Problems with Salivation Flashcards
Examination of SG
- palpation of Parotid and submandibular gland
- quality and quantity of saliva in mouth
E/O
- major salivary gland (size changes)
I/O
- minor SG
- duct orifices
- fluid expression of clear saliva from ducts
Functions of saliva
- acid buffering
- mucosal lubrication
1. speech
2. swallowing - taste facilitation
- antibacterial
All will be compromised if salivary problems arise.
Cause of dry mouth
Pt complain of having a dry mouth
- SG disease
- drugs, ie: anti-muscarinic
- medical conditions affecting the glands itself
- dehydration
- radiotherapy & cancer tx
** anxiety and somatisation disorders- may cause dry mouth when nervous
Salivary gland changes
- with age 17-90
Acinar tissue loss
- 37% submandibular
- 32% parotid
- 45% minor glands
Dryness due to tricyclic medication older pt will feel more dryness than younger pt
Medical conditions
- Indirect effect
- external to gland - Direct effect
- problems with gland itself
What drugs cause Indirect salivary problems?
Anti- muscarinic cholinergic drugs
- Tricyclic antidepressant
- antipsychotics
- antihistamines
- atropine
- diuretics - if overused, cause hypovolaemia and cause pt to develop dry mouth
- cytotoxics- chemotherapy
Drugs and dry mouth
- Anti- muscarinic
- Amitriptyline 26% reduction - Diuretics
- Bendrofluazide 10% reduction - Lithium
- 70% have a significant reduction
- increased caries correlates with drug use
Chronic Medical problems
- Diabetes - Mellitus and Insipidus
- loss of fluid - Renal disease
- Stroke- may not be able to drink properly
- Addison’s disease
- Persisting vomitting
Acute medical problems
- acute oral mucosal disease
- burns
- vesiculobullous disease
- haemorrhage
Direct SG Problems
- Aplasia
- ectodermal dysplasia; glands do not form properly - Sarcoidosis- infiltrate in the gland and prevent it from functioning properly
- HIV disease
- Gland infiltration
- Amyloidosis
- Haemochromatosis - Cystic fibrosis- affects all gland secretion in the body
- can increase caries risk
Ectodermal Dysplasia
- when fully expressed, cna affect hair, nails, teeth, salivary and sweat glands
- hearing and vision may be affected too
- salivary aplasia alone
Hypohidrotic ectodermal dysplasia (X- linked): commonest unusual form
Sarcoidosis
- multi-system disease
- granulomatous change in hilar lymph nodes in lungs
- skin and salivary changes
- ultrasound shows MRI: show changes within gland where are hypoechoic change on ultrasound and often enlargement of parotid and submandibular glands
HIV
- lymphoproliferative changes in gland
- increase in bulk of gland
- reduction in function as active acinar tissue is lost
- can be seen before any changes are noted
- may still be a presenting feature to dental team (when increase size of SG, offer HIV test)***
Amyloid & Haemachromatosis
- damage to gland structure
- amyloidosis through deposition of protein within the gland, which rpvents gland from functioning properly
- haemachromatosis by excess storage of iron within tissues, hence stop salivary tissue from being able to function
- hereditary
- associated with other diseases
- look through a gene mutation test
- if FBC carried out, will notice high levels of ferritin in blood
Radiotherapy and cancer treatment
- Direct radiation effect-> affect vascular supply to the salivary gland, causing blood supply to gradually lost, Salivary function lost
- may be some recovery, but may permanent deficit
- GvHD- inadequent salivary gland tissue
- anti-neoplastic drug
- accumulate in salivary glands and overtime gradually kill acinar cells, prevent gland function
- same for radioiodine
How to assess degree of mucosal dryness?
- Challacombe scale of mucosal dryness
- Measure of 1-10
Challacombe scale 1-3
- mild dryness
- mirror sticks to buccal mucosa and tongue
- saliva frothy
- may not need tx or management
- sugar free chewing gum for 15 mins, twice daily
- routine checkup and monitoring required
Challacombe scale 4-6
- moderate dryness
- no saliva visible in FoM
- tongue shows generalised shortened papillae (mild depapillation)
- altered gingival architecture (smooth appearance)
- sugar free chewing gum/ simple sialogogues may be required
- saliva substitutes and topical fluoride may be helpful
- monitor at regular intervals, especially for early decay and symptom change
- pt may have higher caries rate
Challacombe scale 7-10
- severe dryness
- glassy appearance of oral mucosa, especially palate
- tongue lobulated/ fissured
- cervical caries (more than 2 teeth)
- debris on palate/ sticking to teeth
- no saliva visible
- end stage of Sjogren syndrome and needs to be seen by a specialist
How to investigate salivary disease?
Blood test
- FBC
- U&Es
- Liver function test
- C-reactive protein
- glucose
- Anti Ro antibody
- Anti La antibody
- Antinuclear antibody
- Complement C3 and C4
Functional assay- salivary flow
Tissue assay - labial gland biopsy
Imaging
- plain radiographs - reduced dose- stones
- sialography- contrast to show ducts
- MR sialography - IV contrast
- ultrasound
