Case 7 - Dry Mouth

Question 1

What are some intra-oral signs of xerostomia ?

Answer 1

Glazed appearance (atrophic) gingivae.
Debris adhering to teeth.
Carious lesions at cervical margins of teeth.
High caries rate.
Gloved fingers and mirror sticks to mucosa.
Redness.
No saliva pooling at FoM.
Fissured tongue.

Question 2

What are some symptoms of xerostomia ?

Answer 2

Difficulty with speech, eating and swallowing.
Frequent sipping of water.

Question 3

What are common causes of false xerostomia ?

Answer 3

Mouth breathing.
Mucosal disease.
Psychological.

Question 4

What are common causes of true xerostomia ?

Answer 4

Drugs.
Dehydration.
Sjogren’s syndrome.
Irradiation.
Neurological.
Developmental anomaly.

Question 5

What drugs can cause true xerostomia ?

Answer 5

Anti-muscarinic.
Antihistamines.
Diuretics.
Antidepressants.

Question 6

Define Sjogren’s syndrome.

Answer 6

Autoimmune disorder on which exocrine glands are destroyed causing salivary hypofunction.

Question 7

Define primary Sjogren’s syndrome.

Answer 7

Presence of dry mouth and eyes without autoimmune/CT disease (but can have non-specific signs of autoimmune disease i.e. Raynaud’s).

Question 8

Define secondary Sjogren’s syndrome.

Answer 8

Presence of dry mouth and eyes with associated CT disorder, for example, RA, SLE, mixed CT disease.

Question 9

What test differentiates false and true xerostomia ?

Answer 9

Unstimulated salivary flow test.

Question 10

Describe unstimulated salivary flow test.

Answer 10

Tilt head forward.
Spit into container for 10 mins.

Question 11

Why is it useful to take an unstimulated salivary flow rate test, even when it is strongly suspected that a patient has true xerostomia ?

Answer 11

Baseline reading against which disease severity and progression can be judged.

Question 12

What salivary flow rate would you consider to indicate xerostomia ?

Answer 12

<2ml in 10 mins unstimulated salivary flow - considered to indicate xerostomia.

Question 13

Approximately how much saliva is secreted daily ?

Answer 13

500ml.

Question 14

Patient has xerostomia but suffers oral pain. What should be suspected ?

Answer 14

Superimposed candida infection.
Can use smear and culture.

Question 15

What are characteristic histological features of Sjogren’s syndrome ?

Answer 15

Focal lymphocytic sialadenitis.
Concentric, defined zones of acing atrophy surrounding by normal acini.

Question 16

What autoantibodies are seen in primary Sjogran’s syndrome ?

Answer 16

Positive ssA and ssB.

Question 17

How should a patient with primary Sjogren’s syndrome be managed ?

Answer 17

Preserve salivary secretion.
Prevent and treat caries.
Prescribe salivary substitutes.
Prescribe pilocarpine.
TENS.

Question 18

How can a patient preserve the salivary secretion which remains ?

Answer 18

Frequent sips of water.
Avoid drugs that induce xerostomia.
Maintain fluid intake.
Chewing gum.
Pilocarpine.

Question 19

How should xerostomia patient be managed in related to caries prevention and treatment ?

Answer 19

Dietary anaylsis.
Diet related advice and oral hygiene.
Treat caries.
High fluoride toothpaste - 5000ppmF.

Question 20

Name some options of saliva substitutes.

Answer 20

Biotene.
Saliva orthana.

Glandosane - acidic, do not prescribe to patients with remaining teeth.

Question 21

What prescription of pilocarpine can be prescribed ?

Answer 21

5mg 4x daily.

Question 22

What contraindicates pilocarpine ?

Answer 22

Asthmatics.
COPD.
Pregnancy.

Question 23

How does pilocarpine work in stimulating saliva ?

Answer 23

Smooth muscle stimulant.
Stimulates cholinergic receptors.

Question 24

What is transcutaneous electric nerve stimulation (TENS) ?

Answer 24

Non-pharmalogical treatment technique, causes salivary secretion without side effects.
Small electric current passed through the gland.

Question 25

How many patients with primary Sjogren’s syndrome go onto to develop lymphoma ?

Answer 25

10%> patients with primary Sjogrens syndrome eventually develop low grade lymphoma.