Efficacy and Safety of a Novel Mucoadhesive Clobetasol Patch for Treatment of Erosive Oral Lichen Planus

BACKGROUND

Oral lichen planus (OLP) is a chronic inflammatory disorder of the oral mucosa. Currently there is no approved treatment for oral lichen planus (OLP). We report on the efficacy and safety of a novel mucoadhesive clobetasol patch (Rivelin^® -CLO) for the treatment of OLP.

METHODS

Patients with confirmed OLP and measurable symptomatic ulcer(s) participated in a randomized, double-blind, placebo-controlled, multicenter clinical trial testing a novel mucoadhesive clobetasol patch (Rivelin^® -CLO) in OLP across Europe, Canada and USA. Patients were randomized to placebo (non-medicated), 1, 5, 20 µg Clobetasol/patch, twice daily, for 4 weeks. The primary endpoint was change in total ulcer area compared to baseline. Secondary endpoints included improvement from baseline in pain, disease activity, and quality of life.

RESULTS

Data were analyzed and expressed as mean [SD]. One hundred thirty-eight (138) patients were included in the study; 99 females and 39 males, mean age was 61.1 [11.6] years. Statistical analyses revealed that treatment with 20-μg Rivelin^® -CLO patches demonstrated significant improvement with ulcer area (P=0.047), symptom severity (P=0.001), disease activity (P=0.022), pain (P=0.012), and quality of life (P=0.003) as compared with placebo. Improvement in OLP symptoms from beginning to the end of the study was reported as very much better (best rating) in the 20-µg group (25/32) patients compared to the placebo group (11/30), (P=0.012). Adverse events were mild/moderate. Candidiasis incidence was low (2%).

CONCLUSIONS

Rivelin^® -CLO patches were superior to placebo demonstrating statistically significant, clinically relevant efficacy in objective and subjective improvement and, with a favorable safety profile.

Self-collected unstimulated saliva, oral swab, and nasopharyngeal swab specimens in the detection of SARS-CoV-2

OBJECTIVES

The presence of SARS-CoV-2 virus in the saliva of patients infected with COVID-19 has been confirmed by several studies. However, the use of saliva for the diagnosis of COVID-19 remains limited, because of the discrepancies in the results, which might be due to using different saliva sampling methods. The purpose of this study was to compare the consistency of SARS-CoV-2 detection using two different saliva sampling methods (oral swab and unstimulated saliva) to that of the standard nasopharyngeal swab.

METHODS

Fifty-five subjects were recruited from a pool of COVID-19 inpatient at the Hospital Israelita Albert Einstein (HIAE), Brazil. Nasopharyngeal swab, oral swab, and self-collected unstimulated saliva samples were examined for SARS-CoV-2 using RT-PCR.

RESULTS

Self-collected unstimulated saliva demonstrated 87.3% agreement in the detection of SARS-CoV-2 virus as compared with the nasopharyngeal swab, while oral swab displayed 65.9% agreement when compared to nasopharyngeal swab and 73% when compared to self-collected unstimulated saliva.

CONCLUSION

Unstimulated self-collected saliva samples have shown a higher agreement with the nasopharyngeal swab samples for SARS-COV-2 detection than that obtained when using oral swab samples.

CLINICAL RELEVANCE

This study compares the accuracy of COVID-19 test using different saliva sampling methods to that of nasopharyngeal swab. Given the need for a simple self-applied test that can be performed at home, our findings support the efficacy of self-collected unstimulated saliva samples in the diagnosis of SARS-CoV-2 infection, alleviating the demands for swab supplies, personal protective equipment, and healthcare personnel.

Laser Assisted Non-surgical Periodontal Therapy: A Double Blind, Randomized Clinical Trial

The objective of this study was to examine potential benefits of using laser therapy for secular decontamination in conjunction with scaling and root planing in the treatment of chronic periodontitis. The study was performed on 173 teeth in 14 patients in a split-mouth design, one side received scaling and root planing followed by laser therapy using a carbon dioxide (CO2) laser with an ablative handpiece (test group); the contralateral side received scaling and root planing without laser (control group). Clinical and laboratory parameters were evaluated prior to treatment and at 3 and 6 months following therapy; clinical measurements were performed by two blinded examiners. The clinical parameters included measurement of gingival recession (REC), bleeding on probing (BOP), clinical attachment level (CAL), pocket depth (PD), furcation involvement (FUR), and tooth mobility (MOB). Laboratory testing to determine the levels of periodontal pathogens was performed using PCR techniques. The results of the study revealed statistically significant differences in clinical and laboratory parameters at 3 and 6 months after therapy for both test and control groups, but no significant difference was observed between the two groups. However, sites receiving laser therapy tended to show a greater decrease in probing depths, gain in clinical attachment level, and reduced bacterial levels. In conclusion, the overall results of the study suggest a potential benefit of using laser therapy in conjunction with scaling and root planing for the treatment of chronic periodontitis.

The Role of Occlusion in the Dental Implant and Peri-implant Condition: A Review

Dental implants have become a widely used dental treatment approach. It is important to identify factors that can be detrimental to dental implants and the peri-implant complex. There is controversy regarding whether occlusion plays a role in the implant and peri-implant condition. The present study aims to review the scientific literature regarding this topic. Animal and human studies, and previous reviews on the topic are included and presented. There is a wide heterogeneity among study designs. Several articles demonstrated that occlusion and occlusion overload could detrimentally affect the peri-implant condition, while other articles did not support these results. More studies are needed to help understand the mechanisms by which occlusion might play a role in the peri-implant condition.

