Saliva Disorders Flashcards
What special tests can be done to investigate salivary disease?
Bloods
Functional assays
Tissue assays
Imaging (inc. sialograhy/ultrasound)
How can anxiety cause a disorder in saliva production?
Cephalic control of salivation leading to too little saliva.
Cephalic control of perception leading to too little saliva.
Inhibition in swallowing leading to too much saliva.
What is a somatoform disease?
A disease process with symptoms that cannot be properly explained or identified.
List six common somatoform diseases.
Oral Dysaesthesia
TMD pain
Headache
neck/back pain
Dyspepsia
Irritable Bowel Syndrome (IBS)
What is the normal rate of resting salivary flow?
0.3-0.4mL/min
What is the normal rate of stimulated salivary flow?
1-2mL/min
What rates of salivary flow would be considered hyposalivation, both resting and stimulated?
<0.1mL/min resting
<0.5mL/min stimulated
Which causes of dry mouth can be treated to resolve the symptoms?
Dehydration
Medicines with anti-muscarinic side effects
Medicines causing dehydration
Poor Diabetes control – type 1 or type 2
Somatoform Disorder – diagnosis of exclusion
Which diseases can the dry mouth be treated, but not fully resolved?
Sjögren’s Syndrome
Dry mouth from cancer treatment
Dry mouth from salivary gland disease
What is the treatment for dry mouth where the underlying cause cannot be resolved?
Intensive prevention
Salivary substitutes
Salivary stimulants
What blood tests should be done when investigating dry mouth?
Dehydration – U&Es, Glucose
Autoimmune disease – ANA, Anti-Ro, Anti-La (ENA Screen), CRP
Complement levels – c3 and c4
What special tests might an optitian be able to provide with regards to investigating dry mouth?
Assessment of tear film (preferred)
Schirmer test – tear flow less than 5mm wetting of test paper in 15 mins
How should a dentist manage???????????????
Prevent oral disease
Caries risk assessment
Candida/staphylococci
Angular chelitis
Sore tongue
Maximal preventative strategy
Diet!
Fluoride
Treatment Planning for a caries risk mouth
List four true causes of hypersalivation.
Drug causes
Dementia
CJD
Stroke
List six perceived causes of hypersalivation (causes where there is no increase in flow rate).
Swallowing Failure
Anxiety
Stroke
Motor Neurone Disease
Multiple Sclerosis
Postural Drooling
Being a baby
Cerebral Palsy
What treatment options are there for hypersalivation?
Treat the Cause
Anxiety disorders
Drugs to reduce salivation
Anti-muscarinic agents
Botox to prevent gland stimulation
Biofeedback training
Swallowing control
Surgery to salivary system
Gland removal
Duct repositioning
What clinical signs can be used to assess salivary issues?
E/o examination of major salivary glands
I/o examination of minor salivary glands, ducts, fluid levels
What is the function of saliva?
Acid buffering
Mucosal lubrication (for speech and swallowing)
Taste facilitation
Antibacterial role
What are the main broad causes of xerostomia?
Salivary gland disease
Drugs
Medical conditions + dehydration
Radiotherapy and cancer treatments
Anxiety & somatization disorders
Why does the incidence of xerostomia increase as a patient gets older?
Acinar tissue loss of the major salivary glands, can be between 30-45% of tissue loss leading to reduced function.
What is an indirect problem with a salivary gland?
A problem which does not affect the gland itself, but is results in impacted salivary gland problem.
Give six examples of medications that can cause indirect salivary problems.
Tricyclic anti-depressants
Anti-psychotics
Anti-histamines
Atropine
Diuretics
Cytotoxics
Give six examples of medical conditions that can cause indirect salivary problems.
Diabetes (type 1 and type 2)
Renal disease
Stroke
Addison’s disease
Vomiting conditions
Acute oral mucosal diseases/injuries
List five direct salivary gland problems that can lead to xerostomia?
Aplasia (ectodermal dysplasia)
Sarcoidosis
HIV disease
Gland infiltration
Cystic fibrosis
What is ectodermal dysplasia?
Disorders resulting from abnormalities from the ectodermal structures. Can affect hair, nails, teeth, salivary and sweat glands. Can present as salivary aplasia alone.
What is sarcoidosis?
A condition in which there is an abnormal collection of inflammatory cells that form clumps in the lungs, skin or lymph nodes. This results in persistent dry cough and shortness of breath.
