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ORIGINAL ARTICLE
Year : 2013  |  Volume : 12  |  Issue : 3  |  Page : 94-100

The Role of Salivary Gland Scintigraphy in the Evaluation of Salivary Gland Dysfunction in Uncontrolled Type II Diabetic Patients


1 Department of Oral Medicine and Radiology, K. S. R Institute of Dental Science and Research, Trichengode, Namakkal District, Tamil Nadu, India
2 Department of Oral Medicine and Radiology, Sri Ramachandra Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Web Publication14-Jul-2014

Correspondence Address:
Dr. B Senthilkumar
Old No: 6, New No: 21, Co operative Colony, Namakkal - 637 001, Tamil Nadu
India
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DOI: 10.4103/1450-1147.136733

PMID: 25214812

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   Abstract 

The aim of the present study was to evaluate the salivary gland dysfunction in patients with uncontrolled type II diabetes using salivary gland scintigraphy and then to compare these ratios with quantitative whole salivary secretion rates. Using a gamma camera (siemens-diacam) equipped with a low energy all-purpose collimator, 32 uncontrolled type II diabetic patients and 30 normal healthy patients were studied by injecting a radio isotope (technetium 99m pertechnetate) about 5 mCi was injected intravenously in to anticubital vein and the activity was measured for the 1 st , 20 th and 40 th min. At 20 min after injection, vitamin C chewable tablet was given to stimulate the secretion and continued until the end of the study period (40 min). Before scintigraphy, salivary sampling was carried out in both diabetic and normal individuals in a quiet room, saliva was allowed to accumulate and was expectorated into the collecting vessel approximately once a minute for 15 min and the volume was recorded as Unstimulated salivary flow rate and after 5 min break vitamin C chewable tablet was given to stimulate the secretion and the patient was asked to expectorate the saliva in the collecting vessel for 5 min. The expectorated volume was recorded as stimulated salivary flow rate. The mean of the measurements of scintigraphic ratio and salivary secretion rates were compared using the paired Student's t-test. The scintigraphic mean uptake and excretory ratio (ER) and the salivary flow rates were correlated. The result shows that there was a significant correlation between salivary flow rate and scintigraphic uptake and ER. However, statistically significant result could not be derived as it may be due to smaller sample size and marginal difference in the scintigraphic values between the groups. Salivary gland scintigraphy plays a significant role in the evaluation of salivary gland dysfunction. However, its role as an independent investigative procedure in the evaluation of salivary gland dysfunction requires a study with a larger sample size, may yield a statistical significant result and it can also act as an adjunct along with salivary flow rate procedure.

Keywords: Salivary dysfunction, scintigraphy, technetium-99m pertechnetate, uncontrolled type II diabetes


How to cite this article:
Senthilkumar B, Sathasivasubramanian S. The Role of Salivary Gland Scintigraphy in the Evaluation of Salivary Gland Dysfunction in Uncontrolled Type II Diabetic Patients. World J Nucl Med 2013;12:94-100

How to cite this URL:
Senthilkumar B, Sathasivasubramanian S. The Role of Salivary Gland Scintigraphy in the Evaluation of Salivary Gland Dysfunction in Uncontrolled Type II Diabetic Patients. World J Nucl Med [serial online] 2013 [cited 2020 Nov 30];12:94-100. Available from: http://www.wjnm.org/text.asp?2013/12/3/94/136733


   Introduction Top


There are various body fluids, which are essential for proper function of our body of which saliva is the most valuable fluid that can aid in diagnosis of various diseases, e.g.: Human immunodeficiency virus, hepatitis and renal disease. Hence this valuable oral fluid is critical to the preservation and maintenance of oral health, yet it receives little attention until the quantity is diminished. [1]

In salivary gland dysfunction it can present as either hypersalivation or hyposalivation. Hyposalivation can occur in localized disease, systemic disease, radiation therapy and salivary duct stones. [2] There is great variability in salivary flow rates, the accepted range of normal flow for unstimulated saliva is anything above 0.1 ml/min. For stimulated saliva, the minimum volume for the accepted norm increases to 0.2 ml/min. Any unstimulated flow rate below 0.1 ml/min is considered hypo function and stimulated anything below 0.5 ml/min is considered abnormal. [1],[3] Various factors affecting salivary secretion include diabetes mellitus, Parkinson's disease, cystic fibrosis and sarcoidosis of which diabetes is the most commonly reported disease in daily dental practice.

