MALABAR DENTAL COLLEGE MALABAR ACADEMIC CITY

1. SALIVARY GLAND DISORDERS
AND XEROSTOMIA
DR SHABIL MOHAMED MUSTAFA
ASSOCIATE PROFESSOR
MALABAR DENTAL COLLEGE AND RESEARCH CENTRE

2. CONTENT
CLASSIFICATION OF SALIVARY GLAND DISORDERS
INTRODUCTION XEROSTOMIA
ETIOLOGY
CLINICAL FEATURES
MANAGEMENT OF XEROSTOMIA

3. CLASSIFICATION OF SALIVARY
GLAND DISORDERS
DEVELOPMENTAL DISORDERS
Aberrancy
Aplasia and hypoplasia
Hyperplasia
Atresia
Accessory ducts
Diverticuli
Congenital fistula
FUNCTIONAL DISORDERS
Sialorrhea
Xerostomia
OBSTRUCTIVE DISORDERS
Sialolithiasis
Mucus plug
Stricture and stenosis
Extra ductal cause

4. CYST
Mucocele
Ranula
ASYMPTOMATIC ENLARGEMENT
Sialosis
Allegic
Associated with malnutrition
INFECTION
Viral infection
Bacterial infection
Mycotic infection
AUTOIMMUNE DISORDERS
Sjogren syndrome
Mikulicz’s disease
Uveoparotid fever
Recurrent non specific parotitis

5. INTRODUCTION
XEROSTOMIA
It is the subjective clinical condition of less
than normal amount of saliva.
It is dryness of mouth, which is a clinical
manifestation of salivary gland dysfunction

6. Function of saliva
Saliva is nature’s primary defense system for the
oral environment. Its functions include:
• Acting as a buffer to neutralize acidic challenges
• Aiding in immune response with the presence of
proteins, cytokines, hormones and mucins
• Aiding in proper speech and articulation
• Delivering calcium, phosphate and fluoride
• Performing as a lubricating agent
• Playing an active role in elimination of food and
bacteria
• Protecting exposed root surfaces

7. ETIOOGY
TEMPORARY CAUSES
1. Psychological
2. Duct calculi
3. Sialoadenitis
4. Drug therapy
 PERMANENT CAUSES
1. Radiation induced
2. Developmental abnormalities
3. Systemic alterations
4. Local factors

8. PSYCHOLOGICAL
•Anxiety and depression are well recognized as causes of
reduced salivary flow
DUCT CALCULI
•A blockage of the duct of a major salivary gland,
commonly the submandibular,
can produce dryness on the affected side, together with
pain and swelling in the
gland especially on stimulation.
•If untreated it may lead to progressive fibrosis of the
gland and permanent xerostomia
TEMPORARY CAUSES

9. SIALODENITIS
•Inflammation of the salivary gland can cause reduced
secretion.
•Acute infectious conditions-- mumps and post
operative parotitis
•Chronic infectious condition -- swelling related to
nutritional deficiency and hypersensitivity to iodine
•Intermittent swelling of salivary gland are idiopathic
and are described as
‘ chronic nonspecific sialedinitis’

10. DRUG THERAPY
•The mode of action of decreased salivary flow
generally related to the
parasympathetic activity, usually an anti
muscarine effect.
•Classes of drugs which cause xerostomia
Antihistamine agent-Diphenhydramine
Chlorpheniramine
Decongestant agents-Pseudophedrine
Antidepressant agent-Amitriptyline
Citalopram
Fluoxetine
Paroxetine
Bupropion

11. Anticholinergic agents-Atropine
Scopolamine
Antipsychotic agents- phenothiazine derivatives
Haloperidol
Sedative and anxiolytic agents-Diazepam
Lorazepam
Alprazolam
Antihypertensive agents-Reserpine
Methyldopa
Chlorothiazide
Furosemide
Calcium channel blockers

12. PERMANENT CAUSES
RADIATION INDUSED
•Ionizing radiation to head and neck region for the
treatment of cancers results in
Pronounsed changes in the Slivary gland located to
dose-time-volume factor.
•Damage to the acinar cells has been noted with a
single 100 rads dose of X rays.
•Radiation sensitivity decrease in following order;
parotid gland, submandibular,
sublingual to minor glands

13. •Serous acinar cells to be more sensitive to
radiation, than the mucous cells
As the dose increased, disorganization and
destruction of the acinar cells occur,
resulting in their replacement by fibrous or faulty
tissues
•Both the stimulated and unstimulated salivary
flow rate decreases dramatically with
Increasing radiotherapy

14. DEVELOPMENTAL ABNORMALITIES
•SALIVARY AGENESIS
Complete absence of salivary gland is known as
salivary aplasia or salivary agenesis
It is rare but may occur with other developmental
defect,especially malformation of the craniofacial
anomalies

