[Federal Register Volume 59, Number 98 (Monday, May 23, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-12457]


[[Page Unknown]]

[Federal Register: May 23, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[BPD-782-PN]
RIN 0938-AG45

 

Medicare Program; Noncoverage of Electrostimulation of Salivary 
Glands for the Treatment of Xerostomia (Dry Mouth)

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Proposed notice.

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SUMMARY: This notice announces the Medicare program's proposal not to 
cover electrostimulation of the salivary glands for the treatment of 
xerostomia secondary to Sjogren's syndrome, and electrostimulation 
devices, such as the Salitron System. Public Health Service (PHS) 
studies show that there are insufficient data to establish the clinical 
utility of electrostimulation, to evaluate its long-term effectiveness, 
and to identify those xerostomia patients who would benefit from this 
procedure. Also, PHS reports that electrostimulation is not widely 
accepted as a treatment for xerostomia secondary to Sjogren's syndrome. 
Therefore, it does not meet HCFA's criteria for effectiveness.

DATES: Comments will be considered if we receive them at the 
appropriate address, as provided below, no later than 5 p.m. on July 
22, 1994.

ADDRESSES: Mail written comments (1 original and 3 copies) to the 
following address: Health Care Financing Administration, Department of 
Health and Human Services, Attention: BPD-782-PN, P.O. Box 26688, 
Baltimore, Maryland 21207.
    If you prefer, you may deliver your written comments (1 original 
and 3 copies) to one of the following addresses:

Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., 
Washington, DC 20201, or
Room 132, East High Rise Building, 6325 Security Boulevard, Baltimore, 
MD 21207.

    Because of staffing and resource limitations, we cannot accept 
comments by facsimile (FAX) transmission. In commenting, please refer 
to file code BPD-782-PN. Comments received timely will be available for 
public inspection as they are received, generally beginning 
approximately 3 weeks after publication of a document, in room 309-G of 
the Department's offices at 200 Independence Avenue, SW., Washington, 
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m. 
(phone: (202) 690-7890).

FOR FURTHER INFORMATION CONTACT: Francina C. Spencer (410) 966-4614.

SUPPLEMENTARY INFORMATION:

I. Background

A. Program Description

    Section 1862(a)(1)(A) of the Social Security Act (the Act) 
generally prohibits payment for any expenses incurred for items or 
services ``which, * * * are not reasonable and necessary for the 
diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member.'' We have interpreted this 
statutory provision to exclude from Medicare coverage medical and 
health care services and items that are not demonstrated to be safe and 
effective by acceptable clinical evidence. This prohibition applies to 
items for which claims are submitted under Medicare's durable medical 
equipment (DME) benefit.

B. Medicare Coverage of Electrostimulation of Salivary Glands for the 
Treatment of Xerostomia (Dry Mouth) Secondary to Sjogren's Syndrome

    Patients with chronic xerostomia complain of a continual feeling of 
oral dryness, have difficulty eating dry foods, and are susceptible to 
increased tooth decay, oral pain, tongue fissures, and infection. 
Saliva contains proteins and enzymes that aid digestion, conduct 
electrolytes necessary to maintain hard tooth enamel, and produce 
antibacterial agents to control oral bacteria. Salivary gland 
dysfunction leads to difficulty in speaking, chewing, swallowing, and 
tasting. A decrease in salivary secretion may result from damage to the 
salivary glands caused by chronic infection, irradiation, or systemic 
diseases such as hypertension, diabetes, or Sjogren's syndrome. 
Sjogren's syndrome is a chronic, inflammatory, and autoimmune disease 
in which the salivary and tear glands undergo progressive destruction 
by lymphocytes and plasma cells resulting in decreased production of 
saliva and tears.
    Treatment for xerostomia varies considerably. If Vitamin C tablets, 
gum, and hard candy do not stimulate salivation in patients with some 
salivary gland function, artificial saliva using either an atomizer or 
an intraoral reservoir are used. While these methods relieve the 
symptoms of chronic xerostomia, they usually offer only temporary 
relief. Oral drugs such as pilocarpine and pyridostigmine are effective 
in increasing salivation if there are some functioning salivary gland 
tissues. However, because of side effects and contraindications, the 
usefulness of these drugs is limited.
    On March 27, 1987, Biosonics, Inc. requested marketing approval by 
the FDA of the Salitron System. This device is a battery-powered, hand-
held electrostimulation device for stimulating salivation from existing 
glandular tissue by delivering a small electrical stimulus to the mouth 
using a probe with two metal electrodes. It is used for patients with 
xerostomia secondary to Sjogren's syndrome with residual salivary 
tissue in the oral and pharyngeal regions. Physicians use the device to 
screen patients to determine a response to electrostimulation before 
prescribing the system. After reviewing the recommendation of the 
Dental Devices Panel, FDA's Center for Devices and Radiological Health, 
the FDA granted premarket approval for the Salitron System on May 18, 
1988. The approval was announced in the July 14, 1988, notice entitled 
``Biosonics; Premarket Approval of the Salitron System'' (53 FR 26673). 
At this time, the Salitron System is the only device approved for 
marketing by the FDA for electrostimulation of salivary glands.
    Currently, Medicare does not have a national policy for covering 
electrostimulation of salivary production for treating xerostomia 
secondary to Sjogren's syndrome. Without a national policy, Medicare 
carriers have authority under section 1842(a) of the Act to make 
coverage decisions within the parameters set by the statute, 
regulations, and program instructions. Some carriers are paying for 
electrostimulation of the salivary glands using the Salitron System and 
others are not because they question the medical efficacy of the 
treatment. This has resulted in inconsistent coverage policies among 
carriers.

