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What is the difference between Xerostomia and Salivary hypofunction
- Xerostomia is subjective, it is a symptom
- Salivary hypofunction is objective (sign) can have an objective measure
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Dry mouth epidemiology
- 20% prevalence
- women > men
- Increase with medication use
- Increase in elderly
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Total salivary production
Stimulated
Unstimulated
- Total salivary production: 500-600 ml/day
- Stimulated: 300 ml/day
- Unstimulated: +200 ml/day
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Serous secretion
50% of stimulated volume
20% of unstimulated volume
- Parotids
- exits through Stenson's duct opens in parotid papila
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Mucous and serous (mixed gland) secretion.
65% of unstimulated volume
30% of stimulated volume
- SubMandibular glands
- exits through Warton's ducts oppening opens in caruncule
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Mucous (viscous secretion)
Mucous (very viscous secretion)
7-8% of unstimulated flow each
- Sublingial gland: Bartolini and Rivinus
- Minor salivary glands
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When is dry mouth perceived?
After more than 50% of unstimulated salivary flow is lost (more than 150 ml/day)
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Sialometry
- Difficult to gauge since dependent upon pt normal baseline
- usntimulated<0.1 ml/min
- stimulated <0.5 ml/min
- low flow rates possible in absence of symptoms and viceversa
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What type of stimulation produces copious saliva by all glands with variable protein concentration?
Parasympathetic stimulation
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What type of stimulation produces less volume and generally higher protein concentration in saliva?
Sympathetic stimulation
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What causes dry mouth during anxiety?
Central inhibition
as a result of connections between the primary salivary centers and the higher centers of the brain
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Causes of salivary hypofunctions
- Dehydration
- medications (Rx and OTC)
- direct damage to glands (radiotherapy, chemotherapy, HIV, Sjogren S)
- Decreased mastication (teeth loss, soft diet)
- Affections of the CNS (Alzheimer, Parkinson, cerebral palsy)
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How many Gy will cause temporary salivary dysfunction and how many will cause permanent salivary dysfunction?
- Parotid more radiosensitive than submandibular
- Dose and field are critical
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Autoimmune exocrinopathy
Dry mouth and eyes
- Sjogren Syndrome
- 2-4 million in US. age: mid 50's Female > Male (9:1)
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Which are the types of Sjogren Syndrome (SS)
- Primary SS: salivary and lacrimal involvement
- Secondary SS: salivary and/or lacrimal involvement plus another connective tissue disease
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Dry mouth and oral consequences
- Caries: incipient, recurrent, coronal, root surface
- Dysphagia: difficulty swallowing, incresed duration of dry and wet swallowing, increased risk of aspiration pneumonia
- Dysgeusia: altered taste
- Candidiasis: erythematous, pseudomembranous, angular cheilitis.
- Decreased denture retention: ↓ stability, ↑ complaints
- Frictional Keratosis
- Ulcerations: traumatic, aphthous
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Treatment of dry mouth
- Salivary substitutes: Oasis, xerostom, Biotene, aquoral, caphosol
- Hydration:
64 oz of water, avoid alcohol, caffeine. - Sugarless chewing gum: increases stimulated flow rate (2-3x unstimulated rate)
- Mucoadhesive disk: last 2-4 hours, contains a lubricating agent and citrus flavoring
- Electric stimulation: GenNarino
- Acupuncture
- Prescription Medications: coordinate with prescribing physician, alter dose, administration time, reduce drugs with anticholinergic side effects
- Spilanthes
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What medications can be used to treat Dry mouth?
- Pilocarpine 5 mg tid qhs
- Cevimeline 30mg tid
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Radiographic diagnostic: "fruit laden" branchless tree"
Sjogren Syndrome
Can also be confirmed with the Schimer test (volume of eye tears)
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Duct injury, secretion spills in adjacent connective tissue
- Mucocele: it may occur in any minor S. Gland (pseudocyst) most common location lower lip.