Outline the Challacombe scale of dryness
1 - Mirror sticks to buccal mucosa
2 - Mirror sticks to tongue
3 - Saliva frothy
4 - No pooling of saliva in FoM
5 - Shortened tongue papillae
6 - Altered gingival architecture (smooth)
A score of 1-3 indicates mild dryness
A score of 4-6 indicates moderate dryness
What may cause an increase in salivary gland size?
Viral infection (mumps, HIV)
Secretion retention (duct obstruction, mucocele)
Gland hyperplasia (Sialosis, Sjogren’s Syndrome)
Which vaccine is given to prevent mumps?
The MMR (measles mumps rubella) vaccine.
What is subacute obstruction?
A blockage usually of the submandibular gland, leading to painful swelling in the neck. Typically gets worse around meal times. Caused by Sialolith (stones), mucous, ductal damage from infection.
What type of investigation should be done to investigate blockage of a gland duct?
Sialography
Low dose radiograph
Ultrasound
What is a sialogram?
A sialogram is an X-ray of your salivary glands to diagnose problems like infections, tumors, or stones. It involves injecting a dye into your mouth and taking a radiograph.
What are typical symptoms of a patient with mumps?
Headache
Joint pain
Nausea
Dry Mouth
Mild abdominal pain
Feeling tired
What is the treatment for mumps?
Symptomatic treatment only, very few cases result in serious outcomes.
What virus causes mumps?
Paramyxovirus
How can HIV be a cause of salivary gland swelling?
It causes lympho-proliferative enlargement of the glands, which generally does not improve with treatment. Patient may have no other HIV related symptoms.
What can cause a duct stricture?
Damage or infection in the duct, leading to a narrowed pathway for salivary flow.
What can cause a duct dilatation?
Developmental defect, leading to sialadenits. The defect prevents normal emptying and micro-organisms can grow up the duct.
Where there is no clear cause of silalosis, which factors may contribute to the cause?
Alcohol abuse
Cirrhosis
Diabetes Mellitus
Recreational drug use
What is sialosis?
Major salivary gland enlargement with no obvious glandular cause. Can be unilateral but it is rare.
What are the potential risks of xerostomia?
Caries
Oral infection
Throat infection
Difficulty speaking/swallowing/chewing
Increase risk of denture stomatisis
What is Sjorgren’s Syndrome?
An auto-immune disease, which can many systemic symptoms, but related to dentists can lead to dry mouth and dry eyes.
What are the suggested causes of Sjorgren’s Syndrome?
Genetic predisposition
Environmental
However both are speculative. Likely a cause of Genetic, environmental, infection, and dietary.
Which systemic systems can be involved in Sjogren’s Syndrome?
Lungs
Kidney
Liver
Blood vessels
Nervous system
General fatigue/pain
What are the consequences of Sjogren’s Syndrome to the oro-facial region?
Effects of Oral Dryness
caries risk, denture retention, infections, functional issues –speech/swallow
Salivary enlargement - Sialosis
can occur at any time – usually permanent
Reduction surgery possible but not advised – other health issues
Lymphoma risk
Salivary lymphoma may present with unilateral gland swelling at any stage
Increased general lymphoma risk
What are the oral and ocular symptoms of Sjogren’s Syndrome.
Oral
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
Ocular
Persistent troublesome dry eyes for >3 months
Recurrent sensation of sand/gravel in the eyes
Tear substitutes used >3 times day
Name two tests which can assess lacrimal flow.
Schirmer test
Fluroscein tear film assessment
What can be used to diagnose Sjogren’s Syndrome
Dry eyes/mouth
Autoantibody findings
Imaging findings
Radio nucleotide assessment
Histopathology findings
FOUR or more positive criteria for diagnosis
During extra oral exam what glands are you palpating?
- Parotid
- Submandibular
During intra oral exam what are you examining in regard to salivary glands?
- Minor salivary glands
- Duct orifices
- Fluid expression
- Quantity and quality of saliva
What are the key features of what saliva does?
- Acid buffering
- Mucosal lubrication needed for speech and swallowing
- Taste facilitation
- Antibacterial
What are some causes of xerostomia?
- Salivary gland disease
- Drugs
- Medical conditions and dehydration
- Radiotherapy and cancer txt
- Anxiety and somatisation (perception of mouth is wrong but normal amount of saliva) disorders
What are the two types of effect medical conditions can have on salivary glands?
- Indirect effect (external to gland)
- Direct effect (problems with gland itself)
What are some common drugs that can cause indirect salivary problems?
