The e:ffe:ctof acupuncture on salivary flow rates in patients with xerostomia AL Blom, BDS, I. Dawidson, BDS, and B. Angmar-Mkson, Huddinge, Sweden DEPAR.TMENT
OF CARIOLOGY,
SCHOOL OF DENTISTRY,
DOS, PhD,
KAROLINSKA
INSTITUTET
Of 21 patients with severe xerostomia, 11 were treated with acupuncture and 10 patients received placebo acupuncture. Those patients who received acupuncture treatment showed increased salivary flow rates during iand after the acupuncture treatment. The improved salivary values persisted during the observation year, whereas the patients who received placebo acupuncture showed some improvement of salivary flow rates only during the actual treatment. The results of the present study indicate that acupuncture may be a useful adjunct for the stimulation of salivary flow in some patients with xerostomia.
(ORALSLJRG ORALMEDORALPATHOL~~~~;~~:~~~-S)
T
he symptom of dry mouth (xerostomia) can be caused by varilous diseases associated with the impairment of salivary gland function. Medications and radiation treatment of tumors in the head and neck region are often cau.sesof xerostomia. Primary and secondary Sjogren’s syndrome (SS), the latter of which is associated with rheumatoid arthritis, are well-known causesof xerostomia. Dry mouth can be uncomfortable and may result in difficulties in speaking, chewing, swallowing, increased frequency of infection of the oral mucosa, and rapidly progressive caries.l Currently there are few effective methods for treatment of xerostonnia.The palliative therapies now usedgive only sh(ort-tlermrelief. Theseinclude various methods for stimulation of the salivary flow by sucking tablets or by gum-chewing, or the use of saliva substitutes. Medications such as pilocarpine or nicotinamide have T,V N, 0, Q, S
Q
M R R, S
Medication
Salivary substitutes Mechanical salivary stimulants Analgesics Sedatives and hypnotics Thyroid hormones and other hormones Antihypertensives Heart-stimulating medication Gastroesophageal reflux medication Asthma and allergy medication Cortisone and antihistamines Vitamins, trace demerits
F, G, H A, E, F, G, K D, I B, L 6 1 B, L H A -
N, R, V N, 0, V Q, R, T o”,T,V S
Q
R, s M, T, V U
Experimental group, Patients coded A to L; control group, patients coded M to V.
cording to traditional Chinese medicine.*%9 The needles used were Chinese (Hwa To Brand; diameter 0.32 mm, length 25 mm) and Japanese(Maeda; diameter 0.30 mm, length 30 mm), made of stainless steel, and autoclaved before use. Insertions were done to depths between 0.5 and 2.0 cm after the usual skin sterilizing procedures, and approximately 1 to 3 mm in the ear. Eleven patients received acupuncture, which evoked a tingling, nonpainful sensation (de-qi) at each of the points chosen. Superficial needling (placebo acupuncture) was performed on 10 patients. The needles were inserted only superficially (intradermal), without eliciting any further sensation, 1 to 2 cm from the acupuncture point. Both acupuncture and placebo acupuncture treatments were given twice a week for 20 minutes, and the interval between the two &week acupuncture serieswas 7 to 10 days. Any changesof subjective symptoms and changesin medication during or after the treatment procedure were noted. Evaluation
of salivary
flow rates
Saliva was sampled according to standard techniques used at the Department of Cariology, Karo-
linska Xnstitutett” and at the sametime of the day for each patient. Baseline levels of salivary flow rates for each patient were determined for both resting and paraffin-stimulated saliva on two different occasions before the start of the investigation. Salivary flow rates were measured again twice before the second series of acupuncture treatments. New salivary evaluations were made immediately after the completion of the acupuncture series;at 3 weeks;and 3,6, and 12 months after the end of the acupuncture treatment. Neither the person who evaluated the salivary flow nor the patients themselves knew whether they received acupuncture or superficial needling (placebo acupuncture). The study was approved by the Human Ethics Committee at Huddinge Hospital, Karolinska Institutet. Statistical
methods
Wilcoxon’s signed rank test was used for statistical analysis within each group to compare the changes from baseline levels of salivary flow rates. The differencestested were between baseline values and values at weeks 7, 16, 28, 40, and 64. Wilcoxon’s two-sam-
Efect of acupuncture on salivary flow
Volume 73 Number 3
EXPERIMENTAL Salivary at each
flow rates time point
295
DESIGN were determined as indicated
Fig. 2. Experimental design. Salivary flow rates were determined at each time point as indicated.
