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Background The classical approach to treatment of deep carious lesions approaching the pulp mandates removing all infected and affected dentin. Several studies call this approach into question.

Background. To determine the treatment effects of hyposalivation on denture retention, the authors conducted a systematic review of the literature. Types of Studies Reviewed. The authors reviewed clinical investigations that assessed the treatment effects of hyposalivation on denture retention. They searched six electronic databases for works from 1950 to the second week of September 2007 by using the key words “denture,” “hyposalivation,” “xerostomia,” “dry mouth,” “elderly” and “aged.” They limited the citation search to articles written in English and describing studies that involved human subjects. Results. The authors identified 11 articles in the search; none was a report of a randomized controlled clinical trial. Clinical Implications. The few clinical research studies published on the topic of hyposalivation and denture retention represent a low level of evidence for establishing clinical practice guidelines. The authors found that they could make no conclusions regarding the treatment effects of hyposalivation on denture retention. The article provides a literature review regarding the etiologies and clinical presentation of salivary disorders and xerostomia in elderly people, the role of saliva in denture retention, the effect of dry mouth on denture use and the treatment of dry mouth problems in denture wearers. Prospective clinical trials are needed to establish a framework for evidence-based treatment of denture-wearing patients experiencing dry mouth.

Polypharmacy is a common cause of salivary hypofunction, producing symptoms of dry mouth or xerostomia, especially among older populations. As the number of older people continues to increase, polypharmacy-induced salivary hypofunction is becoming an increasing problem. Many over-the-counter products are available for relieving symptoms of dry mouth, but few have been tested in controlled clinical investigations. The purpose of this investigation was to evaluate the safety and efficacy of a group of topical dry mouth products (toothpaste, mouth rinse, mouth spray and gel) containing olive oil, betaine and xylitol. Forty adults were entered into this single-blinded, open-label, cross-over clinical study and 39 completed all the visits. Subjects were randomly assigned at baseline to using the novel topical dry mouth products daily for 1 week, or to maintain their normal dry mouth routine care. After 1 week, they were crossed over to the other dry mouth regimen. The results demonstrated that the use of the novel topical dry mouth products increased significantly unstimulated whole salivary flow rates, reduced complaints of xerostomia and improved xerostomia-associated quality of life. No clinically significant adverse events were observed. These data suggest that the daily use of topical dry mouth products containing olive oil, betaine and xylitol is safe and effective in relieving symptoms of dry mouth in a population with polypharmacy-induced xerostomia.

Dry mouth (xerostomia) is one of the most common complaints following radiation therapy (RT) for head and neck cancers. Notably, RT causes irreparable damage to salivary glands that increases the risk for severe and long-term oral and pharyngeal disorders. Several strategies in the treatment of head and neck cancers have been developed to prevent RT-induced salivary dysfunction while providing definitive oncologic therapy. These include salivary-sparing RT; cytoprotectants (such as amifostine); combination therapy of high-dose-rate intraoperative RT, external beam RT, plus a cytoprotectant; salivary gland surgical transfer; and gene therapy. Future research that incorporates biologic, pharmacologic, and technologic advancements that optimize therapeutic ratios and minimizes adverse oral sequelae is warranted.

Locoregional recurrence remains a major obstacle to achieving cure of locally advanced head and neck cancers despite maximal resection and postoperative external beam radiation therapy (EBRT). Locoregional failure occurs in 30% to 40% of high-risk resected head and neck cancer patients after standard postoperative EBRT. In an effort to overcome this problem, a number of strategies have been designed to enhance the effectiveness of radiation including concurrent postoperative chemoradiation, accelerated radiation schedules, incorporation of targeted biologic therapies, and improved radiation delivery techniques such as intensity modulated radiation and high-dose rate (HDR) intraoperative radiation therapy. Intraoperative radiation therapy (IORT) represents an important approach to improve outcome in head and neck cancer patients treated with definitive surgery. High-dose rate IORT is defined as the delivery of a single, large dose of radiation at the time of surgery when the tumor bed is exposed. In conjunction with EBRT, HDR-IORT offers several advantages including: (1) conformal delivery of a large dose of radiation while the tumor bed is precisely defined, minimizing the risk of a geographic miss; (2) potential for subsequent dose reduction of EBRT; (3) shortening overall treatment time; and (4) dose-escalation. Because mucositis represents the dose-limiting acute toxicity and xerostomia ranks as the most common long-term quality-of-life complaint, a reduction of the EBRT dose may provide an important benefit in reducing toxicity, especially when combined with the radioprotectant amifostine (Ethyol, WR-2721; MedImmune, Inc, Gaithersburg, MD). The purpose of this article is to review the rationale for integrating HDR-IORT with a reduced dose of postoperative EBRT combined with amifostine to improve locoregional control and quality of life outcomes in advanced-stage resected head and neck cancer patients.

Background Diabetes is a common disease with concomitant oral manifestations that impact dental care. The purpose of this review is to summarize the prevalence, signs, symptoms, diagnosis and treatment of diabetes, as well as dental treatment considerations for the patient with diabetes. Conclusions Safely managing the patient with diabetes requires effective communication among multiple health care providers. Dentists must be familiar with techniques to diagnose, treat and prevent stomatological disorders in patients with diabetes. Practice Implications Dental practitioners will be treating more patients with diabetes in the future, and this article provides an overview of the systemic and oral aspects of the disease that impact dental treatment.

