Journal of Korean Dental Science

Korean Academy of Dental Science (대한치의학회)
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Clinical Guidelines to Diagnose and Manage Dental Patients with Hyposalivation and Xerostomia

  • Jeong-Kui Ku (Department of Oral and Maxillofacial Surgery, School of Dentistry and Institute of Oral Bioscience, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University) ;
  • Pil-Young Yun (Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital) ;
  • Sungil Jang (Department of Oral Biochemistry, Institute of Oral Bioscience, School of Dentistry, Jeonbuk National University) ;
  • Won Jung (Department of Oral Medicine, School of Dentistry and Institute of Oral Bioscience, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University) ;
  • Kyung-Gyun Hwang (Department of Dentistry/Oral and Maxillofacial Surgery, College of Medicine, Hanyang University)
  • Received : 2023.05.22
  • Accepted : 2023.06.05
  • Published : 2023.06.30
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Abstract

Xerostomia is defined as the subjective complaint of dry mouth with or without hyposalivation, which is insufficient salivary secretion from salivary gland. Xerostomia can lead to multiple oral symptoms such as dental caries, halitosis, burning mouth syndrome, and oral candidiasis, which can significantly impact the well-being of patients, especially in geriatric patients who may already have compromised health. Clinical findings of xerostomia include decreased salivary flow and alterations in salivary composition. These changes can lead to various oral health problems such as dental caries, periodontitis, swallowing and speaking difficulties, taste disturbances, halitosis, mucosal diseases, and burning mouth syndrome. Recognizing these clinical manifestations is essential for early diagnosis and appropriate management. Although several reasons and risk factors have been suggested for xerostomia such as aging, chemo-radiation therapy, systemic disease, and Sjögren's syndrome, the polypharmacy is recently highlighted especially in elderly patients. Understanding the etiology and risk factors associated with xerostomia is crucial for effective management. To manage xerostomia patients, a multidisciplinary guideline should be established beyond dental care. Through this literature review, we summarized consideration for diagnostic, therapeutic, nursing essentials for the clinical guideline. By addressing the underlying causes and implementing appropriate treatment strategies, healthcare professionals can improve the quality of life for individuals suffering from xerostomia.

Keywords

Acknowledgement

This research was supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute, funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI20C0013).

References

  1. Millsop JW, Wang EA, Fazel N. Etiology, evaluation, and management of xerostomia. Clin Dermatol. 2017; 35: 468-76.  https://doi.org/10.1016/j.clindermatol.2017.06.010
  2. Tanasiewicz M, Hildebrandt T, Obersztyn I. Xerostomia of various etiologies: a review of the literature. Adv Clin Exp Med. 2016; 25: 199-206.  https://doi.org/10.17219/acem/29375
  3. Barbe AG. Medication-induced xerostomia and hyposalivation in the elderly: culprits, complications, and management. Drugs Aging. 2018; 35: 877-85.  https://doi.org/10.1007/s40266-018-0588-5
  4. Locker D, Slade G. Association between clinical and subjective indicators of oral health status in an older adult population. Gerodontology. 1994; 11: 108-14.  https://doi.org/10.1111/j.1741-2358.1994.tb00116.x
  5. Molek M, Florenly F, Lister INE, Wahab TA, Lister C, Fioni F. Xerostomia and hyposalivation in association with oral candidiasis: a systematic review and meta-analysis. Evid Based Dent. 2022. doi: 10.1038/s41432-021-0210-2. [Epub ahead of print] 
  6. Tan HR, Renton T. Burning mouth syndrome: an update. Cephalalgia Reports. 2020. doi: 10.1177/2515816320970143 
  7. Pedersen AM, Bardow A, Jensen SB, Nauntofte B. Saliva and gastrointestinal functions of taste, mastication, swallowing and digestion. Oral Dis. 2002; 8: 117-29.  https://doi.org/10.1034/j.1601-0825.2002.02851.x
  8. Orellana MF, Lagravere MO, Boychuk DG, Major PW, Flores-Mir C. Prevalence of xerostomia in population-based samples: a systematic review. J Public Health Dent. 2006; 66: 152-8.  https://doi.org/10.1111/j.1752-7325.2006.tb02572.x
  9. Liu B, Dion MR, Jurasic MM, Gibson G, Jones JA. Xerostomia and salivary hypofunction in vulnerable elders: prevalence and etiology. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012; 114: 52-60.  https://doi.org/10.1016/j.oooo.2011.11.014
  10. Nederfors T, Isaksson R, Mornstad H, Dahlof C. Prevalence of perceived symptoms of dry mouth in an adult Swedish population--relation to age, sex and pharmacotherapy. Community Dent Oral Epidemiol. 1997; 25: 211-6.  https://doi.org/10.1111/j.1600-0528.1997.tb00928.x
  11. Nederfors T. Xerostomia: prevalence and pharmacotherapy. With special reference to beta-adrenoceptor antagonists. Swed Dent J Suppl. 1996; 116: 1-70. 
