Xerostomia Lecture Notes PDF

XEROSTOMIA Angela Chi, DMD [email protected] taking photos or video recording during this live class session is not permitted LEARNING OBJECTIVES Define xerostomia. Discuss the clinical features, associated complications,...

XEROSTOMIA Angela Chi, DMD [email protected] taking photos or video recording during this live class session is not permitted LEARNING OBJECTIVES Define xerostomia. Discuss the clinical features, associated complications, differential diagnosis, and management of xerostomia. Discuss the epidemiology, etiopathogenesis, clinical features, differential diagnosis, test findings, management, and prognosis of conditions associated with xerostomia.  MAJOR SALIVARY GLANDS persons IEosa Lwartans duct Goran tek-en, CC BY-SA 4.0 , via Wikimedia Commons, https://commons.wikimedia.org/wiki/File:Salivary_glands_labeled.svg  MINOR SALIVARY GLANDS Sites devoid of minor salivary glands: Anterior hard palate Gingiva Maruyama EO, Aure MH, Xie X, Myal Y, Gan L, et al. (2016) Cell-Specific Cre Strains For Genetic Manipulation in Salivary Glands. PLOS ONE 11(1): e0146711. https://doi.org/10.1371/journal.pone.0146711. Creative Commons Attribution (CC BY) license  FUNCTIONS OF SALIVA Moistening/lubrication for chewing, swallowing, bolus formation, speech (mucin, DIGESTIVE water) Taste Digestive enzymes (amylase, lipase) Modulates pH/buffering capacity (bicarbonates, phosphates, urea) Cleansing PROTECTIVE Antimicrobial activity (immunoglobulins, lactoferrin, lysozyme, lactoperoxidase) Remineralization (Ca, P) XEROSTOMIA “dry mouth” smoking radiation medications multiple  Xerostomia DDx: Iatrogenic: meds, RTX Dehydration Systemic: Sjögren syndrome, diabetes mellitus, sarcoidosis, HIV Local factors: smoking, mouth breathing, decreased mastication (Developmental: salivary gland aplasia)  Xerostomia ~25% of older adults Foamy, thick, “ropey” saliva Tongue may be fissured/atrophic Difficulty chewing/ swallowing/ wearing dentures Dysgeusia altered taste Fig 26.18 Little, James, W. et al. Dental Management of the Medically Compromised Patient - E-Book. Available from: VitalSource Quantity vs. quality Bookshelf, (9th Edition). Elsevier Health Sciences (US), 2017. thick ropey amount  Xerostomia Complications: Candidiasis Increased caries risk (esp. cervical & root caries) Bacterial sialadenitis Mortazavi H, Safi Y, Baharvand M, Jafari S, Anbari F, Rahmani S. Oral White Lesions: An Updated Clinical Diagnostic Decision Tree. Dentistry Journal. 2019; 7(1):15. https://doi.org/10.3390/dj7010015 Creative Commons Attribution License 4.0 Bacterial sialadentis due to saliva flow to clear it Cesar A. Migliorati, Mary A. Aubertin and Marjorie Woods (February 19th 2014). Dry Mouth and Associated lack of Conditions, Diagnosis and Management of Oral Lesions and Conditions: A Resource Handbook for the Clinician, Cesar A. Migliorati and Fotinos S. Panagakos, IntechOpen, DOI: 10.5772/57597. Available from: https://www.intechopen.com/chapters/46275 Creative Commons Attribution 3.0 License  Salivary Flow Measurement Unstimulated salivary flow: collect saliva for 5 mins Unstimulated Saliva (ml/min) >0.25 normal 0.1 - 0.25 low < 0.1 very low  Salivary Flow Measurement Stimulated Salivary Flow: Collect saliva while pt. chews paraffin wax 5 mins. Stimulated Saliva (ml/min) >1.0 normal 0.7 - 1.0 low 600 meds Esp. with polypharmacy Examples: Anticholinergics Antihistamines Antidepressants Antihypertensives Antipsychotics Decongestants Diuretics Sedatives/anxiolytics  Effects of Radiation on Salivary Glands Ionizing radiation  free radicals  cell damage parotid gland 2 FIG 8. 