Purpose Parotid-sparing intensity-modulated radiotherapy (IMRT) for head-and-neck cancer reduces xerostomia compared with standard RT. To assess potential improvements in broader aspects of quality of life (QOL), we initiated a study of patient-reported QOL and its predictors after IMRT. Methods and materials This was a prospective longitudinal study of head-and-neck cancer patients receiving multisegmental static IMRT. Patients were given a validated xerostomia questionnaire (XQ), and a validated head-and-neck cancer-related QOL questionnaire consisting of four multi-item domains: Eating, Communication, Pain, and Emotion. The Eating domain contains one question (total of six) asking directly about xerostomia. In both questionnaires, higher scores denote worse symptoms or QOL. The questionnaires and measurements of salivary output from the major glands were completed before RT started (pre-RT) and at 3, 6, and 12 months after RT. The association between the QOL scores and patient-, tumor-, and therapy-related factors was assessed using the random effects model. Results Thirty-six patients participating in the study completed the questionnaires through 12 months. The XQ scores worsened significantly at 3 months compared with the pre-RT scores, but later they improved gradually through 12 months ( p = 0.003), in parallel with an increase in the salivary output from the spared salivary glands. The QOL summary scores were stable between the baseline (pre-RT) and 3 months after RT scores. Patients receiving postoperative RT (whose pre-RT questionnaires were taken a few weeks after surgery) tended to have improved scores after RT, reflecting the subsidence of acute postoperative sequelae, compared with a tendency toward worsened scores in patients receiving definitive RT. After 3 months, statistically significant improvement was noted in the summary QOL scores for all patients, through 12 months after RT ( p = 0.01). The salivary flow rates, tumor doses, mean oral cavity dose, age, gender, sites or stages of tumor, surgery, and use of chemotherapy were not associated with the QOL scores at any point. The mean dose to the parotid glands correlated with the QOL scores at 3 months ( p = 0.05) but not at other post-RT periods. The XQ and QOL summary scores did not correlate before RT but were significantly correlated at each post-RT point ( p r ) of 0.59, 0.72, and 0.67 at 3, 6, and 12 months, respectively. At these points, the XQ scores also correlated significantly with the scores of each of the individual QOL domains ( p ≤ 0.01), including the domains Pain and Emotion, which did not contain any xerostomia-related question. Conclusion After parotid-sparing IMRT, a statistically significant correlation was noted between patient-reported xerostomia and each of the domains of QOL: Eating, Communication, Pain, and Emotion. Both xerostomia and QOL scores improved significantly over time during the first year after therapy. These results suggest that the efforts to improve xerostomia using IMRT may yield improvements in broad aspects of QOL.

The goals of this study were to facilitate sparing of the major salivary glands while adequately treating tumor targets in patients requiring comprehensive bilateral neck irradiation (RT), and to assess the potential for improved xerostomia. Since 1994 techniques of target irradiation and locoregional tumor control with conformal and intensity modulated radiation therapy (IMRT) have been developed. In patients treated with these modalities, the salivary flow rates before and periodically after RT have been measured selectively from each major salivary gland and the residual flows correlated with glands' dose volume histograms (DVHs). In addition, subjective xerostomia questionnaires have been developed and validated. The pattern of locoregional recurrence has been examined from computed tomography (CT) scans at the time of recurrence, transferring the recurrence volumes to the planning CT scans, and regenerating the dose distributions at the recurrence sites. Treatment plans for target coverage and dose homogeneity using static, multisegmental IMRT were found to be significantly better than standard RT plans. In addition, significant parotid gland sparing was achieved in the conformal plans. The relationships among dose, irradiated volume, and the residual saliva flow rates from the parotid glands were characterized by dose and volume thresholds. A mean radiation dose of 26 Gy was found to be the threshold for preserved stimulated saliva flow. Xerostomia questionnaire scores suggested that xerostomia was significantly reduced in patients irradiated with bilateral neck, parotid-sparing RT, compared to patients with similar tumors treated with standard RT. Examination of locoregional tumor recurrence patterns revealed that the large majority of recurrences occurred inside targets, in areas that had been judged to be at high risk and that had received RT doses according to the perceived risk. Tangible gains in salivary gland sparing and target coverage are being achieved, and an improvement in some measures of quality of life is suggested by our findings. Additional reduction of xerostomia may be achieved by further sparing of the salivary glands and the non-involved oral cavity. A mean parotid gland dose ofor = 26 Gy should be a planning objective if significant parotid function preservation is desired. The pattern of recurrence suggests that careful escalation of the dose to areas judged to be at highest risk may improve tumor control.

Recurrent aphthous stomatitis (RAS) is the most common oral mucosal disorder found in men and women of all ages, races, and geographic regions. There are three forms of the lesions (minor, major, and herpetiform), with major aphthous ulcers causing significant pain and potential for scarring. In HIV-infected individuals, these ulcers occur more frequently, last longer, and produce more painful symptoms than in immunocompetent persons. In addition, they may be associated with similar ulcerations involving the esophagus, rectum, anus, and genitals. The diagnosis of HIV-induced RAS requires a careful history of the condition, and a thorough extra- and intra-oral examination. Oral mucosal biopsies are required for non-healing ulcers in order to exclude the possibility of deep fungal infections, viral infections, and neoplasms. The cause of the ulcers in HIV-positive persons has not been elucidated--local diseases, genetic, immunologic, and infectious factors all probably play a role. The goals of current treatments are to promote ulcer healing, to reduce ulcer duration and pain while maintaining nutritional intake, and to prevent or diminish the frequency of recurrence. Initial therapy for infrequent RAS recurrences includes over-the-counter topical protective and analgesic products. Initial therapy for frequent RAS outbreaks requires topical anesthetics, binding agents, and corticosteroids. Major RAS and non-healing minor or herpetiform RAS may require intralesional corticosteroids and systemic prednisone. Second-line immunomodulators for frequent and non-healing ulcers includes thalidomide and other immunomodulators.

Oropharyngeal mucositis is a common and significant complication of cancer chemotherapy and limits the delivery of chemotherapy, affects the quality of life, and increases the cost of care. Oral mucositis caused by cancer chemotherapy is associated with specific agents, but the origin of oral mucositis is poorly understood. These drugs may have direct toxic effects on the rapidly dividing cells of the oral mucosa and on cellular elements of the connective tissue. Microbial flora may play a role in the development of ulcerative mucositis. Chemotherapy may be directly toxic and affect the mucosa by systemic circulation and may be related to secretion of some chemotherapeutic drugs in the saliva, resulting in topical exposure to the oral environment. Other potential mechanisms include reduced saliva volume and change in saliva constituents that may affect epithelial maintenance and repair, the physiology of the oral microflora, and the interaction between the oral flora and the epithelium. Improved understanding of the mechanisms whereby specific chemotherapeutic agents cause mucositis may lead to management approaches that will reduce the incidence and severity of mucositis, improving quality of life and ensuring delivery of the necessary chemotherapy to improve cancer cure rates.