Clinical practice guidelines for oral management of Sjögren disease: Dental caries prevention

BACKGROUND

Salivary dysfunction in Sjögren disease can lead to serious and costly oral health complications. Clinical practice guidelines for caries prevention in Sjögren disease were developed to improve quality and consistency of care.

METHODS

A national panel of experts devised clinical questions in a Population, Intervention, Comparison, Outcomes format and included use of fluoride, salivary stimulants, antimicrobial agents, and nonfluoride remineralizing agents. The panel conducted a systematic search of the literature according to pre-established parameters. At least 2 members extracted the data, and the panel rated the strength of the recommendations by using a variation of grading of recommendations, assessment, development, and evaluation. After a Delphi consensus panel was conducted, the experts finalized the recommendations, with a minimum of 75% agreement required.

RESULTS

Final recommendations for patients with Sjögren disease with dry mouth were as follows: topical fluoride should be used in all patients (strong); although no study results link improved salivary flow to caries prevention, the oral health community generally accepts that increasing saliva may contribute to decreased caries incidence, so increasing saliva through gustatory, masticatory, or pharmaceutical stimulation may be considered (weak); chlorhexidine administered as varnish, gel, or rinse may be considered (weak); and nonfluoride remineralizing agents may be considered as an adjunct therapy (moderate).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The incidence of caries in patients with Sjögren disease can be reduced with the use of topical fluoride and other preventive strategies.

Sarcoidosis and Sjögren's syndrome: clinical and salivary evaluation

BACKGROUND

Sarcoidosis and Sjögren's syndrome are two different diseases; however, when affecting the salivary glands, both diseases exhibit similar clinical signs and symptoms, which often complicates the diagnosis. The purpose of this study was to investigate the possibility of using salivary electrophoresis to differentiate between the two diseases.

METHODS

Saliva was collected from patients with sarcoidosis and patients with Sjögren's syndrome. Salivary flow rate, total protein, and electrophoretic profiles were examined.

RESULTS

Mean salivary flow rate was 0.41 ± 0.07 ml/min/gland vs. 0.43 ± 0.07 ml/min/gland; total salivary protein was 130.0 ± 29.2 mg% vs. 104.0 ± 8.8 mg% for sarcoidosis vs. Sjögren's syndrome, respectively. No differences were observed in salivary flow rate, total salivary protein, or electrophoretic profile between patients with sarcoidosis and patients with Sjögren's syndrome (P = 0.768, 0.718, and 1.000, respectively).

CONCLUSIONS

Salivary protein electrophoresis does not appear to be useful to differentiate between sarcoidosis and Sjögren's syndrome.

Comparison of Minimally Invasive and Conventional Flap Surgery for Treatment of Intrabony Periodontal Defects: A Pilot Case Controlled Study

The purpose of this study was to compare the clinical outcome of conventional flap surgery and minimally invasive surgery for the regenerative treatment of periodontal intrabony defects in a prospective, case-controlled study design. For this purpose, nine healthy individuals with 15 periodontal intrabony defects were included in the study. Patients were randomly assigned to undergo either minimally invasive surgery or conventional flap surgery for treatment of their intrabony periodontal defect. Each patient had preoperative and postoperative X-ray and measurement of periodontal parameters by a blinded examiner. All bony defects were treated with allograft consisting of enamel matrix derivative and demineralized freeze-dried bone. Results of this study indicated that both minimally invasive and conventional flap surgery improved pocket depth and clinical attachment levels after 6 months of surgery with no significant difference between the two surgeries. The overall result of our study suggests that minimally invasive surgery is as effective as conventional flap surgery in the treatment of intrabony periodontal defects and that both techniques appear to provide a comparable outcome.

How to cite this article

Steffer MR, Harrel SK, Rossmann JA, Kerns DG, Rivera-Hidalgo F, Abraham CM, Al-Hashimi I, Solomon ES, Cipher DJ. Comparison of Minimally Invasive and Conventional Flap Surgery for Treatment of Intrabony Periodontal Defects: A Pilot Case Controlled Study. J Contemp Dent 2013;3(2):61-67.

Prevalence of oral lesions of autoimmune etiology in patients with primary Sjogren's syndrome

OBJECTIVE

The primary objective of this study was to determine the prevalence of oral lesions of autoimmune etiology (OLAIE) in a cohort of patients with primary Sjögren's syndrome (pSS).

MATERIALS AND METHODS

A multi-center retrospective cohort study was conducted at the oral medicine practices of Carolinas Medical Center (CMC), Baylor College of Dentistry (BCD), and the University of Florida (UF). Each site performed a chart review of patients with well-characterized pSS. Clinical variables such as OLAIE, traumatic lesions, and medical conditions were compiled at each site. The association between clinical variables and the presence of OLAIE was then assessed for significance.

RESULTS

We evaluated 155 patients diagnosed with pSS. Nineteen patients with pSS (12.3%) had an OLAIE. CMC reported 11 (21.2%) patients with OLAIE, while BCD and UF reported 4 (7.3%) and 4 (8.3%), respectively. Eleven of the 19 (58%) patients with OLAIE had lichen planus, 6 (32%) had aphthous stomatitis, 1 (5%) had chronic ulcerative stomatitis, and 1 (5%) had lesions of systemic connective tissue disease by immunofluorescence.

CONCLUSION

The results of our analysis suggest that patients with pSS have a 12% prevalence of OLAIE with a wide range (7.3-21.2%) found between practices. This difference is likely related to the different screening protocols for oral dryness between sites.

