Lecture 4- Dry mouth, excess salivation and halitosis Flashcards
What are the main causes of dry mouth
Mouth breathing Salivary gland disease Systemic disease Drugs Physchosocial causes
Causes of salivary gland disease?
Immunological
reactive
neoplastic
inflammatory
infective
systemic-Sialosis
Drugs
metabolic (Diabetes mellitusI
Iatrogenic (radiotherapy)What questions to ask patient about history of presenting complaint?
Ask about mouth dryness
• Ask about mouth dryness
when eating a meal
• Ask about difficulty swallowing dry foods
• Ask about snoring, mouth breathing
• Ask about dry eyes, sensation of grit in the eyes
What should be asked in the medical and drug history?
What medications you are on? ( Remember some cause dry mouth)
Did you change meds at the onset of the symptoms?
Systems review to identify if there could be a systemic cause
What questions should be asked about social history?
Smoker?
Chronic anxiety?
Occupation?
What should be asked about a dental history with dry mouth?
Caries? Are they a denture wearer?
Do they chew gum to relief symtoms
What should be looked for in the extra oral examinations for dry mouth?
Look for salivary gland or lymph node enlargement
INSPECT- the swelling ( Size or symmetry)
PALPATE- Does it feel fixed or movable? Diffuse or discreet?
PALPATE- If enlarged is it tender or painful to palpation
NERVES- Identify any neurological complications- facial nerve palsy etc?
What do in a intra oral exam?
How dry is the mucosa, is it sticking to the mirror?
Palpate and try to express saliva from the ducts?
Look at the typical pattern of dental caries?
any oral mucosal disease?
What should you consider when assessing this patient?
Is the symptom of xerostomia actually acompanied by hypo salivation?
Consider referral?
Consider prescribing symptomatic relief?
Consider their dental needs? High caries risk etc?
What investigations for dry mouth can be undertaken?
ultrasound
The schirmers test ( Blotting paper placed under the eye to measure the tear production)
How to relief and manage these patients?
Artificial saliva eg. Saliva OrthanaTM
Xylitol containing gels
eg. Biotene Oralbalance gel TM
Topical Sialogogic medication: eg. SalivixTM pastilles, sugar free chewing gum
• Systemic Sialogogic medication: eg. Pilocarpine
How to deal with the other dental problems and prevention associated with these patients?
Need to maintain Dental, Periodontal and mucosal health
Prescribe fluoride toothpaste and varnish
Hygiene therapy- Maintain good oral hygiene
What are the systemic causes of hyposalivation
Sjogrens syndrome (SS) Diabetes Mellitus Drugs Chronic kidney disease COPD
Which drugs cause hypo salivation?
- Antipsychotics
- Anticholinergics
- Benzodiazepines
- Diuretics
What is Sjogrens syndrome?
Autoimmune disorder that affects the glandular tissues.
Commonly salivary and lacrimal glands.
F>M
What is Primary SS?
Not associated with rheumatoid disease. SS is a rheumatic disorder however
What is Secondary SS?
It occurs secondary to another rheumatic disorder such as rheumatoid arthritis
what is the trigger of this autoimmune disorder?
Can either be
Cellular immunity- infiltration of glands
Antibody mediated- Antibodies ANTI- RO and Anti- La are found in 40-75% of cases
What are the symptoms of ss?
Fatigue Dry mouth and Eyes Myalgia ( Muscle pain) Arthalgia (joint pain) Pharyngeal, vaginal and anal dryness
what is the management for extra oral symptoms
Drops and lubricating creams for dry eyes
Liase with rheumatologist for joint and muscle pain.
What is the schirmers test?
Blotting paper is placed in the conjunctival fornix of the eye and tear production is measured
According the the schemers test what result would indicate hypo salivation?
<=5mm in 5 mins
What is sialometry?
Measurement of salivary flow . Less than or equal to 15ml in 15 mins of unstimutalted flow = hypo salivation
How can you measure gland function?
Scintiscanning. Measures the uptake of a radioactive isotope into the glandular tissue
How do you take a labial gland biopsy?
5-10 minor salivary glands are taken from the lower lip§
What is the advantage of the labial gland biopsy?
most specific investigation for the diagnosis of SS
What is a disadvantage of a labial gland biopsy
Invasive and risk of paraesthesia to the lip.
What are the requirements for the diagnosis of SS?
Must be all of the following
Symptoms of xerostomia
Objective evidence of hypo salivation
Objective evidence of dry eyes on examination
Must be positive to 2 of the 3 following investigations
Positive labial gland biopsy
Presence of anti bodies (Anti ro and anti la)
postive imaging investigations
Why must we monitor patients with SS
They have a 33X increased chance of malignancy often lymphoma
How to manage SS patietns
Dental care
Give topical and systemic sialogogic medications
What is the effect of radiotherapy on salivary gland tissue?
Progressive reduction of salivary gland tissue and therefore a decrease in production of saliva.
What is the organs or areas of the body can lead to halitosis
The oral cavity Phayngeal GI Maxillary sinus Nasal passage Respiratory pathology
How to manage halitoses
Identify cause and remove it or modify it.
If no pathology is causative then reiterate the importane of good oral hygiene,Give advice on reducing risk factors of halitosis. Topical treatment has been shown to be ineffective.
How to deal with patients who only percieve themselves to have bad breath but they don’t?
Reassure patient
Suspect the possibility of pseudo-halitosis or halitophobia — particularly if they have good oral and dental health.
Talk to the patient about referral for physchosocial especially if the halitophobia is bad.
What causes excess salivation?
Often due to swallowing problem, Can often only be perceived and not actually a problem.
Real causes of excess salivation?
Ill fitting denture GERDS disease ( Acid reflux) Mouth/throat infections and inflammation Drugs such as pilocarpine or Carbi-dopa/levo-dopa Pregnancy
What local conditions effect swallowing efficiency?
Acute sinusitis – Allergies – Chronic sinusitis – Enlarged adenoids – Tumors that affect your tongue or lip movement
What Systemic conditions effect swallowing efficiency
– Cerebral palsy
– Dementia
– Down syndrome
– Multiple sclerosis (a disease in which your body’s immune system attacks the sheath that covers your nerves)
– Myasthenia gravis (a muscle weakness disorder)
– Parkinson’s disease
– Stroke
