Life is a breeze…….. Complicated, real life situations Spotlight on Sjogren’s syndrome - except when you’re dry as a bone primary ‣ dry mouth ‣ 2012 – nearly 6 years ‣ dry eyes ‣ 2016 – down to 3 ‣ an@bodies ‣ 2017 – target 2.5 Anne N. Guignon,RDH, MPH, CSP [email protected] 832-971-4540 4 million Americans Copyright© 2018 2019 © 2019 © 2019 Saliva and tears Demographics Ocular symptoms ‣90% female ‣ abraded cornea ‣age 40 approx - menopause ‣ inflamed lacrimal glands ‣ infeC@ons ‣10% male – 10% ‣ body destroys glands ‣ discomfort ‣under and undiagnosed ‣ lack of flow ‣children – not common ‣ blurry vision ‣ poor quality ‣enlarged paro@d gland ‣ stuck eye lids © 2019 © 2019 © 2019 Improving the patient’s outcome Impact Te st i n g o ral p H IndividualIndividual ! Best ! clinical ! external ! expertise evidence ‣ quality of life EBMEBM$ ‣ financial emo@onal Patient values! ‣ & expectations ‣ 5+ heath care providers © 2019 h"p://med.fsu.edu/index.cfm?page=medicalinforma8cs.ebmTutorialhNp://med.fsu.edu/[email protected] © 2019 © 2019 Complicated, real life situations Complex patients - complex solutions ‣ 70 year old female ‣ severe polypharmacy-induced Who has the xerostomia ‣ high caries risk highest risk? ‣ every 3 months - something new ‣ extremely sensi@ve @ssues ‣ has had severe mucosi@s to everything I have recommended for use in her custom fl trays © 2019 © 2019 © 2019 Challenges ‣ medically complex Dry mouth ‣ life style ‣ self care ‣ challenged immune systems Prevalence and clinical presentation ‣ dry mouth ‣ compliance © 2019 ‣ chronic health issues © 2019 © 2019 Multiple terms - quality of life Hyposalivation Xerostomia ‣ subjec@ve term ‣ dry mouth / syndrome ‣ clinical diagnosis ‣ perceived lack of moisture ‣ hypo-saliva@on ‣ decreased salivary flow ‣ changes in composi@on ‣ xerostomia ‣ insufficient in saliva Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide Wiley, Blackwell. May 2010. © 2019 . Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2019 Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. Villa, A., Connell, C., Aba@, S. (2014). Diagnosis and management of xerostomia and hyposaliva@on. Therapeutics and Clinical Risk Management, 45. © 2019 Prevalence Insufficient flow Visual observations ‣ 30% popula@on ! subtle changes ‣ red, glossy, parched ‣ more women ! 50% decrease - no@ceable ‣ pebbled tongue ‣ 10% early 30s ! pH decreases ‣ cracking in commisures ‣ chapped lips ‣ over age 50 ! increased demineraliza@on ‣ thick, foamy, ropy saliva Takahashi N, Nyvad B.Caries ecology revisited: Microbial dynamics and the caries process. Caries Res. 2008;42(6):409-18. Thomson WM, Lawrence HP, Broadbent JM, Poulton R. The impact of xerostomia on oral-health-related quality of life among younger adults. Health Qual Life OutComes. 2006 Nov 8;4:86. Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 Anil S, Vellappally S, Hashem M, Preethanath RS, Pa@l S, Samaranayake LP. Xerostomia in geriatric pa@ents: a burgeoning global concern. J Inves@g Clin Dent. 2014 Sep 1. © 2019 Graham I, Mount WH. (2005). Preserva@on and restora@on of tooth structure. 2nd Edi@on. Queensland, Australia: Knowledge Books and Sooware. © 2019 Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. © 2019 Clinical complaints Additional complaints ‣ sore mucosa ‣ feel dry when ea@ng? ‣ burning sensa@on ‣ sip liquids to swallow dry ‣ s@Ckiness ‣ difficulty talking ‣ problems chewing food? ‣ halitosis ‣ taste altera@ons ‣ difficulty swallowing ‣ amount of saliva seem metallic taste reduCed? ‣ ‣ dry/sore throat ‣ den@nal hypersensi@vity Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide Wiley, Blackwell. May 2010. Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. © 2019 © 2019 Dry mouth (Xerostomia): Diagnosis, Causes, Complica@ons and Treatment. Dental Professional Version. Delta Dental. 