Managing Problems with Saliva

Question 1

When pt complains of salivary gland disease? what Investigations?

Answer 1

• blood test
• diabetes
• dehydration
• autoimmune disease, Sjogren

Question 2

Assessing salivary function

Answer 2

• by assessing salivary flow
• major SG is harder to assess
• minor SG biopsy will give the same info about immune disease without a higher risk
• minor glands are assess in the lower lip- labial gland biopsy
• may produce a degree of numbness, but most useful way to assess active evidence of inflammatory/ immune salivary gland disease

Question 3

Sialography

Answer 3

• contrast into the glands ducts
• show both possibility of strictor and dilation of duct
• normal acinar pattern
• use less nowadays as there is ionising radiation
• Ultrasound has replaced sialography
• some situations, Magnetic resonance based sialography is used as it does not require cannulation

Question 4

MR sialography

Answer 4

• magnetic resonance sialography
• does not require cannulation of ducts

Question 5

if reduced salivary flow

Answer 5

• normally will have problem in swallowing food, hence affecting eating

Question 6

Frothy saliva?

Answer 6

• reduction salivary flow and increase in protein content
• worse at night because pt wakes and find the mouth is dry
• salivary flow shuts down overnight
• frequently seen in clinic, and difficult to diagnose as pt has no dry mouth

Question 7

How can anxiety and somatisation produce dry mouth?

Answer 7

• produce dryness due to prevention of salivary gland creation by brain

1. ‘cephalic’ control of salivation
   - inhibition of salivation
   - anxiety directly causes real oral dryness
2. ‘cephalic’ control of perception
   - altered perception of reality-> normla info coming from mouth is misunderstood by small changes at synapses
   - more often seen with anxiety disorders

• anxiety can also inhibits swallowing and leads to complaints of too much saliva
• may present as hypersalivation, but its normal salivary flow
• can miss diagnosis

Question 8

Frequent Somatoform Disease

Answer 8

• Oral dysaesthesia/ Burning mouth
• TMD pain
• headache
• neck/ back pain
• dyspepsia without evidence of excess acid
• irritable bowel syndrome (IBS)

Question 9

Dry mouth salivary flow rate

Answer 9

• test unstimulated salivary flow
• ask pt to spit in a tube for 15 mins
• 1.5ml of saliva is normal salivary flow rate
• if less, then hyposalivation
• actual value is debatable (0.1-0.2 ml/min)
• at rest, pt should produce more than 1.5 ml unstimulated in 15 mins
• simple test chairside

Question 10

Treatable causes of dry mouth

Answer 10

1. dehydration - change medication with anti-muscarinic side effects
2. Diabetes- ensure good diabetes control
3. Somatoform disorder- should return pt to feeling a normal comfortable mouth

• more likely to be successful than pt with real salivary gland disease

Question 11

Dry mouth with only symptomatic tx

Answer 11

• Sjogren syndrome
• Dry mouth from cancer tx
• Dry mouth from degenerative salivary gland disease

Pt cannot return to normal state hence clinician will need to try and reduce disability associated with reduction in salivary flow

Question 12

Tx options for only symptomatic tx

Answer 12

• intensive dental prevention
• salivary substitutes*
• salivary stimulants*

*to improve comfort, but pt finds unhelpful

Question 13

Investigating Dry Mouth

Answer 13

1. Salivary flow test
   - less than 1.5ml unstimulated flow in 15 mins
2. Blood test
   - Dehydration: U&Es, Glucose
   - Autoimmune disease: ANA, anti- Ro, anti-La(ENA screen), CRP
   - Complement levels - C3 and C4
3. Imaging
   - salivary ultrasound: look for leopard spots/ sialectasis
   - Sialography: useful where obstruction/ ductal disease is suspected
   - not used anymore due to ionising radiation
4. Dry eyes screen
   - refer to optician for assessment of tear film (preferred way)
   - Schirmer test - tear flow less than 5mm wetting of test paper in 15 mins
5. Tissue examination
   - labial gland biopsy
   - at lower lip and look for lymphocytic infiltrate and focal acinar disease

Question 14

Why is sialography not used anymore?

Answer 14

• due to ionising radiation

Question 15

Which pt would you see ultrasound changes?

Answer 15

• pt with Sjogren’s syndrome
• sialectasis of degenerative salivary disease

Question 16

What investigations are carried out first?

Answer 16

• normally Blood test, then ultrasound scanning
• labial biopsy is then followed to confirm presence of immune disease

Question 17

Dentist’s management of Dry Mouth

Answer 17

1. Prevent oral disease
   - caries risk assessment
   - Candida albicans/ Staphylococci awareness and reduction
   - low sugar diet and OHI
   - Angular chelitis
   - Sore tongue
2. Maximal preventative strategy
   - diet
   - fluoride; toothpaste
   - tx planning for caries risk mouth; easily cleanable surfaces

Question 18

Saliva substitutes

Answer 18

1. Sprays
   - Glandosane (discouraged due to acidic pH)
   - Saliva Orthana: mucin based spray
2. Lozenges
   - Saliva Orthana
   - SST- saliva stimulating tablets
   - more helpful in early stages when some saliva is still present
3. Saliva stimulants
   - Pilocarpine (Salagen)
   - increase residual gland function
   - sweating and tachycardia as side effect
4. Oral care systems
   - Oral Balance
   - MW, gels, toothpaste
   - improve feeling of dryness in the mouth
   - gels can be useful in nightitme; preventing surfaces from sticking to each other by forming a slippy surface on mucosa
5. Frequent sips of water

Pt reports that they are only useful for a few mins.

Question 19

Causes of hypersalivation

Answer 19

• rare condition

1. True actual increase in SF
   - drug causes; increase in salivary stimulation from lack of normal regulation
   - dementia
   - CJD
   - stroke
2. Perceived (common)- no increase in SF
   - swallowing failure due to: anxiety, stroke, motor neuron disease, multiple sclerosis
   - reduce swallowing efficacy and reduces leading to saliva buildup
   - postural drooling: being a baby, cerebral palsy

Question 20

Dealing with excess saliva

Answer 20

1. Treat the cause
   - anxiety disorders
2. Drugs to reduce salivation
   - anti-muscarinic agents
   - Botox into SG to prevent activation of SG from normal cholinergic stimulation
3. Biofeedback training
   - swallowing control
4. Surgery to salivary system
   - Gland removal
   - Duct repositioning