- Treatment with surgical excision
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Intra-ductal expansion due to a sialolith block
Mucous cyst
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Salivary gland stone (major and minor) obstruction of the duct
- Sialolithiasis: common in the floor of the mouth. Associated with the tortuous Wharton's duct.
- Occlusal x-ray
- Treatment: massage
- sialogogues
- surgical removal
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Acute or chronic inflammation of any salivary gland (painful)
- Sialadenitis. The unfection can be bacterial, viral (mumps) or fungal
- acute: parotid, purulent discharge, low grade fever
- Chronic: recurrent acute
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Treatment of acute and chronic sialadenitis
- Acute: Antibiotics, rehydration, surgical drainage.
- Chronic: surgical removal of affected gland
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A mucocele in the floor of the mouth. It may break trough the mylohyoid muscle and enter the neck space
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Diffuse swelling of the affected gland. Unilateral. Replacement of salivary gland tissue by lymphocytes, Squamous metaplasia of duct epithelium. Predilection for women. Asymptomatic
Bening lymphoepithelial lesion
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Replacement of salivary gland tissue by lymphocytes.
Squamous metaplasia of duct epithelium
Sjogren Syndrome
- The diagnostic is done after a minor salivary gland biopsy
- 2 specific antinuclear antibodies Anti SS-A and Anti SS-B
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Firm swelling. Non-inflammatory salivary gland enlargement. BILATERAL, asymptomatic.
Acinar atrophy with infiltration of fat cell (gland replaced by fat)-DM and alcoholism-
Hypertrophy of the salivary gland acinar cell -malnutrition (anorexa nervosa)
- Sialadenosis: slowly swollen of parotid glands
- Associated with diabetes, alcohol, malnutrition, asthma medication
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histopatology:
1. Capsue
2. double layered duct
3. plasmacitoyd cell: very pink with excentric nuclei
- Pleomorphic adenoma (benign mixed tumor): the most common salivary gland tumor. Most commonly found on superficial lobe of parotid and palate.
- treatment is surgical excision
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Slow growing painless mass with overlying mucosa. More uniform pathologic pattern. Usually found in the upper labial mucosa. Microscopically cystic appearance, purple lymphocytes, double layer pink granular cell
- Monomorphic adenoma
- (canalicular, trabecular, basal cell adenoma subtypes)
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Benign neoplasm that occurs almost only in the parotid. Might be associated with EBV and smoking. May occur bilateral
- Warthin tumor (papillary cystadenoma lymphomatosum)
- tratment surgical excision
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Slowly enlarging mass, painless. Occurs centrally in bone. Occurs in children. Epidermoid: island of epithelial cell joined togeather by desmosomes. Cystic spaces. Mucous cells
Mucoepidermoid carcinoma. The most common malignancy of salivary glands
- Two grade prognosis. Low grade: mimics benign neoplasm. A lot of mucous cells and prominent cyst formation, soft- fluctuant, good prognosis
- High grade: malignant tumor, shows necrosis, neural invasion and mitotic activity. Solid firm tumor. poor prognosis. Surgery plus radiation. Occurs centrally in bone
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Slow growing tumor, infiltrates around nerves (painful) histologically swis chees pattern (cribiform)
- Adenoid cyst carcinoma (cylindroma)
- recurrence is common with metastasis. Palate is a common site. Bad long term prognosis
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Malignat mixed tumor of the salivary glands
- Carcinoma ex pleomorphic adenoma: malignant transformation of pleomorphic adenoma. Long standing tumor
- Carcinosarcoma: both epithelial and connective tissue elements are malignant
- Metastizing mixed tumor: histopathologic identical to pleomorfic adenoma with distant metastasis
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Clinical features of adenomas
- encapsulated
- freely movable
- slow growing
- non-tender
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Clinical features of adenocarcinomas
- infiltrative
- fixed
- rapid or slow growing
- larger, painful, rapidly growing
- ulcerated over mucosa
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2 basic x-ray at the dentist office to diagnose a sialolith
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What should be done to increase the chance of capture the obstruction of the gland on the xray?
