Dry Mouth (xerostomia) and Chinese Medicine

Dry Mouth (xerostomia) and Chinese Medicine

22 October 2017 by Caitlin Armit

What is Xerostomia?

Xerostomia is the medical term used to describe the symptom of a severe dry mouth due to reduced salivary flow. This symptom commonly affects patients who are receiving radiotherapy for cancer of the head and neck because of damage to the salivary glands. The impact of xerostomia can be profound because it impacts the ability to sleep, eat and talk. It can also result in increased oral infections, microbial growth, bone infection and irreversible nutritional deficits.

In Traditional Chinese Medicine theory, radiation therapy is a form of fire/heat which damages yin – fluid, blood and nutrients – depleting the qi and strength of the patient. Treatment principles therefore are to clear heat, nourish yin and blood and to calm the patients (Hsu et al 2016). It is thought that acupuncture and Chinese medicine may benefit patients who experience xerostomia by improving local blood flow around the parotid gland (Simcock et al 2012).

Current medications for xerostomia are not always effective and often have side effects including sweating, diarrhoea, frequent urination, nausea and dizziness. For this reason, several research studies have focussed attention on the possible role of acupuncture and Chinese medicine to assist in the treatment of xerostomia.

The research evidence thus far is unclear (see Acupuncture Evidence Project), largely due to a lack of large-scale clinical trials with adequate methodology and reporting. Below are some of the studies which have been undertaken to date.

Acupuncture vs Oral Care Education

A study published on the academic journal Annals of Oncology in 2013 compared the efficacy of acupuncture versus oral care education for xerostomia. In this randomised controlled trial, a total of 145 patients to received either acupuncture for 20 minutes each week over an 8-week period or two oral care educational sessions for one hour, one month apart. Four weeks after these treatments ended, patients were swapped over to receive the other treatment.

Results were measured using a reputable self-report questionnaire about subjective improvements of symptoms (sticky saliva, dry lips, thirst, impact on eating and sleeping) and Schirmer strips to measure the amount of saliva production. No statistically significant changes were found in saliva production however the acupuncture patients were twice as likely to report improvements than the oral care group. The acupuncture group also saw significant improvements in individual symptoms such as eating and sleeping. The researchers noted that these subjective improvements were more significant than the results of the saliva production quantity because the very nature is of xerostomia is that little or no saliva is produced in a meaningful quantity for measurement. The researchers also noted that the improvements noted were difficult to attribute solely to placebo because the effects were so strong given the nature of what was measured – sleeping without waking during the night to sip water and improvements in ability to talk and eat. The published article emphasises that chronic symptoms of cancer treatment are distressing for the patient and that therefore, a modality which can be implemented safely and cheaply in a hospital setting which improves the quality of life for a patient in these circumstances, should be considered.

This study does not provide information about the acupuncture needle technique required or whether the effects of treatments lasted with or without booster treatments. These are issues that need to be explored in future research.

ALTENS vs Pilocarpine medication

A more recent study published in the 2015 issue of International Journal of Oncology, Biology, Physics indicated that acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) could be equally effective as the medication Pilocarpine prescribed for radiation-induced xerostomia. The study was a multi-centre, randomised trial building upon previous studies from 2003 and 2012 – both of which indicated positive results for this treatment.

ALTENS involves placement of electrodes on pre-selected acupuncture points. The electrodes deliver low frequency, high intensity pulses to stimulate the points. This study involved 146 patients from 13 cancer treatment centres across the USA and Canada once inclusion criteria were met. Half of the patients were randomised to receive ALTENS treatments for 20 minutes twice per week for twelve weeks and half were randomised to receive Pilocarpine 5mg oral dose three times per day for 12 weeks. The completion rate was 93% in the acupuncture and 73% in the Pilocarpine group with completion meaning 85% of the assigned treatment.