15. SYSTEMIC ALTERATIONS
•Nutritional-certain deficiency states like pernicious
anemia,
iron deficiency anemia and deficiency of vitamine A
and hormones can cause xerostomia
•Fluid loss-fluid loss associated with hemorrage,
sweating, diarrhea, vomiting
Diabetes mellitus-it is associated with xerostomia

16. •Sjogren syndrome-The combination of the dry
mouth, dry eyes, and often rheumatoid arthritis
Mainly affects women over 40 years of age and is
often accompanied by a mild fever
About the half of the patient with this syndrome
also present with, or go on to develop swelling of
the major salivary glands which display similar
histology to Mickulicz’s disease

17. OTHER SYSTEMIC DISORDERS
Diabetes insipidus
Sarcoidosis
HIV infection
Hepatitis C infection
Graft versus host disease
Psychogenic disorders
LOCAL FACTORS
Decreased mastication
Smoking
Mouth breathing

18. CLINICAL FEATURES
EFFECT OF XEROSTOMIA ON ORAL FUNCTIONS-
•Patient may notice increased thirst, increased uptake
of fluid especially while eating.
•Patient also get difficulty in swallowing, speech and
eating dry food
•There is also burning and tingling sensations in the
mouth
•There is also complaint of frequent oral infections,
intolerance to dental appliances and abnormal taste in
the mouth

19. SALIVARY GLAND ENLARGEMENT
painfull salivary gland enlargement is also present
EFFECT OF XEROSTOMIA ON NORMAL FUNCTIONS
Many times xerostomia is accompanied by hypofuction
of other secretory glands
Blurred visionand occular dryness
Itching, burning and sandy sensation in eye
There is also dryness of pharynx and skin
Itching and burning sensation of vagina

20. CLINICAL MANIFESTATION OF XEROSTOMIA
Dryness of lining oral mucosa ,oral mucosa appears thin
pale and feels dry. tongue blade may adhere to soft
tissues
Tongue may manifest deficiency by atrophy of the
papillae, inflammation, fissuring, cracking and
denudation
Also increased incidence of dental caries

22. dorsum of the tongue may become depapillated (see Figure 2, Panel 1)
or fissured and coated (see Figure 2, Panel 2).
They may have the appearance of a dry shiny mucosa or an absence of a saliva
pool on the floor of the mouth (see Figure 2, Panel 3),
loss of stippling of the gingiva, stained teeth (see Figure 2, Panel 4)
and multiple dental restoration (see Figure 2, Panel 5).

23. CANDIDIASIS
Pseudo membranous and hyperplastic form of
candidiasis occurs.
The reason for occurrence candidiasis is absence of
normal cleansing and antimicrobial activity of the
saliva
RESIDUAL SALIVA
Residual saliva which remains is foamy, thick and
ropey

25. (1)preventive therapy,
(2) symptomatic (palliative) treatment,
(3) local or topical salivary stimulation,
(4) systemic salivary stimulation,
(5) therapy directed at an underlying systemic
disorder.

26. PREVENTIVE THERAPY
The use of topical fluorides in a patient with salivary
gland
hypofunction is absolutely critical to control dental
caries.
FLUORIDE THERAPIES
from low-concentration over-the-counter fluorid
rinses
 highly concentrated prescription fluorides (eg,
1.0% sodium fluoride)

27.  fluoride varnishes
The dosage chosen and the frequency of
application should be determined based on the
severity of the salivary dysfunction and the
rate of caries development

28.  maintain meticulous oral hygiene.
 require more frequent dental visits (usually every
3–4 month work closely with their dentist to maintain
optimal dental health.
 counselled as to diet, avoiding cariogenic foods
and beverages
 Chronic use of alcohol and caffeine can increase
oral dryness and should be minimized.
Patient should--

29. When salivary function is compromised, the
normal process of tooth remineralisation is
compromised and demineralisation is increased,
speeding the loss of tooth structure
Remineralising solutions may be used to alleviate
some of the effects of the loss of normal salivation
Patients with dry mouth also experience an
increase in oral infections, particularly mucosal
candidiasis, thus appropriate antifungal therapies
should be instituted as neccessary

30. SYMPTOMATIC TREATMENT
Patients should be encouraged to sip water
throughout the day; this will help moisten the oral
cavity, hydrate the mucosa, and clear debris from the
mouth.
The use of water with meals can make chewing and
forming the food bolus easier, will ease swallowing, and
will improve taste perception.
Use of sugar-free carbonated drinks is not
recommended as the acidic content of many of these
beverages is high and may increase tooth
demineralization.

