Using the modified schirmer test to measure mouth / dental implant courses

USING THE MODIFIED
SCHIRMER TEST TO
MEASURE MOUTH
DRYNESS
INDIAN DENTAL ACADEMY
Leader in continuing Dental
Education
www.indiandentalacademy.com

INTRODUCTION
• ‘Xerostomia’ is denoted by subjective
symptoms only.
• Methods are divided into those; that measure
secretions from specific glands and those that
measure whole or pooled saliva.
• They are, however, time-consuming techniques
that require special equipment and trained
personnel and they are unwieldy as screening
procedures for xerostomia.

XEROSTOMIA
• The term ‘Dry mouth’ was given by
Bartley in 1868 and ‘Xerostomia’ by
Hutchinson in 1889
• Xerostomia is the subjective sensation
of dry mouth
• Hyposalivation is the objective finding
of a reduced salivary flow rate.

RADIATION INDUCED
XEROSTOMIA
• Radiation
Within one week (10 Gy)
• Salivary output decreases to 60-90%
Total dose more than 60 Gy
• Destruction of serous acini
• Atrophy, adiposis, fibrosis
• Xerostomia

AIM
To use the modified Schirmer test to
measure mouth dryness.

OBJECTIVES
• To determine whether the Schirmer test could
be modified for use as a rapid, objective
screening test.
• Whether this modified Schirmer test (MST)
could distinguish between healthy adults who
do not have and those who have xerostomia
and hyposalivation resulting from receiving
head and neck radiation.

MATERIALS AND
METHODS
• Control group 20 healthy adult
volunteers not having xerostomia lying
within the age group 40-60 years.
• Test group 20 subjects with xerostomia
who had received 50-70 grays of
radiation for head and neck cancer of
the same age group.

• The test will be performed with the
SCHIRMER TEAR TEST strip
manufactured by BELL PHARMA.

MECHANISM OF ACTION
• The test strip is 4 cm strip of Whatman
filter paper (calibrated in 1-mm intervals
from 5-35mm along its length) that has a
rounded notched tab.
• When the filter paper comes in contact
with the saliva , saliva rises through
capillary action.
• Length can be read at designated
intervals.

METHOD

OBSERVATION
Group Readings on the strip
(mm) [range]
1 min 2min 3min
Control
group
10-15 20-25 30-35
Subjects
with
Xerostomia
5-7 10-12 15-20

NORMAL PATIENTS
0 mm
5 mm
10 mm
15 mm
20 mm
25 mm
30 mm
35 mm
40 mm
1 3 5 7 9 11 13 15 17 19
time (minutes)
reading(mm)
Reading On Strip 1 min
Patients with Xerostomia
0 mm
5 mm
10 mm
15 mm
20 mm
25 mm
30 mm
35 mm
1 3 5 7 9 11 13 15 17 19 21
time (minutes)
reading(mm)

STATISTICAL ANALYSIS
• All tests are non parametric
• Comparisons were made between the
control group and the group of subjects
with xerostomia using the Mann-
Whitney Test.
• Exact P values for all values were
computed.

RESULTS
• The control group included 20 healthy
adults (aged 40-60 years); male:female
ratio [M:F]=16:4
• The test group included 20 subjects who
had undergone radiotherapy (aged 40-60
years); male:female ratio [M:F]=19:2
all of whom had xerostomia.

The difference between the MST measurements for
the control subjects and subjects with xerostomia
is striking
ME AN ME DIAN ±SD
¶
ME AN ME DIAN ±SD ME AN ME DIAN ±SD
CONTROL SUBJECTS 12.050 10.000 3.348 22.100 20.000 3.810 33.150 35.000 2.907
SUBJECTS WITH XEROSTOMIA 6.238 5.000 2.965 10.670 10.000 4.650 15.380 15.000 5.580
*MST : Modified Schirmer test.
§ mm: Millimeters.
¶ SD: Standard deviation.
Subject Group
ONE MINUT E S (mm
§
) T W O MINUT E S (mm) T HRE E MINUT E S (mm)
C OMPARISON OF MST * MEASUREMENT S AT ONE, T WO AND T HREE MINUT ES FOR T HE C ONT ROL SUBJEC T S
AND SUBJEC T S WIT H XEROST OMIA

The differences between the control subjects and the test
subjects are highly significant.
ONE M INU T ES T W O M INUT ES T HREE M INUT ES
Control Subjects Versus Xerostomic
Subjects With Xerostomia
< .00005 < .00005 < .00005
T EST RESUL T S FOR MST * C OMPARISONS BET W EEN C ONT ROL AND T EST SUBJEC T S
*M ST : M odified Schirmer test.
Subject Group
P VAL UES

DISCUSSION
• Schirmer’s test is used routinely by
ophthalmologists to measure tear film
wetness for identifying Sjogren’s
syndrome
• Consists of placing a small strip of filter
paper inside the lower eyelid
(conjunctival sac).

