|Year : 2019 | Volume
| Issue : 3 | Page : 234-238
Comparative evaluation of unstimulated whole salivary flow rate and oral symptoms in healthy premenopausal and postmenopausal women - An observational study
Navneet Gill1, Pritesh Ruparelia1, Oshin Verma1, Kosha Ruparelia2
1 Department of Oral Medicine and Radiology, College of Dental Sciences and Research Centre, Ahmedabad, Gujarat, India
2 Department of Oral Medicine and Radiology, AMC Dental College, Ahmedabad, Gujarat, India
|Date of Submission||11-May-2019|
|Date of Acceptance||10-Aug-2019|
|Date of Web Publication||30-Sep-2019|
Dr. Pritesh Ruparelia
47, Jai Ambika Society, Isanpur Road, Maninagar, Ahmedabad, 380 008, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Menopausal women undergo many physiological changes, most of which are due to decreased estrogen production. Little is understood about the relationship between menopause and oral health. Aim and Objectives: To evaluate the association of menopausal status on subjective reports of oral discomfort and on the objective measurement of unstimulated whole salivary flow rate in healthy women. Materials and Methods: A total of 200 women, including 100 postmenopausal and 100 premenopausal women, were divided into two groups based upon their menstrual status. Group I consisted of 100 postmenopausal women in the age group of 44–76 years. Group II consisted of 100 premenopausal women in the age group of 31--45 years. Settings and Design: A standardized visual analog scale questionnaire was administered to obtain subjective sensation of oral discomfort. Unstimulated whole saliva was collected for 5 min by spitting method and the flow rate of saliva was measured per minute. Statistical analysis used: Chi-square, Student's t test, and analysis of variance (ANOVA) were applied. Results: The prevalence and intensity of the subjective symptoms of oral discomfort was significantly higher in postmenopausal women as compared to the premenopausal women (P < 0.001). The unstimulated whole salivary flow rates in pre- and postmenopausal women were 0.4 ± 0.13 and 0.2 ± 0.11 ml/min, respectively (P < 0.001). A significant association between symptoms of oral discomfort [burning sensation (P = 0.001), taste disorders (P < 0.001), dry mouth (P < 0.001)], and unstimulated salivary flow rate was seen in postmenopausal women. Conclusion: The results from this cross-sectional study of healthy females not being treated for any systemic disease, and not taking medications for any medical disorders indicated that the objective measurements of unstimulated whole salivary flow rate are influenced by menopause. In addition, subjective symptoms of oral discomfort are also associated with menopause.
Keywords: Oral discomfort, premenopausal women, postmenopausal women, unstimulated whole salivary flow rate
|How to cite this article:|
Gill N, Ruparelia P, Verma O, Ruparelia K. Comparative evaluation of unstimulated whole salivary flow rate and oral symptoms in healthy premenopausal and postmenopausal women - An observational study. J Indian Acad Oral Med Radiol 2019;31:234-8
|How to cite this URL:|
Gill N, Ruparelia P, Verma O, Ruparelia K. Comparative evaluation of unstimulated whole salivary flow rate and oral symptoms in healthy premenopausal and postmenopausal women - An observational study. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2020 Aug 9];31:234-8. Available from: http://www.jiaomr.in/text.asp?2019/31/3/234/268266
| Introduction|| |
The older age groups are the most rapidly growing segments of the general population. In order to provide more effective medical, dental, and social services to the elderly, it is necessary to better understand the oral consequences of physiological and pathological ageing.
Menopause is the permanent cessation of menstruation and ovarian function, characterized by the lack of estrogen production. While the systemic aspects of menopause are well documented, there is still a need to spread awareness about oral discomfort, as a part of menopausal complaints.
As saliva is essential for maintenance of oral health, it is important to assess the extent to which menopause affects saliva. In the current scenario, a controversy still exists on the association of menopause with salivary flow rate and the association of oral symptoms with salivary flow rate.
The present study was therefore conducted with the purpose of evaluating the association between menopausal status and subjective reports of oral discomfort and on objective measurement of unstimulated whole salivary flow rate in healthy women.
| Materials and Methods|| |
A total of 960 women, who reported to the OPD of College of Dental Sciences and Research Centre, Ahmedabad, were screened for this study, over a period of 3 months.
- Ethics: Study design was approved by the institutional ethical committee and informed consent was taken from all the participants.
- Study design: After following the inclusion and the exclusion criteria, a total of 200 women participated in the study.
