xerostomia and ptyalism are functional disorders of salivary glands that are quite common. This presentation deals with clinical aspect of detecting and managing such patients.

1. MANAGEMENT OF
PTYALISM AND XEROSTOMIA
BY NAYANAASRI.B
INTERN

2. INTRODUCTION
SALIVARY GLANDS
MAJOR
oPAROTID
oSUBMANDIBULAR
oSUBLINGUAL
MINOR
oLABIAL
oBUCCAL
oPALATINE
oGLOSSOPALATINE
oBLANDIN`S AND NUHN`S
oVON EBNER
oPOSTERIOR LINGUAL
oINCISIVE

3. SALIVARY
GLAND
DISORDERS
DEVELOPMENTAL
FUNCTIONAL
INFLAMMATORY
TRAUMATIC
AUTOIMMUNE
NEUROLOGICAL
DEGENERATIVE
VASCULAR
NEOPLASTIC
NON-IFLAMMATORY NON-NEOPLASTIC

4. FUNCTIONAL
SALIVARYGLAND
DISORDER
XEROSTOMIA- it is defined as the subjective sensation
of oral dryness that may or may not be associated with a
reduction in salivary output. The condition may be
transient , prolonged or permanent depending upon the
duration of condition.
PTYALISM- it is defined as an excessive production of
saliva and is the result of either an increase in salivary
production or decrease in salivary clearance.

5. XEROSTOMIA-
ETIOLOGY
 RADIATION INDUCED
>30 GY – REVERSIBLE EFFECTS
>60 GY- IRREVERSIBLE EFFECTS
 PHARMACOLOGICALLY INDUCED (xerogenic drugs)
ANTICHOLINERGIC- EX: ATROPINE
ANTIHYPERTENSIVE-EX: METHYL DOPA
ANTIHISTAMINE- EX: DIPHENHYDRAMINE
ANTIEMETIC- EX: HYOSCINE
ANTISPASMODIC- EX:TIZANDINE
 LOCAL FACTORS
 SYSTEMIC ALTERATIONS- EX:SJOGREN SYNDROME

6. SALIVARYGLAND
HYPOFUNCTION

7. XEROSTOMIA-
SIGNSAND
SYMPTOMS
 SALIVARY GLAND ENLARGEMENT
 HYPOFUNCTION OF OTHER GLANDS
 PALE, THIN, DRY ORAL MUCOSA
 TONGUE- ATROPHIED PAPILLAE, INFLAMMATION,
FISSURING, CRACKING
 DENTAL CARIES
 CANDIDIASIS

8. XERODERMA
XEROPHTHALM
IA

9. ORALMUCOSA
CHANGES

10. Tonguechanges

11. Dentalcaries

12. INVESTIGATION
 SIALOMETRY OR SALIVARY FLOW RATES
 RESTING
 UNSTIMULATED
 WHOLE
 NORMAL RESTING = 0.3 ml/min
 SIALOGRAPHY-
 SS appears as CHERRY BLOSSOM
 SCINTIGRAPHY- with sodium pertechtonate

13. SIALOGRAPHY

14. XEROSTOMIA–
MANAGEMENT
 PREVENTIVE THERAPIES- SUPPLEMENTAL
FLUORIDES, REMINERALIZING SOLUTIONS, ORAL
HYGIENE, NON- CARIOGENIC DIET
 SYMPTOMATIC THERAPY- WATER, ORAL RINSES,
GELS, MOUTHWASHES, ICREASED HUMIDIFICATION,
 LOCAL SALIVARY STIMULATION- SUGAR FREE GUMS
AND MINTS
 SYSTEMIC STIMULATION- PARASYMPATHOMIMETIC
SECRETOGOGUES
 TREATMENT OF UNDERLYING SYSTEMIC
DISORDERS
 STEM CELL THERAPY

15. PREVENTIVE
 TOPICAL FLUORIDE- 1.1% SODIUM
FLUORIDE
 Dental examination every 6 months
 Meticulous oral hygiene
 Diet- non-cariogenic, decaf, decreased alcohol

