Aspirin use and post-operative bleeding from dental extractions.

Aspirin is a common, chronically administered preventive treatment for cardiovascular disease, but is often discontinued prior to invasive dental procedures because of concern for bleeding complications. We hypothesized that aspirin does not cause increased bleeding following a single tooth extraction. Thirty-six healthy persons requiring a tooth extraction were randomized to receive 325 mg/day aspirin or placebo for 4 days. Cutaneous bleeding time (BT) and platelet aggregation tests were obtained prior to extraction. The primary outcome measure, oral BT, and secondary bleeding outcomes were evaluated during and following extraction. No significant baseline differences, except for diastolic blood pressure, were found between groups. There were no differences in oral BT, cutaneous BT, secondary outcome measures, or compliance. Whole-blood aggregation results were significantly different between the aspirin and placebo groups. These findings suggest that there is no indication to discontinue aspirin for persons requiring single-tooth extraction.

The oral mucosa as a therapeutic target for xerostomia.

Autoimmune disorders, medical interventions, and aging are all known to be associated with salivary gland hypofunction, which results in the uncomfortable feeling of dry mouth (xerostomia) and significantly diminished oral health. The current therapeutic regimen includes increasing oral hydration using over-the-counter oral comfort agents and the use of systemic cholinergic drugs to stimulate salivary output. However, these approaches produce very transient relief or are associated with uncomfortable side-effects. Thus, new treatments that provide long-lasting relief from discomfort and improve oral health with minimal side-effects would benefit the therapy of this disease. The processes that mediate fluid loss from the oral cavity, such as the absorption of fluid from the oral mucosa, represent novel therapeutic targets for xerostomia. Preventing fluid absorption from the oral cavity is predicted to improve oral hydration and alleviate the clinical symptoms and discomfort associated with dry mouth. Furthermore, therapeutic strategies that prevent fluid absorption should complement current approaches that increase salivary output. This review discusses the current understanding of oral fluid balance and how these processes may be manipulated to provide relief for those suffering from dry mouth.

99mTc-pertechnetate uptake in parotid acinar cells by the Na+/K+/Cl- co-transport system.

99mTc-Pertechnetate (99mTcO4-) has widespread clinical use in the diagnosis and evaluation of dysfunctions in many different tissues. However, despite the broad clinical application of this radionuclide, very little is known about the mechanism by which 99mTcO4- enters a cell. We report evidence here that 99mTcO4- shares the Na+/K+/Cl- co-transport system localized to the basolateral membrane of rat parotid acinar cells. 99mTcO4- uptake by these cells was quite rapid (t1/2 approximately 30 s), was completely inhibited by the loop diuretics furosemide and bumetanide, and was markedly dependent on the presence of Na+, K+, and Cl- in the extracellular medium. Relative to uptake measured in the presence of physiological extracellular salt concentrations (Hanks' salts), 99mTcO4- uptake was inhibited 80% by sodium replacement and 50% by potassium replacement. When Cl- was replaced with the physiologically inert anion gluconate a threefold stimulation in 99mTcO4- uptake resulted. These observations provide strong evidence that 99mTcO4- can substitute for Cl- as a substrate for the Na+/K+/Cl- co-transporter and indicate that 99mTcO4- uptake by salivary glands (e.g., as seen with salivary scintiscans), and possibly by a variety of other tissues, reflects the functional activity of this co-transport mechanism.

Reduction in MRSA environmental contamination with a portable HEPA-filtration unit.

There is renewed interest in the hospital environment as a potentially important factor for cross-infection with methicillin-resistant Staphylococcus aureus (MRSA) and other nosocomial pathogens. The aim of this study was to evaluate the effectiveness of a portable high-efficiency particulate air (HEPA)-filtration unit (IQAir Cleanroom H13, Incen AG, Goldach, Switzerland) at reducing MRSA environmental surface contamination within a clinical setting. The MRSA contamination rate on horizontal surfaces was assessed with agar settle plates in ward side-rooms of three patients who were heavy MRSA dispersers. Contamination rates were measured at different air filtration rates (60-235 m(3)/h) and compared with no air filtration using Poisson regression. Without air filtration, between 80% and 100% of settle plates were positive for MRSA, with the mean number of MRSA colony-forming units (cfu)/10-h exposure/plate ranging from 4.1 to 27.7. Air filtration at a rate of 140 m(3)/h (one patient) and 235 m(3)/h (two patients), resulted in a highly significant decrease in contamination rates compared with no air filtration (adjusted rate ratios 0.037, 0.099 and 0.248, respectively; P < 0.001 for each). A strong association was demonstrated between the rate of air filtration and the mean number of MRSA cfu/10-h exposure/plate (P for trend < 0.001). In conclusion, this portable HEPA-filtration unit can significantly reduce MRSA environmental contamination within patient isolation rooms, and this may prove to be a useful addition to existing MRSA infection control measures.