C. Recommendation Not to Cover Electrostimulation of Salivary 
Production in the Treatment of Xerostomia Secondary to Sjogren's 
Syndrome

    On May 26, 1988, Biosonics requested that Medicare issue a national 
policy decision that would provide for coverage of the Salitron System. 
Based on our evaluation of their request, we consulted the HCFA 
Physicians Panel. The Panel recommended that OHTA evaluate the safety 
and effectiveness of the Salitron System as well as the criteria used 
to identify xerostomia patients who would benefit from the device.
    On October 4, 1988, we asked OHTA to conduct a full assessment of 
the safety and effectiveness of the Salitron System and to develop 
patient selection criteria. To conduct this assessment, OHTA solicited 
information from clinicians, appropriate private organizations, 
researchers, other government agencies, other components of PHS, and 
the National Institutes of Health (NIH). OHTA evaluated studies, data 
provided to the FDA, published articles, and information from 
respondents to the March 2, 1989, notice entitled ``National Center for 
Health Services Research and Health Care Technology Assessment; 
Assessment of Medical Technology'' (54 FR 8829). In that notice, OHTA 
announced that it was assessing the patient criteria for 
electrostimulation of salivary glands for the treatment of xerostomia 
secondary to Sjogren's syndrome and an electrostimulation device's 
acceptability, cost, and effectiveness relative to other therapies.
    On July 30, 1990, we received OHTA's assessment ``Salivary 
Electrostimulation in Sjogren's Syndrome'' with a bibliography of 
literature and investigations evaluating electrostimulation of salivary 
glands. (A copy of this assessment is included as an addendum to this 
proposed notice.)
    According to OHTA, from the limited studies as well as data 
provided to the FDA, it appears that electrostimulation of salivary 
glands may be useful in managing xerostomia in certain patients. OHTA, 
however, states that there are insufficient data to determine the 
clinical utility of electrostimulation, to evaluate its long-term 
clinical effectiveness, and to identify xerostomia patients who would 
benefit from this procedure. Also, OHTA has determined that 
electrostimulation is not widely accepted as an effective method for 
treating xerostomia secondary to Sjogren's syndrome and that other 
treatments, such as the use of Vitamin C tablets, gum, hard candy, and 
artificial saliva, are available.
    NIH advised OHTA that guidelines specifying the types and 
conditions of xerostomia patients who would benefit from 
electrostimulation cannot be developed without further clinical studies 
of well-characterized patient populations. Given the single published 
study showing that only patients with residual salivary flow in an 
unstimulated state will respond to electrostimulation, NIH suspects 
that those individuals are likely to respond as well to other means of 
salivary stimulation.
    OHTA reviewed the published study, the preliminary investigation, 
and the study presented to the FDA. The 1988 study by M. Steller and 
associates (``Electrostimulation of Salivary Flow in Patients with 
Sjogren's Syndrome'' Journal of Dental Research 1988; 67(60): 1334 
through 1337) revealed that only 3 of 13 patients using an active 
device showed a significant response in salivary production when 
compared to the response of the placebo device group. The 1986 
preliminary investigation conducted by W. W. Weiss and associates 
(``Clinical Trial of an Electronic Stimulatory Device in the Management 
of Xerostomia'' Journal of Oral and Maxillo-facial Surgery November 
1986: M10) did not include a control group or any quantitative 
assessment of salivary response, duration of response, or long-term 
assessment of efficacy. Moreover, 7 of the 9 patients tested had 
residual saliva production before treatment and may have been 
exhibiting a tactile response to the probe. The 1988 study by N. Talal 
and associates (``The Clinical Effects of Electrostimulation on 
Salivary Function of Sjogren's Syndrome Patients'' Rheumatology 
International June 1992; 12(12) 43 through 45), upon which the FDA 
based its approval, describes the clinical effects of 
electrostimulation in 77 patients. Salivary production was measured at 
the start of the study, at 2 weeks, and at 4 weeks. The researchers 
reported that salivation was higher among the group using an active 
device than the placebo device group. However, because of a 
misunderstanding about the length of the study, about half of the 
subjects dropped out of the study by the fourth week.
    Thus, OHTA concluded that additional, long-term studies with larger 
patient populations are needed to define the specific degrees of 
salivary dysfunction that would respond to electrostimulation and to 
determine how long it takes to determine if salivary glands have been 
regenerated. These studies could help determine whether a single 
salivary response to electrostimulation or some other test, such as a 
lip biopsy, should be used to help identify those patients who may 
benefit from electrostimulation. In addition, OHTA stated that to 
determine the effectiveness of electrostimulation, studies should 
include information regarding concomitant therapy and the duration of 
the salivary response to compare the device to other therapies. Studies 
and subsequent management should include quantitative assessment of 
salivary function, assessment of oral conditions, and subjective 
patient evaluations.
    The comments OHTA received from knowledgeable clinicians were 
inconsistent. Some clinicians state that electrostimulation is safe and 
effective while others suggest that the method has been inadequately 
tested and are not convinced that it is more effective than other 
simple, less costly stimulation techniques.
    After OHTA's published report, Biosonics requested review of 
additional data on the use of the Salitron System. On September 21, 
1990, we submitted the data to OHTA. OHTA reported on October 26, 1990, 
that this data had been presented to the FDA and was included in the 
OHTA assessment of July 30, 1990. OHTA concluded that the treatment 
could be reassessed when additional data from a larger patient 
population is available to evaluate the long-term clinical 
effectiveness of electrostimulation and identify those xerostomia 
patients who would benefit from an electrostimulation device.
    On November 2, 1990, we submitted to OHTA another request for a 
review of data from Biosonics. On November 14, 1990, OHTA informed us 
that it had previously reviewed this data and referred us to its 
October 26, 1990, recommendation.
    On October 9, 1992, Biosonics requested a reassessment and 
submitted two new articles on electrostimulation for xerostomia 
published in ``Geriatric Consultant'' and ``Rheumatology 
International.'' One article reported a physician's experience in 
treating 33 patients for 6 months. The other article reported on the 
unpublished clinical study evaluated by the FDA in 1988. We have 
determined that the medical evidence and conclusions upon which OHTA's 
assessment is based are still accurate based on our own medical 
expertise and a thorough review of all the medical literature on the 
subject since the 1990 assessment.

