[Help, I can't burp! A brief overview and case discussion of retrograde cricopharyngeal dysfunction]. / Hilfe, ich kann nicht rülpsen: Falldarstellung und Kurzübersicht zur retrograden krikopharyngealen Dysfunktion.

In this short communication, we discuss the recently described syndrome of retrograde cricopharyngeal dysfunction (R-CPD) with its first description in 2019 by the laryngologist Dr. Bastian. Diagnosis is generally based on typical clinical symptoms, e.g., the inability to belch, a bloated abdomen and retrosternal gurgling noises. We also describe high-resolution esophageal manometry as a new tool to further secure the diagnosis of R­CPD, as well as therapeutic options such as botulinum toxin injections in the cricopharyngeal muscle or cricopharyngeal myotomy and the published data thereon.

Consensus for voice quality assessment in clinical practice: guidelines of the European Laryngological Society and Union of the European Phoniatricians.

INTRODUCTION: To update the European guidelines for the assessment of voice quality (VQ) in clinical practice. METHODS: Nineteen laryngologists-phoniatricians of the European Laryngological Society (ELS) and the Union of the European Phoniatricians (UEP) participated to a modified Delphi process to propose statements about subjective and objective VQ assessments. Two anonymized voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 3/4. The statements with ≥ 3/4 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected. RESULTS: Of the 90 initial statements, 51 were validated after two voting rounds. A multidimensional set of minimal VQ evaluations was proposed and included: baseline VQ anamnesis (e.g., allergy, medical and surgical history, medication, addiction, singing practice, job, and posture), videolaryngostroboscopy (mucosal wave symmetry, amplitude, morphology, and movements), patient-reported VQ assessment (30- or 10-voice handicap index), perception (Grade, Roughness, Breathiness, Asthenia, and Strain), aerodynamics (maximum phonation time), acoustics (Mean F0, Jitter, Shimmer, and noise-to-harmonic ratio), and clinical instruments associated with voice comorbidities (reflux symptom score, reflux sign assessment, eating-assessment tool-10, and dysphagia handicap index). For perception, aerodynamics and acoustics, experts provided guidelines for the methods of measurement. Some additional VQ evaluations are proposed for voice professionals or patients with some laryngeal diseases. CONCLUSION: The ELS-UEP consensus for VQ assessment provides clinical statements for the baseline and pre- to post-treatment evaluations of VQ and to improve collaborative research by adopting common and validated VQ evaluation approach.

[Patient-reported outcome measures for assessing health-related quality of life in patients with voice and swallowing disorders]. / Patient-Reported Outcome Measures zur Erfassung der gesundheitsbezogenen Lebensqualität bei Patienten mit Stimm- und Schluckstörungen.

Standardized and validated patient surveys in the form of questionnaires are becoming increasingly important in otorhinolaryngology. Subjective symptoms and functional limitations but also health-related quality of life are assessed with so-called patient-reported outcome measures (PROMs). Besides patient history and objective findings, these questionnaires can be applied as another important source for ensuring the quality of patient-centered care. In German-speaking countries there are now several PROMs that specifically ask for the patient perspective on voice and swallowing disorders. For patients with voice disorders the following questionnaires based on the Voice Handicap Index (VHI), which are also used internationally, are mainly applied: VHI-30, VHI-12i, and VHI-9i. In the field of oropharyngeal dysphagia, the German versions of the Eating Assessment Tool-10 (EAT-10), des Sydney Swallow Questionnaire SSQ­G, the Swallowing Quality of Life Questionnaire (SWAL-QoL), and the MD Anderson Dysphagia Inventory (MDADI) are currently mostly used.

[Current possibilities and challenges in the treatment of laryngopharyngeal reflux]. / Aktuelle Möglichkeiten und Herausforderungen bei der Therapie des laryngopharyngealen Refluxes.