Fas and Fas-mediated effects on a human salivary cell line in vitro: a model for immune-mediated exocrine damage in Sjögren's syndrome.

Sjögren's syndrome (SS) is an autoimmune exocrinopathy characterized by mononuclear cell infiltration and loss of parenchymal tissue in salivary and lacrimal glands. The mechanisms for these histologic alterations are not known. Apoptotic cell death, induced by the ligation of Fas (APO-1/CD95) with Fas ligand (FasL/CD95L) may be an explanation for the tissue damage seen in SS. Fas and FasL were detected in minor salivary glands from SS patients and healthy individuals using immunohistochemical methods. There was increased expression of both Fas and FasL in the patients. The ability of the Fas-FasL pathway to influence epithelial cell growth and survival was demonstrated in vitro using a human submandibular cell line. The presence of Fas receptor was demonstrated on the cells. Anti-Fas antibody triggered cell death. Cells were also grown in the presence of gamma-interferon (IFN-gamma). IFN-gamma induced an upregulation of Fas receptor expression and pre-treatment of cells with IFN-gamma led to enhanced anti-Fas mediated cell death.

Randomized controlled trial of pilocarpine hydrochloride for the moderation of oral mucositis during autologous blood stem cell transplantation.

Pilocarpine hydrochloride has been reported to increase salivation and decrease oral mucositis in patients receiving head and neck radiotherapy, but there is only one report of its use in a cancer chemotherapy patient population. This prospective, double-blinded, randomized, placebo-controlled trial was undertaken to determine the efficacy of pilocarpine for the moderation of oral mucositis during autologous blood stem cell transplantation. Subjects were randomized to receive a 5 mg tablet of pilocarpine, or a placebo, during and following chemotherapy. Subjects were seen every other day and evaluated for gingival, oral, and oropharyngeal mucositis; nutrition; oral hygiene; eating; speaking; sleeping; pain at rest and/or with swallowing; and mouth dryness. We recorded the mean and highest scores and duration of problems, along with white blood cell counts and differentials, and the use of systemic narcotics for oral mucosal pain. We enrolled and randomized 36 subjects, and there were no statistically or clinically significant differences for the primary outcome of severity of mucositis and no clinically significant differences in any of the other outcome measures. Pilocarpine has no benefit for the moderation of the incidence, severity, or duration of mucositis in patients receiving autologous blood stem cell transplantation.

Pilocarpine treatment of salivary gland hypofunction and dry mouth (xerostomia).

We studied the effects of pilocarpine hydrochloride, a para-sympathomimetic agent, on major salivary gland output and subjective responses in 31 patients with salivary hypofunction. Pilocarpine hydrochloride (5-mg capsules, three times daily) was given for 5 months and a placebo was randomly assigned for 1 month in a double-blind fashion. Objective measurements of major salivary gland output, subjective impressions of oral moisture, treatment-related side effects, and a number of physiologic measures were assessed monthly. Pilocarpine significantly increased salivary output in 21 of the 31 patients. Subjective improvement in the feeling of oral dryness, speaking, chewing, and swallowing were reported by 27 individuals. Side effects, while common, generally were mild and tolerable. There were no significant alterations in cardiovascular or other physiologic measures. We conclude that pilocarpine is an effective and safe treatment for salivary gland hypofunction and xerostomia in selected patients. The increase in major gland output provides beneficial natural secretions and relief of oral dryness.

Treatment of primary Sjögren's syndrome with low-dose natural human interferon-alpha administered by the oral mucosal route: a phase II clinical trial. IFN Protocol Study Group.

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 Sjögren'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 of 150 IU IFN lozenges TID for 12 weeks in subjects with primary Sjögren's syndrome improved salivary output and decreased complaints of xerostomia without causing significant adverse medical events.

Further studies of salivary inhibition of HIV-1 infectivity.

An HIV-1/ATH8-cell cytopathic system was used to characterize the previously reported anti-HIV-1 activity of human saliva. Inhibitory activity was demonstrated by monitoring viable cell counts, HIV-1 p24 core antigen, and reverse transcriptase levels. Nonfiltered whole saliva, sterilized by irradiation, protected the ATH8 cells from HIV-1 infection. When HIV-1/saliva mixtures were filtered following incubation, the quantity of virus was significantly less (approximately 50%) than in HIV-1/media-filtered controls, suggesting that salivary aggregation and/or agglutination may be involved in the inhibitory activity. However, a sufficient number of apparently morphologically intact viral particles were still present in the HIV-1/saliva filtrates to lead to infection. When saliva was filtered prior to incubation with HIV-1, these filtrates showed substantial inhibitory activity, although reduced compared with that of non-prefiltered saliva. We conclude that saliva likely has several means by which to inhibit HIV-1 infectivity.