This case report describes a 14-year-old female referred to Pediatric Dentistry for evaluation and treatment of cyclosporine-induced gingival hyperplasia. Examination of the anterior maxillary area showed a red, vascular, exophytic, soft-tissue mass which had been excised a few months earlier without a histopathologic examination being done. The mass did not appear consistent with gingival overgrowth induced by long-term use of medication, and thus an excisional biopsy was performed, which diagnosed the lesion as a pyogenic granuloma. A review of the literature and management recommendations are discussed.

Recent efforts to reduce xerostomia associated with irradiation (RT) of head and neck cancer include the use of conformal and intensity-modulated RT (IMRT) to partly spare the major salivary glands, notably the parotid glands, from a high radiation dose while treating adequately all the targets at risk of disease. Knowledge of the dose-volume-response relationships in the salivary glands would determine treatment planning goals and facilitate optimization of the RT plans. Recent prospective studies of salivary flows following inhomogeneous irradiation of the parotid glands have utilized dose-volume histograms (DVHs) and various models to assess these relationships. These studies found that the mean dose to the gland is correlated with the reduction of the salivary output. This is consistent with a pure parallel architecture of the functional subunits (FSUs) of the salivary glands. The range of the mean doses, which have been found in these studies to cause significant salivary flow reduction is 26 to 39 Gy.

The lifespan of the US population is increasing, with the elderly desiring successful aging. This goal is jeopardized as multiple systemic conditions and their treatments become more prevalent with age, causing impaired systemic and oral health and influencing an older person's quality of life. To obtain successful aging, a compression of morbidity must be obtained through prevention and management of disease. This paper describes the most common systemic diseases causing morbidity and mortality in persons aged 65+ years: diseases of the heart, malignant neoplasms, cerebrovascular diseases, chronic obstructive pulmonary disease, pneumonia, influenza, diabetes mellitus, trauma, Alzheimer's disease, renal diseases, septicemia, and liver diseases. Disease prevalence and the impact of medications and other therapeutic measures used to treat these conditions are discussed. Oral sequelae are reviewed with guidelines for early detection of these deleterious consequences, considerations for oral treatment, and patient management. An understanding of the impact of systemic diseases and treatment on oral health is imperative for dental practitioners to appropriately treat and manage older patients with these conditions. With a focus on early detection and prevention, oral health care providers can improve the quality of life of this population and aid in the attainment of successful aging.

Purpose: To analyze the patterns of local-regional recurrence in patients with head and neck cancer treated with parotid-sparing conformal and segmental intensity-modulated radiotherapy (IMRT). Methods and Materials: Fifty-eight patients with head and neck cancer were treated with bilateral neck radiation (RT) using conformal or segmental IMRT techniques, while sparing a substantial portion of one parotid gland. The targets for CT-based RT planning included the gross tumor volume (GTV) (primary tumor and lymph node metastases) and the clinical target volume (CTV) (postoperative tumor bed, expansions of the GTVs and lymph node groups at risk of subclinical disease). Lymph node targets at risk of subclinical disease included the bilateral jugulodigastric and lower jugular lymph nodes, bilateral retropharyngeal lymph nodes at risk, and high jugular nodes at the base of skull in the side of the neck at highest risk (containing clinical neck metastases and/or ipsilateral to the primary tumor). The CTVs were expanded by 5 mm to yield planning target volumes (PTVs). Planning goals included coverage of all PTVs (with a minimum of 95% of the prescribed dose) and sparing of a substantial portion of the parotid gland in the side of the neck at less risk. The median RT doses to the gross tumor, the operative bed, and the subclinical disease PTVs were 70.4 Gy, 61.2 Gy, and 50.4 Gy respectively. All recurrences were defined on CT scans obtained at the time of recurrence, transferred to the pretreatment CT dataset used for RT planning, and analyzed using dose–volume histograms. The recurrences were classified as 1) "in-field," in which 95% or more of the recurrence volume (V recur ) was within the 95% isodose; 2) "marginal," in which 20% to 95% of V recur was within the 95% isodose; or 3) "outside," in which less than 20% of V recur was within the 95% isodose. Results: With a median follow-up of 27 months (range 6 to 60 months), 10 regional recurrences, 5 local recurrences (including one noninvasive recurrence) and 1 stomal recurrence were seen in 12 patients, for a 2-year actuarial local-regional control rate of 79% (95% confidence interval 68–90%). Ten patients (80%) relapsed in-field (in areas of previous gross tumor in nine patients), and two patients developed marginal recurrences in the side of the neck at highest risk (one in the high retropharyngeal nodes/base of skull and one in the submandibular nodes). Four regional recurrences extended superior to the jugulodigastric node, in the high jugular and retropharyngeal nodes near the base of skull of the side of the neck at highest risk. Three of these were in-field, in areas that had received the dose intended for subclinical disease. No recurrences were seen in the nodes superior to the jugulodigastric nodes in the side of the neck at less risk, where RT was partially spared. Conclusions: The majority of local-regional recurrences after conformal and segmental IMRT were "in-field," in areas judged to be at high risk at the time of RT planning, including the GTV, the operative bed, and the first echelon nodes. These findings motivate studies of dose escalation to the highest risk regions.

