salivation

Question 1

How would you investigate salivary disease

Answer 1

Blood tests
-FBC
-U&Es,
-Liver function tests
-C-reactive Protein
-Glucose
-Anti Ro Antibody
-Anti La Antibody
-Antinuclear Antibody
-Complement C3 and C4

Functional Assay – Salivary Flow

Tissue Assay – Labial Gland Biopsy

Imaging
-Plain radiographs – reduced dose – stones
-Sialography – contrast to show ducts
-MR Sialography – IV contrast
-Ultrasound

Question 2

What does saliva do

Answer 2

Acid buffering

Mucosal lubrication
-Speech
-Swallowing

Taste facilitation

Antibacterial

Question 3

What can the causes of dry mouth be

Answer 3

Salivary Gland disease

Drugs

Medical Conditions & Dehydration

Radiotherapy & cancer treatments

Anxiety & Somatisation Disorders

Question 4

With age what happens to the salivary glands

Answer 4

Acinar tissue loss

37% Submandibular
32% Parotid
45% Minor glands

Question 5

What way can medical conditions affects the salivary glands

Answer 5

Direct
-Problems with the gland itself

Indirect
-Problems external to the gland

Question 6

What Indirect problems affect the salivary glands

Answer 6

Anti-muscarinic cholinergic drugs

Chronic Medical Problems inducing dehydration

Acute medical Problems

Question 7

What drugs indirectly affect the salivary glands

Answer 7

Tricyclic antidepressant

Antipsychotics

Antihistamine

Atropine

Diuretics

Cytotoxics

Question 8

What is amitriptyline and how much does it reduce saliva by

Answer 8

anti-muscarinic drug and reduces by 26%

Question 9

What is a Bendrofluazide and what does it reduce flow by

Answer 9

Diruetic and reduces by 10%

Question 10

How much does lithium reduce flow by

Answer 10

70%

Question 11

What chronic Medical Problems inducing dehydration cause reduced flow

Answer 11

Diabetes – Mellitus & Insipidus

Renal disease

Stroke

Addison’s Disease

Persisting Vomiting

Question 12

What acute medical problems cause reduced flow

Answer 12

Acute oral mucosal diseases

Burns

Vesiculobullous diseases

Haemorrhage

Question 13

What direct problems are there that affect salivary glands

Answer 13

Aplasia
-Ectodermal dysplasia

Sarcoidosis

HIV disease

Gland infiltration
-Amyloidosis
-Haemochromatosis

Cystic Fibrosis

Question 14

What is the challacombe scale of mucosal dryness

Answer 14

diagnostic medical tool designed to produce a clinical oral dryness score which quantifies the extent of dryness of the mouth, with the aim of making a decision of whether to treat or not

Question 15

What are the values of the challacombe scale

Answer 15

1) Mirror stricks to buccal mucosa

2) Mirror sticks to tongue

3) Saliva frothy

4) No saliva pooling floor of mouth

5) Tongue shows generalised shortened papillae

6) Altered gingival architecture

7) Glossy apperance of oral mucosa

8) Tongue lobulated/fissured

9) Cervical caries

10) Debris on palate or sticking to teeth

Question 16

What do the challcombe scores indicate

Answer 16

1-3= mild dryness may not need treatment, sugar free gum 15mins x2 daily and hydration

4-6= moderate dryness, gum or simple sialogogues may be required. Needs to be investigatd if no clear cause

7-10= Severe dryness, saliva substituues and topical fluoride. Causes needs to be identified and Sjogrens ruled out

Question 17

How does Anxiety and Somatisation Disorders cause dry mouth

Answer 17

‘cephalic’ control of salivation
-Inhibition of salivation, anxiety directly causes ‘real’ oral dryness

‘cephalic’ control of perception
-Altered perception of reality, normal information coming from the mouth is ‘misunderstood’ by small changes at synapses as it is processed
-More often seen with anxiety disorders

