Auricular Acupuncture in the Treatment of Xerostomia

Abstract
Xerostomia, abnormal dryness of the mouth due to decreased secretion of saliva, is a distressing condition
which can significantly impair quality of life in sufferers. In this article, the aetiology, pathology and
treatment of xerostomia by Western medicine is discussed and existing studies into its treatment by
acupuncture are reviewed. The author then describes the treatment of seven xerostomia patients who were
treated using a simple acupuncture protocol. Actual outcomes exceeded the author's expectations with all
patients reporting an increase in salivary flow and the ability to eat and speak as well as improved sleep.

Keywords: xerostomia, acupuncture, dry mouth.

Introduction
Xerostomia, abnormal dryness of the mouth due to decreased secretion of saliva, is a distressing condition
which can significantly impair quality of life in sufferers. As well as dryness of the mouth, it is associated
with rampant dental caries, oral mucosal infections, difficulty in speaking, eating, and swallowing, ulceration or soreness of the oral cavity, altered sense of taste and difficulty in wearing dentures1. Xerostomia
affects approximately one quarter of the population and approximately 40% of adults over 502. In a study
of elderly individuals living in retirement homes, it was found that three quarters were using at least one
medication for xerostomia3.

Aetiology
A number of different factors can give rise to xerostomia.

• It is commonly found as a side effect of medications, especially opioids, diuretics, anticholinergic drugs
and antihistamines.
• It can be caused by endocrine disorders and autoimmune diseases such as Sjogren's syndrome.
• More than 120,000 patients annually are diagnosed with cancer of the head and neck in the USA4 and
their treatment by radiotherapy gives rise to xerostomia in almost all cases5.
• Cancer patients generally exhibit a high prevalence of xerostomia. According to a 1999 study, more than
70% of seriously ill cancer patients suffered from xerostomia6.
It is thought that the decreased salivary secretion among xerostomia patients is due to atrophy of the
secretory cells of the salivary gland and/or dysfunctional changes in the vascular and connective tissues of the salivary glands7. Studies have reported that salivary production usually does not improve for
xerostomia patients and that there is a gradual decrease in salivary gland function89.

Treatment
Treatment for xerostomia is primarily palliative and includes promoting saliva production by increasing
water consumption, using sugarless mints and gum or salivary substitutes, and utilising prescription
medications such as oral pilocarpine1011. Treatment results have been short-term at best. Pilocarpine therapy has been found to be ineffective for a high percentage of patients (30-70% in one study) and may give rise to adverse reactions such as sweating, dizziness, headache, rhinitis, nausea, urinary frequency, tachycardia and visual impairment12.

Amifostine has been used during radiation therapy via intravenous injection in an attempt to minimise
the possibility of xerostomia (as well as mucositis) occuring during treatment through protection against
radiation by the scavenging of free radicals. However, amifostine's impact on the efficacy of the radiation
treatment (due to possible tumour protection) is controversial because there is the possibility that the drug
may protect the tumour from the radiation treatment. In addition, the potential for adverse reactions is
significant. Nausea, vomiting, hypertension and allergic reactions were the most common side effects,
with 53% of those patients who received amifostine experiencing at least one episode of nausea and/or
vomiting1314.



Acupuncture and xerostomia

Existing studies

Previous studies have demonstrated that acupuncture might serve as an effective long-term approach to
the treatment of xerostomia and can significantly reduce untoward effects1516.

The use of acupuncture as a treatment for xerostomia was first reported by the Western medical literature
in 198117, and since 1992, Blom et al have published numerous articles concerning the effectiveness of
acupuncture in its treatment1,9,15,18. A 1997 study showed a significant increase in saliva (compared to
baseline levels) both during and after manual acupuncture stimulation. By contrast, electroacupuncture
had no effect19. In a 1992 study, patients suffering from severe xerostomia, primarily associated with
Sjogren's syndrome and other systemic disease, were randomly divided into treatment and control
groups to determine the effect of acupuncture on salivary flow rates18. The control group patients received
placebo treatment through superficial intradermal placement of acupuncture needles. Patients in the
treatment group exhibited improved salivary flow rates both during and after treatment. These results
lasted throughout the one-year post-treatment observation period. While salivary flow rates improved
for patients in the control group during the experiment, these changes disappeared after the placebo
acupuncture treatment was completed18.

