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Oral Medicine > Salivary Gland Disease and Dry mouth > Flashcards

Salivary Gland Disease and Dry mouth Flashcards

1
Q

During an E/O and I/O examination, what should you examine, in terms of salivary glands?

A

E/O- major salivary glands, feel for lumps and enlargements.

I/O- Minor salivary glands, duct orifices, fluid expression.

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2
Q

What are the main functions of saliva?

A

Lubrication for speech and swallowing
Taste facilitation
Acid buffering
Antibacterial

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3
Q

What are the potential causes of a dry mouth?

A

Medication
Radiotherapy
Salivary gland disease
Dehydration
Anxiety and somatisation disorders
Acinar tissue loss- naturally happens with age.
Poorly controlled diabetes

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4
Q

What sort of medications would cause salivary problems?

A

Tricyclic antidepressants
Antipsychotics
Antihistamine
Atropine
Diuretics- bendroflumethiazide
Cytotoxics
Antimuscarinics- amitriptyline.

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5
Q

What medical conditions can indirectly cause salivary problems?

A

Diabetes
Renal disease
Stroke
Addison’s
Persistent vomiting
Burns
Haemorrhage
Vesiculobullous diseases

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6
Q

What medical conditions can directly affect salivary gland problems?

A

Aplasia- ectodermal dysplasia.
Sarcoidosis
HIV
Gland infiltration- amyloidosis (invasion of amyloid into the gland), haemochromatosis (invasion of iron into the gland).
Cystic fibrosis.

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7
Q

If someone had HIV, what might their initial complaint be?

A

Increase in bulk of the salivary glands.
Reduced function of the glands.

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8
Q

What scale can be used to determine the degree of dry mouth?

A

Challacombe Scale.

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9
Q

Describe the Challacombe scale 1, 2 and 3?

A

1- Mirror sticks to buccal mucosa
2- mirror sticks to tongue
3- Saliva is frothy

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10
Q

Describe the Challacombe scale 4, 5 and 6?

A

4- No saliva pooling in the floor of the mouth.
5- Tongue shows generalised shortened papillae
6- Altered gingival architecture (smooth).

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11
Q

Describe the Challacombe scale 7, 8, 9 and 10?

A

7- glossy appearance of oral mucosa, especially palate
8- tongue lobulated/fissured
9- Cervical caries
10- debris on palate or sticking to teeth

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12
Q

How is anxiety and Somatisation related to dry mouth?

A

Altered perception of reality- normal information coming from the mouth is misunderstood by small changes at synapses as it is processed.
- examine the tissues and there are no signs of disease.

Cephalic control of salivation- inhibition of salivation caused directly by the anxiety.

Anxiety can also inhibit swallowing- lead to complaint of too much saliva.

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13
Q

What investigations might you do in someone complaining of dry mouth?

A

Resting salivary flow
Stimulated salivary flow
Blood tests- FBC, U&E’s, ANA, Anti-Ro, Anti-La, CRP, complement levels.
Imaging- salivary ultrasound, sialography
Dry eyes screen- Tear film test, Shirmer test
Tissue examination- Labial gland biopsy.

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14
Q

What are the first modes of action to consider when managing a dry mouth?

A

Dehydration- get the patient to drink more water.
Chewing sugar free gum to stimulate salivary flow.
Ask GP to review their medication if you think this might be the cause.
Ask GP to check their Diabetes control.
Review after this has been done.

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15
Q

What would be considered abnormally low for resting and stimulate flow of saliva?

A

Resting flow- less than 0.1ml/min
Stimulated flow- less than 0.5ml per min.

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16
Q

As a GDP, what is your role in managing dry mouth?

A

Prevent oral disease- caries risk assessment, OHI, diet advice, fluoride supplementation.

Supply saliva stimulants and replacements as required.

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17
Q

What saliva substitutes/stimulants can you prescribe for patients with dry mouth?

A

Artificial saliva gel- 50g
Artificial saliva spray- 100ml
AS Saliva Orthana spray- 100ml

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18
Q

What saliva substitutes/stimulants can be prescribed for someone with radiotherapy-induced dry mouth or sicca syndrome?

A

Glandosane aerosol spray- 50ml
Bioxtra gel- 40ml
Pilocarpine.

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19
Q

What patients should glandosane not be given to?

A

Dentate patients.
Glandosane has a very low pH.

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20
Q

Why might someone present with enlarged salivary glands?

A

Viral inflammation- Mumps, HIV
Secretion retention- mucocele, duct obstruction
Gland hyperplasia- Sialosis, Sjögren’s syndrome

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21
Q

What causes mumps?

