Magister Scientiae Dentium - MSc(Dent) / Introduction: Xerostomia and reduced salivary flow have been reported often enough among HIV positive patients. Strong associations have also been established between HIV infection and oral effects of reduced salivary flow like xerostomia, high DMFT, increased candidial infection etc. Besides the direct effect of HIV infection, xerostomia and reduced salivary flow have also been reported as a side effect of Highly Active Anti Retroviral reatment (HAART). Studies have shown that xerostomia has a negative effect on the quality of life of people living with HIV & AIDS. Although reduced salivary flow is a main cause for xerostomia, complaints of xerostomia is also found in the absence of salivary flow deficiency. An exact correlation between the two is not always found.Aim: The aim of this study is to compare the prevalence of xerostomia and hyposalivation, in HIV positive patients on HAART, HIV positive patients not on HAART and HIV negative patients, attending Empilweni Gompo community health centre (EGCHC) in East London. Study Methods: This is a cross sectional analytical study. Xerostomia and resting & chewing- stimulated salivary flow rates were measured for 150 patients who were from three groups : group 1-HIV negative, group 2-HIV positive not on HAART and group 3-HIV positive on HAART for more than two years. Each group had 50 patients. Xerostomia was measured using a questionnaire and salivary flow rates were calculated after saliva collection over a three minute period. Results: There was significant difference in the prevalences for xerostomia (p=0.006) and less than normal chewing -stimulated flow rate (p=0.041) among the three groups with the HIV positive group not on HAART showing the greatest deficiency. HAART was not found to have a negative effect on salivary function. A statistical significance was also observed while comparing mean resting (p=0.010) and chewing –stimulated (p=0.034) salivary flow rates among the three groups. The mean salivary flow rate of those complaining of xerostomia was found to be significantly lower than that of those who did not have xerostomia (p=0.005). Conclusion: HIV positive patients not on HAART are more vulnerable to salivary gland dysfunction. HAART in itself does not to adversely affect xerostomic perceptions or salivary flow rates.The xerostomia questionnaire is a useful tool in indicating those with possible low salivary flow rates

O tratamento com o iodo-131, conhecido como iodoterapia, já é bem estabelecido para tumores de tireoide diferenciados, porém, pode ter como importante efeito colateral o desenvolvimento da hipofunção das glândulas salivares. Dados recentes da literatura relatam casos de sialoadenite e xerostomia em pacientes submetidos à iodoterapia, no entanto, poucos estudos analisam o seu efeito na função e morfologia do tecido glandular, o que dificulta o aparecimento de métodos preventivos e curativos para essas complicações. Com isso e baseado em estudos que indicam resultados promissores da terapia fotobiomoduladora, com laser de baixa potência, no tratamento da hipofunção das glândulas salivares; este trabalho teve como objetivo compreender o efeito da iodoterapia sobre as glândulas salivares e analisar se a terapia de fotobiomodulação é capaz de evitar o dano ao tecido. Para isto, foi estabelecido o protocolo de indução da hipofunção das glândulas salivares através da iodoterapia em 70 camundongos BALB/c; os quais foram divididos em três grupos: C, controle (n=30); I, submetidos à iodoterapia (n=20); e IL, submetidos à iodoterapia e terapia fotobiomoduladora para a hipofunção das glândulas salivares (n=20), com um comprimento de onda de 808 nm, espectro infravermelho, potência de 100 mW, energia de 1 J e 10 s por ponto, totalizando uma densidade de energia de 35,7J/cm². Os animais foram avaliados em três tempos experimentais; T1: antes da iodoterapia, T2: 10 dias após a iodoterapia, e T3: 90 dias após a iodoterapia. Logo após a eutanásia, houve a remoção das glândulas salivares parótidas e submandibulares, para análises morfológicas e imuno-histoquímicas, para a determinação quantitativa de células apoptóticas e expressão dos canais de sódio e iodo, cujos resultados mostraram que a iodoterapia com o iodo-131 promoveu, nas glândulas salivares parótida e submandibular, a inibição dos canais de sódio e iodo, aumento de células apoptóticas e alteração do estroma glandular, com diminuição na concentração de colágeno e atrofia das unidades secretoras terminais. Além disso, também foi observado que a TFBM com laser de baixa potência foi eficaz na modulação dos efeitos inflamatórios causados pelo iodo-131, aumentando a produção de colágeno no tecido glandular, modulando a inflamação nas unidades secretoras terminais, reativando expressão do NIS e controlando a apoptose celular. Com os resultados obtidos no presente estudo, concluímos que que a iodoterapia causa hipofunção das glândulas salivares parótidas e submandibulares e que a terapia de fotobiomodulação se mostrou uma terapia eficaz e promissora para prevenir e atenuar estes efeitos colaterais. / Radioiodine treatment (RI), is a usual treatment for thyroid tumours, which may have the salivary gland hypofunction (SGH) as an important side effect. Sialoadenitis and xerostomia were reported in patients submitted to RI, however, only a few studies have analyzed its effect on function and morphology of glandular tissue, which makes it difficult to discover preventive and curative methods for these complications. Based on this and on the positive effects of photobiomodulation therapy (PBMT) in the treatment of HGS, the aim of the present study was to understand the effect of RI on salivary glands and to examine whether the PBMT is capable of preventing tissue damage. Thus, the protocol of induction of SGH by RI was performed in 70 BALB / c mice; which were divided into three groups: C, control (n = 30); I, submitted to RI (n = 20); and IL, submitted to RI and PBMT (n = 20). The animals were analysed in three different experimental times; T1: before RI, T2: 10 days after RI, and T3: 90 days after RI. Shortly after euthanasia, the parotid and submandibular salivary glands, were surgically removed for morphological and immunohistochemical analyzes, for the quantitative determination of apoptotic cells and expression of the sodium and iodine channels. The data showed an inhibition of sodium and iodine channels, increase of apoptotic cells and alteration of the glandular stroma, with destruction of collagen and atrophy of the secretory units in salivary glands, after RI. It was also observed that the PBMT seems to have been effective in modulating the effects of this inflammatory condition, increasing collagen production in the glandular tissue, modulating inflammation in the terminal secretory units, reactivating NIS expression and controlling cellular apoptosis. In conclusion, the RI caused hypofunction of the parotid and submandibular salivary glands and the PBMT was able to prevent and attenuate this side effect.

