salivation Flashcards
How would you investigate salivary disease
Blood tests
-FBC
-U&Es,
-Liver function tests
-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
What does saliva do
Acid buffering
Mucosal lubrication
-Speech
-Swallowing
Taste facilitation
Antibacterial
What can the causes of dry mouth be
Salivary Gland disease
Drugs
Medical Conditions & Dehydration
Radiotherapy & cancer treatments
Anxiety & Somatisation Disorders
With age what happens to the salivary glands
Acinar tissue loss
37% Submandibular
32% Parotid
45% Minor glands
What way can medical conditions affects the salivary glands
Direct
-Problems with the gland itself
Indirect
-Problems external to the gland
What Indirect problems affect the salivary glands
Anti-muscarinic cholinergic drugs
Chronic Medical Problems inducing dehydration
Acute medical Problems
What drugs indirectly affect the salivary glands
Tricyclic antidepressant
Antipsychotics
Antihistamine
Atropine
Diuretics
Cytotoxics
What is amitriptyline and how much does it reduce saliva by
anti-muscarinic drug and reduces by 26%
What is a Bendrofluazide and what does it reduce flow by
Diruetic and reduces by 10%
How much does lithium reduce flow by
70%
What chronic Medical Problems inducing dehydration cause reduced flow
Diabetes – Mellitus & Insipidus
Renal disease
Stroke
Addison’s Disease
Persisting Vomiting
What acute medical problems cause reduced flow
Acute oral mucosal diseases
Burns
Vesiculobullous diseases
Haemorrhage
What direct problems are there that affect salivary glands
Aplasia
-Ectodermal dysplasia
Sarcoidosis
HIV disease
Gland infiltration
-Amyloidosis
-Haemochromatosis
Cystic Fibrosis
What is the challacombe scale of mucosal dryness
diagnostic medical tool designed to produce a clinical oral dryness score which quantifies the extent of dryness of the mouth, with the aim of making a decision of whether to treat or not
What are the values of the challacombe scale
1) Mirror stricks to buccal mucosa
2) Mirror sticks to tongue
3) Saliva frothy
4) No saliva pooling floor of mouth
5) Tongue shows generalised shortened papillae
6) Altered gingival architecture
7) Glossy apperance of oral mucosa
8) Tongue lobulated/fissured
9) Cervical caries
10) Debris on palate or sticking to teeth
What do the challcombe scores indicate
1-3= mild dryness may not need treatment, sugar free gum 15mins x2 daily and hydration
4-6= moderate dryness, gum or simple sialogogues may be required. Needs to be investigatd if no clear cause
7-10= Severe dryness, saliva substituues and topical fluoride. Causes needs to be identified and Sjogrens ruled out
How does Anxiety and Somatisation Disorders cause dry mouth
‘cephalic’ control of salivation
-Inhibition of salivation, anxiety directly causes ‘real’ oral dryness
‘cephalic’ control of perception
-Altered perception of reality, normal information coming from the mouth is ‘misunderstood’ by small changes at synapses as it is processed
-More often seen with anxiety disorders
What frequent Somatoform disorders are there
Oral Dysaesthesia
TMD pain
Headache
neck/back pain
Dyspepsia
Irritable Bowel Syndrome (IBS)
What is the normal salivation flow for resting and stimulated glands
Resting= 0.3-0.4 mL/min
Stimulated= 1-2 mL/min
What does the flow have to be to be hyposalivation
Resting= <0.1 mL/min
Stimulated= <0.5 mL/min
What are the treatable causes of dry mouth
Dehydration
Medicines with anti-muscarinic side effects
Medicines causing dehydration
Poor Diabetes control – type 1 or type 2
Somatoform Disorders
What conditions are there where its only symptomatic treatment of a dry mouth
Sjögren’s Syndrome
Dry mouth from cancer treatment
Dry mouth from salivary gland disease
In a salivary flow test what must the score be for dry mouth
less than 1.5ml unstimulated flow in 15mins
What saliva substitues are there
Sprays
-Glandosane
-Saliva Orthana
Lozenges
-Saliva Orthana
-SST
Salivary stimulants
-Pilocarpine (Salagen)
Oral Care Systems
-Oral Balance
Frequent sips of water
What can cause HYPERsalivation
TRUE (rare) – Actual increase in salivary flow
-Drug causes
-Dementia
-CJD
-Stroke
PERCEIVED (Common) – NO increase in saliva flow
Swallowing Failure:
-Anxiety
-Stroke
-Motor Neurone Disease
-Multiple Sclerosis
Postural Drooling:
-Being a baby
-Cerebral Palsy
What drugs can cause hypersalivation
Parasympathomimetics
Buprenorphine
Anticholinesterases
Haloperidol
Ipecacuanha
Clonazepam
Nicardipine
Clozapine
Remoxipride
Niridazole
Ammonium salts
Bromides
Ethionamide
Iodides
Ketamine
Mercurial salts
How would you deal with 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 could cause a change in salivary gland size
Viral Inflammation
-Mumps
-HIV
Secretion retention
-Mucocele
-Duct obstruction
Gland Hyperplasia
-Sialosis
-Sjögrens 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 are the common sites for a mucocele
Junction Hard/Soft Palate and the Lower lip
What is subacute obstruction
When there is swellings associated with meal times
Thee swelling increases as salivary flow starts and reduces when salivary flow stops
Usually SUBMANDIBULAR
Will eventually be fixed and painful
What is the cause of subacute obstruction
duct obstruction
-Usually duct blockage in submandibular
-Usually duct stricture in parotid
Obstruction by:
-Sialolith (stones)
-mucous plugging
-Ductal damage from chronic infection (scarring)
What investigations for subacute obstruction is there
Low dose plain radiography
lower true occlusal
SIALOGRAPHY – when infection free
Isotope scan if gland function uncertain
Ultrasound assessment of duct system
What happens in duct dilation
Defect prevents normal emptying
Micro-organisms grow and lead to persisting and recurrent sialadenits
Gland function gradually lost and persisting infection leads to gland removal
How do you manage subacute obstruction
Surgical sialolith removal if practical
Sialography for ‘no stone’ cases – washing effect
Consider gland removal if fixed swelling
