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 Mouth and Disorders of Salivation Specialist referral may be indicated if the via various antimicrobial components Digestion Practitioner feels: such as mucin, 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; Salivary gland secretion from Anti-microbial Complex investigations unavailable in the major (parotid, submandibular and Table 1. Functions of saliva. 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 lips and Iatrogenic Treatment requires agents not readily soft palate), 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 – Salivary gland disease 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 – Sarcoidosis teeth (Table 1). The water, mucins 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 sialadenitis) David H Felix, BDS, MB ChB, FDS Dry mouth (xerostomia) 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 anticholinergic activity is usually due to medication or disease. Anticholinergic agents such as atropine, 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 amitriptyline, 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 oral cancer, 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, Anticholinergics hyperparathyroidism or any fever 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 - Sialography; syndrome. the lips adhere one to another, and an - Scintiscanning; examining dental mirror may stick to - Ultrasound; the mucosa because of the reduced