Oral Candida colonization in xerostomic postradiotherapy head and neck cancer patients.

OBJECTIVES: To evaluate (a) oral colonization of Candida species, especially for non-albicans Candida species (NACS), in xerostomic postradiotherapy head and neck cancer patients and (b) risk factors affecting their colonization. MATERIALS AND METHODS: Subjective and objective dry mouth scores, stimulated salivary flow rates, pH and buffering capacity were measured in 72 xerostomic postradiotherapy head and neck cancer patients. Candida counts and species identification were performed using oral rinse samples cultured in Candida Chromagar, followed by polymerase chain reaction and API 20C AUX system. RESULTS: Candida colonization was observed in 87.5% of subjects, with 80.6% and 48.6% of study population colonized by C. albicans and NACS, respectively. NACS was associated with high objective dry mouth scores, denture use, and females (p = .006, .009, and .036, respectively). In addition, Candida glabrata was detected more in females (p = .018) and denture wearers (p = .026), while Candida tropicalis was associated with high objective dry mouth scores (p = .022) and females (p = .027). Quantity of Candida colonization correlated positively with objective dry mouth scores (r = 0.599, p < .001) and negatively with salivary flow rates (r = -0.258, p = .041) and pH (r = -0.290, p = .022). CONCLUSION: NACS colonization was common in xerostomic head and neck cancer patients. Increased signs of dry mouth, female and dental prostheses may promote NACS colonization.

Irradiation-induced secretion of BMP4 by marrow cells causes marrow adipogenesis post-myelosuppression.

Pre-transplant myeloablation is associated with marrow adipogenesis, resulting in delayed engraftment of hematopoietic stem cells (HSCs). This is strongly undesirable, especially when the donor HSCs are fewer in numbers or have compromised functionality. The molecular mechanisms behind irradiation-induced marrow adipogenesis have not been extensively investigated. Here we show that bone marrow (BM) cells, especially T-cells and stromal cells, express and secrete copious amounts of BMP4 in response to irradiation, which causes the bone marrow stromal cells to commit to adipocyte lineage, thereby contributing to an increase in bone marrow adipogenesis. We further demonstrate that Simvastatin inhibits the BMP4-mediated adipogenic commitment of marrow stromal cells by inhibiting Ppar-γ expression. Importantly, Simvastatin does not prevent BMP4 secretion by the BM cells, and thus does not interfere with its salutary role in post-transplant hematopoietic regeneration. Our data identify previously unknown mechanisms operative in marrow adipogenesis post-myeloablation. They also reveal the molecular mechanisms behind the advantage of using Simvastatin as a niche-targeting agent to improve HSC engraftment.

Effectiveness of Positioning Stents in Radiation-Induced Xerostomia in Patients with Tongue Carcinoma: A Randomized Controlled Trial.

PURPOSE: The aim of this study was to perform an objective and subjective evaluation of the efficacy of positioning stents in radiation-induced xerostomia in patients with tongue carcinoma. MATERIALS AND METHODS: A total of 30 patients with tongue carcinoma and undergoing conventional radiotherapy were randomly assigned to control (n = 15) and study (n = 15) groups, without and with a positioning stent, respectively. Assessment of salivary output reduction was done before and after radiotherapy, at 3- and 6-month intervals, by measurement of unstimulated and stimulated salivary flow rates (objective evaluation). Xerostomia (subjective evaluation) was noted using six items from the Quality of Life Head and Neck Module (QLQ-H&N35) as proposed by the European Organization for Research and Treatment of Cancer. The significance level was set at .05. RESULTS: Mean unstimulated and stimulated salivary flow rates at 3- and 6-month intervals revealed significantly (P < .05) higher scores for the study group as compared with the control group. The mean quality of life scores in the study group were significantly (P < .05) lower compared with the control group. CONCLUSION: The use of a positioning stent minimized radiation-induced xerostomia and its symptoms.

Radiotherapy-induced xerostomia, pre-clinical promise of LMS-611.

