Ptyalism and Halitosis

Question 1

Define Ptyalism

Answer 1

= pathologic overproduction of saliva, which may occur from a number of disease states

Question 2

Define Pseudoptyalism

Answer 2

=drooling caused by inability or reluctance to swallow a normal amount of saliva

Question 3

What is the function of saliva?

Answer 3

Saliva lubricates and breaks down ingesta and protects soft oral tissues

Question 4

What are the anatomical parts

Answer 4

Question 5

What are the 4 major parts of the salivary glands?

Answer 5

Parotid, zygomatic, mandibular, and sublingual.

Cats have 2 additional glands linguocaudally to each mandibular first molar tooth called lingual molar glands.

Question 6

What nerve fibres control the salivary glands? What are their functions

Answer 6

• Parasympathetic postganglionic cholinergic nerve fibres control rate of secretion and induce formation of low-protein serous saliva
• Sympathetic stimulation promotes saliva flow through muscle contractions at salivary ducts
• Parasympathetic and sympathetic stimuli result in increased salivary gland secretion
• The sympathetic nervous system affects salivary gland secretions indirectly by innervating the blood vessels that supple the glands

Question 7

How does pseudoptyalism result?

Answer 7

Disruption of the swallowing mechanism, voluntary or involuntary.

Often the voluntary disruption is pain induces whereas the involuntary is caused by obstruction

Question 8

What are the neurologic DDx of pstyalism?

Answer 8

Neurologic:

• trigeminal neuropraxia
• megaesophagus
• facial paralysis
• seizures
• náusea from vestibular disease
• glossopharyngeal
• hypoglossal or vagus nerve lesions that result in the inability to swallow

Question 9

What are the traumatic causes of pstyalism?

Answer 9

Trauma:

• Soft tissue ulceration or laceration
• Electrical burn
• Temporomandibular joint (TMJ) luxation or fracture
• Mandibular fracture

Question 10

What are the developmental DDx causing ptyalism?

Answer 10

Developmental:

• severe brachygnathism
• extensive lip fold
• long tongue

Question 11

What are the toxic DDx causes of ptyalism>

Answer 11

Toxic :

• Organophosphate
• Caustic ingestion
• Animal venom

Question 12

What are the infectious DDx causes of ptyalism?

Answer 12

Infectious:

• acute calici or herpesvirus infection
• rabies
• pseudorabies
• tetanus
• botulism
• URT infection
• Candidiasis
• Severe periodontal disease
• Spirocercosis

Question 13

What are the GIT DDx of ptyalism?

Answer 13

Gastrointestinal:

• Nausea
• hiatal hernia
• megaoesophagus
• GDV
• gastric ulcer
• oesophageal stricture
• esophagitis
• neoplasia
• foreign body

Question 14

What are the metabolic DDx causing ptyalism

Answer 14

Metabolic:

• HE
• Uremia
• EPI
• Hyperthermia

Question 15

What are the immune mediated DDx causing ptyalism?

Answer 15

Immune mediated

• Chronic ulcerated paradental stomatitis (CUPS) in dogs
• caudal stomatitis in cats
• pemphigus
• Bullous pemphigoid
• toxic epidermal necrolysis (TEN)
• masticatory muscle myositis
• myasthenia gravis

Question 16

WHat are the dalivary gland differentail diagnosis causing ptyalism?

Answer 16

• Sialolith
• Foreign body
• Neoplasia
• Hyperplasia
• Infarction
• Sialocele
• Necrosis
• Idiopathic

Question 17

Inability to open mouth could be cause by what?

Answer 17

• Tetanus
• Craniomandibular osteopathy
• MMM
• Neoplasia
• TMJ
• Infection, sialoliths, or neoplasia

Question 18

Inability to close mouth could be cause by?

Answer 18

• Inability to close mouth:
  
  • TMJ/fracture/luxation
  • Neurological (botulism or trigeminal, neuropraxia)
  • Obstructive (neoplasia or foreign body)

Question 19

Diagnostic tests for Ptyalism:

• MDB: CBC + biochem + thyroid panel + urinalysis to rule out ______ and ensure that ______ is safe
• Oral mucosal changes with no obvious cause: _______ and _______ . Note: _____ and ______ are insufficient
• Dental radiographs to identify an oral exam, dental radiographs should be performed.
• Radiographs elucidate __________ cause such as ______ or _______ cyst.
• Patients that present with derangements of jaw motion or maxillofacial swellings should be further evaluated with _____, ______, _____ or _____ ___.
• Oral and maxillofacial causes have been ruled out, further diagnostics are indicated, beginning with _____________.
• If the pstyalisms has not been identified at this point, more specific testing test such as _____, _____, and ________.
• The clinician may also consider tests for _____ and ______