Diabetes is characterized by increased levels of glucose in the blood and abnormalities in the metabolism of lipid, protein induced by diminished levels or total absence of insulin. The incidence of diabetes has increased as people move away from their traditional life-style and patients with diabetes have various oral manifestations such as gingivitis, periodontitis, candidiasis, burning mouth syndrome, delayed wound healing and those who have poor glycemic control are more likely to complain of xerostomia and may have decreased salivary flow up to 82.5%. [4] The cause of salivary dysfunction may be related to polyuria or to alterations in the basement membrane of salivary glands, an investigation revealed parotid gland basement membrane abnormalities in all diabetic subjects as indicated by the binding of immunoglobulin G, albumin and polyvalent immunoglobulin's to ductal and acinar basement membranes'. So variation in parotid diabetic basement membranes evidenced that membranopathy in this is systemic in nature. [5],[6]

There are various methods of measuring the volume and weight of saliva, which are divided in to those that measure secretions from specific glands and those that measure whole or pooled saliva. These methods can be performed under conditions of unstimulated (resting) or stimulated flow. Assessment of whole pooled saliva may be an accurate indicator of overall salivary gland function. [7] There are various imaging techniques used for salivary gland, e.g.: Sialograms, computed tomography, magnetic resonance imaging and ultrasound of which scintigraphy is the only method available that can provide qualitative and quantitative functional assessment of the major salivary glands. [8]

Scintigraphy has been widely used for bone, thyroid, tumors and inflammatory conditions, now recently it is being used for detecting salivary gland hypofunction. Scintigraphy is particularly a valuable tool because it produces dynamic, objective and quantitative measurement of the major salivary gland function and allows for differentiation of abnormalities in saliva production as uptake ratios (UR) and secretion as excretory ratios (ER). [9]

The specific objective were: To evaluate the changes in salivary gland function in patients with uncontrolled type II diabetes using salivary gland scintigraphy.


   Materials and Methods Top


Patient selection criteria

Patients were randomly selected in the Department of oral medicine and the study comprised of 32 uncontrolled type II diabetic patients (22 females and 12 males) and 30 normal healthy individuals (16 females and 14 males) included in the study with age and sex matched. Age group ranges from 40 to 60 years. Patients having any other systemic or nervous illness or taking any medications or having suffered in the past with any type of illness or treatment that could have an effect on the normal functioning of the salivary gland were excluded from the study. Moreover, the study was carried out with patients consent.

Diabetic diagnostic protocol

The American Diabetes Association Expert Committee in 1997 and 1998 revised the diagnostic criteria for diabetes. [10]

A lower cut-off level for fasting plasma glucose (126 mg/dl) and to diagnose diabetes.

Blood glucose test values as related to control of diabetes. [11]

Normal, well-controlled - fasting plasma glucose <126 mg/dl, postprandial <160 mg/dl, hemoglobin (HbA1c)-<6%.

Moderate control-fasting plasma glucose <160/dl, postprandial - <160-200 mg/dl, HbA1c-6-7%.

Uncontrolled - fasting plasma glucose >160 mg/dl, postprandial - >200 mg/dl, HbA1c - >8%.

Saliva sampling

The patients were instructed not to eat, drink or put anything in their mouth or brush their teeth for at least 90 min before the examination. The saliva was collected in a quiet examination room between 7.30 a.m and 9.30 a.m. Unstimulated whole saliva was collected for 15 min. The patients were told to sit still, bow their head and try not to move. Immediately before the test, they were instructed to swallow any saliva, present in their mouth. Saliva was allowed to accumulate and was expectorated in to the collecting vessel approximately once a minute. The volume was recorded and the unstimulated whole salivary secretion rate (USSR) was expressed as ml/min. after 5 min break, stimulated whole saliva was collected for 5 min. The patients were asked to chew vitamin C chewable tablets without swallowing and then expectorate the stimulated saliva in to collecting vessel [Figure 1]. The expectorated volume was recorded and stimulated whole salivary secretion rate (SSSR) expressed as ml/min. USSR and SSSR below or equal to 0.1 ml/min and 0.5 ml/min respectively was considered abnormal. Salivary secretion rates were expressed as mean and standard deviation. [12]
Figure 1: Armamentarium used for collection of saliva and scintigraphic procedure

