6. Salivation Disorders Flashcards
What are the functions of saliva ?
Acid buffering.
Mucosal lubrication - speech, swallowing.
Taste facilitation.
Antibacterial.
What can be the cause of xerostomia ?
Salivary gland disease.
Drugs.
Medical conditions and dehydration.
Radiotherapy and cancer treatments.
Anxiety and somatisation disorders.
Indirect causes of salivary problems - what drugs cause xerostomia ?
Anti-cholinergic drugs i.e. tricyclic antidepressants and antipsychotics.
Anti-muscarinic drugs i.e. amitriptyline.
Antihistamines.
Atropine.
Diuretics i.e. bendrofluazide.
Cytotoxics (chemotherapy).
Lithium.
What percentage reduction of salivary flow do people on amitriptyline experience ?
26%
What percentage reduction of salivary flow do people on bendrofluazide experience ?
10%
What percentage reduction of salivary flow do people on lithium experience ?
70%
Indirect salivary problems - what chronic medical conditions can cause xerostomia ?
Diabetes - mellitus and insipidus.
Renal disease - increase in diuresis.
Stroke.
Addisons disease.
Persistant vomiting.
Indirect salivary problems - what acute medical conditions can cause xerostomia ?
Acute oral mucosal disease.
Burns.
Vesiculobullous disease.
Haemorrhage.
Direct salivary problems - what are some examples of direct salivary gland problems ?
Aplasia - ectodermal dysplasia.
Sarcoidosis.
HIV.
Gland infiltration - amyloidosis and haemochromatosis.
Cystic fibrosis.
What are some symptoms associated with ectodermal dysplasia ?
Disorders that affect hair, nails, teeth (hypodontia, cone shaped teeth), salivary and sweat glands.
Hearing and vision.
Cleft lip and palate.
What subtype of ectodermal dysplasia is most likely to cause salivation problems ?
Hypohidrotic ectodermal dysplasia type (X-linked).
What is sarcoidosis ?
Multisystem disease seen with granulomatous change in lymph nodes in the lung, skin, salivary glands (enlargement of submandibular and parotid glands).
How does HIV affect salivary glands ?
Lympho-proliferative disease which causes increased bulk of gland and reduction in function (active acing tissue lost).
What is amyloidosis ?
Deposition of protein within gland preventing normal function.
What is haemachromatosis ?
Excess storage of iron within the salivary tissues preventing normal function.
Direct salivary problems - what types of cancer treatment cause salivary problems ?
Radiation - reduced blood flow.
Graft vs. host disease (bone marrow transplant).
Antineoplastic drugs - accumulate causing death of acing cells.
Radiodine - accumulate causing death of acing cells.
What is the name of the scale used to assess salivary function and degree of oral dryness ?
Challacombe Scale of Mucosal Dryness.
What is the treatment for first stage Challacombe Scale of Mucosal Dryness ?
Sugar free chewing gum and frequent sips of water.
What is the treatment for second stage Challacombe Scale of Mucosal Dryness ?
Advanced treatment and salivary substitutes.
High caries risk - OH, topical fluoride, dietary advice.
What are some special investigations used in assessing salivary disease ?
Ultrasound.
Sialography (+/- MR).
Radiographs (stones).
Labial gland biopsy (“tissue assay”).
Salivary flow test (“functional assay”).
Blood tests.
What are you looking for in blood tests for assessment of salivary disease ?
Dehydration.
Diabetes.
Autoimmune conditions - Sjorgens.
HIV.
Name some examples of frequent somatoform diseases (complaint fo real symptoms but on examination, disease is not found).
Oral dyaesthesia (burning mouth).
TMD pain.
Headache.
Neck and back pain.
Dyspepsia.
IBS.
How much salivary should be produced unstimulated in 15 mins ?
1.5ml.
Name treatable causes of xerostomia.
Dehydration.
Medicines with anti-muscarinic side effects.
Medicines causing dehydration.
Poor diabetes control.
Somatoform disorder (diagnosis of exclusion).
Name causes of xerostomia with only symptomatic treatment.
Sjorgens syndrome.
Due to cancer treatment.
Due to salivary gland disease.
Name some of the treatment options for symptomatic relief of xerostomia in patients with Sjorgens, xerostomia due to cancer treatment or salivary gland disease.
Intensive dental prevention.
Salivary substitutes.
Salivary stimulants.
Name two salivary substitute sprays.
Glandosane and saliva orthana.
What salivary substitute spray should be recommended ?
Saliva orthana.
Glandosane - has high pH.
Names two salivary lozenges.
Saliva orthana and SST.
Name a salivary stimulant medication.
Prilocarpine.
Why is pilocarpine not tolerated well ?
Causes sweating and tachycardia.
What are examples of true causes of hypersalivation ?
Drug causes.
Dementia.
CJD.
Stroke.
What are examples of perceived causes of hypersalivation ?
Swallowing failure - anxiety, stroke, motor neurone disease, multiple sclerosis.
Postural drooling - baby and cerebral palsy.
How can excess salivation be managed ?
Treat cause - anxiety.
Drugs to reduce salivation - anti-muscarinic agents and bottom to prevent cholinergic gland stimulation.
Biofeedback training - swallowing control.
Surgery to salivary system - gland removal, duct repositioning into pharynx.
What are two forms of surgery which might be considered as last resort to manage excess salivation ?
