CT Disorders and Xerostomia Flashcards
List examples of CT disorders
Rheumatoid arthritis Systemic and discoid lupus erythematosus Systemic sclerosis Sjogrens syndrome Mixed CT disorder
Rheumatoid arthritis features?
Autoimmune
HLA-DR4 60%, genetic factors account for 50%
Inflam disease of synovium and adjacent tissues
Females>Males
Peak incidence 35-50yrs
Mortality risk
40% of individs become disabled 10 yrs post onset
Clinal features of rheumatoid arthritis?
Insidious onset Pain and stiffness of small joints Fatigue and malaise Anaemia Weight loss Muscle weakness and wasting
Neurological effects - carpel tunnel syndrome
Lymphadenopathy
Lung problems - pleural nodules and effusions
15% cases have sjogrens syndrome
TMJ damage in juvenile RA
What percentage of people have their hands, spine, wrist and TMJ affected with rheumatoid arthritis?
Hands 90%
Cervical spine 80%
Wrist 80%
TMJ 30%
Extra-articular manifestations of rheumatoid arthritis?
Weight loss Malaise Fever Lymphadenopathy Rheumatoid nodules Sjogrens syndrome Amyloidosis
How to diagnose rheumatoid arthritis?
Clinical - morning stiffness, symmetrical joint pain, weight loss Radiographic changes = fusion of joints Anaemia Raised ESR, CRP Anti-CCP positive (80% plus) Rheumatoid factor positive (80%)
Management of rheumatoid arthritis?
Education - self management programmes Exercise - fitness and maintain bulk muscle Physio Surgery for progressive deformity Dietary advice - weight reduction
Pharmacotherapy
- DMARDS (disease modifying anti-rheumatic drugs) = hydroxychloroquine, azathioprine, methotrexate
- Corticosteroids - IA/IM/PO
- Biological agents (anti-TNFalpha, non-TMF agents
- Symp relief - NSAIDs
Surgical tx (synovectomy, reconstructive surgery)
NSAID oral side effects?
Stomatitis Eryhthema multiforme Gastrointestinal bleeding - Depapillated tongue - Burning tongue - Candidosis
Methotrexate (DMARD) and hydroxychloroquine side effects?
Methotrexate
- Oral ulceration
Hydroxychloroquine
- Lichenoid reactions
- Pigmentation
Infliximab (biological drug) oral relevance?
Histoplasmosis infection Mandibular osteomyelitis Parotid swelling Ulceration Erythema multiforme
What do biological drugs often cause?
Oral candida
Orofacial aspects of rheumatoid arthritis?
Access
- Individ with RA less likely to visit dentist
Atlanto-axial joint dislocation
- Physical support - pillows, short appts
Impaired manual dexterity
- Electric toothbrush more effective than manual
TMJ
- Commonly affected but one of last joints involved
- May lead to open bite
Secondary sjogrens syndrome
Felty’s syndrome
- RA and splenomegaly and lymphadenopathy
- Increased risk of infection (chronic sinusitis)
- Oral ulceration
- Angular cheilits
Types of lupus erythematosus?
Immunologically mediated condition
2 forms:
DLE (Discoid)
SLE (systemic)
Aetiology of lupus erythematosus?
Genetic predisposition
Environmental trigger (UV, microbes, drugs)
T cell dysregulation of B cell activity
Features of discoid lupus erythematosus?
Affects skin and oral mucosa
F>M
Peak incidence 40yrs
Oral lesions similar to lichen planus in appearance
Diagnosis based on clinical/biopsy/immunology
Appearance of discoid lupus erythematosus lesions on the skin?
Scaly, erythematous patches
Atrophic, hypopigmented areas
Occur on exposed surfaces
May be premalignant
DLE diagnosis?
Clinical appearance
Biopsy
Circulating autoantibodies - ANA, dsDNA, may be positive
DLA management?
Treat as for lichen planus
Difflam MW and spray
Systemic lupus erythematosus features?
Age of onset 30yrs
F:M = 9:1
Up 40% have oral lesions
Systemic features of SLE?
Malar rash Polyarthritis Photosensitivity Lymphadenopathy, anaemia Renal/cardiac/haematological/neurological Oral lesions
Oral lesions with SLE?
