Pathology

Question 1

What is xerostomia?

How much of the population is affected?

Answer 1

The complaint of a dry mouth; if salivary flow rate is <0.1ml/min

• 50% of salivary function must be lost.
• They are prone to increased dental caries, periodontal disease, intolerance of dentures and oral infections, particularly candidiasis
• Epidemiology: Less than 2% population

Question 2

What are the causes of Xerostomia?

Answer 2

• Either disease or medication induced.

‣ Antidepressants ➔ MAO inhibitors

‣ Antihistamines ➔ Ethanolamines e.g. Clemastine, Phenothiazines e.g. Proethazine

‣ Antimuscarinic drugs

‣ Anti-epileptic drugs

‣ Antipsychotics ➔ Phenothiazines e.g. romazine

‣ Antihypertensives -> Beta-blockers/Ca+ channel blockers/ACE inhibitors ‣ Painkillers: Morphine (commonly overlooked)

‣ Diuretics ➔ Benzthiazide, hydroflumethiazide, trichlormethiazide ‣ Cocaine, ecstasy, meth

‣ Result of immune-mediated hypofunction

‣ Sjögren’s syndrome

‣ Radiotherapy for head and neck cancer – especially at parotid.

‣ Diabetes insipidus or mellitis

Question 3

What are the signs and symptoms of xerostomia?

Answer 3

A sticky, dry feeling in the mouth and throat

• Frequent thirst
• Sores in the mouth; sores or split skin at the corners of the mouth; cracked lips
• A burning or tingling sensation in the mouth and especially on the tongue
• A dry, red, raw tongue
• Problems speaking, tasting, swallowing
• Bad breath

Question 4

What are the investigations and diagnoses of xerostomia?

Answer 4

• Sialometry test

‣ measure of saliva over period of time by dribbling into container.

‣ Stimulated by citric acid drop on tongue. Uses radio-opaque die (iodine) into duct (Sialography).

‣ Calculus could be blocking duct.

• Wide variation in the amount of saliva produced by individuals
• Questions such as:

‣ Had a daily feeling of dry mouth for more than 3 months?

‣ Had recurrently or persistently swollen salivary glands?

‣ Drink liquids to aid in swallowing dry food?

‣ Wake up at night to drink liquids?

Question 5

What are the treatments for xerostomia?

Answer 5

Treating underlying cause

• Reduce dose of medication or change drug if possible
• Controlling symptoms
• Frequent sips of cool drinks, sucking pieces of ice/sugar free sweets • Sugar-free chewing gum (with xylitol/chlorhexidine) – may stimulate salivation in patients with residual salivary function
• Petroleum jelly – which can be applied to the lips to prevent drying or cracking
• Artificial saliva
• Sprays contain calcium phosphates etc. pH 6-7
• Biotène Oralbalance® gel and Xerotin® oral spray are both artificial saliva preparations which have Advisory Committee on Borderline Substances (ACBS) approval for the treatment of any patient complaining of dry mouth.
• BioXtra® gel, Glandosane® aerosol spray, Saliva Orthana® spray or lozenges and Saliveze® oral spray are artificial saliva preparations which have ACBS approval only for patients whose dry mouth is secondary to radiotherapy or sicca syndrome.
• Salivary stimulants
• Most effective in patients who have some residual salivary gland function.
• Salivix® pastilles, which act locally as salivary stimulants, are also available and have ACBS approval only for patients whose dry mouth is secondary to radiotherapy or sicca syndrome. – But are acidic!
• Sinclair tablets – stimulate taste buds and have buffer
• Pilocarpine hydrochloride – side effects of vomiting – stimulates parasympathetic
• Sugar-free chewing gum is as effective!

Question 6

What preventative methods are there for xerostomia in post operative radiotherapy patients?

Answer 6

• Surgical transfer of one submandibular gland to the submental space facilitates shielding of the gland during postoperative radiation therapy
• Studies confirm that there is no adverse effect on the function of the gland in this position

Question 7

What is SJOGREN’S SYNDROME?

Answer 7

Autoimmune disease where lymphocytes attack exocrine glands – lacrimal and ALL types of salivary glands

• SIALADENITIS = inflammation of the salivary glands

Question 8

What are the symptoms of sjogren’s syndrome?

Answer 8

Xerostomia and keratoconjunctivitis sicca (dry eye syndrome)

• Reduced saliva and tears -> dry mouth/eyes/vaginal dryness.

Question 9

What are the causes of sjogren’s syndrome?

Answer 9

• Primary ‣ develops on its own
• Secondary ‣ as a result of other disorders, e.g. RA/lupus
• Unknown ‣ genetic/hormonal: oestrogen

Question 10

What are the causes of rheumatoid arthritis?

Answer 10

Autoimmune

Question 11

What are the signs and symptoms of RA?

Answer 11

Pain

• Stiffness
• Inflammation

Question 12

What treatments are there for RA?

Answer 12

Lifestyle changes

• Medication - These are often divided into two types of medication: 1. disease-modifying anti-rheumatic drugs (DMARDs) 2. biological treatments
• Supportive treatments

Surgery

Question 13

How do DMARDs work?

Answer 13

DMARDs work by blocking the effects of the chemicals released when the immune system attacks the joints, which could otherwise cause further damage to nearby bones, tendons, ligaments and cartilage. ‣ Examples of DMARDS include: ‣ Methotrexate ‣ Hydrochloroquine ‣ Sulfasalazine ‣ Leflunomide