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My BDS4 > Oral Med - Saliva (problems, management, enlargement, Sjogrens) > Flashcards

Oral Med - Saliva (problems, management, enlargement, Sjogrens) Flashcards

1
Q

What should be included in an extra-oral examination in relation to identifying problems with saliva? (4)

A

Assess the;
- quality and quantity of saliva
- Minor salivary glands: size changes
- Duct orifices
- Fluid expression of clear saliva (milk the ducts)

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2
Q

What are the functions of saliva? (4)

A
  • Acid buffering
  • Mucosal lubrication
  • Aids Speech
  • Aids Swallowing
  • Taste facilitation
  • Antibacterial
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3
Q

With what patient complaint(s) should we investigate problems with saliva? (2)

A

taste changes

speech and swallowing problems

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4
Q

List the percentages of acinar tissue lost for each major salivary gland with age. (normal)

A
  • 37% Submandibular
  • 32% Parotid
  • 45% Minor glands
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5
Q

Describe the impact of age related salivary gland changes.

when do these become more problematic?

A

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

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6
Q

What are the general causes of dry mouth? (5)

A
  • 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
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7
Q

List the 2 general ways medical conditions can affect the salivary glands.

A
  1. Indirect effect – disease which affect the rest of the body
    - External to the gland
  2. Direct Effect – direct affect on the gland itself
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8
Q

What class of drugs can affect saliva output. Provide examples. (7)

A
  • Anti-muscarinic cholinergic drugs
  • Tricyclic antidepressant
  • Antipsychotics
  • Antihistamine
  • Atropine (premedication agent)
  • Diuretics (overuse = hypovolemia and dry mouth)
  • Cytotoxics (use in chemo, can damage glands)
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9
Q

list chronic medical problems which indirectly affect the salivary glands and can induce dehydration and reduce salivation. (10)

A
  • 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)
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10
Q

What medical conditions directly affect the gland and lead to problems with saliva? (5)

A
  • 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
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11
Q

list the ways in which radiotherapy/other cancer treatments affect the gland? (4)

A

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

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12
Q

How do we measure/classify dry mouth?

A

Challacombe Scale

Measures from 1-10

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13
Q

Describe the challacombe scale from 1-3.

A

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

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14
Q

Describe the challacombe scale from 4-6.

A

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

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15
Q

Describe the challacombe scale from 7-10

A

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)

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16
Q

What salivary test can we do chairside as a GDP?

A

unstimulated salivary flow test

px spits into a tube for 15 mins

results for Expected/normal = 1.5ml of saliva

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17
Q

What investigations would an oral med specialist/other specilaists conduct when investigating salivary flow problems? (5)

A
  • 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
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18
Q

List the order of investigations carried out when assessing saliva and state why they are done in this order.

A

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
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19
Q

What antibodies are investigated in a FBC in a patient with salivary problems and why?

A
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20
Q

Describe the characteristic appearance of a salivary gland affected by sjogrens.

A

leopard spots

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21
Q

How does anxiety cause dry mouth?

A

‘cephalic’ control of salivation
- Inhibition of salivation

Dryness is due to prevention of salivary gland secretion by the brain

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22
Q

How can anxiety also present in relation to saliva?

A

Anxiety can also inhibit swallowing and can lead to a complaint of ‘too much saliva = presents as hypersalivation however salivary flow is normal.

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23
Q

Describe how somatoform diseases can cause dry mouth, is this true dry mouth?

A

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

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24
Q

List normal resting and stimulated flow rates.

A

Resting flow = 0.3-0.4mL/min

Stimulated flow = 1-2mL/min

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25
Q

List abnormal resting and stimulated flow rates.

A

Resting flow = < 0.1mL/min
Stimulated flow = < 0.5mL/min

Hyposalivation goes unnoticed until there is a 50% decrease

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26
Q

List the treatable causes of dry mouth. (5)

A

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

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27
Q

When can dry mouth symptoms only be managed and not treated? (3)

A
  • 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

28
Q

What are the general treatment options for a px whos dry mouth can only be managed and not treated? (3)

A
  • INTENSIVE DENTAL PREVENTION
  • Salivary substitutes = improve comfort
  • Salivary stimulants = improve comfort
29
Q

What is the role of the dentist in management of dry mouth?