Unilateral or bilateral white patches with central area of erythema or ulceration
May involve palate
May be extensive
Diagnosis of SLE?
Clinical Immunological: - Hypegammaglobulinaemia - ANA, ds DNA 90% - Rheumatoid factor 30%
SLE pharmacological management?
85% survival 10 yrs NSAIDs Hydroxychloroquine Corticosteroids Cytotoxic drugs - Cyclophosphamide - Methotrexate - Azathioprine Biological DMARDS (belimumab)
SLE prognosis?
Depends on extent of disorder
Death due to renal involvement
Males>females
What drugs can cause lupus like lesions?
Carbamazepine
Hydralazine
Penicillamine
Scleroderma/systemic sclerosis features?
Autoimmune disorder
Affects mainly females 20-50yrs
Dense collagen is deposited in tissues of the body
Clinical features include raynaud’s phenomenon
What is crest syndrome?
limited cutaneous form of systemic sclerosis (lcSSc)
Presentation: C - Calcinosis (calcium nodules can become ulcerated) R - Raynaud's phenom E - Oesophageal dysfunction S - Scelorodactyly T - Telangiectasia
Features of limited cutaneous systemic sclerosis?
Limited to skin on face, hands and feet
10 yr survival 75%
Features of diffuse cutaneous systemic sclerosis?
More extensive skin involvement
May progress to visceral organs
10 yr survival 55%
Death most often from pulmonary, heart and kidney involvement
Types of systemic sclerosis?
Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis
Crest syndrome
Orofacial manifestations of systemic sclerosis?
Facial skin rigidity Sharp nose Thinning of lips Loss of facial wrinkles Microstomia - Poor access for OH - Increase incidence of dental caries - Increase incidence of periodontal disease (abnormal immunoregulation and obliterative microvasculopathy)
Hypomobile tongue (less mobile)
Dysphagia and xerostomia
PDL widening on XR
Pseudoankylosis of TMJ
Tight cheeks = affects speech, eating, cleaning, deteriorating QoL
Systemic sclerosis diagnosis?
Difficult diagnosis
Clinical
Skin biopsy
Scl-70 autoantibodies
Systemic sclerosis management?
Difficult tx
Aims to reduce symptoms, slow progression of disease, prevent complications, minimise disability
Nifedipine
D-penicilllamine
Corticosteroids
DMARDs
How to manage microstomia?
Exercise programme
- Mouth stretching and oral augmentation
Sectional dentures
Implants
Sjogren’s syndrome features?
Autoimmune exocrinopathy
Primary and secondary (with another systemic autoimmune condition such as RA/SLE)
Focal lymphocytic infiltration of salivary and lacrimal glands
Incidence 0.5-2%
Females only
15% RA pts have secondary SS
30% SLE pts have secondary SS
Aetiology of sjogren’s syndrome?
Genetic predisposition - HLA-B8, HLA-DR3
Viral agents - herpes viruses (EBV, BMV, HHV6), retroviruses
Pathogenesis of sjogren’s syndrome?
Lymphatic infiltration of exocrine glands
Hypertrophy of ductal epithelium: formation of epimyoepithelal islands
Acinar atrophy and fibrosis
Probable hyperactivity of B cells
Symptoms of xerostomia in pts with sjogren’s syndrome?
Difficulty swallowing/chewing dry food Sensitivity to spicy food Altered salty bitter metallic taste Burning mucosa Lack of diminished taste Salivary gland swelling/pain Cough Voice disturbance Nocturnal discomfort
Sjogren’s syndrome oral signs?
Initially often little change
Oral mucosa - dry, atrophic, wrinkled, ulcerated, increased debris
Tongue - dry, red, lobulated, loss of papilla
Teeth - increased caries
Salivary glands - firm on palpation (if swollen)
Diagnosis of sjogren’s syndrome?
European diagnostic criteria:
- I Ocular symptoms
- II Oral symptoms
- III Ocular signs
- IV Histopathology (Biopsy from salivary gland - lower lip minor salivary glands)
- V Salivary gland involvement
- VI Autoantibodies
Primary SS:
- Presence of any 4 of the above items as long as either item IV or VI positive
- Presence of any 3 of III, IV, V, VI
Secondary SS
- Well defined CT disease and presence of item I or II plus any 2 from III, IV and V
Sjogren’s syndrome increases the risk of non-hodgkin’s lymphoma - when is the risk worse?
