Xerostomia and Sjogren’s Syndrome

Xerstomia

Dry mouth is the most common salivary problem. It can be due to reduced salivary flow (hyposalivation) +/or changed salivary composition.

 

Aetiology

Iatrogenic

¨ Drugs (cytotoxics; anti-cholinergics-atropine, antidepressants, opioids, antihistamines, benzodiazepines; drugs acting on sympathetic system-ephedrine, antihypertensives; diuretics)

¨ Radiation (for neoplastic conditions in the head and neck)

      

 

 

 

Disease

¨ Dehydration (diabetes mellitus, chronic renal failure, hyperparathyroidism, fever)

¨ Psychogenic (anxiety)

¨ Salivary gland disease (includes, sjogren’s, sarcoidosis, HIV, Hepatitis C, primary biliary cirrhosis and cystic fibrosis)

¨ Sjogren’s syndrome (see below)

¨ Sarcoidosis

¨ Salivary aplasia (rare, children born without salivary glands)

 

 

Clinical Features

¨ Difficulty swallowing, controlling dentures, speaking

¨ Mouth soreness

¨ Unpleasant taste, or loss of sense of taste

¨ Dry mucosa

¨ Characteristic lobulated tongue-red with partial/complete depapillation

¨ Food debris sticking to teeth

¨ Lack of usual pooling in FOM

¨ Saliva no expressible from parotid duct

 

Complications

¨ Dental caries

¨ Candidiasis (+/or angular cheilitis)

¨ Halitosis

¨ Ascending suppurative sialadentitis

 

Investigations

¨ Sialometry (flow rate measurement)

¨ Sialography (radio-opaque dye introduced to salivary duct - shows dilatation, or duct obstruction)

¨ Salivary scintiscanning (radionuclide used to examine all major salivary glands simultaneously)

¨ Blood tests (ESR, SS-A (Ro) and SS-B (La) antibodies, rheumatoid factor (RF)-exclude Sjogrens, blood glucose-exclude diabetes, serology- exclude hepatitis, serum ACE-exclude sarcoidosis)

¨ Eye tests – Schirmer –to exclude Sjogren’s

¨ Salivary gland biopsy (i.e. labial gland if suspicion of organic disease e.g. Sjogren’s)

¨ Imaging – CXR (exclude sarcoidosis), MRI (exclude Sjogren’s), Ultrasound (exclude Sjogren’s + neoplasia)

¨ Urinalysis – exclude diabetes

 

Management

¨ Any underlying cause rectified, if possible

¨ Avoid factors which increase dryness (alchol, smoking, dry foods)

¨ Mouth hydrated as often as possible (lip balm to lips)

¨ Synthetic Salivary substitutes

-Glandosone (carboxymethylcellulose spray)

-Luborant (carboxymethylcellulose spray)

-Oral balance (lactoperoxidase)

-Saliva Orthana (porcine mucin)

¨ Silogogues e.g. pilocarpine (contra-indications to this)

¨ Sugar-free chewing gum

¨ Oral hygiene advice (avoid cariogenic diet, high standard of OH, regular use of high strength fluoride, regular dental check-ups)

 

 

Sjogren’s Syndrome

The association of dry mouth and dry eyes with lymphoid infiltrate in exocrine glands and autoantibodies. It has 2 main forms:-

¨ Primary Sjogren Syndrome/Sicca Syndrome (SS-1) – absence of connective tissue disease, uncommon, worse oral symptoms, increased risk of lymphoma than SS-2

¨ Secondary Sjogren Syndrome (SS-2) – presence of connective tissue or autoimmune disease, more common

e.g. rheumatoid arthritis (RA), systemic lupus erythematosus, polymyositis, scleroderma, primary biliary cirrhosis

 

Uncommon, most common middle-aged or older, women more frequently

Viral aetiology

Clinical Features

¨ Eyes red with inflammation of conjunctivae, soft crusts at angles (Complaints of eye grittiness, soreness, itching, dryness, blurred vision)

¨ Lacrimal glands may swell

¨ Connective tissue disease (eg long-standing RA)

 

            

Complications

¨ See above

¨ Salivary gland enlargement

¨ Chronic B lymphocyte stimulation can occasionally lead to B-cell lymphoproliferation in mucosal-associated lymphoid tissue (MALT  Lymphoma)

 

Management

¨ See above

¨ Followed up regularly because of possibility of lymphoma (Presents: firm tender salivary swelling, lymphadenopathy, cough, dyspnoea, hepatosplenomegaly, nodular lung lesions)

 

 

 

Radiation Xerostomia

Salivary Gland Enlargement