Salivation, Salivary Gland Swellings and Enlargement, Sjogrens Syndrome Flashcards
What are the functions of Saliva?
(4)
- acid buffering
- mucosal lubrication for speech and swallowing
- taste facilitation
- antibacterial
What causes a dry mouth?
- salivary gland disease
- drugs (anti-cholinergic effects)
- medical conditions and dehydration
- radiotherapy and cancer treatments
- anxiety and somatisation disorders
What are the salivary changes with age?
17-90 years
Acinar tissue loss.
37% submandibular gland
32% parotid gland
45% minor glands
What can indirectly cause salivary problems?
anti-muscarinic cholinergic drugs:
* tricyclic antidepressant
* antipsychotics
* antihistamine
* atropine
* diuretics (overuse)
* cytotoxics (chemotherapy)
chronic medical problems inducing dehydration:
* diabetes (mellitus and insipidus)
* renal disease
* stroke
* addison’s disease
* persistent vomiting
acute medical problems:
* acute oral mucosal diseases
* burns vesiculobullous diseases
* haemorrhage
What can directly cause salivary problems?
- aplasia (ectodermal dysplasia)
- sarcoidosis
- HIV disease
- gland infiltration (amyloidosis, haemochromatosis)
- cystic fibrosis
How can HIV disease affect the saliva?
HIV disease can cause increased size of salivary glands.
What causes amyloid and haemachromatosis?
gene
HFE gene mutation that 1 in 10 people carry
What is the scale that can be used to assess dry mouth?
The Challacombe Scale of Mucosal Dryness.
Score of 1 to 10.
What are the scores on the Challacombe Scale of Oral Dryness, and what do they mean?
1 - mirror sticks to buccal mucosa
2 - mirror sticks to tongue
3 - saliva frothy
Score 1-3 indicates mild dryness. May not need treatment management. Sugar-free chewing gum for 15 mins, twice daily and attention to hydration is needed. Routine checkup monitoring needed.
4 - no saliva pooling in FoM
5 - tongue shows generalised shortenned papillae (mild depapillation)
6 - altered gingival architecture (i.e. smoot)
Score 4-6 indicates moderate dryness. Sugar-free chewing gum or simple sialogogues may be required. Needs to be investigated further if reasons for dryness are not clear. Saliva substitutes and topical fluoride may be helpful. Monitor at regular intervals especially for early decay and symptom change.
7 - glassy appearance of oral mucosa, especially palate
8 - tongue lobulated/fissured
9 - cervical caries (more than 2 teeth)
10 - debris on paalte or sticking to teeth
Score 7-10 indicates severe dryness. Saliva substitutes and topical fluoride usually needed. Cause of hyposalivation needs to be ascertained and Sjogrens Syndrome excluded. Refer for investigation and diagnosis. Patients then need to be monitored for changing symptoms and signs, with possible further specialist input if worsening.
What special investigations can be carried out for salivary disease?
Blood tests:
* FBS
* U&Es
* Liver functions tests
* C-reactive proteinn
* glucose
* anti ro antibody
* anti la antibody
* antinnuclear 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
Why is the labial gland biopsied for investigation of salivary disease?
instead of other glands
There is a risk of damage to the facial nerve is a major gland is biopsied.
Labial gland biopsy has less risk of damage.
List examples of somatoform diseases that can cause a dry mouth.
oral dysaesthesia (burning mouth syndrome)
TMD pain
headache
neck/back pain
dyspepsia (indigestion)
irritable bowel syndrome (IBS)
What is the normal rate of saliva at rest and when stimulated?
Normal resting flow: 0.3-0.4 mL/min
Normal stimulated flow: 1-2mL/min
What is the abnormal rate (hyposalivation) of saliva at rest and when stimulated?
Abnormal resting flow: <0.1mL/min
Abnormal stimulated flow: <0.5mL/min
What investigations should be carried out for a dry mouth?
(5)
Salivary flow tests:
* less than 1.5mL unstimulated flow in 15mins
Blood tests to exclude:
* dehydration - U&Es, Glucose
* autoimmune disease - ANA, Anti-Ro, Anti-La (ENA screen)
* complemet levels - C3 and C4
Imaging:
* salivary ultrasound (preferred) - looking for ‘leopard spots’ or sialectasis
* sialography - useful where obstruction/ductal disease is suspected (uses ionising radiation)
Dry eyes screen:
* refer to optician for assessment of tear film (preferred)
* Schirmer test - tear flow less than 5mm wetting of test paper in 15mins
Labial gland biopsy:
* look for lymphocytic infiltrate and focal acinar disease
How to manage a dry mouth?
Prevention of oral disease:
* caries risk assessment
* candia/staphylococci awareness and reduction (low sugar diet and OHI)
Dietary advice
Fluoride advice and application
Treatment planning for a caries risk mouth
What are examples of salivary “substitutes”?
Sprays - relief for a few minutes only:
* glandosane
* saliva orthana
Lozenges:
* saliva orthana
* saliva stimulating tablets (SST)
Salivary stimulants:
* pilocarpine (Salagen) - side effcts include tachycardia and sweating
Oral Care Systems:
* Oral Balance
Frequent sips of water
What causes hypersalivation?
