Problems with Salivation

Question 1

During extra oral exam what glands are you palpating?

Answer 1

• Parotid
• Submandibular

Question 2

During intra oral exam what are you examining in regard to salivary glands?

Answer 2

• Minor salivary glands
• Duct orifices
• Fluid expression
• Quantity and quality of saliva

Question 3

What are the key features of what saliva does?

Answer 3

• Acid buffering
• Mucosal lubrication needed for speech and swallowing
• Taste facilitation
• Antibacterial

Question 4

What are some causes of xerostomia?

Answer 4

• Salivary gland disease
• Drugs
• Medical conditions and dehydration
• Radiotherapy and cancer txt
• Anxiety and somatisation (perception of mouth is wrong but normal amount of saliva) disorders

Question 5

How do drugs cause xerostomia?

Answer 5

-

Question 6

What percentage of saliva is excreted from each gland?

Answer 6

• 37% submandibular
• 32% Parotid
• 45% Minor glands (sublingual)

Question 7

Why are elderly much more aware of changes in saliva and will feel dry mouth more than a younger person?

Answer 7

• As you age acinar tissue loss occurs
• Less gland reserves so will notice changes of drugs much more than younger person who has adequate saliva flow

Question 8

What are the two types of effect medical conditions can have on salivary glands?

Answer 8

• Indirect effect (external to gland)
• Direct effect (problems with gland itself)

Question 9

What are some common drugs that can cause indirect salivary problems?

Answer 9

Anti-muscarinic cholinerguc drugs
- Tricyclic antidepressant
- Antipsychotics

• Antihistamine
• Atropine
• Diuretics
• Cytotoxics

Question 10

What is the percentage reduction of antimuscarinic drug amitripyline on saliva?

Answer 10

• 26% reduction

Question 11

What is the percentage reduction in saliva of diuretics like bendrofluazide?

Answer 11

• 10% reduction

Question 12

What is the reduction in saliva percentage of Lithium?

Answer 12

• 70%
• People with bipolar - increased caries correlates with drug use

Question 13

What are some Chronic medical problems inducing dehydration which can cause indirect salivary problems?

Answer 13

• Diabetes - Melitus and Insipidus
• Renal disease
• Stroke
• Addison’s disease
• Persisting vomiting

Question 14

What are some acute medical problems which can lead to dehydration and can cause indirect salivary problems?

Answer 14

• Acute oral mucosal disease (painful to drink)
• Burns
• Vesiculobullous disease
• Haemorrhage

Question 15

What are some disease which cause direct salivary gland problems?

Answer 15

• Ectodermal dysplasia (gland not formed properly or at all)
• Sarcoidosis (cause infiltrate into gland and prevent proper function)
• HIV disease
• Gland infiltration like Amyloidosis or Haemochromatosis
• Cystic fibrosis (affects all gland secretion throughout body)

Question 16

Is ectodermal dysplasia x or y linked?

Answer 16

• x- linked
• Hypohidrotic

Question 17

What is Sarcoidosis?

Answer 17

• Multi system disease
• Seen as granulomatous change in the hyler lymoh nodes in lung
• Enlargement of parotid and submandibular glands

Question 18

How does Amyloid cause damage to gland?

Answer 18

• Through deposition of protein within the gland
  which prevent gland from functioning properly

Question 19

How does Haemachromatosis damage the gland?

Answer 19

• Excess storage of iron in tissues which eventually stops salivary gland from functioning

Question 20

During a blood test how can Haemochromatosis be identified?

Answer 20

• from high level of ferritin in blood

Question 21

How does radiotherapy cause saliva reduction?

Answer 21

• Affects vascular supply of gland
• Reduced blood supply to salivary glands
• Some recovery can be seen but most likely permanent deficit

Question 22

How can Graft versus host disease affect saliva?

Answer 22

• Graft versus host disease following bone marrow transplant cause immune damage to glands and over time cause reduction in salivary gland function

Question 23

How do antineoplastic drugs and radioiodine affect saliva?

Answer 23

• Accumulate in salivary glands
• Over time kill off the acinar cells and prevent function

Question 24

What scale do we use to assess dryness?

Answer 24

• Challacombe scale
• Measured from 1-10

Question 25

What are the 1-3 challacombe scale findings?

Answer 25

1- Mirror sticks to buccal mucosa
2- Mirror sticks to tongue
3 - Saliva frothy and bubbling at mouth

Question 26

What is the score of 1-3 on challacombe scale indicative of txt wise?

Answer 26

• Mild dryness
• Sugar free chewing gum for 15 mins twice daily and hydration attention

Question 27

What is the findings of 4-6 on challacombe scale?

Answer 27

4 - No saliva pooling in floor of mouth
5 - Tongue shows generalised shortened papilla
6 - Altered gingival architecture (smooth)

Question 28

What is the score of 4-6 on challacombe scale indicative of?

Answer 28

• Moderate dryness
• Sugar free chewing gum , simple sialoguges required
• Saliva substitues and topical fluoride as increased caries risk
• OHI and prevention

Question 29

What does 7-10 on challacombe score mean?

Answer 29

7 - Glossy appearance of oral mucosa esp palate
8 - Tongue lobulated /fissured
9 - Cervical caries (more than 2 teeth)
10 - Debris on palate or sticking to teeth

Question 30

What is challacombe score 7-10 indicative of txt wise?

Answer 30

• Severe dryness
• Saliva substituese
• Topical fluoride
• Intense OHI
• Usually apparent at end stage of sjogrens syndrome
• Needs assessed by specialist

Question 31

What are some tests useful for investigating salivary disease?

Answer 31

• FBC
• U&Es
• Liver function tst
• C-reactive protein
• Glucose
• Anti ro antibody
• Anti La antibody
• Antinulcear antibody
• Complement C3 and C4

Functional assay - salivary flow

Tissue assay - Labial gland biopsy

Imaging
- Plain radiographs
- Sialogaphy
- MR sialography

Ultrasound