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Aging and Diseases of the Salivary Glands
Biology of Salivary Glands
Domenica G. Sweier DDS
June 4, 2003
June 4, 2003 2
Saliva
Frustrating for the dental team yet necessary for the patient!
June 4, 2003 3
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 4
June 4, 2003 5
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
Subjective• Complaints of dry
mouth (xerostomia)
• Questionnaire
• Thirst
• The “cracker” test
June 4, 2003 6
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 7
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
Dysphagia Dysgeusia Difficulty eating/speaking/
wearing prosthesis Swelling of the salivary
glands Difficulty expressing
saliva Cheek biting Persistent need for fluids Burning tongue
June 4, 2003 8
What Contributes to Xerostomia?
Aging• Hormonal Changes/Menopause
Disease• Local• Systemic
Environmental Insults/Trauma Medications
June 4, 2003 9
Aging
Salivary Quantity in Health• No changes in major
secretions (parotid, submandibular)
• No changes in minor secretions
Salivary Quality in Health• No general changes in
salivary constituents
June 4, 2003 10
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 11
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 12
Diseases/Environmental Factors
Diseases• Local• Systemic
Environmental Factors• Head and Neck Radiation• Chemotherapy• Medications
June 4, 2003 13
Local Diseases
Tumors/Growths• Benign
• Malignant
Obstructive Diseases• Calculi, mucus plugs
• Unusual anatomy
Inflammatory Diseases• Acute viral sialadenitis
• Acute and recurrent bacterial sialadenitis
• Inflammation/Infection secondary to systemic disease
June 4, 2003 14
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
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
June 4, 2003 15
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 16
Submandibular Calculi
June 4, 2003 17
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 18
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 19
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 20
Bacterial Parotiditis
June 4, 2003 21
Systemic Diseases Sjögren’s Syndrome Sarcoidosis Cystic Fibrosis Diabetes Alzheimer’s Disease AIDS Graft vs Host Disease Dehydration
June 4, 2003 22
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 23
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 24
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 25
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 26
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 27
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 28
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 29
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 30
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 31
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
2100- 4000 cGy
June 4, 2003 32
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 33
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 34
Common Side Effects: Systemic
Nausea Vomiting Neutropenia Alopecia Fatigue
June 4, 2003 35
Common Side Effects: Oral
Mucositis and Dermatitis Dysphagia Dysgeusia Trismus Osteo- and soft tissue necrosis Xerostomia
• Fungal infections
• Radiation Caries
June 4, 2003 36
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 pre-therapy
Result is thick, ropey saliva, decreased in amount, with markedly diminished lubricating and protective qualities
June 4, 2003 37
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 38
Saliva Post-Radiation
June 4, 2003 39
Mucositis
June 4, 2003 40
Radiation Caries
June 4, 2003 41
Prosthesis-Induced Stomatitis
June 4, 2003 42
Fungal Infections
June 4, 2003 43
Scrotal Tongue
June 4, 2003 44
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 45
Chemotherapeutics
Drugs commonly associated with oral complications• Methotrexate• Doxorubicin• 5-Fluorouracil (5-FU)• Busulfan• Bleomycin• Platinum coordination complexes
Cisplatin Carboplatin
June 4, 2003 46
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 47
Common Side Effects: Systemic
Fatigue Nausea Constipation Diarrhea Hemorrhage Anemia Neutropenia
Pain Alopecia Peripheral neuropathy CNS disturbances Fluid retention Bladder and kidney
problems
June 4, 2003 48
Common Side Effects: Oral
Mucositis (ulcerative) Reactivation of HSV Dysgeusia Dysphagia Infections
• Fungal
• Periodontium
• periapices
Neuropathies Salivary gland
dysfunction/toxicity• xerostomia
June 4, 2003 49
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