197 Preferences of Sjögren’s syndrome patients for saliva substitutes discoloration might be related that white teeth are important for people in general, as demonstrated by others [34]. In the current study, the flavours of the available saliva substitutes such as “apple”, “lemon”, and “strawberry” were the least preferred, although a previous study has showed that a malic acid (“apple acid”) containing spray significantly stimulated salivary flow rate in patients using antihypertensive medication and improved their xerostomia [35]. However, this positive effect on oral dryness will be less or completely absent in Sjögren’s syndrome patients with an advanced disease process. As mentioned in the Introduction, the severity of the dry-mouth feeling, as measured with XI, may influence the preference of desired flavours. Patients with low xerostomia preferred the use of the flavour “blueberry” more than the respondents with more severe xerostomia. On the other hand, respondents’ severe xerostomia preferred the use of “neutral flavours” in salivary substitutes more. This confirms the hypothesis that severity of oral dryness may play a major role in the preferred saliva substitute flavours. A possible limitation of the current study is that the reported preferences for saliva substitutes are only based on the opinion of Sjögren’s syndrome patients. However, saliva substitutes are also used by patients suffering from oral dryness due to other conditions, including patients using xerogenic medications or polypharmacy, and patients irradiated in the head and neck region [2, 36–38]. Further research should investigate whether the preferences of these other dry-mouth patients are similar to those of Sjögren’s syndrome patients. Another possible limitation of the current study is that the Sjögren’s syndrome patients, who filled in this questionnaire, may be more interested in oral health than other Sjögren’s syndrome patients, or suffer from more severe xerostomia. This may have resulted in an above-average oral dryness which may have affected the preferences of new saliva substitutes. Besides, it is unknown which diagnosis criteria have been used by the patients’ physician to establish the diagnosis of Sjögren’s syndrome, and whether they suffered from primary or secondary Sjögren’s disease. Finally, another limitation is that the actual number of participants in the current study is lower than the number calculated a priori. This indicates that the power of the current study is relatively low, and so all results in which no significant differences were found between the two age or XI-groups should be interpreted with caution. 9
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