Sjögren's syndrome: diagnosis and management

This article reviews current understanding of the clinical manifestations, diagnosis and treatment of Sjögren's syndrome. Sjögren's syndrome is a chronic inflammatory disorder of the exocrine glands with multiple nonexocrine features. It is found predominantly in middle-aged women but exists throughout the population. The diagnosis of Sjögren's syndrome can be challenging because the cardinal sicca symptoms may be subclinical or attributed to other causes, such as medications or aging. Differential diagnosis of Sjögren's syndrome can be confounded by the multiple exocrine manifestations in the mouth, eyes, ears, nose, skin, vagina, and respiratory and gastrointestinal tracts, as well as seemingly unrelated nonexocrine involvement in the thyroid, liver, kidneys and the musculoskeletal, vascular and nervous systems. This article concludes that early diagnosis of Sjögren's syndrome is crucial to prevent and/or minimize potentially life-threatening complications. Periodic follow-up of patients' status and collaboration between the primary-care physician and the rheumatologist, dentist, ophthalmologist and other specialists are indispensable.

Coexistence of Sjögren's syndrome and sarcoidosis: a report of five cases

BACKGROUND

Sjögren's syndrome (SS) and sarcoidosis are diseases that can affect the salivary glands and result in the loss of salivary gland function. Most of the criteria used for the diagnosis of SS exclude sarcoidosis before establishing the diagnosis of SS. However, several reports have suggested the coexistence of both SS and sarcoidosis in the same patient.

OBJECTIVE

The purpose of this study was to present five cases that support a true coexistence of sarcoidosis and SS.

METHODS

Clinical and laboratory findings of patients with evidence of having both SS and sarcoidosis were reviewed. The diagnosis of SS was based on the European community criteria; the diagnosis of sarcoidosis was based on the presence of serological, radiographic and/or histopathologic findings that are consistent with sarcoidosis.

RESULTS

All patients fulfilled the criteria for the diagnosis of both diseases.

CONCLUSION

Our findings appear to support a true coexistence of sarcoidosis with SS. Therefore, it is reasonable to suggest removing the exclusion of sarcoidosis from the diagnostic criteria for SS.

The feasibility of using infrared thermography to evaluate minor salivary gland function in euhydrated, dehydrated and rehydrated subjects

BACKGROUND

Infrared thermography technique (IRT) is utilized by a growing number of disciplines within medicine and dentistry. However, IRT has not been employed in the evaluation of salivary gland dysfunction. The purpose of this study was to examine the feasibility of using thermographic imaging in the evaluation of minor labial salivary gland function in subjects during euhydration, dehydration, and rehydration states.

METHODS

Ten subjects were studied. Upper labial minor salivary gland secretion was quantified whilst simultaneously visualizing lower minor salivary gland output thermographically during each state.

RESULTS

A significant difference was observed in the minor labial salivary flow among euhydrated, dehydrated and rehydrated, states. Despite the lack of statistical difference in the thermographic findings, IRT images reflected noticeable differences among the three hydration states.

CONCLUSION

The overall results of this study suggest that IRT could potentially provide a valuable non-invasive tool for evaluating the relationship between minor labial salivary gland function and hydration status.

Comparison of salivary calmodulin binding proteins in Sjögren's syndrome and healthy individuals

BACKGROUND

Reduction in salivary secretion is the hallmark of Sjögren's syndrome (SS). Calmodulin (CaM) and calmodulin binding proteins (CaMBPs) play a key role in the secretory process of saliva. Recent studies have suggested that SS-B, an autoantibody associated with SS, is a CaMBP. This finding suggests that CaMBP may contribute to the loss of saliva in SS. To better understand the role(s) of these proteins in SS, the purpose of this study was to compare salivary CaMBPs in Sjögren's patients and controls.

METHODS

Saliva samples were collected from 20 patients and 20 age-, race-, and gender-matched controls. CaM overlay was used to identify CaMBPs in saliva of patients and controls.

RESULTS

Higher number of salivary CaMBPs was observed among patients than controls.

CONCLUSIONS

The increased number of salivary CaMBPs in SS may suggest a potential role for these proteins in the pathogenesis of the disease.

Oral lichen planus and oral lichenoid lesions: diagnostic and therapeutic considerations

Several therapeutic agents have been investigated for the treatment of oral lichen planus (OLP). Among these are corticosteroids, retinoids, cyclosporine, and phototherapy, in addition to other treatment modalities. A systematic review of clinical trials showed that particularly topical corticosteroids are often effective in the management of symptomatic OLP lichen planus. Systemic corticosteroids should be only considered for severe widespread OLP and for lichen planus involving other mucocutaneous sites. Because of the ongoing controversy in the literature about the possible premalignant character of OLP, periodic follow-up is recommended. There is a spectrum of oral lichen planus-like ("lichenoid") lesions that may confuse the differential diagnosis. These include lichenoid contact lesions, lichenoid drug reactions and lichenoid lesions of graft-versus-host disease. In regard to the approach to oral lichenoid contact lesions the value of patch testing remains controversial. Confirmation of the diagnosis of an oral lichenoid drug reaction may be difficult, since empiric withdrawal of the suspected drug and/or its substitution by an alternative agent may be complicated. Oral lichenoid lesions of graft-versus-host disease (OLL-GVHD) are recognized to have an association with malignancy. Local therapy for these lesions rests in topical agents, predominantly corticosteroids.

