Oral Medicine — Dental Practitioner Update PDF

3 IN BRIEF Most cases of dry mouth are caused by inadequate fluid intake, or by excess fluid loss — for example in diabetes. Drugs are a common cause of hyposalivation. Hyposalivation also follows irradiation but some systemic diseases may present in this way. Oral Medicine —...

3 IN BRIEF Most cases of dry mouth are caused by inadequate fluid intake, or by excess fluid loss — for example in diabetes. Drugs are a common cause of hyposalivation. Hyposalivation also follows irradiation but some systemic diseases may present in this way. Oral Medicine — Update for the dental practitioner. Dry mouth and disorders of salivation C. Scully1 and D. H. Felix2 This series provides an overview of current thinking in the more relevant areas of oral medicine for primary care practitioners, written by the authors while they were holding the Presidencies of the European Association for Oral Medicine and the British Society for Oral Medicine, respectively. A book containing additional material will be published. The series gives the detail necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders, or discussion of disorders affecting the hard tissues. Approaching the subject mainly by the symptomatic approach — as it largely relates to the presenting complaint — was considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made. Guidance on management and when to refer is also provided, along with relevant websites which offer further detail. ORAL MEDICINE Saliva is essential to oral health. The most obvi- Reduced salivary flow (hyposalivation) 1. Aphthous and other ous and important function of saliva is in eat- and/or common ulcers ing, for taste and to lubricate food and protect Changed salivary composition. 2. Mouth ulcers of more the mucosa and teeth. The water, mucins and serious connotation proline-rich glycoproteins lubricate food and Patients who have chronically decreased sali- 3. Dry mouth and disorders help swallowing, and saliva is essential for nor- vary flow (hyposalivation) suffer from lack of of salivation mal taste perception. Saliva is protective via the oral lubrication, affecting many functions, and 4. Oral malodour washing action, via various antimicrobial com- they may complain of dryness (xerostomia), and ponents such as mucin, histatins, lysozyme and can develop dental caries and other infections 5. Oral white patches lactoferrin, and via specific antibodies to a (candidosis, or acute bacterial sialadenitis) as a 6. Oral red and range of micro-organisms that the host has consequence of the reduced defences. hyperpigmented patches encountered. 7. Orofacial sensation and Salivary gland secretion from the major Causes movement (parotid, submandibular and sublingual) and There are physiological causes of hyposaliva- 8. Orofacial swellings and minor glands (multiple mucous glands scattered tion. Thus a dry mouth is common during peri- lumps throughout the mouth — especially the lips and ods of anxiety, due to sympathetic activity; 9. Oral cancer soft palate) is mainly under neural control, under mouthbreathers may also have a dry mouth 10. Orofacial pain the influence of the autonomic nervous system, and advancing age is associated with dry although various hormones may also modulate its composition. In general, parasympathetic Table 1 Causes of dry mouth 1*Professor, Consultant, Dean, Eastman stimulation increases salivation, while sympa- Iatrogenic Dental Institute for Oral Health Care Sciences, 256 Gray’s Inn Road, UCL, thetic stimulation produces more viscous saliva Drugs University of London, London WC1X 8LD; and therefore appears to depress salivation. 