Transcript Pharmacologically-Mediated Salivary Dysfunction and the

Pharmacologically-Mediated
Salivary Dysfunction and the
Pharmacologic Management of
Salivary Diseases
Biology of Salivary Glands
Domenica G. Sweier DDS
June 9, 2003
Pharmacologically-Mediated
Salivary Gland Dysfunction
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Oral Effects of Prescribed Drugs
RG Smith & AP Burtner, 1994
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Oral Manifestations of Systemic
Agents
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Abnormal hemostasis
Altered host resistance
Angioedema
Coated (black hairy)
tongue
Dry socket
Dysgeusia
Erythema multiforme
Gingival enlargement
 Leukopenia and
neutropenia
 Lichenoid lesions
 Movement disorders
 Soft-tissue reactions
 Salivary gland
enlargement
 Sialorrhea
 Xerostomia
ADA Guide to Dental Therapeutics, 1998
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Abnormal Hemostasis
 Interfere with platelet function
 Decrease prothrombin synthesis in the liver
 Require bleeding profile prior to dental
procedures
• Oral cavity very vascular, need to be sure
bleeding profile is conducive to invasive
treatment
 Examples include coumadin and aspirin
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Altered Host Resistance
 Results from alteration in normal oral microflora leading to
an overgrowth of organisms found as normal oral flora
 Eliminate or replace drug, if possible, and administer
antifungal agents if candidiasis has developed
 Caused by broad-spectrum antibiotics, corticosteroids,
cancer chemotherapeutics, among others
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Angioedema
 Drug induced hypersensitivity involving mucosal
and submucosal layers of upper GI tract
 Mild cases treated with antihistamines
 Severe cases may be life threatening when the
airway is compromised; emergency treatment to
restore airway
 Has been reported with use of ACE inhibitors,
midazolam, ketoconazole
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Coated Tongue
 The most common is Black Hairy Tongue
• Usually black, may be shades of brown
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Hypertrophy of filiform papillae
Mechanism unknown
Asymptomatic
No treatment indicated
Examples include clonazepam,
ketoprofen, tetracycline
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Dry Socket
 Alveolar Osteitis
 Lysis of blood clot prior to it being replaced
by granulation tissue
 Higher incidence in those who smoke and
females using BCPs
 Preventative and palliative treatment
• Do surgery in days 23-28 of BCP cycle
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Dysgeusia
 Taste alteration, medication or metallic taste,
changes and distate for food
 Exact mechanism unknown; however, may be
interaction of medication with trace metal ions
which interact with cell membranes of taste pores
• May have other causes, imperative to confirm it is drug
induced
 No treatment
 Examples include iron, metronidazole
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Erythema Multiforme
 May be immunologic reaction mediated by deposition of An-Ab
complexes in tissues
 Symmetrical mucocutaneous lesions with a predilection for oral
mucosa, hands and feet
• Tongue and lips most involved
 Initial presentation as erythema with vesicles and erosions developing
within hours.
 Normally self-limiting
 Oral lesions heal without scars
 Examples include clindamycin and pentobarbital
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Gingival Enlargement
 Clinically appears as a diffuse swelling of
interdental papillae which coalesces into a nodular
topography
 Theory of direct affect of drug or metabolite on
fibroblast which produces proteins and collagen
 Oral hygiene, mouth breathing, and crowded teeth
may exacerbate condition
 Examples include dilantin, cyclosporin
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Leukopenia and Neutropenia
 Alteration of a person’s hematopoietic status
 Manifested by increased infections, ulcerations,
nonspecific inflammation, bleeding gingiva and
increased bleeding after a dental procedure
 Replace or remove drug if possible
 Examples include chloramphenicol and quinine
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Lichenoid Lesions
 Buccal mucosa and lateral border of tongue most
often
 Wickham’s striae
 Pain after ulcerations develop
 Differ from Lichen Planus in that the drug induced
lesions disappear after the drug is removed
 Examples include furosemide and methyldopa
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Movement Disorders
 Neuroleptic drugs affect muscles of facial
expression and mastication
 Once developed, hard to control and is irreversible
 Difficult to eat, communicate, and wear prostheses
 Movements include:
• Pseudoparkinsonism-rigidity, tremor
• Akathesia-restlessness
• Tardive dyskinesia-repetitive, involuntary
 Examples include thorazine and levodopa
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Soft Tissue Reactions
 Include discoloration, ulcerations, stomatitis,
glossitis, and pigmentation
 A variety of mechanisms
 Examples include
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Coumadin-ulcerations
Accutane-glossitis
Meprobamate-stomatitis
Minocycline-discoloration
Mercury-pigmentation
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Salivary Gland Involvement
 Appear as salivary gland swelling and pain,
may mimic mumps
 Differential diagnosis includes more serious
conditions, accurate diagnosis important
 Mechanism unknown
 Treat by removing or replacing drug, if
possible
 Examples include methyldopa and lithium