15 Kumar, Vinay, et al. Robbins Basic Pathology E- Book. Available from: VitalSource Bookshelf, (10th Edition). Elsevier Limited (UK), 2017. NORMAL ACINAR ATROPHY/ VASCULAR DAMAGE/ FIBROSIS INTIMAL THICKENING Management of Patients w/Oral Complications of Radiotherapy & Chemotherapy COMPLICATION MANAGEMENT Mucositis Prevention (e.g., benzdyamine mouthwash, cryotherapy, low-level laser therapy, Zn supplements); analgesics Xerostomia and radiation caries Sugarless candies/gum, salivary substitutes, buffered solution of glycerine and water Patient education / optimize OH / frequent recalls Fluoride supplementation (gel application via custom trays, PrevDent 5000) Restoration Secondary infection Antifungals/antibiotics/antivirals Loss of taste Zinc supplementation Osteoradionecrosis Prevention (pre-RT dental evaluation and tx); avoid surgery; hyperbaric oxygen therapy Trismus Use of tongue blades to maintain jaw opening  Sjögren Syndrome chronic autoimmune disorder involves salivary & lacrimal glands  Sjögren Syndrome Clinical subtypes: Primary Secondary Etiology: unknown, genetic influences (HLA- DRw52, HLA-B8, HLA-DR3) 0.5% U.S. pop. esp. middle-aged F Sjögren Syndrome XEROPHTHALMIA XEROSTOMIA Scientific Animations, CC BY-SA 4.0 , via Wikimedia Commons, https://commons.wikimedia.org/wiki/File:Sjogrens_Syndrome.jpg  Sjögren Syndrome Sequelae of xerostomia: Dysphagia Dysgeusia Increased caries risk Difficulty wearing dentures Candidiasis Retrograde bacterial sialadenitis Balhaddad Abdulrahman A. et al. https://www.frontiersin.org/article/10.3389/fmats.2020.583861 Pronounced Effect of Antibacterial Bioactive Dental Composite on Microcosm Biofilms Derived From Patients With Root Carious Lesions Frotniers in Matierals 7: 407, 2020. Creative Commons Attribution licence (CC-BY)https://doi.org/10.3389/fmats.2020.583861  Sjögren Syndrome Parotid enlargement (bilateral>unilateral): due to benign lymphoepithelial lesions Fineneedle aspiration bx Calicut Medical College, CC BY-SA 4.0 , via Wikimedia Commons; Template:Dimic Milorad MD, CC BY-SA 3.0 , via Wikimedia https://commons.wikimedia.org/wiki/File:Mikulicz_disease_100X.jpg Commons; https://commons.wikimedia.org/wiki/File:Parotoid_gland_in_Sj%C3%B6gre n%27s_syndrome.JPG  Sjögren Syndrome production Keratoconjunctitivis sicca: Scratchy/gritty sensation, blurred vision, pain testtear SCHIRMER TEST http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/lg-staining/index.htm; https://creativecommons.org/licenses/by-sa/4.0/ https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/The-Schirmer-test.html; Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. https://www.niams.nih.gov/newsroom/spotlight-on-research/new-genetic-susce ptibility-factors-sjog rens-syndrome  Sjögren Syndrome Sialography: Punctate sialectasia as “fruit-laden, branchless tree” van