1. Functional disorders Flashcards
Sialorrhea
(Increase in saliva flow HYPERGUESIA)
Causes
* Psychosis
* Local irritation i.e ill fitting denture/ new denture/ulcer
* Mental retardation
* Certain neurological diseases
* Rabies
* Heavy Metal Poisoning (lead)
* Medication (e.g. Lithium and cholinergic agonsits)
* Poor neuromuscular control (e.g. in cerebral palsy, Bell’s palsy and mandibular surgery)
Clinical features:
1. Drooling
2. Feeling of choking
3. Macerated sores around the mouth, chin and neck that can become secondarily infected.
Treatment
* Anticholinergic medication (Intradermal scopolamine)
* Speech therapy
* Surgery in patients with severe drooling:
(a) Relocation of the submandibular and/or parotid duct
(b) Excision of the submandibular gland and parotid duct ligation
(c) Bilateral tympanic neurectomy with sectioning of the chorda tympani
Xerostomia
(Decrease in saliva flow)
Frequently (not always) associated with salivary gland hypofunction. Prevelance increased with # of drugs person takes.
Causes
* Local factors (Decreased mastication, smoking, Mouth breathing)
* Developmental causes (Salivary gland aplasia)
* Systemic conditions (Sarcoidosis, Sjoegrens syndrome, Lupus, Mumps, Diabetes mellitus and insipidus, HIV, Hepatitis C, GVHD)
* Iatrogenic (H&N radiation, Chemo, Medication)
* Water/Metabolite loss (Vomiting, Hemorrhage, impaired fluid intake)
Clinical features:
* Reduced saliva flow
* Ropey saliva
* Dry mucosa
* Fissured dorsal surface of the tongue with atrophy of the filiform papillae
* Difficulty in mastication and swallowing
* Development of oral candidiasis
* Dental decay (especially cervical and root caries)
Treatment
1. Artificial saliva
2. Sugarless candy
3. Spping on water
4. Oral hygiene products that contain lactoperoxidase, lysozyme and lactoferrin (e.g. Biotene toothpaste and mouth rinse)
5. Discontinue or modify dose
6. Systemic Pilocarpine (5-10mg tds or qid)- promotes saliva secretion (can cause excessive sweating)
Cevimeline hydrochloride (a sialogogue)
Note: Pilocarpine and Cevimeline are contra-indicated in patients with narrow angle glaucoma
7. Frequent dental visits ( due to increased potential for dental caries)
8. Topical fluoride
9. Chlorhexidine rinses
Sialogram appearance
- Leafless fruit laden tree or cherry blossom appearance
Break up time test
Saliva pH is low
Medications that may cause xerostomia:
- Antihistamine agents
e.g. Diphenhydramine - Decongestant agents
e.g. Pseudoephidrine - Antidepressant agents
e.g. Amitryptiline - Antipsychotic agents
e.g. Haloperidol - Sedatives and anxiolytic agents
e.g. Diazepam - Antihypertensive agents
e.g. Calcium channel blockers, Furosemide - Anticholinergic agents
e.g. Atropine
Sjogren’s Syndrome
Chronic, systemic, autoimmune disorder that involves the salivary and lacrimal glands
Clinical features
* Xerostomia (denture sore mouth and angular cheilitis)
* Xeropthalmia (Schirmer test.) i.e. the sicca (“dry”) syndrome.
* Common: Associated diffuse, firm enlargement of the major salivary glands.
* Dry skin, dry mucosal surfaces (nasal and vagina)
Two forms of SS:
1. Primary: Sicca syndrome alone (dry mouth and eyes)
2. Secondary: Sicca syndrome in addition to another associated autoimmune disease (Rheumatoid arthritis)
Etiology: Unknown (genetic)
Epidemiology: Female>Males
Laboratory Values:
* ↑ ESR
* ↑ Serum Immunoglobulin levels (especially IgG)
* A positive RF (Rheumatoid Factor)
Treatment:
Mostly supportive
Dry eyes: Periodic use of artificial tears
Dry mouth: Artificial saliva; sugarless candy or gum…see treatment of xerosotomia
Patients with SS have an increased risk for Lymphoma
MRI shows salt and pepper appearance and microscopically shows epimyoepithelial islands
Minor salivary gland biopsy
Pilocarpine is the most useful drug of txt
Ranula
Ranula- A mucocele that occurs in the floor of the mouth. Latin: “Rana”= frog (swelling resembles a frog’s underbelly)
Source of mucin spillage is usually the sublingual gland, but ranulas may also arise from the submandibular duct, or from minor salivary glands in the floor of the mouth.
Clinical features:
* Blue, dome-shaped, fluctuant swelling in the floor of the mouth.
* Deeper lesions may be normal in colour.
* Can be large and cause elevation of the tongue.
* Usually located lateral to the midline (a feature that may help to distinguish it from a midline dermoid cyst)
* Like other mucoceles, ranulas may rupture and release their mucin contents, only to reform.
Histopathologic features:
* Similar to that of a mucocele.
* Granulation tissue response with foamy histiocytes
Treatment:
1. Removal of Sublingual gland
2. Marsupialization:
Removal of the ROOF of the intraoral lesion
Mucocele
Cause: Rupture of a salivary gland duct and spillage of mucin into the surrounding soft tissues often as a result of trauma
Clinical presentation:
Dome-shaped mucosal swelling that can range from 1 or 2mm to several centimeters in size. Bluish translucent hue due to spilled mucin below the mucosal surface.
(However, deeper mucoceles may be normal in color).
Mostly fluctuant but can be firm on palpation
Duration: few days to several years
Common site: Lower lip 70% , usually lateral to the midline
Epidemiology: Children and young adults
Histopathology:
NOT A TRUE CYST (because it lacks an epithelial lining)
* Area of spilled mucin surrounded by a granulation tissue response i.e. foamy histiocytes (macrophages).
* Adjacent minor salivary glands often contain a chronic inflammatory cell infiltrate and dilated ducts.
Treatment: Excisional biopsy usually curative, some rupture and heal themselves
Prognosis: Excellent (unless feeding glands are not removed).
Superficial mucocele:
-A variant of the mucocele which commonly occurs on the soft palate,
retromolar area and along the posterior buccal mucosa
-Present as single or multiple tense vesicles that measure 1 to 4mm in diameter.
-Sometimes referred to commonly appear at mealtimes.
-Can be confused for a vesiculobullous disorder (especially mucus membrane pemphigoid)
Plunging (Cervical) Ranula
- An unusual clinical variant of the ranula
- Occurs when the spilled mucin dissects through the mylohyoid muscle and produces a swelling in the neck.
- Lesion should also be present in the mouth, otherwise the clinical diagnosis of a ranula may not be suspected.
Medication causing caries due to xerostomia
Methamphetamines. The increasing use of methamphetamine in particular has resulted in an increasing incidence of meth mouth, which is severe tooth decay caused by methamphetamine-induced xerostomia. The damage is exacerbated by the bruxing and clenching caused by the drug and by the heat of the inhaled vapor. This combination causes very rapid destruction of teeth.
Sialograph
Normal appearance of a gland is a leafless tree
