The results of this study show that the frequency of ER admissions due to sialadenitis significantly increases during Ramadan compared to non-Ramadan months over a multi-year analysis. Although, the authors were not able to find any previous report connecting Ramadan and salivary gland disorders, these results correspond with the known connection between sialadenitis and dehydration.
Usually, acute sialadenitis affects one major salivary gland, the most prevalent being the parotid, and is common in medically compromised, hospitalized, or postoperative patients. However, in this study the prevalence of Parotitis in lower than Sub-Mandibular Sialadenitis during Ramadan. It is however difficult to draw conclusions from this observed trend since the study group is small and the differences here were not statistically significant.
Another inciting etiology of sialadenitis is retrograde bacterial contamination from the oral cavity. Predisposing factors for the ductally ascending infection are dehydration, xerogenic drugs and salivary gland diseases associated with ductal obstructions or reduced saliva secretion.[12, 17] Other factors include hypothyroidism, renal failure, diabetes mellitus and Sjögren syndrome. Salivary flow may also be reduced due to use of certain medications, especially those with anticholinergic properties.
Patients suffering from acute sialadenitis present rapid onset of pain and swelling of the affected gland. Physical examination may reveal edema, induration and extreme localized tenderness. Pressure on the gland may express pus from the respective intraoral orifice, requiring antibiotic therapy directed by pus culture.
Management of the condition involves treating the infection and reversing the underlying medical condition and predisposing factors. Salivary flow stimulation by hydration is highly important, as well as application of warm compresses, salivary gland massage, administration of sialagogues such as lemon drops or vitamin C lozenges and oral hygiene.[18, 19] The recommended initial empiric antimicrobial therapy is directed at gram-positive and anaerobic organisms by augmented penicillin that contains beta-lactamase inhibitors (e.g., amoxicillin-clavulanate [Augmentin]) helping treating penicillin-resistant bacteria. Possibly, culture-directed therapy is administered. Rarely, acute suppurative sialadenitis can lead to abscess formation; in those cases, surgical drainage is indicated.
The significant difference in BUN/Creatinine ratio and the fact that Ramadan patients presented dehydration hints that there is a connection between fasting and increased risk for sialadenitis.
Analysis of Leukocyte count uncovered an interesting phenomenon; both groups presented normal Leukocyte counts, although that of the Ramadan group was slightly higher, that were “left shifted”, suggesting a bacterial infection. The Ramadan group seems to have the more serious condition, created by dehydration. This finding is also supported by systematic review showing that patients suffering from any condition that heighten the risk of developing infectious complications should not fast.
These results of this study support our hypothesis and, assuming all other predisposing factors stay the same year-round, we conclude that there may be causality between Ramadan fasting (and subsequent dehydration) and increase in incidence of sialadenitis.
We appreciate that physicians should also take into account the patient’s eagerness, since religion fosters positive psychosocial outcomes and reinforces treatment adherence and compliance in Muslim patients.[1, 20]
Thus, in the case of no medical restriction, fasting should not be discouraged in Muslim patients who are enthusiastic about Ramadan fasting. Physicians should be aware of this risk and patients should be instructed to recognize some warning symptoms.
This study has few limitations: First of all, it is a retrospective study, thus it was assumed that all of the patients were fasting during the month of Ramadan, but this was not confirmed. It will be useful to conduct a prospective study with documented fasting status (if ethically possible). Secondly, it is a cross-sectional study, and thus it is difficult to establish causality, but rather only to look for any association between Ramadan and sialadenitis incidence. Finally, it will be useful to investigate a larger sample over a longer period in order to strengthen the findings in this study.