PURPOSE: Radiotherapy-induced xerostomia (RIX) is the most common permanent side effect of radiotherapy (RT) to the head and neck (H&N). There is no effective topical treatment. LMS-611 is a mimetic of a natural lamellar body which prevents thick secretions like saliva from congesting organs. The primary objective of this study was to assess saliva properties before and during RT to the H&N. The secondary objectives were to re-assess saliva properties with the addition of LMS-611, measure inter-patient variability, correlate patient-reported symptoms with laboratory measurements and design subsequent first-in-human clinical trial of LMS-611. METHODS: Patients with H&N cancer receiving RT as primary treatment were recruited. Patients completed the Groningen RIX (GRIX) questionnaire and provided saliva samples at baseline and weeks 2, 4 and 6 of RT. Saliva adhesiveness and viscosity were tested by measuring time taken to travel 5 cm down an inclined plane. RESULTS: Thirty patients were enrolled. The inclined plane test (IPT) results (s) were as follows: baseline 31.3, week 2 49.7, week 4 51.1 and week 6 55.7. Wide inter-patient variability was seen at baseline. GRIX scores increased as RT progressed. Spearman rank correlation coefficient of inclined plane tests with GRIX scores was -0.06 at baseline, 0.25 at week 2, 0.12 at week 4 and 0.08 at week 6. LMS-611 concentrations of 10 and 20 mg/ml significantly reduced IPT times on saliva samples. CONCLUSIONS: Saliva becomes more visco-adhesive and RIX worsens as RT progresses. There is little correlation between objective and subjective measures of RIX. The addition of LMS-611 to thick, sticky saliva restores its fluidity ex vivo. This warrants in vivo analysis of the effect of LMS-611 upon RIX.

The impact of dairy consumption on salivary inoculum.

Quantitative levels of harmful oral microbes present following complex surgical excisions of head and neck cancer are important since wounds are often contaminated through direct connection to the oral cavity and its flora. This possibility is especially important in irradiated patients who have decreased protective salivary function. In addition, high oral microbial levels increase and intensify oral mucositis leading to significant morbidity in patients treated with radiation therapy. One previously untested surgical teaching to decrease the bacterial inoculum present in the oral cavity is to counsel patients against consuming otherwise nutritious dairy products, as they are thought to coat the oral cavity with rate-limiting nutrients vital for bacterial growth. This risk may extend to individuals with chronic laryngeal penetration or aspiration, since salivary bacterial load might represent a lethal threat in the presence of marginal pulmonary reserve. A crossover study using six healthy adult volunteers and six patients who had previously undergone radiation therapy to an oropharyngeal primary site was performed. Saliva samples were quantitatively cultured in both groups with and without the consumption of dairy products at 1-h and 5-h intervals. Analysis of quantitative cultures demonstrated that the consumption of dairy products had no influence on bacterial levels present in previously radiated subjects and nonirradiated controls. Additionally, the consumption of dairy did not affect the composition of microbes present. Due to the lack of changes in both quantity and composition of oral bacteria seen in this study, patients would not benefit from the avoidance of dairy products.

The influence of parotid gland sparing on radiation damages of dental hard tissues.

OBJECTIVE: The aim of the present study was to evaluate whether radiation damage on dental hard tissue depends on the mean irradiation dose the spared parotid gland is subjected to or on stimulated whole salivary flow rate. MATERIAL AND METHODS: Between June 2002 and October 2008, 70 patients with neck and cancer curatively irradiated were included in this study. All patients underwent dental treatment referring to the guidelines and recommendations of the German Society of Dental, Oral and Craniomandibular Sciences prior, during, and after radiotherapy (RT). During the follow-up period of 24 months, damages on dental hard tissues were classified according to the RTOG/EORTC guidelines. The mean doses (D(mean)) during spared parotid gland RT were determined. Stimulated whole saliva secretion flow rates (SFR) were measured before RT and 1, 6, 12, 24 months after RT. RESULTS: Thirty patients showed no carious lesions (group A), 18 patients developed sporadic carious lesions (group B), and 22 patients developed general carious lesions (group C). Group A patients received a D mean of 21.2 ± 11.04 Gy. Group B patients received a D(mean) of 26.5 ± 11.59 Gy and group C patients received a D(mean) of 33.9 ± 9.93 Gy, respectively. The D(mean) of group A was significantly lower than the D(mean) of group C (p < 0.001). Additionally, the mean SFR 6 months after RT of group A was significantly higher than the mean SFR of group C (p < 0.01). CONCLUSIONS: Irradiation damage on dental hard tissue correlates with increased mean irradiation doses as well as decreased salivary flow rates. CLINICAL RELEVANCE: Parotid gland sparing resulting in a dose below 20 Gy reduces radiation damage on dental hard tissues, and therefore, the dose may act as a predictor for the damage to be expected.