Management of oral epithelial dysplasia: a review

One of the goals of the fourth meeting of The World Workshop on Oral Medicine (WWOM IV) included a review of the pathophysiology and future directions for the clinical management of patients with oral epithelial dysplasia, excluding the lips and oropharynx. In the pathophysiology review of dysplasia since WWOM III (1998-2006), a wide range of molecular changes associated with progression of dysplasia to squamous cell carcinoma were found. These include loss of heterozygosity, dysregulation of apoptosis, aberrant DNA expression, and altered expression of numerous tissue markers. Based on the literature search, no single molecular pathway has been identified as the primary factor in progression of dysplasia to squamous cell carcinoma. A systematic review of medical (i.e., nonsurgical) management strategies for the treatment of dysplastic lesions has shown promising results in short-term resolution of dysplasia in the small number of studies that met eligibility criteria for review. However, because of the limited periods of follow-up reported in these studies, it remains unclear as whether resolution of dysplasia would actually be a long-term benefit of these interventions. This question is particularly germane when it is considered in the context of prevention of future development of squamous cell carcinoma. Because of the lack of randomized controlled trials that have shown effectiveness in the prevention of malignant transformation, no recommendations can be provided for specific surgical interventions of dysplastic oral lesions either.

Experimental chairside test for the rapid diagnosis of oropharyngeal candidiasis

Oral infection with Candida fungal species is very common. Oral candidiasis is usually diagnosed by clinical appearance because no chairside diagnostic methods are available. In contrast, a rapid latex agglutination (RLA) test has proven useful for in-office diagnosis of vulvovaginal candidiasis. This study was undertaken to determine if the RLA technique might be used to provide a quick chairside test for oral candidiasis. Twenty-five patients participated in the study, including 21 patients with clinical evidence suggestive of oral candidiasis serving as the experimental group and 4 patients with apparent good oral health serving as controls. The presence of oral candidiasis was evaluated using RLA, fungal culturing, and cytology. RLA testing was consistent with established diagnostic tests in patients with oral candidiasis. However, RLA false positive results were noted, and the test is highly technique-sensitive and subjective. The technique is worthy of further study to determine its ultimate value in the diagnosis of oral candidiasis.

Xerostomia Secondary to Sj??gren???s Syndrome in the Elderly

Xerostomia is a common symptom in the elderly population. Studies have suggested that the underlying cause of approximately 40% of xerostomia in the elderly is Sjögren's syndrome. Although it is highly prevalent among middle-aged individuals, elderly patients account for up to 20% of Sjögren's syndrome cases. Sjögren's syndrome is a multisystem exocrinopathy characterised by dry mouth and dry eyes with wide-ranging extraglandular involvement. The exocrine manifestations of Sjögren's syndrome affect the mouth, eyes, nose, ears, skin, vagina and the entire respiratory and gastrointestinal systems. The nonexocrine involvement may include the joints, thyroid gland, liver, kidneys and the musculoskeletal, vascular and central nervous systems. Currently, the mechanism(s) of development and progression of Sjögren's syndrome is/are not clear. Inflammation and lymphocytic infiltration of the exocrine glands is a classical feature of Sjögren's syndrome. During the progression of the disease, the acinar cells of the exocrine glands are replaced by fibrosis, rendering the glands nonfunctional. Sjögren's syndrome remains one of the most underdiagnosed conditions, particularly in the elderly population, because the cardinal sicca symptoms, which are the hallmark of the disease, are frequently attributed to aging and/or medications, which consequently delays the diagnosis. This delay in diagnosis imposes significant physical, psychological and economic burdens on elderly patients. The diagnosis of Sjögren's syndrome requires evaluation of both the exocrine and nonexocrine components of the disease. Management of Sjögren's syndrome requires collaboration by the primary-care physician, rheumatologist, ophthalmologist and dentist. This article reviews current understanding of the clinical manifestations, diagnosis and treatment of Sjögren's syndrome with special emphasis on the oral component of the disease.

A comparison of the hormone levels in patients with Sjogren's syndrome and healthy controls

OBJECTIVE

The purpose of this study was to compare the level and relative ratio of estrogen, progesterone, and prolactin in patients with Sjögren's syndrome and healthy controls.

STUDY DESIGN

Serum samples were collected from 17 SS patients and 19 age-, sex- and race-matched controls. All subjects were postmenopausal females who were not currently on hormone replacement therapy. Prolactin levels were measured using ELISA and progesterone and estrogen were measured using EIA.

RESULTS

Mann-Whitney U test revealed a significantly higher levels of prolactin among patients than controls (11.41 ng/ml vs. 6.74 ng/ml, p=0.003) with significantly higher prolactin/ progesterone (18.88 vs. 8.14, p=0.02) and estrogen/ progesterone (71.51 vs. 42.02, p=0.05) ratios. No significant differences were observed in the levels of estrogen and progesterone between patients and controls.

CONCLUSION

Abnormal levels and relative ratios of hormones may play a role in the pathogenesis of Sjögren's syndrome.

Sjögren’s syndrome: a condition with features of chronic graft-versus-host disease: does duct cell adhesion or permeability play a role in pathogenesis?