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Scintigraphy

After salivary sampling, the salivary gland scintigraphy was performed in the department of nuclear medicine with a gamma camera (siemens-diacam) equipped with a low energy all-purpose collimator. The patients were placed in the supine position with the gamma camera close above the face to record activity in the major salivary glands and the surrounding tissues [Figure 2] technetium-99m pertechnetate [Figure 3] about 5 mCi (135MBq) was injected intravenously in to antecubital vein. The activity was measured for the 1 st , 20 th and 40 th min. At 20 min after the injection; vitamin C chewable tablet was given to stimulate the secretion and continued until the end of the study period (40 min). The data were replayed and the regions of interest were selected over four salivary glands to obtain the uptake and ER of the salivary glands [12],[13] [Figure 4].
Figure 2: Gamma camera (siemens-diacam) with low energy all-purpose collimeter

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Figure 3: Technetium-99m pertechnetate-radioactive material

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Figure 4: Scintigraphy in diabetic patients at 1st, 20 and 40th min

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Statistical analysis

A standard statistical software package (SPSS version 12.0, Chicago, IL) was used for the data analysis. The data corresponded to mean ± standard deviation was calculated for both salivary flow rates and mean URs, between diabetic and control group. The measurements were statistically compared (salivary uptake and ER (%) with salivary flow rate using the paired Student's t-test (P < 0.05).


   Results Top


The result of the current study, which was carried out in diabetic and control patients, shows the flow rate analysis between the groups under unstimulated and stimulated conditions. The result infers a significant reduction in the salivary flow rate in diabetic patients, when compared with the control group in both categories of unstimulated and stimulated and the P value was significant (<0.0001) [Table 1] [Graph 1] [Additional file 1].
Table 1: Salivary flow rate analysis in diabetic and control patients with unstimulated and stimulated salivary flow measured in (ml/min)

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The scintigraphic total uptake and ER in diabetic and control groups were compared, the values in these two categories showed a decrease in both uptake and ER in diabetic patients, when compared with control patients. However, when it was subjected to statistical analysis, it was found to be not significant, this could be due to lack of larger sample size and marginal difference between diabetic and control groups [Table 2]a and b [Graph 2] [Additional file 2].
Table 2:

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The scintigraphic mean uptake and ER and the salivary flow rates were correlated. The result shows that there is a significant correlation between salivary flow rates and scintigraphic UR and ER, however statistically significant result could not be derived as it may be due to smaller sample size of 32 numbers and marginal difference in the scintigraphic values between the groups [Table 3]a and b.
Table 3:

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   Discussion Top


The current study was carried out to detect whether diabetic patients have salivary gland dysfunction using salivary gland scintigraphy. And a correlation was made between the scintigraphic ratio and salivary flow rates. Various studies have reported that in India the incidence of diabetes is increasing at an alarming rate. Various literature studies have reported that diabetic patients have diminished salivary dysfunction [14],[15],[16],[17],[18] of which the xerostomia is seen in uncontrolled diabetic patients up to 82.5%. [4] the cause of salivary dysfunction may be related to polyuria or alteration in the basement membrane of the salivary glands. A lot of literature studies have reported the parotid gland basement membrane abnormalities in all diabetic patients. [4],[5],[6]

Previous studies have included diabetic patients with age group of 50-60 years [4] and another study have evaluated in diabetic patients with age of 50-90 years. [19],[20] The present study was performed in sixty two patients (32 diabetic and 30 control) with age range between 40 and 60 years, which was same age range employed by various studies in evaluating the salivary dysfunction. [4],[13] Studies have included more number of females when compared with males, owing to the above studies more number of females was included in the study and both diabetic and normal patients were excluded if they had any other systemic illness or were on any medication that could affect the salivary gland function. [4]

There are various methods of measuring the volume and weight of saliva and they are divided in to those that measure secretions from specific glands and those that measure whole or pooled saliva. These methods can be performed under conditions of unstimulated (resting) and stimulated flow.