Fig. 1. Acupuncture points stimulated during treatment of experimental group were localized in head, ears, hands, and legs. Localpoints: Stomach channel, 3,4,5, 6,7; Small intestine channel, 17. Distal points: Hand, Pericardium channel 6; Heart clhannel7; Large intestine channel 4,8,10; Si, 3, 7; Head, Du channel 20; Torso, Ren channel 9, 17; Legs, St 36; Kidney, 3 or 5; Spleen channel, 6, 8, or 4. Auricular
points:
Slhen-men,vegetativum, kidney, spleen,
mouth, subcortex, pancreas, endocrinum, hormone.
ple rank test was used to compare the changes from baseline levels of the salivary flow rates between the two groups at the same time points. To analyze changesin salivary flow rates occurring with
time after the last acupuncture
treatment,
differences were also tested between week 16 values and values at weeks 28, 40, and 64. RESULTS
The salivary flow rates for each experimental patient before, during, and after the acupuncture
treatment are shown in Table II and for each control patient in Table III. The median and ranges for both groups are summarized in Table IV. The differences‘betweenbaseline levels and salivary flow rates at different time points for each group as well as between the two groups were compared. The differences in salivary flow rates between week 16 and weeks28,40, and 64 were also compared within each group as well as between the two groups. The results are shown in Table V. In addition to quantitative data related to salivary function, qualitative findings were also recorded (Table VI). The symptoms most affected by acupuncture were various chronic pains, circulatory problems (such asvascular spasm),insomnia, and improvement in general health condition. After the abatement of various symptoms, some patients also reduced dosages of their medi’cations (Table VI). In a few cases secondary effects of acupuncture treatment, such as tiny hemorrhages at the acupuncture sites,resulting in small hematomas,were noticed. Tiredness sometim.esoccurred after treatment. DISCUSSION
The present study found that patients who received acupuncture showed improved salivary flow rates both during and after experimental treatment. Furthermore, four of these 11 patients attained normal salivary flow rates. Improved salivary values persisted during the observation year (Table II). The most severe casesappearedto react least to the treatment, an observation also noted in the studies conducted by Pierminova et a1.6and Goidenko et a1.7Patients who receivedplaceboacupuncture showedpositive changes in their salivary flow rates during experimental treatment, but those changesdisappearedafter the placebo acupuncture was completed (Table III). These results were shown to be significant with statistical analyses (Table V). It appears that acupuncture treatment not
Horn, Dawidson, and Angmar-Mhsson
296
ORAL SURG ORAL MED ORAL BATHOL
March 1992 Table II. Salivary flow rates* for unstimuiated and stimulated whole saliva before, during, and after acupuncture treatment for each patient in experimental group
Between AP
A
-.
After AP
-
0.70 1.60
0.40 1.20
0.60 1.56
0.70 I .60
0.36 1.20
0.18 0.96
0.32 1.oo
0.27 1.16
0.32 0.83
0.25 0.82
0.22 0.84
0.24 1.04
0.22 1.08
0.26 1.22
0.46 1.34
0.40 1.24
0.30 1.10
0.02 0.06
0.10 0.12
0.03 0.04
0.04 0.06
0.03 0.12
0.04 0.10
0.20 0.50
0.14 0.44
0.14 0.38
0.10 0.21
0.14 0.52
0.10 0.34
0.12 0.40
0.02 0.20
0.02 0.32
0.06 0.40
0.04 0.42
0.12 0.30
0.10 0.50
0.08 0.36
0.05 0.44
0.04 0.16
0.07 0.16
0.08 0.22
0.10 0.20
0.12 0.22
0.09 0.16
0.08 0.24
0.14 0.18
0.02 0.24
us SS
0.04 0.14
0.01 0.12
0.06 0.16
0.04 0.16
0.06 0.10
0.02 Q.16
0 0.22
0.04 0.10
0.01 O.!l
us ss
0.01 0.60
0.01 0.48
0.04 0.56
0.06 0.74
0.04 0.52
0.10 1.00
0.06 0.76
0.09 0.76
0.04 0.60
us ss
0.03 0.38
0.12 0.24
0.08 0.32
0.04 0.34
0.13 0.38
0.06 0.30
0.08 0.44
0.14 0.48
0.10 0.28
US ss
0.15 0.70
US ss
0.01 0.16
0.01 0.34
0.28 1.06
0.14 1.06
0.34 1.20
us ss
0.04 0.40
0.04 0.54
0.14 0.76
0.08 0.66
0.16 0.76
us SS
0.10 0.48
0.10 0.64
0.26 0.96
0.20 1.16
us ss
0.02 0.02
0.02 0.02
0.04 0.10
us ss
0.08 0.30
0.06 0.22
us ss
0.02 0.30
us ss
-
B -
e
D
E
F
G
H
I
K
L
-
AP, Acupuncture; SS, stimulated saliva; US, unstimulated saliva *Normal values: Unstimulated saliva, 0.25 to 0.35 m!/min (
OF CARIOLOGY,
SCHOOL OF DENTISTRY,
DOS, PhD,
KAROLINSKA
INSTITUTET
Of 21 patients with severe xerostomia, 11 were treated with acupuncture and 10 patients received placebo acupuncture. Those patients who received acupuncture treatment showed increased salivary flow rates during iand after the acupuncture treatment. The improved salivary values persisted during the observation year, whereas the patients who received placebo acupuncture showed some improvement of salivary flow rates only during the actual treatment. The results of the present study indicate that acupuncture may be a useful adjunct for the stimulation of salivary flow in some patients with xerostomia.
