Aging and Diseases of the Salivary Glands

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Aging and Diseases of the Salivary Glands

• Biology of Salivary Glands
• Domenica G. Sweier DDS
• June 4, 2003

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Saliva

• Frustrating for the dental team yet necessary for
  the patient!

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When there is not Enough

• Too little saliva can significantly alter a
  persons quality of life and the morbidity
  associated with multiple systemic conditions
• How little is too little?
• What affects the quality and quantity of saliva
  production and flow?

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Objective vs Subjective

• Objective
• Major gland secretions
• Resting flow rate with a Carlson-Crittenden Cup
• Minor gland secretions
• Whole saliva
• Stimulated flow rate with 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 determined
  rate in healthy individuals not taking
  medications
• Resting Flow Rate 0.3-0.4 ml/min
• Stimulated Flow Rate 1-2 ml/min

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Clinical Signs/Symptoms of Xerostomia

• Dryness of mucous membranes
• Tongue fissuring and lobulation (scrotal tongue)
• Angular cheilosis/cheilitis
• Fungal infections
• Prosthesis-induced stomatitis
• Amputation caries
• Thick, ropey saliva

• Dysphagia
• Dysgeusia
• Difficulty eating/speaking/ wearing prosthesis
• Swelling of the salivary glands
• Difficulty expressing saliva
• Cheek biting
• Persistent need for fluids
• Burning tongue

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What Contributes to Xerostomia?

• Aging
• Hormonal Changes/Menopause
• Disease
• Local
• Systemic
• Environmental Insults/Trauma
• Medications

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Aging

• Salivary Quantity in Health
• No changes in major secretions (parotid,
  submandibular)
• No changes in minor secretions

• Salivary Quality in Health
• No general changes in salivary constituents

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Aging

• If the quality and quantity of saliva doesnt
  change with age, then what accounts for the
  increased incidence of xerostomia and associated
  morbidity among the elderly?
• Medications, diseases, and other environmental
  insults affect both the quality and quantity of
  saliva
• An 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 is 50
  years
• Oral symptoms common, particularly among those
  with systemic complaints
• Cross-sectional and longitudinal studies have
  failed to provide significant and reproducible
  evidence that salivary flow is affected by
  menopause
• Oral complaints most likely the result of the
  types and numbers of xerostomic medications taken
• Anti-hypertensives, anti-depressants, and
  anti-histamines are 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 Diseases

• Tumors/Growths
• Benign
• Malignant
• Obstructive Diseases
• Calculi, mucus plugs
• Unusual anatomy

• Inflammatory Diseases
• Acute viral sialadenitis
• Acute and recurrent bacterial sialadenitis
• Inflammation/Infection secondary to systemic
  disease

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Tumors/Growths

• Primary benign and malignant tumors
• Determine whether benign or malignant since they
  are treated differently
• Incisional biopsy for definitive diagnosis
• Smaller the involved gland, more likely malignant

• Malignant
• Seek medical attention for swelling under the
  chin or around the jawbone, if the face becomes
  numb, facial muscles do not move, or there is
  persistent pain
• Usually treated with a combination of surgery and
  radiation

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Obstruction Sialolithiasis

• Calculi form in the duct, blocking the egress of
  saliva
• Majority in submandibular gland
• Painful swelling which increases at meal time
• Bi-manual palpation in submandibular gland
• X-ray, sialography, CT, ultrasound
• Analgesics, try to push stone out, may need to
  dilate orifice to remove

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Submandibular Calculi
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Unusual Anatomy

• Unusual anatomy in the gland manifested as
  strictures 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 of acute
  viral sialadenitis
• Member of the paramyxoviridae
• Mostly in parotid
• The incubation period is 2-3 weeks
• Acute painful swelling and enlargement
• Fever, headache, loss of appetite
• Most common in children
• Very effective vaccine

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Inflammation/Infection Bacterial

• Types
• Acute suppurative bacterial sialadenitis
• Commonly S. aureus, S. viridans, H. influenzae,
  E. coli
• Chronic recurrent sialadenitis
• May be secondary to some type of obstruction or
  unusual anatomy
• May be due to resistant organism culture to
  determine
• Treatment
• Antibiotics and analgesics
• Rehydrate and stimulate saliva
• May need open drainage/surgery

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Bacterial Parotiditis
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Systemic Diseases

• Sjögrens Syndrome
• Sarcoidosis
• Cystic Fibrosis
• Diabetes
• Alzheimers Disease
• AIDS
• Graft vs Host Disease
• Dehydration

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Sjögrens Syndrome

• Autoimmune disorder affecting lacrimal and
  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 with destruction of
  glandular tissue
• Treatment is palliative

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Sarcoidosis

• Unknown cause believed to be alteration in
  cellular immune function and involvement of some
  allergen
• Any organ but most often the lungs can affect
  the parotid gland
• Granulomatous inflammation
• Most often drugs of choice are corticosteroids