Answer 19

• MDB: CBC + biochem + thyroid panel + urinalysis to rule out metabolic causes and ensure that anaesthesia is safe
• Oral mucosal changes with no obvious cause: surgical biopsy and histopathology
• Note: Cytology and C&S are insufficient
• Dental radiographs to identify an oral exam, dental radiographs should be performed.
• Radiographs elucidate subgingival cause such as tooth root abscess or dentigerous/radicular cyst.
• Patients that present with derangements of jaw motion or maxillofacial swellings should be further evaluated with skull radiographs, nuclear scintigraphy, MRI or CT scan.
• Oral and maxillofacial causes have been ruled out, further diagnostics are indicated, beginning with thoracic abdominal radiographs.
• If the pstyalisms has not been identified at this point, more specific testing test such as upper GI studies, fluoroscopy, and endoscopy.
• The clinician may also consider tests for botulism and rabies

Question 20

Treatment:

• Direct toxic exposure = ___________________________________
• Oral inflammatory diseases _______________________
• Oral traumatic diseases ________________
• Portosystemic shunts ____________________
• Metabolic derangements ___________________
• Idiopathic or incurable condition such as structural or neurologic diseases, ________________________________
• One salivary gland is responsible for increased production,___________________. Cheiloplasty can be performed to help eliminate excessive drooling caused by lip malformation, mandibulectomy, glossectomy, or neurological disorders of swallowing.
• Decreasing overall flow of saliva attempted with ______________
• Idiopathic ptyalism, _________________________
• Ptyalism is a form of epilepsy

Answer 20

Treatment:

• Direct toxic exposure = should be treated with dilutional therapy and supportive care. Water or milk is considered the liquid of choice for dilution
• Oral inflammatory diseases directed towards reducing inflammation. This can be accomplished medically with immunosuppressive agents or surgically with periodontal treatments and/or extractions.
• Oral traumatic diseases treated surgically
• Portosystemic shunts managed surgically or medically
• Metabolic derangements treated as appropriate for the disease process.
• Idiopathic or incurable condition such as structural or neurologic diseases, treatment is directed at decreasing flow of saliva and protecting the epidermis in the chronically wet area.
• One salivary gland is responsible for increased production, surgical excision is treatment of choice. Cheiloplasty can be performed to help eliminate excessive drooling caused by lip malformation, mandibulectomy, glossectomy, or neurological disorders of swallowing.
• Decreasing overall flow of saliva attempted with atropine or glycopyrrolate
• Idiopathic ptyalism, phenobarbital may be effective.
• Ptyalism is a form of epilepsy

Question 21

Define Halitosis

Answer 21

Halitus = meaning “ breath or exhaled air”;

Halitosis = offensive odor of breath

Question 22

What are the classifications of halitosis>

Answer 22

• No universally accepted standardisation in terminology and classification of halitosis
• Pathologic halitosis means breath odor is a sign of disease or a pathologic condition
• Physiologic halitosis is when no disease but malodour by bacterial plaque.
• Halitosis can be classified according to character of odour:
  
  • Sulphurous is caused by volatile sulfur compounds (VSCs): methyl mercaptan, hydrogen sulphide, and dimethyl sulphide.
  • Fruity: caused by acetone
  • Urine or ammoniac breathe: ammonia, dimethyl amine, and trimethylamine
  • Sweet breath: ketones
  • Degree of halitosis: subjective scale from 0 – 3 or can be objectively measured using a commercially available sulphide monitor.

Question 23

What is Gingivitis? What is Gingivitis caused by?

Answer 23

• Gingivitis is the initial reversible stage of the disease
  
  • Inflammation of the gum; no inflammation in the periodontal ligament or alveolar bone
  • Initiated bacterial plaque and can be reversed at the stage of dental prophylaxis is performed and proper home-care maintained.
  • Caused by increase in overall bacteria numbers:
    
    • Primarily motile Gram negative rods and anaerobic species, and early colonisers are Gram positive aerobic and generally minimally pathogenic.
    • These bacteria promote growth of secondary and more periodontopathogen colonisers such as Porphorymonas by using oxygen to make lactate, formate, and succinate
    • The host provides nutrients to pathogenic species in form of blood and crevicular fluid (gingival inflammatory exudate)

Question 24

What is periodontitis?

