Ethanol- and Cigarette Smoke-Related Alternations in Oral Redox Homeostasis

Alcohol abuse as well as smoking cigarettes has been proven to negatively affect the oral environment. The aim of this work was to provide a systematic review of the literature on the influence of ethanol and cigarette smoking on oral redox homeostasis. A search was performed for scientific articles indexed in the PubMed, Medline and Web of Science databases. We identified 32,300 articles, of which 54 were used for the final review, including the results from 2000 to 2021. Among the publications used to write this article, n = 14 were related to the influence of alcohol consumption (clinical studies n = 6, experimental studies n = 8) and n = 40 were related to the influence of smoking (clinical studies n = 33, experimental studies n = 7) on oral redox homeostasis. The reviewed literature indicates that alcohol abusers and smokers are more likely to suffer from salivary gland dysfunction, as well as develop precancerous lesions due to DNA damage. Compared to alcohol abstainers and non-smokers, alcohol drinkers and smokers are also characterized by a deterioration in periodontal health measured by various indicators of periodontal status. In summary, alcohol abuse and smoking are associated with disrupted oral redox homeostasis, which may lead not only to tooth loss, but also contribute to various adverse effects related to mental health, digestive processes and chronic inflammation throughout the human body.

Mechanism, Prevention, and Treatment of Radiation-Induced Salivary Gland Injury Related to Oxidative Stress

Radiation therapy is a common treatment for head and neck cancers. However, because of the presence of nerve structures (brain stem, spinal cord, and brachial plexus), salivary glands (SGs), mucous membranes, and swallowing muscles in the head and neck regions, radiotherapy inevitably causes damage to these normal tissues. Among them, SG injury is a serious adverse event, and its clinical manifestations include changes in taste, difficulty chewing and swallowing, oral infections, and dental caries. These clinical symptoms seriously reduce a patient’s quality of life. Therefore, it is important to clarify the mechanism of SG injury caused by radiotherapy. Although the mechanism of radiation-induced SG injury has not yet been determined, recent studies have shown that the mechanisms of calcium signaling, microvascular injury, cellular senescence, and apoptosis are closely related to oxidative stress. In this article, we review the mechanism by which radiotherapy causes oxidative stress and damages the SGs. In addition, we discuss effective methods to prevent and treat radiation-induced SG damage.

Effect of ischemic preconditioning on radiation damage to the submandibular gland in rats

To investigate the effects of radiation on rat submandibular glands and the possible protective effects of ischemic preconditioning, the submandibular glands of Wistar rats were subjected to in situ radiation after ischemic preconditioning. The glands were exposed to X-radiation at a single dose of 20 Gy. Ischemic preconditioning was achieved by three min of ischemia and three min of reperfusion, repeated three times before irradiation. Salivary secretion, histological changes, alterations in tight junctions, and the levels of oxidative stress, pro-inflammatory cytokines, and water secretion proteins mediated by the muscarinic acetylcholine M3 subtype receptor were determined at 1 and 12 weeks post-irradiation. In glands subjected to irradiation only, the secretion, superoxide dismutase activity, tight junction width, acinar cell number, and M3 receptor and aquaporin-5 levels were lower at 1 and 12 weeks than seen in the ischemically preconditioned irradiated glands. In contrast, tumor necrosis factor-α, malondialdehyde, myeloperoxidase activity, and the expression of the tight junction protein claudin-4 were significantly higher in the irradiated only glands. Our study revealed that radiation caused a series of injury-stress responses, especially damage to the water secretion pathway mediated by the M3 receptor that ultimately led to hyposecretion, which might play an important role in the dysfunction of the irradiated only glands. Ischemic preconditioning reduced the radiation-induced injury to submandibular glands and ameliorated salivary hyposecretion.

Aging-related changes in quantity and quality of saliva: Where do we stand in our understanding?

Saliva is crucial to oral processing of food and consequently is also related to the sensory and textural experience. It is often assumed that the secretion and properties of saliva change with age, which can result in dry mouth conditions, taste aberrations. Such changes may result in reduced nutrient intake and malnutrition besides adversely affecting the quality of life. Based on some recent research findings, this article reviews our current understandings on age-dependent changes on quantity (bulk salivary flow rate) as well as quality of saliva (e.g., composition, viscosity, lubrication) in healthy elderly individuals. The review begins with a short introduction to histological changes of salivary glands upon aging. This is followed by covering different aspects of salivary changes with key articles highlighting decreased flow rate, increased ionic concentration, decreased calcium and mucin content in saliva of elderly subjects consequently affecting the oral coating and flavor perception. We also highlight issues in data associated with respect to variance in saliva collection protocols as well as factors influencing such results other than age, such as health conditions and polypharmacy. Clear gaps in literature have been highlighted with respect to lack of quantitative data in viscoelasticity, rheology, and lubrication properties of saliva in healthy elderly population and the potential impact of changes in these material properties on sensory and textural perception of food and consequently food intake. Such insights will not only have clinical implications for maintaining optimal oral health in elderly population but also serve to optimize food for elderly population. PRACTICAL APPLICATIONS: The population has undergone a fundamental change in its age structure globally, with a rapid increase in elderly population. Innovation of tailored foods is still in its early stage to satisfy the needs of growing aging population. One of the biggest challenges in such food product development is lack of adequate understanding and characterization of endogenous factors, that is, age-related changes in saliva, which may influence oral processing of food and subsequently nutrient intake. Aging affects the salivary glands and alters quantity (flow rate) and quality (e.g., ion and protein composition, rheology, tribology) of saliva. Thus, older adults may suffer from dry mouth, taste aberration, and poor oral hygiene, greatly affecting their quality of life. This review provides insights into how age versus other health conditions influence salivary properties. Understanding of age-dependent changes in salivary rheology and tribology will be of paramount importance to optimize food for elderly population.