A

Paramyxovirus.
Droplet spread
Incubation period is 2-3 weeks.

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22
Q

What symptoms would someone experience if they had mumps?

A

Headache
Joint pain
Nausea
Dry mouth
Mild abdominal pain
Feeling tired
Temperature greater than 38 degrees
Loss of appetite

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23
Q

What treatment is given for someone with mumps?

A

Analgesics and increase fluid intake.

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24
Q

What is a mucocele?

A

Obstruction of a minor salivary gland, which causes retention of salivary fluid within the duct, leading to extravasation of saliva into tissues.

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25
Q

Where are mucoceles often found?

A

In areas of trauma, usually lower lip and junction of hard/soft palate.

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26
Q

What symptoms may someone present with that has a mucocele?

A

“ulcer” on lip that keeps swelling up and bursting.
Salty taste when it bursts.

27
Q

What causes subacute obstruction of a salivary gland duct?

A

Sialolith (stones)
Mucous plugging
Ductal damage from infection- duct stricture

28
Q

What is subacute obstruction?

A

Obstruction of salivary gland duct obstruction.

29
Q

What might a patient complain of that has salivary gland duct obstruction?

A

Swelling that increases as they eat and gradually reduces as the saliva goes by the obstruction.
Progresses over a period of weeks.
Eventually becomes a fixed and painful swelling.

30
Q

Which gland is most commonly associated with subacute obstruction?

A

Submandibular.

31
Q

What investigations might you request if you suspect someone has an obstructed salivary duct?

A

Low dose plain radiography
Lower true occlusal
Sialography- when infection free
Isotope scan if gland function uncertain
Ultrasound assessment of duct system

32
Q

What happens during a sialogram?

A

Dye is placed into the salivary gland duct and a radiograph taken.
Can see if there are any blockages or thinning of the duct.

33
Q

Why is duct dilatation an issue?

A

Duct dilates and allows accumulation of saliva and bacteria within that area.
Leads to recurrent infection and recurrent sialadenitis.

34
Q

What is Chronic Non-specific Sialadenitis?

A

Inflammation and enlargement of salivary gland.
Leads to atrophy of normal glandular tissue and stones appear.
Fibrous scar tissue forms.

35
Q

What is the treatment for chronic non-specific sialadenitis?

A

No treatment- only option is to remove the gland.

36
Q

What is the management of subacute obstruction?

A

If sialolith present- surgically remove this is practical.
SIalography to wash out the duct.
Consider gland removal if fixed swelling.

37
Q

What is sialosis?

A

Non-inflammatory enlargement of major salivary glands.
No obvious glandular cause.
Given as a diagnosis of exclusion when no other cause can be attributed for the hyperplasia.

38
Q

What may have caused the sialosis?

A

Alcohol abuse
Cirrhosis
Diabetes mellitus
Drugs

39
Q

What investigations might you request for sialosis?

A

Blood tests
Glucose test
FBC, U&E’s, LFT’s, bilirubin
BBV screen- HIV, Hep B, Hep C
Autoantibody screen- ANA, anti-Ro, anti-La

Ultrasound scan for Sjogren changes.
MRI of major salivary glands
Labial gland biopsy
Tear film
Sialography
Photography.

40
Q

What is Sjögren’s syndrome?

A

Chronic autoimmune disease of unknown aetiology that affects the salivary glands.

41
Q

What is the aetiology of Sjögren’s syndrome?

A

Genetics - association with anti-Ro and anti-La seems genetic.
Low oestrogen
Incomplete cell apoptosis leads to antigens being improperly exposed.
Dysregulation of inflammatory process with dendritic AP cells recruiting band T cell responses and pro-inflammatory cytokines.
Environmental triggers- Epstein-Barr virus.

42
Q

Describe the pathogenesis of Sjogren’s disease?

A

Patient will already have a genetic predisposition to sjogren’s.
At some point, there will be a trigger (Epstein Barr virus, tissue injury, illness), which will initiate an immune response.
Persistent activation of adaptive immune response- T and B cells.
Development of auto-antibodies which develop from B cells- Anti-Ro and anti-La.
Derangement of innate immune barriers- lymphocyte infiltration and increase cytokine production.
Ultimately causes destruction of acinar cells.

43
Q

Which patients will typically be affected by Sjogren’s?

A

Affects mostly women- symptoms do not develop until the disease is quite advanced.
Usually begin in middle age.

44
Q

If someone has Sjogren’s during pregnancy, what is the risk to the baby?

