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Secchezza del cavo orale
Valeria Mercadante
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La sottoscritta Valeria Mercadante
DICHIARA
che negli ultimi 2 anni non ha avuto rapporti anche
di finanziamento con soggetti portatori di interessi
commerciali in campo sanitario
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Xerostomia
• Xerostomia: sintomo soggettivo di
secchezza del cavo orale
• Iposalivazione: segno oggettivo. Il
flusso salivare e’ inferiore al valore
normale
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Xerostomia
• Molti studi epidemiologici
• Circa il 30% della popolazione 65+
• Circa il 10-15% in giovani adulti (30-
40 anni)
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Xerostomia
Authors Group/Age N. Dry mouthJohnson, 1984 Elderly, institutionalized 154 42%
Osterberg, 1984 55,65,75 973 20%
Sreebny and
Valdini,198918-84 529 29%
Kanapka, 1989 all ages 18,389 27%
Gilbert, 1993 +65 600 39%
Thomson, 1993 +65 359 20%
Locker, 1993 +50 907 18%
Narhi, 1994 80,85,90 386 46%
Samaranayake, 1995 elderly 147 35%
Nederfors, 1997 20-80 3,311 25%
Hochberg, 1998 65-84 2,52 17%
Thomson, 1999 +60 700 21%
Field, 2001 Adults 1,103 13%
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Xerostomia
Question AuthorDoes your mouth feel
distincly dry?Osterberg, 1984
Does you mouth usually
feel dry?
Sreebny and
Valdini,1989
Nederfors, 1997
Is your mouth
sometimes dry?Gilbert, 1993
During the past 4 weeks,
does your mouth feel
dry?
Narhi, 1994
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XerostomiaAuthors Group/Age N. Dry mouth
Johnson, 1984 Elderly, institutionalized 154 42%
Osterberg, 1984 55,65,75 973 20%
Sreebny and
Valdini,198918-84 529 29%
Kanapka, 1989 all ages 18,389 27%
Gilbert, 1993 +65 600 39%
Thomson, 1993 +65 359 20%
Locker, 1993 +50 907 18%
Narhi, 1994 80,85,90 386 46%
Samaranayake, 1995 elderly 147 35%
Nederfors, 1997 20-80 3,311 25%
Hochberg, 1998 65-84 2,52 17%
Thomson, 1999 +60 700 21%
Field, 2001 Adults 1,103 13%
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Maschi vs femmine
21
21
22
25
36
35
20 30 40 50 60 70
17
14
18
19
28
32
20 30 40 50 60 70
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Saliva
• Flusso salivare giornaliero = 1-
1.5 L
• Composizione: 99% acqua;
1% cellule epiteliali esfoliate,
proteine, elettroliti, fluido
crevicolare
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Saliva
• Lubrificazione e protezione meccanica
• Buffering action
• Attivita’ antibatterica
• Attivita’ antifungina
• Attivita’ antivirale
• Gusto e digestione
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Sintomi
• Sensazione di secchezza del cavo
orale
• Disartria
• Disgeusia
• Disfagia
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Segni
• Secchezza del cavo orale
• Carie dentali
• Infiammazione gengivale
• Infezione fungina
• Infezione delle ghiandole salivari
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Eziologia
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Farmaci
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Diabete
• Il diabete mellito e’ una malattia metabolica
caratterizzata da un deficit nella produzione di insulina
con consequente alterazione del metabolismo e nella
concentrazione di glucosio
• 380 milioni in 2025
• Xerostomia dovuta a poliuria & deidratazione
• Prevalenza: 14-62% (Diabete 2); 38.5-53% (Diabete 1)
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Xerostomia & Tiroide
• Tiroidite cronica autoimmune
• Tiroidite di Hashimoto
• Sindrome di Sjogren & Malattie
tiroidee
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Xerostomia &malattie croniche
• Scleroderma
• Sindrome CREST
• Chron’s disease?
• Malattie epatiche autoimmuni
• Amiloidosi
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Viral infections
• 1.2-40% pazienti HIV positivi
• Effetto collaterale dei farmaci HIV?
• Proliferazione di CD8+ cellule nelle
ghiandoli salivari maggiori.
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Viral infections
• Manifestazioni extra-epatiche
• 5-55% pazienti HCV positivi
• Effetto collaterale dei farmaci HCV
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Viral infections
• 25-30% della popolazione
• Antigene nucleare Epstein Barr
significativamente aumentato nei
pazienti di Sjogren rispetto alla
popolazione normale
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Sindrome di Sjogren
• Malattia sistemica, cronica,
autoimmune caratterizzata da
progressiva distruzione delle
ghiandole secretorie esocrine dovuta
ad un infiltrato di linfociti mononucleari
nel parenchima ghiandolare.