Ixeris dentata Extract Increases Salivary Secretion through the Regulation of Endoplasmic Reticulum Stress in a Diabetes-Induced Xerostomia Rat Model

This study aimed to investigate the molecular mechanism of diabetes mellitus (DM)-induced dry mouth and an application of natural products from Ixeris dentata (IXD), a recently suggested regulator of amylase secretion in salivary cells. Vehicle-treated or diabetic rats were orally treated with either water or an IXD extract for 10 days to observe the effect on salivary flow. We found that the IXD extract increased aquaporin 5 (AQP5) and alpha-amylase protein expression in the submandibular gland along with salivary flow rate. Similarly, the IXD extract and its purified compound increased amylase secretion in high glucose-exposed human salivary gland cells. Furthermore, increased endoplasmic reticulum stress response in the submandibular gland of diabetic rats was inhibited by treatment with the IXD extract, suggesting that IXD extract treatment improves the ER environment by increasing the protein folding capacity. Thus, pharmacological treatment with the IXD extract is suggested to relieve DM-induced dry mouth symptoms.

Radiation-Induced Loss of Salivary Gland Function Is Driven by Cellular Senescence and Prevented by IL6 Modulation

Head and neck cancer patients treated by radiation commonly suffer from a devastating side effect known as dry-mouth syndrome, which results from the irreversible loss of salivary gland function via mechanisms that are not completely understood. In this study, we used a mouse model of radiation-induced salivary hypofunction to investigate the outcomes of DNA damage in the head and neck region. We demonstrate that the loss of salivary function was closely accompanied by cellular senescence, as evidenced by a persistent DNA damage response (γH2AX and 53BP1) and the expression of senescence-associated markers (SA-βgal, p19ARF, and DcR2) and secretory phenotype (SASP) factors (PAI-1 and IL6). Notably, profound apoptosis or necrosis was not observed in irradiated regions. Signs of cellular senescence were also apparent in irradiated salivary glands surgically resected from human patients who underwent radiotherapy. Importantly, using IL6 knockout mice, we found that sustained expression of IL6 in the salivary gland long after initiation of radiation-induced DNA damage was required for both senescence and hypofunction. Additionally, we demonstrate that IL6 pretreatment prevented both senescence and salivary gland hypofunction via a mechanism involving enhanced DNA damage repair. Collectively, these results indicate that cellular senescence is a fundamental mechanism driving radiation-induced damage in the salivary gland and suggest that IL6 pretreatment may represent a promising therapeutic strategy to preserve salivary gland function in head and neck cancer patients undergoing radiotherapy.

Mechanism of the protective effect of phenylephrine pretreatment against irradiation-induced damage in the submandibular gland

Irradiation is a fundamental treatment modality for head and neck malignancies. However, a significant drawback of irradiation treatment is the irreversible damage to salivary glands in the radiation field. Although the protective effect of phenylephrine pretreatment on salivary glands following irradiation has previously been demonstrated, the exact mechanism remains unclear. In this study, we investigated the cytoprotective mechanisms of phenylephrine pretreatment in rat submandibular glands following irradiation. Rats were locally irradiated using a linear accelerator in the head and neck region with a single dose of 20 Gy. Phenylephrine (5 mg/kg) was injected intraperitoneally 30 min prior to irradiation and the submandibular glands were collected on day 7 after irradiation. In comparison with the control group, the irradiation-only group demonstrated severe atrophy, enhanced cell proliferation and increased apoptosis. The phenylephrine-pretreated group, however, demonstrated markedly alleviated atrophy, further increased cell proliferation and decreased apoptosis compared with the irradiation-only group. The data indicated that the cytoprotective mechanisms of phenylephrine pretreatment in the submandibular gland following irradiation may be related to improved cell proliferation and inhibition of cell apoptosis.

Pro-apoptotic gene knockdown mediated by nanocomplexed siRNA reduces radiation damage in primary salivary gland cultures

A critical issue in the management of head and neck tumors is radioprotection of the salivary glands. We have investigated whether siRNA-mediated gene knock down of pro-apoptotic mediators can reduce radiation-induced cellular apoptosis in salivary gland cells in vitro. We used novel, pH-responsive nanoparticles to deliver functionally active siRNAs into cultures of salivary gland cells. The nanoparticle molecules are comprised of cationic micelles that electrostatically interact with the siRNA, protecting it from nuclease attack, and also include pH-responsive endosomolytic constituents that promote release of the siRNA into the target cell cytoplasm. Transfection controls with Cy3-tagged siRNA/nanoparticle complexes showed efficiently internalized siRNAs in more than 70% of the submandibular gland cells. We found that introduction of siRNAs specifically targeting the Pkcδ or Bax genes significantly blocked the induction of these pro-apoptotic proteins that normally occurs after radiation in cultured salivary gland cells. Furthermore, the level of cell death from subsequent radiation, as measured by caspase-3, TUNEL, and mitochondrial disruption assays, was significantly decreased. Thus, we have successfully demonstrated that the siRNA/nanoparticle-mediated knock down of pro-apoptotic genes can prevent radiation-induced damage in submandibular gland primary cell cultures.

Clinical management of salivary gland hypofunction and xerostomia in head-and-neck cancer patients: successes and barriers

The most significant long-term complication of radiotherapy in the head-and-neck region is hyposalivation and its related complaints, particularily xerostomia. This review addresses the pathophysiology underlying irradiation damage to salivary gland tissue, the consequences of radiation injury, and issues contributing to the clinical management of salivary gland hypofunction and xerostomia. These include ways to (1) prevent or minimize radiation injury of salivary gland tissue, (2) manage radiation-induced hyposalivation and xerostomia, and (3) restore the function of salivary gland tissue damaged by radiotherapy.

Ultrastructural evaluation of the radioprotective effect of sodium selenite on submandibular glands in rats

The aim of this study was to evaluate the radioprotector effect of sodium selenite on the ultrastructure of submandibular glands in rats. Fifty-seven male albino Wistar rats were randomized to 4 groups: control, irradiated, sodium selenite and irradiated/sodium selenite. The animals in the sodium selenite and irradiated/sodium selenite groups received intraperitoneal injections of sodium selenite (0.5 mg/kg body weight) 24 h before irradiation. The animals belonging to the irradiated and irradiated/sodium selenite groups were submitted to 15 Gy of gamma radiation in the head and neck region. The submandibular glands were removed at 4, 8, 12, 24, 48 and 72 h after irradiation. The ionizing radiation induced damage to the secretory cells, especially the serous cells, right from the first period. Vacuolization, lysis of cytoplasmic inclusions and nuclear alterations occurred. The sodium selenite group also presented cellular alterations in the study periods, but with less damage compared to that caused by radiation. There was greater similarity between the irradiated/sodium selenite group and the control group than with the other groups treated in all study periods. Despite the alterations observed in the sodium selenite group, sodium selenite presented a radioprotective action on the secretory cells of submandibular glands.

