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XEROSTOMIA

XEROSTOMIA. Presenter: 黃雙玉 2004.09.17. Introduction Symptoms & signs Etiology Diagnosis Management. Introduction. Xerostomia (dry mouth): Defined by Dr. Huchinson,1898. Is not a disease but a symptom caused by many factors. Dr. Ronald

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XEROSTOMIA

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  1. XEROSTOMIA Presenter: 黃雙玉 2004.09.17

  2. Introduction • Symptoms & signs • Etiology • Diagnosis • Management

  3. Introduction 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.

  4. 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 salivarygland mucous (primarily) Salivary Gland

  5. Function of Saliva • Lubrication • Initial digestion of food • Modulate the oral flora • Immune mechanism: IgA, IgG, IgM. • Anti-microbial: lysozyme, peroxidase, lactoferrin, agglutinins. • Buffering action: tooth remineralization • Retention of removable denture

  6. Introduction • Symptoms & signs • Etiology • Diagnosis • Management • Summary

  7. Symptoms & Signs • Symptoms: • 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

  8. Symptoms & 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

  9. Introduction • Symptoms & signs • Etiology • Diagnosis • Management • Summary

  10. Etiology • Aging • Foods & drugs • Systemic factors • Radiotherapy • Sjogren’s syndrome • Other salivary gland diseases

  11. Etiology • 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.

  12. Etiology • Foods: alcohol, coffee, coco cola, smoke • Drugs: • Anti-depressants • Anti-histamine • Cimitidine • Anti-cholinergic • Anti-HTN (sympathomimetic drugs) • Anti-inflammatory

  13. Etiology • Systemic factors: • Emotions: nervousness , excitation, depression, stress.. • Encephalitis, brain tumors, stroke, Parkinson’s dis. • Dehydration: diarrhea, vomiting, polyuria of diabetes … • Anemia, nutrition deficiency.

  14. Etiology • 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

  15. Etiology • Sjogren’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

  16. Etiology • Other salivary gland diseases: • Obstruction or infection of gland • Sarcoidosis, amyloidosis • Benign or malignant tumor • Excision of gland or congenital missing

  17. Etiology • Aging • Foods & drugs • Systemic factors • Radiotherapy (>4000rad) • Sjogren’s syndrome • Other salivary gland diseases reversible change irreversible change

  18. Introduction • Symptoms & signs • Etiology • Diagnosis • Management

  19. Diagnosis • History taking • Symptoms & clinical examination • Special investigations • Salivary flow rate, SFR • Salivary scintiscanning • Sialochemical analysis & laboratory values • Labial biopsy • Sialography

  20. Salivary Flow Rate (Sialometry) • Stenson’s duct • Methods: • Resting flow, 10min • Stimulated flow, 10min: citric acid • Results: • Resting flow <0.1ml/minxerostomia • Stimulated flow<0.5ml/minirresponsive xerostomia • Basic, sensitive, time-consuming

  21. Salivary 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

  22. 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

  23. Labial Biopsy • Chisolm & Mason, 1968: • Minor salivary gland & major gland: high relation • Focus: ≥50 lymphocytes & plasma cells • ≥ 1 focus / 4 mm2: SS is diagnosed.

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

  25. Sialography • Instillation of radiopaque fluid into glands • Identification of non-calcified sialoliths & tumors • Unsuitable for diagnosis of xerostomia

  26. Diagnosis • History taking • Symptoms & clinical examination • Special investigations - Salivary flow rate, SFR • Stimulated flow - Salivary scintiscanning - Sialochemical analysis & laboratory values - Labial biopsy - Sialography

  27. Introduction • Symptoms & signs • Etiology • Diagnosis • Management

  28. Management • Dietary & environmental considerations • Preventive Dental Care Measures • Saliva stimulatants • Saliva substitutes

  29. Dietary & 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

  30. Preventive 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..

  31. Saliva Stimulatants • Chewing gums • Diabetic sweets • Sialagogues: • Pilocarpine • 5~10 mg, tid • Bradycardia, sweating, flushing, urgency of urination, GI upset … • Pyridostigmine

  32. Salivary Substitutes • Salivary Substitutes • Carboxy-methyl-cellulose or mucin • Saliva Orthana: contains fluoride. • Mixture of glycerin & citric acid • Natural oral antimicrobial contents: H2O2

  33. Management • Dietary & environmental considerations • Preventive Dental Care Measures • Saliva stimulatants • Saliva substitutes

  34. Thank you for your attention !!

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