Management of ptyalism and xerostomia

xerostomia and ptyalism are functional disorders of salivary glands that are quite common. This presentation deals with clinical aspect of detecting and managing such patients.

1. MANAGEMENT OF PTYALISM AND XEROSTOMIA BY NAYANAASRI.B INTERN

2. INTRODUCTION SALIVARY GLANDS MAJOR PAROTID SUBMANDIBULAR SUBLINGUAL MINOR LABIAL BUCCAL PALATINE GLOSSOPALATINE BLANDIN`S AND NUHN`S VON EBNER POSTERIOR LINGUAL INCISIVE

3. SALIVARY GLAND DISORDERS DEVELOPMENTAL FUNCTIONAL INFLAMMATORY TRAUMATIC AUTOIMMUNE NEUROLOGICAL DEGENERATIVE VASCULAR NEOPLASTIC NON-IFLAMMATORY NON-NEOPLASTIC

4. FUNCTIONAL SALIVARY GLAND DISORDER XEROSTOMIA- it is defined as the subjective sensation of oral dryness that may or may not be associated with a reduction in salivary output. The condition may be transient , prolonged or permanent depending upon the duration of condition. PTYALISM- it is defined as an excessive production of saliva and is the result of either an increase in salivary production or decrease in salivary clearance.

5. XEROSTOMIA-ETIOLOGY RADIATION INDUCED >30 GY – REVERSIBLE EFFECTS > 60 GY- IRREVERSIBLE EFFECTS PHARMACOLOGICALLY INDUCED (xerogenic drugs) ANTICHOLINERGIC- EX: ATROPINE ANTIHYPERTENSIVE-EX: METHYL DOPA ANTIHISTAMINE- EX: DIPHENHYDRAMINE ANTIEMETIC- EX: HYOSCINE ANTISPASMODIC- EX:TIZANDINE LOCAL FACTORS SYSTEMIC ALTERATIONS- EX:SJOGREN SYNDROME

6. SALIVARY GLAND HYPOFUNCTION

7. XEROSTOMIA- SIGNS AND SYMPTOMS SALIVARY GLAND ENLARGEMENT HYPOFUNCTION OF OTHER GLANDS PALE, THIN, DRY ORAL MUCOSA TONGUE- ATROPHIED PAPILLAE, INFLAMMATION, FISSURING, CRACKING DENTAL CARIES CANDIDIASIS

8. XERODERMA XEROPHTHALMIA

9. ORAL MUCOSA CHANGES

10. Tongue changes

11. Dental caries

12. INVESTIGATION SIALOMETRY OR SALIVARY FLOW RATES RESTING UNSTIMULATED WHOLE NORMAL RESTING = 0.3 ml/min SIALOGRAPHY- SS appears as CHERRY BLOSSOM SCINTIGRAPHY- with sodium pertechtonate

13. SIALOGRAPHY

14. XEROSTOMIA – MANAGEMENT PREVENTIVE THERAPIES- SUPPLEMENTAL FLUORIDES, REMINERALIZING SOLUTIONS, ORAL HYGIENE, NON- CARIOGENIC DIET SYMPTOMATIC THERAPY- WATER, ORAL RINSES, GELS, MOUTHWASHES, ICREASED HUMIDIFICATION, LOCAL SALIVARY STIMULATION- SUGAR FREE GUMS AND MINTS SYSTEMIC STIMULATION- PARASYMPATHOMIMETIC SECRETOGOGUES TREATMENT OF UNDERLYING SYSTEMIC DISORDERS STEM CELL THERAPY

15. PREVENTIVE TOPICAL FLUORIDE- 1.1% SODIUM FLUORIDE Dental examination every 6 months Meticulous oral hygiene Diet- non- cariogenic , decaf, decreased alcohol Dental caries

16. SYMPTOMATIC WATER SALIVARY SUBSTITUTE OR ARTIFICIAL SALIVA COMPOSITION OF ARTIFICIAL SALIVA Carboxymethyl cellulose- 10g/L Sorbitol - 30g/L Potassium chloride- 1.2g/L Sodium chloride- 0.843 g/L Magnesium chloride- 0.051 g/L Calcium chloride- 0.146 g/L Dipotassium hydrogen phosphate: 0.342 g/L DISADVANTAGE OF ARTIFICIAL SALIVA Poor patient compliance Viscous than natural saliva Expensive DISCONTINUATION OF DRUG CAUSING XEROSTOMIA

17. CANDIDIASIS TOPICAL ANTIFUNGALS Nystatin-200,000 units DENTURE TREATMENT NYSTATIN CREAM TRIAMCINALONE ACETONIDE CREAM SYSTEMIC ANTIFUNGALS FLUCANAZOLE- 100 mg tablet OD KETACONAZOLE- 200 mg tablet OD or BD

18. LOCAL STIMULATION CHEWING OF GUMS, MINTS, PARAFFIN AND CITRIC ACID CONTAINING LOZENGES AND RINSES. DISADVANTAGES- Short lived Incovenient Citric acid may irritate oral mucosa Continous use may cause demineraliz ation

19. LOCAL STIMULATION TRANSCUTANEOUS ELECTRIC NERVE STIMULATION- Increases salivary secretion in both healthy and radiation induced xerostomia patients. OSTEOINTEGRATED IMPLANT WITH EMBEDDED WETNESS SENSOR- recent advancement ACCUPUNTURE- needles placed in perioral region. low evidence of small increase in saliva secretion.

20. SYSTEMIC STIMULATION BROMHEXINE- MUCOLYTIC AGENT STIMULATE LACRIMAL FUNCTION IN SS INDUCE THIN COPIOUS BRONCHIAL SECRETIONS DOSE: ADULTS- 8 mg TDS, CHILDREN(1- 5 years)- 4 mg BD, CHILDREN( 5-10 years)- 4 mg TDS. ANETHOLETRITHIONE- DIRECTLY ACTING CHOLINERGIC AGONIST DOSE: 1 TO 2 tabs 25 mg TDS.