  12. Alsakran Altamimi M. Update knowledge of dry mouth- A guideline for dentists. Afr Health Sci. 2014; 14: 736-42.  https://doi.org/10.4314/ahs.v14i3.33
  13. Saleh J, Figueiredo MA, Cherubini K, Salum FG. Salivary hypofunction: an update on aetiology, diagnosis and therapeutics. Arch Oral Biol. 2015; 60: 242-55.  https://doi.org/10.1016/j.archoralbio.2014.10.004
  14. Helmick CG, Felson DT, Lawrence RC, Gabriel S, Hirsch R, Kwoh CK, Liang MH, Kremers HM, Mayes MD, Merkel PA, Pillemer SR, Reveille JD, Stone JH; National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum. 2008; 58: 15-25.  https://doi.org/10.1002/art.23177
  15. Mavragani CP, Moutsopoulos HM. The geoepidemiology of Sjogren's syndrome. Autoimmun Rev. 2010; 9: A305-10.  https://doi.org/10.1016/j.autrev.2009.11.004
  16. Zero DT, Brennan MT, Daniels TE, Papas A, Stewart C, Pinto A, Al-Hashimi I, Navazesh M, Rhodus N, Sciubba J, Singh M, Wu AJ, Frantsve-Hawley J, Tracy S, Fox PC, Ford TL, Cohen S, Vivino FB, Hammitt KM; Sjogren's Syndrome Foundation Clinical Practice Guidelines Committee. Clinical practice guidelines for oral management of Sjogren disease: dental caries prevention. J Am Dent Assoc. 2016; 147: 295-305.  https://doi.org/10.1016/j.adaj.2015.11.008
  17. Fox PC. Autoimmune diseases and Sjogren's syndrome: an autoimmune exocrinopathy. Ann N Y Acad Sci. 2007; 1098: 15-21.  https://doi.org/10.1196/annals.1384.003
  18. Kapourani A, Kontogiannopoulos KN, Manioudaki AE, Poulopoulos AK, Tsalikis L, Assimopoulou AN, Barmpalexis P. A review on xerostomia and its various management strategies: the role of advanced polymeric materials in the treatment approaches. Polymers (Basel). 2022; 14: 850. 