Reduce by half the expossure time. This will reduce the burnout
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imaging tools for salivary gland disease that general dentist can request. Uses contrast iodine base material that goes into the salivary gland to see it
- Conventional sialogram:
- CBCT sialogram:
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Contraindication of sialograms
- Acute inflammation of salivary glands: can cause foreign body reaction
- Known sensitivite to iodine-contrast agents
- Anticipated tyroid function test: can give false positive to the thyroid test
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What is the modality of choice to image any soft tissue?
MRI: used for salivary gland neoplasm where soft tissue information is needed
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Where is the most common place of sialolith formation and why?
Submandibular glands: because of the tortuous ducts path towards the floor of the mouth, that is prone to trap mucous secretions (will calcify) The other reason is the secretion been mucous that is more thick
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What kind of radiographic imaging should be prescribed for a patient:
Intermittent, unilateral swelling of the right floor of the mouth at the mealtime
swelling resolves after meal
Hard, mobile nodule
- Either size 4 occlusal film
- or Panoramic film
salivary flow obstruction due to a sialolith
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What kind of radiographic imaging should be prescribed for a patient:
Persistent, unilateral swelling of 3 years duration by the left angle of the jaw
Swelling enlarges at mealtime but never fully resolves afterward
Panoramic
Case 2: salivary flow obstruction secondary to a sialolith
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What kind of radiographic imaging should be prescribed for a patient:
Intermitent, unilateral, right cheek swelling of 1 week duration.
Swelling enlarges at mealtime but never fully resolves afterward.
No significant clinical findings
- Panoramic: but the image shows nothing significant.
- Not all salivary stones are calcified. Mucous plugs
Case3: the pt must be sent for a CBCT sialogram. The result, salivary flow obstruction due to small, non calcified, sialolith
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What kind of radiographic imaging should be prescribed for a patient:
several episodes of asymptomatic swelling of submandibular gland in the past year. Episodes resolve with antibiotics. Symptoms unrelated to mealtime
- Sialodochitis. This is a reactive infection of inflammatory cause.
- Occlusal and pano won't show nothing.
- A CBCT sialogram is indicated for the patient
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inflammation of the salivary duct:
Sialodochitis
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Recurrent pain and swelling of the right parotid gland
History of 2 similar episodes spaced 1 year apart and resolved with antibiotics
Both the ductal and the acinar gland are inflamed. Sialadenitis and sialodochitis are happening at the same time
Sialogram will reveal both obstructions on the duct and fibrosis areas on the acinar portion of the gland
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Dry eyes and dry mouth. Trouble expressing saliva from all major salivary gland
Left parotid sialogram will show a ''Fruit-laden" branchless tree. Patognomonic of Sjogren syndrome
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When you suspect a neoplasm or a tumor (malignant on benign) involving any of the salivary glands, what is the radiographic of choice
MRI
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Salivay gland imaging key points
- 1. Take occlusal and apnoramic films of patient whom you suspect to have salivary flow obstruction 1/2 the exposure time2. Chose film based on the anatomical area of your clinical findings
- 3. Refer when your films give negative findings.
- -Sialogram to rule out radiolucent, noncalcified sialoliths, sialadenitis and Sjogren Syndrome
- 4. Request MRI to rule out salivary gland neoplasm
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Ground glass appearance in the maxilla
Cotton wool appearance in the mandible
Caused by GNAS 1 mutation.
- Fibrous dysplasiaCan cause a superior displacement of the IAN canal.
- Can be monostotic, affecting only one bone Maxilla> Mandible
- Or polyostotic affecting 2+ like in McCune-Albright (cafe au late skin macules and endocrine problems) or in Jaffe-Lichtenstein (cafe au late skin macules)
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Usually seen in 30+ years old, African American, asymptomatic incidental finding.
