n = 32) and healthy controls (n = 25). The average T1, T2 and PD value of the gland in the hyposalivation group were 606.92 ms, 91.85 ms, and 82.52 pu, respectively, whereas those in the control group were 628.08 ms, 80.69 ms, and 91.12 pu, respectively. The T2 and PD values were significantly different between the hyposalivation and control groups. The cut-off T2 value was 85.75 ms (AUC = 0.8131, p < 0.0001) and the cut-off PD value was 81.55 pu (AUC = 0.7588, p = 0.0009).

CONCLUSIONS

T2 and PD values derived from the MDME technique demonstrated strong potential for detecting parotid gland dysfunction in hyposalivation patients. These findings suggest that MDME-based quantitative MRI mapping shows promise in evaluating hyposalivation of the parotid gland and could become a valuable diagnostic tool in clinical settings.

Exploring the impact of advanced glycation end products on diabetic salivary gland dysfunctions

The role of Advanced Glycation End Products (AGEs) in the pathophysiology of salivary gland dysfunction in diabetes has not been fully addressed. In this work, we discuss the pathophysiological mechanisms of salivary gland dysfunctions in diabetes, focusing on the role of AGEs. Hyperglycemia induces the generation and accumulation of AGEs, induces oxidative stress, and activates the receptor for AGEs (RAGE), with detrimental effects on the salivary glands and the submandibular autonomic innervation. Structural and ultrastructural alterations have been described in the three major salivary glands, and hypo-salivation development has been linked to early autonomic neuropathy. Poor metabolic control aggravates the salivary flow rate via injury to the autonomic nerve fiber bundles or direct damage to the secretory acinar cells of the glands. Chronic hyperglycemia, the most crucial feature of diabetes, leads to the generation and accumulation of advanced glycation end products (AGEs). The interest in the role of AGEs in the pathogenesis of diabetic complications has grown exponentially, and AGEs have been implicated as a primary culprit in the pathophysiology of diabetes and its various complications, including neuropathy, nephropathy, retinopathy, vasculopathy, and cardiomyopathy.

A systematic review of salivary gland hypofunction and/or xerostomia induced by non-surgical cancer therapies: prevention strategies

PURPOSE

This systematic review aimed to assess the updated literature for the prevention of salivary gland hypofunction and xerostomia induced by non-surgical cancer therapies.

METHODS

Electronic databases of MEDLINE/PubMed, EMBASE, and Cochrane Library were searched for randomized controlled trials (RCT) that investigated interventions to prevent salivary gland hypofunction and/or xerostomia. Literature search began from the 2010 systematic review publications from the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) up to February 2024. Two independent reviewers extracted information regarding study design, study population, cancer treatment modality, interventions, outcome measures, methods, results, risk of bias (RoB version 2), and conclusions for each article.

RESULTS

A total of 51 publications addressing preventive interventions were included. Eight RCTs on tissue-sparing radiation modalities were included showing significant lower prevalence of xerostomia, with unclear effect on salivary gland hypofunction. Three RCTs on preventive acupuncture showed reduced prevalence of xerostomia but not of salivary gland hypofunction. Two RCTs on muscarinic agonist stimulation with bethanechol suggested a preventive effect on saliva flow rate and xerostomia in patients undergoing head and neck radiation or radioactive iodine therapy. Two studies on submandibular gland transfer showed higher salivary flow rates compared to pilocarpine and lower prevalence of xerostomia compared to no active intervention. There is insufficient evidence on the effectiveness of vitamin E, amifostine, photobiomodulation, and miscellaneous preventive interventions.

CONCLUSION

This systematic review continues to support the potential of tissue-sparing tecniques and intensity-modulated radiation therapy (IMRT) to preserve salivary gland function in patients with head and neck cancer, with limited evidence on other preventive strategies, including acupuncture and bethanecol. Preventive focus should be on optimized and new approaches developed to further reduce radiation dose to the parotid, the submandibular, and minor salivary glands. As these glands are major contributors to moistening of the oral cavity, limiting the radiation dose to the salivary glands through various modalities has demonstrated reduction in prevalence and severity of salivary gland hypofunction and xerostomia. There remains no evidence on preventive approaches for checkpoint inhibitors and other biologicals due to the lack of RCTs.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Dental care professionals' awareness of oral dryness and its clinical management: a questionnaire-based study

BACKGROUND

Despite the high prevalence of oral dryness and awareness of its complications, there is limited research on the clinical management of patients with oral dryness in general dental care.

PURPOSE

To (1) describe and compare awareness among dental care professionals regarding saliva functions, potential causes and complications of oral dryness, and patient management (2) Investigate if the length of professional experience influences these aspects.

METHODS

A digital self-administrated survey was sent to 2668 dental care professionals working in the general dental care, Public Dental Service, in Sweden. Twelve dental care professionals reviewed the questionnaire prior to its distribution. The questionnaire comprised 32 questions about patient management, awareness of saliva functions, causes and complications of oral dryness, and self-assessment queries.

RESULTS

The response rate was 18.6% (241 dentists and 257 dental hygienists). Older adults (65+) were asked more often about dry mouth (93.0%) compared to those aged 18-23 years (50.0%) and those under 18 years (24.9%). Dental hygienists encountered individuals with oral dryness more frequently (61.1%) than dentists (48.5%) (p < 0.01), and more often asked individuals in the age groups 18-23 years (p = 0.003), 24-40 years (p = 0.045), and 41-65 years (p = 0.031) about dry mouth. A higher proportion of dental hygienists (88.3%) than dentists (51.0%) had measured salivary secretion rate, (p < 0.001) and more often suggested preventive dental care 3-4 times a year, (42.5% vs. 30.5%) (p < 0.007). Dentists had a higher awareness of saliva functions, while dental hygienists had a higher awareness about causes and complications of oral dryness. Higher proportions of dentists and dental hygienists with over 10 years of professional experience had measured salivary secretion rate (69.1% vs. 95.7%) compared to their counterparts with less than 10 years of professional experience (35.9% vs. 79.5%) (p < 0.001 for both).

CONCLUSION

Compared to dentists, dental hygienists were more attentive to patients with oral dryness as they encountered these individuals more often, asked more age-groups, suggested frequent preventive measures, and had higher awareness of the causes and complications of oral dryness. Length of professional experience could improve both the management of patients with oral dryness and awareness of its causes, particularly for dental hygienists.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Characterizing clinical findings of Sjögren's Disease patients in community practices using matched electronic dental-health record data

Established classifications exist to confirm Sjögren's Disease (SD) (previously referred as Sjögren's Syndrome) and recruit patients for research. However, no established classification exists for diagnosis in clinical settings causing delayed diagnosis. SD patients experience a huge dental disease burden impairing their quality of life. This study established criteria to characterize Indiana University School of Dentistry (IUSD) patients' SD based on symptoms and signs in the electronic health record (EHR) data available through the state-wide Indiana health information exchange (IHIE). Association between SD diagnosis, and comorbidities including other autoimmune conditions, and documentation of SD diagnosis in electronic dental record (EDR) were also determined. The IUSD patients' EDR were linked with their EHR data in the IHIE and queried for SD diagnostic ICD9/10 codes. The resulting cohorts' EHR clinical findings were characterized and classified using diagnostic criteria based on clinical experts' recommendations. Descriptive statistics were performed, and Chi-square tests determined the association between the different SD presentations and comorbidities including other autoimmune conditions. Eighty-three percent of IUSD patients had an EHR of which 377 patients had a SD diagnosis. They were characterized as positive (24%), uncertain (20%) and negative (56%) based on EHR clinical findings. Dry eyes and mouth were reported for 51% and positive Anti-Ro/SSA antibodies and anti-nuclear antibody (ANA) for 17% of this study cohort. One comorbidity was present in 98% and other autoimmune condition/s were present in 53% respectively. Significant differences were observed between the three SD clinical characteristics/classifications and certain medical and autoimmune conditions (p<0.05). Sixty-nine percent of patients' EDR did not mention SD, highlighting the huge gap in reporting SD during dental care. This study of SD patients diagnosed in community practices characterized three different SD clinical presentations, which can be used to generate SD study cohorts for longitudinal studies using EHR data. The results emphasize the heterogenous SD clinical presentations and the need for further research to diagnose SD early in community practice settings where most people seek care.