2Consultant, Senior Lecturer, Glasgow Irradiation Thus, in acute anxiety, when there is sympa- Dental Hospital and School, 378 Graft versus host disease thetic stimulation, the mouth feels dry. The Sauchiehall Street, Glasgow G2 3JZ / Associate Dean for Postgraduate Dental mouth is also dry if the parasympathetic system Education, NHS Education for Scotland, is inhibited by, for example, various drugs. Any- Disease 2nd Floor, Hanover Buildings, 66 Rose thing that damages the glands, or reduces body Dehydration Street, Edinburgh EH2 2NN Psychogenic *Correspondence to: Professor Crispian fluids can also reduce salivation. Scully CBE Salivary gland disease Email: [email protected] DRY MOUTH (XEROSTOMIA) Sjögren’s syndrome Dry mouth (xerostomia) is a complaint that is the Sarcoidosis Refereed Paper © British Dental Journal 2005; 199: most common salivary problem and is the sub- Salivary aplasia 423–427 jective sense of dryness which may be due to: BRITISH DENTAL JOURNAL VOLUME 199 NO. 7 OCT 8 2005 423 PRACTICE mouth probably because of a reduction of sali- and neck region, such as oral cancer, can vary acini, with a fall in salivary secretory produce profound xerostomia. Other sources of reserve. irradiation such as radioactive iodine (131I) used Very rarely, children are born missing sali- for treating thyroid disease, may also damage vary glands — so-called salivary gland aplasia or the salivary glands, which take up the agenesis. Most salivary gland dysfunction how- radioactive iodine. ever is acquired (Table 1). Drugs, in most older people complaining of Dehydration, as in diabetes mellitus, chronic xerostomia, are the cause. Indeed, the main renal failure, hyperparathyroidism, any fever causes of dry mouth are iatrogenic. There is or diabetes insipidus can cause xerostomia. usually a fairly close temporal relationship between starting the drug treatment or Diseases of salivary glands can also cause increasing the dose, and experiencing the dry salivary dysfunction. These are mainly Sjögren’s mouth. However, the reason for which the syndrome (a multisystem auto-immune drug is being taken may also be important. For condition discussed below); sarcoidosis; HIV example, patients with anxiety or depressive disease; hepatitis C virus infection; liver conditions may complain of dry mouth even diseases; and cystic fibrosis (mucoviscidosis) in the absence of drug therapy (or evidence of (Fig. 1). reduced salivary flow). Finally, it is important to also recognise that Drugs recognised as causes of reduced sali- some patients complaining of a dry mouth have vation include mainly those with anticholiner- no evidence of a reduced salivary flow or a sali- gic, or sympathomimetic, or diuretic activity. vary disorder (ie they have xerostomia but not These include those shown in Table 2. hyposalivation), and in these there may be a Irradiation for malignant tumours in the head psychogenic reason for the complaint. Table 2 Drugs associated with dry mouth Clinical features The patient with hyposalivation may have Drugs which directly damage the salivary glands difficulty in: Cytotoxic drugs Swallowing — especially dry foods such as Drugs with anticholinergic activity biscuits (the cracker sign) Anticholinergic agents such as atropine, atropinics and Controlling dentures hyoscine Speaking, as the tongue tends to stick to the Antireflux agents eg proton-pump inhibitors (such as palate — leading to ‘clicking’ speech. omeprazole) Psychoactive agents with anticholinergic activities such as: Patients may also complain of unpleasant Antidepressants, including tricyclic (eg amitriptyline, taste or loss of sense of taste, or halitosis. nortriptyline, clomipramine and dothiepin [dosulepin]), selective serotonin re-uptake inhibitors (eg fluoxetine), The patient with hyposalivation may com- lithium and others. plain of a dry mouth or these sequelae alone, or Phenothiazines also complain of dryness of the eyes and other Benzodiazepines mucosae (nasal, laryngeal, genital). Those with eye complaints have blurring, light intolerance, Opioids burning, itching or grittiness, and sometimes an Antihistamines inability to cry. Bupropion Systemic features (such as joint pains) may be Drugs acting on sympathetic system suggestive of Sjögren’s syndrome. Drugs with sympathomimetic activity eg ephedrine Examination may reveal that the lips adhere Antihypertensives; alpha 1 antagonists (e.g. terazosin and one to another and an examining dental mirror prazosin) and alpha 2 agonists (e.g. clonidine) may reduce may stick to the mucosa because of the reduced salivary flow. Beta blockers (e.g. atenolol, propranolol) also change salivary protein levels. lubrication. Lipstick