Salivary Dysfunction Flashcards
State the consequences of salivary gland dysfunction and hyposalivation
When saliva is diminished in quantity or altered in composition the following may occur;
• Deterioration of oral soft and mineralized tissues
- Increased levels of dysphagia- patients may have difficulty tasting, tolerating, and swallowing certain foods. These patients may have resultant nutritional intake inadequacies
- Increased risk of Candida infections- very common. Saliva has been shown to be rich in proteins that have potent antifungal properties
- Recent studies also have shown that patients with decreased salivary function more frequently exhibit periodontal disease, especially loss of clinical attachment.
Define sialometry
- Tool used for initial screening and grading severity for hyposalivation. It measures saliva flow
- Salivary flow collection must be performed precisely according to the type of gland and over a period of at least 5 minutes and often up to 15 minutes
Describe how radiographs are used to assess salivary gland function
- In advanced stages can see fibrosis of the salivary glands
- Sialograms are performed with injection of a radiocontrast dye into the salivary ductal system before conventional radiography
- May reveal radiopaque calcifications or, if more advanced, larger, lobular calcifications
- Magnetic resonance imaging (MRI) sialography has been shown to be much more accurate in demonstrating levels of salivary gland destruction
Define xerostomia and its contributing factors
- Subjective symptom of ‘dry mouth’–5 to 46% of population (US) report symptoms of xerostomia
- Contributing factors: gender, age and medications, Sjögren syndrome and radiation therapy of head and neck
Define Sjogren’s syndrome, the three associated conditions and who is most affected
• Sjogren’s syndrome (SS) is an autoimmune disease complex that causes exocrinopathy and affects the salivary and lacrimal glands.
• Keratoconjunctivitis sicca, xerostomia and connective tissue disease (usually, rheumatoid arthritis)
90% of all patients are females. Usually occuurs 4th or 5th decade of life. The condition usually progresses insidiously over several years, often remaining unrecognized.
Describe the 2 main types of Sjogren’s Syndrome
Primary SS:
• Clinically manifests with the primary ocular complication of keratoconjunctivitis sicca
• In the oral cavity, it presents as various levels of salivary gland dysfunction (xerostomia)
Secondary SS:
• Manifests as the presence of keratoconjunctivitis sicca or xerostomia in the presence of a diagnosed systemic connective tissue disease
• The connective tissue disorder from which SS develops most commonly is rheumatoid arthritis, SLE, primary biliary cirrhosis, fibromyalgia, mixed connective tissue disease, polymyositis, Raynaud’s syndrome, and several others are among the associated inflammatory conditions.
Discuss the aetiology of SS
- The precise cause of SS, is unknown, several contributing factors have been identified
- One theory is that the disease results from complications of viral infection with Epstein–Barr virus infection (EBV)
- Exposure to or reactivation of EBV triggers activation of the human lymphocyte antigen (HLA) complex–this results in the release of cytokines (tumor necrosis factor [TNF], interleukin [IL]-2, interferon [IFN]-γ, and others)
- Chronic inflammation, infiltration of lymphocytes, and ultimate destruction of exocrine gland tissue follows
List the 14 oral manifestations associated with SS
- Hyposalivation
- Glossitis
- Mucositis
- Parotid gland hypertrophy
- Candidiasis
- Angular cheilosis
- Taste dysfunction
- Secondary infection
- Increased caries rate
- Periodontitis
- Glossodynia (burning tongue) - tongue often becomes depapillated and fissured
- Dorsal epithelium often is atrophic or eroded, erythematous
- Pain and burning may be spontaneous or elicited with acidic or spicy foods
- Atrophy of the epithelium in the dry environment may render the tissue susceptible to painful excoriation and ulceration- clinical follow-up / maintenance
Acute candidal infection must be treated AND maintenance therapy provided to prevent recurrence of fungal infections
Discuss the medical management of patients with SS
• Patient management for SS traditionally has been palliative and preventive. Relief of the primary symptoms of dryness (oral and ocular) and the secondary burning and discomfort is the main goal
• Restoration and maintenance of a normal homeostatic oral environment is a secondary goal
• Pilocarpine hydrochloride (cholinergic agonist) may be prescribed by GP to stimulate particular nerves to increase saliva production
• Immunosuppressants (e.g. Hydroxychloroquine)
Corticosteriods to decrease inflammation
List the three categories of dental treatment/management of SS
- Provision of moisture and lubrication by stimulation or simulation
- Treatment of secondary mucosal conditions (such as mucositis or candidiasis)
- Prevention of oral disease, provision of maintenance and general support
Describe the dental management for patients with SS
• Meticulous oral hygiene with minimally abrasive fluoridated dentifrices and irrigation devices is paramount
• Frequent professional hygiene recall intervals are also extremely important
• Frequent application of concentrated fluoride varnish and fluoride rinse to prevent the rapid progression of caries
• Over-the-counter fluoride rinses are inadequate; 5000 ppm sodium fluoride
• Can report feeling thirsty and should be advised to drink plenty of water
• Avoid diuretics such as caffeine, tobacco, and alcoholic beverages
• Change medications which may cause dry mouth
Recommend substitutes, oral lubricants, and artificial saliva (may provide some relief for the xerostomia)
Explain the limitations of oral lubricants
- The compounds of carboxymethylcellulose or hydroxymethylcellulose in the products are too viscous or not viscous enough for most patients
- The retention or longevity of their effect is very short-lived, and they provide little relief than water
List 7 conditions associated with the onset of secondary Sjrogren’s syndrome
- Rheumatoid Arthritis: an autoimmune disease of unknown origin characterised by symmetric inflammation of joints, especially of the hands, feet, and knees
- Systemic Lupus Erythematous: an autoimmune disease whereby anti-DNA antibodies are produced, resulting in attacks on organs of the body, damage to the CNS, heart and kidneys
- Primary biliary cirrhosis: suspected to be an autoimmune disease in which the bile ducts in the liver are slowly destroyed
- Fibromyalgia: a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues
- Polymyositis: a persistent inflammatory muscle disease that causes weakness of the skeletal muscles, which control movement
- Raynaud’s syndrome: disease is a condition in which smaller arteries supplying blood to the skin narrow and limit limiting blood circulation to affected areas
- Mixed connective tissue disease: features signs and symptoms of a combination of disorder, primarily of lupus, scleroderma and polymyositis.