Gland removal.
Duct repositioning into pharynx.
What are the three main causes of changes in gland size ?
Viral inflammation.
Secretion retention.
Gland hyperplasia.
What are two examples of viral inflammatory conditions which cause enlargement of salivary glands ?
Mumps and HIV.
What are two examples of secretion retention conditions causing enlargement of salivary glands ?
Mucocele.
Duct obstruction.
What are two examples of gland hyperplasia which cause enlargement of salivary glands ?
Sjorgens syndrome.
Sialosis - unknown cause for hyperplasia.
What vaccine provides protection from mumps ?
MMR.
What is the incubation period for mumps ?
2-3 weeks.
What can be the symptoms of mumps ?
Headache.
Joint pain.
Nausea.
Dry mouth.
Mild abdominal pain.
Lethargy.
Loss of appetite.
Pyrexia of 38C or above.
What is the treatment for mumps ?
Symptomatic tx only.
No antiviral tx available.
Analgesics and increased fluid intake.
Where are mucoceles normally found in the mouth ?
Areas of trauma - soft palate and lip.
A patient with a subacute obstruction of their salivary gland will complain of what ?
Swelling associated with meal times.
Submandibular (sometimes parotid).
Slow and progressive over weeks.
Eventually becoming fixed and painful.
What can be the cause of a subacute salivary gland obstruction ?
Sialolith (stones).
Mucous plugging.
Scarring from chronic infection.
What investigations should be used to assess subacute salivary gland obstruction ?
Low dose plain radiograph.
Sialography if infection free.
Isotope scan if gland function uncertain.
Ultrasound.
What type of radiograph should be used to assess subacute parotid gland obstruction ?
PA.
What type of radiograph should be used to assess subacute submandibular gland obstruction ?
Lower true occlusal.
Why should sialography not be used to detect subacute salivary gland obstruction where there is infection ?
Risk of flushing infection back through duct into gland.
Why is it beneficial to use sialography in detection of subacute salivary gland obstruction ?
Can show stricture or blockage.
Can also provide treatment by dislodging blockage and cause.
What is the problem associated with duct dilation ?
Defect prevents normal emptying.
Causes pooling of saliva in duct system.
Micro-organisms grow and lead to persisting and recurrent sialadenits.
Causes gland function to be gradually lost and persisting infection leads to requirement for gland removal.
How can strictures in the duct system be treated ?
Balloon catheter.
What is chronic non-specific sialadenitis ?
Ducts and acini replaced by scar tissue.
Can affect minor and major glands.
How should a subacute salivary obstruction be managed ?
Surgical sialolith removal.
Sialography to wash.
Gland removal if fixed swelling and risk of persisting and recurring infection.
Define sialosis.
Diagnosis of exclusion - persisting and unexplained major gland enlargement with no obvious glandular cause.
What can sialosis be associated with ?
Alcohol abuse.
Cirrhosis.
Diabetes mellitus.
Drugs.
What are the signs/symptoms of sialosis ?
Normal histology.
Gland will be enlarged.
Not painful.
Rarely have dry mouth.
Normal blood tests.
Define primary Sjorgens syndrome.
Occurs in absence of any other rheumatic disease.
Define secondary Sjorgens syndrome.
Associated with other CT disease i.e. due to SLE, rheumatoid arthritis, scleroderma.
Define Sicca syndrome.
Partial Sjorgens findings - dry eyes or mouth (not both) in absence of autoimmune disease.
Are men or women more likely to suffer Sjorgens syndrome ?
Women (10:1).
What other rheumatic condition is most commonly associated with Sjorgens syndrome ?
SLE (systemic lupus erythema).
What blood marker is a suspicion of Sjorgens syndrome if symptomatic ?
Anti Ro
What are the symptoms of Sjorgen’s syndrome ?
Gradual loss of salivary/lacrimal gland function at 20-30s.
Enlargement of major salivary glands - symmetrical.
Painless.
What is Sjorgen’s syndrome ?
Gradual loss of salivary/lacrimal gland function - due to inflammatory destruction (autoimmune condition mediated by T lymphocytes).
People with Sjorgen’s syndrome are at greater risk of what ?
Any lymphoma.
Salivary marginal B-cell lymphoma.
Caries.
Periodontal disease.
Loss of taste.
Difficulty swallowing.
Poor ocular lubrication.
Lack of tear production.
What scoring system is used to diagnose Sjorgen’s syndrome ?
ACR-EULAR joint criteria.
What appearance will Sjorgen’s syndrome have on sialogram ?
Snowstorm appearance. Loss of acini causing holes in tissue - holes will fill with dye on sialogram.
What appearance with Sjorgens syndrome have histologically in positive labial gland biopsy ?
Collection of lymphocytes (>50) around a duct - “lymphocytic focus”.
Most diagnostic feature on ACR-EULAR criteria.
What tests should be carried out to diagnose Sjorgen’s syndrome ?
Intra-oral examination.
Unstimulated salivary flow (<1.5ml in 15 mins).
Anti-ro antibody blood test.
Baseline MRI of major salivary glands.
Labial gland biopsy.
How should Sjorgen’s syndrome be managed ?
OH - diet, 5000ppm toothpaste.
Symptomatic tx of oral dryness.
Prilocarpine (licensed drug).
Routine dental appointment check ups.
