Problems with salivation Flashcards
How are salivary glands examined?
Palpation of parotid and submandibular glands is completed in EO exam
-> Look for size changes- blockages or tumours
Intraoral examination
-> Minor salivary glands
-> Duct orifices
-> Check for fluid expression of clear saliva
What is the function of saliva?
Acid buffering
Mucosal lubrication
-> Speech
-> Swallowing
Taste facilitation
Antibacterial
What are the causes of dry mouth?
Usually due to degenerative disease
Drugs reduce salivary flow- antimuscarinic cholinergic action which reduces stimulation of glands to produce saliva
Dehydration- prevent access to body fluid required to make saliva
Cancer treatments- direct harm to gland or affect blood supply
Anxiety can present as dry mouth (chronic inhibition of salivation due to this)
Somatisation- patient feels mouth is dry when levels are normal
How much acinar tissue is lost between age 17-90?
37%- Submandibular
32%- Parotid
45%- Minor glands
Acinar tissue loss occurs with age- patient may not notice
-> Drugs can make this worse- patient become more aware of dryness as they get older as they have suffered loss of reserve gland tissue
What are the types of effects medical conditions can have on salivation?
Indirect effect- External to the gland
Direct Effect- Problems within the gland itself
Which anti-muscarinic anti-cholinergic drugs indirectly reduce salivary flow/cause dry mouth?
Tricyclic antidepressant
Antipsychotics
Antihistamine
Atropine- used to actively dry mouth
Cytotoxics- damage to glands
Diuretics- bendroflumothiazide
Lithium (bipolar)- profound reduction in salivation associated with increased caries rate
Which chronic medical issues can cause indirect salivary problems (through lack of hydration)?
Diabetes – Mellitus & Insipidus (loss of fluid)
Renal disease
Stroke- issues drinking properly
Addison’s Disease
Persisting Vomiting
Which acute medical problems can cause indirect salivary issues?
Acute oral mucosal diseases
Burns
Vesiculobullous diseases- fluid loss from skin
Haemorrhage- lack of circulating volume in vascular system
What are the causes of direct salivary gland issues?
Aplasia- Ectodermal dysplasia
Sarcoidosis
HIV disease
Gland infiltration
-> Amyloidosis
-> Haemochromatosis
Cystic Fibrosis
What structures are affected by ectodermal dysplasia?
Hair, Nails, Teeth, Salivary & Sweat glands
-> Hearing and vision may be affected
What genetic pattern does hypohydrotic ectodermal dysplasia follow?
X-linked
What is sarcoidosis?
Granulomatous condition with infiltrate in gland preventing normal function:
Multi-system disease
Often seen in hylar LN in lung
Skin and salivary changes
How does sarcoidosis appear on different forms of imaging?
Ultrasound- hypoechoic change
MR scanning- enlarged parotid/SM glands
How does CF cause issues with salivation?
CF- affects all gland secretion throughout body
Reduction of salivation can increase caries risk and rate
*If developmental- patient may not notice dry mouth as they are used to it (beware if dryness on examination)
How does HIV cause issues with salivation?
Causes lymphoproliferative changes in gland- increase in bulk and reduction in function (loss of active acinar tissue)
May be presenting feature of HIV to dental team (offer test)
How does amyloidosis cause issues with salivation?
Excess deposition of protein within gland preventing function
How does haemochromatosis cause issues with salivation?
Excess storage of iron within tissues stopping gland function (can be hereditary or assoc with other diseases)
How can haemochromatosis be checked for?
Can be checked by gene mutation test
OR
FBC- high level of ferritin indicates haemochromatosis is present
How can radiotherapy affect salivation?
Affects vascular supply to salivary glands causing gradual loss of blood supply and function loss
-> deficit is often permanent
How can GVHD as a result of cancer treatment affect salivation?
Immunological damage to salivary glands can occur which affects ability to produce adequate amounts of saliva
How do anti-neoplastic drugs/radio-iodine used in cancer treatment affect salivary glands?
These can accumulate in salivary glands and kill of acinar cells preventing normal gland function
How does challacombe scale scoring work? How are these scores treated?
Mild dryness (1-3)- sips of water and sugar free gum
Moderate dryness (4-6)- advanced treatment like saliva substitutes (higher caries risk- intensive OH, diet advice and F supplements)
Severe (7-10) should be assessed by specialist
-> seen in end stage sjorgrens disease
*additive
Challacombe scale 1-3:
Each scores one point (additive)
1- Mirror sticks to buccal mucosa
2- Mirror sticks to tongue
3- Frothy saliva
Challacombe scale 4-6:
4- No saliva pooling in floor of mouth
5- Tongue shows generalised shortening of papillae
6- Altered gingival architecture (smoothed)
Challacombe scale 7-10:
7- glassy appearance of oral mucosal (esp palate)
8- tongue lobulated and fissured
9- Cervical caries on >2 teeth
10- Debris sticking on palate/teeth
What blood tests are useful when investigating salivary disease?
FBC
U&Es
Liver function tests
C-reactive Protein
Glucose
Anti Ro Antibody
Anti La Antibody
Antinuclear Antibody
Complement C3 and C4
Which imaging modalities are useful when investigating salivary disease?
Plain radiographs – reduced dose – stones
Sialography – contrast to show ducts
MR Sialography – IV contrast
Ultrasound
What other investigations are helpful for diagnosing salivary disease?
Functional Assay– Salivary Flow
Tissue Assay – Labial Gland Biopsy
