OralMedicine-UpdatefortheDentalTeam

This series provides an overview of current thinking in the more relevant areas of Oral Medicine, for primary care practitioners. The series gives the detail necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders. Approaching the subject mainly by the symptomatic approach, as it largely relates to the presenting complaint, was considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made, along with guidance on management David H Felix Jane Luker Crispian Scully and when to refer, in addition to relevant websites which offer further detail. Oral Medicine: 4. Dry and Disorders of Salivation

Specialist referral may be indicated if the via various components  Digestion Practitioner feels: such as , histatins, lysozyme and  Lubrication  The diagnosis is unclear; lactoferrin, and via specific antibodies to a  Buffering  A serious diagnosis is possible; range of micro-organisms that the host has  Mineralization  Systemic disease may be present; encountered.  Tissue coating  Unclear as to investigations indicated; secretion from  Anti-microbial  Complex investigations unavailable in the major (parotid, submandibular and Table 1. Functions of . primary care are indicated; sublingual) and minor glands (multiple  Unclear as to treatment indicated; mucous glands scattered throughout   Treatment is complex; the mouth – especially the and Iatrogenic  Treatment requires agents not readily soft ), is mainly under neural – Drugs available; control, under the influence of the – Irradiation autonomic nervous system, although  Unclear as to the prognosis; – Graft versus host disease  The patient wishes this. various hormones may also modulate its composition. In general, parasympathetic  Disease stimulation increases salivation, while – Dehydration sympathetic stimulation produces more – Psychogenic viscous saliva and therefore appears to Saliva is essential to oral health. The most – obvious and important function of saliva depress salivation. – Sjögren’s syndrome is in eating, for taste and to lubricate food, Thus, in acute anxiety, when as well as protecting the mucosa and there is sympathetic stimulation, the – teeth (Table 1). The water, and mouth feels dry. The mouth is also dry if – Salivary aplasia the parasympathetic system is inhibited proline-rich glycoproteins lubricate food  Drugs and help swallowing. Importantly, saliva by, for example, various drugs. Anything is essential for normal taste perception. that damages the glands, or reduces body Table 2. Causes of dry mouth. Saliva is protective via the washing action, fluids, can also reduce salivation.

(candidosis, or acute bacterial ) David H Felix, BDS, MB ChB, FDS Dry mouth () as a consequence of the reduced defences. RCS(Eng), FDS RCPS(Glasg), FDS RCS(Ed), Dry mouth (xerostomia) is FRCP(Edin) Postgraduate Dental Dean, a complaint that is the most common Causes NHS Education for Scotland, Jane Luker, salivary problem and is the subjective There are physiological causes BDS, PhD, FDS RCS , DDR RCR, Consultant sense of dryness which may be due to: of hyposalivation. Thus a dry mouth is and Senior Lecturer, University Hospitals  Reduced salivary flow (hyposalivation); common during periods of anxiety, due to Bristol NHS Foundation Trust, Bristol, and/or sympathetic activity; mouthbreathers may Professor Crispian Scully, CBE, MD, PhD,  Changed salivary composition. also have a dry mouth and advancing age MDS, MRCS, BSc, FDS RCS, FDS RCPS, FFD Patients who have chronically is associated with dry mouth, probably RCSI, FDS RCSE, FRCPath, FMedSci, FHEA, decreased salivary flow (hyposalivation) because of a reduction of salivary acini, FUCL, FSB, DSc, DChD, DMed(HC), Dr HC, suffer from lack of oral lubrication, with a fall in salivary secretory reserve. Emeritus Professor, University College affecting many functions, and they may Very rarely, salivary glands London, Hon Consultant UCLH and HCA, complain of dryness (xerostomia), and can may be absent at birth – so-called salivary London, UK. develop dental caries and other infections gland aplasia or agenesis. 738 DentalUpdate December 2012 OralMedicine-UpdatefortheDentalTeam

