Radiation-Induced Xerostomia and Cariogenic Dietary Habits

doi:10.21203/rs.3.rs-1963160/v1

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Radiation-Induced Xerostomia and Cariogenic Dietary Habits

https://doi.org/10.21203/rs.3.rs-1963160/v1

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Journal Publication

published 09 Jan, 2024

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Purpose

Despite the availability of various prevention methods, dental caries continues to be an adverse effect of head and neck radiotherapy (RT). Since conventional approaches do not evaluate the post-treatment alterations in dietary behavior, we assessed the influence of radiation-induced xerostomia on post-RT cariogenic dietary habits.

Methods

Fifty-seven patients responded to the xerostomia questionnaire (XQ) and answered questions regarding daily cariogenic food and beverage (CFB) intake, daily teeth brushing, fluoride application, and subjective total taste acuity (STTA). They also underwent evaluations for the Simplified Oral Hygiene Index (OHI-S), Saxon test, number of decayed-missing-filled teeth (DMFT), and the proportion of DMFT to the test teeth (DMFT rate). Clinical records were searched for information regarding RT modalities, including the median of the mean dose to the parotid glands, post-RT duration, submandibular gland resection, whole-neck irradiation, and the DMFT value and rate before RT. The patients were divided into low- and high-XQ groups based on the median XQ summary score of 47.5 for the two sample tests. Univariable and multivariable regression analyses were used to identify independent factors for CFB intake.

Results

Higher XQ scores were associated with a significantly greater frequency of CFB intake (P=0.020). Regression analysis also identified higher XQ scores (P=0.017) as an independent risk factor for frequent CFB intake.

Conclusion

Radiation-induced xerostomia enhanced CFB intake for oral comfort. Therefore, radiation caries management should target xerostomia-induced dietary habits in addition to oral hygiene and fluoride application.

Xerostomia

Head and Neck Cancer

Radiotherapy

Dental Caries

Dietary Habits

Cariogenic

Radiotherapy (RT), with or without chemotherapy, is a standard treatment for head and neck cancer (HNC). RT enables laryngeal preservation in addition to facilitating postoperative adjuvant therapy in locally advanced patients with HNC. However, it often causes various oral complications during and after treatment, which have a considerable impact on the patients' quality of life (QOL). Acute adverse events include oral mucositis, xerostomia, or dysgeusia, which may persist for years. In addition, late adverse effects include xerostomia, taste disturbances, dental caries, soft-tissue necrosis, and post-radiation osteonecrosis of the jaw [1]. In particular, radiation-induced dental caries, also known as radiation caries, often presents as rampant caries with detrimental effects on the QOL [2]. Despite the severe effects of radiation caries, a successful management strategy for this condition has not been identified, as evidenced by the highest caries index in patients with HNC among all cancer patients [3].

Dental caries is known to have a multifactorial etiology, with a combination of four major factors: 1) host saliva and teeth; 2) cariogenic microflora; 3) substrate or diet; and 4) the exposure time for which the substrate remains in the mouth or frequency of dietary intake [4, 5]. RT has an enormous impact on these risk factors and can cause direct damage to the salivary glands and teeth structure of the host. First, salivary gland dysfunction is a significant cause of dental caries [2]. Alterations in the salivary ionic composition [6] enable easy de-mineralization of teeth by compromising the salivary buffer activity and the re-mineralization capacity of teeth [1]. RT also affects the mineral structure of teeth [7] or activates proteases to decompose teeth structure [8]. Since fluoride supplementation can reduce the influence of host factors by reducing the de-mineralization of enamel, promoting re-mineralization of early enamel caries, and inhibiting bacterial activity in dental plaque [9], the Multinational Association of Supportive Care in Cancer (MASCC) suggests fluoride application for radiation caries prevention [10]. Second, with respect to the bacterial factors, the decreased salivary flow rates resulting from RT allow the proliferation of cariogenic bacterial populations in the saliva [11] or induce changes in the oral bacterial flora [12]. Thus, MASCC recommends that the maintenance of oral hygiene is vital to minimize bacterial risk [10]. Third, although studies on the relationship between substrates and radiation caries are limited, recent studies imply that a diet predominated by soft and carbohydrate-rich foods can affect radiation caries [11, 13]. MASCC has recommended that patients who undergo RT should receive instructions for an appropriate diet [10]. The fourth factor, which refers to the exposure time for which the substrate remains in the mouth or the frequency of dietary intake, has received the least attention for the prevention of radiation caries. However, between-meal habits are well known to be associated with the development of dental caries [14], and general caries-prevention guidelines from the World Health Organization (WHO) recommend limiting sugar intake to a maximum of four times per day [15]. The ecological plaque hypothesis further illustrates that frequent intake of fermentable sugar causes acidic environmental shifts that are more advantageous for the proliferation of cariogenic bacteria [16]. Nevertheless, conventional radiation caries management has not focused on the relationship between exposure time and dental caries.

