[A PhD completed. General conclusions of doctoral research into regional mouth dryness]. / Serie: Hora est. Algemene conclusies promotieonderzoek naar regionale monddroogte.

Dry mouth has a complex aetiology which makes proper diagnosis complicated. Until now, dry mouth diagnosis has mainly focused on the overall oral dryness, without taking into account regional differences within the mouth. This research showed, among other things, that there are unique patterns of oral dryness, each with its own cause. For example, patients suffering from Sjogren's syndrome mainly experienced dryness of the posterior of the palate. Patients with dry mouth due to the side effects of medication, in contrast, experienced the front part of the tongue as the driest. These findings suggest that mapping of intraoral dryness may be a useful diagnostic tool to differentiate between possible causes of dry mouth.

[Knowledge and attitude of oral care providers in the Netherlands on skin lesions]. / Kennis en attitude van mondzorgverleners over huidafwijkingen.

To gain insight into the current knowledge of oral care providers in the Netherlands on facial skin lesions, a survey was distributed to 7,670 oral care providers. Their knowledge was tested by means of 4 multiple-choice questions and on the basis of 5 cases. The survey was completed in full by 90 respondents. The median age was 50.3 years and 62.2% were female. During dental check-ups, 55.6% always examined the face and 41.1% sometimes did so. Compared to the group 41 years old and older, the group 21-40 years of age alerted their patients more often to skin lesions (p = 0.017), was more afraid a specialist would find the referral useless (p < 0.001) and was more in need of a guideline (p = 0.049). The respondents scored 1.90 out of 4 correct answers to the knowledge questions. On the case studies, they scored 1.46 out of 5 for the correct diagnosis, 3.48 out of 5 for the correct choice of policy and 1.01 out of 5 for the combination correct diagnosis and correct policy. The total score was 2.91 out of 9. The results indicate that knowledge on aspects of skin lesions is limited and additional training and the availability of a guideline are necessary.

Salivary film thickness and MUC5B levels at various intra-oral surfaces.

OBJECTIVES: In this study, we investigated the salivary film thickness and the MUC5B levels at various intra-oral locations in healthy volunteers, with a focus on the palate. Besides, measurements of the palatal surface area were included to explore the possible relationships between the palatal surface area and the palatal salivary film and MUC5B levels. MATERIALS AND METHODS: The salivary film thickness was determined using filter strips, which were pressed to the mucosal surfaces of five different intra-oral locations; conductance was then analysed using a Periotron. After elution of the strips, the MUC5B levels at various intra-oral locations were determined using ELISA. The palatal surface area was measured using an intra-oral scanner. The surface area was subsequently calculated using the software. RESULTS: The anterior tongue had the thickest salivary film and also the highest levels of MUC5B, while the anterior palate had the thinnest salivary film and lowest MUC5B levels. There was no association between the palatal surface area and the salivary film thickness of the palate. CONCLUSION: The salivary film and MUC5B levels are unequally distributed over the intra-oral regions of the soft tissues. The lack of association between the palatal surface area and the salivary film thickness indicates that a larger surface area is not associated with a relative thinner palatal salivary film. CLINICAL RELEVANCE: The results of the current study increase our understanding of saliva distribution in the oral cavity and could be used as reference values for future studies.

Correlations of palatal surface area with anthropometric dimensions of the head and face.

PURPOSE: Saliva distribution over the palatal surface plays an important role in the perception of dry mouth. It is envisaged that non-invasive estimation of the palatal surface area by anthropometric measurements of the head and face can be useful in the assessment of oral dryness. For this purpose, the relationship between the palatal surface area and anthropometric measurements of the head and face was investigated. METHODS: The palatal surface was measured in 51 healthy volunteers using an intra-oral scanner. The distances between anthropometric landmarks of the head and face were determined using an anatomical sliding caliper. Correlations between the palatal surface area and the anthropometric landmarks were investigated. RESULTS: The median palatal surface area for the total study population was found to be 2120.6 mm2. Virtually, all anthropometric measurements showed significant differences between females and males. Various head and face measurements had a significant correlation with the palatal surface area. However, these correlations disappeared when the participants were stratified based on their sex, with the exception of mandibular length and palatal width in females. CONCLUSION: The surface area of the palate correlates with nearly all anthropometric measurements of the head and face included in this study. Yet, the clinical applicability seems limited to females.

[Human papillomavirus vaccination available for boys also; information for oral healthcare providers]. / Humaan papillomavirus-vaccinatie nu ook beschikbaar voor jongens: informatie voor mondzorgverleners.