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Sialorrhea
 An increase in salivation
 An increase in cholinergic stimulation by
direct stimulation of parasympathetic
receptors
• Example: pilocarpine HCl
 An inhibition of cholinesterase
• Example: neostigmine
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Xerostomia
 May be a result of another
condition, must determine
cause
 Often reported side effect
of many drugs
 Increased reported effect
with prolonged use of
drugs and when multiple
drugs are used
 Most often in elderly
where there is an increase
in drug use
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Xerostomic Medications
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Anticholinergics
Antihistamines
Antidepressants, antipsychotics
Sedative and hypnotic agents
Antihypertensives
Antiparkinson agents
Problem:
• While xerostomia is often listed as a side effect, few
clinical trials and studies have definitively established
this relationship and/or investigated the mechanisms
Sreebny and Schwartz, Gerodontology 1997
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Given the many drugs that can
induce salivary gland
hypofunction, manifested as
xerostomia, and the variety of
other causes for this condition, it
is imperative that a differential
diagnosis be formulated and an
accurate cause be determined
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Pharmacologic Management of
Salivary Diseases
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Salivary Gland Diseases
 Aging
 Medications
 Obstructions
• Neoplasms
• Foreign body
 Diseases
• Local
• Systemic
 Head and Neck Radiation
 Chemotherapy
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In General
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Encourage patient to visit the dentist regularly
Address problems when they first appear
Encourage meticulous oral hygiene
Encourage the patient to stay well-nourished and
well-hydrated
 Keep an updated list of all medications the patient
is taking (Rx, OTC, regularly or not)
 Update the medical history often
 Keep in communication with physicians and other
health care providers, consult when needed
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Oral Hygiene
 Rinse/wipe oral cavity
and associated
structures after every
meal
 Rinse/wipe any
removable prosthesis
• Denture brush
• Remove at night and
between meals
• Anti-fungal soak
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 Mechanical plaque
removal
• Soft toothbrushes
• Moist gauze
• Toothettes good for
soft tissue cleansing
• Use mild toothpaste
and avoid alcoholcontaining products
 Interdental Aids
• Floss
• Proxy brush
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Treatment Modalities: Outline
 Medication-induced
xerostomia
 Pain/Inflammation
• Stomatitis
• Mucositis
 Infection
• Bacterial
• Fungal
• Viral
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 Hyposalivation
 Caries
 Special Cases
• Head and Neck
Radiation
• Chemotherapy
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Medication-Induced Xerostomia
 Associated more with certain types of medications
 Incidence increases with prolonged use and
polypharmacy
• Increased incidence among elderly
 Use of medications and more of them simultaneously:
prescription and OTC
 Treatment
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Replace medication
Alter dose
Alter administration times
Treat xerostomia and associated symptoms
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Pain and Inflammation
 Rinses
 Coating Agents
 Analgesics
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Pain/Inflammation: Rinses
 Goals
• Cleanse
• Moisturize
• Lubricate
 Preparations
• Salt and soda (1/2 tsp each in 8 oz warm water) every 2
hours
• Salt or soda (1 tsp one or other in 8 oz warm water)
every 2 hours
• Hydrogen peroxide diluted 1:1 in water or saline; 1-2
days maximum
 Particularly useful to debride ulcerated/crusted area
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Pain/Inflammation:
Coating Agents
 Goals
• Sustained moisturizing and lubricating
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Water soluble lubricating jelly
Diclonine hydrochloride 0.5-1.0%
Carbamide peroxide 10%
Home preps
 Milk of magnesia
 Kaolin with pectin suspension
 Avoid preparations containing glycerin
• Hygroscopic
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Pain/Inflammation: Analgesics
 Topical Analgesics
• Lidocaine 2% viscous
• Benadryl 12.5mg/5ml kaopectate
• Capsiacin*
 Systemic Analgesics
• Ibuprofen
• Opioids
 Be aware of agents that cause GI distress and alter
hemostasis
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Infection
 Antifungals
• Nystatin 100,000
units/ml
• Clotrimazole troches
10mg
• When a removable
prosthesis is worn, be
sure to treat is as well:
dilute bleach solution
works well
 Steroids
• Kenalog in Orabase
0.5%
• Temovate 0.05%
 Antibiotics
• Penicillin,
clindamycin,
amoxicillin,
cephalosporins
 Culture resistant
organisms
• Chlorhexidine
gluconate 0.12%
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Caries
 Amputation Caries
 Prevention
• Chlorhexidine gluconate
0.12%
• Fluorides as rinse or applied
via custom trays
 Stannous fluoride gel
0.4%
 Sodium fluoride gel 1.0%,
1.1%
 Act, Fluorigard rinse OTC
fluoride
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• Circumferential decay at or
below the CEJ
compromising the integrity
of the tooth
 Treatment
• Restore with amalgam or
fluoride-containing and leaching glass ionomers and
other restoratives
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Hyposalivation: Substitutes
 Large Selection