A long-term study by Blom and Lundeberg followed 70 patients who had been treated with acupuncture
for xerostomia due to primary and secondary Sjogren's syndrome, irradiation and other causes. Patients
were needled at local points including Juliao ST-3, Daying ST-5, Jiache ST-6, Xiaguan ST-7, Tianrong SI17, Futu L.I.-18, Yifeng SJ-17 and Baihui DU-20, and distal points including Shenmen HE-7, Neiguan
P-6, Sanjian L.I.-3, Hegu L.I.-4, Quchi L.I.-11, Waiguan SJ-5, Zusanli ST-36, Sanyinjiao SP-6, Zulinqi GB41, Taichong LIV-3, Taixi KID-3 and Shuiquan KID-5. All patients received a minimum of twelve and a
maximum of fifteen needles. Results acquired over an observational period as long as three years indicated that acupuncture improved salivary flow rates. Compared to patients who chose not to continue
acupuncture, the rates remained consistently higher for patients who received an additional series of 5-12
acupuncture treatments, as needed9.
A 1999 study of patients in a hospital-based home care setting investigated how acupuncture affected
patients in late-stage palliative care with symptoms of xerostomia and related problems. The results
indicated that "acupuncture had a dramatic effect on xerostomia and subsequently on dysphagia and
articulation."6

Patients with xerostomia due to radiation therapy for head and neck cancer have shown increased salivary
flow rates after acupuncture treatment15. Patients who had received more than 50 Gy of radiation were
assigned at random to a treatment group receiving real acupuncture or a control group receiving placebo
(superficial) acupuncture. Both groups showed a significant increase in salivary flow rates during the one-
year observation period, although the control group demonstrated both a smaller and slower improvement.
The results of this study show the difficulty in using superficial acupuncture as a placebo.

Possible mechanisms of action of acupuncture

It has been suggested that acupuncture increases the release of neuropeptides and stimulates the autonomic
nervous system, enhancing salivary secretion both in healthy subjects and those with xerostomia. Radio
immunoassay analysis has been used to examine xerostomia patients and has determined that acupuncture
significantly increases both vasoactive intestinal polypeptide (VIP) and calcitonin gene-related peptide
(CGRP) in their saliva1,19,20.

Both the sympathetic and parasympathetic nervous systems influence the function of salivary glands and
the rate and nature of salivary flow. Sensory, sympathetic and parasympathetic nerve fibres innervate the
salivary glands. Sympathetic system stimulation produces a low, viscous, protein-rich flow of saliva while
parasympathetic system stimulation has the primary influence on salivary secretion and yields a strong
increase of salivary flow with a low protein content21,22.

Acupuncture has also been shown to increase blood flow to the skin overlying the parotid gland. Blom
et al studied a group that had received acupuncture and a control group that had received superficial
acupuncture. Using laser Doppler flowmetry, they discovered that blood flow to the skin overlying
the parotid gland increased significantly (both during and after acupuncture) for the experimental
(acupuncture) group23.

A new acupuncture treatment for xerostomia

Most of the treatment provided in research that relates to acupuncture and xerostomia has involved placing
needles at numerous points both locally (in the area of the major salivary glands) and distally (that is, on
the arms and legs). In some studies, the number of treatment sessions has ranged from 20-249,24.

In recent years, an acupuncture treatment protocol for xerostomia has been developed that involves fewer
acupuncture points and a great reduction in the number of treatment sessions5,37.This protocol limits the
number of acupuncture points to three on each ear and one on each index finger, reducing the total number
of needles used from 14-24 to 8. The average number of treatments also has been reduced from 20-24 to
approximately 65,16.

The xerostomia inventory (XI) is an instrument that is utilised to evaluate a patient's subjective sensation
of dry mouth25,26. Johnstone et al used the XI to demonstrate a significant improvement in the symptoms
of xerostomia as perceived by patients after treatment with the minimally invasive acupuncture protocol
described above5,16.

Case reports

Seven patients with xerostomia subsequent to head and neck radiation therapy were referred to the author
for acupuncture. Six of the patients had undergone surgery prior to receiving radiation therapy, five for
squamous cell carcinoma of the tongue and one for squamous cell carcinoma of the ear. The seventh patient
received radiation therapy without surgery for nasopharyngeal cancer. The time between the completion of
radiation therapy and the initiation of acupuncture treatment ranged from two months to ten years, with a
median of nine months.

