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Aging and Diseases of the
Salivary Glands
Biology of Salivary Glands
Domenica G. Sweier DDS
June 4, 2001
Saliva
 Frustrating for the dental team yet necessary
for the patient!
June 4, 2001
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, 2001
3
Objective vs Subjective
 Objective
• Major gland secretions
 Resting flow rate with a
Crittenden Cup
• Minor gland secretions
• Whole saliva
 Stimulated flow rate
with citric acid, wax
June 4, 2001
 Subjective
• Complaints of dry
mouth (xerostomia)
• Questionnaire
• Thirst
• The “cracker” test
4
Xerostomia
June 4, 2001
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, 2001
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, 2001
 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
 Disease
• Local
• Systemic
 Environmental Insults/Trauma
 Medications
June 4, 2001
8
Aging
 Salivary Quantity in
Health
• No changes in major
secretions (parotid,
submandibular)
• No changes in minor
secretions
June 4, 2001
 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, 2001
10
Diseases/Environmental Factors
 Diseases
• Local
• Systemic
 Environmental Factors
• Head and Neck Radiation
• Chemotherapy
• Medications
June 4, 2001
11
Local Diseases
 Neoplasms
• Benign
• Malignant
 Obstructive Diseases
• Calculi, mucus plugs
• Unusual anatomy
June 4, 2001
 Inflammatory
Diseases
• Acute viral sialadenitis
• Acute and Recurrent
Bacterial sialadenitis
• Inflammation/Infection
secondary to systemic
disease
12
Neoplasms
 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, 2001
 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
13
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, 2001
14
Submandibular Calculi
June 4, 2001
15
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, 2001
16
Inflammation/Infection: Viral
 Mumps is the most frequent cause of acute viral
sialadenitis
•
•
•
•
•
•
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, 2001
17
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, 2001
18
Bacterial Parotiditis
June 4, 2001
19
Systemic Diseases








Sjögren’s Syndrome
Sarcoidosis
Cystic Fibrosis
Diabetes
Alzheimer’s Disease
AIDS
Graft vs Host Disease
Dehydration
June 4, 2001
20
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, 2001
21
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, 2001
22
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, 2001
23
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, 2001
24
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, 2001
25
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, 2001
26
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, 2001
27
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, 2001
28
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, 2001
29
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, 2001
30
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, 2001
31
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, 2001
32
Common Side Effects: Systemic





Nausea
Vomiting
Neutropenia
Alopecia
Fatigue
June 4, 2001
33
Common Side Effects: Oral






Mucositis and Dermatitis
Dysphagia
Dysgeusia
Trismus
Osteo- and soft tissue radionecrosis
Xerostomia
• Fungal infections
• Radiation Caries
June 4, 2001
34
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, 2001
35
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, 2001
36
Saliva Post-Radiation
June 4, 2001
37
Mucositis
June 4, 2001
38
Radiation Caries
June 4, 2001
39
Prosthesis-Induced Stomatitis
June 4, 2001
40
Fungal Infections
June 4, 2001
41
Scrotal Tongue
June 4, 2001
42
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, 2001
43
Chemotherapeutics
 Drugs commonly associated with oral
complications
•
•
•
•
•
•
Methotrexate
Doxorubicin
5-Fluorouracil (5-FU)
Busulfan
Bleomycin
Platinum coordination complexes
 Cisplatin
 Carboplatin
June 4, 2001
44
Tissue Damage
 The propensity of chemotherapy drugs 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, 2001
45
Common Side Effects: Systemic







Fatigue
Nausea
Constipation
Diarrhea
Hemorrhage
Anemia
Neutropenia
June 4, 2001






Pain
Alopecia
Peripheral neuropathy
CNS disturbances
Fluid retention
Bladder and kidney
problems
46
Common Side Effects: Oral





Mucositis (ulcerative)
Reactivation of HSV
Dysgeusia
Dysphagia
Infections
 Neuropathies
 Salivary gland
dysfunction/toxicity
• xerostomia
• Fungal
• Periodontium
• periapices
June 4, 2001
47
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, 2001
48