Ginkel, M.S.; Glaudemans, A.W.J.M.; van der Vegt, B.; Mossel, E.; Kroese, F.G.M.; Bootsma, H.; Vissink, A. Imaging in Primary Sjögren’s Syndrome. J. Clin. Med. 2020, 9, 2492. https://doi.org/10.3390/jcm9082492 ; Creative Commons CC BY license  Sjögren Syndrome Laboratory tests: Serum IgG RhF nuclear ANA PETEY Anti-SS-A, anti-SS-B (nuclear autoantibodies) (esp. primary) Salivary duct autoantibodies (secondary>primary) secondary  Sjögren Syndrome Histopath: apossai findings Lower lip minor in to Px used gland biopsy FOCAL AGGREGATES OF LYMPHOCYTES Tincani, Angela & Andreoli, Laura & Cavazzana, Ilaria & Doria, Andrea & Favero, Marta & Fenini, Maria-Giulia & Franceschini, Franco & Lojacono, Andrea & Nascimbeni, Giuseppe & Santoro, Amerigo & Semeraro, Francesco & Toniati, Paola & Shoenfeld, Yehuda. (2013). aspects of Sjögren’s syndrome in 2012. BMC medicine. 11. 93. 10.1186/1741-7015-11-93. ; https://creativecommons.org/licenses/by/2.0/Novel  Sjögren Syndrome to opthamologist Tx: refer artificial tears, seal lacrimal punctum artificial salivas, sugarless candy/gum, sialagogues fluoride, OHI Px: increased risk for lymphoma  SARCOIDOSIS Multisystemic granulomatous disorder Idiopathic (abnormal response to antigen, mycobacteria?) U.S.: African Americans > Caucasians WHAT IS “GRANULOMATOUS INFLAMMATION”? histocytes macrophages multi nucleated giant cells  Sarcoidosis Lungs: bilateral hilar lymphadenopathy, Skin: lupus pernio, macules, dry cough, dyspnea, chest discomfort papules, plaques, alopecia Nowack et al., CC BY-SA 2.0 , via Wikimedia Commons https://dermnetnz.org/topics/lupus- https://radiopaedia.org/articles/thoracic-sarcoidos is-staging pernio, https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode  Sarcoidosis Salivary glands: parotid Ocular: uveitis, lacrimal gland involvement enlargement (bilat>unilat), xerostomia Çakmak, S. K, Gönül, M., Gül, Ü., Gündüz, H., Han, Ö., & Kulaçoğlu, S. (2009). Sarcoidosis involving the lacrimal, submandibular, and parotid glands with panda sign. Dermatology Online Journal, 15(3). http://dx.doi.org/10.5070/D380j4r407 Retrieved from https://escholarship.org/uc/item/80j4r407 https://creativecommons.org/licenses/by-nc-nd/4.0/ Heerfordt syndrome (uveoparotid fever): anterior uveitis, parotitis, facial nerve paralysis, fever  Sarcoidosis Intraoral: (rare) Erythema, granularity, papular Diffuse lip swelling Can be 1st manifestation Kadiwala SA, Dixit MB. Gingival enlargement unveiling sarcoidosis: Report of a rare case. Contemp Clin Dent [serial online] 2013 Bouaziz A, Le Scanff J, Chapelon-Abric C, Varron L, Khenifer S, Gleizal A, Bentz MH, Barthel A, Valeyre D, Seve P; Groupe [cited 2021 Oct 7];4:551-5. Available from: https://www.contempclindent.org/text.asp?2013/4/4/551/123087, Creative Sarcoïdose Francophone. Oral involvement in sarcoidosis: report of 12 cases. QJM. 2012 Aug;105(8):755-67. doi: Commons Attribution-NonCommercial-ShareAlike License (CC BY-NC-SA), 10.1093/qjmed/hcs042.  