Elevation of salivary antimicrobial proteins following HIV-1 infection.

Thirty-seven HIV-1-positive patients contributed salivary samples from individual major salivary glands. Nineteen patients were unmedicated and asymptomatic, and 18 patients had developed signs of AIDS. Salivas from 15 healthy males served as controls. Levels of four salivary antimicrobial proteins (lactoferrin, lysozyme, secretory IgA, and histatins) were determined, as well as total fluid output of the major salivary glands. Concentrations of all four salivary antimicrobial proteins were found to be increased in the stimulated submandibular/sublingual saliva of all HIV-1-positive patients as well as the subset of unmediated HIV-1-positive patients. Those patients with evidence of oral candidiasis had the highest concentrations of lysozyme and histatins, potent antifungal proteins, in their saliva. Although the etiology of these protein increases is still unknown, these results further document salivary changes following HIV-1 infection.

Oral defense mechanisms are impaired early in HIV-1 infected patients.

We have examined the hypothesis that individuals infected with human immune deficiency virus type 1 (HIV-1) experience significant, specific alterations in mechanisms protecting the oral cavity prior to the appearance of AIDS-related systemic opportunistic infections. In a study of 13 early-stage, stable anti-HIV antibody positive patients, parotid salivary function was found to be generally intact. In contrast, several indicators of submandibular gland dysfunction were detected. In particular, stimulated fluid output was decreased and salivary lysozyme levels were increased relative to controls by 50-60% for both resting (p less than 0.05) and stimulated (p less than 0.001) conditions. Also, the frequency of albumin detection in submandibular saliva samples was approximately 65% in HIV-1 infected patients vs. 0% in controls (p less than 0.05). In addition, cytologic evaluation of oral mucosa revealed a fivefold increase in the prevalence of candidal hyphae in HIV-1 infected patients compared to controls (41% vs. 8%, p less than 0.05). We conclude that normal oral defense mechanisms show signs of compromise in HIV-1 infected individuals. We suggest that (a) effects of HIV-1 infection are seen early in the oral cavity, (b) impairment of oral defense mechanisms may facilitate entry of microorganisms with an attendant increased risk of morbidity and mortality, and (c) intensive oral surveillance and prophylactic care should be part of the routine management afforded to AIDS patients soon after HIV-1 infection is recognized.

Safety and efficacy of adenovirus-mediated transfer of the human aquaporin-1 cDNA to irradiated parotid glands of non-human primates.

This study evaluated the safety and efficacy of a single administration of a recombinant adenovirus encoding human aquaporin-1 (AdhAQP1) to the parotid glands of adult rhesus monkeys. In anticipation of possible clinical use of this virus to correct irradiation damage to salivary glands, AdhAQP1 was administered (at either 2 x 10(9) or 1 x 10(8) plaque-forming units/gland) intraductally to irradiated glands and to their contralateral nonirradiated glands. Radiation (single dose, 10 Gy) significantly reduced salivary flow in exposed glands. Virus administration resulted in gene transfer to irradiated and nonirradiated glands and was without untoward local (salivary) or systemic (sera chemistry, complete blood count) effects in all animals. However, the effect of AdhAQP1 administration varied and did not result in a consistent positive effect on salivary flow rates for all animals under these experimental conditions. We conclude that a single adenoviral-mediated gene transfer to primate salivary glands is well-tolerated, although its functional utility in enhancing fluid secretion from irradiated parotid glands is inconsistent.

Major salivary gland function in patients with radiation-induced xerostomia: flow rates and sialochemistry.

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.

Magainin-like immunoreactivity in human submandibular and labial salivary glands.

Magainins, antimicrobial peptides secreted by granular glands of frog skin, may be related to the high resistance to infections of this epithelial surface. The oral mucosa of healthy individuals is another tissue in which infection is not frequent, probably owing to the activity of potent salivary and mucosal defense mechanisms. To investigate if magainin-like factors are a component of these oral defense mechanisms, human and animal minor (mucosal) and major salivary glands were examined by immunohistochemistry, using a polyclonal rabbit anti-magainin antibody. Cryostat sections of (para) formaldehyde-fixed tissues were incubated with the antibody and then stained with fluorescein-complexed anti-rabbit IgG. Specific staining was observed in the apical portion of the cytoplasm of ductal epithelial cells of human submandibular and labial salivary glands. Diffuse staining was present in submandibular acinar cells. Bovine, rat, hamster, and mouse tissues were unreactive. The presence of magainin-like substances in human salivary gland duct cells is consistent with reports of the occurrence of other biologically active substances in salivary gland ducts.

