Proc. Nati. Acad. Sci. USA Vol. 83, pp.

6103-6106, August 1986 Medical Sciences

Taste and salivary function

(oral sensation/chemical senses/gustation/salivation/sensory function)

JAMES M. WEIFFENBACH, PHILIP C. Fox, AND BRUCE J. BAUM

Clinical Investigations Section, Clinical Investigations and Patient Care Branch, National Institute of Dental Research, National Institutes of Health, Bethesda, MD 20892

Communicated by Carl Pfaffmann, March 28, 1986

ABSTRACT Human taste perception was remarkably unimpaired in eight individuals with severe, chronic failure of all major and minor salivary gland function. Subjective reports of taste experience and objective measures of suprathreshold sensitivity were within normal limits for the overwhelming majority of these individuals. Impairments of threshold sensitivity for at least one quality was common, but normal thresholds for all four qualities were observed in one individual. These data demonstrated that the functional integrity of the taste system is not dependent upon the presence of normal saliva in the mouth. Thus, the suggestion that a salivary factor is responsible for the maintenance of taste receptor end organs can be rejected and attention directed toward other mechanisms, not dependent on saliva, that might account for the unusual resistance of these cells to environmental insult.

MATERIALS AND METHODS Subjects. The 8 patient subjects of this study were the only
individuals among 75 patients referred to us for evaluation of xerostomia found to have no unstimulated or stimulated saliva flow from any of the major salivary glands. They had severe minor gland pathology as well. All patients were women. Control subjects were participants in the National Institute on Aging's Baltimore Longitudinal Study of Aging and typically Caucasians of upper middle socioeconomic class without major medical problems (6). Clinical Characterization of Salivary Gland Function. All patients presented with a primary complaint of dry mouth. Objective measures of salivary gland function were obtained separately for parotid and submandibular/sublingual glands. Parotid flow was evaluated using Lashley cups positioned over Stenson's duct in accordance with standard procedures (7). Submandibular/sublingual function was evaluated by collecting saliva with a micropipette held at the duct orifice (8). Collection of saliva under resting (unstimulated) conditions was attempted in the morning, at least 2 hr after a meal. Collections were for a minimum of 10 min. Then, to stimulate flow, 2% citric acid solution was applied to the anterior dorsal surface of the tongue by cotton swab. Stimulation at 30-sec intervals continued for a minimum of 10 min. Scintiscanning with technetium pertechnetate was used to image salivary gland uptake and oral secretion of intravenously injected radioactive tracer over the course of 1 hr (9, 10). Biopsy of labial minor salivary glands was accomplished by using standard techniques (11). Lacrimal function was assessed by Schirmer's test (12). Tear production is reflected by the wetting of standardized strips of filter paper (Cooper Vision Pharmaceuticals, Puerto Rico), which are placed in the lower conjunctival fold of each eye for 5 min without anesthesia. The diagnosis of primary sicca (Sjogren's) syndrome was based on objective evidence of lacrimal and salivary dysfunction, characteristic histologic appearance of labial minor salivary glands (13, 14), and the absence of any connective tissue disease. Assessment of Taste. Both subjective and objective measures of taste functioning were obtained. Subjective measures were derived from a structured interview during which patients were queried about changes in their enjoyment of food and specifically asked to report any changes in their sense of taste. Objective measures were based on patient responses to taste stimuli of known composition presented during two 1-hr testing sessions. Patients were instructed to refrain from brushing their teeth, smoking, eating, or drinking anything but water for 1 hr before each session. During each testing session, aqueous solutions of sucrose, sodium chloride, citric acid, and quinine sulfate representing the four basic taste qualities of sweet, salty, sour, and bitter were tasted and expectorated. Each tasting was preceded by a distilled water rinse. Taste detection thresholds were obtained by a two-alternative forced-choice procedure (15). On repeated trials the
6103