Purpose: To determine the relationships between the three-dimensional dose distributions in parotid glands and their saliva production, and to find the doses and irradiated volumes that permit preservation of the salivary flow following irradiation (RT). Methods and Materials: Eighty-eight patients with head and neck cancer irradiated with parotid-sparing conformal and multisegmental intensity modulation techniques between March 1994 and August 1997 participated in the study. The mean dose and the partial volumes receiving specified doses were determined for each gland from dose–volume histograms (DVHs). Nonstimulated and stimulated saliva flow rates were selectively measured from each parotid gland before RT and at 1, 3, 6, and 12 months after the completion of RT. The data were fit using a generalized linear model and the normal tissue complication probability (NTCP) model of Lyman-Kutcher. In the latter model, a "severe complication" was defined as salivary flow rate reduced to ≤25% pre-RT flow at 12 months. Results: Saliva flow rates data were available for 152 parotid glands. Glands receiving a mean dose below or equal to a threshold (24 Gy for the unstimulated and 26 Gy for the stimulated saliva) showed substantial preservation of the flow rates following RT and continued to improve over time (to median 76% and 114% of pre-RT for the unstimulated and stimulated flow rates, respectively, at 12 months). In contrast, most glands receiving a mean dose higher than the threshold produced little saliva with no recovery over time. The output was not found to decrease as mean dose increased, as long as the threshold dose was not reached. Similarly, partial volume thresholds were found: 67%, 45%, and 24% gland volumes receiving more than 15 Gy, 30 Gy, and 45 Gy, respectively. The partial volume thresholds correlated highly with the mean dose and did not add significantly to a model predicting the saliva flow rate from the mean dose and the time since RT. The NTCP model parameters were found to be TD 50 (the tolerance dose for 50% complications rate for whole organ irradiated uniformly) = 28.4 Gy, n (volume dependence parameter) = 1, and m (the slope of the dose/response relationship) = 0.18. Clinical factors including age, gender, pre-RT surgery, chemotherapy, and certain medical conditions were not found to be significantly associated with the salivary flow rates. Medications (diuretics, antidepressants, and narcotics) were found to adversely affect the unstimulated but not the stimulated flow rates. Conclusions: Dose/volume/function relationships in the parotid glands are characterized by dose and volume thresholds, steep dose/response relationships when the thresholds are reached, and a maximal volume dependence parameter in the NTCP model. A parotid gland mean dose of ≤26 Gy should be a planning goal if substantial sparing of the gland function is desired.

The purpose of this investigation was to examine the safety and efficacy of four dosages of natural human interferon-alpha (nHuIFN-alpha) delivered over a 12-week period orally in lozenges (150 IU and 450 IU, once [QD] or three times [TID] daily) compared to placebo in subjects with primary Sjogren's syndrome. This randomized, double-blinded clinical trial demonstrated that nHuIFN-alpha at a dose of 150 IU administered TID by oral lozenge significantly improved stimulated whole saliva output compared to placebo after 12 weeks of treatment. The 150 IU TID dose also was suggestive of benefit for 5 of 7 subjective measures of oral and ocular comfort. IFN lozenges demonstrated a good safety profile, with no serious adverse events found in any treatment group. There were no significant differences between the placebo and the four doses of IFN for adverse events by total number, organ system, severity, dropouts, and number judged to be related to treatment. In conclusion, these results demonstrated that the use...

Radiotherapy (RT) is a common treatment for head and neck cancers, and frequently causes permanent salivary dysfunction and xerostomia. This 2-year longitudinal study evaluated unstimulated and stimulated parotid flow rates in 11 patients with head and neck cancers who received unilateral neck parotid-sparing RT. The results demonstrated that treated parotid glands had essentially no output up to 2 years post-RT. Alternatively, spared parotid flow rates were indistinguishable from pre-RT values at 1 and 2 years post-RT, and increased slightly over time. Total unstimulated and stimulated parotid flow rates 2 years after completion of RT were similar to pre-RT values, suggesting that spared parotid function may compensate for lost function from treated parotid glands. These results demonstrate that unilateral neck parotid-sparing techniques are effective in preserving contralateral parotid glands up to 2 years after the completion of RT.

Purpose: Conformal treatment using static multisegmental intensity modulation was developed for patients requiring comprehensive irradiation for head and neck cancer. The major aim is sparing major salivary gland function while adequately treating the targets. To assess the adequacy of the conformal plans regarding target coverage and dose homogeneity, they were compared with standard irradiation plans. Methods and Materials: Fifteen patients with stage III/IV head and neck cancer requiring comprehensive, bilateral neck irradiation participated in this study. CT-based treatment plans included five to six nonopposed fields, each having two to four in-field segments. Fields and segments were devised using beam's eye views of the planning target volumes (PTVs), noninvolved organs, and isodose surfaces, to achieve homogeneous dose distribution that encompassed the targets and spared major salivary gland tissue. For comparison, standard three-field radiation plans were devised retrospectively for each patient, with the same CT-derived targets used for the clinical (conformal) plans. Saliva flow rates from each major salivary gland were measured before and periodically after treatment. Results: On average, the minimal dose to the primary PTVs in the conformal plans [95.2% of the prescribed dose, standard deviation (SD) 4%] was higher than in the standard plans (91%, SD 7%; p = 0.02), and target volumes receiving p = 0.004 and 0.02, respectively). Similar advantages of the conformal plans compared to standard plans were found in ipsilateral jugular nodes PTV coverage. The reason for underdosing in the standard treatment plans was primarily failure of electron beams to fully encompass targets. No significant differences were found in contralateral jugular or posterior neck nodes coverage. The minimal dose to the retropharyngeal nodes was higher in the standard plans. However, all conformal plans achieved the planning goal of delivering 50 Gy to these nodes. In the conformal plans, the magnitude and volumes of high doses in noninvolved tissue were significantly reduced. The main reasons for hot spots in the standard plans (whose dose calculations included missing tissue compensators) were photon/electron match line inhomogeneities, which were avoided in the conformal plans. The mean doses to all the major salivary glands, notably the contralateral parotid (receiving on average 32% of the prescribed dose, SD 7%) were significantly lower in the conformal plans compared with standard radiation plans. The mean dose to the noninvolved oral cavity tended to be lower in the conformal plans ( p = 0.07). One to 3 months after radiation, on average 60% (SD 49%) of the preradiation saliva flow rate was retained in the contralateral parotid glands and 10% (SD 16%) was retained in the submandibular/sublingual glands. Conclusions: Planning and delivery of comprehensive irradiation for head and neck cancer using static, multisegmental intensity modulation are feasible. Target coverage has not been compromised and dose distributions in noninvolved tissue are favorable compared with standard radiation. Substantial major salivary gland function can be retained.

Depression is a common serious disorder that has a high comorbidity with chronic facial pain. This article provides an overview of the clinical presentation, pathophysiology and diagnosis of depression. In particular, it addresses some of the problems associated with identifying depressive symptoms in dental patients who have chronic facial pain.