From a cariogenic perspective, patients with HNC undergoing RT are regularly exposed to cariogenic food and beverage (CFB) intake. Some QOL studies [17, 18] have shown that these patients often need candies or beverages to relieve the radiation-induced xerostomia. Although Dreizen et al. [19] described that sugar-sweetened food restriction does not have a statistically significant effect on radiation caries prevention, they did not consider the influence of dietary or beverage intake frequency.

Thus, we hypothesized that the high incidence of radiation caries under conventional management is linked to the exposure time or frequency of CFBs. To address this point, this study aimed to investigate the influence of radiation-induced xerostomia on cariogenic dietary frequency.

Eligibility

From March to July 2015, patients with HNC who underwent RT were eligible if they: (1) received radical RT with or without chemotherapy at Shizuoka Cancer Center; (2) were within 20 – 80 years; (3) had an Eastern Cooperative Oncology Group Performance Status ≤1; (4) had not shown any relapse for at least six months after completing RT; and (5) provided signed informed consent to participate in this study. We excluded patients if they had: (1) no teeth, (2) difficulty chewing and swallowing, (3) other causes of xerostomia, such as Sjögren's syndrome, and (4) tooth hypoplasia.

Primary endpoint

The primary endpoint was the difference in the frequency of CFB intake within a day between the groups with severe and less-severe radiation-induced xerostomia. People may consume sugar not only during meals but also through snacks. Snacks are more important in caries development because we rarely perform oral care after a snack. Thus, we divided the day into seven periods for sugar consumption. We asked the patients how many times they usually consumed food and beverages (Table 1) within the following periods: (1) late night (consuming snacks or drinks on waking up in the middle of the night owing to dry mouth), (2) at breakfast (consuming meal and drinks), (3) after breakfast (consuming snacks or drinks), (4) at lunch (consuming meal and drinks), (5) after lunch (consuming snacks or drinks), (6) at dinner (consuming meal and drinks), and (7) after dinner (consuming snacks or drinks). The sum of the frequencies at all periods was defined as the daily frequency of CFB intake for each patient. Xerostomia was assessed using xerostomia questionnaire (XQ) summary scores [20]. Patients were divided into low-XQ and high-XQ groups based on the median XQ summary scores. The frequency of CFB intake was surveyed using a questionnaire in which CFBs and non-CFBs were listed without information on their cariogenicity.

The XQ consists of eight questions: four items assess dryness while eating/speaking, and four items assess dryness while eating. Patients rated each question using an 11-point ordinal Likert scale from 0 to 10. The total score ranged from 0 to 80 points, and higher scores indicated more severe symptoms. When analyzing XQ scores, the total score was multiplied by 1.25 to produce a ﬁnal summary score ranging between 0 and 100 [20].

Definitions of CFB and non-CFB

Foods

We selected a number of food items that we considered to be preferred by xerostomia patients (Table 1). The foods were categorized as cariogenic or non-cariogenic based on the cariogenic potential index (CPI) [21, 22]. The CPI is designed to measure cariogenicity by analyzing four factors: plaque-forming ability, acid-performing ability, ingestion time, and clearance time. Based on CPI, the following foods were defined as cariogenic: caramel (CPI=80), candy (CPI=60), sugar-sweetened chewing gum (CPI=50), and chocolate (CPI=40). A thick liquid diet was not included in this study because it was considered to be consumed for a nutritional need rather than for oral comfort. Among non-cariogenic foods, ice cream (CPI=12), rice crackers (CPI=12), and xylitol chewing gum were chosen. Xylitol chewing gum was added since its caries-prevention ability has been validated in a recent study [23].