Correlations between salivary gland scintigraphy and histopathologic data of salivary glands in patients with primary Sjogren's syndrome

OBJECTIVES

Our aim was to evaluate the association between salivary gland scintigraphy and the clinical parameters, including histological characteristics of salivary glands, in patients with primary Sjogren's syndrome (pSS).

METHODS

Forty-one pSS patients were included in the study. The patients who had received salivary gland scintigraphy and minor salivary gland biopsy were retrospectively analyzed. Salivary gland scintigraphy was interpreted via semi-quantitative methods obtained by calculating the peak uptake and washout of each gland using regions of interest. All specimens were examined by pathologists for focus scores and leukocyte common antigen (LCA) to determine the degree of inflammatory infiltration.

RESULTS

The mean age of pSS patients was 46.4 years, 82.9% were female, and the mean duration of symptoms was 2.5 years. The focus score was negatively correlated to the mean peak uptake (r = ‒0.396; p = 0.019), mean uptake (r = ‒0.388; p = 0.021), and mean percentage washout (r = ‒0.391; p = 0.02). In addition, the focus score and number of LCA positive cells per mm² were correlated with the clinical parameters including erythrocyte sedimentation rate, globulin, rheumatoid factor, unstimulated whole saliva, and stimulated whole saliva flow. The number of LCA positive cells per mm² was negatively correlated to leukocytes and hemoglobin.

CONCLUSION

Although the diagnostic role of salivary gland biopsy is widely accepted and features in the classification criteria of Sjogren's syndrome, salivary gland scintigraphy may be an acceptable alternative method especially if a non-invasive test is required.

Turkish translation and validation of the Xerostomia Inventory

Objectives

The Xerostomia Inventory (XI) was developed to assess the severity of dryness in patients with xerostomia. It has a long and a short form with three- and five-point Guttman-type response options. In this study, we aimed to translate the XI into Turkish, to assess the validity and reliability of both response options in patients with head & neck cancer (HNC) or Sjögren syndrome (SS), and to select the optimal version for Turkish patients.

Patients and methods

Between January 2019 and June 2019, the XI was translated into Turkish (XI-T) and applied to patients aged ≥18 years with HNC and SS. All patients were applied two tests including both the three- and five-point options. The internal consistency was assessed by Cronbach alpha and test-retest reliability by intraclass correlation coefficients (ICCs). Content validity was based on expert opinion and patient reviews.

Results

A total of 186 patients (109 males, 77 females; median age: 54 years; range, 19 to 78 years) answered the XI-T. The number of patients with HNC and SS was 143 (77%) and 43 (23%), respectively. Median XI-T score was 17 for the three-point, and 24 for the five-point option, respectively. Overall internal consistency was satisfactory for both options (α=0.81 and α=0.89, respectively). Overall test-retest reliability was satisfactory and ICCs ranged between 0.71 and 0.92 for the three-point, and 0.36 and 0.94 for the five-point option, respectively. Assessments based on expert opinions and patient reviews also favored the content validity of the scale.

Conclusion

The XI-T with both three- and five-point options is a valid and reliable tool to evaluate the presence and severity of dryness in patients with HNC and SS who experience xerostomia. The three-point option is more comprehensible and can be preferred over the five-point option in the Turkish population.

Safety of High-Dose Botulinum Toxin Injections for Parotid and Submandibular Gland Radioprotection

Botulinum Toxin injections into salivary glands (SG) up to a total dose of 100 units IncobotulinumtoxinA (IncoA) represent the treatment of choice for sialorrhea. However, BTX might also protect SG against sialotoxic radioligand cancer therapies. The radioligand Actinium-225-PSMA effectively targets Prostate Cancer (PCa) metastases but inevitably destroys SG due to unintended gland uptake. A preliminary case series with regular-dose IncoA failed to reduce SG PSMA-radioligand uptake. We therefore increased IncoA dosage in combination with transdermal scopolamine until a clinically relevant SG PSMA-radioligand uptake reduction was achieved. Ten consecutive men with metastasized PCa refractory to all other cancer therapies received gradually increasing IncoA dosages as part of a compassionate use PSMA-radioligand-therapy trial. The parotid gland received six and the submandibular gland three injection points under ultrasound control, up to a maximum of 30 units IncoA per injection point. A maximum total dose of 250 units IncoA was applied with up to 170 units per parotid and 80 units per submandibular gland. Treatment was well tolerated and all side-effects were non-serious. The most frequent side-effect was dry mouth of mild severity. No dysphagia, facial weakness, chewing difficulties or systemic side-effects were observed. SG injections with IncoA up to a total dose of 250 units are safe when distributed among several injection-points under ultrasound control by an experienced physician. These preliminary findings lay the basis for future trials including BTX as major component for SG protection in established as well as newly emerging radioligand cancer therapies.

Role of Photobiomodulation Therapy in Neurological Primary Burning Mouth Syndrome. A Systematic Review and Meta-Analysis of Human Randomised Controlled Clinical Trials

Mitochondrial homeostasis is crucial for energy production and neuronal survival in neurological primary burning mouth syndrome (npBMS). Photobiomodulation therapy (PBMT) has been utilised in npBMS management, however, its role of intervention remains controversial. The aim of this systematic review and meta-analysis of CRD 42020198921 PROSPERO registration reference was to oversee and determine the efficacy of PBMT in patients with npBMS, identifying the gaps and bridge them by proposing recommendations for future studies purposes. PRISMA guidelines and Cochrane Collaboration recommendations followed. Various search engines employed to analyse a total of 351 studies of which 12 were included. A wide range of utilised PBM wavelengths was between 635-980 nm and the power output ranged between 30 mW and 4000 mW. A high risk of bias (RoB) was noted in 7 out of 12 included studies (58.3%), as results of qualitative analysis. Meta-analysis findings of 4 out of 12 studies showed statistically significant intergroup differences (SSID) for visual analogue scale (VAS) values (MD = -1.47; 95% CI = -2.40 to -0.53; Z = 3.07 (p = 0.002) whereas meta-analysis on 5 out of 12 studies revealed SSID for anxiety/depression and quality of life (MD = -1.47; 95% CI = -2.40 to -0.53; Z = 3.07 (p = 0.002), favouring PBMT group to the control treatment strategies. Despite the inconsistency and diversity in PBM parameters (wavelength, power, light source, spot size, emission mode, energy per point, total energy) and treatment protocols (exposure time, number of sessions, time interval between sessions, treatment duration)-majority of the included studies showed positive PBM results. The high RoB and meta-analytical heterogeneity in the eligible studies warrant the necessity to perform well-designed and robust RCTs after acknowledging the drawbacks of the available scientific literature and addressing our suggested recommendations highlighted in our review.

Detection of xerostomia, Sicca, and Sjogren's syndromes in a national sample of adults

Objectives

To assess the prevalence and determinants of xerostomia among adults and identify how many of the ones experiencing xerostomia have Sicca and Sjogren's syndromes.

Materials and methods

This cross-sectional study included 1405 35–74-year-old Lithuanians (51.7% response rate) from the five largest Lithuanian cities and 10 peri-urban and rural areas that were randomly selected from each of the 10 Lithuanian counties. Xerostomia was determined by the self-reported experience of dry mouth as "often" or "always". A dentist diagnosed Sicca syndrome by unstimulated whole sialometry and the Schirmer's test, and all cases were referred to a rheumatologist to confirm Sjogren's syndrome. Self-reported questionnaires collected data about the determinants.