Sensitivity of salivary glands to radiation: from animal models to therapies

Radiation therapy for head and neck cancer causes significant secondary side-effects in normal salivary glands, resulting in diminished quality of life for these individuals. Salivary glands are exquisitely sensitive to radiation and display acute and chronic responses to radiotherapy. This review will discuss clinical implications of radiosensitivity in normal salivary glands, compare animal models used to investigate radiation-induced salivary gland damage, address therapeutic advances, and project future directions in the field.

Cigarette smoke effect on total salivary antioxidant capacity, salivary glutathione peroxidase and gamma-glutamyltransferase activity

Saliva is the first biological fluid that inhaled cigarette smoke (CS) encounters. CS contains several carcinogens known to initiate and promote tumourigenesis and metastasis. One of the aims of this study was to establish if glutathione peroxidase and gamma-glutamyltranspherase (GGT) could be used as possible markers for evaluating the oral oxidative stress caused by smoking. The effect of CS on free radical generation was investigated using two methods. Using different assays, different antioxidants present in saliva may be evidenced due to the different principles on which they are based. Our results indicate that exposure to CS caused a statistically significant decrease of both salivary glutathione peroxidase (p < 0.01) and salivary GGT (p < 0.01). We also found that exposure to CS caused a statistically significant decrease of salivary total antioxidant status (p < 0.01). Such decreases may have a consistent role in the mechanisms by which the toxic effects of CS initiate oral inflammatory diseases, promote precancerous transformations, and destroy the oral cavity homeostasis. Therefore the evaluation of total antioxidant capacity of saliva is important but it must be done together with the evaluation of salivary specific markers of oxidative stress, such as uric acid, albumin and possibly, GGT.

Effect of cevimeline on radiation-induced salivary gland dysfunction and AQP5 in submandibular gland in mice

The aim of this study was to clarify the effects of the muscarinic receptor agonist, cevimeline, on saliva flow and expression of aquaporin5 (AQP5) in submandibular gland after X-ray irradiation. Using a previously established radiation-induced xerostomia model mouse, saliva flow from at 7 days before irradiation to at 28 days after irradiation was investigated in mice that were treated with cevimeline before or after irradiation. Radiation caused a significant decrease in saliva flow compared with nonirradiated salivary glands. Cevimeline post-treatment also caused a significant decrease in saliva flow. In contrast, cevimeline pre-treatment did not significantly decrease saliva flow. Expression of AQP5 fluorescent intensity and mRNA were also analyzed. Irradiation significantly decreased expression of AQP5 in submandibular gland. However, pre-treatment with cevimeline prevented this decrease in AQP5 expression. These data suggest that pretreatment with cevimeline prevents radiation-induced xerostomia and radiation-induced decrease in expression of AQP5 in submandibular gland.

Age- and flow-dependency of salivary viscoelasticity

Measuring salivary viscoelasticity (by relaxation times) is of paramount importance, since salivary rheology behavior has been associated with the development of oral disease conditions (such as dental caries) in animal and human model studies. In addition, novel and improved methods to evaluate salivary distribution and lubrication are of clinical interest. We used a novel method for measuring the viscoelasticity of saliva secreted from the different glands, at rest or under stimulation and at different ages, all conditions where different viscoelastic properties might be clinically important. Submandibular/sublingual salivary viscoelasticity was significantly higher than that of parotid saliva, especially under stimulation. In addition, an age-related reduction in flow rate (by 62%) was demonstrated, accompanied by an increase in both relaxation time (by 54%) and protein (by 48%). Increased salivary viscoelasticity results in compromised salivary rheology and lubrication properties, which may render the oral cavities of the elderly and other xerostomic persons more vulnerable.

Functional relationship between subfornical organ cholinergic stimulation and nitrergic activation influencing cardiovascular and body fluid homeostasis

We have studied the effects of L-NG-nitro arginine methyl esther (L-NAME), L-arginine (LAR), inhibitor and a donating nitric oxide agent on the alterations of salivary flow, water intake, arterial blood pressure (MAP) and heart rate (HR) induced by the injection pilocarpine into the subfornical organ (SFO). Rats (Holtzman 250-300 g) were anesthetized with 2, 2, 2-tribromoethanol (20 mg/100 kg b. wt.) and a stainless steel cannula were implanted into their SFO. The volume of injection was 0.2 microl. The amount of saliva secretion was studied over a 5-min period. Pilocarpine (40 microg), L-NAME (40 microg) and LAR (30 microg) were used in all experiments for the injection into the SFO. Pilocarpine (10, 20, 40, 80 and 160 microg) injected into SFO elicited a concentration-dependent increase in salivary secretion. L-NAME injected prior to pilocarpine into the SFO increased salivary secretion and water intake due to the effect of pilocarpine. LAR injected prior to pilocarpine into the SFO attenuated the salivary secretion and water intake. Pilocarpine, injected into the SFO increased the MAP and decreased heart rate (HR). L-NAME injected prior to pilocarpine into the SFO potentiated the pressor effect of pilocarpine with a decrease in HR. LAR injected into the SFO prior to pilocarpine attenuated the increase in MAP with no changes in HR. The present study suggests that the SFO nitrergic cells interfere in the cholinergic pathways implicated in the control of salivary secretion, fluid and cardiovascular homeostasis.

Peroxynitrite formation in radiation-induced salivary gland dysfunction in mice

Xerostomia frequently arises in patients with head and neck malignancies that are treated by radiation. However, the mechanisms responsible for the destruction of the salivary gland remain unknown. We previously established a xerostomia model of mice and identified the pathway through which nitric oxide (NO) affects the pathogenesis of radiation-induced salivary gland dysfunction. Although the toxicity of NO alone is modest, NO with superoxide anion (O2(*-)) rapidly forms peroxynitrite (ONOO), a more powerful toxic oxidant. In this study, we used the experimental model to examine: 1) when NO and O2(*-) production is maximum in the salivary gland after irradiation;2) whether peroxynitrite, as assessed by nitrotyrosine production, is responsible for salivary gland dysfunction; and 3) the effect of the iNOS selective inhibitor, aminoguanidine (AG), on nitrotyrosine formation. The increases in production of NO and O2(*-) in the salivary gland peaked on day 7 after irradiation. Nitrotyrosine detected immunohistochemically was significantly reduced by AG in the salivary gland. On the basis of these results, we concluded that NO together with O2(*-) forms the more reactive ONOO, which might be an important pathogenic factor in radiation-induced salivary gland dysfunction.