Primary and Secondary Sjögren's syndrome are disease complexes characterized by periductal inflammatory cell infiltration of the salivary and lacrimal glands and manifest as dry mouth and dry eyes. Secondary Sjögren's syndrome may be associated with a connective tissue disorder. Additional extraglandular features in Sjögren's syndrome include a generalized inflammatory exocrinopathy that might be associated with abnormalities of both humoral and cellular mediated immunity. Similar inflammatory changes and extraglandular features, including an altered immune response, have been reported in patients developing graft-versus-host disease after bone-marrow transplantation and in patients with primary biliary cirrhosis. The periductal nature of the inflammatory response involving minor salivary and other glands raises the possibility of altered duct cell adhesion or permeability in playing a role in the aetiopathogenesis of Sjögren's syndrome. The paper pulls together evidence that could be interpreted in this light. Evidence for bacterial or viral factor(s) altering the antigenicity of the histocompartibility (HC) complex on ductal cells in Sjögren's syndrome patients is also described. A hypothesis is proposed for Sjögren's syndrome in which the principal feature is an alteration in salivary gland duct cell adhesion or permeability. A re-evaluation of current knowledge of these two conditions from a clinical and experimental context are interpreted in this light.

Preliminary evaluation of salivary pellicle on nickel-chromium alloy in vivo

OBJECTIVE

The composition of the salivary interface (pellicle) between dental restorations and oral mucosa may be critical to the biocompatibility of the restoration. The purpose of this study was to examine the molecular composition of the salivary pellicle on nickel-chromium alloy in vivo.

METHOD AND MATERIALS

The molecular components of nickel-chromium pellicle was examined with sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blot analyses.

RESULTS

Only limited numbers of salivary proteins were found to participate in the formation of nickel-chromium pellicle in vivo. Salivary amylase and secretory immunoglobulin A were among the proteins identified in the pellicle.

CONCLUSION

In vivo, nickel-chromium pellicle consists of selectively adsorbed salivary proteins. Because both salivary amylase and secretory immunoglobulin A are antimicrobial proteins, it is possible that they play a role in modulating the microbial flora on the nickel-chromium prosthesis.

Reproducibility of biopsy grade in Sjögren's syndrome

The purpose of this study was to examine the reproducibility of biopsy grades at various tissue depths in Sjögren's syndrome. The biopsy grades of 38 minor salivary gland biopsies were examined at 6 microm, 50 microm, 100 microm, 150 microm, 200 microm, and 250 microm tissue depths. Tissue sections were stained with routine hematoxylin and eosin, graded I-IV, and compared with the initial "baseline" biopsy grade. The majority of the biopsies showed a wide range of grade variability at all depths. No tissue depth was consistently reproducible for any grade (P> or =0.41, 0.64, 0.91, and 0.20, respectively). The difference between baseline grades and grades of deeper sections was sufficient to impact the diagnosis of Sjögren's syndrome in approximately 60% of the biopsies (P<0.001). The overall result of this study suggests that examination of multiple sections of minor salivary gland biopsies is advisable to improve the reliability of the grade when evaluating Sjögren's syndrome.

Cytokine concentrations in stimulated whole saliva among patients with primary Sjögren's syndrome, secondary Sjögren's syndrome, and patients with primary Sjögren's syndrome receiving varying doses of interferon for symptomatic treatment of the condition: a preliminary study

Sjögren's syndrome is an autoimmune disorder which causes diminished salivary flow due to autoimmune sialoadenitis. This decrease in saliva flow is the result of inflammation and atrophy of the salivary glands. Most treatment regimens are palliative in nature, but treatment with interferon (IFN) holds promise for Sjögren's syndrome sufferers. Several studies have investigated cytokine concentrations in the salivary glandular tissues from Sjögren's syndrome patients; however, there is little information concerning cytokine expression in saliva. This is especially true with respect to treatment modalities and their effects on local cytokines. A clinical study was conducted to determine salivary interleukin (IL)-6, IFN, and IL-2, concentrations among subjects diagnosed with primary and secondary Sjögren's syndrome and a healthy control group. The primary Sjögren's syndrome showed significantly higher salivary IL-2 and salivary IL-6 than the control and secondary Sjögren's groups. There were no between group differences for salivary IFN concentrations. In addition, the study assessed salivary IL-6, IFN, and IL-2 concentrations among 18 Sjögren's syndrome patients before and after administration of IFN via the oral mucosal route. The results of the study showed that the mean values for the pre- and post-treatment groups for stimulated whole saliva flow rates were 3.15 and 3.74 ml/5 min, respectively. The post-treatment group exhibited a 16.8% increase in stimulated whole saliva flow rates. The salivary IL-6 concentration was 53.3% lower for the post-treatment group (17.79) as compared to the baseline value (33.35). The values for salivary IFN and salivary total protein were virtually unchanged from their baseline values. Salivary IL-2 values, however, were 50% lower in the post-treatment group (3.07) when compared to their respective baseline values (6.10). The results of this study suggest that healthy individuals exhibit lower salivary IL-2 and IL-6 as compared to individuals suffering from primary and secondary Sjögren's syndrome. The results also suggest that administration of IFN via the oral mucosal route may increase salivary flow rates and depress certain cytokines (IL-2, IL-6) associated with inflammatory destruction of salivary glandular tissues in Sjögren's syndrome patients.

Salivary anti-spectrin autoantibodies in Sjögren's syndrome

OBJECTIVE

The purpose of this study was done to compare the anti-spectrin autoantibody levels in the parotid saliva of Sjögren's syndrome patients and in the parotid saliva of healthy control subjects.

METHODS

The salivary anti-spectrin autoantibody levels of 20 Sjögren's patients and of 20 healthy controls were compared by means of the slot blot immunoassay and the alkaline phosphatase method.

RESULTS

Various anti-spectrin autoantibody levels were detected in the saliva of both patients and controls. The color intensity of the blots was scored on a scale of 1 to 3. The scores were deemed to indicate the anti-spectrin autoantibody levels in saliva (1 = low, 2 = moderate, and 3 = high). The Mann-Whitney U test did not reveal a significant difference in the anti-spectrin autoantibody levels of patients and the anti-spectrin autoantibody levels of controls (P > or = .31). These results do not support a pathologic role for anti-spectrin autoantibody in Sjögren's syndrome.