Most salivary gland dysfunction  Drugs which directly damage the salivary glands is acquired (Table 2).  Cytotoxic drugs In most older people complaining of xerostomia, the cause  Drugs with activity is usually due to medication or disease.  Anticholinergic agents such as , atropinics and hyoscine Indeed, the main causes of dry mouth are  Antireflux agents eg proton-pump inhibitors (such as omeprazole) iatrogenic, particularly drug use. There is  Psychoactive agents with anticholinergic activities such as: usually a fairly close temporal relationship between starting the drug treatment or – Antidepressants, including tricyclic (eg , nortriptyline, increasing the dose, and experiencing clomipramine and dothiepin [dosulepin]), selective serotonin re-uptake the dry mouth. However, the cause for inhibitors (eg fluoxetine), lithium and others which the drug is being taken may also  Phenothiazines be important. For example, patients  Benzodiazepines with anxiety or depressive conditions  Opioids may complain of dry mouth even in the absence of drug therapy (or evidence of  Antihistamines reduced salivary flow).  Bupropion Drugs recognized as causes of  Drugs acting on sympathetic system reduced salivation include mainly those  Drugs with sympathomimetics activity eg ephedrine with anticholinergic, or sympathomimetic, or diuretic activity. These include those  Antihypertensives; alpha 1 antagonists (eg terazosin and prazosin) and alpha 2 cited in Table 3. agonists (eg clonidine) may reduce salivary flow. Beta blockers (eg atenolol, Irradiation for malignant propranolol) also change salivary protein levels. tumours in the head and neck region,  Drugs which deplete fluid such as , can produce profound  Diuretics xerostomia. Other sources of irradiation, such as radioactive iodine (131I) used for Table 3. Drugs associated with dry mouth. treating thyroid disease, may also damage the salivary glands, which take up the radioactive iodine. Radiation Dehydration, as in diabetes Neural control DRUGS mellitus, chronic renal failure, hyperparathyroidism or any and diabetes insipidus is an occasional cause of xerostomia. Diseases of salivary glands can also cause salivary dysfunction. These are H 0 Enzymes mainly Sjögren’s syndrome (a multisystem Mucin 2 Na condition discussed below); sarcoidosis; HIV disease; liver diseases; and cystic fibrosis (mucoviscidosis) (Figure 1). Finally, it is important to recognize also that some patients complaining of a dry mouth have no evidence of a reduced salivary flow or a Autoimmune Dehydration salivary disorder (ie they have xerostomia disease but not hyposalivation), and in these there Deposits may be a psychogenic reason for the complaint. Figure 1. Causes of dry mouth. (Reproduced from Scully C. Oral and Maxillofacial Medicine. Elsevier, 2008.)

Clinical features The patient with hyposalivation  Speaking, as the tongue tends to stick to The patient with hyposalivation may have difficulty in: the palate – leading to ‘clicking’ speech. may complain of a dry mouth or these  Swallowing – especially dry foods such Patients may also complain of sequelae alone, or also complain of as biscuits (the cracker sign); unpleasant taste or loss of sense of taste, dryness of the eyes and other mucosae  Controlling dentures; or halitosis. (nasal, laryngeal, genital). Those with eye

December 2012 DentalUpdate 739 OralMedicine-UpdatefortheDentalTeam

Diagnosis Hyposalivation is a clinical diagnosis which can be made by the practitioner predominantly on the basis of the history and examination. It can be helpful to document salivary function by salivary function studies, such as salivary flow rates (sialometry). Collection of whole saliva (oral fluid) is currently the routine technique for sialometry used by many clinicians, despite the fact that it is rather inaccurate and non-specific. It is usually carried out by allowing the patient to sit quietly and dribble into a measuring container over 15 minutes; in a normal person, such an unstimulated whole saliva flow rate exceeds 1.5 ml/15 min (0.1 ml/ min).