Evaluation of radioprotective effect of vitamin E in salivary dysfunction in irradiated rats

The aim of this study was to evaluate the radioprotective effect of vitamin E in salivary gland function, as well as analyse the total protein concentration. For this purpose 90 male rats were used and randomly divided into five experimental groups: control (I), in which animals received olive oil solution but were not irradiated; irradiated-olive oil (II), in which animals received olive oil solution and were irradiated with a single exposure dose of 15 Gy of gamma rays to the head and neck region; irradiated (III), in which animals were only irradiated with a single exposure dose of 15 Gy of gamma rays; vitamin E (IV), in which animals received alpha tocopherol acetate solution but were not irradiated; irradiated-vitamin E (V), in which animals received alpha tocopherol acetate solution before irradiation with a single exposure dose of 15 Gy gamma rays. The animals were sacrificed 4, 8 h and 30 days after the irradiation procedure. No differences were observed in salivary volumes between the groups at 4 and 8 h. At 30 days, the salivary volume in the animals pertaining to the irradiated-olive oil group was significantly reduced in relation to the control group. The only irradiated group (III) presented significantly diminished salivary volume. In the salivary composition, no significant differences were observed in the total protein content between the groups studied. It was concluded that radiation had no effect on the total protein content and that vitamin E protected the salivary function 30 days after irradiation. Thus, vitamin E can be considered as a potential radioprotective substance.

Age-related changes in unstimulated salivary function and composition and its relations to medications and oral sensorial complaints

BACKGROUND AND AIMS

The purpose of the current study was to examine the salivary flow rate and composition in relation to drug consumption and idiopathic oral sensorial complaints (OSC). OSC cover xerostomia, disturbed sense of taste, or burning mouth sensitivity with no established classical etiology (e.g., Sjogren's syndrome, or a response to radiotherapy).

METHODS

A thorough sialometrical and sialochemical analysis was performed for all subjects who were healthy non-hospitalized individuals ranging in age from 18-89 years. Saliva samples were all collected in unstimulated conditions.

RESULTS

The three most significant observations were: a) Elderly people have significantly reduced and altered salivary secretion. Whereas specific concentrations increased, the total values of most salivary components were found to be decreased in the elderly. b) Fifty percent of the elderly make OSC. c) OSC were made mainly by elderly individuals who use drugs.

CONCLUSIONS

Reduction in salivary function and altered composition are age-related. However, when drugs are not involved, a compensatory capacity which avoids OSC apparently exists. In contrast, the effect of drugs on OSC is extensive. The finding that the total amount of salivary components and not only salivary flow rates are reduced in the elderly is of great clinical importance, since such a reduction is expected to be reflected in compromising various salivary functions.

On the mechanism of salivary gland radiosensitivity

PURPOSE

To contribute to the understanding of the enigmatic radiosensitivity of the salivary glands by analysis of appropriate literature, especially with respect to mechanisms of action of early radiation damage, and to supply information on the possibilities of amelioration of radiation damage to the salivary glands after radiotherapy of head-and-neck cancer.

METHODS AND MATERIALS

Selected published data on the mechanism of salivary gland radiosensitivity and radioprotection were studied and analyzed.

RESULTS

From a classical point of view, the salivary glands should not respond as rapidly to radiation as they appear to do. Next to the suggestion of massive apoptosis, the leakage of granules and subsequent lysis of acinar cells was suggested to be responsible for the acute radiation-induced function loss of the salivary glands. The main problem with these hypotheses is that recently performed assays show no cell loss during the first days after irradiation, while saliva flow is dramatically diminished. The water secretion is selectively hampered during the first days after single-dose irradiation. Literature is discussed that shows that the compromised cells suffer selective radiation damage to the plasma membrane, disturbing signal transduction primarily affecting watery secretion. Although the cellular composition of the submandibular gland and the parotid gland are different, the damage response is very alike. The acute radiation-induced function loss in both salivary glands can be ameliorated by prophylactic treatment with specific receptor agonists.

CONCLUSIONS

The most probable mechanism of action, explaining the enigmatic high radiosensitivity for early effects, is selective radiation damage to the plasma membrane of the secretory cells, disturbing muscarinic receptor stimulated watery secretion. Later damage is mainly due to classical mitotic cell death of progenitor cells, leading to a hampered replacement capacity of the gland for secretory cells, but is also caused by damage to the extracellular environment, preventing proper cell functioning.

Effects of EGF and bFGF on Irradiated Parotid Glands

Radiotherapy is common treatment for head-and-neck cancer, during which the salivary glands are often included within the radiation field. The most common side effect of this treatment is the development of oral dryness (xerostomia). This study considers the administration of epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF or FGF2) at physiological concentrations before and after irradiation in order to repair radiation-induced damage in salivary gland cells. As a preliminary examination of the efficacy of this approach we have characterized the effects of EGF and bFGF on the apoptotic response of 15-Gy irradiated rat salivary glands in vitro. Also, we have developed a controlled-release delivery system to effectively administer the growth factor to the gland since local delivery is essential to avoid unwanted protection of cancer cells. In vitro administration of bFGF prior to and immediately after irradiation partially protected (44%) the rat parotid gland. EGF did not show any significant radioprotective effect on parotid glands after a single 15-Gy irradiation dose. Encapsulation, storage and release of bFGF from biodegradable 50/50 PLGA microspheres did not affect the functionality of the growth factor in vitro.