Results

The prevalence of xerostomia was 8.0% (n = 112), Sicca syndrome was diagnosed for 8 participants (0.60%), and Sjogren's syndrome for 2 participants (0.14%), with this being the first time it was diagnosed. Experiencing xerostomia was associated with older age (OR 1.7, 95% CI 1.1–2.6), urban residence (OR 3.3, 95% CI 1.6–5.0), presence of systemic diseases (OR 2.5, 95% CI 1.4–3.3), and the use of alcohol (OR 0.6, 95% CI 0.4–0.9). The higher proportion of participants with Sicca syndrome involved females, of older age, having systemic diseases, and using medications.

Conclusions

The prevalence of xerostomia was 8.0% and the determinants of xerostomia were older age, urban residence, systemic diseases, and absence of using alcohol. In total, 0.6% of participants had Sicca syndrome, which was more prevalent among females, older subjects, those with systematic diseases, and those using medications. Sjogren's syndrome was diagnosed in 0.14% of participants.

Clinical relevance

Dental clinicians need to be trained to identify potential Sjogren's syndrome cases.

Salivary Gland Hypofunction and/or Xerostomia Induced by Nonsurgical Cancer Therapies: ISOO/MASCC/ASCO Guideline

PURPOSE

To provide evidence-based recommendations for prevention and management of salivary gland hypofunction and xerostomia induced by nonsurgical cancer therapies.

METHODS

Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. PubMed, EMBASE, and Cochrane Library were searched for randomized controlled trials published between January 2009 and June 2020. The guideline also incorporated two previous systematic reviews conducted by MASCC/ISOO, which included studies published from 1990 through 2008.

RESULTS

A total of 58 publications were identified: 46 addressed preventive interventions and 12 addressed therapeutic interventions. A majority of the evidence focused on the setting of radiation therapy for head and neck cancer. For the prevention of salivary gland hypofunction and/or xerostomia in patients with head and neck cancer, there is high-quality evidence for tissue-sparing radiation modalities. Evidence is weaker or insufficient for other interventions. For the management of salivary gland hypofunction and/or xerostomia, intermediate-quality evidence supports the use of topical mucosal lubricants, saliva substitutes, and agents that stimulate the salivary reflex.

RECOMMENDATIONS

For patients who receive radiation therapy for head and neck cancer, tissue-sparing radiation modalities should be used when possible to reduce the risk of salivary gland hypofunction and xerostomia. Other risk-reducing interventions that may be offered during radiation therapy for head and neck cancer include bethanechol and acupuncture. For patients who develop salivary gland hypofunction and/or xerostomia, interventions include topical mucosal lubricants, saliva substitutes, and sugar-free lozenges or chewing gum. For patients with head and neck cancer, oral pilocarpine and oral cevimeline, acupuncture, or transcutaneous electrostimulation may be offered after radiation therapy.Additional information can be found at www.asco.org/supportive-care-guidelines.

Novel Multidisciplinary Salivary Gland Society (MSGS) Questionnaire: An International Consensus

Objectives

First, establishment and validation of a novel questionnaire documenting the burden of xerostomia and sialadenitis symptoms, including quality of life. Second, to compare two versions regarding the answering scale (proposed developed answers Q3 vs. 0–10 visual analogue scale Q10) of our newly developed questionnaire, in order to evaluate their comprehension by patients and their reproducibility in time.

Study Design

The study is a systematic review regarding the evaluation of the existing questionnaire and a cohort study regarding the validation of our new MSGS questionnaire.

Materials and Methods

A Multidisciplinary Salivary Gland Society (MSGS) questionnaire consisting of 20 questions and two scoring systems was developed to quantify symptoms of dry mouth and sialadenitis. Validation of the questionnaire was carried out on 199 patients with salivary pathologies (digestive, nasal, or age‐related xerostomia, post radiation therapy, post radioiodine therapy, Sjögren's syndrome, IgG4 disease, recurrent juvenile parotitis, stones, and strictures) and a control group of 66 healthy volunteers. The coherence of the questionnaire's items, its reliability to distinguish patients from healthy volunteers, its comparison with unstimulated sialometry, and the time to fill both versions were assessed.

Results

The novel MSGS questionnaire showed good internal coherence of the items, indicating its pertinence: the scale reliability coefficients amounted to a Cronbach's alpha of 0.92 for Q10 and 0.90 for Q3. The time to complete Q3 and Q10 amounted, respectively, to 5.23 min (±2.3 min) and 5.65 min (±2.64 min) for patients and to 3.94 min (±3.94 min) and 3.75 min (±2.11 min) for healthy volunteers. The difference between Q3 and Q10 was not significant.

Conclusion

We present a novel self‐administered questionnaire quantifying xerostomia and non‐tumoral salivary gland pathologies. We recommend the use of the Q10 version, as its scale type is well known in the literature and it translation for international use will be more accurate. Laryngoscope, 132:322–331, 2022

Recent Advances in Salivary Scintigraphic Evaluation of Salivary Gland Function

Saliva plays an important role in supporting upper gastrointestinal tract function and oral well-being. Salivary dysfunction mainly manifests with a decrease in salivary flow. Among varieties of quantitative methods, salivary scintigraphy is a relatively noninvasive, well-tolerated, reproducible, and objective approach for functional evaluation of salivary disorders, yet the lack of precise quantitative reference values and no standardized protocol limit its generalized utilization. In this article, we review the scintigraphic performance between the visual analysis and quantitative methods in predicting Sjögren’s syndrome and verify the potential aspects of the application in interpreting different disease entities and phases of functional salivary disorders.

The use of BokaFlo™ instrument to measure salivary flow

BACKGROUND

Dry mouth currently affects roughly 20% of the population and is a condition characterized by chronic hyposalivation and/or subjective reports of xerostomia. Low saliva flow can be indicative of other undiagnosed diseases, such as primary Sjogren's syndrome, and may contribute to difficulty chewing, increased caries susceptibility and infection. The passive drool test (PDT) is the primary method used to evaluate patients for hyposalivation but it is time-consuming and inconvenient. New methodology is needed to facilitate increased testing for hyposalivation in the dental clinic. The aim of this study was to evaluate an alternative method to measure salivary flow in dental offices.

METHODS

In this study, we tested a new biomedical device, the BokaFlo™, to measure salivary flow in subjects in comparison to the current PDT standard. Participants completed an oral health questionnaire and saliva flow was evaluated by the PDT and the BokaFlo™ system.

RESULTS

Saliva flow as measured by the BokaFlo™ positively correlated with the saliva flow measured by the PDT methodology (r = 0.22, p < 0.05). The device predicted low saliva flow in subjects with a sensitivity of 0.76 and specificity of 0.84 for subjects with hyposalivation, defined as a saliva flow rate of ≤ 0.1 ml/min. A significant negative correlation between the total oral health questionnaire score and the likelihood of participant exhibiting low salivary flow was observed (r = - 0.31, p < 0.006).

CONCLUSION

The BokaFlo™ was effectively able to measure low saliva flow correlating with the PDT methodology and may provide more efficient testing of saliva flow in the dental office.

Development of a Mobile Application to Enhance Knowledge, Awareness and Communication of Dry Mouth Amongst Dental Practitioners and Patients: A South Texas Oral Health Network Study

BACKGROUND

Dry mouth, also commonly known as "xerostomia", is a prominent symptom that is often overlooked by dental practitioners and patients. The purpose of this study was to pilot the development of a mobile application for assessing dry mouth symptoms. The application will allow patients to self-assess and enhance knowledge, awareness and communication with dental practitioners in their management of dry mouth.

METHOD

The first phase of the study was to draw on common knowledge and awareness by conducting two focus groups of dental professionals and community members on content, practicality, functionality, design, and effectiveness. The second phase of the study was the development of the dry mouth mobile application followed by the third phase of the study that consisted of face-validity interviews to obtain feedback on the application.