Considerando a mucosite oral (MO) e a hipofunção das glândulas salivares (HGS) consequências debilitantes da quimioterapia (QT), este trabalho teve como objetivo induzir, em hamsters, MO e HGS, através do quimioterápico 5- Fluorouracil (5-FU), e comparar, através de análises clínicas, bioquímicas e histológicas, diferentes fototerapias no tratamento da MO, assim como o efeito do laser no tratamento da HGS. Cento e oitenta animais foram divididos em dois grupos, controle e experimental, onde, o grupo controle foi subdividido em grupo C, o qual recebeu somente anestesia/veículo de diluição do quimioterápico e o CQ, o qual recebeu anestesia/quimioterapia e indução da MO. O grupo experimental foi também subdividido em grupo L: com indução de MO e tratamento com LED, 630nm, 1,2J/cm2; LA: MO e tratamento com laser de alta potência (LAP), 808nm, 10J/cm2; LB: MO e tratamento com laser de baixa potência (LBP), 660nm, 6J/cm2 e o LG: sem MO e tratamento com LBP, 780nm, 5J/cm², na região das glândulas salivares (GS) submandibulares (GSSM) e sublinguais GSSL). A MO foi induzida através de ranhuras após QT e foi avaliada, clinicamente, através de escalas específicas. Os animais foram sacrificados após 5, 7 e 10 dias de experimento e a mucosa oral e as GS removidas para análises bioquímicas (TNF- e análise de proteína total, LDH e parâmetros do sistema antioxidante, respectivamente) e histológicas (análise por microscopia de luz e imuno-histoquímica para as amostras de mucosa, e por microscopia de luz, eletrônica de transmissão e imunocitoquímica para as amostras de GS). Após análises estatísticas, os resultados clínicos, bioquímicos e histológicos mostraram que os tratamentos com LBP e LED foram eficazes no tratamento da MO, com diminuição da concentração de TNF- no dia 7 (p<0.05) e completa cicatrização das lesões ao termino do experimento, com maior formação de tecido de granulação e angiogênese. Além disso, a expressão de citoqueratina 10, analisada por imunohistoquímica, apresentou-se menos intensa comparada ao grupo CQ. O LAP não prejudicou a cicatrização final da MO quando comparada ao grupo CQ. O LBP também se mostrou eficaz para a HGS causada pelo 5-FU, uma vez que os parâmetros estudados para o grupo LG foram similares para os animais do grupo C na maior parte dos tempos experimentais. A HGS do grupo CQ foi representada por importantes alterações morfológicas, estruturais e bioquímicas, como a atrofia das unidades secretoras terminais, aumento do estroma glandular na GS sublingual e alterações na expressão de EGF, NGF e PIP2 nas GSSM, assim como alteração na expressão de mucina e p16 nas GSSL. De acordo com as análises bioquímicas, foram observadas alterações na atividade das enzimas antioxidantes catalase, peroxidase e superóxido dismutase e da atividade da enzima lactato desidrogenase (p<0.05) tanto para a GSSM quanto para a GSSL. Com base nos resultados, podemos concluir que as fototerapias com LBP e LED diminuem a severidade da MO por acelerar a reparação tecidual e diminuir o processo inflamatório, assim como o LBP é eficaz no tratamento da HGS induzida pelo quimioterápico 5-FU. / Considering oral mucositis (OM) and salivary glands hipofunction (SGH) debilitating consequences of chemotherapy (CT), the aim of this study was to compare, through clinical, biochemical and histological analysis, different photherapies on the treatment of OM and SGH induced by injections of the chemotherapic agent 5-Fluorouracil in hamsters. One-hundred-eighty animals were divided into two groups, control and experimental, which were subdivided in group C: anesthesia/chemotherapy vehicle and CQ: anesthesia, chemotherapy/OM induction, for control group and in group L: anesthesia, chemotherapy/OM and phototherapy with LED (1,2 J/cm², 1.2 J of total energy), LA: anesthesia, chemotherapy/OM and phototherapy with highpower laser (HPL) (10 J/cm², 10 J of total energy), LB: anesthesia, chemotherapy/OM and phototherapy with low-power laser (LPL) (6 J/cm², 1.2 J of total energy) and LG: anesthesia, chemotherapy and phototherapy with LPL (5 J/cm2) on salivary gland (SG) (submandibular and sublingual) areas for experimental group. The OM was induced by slots on oral mucosa, which were performed after chemotherapy treatment. The OM was analyzed through specific clinical scales and after 5, 7 and 10 days, the animals were sacrificed and the oral mucosa and submandibular and sublingual glands removed for biochemical (TNF- and total protein concentration, LDH and antioxidant system parameters, respectively) and histological (light microscopy and immune-histochemical for OM samples, and light microscopy, electronic transmission and immunocitochemical for SG samples) analysis. After statistical analysis, the clinical, biochemical and histological results showed Led and LPL as efficient treatments for OM, with decrease of TNF- concentration on day 7 (p<0.05) and complete lesions healing on last day of experiment, showing increase of granulation tissue and new blood vessels formation. In agreement, the citokeratin 10 expression by immunehistochemistry, showed less intensity when was compared with CQ group. The HPL had no interference on OM final healing in comparison with CQ group. The LPL also showed good results on treatment of SGH induced by 5- FU. The SGH on CQ group included important morphological, structural and biochemical changes, as acinar atrophy, increase of glandular stroma on sublingual glands and important changes for EGF, NGF and PIP2 expression on submandibular glands, and for mucin and p16 gene expression on sublingual glands. Furthermore, the biochemical analysis showed changes on antioxidant enzime system activity, catalase, peroxidase and superoxide dismutase, and also for dehidrogenase lactate activity (p<0.05). The results of the present study suggest the phototherapies with LPL and LED where efficient on decrease of OM severity, accelerating tissue repair and decreasing the inflammatory process, as well as, the LPL efficient as treatment of SGH induced by 5-FU.