Relationships between age, drugs, oral sensorial complaints and salivary profile

The aim of this study was to investigate the relationships between oral sensorial complaints (OSCs) and salivary flow rate, composition and drug consumption of subjects aged 18-90 years. The results were correlated with both drug consumption and OSCs. Only individuals who were free of conditions that are already known to cause OSCs were included in the study. The three most significant observations were as follows: (1) elderly people have significantly reduced and altered salivary secretion compared with younger people. While specific concentrations increased, the total values of most salivary components decreased in the elderly; (2) 50% of the elderly population have OSCs regarding taste, burning mouth syndrome or xerostomia; and (3) OSCs were more prevalent in elderly people who use drugs than in those who do not. In conclusion, a reduction in salivary function and altered composition are age related. A compensatory capacity that prevents OSCs appears to exist in elderly patients who do not use drugs, but drugs were found to have an extensive effect on OSCs. The finding that the total amounts of salivary components and not only the salivary flow rate were reduced in elderly people is of great clinical relevance, since such a reduction is expected to be reflected in compromising various salivary functions.

Saliva--a pivotal player in the pathogenesis of oropharyngeal cancer

Oropharyngeal (OP) cancer, which is usually squamous cell carcinoma, is the most common head and neck malignancy and accounts for 2–4% of all new cancers. It is primarily induced by exposure to tobacco. The paradigm of cigarette smoke (CS)-induced OP cancer's pathogenesis is based on the assumption that a constant direct attack of various CS carcinogens causes widespread accumulating cellular and DNA aberrations in the OP mucosal cells, in turn eventually resulting in malignant transformation. However, there is never a direct contact between CS and the OP mucosa. Saliva, bathing the mucosa from the oral cavity to the larynx, always intervenes, and CS must first interact with saliva before it reaches the mucosa. The current study investigated the role of saliva in the pathogenesis of OP cancer. A synergistic effect of CS and saliva on oral cancer cells was demonstrated. This synergism is based on the reaction between redox active metals in saliva and low reactive free radicals in CS, which results in the production of highly active hydroxyl free radicals. Thus, when exposed to CS, salivary behavior is reversed and the saliva loses its antioxidant capacity and becomes a potent prooxidant milieu. The devastating role of CS-borne aldehydes was demonstrated as well. Based on these results and on our recent reports demonstrating that CS destroys various salivary components, including protective ones such as peroxidase, the most important salivary antioxidant enzyme, a comprehensive view of the pivotal role of saliva in the pathogenesis of CS-induced OP cancer is suggested.

Lethal synergistic effect of cigarette smoke and saliva in an in vitro model: does saliva have a role in the development of oral cancer?

Exposure of oral mucosal cells to cigarette smoke induces oral cancer, presumably via the injurious effect of free radicals. To explore the effects of cigarette smoke on cells in the presence of saliva, we used peripheral blood lymphocytes (PBL) and exposed them to cigarette smoke, alone or in the presence of saliva. After 80 min exposure to cigarette smoke alone, a time-dependent cellular loss and survival rate of 52% was observed. By contrast, following the exposure of the lymphocytes to cigarette smoke in the presence of saliva, less than 20% of the cells survived. Saliva secreted from the submandibular/sublingual (Sm/Sl) glands was highly cytotoxic, while saliva secreted from the parotid glands was only moderately cytotoxic. Redox active iron ions in saliva and aldehydes in cigarette smoke were shown to play the major injurious roles in this synergistic phenomenon. The salivary-borne redox active iron ions participate in Fenton and Haber-Weiss reactions to transform low-reactive free radicals, which originate from cigarette smoke into highly-reactive .OH(-)-free radicals. In light of these results, a comprehensive mechanism for the induction of oral cancer by cigarette smoke is suggested where saliva may be a pivotal player.

Synergistic effect of cigarette smoke and saliva on lymphocytes—the mediatory role of volatile aldehydes and redox active iron and the possible implications for oral cancer

Oral squamous cell carcinoma (SCC) is most induced by exposure of the oral epithelial cells to tobacco products such as cigarette smoke. This exposure always occurs in the presence of saliva and presumably is induced by free radicals. To explore the effects of CS on cells in the presence of saliva, we used peripheral blood lymphocytes (PBL) and exposed them to CS, alone or in the presence of saliva. We discovered that after 80min, exposure of the lymphocytes to CS alone resulted in a time-dependent cellular loss with a survival rate of 56%, while following lymphocyte exposure to CS in the presence of saliva, less than 15% of the cells survived. This was accompanied by concomitant accumulation of cellular protein carbonyls which could be protected by the exogenous addition of uric acid or glutathione, but not by the addition of ascorbate (Asc), N-acetyl-l-cystein (NAC) or desferal (DES). Exposure of the lymphocytes to aldehydes present in CS, such as acrolein and croton-aldehyde, also resulted in the elevation of protein carbonyls, which was ameliorated primarily by the addition of glutathione. However, lymphocyte exposure to acroline in the presence of saliva did not show the same synergism in cell death observed as when the lymphocytes were exposed to CS and saliva. Thus, we postulated the existence of another mechanism and examined the role of redox active iron as an additional explanation for this synergism. In fact, it was found that in the presence of saliva and ascorbate there was a marked decrease in the lymphocyte survival rate; this was reversed by the addition of the iron chelator desferal. In light of these results, a comprehensive mechanism for the induction of oral cancer by cigarette smoke is suggested, stressing the role of a pivotal player in the process leading to oral cancer which has never been previously considered in this regard - the saliva.

Structural and functional injury in minipig salivary glands following fractionated exposure to 70 Gy of ionizing radiation: an animal model for human radiation-induced salivary gland injury

This study explored the feasibility of developing an animal model for radiation-induced salivary gland injury with a radiation protocol identical to current clinical practice. Three male Hanford minipigs were subjected to fractionated daily irradiation with a total dose of 70 Gy; structural and functional measures were compared with those of a control group of minipigs. We found that irradiated submandibular and parotid glands were one-third to one-half the gross size of control glands. Whereas no pathologic changes were noted in control glands, irradiated glands consistently demonstrated significant parenchymal loss with extensive acinar atrophy and interstitial fibrosis, enlarged nuclei in remaining acinar cells, and ductal dilatation and proliferation. Stimulated salivary flow was reduced by 81% in irradiated animals compared with preirradiation flow (P <.001); salivary flow in the control group increased by 30% during the same period (P <.001). The observed radiation-induced structural and functional salivary gland changes are comparable in every respect to those observed following irradiation of human salivary glands.

