Oral Med - Saliva (problems, management, enlargement, Sjogrens) Flashcards
What should be included in an extra-oral examination in relation to identifying problems with saliva? (4)
Assess the;
- quality and quantity of saliva
- Minor salivary glands: size changes
- Duct orifices
- Fluid expression of clear saliva (milk the ducts)
What are the functions of saliva? (4)
- Acid buffering
- Mucosal lubrication
- Aids Speech
- Aids Swallowing
- Taste facilitation
- Antibacterial
With what patient complaint(s) should we investigate problems with saliva? (2)
taste changes
speech and swallowing problems
List the percentages of acinar tissue lost for each major salivary gland with age. (normal)
- 37% Submandibular
- 32% Parotid
- 45% Minor glands
Describe the impact of age related salivary gland changes.
when do these become more problematic?
Salivary changes with age can make the patient prone to noticing the effect of other actions on the gland e.g. a 20 y/o taking a tricyclic antidepressant notices minimal/slight dryness whereas an 80 y/o who takes the same drug/dose has a greater awareness of the dry mouth as they have lost much more of the gland reserve
What are the general causes of dry mouth? (5)
- Salivary Gland disease (degenerative disease, obstruction or removal of glands)
- Drugs – antimuscarinic cholinergic action (reduces stimulation of the gland)
- Medical Conditions & Dehydration
- Radiotherapy & cancer treatments (directly affect or affect the blood supply)
- Anxiety (inhibit salivation)
Somatisation Disorders: normal volume, mouth isn’t actually dry but they perceive it to be
List the 2 general ways medical conditions can affect the salivary glands.
- Indirect effect – disease which affect the rest of the body
- External to the gland - Direct Effect – direct affect on the gland itself
What class of drugs can affect saliva output. Provide examples. (7)
- Anti-muscarinic cholinergic drugs
- Tricyclic antidepressant
- Antipsychotics
- Antihistamine
- Atropine (premedication agent)
- Diuretics (overuse = hypovolemia and dry mouth)
- Cytotoxics (use in chemo, can damage glands)
list chronic medical problems which indirectly affect the salivary glands and can induce dehydration and reduce salivation. (10)
- Diabetes – Mellitus & Insipidus
- Renal disease
- Stroke (can drink propely)
- Addison’s Disease
- Persisting Vomiting
- Acute medical Problems
- Acute oral mucosal diseases (can drink due to discomfort)
- Burns (fluid loss through the skin)
- Vesiculobullous diseases (fluid loss through the skin)
- Haemorrhage (lack of circulating volume in the vascular system)
What medical conditions directly affect the gland and lead to problems with saliva? (5)
- Ectodermal dysplasia: glands don’t form properly/dont form
- Sarcoidosis
- Multisystem disease
- Granulomatous disease which causes infiltrate in the gland = reduce function
- Also characterised by granulomatous change in the hilar lymph nodes in the lung, skin and salivary changes
- Enlargement of parotid and submandibular gland on MR scanning
- Hypoechoic changes to the gland tissue on ultrasound
- HIV disease
- Causes lymphoproliferative changes in the gland
- Increased bulk and reduced function as the acinar tissue is lost
- Can be a presenting feature of HIV (no other symptoms) – offer an HIV test
- Gland infiltration
- Amyloidosis: via deposition of protein within the gland = prevents function
- Haemochromatosis: excess storage of iron within the tissues = stops salivary tissue functioning. Can be assessed via haematinics (high conc of ferritin In the blood)
Cause damage to the gland structure - Cystic Fibrosis: affects all gland secretions throughout the body
list the ways in which radiotherapy/other cancer treatments affect the gland? (4)
Direct Radiation effects = affect vascular supply = blood supply and saliva function lost due to damage to the gland
Antineoplastic drugs = accumulate in glands and overtime destroy the acinar cells and inhibit function
Radioiodine = accumulate in glands and overtime destroy the acinar cells and inhibit function
Graft versus host effects (after bone marrow transplant) causes immune damage
How do we measure/classify dry mouth?