  19. van Eijk J, van Campen JP, van der Jagt H, Beijnen JH, Tulner LR. Prevalence of xerostomia and its relationship with underlying diseases, medication, and nutrition: a descriptive observational study. J Am Geriatr Soc. 2013; 61: 1836-7.  https://doi.org/10.1111/jgs.12469
  20. Atkinson JC, Grisius M, Massey W. Salivary hypofunction and xerostomia: diagnosis and treatment. Dent Clin North Am. 2005; 49: 309-26.  https://doi.org/10.1016/j.cden.2004.10.002
  21. Pramanik R, Osailan SM, Challacombe SJ, Urquhart D, Proctor GB. Protein and mucin retention on oral mucosal surfaces in dry mouth patients. Eur J Oral Sci. 2010; 118: 245-53.  https://doi.org/10.1111/j.1600-0722.2010.00728.x
  22. Pringle SA, Berkhof B, van Ginkel M, Liefers S, van der Vegt B, Spijkervet FKL, Bootsma H, Vissink A, Kroese FGM. Parotid salivary sodium levels of Sjogren's syndrome patients suggest B-cell mediated epithelial sodium channel disruption. Clin Exp Rheumatol. 2021; 39(Suppl 133): 30-8.  https://doi.org/10.55563/clinexprheumatol/h9hivf
  23. Llena-Puy C. The role of saliva in maintaining oral health and as an aid to diagnosis. Med Oral Patol Oral Cir Bucal. 2006; 11: E449-55. 
  24. Su N, Marek CL, Ching V, Grushka M. Caries prevention for patients with dry mouth. J Can Dent Assoc. 2011; 77: b85. 
  25. Eliasson L, Carlen A, Almstahl A, Wikstrom M, Lingstrom P. Dental plaque pH and micro-organisms during hyposalivation. J Dent Res. 2006; 85: 334-8.  https://doi.org/10.1177/154405910608500410
  26. Hirotomi T, Yoshihara A, Ogawa H, Ito K, Igarashi A, Miyazaki H. A preliminary study on the relationship between stimulated saliva and periodontal conditions in community-dwelling elderly people. J Dent. 2006; 34: 692-8.  https://doi.org/10.1016/j.jdent.2006.01.001
  27. Mizutani S, Ekuni D, Tomofuji T, Azuma T, Kataoka K, Yamane M, Iwasaki Y, Morita M. Relationship between xerostomia and gingival condition in young adults. J Periodontal Res. 2015; 50: 74-9.  https://doi.org/10.1111/jre.12183
  28. de Goes Soares L, Rocha RL, Bagordakis E, Galvao EL, Douglas-de-Oliveira DW, Falci SGM. Relationship between sjogren syndrome and periodontal status: A systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018; 125: 223-31.  https://doi.org/10.1016/j.oooo.2017.11.018
  29. Singh M, Teles F, Uzel NG, Papas A. Characterizing microbiota from Sjogren's syndrome patients. JDR Clin Trans Res. 2021; 6: 324-32.  https://doi.org/10.1177/2380084420940623
  30. Humphrey SP, Williamson RT. A review of saliva: normal composition, flow, and function. J Prosthet Dent. 2001; 85: 162-9.  https://doi.org/10.1067/mpr.2001.113778
  31. Chawhuaveang DD, Yu OY, Yin IX, Lam WY, Mei ML, Chu CH. Acquired salivary pellicle and oral diseases: a literature review. J Dent Sci. 2021; 16: 523-9.  https://doi.org/10.1016/j.jds.2020.10.007
  32. Rogus-Pulia NM, Logemann JA. Effects of reduced saliva production on swallowing in patients with Sjogren's syndrome. Dysphagia. 2011; 26: 295-303.  https://doi.org/10.1007/s00455-010-9311-3
  33. Rogus-Pulia NM, Gangnon R, Kind A, Connor NP, Asthana S. A pilot study of perceived mouth dryness, perceived swallowing effort, and saliva substitute effects in healthy adults across the age range. Dysphagia. 2018; 33: 200-5.  https://doi.org/10.1007/s00455-017-9846-7
  34. Roh JL, Kim AY, Cho MJ. Xerostomia following radiotherapy of the head and neck affects vocal function. J Clin Oncol. 2005; 23: 3016-23.  https://doi.org/10.1200/JCO.2005.07.419