II. Provisions of This Proposed Notice

    OHTA concluded that there are insufficient data to determine the 
clinical utility of electrostimulation, to evaluate its long-term 
clinical effectiveness, and to identify xerostomia patients who would 
benefit from this procedure and that electrostimulation is not widely 
accepted as an effective treatment for xerostomia. Based on these 
conclusions, we have determined that electrostimulation of salivary 
glands and the electrostimulation device, the Salitron System, do not 
meet our criteria for effectiveness. Therefore, we propose to publish a 
final notice announcing a national coverage decision that Medicare does 
not cover electrostimulation of salivary glands for treating xerostomia 
secondary to Sjogren's syndrome.
    The provisions of this notice would not affect any existing 
Medicare regulations. However, they would be incorporated in the 
Medicare Coverage Issues Manual (HCFA Pub. 6).

III. Response to Comments

    Because of the large number of items of correspondence we normally 
receive on proposed notices, we are not able to acknowledge or respond 
to them individually. We will consider all comments that we receive by 
the date and time specified in the DATES section of this preamble, and 
if we proceed with a subsequent document, we will respond to the 
comments in the preamble to that document.

IV. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et seq.).

V. Regulatory Impact Statement

A. Introduction

    Currently, Medicare does not have a national policy for covering 
electrostimulation of salivary production for treating xerostomia 
secondary to Sjogren's syndrome. Medicare carriers have authority to 
make coverage decisions within the parameters set by the statute, 
regulations, and program instructions. Because this service is not 
ordered often and because of the low total allowed charges by Medicare 
Part B for this service, less than $26,000 in calendar year (CY) 1991, 
and no reported payments in CY 1992, we believe this proposed notice 
would result in negligible savings during calendar years 1994 through 
1998.

B. Regulatory Flexibility Act

    We generally prepare a regulatory flexibility analysis that is 
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601 
through 612) unless the Secretary certifies that a notice would not 
have a significant economic impact on a substantial number of small 
entities. For purposes of the RFA, all physicians prescribing and 
suppliers distributing a device to stimulate salivary production from 
existing glandular tissue are considered to be small entities.
    In addition, section 1102(b) of the Act requires the Secretary to 
prepare a regulatory impact analysis if a notice may have a significant 
impact on the operations of a substantial number of small rural 
hospitals. This analysis must conform to the provisions of section 603 
of the RFA. For purposes of section 1102(b) of the Act, we define a 
small rural hospital as a hospital that is located outside of a 
Metropolitan Statistical Area and has fewer than 50 beds.
    The Medicare program paid for 41 electrostimulation devices during 
CY 1991 totaling an estimated $26,000 at an average cost of 
approximately $630 each. It appears that carriers are no longer paying 
for this electrostimulation device, thereby explaining why no invoices 
for this device were processed in CY 1992. In the absence of this 
notice, it is possible that the number of devices prescribed by 
physicians would increase and carriers would resume payment. Physicians 
have at least two alternate methods for treating xerostomia. One method 
is to rely on the use of artificial saliva in conjunction with the 
sipping of liquids for moisture. The second alternative is the use of 
gums and candies to induce saliva. Since there are alternative 
treatment methods, we believe this proposed notice would affect 
physicians and beneficiaries minimally.
    Therefore, we are not preparing analyses for either the RFA or 
section 1102(b) of the Act since we have determined, and the Secretary 
certifies, that this proposed notice would not result in a significant 
economic impact on a substantial number of small entities and would not 
have a significant impact on the operations of a substantial number of 
small rural hospitals.
    In accordance with the provisions of Executive Order 12866, this 
proposed notice was not reviewed by the Office of Management and 
Budget.

(Secs. 1861 and 1862 of the Social Security Act (42 U.S.C. 1395x and 
1395y))

(Catalog of Federal Domestic Assistance Program No 93.774, 
Medicare--Supplementary Medical Insurance)

    Dated: March 3, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
    Dated: April 7, 1994.
Donna E. Shalala,
Secretary.

Salivary Electrostimulation in Sjogren's Syndrome

Number 8

Patient Selection Criteria for Electrostimulation of Salivary 
Production in the Treatment of Xerostomia Secondary to Sjogren's 
Syndrome

