Problems with salivation

Question 1

How are salivary glands examined?

Answer 1

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

Question 2

What is the function of saliva?

Answer 2

Acid buffering

Mucosal lubrication
-> Speech
-> Swallowing

Taste facilitation

Antibacterial

Question 3

What are the causes of dry mouth?

Answer 3

 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

Question 4

How much acinar tissue is lost between age 17-90?

Answer 4

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

Question 5

What are the types of effects medical conditions can have on salivation?

Answer 5

Indirect effect- External to the gland

Direct Effect- Problems within the gland itself

Question 6

Which anti-muscarinic anti-cholinergic drugs indirectly reduce salivary flow/cause dry mouth?

Answer 6

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

Question 7

Which chronic medical issues can cause indirect salivary problems (through lack of hydration)?

Answer 7

Diabetes – Mellitus & Insipidus (loss of fluid)

Renal disease

Stroke- issues drinking properly

Addison’s Disease

Persisting Vomiting

Question 8

Which acute medical problems can cause indirect salivary issues?

Answer 8

Acute oral mucosal diseases

Burns

Vesiculobullous diseases- fluid loss from skin

Haemorrhage- lack of circulating volume in vascular system

Question 9

What are the causes of direct salivary gland issues?

Answer 9

Aplasia- Ectodermal dysplasia

Sarcoidosis

HIV disease

Gland infiltration
-> Amyloidosis
-> Haemochromatosis

Cystic Fibrosis

Question 10

What structures are affected by ectodermal dysplasia?

Answer 10

Hair, Nails, Teeth, Salivary & Sweat glands
-> Hearing and vision may be affected

Question 11

What genetic pattern does hypohydrotic ectodermal dysplasia follow?

Answer 11

X-linked

Question 12

What is sarcoidosis?

Answer 12

Granulomatous condition with infiltrate in gland preventing normal function:
 Multi-system disease
 Often seen in hylar LN in lung
 Skin and salivary changes

Question 13

How does sarcoidosis appear on different forms of imaging?

Answer 13

Ultrasound- hypoechoic change

MR scanning- enlarged parotid/SM glands

Question 14

How does CF cause issues with salivation?

Answer 14

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)

Question 15

How does HIV cause issues with salivation?

Answer 15

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)

Question 16

How does amyloidosis cause issues with salivation?

Answer 16

Excess deposition of protein within gland preventing function

Question 17

How does haemochromatosis cause issues with salivation?

Answer 17

Excess storage of iron within tissues stopping gland function (can be hereditary or assoc with other diseases)

Question 18

How can haemochromatosis be checked for?

Answer 18

Can be checked by gene mutation test

OR

FBC- high level of ferritin indicates haemochromatosis is present

Question 19

How can radiotherapy affect salivation?

Answer 19

Affects vascular supply to salivary glands causing gradual loss of blood supply and function loss

-> deficit is often permanent

Question 20

How can GVHD as a result of cancer treatment affect salivation?

Answer 20

Immunological damage to salivary glands can occur which affects ability to produce adequate amounts of saliva

Question 21

How do anti-neoplastic drugs/radio-iodine used in cancer treatment affect salivary glands?

Answer 21

These can accumulate in salivary glands and kill of acinar cells preventing normal gland function

Question 22

How does challacombe scale scoring work? How are these scores treated?

Answer 22

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

Question 23

Challacombe scale 1-3:

Each scores one point (additive)

Answer 23

1- Mirror sticks to buccal mucosa
2- Mirror sticks to tongue
3- Frothy saliva

Question 24

Challacombe scale 4-6:

Answer 24

4- No saliva pooling in floor of mouth
5- Tongue shows generalised shortening of papillae
6- Altered gingival architecture (smoothed)

Question 25

Challacombe scale 7-10:

Answer 25

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

Question 26

What blood tests are useful when investigating salivary disease?

Answer 26

FBC
U&Es
Liver function tests
C-reactive Protein
Glucose
Anti Ro Antibody
Anti La Antibody
Antinuclear Antibody
Complement C3 and C4

Question 27

Which imaging modalities are useful when investigating salivary disease?

Answer 27

Plain radiographs – reduced dose – stones

Sialography – contrast to show ducts

MR Sialography – IV contrast

Ultrasound

Question 28

What other investigations are helpful for diagnosing salivary disease?

Answer 28

Functional Assay– Salivary Flow

Tissue Assay – Labial Gland Biopsy