(ORALSLJRG ORALMEDORALPATHOL~~~~;~~:~~~-S)
T
he symptom of dry mouth (xerostomia) can be caused by varilous diseases associated with the impairment of salivary gland function. Medications and radiation treatment of tumors in the head and neck region are often cau.sesof xerostomia. Primary and secondary Sjogren’s syndrome (SS), the latter of which is associated with rheumatoid arthritis, are well-known causesof xerostomia. Dry mouth can be uncomfortable and may result in difficulties in speaking, chewing, swallowing, increased frequency of infection of the oral mucosa, and rapidly progressive caries.l Currently there are few effective methods for treatment of xerostonnia.The palliative therapies now usedgive only sh(ort-tlermrelief. Theseinclude various methods for stimulation of the salivary flow by sucking tablets or by gum-chewing, or the use of saliva substitutes. Medications such as pilocarpine or nicotinamide have T,V N, 0, Q, S
Q
M R R, S
Medication
Salivary substitutes Mechanical salivary stimulants Analgesics Sedatives and hypnotics Thyroid hormones and other hormones Antihypertensives Heart-stimulating medication Gastroesophageal reflux medication Asthma and allergy medication Cortisone and antihistamines Vitamins, trace demerits
F, G, H A, E, F, G, K D, I B, L 6 1 B, L H A -
N, R, V N, 0, V Q, R, T o”,T,V S
Q
R, s M, T, V U
Experimental group, Patients coded A to L; control group, patients coded M to V.
cording to traditional Chinese medicine.*%9 The needles used were Chinese (Hwa To Brand; diameter 0.32 mm, length 25 mm) and Japanese(Maeda; diameter 0.30 mm, length 30 mm), made of stainless steel, and autoclaved before use. Insertions were done to depths between 0.5 and 2.0 cm after the usual skin sterilizing procedures, and approximately 1 to 3 mm in the ear. Eleven patients received acupuncture, which evoked a tingling, nonpainful sensation (de-qi) at each of the points chosen. Superficial needling (placebo acupuncture) was performed on 10 patients. The needles were inserted only superficially (intradermal), without eliciting any further sensation, 1 to 2 cm from the acupuncture point. Both acupuncture and placebo acupuncture treatments were given twice a week for 20 minutes, and the interval between the two &week acupuncture serieswas 7 to 10 days. Any changesof subjective symptoms and changesin medication during or after the treatment procedure were noted. Evaluation
of salivary
flow rates
Saliva was sampled according to standard techniques used at the Department of Cariology, Karo-
linska Xnstitutett” and at the sametime of the day for each patient. Baseline levels of salivary flow rates for each patient were determined for both resting and paraffin-stimulated saliva on two different occasions before the start of the investigation. Salivary flow rates were measured again twice before the second series of acupuncture treatments. New salivary evaluations were made immediately after the completion of the acupuncture series;at 3 weeks;and 3,6, and 12 months after the end of the acupuncture treatment. Neither the person who evaluated the salivary flow nor the patients themselves knew whether they received acupuncture or superficial needling (placebo acupuncture). The study was approved by the Human Ethics Committee at Huddinge Hospital, Karolinska Institutet. Statistical
methods
Wilcoxon’s signed rank test was used for statistical analysis within each group to compare the changes from baseline levels of salivary flow rates. The differencestested were between baseline values and values at weeks 7, 16, 28, 40, and 64. Wilcoxon’s two-sam-
Efect of acupuncture on salivary flow
Volume 73 Number 3
EXPERIMENTAL Salivary at each
flow rates time point
295
DESIGN were determined as indicated
Fig. 2. Experimental design. Salivary flow rates were determined at each time point as indicated.