Selection and description of participants
The women were divided into two groups based upon their menstrual status. Group I consisted of 100 postmenopausal women in the age group of 44–76 years. Group II consisted of 100 premenopausal women in the age group of 31--45 years.
The inclusion criteria for premenopausal women were the last spontaneous menstrual bleed less than 6 months ago and that for postmenopausal women was last spontaneous menstrual bleed more than 12 months ago.
Exclusion criteria included subjects with systemic diseases, oral candidiasis, smokers, obese patients (body mass index > 24), mouth breathers, history of radiotherapy, alcoholism, and those under medication., Patients with complete dentures and those having fewer than 20 teeth were also excluded from the study. The selected participants were asked to answer a questionnaire with a list of oral discomfort symptoms.
The questionnaire was designed to produce “yes” or “no” answers to a series of questions about three oral symptoms -subjective dry mouth (subjective oral dryness), burning mouth (burning sensation at the oral mucosa), and perceived taste disturbance (distorted taste or loss of taste). This questionnaire was in accordance with the one designed by Toidaet al.
The questions –
- Does your mouth usually feel dry?
- Does your mouth usually have a burning sensation?
- Does your mouth usually have a taste disturbance (distorted taste or loss of taste), were used as indicators of subjective dry mouth, burning mouth, and taste disturbance respectively.
If the participants answered “yes”, the intensity of the complaints was assessed by using visual analog scales for dry mouth (VAS-DM), for burning mouth (VAS-BM) and for taste disturbance (VAS-TD), each of which was graded from 0 to 100, where 0 is no subjective symptoms and 100 is the worst symptom imaginable; thus, intensity of subjective symptoms was presented as an integer from 0 to 100. The subjects were asked to mark their responses to each item by placing a vertical line on the 100 mm horizontal scale.
On the contrary, for the participants who answered “No,” a VAS value of 0 was given.
The questionnaire was filled by individuals prior to the measurement of unstimulated salivary flow rate to avoid the possibility that the VAS scores may be affected by knowing the unstimulated salivary flow rate value.,
The whole unstimulated salivary flow rate (USFR) was determined by spitting method, described by Navazesh and Kumar., Saliva was collected in a graduated test tube graded in 0.2 ml increments upto 10 ml, fitted in a funnel. Saliva was collected in a quiet environment and the samples were collected from all subjects between 9 a.m. and 11 a.m. to minimize any circadian rhythm effects.
With low forced spitting, the unstimulated saliva was then collected per minute for 5 minutes in the graduated test tube fitted with funnel.
The flow rate was then calculated in milliliters per minute. In both the groups, a value less than 0.1 ml/min was considered 'very low', between 0.1-0.2 ml/min was considered 'low' and more than 0.2 ml/min was considered 'normal'. Women in both groups were further divided into 'normal', 'low' and 'very low' USFR subgroups.
(C) STATISTICS: The statistical analysis in the present observational study was done using SPSS (Statistical Package for Social Sciences) Version 15.0 statistical Analysis Software. The values were represented in Number (%) and Mean ± SD. Chi-square, Student's t test, Analysis of variance (ANOVA) were applied. A criterion of P <.05 was accepted for significance in all statistical tests.
| Results|| |
Prevalence and intensity of subjective oral dryness, subjective burning sensation and altered taste sensation in both the groups is summarized in [Table 1] and [Table 2] respectively.
|Table 1: Prevalence of oral discomfort, subjective oral dryness, burning sensation, and taste disorders in both groups|
Click here to view
|Table 2: Comparison of intensity of oral discomfort symptoms in two groups|
Click here to view
Mean and Level [Quantity per minute]-wise comparison of whole USFR between both the groups is outlined in [Table 3] and [Table 4], respectively.
|Table 3: Comparison of whole unstimulated salivary flow rate (USFR) in two groups|
Click here to view
|Table 4: Level.wise comparison of whole unstimulated salivary flow rate (USFR) in two groups|
Click here to view
Association between whole unstimulated salivary flow rate and intensity of oral symptoms in both the groups is elaborated in [Table 5].
|Table 5: Association between whole unstimulated salivary flow rate and intensity of oral symptoms in Post and premenopausal women|
Click here to view
| Discussion|| |
Menopause with its absence of specific hormonal stimuli may be a cause or a predisposing factor for oral discomfort. In addition, researchers have proposed that menopause may also affect salivary gland function, since salivary glands contain sex hormone receptors.
Many studies have examined salivary flow rates in the context of aging, but the results are conflicting. Some authors have reported significantly lower salivary flow with age,,,,, and others have not.,, Affoo et al. suggested that no age-related decreases in unstimulated or stimulated parotid saliva occur.