A

Neo-natal lupus.

45
Q

What is the difference between primary and secondary Sjogren’s?

A

Primary- no connective tissue disease
Secondary- Sjogren’s develops as a result of connective tissue disease- SLE, rheumatoid arthritis.

46
Q

What is Sicca syndrome?

A

Partial Sjogren’s findings.
Dry eyes or dry mouth but not both.

47
Q

What are the consequences of Sjogren’s?

A

Gradual loss of salivary/lacrimal gland tissue through inflammatory destruction.

Enlargement of major salivary glands- usually symmetrical and painless.

Increased risk of lymphoma- 10-15%.

48
Q

Describe the histological findings in Sjogren’s?

A

Large purple areas represent lymphocytic foci- area of more than 50 lymphocytes all clumped together.
- more than 2 foci would indicate Sjogren’s.

Adipose infiltration into he gland.
Ductal dilation.

49
Q

What diagnostic criteria could you use to diagnose sjogren’s?

A

American-European Consensus Group (2002)
ACR-EULAR joint criteria (2016).

50
Q

Describe the AECG criteria.

A

Dry eyes/mouth
Anti-Ro and Anti-La antibodies present
Ultrasound or sialogram shows “snowstorm appearance” or salivary gland- holes in the gland.
Histopathological assessment via labial gland biopsy.

4 or more to be positive for Sjogren’s.

51
Q

Describe the ACR/EULAR diagnostic criteria.

A

Labial gland biopsy for histopathological analysis- Lymphocytic focus score greater than 1.

Autoantibody findings- anti-Ro.

Ultrasound of salivary gland- snowstorm sialogram.

Dry eyes/dry mouth- Schirmer test, challacombe scale, objective salivary flow, unstimulated salivary flow.

Ocular staining test- less than 5mm wetting in 5 mins.

Kidney function tests, HbA1c.

Need a score of 4 to be diagnosed.

52
Q

Describe the eye and oral symptoms that someone would feel if they had Sjogren’s?

A

Daily feeling of a dry mouth for greater than 3 months.
Recurrent swelling of salivary glands as an adult.
Frequently drink fluids to eat dry food.

Feeling of grit in the eye.
Persistent dry eyes for 3 months.
Tear substitutes used more than 3 times a day.

53
Q

What tests would you request in order of first to last?

A

Look in the patients mouth first- Challacombe scale.
Unstimulated salivary flow- less than 1.5ml in 15 minutes.
Blood tests- anti-Ro antibodies.
Salivary ultrasound scan- look for snowstorm appearance.
Baseline MRI for comparison for lymphoma screen later on.

Then finally labial gland biopsy for histopathological analysis.
- important to discuss the risks of this with the patient.

54
Q

What risks would you tell the patient regarding a labial gland biopsy?

A

Pain, bruising, swelling, bleeding.

Risk of nerve damage- lower lip will be numb, as well as teeth on that side.
Painful recovering afterwards.
Damage to adjacent structures.

55
Q

What are the complications of Sjogren’s?

A

Difficulty eating and speaking.
Caries, denture retention, infections.

Salivary gland enlargement.

Lymphoma risk.

56
Q

How would you manage a patient with Sjogren’s?

A

Saliva replacement-
- artificial saliva gel- 50g.
- artificial saliva oral spray- 100ml.
- AS saliva orphans spray- 100ml.

Bioxtra gel- 40ml
Glandosane aerosol spray- 50ml

Pilocarpine- unwanted side effects.

57
Q

What cells within the salivary glands produce saliva?

A

Acinar cells

58
Q

What type of secretions come from the parotid gland?

A

Serous

59
Q

What type of secretions come from the submandibular gland?

A

Mixed serous and mucous

60
Q

What type of secretions come from the sublingual gland?

A

Mucous

61
Q

What can cause hypersalivation?

A

Stroke
MND
Parkinson’s
Dementia
Drug use
MS
Cerebral palsy- postural drooling

62
Q

How would you deal with excess saliva?

A

Treat the cause- anxiety

Drug to reduce salivation- Anti-muscarinic agents.
Botox to prevent gland stimulation

Swallowing control

Surgery to salivary system- gland removal.

63
Q

Why is Pilocarpine not tolerated well?

A

Causes sweating
Palpitations
Vomiting
Headache
Hypotension
Excessive tearing from the eyes

64
Q

What might be done in a secondary setting for someone with SS?

A

Pilocarpine
Hydroxychloroquine
IV Methylprednisolone
Methotrexate, azathioprine

Oral Medicine (15 decks)

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