Challacombe Scale
Measures from 1-10
Describe the challacombe scale from 1-3.
1 - mirror sticks to buccal mucosa
2 - mirror sticks to tongue
3 - saliva is frothy
= mild dryness
= may not need tx or management
= sugar free gum for 15 mins 2x daily and attention to hydration
= many drugs can cause milld dryness
= check ups and monitor
Describe the challacombe scale from 4-6.
4 = no saliva pooling in the FOM
5 = Tongue shows generalised shortened papillae (mild depapillation)
6 = altered gingival architecture (smooth)
= moderate dryness
= sugar-freee gum and simple sialogues may be required
= investigate further if reasons for dryness not clear
= saliva substitutes adn topical fluoride helpful
= monitor at regular intervals esp for early decay and symptom change
Describe the challacombe scale from 7-10
7 = glassy appearance of oral mucosa, esp palate
8 = tongue lobulated/fissured
9 = cervical caries (more than 2 teeth)
10 = debris on palate or sticking to teeth
= severe dryness
= saliva subs and topical fluoride
= find cause of hyposalivation and exclude sjogrens
= refer for investigations and diagnosis
= monitor for changing signs and symptoms (specialist input if worseneing)
What salivary test can we do chairside as a GDP?
unstimulated salivary flow test
px spits into a tube for 15 mins
results for Expected/normal = 1.5ml of saliva
What investigations would an oral med specialist/other specilaists conduct when investigating salivary flow problems? (5)
- Blood tests
- FBC
- Dehydration = U&Es, glucose
- Liver function tests
- C-reactive Protein
- Autoimmune disease = Anti Ro Antibody, Anti La Antibody (ENA screen), Antinuclear Antibody, CRP.
- Complement levels = C3 and C4
- Functional Assay– Salivary Flow
- Tissue Assay – Labial Gland Biopsy - lower lip – looking for lymphocytic infiltrate and focal acinar disease
- Must consider risks and ensure informed consent
- Only carried out if there are other pieces of evidence that suggest salivary gland disease
- Imaging:
- Plain radiographs (reduced dose) = useful for assessing obstruction e.g. stones
- Ultrasound (replaces need for sialography and preferred ) : assess leopard spots or sialectasis
- Sialography with contrast = show obstruction/ductal disease/strictures/dilatation
- MR Sialography – IV contrast
- Dry eyes screen
- Refer to optician for assessment of tear film (preferred)
- Schirmer test – tear flow less than 5mm wetting of test paper in 15 mins
List the order of investigations carried out when assessing saliva and state why they are done in this order.
Blood tests, US scanning carried out first followed by labial gland biopsy to confirm presence of immune disease
- Risks of biopsy: numbness of the lip in the biopsy area
What antibodies are investigated in a FBC in a patient with salivary problems and why?
Describe the characteristic appearance of a salivary gland affected by sjogrens.
leopard spots
How does anxiety cause dry mouth?
‘cephalic’ control of salivation
- Inhibition of salivation
Dryness is due to prevention of salivary gland secretion by the brain
How can anxiety also present in relation to saliva?
Anxiety can also inhibit swallowing and can lead to a complaint of ‘too much saliva = presents as hypersalivation however salivary flow is normal.
Describe how somatoform diseases can cause dry mouth, is this true dry mouth?
All about perception
Salivary flow is normal but the ability to feel/recognise moistness in the mouth is reduced.
No = complaints of a dry mouth with no dryness problem
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
List normal resting and stimulated flow rates.
Resting flow = 0.3-0.4mL/min
Stimulated flow = 1-2mL/min
List abnormal resting and stimulated flow rates.