Laryngopharyngeal reflux (LPR) is characterized by backflow of gastric or gastroduodenal content and gases into the upper aerodigestive tract, which can damage the mucus membranes of the larynx and pharynx. It is associated with a variety of symptoms such as retrosternal burning and acid regurgitation, or other unspecific symptoms such as hoarseness, globus sensation, chronic cough, or mucus hypersecretion. Due to the lack of data and the heterogeneity of studies, diagnosis of LPR is problematic and challenging, as recently discussed. Moreover, the different therapeutic approaches are also discussed controversially in the face of the poor evidence base, and include pharmacologic and conservative dietary measures. Hence, in the following review, the available options for treatment of LPR are critically discussed and summarized for daily clinical use.

[Transcultural German translation of the reflux symptom score-12 questionnaire]. / Transkulturelle deutschsprachige Übersetzung des Fragebogens Reflux Symptom Score-12.

In addition to clinical and instrumental methods as well as medical history, questionnaires are well-established tools in the diagnosis of laryngopharyngeal reflux (LPR). Recently, the reflux symptom score (RSS) as well as the short version of it, the RSS-12, which are self-administered patient-reported outcome questionnaires, have been published as an alternative to the well-established reflux symptom index (RSI). The RSS-12 assesses severity and frequency of LPR symptoms as well as the impact on quality of life and has been shown to have high reliability and validity. However, so far, only French, English, and Portuguese versions of the RSS-12 have been published. Hence, the aim of this study was to prepare a transcultural German translation of the RSS-12 (G-RSS-12) to provide a new clinical and scientific tool for the diagnosis of LPR in German-speaking regions.

[Office-based phonosurgery]. / Ambulante Phonochirurgie.

Significant and new impulses regarding the treatment concept for outpatient phonosurgery on unsedated patients are currently coming from various Anglo-American authors. These "office-based procedures" have been propagated as an alternative to many conventional surgical interventions under anesthesia. The main reason for this remarkable development is the use of new endoscopic techniques in combination with photoangiolytic laser (KTP and blue laser), which allow safe and efficient phonosurgical procedures. Patient acceptance is high since outpatient procedures are considered to have a lower surgical risk. Despite the widespread euphoria, there is a lack of studies evaluating the medical decision criteria and safety management of office-based laryngeal surgery.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology.

INTRODUCTION: Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies. RECOMMENDATIONS: This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with. CONCLUSIONS: The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online ( https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf ).

Assessment of Surgical Complications With Respect to the Surgical Indication: Proposal for a Novel Index.

Introduction: The Clavien-Dindo classification is a broadly accepted surgical complications classification system, grading complications by the extent of therapy necessary to resolve them. A drawback of the method is that it does not consider why the patient was operated on primarily. Methods: We designed a novel index based on Clavien-Dindo but with respect to the surgical indication. We surveyed an international panel of otolaryngologists who filled out a questionnaire with 32 real case-inspired scenarios. Each case was graded for the surgical complication, surgical indication, and a subjective rating whether the complication was acceptable or not. Results: Seventy-seven otolaryngologists responded to the survey. Mean subjective rating and surgical complication grading for each scenario showed an inverse correlation (r 2 = 0.147, p = 0.044). When grading the surgical complication with respect to the surgical indication, the correlation with the subjective rating increased dramatically (r 2 = 0.307, p = 0.0022). Conclusion: We describe a novel index grading surgical complications with respect to the surgical indication. In our survey, most respondents judged a complication as acceptable or not according to its grade but kept in mind the surgical indication. This subjective judgment could be quantified with our novel index.

Fundamental Frequency and Intensity Effects on Cepstral Measures in Vowels from Connected Speech of Speakers with Voice Disorders.

OBJECTIVE: Cepstral peak prominence (CPP) and smoothed CPP (CPPS) have been described as reliable parameters to detect overall dysphonia in standardized connected speech samples. Recent studies indicate that vocal intensity (sound pressure level, SPL) and fundamental frequency (fo) changes may influence cepstral measurement results in healthy speakers. The main aim of the present work was to investigate the effects of prosody related SPL and fo variations on cepstral measures in speech of adults with voice disorders. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Recordings of CAPE-V sentences from 27 voice disordered Brazilian Portuguese speakers (19 women, eight men) with a mean age of 45 years (SD = 13) were investigated. Five /a/ vowels were manually extracted from stressed syllables in different positions. Voice fo (Hz), SPL (dBA), CPP (dB), and CPPS (dB) were computed using PRAAT. Statistical analysis included Linear Mixed Models with ANCOVA and Bonferroni post hoc tests. RESULTS: Voice SPL as single factor and combined with fo had a highly significant effect (P ≤ 0.001), while fo alone had no significant impact on both CPP and CPPS (P ≥ 0.77). Voice fo, SPL, CPP, and CPPS of the first vowel were all significantly lower than of the last vowel (P ≤ 0.03). CONCLUSION: In vowel samples from connected speech of adults with voice disorders, we observed better CPP and CPPS in higher voice SPL alone and combined with higher fo. Further, the vowel position influenced the present results. A larger clinical study should confirm how prosody related SPL and fo and vowel position effects could be controlled for in connected speech samples.