Worse in pts with: Vasculitis peripheral neuropathy anemia lymphopenia chronic glandular swelling
Sjogren’s syndrome management?
Palliative;
- Increase lubrication
- Maintain oral/dental health
- Review candida status
Therapeutic
- Pilocarpine
- Immunomodulating agents
What is xerostomia?
Symptom of oral dryness
May exist with or without hyposalivation
Hyposalivation = actual decrease in saliva flow rate
Types of salivary glands?
3 Major
- Parotid
- Submandibular
- Sublingual
> 600 minor salivary glands
Within lips/cheeks and palate
Salivary gland tissue - what produces saliva and what are the types of saliva?
Acini = saliva producing cells
Serous - watery secretion
Mucous - viscous saliva
Parotid glands mainly serous cells
Other glands mainly mucous
Components of saliva?
99.4% water
Organic solids:
- Protein
- Gamma globulin
- Amylase
- Lactoferrin
- Glucose
- Lipids
Inorganic
- Sodium
- K
- Ca
- F
- Cl
How is saliva formed?
Salivary gland secretion mainly under autonomic nervous control
Various hormones may modify salivary composition
Salivary flow mainly a result of parasympathetic activity
Vasodilation in BVs within glands
2 components of saliva:
- Fluid component includes ions produced by parasympathetic stimulation
- Protein component arising from secretory vesicles in acini - released in response to sympathetic stimulation
Effects of parasympathetic stimulation stronger and longer lasting
Parasymp stimulation - copious saliva of low protein concentration
Symp stimulation - little saliva but with high protein concentration
What is the flow rate of saliva?
500mls saliva in 24hrs Resting flow rate 0.3ml/min Flow rate during sleep 0.1/minute During eating/chewing 4-5ml/minute Unstimulated conditions - 60% saliva from submandibular glands, 20% from parotids and 2-5% from sublingual glands During eating parotid contributes to 50% saliva Smell/taste affect salivary flow Anxiety can decrease salivary flow
Functions of saliva?
Lubricant effect
Physical cleaner
Caries control - buffers acid
Saliva saturation with ca and phosphate = prevents demineralisation
Pellicle formation - salivary proteins form barrier
Antimicrobial
Taste
Digestion of carbohydrates begins (amylase)
Effects of long standing xerostomia?
Difficulties in oral function and wear of dentures Freq of caries (particularly cervical caries) Acute gingivitis Dysarthria Dysphagia Taste disturbances Susceptibility to oral candida Burning tongue/depapillation of tongue Dry, cracked lips Salivary gland enlargement
Causes of dry mouth?
Physiological:
- Dehydration
- Mouth breathing
- Anxiety
Congenital
- Salivary gland hypoplasia
Iatrogenic
- Drugs - antidepressants (tricyclics and SSRIs), antihistamines, diuretics, sedatives etc
- Radiation
Disease
- Sjogren’s syndrome
- HIV
- Sarcoidosis
- HCV
Congential
- Ectodermal dysplasia (hypodontia and missing salivary glands)
Radiation induced salivary dysfunction?
Therapeutic doses of radiation for head and neck cancer - permanent reduction in salivary gland function
Damage dependent on no and volume of salivary glands exposed
26Gy = threshold below which recovery of 25% stimulated saliva flow rate can occur
Saliva can become sticky
How to take a history for xerostomia?
Does your mouth usually feel dry? Does your mouth feel dry when eating? Difficulty swallowing food? Require liquids to swallow foods? Water to bed at night? Soreness of mouth? Difficulty wearing dentures? Dryness of eye/skin/genital area?
PMH Anxiety/depression Drug history SH - smoking/alcohol FH - autoimmune diseases
Xerostomia clinical examination?
General appearance Extraoral - CT disease features, salivary gland swellings Intraoral: - Lack of pooling of saliva in floor of mouth - Dental mirror sticks to mucosa - Food retention - Gingival health - Caries - Candidosis - Depapillation/lobulation of tongue
Xerostomia investigations?