Sarcoidosis Non-necrotizing granulomatous inflammation https://commons.wikimedia.org/wiki/File:Sarcoidosis_2.jpg; Yale Rosen, CC BY-SA 2.0 , via Wikimedia Commons MICROSCOPIC DIFFERENTIAL DIAGNOSIS FOR GRANULOMATOUS INFLAMMATION Deep fungal infection Mycobacterial infection Foreign body reaction Sarcoidosis Crohn disease Orofacial granulomatosis  Sarcoidosis Dx: Clinical findings Biopsy: negative stains & cultures for organisms Radiographic (CXR) Elevated serum ACE Minor salivary gland bx  Sarcoidosis Tx: Initial observation Corticosteroids / other immunosuppressives/ TNF-alpha inhibitors Px: Variable 60% spontaneously resolve within 2 yrs 4-10% mortality (cardiac, CNS, pulmonary) HIV-ASSOCIATED SALIVARY GLAND DISEASE ~ 5 to 10% of HIV-infected patients  HIV-ASSOCIATED SALIVARY GLAND DISEASE Children > adults Bilateral > unilateral parotid enlargement Lymphoepithelial cysts Diffuse infiltrative lymphocytosis syndrome Lymphadenopathy (cervical/intraparotid) Dry mouth Tx: ART, sialogogues, prednisone Px: risk for lymphoma Sekikawa Y, Hongo I. HIV-associated benign lymphoepithelial cysts of the parotid glands confirmed by HIV-1 p24 antigen immunostaining Case Reports 2017;2017:bcr-2017-221869. Creative Commons Attribution Non Commercial (CC BY-NC 4.0) Sekikawa Y, Hongo I. HIV-associated benign lymphoepithelial cysts of the parotid glands confirmed by HIV-1 p24 antigen immunostaining Case Reports 2017;2017:bcr-2017-221869. Creative Commons Attribution Non Commercial (CC BY-NC 4.0)  Did not reach Salivary Gland Aplasia Isolated or syndrome-associated (e.g., mandibulofacial dysostosis, hemifacial microsomia, LADD syndrome) Mandibulofacial Dysostosis a.k.a. Treacher Collins syndrome Defects of 1st/2nd branchial arch structures TCOF1 mutations, AD; 1 in 50,000 live births Hypoplastic zygomas, narrow face/depressed cheeks Coloboma (notch at outer eyelid) Ear anomalies Hypoplastic mandible, cleft palate/facial cleft Parotids may be absent/hypoplastic Hypoplastic pharynx/feeding & respiratory (Before) difficulties (After surgery) TX: surgery if severe Fig 5.5 Proffit, David Sarver, Henry Fields, Brent Larson, W. Contemporary Orthodontics. Available from: VitalSource Bookshelf, (6th Edition). Elsevier Health Sciences (US), Hemifacial Microsomia Congenital disorder Etiology unknown (not inherited, possibly disruption of vascular supply during development) Asymmetric development of facial structures - including mandible, ear, eye, facial soft tissues Cascone P, Vellone V, Ramieri V, et al. Reconstruction of the Adult Hemifacial Microsomia Patient with Temporomandibular Joint Total Joint Prosthesis and Orthognathic Surgery. Case Reports in Surgery. 2018 ;2018:2968983. DOI: 10.1155/2018/2968983. PMID: 29736288; PMCID: PMC5874988. Creative Commons Attribution License 4.0  Lacrimo-auriculo-dento-digital Syndrome AD, FGFR2/FGFR3/FGF10 mutations Ryu YH, Kyun Chae J, Kim JW, Lee S. Lacrimo-auriculo-dento-digital syndrome: A novel mutation in a Korean family and review of literature. Mol Genet Genomic Med. 2020 Oct;8(10):e1412. doi: 10.1002/mgg3.1412. https://creativecommons.org/licenses/by-nc-nd/4.0/ References/Resources Neville B, Damm D, Allen C, Chi A. Oral and Maxillofacial Pathology. Available from: VitalSource Bookshelf, (4th Edition). Elsevier Health Sciences (US): pages 41-42, 248, 310-312, 432-437, 785-788 Little JW, et al. Dental Management of the Medically Compromised Patient - E-Book. Available from: VitalSource Bookshelf, (9th Edition). Elsevier Health Sciences (US), 2017. pages 502-511