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XEROSTOMIA

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

Salivary Gland

Parotid gland

Sublingual gland

major source when eating

only 2-3% of saliva

serous acini only

mucous (primarily) + serous

Submandibular gland
the most responsible when no

stimuli
serous (primarily) + mucous acini

Minor salivary gland


mucous (primarily)

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

Introduction

Symptoms

& signs

Etiology
Diagnosis
Management
Summary

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

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

Introduction

Symptoms

& signs

Etiology
Diagnosis
Management
Summary

Etiology

Aging
Foods & drugs
Systemic factors
Radiotherapy
Sjogrens syndrome
Other salivary gland diseases

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

When become elder, mucin secretion increase.

Scott, 1977

Etiology

Foods: alcohol, coffee, coco cola, smoke


Drugs:
Anti-depressants
Anti-histamine
Cimitidine
Anti-cholinergic
Anti-HTN (sympathomimetic drugs)
Anti-inflammatory

Etiology

Systemic factors:
Emotions: nervousness , excitation, depression, stress..
Encephalitis, brain tumors, stroke, Parkinsons dis.

Dehydration: diarrhea, vomiting, polyuria of

diabetes
Anemia, nutrition deficiency.

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

Etiology

Sjogrens 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

Etiology

Other salivary gland diseases:


Obstruction or infection of gland
Sarcoidosis, amyloidosis
Benign or malignant tumor

Excision of gland or congenital missing

Etiology

Aging
Foods & drugs
reversible change
Systemic factors
Radiotherapy (>4000rad)
irreversible
Sjogrens syndrome
Other salivary gland diseases

change

Introduction

Symptoms

& signs

Etiology
Diagnosis
Management

Diagnosis

History taking
Symptoms & clinical examination
Special investigations

Salivary flow rate, SFR


Salivary scintiscanning
Sialochemical analysis & laboratory values
Labial biopsy
Sialography

Salivary Flow Rate (Sialometry)


Stensons duct
Methods:

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 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

Sjogrens syndrome: have diagnostic value

Laboratory Values

Sjogrens syndrome
Elevated ESR, IgG, RF
Positive auto-antibodies: anti-nuclear, ANA

anti-SS-A, anti-Ro
anti-SS-B, anti-La

Labial Biopsy

Chisolm & 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

Sialography

Instillation of radiopaque fluid into glands


Identification of non-calcified sialoliths & tumors
Unsuitable for diagnosis of xerostomia

Diagnosis

History taking
Symptoms & clinical examination
Special investigations
- Salivary flow rate, SFR

Stimulated flow

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

Introduction

Symptoms

& signs

Etiology
Diagnosis
Management

Management

Dietary & environmental considerations


Preventive Dental Care Measures
Saliva stimulatants
Saliva substitutes

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

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..

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

Pyridostigmine

Salivary Substitutes

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

Management

Dietary & environmental considerations


Preventive Dental Care Measures
Saliva stimulatants
Saliva substitutes

Thank you for


your attention !!