Management of problems with Saliva Flashcards
What salivary related conditions do blood tests help us diagnose?
Diabetes
Dehydration
Autoimmune diseases- sjogrens
What is the issue with major gland investigation?
Damage to facial nerve
Why is labial gland biopsy done instead of major glands?
- Histopathology of inflammatory changes in major glands is reflected in minor
- Minor gland biopsy (labial gland in lip)- gives same info about immune/inflammatory diseases in major glands without risk
What are the risks of labial gland biopsy?
Risk of labial gland biopsy- area of numbness (informed consent- only if other evidence of salivary gland disease)
What is sialography useful for investigating?
Strictures and dilatation of ducts
- MR requires no cannulation
Why has ultrasound replaced sialography?
No ionising radiation in ultrasound
What causes saliva to be frothy?
Protein content
What is a somatisation disorder?
significant symptoms that are real to patient but no evidence with disease in tissues of the patient
How can anxiety and somatisation disorders affect salivation/swallowing?
‘cephalic’ control of salivation
-> Inhibition of salivation – anxiety directly causes ‘real’ oral dryness
‘cephalic’ control of perception (anxiety disorders)
-> Altered perception of reality – ability to detect moistness is altered by small changes at synapses as it is processed (saliva levels are normal)
Anxiety can also inhibit swallowing and can lead to patient feeling they have excess salivation
What are other examples of somatoform disorders?
Oral Dysaesthesia
TMD pain
Headache
neck/back pain
Dyspepsia- with no evidence of excess of acid
Irritable Bowel Syndrome
What is the resting and stimulated salivary flow rate in normal patients?
Resting- 0.3-0.4 ml/min
Stimulated- 1-2 ml/min
What is the resting and stimulated salivary flow rate in patients with hyposlaivation?
Resting- <0.1 ml/min
Stimulated- <0.5 ml/min
-> Patients only really notice when salivation has decreased by 50%
What are the treatable causes of dry mouth?
Dehydration
Use of medicines with anti-muscarinic side effects Or that cause dehydration
Poor diabetes control- T1/T2
Somatoform disorders
-> Management of these should return normal function and patient comfort
What are the conditions causing dry mouth for which only symptomatic treatment is available?
Sjogren’s
Dry mouth from cancer tx
Dry mouth from salivary gland disease
What are the treatment options for dry mouth caused by sjogrens, cancer tx, gland disease?
Intensive dental prevention
Salivary stimulants
Salivary replacements
What flow test is done for dry mouth?
Patient spits into tube for 15 mins
-> if less than 1.5ml unstimulated flow in this time it suggests dry mouth
What blood tests are done to investigate cause of dry mouth?
Dehydration – U&Es, Glucose (diabetes)
Autoimmune disease – ANA, Anti-Ro, Anti-La (ENA Screen), CRP
Complement levels – c3 and c4
What imaging can be done when investigating cause of dry mouth?
Salivary ultrasound – looking for leopard spots (sjogrens) OR sialectasis
Sialography – useful where obstruction/ductal disease is suspected
Why is a dry eyes screen done at same time when investigating cause of salivary disease?
Salivary gland disease is often associated with lacrimal disease
What tests are done as part of dry eye screen?
Refer to optician for assessment of tear film (preferred)
Schirmer test – tear flow less than 5mm wetting of test paper in 15 mins
What are the signs of disease in a labial gland biopsy?
Lymphocytic infiltrate and focal acinar disease
What should dentists do to manage dry mouth?
Prevent oral disease:
-> Caries risk assessment
-> Candida/staphylococci awareness and reduction – low sugar diet and OHI (angular chelitis)
Maximal preventative strategy
-> Diet advice
-> Fluoride
-> Treatment Planning for high caries risk
Which saliva substitutes are available?
Sprays
-> Glandosane- acidic so discouraged
-> Saliva Orthana
Lozenges
-> Saliva Orthana
-> SST
Salivary stimulants
-> Pilocarpine (Salagen)
Oral Care Systems
-> Oral Balance- gels (to stop mucosa sticking), toothpastes
Frequent sips of water
Sugar free gum
What is the side effect of Pilocarpine?
Increased residual gland function- excess sweating
Tachycardia
What are the issues with saliva substitutes?
Lack of persisting relief- may work briefly
Patients find difficulty in using often enough to get proper relief
What are the true causes of hypersalivation? (actual increase in flow)
Drug causes
Dementia
CJD
Stroke
What drugs are associated with hypersalivation?
Parasympathomimetic
Buprenorphine
Anticholinesterases
Haloperidol
Ipecacuanha
Clonazepam
Nicardipine
Clozapine
What are the causes of swallowing failure which can lead to perceived hypersalivation?
Anxiety
Stroke
Motor Neurone Disease
Multiple Sclerosis
What causes drooling in MND/MS?
Frequency and efficacy of swallowing is reduced resulting in saliva build up and drooling
What patients suffer postural drooling?
Babies
Cerebral palsy
-> no issue swallowing or with excess saliva but with keeping head up right
What drugs can be used to reduce salivation?
Anti-muscarinics
Botox- prevents activation of glands by cholinergic stimulation
What can help stroke victims with swallowing control?
Biofeedback training
What surgeries can be used to prevent excess salivation ?
Duct repositioning (CP/MND if head positioning causing issue)- moved into pharynx from front of mouth
-> saliva empties directly into pharynx for easier swallowing
Gland removal- last resort