CoordenaÃÃo de AperfeÃoamento de Pessoal de NÃvel Superior / Este trabalho teve como objetivo elucidar o efeito do 5-fluorouracil (5-FU) em glÃndulas salivares maiores, fluxo e composiÃÃo salivar, utilizando um modelo prà estabelecido de mucosite oral (MO) induzida em hamsters. A MO foi induzida por administraÃÃes intraperitoneais de 5-FU, nos 1 e 2 dias do modelo experimental (60mg/kg e 40mg/kg, respectivamente). No 4 dia, os animais foram submetidos ao trauma mecÃnico em mucosa jugal. Previamente a coleta das glÃndulas salivares, foi administrado pilocarpina (10mg/kg) para a medida do fluxo salivar e posterior coleta da saliva. As glÃndulas salivares maiores foram coletadas para anÃlise histopatolÃgica, contagem das cÃlulas inflamatÃrias, avaliaÃÃo do estresse oxidativo (SOD, CAT, nitrito/nitrato, NPSH e MDA), quantificaÃÃo de citocinas prÃ-inflamatÃrias (TNF-&#945; e IL-1&#946;) e investigaÃÃo de morte e proliferaÃÃo celular celular, nÃveis de CAT, SOD, lisozima e IgA foram avaliados em amostras de saliva. Os resultados mostraram que o 5-FU reduziu significativamente o fluxo salivar estimulado pela pilocarpina no 4 dia do modelo experimental, associado ao aumento dos nÃveis de SOD na saliva. No 10 dia, foi observada recuperaÃÃo do fluxo salivar, concomitante a reduÃÃo dos nÃveis de lisozima de saliva. AlÃm disso, o 5-FU promoveu vacuolizaÃÃo na glÃndula parÃtida e edema periductal na glÃndula submandibular no 4 dia, associada ao aumento do influxo de cÃlulas inflamatÃrias, principalmente no 4 dia na glÃndula submandibular e nos 4 e 10 dias na glÃndula parÃtida. O 5-FU estimulou a produÃÃo de citocinas prÃ-inflamatÃrias (IL-1&#946; e TNF-&#945;) no dia 10 nas glÃndulas submandibular e sublingual concomitante ao estresse oxidativo. Contudo, apesar do aumento do estresse oxidativo no 10 dia, o 5-FU produziu efeito inibitÃrio das mesmas citocinas prÃ-inflamatÃrias na glÃndula parÃtida. De acordo com os resultados acima descritos, podemos concluir que o 5-FU induz resposta inflamatÃria nas glÃndulas salivares maiores, mais frequentemente observado 10 dias apÃs a primeira administraÃÃo do 5-FU, o que pode contribuir para a hipofunÃÃo das glÃndulas salivares, levando a alteraÃÃes no fluxo e composiÃÃo salivar. / The aim of this study was to elucidate the effect of 5-Fluorouracil (5-FU) on major salivary glands, salivary flow and saliva composition using an established oral mucositis (OM) model, in hamsters. OM was induced by two intraperitoneal administrations of 5-FU on 1st and 2nd days of the experimental model (60mg/kg and 40mg/kg, respectively), followed by cheek pouch mucosa scratch. Pilocarpine stimulated salivary flow were measured, saliva was collected, salivary glands were harvested for histopathologycal analysis, measurement of inflammatory cells, evaluation of oxidative stress (SOD, CAT, nitrite, NP-SH and MDA), quantification of pro-inflammatory cytokines (TNF-&#945; and IL-1&#946;) and investigation of cell death and proliferation. CAT and lysozyme activities and IgA and SOD levels were evaluated in saliva samples. This study demonstrated that 5-FU significantly reduced the pilocarpine stimulated salivary flow rate on the 4th experimental day, associated with an increase in SOD levels in saliva. Recovery of salivary flow was observed on day 10, when a decrease in the saliva lysozyme levels was detected. In addition, 5-FU promoted vacuolization in parotid gland and periductal edema in submandibular gland, combined with an increase in the inflammatory cells influx, mostly observed on the 4th day in submandibular gland and on 4th and 10th days in parotid gland. 5-FU stimulated pro-inflammatory cytokines (TNF-&#945; and IL-1&#946;) production on 10th day in submandibular and sublingual glands associated with oxidative stress. Although the stimulation of oxidative stress on 10th day, 5-FU promoted inhibitory effect on both pro-inflammatory cytokines in parotid gland. According to the above mentioned results, 5-FU induced an inflammatory response in major salivary glands, most observed 10 days after its first injection, which may contribute to glands hypofunction, leading to alterations in the salivary flow rate and composition.

