XEROSTOMIAXEROSTOMIA

Presenter: 黃雙玉 2004.09.17

IntroductionSymptoms & signsEtiology DiagnosisManagement

IntroductionIntroduction

Xerostomia (dry mouth):Defined by Dr. Huchinson,1898.Is not a disease but a symptom caused by many

factors. Dr. Ronald

Not all people who complains of xerostomia actually has salivary gland dysfunction.

Salivary GlandSalivary Gland Parotid gland

– major source when eating– serous acini only

Submandibular gland– the most responsible when no

stimuli– serous (primarily) + mucous acini

Sublingual gland– only 2-3% of saliva– mucous (primarily) + serous

Minor salivary gland– mucous (primarily)

Function of SalivaFunction of SalivaLubricationInitial digestion of food Modulate the oral flora

– Immune mechanism: IgA, IgG, IgM.– Anti-microbial: lysozyme, peroxidase, lactoferrin,

agglutinins.Buffering action: tooth remineralizationRetention of removable denture

IntroductionSymptoms & signsEtiology DiagnosisManagementSummary

Symptoms & SignsSymptoms & SignsSymptoms:

– Oral dryness (most common)– Halitosis– Burning sensation – Loss of sense of taste or bizarre taste– Difficulty in swallowing – Tongue tends to stick to the palate – Decreased retention of denture

Symptoms & SignsSymptoms & Signs Signs:

– Saliva pool disappear– Mucosa: dry or glossy– Duct orifices: viscous and opaque saliva– Tongue: glossitis fissured red with papilla atrophy– Angular cheilitis– Rampant caries: cervical or cusp tip– Periodontitis– Candidiasis

IntroductionSymptoms & signsEtiology DiagnosisManagementSummary

EtiologyEtiology Aging Foods & drugs Systemic factors Radiotherapy Sjogren’s syndrome Other salivary gland diseases

EtiologyEtiology Aging:

– Dry mouth: >50y/o:10%, >65y/o:40%. Mashvash N, 1983

– 46% of 341 subjects (98M, 243F) had noticed subjective xerostomia, more frequent in women.

T.O. Narhi, 1994

– Acinar tissue was replaced by fat and connective tissue. Waterhouse, 1973 Scott, 1977

– When become elder, mucin secretion increase.

EtiologyEtiologyFoods: alcohol, coffee, coco cola, smokeDrugs:

– Anti-depressants– Anti-histamine

Cimitidine

– Anti-cholinergic– Anti-HTN (sympathomimetic drugs)– Anti-inflammatory

EtiologyEtiologySystemic factors:

– Emotions: nervousness , excitation, depression, stress.. – Encephalitis, brain tumors, stroke, Parkinson’s dis.– Dehydration: diarrhea, vomiting, polyuria of diabetes

…– Anemia, nutrition deficiency.

EtiologyEtiology

Radiotherapy– Acini atrophy fibrosis or replaced by fatty tissue– Serous acini: more sensitive to R/T– Saliva: thickened, altered electrolytes, pH↓, secretion of immunoglobulins↓– >1000rad (2-3wk): felt oral dryness– >4000rad: irreversible change

EtiologyEtiologySjogren’s syndrome:

– Systemic autoimmune disorder, exocrine invasion mainly– 80-90% in female, middle-aged– 1o sicca syndrome

Xerostomia (82%) Keratoconjunctivitis sicca (KCS)

– 2o sicca syndrome: Sicca syndrome + other autoimmune C.T. diseases

(rheumatoid arthritis> SLE> scleroderma, polymyositis…)

– Possibility of development of MALToma

EtiologyEtiology

Other salivary gland diseases:– Obstruction or infection of gland– Sarcoidosis, amyloidosis– Benign or malignant tumor– Excision of gland or congenital missing

EtiologyEtiology Aging Foods & drugs Systemic factors Radiotherapy (>4000rad) Sjogren’s syndrome Other salivary gland diseases

irreversible change

reversible change

IntroductionSymptoms & signsEtiology DiagnosisManagement

DiagnosisDiagnosisHistory takingSymptoms & clinical examinationSpecial investigations

– Salivary flow rate, SFR– Salivary scintiscanning– Sialochemical analysis & laboratory values – Labial biopsy– Sialography

Salivary Flow Rate (Sialometry)Salivary Flow Rate (Sialometry)Stenson’s ductMethods:

– Resting flow, 10min– Stimulated flow, 10min: citric acid

Results:– Resting flow <0.1ml/minxerostomia– Stimulated flow<0.5ml/minirresponsive xerostomia

Basic, sensitive, time-consuming

Salivary ScintiscanningSalivary Scintiscanning

TC99 sodium pertechnetate Empty: 10.20.30.40.50.80 min Uptake of TC99 by salivary

gland: functional acinar tissue is present

High sensitivity, non-invasive

Sialochemical Analysis Saliva:

– Na+, K+, IgA, amylase, albumin….– Lack of specificity

Sjogren’s syndrome: have diagnostic value

Laboratory Values

Sjogren’s syndrome– Elevated ESR, IgG, RF– Positive auto-antibodies: anti-nuclear, ANA anti-SS-A, anti-Ro anti-SS-B, anti-La

Labial BiopsyLabial BiopsyChisolm & Mason, 1968:

– Minor salivary gland & major gland: high relation – Focus: ≥50 lymphocytes & plasma cells– ≥ 1 focus / 4 mm2: SS is diagnosed.

Parotid gland:- Slight acinar destruction- Dense lymphocytic infiltrate- Early proliferation of ductal cells

SialographySialography

Instillation of radiopaque fluid into glands– Identification of non-calcified sialoliths & tumors– Unsuitable for diagnosis of xerostomia

DiagnosisDiagnosisHistory takingSymptoms & clinical examinationSpecial investigations

- Salivary flow rate, SFR Stimulated flow

- Salivary scintiscanning - Sialochemical analysis & laboratory values - Labial biopsy - Sialography

IntroductionSymptoms & signsEtiology DiagnosisManagement

ManagementManagementDietary & environmental considerationsPreventive Dental Care Measures Saliva stimulatantsSaliva substitutes

Dietary & Environmental ConsiderationsDietary & Environmental Considerations Dietary:

– Avoid drugs that may produce xerostomia– Avoid dry & bulky foods– High fluid intake & rinsing with water– Avoid alcohol, smoking and sugar– Take protein and vitamin supplements

Environment:– Maintain optimal air humidity in the home– Use Vaseline to protect the lips

Preventive Dental Care MeasuresPreventive Dental Care Measures Smooth sharp cusps, occlusal grooves or fissures, irregular fillings. Check and adjust the denture. OHI. Topical fluoride with carrier use. Fluoride rinses & chlorhexidine rinses. Antifungal medications:

– Denture: Miconazole gel,amphotericin or nystatin ointment– Topical: Nystatin, amphotercin suspension or fluconazole..

Saliva StimulatantsSaliva StimulatantsChewing gumsDiabetic sweetsSialagogues:

– Pilocarpine5~10 mg, tidBradycardia, sweating, flushing, urgency of urination, GI upset …

– Pyridostigmine

Salivary SubstitutesSalivary Substitutes

Salivary Substitutes– Carboxy-methyl-cellulose or mucin– Saliva Orthana: contains fluoride. – Mixture of glycerin & citric acid

– Natural oral antimicrobial contents: H2O2

ManagementManagementDietary & environmental considerationsPreventive Dental Care Measures Saliva stimulatantsSaliva substitutes

Thank you for Thank you for your attention !!your attention !!