Recently, the Dutch National Immunization Programme has started to offer the human papillomavirus (HPV) vaccination to boys as well as girls from the age of 10. The vaccine protects against long-term HPV infection, which can lead to cervical, anogenital and oropharyngeal cancer. Besides malignant disorders, a HPV infection can also lead to certain disorders of the skin and oral cavity. Since the national HPV vaccination campaign has probably resulted in more awareness among patients about the relation between HPV and oropharyngeal cancer, patients may consult oral healthcare professionals with questions about HPV infection. Oral healthcare professionals are thus able to play a role in preventing HPV related disorders by counseling their patients on HPV. They can also contribute to early diagnosis of HPV related oral and oropharyngeal disorder, although the possibility of detecting oropharyngeal cancer during routine dental examination  is limited.

[Knowledge of Dutch dentists regarding HPV associated cancer of the oropharynx]. / Kennis van Nederlandse tandartsen over orofarynxkanker veroorzaakt door het humaan papillomavirus.

Worldwide and also in the Netherlands there is an increasing human papillomavirus (HPV)-attributable oropharyngeal cancer incidence. This type of cancer is more common at a younger age than the classical oropharyngeal cancer, which is usually caused by smoking and excessive drinking. Most often, the tumor occurs in the tonsils and at the base of the tongue. This study explored the level of knowledge of dentists about oropharyngeal cancer, its association with the human papillomavirus and their willingness to play a role in prevention. 7.364 digital questionnaires were sent to oral health-care providers and data from 607 dentists was analyzed. 48% of knowledge questions were answered correctly by more than half of the respondents. Significantly more female caregivers were aware of the relationship between HPV and oropharyngeal cancer and the availability of an HPV vaccine. Respondents considered it important that the relationship between HPV and oropharyngeal cancer is discussed with patients and that a protocol is developed that is useful in screening for mouth and throat cancer.

[Dry mouth. Case histories from a saliva clinic]. / De droge mond. Casuïstiek uit het speekselspreekuur.

Three patients who were referred to the saliva of the Center for Special Care Dentistry (Stichting Bijzondere Tandheelkunde, SBT) in Amsterdam clearly demonstrate that in the case of patients suffering from xerostomia, it can be useful to have the saliva secretion rate determined and to take saliva into account in the aetiology and in developing a dental treatment plan. In the first case, a 39-year-old woman presented with dry mouth associated with Sjögren's syndrome. A fair degree of saliva secretion was still possible. The teeth were characterised by wear, caries lesions and sensitivity. The second patient was a 42-year-old man suffering from dry mouth associated with the use of medications. His teeth were weakened to the point of deciding to create conventional full dentures, despite a possible moderate prognosis due to oral dryness. The third patient, a 79-year-old woman, was suffering from severe dry mouth, associated with Sjögren's syndrome. Due to the ruinous condition of her teeth and extreme dry mouth, the decision was made to remove the remaining dentition and insert implant-retained dentures.

[Saliva testing in the daily practice]. / Speekselonderzoek in de dagelijkse praktijk.

Saliva is a very multifaceted fluid with many different functions and it plays an essential role in oral health. With an aging population, dental professionals will increasingly be confronted with patients with reduced saliva secretion (hyposalivation) or dry mouth (xerostomia). Clinical symptoms as a result of dry mouth vary from mild to severe damage to the hard and soft tissues. Therefore it is important to establish whether a patient is suffering from hyposalivation and if so, whether the patient is able to activate the saliva secretion. Based on saliva testing, hyposalivation and dry mouth can be diagnosed in the general dental practice and be taken into account in prevention and treatment plans.

[Intraoral differences in perceived oral dryness as determined by means of the Regional Oral Dryness Inventory]. / Intraorale verschillen in ervaren monddroogte, bepaald door middel van de Regional Oral Dryness Inventory.

A sensation of dry mouth can be determined with a general questionnaire, the Xerostomia Inventory (XI). This questionnaire, however, does not distinguish among regional differences of oral dryness. In this study, therefore, a new questionnaire was evaluated, the Regional Oral Dryness Inventory (RODI), quantifying the severity of dryness in various intraoral locations. 337 patients participated in this study with an average age of 54 ± 17 years. It appeared there is a significant difference in the sensation of dry mouth between different intraoral locations; the perceived dryness scored highest for the posterior palate and lowest for the floor of the mouth. Introduction of the RODI might help to discriminate among different potential causes of oral dryness in patients. The RODI is highly accessible and easy to carry out in dental practices during routine clinical assessment.