Background It is generally accepted that age-related changes occur in voluntary muscle. Studies of hand grip strength and aging demonstrate a decrease in strength with age; however, there are little data regarding tongue function. The purpose of this study was to determine the relationship of increased age to tongue strength and endurance. Methods A pressure transducer, the Iowa Oral Performance Instrument, was used to measure maximal strength and endurance of both the hand and tongue. Ninety-nine healthy volunteers from the oral physiology component of the Baltimore Longitudinal Study of Aging were divided into four age groups, ranging from 21 to 96 years of age. A multivariate analysis of variance was used to determine differences in strength and endurance between age groups and genders. Regression analysis was done to determine the relationship of strength and endurance with age. Results Gender analysis indicated that both tongue and hand strength were greater in males; however, tongue and hand endurance demonstrated no gender differences. The strength in both the tongue and hand decreased with age. Individuals over the age of 79 years showed statistically decreased tongue strength, and individuals over the age of 59 years showed statistically decreased hand strength. There was no significant change in the tongue and hand endurance with age. Conclusions The results of this study suggest that tongue function is gender- and age-dependent and follows the same trends as hand function. Tongue strength is decreased in older individuals and females, while tongue endurance is gender- and age-independent.

Purpose : To minimize xerostomia in patients receiving bilateral head and neck irradiation (RT) by using conformal RT planning to spare a significant volume of one parotid gland from radiation. Methods and Materials : The study involved 15 patients with head and neck tumors in whom bilateral neck radiation was indicated. The major salivary glands and the targets (tumor, surgical bed, metastases to lymph nodes, and the locations of lymph nodes at risk for metastases) were outlined on axial computed tomography images. Beam's-eye view (BEV) displays were used to construct conformal beams that delivered the prescribed doses to the targets while sparing from direct radiation most of one parotid gland. The gland that was planned to be spared resided in the neck side that was judged in each patient to be at a lesser risk of metastatic disease. Major salivary gland flow rates and the responses to a subjective xerostomia questionnaire were assessed before, during, and after radiation. Results : Radiation planning for patients with central oropharyngeal tumors required the generation of multiple axial nonopposed beams. The resulting isodoses encompassed the targets, including the retropharyngeal nodes and the jugular nodes up to the base of skull bilaterally, while limiting the dose to the oral cavity, spinal cord, and one parotid gland. For patients with lateralized tumors, the ipsilateral neck side was treated up to the base of the skull ; in the contralateral neck side, the treatment included the subdigastric nodes but excluded the jugular nodes at the base of the skull and most of the parotid gland. This was accomplished by a moderate gantry angle that was chosen using the BEV displays. Three months following the completion of radiation, the spared parotid glands retained on average 50% of their unstimulated and stimulated flows. In contrast, no saliva flow was measured from the unspared glands in any of the patients. Subjective xerostomia was absent, mild, or not different from that reported before radiation in 10 of 15 patients (67%). Conclusion : Partial parotid gland sparing is feasible by using three-dimensional planning in patients undergoing bilateral head and neck radiation. Approximately 50% of the saliva flow from the spared glands may be retained, and most patients thus treated have no or mild xerostomia in the early period after the completion of radiation. Whether tumor control and late complications are comparable to standard radiation will be assessed as more experience is gained.

Objective . To determine if three-dimensional treatment planning and conformational dose delivery could minimize radiation dose and salivary gland dysfunction to contralateral parotid glands in patients with unilateral head and neck cancers. Study design . Fifteen patients with unilateral head and neck cancers were treated with three-dimensional treatment planning. Unstimulated and stimulated bilateral parotid saliva was collected before radiotherapy, weekly during treatment, and 1, 3, 6, and 12 months after the completion of radiotherapy. Results . Treated parotid glands received an average dose of 4949 cGy, whereas spared glands received only 355 cGy. Unstimulated and stimulated parotid flow rates decreased dramatically in treated glands after the initiation of radiotherapy and were significantly lower at 1 year after radiotherapy compared with baseline. Conversely, parotid flow rates in spared glands underwent mild changes during radiotherapy and were similar at 1 year after radiotherapy compared with baseline. Conclusion . Parotid gland function can be preserved for at least 1 year in patients with unilateral head and neck cancers with three-dimensional treatment planning.

Recurrent aphthous ulceration or recurrent aphthous stomatitis is the most common oral mucosal disease known to human beings. Despite much clinical and research attention, the causes remain poorly understood, the ulcers are not preventable, and treatment is symptomatic. The most common presentation is minor recurrent aphthous stomatitis: recurrent, round, clearly defined, small, painful ulcers that heal in 10 to 14 days without scarring. Major recurrent aphthous stomatitis lesions are larger (greater than 5 mm), can last for 6 weeks or longer, and frequently scar. The third variety of recurrent aphthous stomatitis is herpetiform ulcers, which present as multiple small clusters of pinpoint lesions that can coalesce to form large irregular ulcers and last 7 to 10 days. Diagnosis of all varieties is usually made after clinical examination. Many local and systemic factors have been associated with these conditions, and there is evidence that there may be a genetic and immunopathogenic basis for recurrent aphthous ulceration. Management of this condition depends on the clinical presentation and symptoms and includes analgesic, antimicrobial, and immunomodulatory drugs. As dental clinicians and researchers become better trained in oral medicine and stomatology, it is anticipated that the pathophysiology, prevention, and treatment of recurrent aphthous ulceration will improve in the future.

Some have suggested that gingival and periodontal health is related to salivary gland function; however, there are few data to support this hypothesis. The purpose of this study was to determine if correlations existed between major salivary gland flow rates and gingival and periodontal conditions in people of different ages. The results suggest that there is no consistent relationship between major salivary gland flow rates and gingival and periodontal conditions in healthy people.