Resting flow = < 0.1mL/min
Stimulated flow = < 0.5mL/min
Hyposalivation goes unnoticed until there is a 50% decrease
List the treatable causes of dry mouth. (5)
Where management can return the salivary flow back to normal
- Dehydration
- Changing Medicines with anti-muscarinic side effects
- Preventing Medicines cfrom ausing dehydration
- Diabetes control – type 1 or type 2
- Managing somatoform Disorder – diagnosis of exclusion
Management of these should return the patient’s oral comfort
When can dry mouth symptoms only be managed and not treated? (3)
- Sjögren’s Syndrome
- Dry mouth from cancer treatment
- Dry mouth from degenerative salivary gland disease
Px cannot be returned to normal and the clinician must reduce the disability associated with reduced salivary flow
What are the general treatment options for a px whos dry mouth can only be managed and not treated? (3)
- INTENSIVE DENTAL PREVENTION
- Salivary substitutes = improve comfort
- Salivary stimulants = improve comfort
What is the role of the dentist in management of dry mouth?
Prevent oral disease:
Caries risk assessment & Maximal preventative strategy
- 5000ppm toothpaste
- Manage diet
- Planning tx for a HR mouth = ensure cleansable surfaces and good OH
Candida/staphylococci awareness and reduction – low sugar diet and OHI
- Angular chelitis
- Sore tongue
Advise/prescribe:
spray - Saliva Orthana
Lozenges
- Saliva Orthana
- SST (saliva stimulating tablets)
Oral Care Systems
- Oral Balance
Mouthwashes, gels and toothpastes
Advise:
* Frequent sips of water (most useful)
* Or sugar free gum (stimulates residual saliva)
List some drugs that cause cause hypersalivation. (16)
Parasympathomimetics
* Buprenorphine
* Anticholinesterases
* Haloperidol
* Ipecacuanha
* Clonazepam
* Nicardipine
* Clozapine
* Remoxipride
* Niridazole
* Ammonium salts
* Bromides
* Ethionamide
* Iodides
* Ketamine
* Mercurial salts
What are true causes of hypersalivation - rare (2)
Drugs
Degenerative brain diseases: increase in salivary stimulation from a lack of normal regulation
- Dementia
- CJD
- Stroke
What are causes of perceived hypersalivation? - most common (4)
NO increase in saliva flow however Swallowing Failure present and saliva pools
- Anxiety
- Stroke
- Motor Neurone Disease
- Multiple Sclerosis
How do we treat hypersalivation? (5)
- Treat the Cause e.g. Anxiety disorders
- Drugs to reduce salivation in true hypersalivation conditions, degenerative brain diseases or in swallowing problems.
- Anti-muscarinic agents e.g. hyoscine
- Botox to prevent gland stimulation (in severe cases) and prevent activation of the salivary glands
- Biofeedback training (in stroke patients)
- Swallowing control
- Surgery to salivary system (in cerebral palsy and some MND)
- Duct repositioning
- Gland removal (rare and last resort)
What are the causes of gland swellings/enlargements? (6)
- Viral Inflammation
- Mumps
- HIV
- Secretion retention/obstruction
- Mucocele minor glands)
- Duct obstruction (larger salivary glands)
- Gland Hyperplasia
- Sialosis = when there is an unknown cause of hyperplasia
- Sjögrens Syndrome (most common and know)
What are the symptoms of mumps? (9)
- Headache
- Joint pain
- Nausea
- Dry mouth
- Mild abdominal pain
- Feeling tired
- loss of appetite
- Pyrexia of 38C, or above
If someone whos not a child contracts = much more severe symptoms;
Especially the abdominal pain from pancreatic involvement and the testicular involvement (can lead to males being infertile)
How is mumps treated?
Treatment for children = symptomatic treatment only e.g. analgesics and fluid intake
What is a mucocele?
Where obstruction of a minor gland leads to a swelling in the mucosa forming filled with saliva = SECRETION RETENTION
Describe a mucous retention cyst.
Where obstruction of a minor gland within the ductal system leads to a swelling in the mucosa forming filled with saliva
Describe a mucous extravasation cyst.
Where obstruction of a minor gland can be spilled out in the tissues from a ruptured duct
How does a mucocele present, what do patients complain of? (4)
- RECURRENT swelling = bursts in a few days
- ‘salty taste’
- Then cycle repeats
- No discomfot
What is a subacute obstruction?