Anti-muscarinic cholinerguc drugs
- Tricyclic antidepressant
- Antipsychotics
- Antihistamine
- Atropine
- Diuretics
- Cytotoxics
What is the percentage reduction of antimuscarinic drug amitripyline on saliva?
- 26% reduction
What is the percentage reduction in saliva of diuretics like bendrofluazide?
- 10% reduction
What is the reduction in saliva percentage of Lithium?
- 70%
- People with bipolar - increased caries correlates with drug use
What are some Chronic medical problems inducing dehydration which can cause indirect salivary problems?
- Diabetes - Melitus and Insipidus
- Renal disease
- Stroke
- Addison’s disease
- Persisting vomiting
What are some disease which cause direct salivary gland problems?
- Ectodermal dysplasia (gland not formed properly or at all)
- Sarcoidosis (cause infiltrate into gland and prevent proper function)
- HIV disease
- Gland infiltration like Amyloidosis or Haemochromatosis
- Cystic fibrosis (affects all gland secretion throughout body)
Is ectodermal dysplasia x or y linked?
- x- linked
- Hypohidrotic
How does Amyloid cause damage to gland?
- Through deposition of protein within the gland
which prevent gland from functioning properly
How does Haemachromatosis damage the gland?
- Excess storage of iron in tissues which eventually stops salivary gland from functioning
During a blood test how can Haemochromatosis be identified?
- from high level of ferritin in blood
How does radiotherapy cause saliva reduction?
- Affects vascular supply of gland
- Reduced blood supply to salivary glands
- Some recovery can be seen but most likely permanent deficit
How can Graft versus host disease affect saliva?
- Graft versus host disease following bone marrow transplant cause immune damage to glands and over time cause reduction in salivary gland function
How do antineoplastic drugs and radioiodine affect saliva?
- Accumulate in salivary glands
- Over time kill off the acinar cells and prevent function
What scale do we use to assess dryness?
- Challacombe scale
- Measured from 1-10
What are the 1-3 challacombe scale findings?
1- Mirror sticks to buccal mucosa
2- Mirror sticks to tongue
3 - Saliva frothy and bubbling at mouth
What is the score of 1-3 on challacombe scale indicative of txt wise?
- Mild dryness
- Sugar free chewing gum for 15 mins twice daily and hydration attention
What is the findings of 4-6 on challacombe scale?
4 - No saliva pooling in floor of mouth
5 - Tongue shows generalised shortened papilla
6 - Altered gingival architecture (smooth)
What is the score of 4-6 on challacombe scale indicative of?
- Moderate dryness
- Sugar free chewing gum , simple sialoguges required
- Saliva substitues and topical fluoride as increased caries risk
- OHI and prevention
What does 7-10 on challacombe score mean?
7 - Glossy 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
What is challacombe score 7-10 indicative of txt wise?
- Severe dryness
- Saliva substituese
- Topical fluoride
- Intense OHI
- Usually apparent at end stage of sjogrens syndrome
- Needs assessed by specialist
What are some tests useful for investigating salivary disease?
- FBC
- U&Es
- Liver function tst
- C-reactive protein
- Glucose
- Anti ro antibody
- Anti La antibody
- Antinulcear antibody
- Complement C3 and C4
Functional assay - salivary flow
Tissue assay - Labial gland biopsy
Imaging
- Plain radiographs
- Sialogaphy
- MR sialography
Ultrasound
How can anxiety cause dry mouth?
- Cephalic inhibition of saliva due to anxiety directly causes real oral dryness
- Reduced salivary flow
- Feel like when you are to give a speech etc
What has replaced sialography for investigating salivary disease due to sialography containing radiation?
- Ultrasound
How can somatisation disorders cause dry mouth?
- There is a cephalic control of perception
- Altered perception of reality
- Normal info coming from mouth is misunderstood by small changes at synapses as it is processed
- Normal salivary flow
- Can be seen with anxiety disorders too
Other than dry mouth what else can anxiety cause?
- Inhibit swallowing
- Lead to complaint of too much saliva
What are some frequent Somatoform disease ?
- Oral dysesthesia
- TMD pain
- Chronic headache
- Neck/back pain
- Dyspepsia
- IBS
What is the normal rate of resting and stimulated flow of saliva?
- Resting flow = 0.3-0.4mL/min
- Stimulated flow 1-2mL/min
What is Hyposalivation resting and stimulated flow of saliva?