Beverages

Among commercial beverages, carbonated juices, fruits or vegetable juices, and sports drinks show cariogenic potential, while bottled water, tea without sugar, and milk have been shown to be non-cariogenic in analyses based on pH and adhesive soluble glucan products [24]. We defined cariogenic beverages as follows: carbonated juice, fruit or vegetable juices, sports drinks, and tea/coffee with sugar. Water, green tea, and milk were chosen as non-cariogenic beverages. Green tea was included considering its relevance to the Japanese cultural background.

Secondary endpoints

Secondary endpoints were as follows: (1) dental caries status, (2) oral hygiene status, (3) other factors related to radiation-induced xerostomia, and (4) independent factors for frequent CFB intake. The following variables were observed for these endpoints: (1) the number of decayed-missing-filled teeth (DMFT value) [25] and the proportion of the DMFT value to test teeth before and after RT (DMFT rate); (2) Simplified Oral Hygiene Index (OHI-S) [26], daily tooth-brushing frequency, including the use of fluoride toothpaste and professional fluoride application; (3) Saxon test for objective saliva flow rates [27], subjective total taste acuity (STTA) [28, 29], history of whole-neck irradiation, radiation modalities, the median of the mean radiation dose to the parotid glands on the tumor side and contralateral side, submandibular gland resection, and post-RT duration; and (4) a total of nine variables, including patient characteristics and other factors, that were considered to promote frequent CFB intake. When the tumor side could not be distinguished, such as in ethmoid sinus, nasal cavity, or nasopharynx cancer, the average radiation dose of the left and right parotid glands was assumed as the dose for both the tumor and the contralateral side. The DMFT value is the sum of decayed, missing, and filled teeth, often described as the DMFT index. Although previous studies have offered differing opinions regarding whether the mean or median is the representative value [30, 31], our study defined the median as the representative value. The DMFT rate was calculated as the DMFT value divided by 28, the number of test teeth. We did not include wisdom teeth while evaluating the DMFT value, in accordance with the website of Malmö University Oral Health Country/Area Profile Project (https://ccarobonapp.mau.se/methods-and-indices/).

Statistical analysis

Wilcoxon's rank-sum test was used to compare continuous variables between the low- and high-XQ groups. Fisher's exact test was used for categorical variables. For the frequency of CFB and non-CFB, the comparisons between low- and high-XQ groups were tested, and both were treated as continuous and categorical data to clear their distributions. The frequencies of CFB and non-CFB were divided into 3 categories (0, 1 and 2 or more). Univariable and multivariable regression analyses were used to assess the association with CFB intake frequency. To determine their clinical importance, nine variables thought to be relevant to CFB intake were analyzed. A negative binomial model was applied to the count data of CFB intake frequency. Risk factors were examined in the multivariable regression analysis using variables with P-values of <0.05 in the univariable regression. All statistical analyses were performed using R version 4.0.3 (R Foundation for Statistical Computing, Vienna, Austria). P values <0.05 were considered statistically significant.

Patient characteristics

A total of 57 patients participated in this study. The main characteristics are listed in Table 2. The majority of the patients were male (n=45, 78.9%) who received treatment for oral cavity or oropharynx cancer (n=30, 52.6%), underwent RT with chemotherapy (n=37, 56%) and received conventional RT (n=47, 82.5%). The median of the mean dose to the parotid glands on the tumor side and contralateral side was 42.3 and 31.9 Gy, respectively. The median post-RT duration was 883 days. Submandibular gland resection was performed in 42.1% of the patients. More than half of the patients underwent whole-neck irradiation (n=29, 50.9%). There was a significant difference in the proportion of patients who underwent whole-neck irradiation between the low- and high-XQ groups (P=0.008).