RESULTS

Fifty two percent (n=15) of the dental professionals estimated being aware of the prevalence of dry mouth in 40% or more of their patients. Thirty Nine percent of (n=9) community estimated being aware of the prevalence of dry mouth in 40% or more of the community. When asked about their awareness of the etiologies of dry mouth, 100% (n=29) of dental professionals reported that multiple medications and smoking were primary factors whereas the community members indicated that illness and dehydration (87%, n=20) were primary factors in dry mouth. Dental professional's (25% n=7) were very confident in recognizing symptoms and 28% (n=8) were very confident they knew how to manage dry mouth symptoms. Furthermore, 22% (n=5) of the community members were also very confident about recognizing dry mouth symptoms and 13% (n=3) were very confident knowing how managing it. The ToP report generated from the discussions identified "themes" that were utilized in the development of the mobile application. Most individuals who participated in the validity interviews agreed that the dry mouth mobile application was useful, appealing, easy to use and the self-assessment test gave clear and concise information. The application was made available to download from the iTunes Appstore (2019-2020).

CONCLUSION

The dry mouth pilot study indicated that the mobile application was beneficial for self-assessment and easy to use. Development of advanced technology tools such as the dry mouth application can promote communication between patients and their dental practitioners to discuss management options for dry mouth.

Differences in perceived intra-oral dryness in various dry-mouth patients as determined using the Regional Oral Dryness Inventory

Objectives

Recently, it was shown that the Regional Oral Dryness Inventory (RODI) could determine differences in dry-mouth perception at different intra-oral locations. The main aim of this study was to determine whether the RODI might help to discriminate between various causes of oral dryness in dry-mouth patients. The second aim was to ascertain whether the RODI could become an additional diagnostic tool in dry-mouth patients.

Materials and methods

Data were collected retrospectively from patients who visited a specialized saliva clinic. Salivary flow rates, Xerostomia Inventory scores, and RODI scores were extracted from the medical records. Patients were stratified into subgroups according to their health status.

Results

Five hundred twenty-eight patients participated in this study (mean age of 59.6 ± 16.0 years; 68.4% female). Specific patient groups differed with regard to the region of the mouth they experienced as the most and least dry. The posterior palate was the area perceived as most dry by controls and Sjögren patients. In patients using limited or multiple medications, it was the anterior tongue. RODI scores also differed significantly among dry-mouth patient groups: whereas controls and patients using limited medication had the lowest RODI scores and experienced less intra-oral dryness, Sjögren patients had the highest RODI scores.

Conclusion

Our use of the RODI questionnaire showed that perceived intra-oral dryness differed between the various dry-mouth patients.

Clinical relevance

The RODI can be a valuable clinical diagnostic tool in dry-mouth diagnostics, in which it can be used to discriminate between the various causes of oral dryness in patients.

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.

Impact and Efficacy of Topical Dry Mouth Products in Haemodialysis Patients with Xerostomia: A Pilot Study

Purpose: Previous studies have shown that haemodialysis (HD) patients frequently suffer from xerostomia. This problem is associated with difficulties in oral functions, increased risk of oral diseases and interdialytic weight gain (IDWG). The aims of this preliminary study are to evaluate the efficacy and safety of topical dry mouth products in treating xerostomia in HD patients and their impact in reducing IDWG. Materials and Methods: We included 25 HD patients that suffered from xerostomia and complied with inclusion criteria. Subjects received toothpaste, mouthwash and mouth gel for dry mouth. The duration of treatment was 4 weeks. Patients filled out a visual analogue scale (VAS) for xerostomia and Oral Heath Impact Profile (OHIP)-14 questionnaires. Clinical data and IDWG were collected of the medical history of HD patients. Questionnaires and IDWG were collected at baseline, 2 and 4 weeks post-treatment. Results: Twenty-five patients completed the study (56% male and 44% female). The mean age was 63.52 ± 12.50 years. The topical treatment statistically significantly (p = 0.0001) alleviated the symptoms of xerostomia and improved their quality of life (OHIP-14 scores) (p = 0.0001). We observed a statistically significantly IDWG (kg) and IDWG% reduction (p = 0.03) after the use of topical treatment for xerostomia. None of the patients reported side effects. Conclusions: Xerostomia might affect the quality of life and increase the IDWG of these patients. The daily use of topical treatment for xerostomia could decrease thirst and IDWG, improving the quality of life of HD patients. Future randomised studies are needed to confirm these results.

Erosive assessment of dry mouth lozenges and tablets on enamel and dentin

OBJECTIVES

To assess the erosive potential of dry mouth lozenges and tablets on enamel and dentin.

MATERIALS AND METHODS

The following lozenges and tablets were tested: Salese, Oracoat Xylimelts, Cotton Mouth, TheraBreath, DenTek OraMoist, SmartMouth, ACT, CVS Health, Rite Aid, Med Active, and Hager Pharma. pH Analysis: Each lozenge or tablet was crushed with a pestle and mortar and 5 g of the resultant powder was dissolved in 10 ml of distilled water (pH 7.02) The pH of each lozenge solution was assessed by using a calibrated pH meter. Titratable Acidity (TA) was determined by adding 0.1 M of NaOH to each homogenous tablet solution until the pH reached 7.0. Gravimetric Analysis was measured with freshly extracted molars crown/roots were sectioned at the CEJ and enamel and dentin specimens were fabricated. The specimens were then submerged in 5 ml of solution containing 2.5 gm of crushed tablets for 24 h, 48 h, 96 h and 14 days with measurements performed at each interval after drying. The solutions were renewed at each interval.

RESULTS

Significant correlation between pH and TA was observed for lozenges and tablets evaluated (p < 0.0001). Both variables were strongly correlated with enamel and dentin loss (p < 0.0001). For enamel, DenTek resulted in significantly more substance loss (p < 0.05) than with the other tested products, while Xylimelts presented the lowest percentage of substance loss. For dentin, Cotton Mouth resulted in the highest substance loss, and Xylimelts presented the lowest percentage of substance loss.

CONCLUSIONS

There is a strong correlation between the pH, tritatable aciditiy, and erosive potential of these products. DenTek and Cotton Mouth reported erosive effect to the enamel and dentin, respectively. Xylimelts performed better than the rest of the products in relationship to enamel and dentin.

Dry mouth diagnosis and saliva substitutes-A review from a textural perspective

The aim of this review is to assess the objective and subjective diagnosis, as well as symptomatic topical treatment of dry mouth conditions with a clear focus on textural perspective. We critically examine both the current practices as well as outline emerging possibilities in dry mouth diagnosis and treatment, including a patent scan for saliva substitutes. For diagnosis, salivary flow rates and patient-completed questionnaires have proven to be useful tools in clinical practice. To date, objective measurements of changes in mechanical properties of saliva via rheological, adsorption, and tribological measurements and biochemical properties of saliva such as assessing protein, mucins (MUC5B) are seldom incorporated into clinical diagnostics; these robust diagnostic tools have been largely restricted to application in non-clinical settings. As for symptomatic treatments of dry mouth, four key agents including lubricating, thickening, adhesive, and moisturizing agents have been identified covering the overall landscape of commercial saliva substitutes. Although thickening agents such as modified celluloses, polysaccharide gum, polyethylene glycol, and so forth are most commonly employed saliva substitutes, they offer short-lived relief from dry mouth and generally do not provide boundary lubrication properties of real human saliva. Innovative technologies such as self-assembly, emulsion, liposomes, and microgels are emerging as novel saliva substitutes hold promise for alternative approaches for efficient moistening and lubrication of the oral mucosa. Their adoption into clinical practice will depend on their efficacies, duration of relief, and ease of application by the practitioners and patient compliance.

Effectiveness of an intraoral thermoformed splint with magnet device in patients with xerostomia and hyposalivation: A pilot study

AIM

The aim of the study was to examine the effectiveness of intraoral thermoformed splint with a magnet device over a period of 3 months, that is, to assess acceptability of this method of treatment using both objective and self-reported measures.

