aging and salivary glands

7/28/2019 Aging and Salivary Glands

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AGINGANDTHE SALIVARY

GLANDS


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SALIVA

Frustrating for the dental team yet necessary forthe patient!

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WHENTHEREISNOT ENOUGH

Too little saliva can significantly alter a personsquality of life and the morbidity associated withmultiple systemic conditions How little is too little? What affects the quality and quantity of salivaproduction and flow?

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OBJECTIVEVS SUBJECTIVEJ

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Objective Major gland secretions

Resting flow rate with aCarlson-Crittenden Cup

Minor gland secretions Whole saliva

Stimulated flow ratewith citric acid, wax

Subjective Complaints of dry

mouth (xerostomia)

Questionnaire Thirst The cracker test


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XEROSTOMIA

Commonly referred to as dry mouth Diminished salivary flow rate, typically accepted

as a 50% decrease in the clinically determinedrate in healthy individuals not takingmedications Resting Flow Rate 0.3-0.4 ml/min Stimulated Flow Rate 1-2 ml/min

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CLINICAL SIGNS/SYMPTOMSOFXEROSTOMIA

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Dryness of mucousmembranes

Tongue fissuring andlobulation (scrotaltongue)

Angular cheilosis/cheilitis Fungal infections Prosthesis-induced

stomatitisAmputation caries Thick, ropey saliva

Dysphagia Dysgeusia Difficulty eating/

speaking/ wearingprosthesis

Swelling of thesalivary glands

Difficulty expressingsaliva

Cheek biting

Persistent need forfluids Burning tongue


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WHAT CONTRIBUTESTO XEROSTOMIA?

Aging Hormonal Changes/Menopause

Disease Local Systemic

Environmental Insults/Trauma Medications

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AGINGJ

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Salivary Quantity inHealth No changes in major

secretions (parotid,submandibular)

No changes in minorsecretions

Salivary Quality inHealth No general changes in

salivary constituents


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AGING

If the quality and quantity of saliva doesntchange with age, then what accounts for theincreased incidence of xerostomia and associatedmorbidity among the elderly? Medications, diseases, and other environmental

insults affect both the quality and quantity of salivaAn increase in incidence of these insults generally

associated with an increase in age

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MENOPAUSE

Average age of onset of menopause in USA is50 years

Oral symptoms common, particularly amongthose with systemic complaints

Cross-sectional and longitudinal studies havefailed to provide significant and reproducibleevidence that salivary flow is affected bymenopause Oral complaints most likely the result of the types

and numbers of xerostomic medications takenAnti-hypertensives, anti-depressants, and anti-histaminesare common in this group

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DISEASES/ENVIRONMENTAL FACTORS

Diseases Local Systemic

Environmental Factors Head and Neck Radiation Chemotherapy Medications

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LOCAL DISEASESJ

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Tumors/Growths Benign Malignant

Obstructive Diseases Calculi, mucus plugs Unusual anatomy

InflammatoryDiseases Acute viral

sialadenitis

Acute and recurrentbacterial sialadenitis

Inflammation/Infection secondary tosystemic disease


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TUMORS/GROWTHSJune

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Primary benign andmalignant tumors Determine whether

benign or malignantsince they are treated

differently Incisional biopsy for

definitive diagnosis Smaller the involved

gland, more likelymalignant

Malignant Seek medical attention

for swelling under thechin or around the

jawbone, if the face

becomes numb, facialmuscles do not move, orthere is persistent pain

Usually treated with acombination of surgeryand radiation


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OBSTRUCTION: SIALOLITHIASIS

Calculi form in the duct, blocking theegress of saliva Majority in submandibular gland

Painful swelling which increases at mealtime

Bi-manual palpation in submandibulargland

X-ray, sialography, CT, ultrasoundAnalgesics, try to push stone out, mayneed to dilate orifice to remove