Frequency of CFB intake

The high-XQ group showed a significantly higher frequency of CFB intake throughout the day (P=0.028) and after lunch (P=0.008). There were no significant intergroup differences in CFB intake at the various time points (i.e., late night, at breakfast, after breakfast, at lunch, after lunch, at dinner, and after dinner). There were no significant differences in non-CFB intake at any time point. Overall, the median daily frequency of CFB intake was 1 (0–18), and that of non-CFB intake was 9 (0–47). Most instances of CFB intake took place after lunch, followed by after breakfast and after dinner. The high-XQ group showed a greater frequency of CFB intake at all time points except at dinner (Figure 1). When we treated CFB and non-CFB as categorical variables, the results were comparable to those of continuous variables. Detailed data on frequency distributions are presented in Table S1 (Online Resource 1).

Dental caries, oral hygiene, and other factors related to xerostomia

Significant intergroup differences were observed in the XQ summary scores (P<0.001), Saxon test (P=0.012), and STTA (P=0.002). The overall medians and ranges were as follows: XQ summary score, 47.5 (0–95); Saxon test, 0.71 g (0.03–4.77 g); and STTA, 1 (0–4). The DMFT value and DMFT rate before and after RT showed no significant differences. The overall dental caries status was as follows: the median DMFT values before and after RT were 15 (0–28) and 19 (0–28), respectively; the median DMFT rates before and after RT were 53.6% and 67.9%, respectively; and the median increment in DMFT values was 1 (0–18).

The two groups showed no significant differences in oral hygiene. The overall median OHI-S was 0.66 (0–2.33); the median frequency of tooth brushing was three times a day (1–4); fluoride toothpaste was used in 33 patients (57.9%); professional fluoride application was performed in 47 patients (82.5%).

Univariable and multivariable regression analyses

The univariable regression analysis of the negative binomial model showed that the high-XQ score was statistically significant (relative risk, 2.31; 95% confidence interval (CI), 1.17–5.05; P=0.017) and associated with the increment of CFB frequency. These results also indicated that there were no other risk factors, and thus a multivariable analysis could not be performed.

Key result

This study revealed that radiation-induced xerostomia increased the frequency of cariogenic dietary intake. As a patient-reported outcome, this finding provides new insights for radiation caries prevention.

Incentives for frequent CFB intake

The results illustrated two factors influencing frequent CFB intake in the patients: 1) radiation-induced xerostomia and 2) the interval between lunch and dinner. First, severe xerostomia increased the need for oral comfort. The possible reasons for selecting CFBs for oral comfort include patients' inability to distinguish between CFBs and non-CFBs and taste disturbances. As reported by Maes et al., the perception of sweetness was the earliest-improving gustation after RT [32], and there was a significant difference in STTA between the low- and high-XQ groups in this study. Second, the duration after lunch until before dinner usually involves mixed motives, including the need for oral comfort and teatime snacks, leading to frequent CFB intake. Patients are often engaged in daytime activities during this interval and require oral comfort, and the habit of consuming teatime snacks provided an additional cause for CFB intake in this interval. However, the need for oral comfort had a notable effect on CFB intake. Although patients in both groups showed a regular between-meal eating habit, with a moderate increase at every interval between meals (Figure 1), the high-XQ group always showed more frequent CFB intake and a significant difference in snack consumption after lunch.

Validity of our definitions for CFBs

Our definitions of CFBs were based on Japanese studies [21, 24] and were also consistent with the evaluations performed in other international studies on cariogenicity. Cariogenicity has been reported in sugar-sweetened chewing gum [33], chocolate [34, 35], candies [33], caramel [33], carbonated juices [33, 36–38], sports drinks [37], fruit or vegetable juices [33, 36], and coffee or tea with sugar [33, 34]. However, milk [35, 36, 39, 40] and tea without sugar [40] were shown to be non-cariogenic. Classifying ice cream as non-CFB may be controversial since some studies regard it as cariogenic [33–35]. Likewise, one study also considered fruit juice as non-cariogenic [35]

High morbidity in dental caries under conventional management

Even though oral hygiene was performed well; the median daily teeth-brushing times illustrated good self-caring, and regular fluoride application was almost appropriate; this study demonstrated a high overall incidence of xerostomia and radiation caries, as the median post-RT DMFT value of 19.0 exceeded the value (17.01) in a previous report [3], while the median XQ summary score of 47.5 was higher than the approximate value of 40 at 12–18 months after RT in another study [20]. Moreover, the median salivary flow rate of 0.71 g in the Saxon test was markedly below the reference value for xerostomia diagnosis [27].