The effects of heparan sulphate mimetic RGTA-OTR4120 on irradiated murine salivary glands.

BACKGROUND: This study focuses on the potential of ReGeneraTing Agent OTR4120 (RGTA-OTR4120) to treat radiation-induced damage of salivary glands. RGTAs are biopolymers designed to mimic the effects of heparan sulphate, thereby stimulation tissue repair and regeneration. METHODS: C3H mice were irradiated with a single dose of 15 Gy in the head and neck region. RGTA-OTR4120 was injected 24 h after radiotherapy, followed by weekly injections. At 2, 6 and 10 weeks after radiotherapy, salivary flow rates were measured and animals were sacrificed to obtain parotid and submandibular glands for histology. Periodic acid Schiff stain was performed to visualize mucins that are produced by acinar cells. Amylase and total protein content were measured in saliva samples. RESULTS: Salivary flow rates were increased at 2 weeks, but not at 6 and 10 weeks after radiotherapy with RGTA-OTR4120 administration, compared to irradiated controls. Two and 10 weeks after radiotherapy, the mucin production activity of acinar cells was increased under influence of RGTA administration. RGTA-OTR4120 did not influence amylase or total protein secretion. CONCLUSION: RGTA-OTR4120 administration has a positive effect on salivary flow rates in irradiated mice on the short term. The effect was absent 10 weeks after radiotherapy, while at that time point, mucin producing activity of acinar cells was elevated by RGTA-OTR4120 administration. Given these results and the advantages of RGTA use in irradiated patients, further investigation on the potential of this drug to treat radiation-induced salivary gland damage, alone or in combination with other drugs, such as amifostine, is suggested.

Evaluation of saliva flow rates, Candida colonization and susceptibility of Candida strains after head and neck radiation.

Hyposalivation is a long-term effect in patients receiving head and neck radiation. Radiotherapy can predispose oral colonization by Candida species of the mucosa. This study aims to evaluate the correlation between hyposalivation, measured by unstimulated saliva flow rates (SFR) and fungal colonization of the oral cavity, and also the resistance of isolated Candida strains to antimicrobial therapy. Fifty-three consecutive patients with radiotherapy were examined for late radiation damage on dental hard tissue and the salivary glands (SFR over a period of 5 min). The SFR were divided into three different values of hyposalivation: grade I (SFR 0.1-0.25 ml/min), grade II (SFR ≤0.1 ml/min), and grade III (SFR = 0.0 ml/min). Candidal colonization was defined using Sabouraud agar and identified using API 20C AUX (biomerieux) in the patients' rinsing water. Susceptibility was tested with Etest (amphotericin B, ketoconacole, voriconacole, and fluconacole). Hyposalivation grade I was detected in 23% (9.1 × 10(1) colony forming units (cfu); range, 200-5,900 cfu), hyposalivation grade II in 26% (4.3 × 10(1) cfu; range, 110-3,300 cfu), and hyposalivation grade III in 51% (2.0 × 10(3) cfu; range, 300-19,475 cfu) of patients. A significant correlation between the SFR and candidal colonization and clinical presentation (European Organization for Research and Treatment of Cancer (EORTC) score) was detected (Mann-Whitney test, p = 0.031). Twenty Candida albicans and 27 non-albicans species were identified. The resistance of C. albicans was higher than that of non-albicans strains against antimicrobial agents. By comparison, amphotericin B showed the greatest and fluconazole the least effect. A higher value of hyposalivation correlates with a higher risk of candidal colonization in patients who have received radiotherapy and also with a higher EORTC score. The spectrum of Candida is wide and susceptibility against antifungal therapy differs. In long-term examinations of patients with xerostomia after radiotherapy, the EORTC score can be used to measure hyposalivation. Reduced susceptibility of C. albicans might introduce complications to therapy. Findings of more non-albicans strains show a change in colonization which should be examined in further studies.