Tasting ordinarily occurs in the presence of saliva and is mediated by sensory end organs that are chronically exposed to the fluids produced by the major and minor salivary glands. Although taste sensitivity is maintained and may even be enhanced when the salivary fluids bathing the tongue are temporarily replaced with distilled water (1), the long-term maintenance of taste end organs and their continued normal functioning has been reported to require normal salivary gland function (2). The proposal that the differentiation, growth, and maintenance of taste buds depend on the presence of normal saliva has encouraged attempts to isolate and characterize a salivary component essential for continued taste functioning (3, 4). Normal taste performance by even a single individual with chronic complete salivary gland failure would demonstrate that taste function could be maintained without saliva and would present a significant challenge to this hypothesis concerning the biochemistry of taste. In the present report, we document adequate-to-normal taste function in eight individuals with no salivary function. Although salivary gland failure may lead to oral dryness, the subjective experience of oral dryness (xerostomia) is not a reliable indicator of salivary gland dysfunction (5). Individuals referred to us with a primary complaint of oral dryness exhibited marked variation in objective measures of glandular function. Most patients displayed some degree of altered salivary physiology. Some were significantly impaired. Remarkably, the first individual found to have objective evidence of complete failure of all major and minor salivary gland function also exhibited normal taste function by both subjective and objective criteria. This dissociation of taste performance from salivary gland function was confirmed and further explored in subsequent studies of seven additional patients with long-term absence of saliva.
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subject was required to specify which of two 0.5-ml samples pipetted onto the tongue elicited a taste. Each sample was preceded by a distilled water rinse, which was expectorated. One sample was always a taste solution, and the other was always distilled water. The order of presentation was predetermined by a random process, while the concentration of the taste sample depended upon the correctness of the subject's discrimination. The concentration of the test stimulus was increased after every error and reduced when correct responses were obtained on two successive trials at the same concentration. Thus, a series of trials where stimulus concentration increased was followed by a series where it decreased and vice versa. An initial series with sucrose test stimuli was followed by one with sodium chloride, one with citric acid, and one with quinine sulfate. Test substances were rotated in this sequence until five series had been achieved for each. In accordance with standard procedures (16), the first series for each quality was disregarded, and the threshold was defined as the mean of the logarithmic concentration of the extreme values for the last four series obtained with each solution. To evaluate the patient's thresholds, the percentile ranks of her values for each quality relative to age-and-sex-appropriate control subjects were calculated. Control subjects were drawn from a pool of 145 volunteer participants in the National Institute on Aging's study of aging. Thresholds for 90 subjects have been reported (16). Values for 55 additional participants were obtained by the same measurement procedure. Comparisons were made with all control subjects for sucrose thresholds because this measure showed no significant effect for age or sex (16). Since citric acid thresholds showed a sex effect (16), only female control subjects were used to evaluate thresholds for this substance. For sodium chloride and quinine sulfate, which showed age effects (16), control groups for each patient were limited to those control subjects with ages within 10 years of the patient's. The sodium chloride and quinine sulfate threshold control group for the 82-year-old subject consisted of 33 subjects. All other control groups for these substances numbered between 48 and 60 subjects. The direct scaling pf taste intensity was accomplished through a cross-modal matching procedure in which subjects extended the blade of a retractable tape measure to match the perceived intensity of 5-ml samples of "tastant" solutions (17). Subjects were instructed to express the ratio between subjective intensities in terms of distances in space. For example, if one stimulus were perceived as 2 times as strong as another, the measuring tape blade should be pulled out twice as far. Tastant concentrations for sucrose and sodium chloride covered the interval 0.056-1.8 M in approximately quarter-logarithmic steps. Limiting concentrations were 1.0 and 32 mM for citric acid and 10-320 ,uM for quinine sulfate. The seven stimulus concentrations within a series and a distilled water blank were each presented three times, in an order predetermined by a separate controlled randomization for each subject. Series were always presented in the order sucrose, sodium chloride, citric acid, and quinine sulfate, with all stimuli of one series being presented before any of the next. The rate at which the logarithm of judged intensity increases with logarithmic increases in the molar concentration of the stimulus is reflected in the slope of the psychophysical function. For each individual, slopes were derived to reflect the performance relative to each stimulus substance. In each case least-squares analyses were applied to the logarithm of the mean of the first two ratings elicited by each stimulus concentration. When the first two presentations of a stimulus concentration elicited zero responses, responses to that and all lower concentrations of that tastant were excluded from the analysis. A participant's perception of each of the four

tastants was further characterized by the intraclass correlation coefficient. The intraclass correlation coefficient is the proportion of the total variance in an individual's repeated ratings of a tastant series that is accounted for by variation in stimulus concentration. Thus, intraclass correlation coefficients reflect the reliability of repeated judgments. High values are obtained when agreement between repeated judgments of the same stimulus concentration is close. Lower values reflect larger trial-to-trial variation in judged intensity. Intraclass correlation coefficients were derived after the manner of Hays (18), from one-way analyses of variance of the subject's responses to each tastant series. Percentile ranks for each patient's performance were calculated in relation to age-and-sex-appropriate control values from published data for 170 volunteer participants in the longitudinal study of the National Institute on Aging (17). Control group size for slope and for sucrose intraclass correlation was 170. For all other intraclass correlation measures, the control group size was 39 for the 82-year-old subject and varied from 49 to 62 for the other subjects.

