AGING AND THE SALIVARY GLANDS

SALIVA
June 4, 2003

Frustrating

for the dental team yet necessary for

the patient!

WHEN THERE IS NOT ENOUGH

June 4, 2003

Too

little saliva can significantly alter a persons 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

OBJECTIVE VS SUBJECTIVE
June 4, 2003

Objective

Subjective

Major gland secretions

Resting flow rate with a Carlson-Crittenden Cup

Minor gland secretions Whole saliva

Stimulated flow rate with citric acid, wax

Complaints of dry mouth (xerostomia) Questionnaire Thirst The cracker test

XEROSTOMIA
June 4, 2003

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

CLINICAL SIGNS/SYMPTOMS OF XEROSTOMIA

June 4, 2003

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

WHAT CONTRIBUTES TO XEROSTOMIA?

June 4, 2003

Aging

Hormonal Changes/Menopause Local Systemic

Disease

Environmental Medications

Insults/Trauma

AGING
June 4, 2003

Salivary Quantity in Health

Salivary

Quality in

Health

No changes in major secretions (parotid, submandibular) No changes in minor secretions

No general changes in salivary constituents

AGING
June 4, 2003

If

the quality and quantity of saliva doesnt 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

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MENOPAUSE
June 4, 2003

Average

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

age of onset of menopause in USA is

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

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DISEASES/ENVIRONMENTAL FACTORS
June 4, 2003

Diseases

Local Systemic

Environmental

Factors

Head and Neck Radiation Chemotherapy Medications

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LOCAL DISEASES
June 4, 2003

Tumors/Growths

Inflammatory

Benign Malignant

Diseases

Obstructive

Diseases

Calculi, mucus plugs Unusual anatomy

Acute viral sialadenitis Acute and recurrent bacterial sialadenitis Inflammation/ Infection secondary to systemic disease

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TUMORS/GROWTHS
June 4, 2003

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

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OBSTRUCTION: SIALOLITHIASIS
June 4, 2003

Calculi

form in the duct, blocking the egress of saliva

Majority in submandibular gland

Painful

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

swelling which increases at meal

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SUBMANDIBULAR CALCULI
June 4, 2003

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UNUSUAL ANATOMY
June 4, 2003

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

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INFLAMMATION/INFECTION: VIRAL
June 4, 2003

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

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INFLAMMATION/INFECTION: BACTERIAL
June 4, 2003

Types

Acute suppurative bacterial sialadenitis Chronic recurrent sialadenitis

Commonly S. aureus, S. viridans, H. influenzae, E. coli

Treatment

May be secondary to some type of obstruction or unusual anatomy May be due to resistant organism; culture to determine

Antibiotics and analgesics Rehydrate and stimulate saliva May need open drainage/surgery
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BACTERIAL PAROTIDITIS
June 4, 2003

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SYSTEMIC DISEASES
June 4, 2003

Sjgrens

Syndrome Sarcoidosis Cystic Fibrosis Diabetes Alzheimers Disease AIDS Graft vs Host Disease Dehydration

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SJGRENS SYNDROME
June 4, 2003

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

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SARCOIDOSIS
June 4, 2003

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

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CYSTIC FIBROSIS
June 4, 2003

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

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DIABETES
June 4, 2003

Uncontrolled

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

blood glucose levels may contribute

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ALZHEIMERS DISEASE
June 4, 2003

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

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AIDS
June 4, 2003

HIV-Associated

SGD)

Salivary Gland Disease (HIV-

Enlargement of the major salivary glands Xerostomia Some similarities to autoimmune diseases HIV itself not consistently found to be in glandular tissue

Medications

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GRAFT VS HOST DISEASE (GVHD)

June 4, 2003

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

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DEHYDRATION
June 4, 2003

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)

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HEAD AND NECK CANCER: RADIATION THERAPY

June 4, 2003

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
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RADIATION DOSE
June 4, 2003

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 21004000 cGy

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TISSUE RESPONSE
June 4, 2003

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

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TISSUE CHANGES
June 4, 2003

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

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COMMON SIDE EFFECTS: SYSTEMIC

June 4, 2003

Nausea Vomiting Neutropenia Alopecia Fatigue

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COMMON SIDE EFFECTS: ORAL

June 4, 2003

Mucositis

and Dermatitis Dysphagia Dysgeusia Trismus Osteo- and soft tissue necrosis Xerostomia

Fungal infections Radiation Caries

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RADIATION: XEROSTOMIA
June 4, 2003

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

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RADIATION: MUCOSITIS
June 4, 2003

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

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SALIVA POST-RADIATION

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June 4, 2003

MUCOSITIS

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June 4, 2003

RADIATION CARIES
June 4, 2003

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PROSTHESIS-INDUCED STOMATITIS
June 4, 2003

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FUNGAL INFECTIONS
June 4, 2003

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SCROTAL TONGUE

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June 4, 2003

CHEMOTHERAPY
June 4, 2003

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

Oral

complications from direct damage to oral tissues secondary to chemotherapy and indirect damage due to regional or systemic toxicity

Many side effects in all body systems

Frequency and severity related to systemic immune compromise, i.e. myelosuppresion

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CHEMOTHERAPEUTICS
June 4, 2003

Drugs

commonly associated with oral complications

Methotrexate Doxorubicin 5-Fluorouracil (5-FU) Busulfan Bleomycin Platinum coordination complexes
Cisplatin Carboplatin

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TISSUE DAMAGE
June 4, 2003

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 prechemotherapy state when allowed time to heal after therapy

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COMMON SIDE EFFECTS: SYSTEMIC

June 4, 2003

Fatigue Nausea Constipation Diarrhea Hemorrhage Anemia Neutropenia

Pain Alopecia Peripheral

neuropathy CNS disturbances Fluid retention Bladder and kidney problems

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COMMON SIDE EFFECTS: ORAL

June 4, 2003

Mucositis

(ulcerative) Reactivation of HSV Dysgeusia Dysphagia Infections

Neuropathies Salivary

gland dysfunction/toxicity
xerostomia

Fungal Periodontium periapices

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SUMMARY
June 4, 2003

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 Radiation Chemotherapy

Environmental insults/trauma Medications

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