16. SYMPTOMATIC
 WATER
 SALIVARY SUBSTITUTE OR ARTIFICIAL SALIVA
COMPOSITION OF ARTIFICIAL SALIVA
•Carboxymethyl cellulose- 10g/L
•Sorbitol- 30g/L
•Potassium chloride- 1.2g/L
•Sodium chloride- 0.843 g/L
•Magnesium chloride- 0.051 g/L
•Calcium chloride- 0.146 g/L
•Dipotassium hydrogen phosphate: 0.342 g/L
DISADVANTAGE OF ARTIFICIAL SALIVA
•Poor patient compliance
•Viscous than natural saliva
•Expensive
 DISCONTINUATION OF DRUG CAUSING
XEROSTOMIA

17. CANDIDIASIS
 TOPICAL ANTIFUNGALS
 Nystatin-200,000 units
 DENTURE TREATMENT
 NYSTATIN CREAM
 TRIAMCINALONE ACETONIDE CREAM
 SYSTEMIC ANTIFUNGALS
 FLUCANAZOLE- 100 mg tablet OD
 KETACONAZOLE- 200 mg tablet OD or BD

18. LOCAL
STIMULATION
 CHEWING OF GUMS, MINTS, PARAFFIN AND CITRIC
ACID CONTAINING LOZENGES AND RINSES.
DISADVANTAGES-
•Short lived
•Incovenient
•Citric acid may irritate oral mucosa
•Continous use may cause demineralization

19. LOCAL
STIMULATION
 TRANSCUTANEOUS ELECTRIC NERVE
STIMULATION-
Increases salivary secretion in both healthy and
radiation induced xerostomia patients.
 OSTEOINTEGRATED IMPLANT WITH EMBEDDED
WETNESS SENSOR-
recent advancement
 ACCUPUNTURE-
needles placed in perioral region.
low evidence of small increase in saliva secretion.

20. SYSTEMIC
STIMULATION
 BROMHEXINE-
 MUCOLYTIC AGENT
 STIMULATE LACRIMAL FUNCTION IN SS
 INDUCE THIN COPIOUS BRONCHIAL SECRETIONS
 DOSE: ADULTS- 8 mg TDS, CHILDREN(1- 5 years)- 4 mg
BD, CHILDREN( 5-10 years)- 4 mg TDS.
 ANETHOLETRITHIONE-
 DIRECTLY ACTING CHOLINERGIC AGONIST
 DOSE: 1 TO 2 tabs 25 mg TDS.

21. SYSTEMIC
STIMULATION
 PILOCARPINE HCL
 FDA APPROVED DRUG SPECIFIC TO XEROSTOMIA
 PARASYMPATHOMIMETIC DRUG
 ICREASES SECRETION BY EXOCRINE GLAND
 CONTRAINDICATED IN ASTHMATICS
 DOSE: 5 mg TDS.
 SIDE EFFECTS- SWEATING, HOT FLASHES, URINARY
FREQUENCY, DIARRHEA, BLURRED VISION.
 CEVIMELINE
 PARASYMPATHOMIMETIC AGONIST
 ACTS ON M1, M3 RECEPTORS

22. STEMCELL
THERAPY
 THERE ARE CELLS WITHIN SALIVARY DUCT
CAPABLE OF PROLIFERATION AND
DIFFERENTIATION CALLED STEM CELL OR
PROGENITOR CELLS.
 APPLICATION OF SPECIFIC GROWTH FACTORS TO
THESE CELLS INDUCE DIFFERENTIATION INTO
FUNCTIONAL UNITS

23. SUMMARY

24. PTYALISM-
ETIOLOGY
 DRUGS- EX: PILOCARPINE, CEVIMALINE, LITHIUM,
BETHANECHOL, PHYSOSTIGMINE, CLOZAPINE,
RISPERIDONE, NITRAZEPAM
 NEUROLOGIC DISEASES- EX: PARKINSON`S
DISEASE WILSON`S DISEASE, AMYOTROPHIC
LATERAL SCLEROSIS, DOWN SYNDROME, FRAGILE
X SYNDROME, AUTISM, CEREBRAL PALSY
 PROTECTIVE BUFFER IN RESPONSE TO GERD
 LOCAL FACTORS: STOMATITIS, ANUG, ERYTHEMA
MULTIFORME.
 HEAVY METAL POISONING: IRON, LEAD, ARSENIC,
MERCURY, THALLIUM