Prepared by: Martin Erlichman

Introduction

    Electrostimulation has been introduced as a technique for 
increasing salivary output in the treatment of patients with 
xerostomia (dry mouth) secondary to Sjogren's syndrome. The 
procedure uses an electrostimulation device (salivation 
electrostimulator) to increase salivary production from existing 
glandular tissue. The device delivers a small electrical stimulus to 
the mouth via a probe. The electrostimulation device consists of an 
electric control module, a connecting cord, and a hand-held stimulus 
probe with two metal electrodes. The device may be battery-powered. 
Patients with residual salivary tissue in the oral and pharyngeal 
regions who demonstrate a decrease in the flow rate of saliva are 
potential candidates for this procedure.
    Xerostomia may be the result of Sjogren's syndrome, other 
diseases, medications, or radiation therapy to the head and neck. To 
determine that the xerostomia has resulted from Sjogren's syndrome, 
clinicians also confirm the presence of keratoconjunctivitis sicca 
(dry eye) and a positive lip biopsy with or without the presence of 
a connective tissue disease. It is estimated that more than one 
million people, mostly women, suffer from Sjogren's syndrome in the 
United States.1
    Xerostomia is usually defined as a symptom that exists when 
saliva production is less than 0.1 mL/min (or 0.1 g/min). However, 
the symptom of xerostomia has been reported to appear when normal 
salivary output declines by approximately 50%, regardless of the 
starting value. Normal saliva production has been estimated to be 
600 mL/24h.2 Patients with chronic xerostomia complain of a 
continual feeling of oral dryness and find it difficult to eat dry 
foods.3 In addition to the subjective complaints, the patient 
with salivary gland dysfunction is susceptible to increased dental 
caries, oral pain, frequent infections, and difficulties in 
speaking, chewing, and swallowing.4 Several tests are available 
for measuring salivary function. According to Fox et al,5 
evaluation of salivary gland function can be assessed by stimulated 
saliva collection and analysis. The biopsy of the salivary glands, 
usually obtained from the lower lip, is used to differentiate true 
Sjogren's syndrome from other forms of salivary gland dysfunction.
    The approach to the treatment of this condition varies 
considerably. In some patients, xerostomia may be managed by sipping 
water frequently. Other patients stimulate salivary flow with 
sugarless mints or gum.6 Salivary substitutes such as a 
carboxymethylcellulose-based artificial saliva have been used by 
some patients to supplement low quantities of salivary flow. 
Pharmacologic agents have been introduced to treat the oral dryness 
of salivary gland dysfunction in patients where unstimulated 
salivary flow was low or nonexistent but where some functional 
salivary gland tissue existed. Fox et al4 reported that 
pilocarpine was effective for relieving xerostomia by increasing 
natural salivary function. The production of endogenous saliva is of 
greatest benefit to the patient both for its convenience and the 
importance of natural saliva to oral functions. Recently, attempts 
to increase saliva production have utilized electrical stimulation. 
Preliminary investigations were reported by Weiss et al7 in 
1986.
    This report will examine the published literature and other 
available evidence to evaluate the electrostimulation of salivary 
production and determine if there are xerostomic patients who would 
benefit from this procedure.