or food debris may be seen Drugs which deplete fluid sticking to the teeth or soft tissues, and the usual pooling of saliva in the floor of the mouth may Diuretics be absent. Thin lines of frothy saliva may form along lines of contact of the oral soft tissues, on the tongue, or in the vestibule. Saliva may not be expressible from the parotid ducts. The tongue is dry (Fig. 2) and may become characteristically lobulated and usually red, with partial or com- plete depapillation (Fig. 3). Complications of hyposalivation can include: Dental caries — which tends to involve smooth surfaces and areas otherwise not very prone to caries — such as the lower incisor region and roots. Hyposalivation may explain patients with uncontrollable Fig. 1 Saliva production recurrent caries, who are apparently comply- and factors inhibiting it ing with dietary advice. 424 BRITISH DENTAL JOURNAL VOLUME 199 NO. 7 OCT 8 2005  PRACTICE Diagnosis Hyposalivation is a clinical diagnosis which can Keypoints for dentists: be made by the practitioner predominantly on dry mouth the basis of the history and examination. Diagnosis is clinical but investigations may be indicated, including: It can be helpful to document salivary func- tion by salivary function studies such as salivary Blood tests (ESR and SS-A and SS- flow rates (sialometry). Collection of whole saliva B antibodies; see below) (oral fluid) is currently the routine technique for Eye tests (Schirmer; see below) sialometry used by many clinicians, despite the Urinalysis fact that it is rather inaccurate and non-specific. Salivary flow rate tests (sialometry) It is usually carried out by allowing the patient Salivary gland biopsy (labial gland to sit quietly and dribble into a measuring con- biopsy) tainer over 15 minutes; in a normal person, such Imaging an unstimulated whole saliva flow rate exceeds Chest radiograph 1.5 ml/15 min (0.1 ml/min). Sialography The specialist may be needed to: Scintiscanning Study and document the degree of salivary Ultrasound dysfunction Determine the cause Arrange future dental care although much of Key points for patients: this can be undertaken in the primary care dry mouth environment. Saliva helps swallowing, talking, and taste, and protects the mouth Investigations may be indicated to exclude Where saliva is reduced there is a systemic disease, particularly to exclude: risk of dental decay (caries), Fig. 2 Dry mouth Sjögren’s syndrome and connective tissue halitosis, altered taste, mouth disorders soreness and infections Diabetes Saliva may be reduced by radiotherapy or chemotherapy, Sarcoidosis various drugs, after bone marrow Viral infections (hepatitis C; HIV). transplant, in diabetes, in some viral infections, in Commonly used investigations may thus include: anxiety/stress/depression, or in Blood tests (mainly to exclude diabetes, salivary gland disorders. Sjögren’s syndrome, sarcoidosis, hepatitis and Diagnosis is clinical but investigations may be indicated, other infections) including Eye tests (eg Schirmer test mainly to exclude Blood tests Sjögren’s syndrome) Eye tests Salivary gland biopsy (if there is suspicion of organic disease such as Sjögren’s syndrome ) Urinalysis Imaging (mainly to exclude Sjögren’s Salivary flow rate Fig. 3 Dry mouth and lobulated tongue Salivary gland biopsy syndrome, sarcoidosis or neoplasia). X-rays or scans Candidosis (Fig. 4) — which may cause a It is important to remember, as stated above, burning sensation or mucosal erythema, that in some patients complaining of a dry lingual filiform papillae atrophy, and angular mouth no evidence of a reduced salivary flow or stomatitis (angular cheilitis) a salivary disorder can be found. There may then Halitosis (Article 4) be a psychogenic reason for the complaint. Ascending (suppurative) sialadenitis — which presents with pain and swelling of a major Management (see below) salivary gland, and sometimes purulent discharge from the duct. SJÖGREN’S SYNDROME Sjögren’s syndrome (SS) is an uncommon condi- tion, the association of dry mouth and dry eyes. The other key features of SS are evidence of an autoimmune reaction shown usually by serum autoantibodies and sometimes confirmed