Question 18

What frequent Somatoform disorders are there

Answer 18

Oral Dysaesthesia

TMD pain

Headache

neck/back pain

Dyspepsia

Irritable Bowel Syndrome (IBS)

Question 19

What is the normal salivation flow for resting and stimulated glands

Answer 19

Resting= 0.3-0.4 mL/min

Stimulated= 1-2 mL/min

Question 20

What does the flow have to be to be hyposalivation

Answer 20

Resting= <0.1 mL/min

Stimulated= <0.5 mL/min

Question 21

What are the treatable causes of dry mouth

Answer 21

Dehydration

Medicines with anti-muscarinic side effects

Medicines causing dehydration

Poor Diabetes control – type 1 or type 2

Somatoform Disorders

Question 22

What conditions are there where its only symptomatic treatment of a dry mouth

Answer 22

Sjögren’s Syndrome

Dry mouth from cancer treatment

Dry mouth from salivary gland disease

Question 23

In a salivary flow test what must the score be for dry mouth

Answer 23

less than 1.5ml unstimulated flow in 15mins

Question 24

What saliva substitues are there

Answer 24

Sprays
-Glandosane
-Saliva Orthana

Lozenges
-Saliva Orthana
-SST

Salivary stimulants
-Pilocarpine (Salagen)

Oral Care Systems
-Oral Balance

Frequent sips of water

Question 25

What can cause HYPERsalivation

Answer 25

TRUE (rare) – Actual increase in salivary flow -Drug causes -Dementia -CJD -Stroke PERCEIVED (Common) – NO increase in saliva flow Swallowing Failure: -Anxiety -Stroke -Motor Neurone Disease -Multiple Sclerosis Postural Drooling: -Being a baby -Cerebral Palsy

Question 26

What drugs can cause hypersalivation

Answer 26

Parasympathomimetics Buprenorphine Anticholinesterases Haloperidol Ipecacuanha Clonazepam Nicardipine Clozapine Remoxipride Niridazole Ammonium salts Bromides Ethionamide Iodides Ketamine Mercurial salts

Question 27

How would you deal with Hypersalivation

Answer 27

Treat the Cause -Anxiety disorders Drugs to reduce salivation -Anti-muscarinic agents -Botox to prevent gland stimulation Biofeedback training -Swallowing control Surgery to salivary system -Gland removal -Duct repositioning

Question 28

What could cause a change in salivary gland size

Answer 28

Viral Inflammation -Mumps -HIV Secretion retention -Mucocele -Duct obstruction Gland Hyperplasia -Sialosis -Sjögrens Syndrome

Question 29

What are the symptoms of mumps

Answer 29

Headache Joint pain Nausea Dry mouth Mild abdominal pain Feeling tired loss of appetite Pyrexia of 38C, or above

Question 30

What are the common sites for a mucocele

Answer 30

Junction Hard/Soft Palate and the Lower lip

Question 31

What is subacute obstruction

Answer 31

When there is swellings associated with meal times Thee swelling increases as salivary flow starts and reduces when salivary flow stops Usually SUBMANDIBULAR Will eventually be fixed and painful

Question 32

What is the cause of subacute obstruction

Answer 32

duct obstruction -Usually duct blockage in submandibular -Usually duct stricture in parotid Obstruction by: -Sialolith (stones) -mucous plugging -Ductal damage from chronic infection (scarring)

Question 33

What investigations for subacute obstruction is there

Answer 33

Low dose plain radiography lower true occlusal SIALOGRAPHY – when infection free Isotope scan if gland function uncertain Ultrasound assessment of duct system

Question 34

What happens in duct dilation

Answer 34

Defect prevents normal emptying Micro-organisms grow and lead to persisting and recurrent sialadenits Gland function gradually lost and persisting infection leads to gland removal

Question 35

How do you manage subacute obstruction

Answer 35

Surgical sialolith removal if practical Sialography for ‘no stone’ cases – washing effect Consider gland removal if fixed swelling