CONCLUSIONS

The overall result of this study substantiates that anti-spectrin autoantibodies occur naturally in saliva. Their role in immune surveillance or pathology is not clear at present.

Elevated proapoptotic Bax and caspase 3 activation in the NOD.scid model of Sjögren's syndrome

OBJECTIVE

Salivary gland epithelial cells in patients with Sjögren's syndrome (SS) and in NOD and NODscid mice express Fas and Fas ligand, and these cells die from apoptosis. To elucidate the intracellular molecular mechanisms responsible for this salivary gland epithelial cell apoptosis, expression of the Bcl-2 family of proteins (Bcl-2, Bcl-xL, Bax) and caspase (caspases 3 and 8) was studied in young (ages 8-10 weeks) and old (ages 17-28 weeks) NOD and NOD.scid mice.

METHODS

Sections of frozen salivary gland tissue were obtained from NOD and NOD.scid mice and from the lip biopsy material of SS patients. Immunohistochemistry or Western blot analysis was performed to assess the apoptotic-associated proteins.

RESULTS

Levels of Bax and caspase 3 were elevated in the epithelial cells of glands from old NOD mice, but not in those from young NOD mice. In contrast, epithelial cells from both young and old NOD.scid mice exhibited strong expression of Bax and caspase 3. Western blot analysis showed that the activated form of caspase 3 was increased 2-5-fold in the glands from old NOD, old NOD.scid, and young NOD.scid mice compared with those from young NOD mice. Caspase 3 was also significantly elevated (P < 0.01) in SS patients whose focus scores were grade 3 or 4. In the SS patients' biopsy tissue and in the mouse glands, cells with fragmented DNA were positive for caspase 3.

CONCLUSION

These results demonstrate that salivary gland epithelial cells in NOD and NOD.scid mice overexpress the proapoptotic molecules Bax and caspase 3. Bax could be the gene responsible for initiation of caspase activation, epithelial cell destruction, and lymphocyte glandular localization in SS.

Frequency and predictive value of the clinical manifestations in Sjögren's syndrome

The purpose of this study was to examine the frequency and predictive value of glandular and extraglandular manifestations in S ogren's syndrome (SS). The clinical profiles of 169 SS patients were compared to those of 44 non-SS controls. The specific symptoms examined were oral, ocular, vaginal, gastric, pulmonary, skin, joint and muscle pain. Statistical analyses were performed on both individual and grouped symptoms. Chi-squared analyses showed that the frequency of all symptoms was significantly higher among patients than controls. Stepwise discriminant analysis of individual symptoms suggests that the combined symptoms of dry mouth, sore mouth, and dry eyes correctly classified 93% of SS and 97.7% of the controls. While grouped gastric, muscle, psychological, vaginal, skin, nasal, and thyroid symptoms correctly classified 64.3% of SS and 86.1% of the controls. This is the first study to examine the diagnostic value of multi-system manifestation in SS. The overall results suggest that a comprehensive questionnaire of various symptoms may assist the diagnosis of SS. The high predictive value of the combined symptoms confirms their value in the evaluation of SS.

Effect of xerostomic medications on stimulated salivary flow rate in patients with Sjögren's syndrome

OBJECTIVE

The purpose of this study was to examine the effect of xerostomic medications on the salivary output of patients with Sjögren's syndrome.

METHOD AND MATERIALS

Of 62 patients evaluated in this study, 23 were not using medication, and 39 were using between 1 and 6 medications with xerostomic side effect.

RESULTS

The mean +/- SEM stimulated parotid output was 0.33 +/- 0.07 mL/min per gland for patients who were not using medication and 0.33 +/- 0.04 mL/min per gland for patients using (1 to 6) medications. Analyses did not reveal a significant difference in salivary output between these groups. The salivary output of patients using various numbers of medications (1 or 2; 3 or 4; 5 or 6) was also compared. Analysis revealed no significant difference in salivary output related to the number of xerostomic medications used.

CONCLUSION

The use of xerostomic medications may not necessarily affect stimulated parotid flow rate in patients with Sjögren's syndrome. These results suggested that gustatory stimulation may be adequate to overcome the inhibitory effect induced by xerostomic medications.

A pilot study on the effect of radiation on calmodulin in rat submandibular salivary glands

Xerostomia and loss of salivary gland secretion is one of the most common complications of the radiation treatment of head-and-neck malignancies. The secretory mechanism in the salivary glands can be modulated by the concentration of intracellular Ca2+. Calmodulin is a calcium-binding protein that is widely distributed in nature and is involved in regulating intracellular calcium. In this study the effect of radiation on the concentration of calmodulin in rat salivary glands was investigated. Fourteen rats were divided into three groups: R1 (n = 4) and R2 (n = 5) received a single dose of 15 Gy and group C (n = 5) received no radiation. R1 and R2 animals were killed at weeks 2 and 10 post-irradiation, respectively. The submandibular glands were removed, homogenized and their total calmodulin was determined. The mean calmodulin concentrations were 6.4+/-1.1 microg/gland for controls, 14.1+/-3.7 microg/gland for R1 and 68.2+/-14.4 microg/gland for R2. Kruskal-Wallis ANOVA revealed a significant increase in the concentration of calmodulin following irradiation (p = 0.003). The relationship between this increase and the loss of salivary gland function is not yet clear.

Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjögren syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group

BACKGROUND

Patients with Sjögren syndrome (SS) experience slowly progressive infiltration of lacrimal and salivary glands by mononuclear cells. This leads to diminished secretions, with resultant symptoms of xerostomia and xerophthalmia. Although pilocarpine hydrochloride tablets are currently indicated for the treatment of radiation-induced xerostomia, their effects on dry mouth or dry eyes in patients with SS are unclear.

OBJECTIVE

To assess the safety and efficacy of pilocarpine (Salagen) tablets as symptomatic treatment for dry mouth and dry eyes caused by SS in a multicenter, doubleblind, placebo-controlled trial.

METHODS

After providing written informed consent, 373 patients with primary or secondary SS and clinically significant dry mouth and dry eyes were randomized to receive 2.5-mg pilocarpine, 5-mg pilocarpine, or placebo tablets 4 times daily for 12 weeks. Symptoms were assessed by questionnaires with visual analog scales or categorical checkboxes. Whole-mouth salivary flow rates were measured.

RESULTS

A significantly greater proportion of patients in the 5-mg pilocarpine group showed improvement compared with the placebo group (P< or =.01) in global assessments of dry mouth, dry eyes, and other symptoms of dryness (P< or =.05). Salivary flow was significantly increased 2- to 3-fold (P<.001) after administration of the first dose and was maintained throughout the 12-week study. The most common adverse effect was sweating, and no serious drug-related adverse experiences were reported.

CONCLUSION

Administration of 5-mg pilocarpine tablets 4 times daily (20 mg/d) was well tolerated and produced significant improvement in symptoms of dry mouth and dry eyes and other xeroses in patients with SS.

Salivary histatins in patients with recurrent oral candidiasis

The level of salivary histatins was evaluated in 20 patients with a history of recurrent oral candidiasis and in age-, sex-matched healthy controls. Salivary pH, flow rate, total protein and histatins were compared. Results of this study indicated that salivary pH was significantly lower among patients than controls (5.9 vs. 6.3, respectively, P = 0.002). No significant difference was observed in the mean flow rate and total protein between patients and controls (0.39 ml/min/gland vs. 0.46 ml/min/gland and 112.4 mg% vs. 113.0 mg%, respectively). However, the mean salivary histatin levels were significantly higher among patients than controls, both in terms of concentration (16.8 mg% vs. 11.1 mg%, P = 0.016) as well as a ratio of total protein (15 mg/g vs. 10 mg/g, P = 0.018). These findings indicate that oral candidiasis is associated with increased levels of salivary histatin. Such a finding suggests that oral candidiasis may modulate the levels of salivary histatin.

Salivary electrophoresis in the diagnosis of Sjögren's syndrome

OBJECTIVE

The purpose of this study was to investigate the potential use of salivary electrophoresis for the diagnosis of Sjögren's syndrome.

METHODS

Salivary protein profiles of 43 patients and 39 healthy control subjects were compared on three different gel electrophoresis systems: sodium dodecylsulfate-polyacrylamide gel electrophoresis, anionic polyacrylamide gel electrophoresis, and immobilized pH gradient gel electrophoresis (isoelectric point, 3.5-5.0).

RESULTS

Most of the patients with Sjögren's syndrome exhibited an electrophoretic profile that was different from that of the healthy control subjects. Among the three gel electrophoresis systems examined, the immobilized pH gradient system appeared to be the most reliable for Sjögren's syndrome. Tests of accuracy revealed that the immobilized pH gradient system exhibits high specificity (97%), sensitivity (95%), positive predictive value (97%), and negative predictive value (95%) in the diagnosis of Sjögren's syndrome.

CONCLUSIONS

Our results suggest that salivary electrophoresis is a potentially useful test for the diagnosis of Sjögren's syndrome.

Evaluation of major parotid glycoproteins in patients with burning mouth syndrome

OBJECTIVE

This study was to investigate the potential role of salivary glycoproteins in burning mouth syndrome.

STUDY DESIGN

This study compared major parotid glycoproteins in a group of patients with burning mouth syndrome and age-, sex-, race-matched healthy controls.

RESULTS

By use of a glycoprotein detection kit, saliva from both patients and controls exhibited three major parotid glycoprotein banding patterns consisting of either one or two bands, molecular weights 58 kDa and 77 kDa. The strong lectin reactivity of major parotid glycoproteins with Ricinus communis agglutinin suggests that galactose is the most prevalent terminal sugar. In addition, major parotid glycoproteins were shown to express blood group antigen H. On the basis of metachromatic characteristics and immunologic reactivity, major parotid glycoproteins appear to be members of the proline rich protein multigene family, proline rich glycoprotein, genetic polymorphism G1. No qualitative difference was observed in major parotid glycoprotein banding patterns between patients and controls.

CONCLUSION

These findings do not support a role for major parotid glycoproteins in burning mouth syndrome.

Characterization of in vivo salivary-derived enamel pellicle

Salivary proteins and glycoproteins that participate in the formation of 2-h in vivo enamel pellicle were determined utilizing polyacrylamide gel electrophoresis [sodium dodecyl sulphate (SDS)-PAGE and anionic PAGE]/Western transfer analyses, and specific radiolabelling/SDS-PAGE fluorography. The sensitivity of these methods permitted the identification of individual members of different salivary protein families. The major components of this pellicle were salivary alpha-amylase, cysteine-containing phosphoprotein (CCP or cystatins), salivary mucin and sIgA. Glycosylated amylase was present in larger quantity than the non-glycosylated species. Only CCP1 (cystatin SA-I) of the cysteine-containing phosphoprotein family was identified. The higher molecular-weight salivary mucin (MG1), but not the lower molecular-weight species (MG2), was detected. These results extend earlier observations regarding the selective nature of salivary protein adsorption to enamel surface by demonstrating that only specific members of salivary protein families are involved in 2-h in vivo enamel pellicle formation. The findings also suggest that individual family members may have different functions in the mouth.