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Cystic Fibrosis

• Faulty transport of sodium and chloride from
  within cells lining lungs and pancreas to their
  outer surface
• Causes production of an abnormally thick sticky
  mucus
• Obstruction of pancreas leads to digestive
  problems inability to digest and absorb
  nutrients
• Gene has been identified and cloned
• No known cure therefore palliative treatment

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Diabetes

• Uncontrolled blood glucose levels may contribute
  to 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 a
  decrease in cognition and mobility
• May affect the neurological component to salivary
  production and/or flow
• Xerostomic medications
• Complicated by behavior which makes it difficult
  to maintain a healthy dentition
• Poor oral hygiene
• Poor 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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Graft vs Host Disease (GVHD)

• Immune cells of an allogenic transplant attack
  recipient
• Acute, lt 100 days, and chronic gt 100 days
• Major cause of morbidity and mortality
• Initial presentation as a red rash
• Salivary gland involvement with swelling and
  inflammation
• Progresses quickly to life-threatening condition
• Treat by increasing immunosuppression

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Dehydration

• Defined as the loss of water and essential body
  salts (electrolytes) needed for body function
• Sweating, diarrhea, emesis, blood loss, etc.
• Symptoms include flushed face, dry, warm skin,
  fatigue, cramping, reduced amount of urine
• Oral signs/symptoms
• Xerostomia, dry tongue
• Thick, sticky saliva
• Dry, cracked lips (cheilosis)

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Head and Neck Cancer Radiation Therapy

• Goal is to kill cancer cells
• Measured in Gray (Gy) units of absorbed
  radiation 1 Gy 100 cGy 100 rads
• Can be used alone or combined with surgery and/or
  chemotherapy
• Three main routes
• External beam (most head and neck)
• Brachytherapy (body cavities)
• Interstitial

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Radiation Dose

• Dependent on tumor tissue/type
• Average of 200 cGy daily for 5 consecutive days
  with two days of rest
• Total cummulative dose ranges from 5000 cGy to
  8000 cGy for advanced tumors
• Threshold of permanent destruction is 2100- 4000
  cGy

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Tissue Response

• 25 Gy Bone marrow, lymphocytes, GI epithelium,
  germinal cells
• 25-50 Gy Oral epithelium, endothelium of blood
  cells, salivary glands, growing bone and
  cartilage, collagen
• Doses gt 50 Gy bone and cartilage, skeletal
  muscle

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Tissue Changes

• Irradiated tissue becomes hypocellular,
  hypovascular, and hypoxic resulting in fibrosis
  and vascular occlusion
• The destruction is mostly permanent
• Irradiated tissue does not re-vascularize with
  time
• As a result, irradiated tissue does not heal well
  after injury

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Common Side Effects Systemic

• Nausea
• Vomiting
• Neutropenia
• Alopecia
• Fatigue

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Common Side Effects Oral

• Mucositis and Dermatitis
• Dysphagia
• Dysgeusia
• Trismus
• Osteo- and soft tissue necrosis
• Xerostomia
• Fungal infections
• Radiation Caries

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Radiation Xerostomia

• Parotid gland is more susceptible than the
  submandibular or sublingual glands
• See a slight improvement after therapy but will
  soon plateau at a lower level than pre-therapy
• Result is thick, ropey saliva, decreased in
  amount, with markedly diminished lubricating and
  protective qualities

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Radiation Mucositis

• The oral eipthelium will get a sun burn like
  inflammation
• This will be exacerbated by the lack of the
  lubricating properties of saliva
• The result will be a red, irritated, dry mucosa

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Saliva Post-Radiation
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Mucositis
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Radiation Caries
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Prosthesis-Induced Stomatitis
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Fungal Infections
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Scrotal Tongue
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Chemotherapy

• Is given orally, IV, by injection (SQ, IM, IL),
  or topically in cycles depending on the treatment
  goals (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 oral
  tissues secondary to chemotherapy and indirect
  damage 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 oral complications
• Methotrexate
• Doxorubicin
• 5-Fluorouracil (5-FU)
• Busulfan
• Bleomycin
• Platinum coordination complexes
• Cisplatin
• Carboplatin

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Tissue Damage

• The propensity of chemotherapy to damage tissue,
  specifically oral tissues, is dependent on each
  individual drug and its ability 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 to heal after therapy

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Common Side Effects Systemic

• Fatigue
• Nausea
• Constipation
• Diarrhea
• Hemorrhage
• Anemia
• Neutropenia

• Pain
• Alopecia
• Peripheral neuropathy
• CNS disturbances
• Fluid retention
• Bladder and kidney problems

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Common Side Effects Oral

• 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 leading to
  salivary hypofunction, healthy aging does not
  appear to be one of them
• The main insults leading to salivary gland damage
  and/or hypofunction are
• Disease
• Local
• Systemic
• Environmental insults/trauma
• Radiation
• Chemotherapy
• Medications