Role of nitric oxide of the median preoptic nucleus (MnPO) in the alterations of salivary flow, arterial pressure and heart rate induced by injection of pilocarpine into the MnPO and intraperitoneally

We investigated the effect of L-NAME, a nitric oxide (NO) inhibitor and sodium nitroprusside (SNP), an NO-donating agent, on pilocarpine-induced alterations in salivary flow, mean arterial blood pressure (MAP) and heart rate (HR) in rats. Male Holtzman rats (250-300 g) were implanted with a stainless steel cannula directly into the median preoptic nucleus (MnPO). Pilocarpine (10, 20, 40, 80, 160 g) injected into the MnPO induced an increase in salivary secretion (P<0.01). Pilocarpine (1, 2, 4, 8, 16 mg/kg) ip also increased salivary secretion (P<0.01). Injection of L-NAME (40 g) into the MnPO prior to pilocarpine (10, 20, 40, 80, 160 g) injected into the MnPO or ip (1, 2, 4, 8, 16 mg/kg) increased salivary secretion (P<0.01). SNP (30 g) injected into the MnPO or ip prior to pilocarpine attenuated salivary secretion (P<0.01). Pilocarpine (40 g) injection into the MnPO increased MAP and decreased HR (P<0.01). Pilocarpine (4 mg/kg body weight) ip produced a decrease in MAP and an increase in HR (P<0.01). Injection of L-NAME (40 g) into the MnPO prior to pilocarpine potentiated the increase in MAP and reduced HR (P<0.01). SNP (30 g) injected into the MnPO prior to pilocarpine attenuated (100%) the effect of pilocarpine on MAP, with no effect on HR. Administration of L-NAME (40 g) into the MnPO potentiated the effect of pilocarpine injected ip. SNP (30 g) injected into the MnPO attenuated the effect of ip pilocarpine on MAP and HR. The present study suggests that in the rat MnPO 1) NO is important for the effects of pilocarpine on salivary flow, and 2) pilocarpine interferes with blood pressure and HR (side effects of pilocarpine), that is attenuated by NO.

Inhibition of oral peroxidase activity by cigarette smoke: in vivo and in vitro studies

Oral peroxidase (OPO), the pivotal enzyme in the salivary antioxidant system, seems to be of paramount importance in the oral defense mechanism, especially against the attack of free radicals related to cigarette smoke (CS) and the evolution of oral cancer. The major inducer of oral cancer is exposure to tobacco, which is responsible for 50-90% of cases worldwide. The purpose of our study was to elucidate the outcome of interaction between CS and OPO in smokers and nonsmokers. After smoking a single cigarette, a sharp drop of OPO activity was observed in both groups: 42.5% in smokers and 58.5% in nonsmokers (p <.05). After 30 min, the level of activity returned to 90-100% of the presmoking level, presumably due to the secretion of new saliva into the oral cavity. The difference between the two groups was also observed after exposure of saliva to one cigarette in smoking flasks (in vitro studies); however, as expected, no recovery of activity was observed in either group. Similarly, the OPO activity loss was accompanied by increased carbonylation of the salivary proteins, an indicator of the oxidative damage to proteins. These results may be of great clinical importance, as heavy smokers smoke 20 cigarettes or more on a daily basis. Accordingly, most of the time the oral epithelium of heavy smokers is essentially unprotected by OPO against the deleterious effects of thiocyanate ions and hydroxyl radicals produced by unremoved hydrogen peroxide in the presence of the salivary redox-active metal ions. This may pave the way for the CS-induced and saliva-mediated initiation and progression of oral cancer.

The enigmatic mechanism of irradiation-induced damage to the major salivary glands

Irradiation is a central treatment modality administered for head and neck malignancies. Its major and most devastating side-effect is an induced damage to the major salivary glands. This article aims at suggesting a comprehensive explanation for the underlying mechanism of this damage, which has been considered as enigmatic throughout the 90 years since it was first described in 1911. The mechanism suggested is based on the considerable literature concerning this enigma in rat salivary glands. According to this proposed mechanism, the irradiation results in a sublethal DNA damage, which manifests and becomes lethal at a delayed phase. Thus, when the acinar progenitor cells are going through a reproductive phase when parenchymal replenishment is required, they die. The injurious agents, which result in this delayed reproductive cell death, appear to be highly redox-active transition metal ions, such as iron and copper. These metal ions, which seem to be associated with secretion granules, are not necessarily contained within the granules as previously suggested, but rather are probably located at sites more proximal to the DNA.

Characterization of the differentiated antioxidant profile of human saliva

Saliva is armed with various defense mechanisms, such as the immunological and enzymatic defense systems. In addition, saliva has the ability to protect the mucosa against mechanical insults and to promote its healing via the activity of epidermal growth factor. However, another defense mechanism, the antioxidant system, exists in saliva and seems to be of paramount importance. The most interesting finding of the present study was the demonstration of the existence of much higher concentrations of the various salivary molecular and enzymatic antioxidant parameters in the parotid saliva compared with the submandibular/sublingual saliva. For example, peroxidase, superoxide dismutase, uric acid, and total antioxidant status were higher in resting parotid saliva compared with resting submandibular/sublingual saliva by 2405, 235, 245, and 147%, respectively. Another important finding was the distinction between the salivary antioxidant system and the immunological and enzymatic protective systems, as represented by the salivary concentrations of secretory IgA and lysozyme, respectively. These findings suggest that the profound antioxidant capacity of saliva secreted from parotid glands is related either to the different physiological demands related to eating (parotid predominance), to oral integrity maintenance (submandibular/sublingual predominance), or to the high content of deleterious redox-active transitional metal ions present in parotid saliva. This also may signify that our oral cavity environment is only partially protected against oxidative stress during most of the day and night.