Effects of Fundamental Frequency, Vocal Intensity, Sample Duration, and Vowel Context in Cepstral and Spectral Measures of Dysphonic Voices.

Purpose Smoothed cepstral peak prominence (CPPS) and harmonics-to-noise ratio (HNR) are acoustic measures related to the periodicity, harmonicity, and noise components of an acoustic signal. To date, there is little evidence about the advantages of CPPS over HNR in voice diagnostics. Recent studies indicate that voice fundamental frequency (F0) and intensity (sound pressure level [SPL]), sample duration (DUR), vowel context (speech vs. sustained phonation), and syllable stress (SS) may influence CPPS and HNR results. The scope of this work was to investigate the effects of voice F0 and SPL, DUR, SS, and token on CPPS and HNR in dysphonic voices. Method In this retrospective study, 27 Brazilian Portuguese speakers with voice disorders were investigated. Recordings of sustained vowels (SVs) /a:/ and manually extracted vowels (EVs) /a/ from Consensus Auditory-Perceptual Evaluation of Voice sentences were acoustically analyzed with the Praat program. Results There was a highly significant effect of F0, SPL, and DUR on both CPPS and HNR (p < .001), whereas SS and vowel context significantly affected CPPS only (p < .05). Higher SPL, F0, and lower DUR were related to higher CPPS and HNR. SVs moderately-to-highly correlated with EVs for CPPS, whereas HNR had few and moderate correlations. In addition, CPPS and HNR highly correlated in SVs and seven EVs (p < .05). Conclusion Speaking prosodic variations of F0, SPL, and DUR influenced both CPPS and HNR measures and led to acoustic differences between sustained and excised vowels, especially in CPPS. Vowel context, prosodic factors, and token type should be controlled for in clinical acoustic voice assessment.

Cervical Spine Disability in Correlation with Subjective Voice Handicap in Patients With Voice Disorders: A Retrospective Analysis.

OBJECTIVE: Neck muscle dysfunction has been considered as risk factor or consequence of voice disorders. This study investigates the correlation between neck and voice-related subjective symptoms in patients with voice disorders. STUDY DESIGN: Retrospective case-control study. METHODS: 100 adult patients (59 female and 41 male) over 18 years with a mean age of 50.01 years (SD 16, range 24-87), of which 68 were under 60 years, were included. 50 patients had organic voice pathologies and 50 functional dysphonia. Outcome measures were the Voice Handicap Index 9 international (VHI-9i) and the Neck Disability Index (NDI-G). Spearman rank order coefficient was applied to determine the correlation between overall and single item VHI and NDI results. Subanalyses were done for functional vs. organic disorder, gender and age ± 60 years. RESULTS: Mean overall VHI-9i (13.93, SD = 7.81, range = 0-31) and mean NDI-G (6.07, SD = 7.71, range = 0-43) showed a significant mild correlation (rs = 0.220, P = 0.02). Split into subgroups the relation was stronger in patients with organic pathologies (rs = 0.297, P = 0.03), but not significant in functional disorders (r = 0.148, P = 0.30). There was a moderate relation in men (rs = 0.317, P = 0.04). Single item correlation was highest between VHI-9i item P4 (physiological) and NDI-G item reading (cognitive functioning) (rs = 0.480, P = 0.002). CONCLUSION: Specifically patients with organic voice disorders showed increased voice symptoms with the presence of neck dysfunction. This indicates a risk for a functional imbalance of the muscles surrounding the larynx, which in extreme cases may hinder functional voice rehabilitation even after phonosurgery. Therefore, neck dysfunction should be considered in voice diagnostics.