MATERIALS AND METHODS

This study was designed as a prospective clinical pilot trial. 22 patients with xerostomia and hyposalivation were included. Xerostomia was assessed using a 4-question xerostomia questionnaire score and a test for unstimulated salivary flow rates. Evaluations were performed before the treatment and 3 months after the treatment using a thermoformed splint with a magnet device.

RESULTS

There was a significant reduction in subjective symptoms after using a thermoformed splint with a magnet device for 3 months. For all 4 scored items, there was a statistically significant difference (P < .001) in median VAS scores before and 3 months after treatment. There was also a statistically significant difference in USFR before (0,15 ± 0,04 ml/min) and after treatment (0,24 ± 0,03 mL/min).

CONCLUSION

Our findings indicate that the use of this device alleviated oral dryness and stimulated the function of the submandibular salivary gland. An intraoral thermoformed splint with a magnet device is safe, physiologically indifferent, useful, and effective in treating xerostomia and hyposalivation.

Hyposalivation, oral health, and Candida colonization in independent dentate elders

Hyposalivation is an important problem in elders and could interfere with several oral functions and microbial ecology. While the number of independent elders who retain more natural teeth increases worldwide, few studies examined hyposalivation in this population. Thus, this study aims to examine relationships between hyposalivation, oral health conditions and oral Candida colonization in independent dentate elders and evaluate factors associated with salivary flow and Candida carriage. We conducted a cross-sectional study in fifty-three dentate elders (≥65 years old with at least 4 pairs of posterior occlusal contacts) with no, or well-controlled, systemic conditions. Participants were interviewed for medical history, subjective dry mouth symptoms, oral hygiene practices and denture information. Unstimulated and stimulated salivary flow rates, objective dry mouth signs, gingival, tongue-coating, and root-caries indices were recorded. Stimulated saliva was cultured on Sabouraud-dextrose agar for Candida counts. Candida species were identified using chromogenic Candida agar and polymerase chain reaction. Statistical significance level was set at p<0.05. The results showed that hyposalivation was associated with higher gingival and tongue-coating indices (p = 0.003 and 0.015, respectively), but not root-caries index. Hyposalivation was also associated with higher prevalence of oral Candida colonization (p = 0.010; adjusted OR = 4.36, 95% confidence interval = 1.29–14.72). These two indices and Candida load were negatively correlated with unstimulated and stimulated salivary flow rates. Interestingly, non-albicans Candida species were more prevalent in denture wearers (p = 0.017). Hence, hyposalivation is a risk factor for poorer oral health and oral Candida colonization in independent dentate elders. Because of its potential adverse effects on oral and systemic health, hyposalivation should be carefully monitored in elders.

Saliva substitute mouthwash in nasopharyngeal cancer survivors with xerostomia: a randomized controlled trial

Objectives

Xerostomia is a prevalent sequelae among nasopharyngeal cancer (NPC) survivors; yet, effective treatment protocols have been elusive. This study was a prospective randomized clinical trial to compare the effects of saliva substitute mouthwash in nasopharyngeal cancer survivors with xerostomia, between two treatment arms, conducted in a tertiary center.

Materials and methods

This study measured the effects within 4 weeks in relation to summated xerostomia inventory (SXI) and unstimulated whole saliva (UWS). Patients randomized into the interventional arm were prescribed an immunologically active saliva substitute (IASS), while patients in the control arm were prescribed a non-immunologically active mouthwash as placebo.

Results

The study population consisted of 94 patients. There was a significant difference in SXI difference (p < 0.0001) and UWS difference (p < 0.0001) between control and interventional arms. No harmful side effects associated with the use of either mouthwash encountered throughout the study duration.

Conclusion

IASS mouthwash significantly reduces subjective xerostomia scores measured using SXI and improves objective measurement of salivary flow using UWS among nasopharyngeal cancer survivors with xerostomia.

Clinical relevance

IASS is significantly more effective in improving subjective and objective xerostomia measurements compared to non-immunologically active mouthwash. Additionally, this treatment is very safe, with superior side effect profiles.

Trial registration

ClinicalTrials.gov Identifier: NCT04491435

Transcriptomic Profile of Genes Encoding Proteins Involved in Pathogenesis of Sjögren's Syndrome Related Xerostomia-Molecular and Clinical Trial

Sjögren’s syndrome (SS) is characterized by xerostomia. We aimed to investigate and compare gene expressions in the labial salivary glands of SS patients with xerostomia SS (sicca) and without xerostomia SS (non-sicca) and of healthy subjects (HS) by means of microarray analysis, and to find genes involved in xerostomia. The study group comprised 11 SS patients (3 SS (sicca) and 8 SS (non-sicca)) and 9 HS. The relative gene expression changes were validated with RT-qPCR in the larger study group. Among the differently expressed genes belonging to the “secretion” ontology group with a fold change >2 and with a p value < 0.05, the Transmembrane P24 Trafficking Protein 10 (TMED10), Protein Disulfide Isomerase Family A Member 4 (PDIA4), Calnexin (CANX), Amyloid Beta Precursor Protein (APP), and Transmembrane BAX Inhibitor Motif Containing 6 (TMBIM6) gene expressions in both SS (sicca) and SS (non-sicca) groups were lower than in HS. Significant correlations were observed between TMED10, PDIA4, and CANX gene expression in SS (sicca) patients compared to the controls. There were no differences between the SS (sicca) and SS (non-sicca) study groups in the expression of the aforementioned genes. Results indicate their role in the endoplasmic reticulum system, their overlapping function and the loss of the APP neuroprotective function in xerostomia. It has a multifactorial origin and can be triggered by disturbances to the various signaling pathways in saliva secretion.

Reliability of Screening Methods to Diagnose Oral Dryness and Evaluate Saliva Secretion

In this study, we evaluated the reliability and reproducibility of widely implemented salivary flow rate and oral dryness tests. In experiment 1, twenty young and healthy Japanese participants volunteered to participate. For each participant, the oral moisture (OM) level, unstimulated whole saliva volume (U-WSV), and stimulated whole saliva volume (S-WSV) were measured at the same time on two separate days. In experiment 2, twenty-seven patients who were over 65 years of age volunteered to participate. The OM level and U-WSV were measured at the same time on two separate days. In Experiment 1, the intra-class correlation coefficients (ICCs) corresponding to the S-WSV, U-WSV, and OM level were 0.23, 0.28, and 0.16, respectively, for the young participants. In Experiment 2, the ICCs corresponding to the U-WSV/spitting and OM level were 0.83 and 0.12, respectively, for the older participants. The results of Bland–Altman analysis confirmed the absence of systematic error, with the exception of the OM level results in Experiment 2, which indicated systematic bias. In conclusion, we believe that there is currently no consistent and reliable screening test for assessing salivary flow rate and oral dryness, although the spitting test was determined to be highly reliable.

