The results of this study show that the frequency of ER admissions due to acute sialadenitis significantly increased during Ramadan compared to non-Ramadan months over a multi-year analysis. Although, the authors were not able to find any previous report associating Ramadan and salivary gland disorders, these results correspond with the known connection between acute sialadenitis and dehydration.
In most cases, acute sialadenitis affects one major salivary gland, with the parotid being the most prevalent,[13–15] and the prevalence of acute sialadenitis increases in medically compromised, hospitalized, or postoperative patients. However, in this study the prevalence of parotitis was lower than that of submandibular sialadenitis during Ramadan. This trend in prevalence was present in a few previous reports; however, it is 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 acute sialadenitis is retrograde bacterial contamination from the oral cavity.[15, 21] Predisposing factors for the ductally ascending infection are dehydration, xerogenic drugs and salivary gland diseases associated with ductal obstructions or reduced saliva secretion.[12, 22] Other factors include hypothyroidism, renal failure, HIV, diabetes mellitus and Sjögren syndrome.
As previously mentioned, patients suffering from acute sialadenitis present pain and swelling of the affected gland, which may be accompanied by the expression of pus from the respective intraoral orifice, requiring antibiotic therapy directed by culture of the pus.
The management of the condition involves treating the infection and reversing the underlying medical condition and predisposing factors.[12, 19] Salivary flow stimulation by hydration is highly important, as well as the application of warm compresses, salivary gland massage, the administration of sialagogues such as lemon drops or vitamin C lozenges and oral hygiene. [23–25] The recommended initial empiric antimicrobial therapy is directed at gram-positive (most commonly Staphylococcus aureus)[26–28] and anaerobic organisms with the use of augmented penicillin that contains beta-lactamase inhibitors (e.g., amoxicillin-clavulanate) to help in the treatment of penicillin-resistant bacteria.[19, 26–28] Other options include clindamycin, cefoxitin, imipenem, and the combination of metronidazole and a macrolide. Culture-directed therapy is also possibly administered. Rarely, acute suppurative sialadenitis can lead to abscess formation; in those cases, surgical drainage is indicated. Rarely, acute suppurative sialadenitis can lead to abscess formation; in those cases, surgical drainage is indicated.
The significant difference in the BUN/creatinine ratio between Ramadan and non-Ramadan sialadenitis patients and the fact that Ramadan sialadenitis patients presented dehydration hint that there is an association between fasting and an increased risk for acute sialadenitis. It is important to mention that the BUN/creatinine ratio is considered abnormal at a value >20:1; however, the difference between the groups is important and significant and shows that the study group was less hydrated than the control group.
The analysis of leukocyte count uncovered an interesting phenomenon; both groups presented normal leukocyte counts (although that of the Ramadan sialadenitis group was slightly higher) that were “left shifted”, suggesting a bacterial infection. The Ramadan sialadenitis group seemed to have the more serious condition, created by dehydration. This finding is also supported by a systematic review showing that patients suffering from any condition that heightens the risk of the development of 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 an increase in the incidence of acute sialadenitis.
We suggest that physicians should also consider the patient’s eagerness, since religion fosters positive psychosocial outcomes and reinforces treatment adherence and compliance in Muslim patients.[1, 29]
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 a few limitations. First, 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). Second, with this study design, it is difficult to establish causality; rather, only any association between Ramadan and sialadenitis incidence can be determined. Finally, it will be useful to investigate a larger sample over a longer period in order to strengthen the findings in this study.