  35. Chambers MS, Garden AS, Kies MS, Martin JW. Radiation-induced xerostomia in patients with head and neck cancer: pathogenesis, impact on quality of life, and management. Head Neck. 2004; 26: 796-807.  https://doi.org/10.1002/hed.20045
  36. Anil S, Vellappally S, Hashem M, Preethanath RS, Patil S, Samaranayake LP. Xerostomia in geriatric patients: a burgeoning global concern. J Investig Clin Dent. 2016; 7: 5-12.  https://doi.org/10.1111/jicd.12120
  37. Roh JL, Kim HS, Kim AY. The effect of acute xerostomia on vocal function. Arch Otolaryngol Head Neck Surg. 2006; 132: 542-6.  https://doi.org/10.1001/archotol.132.5.542
  38. Matsuo R. Role of saliva in the maintenance of taste sensitivity. Crit Rev Oral Biol Med. 2000; 11: 216-29.  https://doi.org/10.1177/10454411000110020501
  39. Hershkovich O, Nagler RM. Biochemical analysis of saliva and taste acuity evaluation in patients with burning mouth syndrome, xerostomia and/or gustatory disturbances. Arch Oral Biol. 2004; 49: 515-22.  https://doi.org/10.1016/j.archoralbio.2004.01.012
  40. Tanaka M. Secretory function of the salivary gland in patients with taste disorders or xerostomia: correlation with zinc deficiency. Acta Otolaryngol Suppl. 2002; (546): 134-41. 
  41. Ikebe K, Sajima H, Kobayashi S, Hata K, Morii K, Nokubi T, Ettinger RL. Association of salivary flow rate with oral function in a sample of community-dwelling older adults in Japan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002; 94: 184-90.  https://doi.org/10.1067/moe.2001.124001
  42. Lu DP. Halitosis: an etiologic classification, a treatment approach, and prevention. Oral Surg Oral Med Oral Pathol. 1982; 54: 521-6.  https://doi.org/10.1016/0030-4220(82)90190-6
  43. Aylikci BU, Colak H. Halitosis: from diagnosis to management. J Nat Sci Biol Med. 2013; 4: 14-23.  https://doi.org/10.4103/0976-9668.107255
  44. Lee YH. Xerostomia and halitosis: a review and current concepts. J Korean Dent Assoc 2017; 55: 640-56. 
  45. Koshimune S, Awano S, Gohara K, Kurihara E, Ansai T, Takehara T. Low salivary flow and volatile sulfur compounds in mouth air. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 96: 38-41.  https://doi.org/10.1016/S1079-2104(03)00162-8
  46. Campisi G, Panzarella V, Matranga D, Calvino F, Pizzo G, Lo Muzio L, Porter S. Risk factors of oral candidosis: a twofold approach of study by fuzzy logic and traditional statistic. Arch Oral Biol. 2008; 53: 388-97.  https://doi.org/10.1016/j.archoralbio.2007.11.009
  47. Lynge Pedersen AM, Nauntofte B, Smidt D, Torpet LA. Oral mucosal lesions in older people: relation to salivary secretion, systemic diseases and medications. Oral Dis. 2015; 21: 721-9.  https://doi.org/10.1111/odi.12337
  48. Maltsman-Tseikhin A, Moricca P, Niv D. Burning mouth syndrome: will better understanding yield better management? Pain Pract. 2007; 7: 151-62.  https://doi.org/10.1111/j.1533-2500.2007.00124.x
  49. Bartoshuk LM, Catalanotto F, Hoffman H, Logan H, Snyder DJ. Taste damage (otitis media, tonsillectomy and head and neck cancer), oral sensations and BMI. Physiol Behav. 2012; 107: 516-26.  https://doi.org/10.1016/j.physbeh.2012.06.013
  50. Poon R, Su N, Ching V, Darling M, Grushka M. Reduction in unstimulated salivary flow rate in burning mouth syndrome. Br Dent J. 2014; 217: E14. 