Reliable acoustic measurements in children between 5;0 and 9;11 years: Gender, age, height and weight effects on fundamental frequency, jitter and shimmer in phonations without and with controlled voice SPL.

BACKGROUND: Current pediatric voice assessment guidelines include instrumental measurements of fundamental frequency (F0) and the perturbation indices jitter and shimmer. In children below 10 years, gender, age, height and weight effects on these parameters have been inconsistently characterized. Recent research in healthy children showed, that differences in habitual speaking voice intensity (voice SPL) under the usual assessment procedure significantly affect jitter and shimmer. These effects were reduced in phonations with controlled voice SPL >80dBA. Reliable measurement methods and description of physiologic influencing factors are essential to identify pathologic voices. OBJECTIVE: This cross-sectional single cohort study investigates in children between 5;0 and 9;11 years how gender, age, height and weight affect voice F0, jitter and shimmer in phonations at individually "medium" voice intensity (modeling the usual clinical practice) and with controlled voice SPL >80dBA. SUBJECTS AND METHODS: 68 vocally healthy children (39 f/29 m) aged 5;0-9;11 years provided 3 prolonged phonations of/a/at individually "medium" and controlled voice intensity at ">80dBA" (visual feedback, 10cm distance). F0 (Hz), jitter (%), shimmer (%) and voice SPL (dBA) were determined with PRAAT. Gender, age, height and weight effects without and with controlled voice SPL were assessed by descriptive statistics, Analysis of Variance and Linear Mixed Models. RESULTS: F0 (Hz), jitter (%), shimmer (%) and voice SPL (dBA) were significantly different in medium voice compared to >80dBA (p<0.01). In medium phonations girls had a higher F0 than boys (girls: 276.7(50.7), boys: 261.5(33.7)), but with >80dBA this difference was only minimal (girls: 328.9(52.2), boys 327.9(51.2)). Mean jitter (0.27(0.10)) and shimmer (4.34(1.68)) were smaller and showed less spread (jitter: 0.5(0.26); shimmer: 9.47(3.47)) with >80dBA. Gender, age, height and weight had no significant effects on F0, jitter, shimmer and voice SPL in both phonation types (p-range=0.42-0.99). CONCLUSIONS: Neither without nor with controlled voice SPL there were systematic gender, age, height or weight effects on voice F0, jitter and shimmer. Gender related F0 discrepancies were equalized in phonations with >80dBA. In children below 10 years gender related acoustic voice differences may be mainly linked to behavior, which should be considered in future works regarding physiologic voice development.

Clinical relevance of speaking voice intensity effects on acoustic jitter and shimmer in children between 5;0 and 9;11 years.

BACKGROUND: Current voice assessment recommendations for dysphonic children comprise instrumental acoustic measurements of the perturbation parameters jitter and shimmer. In healthy adults and children changes in speaking voice sound pressure level (voice SPL) have significant confounding effects on both parameters. In adults these effects were considerably reduced in phonations with controlled voice SPL >80dBA (10cm distance). However, it is unclear if these findings apply to children and if children are able to control for their own voice intensity. OBJECTIVE: This cross-sectional single cohort study investigates voice SPL effects on jitter and shimmer in children between 5;0 and 9;11 years phonating at individually "medium" (modeling "comfortable" loudness of the usual clinical protocol), "soft" and "loud" voice and a prescribed intensity level of ">80dBA" (10cm distance, with visual control). Further both their ability to phonate at a prescribed voice intensity level and the effect on SPL related confounding effects were studied. SUBJECTS AND METHODS: A total of 68 healthy children (39 f/29m) aged 5;0 to 9;11 years were included. All phonated the vowel/a/for 5s, three times at four defined voice intensity levels (soft/medium/loud/>80dBA) each. Jitter (%), shimmer (%) and voice SPL (dBA) were determined using PRAAT. Voice intensity level effects were assessed by descriptive statistics, Analysis of Variance (ANOVA) and Linear Mixed Models (LMM). RESULTS: There were significant differences for jitter and shimmer between all voice tasks (p<.01). Jitter and shimmer were lowest and showed the smallest spread in controlled phonations ">80dBA". 19 children below 7;0 years could not perform the voice tasks and were excluded from the study. CONCLUSIONS: This practical study demonstrated a significant effect of voice loudness and task on jitter and shimmer in children. Since the observed confounding effects were large compared to treatment effects, jitter and shimmer may not be meaningful without adequate control of voice SPL. In phonations at ">80dBA" (10cm distance) voice SPL related effects were considerably reduced. However, this assessment protocol was suitable only for children above 7;0 years. Application of this task to future studies of dysphonic children may yield clinically valuable information.