Incidence of physician-diagnosed primary Sjögren syndrome in residents of Olmsted County, Minnesota.

OBJECTIVES: To estimate the incidence of physician-diagnosed primary Sjögren syndrome (SS) among residents of Olmsted County, Minnesota, in the setting of usual medical care and to determine how often objective criteria are available in the medical records of such patients. PATIENTS AND METHODS: We reviewed all medical records of residents in Olmsted County with physician-diagnosed SS from 1976 to 1992 to determine whether they had undergone objective tests for keratoconjunctivitis sicca, salivary dysfunction, or serologic abnormality. Confounding illnesses were excluded. To identify misclassified cases, all records from patients with xerostomia or keratoconjunctivitis sicca were also reviewed. The average annual SS incidence rates were calculated by considering the entire population to be at risk. RESULTS: Of 75 patients with onset of SS during the study period, 53 had primary SS. All patients were white, 51 (96.2%) were women, and the mean +/- SD age was 59+/-15.8 years. The age- and sex-adjusted annual incidence was 3.9 per 100,000 population (95% confidence interval, 2.8-4.9) for patients with primary SS. Eleven patients (20.8%) with physician-diagnosed SS had no documentation of objective eye, mouth, or laboratory abnormalities. Objective evaluations performed most frequently were laboratory and ocular tests and least often were investigations of xerostomia. CONCLUSIONS: The average annual incidence rate for physician-diagnosed primary SS in Olmsted County is about 4 cases per 100,000 population. These data probably underestimate the true incidence because they are based on usual medical care of patients with SS in a community setting, rather than on a case-detection survey. In the future, a true incidence may be possible with a higher index of suspicion, greater attention to objective tests, and increased awareness of new classification criteria for SS. For epidemiological studies based on existing data, application of current criteria may not be feasible, and consensus on criteria for such studies would be useful.

Differential cytokine mRNA expression in human labial minor salivary glands in primary Sjögren's syndrome.

Cytokines are known to be involved in a number of autoimmune conditions and are increasingly viewed as key components in numerous aspects of normal and abnormal cell functions. The purpose of the present study was to investigate possible immunopathogenic mechanisms within the labial minor salivary glands of patients with primary Sjögren's syndrome (pSS) by examining differential cytokine gene expression in individual cell populations (acini, ducts, or lymphoid cells). A cell-specific microdissection technique in combination with reverse transcription-polymerase chain reaction (RT-PCR) and Southern hybridization using 32P-labeled cytokine gene-specific probes was utilized to measure cytokine messenger RNA expression in individual cell populations of patients and healthy controls. mRNAs for interleukin 2 (IL-2), interleukin 6 (IL-6), interleukin 10 (IL-10), tumor necrosis factor alpha (TNF-alpha), interferon gamma (IFN-gamma) and transforming growth factor beta 1 (TGF-beta1) were detected in the epithelial cells (acini and ducts) and lymphoid cells of the labial minor salivary glands of pSS patients. The expression levels of these mRNAs in the epithelial cells were either up- or down-regulated by adjacent focal infiltrating lymphoid cells. mRNAs for all of the above cytokines, with the exception of IFN-gamma, were detected in salivary tissues of healthy volunteers. The epithelial cells in the salivary glands are active participants in the autoimmune-mediated process of pSS, as evidenced by their ability to express a high frequency and wide variety of cytokines. The presence of an infiltrating lymphoid focus within the gland appeared to modulate cytokine gene expression by the salivary epithelial cells.

Effects of X irradiation on the function of rat salivary glands at 3 and 40 days.

The purpose of this study was to examine the effects of different doses of X irradiation on the major rat salivary glands. The flow rates of the salivary glands were measured simultaneously in both parotid and submandibular glands of mature male Wistar rats at 3 and 40 days after head and neck irradiation with single doses of 2.5, 5, 7.5, 10, or 15 Gy. The parotid and submandibular glands were weighed at the time of saliva collection and total body weight was obtained weekly. Significant reductions in parotid salivary flow at 3 days and parotid and submandibular flow at 40 days were found. Diminished saliva output was dose-dependent and significantly reduced at radiation exposures of 7.5 Gy and greater. Submandibular function deteriorated between 3 and 40 days and the extent of hypofunction was comparable to the parotid gland at the latter time. Parotid and submandibular gland weights were reduced by irradiation in a dose-dependent manner at both 3 and 40 days. The effects were similar for both glands at the latter time. Total body weight was also reduced by the head and neck irradiation in a dose-dependent manner. There was significant mortality in the group receiving 15 Gy irradiation between 7 and 14 days after irradiation. The results demonstrate that parotid and submandibular glands may be affected comparably by equal doses of head and neck irradiation when examined at later times. In the period immediately after irradiation, there are significant differences in the responses of the major salivary glands.