Assessment of results were measured at baseline (before treatment) and at four, six, nine and fifteen months after the date of their group allocation. Results were measured by self report questionnaire (Xerostomia-Related Quality of Life Scale). Ninety-six participants completed all of these assessments and were included in the analysis. Baseline scores were subtracted from follow up scores and therefore, a negative change would indicate improvement in xerostomia. The average change in scores consistently improved for patients in the ALTENS arm however these were not statistically significant. The proportions of patients who had 20% or more improvement from their baseline scores were consistently higher in the ALTENS arm and this difference was still significant at the final fifteen month follow up.

With regards to adverse events, one participant in the ALTENS group experienced a headache and two in the medication group experienced dry mouth and blurred vision. Fifteen patients in the ALTENS group reported adverse events of grade three or less compared to 45 patients in the medication group. At nine months follow up these differences were not statistically significant. Some patients in the ALTENS group demonstrated lasting responses which indicates the possibility of treatment to induce salivary gland tissue regeneration.

Chinese Herbal Medicine vs Standard Care

This 2016 study was a non-randomised intervention focussed on the quality of life and symptom control for patients during radiotherapy, with or without chemotherapy. It involved the use of Chinese herbal medicine instead of acupuncture treatment and was approved by the Institutional Review Board of the Chang Gung Memorial Hospital in Taiwan.

Patients included males and females between ages 20 and 75 who were able to choose which group they would be in. The inpatients would get partial support for their hospital costs and outpatients were provided with tube feeding milk to increase compliance. A total of 91 patients were enrolled in the study with 32 patients electing to participate as inpatients and 59 electing conventional treatment. In the end, 30 of the 32 inpatients completed the study and 50 of the 59 outpatients completed the study. There were no significant differences between groups in terms of gender, age, height, body weight, BMI, tumour stage, location, and modes of treatment.

Inpatients received integrated TCM treatment from the first week of radiotherapy until the end of radiotherapy or for at least six weeks during radiotherapy. They received concentrated extract powders manufactured by certified pharmaceutical companies, liquid preparations for gargling made from herbal medicines, and topical gels. The medications were dispensed by nurses in the Chinese medicine ward and were selected according to the individual patients presentations and symptomatic complaints. The control group received only conventional cancer treatments in the oncology outpatient department.

Patients with terminal cancer, those with unstable vital signs or impaired renal or hepatic function, uncontrolled psychiatric problems or altered mental status were excluded from the study. The study also excluded patients using other Chinese medicine treatments.

Measurement tools included the Quality of Life Questionnaire – Head and Neck Module, Acute Post-RT Toxicity, Quality of Life Questionnaire – Generic, and Renal and Hepatic Function changes.

Results showed that the patients who received complementary TCM experienced an improvement in subjective perception of dry mouth and the objective findings recorded by clinicians were less severe than those in the control group. Also, the patients in the TCM group indicated better emotional function and less difficulty with social contact than the control group.

The authors acknowledge that prolonged hospitalisation may have impacted results for the TCM group either positively or negatively. It is also unclear as to whether financial benefits for the inpatients impacted results. The authors also acknowledge that lack of randomisation is a limitation of this study as was the inability to follow up with patient’s long term to see if TCM had a lasting result.

What does it all mean?

The results of these studies show some promising findings that TCM may be a valuable adjunct treatment for xerostomia for patients undergoing radiotherapy and chemotherapy for head and neck cancers. There are clearly some methodological weaknesses in these studies and unanswered questions for future research projects to tackle however this is a worthwhile field to explore. Xerostomia is a distressing condition adding insult to injury for cancer patients. If TCM can help to improve subjective and objective outcomes and improve quality of life for these patients without the side effects of current best available medications then this may be a welcome adjunct treatment. The current status is that we need higher quality rigorous studies to understand the mechanisms behind how acupuncture may be improving blood flow to the parotid gland and any other factors which improve symptoms.

 

ARIX: A randomised trial of acupuncture v oral care sessions in patients with chronic xerostomia following treatment of head and neck cancer

Acupuncture-Like Transcutaneous Electrical Nerve Stimulation Versus Pilocarpine in Treating Radiation-Induced Xerostomia: Results of RTOG 0537 Phase 3 Study.

Efficacy of Traditional Chinese Medicine in Xerostomia and Quality of Life during Radiotherapy for Head and Neck Cancer: A Prospective Pilot Study

 
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