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ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 4  |  Page : 205-208

Comparison of modified Schirmer's test and clinical oral dryness score scale in the clinical assessment of oral dryness in postmenopausal women


Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of Dental Sciences, Puducherry, India

Date of Submission13-Jul-2019
Date of Acceptance11-Oct-2019
Date of Web Publication22-Jan-2020

Correspondence Address:
Dr. P Roland Prethipa
Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute of Dental Sciences Pondicherry, Puducherry
India
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DOI: 10.4103/srmjrds.srmjrds_48_19

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  Abstract 

Aims: The aim of this study was to assess the oral dryness in postmenopausal women and to correlate the salivary flow rate determined by modified Schirmer's test (MST) with the clinical oral dryness score (CODS) obtained from Challacombe Scale. Subjects and Methods: Forty postmenopausal women were questioned regarding their oral dryness status. Patients complaining of xerostomia formed the case group and rest formed the control group. CODS was assessed based on the ten features of oral dryness. Unstimulated whole salivary flow rate was assessed by MST. Statistical Analysis Used: All data were analyzed using inferential statistics such as Chi-square, Fisher's exact test, and Spearman correlation, and the analysis was carried out with SPSS 17. Results: There was statistically significant difference between case and control group with regard to CODS (P = 0.001) and modified Schirmer's (P = 0.004). A low-negative correlation was observed between modified Schirmer's score and CODS (r = -0.17). Conclusion: Since CODS correlated with modified Schirmer's score, it indicates that CODS can be utilized for semiquantitative assessment of oral dryness.

Keywords: Clinical oral dryness score, modified Schirmer's test, postmenopausal women


How to cite this article:
Prethipa P R, Kumaran JV, Vasudevan SS, Daniel MJ. Comparison of modified Schirmer's test and clinical oral dryness score scale in the clinical assessment of oral dryness in postmenopausal women. SRM J Res Dent Sci 2019;10:205-8

How to cite this URL:
Prethipa P R, Kumaran JV, Vasudevan SS, Daniel MJ. Comparison of modified Schirmer's test and clinical oral dryness score scale in the clinical assessment of oral dryness in postmenopausal women. SRM J Res Dent Sci [serial online] 2019 [cited 2020 Feb 25];10:205-8. Available from: http://www.srmjrds.in/text.asp?2019/10/4/205/276368


  Introduction Top


Menopause is a natural process which takes place in the fifth decade of a woman's life, resulting in the permanent cessation of menstruation after depletion of ovarian function for more than 12 months.[1] Oral mucosa and salivary glands contain sex hormone receptors, thereby hormonal fluctuations have a strong influence on the oral cavity.[2] The present study was carried out to assess and to correlate the oral dryness amongst the postmenopausal women using clinical oral dryness score (CODS) scale and modified Schirmer's test (MST).


  Subjects and Methods Top


This study included forty postmenopausal women with at least minimum of 12 months of amenorrhea who reported to the department of oral medicine and radiology. Patients with certain systemic illnesses such as diabetes mellitus and Sjogren's syndrome; those under medications which can alter the salivary flow such as antihypertensives, corticosteroids, etc.; and those with poor gingival and periodontal health were excluded from the study.

The presence of xerostomia was assessed using a questionnaire proposed by Kaur et al.[3] The patients who affirmatively answered for more than three questions formed the case group and the remaining formed the control group.

The CODS used in this study comprises a ten-point scale; each point signifying a feature of dryness in the mouth as follows: (1) Mouth mirror sticks to buccal mucosa; (2) Mouth mirror sticks to tongue; (3) Lobulated/fissured tongue; (4) Depapillation of tongue; (5) Frothy saliva; (6) Absence of salivary pooling in floor of mouth; (7) Oral mucosa appears glassy, especially palate; (8) Debris on palate (excluding debris under dentures); (9) Altered/smooth gingival architecture; and (10) Active or recently restored (last 6 months) cervical caries (>2 teeth). The scores were recorded and summed up together resulting in a total CODS.[4],[5] The examiner recorded the above-mentioned characteristic features seen in the patient's mouth, with the help of a specially designed chart with pictures of dry mouth features.

