Download Xerostomia

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Xerostomia
2 Clinical points
Although the definition of xerostomia—dry mouth due to lack of saliva—may be simple, the effects
and origin of this common oral complaint are far from it. Its effects on the oral cavity range from
complete devastation, such as with methamphetamine (Tik) abusers, to minor irritation that can be
addressed with over-the-counter remedies. One of the most common complaints of the oral cavity, the
diagnosis of xerostomia is often subjective and a myriad of health issues, lifestyle factors, and
medical treatments may contribute to the condition.
Saliva
Xerostomia is the subjective complaint of dry mouth resulting from a decrease in the production of
saliva, also known as hypo-salivation. Whole saliva is a mixture of saliva from both the major and
minor salivary glands and crevicular gingival fluid and non-adherent (floating) oral bacteria and food
debris. Composed of more than 99% water, saliva also contains sodium, potassium, calcium,
magnesium, bicarbonate, and phosphate. Salivary function falls into five categories
1. Lubrication and protection: Saliva lubricates the oral cavity, facilitating mastication
(chewing), swallowing, and speech—all while protecting the tissues from mechanical trauma.
Saliva also protects the oral mucosa, gingiva, and teeth from harmful irritants and
antimicrobial activity.
2. Buffering and clearance: The buffering and clearing action of saliva is attributed to the
bicarbonate buffering system, although phosphate, urea, and amphoteric proteins (acts both
as a base and an acid) and enzymes also contribute to the buffering action of saliva. The
diffusion of bicarbonate ions into plaque neutralizes microbial acids through their buffering
ability. As a result, ammonia is generated that subsequently forms amines, which serve as
buffers. Amines are a base with a pH>7. Ammonia is also released from urea after it has
been metabolized by bacterial plaque, therefore increasing plaque pH and decreasing the
likelihood of caries progression. The ability of salivary buffers to alter plaque pH is determined
by plaque thickness and number of bacteria present. The buffering action of saliva is more
effective during times of stimulated high salivary rates, as compared to periods of low flow
with unstimulated saliva where its effects are nearly negligible. In other words, when reduced
levels of saliva are present, there is an increased risk of caries.
3. Maintenance of tooth integrity: Saliva supports the integrity of teeth by facilitating
remineralisation. This process of replacing lost minerals through the organic matrix of the
enamel is provided by high, supersaturated concentrations of calcium and phosphate
controlled by salivary proteins. Fluoride ions present within the saliva increase the rate of
crystal formation. The assimilation of fluoride ion into enamel structure forms a fluorapatitelike coating that makes the tooth structure more resistant to caries.
4. Antibacterial activity: The components of saliva, such as the mucosal antibody
immunoglobulin A (IgA) and the protein based enzyme peroxidase, provide its antibacterial
qualities, which protect the teeth from physical, chemical, and microbial attacks. Gingival
crevicular fluid from within the parotid glands produces the enzymes—lysozymes—that are
capable of destroying bacteria cell walls, in effect killing the bacteria. Saliva also inhibits
cysteine-proteinase, an enzyme involved in periodontitis.
5. Taste and digestion: Saliva is capable of enhancing taste and is responsible for the initial
steps of digestion. The composition of saliva enhances the tasting capacity for nutritional
sources and salty foods. Salivary amylase (an enzyme) begins the initial breakdown of starch
into smaller sugar molecules. The majority of starch breakdown occurs from the action of
pancreatic amylase. Fat digestion also appears to be initiated in the oral cavity by salivary
enzymes. The lubricating function of saliva, which aids in swallowing, is saliva's most
important contribution to the digestive system.
Symptoms
It is believed that a third of people over 65 suffer from xerostomia. It is not life threatening, but can have a
serious impact on the quality of life. Xerostomia may affect patients' dietary habits, speech, mastication,
as well as the ability to swallow, taste, and retain food in the oral cavity. An aversion to dry foods, sore
tongue, thirst, halitosis, oropharyngeal burning, and intolerance to spicy foods are also effects of
xerostomia.
Patients may also experience difficulty wearing their dentures, develop denture sores, have night time
oral discomfort, and mucus and plaque accumulation. Patients presenting with xerostomia are at
increased risk for hypo-salivation associated caries, periodontitis, tooth loss, and the development of
oral and oropharyngeal infections, such as candidiasis.
The fungal infection can also lead to angular cheilitis,
a condition where the fissures at the corners of the
mouth
become inflamed. A furrowed, erythematous (red)
pebbled,
cobblestoned, or fissured tongue and complete or
partial
depapillation of the dorsum of the tongue are also
characteristic
of progressive xerostomia.