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SUBMANDIBULAR CALCULIJune

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UNUSUAL ANATOMY

Unusual anatomy in the gland manifested asstrictures in the duct system Recurrent obstruction with associated pain and

inflammation of glands

Pooling of saliva leading to secondary infection May need surgery to remove affected area of gland or entire

gland

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INFLAMMATION/INFECTION: VIRAL

Mumps is the most frequent diagnosis ofacute viral sialadenitis Member of the paramyxoviridae Mostly in parotid The incubation period is 2-3 weeksAcute painful swelling and enlargement Fever, headache, loss of appetite Most common in childrenVery effective vaccine

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INFLAMMATION/INFECTION: BACTERIAL

TypesAcute suppurative bacterial sialadenitis

Commonly S. aureus, S. viridans, H. influenzae, E. coli Chronic recurrent sialadenitis

May be secondary to some type of obstruction or unusualanatomy

May be due to resistant organism; culture to determineTreatment

Antibiotics and analgesics Rehydrate and stimulate saliva May need open drainage/surgery

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SYSTEMIC DISEASES

Sjgrens SyndromeSarcoidosisCystic FibrosisDiabetesAlzheimers DiseaseAIDSGraft vs Host DiseaseDehydration

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SJGRENS SYNDROME

Autoimmune disorder affecting lacrimaland salivary glands Xerostomia and keratoconjunctivitis sicca

Primary and Secondary disease The latter associated with another

autoimmune disorder such as RA, SLE, etc.

Dense inflammatory infiltrate withdestruction of glandular tissue

Treatment is palliative

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SARCOIDOSIS

Unknown cause; believed to be alteration incellular immune function and involvement ofsome allergen

Any organ but most often the lungs; can affectthe parotid gland

Granulomatous inflammation Most often drugs of choice are corticosteroids

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CYSTIC FIBROSIS

Faulty transport of sodium and chloridefrom within cells lining lungs andpancreas to their outer surface

Causes production of an abnormally thicksticky mucus

Obstruction of pancreas leads to digestiveproblems; inability to digest and absorbnutrients

Gene has been identified and clonedNo known cure therefore palliativetreatment

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DIABETES

Uncontrolled blood glucose levels may contributeto xerostomia

Medications may induce xerostomia May get enlargement and inflammation of

parotid glands (common in endocrine diseases) Difficulty to ward off infection: candidiasis,

gingivitis, periodontitis, and caries

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ALZHEIMERS DISEASE

A neurodegenerative disorder leading to adecrease in cognition and mobility

May affect the neurological component tosalivary production and/or flow

Xerostomic medications Complicated by behavior which makes it

difficult to maintain a healthy dentitionPoor oral hygienePoor cooperation for dental care and treatment in a

conventional setting

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AIDS

HIV-Associated Salivary Gland Disease (HIV-SGD) Enlargement of the major salivary glands Xerostomia Some similarities to autoimmune diseases HIV itself not consistently found to be in glandular

tissue

Medications

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GRAFTVS HOST DISEASE (GVHD)

Immune cells of an allogenic transplantattack recipient

Acute, < 100 days, and chronic > 100 daysMajor cause of morbidity and mortalityInitial presentation as a red rashSalivary gland involvement with swelling

and inflammationProgresses quickly to life-threatening

conditionTreat by increasing immunosuppression

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DEHYDRATION

Defined as the loss of water and essentialbody salts (electrolytes) needed for bodyfunction Sweating, diarrhea, emesis, blood loss, etc.