Previous studies have assessed that whole pooled saliva may be a more accurate indicator of overall salivary gland dysfunction, the draining and spitting methods being the simplest and more reproducible. [7],[15],[19],[20] The whole salivary measurement are easier to perform, requiring only simple collection with weighing device, [7] the similar method was used as reported in the earlier studies.

For collection of saliva, various collecting vessels were used, e.g.: Centrifuge tubes, graduated tube fitted with glass funnel. Similar graduated tube fitted with glass funnel was used. Initially, unstimulated whole saliva was collected for 15 min and the stimulated saliva was collected for 5 min in individual containers. The collected saliva was measured in milliliters per minute. [19],[20]

A lot of studies in the past have been carried out in diabetic patients to detect salivary dysfunction, but only few studies in the past have used scintigraphy for assessing the salivary dysfunction in diabetic patients. [13] The imaging techniques used for visualizing salivary gland include sialography, computed tomography, magnetic resonance imaging, ultrasound and scintigraphy. Scintigraphy is the widely used method that can provide functional assessment of salivary glands. [8]

A number of studies in the past have used scintigraphy to detect the glandular dysfunction in diabetic patients, chronic renal failure; parenchymal damage after treatment with radio iodine and in patients with xerostomia due to aging and medication. [12],[13],[21],[22],[23],[24] Hence scintigraphy was chosen as a choice in the present study.

A number of studies have used technetium99m pertechnetate for imaging of salivary dysfunction. [13],[21],[22] Technetium 99m pertechnetate with its monochromatic energy of 140 keV is physically the ideal isotope for imaging. Due to their short half-life these isotopes can be used in very large amounts of order of millicuries, without causing radiation hazards to patients. This paves for excellent images with sharp contrast. [25] Technetium 99m pertechnetate was injected in millicuries and about 5 mCi (135MBq) was injected in to anticubital vein and the activity was recorded using gamma camera equipped with a low energy all-purpose collimator for data analysis. [12]

This study was conducted to evaluate the role of scintigraphy in the detection of salivary gland dysfunction in uncontrolled type II diabetic patients. The study comprised of 32 uncontrolled type II diabetic patients and 30 normal individuals as controls, they were age and sex matched. Salivary flow rates, both unstimulated and stimulated were measured and compared between groups. It showed a marked decrease in the salivary flow rates in diabetic patients and it was found to be statistically significant.

The salivary gland scintigraphy with isotope technetium-99m pertechnetate was carried out in both the groups, the UR (unstimulated) and ER (stimulated) were recorded mean scintigraphic values of all four major salivary glands, when compared between diabetic and controls showed a marginal decrease in both UR (unstimulated) and ER (stimulated) in diabetic patients which leads to conclusion that there is a decrease in salivary gland function in diabetic patients. However, statistical significant result could not be derived. This result was comparable with Kao et al. were all the four major salivary glands in type II diabetic patients had significantly lower uptake and ER. [13]

The comparison of flow rate and scintigraphic analysis also showed a correlation between the individual values within the groups. The result of the present study leads to conclusion that salivary gland scintigraphy play a vital role in the evaluation of salivary gland dysfunction. However, its role as an independent investigative procedure in the evaluation of salivary gland dysfunction, requires a study with a larger sample size, may yield a statistical significant result and it can also act as an adjunct along with salivary flow rate procedure.

 
   References Top

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2.Scully C, Felix DH. Oral medicine-Update for the dental practitioner: Dry mouth and disorders of salivation. Br Dent J 2005;199:423-7.  Back to cited text no. 2
    
3.Sreebny LM. Saliva in health and disease: An appraisal and update. Int Dent J 2004;50:149-58.  Back to cited text no. 3
    
4.Quirino MR, Birman EG, Paula CR. Oral manifestations of diabetes mellitus in controlled and uncontrolled patients. Braz Dent J 1995;6:131-6.  Back to cited text no. 4
    