BACKGROUND Early studies suggested that salivary gland dysfunction was a normal sequela of aging. Recent research on healthy, different-aged adults has led to a revision of these former conclusions. Parotid gland function appears to be age-stable, yet there is no consensus on submandibular/sublingual output. To date, there have only been two longitudinal studies utilizing healthy individuals examining parotid function, and no published longitudinal studies on submandibular/sublingual output. The purpose of this study was to examine unstimulated and stimulated major salivary gland flow rates in unmedicated, essentially healthy subjects, over a 3-year period. METHODS Thirty-seven males and females, aged 26-90 years of age, were examined twice over a 3-year period at the Clinical Center of the National Institutes of Health. All were healthy, community-dwelling adults, without systemic diseases, and not taking any medications. Unstimulated and 2% citrate-stimulated parotid and submandibular/sublingual salivary gland flow rates were assessed at both visits, and changes over time were evaluated according to the subject's age at initial visit. RESULTS There were no significant flow rate differences over a 3-year time period for unstimulated and stimulated parotid and submandibular/sublingual flow rates. CONCLUSIONS Major salivary gland output is aged-stable in healthy persons over a 3-year period. The data from this study suggest that salivary gland dysfunction in an older person should not be considered a normal process of aging.

Though it has been the subject of much research, burning mouth syndrome--a chronic oral-facial pain condition that affects many U.S. adults--remains poorly understood. It has been associated with numerous oral and systemic conditions. Treatment options frequently include various medications. While patients with symptoms of BMS are more likely to seek care from physicians, dentists should be involved in the evaluation and management of these patients.

Periodontal diseases are among the most prevalent conditions in adults, and afflict many individuals of all ages. They refer to a cluster of inflammatory conditions of the periodontium, the tissues that surround the teeth. Ultimately, periodontal diseases cause the loss of alveolar bone support and may lead to tooth loss. The clinical presentation of periodontal diseases is primarily independent of the age of a person, and successful diagnosis and treatment can be achieved in both young and old individuals. These diseases primarily include gingivitis, periodontitis and oral vesiculobullous diseases of the gingival tissues. Multiple oral, systemic and behavioural factors contribute to the occurrence and progression of these conditions. Appropriate treatment requires accurate diagnosis and the use of oral nonsurgical and surgical techniques, topical and systemic medications and an emphasis on self-applied oral hygiene practices.

Stimulated parotid salivary flow rates were compared in elderly normotensive, hypertensive, and controlled hypertensive African-Americans, the latter group taking hydrochlorothiazide (HCTZ). The normotensive group consisted of 15 healthy unmedicated subjects with systolic blood pressures of less than 150 mm Hg and diastolic pressures less than 90 mm Hg. The hypertensive group consisted of 10 unmedicated subjects with systolic pressures greater than 160 mm Hg and diastolic pressures greater than 100 mm Hg. The controlled hypertensive group consisted of 20 subjects taking HCTZ (50 mg, daily) with controlled blood pressures similar to the normotensive control group. Stimulated parotid salivary samples were collected from each subject. A 2% citrate solution applied to the dorsum of the tongue was used for stimulation. The results showed no significant differences in stimulated parotid flow rates between normotensive and uncontrolled hypertensive subjects. However, the medicated, controlled hypertensive subjects had a significant reduction of stimulated parotid salivary flow rates compared to both the normotensive and hypertensive groups.

Although hypertension is a prevalent condition among the elderly, little is known with respect to the influence of hypertension on oral health and function. Therefore a study was conducted that compared stimulated parotid salivary flow rates in elderly persons (65 years and older) from two diverse populations who are normotensive, mild, and severe hypertensive. The normotensive group consisted of 45 healthy subjects with systolic blood pressures of less than 140 mm Hg and diastolic pressures less than 90 mm Hg. The mildly hypertensive group consisted of 14 otherwise healthy subjects with either systolic pressures greater than 140 mm Hg or diastolic pressures greater than 90 mm Hg. The severely hypertensive group consisted of 10 otherwise healthy subjects with either systolic pressures greater than 180 mm Hg and/or diastolic pressures greater than 100 mm Hg. All three groups were not taking any prescription or nonprescription medications. Samples of 2% citrate-stimulated parotid saliva were collected from each subject. The results showed no significant differences in stimulated parotid flow between normotensive, mildly hypertensive, and severely hypertensive subjects. These results suggest that hypertension per se has no influence on stimulated parotid salivary gland flow rates in otherwise healthy, elderly unmedicated white and African-American persons.

It is not clear if aging distinctions can be made at the level of an organ or organism. The purpose of this study was to determine if a general definition of systemic aging, primary aging (influence of the passage of time), versus secondary aging (influence of extrinsic factors), can be used to discriminate the functional status of an individual organ system, the oral cavity. Thirty healthy, nonmedicated subjects (that is, those who exhibit primary aging) and 42 persons being treated for medical problems and taking prescription medications (that is, those who exhibit secondary aging), aged 75 to 96 years, from the oral physiology component of the Baltimore Longitudinal Study of Aging were evaluated. A standardized examination assessed gingival, periodontal, dental, and oral mucosal tissues. There were few substantive differences in oral health and function between primary and secondary aging subjects. Thus use of broad definitions of aging in an organism did not lead to meaningful predictions of the health or function of an individual organ system. Furthermore, the similarity in the oral condition between both groups studied here suggests substantial resiliency of the oral cavity during aging.

Gustatory and olfactory problems have deleterious consequences to systemic health, nutritional status and quality of life. Since patients with these problems are initially seen by dentists, they should be identified, treated and referred to other health care providers when appropriate. Care of these patients should be included in the general dental practice.

Radiation therapy for cancer of the head and neck region often causes salivary gland dysfunction and xerostomia. Several reports suggest that the submandibular/sublingual (SM/SL) glands may be less radiosensitive than the parotid. The purpose of this study was to evaluate differential radiation effects on the major salivary glands. Fifty patients with radiation-induced xerostomia were evaluated (33 males, 17 females; mean age 52.7). The average total tumor dose was 6034 cGy. Major salivary gland function was compared with that of 50 non-irradiated controls. Salivary flow rates included unstimulated and stimulated flows of both the parotid and SM/SL glands. Sialochemical analyses included total protein, lysozyme, lactoferrin, sodium, chloride, and potassium. All four measures of salivary flow were significantly reduced in patients as compared to controls (p = .0001). Like the parotid, submandibular/sublingual gland dysfunction appears to be radiation dose- and field-dependent. Patients in the lowest radiation dose quartile (or = 5000 cGy) had significantly increased salivary flow compared to those in the highest dose quartile (or = 6800 cGy; p = .025). Glands that were partially irradiated were more likely to have some residual function than fully irradiated glands (p = .003). Lactoferrin content was increased in parotid saliva of radiation patients (p = .0001). Chloride content was significantly increased also (p = .0001). The SM/SL glands are clearly dysfunctional in post-irradiation xerostomia patients compared to controls, in terms of both flow rates and sialochemistry.