BACKGROUND: Vestibular rehabilitation (VR) improves symptoms and function in some but not all patients with bilateral vestibular hypofunction (BVH). OBJECTIVE: The purpose of this retrospective study was to examine change following vestibular rehabilitation and to identify factors associated with rehabilitation outcome in patients with BVH. METHODS: Data from 69 patients with BVH were analyzed. Factors studied included patient characteristics, subjective complaints and physical function. Outcome measures included symptom intensity, balance confidence, quality of life, gait speed, fall risk, and dynamic visual acuity. Bivariate correlations were used to examine relationships of patient characteristics and baseline measures with outcome measures. One-way ANOVAs were used to compare outcomes in patients with BVH versus unilateral vestibular hypofunction (UVH). RESULTS: As a group, patients with BVH improved in all outcome measures except disability following a course of vestibular rehabilitation (VR); however, only 38-86% demonstrated a meaningful improvement, depending on the specific outcome measure examined. Several factors measured at baseline - age, DGI score, gait speed and perceived dysequilibrium - were associated with outcomes. For example, greater age was related to higher DVA scores at discharge; lower initial DGI scores were related to higher Disability scores at discharge. Compared to patients with UVH, reported previously [9], a smaller percentage of patients with BVH improve and to a lesser extent. CONCLUSION: Consideration of baseline factors may provide guidance for setting patient goals. Further research is needed determine what factors predict outcome and to develop more effective treatment strategies for those patients who do not improve.