21. SYSTEMIC STIMULATION PILOCARPINE HCL FDA APPROVED DRUG SPECIFIC TO XEROSTOMIA PARASYMPATHOMIMETIC DRUG ICREASES SECRETION BY EXOCRINE GLAND CONTRAINDICATED IN ASTHMATICS DOSE: 5 mg TDS. SIDE EFFECTS- SWEATING, HOT FLASHES, URINARY FREQUENCY, DIARRHEA, BLURRED VISION. CEVIMELINE PARASYMPATHOMIMETIC AGONIST ACTS ON M1, M3 RECEPTORS

22. STEM CELL THERAPY THERE ARE CELLS WITHIN SALIVARY DUCT CAPABLE OF PROLIFERATION AND DIFFERENTIATION CALLED STEM CELL OR PROGENITOR CELLS. APPLICATION OF SPECIFIC GROWTH FACTORS TO THESE CELLS INDUCE DIFFERENTI A TION INTO FUNCTIONAL UNITS

23. SUMMARY

24. PTYALISM-ETIOLOGY DRUGS- EX: PILOCARPINE, CEVIMALINE, LITHIUM, BETHANECHOL, PHYSOSTIGMINE, CLOZAPINE, RISPERIDONE, NITRAZEPAM NEUROLOGIC DISEASES- EX: PARKINSON`S DISEASE WILSON`S DISEASE, AMYOTROPHIC LATERAL SCLEROSIS, DOWN SYNDROME, FRAGILE X SYNDROME, AUTISM, CEREBRAL PALSY PROTECTIVE BUFFER IN RESPONSE TO GERD LOCAL FACTORS: STOMATITIS, ANUG, ERYTHEMA MULTIFORME. HEAVY METAL POISONING: IRON, LEAD, ARSENIC, MERCURY, THALLIUM

25. PTYALISM- CLINICAL FEATURES DROOLING LIP CHAPPING MALODOR PERIORAL INFECTIONS TRAUMATIC ULCERS SCONDARY FUNGAL INFECTIONS SEVERE CASES- ASPIRATION PNEUOMONIA

26. PTYALISM- MANAGEMENT PHYSICAL THERAPY MEDICATIONS SURGERY RADIATION THERAPY BIOFEEDBACK REMOVAL OF LOCAL FACTORS

27. PHYSICAL THERAPY ORAL MOTOR TRAINING EXERCISES FOR SWALOWING SPEECH THERAPY KEY NON-SURGICAL MANAGEMENT PALATAL TRAINING DEVICES 6 MONTH FORMAT

28. PHYSICAL THERAPY POSITIONING- GOOD POSTURE, PROPER TRUNK AND HEAD CONTROL EATING AND DRINKING SKILLS- TECHNIQUES IN LIP CLOSURE, TONGUE MOVEMENT AND SWALLOWING ORAL FACIAL FACILITATIONS EXERCISES BY SPEECH THERAPISTS BRUSHING-EFFECT CAN BE SEEN UPTO 20-30 MINUTES DONE BEFORE MEALS VIBRATION MANIPULATION- STROKING TAPPING, PATTING, FIRM PRESSSURE DIRECTLY ON MUSCLES BEHAVIOUR THERAPY- POSITIVE AND NEGATIVE REINFORCEMENT

29. MEDICATIONS ATROPINE ANTAGINIST OF MUSCARINIC ACTIONS OF Ach. DOSE- ADULTS: 0.4 mg EVERY 4 TO 6 HRS; CHILD- 0.01 mg/kg. SIDE EFFECTS- CONTRAINDICATED FOR PATIENTS WITH ASTHMA AND GLAUCOMA PATIENTS SCOPOLAMINE DOSE- 0.4 mg TRANSDERMAL SCOPOLAMINE IS MORE EFFECTIVE LASTS FOR 3 DAYS METHANTHALINE- 50-100 mg PROPANTHALINE-15-30 mg GLYCOPYRROLATE BENZTROPINE DIPHENHYDRAMINE HCL

30. PHARMACOLOGY THERAPY BOTULINUM TOXIN BOTULINUM TOXIN TYPE A- BTx -A BTx -A SELECTIVELY BINDS TO CHOLINERGIC NERVE TERMINALS AND RAPIDLY ATTACHES TO ACCEPTOR MOLECULES AT THE PRESYNAPTIC NERVE SURFACE. THIS RESULTS IN INHIBITION OF Ach AND REDUCES FUNCTION OF PARASYMPATHETIC CONTROLLED EXOCRINE GLANDS REVERSIBLE DOSE- 30-40 UNITS INJECTED TO PAROTID AND SUBMANDIBULAR GLANDS UNDER ULTRASOUND GUIDANCE SIDE EFFECS-DYSPHAGIA, WEAK MASTICATION, DAMAGE TO FACIAL ARTERY AND NERVE

31. SURGERY RELOCATION OF DUCT {WILKE}- RELOCATION OF STENSON AND WHARTON DUCT POSTERIORLY TO TONSILLAR FOSSA BILATERAL TYMPANIC NEURECTOMY- SECTIONING OF CHORDA TYMPANI NERVE DESTROYS PARASYMPATHETIC INNERVATIONS TO GLAND INTRADUCTAL LASER PHOTOCOAGULATION EXCISION

32. RADIATION THERAPY DOSE: 6000 RAD SIDE EFFECTS- XEROSTOMIA DENTAL CARIES OSTEORADIONECROSIS

33. References Burket’s oral medicine. 12 th edition Anil Ghom. Textbook of oral medicine. 4 th edition