Size of the associations between anticholinergic burden tool scores and adverse outcomes in older patients

Background Several anticholinergic scales and equations to evaluate the anticholinergic burden have been previously created. Association of these instruments with the anticholinergic outcomes are usually estimated by means of hypothesis contrast tests, which ignore the size of the association effect. Objective To evaluate the effect size of the associations between the scores on cumulative anticholinergic burden instruments with peripheral or central anticholinergic adverse outcomes in older patients. Setting Internal medicine ward of a Tertiary University Hospital. Methods A case-control study was conducted in patients over 65 years who were admitted to two internal medicine wards of a Portuguese university hospital. The Anticholinergic Drug Scale, Anticholinergic Risk Scale, Anticholinergic Cognitive Burden scale and Drug Burden Index were used to calculate the patients' anticholinergic burden. Peripheral (dry mouth-swab technique; dry eye-Schirmer test) and central (falls and cognitive impairment-Mini-Mental State Examination) anticholinergic adverse outcomes were investigated. The Barthel Index was used to assess overall physical functionality. The Mann-Whitney test was used to evaluate probabilistic differences in the anticholinergic scores between case and control individuals. To establish the effect size of the associations, the area under the curve of the receiver operating characteristics curve was calculated. Main outcome measure Anticholinergic adverse effects. Results A total of 250 patients (mean age 81.67 years, standard deviation 7.768; 50% females) were included. In total, 148 patients (59.2%) presented with dry mouth, 85 (34%) with dry eye, 141 (56.4%) with impaired functionality, 44 (17.6%) with a history of falls and 219 (87.6%) with cognitive impairment. Significant differences (p < 0.05) were obtained for the majority of the associations between Anticholinergic Drug Scale, Anticholinergic Risk Scale, Anticholinergic Cognitive Burden and Drug Burden Index and adverse effects. Conversely, the effect sizes of these associations ranged from "fail" (area under the curve 0.5 to 0.6) to "fair" (area under the curve 0.7 to 0.8). Conclusion Although significant differences in the scores of anticholinergic burden instruments and adverse outcomes may exist, the effect sizes of these associations ranged from 'fail' to 'fair', which limits their utility in preventing anticholinergic adverse outcomes with medication review interventions.

A Further Introduction to Dental Sleep Medicine

Dental sleep medicine traditionally focuses on sleep-related breathing disorders, such as snoring and obstructive sleep apnea. However, everyday practice shows that also other sleep disorders touch on dentistry, including sleep-related orofacial pain, xerostomia, hypersalivation, gastroesophageal reflux disease and bruxism. A new definition, which covers all the diagnostic and treatment aspects of these disorders, has therefore been formulated for dental sleep medicine. This article describes why this development started and sketches the current state of affairs regarding the discipline of dental sleep medicine. The different dental sleep disorders are also described briefly, with special focus on the more remarkable associations between them.

Photobiomodulation Therapy in the Treatment of Oral Mucositis, Dysphagia, Oral Dryness, Taste Alteration, and Burning Mouth Sensation Due to Cancer Therapy: A Case Series

Oral complications of cancer therapy, such as oral dryness, dysphagia, and taste alteration, are associated with a negative impact in the quality of life of the patients. Few supportive care measures are available for such complications. This case series reveals the effectiveness of the photobiomodulation (PBM) therapy when used in a specific protocol and parameters, in the management of oral complications related to cancer therapy. Dysphagia was measured using the functional outcome swallowing scale for staging oropharyngeal dysphagia (FOSS). Oral mucositis was measured according to the National Cancer Institute scale. The quantity of the whole resting and stimulated saliva was measured in order to assess the oral dryness. In addition, the taste alteration was measured according to a protocol suggested by the International Standards organization (ISO). Sensation of burning mouth was measured using a visual analogue scale. These measurements were made before treatment, during, and at the end of the treatment. Diode laser 635 nm was used in 3 J/cm2. Five sessions interleaved with 24 h breaks were conducted for the dysphagia and oral dryness, and 10 sessions were conducted for the taste alteration and burning mouth sensation. Regardless of the limitations of this case series, PBM can be considered safe, time saving, and a promising approach for the management of the oral complications due to cancer therapy and the quality of life of cancer patients.

Distinct Salivary Gland Features in Sjögren's Syndrome and Lupus Erythematosus Sialadenite

BACKGROUND

Primary Sjögren's syndrome (pSS) is an important cause of xerostomia, and the presence of this symptom in lupus erythematosus (LE) is usually referred to as secondary SS. Although these diseases share many clinical and laboratory aspects, the histopathological changes of minor salivary glands (MSG) have been widely evaluated to determine whether this damage is specific for each disease. Based on this query, the aim of this study was to analyze morphological findings of minor salivary glands in pSS or LE.

METHODS

Two groups of 30 (MSG) from patients with pSS and LE were histopathologically evaluated, and the results were statistically analyzed using the two-tailed Fisher exact test.

RESULTS

The morphological changes were distinct among the groups and statistically significant. In pSS, the most evident features were the focal lymphocytic ductal aggression, with the focus score ≥1 and the periductal fibroplasia, while in LE, perivascular inflammatory infiltrate, spongiosis of ductal cells not associated with the exocytosis, and hyalinization of the periductal basement membrane were detected.

CONCLUSIONS

These results indicated that in each disorder, MSG have their specific morphological changes, which lead to xerostomia, and the impairment of MSG in LE is probably due to a lupus sialadenitis.

Associations between tooth wear and dental sleep disorders: A narrative overview

Objectives

Tooth wear is a common finding in adult patients with dental sleep disorders. The aim of this paper was to review the literature on the possible associations between tooth wear and the following dental sleep disorders: sleep‐related oro‐facial pain, oral moistening disorders, gastroesophageal reflux disease (GERD), obstructive sleep apnoea syndrome (OSAS) and sleep bruxism.

Methods

A PubMed search was performed on 1 June 2018 using MeSH terms in the following query: Tooth Wear AND (Facial Pain OR Temporomandibular Joint Disorders OR Xerostomia OR Sialorrhea OR Gastroesophageal Reflux OR Sleep Apnea Syndrome OR Sleep Bruxism).

Results

The query yielded 706 reports on tooth wear and the mentioned dental sleep disorders. Several associations between tooth wear and the dental sleep disorders were suggested in the literature. It could be concluded that: (a) tooth wear is associated with dental pain and/or hypersensitivity; (b) oral dryness is associated with tooth wear, oro‐facial pain and sleep bruxism; (c) GERD is associated with tooth wear, oro‐facial pain, oral dryness, OSAS and sleep bruxism; (d) OSAS is associated with oral dryness, GERD and sleep bruxism; and (e) sleep bruxism is associated with tooth wear.

Conclusions

Tooth wear is associated with the dental sleep disorders oro‐facial pain, oral dryness, GERD and sleep bruxism. The dental sleep disorders are interlinked with each other, which leads to indirect associations as well, and makes the consequences of each single condition difficult to disentangle. Knowledge of these associations is clinically relevant, but more research is needed to confirm their validity.

Temporomandibular Disorders and Oral Features in Early Rheumatoid Arthritis Patients: An Observational Study

Aims: Temporomandibular disorders (TMD) represent a heterogeneous group of inflammatory or degenerative diseases of the stomatognatic system, with algic and/or dysfunctional clinical features involving temporomandibular joint (TMJ) and related masticatory muscles. Rheumatoid Arthritis (RA) is an autoimmune polyarthritis characterized by the chronic inflammation of synovial joints and oral implications such as hyposalivation, difficulty in swallowing and phoning, feeling of burning mouth, increased thirst, loss of taste or unpleasant taste and smell, dental sensitivity. The aim of this observational study was to investigate the prevalence of TMD symptoms and signs as well as oral implications in patients with Early Rheumatoid Arthritis (ERA), that is a RA diagnosed within 12 months, compared with a control group. Methods: The study group included 52 ERA patients (11 men, 41 women) diagnosed according to the 2010 ACR/EULAR Classification Criteria for Rheumatoid Arthritis. A randomly selected group of 52 patients not affected by this disease, matched by sex and age, served as the control group. The examination for TMD signs and symptoms was based on the standardized Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) by means of a questionnaire and through clinical examination. Results: Regarding the oral kinematics, the left lateral excursion of the mandible was restricted in statistically significant way in ERA patients (p=0.017). The endfeel values were significantly increased in ERA group (p=0.0017), thus showing the presence of a higher muscle contracture. On the other side, the study group complained less frequently (67.3%) of TDM symptoms (muscle pain on chewing, pain in the neck and shoulders muscles, difficulty in mouth opening, arthralgia of TMJ, tinnitus) than controls (90.4%) (χ²= 8.301 p=0.0039). The presence of TMJ noises was significantly lower in the study group (χ²= 3.869 p=0.0049), as well as presence of opening derangement (χ²= 14.014 p=0.0002). The salivary flow was significantly decreased in the study group respect to the control one (p<0.0001). Conclusions: The data collected show a weak TMJ kinematic impairment, a paucisymptomatic muscle contracture (positive endfeel) and a remarkable reduction of salivary flow in ERA patients. Myofacial pain (MP) evoked by palpation was more frequent and severe in the control group than in the study one, this result being highly significant.