RESULTS The initial patient exhibited numerous signs and symptoms of diminished saliva production that had been present for more than 7 years (Table 1, patient 1). This patient presented no taste complaints. Her enjoyment of food was reduced by a painful oral mucositis, but she specifically denied any diminution or change in taste perception. These subjective reports were completely supported by objective tests of threshold and suprathreshold sensitivity. Thresholds, which reflect the weakest concentration of an aqueous tastant solution that is reliably discriminated from distilled water, were well within normal limits. Sensitivity to stronger solutions that produce taste sensations more closely analogous to those encountered outside the laboratory was also normal. Suprathreshold sensitivity was within normal limits whether assessed in terms of the relation of increments in judged intensity to concentration (slope of the psychophysical function) or the reliability of repeated judgements (intraclass correlation coefficient). The patient's performance with stimuli from each taste quality on each measure was assessed relative to that of generally healthy subjects of the National Institute on Aging's Baltimore Longitudinal Study. The percentile ranks given in Table 2 reflect the percentage of age-and-sexappropriate control subjects who performed less adequately than the patient. Seven additional patients with severe salivary gland dysfunction were also assessed. None had any unstimulated or stimulated flow from the major salivary glands. Each presented convincing evidence of minor salivary gland deterioration. Further evidence confirming the abnormal salivary gland function of these patients is given in Table 1 (patients 2-8). The majority of these patients resembled the initial patient in being free from taste complaints. Only two reported reduced enjoyment of eating; one cited a reduction and the other an increase in taste intensity. Thus, although most of these patients believed their taste perception to be normal, taste complaints or a subjective appreciation of distorted taste perception may occur in conjunction with salivary gland dysfunction. The objective findings for threshold and suprathreshold performance for the entire patient group are displayed in Table 3. Percentile scores below the 10th percentile are considered indicative of impaired performance and are assigned a plus (+). Four of 32 intraclass correlation values and 5 of the 32 slopes fell below the 10th percentile. Performance on the suprathreshold task, as measured by the intraclass correlation coefficient and slope, was like that which might

Medical Sciences: Weiffenbach et al.

Table 1. Clinical characterization of patients with salivary gland dysfunction Years . Labial minor Patient of oral Salivary output gland Age/
no. 1

Proc. Natl. Acad. Sci. USA 83 (1986)

6105

Salivary scitiscan
Uptake None
None

Sex

35/F
34/F

dryness 7

2 3 4

13
6

68/F

Oral signs Dry mucosa; caries Red, dry mucosa; caries Dry mucosa; caries

Parotid 0

Sub* 0

histology CIIF

Secretion None

Lacrimal dysfunction +
+

Diagnosis PSS
PSS
PSS

0
0

0 0 0

CIIF

None

CIIF/severe acinar atrophy

Minimal

Slight
None

71/F

Red, dry
mucosa; fissured tongue

CIIF/marked
lobular destruction

Minimal

PSS

5 6 7

82/F
45/F

2 7
4 14

Red, dry
mucosa

0
0

0 0 0

CIIF/marked
lobular destruction ND

Minimal

None
None

PSS

Red, dry
mucosa; caries Dry mucosa; caries

Minimal Minimal

+
+

PSS CNSS

61/F

0 0

SII; no foci

None

CNSS None None atrophy; no foci ND, not done; CIIF, chronic inflammatory infiltrate/foci; SII, scattered inflammatory infiltrate; PSS, primary sicca syndrome; CNSS, chronic nonspecific sialadenitis.
8

56/F

Dry

SII/severe

mucosa; caries

*Submandibular/sublingual.
be obtained if the patients were drawn randomly from the same population as the controls. There was no preponderance of low percentile scores, which might indicate impairment of the patients relative to control subjects. In contrast, 17 of 32 (53%) of the detection thresholds were at or below the 10th percentile. This suggests that patients are more likely than controls to have impaired sensitivity to weak stimuli. However, as noted earlier, patient 1 demonstrated unimpaired performance by each measure, including the detection threshold for each quality. Thus, while individuals with chronic severe salivary gland dysfunction were not notably impaired with respect to perception of suprathreshold taste stimuli, their performance of a taste detection task could be impaired. Such impairment was not, however, an inevitable consequence of the absence of saliva.

tive measures of major and minor salivary gland function (including the findings of flow-rate studies, salivary scintiscanning, and minor gland biopsy) indicated a complete absence of gland activity in this patient. Nonetheless, she demonstrated normal taste function by subjective report and objective tests of threshold and suprathreshold sensitivity for each of the four basic taste qualities. Thus, loss of taste function is not a necessary consequence of salivary gland failure. Second, the observation that performance on tasks involving stimuli near threshold might be impaired while
Table 3. Taste performance of patients with chronic salivary gland dysfunction Patient 4 8 Taste performance 1 2 5 7 3 6

DISCUSSION
Two points arise immediately from this study. First, the dissociation of normal taste performance from normal salivary gland function is demonstrated by patient 1. All objecTable 2. Taste performance of patient with chronic absence of salivary gland function: Percentile ranks relative to normal controls Sodium Citric Quinine Taste quality stimuli Sucrose chloride acid sulfate Threshold 49 56 40 12 Suprathreshold 90 90 89 83 Slope Intraclass correlation 69 78 76 81 *The control group size for slope measures is 170. Control groups for intraclass correlation coefficients are 170 for sucrose and sodium chloride and 53 for citric acid and quinine sulfate. Control groups for thresholds are 145 for sucrose, 69 for citric acid, and 48 for sodium chloride and quinine sulfate.