Purification, molecular cloning, and sequencing of salivary cystatin SA-1

A "long form" salivary thiol protease inhibitor, designated cystatin SA-I, was purified to homogeneity from human submandibular-sublingual saliva by sequential gel filtration and ion-exchange chromatography. Automated peptide sequencing data revealed that cystatin SA-I shares sequence homologies with salivary cystatin SN, except that it contains an additional octapeptide at its NH2 terminus. To further characterize the molecular basis of salivary cystatin diversity, a mixed-base oligonucleotide probe corresponding to a region within the NH2-terminal sequence of the salivary cystatins was synthesized. This probe was used to screen a portion of a human submandibular gland cDNA library. The cDNA insert of a clone, designated pBR HSMSF 10G5.1, carried the entire peptide coding sequence of cystatin SA-I. The secretory peptide signal coding sequence was immediately followed by a sequence encoding the eight amino acid residues found at the NH2 terminus of purified cystatin SA-I. To estimate the number of genes encoding cystatins in the human genome, fragments of the pBR HSMSF 10G5.1 insert were used as probes in Southern blot analyses of human genomic DNA. These analyses revealed that the human genome carries 4-7 homologous cystatin genes. Collectively, our data suggest that some of the diversity in salivary cystatins could be generated by expression of different members of a multigene family and by posttranslational proteolytic cleavage of NH2-terminal regions (cystatin SA-I to cystatin SN).

Oral amyloidosis: two unusual case presentations

Two cases of oral amyloidosis are reported. In each case there were unusual oral manifestations. In the first case the patient's only complaints were of recurrent swelling of the submandibular glands and xerostomia. The diagnosis of amyloidosis was determined from a labial salivary gland biopsy. In the second case an enlarged tongue had produced displacement of the teeth, causing malocclusion. The resulting difficulty in chewing stimulated the patient to seek advice. In each case the diagnosis was confirmed by electron microscopy, Congo red staining, and serum and urine electrophoresis.

Structural aspects of salivary glycoproteins

The protective functions of saliva are attributed, in part, to its serous and mucous glycoproteins. We have studied, as representative molecules, the proline-rich glycoprotein (PRG) from human parotid saliva and the high (MG1) and low (MG2) molecular weight mucins from submandibular-sublingual saliva. PRG (38.9 kDa) contains 40% carbohydrate consisting of 6 triantennary N-linked units and a single peptide chain of 231 amino acids, 75% of which = PRO + GLY + GLN. PRG's secondary structure is comprised of 70% random coil (naked regions) and 30% beta-turns (glycosylated domains). MG1 (greater than 10(3) kDa) contains 15% protein (several disulfide linked subunits), 78% carbohydrate (290 units of 4-16 residues), 7% sulfate, and small amounts of covalently linked fatty acids. MG2 (200-250 kDa) contains 30% protein (single peptide chain), 68% carbohydrate (170 units of 2-7 residues), and 2% sulfate. The major carbohydrate units of MG2 are: NeuAc alpha 2,3Gal beta 1,3GalNAc,Gal beta 1,3GalNAc, and Fuc alpha 1,2Gal beta 1,3GalNAc. MG1 contains hydrophobic domains, as evidenced by its ability to bind fluorescent hydrophobic probes; MG2 does not. Collectively, the biochemical and biophysical comparisons between MG1 and MG2 indicate that these two mucins are structurally different. Several functional properties of MG1, MG2, and PRG have been examined, including their presence in two-hour in vivo enamel pellicle, binding to synthetic hydroxyapatite, lubricating properties, and interactions with oral streptococci. The data presented suggest that these glycoproteins may have multiple functions which are predicated, in part on their carbohydrate units. The potential significance of the structure-function relationships of these glycoproteins to the oral ecology is discussed.

Use of the photoaffinity cross-linking agent N-hydroxysuccinimidyl-4-azidosalicylic acid to characterize salivary-glycoprotein-bacterial interactions

The present study has utilized the iodinatable cross-linking agent N-hydroxysuccinimidyl-4-azidosalicylic acid (ASA) to examine the specific interaction between the proline-rich glycoprotein (PRG) of human parotid saliva and Streptococcus sanguis G9B. The binding of 125I-ASA-PRG to Streptococcus sanguis G9B displayed saturation kinetics, reversibility and was inhibited by unlabelled PRG. Inhibition studies with other glycoproteins and saccharides indicated that binding was mediated by a bacterial adhesin with specificity towards N-acetylneuraminic acid, galactose, and N-acetylgalactosamine. After cross-linking, the 125I-ASA-PRG-adhesin complex could be extracted with SDS and separated from uncoupled 125I-ASA-PRG by gel filtration on Sepharose CL-6B. Approx. 1% of the 125I-ASA-PRG was cross-linked to the bacterial surface. Examination of the 125I-ASA-PRG-adhesin complex by SDS/polyacrylamide-gel electrophoresis/fluorography on 5% -(w/v)-polyacrylamide gels revealed that PRG was bound to two bacterial components. These findings support our previous suggestion that human salivary glycoproteins can specifically interact with oral streptococci and that these interactions occur between the glycoprotein's carbohydrate units and lectin(s) on the bacterial cell surface.