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Sindrome di Sjogren
• Primaria: Non associate con altre
patologie del tessuto connettivo
• Secondaria: Associata con una o
piu’ CTD (artrite reumatoide, SLE,
scleroderma, cirrosi biliare primaria,
dermatomiosite)
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sindrome di sjogren - criteri diagnostici
• Subjective symptoms of xerostomia or swelling in
adulthood
• Subjective symptoms of xerophalmia (dry eyes)
• Schirmer’s test (or Rose Bengal) (objective dry
eyes)
• Scintiscan or sialography or sialometry (objective
hyposalivation)
• Histopathology (Focus score >_1)
• Serology (anti-Ro/SSA e anti-La/SSB)
Primary ss
Any 4 of 6, as long as 5 or 6 are present
3 of the 4 objective criteria
Sensivitity= 97.2%Specificity= 48.6%
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• Subjective symptoms of xerostomia or swelling in
adulthood
• Subjective symptoms of xerophalmia (dry eyes)
• Schirmer’s test (or Rose Bengal) (objective dry
eyes)
• Scintiscan or sialography or sialometry (objective
hyposalivation)
• Histopathology (Focus score >_1)
• CTD
Secondary ss
CTD + criteria 1 or 2 +
2 criteria among 3,4,5
Sensivitity= 97.2%Specificity= 64.7%
sindrome di sjogren - criteri diagnostici
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Criteri di esclusione
• Radioterapia testa-collo
• HCV
• Acquired immunodeficiency disease
(AIDS)
• Pre-esistente lymphoma
• Sarcoidosi
• Graft vs host disease
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Nuovi criteri diagnostici of ss (2012)
nih/acr
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• At least 2 of the following 3 criteria:
• Anti-SSA/B blood test: 1) Positive serum levels of
either the SSA and/or SSB antibody and/or 2)
positive serum levels of the rheumatoid factor
antibody (RF) AND elevated antinuclear antibody
(ANA) titers
• Ocular surface staining: A score of > 3
• Salivary gland biopsy: Presence of focal lymphocytic
sialadenitis with a focus score > 1 focus/4 mm3 in
labial salivary gland biopsy samples.
Nuovi criteri diagnostici of ss (2012)
nih/acr
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• Si esegue posizionando due striscioline di carta bibula millimetrate nel
fornice congiuntivale e si attende alcuni minuti (5 min.). Al termine si
misura la porzione di strisciolina inumidita (<5mm in 5 minutes).
Schirmer test
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Sialometria
• Flusso salivare non stimolato: <1.5 mL/15 min
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Sjogren & malignancy
• Rischio di NHL 40 volte piu’ alto
• Mucosa-associated lymphoid tissue (MALT)
• 2-4% dei pazienti
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Xerostomia indotta da radioterapia
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Prevalenza
La prevalenza della xerostomia indotta da radioterapia varia a seconda della tecnica di
radiotherapy, dose e campio di irradiazione
Text
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diagnosis
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Terapia
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Pilocarpina
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Sostituti salivari
• Possono essere efficaci ma efficacia di breve durata
• Proprieta’ fisiche differenti dalla saliva
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Agopuntura
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Future terapie
• Salivary gene therapy
• Electrostimulazione
• Terapia a base di cellule
staminali
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Gene therapy
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Gene therapy
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Gene therapy
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Cellule staminali
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Elettrostimolazione
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• LEONIDAS-2
• Long-term Evaluation of the Effectiveness Of a Novel
Intra-oral electrostimulator for the treatment of
raDiotherapy-ASsociated dry mouth
• Funding body: National Institute of Health and
Research (NIHR)
• Grant: £250,000
• 2-centre, equally randomized, sham-controlled,
double blind parallel-group trial of 12 months therapy
• 84 pazienti cancro testa/collo
• LEONIDAS-1
• Long-term effectiveness of a novel intra-oral electro-
stimulator for the treatment of dry mouth in patients
with Sjogren's syndrome: a feasibility study
• Funding body: Arthritis Research
• Grant: £30,000
• 2-centre, equally randomized, sham-controlled,
double blind parallel-group trial of 6 months therapy
• 30 pazienti Sjogren’s
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Statistical analysis
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Grazie per
l’attenzione