XEROSTOMIA

Oedijani-SantosoBagian/SMF Gigi dan MulutFK Undip/RSUP dr Kariadi

Semarang

Anatomy and PhysiologySalivary gland

XEROSTOMIA=DECREASED SALIVARY SECRETION =

ASIALORRHEA - physiologic in the aged- psychic stimuli ------ depressive- dehydration states- drug that depress parasymphatetic activity, antihistamines, decongestants, muscle relaxants - irradiation of the head & neck- Tobacco use : smoking , chewing

SYMPTOMS

- Dryness of all the oral mucosal surfaces including the lip and throat difficulty chewing, swallowing and speaking

- the mucosa sensitive to spicy and coarse food

- A changed sense of taste

- Problems wearing dentures

- Long term effect :Gum DiseaseTooth DecayTrouble EatingDifficulty SpeakingPainful TongueInflammation& Other Health Risks : fungal infection - cause xerostomia as well, such as Sjögren's syndrome, diabetes, Parkinson's disease, HIV/AIDS & other illnesses.

CLINICAL EXAMINATION

- Mucosal dryness

- lips cracked, peeling, atrophy

- buccal mucosa pale and corrugated

- Tongue smooth, reddened with loss papillation

- increase erosion and caries (decay on root surface)

- Increase prevalence and severity of periodontal disease

Tongue Smooth with loss papillation

Lips cracked and atrophy

Cervical Caries and Severe Periodontal disease

POST RADIOTHERAPY

- Salivary tissue, serous acini, is highly vulnerable to radiation damage, and the parotid glands are damaged most readily.

- The conventional treatments for oral carcinoma a rapid decrease in flow occurs during the first week of radiotherapy, with an eventual approximate 95% reduction

- The early response atrophy of the secretory cells without inflammation induced apoptosis

- the late response with inflammation induced necrosis.

- Serous acini are affected earlier than mucinous acini thick viscous secretion

- Saliva production rapidly ↓ reduced 50% in after 1 week std radiation

- After 5 weeks of radiotherapy salivary flow virtually ceases and rarely completely recovers.

- The sensation of dry mouth ↓ after a few months - year a result of compensatory hypertrophy of unirradiated salivary gl tissue.

- After 6-12 month, little further improvement occurs.

- The degree of xerostomia degree of exposure of the salivary tissue.

- Xerostomia the parotid glands are involved.

- Mantle, unilateral, and bilateral fields of radiation can be associated with a reduction in salivary flow of 30-40%, 50-60%, and approximately 80%, respectively.

- Radiotherapy to the nasopharynx damages both of the parotid gl severe and permanent xerostomia.

- Radiotherapy to a salivary tumor avoid the contralateral gland and not cause severe xerostomia.

- Radiotherapy of oral cancer normally avoid at least part of the parotid glands xerostomia tends not to be severe

- Xerostomia discomfort and loss of taste and appetite.

- Xerostomia, with secondary symptoms of increased dental caries, difficulty in chewing, swallowing and speaking, and an increased incidence of oral candidiasis significant effect on the quality of life

STIMULATION OF SALIVARY FUNCTION

Residual salivary tissue stimulated pharmacologic stimuli (cholinergic agents) Pilocarpine parasympathomimetic agent effect at the muscarinic cholinergic receptor of acinar cells relieving symptoms and improving salivation (5 mg/3x daily)

Sugar-free chewing gum may be a useful stimulus

SYMPTOMATIC TREATMENT

- Frequent of sipping water during eating, and often need to keep water by their bedsides

- Saliva substitutes contain carboxymethylcellulose or hydroxyehtylcellulose, mucins and constituents enamel remineralization lubrication, surface wetting, ↓ microorg, pleasant taste, long duration, low cost

Advise xerostomia patients : - to avoid agents such as medications (antihistamine, decongestant), caffeine, tobacco, and alcohol that may further impair salivation.

- Breathe through your nose, not your mouth

Steps to protect the teeth help the dry mouth condition:- Brush with a fluoride toothpaste and floss the teeth.

- Use a fluoride rinse or brush-on fluoride gel before bedtime.

- See the dentist at least twice yearly to have teeth examined and plaque removed prevent tooth decay and period disease

SJOGREN'S SYNDROME

- A patient’s with eye, throat, nasal, skin, or vaginal dryness, in addition to xerostomia systemic condition

- people who get Sjogren's syndrome are older than 40.

- Nine of 10 are women.

-Sjogren's syndrome is an autoimmune disease

- A chronic autoimmune disease : the body's white blood cells destroy the exocrine glands, specifically the salivary and lacrimal glands saliva and tears ↓

- The cause of Sjögren’s syndrome is unknown, it is believed to be under the influence of a combination of genetic, environmental, and several other factors, as is the case with many other autoimmune disorders.