• Mouthwashes,
toothpastes,
moisturizers, gums
 Poor patient
acceptance
• Feels like someone
else’s saliva
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 “Home” Remedy Best
Tolerated
• Frequents sips of water
• Ice Chips
 Avoid larger ice cubes
since the larger surface
may actually stick to the
dry mucosa
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OTC Saliva Substitutes
Common OTC Saliva Substitutes
Product
Comments
Entertainer’s Secret
60 ml spray
Glandosane
Preservative- free? 50 ml spray
Unflavored, lemon, mint
Moi-Stir Swabsticks
Packets of three
Mouthkote
5, 60, 240 ml solution Citrus
flavor
Optimoist
60, 355 ml spray Fluoride
Oralbalance, biotène
Preservative-free? Gel Unflavored
Salive Substitute (Roxane)
Preservative-free 5, 120 ml vials
Salivart
Preservative-free 25, 75 ml spray
Unflavored
Salix
100 count lozenges
Sodium carboxymethyl cellulose
0.5% solution, 8 oz rinse
Sterile Water
Sip as needed
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Saliva Subs: Constituents
 Proteins
• Lactoferrin
 Coating Agents
• Carboxymethyl
cellulose
 Preservatives
• Preferably none
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 Enzymes
• Lactoperoxidase
• Glucose Oxidase
• Lysozyme
 Flavorings
• Mint
• Citrus
• None
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Hyposalivation: Stimulation
 Gustatory
• Sugarless hard candies
• Avoid citric candies
since they may irritate
mucositis and promote
acidic destruction of
tooth structure
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 Mechanical
• Sugarless chewing
gums
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Hyposalivation: Pharmacologic
Stimulation
Salagen®
 Pilocarpine HCl
 5mg tablets, one three
to four times daily
 Titrate up to two tablets
per dose, not to exceed
30mg daily dose
 Muscarinic agonist
 Targeted for Sjögren’s
Syndrome
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Evoxac
TM
 Cevimeline HCL
 30mg taken three times
per day
 Insufficient evidence
for higher or more
frequent dosing
 Muscarinic agonist
 Targeted for Sjögren’s
Syndrome
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Special Cases
 Head and Neck Radiation
 Chemotherapy
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Radiation: Pre-Therapy
 Referral from Physician for consult
 Thorough Medical history including
medications
 Obtain plan of (surgery and) radiation
including field(s), amount, duration
 Complete dental exam, x-rays, and
treatment planning
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Radiation: Dental Treatment
 Complete all invasive treatment 10-14 days prior
to radiation
 When in doubt  extract
 Fabricate fluoride trays, provide Rx
• Use cotton-tipped applicators if needed
 Instruction on diet, hydration, oral hygiene
 Instruct on exercises using tongue depressors
 Educate on signs/symptoms of disease
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Radiation: During
 Weekly checks
 Monitor oral hygiene
• Reinforce techniques
 Monitor muscle
trismus
 Monitor salivary flow
• Salivary substitutes
• Salivary stimulation
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 Address problems at
first sign
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Mucositis/stomatitis
Candidiasis
Cheilosis/cheilitis
Caries
 Supportive
• Encouragement
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Radiation: After
 Place Patient on 3
month recall or less
 Avoid any invasive
therapy if at all
possible
• Tissues will not heal as
quickly
• Wait at least 6 mos
prior to construction
removable prosthesis
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 Continue
• Fluoride trays
• Supportive salivary
therapy
• Monitor for fungal
infections
• Monitor for bacterial
infections
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Chemotherapy: Pre-Therapy
 Referral from Physician for consult
 Thorough Medical history including medications
 Obtain plan of therapy, which drugs, amount,
duration
• Determine timing of myelosuppresion
 Complete dental exam, x-rays, and treatment
planning
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Chemotherapy:
Dental Treatment
 Complete all invasive treatment 10-14 days
prior to chemotherapy
 Avoid periodontal and endodontic surgery
• Any surgery with active soft tissue disease-extract
 Fabricate fluoride trays, provide Rx
 Instruction on diet, hydration, oral hygiene
 Educate on signs/symptoms of disease
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Chemotherapy: During
 Weekly checks
 Monitor oral hygiene
• Reinforce techniques
 Monitor
myelosuppresion
 Monitor salivary flow
• Salivary substitutes
• Salivary stimulation
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 Address problems at
first sign
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Mucositis/stomatitis
Candidiases
Cheilosis/cheilitis
Caries
 Supportive
• Encouragement
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Chemotherapy: After
 Allow tissues to heal when chemotherapy
completed
• This varies with the drug(s) used
 May return to pre-chemotherapy recall
interval
 Treatment plan and provide dental treatment
per pre-chemotherapy
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Summary
 PharmacologicallyMediated Salivary
Dysfunction
• Many medications
affect the oral cavity,
salivary function
specifically
• Xerostomia
• Seen mostly in elderly
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 Pharmacologic
Management of
Salivary Disease
• Much morbidity
affecting quality of life
seen in salivary
dysfunction/disease
• Review techniques to
manage the morbidity
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