True (rare) causes of hypersalivation - actual increase in salivary flow:
* drug causes
* dementia
* CJD
* stroke
Perceived (common) causes of hypersalivation - no increase in saliva flow:
* swallowing failure (anxiety, stroke, motor neurone disease, multiple sclerosis)
* postural drooling (being a baby, cerebral palsy)
How to manage hypersalivation?
(4)
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 causes changes in gland size?
(3)
viral inflammation:
* mumps
* HIV
secretion retention:
* mucocele
* duct obstruction
gland hyperplasia:
* sialosis
* sjogrens syndrome
What are the signs and symptoms of mumps?
headache
joint pain
nausea
dry mouth
mild abdominal pain
feeling tired
loss of appetite
pyrexia of 38C or above
The MMR vaccine protects us from mumps.
What causes mumps?
paramyxovirus through droplets
incubation period is 2-3 weeks
1/3 have no symptoms
Where are the common sites for mucocele?
junction of hard/soft palate
lower lip
What is a mucocele?
secretion retention in the duct
extravasated into the tissues
recurrent swelling (bursts in days)
has a salty taste
What are the common causes of salivary duct obstruction?
- usually duct blockage in submandibular
- usually duct stricture in parotid
- sialolith (stones)
- ‘mucous’ plugging (not visible on xrays)
- ductal damage from chronic infection (scarring)
What are the features of a salivary duct obstruction?
swelling that is associated with meals:
* increases as salivary flow starts
* reduced when salivary flow stops
usually submandibular, occasionally parotid
can be slowly progressive, over weeks
eventually fixed and painful
How can a salivary duct obstruction be investigated?
- low-dose plain radiography (lower true occlusal, or peri-apical parotid)
- sialography (when infection free)
- isotope scan if gland function uncertain
- ultrasound assessment of duct system
What happens when a duct is dilatated?
duct dilatation
- defect prevents normal emptying
- micro-organisms grow and lead to persisting and recurrent sialadenitis
- gland function gradually lost and persisting infection leads to gland removal
- may follow recurrent parotitis of childhood at age 20-30
How to manage salivary duct obstruction?
- surgical sialolith (salivary stone) removal if practical
- sialography for ‘no stone’ cases - washing effect
- consider gland removal if fixed swelling
What are the possible outcomes of salivary duct obstruction?
- reformation of stone/obstruction
- deformity of duct - stasis & infection
- gland damage - low salivary flow, ascending function
What is sialosis?
Major salivary gland enlargement, with no identified cause.
May be associated with alcohol abuse, cirrhosis, diabetes mellitus, drugs.
How can sialosis be diagnosed?
Diagnosis by exclusion
What is Sicca Syndrome?
dry eyes or mouth
partial sjogrens findings
What is Sjogrens Syndrome, and name the types.
Sjogrens Syndrome is an autoimmune disease affecting the salivary glands with or without connective tissue disease.
Primary SS - no connective tissue disease
Secondary SS - connective tissue disease (SLE, rheumatoid arhtritis, scleroderma)
What is the risk to the baby if a pregnant mother has Sjogrens Syndrome?
risk of neonatal lupus
What is the incidence of Sjogrens Syndrome between men and women?
female 10:1 male
Describe the speculative genetic aetiology of Sjogrens Syndrome.
Genetic predisposition, associated with anti-Ro and anti-La.
Incomplete cell apoptosis leads to anntigens being improperly exposed.
Dysregulation of inflammatory process with dendritic AP cells recruiting Band T cell responses and pro-inflammatory cytokines.
What are the effects of Sjogrens Syndrome?
consequences
- gradual loss of salivary/lacrimal gland tissue through inflammatory destruction
- enlargement of major salivary glands (usually symmetrical and painless)
- increased risk of any lymphoma (5%) (salivary marginal B-cell (MALT) lymphoma)
- oral and ocular effects of loss of saliva and tears (taste loss, caries risk, candidal infection risk)
Name 2 scoring systems to aid in the diagnosis of Sjogrens Syndrome.
American-European Consensus Group (AECG) 2022
ACR-EULAR joint criteria 2016
According to AECG
What are the oral symptoms of Sjogrens Syndrome?
- 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
- abnormal unstimulated whole salivary flow (UWS) <1.5mL in 15mins
According to AECG
What are the ocular symptoms of Sjogrens Syndrome?
- persistent troublesome dry eyes for >3 months
- recurrent sensation of sand/gravel in the eyes
- tear substitues used >3 times daily
- abnormal Schirmer test <5mm wetting in 5 minutes
Fluorescein Tear Film assessment is preferred (more comfortable).
What is the management of Sjogrens Syndrome?
(1) symptomatic; (2) asymptomatic
Patient presenting with a dry mouth and salivary deficit:
* dietary advice
* OHI
* 5000ppm fluoride toothpaste
* salivary stimulants e.g. pilocarpine (side effects: sweating and palpitations)
Patient presenting early, with no dry mouth:
* liaise with rheumatologist (SS is a multi-system disease)
* consider immune modulating treatment (hydroxychloroquine, methotrexate)
According to AECG
What is a positive labial gland biopsy?
- collection of >50 lymphocytes around a duct (lymphocytic focus)
- generalised lymphocytic infiltrate is “non-specific sialadenitis”
- > 1 focus score (FS) consistent with Sjogrens Syndrome
The most diagnostic feature on ACR-EULAR criteria