Efficacy of Artificial Salivary Substitutes in Treatment of Xerostomia: A Systematic Review

Aim:

To provide an update on artificial saliva used to maintain the health of the oral cavity of patients with severe hyposalivation.

Materials and Methods:

A literature search was conducted in April 2018 in three electronic databases (The Cochrane Central Register of Controlled Trials [CENTRAL], PubMed, and Embase) by combining key words and terms related to the population and intervention of the topic.

Results:

The databases search resulted in 455 titles and abstracts. Of these, 21 were judged to meet inclusion criteria and full texts were read. Finally, 10 clinical trials were included for qualitative synthesis.

Conclusion:

Published evidence suggests that all the artificial saliva products tested in included studies reduced symptoms of xerostomia. These products should specifically be selected according to the patients’ concerns and needs. However, the included studies presented a wide range of products and suffered from high risk of bias. Therefore, long-term randomized controlled trials on effects of various products are required.

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 functions in mastication, taste and textural perception, swallowing and initial digestion

Saliva exerts multiple functions in relation to the initial digestive processes taking place in the upper parts of the gastrointestinal tract. Ingestion of food and beverages, in turn, is a strong stimulus for secretion of saliva with a differential composition depending on the neuronal stimulation pattern. This review paper provides insight into the mechanisms by which saliva acts in relation to taste, mastication, bolus formation, enzymatic digestion and swallowing. Also, the protective functions of saliva including maintenance of dental and mucosal integrity will be discussed as they indirectly influence the digestive process. The final part of this study focuses on the implications of xerostomia and salivary gland dysfunction on gastrointestinal functions.

Orofacial Manifestations and Temporomandibular Disorders of Sjögren Syndrome: An Observational Study

AIMS: Sjӧgren Syndrome is a disorder involving oral tissues, with xerostomia, dysgeusia, dysphagia, tooth decay, gingivitis, angular cheilitis and glossitis. Temporomandibular disorders are a generic term referred to clinical conditions involving the jaw muscles and temporomandibular joint. The aim of this study was to investigate the prevalence of oral manifestations and temporomandibular disorders (TMD) in Sjӧgren Syndrome (SS) patients compared with healthy people. METHODS: The study group included 72 SS patients (2 men, 70 women) diagnosed according to the American-European Consensus Group (AECG) Criteria. A randomly selected group of 72 patients, matched by sex and age, served as control group. The examination for TMD signs and symptoms was based on the standardized Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) through a questionnaire and clinical examination. RESULTS: SS patients complained more frequently (95.8%) of oral symptoms (xerostomia, dysgeusia, dysphagia) than controls (22.2%) (χ²= 80.66 p< 0.001). TMD symptoms (muscle pain on chewing, difficulty in mouth opening, arthralgia, headaches, tinnitus) were complained by 91.7% of SS patients and by 84.7% of controls (χ²= 1,667 p= 0,196). At the clinical examination, 91,7% of SS had at least one oral sign respect to 75 % of controls. The salivary flow measurements showed high statistical significance between the two groups (Unpaired test, p< 0,0001). Myofascial pain (caused by muscular contracture) was significantly higher in the study group than in the control one (p≤ 0,05). Furthermore 18,05% of SS patients showed deflection versus 5,5% of controls (χ²=5,402 p=0,020). CONCLUSIONS: Sjӧgren's Syndrome seems to play a role in temporomandibular joint disorders.

Validity and reliability of a Portuguese version of the Summated Xerostomia Inventory-5

OBJECTIVES

The aim of this study was to validate and determine the reliability of the Portuguese version of the Summated Xerostomia Inventory.

BACKGROUND

Many conditions such as head and neck radiation, autoimmune diseases or polypharmacy are characterised by hyposalivation which can affect oral and systemic quality of life. As such, this condition must be assessed, and the English version of the Xerostomia Inventory has been increasingly used to determine the severity of dry mouth perception.

MATERIALS AND METHODS

This was a descriptive cross-sectional study, which employed volunteers suffering from hyposalivation after local ethical committee clearance. Each patient signed an informed consent and responded to the Portuguese version of the questionnaire in the form of an interview. This was repeated again after 2 weeks. A standard single question provided a validity check. Data were analysed using Cronbach's α to test its reliability and total and interitem correlation, and intraclass correlation to determine its internal consistency and test-retest reliability. Significance was set at .05.

RESULTS

A sample of 103 volunteers was recruited. Cronbach's α was .84 and .87 for the first and second test administrations, respectively. The intraclass correlation coefficient value for the test-retest reliability was .93, and scores for the individual items ranged from .79 to .90. The correlation between the total score of the questionnaire and standard single dry mouth question was .66, indicating a very good correlation.

CONCLUSION

Demonstrating excellent psychometric properties, the Summated Xerostomia Inventory (Portuguese Version) is a valid tool for quantifying Xerostomia in a dry mouth-afflicted population.

Risk factors associated with xerostomia in haemodialysis patients

BACKGROUND

To determine the prevalence of xerostomia and hyposalivation in Haemodialysis (HD) patients, to clarify risk factors, assess patient's quality of life, and to establish a possible correlation among interdialytic weight gain (IDWG) and xerostomia.

MATERIAL AND METHODS

This study was performed on a group of 50 HD patients. Data were collected using a questionnaire containing demographic and clinical variables, a visual analogue scale (VAS) for xerostomia, IDWG, and an oral health impact profile questionnaire (OHIP-14). Unstimulated whole saliva (UWS) and stimulated whole saliva (SWS) were collected.

RESULTS

A total of 28 HD patients (56%) suffered xerostomia. Dry mouth was associated with hypertension (OR, 5.24; 95% CI, 1.11-24.89) and benzodiazepine consumption (OR, 5.96; 95% CI, 1.05-33.99). The mean xerostomia VAS and OHIP-14 scores were 31.74±14.88 and 24.38±11.98, respectively. No significant correlation was observed between IDWG% and VAS and OHIP total score. Nonetheless, a positive correlation between VAS level of thirst and IDWG% was found (r=0.48 p=0.0001). UWS and SWS means (determined in 30 patients) were 0.16±0.17 and 1.12±0.64, respectively. Decreased values of UWS and SWS were reported in 53.33% and 36.66% of HD patients.

CONCLUSIONS

Xerostomia in HD has a multifactorial aetiology due to accumulative risks as advanced age, systemic disorders, drugs, fluid intake restriction, and salivary parenchymal fibrosis and atrophy. Therefore, it is important to detect possible xerostomia risk factors to treat correctly dry mouth in HD patients and avoid systemic complications.

Longitudinal analysis of quality of life in patients with undifferentiated connective tissue diseases

INTRODUCTION/OBJECTIVES

To prospectively assess the quality of life (QoL) of patients affected by undifferentiated connective tissue diseases (UCTDs) and to identify factors associated with changes over time.

PATIENTS AND METHODS

A total of 46 consecutive UCTD patients completed the Short-Form 36 (SF-36) questionnaire at presentation and then yearly. At each 6-month visit, all patients underwent a detailed history taking and a laboratory and physical assessment, in order to follow the evolution of the disease over time and to assess the the co-existence of fibromyalgia.