These results indicated that the conventional strategy for radiation caries management mainly focused on oral hygiene and topical fluoride application while inadequately targeting the cariogenic factors related to the host and the bacteria. We suggest that time-related factors, such as the frequency of CFB intake, should receive greater attention.

Limitations

The limitations of this study were as follows: there may have been selection bias in the types of CFB, the DMFT value was not an exact measure for radiation caries, and the dental caries occurrence was statistically tested in a sample population with high morbidity.

Patients may have had other CFBs, such as jellies, that were not chosen in our questionnaire because we limited the volume of questionnaires to save time for dental practice surveys. The nature of the DMFT value may have resulted in no significant differences in dental caries morbidity between the low- and high-XQ groups. According to the website of Malmö University, if a tooth has both caries lesion and filling, it is considered as only decayed but not both filled and decayed. Hence, the maximum DMFT score in every single tooth cannot exceed 1, even if the tooth repeatedly experienced tooth decay, which could have underestimated the number of caries relapses. Another possible reason for the lack of a significant difference in the morbidity of dental caries could be the overall high incidence of xerostomia and dental caries. Compared with healthy controls, we could have shown a significant relationship between xerostomia and dental caries.

Suggestions for radiation caries management

Future programs for radiation caries management should consider taking substrates and their durations into account, specifically the frequency of CFB intake. Since dietary habits depend on patients' self-control, imparting oral health education to patients is essential to help them choose tooth-friendly oral-comforting foods. Patient education should include appropriate knowledge to avoid CFBs for oral comfort, limit CFBs for snacks, and adopt preventive methods after CFB intake. These methods also need to be recognized by a multi-disciplinary team that includes nutritional management.

Patients should be advised to check packages' labels so as to stay off fermentable carbohydrates and acids. Fermentable carbohydrates include sugar and free sugars of monosaccharides and disaccharides such as sucrose, glucose, fructose, lactose, maltose, and starch added to foods and beverages [41]. Fermentable carbohydrates allow oral bacteria in dental plaque to form organic acids, which can cause de-mineralization at a critical pH of 5.5 [15]. Sugar-sweetened foods with stickiness, such as caramel, are the most cariogenic due to their adhesiveness to teeth [22]; hence, they should be avoided as much as possible. If patients want sweetness for oral comfort, alternative sweeteners such as xylitol gum or candies should be recommended. Although we encountered some patients who had difficulty chewing gum due to severe xerostomia, Kaae et al. reported that chewing gum increased saliva flow in patients with HNC via physical or mechanical saliva stimulation [42].

Moreover, one study showed that de-mineralization occurs more easily in dentin with a higher critical pH of 6.5 than in enamel with a critical pH of 5.5 [38]. The higher critical pH of dentin should be noted for older patients who tend to have gingival recession [12, 38]. Similarly, acidity in PET-bottled beverages also needs to be considered, even if they are not sugar-sweetened, since they have a low pH because of the presence of carbonic acid, phosphoric acid, or citric acid [38].

Even if CFB intake for xerostomia palliation could be controlled, CFBs are sometimes necessary for nutritional purposes, and some patients may want to enjoy snacks. Oral hygiene or rinsing of the mouth may be necessary after intake of nutritional aid such as a thick liquid diet. To limit the frequency of CFBs as snacks, we may refer to the WHO guideline for sugar intake, that is, a maximum of four times per day [15]. However, specific guidelines for sugar intake in patients with radiation-induced xerostomia will be considered in future studies.

This study revealed that radiation-induced xerostomia triggered the frequent intake of CFBs for oral comfort. Salivary gland dysfunction poses a caries risk not only by directly affecting the teeth but also by indirectly promoting cariogenic dietary habits. In addition to oral hygiene and fluoride application, radiation caries management should target the cariogenic dietary habits acquired due to xerostomia.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Conflict of interest

All authors have no conflict of interest.

Ethical approval

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and its later amendments. This study was approved by the institutional review board of Shizuoka Cancer Center (T26-61-26-1).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent for publication

The participants have consented to the submission of the report to the journal.

Availability of data and material

The data that support the findings of this study are available from the corresponding author, T. Yurikusa, upon reasonable request.