Regional differences in perceived oral dryness as determined with a newly developed questionnaire, the Regional Oral Dryness Inventory.

OBJECTIVES: Several questionnaires, such as the internationally validated and frequently used Xerostomia Inventory (XI), have been developed to quantify the subjective feeling of a dry mouth. These questionnaires quantify the overall perception of dry mouth but lack the possibility to differentiate between various intra-oral regions. In this light, a novel questionnaire, the Regional Oral Dryness Inventory (RODI), which quantifies the severity of dryness at various locations in the mouth, was evaluated. MATERIALS AND METHODS: A retrospective case report study was designed. Data were collected from patients who visited the saliva clinic for Special Care Dentistry in Amsterdam. Data, including the saliva secretion rates, RODI scores, the Xerostomia Inventory (XI) score, and Clinical Oral Dryness Score (CODS), were extracted from the electronic health record system Oase Dental. RESULTS: A total of 337 patients participated in this study with an average age of 54 ± 17 years. The majority of the patients were female (68.5%). The perceived dryness as determined by the RODI was the highest for the posterior palate and the lowest for the floor of the mouth. The highest correlations were found between the corresponding regions in the RODI and regionally related individual items of the XI and CODS. CONCLUSION: There is a significant difference in dry-mouth feeling at different intra-oral locations. CLINICAL RELEVANCE: Regional evaluation of xerostomia with RODI might improve diagnosis of xerostomia by helping to discriminate between different potential causes of oral dryness in patients and for evaluating the efficacy of mouth-moistening products. RODI is highly accessible and easy to perform in dental practices during routine clinical assessment.

[Early oral symptoms of Parkinson's disease]. / Vroege orale symptomen van de ziekte van Parkinson.

A family dentist established that the oral self-care of a 58-year-old man was suddenly inadequate. The dental hygienist who had been recruited subsequently noticed that the dexterity of the man was inadequate. The man's general medical practitioner referred him to a neurologist, who diagnosed Parkinson's disease. Due to this problematic situation, the man was off the family dentist's radar for approximately 1 year. Thereafter, a course of intensive support for his oral health behaviour was initiated. Given the progressivity of Parkinson's disease, it makes sense to aim at an oral health plan resistant to the patient's life course. The family dentist should be aware of his continuing responsibility to provide care and supervision until such time when informal and professional domiciliary care are no longer satisfactory or achievable and admission to a care facility is unavoidable. Only then can the family dentist hand over his responsibility to the geriatric dentist allied to that specific care facility.

Tooth loss in Sjögren's syndrome patients compared to age and gender matched controls.

BACKGROUND: To analyze the prevalence and location of tooth loss in Sjögren's syndrome (SS) patients and compare them with an age- and gender-matched control group. MATERIAL AND METHODS: Dental charts and x-rays of 108 (SS) patients were retrieved from an academic dental center and special care dentistry department. For each SS patient, an age- and gender-matched non-SS patient was randomly selected. Medication, number of extractions and date and location of extractions were assessed. Differences between SS and non-SS patients were analyzed using Mann-Whitney U tests, Chi-square tests and Fisher's exact tests. RESULTS: Significantly more SS patients were edentulous compared to the non-SS group (14.8% versus 1.9%, p = 0.001). SS patients had a 61% higher risk to have experienced one or more extractions than control patients. In the SS group, there was a non-significant tendency for more maxillary teeth to have been extracted than mandibular teeth (42:34). In the control group, the number of extractions in the maxilla and mandible were comparable (21:20). When divided into sextants, the number of SS patients with one or more extractions was significantly higher than for non-SS patients for each sextant (p = 0.001 to p = 0.032). The largest difference in the proportion of patients with one or more extractions between the SS and non-SS patients occurred in the upper anterior sextant (3.4 times more frequent). CONCLUSIONS: SS patients are more prone to experience dental extractions compared to patients without SS. It could be speculated that this is related to a decreased salivary secretion.

Saliva parameters and erosive wear in adolescents.

The aim of this study was to investigate the relationship between several parameters of saliva and erosive wear in adolescents. (Un-)stimulated saliva was collected from 88 adolescents with erosion and 49 controls (age 16 ± 1 years). Flow rate, pH and buffer capacity were determined immediately. Total protein content, carbonic anhydrase VI, amylase, albumin, calcium, phosphate, urea, sodium, chloride and potassium were measured at a later time. Unstimulated flow rate was found to be significantly lower in subjects with erosive wear (p = 0.016). The chloride concentration in unstimulated saliva was found to be significantly higher in the erosion group (p = 0.019).