Sialometry
Schirmer’s test
Rose bengal staining
Radiological
- Ultrasound
- Sialography
- Salivary scintigraphy
- PET scan
- MRI
- CT
Lab based
- Immunology - ENA/ANA/Rh factor
- Haematology - FBC/CRP/ESR, HbA1c (glucose diabetes) Liver func, thyroid function, immunoglobulins
Labial gland biopsy
- Examine at least 5 lobules of minor glands
Histopathological features supportive of sjogrens:
- Acinar loss
- Duct dilation
- Focal aggregate of at least 50 lymphocytes
Treatment of xerostomia?
Directed at underlying cause Prevention key Assess pts before radio and chemo tx Manage xerostomia early Prevent dental complications Multidisciplinary approach often required
Improve symptoms
- Salivary substitutes
- Stimulate saliva - sialogogues
- OH
Manage candidosis
- Antifungals
- Denture hygiene
Prevent/treat caries, gingivitis:
- F-
- Antibac MW
- OH advice
- Scale and polish
- Diet advice
Investigations
- Antibiotics?
- USS?
Dental caries prevention strategy?
Pt education Diet and nutrition counselling Hygiene control Fluoride Microbial control Rehydration therapy Dental tx considerations
Diet and nutrition counselling for xerostomia?
Avoid soft sticky and liquid diets which promote plaque formation
Eliminate salty spicy foods - irritant
Non cariogenic foods - suggest sugar substitutes
Limit caffeine - dehydration
Hygiene control for xerostomia?
Soft electric toothbrush ID brush, floss Disclosing tablets Children's toothpaste - mint irritant Oranurse toothpaste - bland
Microbial control for xerostomia?
High levels of lactobacilli reported Chlorhexidine rinse Chlorhexidine varnish F rinse has some antimicrobial activity Alcohol containing mouthwashes avoided
Dental tx for xerostomia pts?
3-4 monthly visits
Consider F applications
Remember fragility of oral tissues
Consider FS
Glass ionomer for provisional restorations
Dentine of exposed roots - dentine bonding resin adhesive systems
Amalgam more successful than bonded materials
Tongue can adhere to and dislodge denture
Mucosal irritation and ulceration common
Implants - increased comfort and function of prostheses
Management of dry mouth?
Oral moisturisers Gustatory and mechanical stimulation of salivation Milder toothpastes and alcohol free MW Saliva substitutes Lip creams and ointments Systemic therapy
Frequent sips of water
Saline solutions
Water plus sodium bicarbonate
Overuse of water removes mucous saliva from oral tissues = increases dry mouth sensation
Gustatory and mechanical stimulants for saliva?
Acidic stimulation - uncomfortable and increase enamel demineralisation
Sugarless chewing gum
Lozenges
Acupuncture
- Stimulated salivary function affected
Electrostimulation
Saliva substitutes?
Carboxymethyl cellulose, mucin, oils, glycerin Majority of pts prefer water Relief insignificant and short lived Impractical to handle Expensive Mucin may have better pt acceptance
ph>6 dentate pts = use saliva orthana ph<6 edentulous subjects = glandosane Glycerin Olive oil Anhydrous crystalline maltose
Systemic therapy for sjogren’s syndrome?
Used when residual secretory capacity in salivary glands exists may use cholinergic agents:
Pilocarpine
- Approved for tx of radiation induced sjogrens
Interferon alpha
- Improvement of salivary gland histopathology
Infliximab
- Increases salivary flow rate
- Improved symptoms of oral dryness
- Increased risk lymphoma
Hydroxychloroquine
- Improved oral discomfort
- Flow rate increased in 82% pts
- Improved oral discomfort
- 40% decrease in number of oral infections
- Few adverse effects
Corticosteroid irrigation of parotid gland
- Increased flow rate
- Symptom relief
- Risk of infec and pain
Pilocarpine adverse effects?
Flushing, sweating, urinary infrequency
Pilocarpine contraindications?
Uncontrolled asthmatics
Narrow angle glaucoma
Acute iritis
Oral candidosis prevention?
Denture hygiene
Do not wear at night
Chlorhexidine MW 3x weekly
Acrylic dentures soaked in milton solution diluted to 50% with water
Metal dentures soaked in 0.2% chlorhexidine