- Resting flow = <0.1mL/min
- Stimulated flow = <0.5mL/min
On clinic how can you test salivary flow?
- Test unstimulated salivary flow
- Spit into test tube for 15 mins
- Expect 0.3-0.4mL/min
What are some treatable causes of dry mouth?
- Dehydration
- Medicines with anti-muscarinic side effects
- Medicines causing dehydration
- Poor diabetes control - type 1 or 2
- Somatoform disorder
- Management of these should return pt oral comfort
What are some causes of dry mouth with only symptomatic txt?
- Sjogren’s syndrome
- Dry mouth from cancer txt
- Dry mouth from salivary gland disease
What are the txt options for cases of dry mouth with only symptomatic txt
- Intensive dental prevention to prevent other oral disease that can cause symptoms
- Frequent sips of cool drinks
- Suagr free chewing gum
- Artificial salvia gel
- Saliva orthana
- Bioxtra
- Glandosane
What blood test should be carried out when investigating dry mouth?
To test dehydration - U&Es , Glucose
To test autoimmune disease ANA, Anti-Ro, Anti-La (ENA screen), CRP
To test complement levels - c3 and C4
What imaging test can be carried out when investigating dry mouth?
Salivary ultrasound - looking for leopard spots or sialectasis
Sialography - useful were obsrtuction/ductal disease is suspected
What dry eyes screen can be done to investigate dry mouth?
- Schirmer test
- Tear flow less than 5mm wetting of test paper in 15mins
- Refer to optician for assessment of tear film
What tissue examination can be done when investigating dry mouth?
- Labial gland biopsy of lower lip
- Looking for lymphocytic infiltrate and local acinar disease
- Last resort to confirm presence of gland disease
What is the maximal preventative strategy?
- Encourgaed for low sugar diet and intense OHI as increased risk of candida/staphylococci infections (angular chelitis/sore tongue)
- Topical sodium fluoride 22,600ppm F-
- Prescribed 2800ppmF- (0.619%) sodium fluoride toothpaste
- Prescribe 5000ppm 1.1% sodium fluoride toothpaste
- Sodium fluoride mouthwash 0.05%
- Caries free mouth txt plan
Why is Saliva orthana preferred over glandosane?
- Glandosane has high pH so may be unsuitable for dentulous pts (only suitable for radiotherapy or sicca syndrome)
- Orthana has mucin based structure
What are some TRUE causes of hypersalivation?
- Rare but do cause an actual increase in salivary flow from lack of normal regulation
- Drug causes
- Dementia
- CJD
- Stroke
What are some common PERCEIVED causes of hypersalivation?
Can be either Swallowing failure of Postural drooling
Swallowing failure where saliva pools in mouth
- Anxiety
- Stroke
- Motor neurone disease
- Multiple sclerosis
Postural drooling where pt has difficulty in getting head into position to swallow
- Being a baby
- Cerebral palsy
What are some txt for excess saliva?
- If due to anxiety txt anxiety disorder
- Drugs to reduce salivation like anti-muscarinic agents or botox to prevent gland stimulation
- Biofeedback training for swallowing control
- Surgery to salivary system i.e. gland removal or duct repositioning into pharynx where swallowing saliva much more manageable
What are the 3 reasons for change in gland size?
- Viral inflammation
- Secretion retention
- Gland hyperplasia
What can cause viral inflammation in glands?
- Mumps
- HIV
What can cause secretion retention in glands?
- Mucocele
- Duct obstuction
What can cause gland hyperplasis?
- Sialosis (unknown cause)
- Sjogrens syndrome
What are the symptoms of mumps?
- Headache
- Joint pain
- Nausea
- Dry mouth
- Mild abdominal pain
- feeling tired
- Loss of appetite
- Pyrexia of 38C or above
What type of virus is mumps and how is it spread?
- Paramyxovirus
- Droplet spread
- Incubation 2-3weeks
- Symptomatic txt only
What is the type of enlargement seen in salivary glands due to HIV?
- Lympho-proliferative enlargement
When you have unexplained salivary swelling what disease can this be associated with?
- HIV
- Pt may present with no HIV symptoms but also can present with HIV diagnosis
What is a Mucocele?
- Swelling in the mucosa filled with saliva
Where can you find a mucocele?
- In the duct
- Extravasated in to the tissues (mucous extravasation system)
- Common to find in lower lip and soft palate (areas of trauma)
What will a pt complain of for a mucocele?
- Recurrent swelling which may burst in mater of days
- Salty taste when bursts
When should a mucocele be removed by oral surgeon?
