Deserted mouth unveiled/ oral surgery courses

DESERTED MOUTHDESERTED MOUTH
UNVEILEDUNVEILED……..……..
11
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
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INTRODUCTIONINTRODUCTION
Normal daily salivary output : 1litre/day
XEROSTOMIA
22www.dentalacademy.comwww.dentalacademy.com

XEROSTOMIAXEROSTOMIA
Defined as a subjective complaint of oral dryness
that may result from a decrease in the production
of saliva; encompasses spectrum of oral complaints
Most common presentation of salivary gland disease;
but not always associated with salivary gland
hypofunction

Indian Dental academyIndian Dental academy
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Leader continuing dental educationLeader continuing dental education
Offer both online and offline dentalOffer both online and offline dental
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44

CAUSESCAUSES
Salivary causes
Salivary gland disorders
– Aplasia
– Sialolithiasis
– Sialadenitis
– Primary Sjogren’s
syndrome
– Secondary Sjogren’s
syndrome
Medications
Head & neck radiation
therapy
SALIVARY NON-SALIVARY

Dehydration
Central cognitive
alterations- cerebro-
vascular accidents
Oral sensory disturbances
Psychological conditions
&Neurological disorders
– Mental depression
– Narcolepsy
– Parkinson’s disease
– Bell’s palsy
– Alzheimer’s disease
NON-SALIVARY CAUSES

SYSTEMIC CONDITIONS THAT MAY HAVE
XEROSTOMIA AS A SYMPTOM
Endocrine
Diabetes
Hyper & hypothyroidism
Addison’s disease
Cushing’s syndrome
Malnutrition
Eating disorders
Anorexia nervosa
Anemia
Alcohol abuse
Atrophic gastritis
Autoimmune
Granulomatous diseases
GVHD/Bone marrow transplantation
HIV/AIDS
Others
Liver disease Renal dialysis

CONSIDERATIONSCONSIDERATIONS
 Some patients who complain of dry mouth do not
have evidence of reduced salivary flow
 Patients with salivary dysfunction rarely complain
of oral dryness as a solitary symptom
Wide range of flow rates fall within the normal
physiological range - hence difficult to substantiate
salivary gland hypofunction in patients who complain
of xerostomia

Chief Complaint (symptomatic / asymptomatic)
Dry mouth questionnaire
Medical history and review of systems
Yes No
Clinical evaluation
Yes
Further diagnostic work up

Questions that help identify people with or at risk of
developing salivary gland hypofunction
1. Does the amount of saliva in your mouth seem to be too
little? Too much? Or you do not notice it?
An ‘yes’ response to this question is an indication of reduced
unstimulated saliva
2. Do you have any difficulties in swallowing?
3. Does your mouth feel dry when eating a meal?
4. Do you sip liquids to aid in swallowing dry food?
An ‘yes’ response to these indicates reduced stimulated saliva
[Source: JADA 1987;115;581-4] 1010www.dentalacademy.comwww.dentalacademy.com

SYMPTOMATIC PATIENTSSYMPTOMATIC PATIENTS
Onset
Frequency, duration
Severity
Dry mouth
Hoarse voice
Trouble while eating, speaking, swallowing & chewing
Frequent need to sip water while eating dry food
Awakening at night with oral dryness
Loss of taste acuity
Oral pain, Stomatodynia
Sensitivity to spicy or coarse food
Denture discomfort
Dry/irritated eyes
Dryness of the skin
& vagina

CLINICAL EVALUATION
Tongue blade test:
To assess tissue dryness.
.
General
PhysicalPhysical
EmotionalEmotional
Soft tissue examination
Desiccated and friable
Erythematous
Cobblestoned / fissured tongue
Atrophy of filiform papillae
Candidiasis

Salivary gland evaluation
Enlargement
Tenderness on palpation
Lack of saliva flow on palpation
Blood /pus in saliva on palpation
Atrophic salivary ducts
Hard tissue examination
Primary & secondary caries
Cervical / Root surface caries in elderly
New & recurrent carious lesions

FURTHER DIAGNOSTIC EVALUATION
Sialometry
Sialochemistry
Scintigraphy
Microbial tests
Serologic tests
Histologic tests
Salivary gland imaging- sialography, plain
film radiography, ultrasonography, CT, MRI

Sialometric Evaluation
Saliva collection
Stimulated saliva flow rates
of <0.7mL/min considered abnormally low.
Unstimulated saliva flow rate
of <0.1mL/min
FactorsFactors
Patient positionPatient position
HydrationHydration
Diurnal/ seasonal variationDiurnal/ seasonal variation
TimeTime