Three of the patients were men and four were women, ranging in age from 41-62, with an average age of

51.5 and a median age of 59. Two of the patients had not used pilocarpine to stimulate salivary secretion,
while two had stopped using it due to adverse reactions and a lack of effectiveness. Three patients who
had been taking pilocarpine at the time of their first acupuncture visit decreased usage and subsequently
stopped it during and after the acupuncture treatment. Two patients received amifostine initially during
radiation therapy but discontinued it due to severe nausea and vomiting.
Patients typically came to their first acupuncture appointment with a bottle of water and, on occasion,
a bottle of artificial saliva. All of the patients reported suffering from the xerostomia-related symptoms
discussed earlier. In addition, all of the patients awoke frequently throughout the night to drink water.
During each patient's first visit, the need for a rigorous oral hygiene home care/prevention program
was discussed. At that time, the patient received written information describing various artificial saliva
products and medications designed to help patients suffering from xerostomia27. Patients were advised to
work closely with their oral health care professionals to develop an appropriate programme.

The seven patients were treated with the acupuncture protocol developed by Niemtzow5,16. Three points
were needled on each ear: Shen Men (to calm the mind, reduce inflammation and hypersensitivity and to
support other auricular points28), point Zero (designed to bring about homeostasis29), and Salivary Gland
2/Prime. In addition, an extra point was needled bilaterally at the radial end of the distal phalangeal crease
of the index finger, on the border of the red and white skin. Patients were given sugarless mints during
treatment to help stimulate salivary flow, although the mints usually produced little, if any, saliva without
the use of acupuncture.

Patients were usually treated once a week for four to five weeks, followed by two or three biweekly
sessions, each treatment session lasting 45-50 minutes. The number of treatment sessions for the seven
patients ranged from 6-14, with a mean of 8 visits.
Salivary flow often improved during the first visit and the duration of improvement increased with each
subsequent visit. In the eight months after treatment, all of the patients continued to report a reduction in
the symptoms of xerostomia, the need to awaken at night for water and difficulty in eating and swallowing.
Increases were reported in the flow of saliva, the ability to speak for longer periods of time and the ability
to eat a wider range of food.

Studies have demonstrated that although acupuncture increases the volume of saliva, salivary flow does
not reach the full level exhibited prior to radiation treatment5,16. While all of the patients in this study have
reported being pleased with the results of treatment to some degree, none of the patients reported 100%
return of saliva.

Fig. 1. Auricular acupuncture points.

Fig. 2. An acupuncture point on the index finger.

Both before the start of treatment and at its completion, patients were asked to subjectively rate their level
of salivary flow against their pre-radiation/presurgery level. These levels were rated with a Visual Analog
Scale (VAS), in which 0 indicated no saliva and 10 indicated a level of saliva equivalent to pre-radiation/
pre-surgery treatment levels. VAS scores prior to acupuncture treatment ranged from 0.0-2.5, with a mean
score of 0.86. VAS scores after acupuncture treatment ranged from 2.5-7.0, with a mean score of 3.5. One
patient reported that the increased flow of saliva was intermittent instead of continual, while another
patient reported that sugarless mints were necessary to stimulate maximum salivary flow.

Conclusion

All of the patients treated by the author, including those patients inconvenienced by the need to travel from
surrounding states for their appointments, have indicated that they were pleased they elected to pursue
acupuncture treatment for their xerostomia. For these patients, xerostomia was only part of a series of
traumatic life events with potentially serious physical and emotional consequences. Others included the
diagnosis of a malignancy, surgical intervention, radiation treatment, pain, disfigurement and dysfunction.
Acupuncture could play a significant role in enhancing the guality of life of these individuals and others
suffering from xerostomia as well as many of the sequelae of cancer and its treatment.

Note
The acupuncture protocol used in this study was developed by Dr. Richard Niemtzow. More information
on the treatment is available at http://www.n5ev.com


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Dr. Morganstein is Director, Enrichment Program, and Dean's Faculty and Clinical Professor, Health
Promotion and Policy, Baltimore College of Dental Surgery, University of Maryland Dental School. Dr.
Morganstein completed his training in acupuncture at the UCLA Medical School/Helm's Medical Institute, Medical Acupuncture for
Physicians Program, where he now serves as a clinical faculty preceptor. He practiced acupuncture for oral
and craniofacial disorders in the Brotman Facial Pain Center at the University of Maryland Dental School during the time of this study and is currently doing the same in private practice. He is presently continuing his training in acupuncture at the Tai Sophia Institute for the Healing Arts in Laurel, Maryland, USA.