The prevalence of dental caries is also related to salivary flow. Those presenting with xerostomia
exhibit recurrent decay at cervical margins (class V), incisal margins, and cusp tips (class VI).
Patients are often unaware of a decrease in salivary flow until they present with one or more of these
complications. Consequently, patients don't usually seek treatment from a dental practitioner until the
development of symptoms.
Diagnoses
The diagnosis of xerostomia is based on clinical examination and thorough medical, drug, and family
histories. We can facilitate the diagnostic process by asking specific questions. A complaint of oral
dryness is not always a direct indicator of salivary gland dysfunction. Psychological issues can also
cause xerostomia.
There is four indicators of salivary gland dysfunction: 1) dry lips; 2) buccal mucosal dryness; 3)
delayed or absence of salivation on palpation; 4) high total score on the decayed, missing, or filled
teeth index (DMFT).
If a patient has all of these factors, further diagnostic evaluations, such as measurements of salivary
flow rate (sialometry), biopsy of minor salivary glands, or a combination should be performed.
In patients with xerostomia, external palpitation of the submandibular and parotid glands may cause
delayed or no salivary flow. Running your finger over the mucosa, should be smooth and lubricated as
opposed to having the finger sticking to the tissue.
Great variability exists in individual salivary flow rates. Due to this large variability, it is difficult for the
professional to objectively evaluate salivary gland dysfunction in patients complaining of
xerostomia. Sialometric analysis of unstimulated saliva can be performed by having the patient dribble
saliva into a measuring vessel for a specified amount of time (between 3 minutes and 5 minutes).
Unstimulated salivary flow rates of <0.1 ml/min are considered to be diagnostic of
xerostomia/hypofunction. Xerostomia is a subjective experience. A patient with oral mucosa that
appears moist and a salivary flow rate >0.15 ml/min may still report a dry feeling in his or her mouth.
To confirm the subjective complaint of xerostomia, other methods of examination are available.
Sialographic studies involve the injection of a radio-opaque dye into the major salivary glands to
determine if salivary gland obstruction and/or damage are present, which is often seen in patients with
Sjogren's syndrome. Sjogren’s syndrome is a systemic autoimmune disease in which immune cells
attack and destroy the exocrine glands that produce tears and saliva.
To assess salivary gland function, quantitative salivary scintigraphy (nuclear scanning) can be used.
A biopsy from the lower lip may be helpful in the diagnosis of Sjogren's syndrome if the biopsy
reveals focal lymphocytic infiltrates in the minor salivary glands. Biopsy of minor salivary glands is
also required to diagnosis salivary gland neoplasms (a new and abnormal growth of tissue in some
part of the body, esp. as a characteristic of cancer). The use of fine needle aspiration can aid in the
identification of malignant lesions.
Effective management and treatment of xerostomia cannot begin without an accurate diagnosis.
Signs of xerostomia should be noted and monitored.
Next month we will be looking at the management and treatment of xerostomia.
Question time
1.
2.
3.
4.
5.
Xerostomia is also known as hypo-salivation.
Whole saliva is a mixture of saliva from both the major and minor salivary glands.
Xerostomia affects chewing, swallowing, speech and cleaning routine.
When reduced levels of saliva are present, there is an increased risk of caries.
The ability of salivary buffers to alter plaque pH is determined by plaque thickness and
number of bacteria present.
6. The thicker the plaque and the more bacteria present, the better the buffering action of saliva.
7. Saliva helps with the remineralisation of dental enamel.
8. Saliva has an anti-bacterial function.
9. Xerostomia patients have an increased risk of periodontitis.
10. The initial breakdown of fats is saliva's most important contribution to the digestive system.
11. Xerostomia patients have a red, pebbled tongue.
12. Psychological issues cannot cause xerostomia.
13. Sialometry is the analysis of saliva.
14. Unstimulated salivary flow rates of <0.5 ml/min are considered to be diagnostic of xerostomia.
15. Salivary gland obstruction can cause xerostomia.
16. Salivary gland obstruction cannot be diagnosed.
17. Sjogren’s syndrome is a systemic autoimmune disease in which immune cells attack and
destroy the exocrine glands that produce saliva and mucus.
18. A neoplasm is a new and abnormal growth of tissue in some part of the body, esp. as a
characteristic of cancer.
19. Nuclear medicine can be used in extreme cases to treat xerostomia.
20. Notes should be kept about complaints of dry mouth.
References :
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Dimensions of Dental Hygiene Oct 2010
Xerostomia from the beginning. Paula K. Friedman, DDS, MSD, MPH, Darren Isfeld, DMD
Read the full article:
http://www.dimensionsofdentalhygiene.com/ddhnoright.aspx?id=10240