Figure 3. Xerostomia and lobulated tongue. Keypoints: dry mouth

Figure 2. Dry mouth. Diagnosis is clinical but investigations may be indicated, including:  Blood tests (ESR and SS-A and SS-B antibodies; see below); complaints have blurring, light intolerance,  Eye tests (Schirmer; see below); burning, itching or grittiness, and  Urinalysis; sometimes an inability to cry.  Salivary flow rate tests (sialometry); Systemic features (such as joint  Salivary gland biopsy (labial gland pains) may be suggestive of Sjögren’s biopsy); syndrome.  Imaging; Figure 4. Dry mouth and caries in Sjögren’s Examination may reveal that - ; syndrome. the lips adhere one to another, and an - Scintiscanning; examining dental mirror may stick to - Ultrasound; the mucosa because of the reduced - Chest radiograph (if suspected lubrication. Lipstick or food debris may be sarcoidosis). seen sticking to the teeth or soft tissues, The Specialist may be needed and the usual pooling of saliva in the to: floor of the mouth may be absent. Thin  Study and document the degree of lines of frothy saliva may form along lines salivary dysfunction; of contact of the oral soft tissues, on the  Determine the cause; tongue, or in the vestibule. Saliva may not  Arrange future dental care, although be expressible from the parotid ducts. The much of this can be undertaken in the tongue is dry (Figure 2) and may become Figure 5. Dry mouth complicated by candidosis. primary care environment. characteristically lobulated and usually Investigations that may be red, with partial or complete depapillation indicated to exclude systemic disease, (Figure 3). recurrent caries. particularly to exclude: Complications of hyposalivation  Candidosis – which may cause a burning  Sjögren’s syndrome and connective can include: sensation or mucosal erythema (Figure tissue disorders;  Dental caries – which tends to involve 5), lingual filiform papillae atrophy, and  Diabetes; smooth surfaces and areas otherwise not angular (angular ).  Sarcoidosis; very prone to caries – such as the lower  Halitosis (Article 5).  Viral infections (hepatitis C; HIV). incisor region and roots (Figure 4).  Ascending (suppurative) sialadenitis Commonly used investigations Hyposalivation may explain why – which presents with pain and swelling may thus include: patients, who are apparently complying of a major salivary gland, and sometimes  Blood tests (mainly to exclude diabetes, with dietary advice, have uncontrollable purulent discharge from the duct. Sjögren’s syndrome, sarcoidosis, hepatitis 740 DentalUpdate December 2012 OralMedicine-UpdatefortheDentalTeam

auto-antibodies and sometimes confirmed SS-1 SS-2 by demonstrating mononuclear cell Dry mouth Yes Yes infiltrates in a labial salivary gland biopsy. Sjögren’s syndrome can affect any age, Dry eyes Yes Yes but the onset is most common in middle Connective tissue disease No Yes age or older. The majority of patients are women with a female:male ratio of 9:1 Extraglandular problems More common Less common

Table 4. Sjögren’s syndrome. Aetiopathogenesis Sjögren’s syndrome is an auto- and other infections); immune disease affecting mainly exocrine  Eye tests (eg Schirmer test mainly to glands like the salivary glands, lacrimal exclude Sjögren’s syndrome); glands and pancreas. There may be a viral  Salivary gland biopsy (if there is suspicion aetiology and a genetic predisposition. of organic disease, such as Sjögren’s The most common type of SS syndrome); is secondary Sjögren’s syndrome (SS-2),  Imaging (mainly to exclude Sjögren’s which comprises dry eyes and dry mouth syndrome, sarcoidosis or neoplasia). and a connective tissue or auto-immune It is important to remember, disease, most commonly rheumatoid as stated above that, in some patients arthritis (RA). Other connective tissue complaining of a dry mouth, no evidence disorders may be associated, eg systemic of a reduced salivary flow or a salivary and scleroderma disorder can be found. There may then be (Table 4). However, SS can appear by itself, a psychogenic reason for the complaint. and in the absence of a connective tissue disease is often termed sicca syndrome, usually referred to as primary Sjögren’s Management (see below) syndrome (SS-1). Nevertheless, both forms Sjögren’s syndrome Sjögren’s syndrome (SS) is an uncommon condition found in association with dry mouth and dry eyes. The other key features of SS are evidence of an auto- immune reaction, shown usually by serum Figure 6. swelling.

Figure 8. Ultrasound appearance of normal parotid gland showing a uniform echotexture.

