Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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! June 4, 2003 2 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? June 4, 2003 3 June 4, 2003 4 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 June 4, 2003 Subjective • Complaints of dry mouth (xerostomia) • Questionnaire • Thirst • The “cracker” test 5 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 June 4, 2003 6 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 June 4, 2003 Dysphagia Dysgeusia Difficulty eating/speaking/ wearing prosthesis Swelling of the salivary glands Difficulty expressing saliva Cheek biting Persistent need for fluids Burning tongue 7 What Contributes to Xerostomia? Aging • Hormonal Changes/Menopause Disease • Local • Systemic Environmental Insults/Trauma Medications June 4, 2003 8 Aging Salivary Quantity in Health • No changes in major secretions (parotid, submandibular) • No changes in minor secretions June 4, 2003 Salivary Quality in Health • No general changes in salivary constituents 9 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 June 4, 2003 10 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 June 4, 2003 11 Diseases/Environmental Factors Diseases • Local • Systemic Environmental Factors • Head and Neck Radiation • Chemotherapy • Medications June 4, 2003 12 Local Diseases Tumors/Growths • Benign • Malignant Obstructive Diseases • Calculi, mucus plugs • Unusual anatomy June 4, 2003 Inflammatory Diseases • Acute viral sialadenitis • Acute and recurrent bacterial sialadenitis • Inflammation/Infection secondary to systemic disease 13 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 June 4, 2003 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 14 Obstruction: Sialolithiasis Calculi form in the duct, blocking the egress of saliva • Majority in submandibular gland 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 June 4, 2003 15 Submandibular Calculi June 4, 2003 16 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 June 4, 2003 17 Inflammation/Infection: Viral Mumps is the most frequent diagnosis of acute viral sialadenitis • • • • • • • 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 June 4, 2003 18 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 June 4, 2003 19 Bacterial Parotiditis June 4, 2003 20 Systemic Diseases Sjögren’s Syndrome Sarcoidosis Cystic Fibrosis Diabetes Alzheimer’s Disease AIDS Graft vs Host Disease Dehydration June 4, 2003 21 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 June 4, 2003 22 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 June 4, 2003 23 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 June 4, 2003 24 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 June 4, 2003 25 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 June 4, 2003 26 AIDS HIV-Associated Salivary Gland Disease (HIV-SGD) • • • • Enlargement of the major salivary glands Xerostomia Some similarities to autoimmune diseases HIV itself not consistently found to be in glandular tissue Medications June 4, 2003 27 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 June 4, 2003 28 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) June 4, 2003 29 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 June 4, 2003 30 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 June 4, 2003 31 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 June 4, 2003 32 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 June 4, 2003 33 Common Side Effects: Systemic Nausea Vomiting Neutropenia Alopecia Fatigue June 4, 2003 34 Common Side Effects: Oral Mucositis and Dermatitis Dysphagia Dysgeusia Trismus Osteo- and soft tissue necrosis Xerostomia • Fungal infections • Radiation Caries June 4, 2003 35 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 June 4, 2003 36 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 June 4, 2003 37 Saliva Post-Radiation June 4, 2003 38 Mucositis June 4, 2003 39 Radiation Caries June 4, 2003 40 Prosthesis-Induced Stomatitis June 4, 2003 41 Fungal Infections June 4, 2003 42 Scrotal Tongue June 4, 2003 43 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 June 4, 2003 44 Chemotherapeutics Drugs commonly associated with oral complications • • • • • • Methotrexate Doxorubicin 5-Fluorouracil (5-FU) Busulfan Bleomycin Platinum coordination complexes Cisplatin Carboplatin June 4, 2003 45 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 June 4, 2003 46 Common Side Effects: Systemic Fatigue Nausea Constipation Diarrhea Hemorrhage Anemia Neutropenia June 4, 2003 Pain Alopecia Peripheral neuropathy CNS disturbances Fluid retention Bladder and kidney problems 47 Common Side Effects: Oral Mucositis (ulcerative) Reactivation of HSV Dysgeusia Dysphagia Infections Neuropathies Salivary gland dysfunction/toxicity • xerostomia • Fungal • Periodontium • periapices June 4, 2003 48 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 June 4, 2003 49