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IAHPC Hospice and Palliative Care Newsletter


2005; Volume 6, No 6, June


Article of the Month

Carla Ripamonti, MD

Many ways to help support palliative care.

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Message from the Chair & Executive Director:
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Liliana De Lima, MHA

Article of the Month:
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IAHPC Traveling Scholar’s Report:
Martha Ximena Leon, MD

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Roger Woodruff, MD

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'The Right to Die' and 'The Right to Live' Debate:
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The management of xerostomia in patients on haemodialysis: comparison of artificial saliva and chewing gum

Author(s): Bots CP, Brand HS, Veerman ECI et al.
Abstract:  Palliative Medicine 2005; 19: 202-207

Patients on haemodialysis (HD) therapy because of end stage renal disease (ESRD), have several oral complications present, among them are an impaired salivary flow rate and an increased subjective sensation of dry mouth, or xerostomia - both negatively influence their quality of life.

HD treatment has a direct effect on the degree of xerostomia, however, other factors such as medication, depression or HD-induced stress all may play a role in the perception of dry mouth.

The aim of this study in ESRD patients on chronic HD was to compare the effectiveness, taste, global assessment and the patients’ preference for artificial saliva versus sugar-free chewing gum.

In a multi-centre study, 89 ESRD patients, undergoing HD for at least 3 months, with an age greater than 18 years, and who were mentally and physically able to participate and complete the study, gave their consent and entered the study. Sixty-five (73%) of them (42 men and 23 women, mean age 54.6 years) completed the 6-week crossover clinical trial.

After baseline measurements, patients were randomly allocated to either chewing gum (menthol-containing, sugar free, Freedent White Wm. Wrigley Jr. Company, Chicago , USA ) or the artificial saliva (Xialine, Lommerse Pharma BV , Oss , Holland ) or vice versa. Between the two-treatment periods, there was a two-week wash-out period. At the beginning and at the end of each 2 week period, the perceived xerostomia was measured by means of the Xerostomia Inventory (XI) (ref. Thomson WM et al. Community Dent Health 1999; 16: 12 -17). The effectiveness of the treatment, preferences, and side effects were assessed by means of a questionnaire (100 mm VAS).

The patients had to chew 1-2 pieces of gum, six times a day for at least 10 min during the day when their mouth was dry. During the artificial saliva treatment period the patients had to spray saliva substitute 3 consecutive times for at least 6 times a day and also during the night as needed.

Chewing gum was found to be easier to use (p<0.05), produce a more significant effect on thirst relief (p<0.001) and xerostomia (p<0.001) and had a more pleasant (p<0.05), flavourful (p<0.001) and intense taste (p<0.001) than artificial saliva. Thirty-seven per cent of patients on chewing gum preferred sweet mint flavour, whereas 28% preferred a stronger flavour such as peppermint.

The therapy was beneficial in 47 (72%) patients on chewing gum and in 28 (43%) patients on artificial saliva (p<0.001). The therapies were both beneficial in 22 patients, whereas both therapies were not beneficial for 8 patients.

A significantly higher number of patients (70%) on chewing gum compared to those on artificial saliva (39%) (p<0.001) were pleased to continue for a longer period.

The global assessment was in favour of chewing gum (p<0.001). However, for patients greater than 64 years, the global assessment for artificial saliva was significantly higher than that reported by the younger people.

At the end of the study 39 patients (60%) preferred chewing gum and 10 patients (15.4%) the saliva substitute (p<0.001).

Why I chose this article

Xerostomia is a frequent symptom reported by cancer patients particularly those treated with radiotherapy for head & neck cancer. In this setting some clinical trials have been carried out.

Bots et al. present the results of the first cross over study performed in patients on haemodialysis therapy who have xerostomia. According to different authors, the prevalence of xerostomia in HD patients ranges between 33% and 76%.

The authors of this paper show that a simple, delicious and low cost therapy such as a chewing gum is able to reduce xerostomia in this population of patients.

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC

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