RESULTS

At presentation, scores lower than the average of the general population were detected in 34 (74%) and 41 (89%) patients in the physical and mental domains, respectively. No difference between patients with and without Raynaud's phenomenon was detected. Fibromyalgia was the only independent variable associated with an impaired physical component summary score (p = 0.0009). No patient feature was found to be associated with the basal mental component summary score. During 24 months of follow-up, a significant improvement (ie, a change ≥5 from baseline) in physical component summary and mental component summary scores was observed in 14 (33.3%) and 20 (43.4%) patients, respectively. Patients who significantly improved in the physical domain more frequently had a history of glucocorticoids intake (p<0.001), while those who improved in the mental component more frequently had a history of either glucocorticoids (p = 0.043) or immunosuppressors (p = 0.037) intake during follow-up.

CONCLUSION

UCTD patients perceive a worse QoL, regardless of Raynaud's phenomenon Fibromyalgia is one of the major contributors of physical QoL, whereas no factor influencing mental component has been identified. An improvement in QoL can be observed in less than half of patients over a 2-year follow-up. Larger studies are needed to identify factors influencing QoL and to define the role of pharmacological treatments.

Managing xerostomia and salivary gland hypofunction: executive summary of a report from the American Dental Association Council on Scientific Affairs

BACKGROUND AND OVERVIEW

Xerostomia, also known as "dry mouth," is a common but frequently overlooked condition that is typically associated with salivary gland hypofunction, which is the objective measurement of reduced salivary flow. Patients with dry mouth exhibit symptoms of variable severity that are commonly attributed to medication use, chronic disease and medical treatment, such as radiotherapy to the head and neck region. Chronic xerostomia significantly increases the risk of experiencing dental caries, demineralization, tooth sensitivity, candidiasis and other oral diseases that may affect quality of life negatively. This article presents a multidisciplinary approach to the clinical management of xerostomia, consistent with the findings of published systematic reviews on this key clinical issue.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Initial evaluation of patients with dry mouth should include a detailed health history to facilitate early detection and identify underlying causes. Comprehensive evaluation, diagnostic testing and periodic assessment of salivary flow, followed by corrective actions, may help prevent significant oral disease. A systematic approach to xerostomia management can facilitate interdisciplinary patient care, including collaboration with physicians regarding systemic conditions and medication use. Comprehensive management of xerostomia and hyposalivation should emphasize patient education and lifestyle modifications. It also should focus on various palliative and preventive measures, including pharmacological treatment with salivary stimulants, topical fluoride interventions and the use of sugar-free chewing gum to relieve dry-mouth symptoms and improve the patient's quality of life.

The effect of clinical setting on the unstimulated salivary flow rate

OBJECTIVE

Unstimulated whole saliva (UWS) sialometry uses the spitting method to assess occurrence of hyposalivation. This study compares the UWS flow rates in volunteers sitting in a laboratory or in a clinical setting, in order to evaluate the influence of environment on salivary secretion.

DESIGN

25 healthy volunteers were recruited and divided into two groups to perform UWS sialometry under the two different settings (T1). Eleven weeks later, the participants repeated the same test (T2). At a unique time point and under the clinical setting, 18 patients complaining of xerostomia also performed the UWS sialometry; these values were used as control to corroborate findings.

RESULTS

Different scenarios - laboratory one vs. clinical one - did not affect measurements of mean UWS flow rates. Both intra- and inter-individual variabilities, reported as standard error of the mean (SEM) and within-subject variance (WSV), resulted below the threshold of 0.1g/min. A significant difference was found between UWS flow rates from healthy volunteers and those from patients with xerostomia (p<0.05). Test/retest reliability showed a moderate correlation of datasets collected at the two time points from healthy volunteers (T1 vs. T2, 11 weeks later): under laboratory and clinical settings, Pearson's coefficients of correlation were r=0.62 and r=0.32, respectively.

CONCLUSIONS

Type of environment did not influence UWS sialometry via spitting method, which appeared reliable for intra-day analysis of the salivary flow rate, although prone to physiological variations over time.

Evaluation of Xerostomia and salivary flow rate in Hashimoto's Thyroiditis

BACKGROUND

One of the most common causes of hypothyroidism is Hashimoto's Thyroiditis (HT). Early detection of dry mouth is critical in preserving and promoting systemic and oral health. In this study we have assessed, for the first time, salivary function and xerostomia in HT patients who have not been involved with Sjögren's syndrome.

MATERIAL AND METHODS

HT was diagnosed in 40 patients based on clinical findings and positive anti-thyroid peroxidase antibodies (anti-TPO). Controls, matched by sex, age and body mass index (BMI), and with no history of thyroid disease, were selected. A questionnaire was used for diagnosis of xerostomia. Saliva samples were taken between 8 a.m. and 9 a.m., and at least 2 hours after the last intake of food or drink. The flow rate was calculated in milliliters per minute.

RESULTS

Xerostomia was significantly higher in patients with HT. Unstimulated salivary flow rate was significantly lower in the HT group. Stimulated salivary flow rate was lower in HT group, but the difference was not significant.

CONCLUSIONS

The patients with HT experienced xerostomia, and their salivary flow rate was diminished. Spitting the saliva then assessing salivary flow rate based on milliliter per minute is non-invasive, fast, and simple for chair-side diagnosis of dry mouth. Autoimmune diseases can be accompanied by salivary gland dysfunction. This may be due to the effect of cytokines in the autoimmune process or because of thyroid hormone dysfunctions.

Xerostomia, Hyposalivation, and Salivary Flow in Diabetes Patients

The presence of xerostomia and hyposalivation is frequent among diabetes mellitus (DM) patients. It is not clear if the presence of xerostomia and hyposalivation is greater in DM than non-DM patients. The aims of this systematic review are (1) to compare the prevalence rates of xerostomia, (2) to evaluate the salivary flow rate, and (3) to compare the prevalence rates of hyposalivation in DM versus non-DM population. This systematic review was conducted according to the PRISMA group guidelines by performing systematic literature searches in biomedical databases from 1970 until January 18th, 2016. All studies showed higher prevalence of xerostomia in DM patients in relation to non-DM population, 12.5%-53.5% versus 0-30%. Studies that analyzed the quantity of saliva in DM population in relation to non-DM patients reported higher flow rates in non-DM than in DM patients. The variation flow rate among different studies in each group (DM/CG) is very large. Only one existing study showed higher hyposalivation prevalence in DM than non-DM patients (45% versus 2.5%). In addition, quality assessment showed the low quality of the existing studies. We recommend new studies that use more precise and current definitions concerning the determination and diagnosis of DM patients and salivary flow collection.

High prevalence of hyposalivation in individuals with neurofibromatosis 1: a case-control study

BACKGROUND

Neurofibromatosis type 1 (NF1) is one of the most common genetic diseases in humans and has widely variable expressivity. Oral manifestations are common, but there are no studies that investigated functional alterations in salivary glands in NF1. Our aim was to evaluate the salivary flow rate in NF1 individuals, comparing to a control group, and to investigate the possible causes and some consequences of salivary gland alteration.

METHODS

This is a case-control study that evaluated the salivary flow rate of NF1 individuals (n = 49) and compared to an age and sex-matched control group. We have also investigated the possible causes and consequences of hyposalivation in NF1 individuals through anamnesis, a specific questionnaire, physical examination, tongue coating evaluation and cytopathological exam to assess the prevalence of oral candidiasis.

RESULTS

Hyposalivation at rest was present in 59% (29/49) of NF1 individuals in contrast to 22% (11/49) in the control group, being statistically significant (P <0.0001; Wilcoxon rank-sum test). The analysis of the adjusted residual showed that the prevalence of hyposalivation in NF1 individuals (46.9%) was 4-fold higher than in controls (10.2%). None of the possible causes of hyposalivation (medications, low liquid intake, caffeinated or stimulant drink use, mouth breathers, alcohol, smoke and plexiform neurofibroma close to or involving major salivary glands areas) had important impact on the salivary flow rate in NF1 individuals.

CONCLUSIONS

Hyposalivation may be a consequence of NF1, as occurs in other genetic diseases. More studies are necessary to understand if there is and what is the relationship between NF1 and hyposalivation.