Effects of radiation on Ca2+signaling in salivary epithelial cell lines transfected with Bcl-2 and Bcl-XL

The effects of radiation on the Ca2+ signaling system in HSY cells transfected with the Bcl-2 or Bcl-XL gene were studied. Bcl-2 overexpression did not alter carbachol (CCh)-elicited initial increase in cytosolic free Ca2+ concentrations ([Ca2+]i), but Bcl-XL overexpression dramatically reduced this response. Exposure to 10 Gy gamma-ray did not alter basal [Ca2+]i. By contrast, the CCh-stimulated initial [Ca2+]i increase was reduced at 0.5 and 4 h post-irradiation in all cell types and remained decreased at 24 h in wild-type and control-transfected cells, but recovered in Bcl-2- and Bcl-XL-transfectants. The formation of inositol 1,4,5-trisphosphate (IP3) in response to CCh at 4-h post-irradiation was decreased in wild-type and control-transfected cells, but not in Bcl-2 and Bcl-XL transfectants. The capacity of the IP3-sensitive Ca2+ store was significantly reduced by radiation in all cells except Bcl-XL transfectants. Ca2+ influx after stimulation with CCh was suppressed by exposure to radiation in wild-type and control-transfected cells, but not in Bcl-2- and Bcl-XL-transfectants. However, radiation enhanced Ca2+ influx activated by thapsigargin in all cell types. These results suggest that 1) radiation diminishes IP3 formation and Ca2+ release in response to CCh, but potentiates the store-operated Ca2+ influx; and 2) overexpression of Bcl-2 or Bcl-XL partially protects cells from radiation-induced inhibition of Ca2+ signaling.

Extended-term effects of head and neck irradiation in a rodent

Radiotherapy to the head and neck is a common treatment for malignancies of the region. Unfortunately, exposure to irradiation often results in a variety of complications, most of which are localised and expressed in the short term following irradiation. However, prolonged and systemic effects may have greater clinical importance as the survival rate of head and neck irradiated patients is increasing yearly. Six groups of 18-20 rats were evaluated during a 1 year study. The non-irradiated control group was compared with 2.5 Gy, 5, 7.5, 10 and 15 Gy irradiated groups. We found a dose-dependent reduction in both survival and body weight in our rat models following a delayed, prolonged and chronic process. Dying animals were emaciated, dehydrated and starved, and many were blind and immunocompromised. While the exact underlying mechanism of this delayed, but devastating, phenomenon has not yet been determined, the delayed xerostomia inflicted on these animals may, at least partially, explain it. The clinical implications for head and neck patients require further evaluation, but our data should be considered, in the context of the available evidence for the long-term effects of head and neck irradiation in humans.

Prophylactic effects of pilocarpine hydrochloride on xerostomia models induced by X-ray irradiation in rats

1. In the present study, we investigated the prophylactic effects of pilocarpine hydrochloride on xerostomia models induced by either single (15 Gy) or repeated (8.6 Gy x3 days) X-ray irradiation in rats. Pilocarpine hydrochloride was administered orally 90 min before each irradiation session. Then, 7 days later, salivary volume, amylase activity and protein concentration in the saliva secreted from the right parotid gland were measured before and after a subsequent administration of pilocarpine hydrochloride (intraduodenal). 2. In irradiated no-pretreatment rats, irradiation induced a significant reduction in both spontaneous and pilocarpine hydrochloride-stimulated secretion (both total salivary volume and flow rate), regardless of the protocol used for X-ray exposure. In irradiated, pilocarpine hydrochloride-pretreated rats, salivary secretion was increased after stimulation by pilocarpine hydrochloride (intraduodenal) to a degree that depended on the pretreatment dose of pilocarpine hydrochloride (p.o.) in both xerostomia models. 3. There were no differences in amylase or protein concentrations between irradiated rats pretreated with pilocarpine hydrochloride and irradiated no-pretreatment control rats. 4. A decrease in the weight of the parotid gland was observed in rats exposed to either the single dose or repeated irradiation protocols. Changes in the submandibular gland were less marked than those in the parotid gland. These changes in gland weight were not affected by pilocarpine hydrochloride pretreatment. 5. The responsiveness of the parotid gland to subsequent stimulation with pilocarpine hydrochloride was apparently preserved in both xerostomia models by pretreatment with pilocarpine hydrochloride, which itself increased salivary secretion. This suggests that pilocarpine hydrochloride may exert functional protective effects against xerostomia that occurs following irradiation therapy through a stimulation of salivary secretion.

New insights into salivary lactate dehydrogenase of human subjects

Lactate dehydrogenase (LDH) is a ubiquitous enzyme that plays a significant role in the clinical diagnosis of pathologic processes. The purpose of the current study was to examine LDH activity and isoenzyme profile of whole saliva and to compare it with the LDH activity of salivary glands and plasma before and after exposure to cigarette smoke (CS). The range of LDH activity in whole saliva at rest was 360 to 430 U/L. The mean +/- SEM of LDH activity in parotid and submandibular/sublingual salivary secretions was 41.3 +/- 19.2 U/L and 77.5 +/- 30.4 U/L, respectively, which implied that 75% of the whole-saliva LDH originated from an extra-salivary gland source. The profile of salivary LDH isoenzymes was found to have an entirely different pattern from that found in plasma, similar to that found in oral epithelium, indicating that the major source of salivary LDH is probably the oral epithelium-shedding cells. Therefore, salivary LDH may be evaluated for possible oral mucosal pathologies in a manner similar to that used for evaluating other tissue pathologies--such as those in heart, muscle, or liver--that can be detected in plasma. Exposure of whole saliva to CS in vitro resulted in a 41% reduction in LDH activity. However, CS exposure had no effect on LDH activity in plasma. Whole saliva, in contrast to plasma, contains redox-active metal ions such as iron and copper that may enhance LDH loss of activity. Therefore we conclude that whole saliva in the presence of CS becomes a potent protein-modifying agent that can destroy some of its endogenous components.

Natural history and prevention of radiation injury

Radiation therapy for cancers of the head and neck can irreversibly damage the salivary glands. Xerostomia (subjective oral dryness) develops within the first week of therapy and is progressive, with devastating effects on the quality of life of the individual. The xerostomia does not correlate with the degree of salivary gland hypofunction. The mechanism of tissue injury in humans is still unclear, but much progress has been made with animal models. This paper reviews the natural history of radiation damage to human salivary glands and highlights the inter-individual variations in the responses to and recovery from therapeutic radiation. The degree of salivary gland damage is correlated to the dose of radiation delivered and the volume of gland included in the field of radiation. The molecular mechanism of acute radiation damage is not fully understood; however, long-term salivary gland dysfunction is associated with both loss of gland weight and loss of acinar cells. Various strategies have been used to prevent or alleviate the problem of salivary gland hypofunction following therapeutic radiation. This paper reviews the progress made to date and the possibilities for future interventions to prevent radiation damage.