Olfactory function diminishes with increasing age, which may impact on the safety and quality of life of older persons. This study examined the influence of age, gender, medical treatment, and medications on smell identification in a group of generally healthy individuals. Males (n = 221) and females (n = 166) between the ages of 19 and 95 years, from the oral physiology component of the Baltimore Longitudinal Study of Aging, were administered the University of Pennsylvania Smell Identification Test [UPSIT; (1)]. Older subjects had lower UPSIT scores, were more likely to be anosmic, and more often complained about their sense of smell and taste compared to younger subjects. Females had higher UPSIT scores compared to males. Although these age and gender effects are comparable to previous findings, performance among all subjects was superior to other studies; this is attributable, in part, to the overall healthy status of the population. Subjects being treated for medical problems and taking prescription medications had slightly lower UPSIT scores and more smell and taste complaints compared to other subjects, but these findings did not achieve statistical significance. Results suggest that age-related declines in olfaction occur as a part of the normal physiological aging process.

This review describes an approach to examining the interaction of aging and systemic disease on a key aspect of oral physiology, salivation. The approach requires several steps: defining general health, and a specific physiological function, at different ages; defining a disease of interest and the influence of the disease on the specific physiological function; and determining if the disease can affect performance of the physiological function with increased age.

The oral cavity is responsible for two essential functions: the production of speech and the initiation of alimentation. All of the specialized oral tissues and sensory systems that allow for the execution of these functions are susceptible to age-, disease-, and treatment-related changes, and alterations in any one or more function may result in deleterious consequences to the host and impact on the quality of life. Oral physiology is generally believed to be age-stable in healthy individuals; however, in the presence of single or multiple medical diseases and their treatment, these functions deteriorate. This article focuses on the influence of common geriatric diseases, disorders, and impairments on oral health and function. Data are presented to suggest that oral health is altered in the presence of heart, cerebrovascular, liver, and renal diseases, cancer, COPD, diabetes, pneumonia, and influenza. Arthritic, hearing, visual, orthopedic, and speech impairments multiple medical problems. Finally, adjustments in treatment and management strategies may be necessary for older patients with these diseases and impairments.

Sequential salivary gland scintigraphy with 99mTc-technetium pertechnetate (Tc-99) is a safe, minimally invasive test for study of major salivary glands. However, its relationship to salivary function has not been investigated in detail. We have investigated the relationship between major salivary gland flow rates and Tc-99 scans and developed a new rating scale using scans of a control group with normal salivary function. Salivary flow rates and Tc-99 scans were obtained from healthy, non-medicated subjects (n = 33) and from xerostomic patients (n = 22). There were significant differences between the groups for salivary flow rates and Tc-99 ratings. Significant correlations were found between salivary flow rates and Tc-99 ratings in the control and xerostomic groups. The Tc-99 rating scale proved reliable in assessing salivary dysfunction, and showed a high inter-examiner correlation. These results demonstrate the usefulness of salivary gland scintigraphy in assessing major salivary gland flow rates and the utility of a new rating scale.

Treatment of a human salivary epithelial cell line, HSG-PA, with the calmodulin antagonist N-(6-aminohexyl)-5-chloro-1-naphthalenesulfonamide (W7; 20-70 microM) increased 86Rb (K+) influx and efflux in a manner similar to that resulting from muscarinic (carbachol; Cch) or calcium ionophore (A23187) stimulation. Unlike the Cch or A23187 responses, the W7 responses were not blocked by 0.1 mM atropine (muscarinic antagonist) or phorbol-12-myristate-13-acetate (0.1 microM). Like Cch- or A23187-stimulated 86Rb fluxes, W7-stimulated 86Rb fluxes were substantially blocked by the K+ channel inhibitors quinine (0.25 mM) and scorpion venom-containing charybdotoxin (33 micrograms/mL), while 5 mM tetraethylammonium chloride (K+ channel blocker), furosemide (0.1 mM; Na+,K+,2Cl- co-transport inhibitor) and ouabain (10 microM; Na+,K(+)-ATPase inhibitor) were ineffective. Purified charybdotoxin (10 nM) also blocked W7-stimulated 86Rb influx, as well as 86Rb influx stimulated by Cch or A23187. Although Quin 2 fluorescence measurements indicated that W7 increased free intracellular Ca2+ concentration ([Ca2+]i), the magnitude of the increase appeared to be insufficient to solely account for the W7-stimulated increases in 86Rb fluxes (i.e. K+ channel activity). Ca2+ was involved in the W7 response, however, as lack of Ca2+ in the incubation medium reduced the W7-stimulated increases in 86Rb influx and efflux. Taken together, our results suggest that W7 increased K+ fluxes in HSG-PA cells by interacting, directly or indirectly, with the K+ transport machinery (K+ channels) in a manner different from that observed during muscarinic stimulation, and also in a manner not accounted for solely by the formation of a typical muscarinic- or calcium ionophore-generated calcium signal.

Oral mucosal status in 182 different-aged, healthy, community-dwelling persons was evaluated. Ninety-four men and 88 women, ranging in age between 20 and 95 years, participated in this study. Oral mucosal status was assessed according to both subjective complaints and a semiquantitative clinical rating scale. No changes in either criterion were detected with increasing age. Oral mucosal status of the older subjects of this study was comparable to that found in a previous study with a randomly enrolled, noninstitutionalized older population in Iowa. The results of this study suggest that aging per se does not lead to changes in the appearance of oral mucosa.

Saliva is important for the preservation and maintenance of oral health. It is unclear, however, how much saliva is required to maintain normal oral function. Major salivary gland flow rates, objective measurements of oral health, and subjective complaints of oral problems were assessed in different-aged, healthy persons. Results suggest that the comparison of major salivary gland flow rates of an individual with population standards to identify patients susceptible to the effects of salivary dysfunction is unreliable. Changes in salivary function over time are a more meaningful gauge of the impact of saliva on oral health. The clinician should monitor salivary production to identify patients with declining salivary gland output.

