Xerostomia Sjogrens and sailography DEPARTMENT OF ORAL MEDICINE

Xerostomia Sjogrens and sailography DEPARTMENT OF ORAL MEDICINE & RADIOLOGY Dentistry Explorer

Cluster of grapes on a stem Dentistry Explorer

• Controlled by sympathetic and parasympathetic system • Muscarinic- cholinergic receptor- fluid from acini and beta-adrenergic receptors- protein (acini and duct) • Acini destroyed in SS and muscarinic agonist or parasympathomimetics – fluid secretion stimulation. Dentistry Explorer

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Xerostomia • Xerostomia is a subjective compliant of dry mouth as result of an abnormal decrease in the production or salivary flow. • Common in females and the elderly. • Saliva-foamy or thick and “ropy”. There is a lack of polling of saliva in the floor or the mouth and the mucosa appears dry. • The dorsal tongue is often fissured with atrophy of the filiform papilla )dysguesia). Dentistry Explorer

Xerostomia: Clinical Features • Mastication and speech difficulty, dysphagia. • The clinical findings do not always correspond to the degree of salivary flow. • The incidence of oral candidiasis increases cervical and root caries; “radiation” caries (xerostomia mucositis). • Eye nose throat, skin dryness Dentistry Explorer

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Dentistry Explorer

Dentistry Explorer

Dentistry Explorer

Investigation • Salivary flow rates and composition (sailochemistry) (Carlson crittenden collector or segregator) Stimulate with paraffin wax 60/min • Biopsy of minor salivary glands • Sailography Dentistry Explorer

Xerostomia: Cause, • Xerostomia can salivary or non salivary causesalivary gland aplasia, aging, smoking, mouth breathing, local radiation therapy, Sjögren syndrome, HIV infection, SLE, thyriod, depression, anxiety, drugs etc. Dentistry Explorer

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Dentistry Explorer

Treatment • Treatments preventive palliative stimulation local or systemic and cause t/t fu 4 -5 month • Artificial salivas, surgarfree gum, hard candy, mint, sialagogues such as pilocarpine (cholinergic) bethanecal, anetholetrithione, interferon alpha • Changing the patient’s medication. • Medication with meal and hour before bedtime • Xerostomia predisposes to increased dental caries and oral candidiasis. Dentistry Explorer

• Patient education and identifying cause and treatment. • Symptomatic treatment (ice chips and water with meal and all day 2% milk or olive oil, avoid glycerine) • Salivary substitute (CMC< mucin) before sleep or speaking • Acupucture • Local and systemic stimulation of salivary gland • Na. F 1% or Floride varnish • Oral hygiene and non cariogenic diet Dentistry Explorer

Dentistry Explorer

Dentistry Explorer

Dentistry Explorer

Investigation • Most decreased clearance, swallowing study • Unstimulated >2 -3. 5 ml/min if >5 ml R/O clearance issue • Blood investigation heavy metal and organophosphate, pregancy, androgens levels, acute CT scan to R/O CVA/ CNS mass Dentistry Explorer

Scopolamine transdermal patches, propantheline, benztropine and diphenhydramine, botolinum toxin-A (7. 5 to 15 units) transient for 2 -3 month) Dentistry Explorer

Sjogrens Syndrome & Benign Lymphoepithelial Lesion Dentistry Explorer

SJOGREN’S SYNDROME Dentistry Explorer

INTRODUCTION • Sjogren’s syndrome is a chronic autoimmune disease characterized by symptoms of oral & ocular dryness and lymphocytic infiltration & destruction of the exocrine glands Dentistry Explorer

TYPES • PRIMARY: Affects only salivary & lacrimal glands • SECONDARY: Affects salivary & lacrimal glands along with any connective tissue disorders (rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis etc. ) Dentistry Explorer

CLINICAL FEATURES • Xerostomia • Dry cracked lips, pale oral mucosa • Angular chelitis • Depapillated tongue, fissuring • Increased dental caries & erosion of enamel structure • Enlarged salivary glands • Difficulty in swallowing, chewing, speaking • Dry eyes • Skin and other mucosal surfaces may also be dry Dentistry Explorer

CLINICAL FEATURES Dentistry Explorer

INVESTIGATIONS • • • Sialometry Sialochemistry Schirmer’s test Break up time test Rose Bengal dye test Serology • • Dentistry Explorer Sialography MRI Scintigraphy Minor salivary gland biopsy

INVESTIGATIONS • SIALOMETRY: unstimulated saliva is secreted per minute <0. 1 ml/min and stimulated <0. 7 ml/min • SIALOCHEMISTRY: In SS, there will be increased levels of potassium, Immunoglobulins & candidal carriage rate Dentistry Explorer

• Schirmer’s Test Two 5 x 35 mm strips of red litmus paper placed behind the slightly drawn lower lid of both the eyes in the area of the conjunctival sac. Strips of paper are left in place for 5 min Moistening of 5 mm or less is considered as a positive finding. Dentistry Explorer

• Rose Bengal Dye test Cornea is stained using rose Bengal dye Slit lamp examination reveals the stained corneal cells with their devitalized nuclei. Stained areas represent the presence of corneal damage from inadequate lacrimation BUT is performed using a slit lamp Note interval between a complete blink and the appearance of a dry spot on the cornea. Dentistry Explorer