Partial protection of rat parotid glands from irradiation-induced hyposalivation by manganese superoxide dismutase

Head-and-neck irradiation in rats often results in reduction of water and food intake, weight loss, hyposalivation, and suppression of the white blood cell (WBC) count. Oxygen free radicals are believed to be involved in this deleterious process. Superoxide dismutase (SOD) is known to act as a first line of antioxidant defence against oxygen free radicals. Here, the protective effect of manganese SOD (MnSOD) and copper/zinc SOD (Cu/ZnSOD) against irradiation-induced injuries to the head and neck in rats was investigated. Wistar rats were irradiated with 15 Gy X-rays delivered to the head-and-neck region. MnSOD (50 mg/kg) or Cu/ZnSOD (100 mg/kg) were administered before and after irradiation. Body weight, food and water intake, WBC counts, and parotid and submandibular salivary functions were examined. Irradiation of 15 Gy resulted in a significant reduction of the parotid flow rate by 73% compared with non-irradiated controls (p<0.05). MnSOD but not Cu/ZnSOD partially reduced this effect on the parotid gland by 25% (p<0.05). Both MnSOD and Cu/ZnSOD demonstrated a protective effect against irradiation-induced WBC suppression, by 35% and 25%, respectively (p<0.05). Treatment with SOD did not protect the animals against irradiation-induced reduction in oral intake and weight loss, or against submandibular hypofunction. These results suggest that SOD partially protects against head-and-neck irradiation-induced injury. Both MnSOD and Cu/ZnSOD partially protect against irradiation-induced WBC loss. The parotid gland is partially protected by MnSOD but not Cu/ZnSOD, while the submandibular gland is not protected by either MnSOD or Cu/ZnSOD.

Effect of cigarette smoke on salivary proteins and enzyme activities

Exposure of human plasma in vitro to gas-phase cigarette smoke (CS) causes a marked modification of plasma proteins as measured by protein carbonyl assay. Aldehydes present in CS may cause this elevation of protein carbonyls by reacting with sulfhydryl groups of proteins. Saliva is the first body fluid to confront the inhaled CS. Thus, in vitro exposure of saliva to nine "puffs" of CS also showed a distinct increase in protein carbonyls. Ascorbate and desferrioxamine mesylate had little effect on protein carbonyl formation, while GSH and N-acetylcysteine considerably inhibited the accumulation of protein carbonyls due to CS exposure. Following the exposure to CS, the activities of several salivary enzymes-amylase, lactic dehydrogenase (LDH), and acid phosphatase-were found to be significantly reduced (34, 57, and 77%, respectively). However, CS had no effect on the activities of aspartate aminotransferase and alkaline phosphatase. Addition of 1 mM of GSH and N-acetylcysteine considerably protected LDH and amylase activities, suggesting that sulfhydryl groups are affected in LDH and amylase. On the other hand, addition of 1 mM ascorbate caused a further loss of LDH and amylase activities, which could be partially prevented by the addition of desferrioxamine mesylate, implicating metal-catalyzed oxidation processes. Finally, loss of acid phosphatase activity was completely unaffected by any of the above antioxidants. It is concluded that the loss of salivary enzyme activities may be due to various agents in the CS that affect the enzyme activities via different mechanisms.

Histopathological study of the human submandibular gland in graft versus host disease

Major salivary gland dysfunction and severe xerostomia is one of the manifestations of graft versus host disease (GVHD). The histopathological evaluation of the major salivary gland in patients with GVHD has never been reported. The pathological findings of the submandibular glands in a GVHD patient who succumbed to the disease are described. Lymphocytic infiltration, parenchymal destruction, and fibrosis were observed, which may provide the pathophysiological mechanism for the xerostomia and hyposalivation observed in GVHD.

Toxicity antagonists in head and neck cancer

Clinical trials of altered fractionation and concurrent chemoradiation regimens have better elucidated the limits of both acute and late normal tissue toxicities in the head and neck. Acute effects on mucosal epithelium represent the principal barrier to intensification of radiation or chemoradiation schedules. Late soft tissue injury and organ dysfunction limit efforts to escalate radiation total dose. New insights into the cellular and molecular mechanisms of injury repair allow new strategies in the management and prevention of treatment-related toxicity. Toxicity antagonists are agents that directly interfere with the mechanism of toxicity or modulate the normal tissue response to injury. This article reviews 10 agents under development. Not only could such interventions reduce treatment-related morbidity, but they may also allow treatment intensification in advanced disease.

Protection against irradiation-induced damage to salivary glands by adrenergic agonist administration

PURPOSE

Irradiation [IR]-induced damage to major salivary glands is an entity first described at the beginning of our century, yet its underlying mechanism is still enigmatic. Exposure of the salivary glands to IR is often inevitable when delivering radiotherapy for malignancies of the head and neck region. Frequently, this results in rapidly developing, life-long severe xerostomia for which no adequate prevention or treatment is available. The purpose of this study was to examine the role of secretion granules in serous cells of the parotid (P) and submandibular (SM) glands as mediators in the IR-induced salivary damage. Functional parameters (flow rate and gland weight), and total body weight were examined at both early term (4 days) and extended term (2 months) post-IR in male Wistar rats exposed to 15 Gy of head and neck irradiation following stimulation for granule secretion (degranulation).

METHODS AND MATERIALS

At 4 days, it was demonstrated that IR reduced P flow rate, P gland weight, total body weight, and submandibular/sublingual gland weight by 89, 33, 30, and 32% (p < 0.01), respectively, while SM flow rate was not altered significantly. At 2 months, these parameters were reduced by 59, 37, 31, and 37%, respectively, and the SM flow rate was reduced by 39% (p < 0.01).

RESULTS

Pilocarpine, a muscarinsic agonist which, albeit its efficacy as a salivary watery secretion stimulator, causes only limited degranulation, did not protect significantly any of the reduced parameters at either term. In contrast, cyclocytidine, an adrenergic agonist that is a very potent salivary degranulating agent, protected the P against the weight loss at 4 days and 2 months, and against the flow rate reduction at 2 months. The P weight and flow rate were protected to the extent that their values were not significantly different than those of the nonirradiated controls. Cyclocytidine also partially protected against the body weight reduction at 2 months. Our results emphasize the importance of secretion granules as mediatory agents in IR-induced P damage, and more so at the extended term. The demonstrated protective role of adrenergic agonists against IR damage to the P may be of importance in the clinical setting.