Background

    Sjogren's syndrome is a chronic inflammatory and autoimmune 
disease in which the salivary and lacrimal glands undergo 
progressive destruction by lymphocytes and plasma cells resulting in 
decreased production of tears and saliva.8 Sjogren's syndrome 
is seen predominantly in middle-aged elderly women.9 Females 
are involved 10 times more commonly than males. Secondary effects of 
xerostomia include impairment in the normal movement of lips and 
tongue, thereby hampering speech, mastication, and 
swallowing.10 Additional signs include oral soreness, adherence 
of food to buccal surfaces, fissuring of the tongue, an altered 
sense of taste, and a marked increase in dental caries and 
infection. Soreness and redness of the mucosa are usually the result 
of candidal infection, which is found in approximately 70% of the 
Sjogren's syndrome patients.11
    Complaints resulting from dryness of the mouth are varied and 
often describe the difficulties encountered in trying to eat dry 
foods without sufficient lubrication.11 Many subjects require 
frequent ingestion of liquids. They may resort to carrying water 
bottles or hard candy.
    The parotid gland enlarges in many patients secondary to 
cellular infiltration and ductal obstruction. Usually asymptomatic 
and self-limited, the enlargement can be recurrent and associated 
with pain or erythema. Focal infiltrates of lymphocytes are also 
found in the minor salivary glands of the lower lip. Biopsy provides 
histologic confirmation and quantification of the degree of 
infiltration.
    The subjective imprsssion of xerostomia, or oral dryness, may 
not reflect actual salivary gland capabilities.\12\ Salivary flow 
rate estimation is a sensitive indicator of salivary gland function. 
A suction cup is used to obtain parotid saliva from the gland after 
the tongue is stimulated with citric acid. Although the parotid 
glands make the major contribution to the total salivary flow, the 
submandibular glands are the most consistently affected glands in 
patients with Sjogren's syndrome. Measurement of parotid function 
may result in false-normal valuse. In Sjogren's syndrome, 
measurement of the submandibular/sublingual secretions are a 
sensitive indicator of salivary gland hypofunction. According to Fox 
et al\12\ alterations in submandibular/sublingual function have the 
greatest impact on the sensation of oral dryness.
    Another useful technique for studying the salivary glands is lip 
biopsy. The technique is a sensitive and specific diagnostic 
procedure for Sjogren's syndrome. It is well tolerated and causes no 
disfigurement. The changes in the minor glands of the lower lip show 
a close correlation with those in the major salivary glands.\11\ In 
addition to confirming the diagnosis, biopsy allows quantification 
of the degree of lymphocytic infiltration and tissue damage. 
Aggregates of lymphocytes within the acinar tissue are scored. An 
aggregate of 50 or more cells represents a focus. The number of foci 
within 4mm\2\ of glandular tissue is determined and constitutes the 
focus score. A focus score of more than 1 is characteristic of 
Sjogren's syndrome.\8\
    Salivary scintigraphy, which measures the uptake, concentration, 
and excretion of technetium pertechnetate by the major salivary 
glands, is also a sensitive index of glandular function. However, it 
is expensive, requires exposure to a radionuclide, and has little 
advantage over the other two procedures.\8\
    The symptoms of dry eyes and dry mouth in the absence of any 
drug treatment or other disorder likely to be causal suggest a 
diagnosis of Sjogren's syndrome.\11\ According to Talal\8\ the 
diagnosis of Sjogren's syndrome is based upon the confirmed presence 
of two of the following three criteria: (1) a focus score of more 
than 1 in the labial salivary gland biopsy, (2) dry eye 
(keratoconjunctivitis sicca), and (3) an associated connective 
tissue or lymphoproliferative disorder. The triad of dry eyes, dry 
mouth, and a connective tissue or collagen disease, usually 
rheumatoid arthritis, is termed secondary Sjogren's syndrome.\11\ 
Dry eyes and dry mouth in the absence of a collagen disease is 
referred to as primary Sjogren's syndrome. The use of diuretics, 
anti-hypertensive drugs, antihistamines, antipsychotic, and 
antidepressants may diminish lacrimal and salivary gland 
function.\13\ Because the use of anticholinergic drugs as well as a 
number of other medications may be the single most frequent cause of 
xerostomia, it is essential to estsblish the presence of focal 
lymphoid infiltrates and autoimmunity in a patient suspected of 
having Sjogren's syndrome. Supportive serologic data would include 
the presence of antinuclear antibodies, an elevated erythrocyte 
sedimenation rate, and the presence of anti-SS-A and anti-SS-B 
antibodies.
    Treatment of xerostomia is difficult and includes preventing 
caries, treating and retreating oral candidiasis, and attempting to 
relieve the symptoms of dry mouth by increasing fluid intake, 
replacing absent saliva with saliva substitutes, or stimulating the 
remaining glandular tissue to secrete. Patients presenting with 
milder stages of xerostomia may benefit from frequent small sips of 
water or other fluids such as fruit nectars, and this may be as 
effective as any other means of alleviating symptoms. Sialagogues 
such as vitamin C tablets, sugarless chewing gum, mints, or hard 
candies may offer temporary relief through masticatory or gustatory 
stimulation. For other patients, saliva substitutes may ameliorate 
symptoms and possibly increase salivary flow. Efforts at relieving 
the symptoms of chronic xerostomia through the use of salivary 
substitutes and by stimulating salivary flow usually offer only 
temporary relief from dryness. Nevertheless, appropriate management 
of patients with xerostomia requires that those patients whose 
salivary flow can be increased by means of sialagogues be 
distinguished from those patients whose salivary flow cannot be 
stimulated, or whose flow is insufficiently stimulated.\14\ Patient 
response can be tested with the use of a mechanical (paraffin 
chewing) or a gustatory (citric acid) stimulant.\15\ The placement 
of citric acid crystals or a 2% citric acid solution in the mouth 
will stimulate demonstrable salivary flow within a few minutes in 
responsive patients.\12\,\14\
    Where stimulation of salivary flow by sialagogues has been 
ineffective, saliva substitutes have been applied symptomatically to 
alleviate mucosal discomfort and to air oral functioning.\10\ 
Artifical saliva substitutes usually contain carboxymethylcellulose 
with or without the presence of natural mucins. 
Carboxymethylcellulose is used to impart lubrication and viscosity. 
Saliva substitutes that contain natural mucins maintain a surface 
tension similar to that of natural salival. Salts are added to 
artifical saliva to mimic the electrolyte content of natural 
saliva.\15\ According to Brastings,\16\mucin-containing salivas are 
preferred by patients because carboxy-methylcellulose compounds seem 
to be uncomfortably sticky. Preparations containing mucin are 
considered to provide formualtions that most closely resemble human 
saliva.\17\ When applied using an atomizer, saliva substitutes wet 
the oral cavity for about 30 minutes.\18\ In addition, intraoral 
reserviors have been designed to allow continuous wetting of the 
oral surfaces. Recently, a denture with a palatal reservoir for 
artificial saliva has been constructed. The reservoir holds 2-3 cc 
of substitute and needs to be refilled every 2-5 hours.\16\ Several 
saliva substitutes are available and appear to be most successful 
when used at night.\3\
    Parasympathomimetic drugs have been used as pharmacologic 
sialagogues in the treatment of xerostomia. Fox et al\4\ 
demonstrated that in persons with documented salivary gland disease 
who have some functional salivary gland tissue, an orally 
administered systemic agent is effective in relieving xerostomia and 
increasing silivary output. Orally administered pilocarpine 
increases the production of saliva by parotid and submandibular or 
sublingual glands and relieves the sensation of oral dryness. The 
investigators suggest that a sustained-release form of the drug may 
offer increased therapeutic benefit. Scully\11\ recommends 
pyridostigmine because it is longer acting with fewer side effects 
than other pharmacologic agents. According to Vissink et at\14\ the 
usefulness of pharmacologic sialagogues is limited because of their 
side effects and contraindications.
    By application of the concept of electrically stimulating nerves 
to elicit a response, electrostimulation was developed for use in 
the oral cavity to stimulate the salivary reflex. Investigators have 
reported that electro-stimualtion increases salivary output and 
should be used to treat patients with xerostomia secondary to 
Sjogren's syndrome.\37\ The cost of a battery-operated, hand-held 
stimulus probe that can provide electrical stimulation to the tongue 
and hard palate is approximately $1,500.

Rationale

    Proponents of electrostimulation as a method to increase 
salivary production suggest that this procedure enhances the 
patient's ability to generate saliva by augmenting normal 
physiologic salivary reflexes. Salivary secretion is normally 
controlled by reflex stimulation with effector nerve impulses 
traveling along sympathetic as well as parasympathetic nerves to the 
glands. Sympathetic nerve stimualtion produces a sparse viscous 
secretion, whereas the parasympathetic nerve stimualtion produces a 
voluminous watery secretion.\19\ The dual secretion (saliva) is a 
flued mixture produced from paired major salivary glands (parotid, 
submandibular, and sublingulal) and many smaller aggregations of 
minor salivary glands imbedded in the submucosa of the cheeks, lips, 
hard and soft palates, and tongue.
    Proponents believe that xerostomia secondary to Sjogren's 
syndrome can be caused by interruption of the stimulus that elicits 
salivation at the effector site; such interruption results from loss 
of glandular tissue with replacement by round cell infiltration, 
scar, or fatty tissue. They postulate that an electronic device that 
touches the tongue and roof of the mouth simultaneously will 
stimulate tactile receptors, taste receptors, and intrinsic muscle 
mechanoreceptors within the mucosa of the dorsum of the tongue and 
the roof of the mouth. This produces electrical stimuation to the 
oral and pharyngeal afferent nervous system resulting in a reflex 
volley of efferent impulses to all residual salivary tissue, major 
and minor, in the oral and pharyngeal regions causing salivation.