Long-term salivary function after conditioning with busulfan, fractionated or single-dose TBI.

OBJECTIVES: Does conditioning with fractionated total body irradiation (fTBI) or busulfan (Bu) causes less salivary dysfunction compared with single dose (sTBI) after hematopoietic stem cell transplantation (HSCT). PATIENTS AND METHODS: A total of 74 adolescents below 13 years of age received allogeneic HSCT and conditioning with either: sTBI, fTBI or Bu. The unstimulated (USSR) and stimulated (SSSR) whole salivary secretion rates were measured at 15 years of age. RESULTS: Irrespective of conditioning type, there were no significant differences in USSR or SSSR between groups. Girls had a significantly lower SSSR, 0.7 ± 0.3 ml per min compared with 1.1 ± 0.4 ml per min in boys (P < 0.001). A significant correlation between age at HSCT and SSSR at 15 years of age (P = 0.02) in children conditioned with sTBI was found as well as an inverse correlation between the plasma area under curve (AUC) of Bu and SSSR. In the multivariate model, only female sex was significantly correlated with low SSSR at 15 years of age (OR 3.93, 95% CI 1.21-12.79; P = 0.021). CONCLUSION: No differences in long-term whole salivary function after HSCT in adolescents receiving conditioning with sTBI, fTBI or Bu were found. Total systemic exposure to Bu was negatively correlated with stimulated salivary secretion.

Does hyperbaric oxygen treatment have the potential to increase salivary flow rate and reduce xerostomia in previously irradiated head and neck cancer patients? A pilot study.

Irradiated head and neck cancer survivors treated in the Hyperbaric Oxygen (HBO) Unit, Copenhagen University Hospital, spontaneously reported improvement of radiation-induced dry mouth feeling. The aim of this pilot study was to evaluate salivary flow rate and xerostomia before and after HBO in irradiated head and neck cancer patients. Eighty patients eligible for HBO treatment on the indication of prevention/treatment of osteoradionecrosis or soft tissue radiation injury were consecutively sampled, of whom 45 had hyposalivation (i.e. unstimulated whole saliva (UWS) flow rate <0.1ml/min), and 69 complained of xerostomia. UWS and stimulated whole saliva (SWS) were collected prior to and after 30 sessions of hyperbaric oxygen treatment over 6weeks. Xerostomia was assessed using the visual analogue scale (VAS). Each HBO session involved compression to 243kPa (2.4 ATA) for 90min while breathing 100% oxygen from a facemask or hood. There was a significant decrease in xerostomia (p<0.001) and slight increase in UWS (p<0.001) and SWS (p<0.001) flow rate, from before HBO as compared to after. Twenty-five of 45 patients with hyposalivation achieved an increased UWS flow rate after HBO. In 12 of these, the flow rates increased to levels not associated with hyposalivation. Patient-assessed improvement of xerostomia and slightly increased UWS and SWS secretion after HBO treatment suggest that HBO may have a beneficial effect on radiation-induced salivary gland damage.

Progress of oral sequelae during head-neck radiotherapy.