Acute effects of X irradiation on the function of rat salivary glands.

Radiation-induced damage to salivary glands has been recognized for over 80 years. However, the mechanisms responsible for the destruction of gland parenchyma are still not known. The purpose of this study was to describe alterations in salivary function in the rat within the first 24 h after irradiation. Saliva was collected from the parotid and submandibular glands during radiation treatment and at four times (0.5, 1, 4, and 24 h) after 15 Gy X irradiation delivered to the head and neck. Total body weight, submandibular gland weight, and food and water intake were monitored and the total protein, sodium, and potassium content of the salivas was analyzed. The effects of radiation on salivary glands of the rat could be demonstrated by 24 h. Parotid salivary flow was reduced and the sodium concentration was significantly less than that in control animals. Submandibular gland weights declined markedly by 24 h. These effects appear to be influenced significantly by the animals' limited intake of food and water during this period, as well as the anesthesia administered.

Irradiation-induced damage to the salivary glands: the role of redox-active iron and copper.

The mechanism of irradiation-induced hypofunction of the salivary glands is a process that is not fully understood. Here we examine the hypothesis that intracellular and redox-active ions of iron and copper, which are associated with the secretion granules, play a catalytic role in the irradiation-induced damage. Rats were subjected to head and neck irradiation (15 Gy X rays) and allowed to recover for 2 months. The function of the parotid and submandibular glands was then determined by pilocarpine-stimulated salivary secretion. A 45% decrease in the function of both glands was obtained when compared to nonirradiated controls. Treatment prior to irradiation (90 min) with cyclocytidine (200 mg/kg) led to a massive degranulation of the parotid gland and yielded nearly complete protection from radiation-induced damage. In contrast, pilocarpine stimulation prior to irradiation led to a marginal degranulation of the parotid gland and yielded only 13% protection. Neither agent caused degranulation of the submandibular gland mucous cells or yielded functional protection of this gland. Treatment with both agents yielded a marked increase in iron, copper and manganese levels in the parotid gland saliva. An analogous marked increase in the redox activity of iron and copper ions was recorded for the parotid saliva stimulated by pilocarpine and cyclocytidine. Pilocarpine-stimulated submandibular gland saliva contained metal levels similar to those of the parotid gland saliva. However, no redox activity and no increase in metal mobilization could be demonstrated in the submandibular gland saliva stimulated by both agents. The correlation between the patterns of gland degranulation, mobilization of redoxactive metals and the protection of gland function, for both parotid and submandibular glands, focuses attention on the catalytic roles played by transition metal ions in promoting free radical reactions, which likely participate in the process of injury to the tissue.

Effects of ionizing radiation and beta-adrenergic stimulation on the expression of early response genes in rat parotid glands.

There is little known about the regulation of gene expression in rat parotid glands after exposure to ionizing radiation. The present studies investigate the effects of in vivo ionizing radiation, with subsequent stimulation of beta-adrenergic receptors by isoproterenol, on parotid gland function and on the expression of the early response genes, c-fos, c-jun, and jun B. Ionizing radiation diminished parotid gland weight and saliva output. Treatment of irradiated rats with isoproterenol increased the gland weight to levels similar to those in nonirradiated rats. However, such treatment had no effect on saliva output as indicated by measurements of parotid salivary flow rate. Irradiation alone increased the expression of c-fos, c-jun, and jun B. The combination of irradiation and isoproterenol had an additional effect on the levels of c-fos and jun B mRNAs and proteins particularly at earlier experimental times (1 to 8 h). Isoproterenol alone induced high levels of c-fos and jun B mRNA but not of c-jun mRNA. However, c-jun mRNA was induced markedly by radiation and 8 h of isoproterenol treatment, indicating a combined effect on c-jun gene expression. These observations suggest that the expression of the proto-oncogenes c-fos, c-jun, and jun B is probably regulated through differential signal transduction pathways which may be activated by these external stimuli and may be associated with functional changes induced in the rat parotid gland by ionizing radiation and by ionizing radiation and isoproterenol.