- If mucocele becomes hard but will not cause damage if left alon until child becomes of age to get LA instead of GA to remove
What is a Subacute obstruction?
- Swelling associated with the major glands (usually submandibular as duct is longer than parotid)
- Usually associated with duct blockages either by stones or mucous plugging
With a subacute obstruction what will the pt complain of in regard to the swelling?
- Swelling associated with meals
- Swelling increases when ot eating as salivary flow starts
- Swelling decreases when salivary flow stops after meal finished
What is the progression rate of subacute obstruction?
- Slowly progressive over weeks
-Eventually becomes fixed and painful as gland is blocked and saliva cant escape
In a subacute obstruction what is the difference in outcome between submandibular and parotid?
Usually duct blockage in submandibular
- Usually duct structure in parotid
What are some causes of subacute obstruction?
- Sialolith (stones)
- Mucous plugging
- Ductal damage from chronic infection
What does this image show?
- Lower true occlusal radiograph
- Acceptable
- Sialoltih (stones)
What investigations can be done for subacute obstruction?
- Low does plain radiography
- Lower true occlusal
- Sialography (only when infection free as can further push mucous plug into gland and cause worse blocakge)
- isotope scan if gland function uncertain
- Ultrasound assessment of duct system
What does this image show?
- OPT
- Shows right side submandibular
What does this image show?
- Duct stricture using sialogram
- Stone in the parotid duct causing a stricture
- Infection most likely to have cause stone and stricture
What does this image show? How does this occur? What childhood disease may cause this?
- Duct dilatation
- Defects prevent normal emptying
- Micro0orgs grow and lead to persisting and recurrent sialadenitis
- Gland function gradually lost and persisting infections lead to gland removal
- Recurrent Parotitis of childhood
What is the management of Subacute obstruction?
- Surgical sialolith removal
- If no stone present then use Sialograpahy (washing effect)
- Consider gland removak if fixed swelling
what is the outcome of subacute obstruction if not managed?
- Reformation of stone/obstruction
- Deformity of duct - can lead to stasis and infection
- Gland damage with low salivary flow, ascending infection
What is Sialosis?
- Major salivary gland enlargement with no obvious glandular cause
- Shows bilateral enlargement with no focal enlargement and generalised diffuse change
Perhaps
- Alcohol abuse
- Cirrhosis
- Diabetes Mellitus
- Drugs
What is Sjogrens Syndrome?
- Chronic autoimmune disease affecting salivary glands and tear glands
What are the 3 classifications of Sjogrens Syndrome?
- Sicca syndrome
- Primary sjogrens
- Secondary sjogrens
What is Sicca syndrome?
- Partial sjogrens findings
- Either dry eyes or dry mouth not both
What is primary sjogrens syndrome?
- Dry eyes and dry mouth
- But no other connective tissue disease
What is Secondary sjogrens syndrome?
- Dry eyes and dry mouth
- Has other Connective tissue disease
- e.g. SLE, RA, Scleroderma
What are some common triggers that when they are interlinked makes a susceptible pt more likely of developing auto-immune disease>
- Genetics
- Infections
- Dietary components
- Toxic chemicals
What is the epidemiology of sjogrens syndrome?
- 0.2-1.2% have this disease
- Half this figure have another connective tissue disease
- 10:1 women
Why is there diagnostic delay in sjogren’s syndrome?
- Late presentations of disease due to disease not causing any pain when affecting the tissues
- Most likely only get diagnosed when pt present with dry mouth, by this time the salivary glands have been too affected for thorough intervention
If sjogrens is present during reproductive phase of pregnancy what is there a risk for the baby of?
- Neonatal lupus
- Can lead to complete heart block leading baby to need pacemaker fitted later on
There is systemic involvement in secondary sjogrens syndrome. What systems are the most involved?
- Lungs
- Kidney (renal)
- Liver
- Pancreas
- Blood vessels
- Nervous
- Due to vasculitic changes due to autoimmune process
What is the sjogrens syndrome aetiology?
- Genetic predisposition (association with anti-Ro and anti-La)
- Low oestrogen gives risk of getting CT disease
- Incomplete cell apoptosis leads to antigens being improperly exposed
- Dysregulation of inflammatory process with dendritic AP cells recruiting Band T cell responses and pro-inflam cytokines
Weak evidence of EBV (epstein bar virus) association - reactive change rather than causative
What are the consequences of sjogrens syndrome?
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