Commonly found in mandubular anterior incisors.
Epicent is always on the root apex but the teeth are vital
- Cemento-osseous dysplasia: teeth are vital checked with the vitality test.
- Can be periapical -anterior teeth-
- focal -posterior mandible on edentilous areas
- floral -multiple quadrant involved as seen on panoramic- (this subtypes are not clinicaly important only for exam)
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Multiple, well defined radiopacities with radiolucent rims at the periapical level of the mandibular or maxillary ridge
Florid cemento-osseous dysplasia
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In which Bening fibrous osseous lesion an implant placement should be avoided?
In cemento-osseous dysplasia because it will mature into a sclerotic radiopaque (calcified) masses of cementum/bone with minimal to no blood supply
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True neoplasm (benign) of the bone that will continue to grow w/o treatment. Can centrally grow in the bone causing the expansion of it.
- Ossifying fibroma
- Small lesions can be similar to cemento-osseous lesion. Another x-ray should be taken in 6-12 month to compare and if it is showing signs of growing that confirm Ossifying fibroma diagnostic
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Autosomal dominant condition affecting the entire skeleton. Short stature, hypoplastic clavicles. Supernumeray teeth, retention of primary t, delayed eruption of permanent t, and increase in prevalence of Cleft Palate
Cleidocranial dysplasia
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Supernumeray teeth, osteomas and colon cancer
Garder Syndrome: multiple jaw bone osteomas on the angle of the jaw. Premalignat colon polyps that will transform into malignancy and may kill the patient if not diagnostic on time
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Autosomal dominant, impaired collagen maturation, opalescent teeth, history of fracture (fragile bone)
Osteogenesis imperfecta (Brittle bone disease)
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Autosomal dominant, bone marrow failure (hepatosplenomegaly) impairment of the osteoclastic function, increased bone density, delayed tooth eruption
- Osteopetrosis (marble bone disease) The inability to repair the bone after an extraction will lead to osteomielitis
- Can be infantile (severe) or adult (benign)
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Elevated serum alkaline phosphatase.
Generalized, very exuberant hypercementosis
Symmetrical cotton wool appearance
- Paget's disease of bone
- Progressive symmetric bilateral bone enlargement (my denture or my hat does not fit anymore)
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Key points to remember about polyostotic bone conditions
- Supernumerary teeth: cleidocranial dysplasia (clavicle) and Gardner syndrome (colon)
- Osteogenesis imperfecta (brittle bone disease): similar dendal findings as dentinogenesis imperfecta. Oppalescent teeth
- Osteopetrosis: osteomyellitis can be a consequence of extraction due to the minimal blood supply
- Progressive bone enlargment: common presentation of Paget disease of bone
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Progressive symmetric jaw enlargement.
Hypercementosis and cotton wool appearence
Elevated serum alkaline phosphatase
Paget's disease of bone
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Multilocular differential
- MACHO
- M- mixoma
- A- ameloblastoma
- C- central giant cell lesion
- H- hemangioma
- O- odontogenic keratocyst
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idiopathic increase bone formation leading to dense bone islands
- idiopatic osteosclerosis: enostosis. The cancellous bone starts to create more bone untill it becomes as dense as cortical
- completely homogeneous radiopaque, well defined, normal pdl space
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scallops around the roots; preserves lamina dura; usually seen on teenagers on the anterior mandible
- Simple bone cyst
- does not destroy bone. Can be seen in the presence of cemento-osseous dysplasia
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seen in pediatric patients. Expansile lesion centrally in bone. can be multilocular, purple hue due to vascularization
Central giant cell lesion
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plump cheeck pediatric patien. Symetric and bilateral
Cherubism
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rare pseudocyst. Painfull, rapid growth, expansion of posterior mandible
aneurismal bone cyst
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