Lecture 4- Dry mouth, excess salivation and halitosis

Question 1

What are the main causes of dry mouth

Answer 1

Mouth breathing
Salivary gland disease
Systemic disease
Drugs
Physchosocial causes

Question 2

Causes of salivary gland disease?

Answer 2

Immunological
reactive
neoplastic
inflammatory
infective
systemic-Sialosis
                Drugs
                metabolic (Diabetes mellitusI
                Iatrogenic (radiotherapy)

Question 3

What questions to ask patient about history of presenting complaint?

Answer 3

Ask about mouth dryness
• Ask about mouth dryness
when eating a meal
• Ask about difficulty swallowing dry foods
• Ask about snoring, mouth breathing
• Ask about dry eyes, sensation of grit in the eyes

Question 4

What should be asked in the medical and drug history?

Answer 4

What medications you are on? ( Remember some cause dry mouth)
Did you change meds at the onset of the symptoms?
Systems review to identify if there could be a systemic cause

Question 5

What questions should be asked about social history?

Answer 5

Smoker?
Chronic anxiety?
Occupation?

Question 6

What should be asked about a dental history with dry mouth?

Answer 6

Caries? Are they a denture wearer?

Do they chew gum to relief symtoms

Question 7

What should be looked for in the extra oral examinations for dry mouth?

Answer 7

Look for salivary gland or lymph node enlargement
INSPECT- the swelling ( Size or symmetry)
PALPATE- Does it feel fixed or movable? Diffuse or discreet?
PALPATE- If enlarged is it tender or painful to palpation
NERVES- Identify any neurological complications- facial nerve palsy etc?

Question 8

What do in a intra oral exam?

Answer 8

How dry is the mucosa, is it sticking to the mirror?
Palpate and try to express saliva from the ducts?
Look at the typical pattern of dental caries?
any oral mucosal disease?

Question 9

What should you consider when assessing this patient?

Answer 9

Is the symptom of xerostomia actually acompanied by hypo salivation?
Consider referral?
Consider prescribing symptomatic relief?
Consider their dental needs? High caries risk etc?

Question 10

What investigations for dry mouth can be undertaken?

Answer 10

ultrasound

The schirmers test ( Blotting paper placed under the eye to measure the tear production)

Question 11

How to relief and manage these patients?

Answer 11

Artificial saliva eg. Saliva OrthanaTM
Xylitol containing gels
eg. Biotene Oralbalance gel TM

Topical Sialogogic medication: eg. SalivixTM pastilles, sugar free chewing gum
• Systemic Sialogogic medication: eg. Pilocarpine

Question 12

How to deal with the other dental problems and prevention associated with these patients?

Answer 12

Need to maintain Dental, Periodontal and mucosal health
Prescribe fluoride toothpaste and varnish
Hygiene therapy- Maintain good oral hygiene

Question 13

What are the systemic causes of hyposalivation

Answer 13

Sjogrens syndrome (SS)
Diabetes Mellitus
Drugs
Chronic kidney disease
COPD

Question 14

Which drugs cause hypo salivation?

Answer 14

• Antipsychotics
• Anticholinergics
• Benzodiazepines
• Diuretics

Question 15

What is Sjogrens syndrome?

Answer 15

Autoimmune disorder that affects the glandular tissues.
Commonly salivary and lacrimal glands.
F>M

Question 16

What is Primary SS?

Answer 16

Not associated with rheumatoid disease. SS is a rheumatic disorder however

Question 17

What is Secondary SS?

Answer 17

It occurs secondary to another rheumatic disorder such as rheumatoid arthritis

Question 18

what is the trigger of this autoimmune disorder?

Answer 18

Can either be
Cellular immunity- infiltration of glands
Antibody mediated- Antibodies ANTI- RO and Anti- La are found in 40-75% of cases

Question 19

What are the symptoms of ss?

Answer 19

Fatigue
Dry mouth and Eyes
Myalgia ( Muscle pain)
Arthalgia (joint pain)
Pharyngeal, vaginal and anal dryness

Question 20

what is the management for extra oral symptoms

Answer 20

Drops and lubricating creams for dry eyes

Liase with rheumatologist for joint and muscle pain.

Question 21

What is the schirmers test?

Answer 21

Blotting paper is placed in the conjunctival fornix of the eye and tear production is measured

Question 22

According the the schemers test what result would indicate hypo salivation?

Answer 22

<=5mm in 5 mins

Question 23

What is sialometry?

Answer 23

Measurement of salivary flow . Less than or equal to 15ml in 15 mins of unstimutalted flow = hypo salivation

Question 24

How can you measure gland function?

Answer 24

Scintiscanning. Measures the uptake of a radioactive isotope into the glandular tissue

Question 25

How do you take a labial gland biopsy?

Answer 25

5-10 minor salivary glands are taken from the lower lip§

Question 26

What is the advantage of the labial gland biopsy?

Answer 26

most specific investigation for the diagnosis of SS

Question 27

What is a disadvantage of a labial gland biopsy

Answer 27

Invasive and risk of paraesthesia to the lip.

Question 28

What are the requirements for the diagnosis of SS?

Answer 28

Must be all of the following Symptoms of xerostomia Objective evidence of hypo salivation Objective evidence of dry eyes on examination Must be positive to 2 of the 3 following investigations Positive labial gland biopsy Presence of anti bodies (Anti ro and anti la) postive imaging investigations

Question 29

Why must we monitor patients with SS

Answer 29

They have a 33X increased chance of malignancy often lymphoma

Question 30

How to manage SS patietns

Answer 30

Dental care | Give topical and systemic sialogogic medications

Question 31

What is the effect of radiotherapy on salivary gland tissue?

Answer 31

Progressive reduction of salivary gland tissue and therefore a decrease in production of saliva.

Question 32

What is the organs or areas of the body can lead to halitosis

Answer 32

``` The oral cavity Phayngeal GI Maxillary sinus Nasal passage Respiratory pathology ```

Question 33

How to manage halitoses

Answer 33

Identify cause and remove it or modify it. If no pathology is causative then reiterate the importane of good oral hygiene,Give advice on reducing risk factors of halitosis. Topical treatment has been shown to be ineffective.

Question 34

How to deal with patients who only percieve themselves to have bad breath but they don't?

Answer 34

Reassure patient Suspect the possibility of pseudo-halitosis or halitophobia — particularly if they have good oral and dental health. Talk to the patient about referral for physchosocial especially if the halitophobia is bad.

Question 35

What causes excess salivation?

Answer 35

Often due to swallowing problem, Can often only be perceived and not actually a problem.

Question 36

Real causes of excess salivation?

Answer 36

``` Ill fitting denture GERDS disease ( Acid reflux) Mouth/throat infections and inflammation Drugs such as pilocarpine or Carbi-dopa/levo-dopa Pregnancy ```

Question 37

What local conditions effect swallowing efficiency?

Answer 37

``` Acute sinusitis – Allergies – Chronic sinusitis – Enlarged adenoids – Tumors that affect your tongue or lip movement ```

Question 38

What Systemic conditions effect swallowing efficiency

Answer 38

– Cerebral palsy – Dementia – Down syndrome – Multiple sclerosis (a disease in which your body's immune system attacks the sheath that covers your nerves) – Myasthenia gravis (a muscle weakness disorder) – Parkinson's disease – Stroke