Suprathreshold Interclass correlation Sucrose Sodium chloride Citric acid Quinine sulfate Slope Sucrose

+
-

+
+

+
-

+
-

+ Sodium chloride + Citric acid + + Quinine sulfate Threshold + + + + + Sucrose + + + Sodium chloride + + + + + Citric acid + - + + + Quinine sulfate Plus (+) indicates performance below the 10th percentile relative to generally healthy control subjects. See the text for control group sizes.

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sensitivity to suprathreshold stimuli was intact reinforces the position that threshold measures reflect an aspect of sensory function that may be unrelated to the quality of taste perception outside the laboratory (19). For example, an individual who has lost the ability to discriminate a solution containing barely detectable amounts of sugar from tasteless water might still taste stronger solutions normally and require no additional sugar to bring their coffee to its accustomed
sweetness. This study demonstrates that normal salivary gland function is not necessary for the maintenance of normal taste perception. Although saliva is critical for complete oral comfort and function, it is not essential to the preservation of an intact taste system. Even in the chronic absence of saliva, the structures subserving taste maintain their functional integrity. Thus, the search for a salivary component responsible for the maintenance of taste end organs may be questioned. When the protection afforded by saliva is absent, taste system cells continue to be fully functional for a long time, although other oral soft tissues and the teeth are not maintained. This finding suggests that it may be more fruitful to explore the unique properties of the taste cells themselves than to search for exogenous salivary factors that protect them.
We thank Mary R. Bowers and Kathy Brown for technical support and Judy Tunis, Bonita K. DeBrie, and Melinda Brown for excellent and patient secretarial assistance. 1. McBurney, D. H. & Pfaffmann, C. (1963) J. Exp. Psychol. 65, 523-529.

2. Henkin, R. I. (1984) Biol. Trace Elem. Res. 6, 263-280. 3. Henkin, R. I., Lippoldt, R. E., Bilstad, J. & Edelhoch, H. (1975) Proc. Natl. Acad. Sci. USA 72, 488-492. 4. Shatzman, A. R. & Henkin, R. I. (1980) Biochim. Biophys. Acta 623, 107-118. 5. Mandel, I. D., Katz, R., Zengo, A., Kutscher, A. H., Greenberg, R. A., Katz, S., Scharf, R. & Pintoff, A. (1967) J. Oral Ther. Pharmacol. 4, 192-199. 6. Baum, B. J. (1981) Community Dent. Oral Epidemiol. 9, 128-134. 7. Lashley, K. S. (1916) J. Exp. Psychol. 1, 461-463. 8. Fox, P. C., van der Ven, P. F., Sonies, B. C., Weiffenbach, J. M. & Baum, B. J. (1985) J. Am. Dent. Assoc. 110, 519-525. 9. Grove, A. S. & Di Chiro, G. (1968) Am. J. Roentgenol. Radium Ther. Nucl. Med. 102, 109-116. 10. Katz, W. A., Ehrlich, G. E., Gupta, V. P. & Shapiro, B. (1980) Arch. Intern. Med. 140, 949-951. 11. Fox, P. C. (1985) Plastic Reconstr. Surg. 75, 592-593. 12. van Bijsterveld, 0. P. (1969) Arch. Ophthalmol. 82, 10-14. 13. Chisholm, D. M. & Mason, D. K. (1968) J. Clin. Pathol. 21, 656-660. 14. Greenspan, J. S., Daniels, T. E., Talal, N. & Sylvester, R. A. (1974) Oral. Surg. Oral Med. Oral Pathol. 37, 217-229. 15. Wetherill, G. B. & Levitt, H. H. (1965) Brit. J. Math. Stat. Psychol. 18, 1-10. 16. Weiffenbach, J. M., Baum, B. J. & Burghauser, R. (1982) J. Gerontol. 37, 372-377. 17. Weiffenbach, J. M., Cowart, B. J. & Baum, B. J. (1986) J. Gerontol. 41, 460-468. 18. Hays, W. L. (1963) Statistics for Psychologists (Holt, Rinehart & Winston, New York). 19. Cowart, B. J. (1981) Psychol. Bull. 90, 43-73.