2011 © 2019 Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. problems tas@ng? ‣ night @me ‣ dry during ‣ tongue burn? ‣ ‣dry eyes ‣reCurring deCay problems wake up dry the day@me ‣ sensi@ve to acidic, salty ‣ ‣ difficulty swallowing? eyes feel sandy chew gum/Candy for relief or spicy foods? ‣ ‣ Dry mouth (Xerostomia): Diagnosis, Causes, Complica@ons and Treatment. Dental Professional Version. Delta Dental. 2011 Dry mouth (Xerostomia): Diagnosis, Causes, Complica@ons and Treatment. Dental Professional Version. Delta Dental. 2011 © 2019 © 2019 Dry mouth (Xerostomia): Diagnosis, Causes, Complica@ons and Treatment. Dental Professional Version. Delta Dental. 2011 © 2019 Saliva - The magic fluid Digestion ‣ chewing ‣ bolus ‣ swallowing ‣ enzymes Saliva functions ‣ taste Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 and benefits © 2019 © 2019 © 2019 Protection Protection Additional functions ‣ dilu@on ‣ buffering-neutralizes ‣ lubrica@on ‣ remineraliza@on ‣ cleansing ‣ an@-microbial ‣ speech ‣ kissing ‣ increase pH ‣ healing ‣ nutri@on ‣ licking ‣ social interac@on ‣ exCre@on de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composi@on and func@ons: A comprehensive review. J Contemp Dent Pract 2008 March; (9)3:072-080. de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composi@on and func@ons: A comprehensive review. J Contemp Dent Pract 2008 March; (9)3:072-080. Hara AT, Zero DT. The caries environment: saliva, pellicle, diet, and hard @ssue ultrastructure. Dent Clin North Am. 2010 Jul;54(3):455-67. Hara AT, Zero DT. The caries environment: saliva, pellicle, diet, and hard @ssue ultrastructure. Dent Clin North Am. 2010 Jul;54(3):455-67. Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2019 Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2019 © 2019 astoundingminds.blogspot.com/2012/04/boiling-point-of-human-saliva.html Sources The kiss 90% - whole saliva ‣paro@d - 30% ‣ longest - 58 hours, 35 minutes and 58 sec ‣sub-mandibular- 60% ‣ lowers cor@sol levels ‣sub-lingual - 5% ‣ heart beats faster ‣10% - minor glands - 5% ‣ more oxygen reaches your brain Saliva - found throughout the mouth © 2018 © 2018 © 2018 www.lifedaily.com/12-most-surprising-facts-about-kissing/ Accessed 10/1/15. production, composition, flow Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 Healthy saliva - composition Secretions Salivary protein serous and mucous functions also contains ! proteins ! antibacterial ! tissue coating ! enzymes ! paro@d - serous and enzymes ! antifungal ! wound healing mucins ! ! submandibular - 90% serous, 10% muCous ! remineralization 99% water ! antiviral ! buffering compounds ! digestion ! sublingual and minor - 80% daily mucous ! buffering Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 ! ! lubrication © 2019 © 2019 tasting © 2019 Types of flow Mucins - wetness and comfort Proline-rich proteins proteins with carbohydrate chains and arginine !spontaneous minor salivary glands - mucins ! lubricates !s@mulated ! Controls viscosity / elas@city ! PRPs - 70% of all salivary proteins paro/d - serous ! affects s@ckiness ! forma@on / func@on acquired pellicle !uns@mulated (res@ng) ! saliva contact with oral cavity ! arginine - ammonia produc@on sublingual and minor - serous and mucous ! buffering compounds Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. © 2019 Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2019 © 2019 Healthy - daily flow rate Flow rate - visual inspection Testing flow rate / per min 0.5 to 1.5 liters ‣ retract lower lip ‣ chew wax - 5 min ‣ spit in cup ‣ res@ng - 0.25 to 0.4 /min ‣ dry with gauze • normal - 1 to 3ml ‣ 1 min - drops on mucosa ‣ s@mulated - 1 - 3 ml / min • low - 0.7 to 1 ml ‣ sufficient flow - pooling in floor of mouth ‣ establish a baseline! • very low - < 0.7 ml Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2019 © 2019 Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2019 Stimulated saliva Stimulated saliva Saliva – Fast facts……. ‣ quality improves - proteins 80 - 90%