by demonstrating mononuclear cell infiltrates in a labial salivary gland biopsy. Sjögren’s syndrome can affect any age but the onset is most common in middle age or older. The majority of patients are women. Aetiopathogenesis SS is an autoimmune disease affecting mainly Fig. 4 Dry mouth complicated by candidosis exocrine glands like the salivary glands, lacrimal BRITISH DENTAL JOURNAL VOLUME 199 NO. 7 OCT 8 2005 425 PRACTICE glands and pancreas. There may be a viral aeti- Oral complaints (often the presenting feature) ology and a genetic predisposition. including: The most common type of SS is secondary Xerostomia Sjögren’s syndrome (SS-2) which comprises dry Swollen salivary glands; causes include eyes and dry mouth and a connective tissue or chronic sialadenitis as part of the fundamen- autoimmune disease usually rheumatoid arthri- tal autoimmune disease process, ascending tis (RA) (Table 3). However, SS can appear by bacterial sialadenitis which can arise if bacte- itself, and in the absence of a connective tissue ria ascend the ducts because salivation is disease is often termed sicca syndrome, usually impaired, benign lymphoepithelial lesions/ referred to as primary Sjögren’s syndrome (SS- myoepithelial sialadenitis (pseudolymphoma) 1). Nevertheless, both forms are chronic and can and lymphoma (Fig. 6). affect not only the salivary glands (Fig. 5), but also extraglandular tissues. Chronic B lympho- cyte stimulation can occasionally lead to B cell neoplasms such as lymphoma. Table 3 Sjögren’s syndrome SS-1 SS-2 Dry mouth Yes Yes Dry eyes Yes Yes Connective tissue No Yes disease Extraglandular More common Less common problems Fig. 6 Complications of Sjögren’s syndrome However, SS is a more generalised disorder which involves not only the exocrine salivary and lacrimal glands, but can have a range of other complications, summarised in Figure 6. Diagnosis Diagnosis is made from the history and clinical features, and may be confirmed by autoantibody studies and sometimes by other investigations such as sialometry and labial salivary gland biopsy. In specialist units various international criteria are used to confirm the diagnosis. There is no specific treatment yet for SS, but the hyposalivation can be managed, and dental pre- ventive care is essential. The dental team have an important role to play in this. Management of hyposalivation Any underlying cause of xerostomia should if possible be rectified; for example, xerostomia- producing drugs may be changed for an alterna- tive, and causes such as diabetes should be treated. Patients should be educated into efforts to Fig. 5 Parotid gland swelling avoid factors that may increase dryness , and to keep the mouth moist (Table 4). SS is often characterised by a raised erythrocyte sedimentation rate (ESR) and several autoanti- Salivary substitutes may help symptomatically. bodies — particularly antinuclear factor (ANF) A variety are available including: and rheumatoid factor (RF), and more specific Water or ice chips; frequent sips of water are antinuclear antibodies known as SS-A (Ro) and generally effective SS-B (La). Synthetic salivary substitutes (Table 5). Clinical features As patients with objective xerostomia are at SS presents mainly with eye complaints which increased risk of developing caries it is impor- include sensations of grittiness, soreness, itch- tant that they take a non-cariogenic diet and ing, dryness, blurred vision or light intolerance. maintain a high standard of oral hygiene. The The eyes may be red with inflammation of the regular use of topical fluoride agents forms an conjunctivae and soft crusts at the angles (ker- important component of their long-term care. atoconjunctivitis sicca). The lacrimal glands Salivation may be stimulated by using may swell. diabetic sweets or chewing gums (containing 426 BRITISH DENTAL JOURNAL VOLUME 199 NO. 7 OCT 8 2005  PRACTICE Table 4 Ten tips for managing a dry mouth Table 5 Some salivary replacements Drink enough water, and sip on water and other non-sugary UK trade names Offered as Contains Main Comments fluids throughout the day. Rinse with water after meals. fluoride constituents Keep water at your bedside. AS