However, variations in study designs, saliva collection methods, and selection of outcome measures may account for the lack of consistent findings among studies.
Therefore, to minimize age related alterations in the USFR, premenopausal women above 30 years were included in this study.
Flink et al., reported that the loss of teeth was responsible for the decrease in bite force and subsequent decrease in salivary flow rate. Thus, subjects with less than 20 teeth were also not included in this study.
In the present study, the prevalence of oral dryness was 44%, burning sensation was 4%, and taste disorder was 5.1% in postmenopausal women. These results were in accordance with most of the previous studies, thereby revalidating their findings ,,,,, However, the intensity of subjective oral dryness and the severity of taste disturbance in the postmenopausal women was significantly higher as compared to premenopausal women. Oral dryness could be due to the hormonal alterations taking place at menopause, causing vasomotor, neurological, and psychological changes, whereas the reasons for dysgeusia in menopause appear to be multifactorial, involving the interaction of biological and psychological systems.
In our study, the severity of burning sensation was lower as compared to previous studies. A possible explanation for this could be that our study was performed on healthy menopausal women, while most of the previous studies assessed the intensity of burning sensation on diagnosed cases of burning mouth syndrome which included both elderly women as well as men.,
Although in most of the studies, stimulated saliva was determined, in this study, estimation of the USFR was preferred. Saliva collected without any masticatory or gustatory stimulus is a more reliable indicator of reduced salivary flow rate.
The mean whole USFR in postmenopausal women in this study was higher as compared to the USFR reported by Mojabi et al. in their study. The reason for decreased values in their study, despite an equal sample size as ours, could be the fact that they used a 5 cc syringe to aspirate the saliva expectorated in a disposable cup, per minute by the subject. It is possible that not all of the saliva was aspirated completely from the cup, which might account for the decreased USFR in their study.
Our results were in accordance with the previous reported literature, thereby reaffirming that decreased salivary flow rate does exist following menopause.,,
The present study demonstrated a significant association between the prevalence of oral discomfort and USFR in postmenopausal women. Our results were in contrast to the study conducted by Agha-Hosseini et al. who reported no significant differences in the salivary flow rates in menopausal women with and without oral dryness. However, they assessed the stimulated salivary flow rates as opposed to the USFR determination in our study.
The results of our study clearly indicate that menopausal women experience significant oral discomfort compared to premenopausal women.
| Conclusion|| |
The results of the present study point out the high prevalence of oral discomfort in menopausal women which may have debilitating repercussions on the health-related quality of life of these women.
This study has also addressed an important clinical issue regarding the relationship between oral sensorial complaints and salivary flow rate in menopausal women. Every effort should be made by the clinician to improve the quality of life in these women by administering artificial saliva, maintaining good oral hygiene, and enhancing natural salivary secretion with secretagogues, if required. More studies on the effect of Hormone replacement therapy (HRT) on amelioration of oral discomfort symptoms and salivary flow rates must also be explored.
The study received approval from the ethical committee of the institution where the study was conducted (College of Dental Sciences and Research Centre, Bopal, Ahmedabad), on 3/5/2018 and informed consent was taken from all the patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ship JA, Patton LL, Tylenda CA. An assessment of salivary function in healthy premenopausal and postmenopausal females. J Gerontol 1991;46:M11-5.
Yalcin F, Gurgan S, Gurgan T. The effect of menopause, hormone replacement therapy (HRT), alendronate (ALN) and calcium supplements on saliva. J Contemp Dent Pract 2005;6:10-17.
Aryeh HB, Gottleib I, Ish-Shalom S, David A, Szargel H, Laufer D. Oral complaints related to menopause. Maturitas 1996;24:185-9.
Mojabi KB, Esfahani M, Hashemi HJ. Evaluation of unstimulated salivary flow rate and oral symptoms in menopausal women. J Dent (Tehran) 2007;4:103-7.
Mirzaii-Dizgah I, Agha-Hosseini F. Stimulated and unstimulated saliva progesterone in menopausal women with oral dryness feeling. Clin Oral Invest 2011;15:859-62.
Shigeyama C, Ansai T, Awano S, Soh I, Yoshida A, Hamasaki T, et al
. Salivary levels of cortisol and chromogranin A in patients with dry mouth compared with age-matched controls. Oral Surg Oral Med Oral Pathol Oral Radiod Endod 2008;106:833-9.
