managing problems with saliva Flashcards
key feature to ask on assessment when pt C/O is dry mouth
Mrs P - 54 year lady
* Referred by dentist. Complains of having a dry mouth.
* Drinks water frequently
* Worst at night
* Bad when speaking
* No problems eating
* Examination shows normal ‘frothy’ saliva
no problem on eating
* Reduced salivary flow would have a problem swallowing food
* Normal for salivary flow to shut down overnight (so wake up with a drier mouth)
* Control of salivation issue here – challenge for dentist doesn’t match with pt who actually has lack of saliva
how cna anxiety and somatisation disorders produce a ‘dry mouth’
2
‘cephalic’ control of salivation
* Inhibition of salivation – anxiety directly causes ‘real’ oral dryness
‘cephalic’ control of perception
* Altered perception of reality – normal information coming from the mouth is ‘misunderstood’ by small changes at synapses as it is processed
* More often seen with anxiety disorders
Anxiety can also inhibit swallowing and can lead to a complaint of ‘too much saliva’!
‘cephalic’ control of salivation
Inhibition of salivation – anxiety directly causes ‘real’ oral dryness
‘cephalic’ control of preception
- Altered perception of reality – normal information coming from the mouth is ‘misunderstood’ by small changes at synapses as it is processed
- More often seen with anxiety disorders
6 common somatoform disorders
- Oral Dysaesthesia (burning mouth)
- TMD pain
- Headache
- neck/back pain
- Dyspepsia
- Irritable Bowel Syndrome (IBS)
what are somatoform disorders
No active disease of tissue under complaint but has significant symptoms that are real to the pt
saliva flow test for dry motuh
Test unstimulated salivary flow – spit into tube for 15 mins – expect more than 1.5ml of saliva
Resting – 0.1/min – hyposalivation
5 treatable causes of dry mouth
- Dehydration
- Medicines with anti-muscarinic side effects
- Medicines causing dehydration
- Poor Diabetes control – type 1 or type 2
- Somatoform Disorder – diagnosis of exclusion
management of tehse should return the pt oral comfort
3 cases where pt has dry mouth but can only offer symptomatic tx
- Sjögren’s Syndrome
- Dry mouth from cancer treatment
- Dry mouth from salivary gland disease
pt cannot return to normal salivary situation, dentist must try and reduce the disability associated with reduced salivary flow
symptomatic tx options for dry mouth
INTENSIVE DENTAL PREVENTION
Improve comfort (many pt find them unhelpful)
* Salivary substitutes
* Salivary stimulants
5 investigations for dry mouth
Salivary Flow tests – less than 1.5ml unstimulated flow in 15mins
Blood tests
* Dehydration – U&Es, Glucose
* Autoimmune disease – ANA, Anti-Ro, Anti-La (ENA Screen), CRP
* Complement levels – c3 and c4
Imaging
* Salivary ultrasound – looking for ‘leopard spots’ or sialectasis of degenerative salivary disease
* Sialography – useful where obstruction/ductal disease is suspected
Dry eyes screen
* Refer to optician for assessment of tear film (preferred) - Part of normal eye examination now
* Schirmer test – tear flow less than 5mm wetting of test paper in 15 mins
Tissue examination
* Labial gland biopsy – lower lip – looking for lymphocytic infiltrate and focal acinar disease (major glands hard to access)
* Invasive, small risk of lip numbness – usually need other evidence of salivary gland disease first, informed consent by pt
* bloods, ultrasound first then this is to confirm presence of immune disease
dentist management of the dry mouth
aim
prevent oral disease
* caries risk assessment
* candida/staphlyococci awareness and reduction - low sugar diet and OHI to prevent (angular cheilitis, oral thrush)
* sore tongue
maximal dental prevention strategy for dry mouth
3
diet advice
fluoride
tx planning and caries risk assessment
pt issues with saliva substitutes
many pts only find useful for few mins after, not persisting relief
types of saliva substitures
5
Sprays
* Glandosane – acidic pH - avoid
* **Saliva Orthana **
Lozenges
* Saliva Orthana
* SST
Salivary stimulants
* Pilocarpine (Salagen)
* Sweating and tachycardia side effects unpleasants
Oral Care Systems
* Oral Balance
* Gels particularly useful at night – prevent oral mucosal surfaces from sticking to each other
Frequent sips of water
Sprays and lozenges are not useful when flow too low – only early stage