Symptoms include flushed face, dry, warmskin, fatigue, cramping, reduced amountof urine

Oral signs/symptoms Xerostomia, dry tongue Thick, sticky saliva Dry, cracked lips (cheilosis)

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HEADAND NECKCANCER: RADIATIONTHERAPY

Goal is to kill cancer cellsMeasured in Gray (Gy) units of absorbed

radiation: 1 Gy = 100 cGy = 100 radsCan be used alone or combined with

surgery and/or chemotherapyThree main routes

External beam (most head and neck) Brachytherapy (body cavities)

Interstitial

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RADIATION DOSE

Dependent on tumor tissue/typeAverage of 200 cGy daily for 5 consecutive days

with two days of rest

Total cummulative dose ranges from 5000 cGy to8000 cGy for advanced tumors

Threshold of permanent destruction is 2100-4000 cGy

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TISSUE RESPONSE

25 Gy: Bone marrow, lymphocytes, GIepithelium, germinal cells

25-50 Gy: Oral epithelium, endothelium of bloodcells, salivary glands, growing bone and cartilage,

collagen Doses > 50 Gy: bone and cartilage, skeletal

muscle

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TISSUE CHANGES

Irradiated tissue becomes hypocellular,hypovascular, and hypoxic resulting infibrosis and vascular occlusion

The destruction is mostly permanent Irradiated tissue does not re-vascularize with

time

As a result, irradiated tissue does not healwell after injury

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COMMON SIDE EFFECTS: SYSTEMIC

NauseaVomiting NeutropeniaAlopecia Fatigue

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COMMON SIDE EFFECTS: ORAL

Mucositis and DermatitisDysphagiaDysgeusiaTrismusOsteo- and soft tissue necrosisXerostomia

Fungal infections Radiation Caries

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RADIATION: XEROSTOMIA

Parotid gland is more susceptible than thesubmandibular or sublingual glands

See a slight improvement after therapy but willsoon plateau at a lower level than pre-therapy

Result is thick, ropey saliva, decreased inamount, with markedly diminished lubricatingand protective qualities

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RADIATION: MUCOSITIS

The oral eipthelium will get a sun burn likeinflammation

This will be exacerbated by the lack of thelubricating properties of saliva

The result will be a red, irritated, dry mucosa

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SALIVA POST-RADIATION Ju

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MUCOSITISJu

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RADIATION CARIESJu

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PROSTHESIS-INDUCED STOMATITISJu

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FUNGAL INFECTIONSJu

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SCROTAL TONGUE June

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CHEMOTHERAPY

Is given orally, IV, by injection (SQ, IM, IL), ortopically in cycles depending on the treatmentgoals (type of cancer, how your body responds,how well you body recovers, etc.)

Affects all rapidly dividing cells Many side effects in all body systems

Oral complications from direct damage to oraltissues secondary to chemotherapy and indirectdamage due to regional or systemic toxicity Frequency and severity related to systemic immune

compromise, i.e. myelosuppresion

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CHEMOTHERAPEUTICS

Drugs commonly associated with oralcomplications Methotrexate Doxorubicin 5-Fluorouracil (5-FU) Busulfan Bleomycin Platinum coordination complexes

CisplatinCarboplatin

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TISSUE DAMAGE

The propensity of chemotherapy todamage tissue, specifically oral tissues, isdependent on each individual drug and itsability to induce myelosuppresion

(neutropenia)Drugs differ on the timing of

myelosuppresion Consider this when treating patients

undergoing chemotherapy

Tissues, oral tissues, return to pre-chemotherapy state when allowed time toheal after therapy

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COMMON SIDE EFFECTS: SYSTEMICJune

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Fatigue Nausea Constipation Diarrhea HemorrhageAnemia Neutropenia

PainAlopecia Peripheral

neuropathy

CNS disturbances Fluid retention Bladder and kidney

problems


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COMMON SIDE EFFECTS: ORALJune

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Mucositis (ulcerative) Reactivation of HSV Dysgeusia Dysphagia Infections

Fungal Periodontium periapices

Neuropathies Salivary gland

dysfunction/toxicity xerostomia


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SUMMARY

While there appear to be many insults leadingto salivary hypofunction, healthy aging doesnot appear to be one of them

The main insults leading to salivary glanddamage and/or hypofunction are DiseaseLocal

Systemic Environmental insults/trauma

RadiationChemotherapy

Medications

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aging and salivary glands

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