OBJECTIVE: To evaluate xerostomia, mucositis and dental caries during head and neck radiotherapy. METHODS: Twenty patients with nasopharyngeal carcinoma were included. Oral examinations were conducted before radiotherapy, after dosage of 2000 cGy irradiation, immediately after the termination of radiotherapy, and 1 month and 6 months after termination of the radiotherapy. Oral hygiene instruction, effective oral care and dental intervention were performed during the treatment. Salivary flow rate was evaluated by modified Schirmer's test. Xerostomia, mucositis and dental caries status were evaluated based on oral examinations. RESULTS: Salivary flow rate decreased significantly after the first dosage of 2000 cGy, and was aggravated with the increase in irradiation dosage until the termination of radiotherapy. Xerostomia and mucositis were observed in parallel with the reduction of saliva flow rate, and were aggravated with the increase in irradiation dosage. Mucositis began to recover within 1 month after the termination of radiotherapy and fully recovered within 6 months after the termination of the radiotherapy. Six months after the termination of irradiation, new carious lesions were detected in two patients. CONCLUSION: Oral sequelae developed during radiotherapy of the head and neck. Oral health instructions and effective intervention were essential before, during and after the radiotherapy.

Involvement of salivary glands in regulating the human nitrate and nitrite levels.

OBJECTIVE: To study the dynamic fluctuations of nitrate and nitrite content in humans following damage to major salivary glands. METHODS: Fifteen nasopharyngeal carcinoma patients, scheduled to undergo IMRT, were recruited. The prescription dose to GTV, CTV1 and CTV2, was 68, 60 and 54 Gy, respectively, in 30 fractions, 1 fraction/day. Saliva, serum and urine samples were collected at baseline, RT10, RT20 and at endpoint of radiation. Ions concentration was determined using ion chromatography. RESULTS: Salivary flow rates and nitrate content decreased over time (p<0.0001), whereas serum and urinary nitrite rose. Salivary nitrite increased transiently and then plateaued. Cumulative irradiation dose to salivary glands correlated with nitrate content in serum (p<0.0001), but not in saliva and urine (p=0.876 and p=0.175). The salivary flow rates correlated to the nitrate content in serum (p<0.0001), but not in saliva and urine (p=0.230 and p=0.428). CONCLUSIONS: Nitrate and nitrite contents in saliva, serum or urine changed in response to salivary gland damage. Salivary glands are associated with the metabolism of both ions in humans. The decreased serum nitrate appears to provide adjuvant information about salivary dysfunction.

The influence of handheld mobile phones on human parotid gland secretion.

BACKGROUND: Handheld mobile phones (MPHs) have become a 'cultural' accessory device, no less so than a wrist watch. Nevertheless, the use of MPHs has given rise to great concern because of possible adverse health effects from exposure to the radiofrequency radiation (RFR) emitted by the device. Previous studies suggested correlation between MPH and salivary gland tumors. OBJECTIVE: To evaluate whether MPH induces physiologic changes in the adjacent parotid gland, located on the dominant side, in terms of secretion rates and protein levels in the secreted saliva. MATERIALS AND METHOD: Stimulated parotid saliva was collected simultaneously from both glands in 50 healthy volunteers whose MPH use was on a dominant side of the head. RESULTS: A significantly higher saliva secretion rate was noticed in the dominant MPH side compared with that in the non-dominant side. Lower total protein concentration was obtained in the dominant compared with the non-dominant MPH side among the right dominant MPH users. CONCLUSIONS: Parotid glands adjacent to handheld MPH in use respond by elevated salivary rates and decreased protein secretion reflecting the continuous insult to the glands. This phenomenon should be revealed to the worldwide population and further exploration by means of large-scale longitudinal studies is warranted.

[Alterations in nocturnal melatonin secretion in patients with optic neuropathies]. / Alteraciones de la secreción nocturna de melatonina y neuropatías ópticas.

OBJECTIVE: To study nocturnal melatonin suppression induced by exposure to light in patients with bilateral optic neuropathies. METHODS: Observational, prospective case control study. Twenty patients were included in this study and distributed in 3 groups: Group A (n=5, Healthy Control Subjects), Group B (n=10, Experimental Patients) and Group C (n=5, Blind Control Subjects). LogMAR best-corrected visual acuity, standard automated perimetry mean deviation, retinal nerve fiber layer thickness by Optical Coherence Tomography and multifocal electroretinograpy (mfERG) were used to evaluate the changes. Melatonin was analysed in the saliva by radioimmunoassay after exposure to light (600 lux for 1 hour) (nocturnal melatonin suppression test). RESULTS: Statistically significant differences between the groups were found. No changes in the mfERG results were detected. The nocturnal melatonin suppression test was positive in all cases in Group A, 50% in Group B and none in Group C. CONCLUSIONS: Half of the patients with optic neuropathies and severe visual loss were shown to suffer significant melatonin regulation anomalies, probably due to the dysfunction of the intrinsically photosensitive retinal ganglion cells (ipRGC).