Unstimulated whole saliva was calculated by carrying out MST. The MST was accomplished for all the participants between 9 am and noon. Prior to the test, all the participants abstained from consuming food and water intake for 2 h. Following a few minutes of rest, Patients were asked to sit upright in a dental chair. The patients were asked to swallow once to clear the residual salivary secretion in the mouth, and they were told not to swallow while performing the test. And during the test, the participants were asked to lift their tongues, and they were retracted slightly, to prevent inadvertent wetting of the test strips. The test strip was grasped vertically with the help of cotton plier, and the rounded end was placed on the floor of the mouth, either to the right or the left of the lingual frenum.[6] Change in the color of the strip on wetting was noticed. Based on the length of moistening of the strip, readings were recorded immediately after 1 min.

The unstimulated whole salivary flow rates were categorized as very low (<0.1 ml/min), low (0.1–0.25 ml/min), and normal (>0.25 ml/min), according to the classification of whole saliva flow rate proposed by Ericsson and Hardwick.[7]

All data were analyzed using Chi-square test, Fisher's exact test, and Spearman's correlation test. All the analyses were performed using Statistical Package for the Social Sciences (SPSS), SPSS Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc.


  Results Top


Distribution of participants determined with the CODS obtained from Challacombe scale showed that majority (65%) of them were in the moderate category, followed by mild (32%) and severe (3%), respectively [Figure 1].
Figure 1: Distribution of clinical oral dryness score

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Distribution of participants determined by MST [Figure 2] showed 70% of the population had low salivary flow followed by very low salivary flow among 23% and 7% had normal salivary flow.
Figure 2: Proportion of unstimulated whole saliva using modified Schirmer's test

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Association of subjective oral dryness with CODS scores among postmenopausal women [Table 1] showed that there was a considerable difference in the CODS scores between the patients reported with oral dryness when compared to those people who did not report with oral dryness with a P = 0.01.
Table 1: Association of subjective oral dryness with CODS scores among post-menopausal women (n=40)

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Association of subjective oral dryness with unstimulated whole saliva determined using MST among postmenopausal women [Table 2] showed that there was a considerable difference in the unstimulated whole saliva among patients reported with oral dryness when compared to those people who did not report with oral dryness with P = 0.04.
Table 2: Association of subjective oral dryness with unstimulated whole saliva determined by Modified Schirmerfs Test among post-menopausal women (n=40)

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The correlation between the salivary flow rate determined by CODS obtained from Challacombe scale and MST [Figure 3] showed that there was a weak negative correlation between CODS and modified Schirmer's score with a r value of −0.17 which implied that when there was a decrease in unstimulated whole saliva, then there was an increase in the CODS scoring.
Figure 3: Correlation of clinical oral dryness score scale and modified Schirmer's score

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  Discussion Top


Saliva is essential for the maintenance of good health of oral tissues. Unstimulated and stimulated submandibular and sublingual salivary gland flow rate was reduced in postmenopausal women in comparison with premenopausal women; a finding not related to any medication effect. Changes in salivary function may cause damage to the oral tissues and have a huge impact on the patient's quality of life.[8]

Bakke et al. have stated that xerostomia was higher in women than in men in all age groups. They concluded that there was a remarkable increase of xerostomia in the age range of 50 and 75, particularly among women.[9] Our study also provided evidence that majority of the postmenopausal women (65%) had a moderate level of oral dryness as assessed by CODS scale.

Wavering of the estrogen levels can influence the salivary flow rates of the individual. In comparison with the menstruating women, postmenopausal women have low flow rates of saliva.[2] Minicucci et al. assessed salivary flow rates among menopausal and premenopausal women, and they concluded that the menopausal group showed reduction in salivary flow rate.[1]

As per the study conducted by Wardropa et al., in 33% of postmenopausal women, oral discomfort was reported without other oral changes. Moreover, peri-/postmenopausal women reported considerably the higher prevalence of oral discomfort than in premenopausal women (43% vs. 6%).[10]

In a dental practice, CODS can provide a rapid, simple, and objective method to determine the salivary gland function. Osailan et al. recommended the use of CODS for the routine assessment of the severity of hyposalivation.[5]

Jager et al. analyzed the patients and grouped them based on their degree of salivation (hypo, low, normal, or high salivation) and stated that in the hyposalivation group, there was a significant association between CODS and the other parameters[4] which is in concordance with our study that showed a significant difference between patients reported with oral dryness than those without oral dryness using CODS scale.