Reduction of erosion by protein-containing toothpastes.

AIM: To assess the effect of protein-containing toothpastes on the progression of dental erosion in situ (with pellicle) and in vitro (without pellicle). METHODS: A combined split-mouth (extraoral water or toothpaste brushing) and crossover (type of toothpaste) setup was used. Two protein-containing (high/low concentrations of colostrum) and one nonprotein (placebo) toothpaste were investigated. Sixteen volunteers wore intraoral appliances containing 2 human enamel samples on 3 afternoons for pellicle growth during 90 min. One enamel sample was brushed for 5 s with one of the three toothpastes and subsequently exposed to a slurry of the corresponding toothpaste for 2 min. The other sample was exposed to water. Both samples were subsequently exposed to citric acid (extraorally). Loss of calcium and inorganic phosphate were determined. The same sequence of exposures was applied to 16 enamel samples in an in vitro setup without pellicle. RESULTS: With the in situ-formed pellicle, all toothpastes significantly reduced calcium loss compared to water brushing, although no significant differences were found among toothpastes (p = 0.073). For the loss of phosphate, a significant reduction could be found with the use of the high-protein toothpaste compared to the nonprotein toothpaste. Overall there were only slight differences between the toothpastes. Toothpaste effects were less clear in the in vitro experiment. CONCLUSION: The addition of proteins to toothpaste shows some promise for the prevention of erosion. Further research is needed to investigate the performance of the protein-containing toothpastes in longer in situ studies with regard to erosive wear.

Estimated erosive potential depends on exposure time.

OBJECTIVES: Evaluate erosive potential of beverages, using exposure times from 3 to 30 min, and to analyse the relationship between erosion and several drink parameters. METHODS: pH, calcium, phosphate and fluoride concentration, saturation, titratable-acidity to pH 5.5 and the viscosity of sixteen beverages were measured or calculated. Enamel samples (N = 90) were serially exposed to 1 ml of the beverages for 3, 6, 9, 15 and 30 min and erosion was measured as the loss of calcium to the beverage. Rate of erosion per min was calculated by linear curve fitting using all exposure times. Linear regression analysis was performed to determine the correlation between erosion and the drink parameters. A limited multivariate analysis was performed for the outcome parameter with the highest univariate correlations (erosion per minute) and 4 drink variables. RESULTS: A negative relationship was observed only for pH for all exposure times. Only for erosion per min a significant relationship with pH and saturation was found. In a model for erosion per min using only saturation, fluoride concentration, titratable acidity and viscosity, both saturation and viscosity were shown to have a significant effect (p = 0.01 and p = 0.05, respectively). CONCLUSION: Exposure times between 3 and 30 min result in very different estimates of erosive potential. There is no sound theoretical ground for preferring one or other exposure time/outcome as being more clinically relevant. CLINICAL RELEVANCE: This study shows that effect of the choice of study methodology on the measurement of erosive potential of beverages is large.

Reduction of erosive wear in situ by stannous fluoride-containing toothpaste.

BACKGROUND/AIMS: Stannous fluoride (SnF) has been suggested as a dental erosion-preventive agent. The aim of this single-centre, randomized, double-blind, in situ study was to evaluate the effect of toothpastes with SnF in the prevention of erosive enamel wear. METHODS: A combined split-mouth (extra-oral water or toothpaste brushing) and crossover (type of toothpaste) set-up was used. Twelve volunteers wore palatal appliances containing human enamel samples. Three toothpastes were used, in three consecutive runs, in randomized order: two toothpastes containing SnF (coded M and PE) and one toothpaste containing only sodium fluoride (coded C). On day 1 of each run the appliances were worn for pellicle formation. On days 2-5 the samples were also brushed twice with a toothpaste-water slurry or only water (control). Erosion took place on days 2-5 extra-orally 3 times a day (5 min) in a citric acid solution (pH 2.3). Enamel wear depth was quantified by optical profilometry. The effect of toothpastes was tested using General Linear Modeling. RESULTS: Average erosive wear depth of control samples was 23 µm. Both SnF toothpastes significantly reduced erosive wear: M by 34% (SD 39%) and PE by 26% (SD 25%). The control toothpaste reduced erosive wear non-significantly by 7% (SD 20%). Both SnF-containing toothpastes significantly reduced erosive wear compared to the sodium fluoride toothpaste. CONCLUSION: We conclude that SnF-containing toothpastes are able to reduce erosive tooth wear in situ.