Review of Available Literature

    It has long been known that the nerves to salivary glands 
control the secretion of saliva. According to Garrett\19\ an 
experiment in 1850 by Ludwig demonstraed that electrical stimulation 
of the chordalingual nerve in the dog caused a copious secretion of 
submandibular saliva.
    In 1986 Weiss et al\7\ reported on the use of an electronic 
stimulator as a mothod for increasing salivary production. In this 
prelimianry investigation, 9 of the 24 patients with a primary 
complaint of xerostomia had Sjogren's syndrome (diagnosed on the 
basis of mdical history only). Following a visual examination of the 
oral cavity as well as a gloved finger test to determine the 
presence of moisture (any reflection was considered a sign of 
wetness), patients were administered a 3-minute stimulus to the 
tongue and roof of the mouth with the probe (electrodes) of the 
hand-held stimulator. The maximum voltage delivered by the device is 
6V with a current of 9 A. Patient tolerance controls and 
determines the level of stimulation. Two subsequent stimulations of 
3 minutes each were conducted at the same sitting by most of the 
patients (actual numbers not reported). Each stimulation procedure 
was followed by a subjective patient evaluation of improvement and a 
repeat clinical examination.
    According to the investigators, prior to stimulation, seven of 
the nine patients with Sjogren's syndrome were considered to have 
slight amounts of moisture present, and the remaining two patients 
had ``no moisture'' present. Following stimulation, all nine 
patients reported subjective impressions of increased salivation as 
compared with prestimulation conditions. Clinical assessment was in 
agreement with the subjective patient evaluations. Weiss et al.\7\ 
reported that the electronic device stimulates residual salivary 
tissue in the oral and pharyngeal regions, producing increased 
salivation.
    In 1988, Steller et al.\3\ conducted a study of electrical 
stimulation of salivary flow in patients with biopsy-proven 
Sjogren's syndrome. The response to an electrical stimulus applied 
to the tongue and hard palate was observed in a randomized, double-
blind, 4-week study of 29 subjects with xerostomia secondary to 
Sjogren's syndrome. To be eligible to participate in the study, 
subjects had to have an unstimulated whole (total gland secretions) 
salivary flow rate of less than 0.2 g/min. Patients were randomly 
assigned to active or placebo devices, which they used for 3 
minutes, three times a day for 4 weeks. Response to stimulation was 
assessed as whole saliva flow rates, which were measured at weeks 0, 
2, and 4, both before and after stimulation with the device.
    According to the investigators, there were no statistically 
significant differences between changes in prestimulation whole 
saliva flow rates or differences between the net changes in mean 
whole saliva flow rate (poststimulation minus prestimulation flow) 
of the active and placebo groups at each visit. The investigators 
did find the changes in mean poststimulation whole saliva flow rates 
between subjects using active and placebo devices from weeks 0 to 4 
of the study to be statistically significant. However, analysis of 
the results showed that the mean increase in the poststimulation 
flow rate of the active device group (13 subjects) was due mainly to 
the responses of three subjects who showed marked increases in their 
whole saliva flow rates during the study. The investigators noted 
that the initial salivary flow rates of these subjects were the 
highest in that group, and their labial salivary gland focus scores 
were among the lowest.
    The investigators concluded that some Sjogren's syndrome 
patients with residual salivary flow show significant responses to 
electrical stimulation, but others with low or absent whole saliva 
flow rates do not respond. During the 4-week study period no change 
in the appearance of the oral mucosa was observed at the site of 
electrode placement, and no marked changes or patterns of variation 
in subjects' pulse and blood pressure were observed before or after 
the device was used.