Saliva Orthana Spray + /- Mucin Spray contains fluoride Replace missing saliva with salivary substitutes, eg Artificial or lozenge Xylitol but is unsuitable if there Saliva, (Glandosane, Luborant, Biotene Oralbalance, AS are religious objections Saliva Orthana, Salivace, Saliveze). Alcohol-free to porcine mucin mouthrinses (BioXtra and Biotène), or moisturising gels Biotene Oralbalance Gel - Glycerate polymer (Oralbalance, BioXtra) may help. base, lactoperoxidase, Stimulate saliva with: glucose oxidase, xylitol sugar-free chewing gums ( eg EnDeKay, Orbit, Biotène BioXtra Gel - Colostrum, dry mouth gum or BioXtra chewing gum) or lactoperoxidase, glucose oxidase, xylitol diabetic sweets or Luborant Spray + Carboxymethylcellulose May contain fluoride Salivix or SST if advised or drugs that stimulate salivation (eg pilocarpine [Salagen]) Glandosane Spray - Carboxymethylcellulose if advised by a specialist. Salivace Always take water or non-alcoholic drinks with meals and Saliveze avoid dry or hard crunchy foods such as biscuits, or dunk in liquids. Take small bites and eat slowly. Eat soft creamy foods (casseroles, soups), or cool foods with a high liquid content — melon, grapes, or ice cream. Moisten foods with http://www.nidcr.nih.gov/HealthInforma- gravies, sauces, extra oil, margarine, salad dressings, sour tion/DiseasesAndConditions/SjogrenSjö- cream, mayonnaise or yogurt. Pineapple has an enzyme that grensSyndrome.htm helps clean the mouth. Avoid spices. http://www.sjsworld.org/ Avoid anything that may worsen dryness, such as: http://www.nidcr.nih.gov/HealthInforma- drugs, unless they are essential (eg antidepressants) tion/DiseasesAndConditions/DryMouthXe- alcohol (including in mouthwashes) rostomia/drymouth.htm smoking http://www.oralcancerfoundation.org/den- caffeine (coffee, some soft drinks such as colas) tal/xerostomia.htm mouthbreathing. SIALORRHOEA (HYPERSALIVATION; PTYALISM) Protect against dental caries by avoiding sugary Infants frequently drool but this is normal. The foods/drinks and by: complaint of sialorrhoea (excess salivation) is reducing sugar intake (avoid snacking and eating last thing at night) uncommon and may be true salivary hyper- secretion — usually caused by physiological fac- avoiding sticky foods such as toffee tors such as menstruation or early pregnancy, keeping your mouth very clean (twice daily local factors such as teething or oral inflamma- toothbrushing and flossing) tory lesions, food or medications (those with using a fluoride toothpaste cholinergic activity such as pilocarpine, tetra- using fluoride gels or mouthwashes (0.05% fluoride) benazine, clozapine), or by nasogastric intuba- daily before going to bed tion. In some cases, apparent hypersalivation is having regular dental checks. caused not by excess saliva production but by an Protect against thrush, gum problems and halitosis by: inability to swallow a normal amount of saliva keeping your mouth very clean (false sialorrhoea) caused by neuromuscular keeping your mouth as moist as possible dysfunction (eg in Parkinson’s disease, cerebral rinsing twice daily with chlorhexidine (eg Chlorohex, palsy, or learning disability) or by pharyngeal or Corsodyl, Eludril) or triclosan (eg Plax) oesophageal obstruction, such as by a neoplasm. brushing or scraping your tongue Treatment is of the underlying cause if possi- keeping dentures out at night ble and then the use of behavioural approaches or antisialogogues. Occasionally, surgery to disinfecting dentures in hypochlorite (eg Milton, Dentural) redirect the salivary gland ducts into the using antifungals if recommended by specialist. oropharynx may be helpful. Protect the lips with a lip salve or petroleum jelly (eg Vaseline). Avoid hot dry environments — consider a humidifier for the bedroom. sorbitol or xylitol, not sucrose). Cholinergic drugs that stimulate salivation (sialogogues), such as pilocarpine, or cevimeline should be used only by a specialist. Oral complications should be prevented and treated. Useful websites: Patients to refer http://www.arc.org.uk/about_arth/book- Suspected Sjögren’s syndrome lets/6041/6041.htm BRITISH DENTAL JOURNAL VOLUME 199 NO. 7 OCT 8 2005 427