  51. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. Ther Clin Risk Manag. 2014; 11: 45-51.  https://doi.org/10.2147/TCRM.S76282
  52. Fox PC, Busch KA, Baum BJ. Subjective reports of xerostomia and objective measures of salivary gland performance. J Am Dent Assoc. 1987; 115: 581-4.  https://doi.org/10.1016/S0002-8177(87)54012-0
  53. Thomson WM, Chalmers JM, Spencer AJ, Williams SM. The xerostomia inventory: a multi-item approach to measuring dry mouth. Community Dent Health. 1999; 16: 12-7. 
  54. van der Putten GJ, Brand HS, Schols JM, de Baat C. The diagnostic suitability of a xerostomia questionnaire and the association between xerostomia, hyposalivation and medication use in a group of nursing home residents. Clin Oral Investig. 2011; 15: 185-92.  https://doi.org/10.1007/s00784-010-0382-1
  55. Eisbruch A, Rhodus N, Rosenthal D, Murphy B, Rasch C, Sonis S, Scarantino C, Brizel D. How should we measure and report radiotherapy-induced xerostomia? Semin Radiat Oncol. 2003; 13: 226-34.  https://doi.org/10.1016/S1053-4296(03)00033-X
  56. Pai S, Ghezzi EM, Ship JA. Development of a Visual Analogue Scale questionnaire for subjective assessment of salivary dysfunction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001; 91: 311-6.  https://doi.org/10.1067/moe.2001.111551
  57. Jun MK, Ku JK, Kim IH, Park SY, Hong J, Kim JY, Lee JK. Hospital dentistry for intensive care unit patients: a comprehensive review. J Clin Med. 2021; 10: 3681. 
  58. Chen YC, Chen HY, Hsu CH. Recent advances in salivary scintigraphic evaluation of salivary gland function. Diagnostics (Basel). 2021; 11: 1173. 
  59. Lee JM, Garon E, Wong DT. Salivary diagnostics. Orthod Craniofac Res. 2009; 12: 206-11.  https://doi.org/10.1111/j.1601-6343.2009.01454.x
  60. Yoshida H, Ueda M, Yamamoto S, Matsushita T, Ishikawa H, Nakanishi T, Naruse K, Matsuse K, Shibuya T, Takahashi K, Baba K, Miyake T, Ohkubo T, Morita S. Clinical study of the blood test data of outpatients with dry mouth syndrome during their initial visit. J Osaka Dent Univ. 2017; 51: 89-93. 
  61. Lopez-Pintor RM, Casanas E, Gonzalez-Serrano J, Serrano J, Ramirez L, de Arriba L, Hernandez G. Xerostomia, hyposalivation, and salivary flow in diabetes patients. J Diabetes Res. 2016; 2016: 4372852. 
  62. Mortazavi H, Baharvand M, Movahhedian A, Mohammadi M, Khodadoustan A. Xerostomia due to systemic disease: a review of 20 conditions and mechanisms. Ann Med Health Sci Res. 2014; 4: 503-10.  https://doi.org/10.4103/2141-9248.139284
  63. Sebastian A, Woytala P, Madej M, Proc K, Czesak-Woytala K, Sebastian M, Zub K, Wiland P. Is it possible to not perform salivary gland biopsy in targeted patients according to unstimulated salivary flow results in patients with suspected Sjogren's syndrome? Rheumatol Int. 2021; 41: 1125-31.  https://doi.org/10.1007/s00296-021-04840-4
  64. Liquidato BM, Barros MD, Bussoloti Filho I, Pereira CSB, Macea MIM. Minor. salivary glands morphology in xerostomia patients. Int J Morphol 2006; 24: 489-93.  https://doi.org/10.4067/S0717-95022006000400031
  65. Thomson WM, Lawrence HP, Broadbent JM, Poulton R. The impact of xerostomia on oral-healthrelated quality of life among younger adults. Health Qual Life Outcomes. 2006; 4: 86. 