A

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)

30
Q

List some drugs that cause cause hypersalivation. (16)

A

Parasympathomimetics
* Buprenorphine
* Anticholinesterases
* Haloperidol
* Ipecacuanha
* Clonazepam
* Nicardipine
* Clozapine
* Remoxipride
* Niridazole
* Ammonium salts
* Bromides
* Ethionamide
* Iodides
* Ketamine
* Mercurial salts

31
Q

What are true causes of hypersalivation - rare (2)

A

Drugs

Degenerative brain diseases: increase in salivary stimulation from a lack of normal regulation
- Dementia
- CJD
- Stroke

32
Q

What are causes of perceived hypersalivation? - most common (4)

A

NO increase in saliva flow however Swallowing Failure present and saliva pools

  • Anxiety
  • Stroke
  • Motor Neurone Disease
  • Multiple Sclerosis
33
Q

How do we treat hypersalivation? (5)

A
  • 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)
34
Q

What are the causes of gland swellings/enlargements? (6)

A
  • 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)
35
Q

What are the symptoms of mumps? (9)

A
  • 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)

36
Q

How is mumps treated?

A

Treatment for children = symptomatic treatment only e.g. analgesics and fluid intake

37
Q

What is a mucocele?

A

Where obstruction of a minor gland leads to a swelling in the mucosa forming filled with saliva = SECRETION RETENTION

38
Q

Describe a mucous retention cyst.

A

Where obstruction of a minor gland within the ductal system leads to a swelling in the mucosa forming filled with saliva

39
Q

Describe a mucous extravasation cyst.

A

Where obstruction of a minor gland can be spilled out in the tissues from a ruptured duct

40
Q

How does a mucocele present, what do patients complain of? (4)

A
  • RECURRENT swelling = bursts in a few days
  • ‘salty taste’
  • Then cycle repeats
  • No discomfot
41
Q

What is a subacute obstruction?

A

Obstruction of a major gland = secretion retention

42
Q

How does a subacute obstruction present? (4)

A
  • 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
43
Q

What can cause a subacute obstruction? (3)

A
  • 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
44
Q

What can occur is a subacute obstruction isn’t addressed?

A

The back pressure can cause damage to the glands = scarring

45
Q

How do we investigate subacute obstructions?

A
  • 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
46
Q

Why are subacute obstructions investigated with a low dose radiograph?

A

low dose ensure stones can be seen as they have a low calcium content

47
Q

With what obstruction is sialography useful for diagnosing subacute obstructions?

A

mucous plugs

48
Q

What does duct dilatation prevent?

what are the consequences of this? (2)

A

normal emptying

= Micro-organisms grow and lead to persisting and recurrent sialadenits

= Gland function is gradually lost and persisting infection leads to gland removal

49
Q

what occurs in sialadenitis?

A

Normal acinar tissue lost and replaced by fibrous scar tissue

50
Q

What are the treatmetn options for a subacute obstruction? (2)

A

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
51
Q

What is sialosis

A

Persisting major salivary gland enlargement/hyperplasia with no obvious glandular cause identified

52
Q

What are the suggested causes of sialosis - salivary gland hyperplasia? (4)

A

 Alcohol abuse
 Cirrhosis
 Diabetes Mellitus
 Drugs

53
Q

How do we investigate sialosis? (6)

A

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
54
Q

How do we classify sjogrens? (3)

A
  1. Sicca Syndrome = Partial Sjögrens findings
    - Dry eyes OR mouth (not both)
  2. Sjögrens Syndrome
    * Primary = no other connective tissue disease effects are found
  • Secondary = connective tissue disease
  • Systemic lupus erythematous, Rheumatoid Arthritis, Scleroderma
55
Q

What is sjogrens?

A

A Systemic multisystem disease which is autoimmune

56
Q

Why is there a diagnostic delay in px’s with sjogrens?

A

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.
57
Q

What are the suggested causes of sjogrens? (2)

A

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

58
Q

What are the consequences of sjogrens? (3)

A

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
59
Q

In terms of histology, how is sjogrens diagnosed?

A

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

60
Q

How do we diagnose sjogrens? (2)

Summarise the diagnostic criteria

A

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

  1. 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)

61
Q

With regards to the AECG scoring system, what 3 features provide a positive oral score?

what test is used to aid this?

A
  • 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

62
Q

With regards to the AECG scoring system, what 3 features provide a positive ocular score?

what test(s) is used to aid this?

A
  • 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

63
Q

What are the most commonly associated antibodies with sjogrens syndrome?

A

Anti-Ro and Anti-La antibodies

64
Q

How do we investigate a px if sjogrens syndrome is suspected? (4)

what do we do if we are still unsure about the diagnosis?

A
  • 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

65
Q

How do we manage a px presenting with a dry mouth from sjogrens syndrome? (3)

A

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)

66
Q

How do we manage a px if sjogrens syndrome has been diagnosed early and they are not presenting with a dry mouth? (2)

A

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

67
Q

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?

A

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

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