Aging and Diseases of the Salivary Glands

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

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

Subjective
Complaints of dry mouth (xerostomia) Questionnaire Thirst The cracker test

Minor gland secretions Whole saliva

Stimulated flow rate with citric acid, wax

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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
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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

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

Obstructive Diseases
Calculi, mucus plugs Unusual anatomy

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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
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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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 Types

Inflammation/Infection: Bacterial

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
Sjgrens Syndrome Sarcoidosis Cystic Fibrosis Diabetes Alzheimers Disease AIDS Graft vs Host Disease Dehydration
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Sjgrens 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, < 100 days, and chronic > 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 21004000 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 > 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 pretherapy 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
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Neuropathies Salivary gland dysfunction/toxicity

xerostomia

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
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