ORAL SCHIRMER’S TEST
Based on measurement of
wetted length of filter
paper strip
WAFER TEST
Based on Time of
dissolution of wafer
measured from the
moment when the wafer is
put upto the time when the
wafer dissolves
SALIVARY FERNING TEST
Ferning phenomenon
based on uniformity,
branching , spreading &
integrity of arborization [ferns]
SAXON TEST
involves chewing on folded ,sterile
sponge for 2 minutes. Saliva
production is quantified by
weighing the sponge before and
after chewing
Type I Type II Type III Type IV

DIAGNOSTIC APPROACH
IN……..

PSYCOLOGICAL AND NEUROLOGICAL CONDITIONS
Xerostomia occurs during periods of acute anxiety, depression
and stress owing to predominant sympathetic stimulation
during such periods which causes sparser and more viscous
salivary flow
Assessment of depression
– Beck Depression Inventory Swedish version of revised 21
item focuses on affective, cognitive, somatic and
behavioral aspects of depression
Assessment of Anxiety
– State-Trait Anxiety Inventory
Assessment of stress
– General Perceived stress questionnaire- emphasizes
cognitive perceptions more than emotional states or
specific life events
[ Source :J of Psychosomatic Research 37: 19-32]

ORAL SENSORY DISTURBANCESORAL SENSORY DISTURBANCES
Taste assessment:Taste assessment:
SaltSalt
SweetSweet
SourSour
BitterBitter

XEROSTOMIA DUE TO NEUROLOGICAL
CONDITIONS
Major depressive disorder
• Chief complaint: chronic facial pain,Chief complaint: chronic facial pain,
burning sensation of the oralburning sensation of the oral
mucosa[often on the tongue] or TMJmucosa[often on the tongue] or TMJ
disorderdisorder
• Other oral signs of dry mouthOther oral signs of dry mouth

MDD contd…MDD contd…
DDysphoriaysphoria
AnhedoniaAnhedonia
IInsomniansomnia
PPsychomotor retardationsychomotor retardation
SSomatic complaintsomatic complaints
SSocial withdrawalocial withdrawal
Substance abuseSubstance abuse
Weight loss/gainWeight loss/gain
Rise in circulatory cortisolRise in circulatory cortisol
levelslevels
Neuroimaging studiesNeuroimaging studies
a. Abnormalities in blood flowa. Abnormalities in blood flow
b. Abnormalities in glucoseb. Abnormalities in glucose
metabolism in limbic systemmetabolism in limbic system
and amygdalaand amygdala

ALZHIEMER’S DISEASE
Characteristic features
– Reduced ability to perform activities of daily living
– Loss of memory
– Apraxia : inability to perform certain acts or
movements; can be tested by asking the patient to
use objects or to make or initiate certain movement

Assessment of aphasia
Formal analysis
Speech defects can be analyzed
Assessment of spoken speech
Paraphasia, neologisms, articulatory disturbances, orofacial apraxia,
speech repetition
Assessment of written language
Reading test
Writing test

INVESTIGATIONS [of dementia in general]
Imaging of head-
– CT/MRI: CT scan reveals diffuse atrophy of cerebral cortex,
wide sulci and dilated ventricles
Blood tests
– Full blood count, ESR
– Urea and electrolytes, glucose
– Calcium, LFTs
– Thyroid function tests
– Vitamin B 12 assay
– VDRL test
– ANA, anti-ds DNA
Chest radiograph
EEG 2424www.dentalacademy.comwww.dentalacademy.com

Xerostomia in patients with diabetes/suspected
diabetes
Medical & oral health history
Dental examination- caries, periodontal assessment
Assessment of salivary function
– Subjective assessment
– Objective assessment- salivary flow rates
Taste assessment

Assessment of diabetes complications
– Glycemic control: Elevated glycosylated Hb
levels is associated with greater progression of
hyposalivation
– Nephropathy
Urinary albumin- 200gm/min in 2 of 3, timed
urine samples
Serum creatinine - >180 mol/L

– Neuropathy
Peripheral neuropathy : assessment of distal
symmetrical polyneuropathy, according to clinical
examination methods- Diabetic Control &
Complication Trial protocol
Autonomic neuropathy: assessed as the ratio of
expiratory: inspiratory interval measurements
standardized from repeated maximal breathing
during ECG recordings[autonomic neuropathy
considered if the ratio is ≤1.10]
– Retinopathy- sterioscopic fundus photographs
– Peripheral vascular disease: ankle : arm B.P ratio
of <0.8 is considered positive