Code availability

Not applicable

Authors' contributions

Conceptualization: Miho Kawashima, Takanori Kawabata, Keita Mori, and Takashi Yurikusa; Methodology: Miho Kawashima, Takanori Kawabata, Keita Mori, and Takashi Yurikusa; Data collection: Miho Kawashima, Chikako Ando, Megumi Sakuma, Hirofumi Ogawa, Tetsuo Nishimura, and Takashi Yurikusa; Formal analysis and investigation: Takanori Kawabata and Keita Mori; Writing - original draft preparation: Miho Kawashima, Takanori Kawabata and Takashi Yurikusa; Writing - review and editing: Takashi Aoyama, Hirofumi Ogawa, Tomoya Yokota, Yusuke Onozawa, Takashi Mukaigawa, Tetsuo Nishimura and Keita Mori; Supervision: Takashi Yurikusa.

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Table 1. Definitions of CFB and non-CFB

	Foods	Beverages
Cariogenic
	Caramel	Carbonated juice
	Candy	Fruit or vegetable juice
	Sugar-sweetened chewing gum	Sports drink
	Chocolate	Coffee or tea with sugar
Non-cariogenic
	Ice cream	Bottled water
	Rice cracker	Green tea
	Xylitol chewing gum	Milk

CFB, Cariogenic food and beverage; non-CFB, non-cariogenic food and beverage

Table 2. Patient characteristics

	Overall n = 57	Low XQ score n = 26 (45.6%)	High XQ score n = 31 (54.4%)	P-value
Age (years)	65 (25–80)	64 (29–76)	65 (29–78)	0.784
Sex	65 (25–80)	64 (29–76)	65 (29–78)	0.755
Male	45 (78.9%)	20 (76.9%)	25 (80.6%)
Female	12 (21.1%)	6 (23.1%)	6 (19.4%)
Tumor site
Maxillary/ethmoid sinus, nasal Cavity, or nasopharynx	17 (29.8%)	9 (34.6%)	8 (25.8%)	0.240
Maxillary/ethmoid sinus, nasal Cavity, or nasopharynx
Oral cavity or oropharynx	30 (52.6%)	12 (46.2%)	18 (58.1%)
Hypopharynx or larynx	5 (8.8%)	1 (3.8%)	4 (12.9%)
Parotid or submandibular gland	5 (8.8%)	4 (15.4%)	1 (3.2%)
Radiation modality				0.486
Conventional RT	47 (82.5%)	20 (76.9%)	27 (87.1%)
IMRT	10 (17.5%)	6 (23.1%)	4 (12.9%)
Median of the mean dose to the parotid glands (Gy)
Tumor side	42.3(5.21–68.4)	40.41 (5.2–64.4)	43.4 (14.6–68.4)	0.130
Contralateral side	31.9 (0.3–66.5)	12.56 (0.32–51.97)	38.3 (1.16–66.53)	0.069
Post-radiation duration (days)	863 (192–4141)	769 (192–4141)	863 (237–3999)	0.753
Submandibular gland resection	2 (42.1%)	12 (46.2%)	12 (38.7%)	0.601
Concomitant chemotherapy	37 (64.9%)	15 (57.7%)	22 (71.0%)	0.405
RT as adjuvant therapy	28 (49.1%)	15 (57.7%)	13 (41.9%)	0.292
Whole-neck irradiation	29 (50.9%)	8 (30.8%)	21 (67.7%)	0.008^*