Figure 9. Ultrasound of a parotid gland showing classical appearance of Sjögren’s syndrome. Figure 7. Sjögren’s syndrome – a multisystem disease. (Reproduced from Scully C. Oral and Maxillofacial Multiple rounded hypo-echoic areas distributed Medicine. Elsevier, 2008.) throughout the gland.

December 2012 DentalUpdate 741 OralMedicine-UpdatefortheDentalTeam

are chronic and can affect not only the salivary glands, but also extraglandular  Drink enough water, and sip on water and other non-sugary fluids tissues. Chronic B lymphocyte stimulation throughout the day. Rinse with water after meals. Keep water at your bedside. can occasionally lead to B cell neoplasms,  Replace missing saliva with salivary substitutes (eg Artificial Saliva, such as lymphoma. Glandosane, Luborant, Biotene Oralbalance, AS Saliva Orthana, Salivace, Saliveze). Sjögren’s syndrome is often Alcohol-free mouthrinses (BioXtra and Biotène), or moisturizing gels (Oralbalance, BioXtra) may help. characterized by a raised erythrocyte  Stimulate saliva with: sedimentation rate (ESR) and several – Sugar-free chewing (eg EnDeKay, Orbit, Biotène dry mouth gum or auto-antibodies – particularly antinuclear BioXtra chewing gum); or factor (ANF) and rheumatoid factor (RF), – Diabetic sweets; or and more specific antinuclear antibodies – Salivix or SST if advised; or known as SS-A (Ro) and SS-B (La). – Drugs that stimulate salivation (eg [Salagen]) if advised by a Specialist. Clinical features  Always take water or non-alcoholic drinks with meals and avoid dry or Sjögren’s syndrome presents hard crunchy foods such as biscuits, or dunk in liquids. Take small bites and eat mainly with eye complaints which include slowly. Eat soft creamy foods (casseroles, soups), or cool foods with a high sensations of grittiness, soreness, itching, liquid content − melon, grapes or ice cream. Moisten foods with gravies, sauces, dryness, blurred vision or light intolerance. extra oil, margarine, salad dressings, sour cream, mayonnaise or yoghurt. Pineapple The eyes may be red with inflammation has an enzyme that helps clean the mouth. Avoid spices. of the conjunctivae and soft crusts at the  Avoid anything that may worsen dryness, such as: angles (keratoconjunctivitis sicca). The – Drugs, unless they are essential (eg antidepressants); lacrimal glands may swell. – Alcohol (including in mouthwashes); Oral complaints (often the – Smoking; presenting feature) including: – Caffeine (coffee, some soft drinks such as Colas);  Xerostomia; – Mouthbreathing.  Swollen salivary glands (Figure 6);  Protect against dental caries by avoiding sugary foods/drinks and by: causes include chronic sialadenitis as – Reducing sugar intake (avoid snacking and eating last thing at night); part of the fundamental auto-immune – Avoiding sticky foods such as toffee; – Keeping your mouth very clean (twice daily toothbrushing and disease process, ascending bacterial flossing); sialadenitis which can arise if bacteria – Using a fluoride toothpaste; ascend the ducts because salivation – Using fluoride gels or mouthwashes (0.05% fluoride) daily before going is impaired, benign lymphoepithelial to bed; lesions/myoepithelial sialadenitis – Using amorphous calcium phosphate (Tooth Mousse); (pseudolymphoma) and lymphoma. – Having regular dental checks. However, SS is a more  Protect against thrush, gum problems and halitosis by: generalized disorder which involves not – Keeping your mouth very clean; only the exocrine salivary and lacrimal – Keeping your mouth as moist as possible; glands, but can have a range of other – Rinsing twice daily with chlorhexidine (eg Chlorohex, Corsodyl, Eludril) or complications, summarized in Figure 7. triclosan (eg Plax); – Brushing or scraping your tongue; Diagnosis – Keeping dentures out at night; Diagnosis is made from the – Disinfect dentures in hypochlorite (eg Milton, Dentural); history and clinical features, and may – Use antifungals if recommended by Specialist. be confirmed by auto-antibody studies  Protect the lips with a salve or petroleum jelly (eg Vaseline). and sometimes by other investigations,  Avoid hot dry environments such as ultrasound (Figures 8 and 9), – Consider a humidifier for the bedroom. sialometry and labial salivary gland biopsy. Table 5. Nine steps for managing a dry mouth. In Specialist units various international criteria (American/European consensus diagnostic criteria) are used to confirm the is essential. The dental team have an Patients should be educated diagnosis. important role to play in this. into efforts to avoid factors that may Any underlying cause of increase dryness, and to keep the mouth Management of hyposalivation xerostomia should, if possible, be rectified; moist (Table 5). There is no specific treatment for example, xerostomia-producing drugs Salivary substitutes or mouth- yet for SS, but the hyposalivation can be may be changed for an alternative, and wetting agents may help symptomatically; managed, and dental preventive care causes such as diabetes should be treated. various are available including: 742 DentalUpdate December 2012 OralMedicine-UpdatefortheDentalTeam