SYSTEMIC LUPUS ERYTHEMATOSUSSYSTEMIC LUPUS ERYTHEMATOSUS
Oral complaintsOral complaints : Xerostomia, stomatodynia,: Xerostomia, stomatodynia,
candidiasis, periodontal disease & dysguesiacandidiasis, periodontal disease & dysguesia
DIAGNOSIS
COMMON FINDINGS
ORAL LESIONS
CARDIAC/KIDNEY
INVOLVEMENT
NEUROLOGIC SYMPTOMS

Blood examinationBlood examination
– AnemiaAnemia
– Leukopenia [<4000/cu mm]Leukopenia [<4000/cu mm]
– Lymphopenia [<1500/cu mm]Lymphopenia [<1500/cu mm]
– Thrombocytopenia [< 100,000/cu mm]Thrombocytopenia [< 100,000/cu mm]
Urine examinationUrine examination
– Proteinuria [> 500 mg/24 hr]Proteinuria [> 500 mg/24 hr]
– Cellular castsCellular casts
Direct immunofluorescenceDirect immunofluorescence
– Lupus band testLupus band test
SerologySerology - ANAs- ANAs
INVESTIGATIONS

HIV ASSOCIATED XEROSTOMIA
Neoplastic & non-neoplastic lesions occur in salivary
glands
Benign [unilateral/bilateral] enlargement of salivary
glands

–
Stimulated salivary flow rates
– Eye examination- for kerato-conjunctivitis
sicca
– Serology – for anti-nuclear antibodies,
rhematoid factor, SS-A &SS-B antibodies–
these are absent in HIV
– Sialochemistry :increased albumin &
borderline increase of IgA ,protein & lysozyme
– CT: multicentric cysts/larger cysts ranging
from0.5-4 cm in diameter
– MRI
– Ultrasound
– FNA/BIOPSY
Diagnostic procedures

Diagnosis in Xerostomia in Chronic GVHD
Clinical features
Skin changes
Sialometric Analysis
Sialochemistry
– Higher salivary concentration of sodium,
epithelial growth factor, total protein, albumin
and IgG
– Decreased concentration of IgA
Biopsy :expression of adhesion molecules on
the salivary ductal epithelial cells[VCAM-1] is
more profound in GVHD

Xerostomia in Granulomatous conditions
TUBERCULOSIS
Salivary gland swelling,
granuloma/cyst formation
within the salivary glands
PCR based salivary assays
to detect mycobacterium
tuberculosis
Salivary tests for diagnosis
of tuberculosis
Cultures
SARCOIDOSIS
Bilateral, painless, firm
salivary gland enlargement
Heerfordt’s syndrome-
Uveitis
Facial palsy
Parotid swelling
Histopathology– classic
non-caseating granulomas
Serum chemistry-calcium
level, autoimmune
serologies increased
angiotensin-1 converting
enzyme concentration

Xerostomia in nutritional deficiencyXerostomia in nutritional deficiency
disordersdisorders
Anorexia Nervosa
HHistory
Salivary gland enlargement
Total and salivary specific amylase levels
Eating disorders

Alcohol abuse
Acute alcohol consumption-
Diagnosis
- Enhanced output of total protein & amylase
- Decrease in the output of electrolytes
Chronic alcoholism
Diagnosis
– Fatty tissue changes
– Acinar hypertrophy, Accumulation
of secretory granules
– Enlargement of lumen within
the ductal system

Clinical manifestations
– Sialadenitis
– Chronic major salivary gland enlargement
– Absence of symptoms of dry eyes
Histopathology
Salivary gland imaging – CT, MRI and ultra sound
scan
Detection of HCV DNA in the saliva
Serologic detection of anti- HCV antibodies and HCV
DNA
Xerostomia in HCV Infection

Conclusion
It is important to recognize that, xerostomia is not a
diagnosis, but a symptom with various possible
causes. Diagnosis of the underlying systemic cause
is the need of the hour
The series of steps described in this paper enhance
dentist's ability for early detection of salivary gland
hypofunction in both with or without dry mouth.

As Oral Physicians, in an attempt to lower the
incidence of devastating effects on oral health, and
institute appropriate management, we can diagnose
the possible cause of Xerostomia in a timely manner
and ultimately enhance the quality of life.

Thank u…………..

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