25. PTYALISM-
CLINICAL
FEATURES
 DROOLING
 LIP CHAPPING
 MALODOR
 PERIORAL INFECTIONS
 TRAUMATIC ULCERS
 SCONDARY FUNGAL INFECTIONS
 SEVERE CASES- ASPIRATION PNEUOMONIA

26. PTYALISM-
MANAGEMENT
 PHYSICAL THERAPY
 MEDICATIONS
 SURGERY
 RADIATION THERAPY
 BIOFEEDBACK
 REMOVAL OF LOCAL FACTORS

27. PHYSICAL
THERAPY
 ORAL MOTOR TRAINING
 EXERCISES FOR SWALOWING
 SPEECH THERAPY
 KEY NON-SURGICAL MANAGEMENT
 PALATAL TRAINING DEVICES
 6 MONTH FORMAT

28. PHYSICAL
THERAPY
 POSITIONING- GOOD POSTURE, PROPER TRUNK
AND HEAD CONTROL
 EATING AND DRINKING SKILLS- TECHNIQUES IN LIP
CLOSURE, TONGUE MOVEMENT AND SWALLOWING
 ORAL FACIAL FACILITATIONS
 EXERCISES BY SPEECH THERAPISTS
 BRUSHING-EFFECT CAN BE SEEN UPTO 20-30
MINUTES DONE BEFORE MEALS
 VIBRATION
 MANIPULATION- STROKING TAPPING, PATTING, FIRM
PRESSSURE DIRECTLY ON MUSCLES
 BEHAVIOUR THERAPY- POSITIVE AND NEGATIVE
REINFORCEMENT

30. MEDICATIONS
 ATROPINE
 ANTAGINIST OF MUSCARINIC ACTIONS OF Ach.
 DOSE- ADULTS: 0.4 mg EVERY 4 TO 6 HRS; CHILD- 0.01
mg/kg.
 SIDE EFFECTS- CONTRAINDICATED FOR PATIENTS WITH
ASTHMA AND GLAUCOMA PATIENTS
 SCOPOLAMINE
 DOSE- 0.4 mg
 TRANSDERMAL SCOPOLAMINE IS MORE EFFECTIVE
LASTS FOR 3 DAYS
 METHANTHALINE- 50-100 mg
 PROPANTHALINE-15-30 mg
 GLYCOPYRROLATE
 BENZTROPINE
 DIPHENHYDRAMINE HCL

31. PHARMACOLOGY
THERAPY
 BOTULINUM TOXIN
 BOTULINUM TOXIN TYPE A- BTx-A
 BTx-A SELECTIVELY BINDS TO CHOLINERGIC NERVE
TERMINALS AND RAPIDLY ATTACHES TO ACCEPTOR
MOLECULES AT THE PRESYNAPTIC NERVE SURFACE.
 THIS RESULTS IN INHIBITION OF Ach AND REDUCES
FUNCTION OF PARASYMPATHETIC CONTROLLED
EXOCRINE GLANDS
 REVERSIBLE
 DOSE- 30-40 UNITS INJECTED TO PAROTID AND
SUBMANDIBULAR GLANDS UNDER ULTRASOUND
GUIDANCE
 SIDE EFFECS-DYSPHAGIA, WEAK MASTICATION,
DAMAGE TO FACIAL ARTERY AND NERVE

32. SURGERY
 RELOCATION OF DUCT {WILKE}- RELOCATION OF
STENSON AND WHARTON DUCT POSTERIORLY TO
TONSILLAR FOSSA
 BILATERAL TYMPANIC NEURECTOMY- SECTIONING
OF CHORDA TYMPANI NERVE DESTROYS
PARASYMPATHETIC INNERVATIONS TO GLAND
 INTRADUCTAL LASER PHOTOCOAGULATION
 EXCISION

33. RADIATION
THERAPY
 DOSE: 6000 RAD
 SIDE EFFECTS-
 XEROSTOMIA
 DENTAL CARIES
 OSTEORADIONECROSIS

35. References
 Burket’s oral medicine. 12th edition
 Anil Ghom. Textbook of oral medicine. 4th edition