Fontana et al. assessed the association of various traditional methods such as volumetric/gravimetric methods and MST. Among all the tests, MST was considered to be a simple, practical, cost-effective, standardized, and easy to perform method in clinical practice. Previous studies have revealed that MST value of <25 mm at 3 min, indicative of hyposalivation, provided high sensitivity and specificity. Another study demonstrated that MST value of >28 mm at 3 min was normal. Chen et al. stated that an MST value of <15 mm at 3 min was indicative of severe xerostomia and hyposalivation.[11]

The advantages of this method include easy acceptance of the test strip by the patients and ease of implementation by the examiner; also, this method is less time-consuming.[12]

Hosseinimehvar et al. performed a study on risk of hyposalivation in menopausal patients using MST and modified Fox questionnaire and found the incidence of hyposalivation in postmenopausal women was more than in premenopausal women. According to the MST, the prevalence of hyposalivation was 35% in premenopausal women and 65% in postmenopausal women.[12] The result exhibited a statistically significant difference between the two groups.

In our study, the liaison of the subjective oral dryness with the unstimulated whole saliva determined by MST showed 70% of the population had low salivary flow followed by very low salivary flow among 23% and 7% had normal salivary flow a significant difference of the unstimulated whole saliva between the case and control group.

The relationship of CODS scale and modified Schirmer's score was assessed and the study exhibited a weak negative correlation which implied that there was a reduction in the unstimulated salivary flow rate assessed by MST with increase in CODS scoring or vice versa.

The main drawback of our study was less sample size, and CODS cannot be used for edentulous cases. Hence, to validate our results, further researches with large sample sizes must be required and recommendations should be put forth to modify the CODS scale for edentulous patients.


  Conclusion Top


The outcomes of this study inferred that majority of postmenopausal women had moderate level of oral dryness. CODS scale and Modified Schirmer's score showed highly significant results in assessing oral dryness.

Since CODS scale correlated with MST, it can be used by dental practitioners as a routine chairside procedure, which involves visual assessment of the oral cavity on the basis of several signs of oral dryness. It can necessitate for intervention, referral for primary care or beneficial in assessing the effectiveness of the treatment given for hyposalivation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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.  Back to cited text no. 1
    
2.
Suri V, Suri V. Menopause and oral health. J Midlife Health 2014;5:115-20.  Back to cited text no. 2
    
3.
Kaur K, Kaur P, Singh B, Singh K, Kaur K, Narang RS. Gustatory functional level and oral dryness. J Adv Med Dent Sci Res 2018;6:109-12.  Back to cited text no. 3
    
4.
Jager DHJ, Bots CP, Forouzanfar T, Brand HS. Clinical oral dryness score: Evaluation of a new screening method for oral dryness. Odontology 2018;106:439-44.  Back to cited text no. 4
    
5.
Osailan SM, Pramanik R, Shirlaw P, Proctor GB, Challacombe SJ. Clinical assessment of oral dryness: Development of a scoring system related to salivary flow and mucosal wetness. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:597-603.  Back to cited text no. 5
    
6.
Dyasanoor S, Saddu SC. Association of xerostomia and assessment of salivary flow using modified schirmer test among smokers and healthy individuals: A Preliminutesary study. J Clin Diagn Res 2014;8:211-3.  Back to cited text no. 6
    
7.
Chengappa RK, Narayanan VS, Khan AM, Rakaraddi MP, Puttaswamy KA, Puttabuddi JH. Utility of two methodologies in the clinical assessment of oral dryness in postmenopausal women. J Midlife Health 2016;7:114-8.  Back to cited text no. 7
    
8.
Newadkar UR. Mouth on fire: Oral discomfort in postmenopausal women may be surprising!! J Midlife Health 2015;6:184-6.  Back to cited text no. 8
    
9.
Alsakran Altamimi M. Update knowledge of dry mouth- A guideline for dentists. Afr Health Sci 2014;14:736-42.  Back to cited text no. 9
    
10.
Mutneja P, Dhawan P, Raina A, Sharma G. Menopause and the oral cavity. Indian J Endocrinol Metab 2012;16:548-51.  Back to cited text no. 10
    
11.
Chen A, Wai Y, Lee L, et al. Using the modified Schirmer test to measure mouth dryness: a preliminutesary study. J Am Dent Assoc. 2005; 136:164-70.  Back to cited text no. 11
    
12.
Hosseinimehvar B, Alaee A, Azizi A, Shafizadeh N. Risk of hyposalivation in menopausal patients. J Res Dentomaxillofac Sci 2017;2:16-21.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Subjects and Methods
Results
Discussion
Conclusion
References
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