The elderly represent the most rapidly growing segment of the U.S. population, and the majority of this group are females. The average woman can anticipate living about a third of her life beyond menopause, and many U.S. women undergo hormonal replacement in an attempt to relieve menopausal symptoms. Little is understood about the relationship between menopause, hormonal replacement therapy, and the oral structures, although oral discomfort, xerostomia, and salivary hypofunction have been associated with postmenopausal women. The effects of menopausal status and estrogen therapy on subjective reports of oral dryness and discomfort and objective measurements of major salivary gland output were assessed in 43 healthy premenopausal and postmenopausal females. No complaints of xerostomia or burning mouth and no alterations in the quantity of saliva occurred in this population. This study suggests that among healthy women salivary gland function is not significantly influenced by menopause or hormonal replacement therapy.

This two armed, self-controlled, investigator blinded, clinical study tested the efficacy of an ultraviolet (UV) light toothbrush holder (Violight) to decrease toothbrush bacterial contamination.25 subjects were randomly assigned to control or experimental groups and received two toothbrushes for home use on either even or odd days. The control group rinsed both toothbrushes after use in cold tap water with no mechanical manipulation. The experimental group rinsed one toothbrush in cold running water while storing the other toothbrush in the Violight toothbrush holder after use. The toothbrushes were returned after 2 weeks use in sealed plastic bags and were analyzed for the number of colony forming units (CFU) of S. mutans, S. salivarius, lactobacilli, E. coli, and other coliforms, and total bacterial counts by culture. An additional analysis of the total bacterial profile was performed using denaturing gradient gel electrophoresis (DGGE).The Violight toothbrush holder reduced total CFU by an average of 86% (ANCOVA, P = 0.037). In addition, a tendency was noted for a reduction in total bacterial population as detected by DGGE.

Background The objective of this literature review is to summarize information about the etiology, diagnosis, oral sequelae and treatment of dry mouth in elderly patients. Types of Studies Reviewed The authors conducted a comprehensive review of the English-based scientific literature from the past 10 years. They selected the studies on the basis of clinical investigations to provide an objective assessment of dry mouth problems among older people. Results Dry mouth (salivary hypofunction, xerostomia) is a common problem among older people. It causes significant oropharyngeal disorders, pain and an impaired quality of life. Dry mouth has many causes, from local salivary disorders to a plethora of medications and medical conditions. Treatments are designed to correct the underlying cause and/or to enhance salivation with topical and systemic stimulants. Early intervention for dry mouth problems helps prevent the deleterious consequences of this disorder in elderly people. Clinical Implications Clinicians must be aware of dry mouth problems in older patients, and they should be prepared to provide a diagnosis and administer treatment to protect a patient's oropharyngeal health and quality of life.

Submandibular salivary glands (SMGs) dysfunction contributes to xerostomia after radiotherapy (RT) of head-and-neck (HN) cancer. We assessed SMG dose-response relationships and their implications for sparing these glands by intensity-modulated radiotherapy (IMRT).A total of 148 HN cancer patients underwent unstimulated and stimulated SMG salivary flow rate measurements selectively from Wharton's duct orifices, before RT and periodically through 24 months after RT. Correlations of flow rates and mean SMG doses were modeled throughout all time points. IMRT replanning in 8 patients whose contralateral level I was not a target incorporated the results in a new cost function aiming to spare contralateral SMGs.Stimulated SMG flow rates decreased exponentially by (1.2%)(Gy) as mean doses increased up to 39 Gy threshold, and then plateaued near zero. At mean dosesor =39 Gy, but not higher, flow rates recovered over time at 2.2%/month. Similarly, the unstimulated salivary flow rates decreased exponentially by (3%)(Gy) as mean dose increased and recovered over time if mean dose was39 Gy. IMRT replanning reduced mean contralateral SMG dose by average 12 Gy, achievingor =39 Gy in 5 of 8 patients, without target underdosing, increasing the mean doses to the parotid glands and swallowing structures by average 2-3 Gy.SMG salivary flow rates depended on mean dose with recovery over time up to a threshold of 39 Gy. Substantial SMG dose reduction to below this threshold and without target underdosing is feasible in some patients, at the expense of modestly higher doses to some other organs.

Diabetes is a common disease with concomitant oral manifestations that impact dental care. The purpose of this review is to summarize the prevalence, signs, symptoms, diagnosis and treatment of diabetes, as well as dental treatment considerations for the patient with diabetes.Safely managing the patient with diabetes requires effective communication among multiple health care providers. Dentists must be familiar with techniques to diagnose, treat and prevent stomatological disorders in patients with diabetes.Dental practitioners will be treating more patients with diabetes in the future, and this article provides an overview of the systemic and oral aspects of the disease that impact dental treatment.

The oral hard and soft tissues assist in three essential functions in human physiology: (1) the initiation of alimentation, (2) protection of the host, and (3) communication. The teeth, the periodontium, the alveolar supporting bone, and the mucosal soft tissues exist to prepare food for deglutition. The oral cavity is exposed to the external world and is potentially vulnerable to a limitless number of environmental insults. Accordingly, oral mucosal tissues in addition to saliva and a complex array of neuroand chemo-sensory tissues provide host defense against a plethora of potential dangerous microbes and noxious compounds. They also contribute to the enjoyment of food and alert a person to potential problems. The tongue, muscles of facial expression and mastication, and oral mucosal tissues enable speech and communication. Importantly, the activities of the oral hard and soft tissues, muscles of mastication and facial expression, and neuroand chemo-sensory tissues are finely coordinated, and a disturbance in any one function can significantly compromise speech, alimentation, host defense, and diminish the quality of a patient’s life. With the increased longevity of many older populations in the world, there has arisen greater risk for developing oral disorders. Furthermore, significant increases in the retention of teeth have occurred in recent decades (Beltran-Aguilar et al., 2005), which has resulted in a greater number of tooth surfaces at risk for dental decay and periodontal diseases in older populations. Therefore, there is a greater burden on health care practitioners to prevent, identify and expeditiously treat oral hard and soft tissue disorders in older adults. Prompt treatment and identification of these disorders will prevent the development of problems with