This work reports the use of a head-motion monitoring system to record patient head movements while completing in-home exercises for vestibular rehabilitation therapy. Based upon a dual-axis gyroscope (yaw and pitch, ± 500-degrees/sec maximum), angular head rotations were measured and stored via an on-board memory card. The system enabled the clinician to document exercises at home. Several measurements were recorded in one patient with unilateral vestibular hypofunction: The total time of exercise for the week (118 minutes) was documented and compared with expected weekly exercise time (140 minutes). For gaze stabilization exercises, execution time of 60 sec was expected, and observed times ranged from 75-100 sec. An absence of rest periods between each exercise instead of the recommended one minute rest period was observed. Maximum yaw head velocities from approximately 100-350 degrees/sec were detected. A second subject provided feedback concerning the ease of use of the HAMMS device. This pilot study demonstrates, for the first time, the capability to capture the head-motion “signature” of a patient while completing vestibular rehabilitation exercises in the home and to extract exercise regime parameters and monitor patient adherence. This emerging technology has the potential to greatly improve rehabilitation outcomes for individuals completing in-home gaze stabilization exercises 1 .

Abstract available through Journal of Vestibular Research.

Description:It is estimated that 35.4% of adults in the United States have vestibular dysfunction requiring medical attention, and the condition results in a substantial increase in fall risk. The Neurology Section and APTA supported the development of a clinical practice guideline (CPG) for vestibular rehabilitation of peripheral vestibular hypofunction. A Cochrane Database systematic review concluded that there is moderate to strong evidence in support of vestibular rehabilitation in the management of patients with unilateral vestibular hypofunction for reducing symptoms and improving function. The purpose of the CPG is to review the peer-reviewed literature and make recommendations based on the quality of the research for the treatment of peripheral vestibular hypofunction. The speakers will present the findings of clinical practice guidelines (CPG) for vestibular rehabilitation, including clinical and research recommendations. The session will use a case-based approach to illustrate implementation of these guidelines in clinical practice. Learning Objectives:1 . Describe and discuss the action statements from the vestibular rehabilitation CPG. 2. Implement the action statements into clinical practice. 3. Identify the gaps in the evidence and future research directions in vestibular rehabilitation.

Host Maureen Clancy PT, DPT, OCS is joined by Dr. Courtney Hall PT, PhD and Dr. Sue Whitney PT, PhD, NCS, ATC, FAPTA in a dicsussion on vestibular hypofunction. This podcast reviews the medical conditions that would lead to a diagnosis of hypofunction, clincal testing, treatment, exercise prescription, and the key updates from the recent CPG on vestibular hypofunction. For additional information please go to: http://www.neuropt.org/professional-resources/anpt-clinical-practice-guidelines/vestibular-hypofunction-cpg

BACKGROUND: Current vestibular rehabilitation for peripheral vestibular hypofunction is an exercise-based approach that improves symptoms and function in most, but not all patients, and includes gaze stabilization exercises focused on duration of head movement. One factor that may impact rehabilitation outcomes is the speed of head movement during gaze stability exercises. OBJECTIVE: Examine outcomes of modified VOR X1 exercises that emphasize a speed-based approach for gaze stabilization while omitting substitution and habituation exercises. Balance training focused on postural realignment and hip strategy performance during altered visual and somatosensory inputs. METHODS: A retrospective chart review of 159 patients with vestibular deficits was performed and five outcome measures were analyzed. RESULTS: All outcomes – self-report dizziness and balance function, dynamic gait index, modified clinical test of sensory interaction and balance, and clinical dynamic visual acuity improved significantly and approached or achieved normal scores. CONCLUSIONS: The combination of modified VOR X1 gaze stability exercises, wherein patients achieved high-velocity head movement (240°/s) during short exercise bouts, with “forced use” gait and balance exercises for postural realignment and hip strategy recruitment, achieved 93–99% of normal scores for all five outcomes. These results compare favorably to the outcomes for current VR techniques and warrant further investigation.