31.  An increase in environmental humidity is
exceedingly important.
The use of room humidifiers, particularly at night,
may lessen discomfort markedly. As part of the
normal diurnal variation, salivary flow drops almost
to zero during rest.
In individuals who have any degree of secretary
hypo function, the desiccation of the mucosa is
particularly troublesome at night, and frequent
awakening may interfere with restorative
sleep.

32. There are a number of oral rinses, mouthwashes, and
gels
available for dry mouth patients.
Patients should be cautioned to avoid products
containing alcohol, sugar, or strong flavorings that may
irritate sensitive dry mucosa.
 Moisturizing creams are important. The frequent use
of products containing aloevera or vitamin E should be
encouraged.
Persistent cracking and erythema at the corners of
the mouth (angular cheilitis) should be investigated for
a fungal or bacterial cause.

33. There are many commercially available salivary
substitutes.(‘artificial salivas’) .
Although there is clearly a role for the use of saliva
replacements, particularly in individuals who have no
residual salivary gland function, it must be recognized
that this is not a highly effective symptomatic therapy
Composition
carboxymethylcellulose-10gm/l
sorbitol-30gm/l
potassium chloride1.2gm/l
sodium chloride-.843gm/l
magnesium chloride-0.051gm/l
calcium chloride-0.146gm/l
dipotassium hydrogen phosphate
0.342gm/l

34. SALIVARY STIMULATION
Chewing will helps stimulation of saliva provided by
gums or mints, can be very effective in relieving
symptoms for patients who have remaining salivary
function.
However, patients with dry mouth must be told not
to use
products that contain sugar as a sweetener due to the
increased
risk of dental caries.
LOCAL STIMULATION

35. Electrical stimulation has also been examined ,device
that delivers a very low-voltage electrical charge to the
tongue and palate has been described, although its
effect was modest in patients with dry mouth.
Acupuncture, with application of needles in the
perioral and other regions, has been proposed as a
therapy for salivary gland hypofunction and
xerostomia.

36. The use of systemic secretogogues
bromhexine, anetholetrithione,
pilocarpine HCl, and cevimeline HCl.
Bromhexine
is a mucolytic agent used for lacrimal function in
patients with Sjögren’s syndrome, although this is
controversial.
SYSTEMIC STIMULATION

37. Anetholetrithione
is a mucolytic agent that has been shown to increase
salivary output in clinical trials with mild adverse
effects may up-regulate muscarinic receptors.
In patients with mild salivary gland hypofunction,
anetholetrithione significantly increased saliva flow.
However, it was ineffective in patients with marked
salivary gland hypofunction.
One study suggested a possible synergistic effect of
anetholetrithione in combination with pilocarpine.

38. Pilocarpine HCl is FDA approved specifically for the
relief of xerostomia following radiotherapy for head
and neck cancers and for those with Sjögren’s
syndrome.
Pilocarpine HCl is a parasympathomimetic drug,
functioning as a muscarinic cholinergic agonist, which
increases salivary output and stimulates any remaining
gland function.
The adverse effects of pilocarpine in human studies
are common and are usually mild, consistent with the
known mechanism of action of the drug.
.

39. Sweating is the most common side effect, with other
frequently reported side effects, including hot
flashes, urinary frequency, diarrhea, and blurred
vision.
After administration of pilocarpine, salivary output
increases fairly rapidly, usually reaching a maximum
within 1 hour.
The best-tolerated doses are those of 5.0 to 7.5 mg,
given three or four times daily.
The duration of action is approximately 2 to 3 hours.

40. Pilocarpine is contraindicated for patients with
pulmonary disease, asthma, cardiovascular
disease, or narrow angle glaucoma.
Patients do not appear to develop tolerance to
pilocarpine following prolonged use.
Pilocarpine has been shown to be a safe and effective
therapy for patients with diminished salivation but
who have some remaining secretory function that can
be stimulated

41. Cevimeline HCl is another parasympathomimetic
agonist that is FDA approved for the treatment of
symptoms of oral dryness in Sjögren’s syndrome.
Cevimeline is prescribed at 30 mg/three times daily.
This medication reportedly selectively targets the M1
and M3 muscarinic receptors of the
salivary and lacrimal glands.

42. However, in clinical use, its side effects are similar to
those of pilocarpine, and it still must be used with
caution in patients with a history of glaucoma or
cardiovascular, respiratory, or gallbladder disease and
in patients who use various medications.
The duration of secretogogue activity is longer than
pilocarpine (3–4 hours), and the onset is somewhat
slower.
Cevimeline is presently in clinical trials for
postradiotherapy xerostomia.

43. CONCLUSION
Xerostomia refers to a subjective sensationof a dry
mouth; it is frequently but not always associated with
salivary gland hypofunction. A number of factors may
play a role in the cause of xerostomia