Download Aging and Diseases of the Salivary Glands

Aging and Diseases of the
Salivary Glands
Biology of Salivary Glands
Domenica G. Sweier DDS
June 4, 2003
Saliva
 Frustrating for the dental team yet necessary
for the patient!
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When there is not Enough
 Too little saliva can significantly alter a
person’s quality of life and the morbidity
associated with multiple systemic
conditions
• How little is too little?
• What affects the quality and quantity of saliva
production and flow?
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Objective vs Subjective
 Objective
• Major gland secretions
 Resting flow rate with a
Carlson-Crittenden Cup
• Minor gland secretions
• Whole saliva
 Stimulated flow rate
with citric acid, wax
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 Subjective
• Complaints of dry
mouth (xerostomia)
• Questionnaire
• Thirst
• The “cracker” test
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Xerostomia
 Commonly referred to as “dry mouth”
 Diminished salivary flow rate, typically
accepted as a 50% decrease in the clinically
determined rate in healthy individuals not
taking medications
• Resting Flow Rate 0.3-0.4 ml/min
• Stimulated Flow Rate 1-2 ml/min
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Clinical Signs/Symptoms of
Xerostomia
 Dryness of mucous
membranes
 Tongue fissuring and
lobulation (scrotal tongue)
 Angular cheilosis/cheilitis
 Fungal infections
 Prosthesis-induced
stomatitis
 Amputation caries
 Thick, ropey saliva
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 Dysphagia
 Dysgeusia
 Difficulty eating/speaking/
wearing prosthesis
 Swelling of the salivary
glands
 Difficulty expressing
saliva
 Cheek biting
 Persistent need for fluids
 Burning tongue
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What Contributes to Xerostomia?
 Aging
• Hormonal Changes/Menopause
 Disease
• Local
• Systemic
 Environmental Insults/Trauma
 Medications
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Aging
 Salivary Quantity in
Health
• No changes in major
secretions (parotid,
submandibular)
• No changes in minor
secretions
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 Salivary Quality in
Health
• No general changes in
salivary constituents
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Aging
 If the quality and quantity of saliva doesn’t
change with age, then what accounts for the
increased incidence of xerostomia and
associated morbidity among the elderly?
• Medications, diseases, and other environmental
insults affect both the quality and quantity of
saliva
 An increase in incidence of these insults generally
associated with an increase in age
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Menopause
 Average age of onset of menopause in USA is 50
years
 Oral symptoms common, particularly among those
with systemic complaints
 Cross-sectional and longitudinal studies have
failed to provide significant and reproducible
evidence that salivary flow is affected by
menopause
• Oral complaints most likely the result of the types and
numbers of xerostomic medications taken
 Anti-hypertensives, anti-depressants, and anti-histamines are
common in this group
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Diseases/Environmental Factors
 Diseases
• Local
• Systemic
 Environmental Factors
• Head and Neck Radiation
• Chemotherapy
• Medications
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Local Diseases
 Tumors/Growths
• Benign
• Malignant
 Obstructive Diseases
• Calculi, mucus plugs
• Unusual anatomy
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 Inflammatory
Diseases
• Acute viral sialadenitis
• Acute and recurrent
bacterial sialadenitis
• Inflammation/Infection
secondary to systemic
disease
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Tumors/Growths
 Primary benign and
malignant tumors
• Determine whether
benign or malignant
since they are treated
differently
• Incisional biopsy for
definitive diagnosis
• Smaller the involved
gland, more likely
malignant
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 Malignant
• Seek medical attention for
swelling under the chin or
around the jawbone, if the
face becomes numb, facial
muscles do not move, or
there is persistent pain
• Usually treated with a
combination of surgery and
radiation
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Obstruction: Sialolithiasis
 Calculi form in the duct, blocking the egress of
saliva
• Majority in submandibular gland
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Painful swelling which increases at meal time