Answer 24

• Periodontitis is the later stage of disease process;
  
  • Defined as an inflammatory disease of supporting structures of the teeth (the periodontal ligament and the alveolar bone) caused by micro-organisms.
  • Initiated by plaque, the progression of disease is regulated by patients’ immune response
  • Often the host response damages the periodontal tissues

Question 25

What is plaque? When does the pellicle form?

Answer 25

* Plaque is biofilm consisting of oral bacteria in a matrix of salivary glycoproteins and extracellular polysaccharides * Plaque formation begins with formation of the pellicle. * The pellicle is thin, saliva-derived layer including numerous proteins, enzymes, and other molecules that act as bacteria attachment site * It takes 24 hours for plaque to form if undisturbed, and 4 days for the bacterial flora to change from Gram-positive to Gram-negative bacteria. The bacterial change initiates gingivitis.

Question 26

* What VSCs cause halitosis? How do they aggravate the periodontitis process? * What bacteria possess proteolytic activity?.

Answer 26

* VSCs especially hydrogen sulphide (H₂S), methylmercapten (CH₃SH) and dimethyl sulphide ((CH3)₂S) cause halitosis. These compounds result from proteolytic degradation peptides by oral microorganisms. * present in saliva and gingival crevicular fluid, interdental plaque, and blood. * Also come from shed epithelium, food debris, and discharge from nasopharynx * Only gram negative anaerobic bacteria possess proteolytic activity. The bacteria associated with gingivitis and periodontitis are gram negative anaerobes and produce VSCs * VSC levels correlate with depth of periodontal pocket – deeper pockets contain more bacteria and higher percentage of anaerobic species. * VSCs in breath increases with number, depth and bleeding tendency of periodontal pockets. * The VSC aggravate the periodontitis process * Increase pocket and mucosal epithelium permeability * Expose underlying periodontium to bacterial metabolites * Low oxygen in pockets -\> results in low pH and activation of decarboxylation of amino acids (e.g. lysine, ornithine) to cadaverine and putrescine (malodorous diamines)

Question 27

What does the treatment of periodontal disease involve?

Answer 27

* Plaque control using dental prophylaxis * Pre surgical exam, 0.12% chlorhexidine lavage, supra & sub-gingival scaling, polishing, sulcal lavage, periodontal probing, oral evaluation, dental charting, dental radiographs, treatment planning, and surgery if necessary * \>0.5mm in cats and 3mm in dogs require deeper form of cleaning +/- periocuetic * \>6mm deep, furcation exposure level II or III, require periodontal flap surgery or extraction to eradicate infection * Plaque colonises tooth surface within 24 hours of cleaning * Periodontal pockets become reinfected within 2 weeks of prophylaxis without home case

Question 28

Apart from periodontal disease, What are the other oral causes of halitosis?

Answer 28

* Infection, ulceration, tumours, and foreign bodies * Intertrigo & skin fold pyoderma; overgrowth or colonisation of skin folds by normal skin bacteria and yeast * Lip folds: brachycephalic breeds, spaniels, water dogs * Clinical signs: hair loss, redness, accumulation of debris in lip folds around the mouth

Question 29

What are the gastroesophageal causes of halitosis?

Answer 29

* Megaesophagus = dilation and decreased peristalsis * Halitosis+ regurgitation, weight loss, and coughing. * Helicobacter pylori infections and gastresophageal reflux disease * Systemic diseases: * Diabetes mellitus = chronic hyperglycemia due to defective insulin secretion or action. * Lack of insulin leads to uncontrolled lipolysis and elevates levels of free patty acids in plasma * -\> Results in formation of ketones used for energy production * -\> breakdown of acetoacetate (ketone) to acetone and exhaled gives a distinctive rotten “apple smell” * Kidney insufficiency (uremia) - \> increase uric acid levels that is exhaled creating ammonium like ‘fish odor’ breath * Liver disease cause ammonium to accumulate in blood and be exhaled. * Foetor hepaticus is a peculiar odor and a late sign of liver diseases * Malodour by end-stage liver disease has sweet odor, described as ‘dead mice’.

Question 30

What are the bronchi and lung DDx of halitosis?

Answer 30

* Chronic bronchitis and bronchiectasis * Bronchiestasis is chronic airway disease leading to dilation of bronchi and collection of mucus and cell debris within air passages

Question 31

What are the tonsilar causes of halitosis?

Answer 31

* Chronic caseous tonsillitis, tonsillolithiasis, and to lesser extent peritonsillar abscess, actinomyocis, fungating malignancies and different kind of tumors