• Normal =>15mm wetting of the paper after 5
minutes.
• Mild -14-9mm wetting of the paper after 5
minutes.
• Moderate - 8-4mm wetting of the paper after 5
minutes.
• Severe - <4 mm wetting of the paper after 5
minutes.

• Modified Schirmer Test is used to
determine mouth dryness.

• In this study nonxerostomic healthy subjects
had a mean reading of approximately 33 mm
at three minutes while subjects with
xerostomia had a mean reading of 15 mm.
• Austin Chen, Yolanda Wai et al performed the
modified schirmer test on test group of
patients
who had received radiation as well as those
suffering from chronic graft versus host disease
using colour bar test strip with mean readings
of 30 mm and 7 mm respectively.

• Pia Lo´ pez-Jornet et al performed the test on
patients suffering from sjogren’s syndrome
using a caliberated Whatman filter paper strip
with a mean reading of 26 mm at 3 minutes.
• Davis CC et al used the Schirmer test strip
placed between two tongue depressors, with a
protruding 3-mm end placed against the
patient’s parotid papilla for five minutes with
mean readings between 10.6 and 15.6 mm at 3
minutes.
• Bermejo-Fenoll A et al used a paper strip
measuring 1 × 17 centimetres encased in a
sterilized polyethylene bag.

ADVANTAGES
• The strip is inexpensive, readily available
and requires only cotton pliers which may
be used to hold the strip.
• It has wide patient acceptability.
• It is a simple test that potentially can be
performed routinely in any office setting.
• Takes less than five minutes to perform.

LIMITATIONS
• Inter subject variation
• Lack of standardization
• No restrictions on food or fluid intake
before the test.
• Variability in the amount of residual
saliva left in the mouth after
swallowing.www.indiandentalacademy.com

CONCLUSION
• The healthy volunteers had significantly higher
mean readings at all three time points.(one, two
and three minutes )
• The Modified Schirmer Test is inexpensive, easy
to perform and well tolerated by the patients.
• Readily distinguishes between healthy patients
and patients with profound xerostomia and
hyposalivation.

REFERENCES
• Austin Chen, Yolanda Wai, Linda Lee et al Using the
modified Schirmer test to measure mouth dryness: A
preliminary study J Am Dent Assoc 2005;136:164-170
• Bermejo-Fenoll et al A simple test for salivary gland
hypofunction using Oral Schirmer’s test J Oral Pathol
Med (2006) 35:244-8
• Carlson AJ, Crittenden AL. The relation of ptyalin
concentration to the diet and to the rate of secretion of
the saliva. Am J Physiol 1910;26:169-77
• Shern RJ, Fox PC, Cain JL, Li SH. A method for
measuring the flow of saliva from the minor salivary
glands. J Dent Res 1990;69:1146-9.
• Speirs RL. Secretion of saliva by human lip mucous
glands and parotid glands in response to gustatory
stimuli and chewing. Arch Oral Biol 1984;29:945-8.

• Navazesh M, Christensen C, Brightman V. Clinical
criteria for the diagnosis of salivary gland hypofunction.
J Dent Res 1992;71:1363-9.
• Kohler PF, Winter ME. A quantitative test for
xerostomia: the Saxon test, an oral equivalent of the
Schirmer test. Arthritis Rheum1985;28:1128-32.
• Navazesh M, Christensen CM. A comparison of whole
mouth resting and stimulated salivary measurement
procedures. J Dent Res 1982;61:1158-62.
• Sánchez-Guerrero J, Aguirre-García E, Pérez-Dosal
MR, Kraus A,Cardiel MH, Soto-Rojas AE. The wafer
test: a semi-quantitative test to screen for xerostomia.
Rheumatology 2002;41:381-9.

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