  66. Morita L, da Silva VB, Takeda LM, Choi IGG, Kim JH, Hisatomi M, Arita ES. Radiographic aspects of major salivary glands in sialography. Clin Lab Res Den. 2019. doi: 10.11606/issn.2357-8041.clrd.2019.150319 
  67. Plemons JM, Al-Hashimi I, Marek CL; American Dental Association Council on Scientific Affairs. Managing xerostomia and salivary gland hypofunction: executive summary of a report from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2014; 145: 867-73.  https://doi.org/10.14219/jada.2014.44
  68. Bozorgi C, Holleufer C, Wendin K. Saliva secretion and swallowing-the impact of different types of food and drink on subsequent intake. Nutrients. 2020; 12: 256. 
  69. Dalodom S, Lam-Ubol A, Jeanmaneechotechai S, Takamfoo L, Intachai W, Duangchada K, Hongsachum B, Kanjanatiwat P, Vacharotayangul P, Trachootham D. Influence of oral moisturizing jelly as a saliva substitute for the relief of xerostomia in elderly patients with hypertension and diabetes mellitus. Geriatr Nurs. 2016; 37: 101-9.  https://doi.org/10.1016/j.gerinurse.2015.10.014
  70. Johnson JT, Ferretti GA, Nethery WJ, Valdez IH, Fox PC, Ng D, Muscoplat CC, Gallagher SC. Oral pilocarpine for post-irradiation xerostomia in patients with head and neck cancer. N Engl J Med. 1993; 329: 390-5.  https://doi.org/10.1056/NEJM199308053290603
  71. Vivino FB, Al-Hashimi I, Khan Z, LeVeque FG, Salisbury PL 3rd, Tran-Johnson TK, Muscoplat CC, Trivedi M, Goldlust B, Gallagher SC. Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjogren syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group. Arch Intern Med. 1999; 159: 174-81.  https://doi.org/10.1001/archinte.159.2.174
  72. Fife RS, Chase WF, Dore RK, Wiesenhutter CW, Lockhart PB, Tindall E, Suen JY. Cevimeline for the treatment of xerostomia in patients with Sjogren syndrome: a randomized trial. Arch Intern Med. 2002; 162: 1293-300.  https://doi.org/10.1001/archinte.162.11.1293
  73. Wolff A, Fox PC, Porter S, Konttinen YT. Established and novel approaches for the management of hyposalivation and xerostomia. Curr Pharm Des. 2012; 18: 5515-21.  https://doi.org/10.2174/138161212803307509
  74. Kaae JK, Stenfeldt L, Eriksen JG. Xerostomia after radiotherapy for oral and oropharyngeal cancer: increasing salivary flow with tasteless sugar-free chewing gum. Front Oncol. 2016; 6: 111. 
  75. Risheim H, Arneberg P. Salivary stimulation by chewing gum and lozenges in rheumatic patients with xerostomia. Scand J Dent Res. 1993; 101: 40-3.  https://doi.org/10.1111/j.1600-0722.1993.tb01644.x
  76. Momm F, Volegova-Neher NJ, Schulte-Monting J, Guttenberger R. Different saliva substitutes for treatment of xerostomia following radiotherapy. A prospective crossover study. Strahlenther Onkol. 2005; 181: 231-6.  https://doi.org/10.1007/s00066-005-1333-7
  77. Furness S, Worthington HV, Bryan G, Birchenough S, McMillan R. Interventions for the management of dry mouth: topical therapies. Cochrane Database Syst Rev. 2011; (12): CD008934. 
  78. Vadcharavivad S, Boonroung T. Original article. Effects of two carboxymethylcellulose-containing saliva substitutes on post-radiation xerostomia in head and neck cancer patients related to quality of life. Asian Biomedicine. 2017; 7: 193-202. 