5.Ship JA. Diabetes and oral health: An overview. J Am Dent Assoc 2003;134 Spec No: 4S-10.  Back to cited text no. 5
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6.Murrah VA, Crosson JT, Sauk JJ. Parotid gland basement membrane variation in diabetes mellitus. J Oral Pathol 1985;14:236-46.  Back to cited text no. 6
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7.Chen A, Wai Y, Lee L, Lake S, Woo SB. Using the modified Schirmer test to measure mouth dryness: A preliminary study. J Am Dent Assoc 2005;136:164-70.  Back to cited text no. 7
    
8.Cohen-Brown G, Ship JA. Diagnosis and treatment of salivary gland disorders. Quintessence Int 2004;35:108-23.  Back to cited text no. 8
    
9.Loutfi I, Nair MK, Ebrahim AK. Salivary gland scintigraphy: The use of semiquantitative analysis for uptake and clearance. J Nucl Med Technol 2003;31:81-5.  Back to cited text no. 9
    
10.Seshiah V. Diagnosis of diabetes mellitus: Rationale for glucose challenge. Asian J Diabetology 2003;5:150-3.  Back to cited text no. 10
    
11.Wilkins EM. Clinical Practice of Dental Hygienist. Vol. 23.  Publisher: Lippincott Williams and wilkins; 1999. p. 31-7.  Back to cited text no. 11
    
12.Bågesund M, Richter S, Agren B, Dahllöf G. Correlation between quantitative salivary gland scintigraphy and salivary secretion rates in children and young adults treated for hematological, malignant and metabolic diseases. Dentomaxillofac Radiol 2000;29:264-71.  Back to cited text no. 12
    
13.Kao CH, Tsai SC, Sun SS. Scintigraphic evidence of poor salivary function in type 2 diabetes. Diabetes Care 2001;24:952-3.  Back to cited text no. 13
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14.Torres SR, Peixoto CB, Caldas DM, Silva EB, Akiti T, Nucci M, et al. Relationship between salivary flow rates and Candida counts in subjects with xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:149-54.  Back to cited text no. 14
    
15.Meurman JH, Collin HL, Niskanen L, Töyry J, Alakuijala P, Keinänen S, et al. Saliva in non-insulin-dependent diabetic patients and control subjects: The role of the autonomic nervous system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:69-76.  Back to cited text no. 15
    
16.Guggenheimer J, Moore PA. Xerostomia: Etiology, recognition and treatment. J Am Dent Assoc 2003;134:61-9.  Back to cited text no. 16
    
17.Wilson P. Diabetes. J Diabet Care 2000;23:234-40.  Back to cited text no. 17
    
18.Wu AJ, Ship JA. A characterization of major salivary gland flow rates in the presence of medications and systemic diseases. Oral Surg Oral Med Oral Pathol 1993;76:301-6.  Back to cited text no. 18
    
19.Chavez EM, Taylor GW, Borrell LN, Ship JA. Salivary function and glycemic control in older persons with diabetes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:305-11.  Back to cited text no. 19
    
20.Chávez EM, Borrell LN, Taylor GW, Ship JA. A longitudinal analysis of salivary flow in control subjects and older adults with type 2 diabetes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:166-73.  Back to cited text no. 20
    
21.Bohuslavizki KH. Quantitative salivary gland scintigraphy in diagnosis of parenchymal damage after treatment with radioiodine. Nucl med commun 1996;17:681-6.  Back to cited text no. 21
    
22.Kagami H. Assessment of aging and medications on salivary gland function in patients with xerostomia using 99 m-scintigraphy. Nagoya J Med Sci 1995;58:149-55.  Back to cited text no. 22
    
23.Kao CH. Decreased salivary function in patients with end stage renal disease requiring hemodialysis. AM J Kidney Dis 2000;36:1110-4.  Back to cited text no. 23
    
24.Hermann GA, Vivino FB, Shnier D, Krumm RP, Mayrin V. Diagnostic accuracy of salivary scintigraphic indices in xerostomic populations. Clin Nucl Med 1999;24:167-72.  Back to cited text no. 24
    
25.Sivaramakrishanan V. The use of radioisotopes in nuclear medicine: A review. Official J Radiol Assoc 1978;11:70-5.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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