Xerostomia/Bulimia Flashcards
Etiology of Xerostomia (Most Frequent)
Medication side effect, Head/neck radiation therapy, Sjogren syndrome
Classes of Drugs with >10% Xerostomia Incidence (nine)
Anticholinergic - Atropine
Antihistamines - Loratradine
Antihypertensives - Lisinopril
Antidepressants - Citalopram, Haloperidol, Phenelzine
Diuretics - HCTZ
Muscle relaxants - Tizandinine
Pain medication - Opioids
Sedative - Diazepam
Radiation Therapy and Xerostomia
How quickly does salivary flow decrease? By how much?
Salivary flow decreases 50-60% within the first week.
Radiation Dose and Salivary Recovery
Recovery unlikely with parotid mean radiation doses > 24-26 Gy.
Sjogren Syndrome Characteristics
Oral and ocular dryness, Lymphocytic infiltration, More common in women > 40, Primary vs. Secondary
Sjogren Syndrome Onset
Unusual after 65; dry mouth after this age more likely due to age-related exocrine atrophy.
Other Potential Causes of Xerostomia
Autoimmune disorders (SLE, RA, Thyroid disease, PBC), Mouth breathing, Dehydration, Diabetes, Nerve damage, ESRD, GVHD, HIV/AIDS
Xerostomia Pathophysiology (Salivary Glands)
Salivary acini and ducts produce serous and mucinous fluids. Nerve stimulation releases ACh (M3 receptors) to produce saliva.
Medication-Induced Xerostomia Mechanism
Affects CNS or neuroglandular junction. Suppresses ACh production or occupies muscarinic/adrenergic receptors.
Radiation-Induced Xerostomia Mechanism
Quantitative and qualitative changes in salivary glands. Serous acini are most susceptible. Acinar atrophy and chronic inflammation.
Sjogren Syndrome Pathophysiology
Autoimmune disorder that affects moisture producing glands in the body. Sicca is latin for dryness.
Xerostomia Symptoms
Oral dryness, Burning/soreness, Diminished/altered taste, Difficulty swallowing, Thickened saliva, Sensitivity to foods, Loss of appetite
Xerostomia Evaluation
Clinical diagnosis (history and physical). Check medication list. Sialometry (stimulated <0.5-0.7 mL/min, unstimulated <0.1 mL/min)
Xerostomia Evaluation (Additional Tests)
Sialography, Biopsy (if systemic cause suspected), Labs (ESR, anemia, RF, autoantibodies for Sjogren), Lip biopsy
Xerostomia Treatment (Initial)
Patient education (frequent sipping, sugar-free gum/candy, avoid triggers, oral hygiene). Local measures (artificial saliva)
Xerostomia Treatment (Pharmacological)
Sialogogues (Pilocarpine, Cevimeline - stimulate saliva). Topical Physostigmine (cholinesterase inhibitor). Malic acid, Anethole trithionate
Xerostomia Differential Diagnosis
Primary/Idiopathic Sjogren’s syndrome (aka Sicca Syndrome), Other autoimmune diseases, Drug-induced sicca syndrome. Rule out: Sarcoidosis, GPA, IgG4-related disease, HCV, HIV, GVHD, ESRD, Head/neck radiation
Xerostomia Complications
Poor nutrition, Gingivitis/Periodontitis, Caries, Halitosis, Candidiasis, Enamel erosion, Anxiety/Depression
Xerostomia Deterrence/Patient Education
Communicate symptoms, Preventative measures (sipping water, chewing gum, humidifier, avoid triggers), Regular dental follow-up
ACP Position Statement:
Eating disorders affects what rate of women?
GERD is a risk factor for what two conditions?
A. 1 in 8 young women
B. Barrett’s esophagus and esophageal adenocarcinoma
Reduced salivary flow in bulimics is typically linked to what?
Does the reduced flow affect stimulated or unstimulated flow rate?
Do any glands get enlarged?
Anti-depressants rather than dietary habits
Primarily affects unstimulated whole salivary flow rate
- Parotid gland enlargement can occur, but in a minority
What type of bulimia nervosa did your patient have?
Why does a bulimic patient’s salivary flow decrease?
Purging type (not binge eating type)
B. Dehydration (due to exercise) vomiting, drugs (anti-depressants like SSRI like fluoxetine or TCA)
How does saliva normally help a patient’s protection against erosion? (2)
Why do food choices for purging bulimics have an impact on dental caries?
Why don’t we necessarily always see high caries rates in patients with bulimia though?
- Neutralizing effect
- Saliva contributes to acquired pellicle (which is diffusion barrier to acid erosion)
The food choices may be foods that they typically deny themselves like high energy and sugary foods.
S. mutant may be unable to metabolize below oral pH of 4.2. Also high fat foods eaten are not cariogenic.
What is stimulated saliva normal rate (ml/min)?
What is unstimulated?
What does it decrease to during sleep?
What does it increase to when chewing?
Stim: 1-2 ml/min (1 to 1.5 L/day)
Unstim: .3-.5 ml/min
Sleep: .1 ml/min
Chewing: 4-5 ml/min
What are the secretary cells for saliva?
Composition of saliva?
Acinar
99% water, rest is mucins, electrolytes, epithelial cells, salivary amylase, lipidase.
What are signs of bulimia on a patient’s hands called?
Are the eroded surfaces glossy or dull?
What kind of soft tissue lesions can occur? Why are they at higher risk for these?
Russell’s sign or calluses on the knuckles. Or cracked/dry fingernails
Glossy
Angular chelitis, candidiasis, glossitis, and oral mucosal ulceration, stemming from nutritional deficiencies
American Psychiatric Association
- How often does binge eating and inappropriate compensatory behaviors occur a week and for how many months?
- What are the two types of bulimia nervosa?
- At least twice a week for three months
- Purging and non-purging