Effect of supraglottic and super-supraglottic swallows on tongue pressure production against hard palate.

The objectives of this study were to evaluate the state of tongue pressure production during supraglottic swallow (SS) and super-supraglottic swallow (SSS) performed by healthy adults, and to investigate the effects of these swallowing maneuvers on the oral stage of swallowing. The participants were 19 healthy individuals. Tongue pressure against the hard palate during swallowing was measured using a tongue pressure sensor sheet system with five pressure-sensitive points. The tasks comprised swallowing 5 mL of water by normal wet swallow, SS, and SSS, and the parameters for analysis were the duration, the maximal magnitude, and the integrated value of tongue pressure during swallowing. The duration of tongue pressure was significantly longer at the anterior-median part of the hard palate during both SS and SSS than with normal wet swallow. The maximal magnitude increased significantly only at the posterior part of the hard palate during SS, but at all points during SSS. The integrated value increased significantly only at the posterior-median part of the hard palate during SS, but at all points except the mid-median part of the hard palate during SSS. The maximal magnitude and integrated value were also significantly higher at the anterior-median and posterior circumferential parts during SSS than during SS. These results show that these two swallowing maneuvers, which are known primarily as techniques to protect the airway, also function to strengthen the tongue pressure produced by the contact between the tongue and the hard palate during swallowing and this effect is more pronounced during SSS.

Diagnostic and therapeutic pitfalls in benign vocal fold diseases.

More than half of patients presenting with hoarseness show benign vocal fold changes. The clinician should be familiar with the anatomy, physiology and functional aspects of voice disorders and also the modern diagnostic and therapeutic possibilities in order to ensure an optimal and patient specific management. This review article focuses on the diagnostic and therapeutic limitations and difficulties of treatment of benign vocal fold tumors, the management and prevention of scarred vocal folds and the issue of unilateral vocal fold paresis.

A genetic basis for mechanosensory traits in humans.

In all vertebrates hearing and touch represent two distinct sensory systems that both rely on the transformation of mechanical force into electrical signals. There is an extensive literature describing single gene mutations in humans that cause hearing impairment, but there are essentially none for touch. Here we first asked if touch sensitivity is a heritable trait and second whether there are common genes that influence different mechanosensory senses like hearing and touch in humans. Using a classical twin study design we demonstrate that touch sensitivity and touch acuity are highly heritable traits. Quantitative phenotypic measures of different mechanosensory systems revealed significant correlations between touch and hearing acuity in a healthy human population. Thus mutations in genes causing deafness genes could conceivably negatively influence touch sensitivity. In agreement with this hypothesis we found that a proportion of a cohort of congenitally deaf young adults display significantly impaired measures of touch sensitivity compared to controls. In contrast, blind individuals showed enhanced, not diminished touch acuity. Finally, by examining a cohort of patients with Usher syndrome, a genetically well-characterized deaf-blindness syndrome, we could show that recessive pathogenic mutations in the USH2A gene influence touch acuity. Control Usher syndrome cohorts lacking demonstrable pathogenic USH2A mutations showed no impairment in touch acuity. Our study thus provides comprehensive evidence that there are common genetic elements that contribute to touch and hearing and has identified one of these genes as USH2A.

Feeding dystonia in McLeod syndrome.