Bi-manual palpation in submandibular gland
X-ray, sialography, CT, ultrasound
Analgesics, try to push stone out, may need to
dilate orifice to remove
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Submandibular Calculi
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Unusual Anatomy
 Unusual anatomy in the gland manifested as
strictures in the duct system
• Recurrent obstruction with associated pain and
inflammation of glands
• Pooling of saliva leading to secondary infection
 May need surgery to remove affected area of gland
or entire gland
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Inflammation/Infection: Viral
 Mumps is the most frequent diagnosis of acute
viral sialadenitis
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Member of the paramyxoviridae
Mostly in parotid
The incubation period is 2-3 weeks
Acute painful swelling and enlargement
Fever, headache, loss of appetite
Most common in children
Very effective vaccine
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Inflammation/Infection:
Bacterial
 Types
• Acute suppurative bacterial sialadenitis
 Commonly S. aureus, S. viridans, H. influenzae, E. coli
• Chronic recurrent sialadenitis
 May be secondary to some type of obstruction or unusual
anatomy
 May be due to resistant organism; culture to determine
 Treatment
• Antibiotics and analgesics
• Rehydrate and stimulate saliva
• May need open drainage/surgery
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Bacterial Parotiditis
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Systemic Diseases
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Sjögren’s Syndrome
Sarcoidosis
Cystic Fibrosis
Diabetes
Alzheimer’s Disease
AIDS
Graft vs Host Disease
Dehydration
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Sjögren’s Syndrome
 Autoimmune disorder affecting lacrimal and
salivary glands
• Xerostomia and keratoconjunctivitis sicca
 Primary and Secondary disease
• The latter associated with another autoimmune disorder
such as RA, SLE, etc.
 Dense inflammatory infiltrate with destruction of
glandular tissue
 Treatment is palliative
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Sarcoidosis
 Unknown cause; believed to be alteration in
cellular immune function and involvement
of some allergen
 Any organ but most often the lungs; can
affect the parotid gland
 Granulomatous inflammation
 Most often drugs of choice are
corticosteroids
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Cystic Fibrosis
 Faulty transport of sodium and chloride from
within cells lining lungs and pancreas to their
outer surface
 Causes production of an abnormally thick sticky
mucus
 Obstruction of pancreas leads to digestive
problems; inability to digest and absorb nutrients
 Gene has been identified and cloned
 No known “cure” therefore palliative treatment
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Diabetes
 Uncontrolled blood glucose levels may
contribute to xerostomia
 Medications may induce xerostomia
 May get enlargement and inflammation of
parotid glands (common in endocrine
diseases)
 Difficulty to ward off infection: candidiasis,
gingivitis, periodontitis, and caries
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Alzheimer’s Disease
 A neurodegenerative disorder leading to a
decrease in cognition and mobility
 May affect the neurological component to salivary
production and/or flow
 Xerostomic medications
• Complicated by behavior which makes it difficult to
maintain a healthy dentition
 Poor oral hygiene
 Poor cooperation for dental care and treatment in a
conventional setting
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AIDS
 HIV-Associated Salivary Gland Disease
(HIV-SGD)
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Enlargement of the major salivary glands
Xerostomia
Some similarities to autoimmune diseases
HIV itself not consistently found to be in
glandular tissue
 Medications
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Graft vs Host Disease (GVHD)
 Immune cells of an allogenic transplant attack
recipient
 Acute, < 100 days, and chronic > 100 days
 Major cause of morbidity and mortality
 Initial presentation as a red rash
 Salivary gland involvement with swelling and
inflammation
 Progresses quickly to life-threatening condition
 Treat by increasing immunosuppression
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Dehydration
 Defined as the loss of water and essential body
salts (electrolytes) needed for body function
• Sweating, diarrhea, emesis, blood loss, etc.