Effect of same-dose single or dual field irradiation on damage to miniature pig parotid glands.

AIM: To evaluate the effect of single or dual field irradiation (IR) with the same dose on damage to miniature pig parotid glands. METHODOLOGY: Sixteen miniature pigs were divided into two IR groups (n=6) and a control group (n=4). The irradiation groups were subjected to 20 Gy X-radiation to one parotid gland using single-field or dual-field modality by linear accelerator. The dose-volume distributions between two IR groups were compared. Saliva from parotid glands and blood were collected at 0, 4, 8 and 16 weeks after irradiation. Parotid glands were removed at 16 weeks to evaluate tissue morphology. RESULTS: The irradiation dose volume distributions were significantly different between single and dual field irradiation groups (t=4.177, P=0.002), although dose volume histogramin (DVH) indicated the equal maximal dose in parotid glands. Saliva flow rates from IR side decreased dramatically at all time points in IR groups, especially in dual field irradiation group. The radiation caused changes of white blood cell count in blood, lactate dehydrogenase and amylase in serum, calcium, potassium and amylase in saliva. Morphologically, more severe radiation damage was found in irradiated parotid glands from dual field irradiation group than that from single field irradiation group. CONCLUSION: Data from this large animal model demonstrated that the radiation damage from the dual field irradiation was more severe than that of the single field irradiation at the same dose, suggesting that dose-volume distribution is an important factor in evaluation of the radiobiology of parotid glands.

Effects of radiation and alpha-tocopherol on saliva flow rate, amylase activity, total protein and electrolyte levels in oral cavity cancer.

OBJECTIVE: The objective of the present study was to evaluate early and late effects of radiation and a-tocopherol on the secretion rate of saliva and on selected saliva salivary parameters in oral cavity cancer patients. PATIENTS & METHODS: Eighty-nine histologically confirmed oral cavity cancer patients (OCC) were enrolled in the study. Resting whole saliva was collected before, during and at the end of the radiation therapy (RT) and simultaneous supplementation with alpha - tocopherol to the radiation treated patients (RT + AT). RESULTS: Salivary flow rate, pH, amylase activity, total protein, sodium and potassium were analyzed. Increased pH, potassium and decreased flow rate, amylase activity, protein content and sodium were observed in 6 weeks of radiation treated patients when compared to OCC patients. A significant improvement of those parameters was observed on alpha - tocopherol supplementation in RT + AT patients. CONCLUSION: Supplementation with alpha - tocopherol improves the salivary flow rate thereby, maintains salivary parameters.

Effect of defocused infrared diode laser on salivary flow rate and some salivary parameters of rats.

This study aims to investigate whether infrared diode low-level laser therapy (LLLT) increased salivary flow rate and altered pH value, protein concentration, and peroxidase and amylase activities in saliva of rats. Wistar rats were used and divided into three groups. Experimental groups (A and B) had their parotid, submandibular and sublingual glands submitted to diode laser, 808-nm wavelength, on two consecutive days. The dose results were 4 and 8 J/cm(2), respectively. A red guide light was used to visualize the irradiated area. Group C was irradiated only with red pilot beam and served as control. The saliva samples were collected after each irradiation step (first and second collection days) and 1 week after the first irradiation (seventh day). Statistical analysis was performed, and differences were observed according to different days of salivary collection. The results showed that salivary flow rate for groups A and B was higher on the seventh day if it is compared to data obtained for the first day (p < 0.05). LLLT applications on salivary glands are a therapy procedure that requires further studies.

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

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