^*P-value < 0.05

IMRT, intensity modulated radiation therapy; RT, radiotherapy

Table 3. Frequency of CFB and non-CFB intake

	Overall	Low XQ score (XQ < 47.5)	High XQ score (XQ ≥ 47.5)	P-value
CFB
Total in a day	1 (0–18)	0.5 (0–8)	2 (0–18)	0.028^*
Late night	0 (0–4)	0 (0–0)	0 (0–4)	1.000
At breakfast	0 (0–2)	0 (0–1)	0 (0–2)	0.581
After breakfast	0 (0–6)	0 (0–3)	0 (0–6)	0.643
At lunch	1 (0–2)	0 (0–1)	0 (0–2)	0.639
After lunch	0 (0–12)	0 (0–3)	1 (0–12)	0.008^*
At dinner	0 (0–4)	0 (0–4)	0 (0–1)	1.000
After dinner	0 (0–6)	0 (0–1)	0 (0–6)	0.529
Non-CFB
Total in a day	9 (0–47)	7 (0–30)	9 (0–47)	0.438
Late night	0 (0–4)	0 (0–2)	0 (0–4)	0.948
At breakfast	1 (0–10)	2 (0–3)	1 (0–10)	0.884
After breakfast	1 (0–15)	1 (0–8)	1 (0–15)	0.251
At lunch	1 (0–10)	1 (0–3)	1 (0–10)	0.600
After lunch	2 (0–15)	2 (0–8)	2 (0–15)	0.445
At dinner	1 (0–3)	1 (0–3)	1 (0–3)	0.389
After dinner	1 (0–15)	1 (0–9)	1 (0–15)	0.951

^*P-value < 0.05

CFB, cariogenic food and beverage; XQ, xerostomia questionnaire

Table 4. Dental caries, oral hygiene status, and other factors related to xerostomia

	Overall n = 57	Low XQ score n = 26 (45.6%)	High XQ score n = 31 (54.4%)	P-value
XQ summary score	47.5 (0–95)	11.25 (0–46.25)	65 (47.5–95)	<0.001^*
Saxon test (g)	0.71 (0.03–4.77)	0.81 (0.12–4.77)	0.57 (0.03–2.63)	0.028^*
STTA	1 (0–4)	1 (0–2)	1 (0–4)	0.001^*
Daily frequency of tooth brushing	3 (1–4)	3 (1–4)	3 (1–4)	0.270
OHI-S	0.66 (0–2.33)	0.66 (0–1.66)	0.5 (0–2.33)	0.445
Use of fluoride toothpaste	33 (57.9%)	12 (46.2%)	21 (67.7%)	0.711
Topical fluoride application	47 (82.5%)	21 (80.8%)	25 (80.6%)	1.000
DMFT value
before RT	15 (0–28)	14 (0–28)	15 (0–28)	0.986
after RT	19 (0–28)	17 (3–28)	22 (0–28)	0.244
DMFT rate
before RT	53.6% (0–100%)	50.0% (0–100%)	53.6% (0–100%)	0.990
after RT	67.9% (0–100%)	60.7% (11–100%)	78.6% (0–100%)	0.248
Increment of
DMFT value	1 (0–18)	1 (0–13)	1 (0–18)	0.270
DMFT rate	3.6% (0–64%)	3.6% (0–46.4%)	3.6% (0–64.3%)	0.286

^*P-value < 0.05

DMFT, decayed-missing-filled teeth; OHI-S, Simplified Oral Hygiene Index; RT, radiotherapy; STTA, subjective total taste acuity; XQ, xerostomia questionnaire

Table 5. Negative binomial regression for frequent CFB intake

	Univariable analysis
	RR	95% CI	P-value
Age	1.00	0.97–1.03	0.874
Sex
Male	Ref
Female	2.31	0.97–5.44	0.054
XQ
Low XQ score	Ref
High XQ score	2.43	1.17–5.05	0.017^*
STTA	1.11	0.78–1.60	0.559
Saxon test (g)	1.19	0.76–1.88	0.440
Whole-neck RT	0.82	0.39–1.75	0.614
Mean dose to parotid gland (Gy)
Tumor side	1.00	0.97–1.02	0.730
Contralateral side	1.00	0.97–1.01	0.338
Tumor site
Hypopharynx or Larynx	Ref
Oral cavity or Oropharynx	1.69	0.42–6.75	0.461
Maxillary/ ethmoid sinus, nasal cavity, or nasopharynx	1.54	0.36–6.60	0.564
Parotid or submandibular gland	0.56	0.08–3.80	0.550
Post-radiation durations	1.00	1.00–1.00	0.634

CFB, cariogenic food and beverage; CI, confidence interval; Ref: reference category (RR=1.00); RR, relative risk; RT, radiotherapy; XQ, xerostomia questionnaire

^*P<0.05

No competing interests reported.

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Radiation-Induced Xerostomia and Cariogenic Dietary Habits

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