  79. Nuchit S, Lam-Ubol A, Paemuang W, Talungchit S, Chokchaitam O, Mungkung OO, Pongcharoen T, Trachootham D. Alleviation of dry mouth by saliva substitutes improved swallowing ability and clinical nutritional status of post-radiotherapy head and neck cancer patients: a randomized controlled trial. Support Care Cancer. 2020; 28: 2817-28.  https://doi.org/10.1007/s00520-019-05132-1
  80. Papas A, Singh M, Harrington D, Rodriguez S, Ortblad K, de Jager M, Nunn M. Stimulation of salivary flow with a powered toothbrush in a xerostomic population. Spec Care Dentist. 2006; 26: 241-6.  https://doi.org/10.1111/j.1754-4505.2006.tb01661.x
  81. Strietzel FP, Lafaurie GI, Mendoza GR, Alajbeg I, Pejda S, Vuletic L, Mantilla R, Falcao DP, Leal SC, Bezerra AC, Tran SD, Menard HA, Kimoto S, Pan S, Martin-Granizo RA, Lozano ML, Zunt SL, Krushinski CA, Melilli D, Campisi G, Paderni C, Dolce S, Yepes JF, Lindh L, Koray M, Mumcu G, Elad S, Zeevi I, Barrios BC, Lopez Sanchez RM, Beiski BZ, Wolff A, Konttinen YT. Efficacy and safety of an intraoral electrostimulation device for xerostomia relief: a multicenter, randomized trial. Arthritis Rheum. 2011; 63: 180-90.  https://doi.org/10.1002/art.27766
  82. Loncar B, Stipetic MM, Baricevic M, Risovic D. The effect of low-level laser therapy on salivary glands in patients with xerostomia. Photomed Laser Surg. 2011; 29: 171-5.  https://doi.org/10.1089/pho.2010.2792
  83. Shacham R, Puterman MB, Ohana N, Nahlieli O. Endoscopic treatment of salivary glands affected by autoimmune diseases. J Oral Maxillofac Surg. 2011; 69: 476-81.  https://doi.org/10.1016/j.joms.2010.10.002
  84. Gallo A, Martellucci S, Fusconi M, Pagliuca G, Greco A, De Virgilio A, De Vincentiis M. Sialendo-scopic management of autoimmune sialadenitis: a review of literature. Acta Otorhinolaryngol Ital. 2017; 37: 148-54.  https://doi.org/10.14639/0392-100X-1605
  85. De Luca R, Trodella M, Vicidomini A, Colella G, Tartaro G. Endoscopic management of salivary gland obstructive diseases in patients with Sjogren's syndrome. J Craniomaxillofac Surg. 2015; 43: 1643-9.  https://doi.org/10.1016/j.jcms.2015.06.036
  86. Karagozoglu KH, Vissink A, Forouzanfar T, de Visscher JGAM, Maarse F, Brand HS, van de Ven PM, Jager DHJ. Sialendoscopy increases saliva secretion and reduces xerostomia up to 60 weeks in Sjogren's syndrome patients: a randomized controlled study. Rheumatology (Oxford). 2021; 60: 1353-63.  https://doi.org/10.1093/rheumatology/keaa284
  87. Lee C, Kim JE, Huh KH, Yi WJ, Heo MS, Lee SS, Choi SC. Therapeutic effect of intraductal irrigation of the salivary gland: a technical report. Imaging Sci Dent. 2017; 47: 123-7.  https://doi.org/10.5624/isd.2017.47.2.123
  88. Yoo C, Vines JB, Alexander G, Murdock K, Hwang P, Jun HW. Adult stem cells and tissue engineering strategies for salivary gland regeneration: a review. Biomater Res. 2014; 18: 9. 
  89. Baum BJ, Alevizos I, Chiorini JA, Cotrim AP, Zheng C. Advances in salivary gland gene therapy - oral and systemic implications. Expert Opin Biol Ther. 2015; 15: 1443-54. https://doi.org/10.1517/14712598.2015.1064894