Fig. 1. Acupuncture points stimulated during treatment of experimental group were localized in head, ears, hands, and legs. Localpoints: Stomach channel, 3,4,5, 6,7; Small intestine channel, 17. Distal points: Hand, Pericardium channel 6; Heart clhannel7; Large intestine channel 4,8,10; Si, 3, 7; Head, Du channel 20; Torso, Ren channel 9, 17; Legs, St 36; Kidney, 3 or 5; Spleen channel, 6, 8, or 4. Auricular
points:
Slhen-men,vegetativum, kidney, spleen,
mouth, subcortex, pancreas, endocrinum, hormone.
ple rank test was used to compare the changes from baseline levels of the salivary flow rates between the two groups at the same time points. To analyze changesin salivary flow rates occurring with
time after the last acupuncture
treatment,
differences were also tested between week 16 values and values at weeks 28, 40, and 64. RESULTS
The salivary flow rates for each experimental patient before, during, and after the acupuncture
treatment are shown in Table II and for each control patient in Table III. The median and ranges for both groups are summarized in Table IV. The differences‘betweenbaseline levels and salivary flow rates at different time points for each group as well as between the two groups were compared. The differences in salivary flow rates between week 16 and weeks28,40, and 64 were also compared within each group as well as between the two groups. The results are shown in Table V. In addition to quantitative data related to salivary function, qualitative findings were also recorded (Table VI). The symptoms most affected by acupuncture were various chronic pains, circulatory problems (such asvascular spasm),insomnia, and improvement in general health condition. After the abatement of various symptoms, some patients also reduced dosages of their medi’cations (Table VI). In a few cases secondary effects of acupuncture treatment, such as tiny hemorrhages at the acupuncture sites,resulting in small hematomas,were noticed. Tiredness sometim.esoccurred after treatment. DISCUSSION
The present study found that patients who received acupuncture showed improved salivary flow rates both during and after experimental treatment. Furthermore, four of these 11 patients attained normal salivary flow rates. Improved salivary values persisted during the observation year (Table II). The most severe casesappearedto react least to the treatment, an observation also noted in the studies conducted by Pierminova et a1.6and Goidenko et a1.7Patients who receivedplaceboacupuncture showedpositive changes in their salivary flow rates during experimental treatment, but those changesdisappearedafter the placebo acupuncture was completed (Table III). These results were shown to be significant with statistical analyses (Table V). It appears that acupuncture treatment not
Horn, Dawidson, and Angmar-Mhsson
296
ORAL SURG ORAL MED ORAL BATHOL
March 1992 Table II. Salivary flow rates* for unstimuiated and stimulated whole saliva before, during, and after acupuncture treatment for each patient in experimental group
Between AP
A
-.
After AP
-
0.70 1.60
0.40 1.20
0.60 1.56
0.70 I .60
0.36 1.20
0.18 0.96
0.32 1.oo
0.27 1.16
0.32 0.83
0.25 0.82
0.22 0.84
0.24 1.04
0.22 1.08
0.26 1.22
0.46 1.34
0.40 1.24
0.30 1.10
0.02 0.06
0.10 0.12
0.03 0.04
0.04 0.06
0.03 0.12
0.04 0.10
0.20 0.50
0.14 0.44
0.14 0.38
0.10 0.21
0.14 0.52
0.10 0.34
0.12 0.40
0.02 0.20
0.02 0.32
0.06 0.40
0.04 0.42
0.12 0.30
0.10 0.50
0.08 0.36
0.05 0.44
0.04 0.16
0.07 0.16
0.08 0.22
0.10 0.20
0.12 0.22
0.09 0.16
0.08 0.24
0.14 0.18
0.02 0.24
us SS
0.04 0.14
0.01 0.12
0.06 0.16
0.04 0.16
0.06 0.10
0.02 Q.16
0 0.22
0.04 0.10
0.01 O.!l
us ss
0.01 0.60
0.01 0.48
0.04 0.56
0.06 0.74
0.04 0.52
0.10 1.00
0.06 0.76
0.09 0.76
0.04 0.60
us ss
0.03 0.38
0.12 0.24
0.08 0.32
0.04 0.34
0.13 0.38
0.06 0.30
0.08 0.44
0.14 0.48
0.10 0.28
US ss
0.15 0.70
US ss
0.01 0.16
0.01 0.34
0.28 1.06
0.14 1.06
0.34 1.20
us ss
0.04 0.40
0.04 0.54
0.14 0.76
0.08 0.66
0.16 0.76
us SS
0.10 0.48
0.10 0.64
0.26 0.96
0.20 1.16
us ss
0.02 0.02
0.02 0.02
0.04 0.10
us ss
0.08 0.30
0.06 0.22
us ss
0.02 0.30
us ss
-
B -
e
D
E
F
G
H
I
K
L
-
AP, Acupuncture; SS, stimulated saliva; US, unstimulated saliva *Normal values: Unstimulated saliva, 0.25 to 0.35 m!/min (