Hematological investigations Immunological and Serological Studies • 25% of the individuals have mild normocytic, normo chromic anemia • leucopenia, mild eosinophilia, elevated ESR (> 30 mm/hr, Westergren) Immunological studies marked elevation of gamma globulin High titres of immunoglobulin G, A, M, D, E. Serum albumin levels are depressed Presence of autoantibodies against nuclear antigens SSA/Ro or SS-B/La • Rheumatoid factor • • Dentistry Explorer

INVESTIGATIONS Cherry Blossom Appearance Dentistry Explorer

INVESTIGATIONS Dentistry Explorer

INVESTIGATIONS reveals the benign lyphoepithelial lesion, characterized by epimyoepithelail islands in a lymphocytic infiltrate. Dentistry Explorer

Minor salivary gland biopsy numbers of infiltrating mononuclear cells are counted aggregate of 50 or more cells (Focus) per 4 mm 2. - DIAGNOSTIC The score range is 0 to 12 • score of 1 is considered positive for SS in some criteria • Other criteria require the score to be > 1. Dentistry Explorer

COMPLICATIONS • Increased incidence of malignant lymphomas • Suspect lymphomas when monoclonal gammopathy or any lymphadenopathy is detected in SS patients Dentistry Explorer

TREATMENT • Symptomatic therapies like artificial saliva, oral rinses, frequent water sipping, artificial tears • Stimulatory therapies like chewing sugar free gum, sucking sugar free candies • Sialogogues like pilocarpine, cevimeline Dentistry Explorer

RECENT TREATMENT MODALITIES • Interferon alpha lozenges • Dehydroepiandrosterone Dentistry Explorer

SIALOGRAPHY Dentistry Explorer

SIALOGRAPHY • Sialography is the radiographic visualization of the salivary gland following retrograde instillation of soluble contrast material into the ducts Dentistry Explorer

INDICATIONS • To determine any obstruction in the gland • To assess the extent of ductal and glandular destruction secondary to any obstruction. • To determine the functional capacity of the salivary gland (in case of xerostomia, SS). • To determine the location, size, nature and origin of a tumour. Dentistry Explorer

CONTRAINDICATIONS • Active infections • Allergy to contrast media • Prior to thyroid function tests & imaging of thyroid • Salivary calculi close to the duct opening Dentistry Explorer

CONTRAST AGENTS OIL BASED Cannot be diluted by saliva Needs more pressure Will not be absorbed by tissues Complication like granulomas, retention of dyes • Good contrast • Ex: Lipiodol, Ethiodol, Pantopaque • • • WATER BASED • Can be diluted by saliva, hence short acting • Needs less pressure • Can be absorbed by tissues • Less complications • Less contrast, hence high viscosity agents can be used • Ex: Hypaque, Sinograffin, Iohexol, Diatrizoate, Metrizoate Dentistry Explorer

PHASES OF SIALOGRAPHY • PREOPERATIVE PHASE • FILLING PHASE • EMPTYING PHASE Dentistry Explorer

INSTRUMENTS NEEDED FOR SIALOGRAPHY • • Diagnostic instruments Universal infection control devices Lacrimal probe Cannula & extension tubes Contrast media Sialogogues Syringes Emergency drugs Dentistry Explorer

PRE OPERATIVE PHASE • Scout radiographs: OPG, lateral oblique, occlusal, puffed cheek PA skull, IOPA • Note presence/position of any radiopaque obstruction • Assess the position of shadows cast by anatomical stuctures • Assess exposure factors Dentistry Explorer

FILLING PHASE • Relevant duct orifice needs to be found, probed, dilated & then cannulated • Introducing contrast media (0. 7 ml for parotid & 0. 5 ml for submandibular gland) • Filling phase radiographs are taken. Ideally at least two different views at right angles are taken Dentistry Explorer

Methods of introducing contrast media • Simple injection technique • Hydrostatic technique • Continuous infusion pressure-monitored technique Dentistry Explorer

EMPTYING PHASE • Cannula is removed & patient allowed to rinse out • Use sialogogues (citric acid) to aid in excretion of contrast medium • After 1, 5 and 30 minutes, emptying phase radiographs are taken (crude assessment of function) Dentistry Explorer

INTERPRETATION • Assess the degree of filling the duct structure • Assess the main duct, noting diameter of duct, course, direction of duct, presence & position of filling defects • Assess the duct within gland, noting branching & tapering, overall pattern & shape of ducts, overall glandular filling, presence & position of any filling defects • Assess the degree of emptying Dentistry Explorer

SIALOGRAMS Dentistry Explorer

PATTERNS OF SIALOGRAMS • Tree in winter (parotid) • Bush in winter (submandibular) • Sialolith: Filling defect • Sialodochitis: Sausage string appearance • Sialadenitis: Sialectasis Dentistry Explorer Normal

Sjogren syndrome • Punctate sialectasis or snowstorm or branchless fruit laden tree or cherry blossom appearance • Intrinsic tumors: Ball in hand Dentistry Explorer

RECENT ADVANCES • Interventional sialography using ballon catheters & small Dormia baskets under fluoroscopic guidance Dentistry Explorer

THANK YOU Dentistry Explorer