Obstruction of a major gland = secretion retention
How does a subacute obstruction present? (4)
- Swelling associated with meals
- increases as salivary stimulation/flow starts
- swelling reduces when salivary flow stops and stimulation stops and saliva is released past the obstruction
- Usually submandibular (since the pathway is longer), occasionally Parotid
- Can be slowly progressive over weeks
- Eventually becomes fixed & painful as the gland completely obstructs
What can cause a subacute obstruction? (3)
- Sialolith (stones)
- Can occur in the duct and the gland itself
- ‘mucous’ plugging (same symptoms as stone just not visible on x-ray)
- Ductal stricture from damage during chronic infection = scarring
What can occur is a subacute obstruction isn’t addressed?
The back pressure can cause damage to the glands = scarring
How do we investigate subacute obstructions?
- Low dose plain radiography – low dose ensure stones can be seen as they have a low calcium content
- lower true occlusal
- PA type placed in cheek (parotid)
- SIALOGRAPHY – when infection free and not during an acute episode
- Useful when there is no stone (use: mucous plug obstruction)
- Diagnostic tool and a treatment
- Isotope scan if gland function uncertain
- Ultrasound assessment of duct system
Why are subacute obstructions investigated with a low dose radiograph?
low dose ensure stones can be seen as they have a low calcium content
With what obstruction is sialography useful for diagnosing subacute obstructions?
mucous plugs
What does duct dilatation prevent?
what are the consequences of this? (2)
normal emptying
= Micro-organisms grow and lead to persisting and recurrent sialadenits
= Gland function is gradually lost and persisting infection leads to gland removal
what occurs in sialadenitis?
Normal acinar tissue lost and replaced by fibrous scar tissue
What are the treatmetn options for a subacute obstruction? (2)
No symptoms = no treatment need
- Rapidly remove the cause of the blockage = urgent
- Surgical sialolith removal if practical
- use Sialography for ‘no stone’ cases – as dye has a washing effect and is diagnostic
- Consider gland removal if fixed swelling and no obvious cause
- Also considered in persistent and recurring infection occurs
What is sialosis
Persisting major salivary gland enlargement/hyperplasia with no obvious glandular cause identified
What are the suggested causes of sialosis - salivary gland hyperplasia? (4)
Alcohol abuse
Cirrhosis
Diabetes Mellitus
Drugs
How do we investigate sialosis? (6)
Diagnosed by exclusion;
= exclude sjogrens
Blood tests:
* Glucose
* FBC, U&Es, LFTs, bilirubin
* BBV screen – HIV, Hep B, Hep C
* AutoAntibody Screen - ANA, anti-Ro, anti-La
- MRI of major salivary glands
- USS for Sjögren’s changes – exclude
- Labial gland biopsy
- Tear film
- Sialography – occasionally
- Photography
How do we classify sjogrens? (3)
- Sicca Syndrome = Partial Sjögrens findings
- Dry eyes OR mouth (not both) - Sjögrens Syndrome
* Primary = no other connective tissue disease effects are found
- Secondary = connective tissue disease
- Systemic lupus erythematous, Rheumatoid Arthritis, Scleroderma
What is sjogrens?
A Systemic multisystem disease which is autoimmune
Why is there a diagnostic delay in px’s with sjogrens?
due to late presentations the disease is hidden in the salivary glands and there is no obvious pain
- by the time presentation occurs/dry mouth noticable the majority of acinar cells have been destroyed.
What are the suggested causes of sjogrens? (2)
Speculative genetic;
Genetic predisposition – runs in families, but no specific inheritance pattern has been identified
- Association (not causative) with anti-Ro and anti-La = appears genetic
- More prevalent in females due to oestrogen
- Incomplete cell apoptosis leads to antigens being improperly exposed = developing sjogrens changes
- Dysregulation of inflammatory process with dendritic AP cells recruiting Band T cell responses and pro-inflammatory cytokines production
speculative environment:
EBV association – weak evidence – may be reactive rather than causative
What are the consequences of sjogrens? (3)
Most immediate consequences for patients are the Oral and Ocular effects of loss of saliva and tears e.g. caries risk, oral infection, reduced lubrication and taste and dry eyes
- Gradual loss of salivary/lacrimal gland function through inflammatory destruction of the tissue
- Enlargement of major salivary glands – usually symmetrical and Usually painless
- Usually a late finding
- Increased risk of;
- Any lymphoma (5% quoted)
- Salivary marginal B-cell (MALT) Lymphoma
In terms of histology, how is sjogrens diagnosed?