Discussion

    Xerostomia is a complaint of elderly individuals, particularly 
women.\6\ Decreases in both quantity of saliva as well as 
composition cause a multitude of problems. In a healthy mouth, 
copious saliva containing essential electrolytes, glycoproteins, and 
antimicrobial enzymes continually lubricates and protects the oral 
mucosa, thus cleaning the mouth, regulating acidity, maintaining the 
integrity of the teeth, and destroying bacteria.
    Currently, xerostomia is managed on the basis of subjective 
symptoms, evidence of reduction in salivary flow, and complications 
that result from dry mouth. To alleviate some of the problems 
resulting from salivary dysfunction, pharmacologic sialagogues such 
as pilocarpine and pyridostigmine as well as sialagogues that 
include sugarless chewing gum, mints, or candy are prescribed in 
order to stimulate more salivary flow.\18\ Sialagogues are effective 
only if salivary gland function is present.
    The preliminary investigation by Weiss et al.\7\ in 1986 
demonstrated that a probe providing electrical stimulation applied 
to the tongue and hard palate of patients with xerostomia presumed 
secondary of Sjogren's syndrome produces a salivary response. The 
salivary response was obtained in the nine patients following a 
single session of one to three electrical stimulations of 3 minutes 
each. As a preliminary investigation, this study did not include a 
control group or any quantitative assessment of salivary response, 
duration of response, or long-term assessment of efficacy. Moreover, 
seven of the nine patients tested exhibited residual saliva 
production prior to treatment and may have been exhibiting a tactile 
response to the probe.
    The only other published report determining whether an 
electrical stimulus applied to the tongue and hard palate could 
stimulate salivary flow in subjects with xerostomia secondary to 
Sjogren's syndrome is the randomized, double-blind, 4-week study 
reported by Steller et al. in 1988.\3\ The results of this short-
term study indicate that some Sjogren's patients with residual 
salivary flow in an unstimulated state (<0.11-0.20 g/2 min) show a 
significant response to electrical stimulation, but others with low 
(less than 0.11 g/2 min) or absent whole saliva rates do not respond 
or respond to a clinically insignificant degree. Only 3 of 13 
patients using the active device showed a significant response 
(about 0.6-1.0 g/2 min) in salivary production when compared with 
the responses of the placebo group. The whole saliva flow rates of 
the remaining 10 subjects in the active group remained below 0.25 g/
2 min throughout the study and were not of the order of magnitude 
necessary to indicate a significant salivary response. Whole saliva 
flow rates of 10 subjects in the placebo group remained below 0.20 
g/2 min throughout the study. It appears that additional studies 
with larger patient populations are needed to define specific 
degrees of salivary function or dysfunction that would respond to 
electrical stimulation. These studies could help to determine 
whether a single salivary response to electro-stimulation or some 
other test such as lip biopsy focus score should be used to help 
identify those patients who may benefit from the technique.
    Guidelines that would specify which types of Sjogren's patients 
with what degree of xerostomia and at what points in their clinical 
evaluation or management would benefit from electrostimulation 
cannot be developed without further clinical investigation. Long-
term studies of well-characterized patient groups will also help to 
determine how long it takes to achieve a response. According to some 
investigators, this should allow sufficient time to determine if any 
regeneration of the salivary gland parenchyma is achieved. In order 
to determine the effectiveness of electrical stimulation of salivary 
flow in Sjogren's patients, studies should include information 
regarding concomitant therapy (continued frequent water sipping or 
use of other sialagogues) and the duration of the salivary response 
so that it can be compared with the use of other therapies. Studies 
and subsequent management of Sjogren's patients with dry mouth 
should include quantitative assessment of salivary function 
(unstimulated and stimulated, whole and individual gland salivas), 
assessment of oral conditions for signs of salivary hypofunction, 
and subjective patient evaluations.
    Salivary glands in patients who suffer from rheumatoid diseases 
show varying degrees of destruction. This damage is progressive and 
considered irreversible by some investigators.\17\ The ability to 
induce secretion in individuals with these conditions will be 
inversely related to the glandular damage. The study by Stellar et 
al\3\ shows that a device providing electrical stimulation to treat 
dry mouth in patients with Sjogren's syndrome appears to be 
effective after 4 weeks of study in only a small percentage of 
patients. These patients may represent a group with less advanced 
disease (lesser degree of lymphocytic infiltration) and a greater 
amount of functional salivary parenchyma. These individuals would 
likely respond equally well to mechanical, chemical, tactile, and 
pharmacologic means of salivary stimulation. Anything that enhances 
mastication will induce secretion. So, too, will salts and citric 
acid solutions. While all of these techniques are effective, their 
effects are transient; however, there have been no studies to 
demonstrate that electrical stimulation provides any advantage or is 
more effective than other existing techniques.
    Successful treatment for dry mouth is recorded as both 
subjective and objective increases in saliva output. According to 
Fox et al,\5\ patient complaints of xerostomia or oral dryness may 
not reflect actual salivary gland capabilities or function. 
Subjective assessments alone are not adequate for diagnostic or 
therapeutic purposes. Although there is no fixed salivary level for 
intervention, xerostomia is generally associated with whole saliva 
flow rates of less than 0.1 mL/min. For some patients, a 50% 
reduction in salivary output leads to the subjective impression of 
dry mouth. However, the level of diminished salivary output where a 
patient becomes subject to increased risk of oral disease or 
dysfunction is not known. Moreover, there is a wide variability of 
``normal'' salivary output. A 50% decline for one individual might 
still result in a flow rate greater than another individual's normal 
output. Some investigators feel that if the minor salivary glands 
can be stimulated to coat the mucosa with a thin layer of mucous, 
the sensation of dryness will be relieved. Even very small increases 
in saliva output may be beneficial in preventing or minimizing the 
oral effects of salivary dysfunction. Long-term clinical studies are 
needed to examine these issues.

