AgingandDiseasesoftheSalivaryGlandsBiologyofSalivaryGlandsDomenicaG.SweierDDSJune4,2003銷售信

June4,20031SalivaFrustratingforthedentalteamyetnecessaryforthepatient!June4,20032WhenthereisnotEnoughToolittlesalivacansignificantlyalteraperson’squalityoflifeandthemorbidityassociatedwithmultiplesystemicconditionsHowlittleistoolittle?Whataffectsthequalityandquantityofsalivaproductionandflow?June4,20033June4,20034ObjectivevsSubjectiveObjectiveMajorglandsecretionsRestingflowratewithaCarlson-CrittendenCupMinorglandsecretionsWholesalivaStimulatedflowratewithcitricacid,waxSubjectiveComplaintsofdrymouth(xerostomia)QuestionnaireThirstThe“cracker”testJune4,20035XerostomiaCommonlyreferredtoas“drymouth”Diminishedsalivaryflowrate,typicallyacceptedasa50%decreaseintheclinicallydeterminedrateinhealthyindividualsnottakingmedicationsRestingFlowRate0.3-0.4ml/minStimulatedFlowRate1-2ml/minJune4,20036ClinicalSigns/SymptomsofXerostomiaDrynessofmucousmembranesTonguefissuringandlobulation(scrotaltongue)Angularcheilosis/cheilitisFungalinfectionsProsthesis-inducedstomatitisAmputationcariesThick,ropeysalivaDysphagiaDysgeusiaDifficultyeating/speaking/wearingprosthesisSwellingofthesalivaryglandsDifficultyexpressingsalivaCheekbitingPersistentneedforfluidsBurningtongueJune4,20037WhatContributestoXerostomia?AgingHormonalChanges/MenopauseDiseaseLocalSystemicEnvironmentalInsults/TraumaMedicationsJune4,20038AgingSalivaryQuantityinHealthNochangesinmajorsecretions(parotid,submandibular)NochangesinminorsecretionsSalivaryQualityinHealthNogeneralchangesinsalivaryconstituentsJune4,20039AgingIfthequalityandquantityofsalivadoesn’tchangewithage,thenwhataccountsfortheincreasedincidenceofxerostomiaandassociatedmorbidityamongtheelderly?Medications,diseases,andotherenvironmentalinsultsaffectboththequalityandquantityofsalivaAnincreaseinincidenceoftheseinsultsgenerallyassociatedwithanincreaseinageJune4,200310MenopauseAverageageofonsetofmenopauseinUSAis50yearsOralsymptomscommon,particularlyamongthosewithsystemiccomplaintsCross-sectionalandlongitudinalstudieshavefailedtoprovidesignificantandreproducibleevidencethatsalivaryflowisaffectedbymenopauseOralcomplaintsmostlikelytheresultofthetypesandnumbersofxerostomicmedicationstakenAnti-hypertensives,anti-depressants,andanti-histaminesarecommoninthisgroupJune4,200311Diseases/EnvironmentalFactorsDiseasesLocalSystemicEnvironmentalFactorsHeadandNeckRadiationChemotherapyMedicationsJune4,200312LocalDiseasesTumors/GrowthsBenignMalignantObstructiveDiseasesCalculi,mucusplugsUnusualanatomyInflammatoryDiseasesAcuteviralsialadenitisAcuteandrecurrentbacterialsialadenitisInflammation/InfectionsecondarytosystemicdiseaseJune4,200313Tumors/GrowthsPrimarybenignandmalignanttumorsDeterminewhetherbenignormalignantsincetheyaretreateddifferentlyIncisionalbiopsyfordefinitivediagnosisSmallertheinvolvedgland,morelikelymalignantMalignantSeekmedicalattentionforswellingunderthechinoraroundthejawbone,ifthefacebecomesnumb,facialmusclesdonotmove,orthereispersistentpainUsuallytreatedwithacombinationofsurgeryandradiationJune4,200314Obstruction:SialolithiasisCalculiformintheduct,blockingtheegressofsalivaMajorityinsubmandibularglandPainfulswellingwhichincreasesatmealtimeBi-manualpalpationinsubmandibularglandX-ray,sialography,CT,ultrasoundAnalgesics,trytopushstoneout,mayneedtodilateorificetoremoveJune4,200315SubmandibularCalculiJune4,200316UnusualAnatomyUnusualanatomyintheglandmanifestedasstricturesintheductsystemRecurrentobstructionwithassociatedpainandinflammationofglandsPoolingofsalivaleadingtosecondaryinfectionMayneedsurgerytoremoveaffectedareaofglandorentireglandJune4,200317Inflammation/Infection:ViralMumpsisthemostfrequentdiagnosisofacuteviralsialadenitisMemberoftheparamyxoviridaeMostlyinparotidTheincubationperiodis2-3weeksAcutepainfulswellingandenlargementFever,headache,lossofappetiteMostcommoninchildrenVeryeffectivevaccineJune4,200318Inflammation/Infection:BacterialTypesAcutesuppurativebacterialsialadenitisCommonlyS.aureus,S.viridans,H.influenzae,E.coliChronicrecurrentsialadenitisMaybesecondarytosometypeofobstructionorunusualanatomyMaybeduetoresistantorganism;culturetodetermineTreatmentAntibioticsandanalgesicsRehydrateandstimulatesalivaMayneedopendrainage/surgeryJune4,200319BacterialParotiditisJune4,200320SystemicDiseasesSj?gren’sSyndrome