 Where saliva is reduced, there is a risk UK trade Offered as Contains Main constituents Comments of dental decay (caries), halitosis, altered names fluoride taste, mouth soreness and infections;  Saliva may be reduced by radiotherapy AS Saliva Spray or +/- Mucin Spray contains or chemotherapy, various drugs, after Orthana lozenge Xylitol fluoride but is bone marrow transplant, in diabetes, in unsuitable if some viral infections, in anxiety/stress/ there are depression, or in salivary gland disorders; religious  Diagnosis is clinical but investigations objections to may be indicated, including: porcine mucin – Blood tests; – Eye tests; Biotene Gel - Glycerate polymer – Urinalysis; Oralbalance base, – Salivary flow rate; lactoperoxidase, – Salivary gland biopsy; glucose oxidase, – X-rays or scans. xylitol

Useful websites: BioXtra Gel - Colostrum, http://www.bssa.uk.net/ lactoperoxidase, http://www.nidcr.nih.gov/AtoZ/LetterS/ glucose oxidase, SjogrenSyndrome/ xylitol http://sjsworld.org/

http://www.nidcr.nih.gov/OralHealth/ Luborant Spray + Carboxymethylcellulose Topics/DryMouth/

Glandosane Spray - Carboxymethylcellulose ‘Glandosane’ has a low pH Sialorrhoea (; and therefore ptyalism) is best Infants frequently drool but this avoided in is normal. The complaint of sialorrhoea patients with a (excess salivation) is uncommon and natural may be true salivary hypersecretion: dentition usually caused by physiological factors such as menstruation or early , Saliveze local factors such as teething or oral inflammatory lesions, food or medications Xerotin (those with cholinergic activity such as pilocarpine, tetrabenazine, ), or Salinum Liquid - Linseed and phosphate bynasogastric intubation. In some cases, buffer apparent hypersalivation is caused not by excess saliva production but by an Table 6. Some salivary replacements (mouth-wetting agents). inability to swallow a normal amount of saliva (False sialorrhoea) caused by neuromuscular dysfunction (eg in  Water or ice chips: frequent sips of by using diabetic sweets or chewing gums Parkinson’s disease, cerebral palsy, or water are generally effective; (containing sorbitol or xylitol, not sucrose). learning disability) or by pharyngeal or  Synthetic salivary substitutes (Table 6). Cholinergic drugs that stimulate salivation oesophageal obstruction, such as by a As patients with objective (sialogogues), such as pilocarpine or neoplasm. xerostomia are at increased risk of cevimeline, should be used only by a Treatment is of the developing caries, it is important that Specialist. Oral complications should be underlying cause if possible and then they take a non-cariogenic diet and prevented and treated. the use of behavioural approaches or maintain a high standard of oral hygiene. antisialogogues. Occasionally, surgery to The regular use of topical fluoride agents redirect the salivary gland ducts into the and ACP (amorphous calcium phosphate) Keypoints for patients: dry oropharynx may be helpful. form important components of mouth long-term care.  Saliva helps swallowing, talking and Patients to refer: Salivation may be stimulated taste, and protects the mouth;  Suspected Sjögren’s syndrome. December 2012 DentalUpdate 743