BACKGROUND: The X-linked McLeod syndrome belongs to the group of neuroacanthocytosis syndromes and has a Huntington-disease-like phenotype with a choreatic movement disorder, cognitive alterations, and psychiatric symptoms. Another neuroacanthocytosis syndrome, the autosomal recessive chorea-acanthocytosis, has a similar presentation, but distinct clinical features, believed to be characteristic, such as tongue protrusion dystonia, feeding dystonia, and rubber-man-like appearance. METHODS: This work comprised a case series of 3 patients with McLeod syndrome. RESULTS: The 3 patients with McLeod syndrome developed severe feeding dystonia and tongue protrusion as well as rubber-man-like appearance in 1 patient during the course of the disease. CONCLUSION: These observations indicate that there is an extended phenotypic overlap between McLeod syndrome and chorea-acanthocytosis.

Significance of salivary adrenomedullin in the maintenance of oral health: stimulation of oral cell proliferation and antibacterial properties.

Adrenomedullin (ADM) promotes epithelial cell proliferation and antimicrobial activity in the gastrointestinal tract. Since ADM is also present in saliva, it was the objective of our study to investigate the role of salivary ADM in the maintenance of oral health. We found mRNA for ADM and the specific receptors CRLR-RAMP2 and CRLR-RAMP3 expressed by the salivary glands and by oral keratinocytes. The hormone was detected in the glandular tissues by western blot, being slightly bigger than the synthetic peptide, indicating a posttranslational modification. ADM was localized using immunohistochemistry and immunofluorescence. Staining specific for ADM was observed near the cell nuclei of the salivary ducts and acini. There was no correlation between ADM from matched saliva and serum of healthy volunteers. The physiological role of salivary ADM in the oral cavity was investigated by incubating buccal keratinocytes with ADM and measurement of the cell proliferation using bromodeoxyuridine (BrDU) assays. There was a significant, dose dependent increase (up to 5-fold; p<0.001) of the BrDU incorporation after stimulation with ADM (1.5 to 50 ng/mL). The antibacterial properties of salivary ADM was studied by incubation of Gram+ and Gram- bacteria and yeast, isolated from human oral flora, with ADM (0.01-1000 ng/mL) for 24 h. Bacterial growth was inhibited dose dependently (p<0.001), whereas the yeast was not affected. This finding was consistent when using radial growth inhibition test on agarose plates as well as photometric measurement in microtiter plates. Our findings suggest an important role of salivary ADM in the maintenance of oral health, being involved as well as in oral cell proliferation and anti-bacterial defense.

Identification of ghrelin in human saliva: production by the salivary glands and potential role in proliferation of oral keratinocytes.

BACKGROUND: We investigated whether ghrelin is present in human saliva, is produced by salivary glands, and physiologic consequences of these findings. METHODS: Expression of ghrelin and specific receptor mRNA was determined by PCR. Proteins were identified by immunoblotting and size-exclusion fast protein liquid chromatography (FPLC) with consecutive RIA. Specific RIAs were used for quantification of salivary total and bioactive ghrelin. Distribution of ghrelin was investigated by immunohistochemistry in cryosections of the salivary glands. The effect of ghrelin on incorporation of 5-bromo-2'-deoxyuridine as a measure of cell proliferation was investigated in primary oral keratinocytes. RESULTS: Ghrelin is produced by the salivary glands. The hormone was identified in saliva and glands by immunoblotting and by FPLC fractionation of saliva. Immunohistochemistry demonstrated ghrelin distribution in the salivary glands. The receptor was also produced by the glands and by oral keratinocytes and was shown to be functional. Comparison of total ghrelin values for healthy individuals (body mass index, 18-27 kg/m2) showed significantly lower concentrations in saliva than in serum (P < 0.01). The correlation between both matrices was r2 = 0.56 (P < 0.001) with a negative correlation to body mass index (r2 = 0.314; P < 0.01). Bioactive acylated ghrelin was also present in saliva. Incubation of keratinocytes with ghrelin led to significantly increased cell proliferation (P < 0.001). This effect could be completely suppressed by co-incubation with NOX-B11 (50 nmol/L), a novel specific inhibitor of acylated ghrelin. CONCLUSIONS: Ghrelin in saliva is produced and released by salivary glands. The effect of ghrelin on oral cell proliferation adds to the pro-proliferative action of other salivary growth factors.