Effect of salivary factors on the susceptibility of hydroxyapatite to early erosion.

OBJECTIVE: Salivary pellicle is known to reduce the erosion of enamel and differences in the level of protection exist between individual saliva sources, but which parameters or components are important is not known. The focus of this study was to investigate the relationship between saliva parameters and early erosion of hydroxyapatite (HAp) with an in situ grown saliva film. METHODS: Twenty-eight volunteers carried two HAp and one porcelain discs in their buccal sulcus for 1.5 h. Next, the discs covered with pellicle and the attached saliva film were exposed extraorally to 50 mM (pH = 3) citric acid for 2 min and unstimulated and stimulated saliva was collected. Calcium loss from HAp after erosive challenge was measured, corrected for calcium loss from pellicle on porcelain discs and averaged. Several salivary parameters were analysed. Pearson's linear correlation and multiple regression analysis were used to study the relation between saliva parameters and HAp erosion. RESULTS: Significant correlations were found between HAp erosion and the concentration of phosphorus in unstimulated saliva (r = 0.40, p = 0.03) and between HAp erosion and the concentration of sodium (r = -0.40, p = 0.03), chloride (r = -0.47, p = 0.01), phosphorus (r = 0.45, p = 0.01) and flow (r = -0.39, p = 0.04) of stimulated saliva. Multivariate analysis revealed a significant role in the HAp erosion for sodium, urea, total protein, albumin, pH and flow of unstimulated saliva and for sodium, potassium, urea, and phosphorus of stimulated saliva. CONCLUSIONS: Several salivary parameters are associated with the susceptibility of HAp to erosion.

Influence of beverage composition on the results of erosive potential measurement by different measurement techniques.

The influence of beverage composition on the measurement of erosive potential is unclear. The aim of this study was to evaluate whether beverage composition influences the measurement of erosive potential and to evaluate the influence of exposure in small and large volumes. Eleven beverages were included: water (control), 3 alcopops, 2 beers and 5 soft drinks. For each beverage 15 bovine enamel samples were used: 5 for chemical and 10 for profilometric analysis. After exposure to the beverages (63 min) the resulting solutions were analyzed for Ca and inorganic phosphorus (P(i)) content. The samples for optical profilometry were submersed sequentially in 500 ml or in 1 ml of the drinks for 3, 6, 9, 15 and 30 min (total 63 min). For some of the beverages high baseline concentrations of Ca (energy drink) or P(i) (cola drink, cola lemon drink, beer, beer lemon) were found. Some of the beverages showed a good correlation between the chemical methods. Profilometry (both for 1 and 500 ml) showed generally lower enamel losses than the chemical methods. Lower enamel losses were found for the profilometry 1 ml compared to the profilometry 500 ml only for the cola drinks. It can be concluded that the composition of the beverages had a significant effect on the determination of the erosive potential with chemical analyses. Drink composition also influenced the effect of small versus large exposure volumes, indicating the need for standardization of exposure parameters.

Inhibition of erosive wear by fluoride varnish.

It has been suggested that fluoride products with a protective mechanical component are advantageous in the prevention of erosive wear. The aim of this study was to evaluate in situ the effect of fluoride varnish (FV) in the prevention of wear due to erosion and combined erosion and toothbrush abrasion. Eleven volunteers wore for 3 weeks, during working hours, appliances containing 2 control and 2 FV-treated human enamel samples. Erosion took place extraorally 3 times a day (5 min) in the soft drink Sprite. At the end of each experimental day one control and one FV sample (C-er+abr and FV-er+abr) were brushed (5 s) with fluoridated dentrifice. The remaining control and FV sample (C-er and FV-er) were left unbrushed. Enamel volume loss was quantified by optical profilometry at day 5, 10 and 15. A statistically significant progression in enamel loss was found for the C-er, C-er+abr and FV-er+abr groups (p < 0.001, p < 0.001 and p = 0.001, respectively) but not for the FV-er group (p = 0.053). The values of cumulative normalized volume loss (x10(8) mum) at day 15 were: C-er 5.53 +/- 2.14, C-er+abr 5.70 +/- 2.07, FV-er 0.79 +/- 0.67 and FV-er+abr 2.76 +/- 1.35. The FV-er and FV-er+abr groups showed significant lower volume loss than the C-er group (p < 0.001 and p = 0.005, respectively) and the C-er+abr group (p < 0.001 and p = 0.002, respectively). The results indicate that fluoride varnish is effective in the reduction of erosive wear.