Yeh CK, Johnson DA, Dodds MWJ, Sakai S, Rugh JD, Hatch JP. Association of salivary flow rates with maximum bite force. J Dent Res 2000;79:1560-5.
Smith CH, Boland B, Daureeawoo Y, Donaldson E, Small K, Tuomainen J. Effect of aging on stimulated salivary flow in adults. J Am Geriatr Soc 2013;61:805-8.
Toida M, Nanya Y, Takeda-Kawaguchi T, Baba S, Lida K, Kato K. Oral complaints and stimulated salivary flow rate in 1188 adults. J Oral Pathol Med 2010;39:407-19.
Navazesh M. How can oral health providers determine if patients have dry mouth? J Am Dent Assoc 2003;134:613-20.
Navazesh M, Kumar SKS. Measuring salivary flow: Challenges and opportunities. J Am Dent Assoc 2008;139:35S-40S.
Minicucci EM, Pires RB, Vieira RA, Miot HA, Sposto MR. Assessing the impact of menopause on salivary flow and xerostomia. Aust Dent J 2013;58:230-4.
Vilas SF, Shashikant MC, Ali IM. Evaluation of the effects of transcutaneous electrical nerve stimulation on whole saliva flow: A clinical study. J Indian Acad Oral Med Radiol 2009;21:7-11. [Full text]
Wardop RW, Hailes J, Burger H, Reade PC. Oral discomfort at menopause. Oral Surg Oral Med Oral Pathol 1989;67:535-40.
Suri V, Suri V. Menopause and oral health. J Midlife Health 2014;5:115-20.
Pai S, Ghezzi EM, Ship JA. Development of a visual analog scale questionnaire for subjective assessment of salivary dysfunction. Oral Surg Oral Med Oral Pathol Oral Radiod Endod 2001;91:311-6.
Gutman D, Ben-Aryeh H. The influence of age on salivary content and rate of flow. Int J Oral Surg 1974;3:314-7.
Flink H, Bergdahl M, Tegelberg A, Rosenblad A, Lagerlöf F. Prevalence of hyposalivation in relation to general health, body mass index and remaining teeth in different age groups of adults. Community Dent Oral Epidemiol 2008;36:523-31.
Affoo RH, Foley N, Garrick R, Siqueira WL, Martin RE. Meta-analysis of salivary flow rates in young and older adults. J Am Geriatr Soc 2015;63:2142-51.
Nederfors T, Isaksson R, Mörnstad H, Dahlöf 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.
Ship JA, Baum BJ. Is reduced salivary flow normal in old people? Lancet 1990;336:1507.
Shern RJ, Fox PC, Li SH. Influence of age on the secretory rates of the human minor salivary glands and whole saliva. Arch Oral Biol 1993;38:755-61.
Eliasson L, Birkhed D, Heyden G, Strömberg N. Studies on human minor salivary gland secretions using the Periotron method. Arch Oral Biol 1996;41:1179-82.
Dangore-Khasbage SB, Degwekar SS, Bhowate RR, Motwani MB, Indurkar AD, Lohe VK, et al
. Comparative evaluation of gustatory function between postmenopausal women and age-matched men. Oral Dis 2010;16:469-75.
Ferguson MM, Carter J, Boyle P, McK Hart D, Lindsay R. Oral complaints related to climacteric symptoms in oöphorectomized women. J R Soc Med 1981;74:492-8.
Lamey PJ. Burning mouth syndrome. Dermatol Clin 1996;14:339-54.
Granot M, Nagler R. Association between regional idiopathic neuropathy and salivary involvement as the possible mechanism for oral sensory complaints. J Pain 2005;6:581-7.
Heidari Z, Mahmoudzadeh-Sagheb HR, Noori Mugahi MH. Burning mouth syndrome in Zahedan; The south east of Islamic Republic of Iran. J Dent (Tehran) 2005;2:152-8.
López-Jornet P, Camacho-Alonso F, Lucero-Burdego M. Quality of life in patients with burning mouth syndrome. J Oral Pathol Med 2008;37:389-94.
Närhi TO. Prevalence of subjective feelings of dry mouth in the elderly. J Dent Res 1994;73:20-5.
Kullander S, Sonesson B. Studies on saliva in menstruating, pregnant and postmenopausal women. Acta Endocrinol (Copenh) 1965;48:329-36.
Agha-Hosseini F, Mirzaii-Dizgah I, Moghaddam PP, Akrad ZT. Stimulated whole salivary flow rate and composition in menopausal women with oral dryness feeling. Oral Dis 2007;13:320-3.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]