Blue dots around the ducts/acinar cells are T lymphocytes which have been attracted to the area causing gland destruction.
These areas are called lymphocytic foci and are positive when > 50 lymphocytes present in the one place
For a patient to be positive for sjogrens histopathologically = More than 1 foci is considered diagnostic
How do we diagnose sjogrens? (2)
Summarise the diagnostic criteria
Complex – no single test yet gives ‘the answer’
Balance of probabilities from multiple criteria = most accurate way
scoring systems in use:
1. American-European Consensus Group (2002)
Don’t need to have all of the criteria to have a diagnosis;
FOUR or more = positive criteria for primary Sjogren diagnosis
However you must also have a positive serology or histopathology recording
- ACR-EULAR joint criteria (2016)
Variety of different prognostic ratios for each of these different symptoms;
Histopathology findings = most important/heavily weighted (Weight 3)
Labial gland biopsy = focus score >1
Autoantibody findings = the next most important/useful (Weight 3)
Presence of anti-Ro antibodies only
Dry eyes/mouth (Weight 1)
- objective salivary flow
- Schirmer test
Ultrasound now accepted as well (from 2020) (weight 1)
With regards to the AECG scoring system, what 3 features provide a positive oral score?
what test is used to aid this?
- Daily feeling of a dry mouth for >3 months
- Recurrent swelling of salivary glands as an adult
- Frequently drink liquid to aid swallowing dry foods
Abnormal UNSTIMULATED whole salivary flow (UWS) = <1.5ml in 15 mins
With regards to the AECG scoring system, what 3 features provide a positive ocular score?
what test(s) is used to aid this?
- Persistent troublesome dry eyes for >3 months
- Recurrent sensation of sand/gravel in the eyes
- Tear substitutes used >3 times day
Abnormal Schirmer test: <5mm wetting in 5 minutes
- Fluorescein tear film assessment preferred as the ocular diagnostic test over Schirmer test
What are the most commonly associated antibodies with sjogrens syndrome?
Anti-Ro and Anti-La antibodies
How do we investigate a px if sjogrens syndrome is suspected? (4)
what do we do if we are still unsure about the diagnosis?
- UWS (unstimulated whole saliva) in 15 mins - <1.5ml
- Blood test for Anti-Ro antibody
- Salivary USS
- Baseline MRI of major salivary glands (if suspected) – useful for comparison for future lymphoma screen
labial gland biopsy
How do we manage a px presenting with a dry mouth from sjogrens syndrome? (3)
Management will never restore original function
If a patient is presenting with a dry mouth and salivary deficit = Gland function is already very low
* Oral Health needs paramount – diet, OHI, 5000ppm toothpaste
* Symptomatic treatment of oral dryness
* Salivary stimulants – pilocarpine (think side effects)
How do we manage a px if sjogrens syndrome has been diagnosed early and they are not presenting with a dry mouth? (2)
If patient presenting early – NO dry mouth yet = active gland disease
* Liaise with rheumatologist – multisystem disease
* Consider Immune modulating treatment – hydroxychloroquine, methotrexate – to halt the disease process and prevent symptoms developing in the future
what are the complications of sjogrens?
Why is it important to ensure sjogrens px’s have regular check ups and are educated about their disease?
Effects of Oral Dryness:
caries risk, denture retention, infections, functional issues –speech/swallow
Salivary enlargement
- can occur at any time and usually permanent
- Reduction surgery possible but not advised
Lymphoma risk:
- Salivary lymphoma
- Increased general lymphoma risk too
Lymphoma can present years after diagnosis - therefore it is difficult to continuously review with specialists = make patients aware and ensure regular check-ups with the GDP