 Symptoms include flushed face, dry, warm skin,
fatigue, cramping, reduced amount of urine
 Oral signs/symptoms
• Xerostomia, dry tongue
• Thick, sticky saliva
• Dry, cracked lips (cheilosis)
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Head and Neck Cancer:
Radiation Therapy
 Goal is to kill cancer cells
 Measured in Gray (Gy) units of absorbed
radiation: 1 Gy = 100 cGy = 100 rads
 Can be used alone or combined with surgery
and/or chemotherapy
 Three main routes
• External beam (most head and neck)
• Brachytherapy (body cavities)
• Interstitial
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Radiation Dose
 Dependent on tumor tissue/type
 Average of 200 cGy daily for 5 consecutive
days with two days of rest
 Total cummulative dose ranges from 5000
cGy to 8000 cGy for advanced tumors
 Threshold of permanent destruction is 21004000 cGy
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Tissue Response
 25 Gy: Bone marrow, lymphocytes, GI
epithelium, germinal cells
 25-50 Gy: Oral epithelium, endothelium of
blood cells, salivary glands, growing bone
and cartilage, collagen
 Doses > 50 Gy: bone and cartilage, skeletal
muscle
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Tissue Changes
 Irradiated tissue becomes hypocellular,
hypovascular, and hypoxic resulting in fibrosis
and vascular occlusion
 The destruction is mostly permanent
• Irradiated tissue does not re-vascularize with time
 As a result, irradiated tissue does not heal well
after injury
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Common Side Effects: Systemic
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Nausea
Vomiting
Neutropenia
Alopecia
Fatigue
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Common Side Effects: Oral
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Mucositis and Dermatitis
Dysphagia
Dysgeusia
Trismus
Osteo- and soft tissue necrosis
Xerostomia
• Fungal infections
• Radiation Caries
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Radiation: Xerostomia
 Parotid gland is more susceptible than the
submandibular or sublingual glands
 See a slight improvement after therapy but
will soon plateau at a lower level than pretherapy
 Result is thick, ropey saliva, decreased in
amount, with markedly diminished
lubricating and protective qualities
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Radiation: Mucositis
 The oral eipthelium will get a “sun burn”
like inflammation
 This will be exacerbated by the lack of the
lubricating properties of saliva
 The result will be a red, irritated, dry
mucosa
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Saliva Post-Radiation
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Mucositis
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Radiation Caries
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Prosthesis-Induced Stomatitis
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Fungal Infections
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Scrotal Tongue
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Chemotherapy
 Is given orally, IV, by injection (SQ, IM, IL), or
topically in cycles depending on the treatment
goals (type of cancer, how your body responds,
how well you body recovers, etc.)
 Affects all rapidly dividing cells
• Many side effects in all body systems
 Oral complications from direct damage to oral
tissues secondary to chemotherapy and indirect
damage due to regional or systemic toxicity
• Frequency and severity related to systemic immune
compromise, i.e. myelosuppresion
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Chemotherapeutics
 Drugs commonly associated with oral
complications
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Methotrexate
Doxorubicin
5-Fluorouracil (5-FU)
Busulfan
Bleomycin
Platinum coordination complexes
 Cisplatin
 Carboplatin
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Tissue Damage
 The propensity of chemotherapy to damage tissue,
specifically oral tissues, is dependent on each
individual drug and its ability to induce
myelosuppresion (neutropenia)
 Drugs differ on the timing of myelosuppresion
• Consider this when treating patients undergoing
chemotherapy
 Tissues, oral tissues, return to pre-chemotherapy
state when allowed time to heal after therapy
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Common Side Effects: Systemic
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Fatigue
Nausea
Constipation
Diarrhea
Hemorrhage
Anemia
Neutropenia
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Pain
Alopecia
Peripheral neuropathy
CNS disturbances
Fluid retention
Bladder and kidney
problems
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Common Side Effects: Oral
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Mucositis (ulcerative)
Reactivation of HSV
Dysgeusia
Dysphagia
Infections
 Neuropathies
 Salivary gland
dysfunction/toxicity
• xerostomia
• Fungal
• Periodontium
• periapices
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Summary
 While there appear to be many insults leading to
salivary hypofunction, healthy aging does not
appear to be one of them
 The main insults leading to salivary gland damage
and/or hypofunction are
• Disease
 Local
 Systemic
• Environmental insults/trauma
 Radiation
 Chemotherapy
• Medications
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