Pathway Implicated in the Pathogenesis of Sjogren’s syndr

RISK FACTORS

= Age. Sjogren's syndrome is usually diagnosed in people older than 40.

= Sex. Women are much more likely to have Sjogren's syndrome.

= Rheumatic disease. It's common for people who have Sjogren's syndrome to also have a rheumatic disease — such as rheumatoid arthritis or lupus.

Genetic factors- high prevalence of autoimmune disorders in families of Sjögren’s syndrome is linked with a genetic predisposition

- Studies on the polymorphisms of human leukocyte antigen (HLA)-DR and HLA-DQ gene regions in Sjögren’s syndrome patients show differential susceptibility to the syndrome due to different types of the resulting autoantibody production

Hormonal factors=high prevalence in women, sex hormones, especially estrogen affect humoral and cell-mediated immune responses affecting susceptibility to the syndrome.

= Androgens are generally considered to prevent autoimmunity.

= mice models suggest estrogen deficiency stimulates presentation of autoantigens, inducing Sjogren’s syndrome-like symptoms

Environmental (exogenous) factors= Viral proteins, engulfed molecules degraded self-structures initiate autoimmunity ↑ Sjögren’s syndrome

= Epstein-Barr virus, hepatitis C, and human T-cell leukemia virus-1 infectious agents in Sjögren’s syndrome

= Damaged self-structures targeted for apoptosis exposed to the immune system, triggering autoimmunity in exocrine glands autoimmune responses

COMPLICATIONS

= Dental cavities. Saliva helps protect the teeth from the bacteria that cause cavities. Dry mouth caries ↑

= Yeast infections. Dry mouth more likely to develop oral thrush, a yeast infection in the mouth.

= Vision problems. Dry eyes can lead to light sensitivity, blurred vision and corneal ulcers.

LESS COMMON COMPLICATIONS

= Lungs, kidneys or liver. Inflammation pneumonia, bronchitis or other problems in the lungs; problems with kidney function; and may cause hepatitis or cirrhosis in the liver.

= Lymph nodes. A small percentage of people with Sjogren's syndrome develop cancer of the lymph nodes (lymphoma).

= Nerves. May develop numbness, tingling and burning in the hands and feet (peripheral neuropathy).

Symptoms of Sjogren’s syndrome

Primary Symptoms

Dry Eye

Gritty, sandy feeling, stinging feeling

Dry Mouth

Dry, cracked tongue

Sore throat

Burning throat

Difficulty talking

Difficulty swallowing

Difficulty chewing dry food

Change in sense of taste/smell

Increase in cavities

Mouth sores

Cracked lips

Other Symptoms

Swollen parotid glands

Nausea

Dry skin

Joint pain

Dry nose

Reflux

Muscle pain

Fatique

Muscle weakness

Low-grade fever

Vaginal dryness

Neuropathy

Dizziness

Dental care= Xerostomia ideal environment for the proliferation of bacteria cavities preventive dental treatment

= Treatments: topical fluoride application to strengthen tooth enamel and frequent teeth cleanings

= Cavities must also be treated

This treatment regimen is the same as that used for all xerostomia patients, such as those undergoing head and neck radiation therapy

MEDICATIONS

= Increase production of saliva. Drugs such as pilocarpine (Salagen) and cevimeline (Evoxac) can increase the production of saliva, and sometimes tears.

Side effects may include sweating, abdominal pain, flushing and increased urination.

= arthritis symptoms : nonsteroidal anti-inflammatory drugs (NSAIDs) or other arthritis medications.

= Yeast infections : antifungal medications.

= Prescription eyedrops : aren't helpful

= Hydroxychloroquine (Plaquenil), a drug designed to treat malaria, is often helpful : suppress the immune system, such as methotrexate, also may be prescribed.

TO HELP WITH DRY MOUTH

= Increase fluid intake. Drinking lots of fluids, particularly water, helps to reduce dry mouth.

= Stimulate saliva flow. Sugarless gum or hard candies can boost saliva flow. Because Sjogren's syndrome increases the risk of dental cavities, limit sweets, especially between meals. Lemon juice in water also can help stimulate saliva flow.

= Try artificial saliva. Saliva replacement products often work better than plain water because they contain a lubricant that helps the mouth stay moist longer. These products may come as a spray or lozenge.

= Use nasal saline spray. A nasal saline spray can help moisturize and clear nasal passages can breathe freely through the nose. A dry, stuffy nose can increase mouth breathing.

ORAL HEALTH

Dry mouth increases the risk of dental cavities and tooth loss :

= Brush the teeth and floss after every meal.

= Schedule regular dental appointments, at least every six months.

= Use daily topical fluoride treatments and antimicrobial mouthwashes.

SELAMAT BELAJARSUKSES SELALU