Consultations

    According to the National Institutes of Health (NIH), 
electrostimulation may be useful in management of salivary 
hypofunction, but adequate data for definitive conclusions are not 
available. Electrostimulation is not widely accepted as an effective 
method of treating xerostomia secondary to Sjogren's syndrome. In 
addition, the number of published studies is limited.
    NIH has informed OHTA that guidelines that specify which types 
of xerostomic patients with which conditions and at what points in 
their clinical evaluation and/or management would benefit from 
electrostimulation cannot be developed without further clinical 
studies utilizing well-characterized patient populations. Given the 
single published study showing that only patients with residual 
salivary flow in an unstimulated state will respond to 
electrostimulation, NIH suspects that those individuals would likely 
respond as well to other means of salivary stimulation, including 
gustatory or masticatory stimuli. NIH has expressed doubt as to 
whether electrostimulation using a limited stimulus time (3 minutes, 
three times a day) could provide sufficient duration of increased 
salivary output to have a significant impact on the oral health or 
symptoms of the patient.
    The Food and Drug Administration (FDA) has informed OHTA that in 
May 1988 a manufacturer received premarket approval for a salivation 
electrostimulator device based upon submission\20\ of engineering, 
preclinical, and clinical studies and the recommendation of the 
Dental Devices Panel, FDA's Center for Devices and Radiological 
Health. The short-term double-blind clinical study of the device was 
conducted at three institutions and included 40 patients using an 
active device and 37 patients assigned a placebo. The work by 
Steller et al\3\ discussed in the literature review section is part 
of this submission. Based on the data submitted, the FDA found an 
increase in saliva production from the patient group using the 
active device compared with the patient group using the placebo 
device. Subjective improvement of a burning sensation of the tongue 
was noted by 12 of 22 patients treated with the active device, and 
an improvement in the ability to swallow was reported by 13 of these 
patients.
    The manufacturer provided the FDA with a long-term clinical 
study of 34 patients with Sjogren's syndrome and xerostomia that was 
intended to follow patients for up to 12 months. Patients were 
assessed by the physician for moisture (oral examination) prior to 
the study and at visits on 1, 3, 6, and 12 months following 
stimulation. Eleven of 12 patients who completed 12 months of 
electrical stimulation were found on the last visit to have a 
discernible improvement in salivary status when compared with the 
initial assessment. As a followup to this study, a group of 23 
patients was surveyed by the manufacturer via telephone to assess 
changes in quality of life after using electrical stimulation for 6-
18 months. Patients indicated improvement that included increased 
ease of swallowing and improved dental checkups as well as education 
in burning tongue sensation, sleep interruptions, and water intake.
    This device is indicated for use in patients with xerostomia 
secondary to Sjogren's syndrome and intended to stimulate salivary 
production from existing glandular tissue. Patients who show an 
initial response to electrostimulation are considered to be 
candidates for this therapy. According to the FDA there are no 
contraindications associated with the use of this device.

Medical Specialty and Clinician Responses

    Medical specialty groups such as The American Dental Association 
were unable to provide any information regarding the 
electrostimulation of salivary glands.
    Comments from clinicians with knowledge of or experience with 
electrical stimulation of salivary production are equivocal. Some 
expressed the opinion that electrostimulation is a safe and 
effective method for the treatment of xerostomia secondary to 
Sjogren's syndrome. Others suggested that the method has been 
inadequately tested. Some clinicians recommended beginning 
electrical stimulation of the salivary glands in patients with 
Sjogren's syndrome and dry mouth early in the course of the disease 
in order to possibly prevent, modify, or even reverse the 
progression of a salivary gland atrophy. Other clinicians are not 
convinced that electrostimulation is more effective than other 
simple, less costly stimulation techniques such as gustatory 
stimulation or intraoral tactile stimulation.

Summary

    Electrostimulation has been introduced as a technique for 
increasing salivary output in the treatment of patients with 
xerostomia (dry mouth) secondary to Sjogren's syndrome. The 
procedure uses an electrostimulation device (salivation 
electrostimulator) to increase salivary production from existing 
glandular tissue. The device delivers a low-voltage electrical 
stimulus to the mouth via a probe. Patients with residual salivary 
tissue in the oral and pharyngeal regions who demonstrate a decrease 
in the flow rate of saliva are potential candidates for this 
procedure.
    It is estimated that more than one million people in the United 
States, predominantly middle-aged and elderly women, suffer from 
Sjogren's syndrome. Patients with chronic xerostomia complain of a 
continual feeling of oral dryness and have difficulty eating dry 
foods. These patients are susceptible to increased caries, oral 
pain, infection, and have difficulty speaking, chewing, and 
swallowing.
    The approach to the treatment of xerostomia in Sjogren's 
patients is usually determined by the level of severity of the 
symptoms. Appropriate management of patients with xerostomia 
requires that those patients whose salivary flow can be increased by 
means of sialagogues be distinguished from those patients whose 
salivary flow is either unaffected or insufficiently stimulated. To 
alleviate some of the complications due to salivary dysfunction in 
those patients who respond to stimuli, pharmocologic sialagogues as 
well as sialagogues that include sugarless gums, mints and candies 
are prescribed in order to increase salivary flow.
    Recently, electrostimulation via a hand-held stimulus probe has 
been introduced as a method of treatment in xerostomia secondary to 
Sjogren's syndrome. From the single published study as well as data 
provided to the FDA, it appears that an electrical stimulus applied 
to the tongue and hard palate (by a battery-operated device) may be 
useful in the management of salivary hypofunction in certain 
patients. It appears, however, that there are insufficient data at 
the present time to determine the clinical utility of 
electrostimulation, to evaluate the long-term clinical effectiveness 
of this modality of salivary production, or to identify those 
xerostomic patients who would benefit from this procedure. Also, 
electrostimulation is not widely accepted as an effective method of 
treatment for xerostomia secondary to Sjogren's syndrome. The number 
of published studies is limited and other less expensive treatments 
are available. Further research of electrical stimulation of 
salivary flow is required to determine its role in the treatment of 
Sjogren's patients with xerostomia.

References

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2. Peterson JK. Xerostomia. Scand J. Rheumatol 1986;61(suppl):185--
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flow in patients with Sjogren's syndrome. J Dent Res. 
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4. Fox PC, Baum BJ, Mandel ID. Pilocarpine for the treatmnt of 
xerostomia associated with salivary gland dysfunction. Oral Surg 
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13. Talal N. Overview of Sjogren's syndrome. J Dent Res 
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14. Vissink A, Johannes's-Gravenmade E, Panders AK, et al. Treatment 
of Hyposalivation. Ear Nose Throat J 1988;67:179--185.
15. Levine MJ, Aquirre A, Hatton MN, et al. Artificial salivas: 
Present and future. J Dent Res 1987;66:693--698.
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Dent J 1987;54(5):23--24.
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Effectiveness Data: Salivation Electro-Stimulation Device, 
(unpublished report), 1988.

[FR Doc. 94-12457 Filed 5-20-94; 8:45 am]
BILLING CODE 4121-01-P