SarcoidosisCysticFibrosisDiabetesAlzheimer’sDiseaseAIDSGraftvsHostDiseaseDehydrationJune4,200321Sj?gren’sSyndromeAutoimmunedisorderaffectinglacrimalandsalivaryglandsXerostomiaandkeratoconjunctivitissiccaPrimaryandSecondarydiseaseThelatterassociatedwithanotherautoimmunedisordersuchasRA,SLE,etc.DenseinflammatoryinfiltratewithdestructionofglandulartissueTreatmentispalliativeJune4,200322SarcoidosisUnknowncause;believedtobealterationincellularimmunefunctionandinvolvementofsomeallergenAnyorganbutmostoftenthelungs;canaffecttheparotidglandGranulomatousinflammationMostoftendrugsofchoicearecorticosteroidsJune4,200323CysticFibrosisFaultytransportofsodiumandchloridefromwithincellslininglungsandpancreastotheiroutersurfaceCausesproductionofanabnormallythickstickymucusObstructionofpancreasleadstodigestiveproblems;inabilitytodigestandabsorbnutrientsGenehasbeenidentifiedandclonedNoknown“cure”thereforepalliativetreatmentJune4,200324DiabetesUncontrolledbloodglucoselevelsmaycontributetoxerostomiaMedicationsmayinducexerostomiaMaygetenlargementandinflammationofparotidglands(commoninendocrinediseases)Difficultytowardoffinfection:candidiasis,gingivitis,periodontitis,andcariesJune4,200325Alzheimer’sDiseaseAneurodegenerativedisorderleadingtoadecreaseincognitionandmobilityMayaffecttheneurologicalcomponenttosalivaryproductionand/orflowXerostomicmedicationsComplicatedbybehaviorwhichmakesitdifficulttomaintainahealthydentitionPoororalhygienePoorcooperationfordentalcareandtreatmentinaconventionalsettingJune4,200326AIDSHIV-AssociatedSalivaryGlandDisease(HIV-SGD)EnlargementofthemajorsalivaryglandsXerostomiaSomesimilaritiestoautoimmunediseasesHIVitselfnotconsistentlyfoundtobeinglandulartissueMedicationsJune4,200327GraftvsHostDisease(GVHD)ImmunecellsofanallogenictransplantattackrecipientAcute,<100days,andchronic>100daysMajorcauseofmorbidityandmortalityInitialpresentationasaredrashSalivaryglandinvolvementwithswellingandinflammationProgressesquicklytolife-threateningconditionTreatbyincreasingimmunosuppressionJune4,200328DehydrationDefinedasthelossofwaterandessentialbodysalts(electrolytes)neededforbodyfunctionSweating,diarrhea,emesis,bloodloss,etc.Symptomsincludeflushedface,dry,warmskin,fatigue,cramping,reducedamountofurineOralsigns/symptomsXerostomia,drytongueThick,stickysalivaDry,crackedlips(cheilosis)June4,200329HeadandNeckCancer:RadiationTherapyGoalistokillcancercellsMeasuredinGray(Gy)unitsofabsorbedradiation:1Gy=100cGy=100radsCanbeusedaloneorcombinedwithsurgeryand/orchemotherapyThreemainroutesExternalbeam(mostheadandneck)Brachytherapy(bodycavities)InterstitialJune4,200330RadiationDoseDependentontumortissue/typeAverageof200cGydailyfor5consecutivedayswithtwodaysofrestTotalcummulativedoserangesfrom5000cGyto8000cGyforadvancedtumorsThresholdofpermanentdestructionis2100-4000cGyJune4,200331TissueResponse25Gy:Bonemarrow,lymphocytes,GIepithelium,germinalcells25-50Gy:Oralepithelium,endotheliumofbloodcells,salivaryglands,growingboneandcartilage,collagenDoses>50Gy:boneandcartilage,skeletalmuscleJune4,200332TissueChangesIrradiatedtissuebecomeshypocellular,hypovascular,andhypoxicresultinginfibrosisandvascularocclusionThedestructionismostlypermanentIrradiatedtissuedoesnotre-vascularizewithtimeAsaresult,irradiatedtissuedoesnothealwellafterinjuryJune4,200333CommonSideEffects:SystemicNauseaVomitingNeutropeniaAlopeciaFatigueJune4,200334CommonSideEffects:OralMucositisandDermatitisDysphagiaDysgeusiaTrismusOsteo-andsofttissuenecrosisXerostomiaFungalinfectionsRadiationCariesJune4,200335Radiation:XerostomiaParotidglandismoresusceptiblethanthesubmandibularorsublingualglandsSeeaslightimprovementaftertherapybutwillsoonplateauatalowerlevelthanpre-therapyResultisthick,ropeysaliva,decreasedinamount,withmarkedlydiminishedlubricatingandprotectivequalitiesJune4,200336Radiation:MucositisTheoraleiptheliumwillgeta“sunburn”likeinflammationThiswillbeexacerbatedbythelackofthelubricatingpropertiesofsalivaTheresultwillbeared,irritated,drymucosaJune4,200337SalivaPost-RadiationJune4,200338MucositisJune4,200339RadiationCariesJune4,200340Prosthesis-InducedStomatitisJune4,200341FungalInfectionsJune4,200342ScrotalTongueJune4,200343ChemotherapyIsgivenorally,IV,byinjection(SQ,IM,IL),ortopicallyincyclesdependingonthetreatmentgoals(typeofcancer,howyourbodyresponds,howwellyoubodyrecovers,etc.)AffectsallrapidlydividingcellsManysideeffectsinallbodysystemsOralcomplicationsfromdirectdamagetooraltissuessecondarytochemotherapyandindirectdamageduetoregionalorsystemictoxicityFrequencyandseverityrelatedtosystemicimmunecompromise,i.e.myelosuppresionJune4,200344ChemotherapeuticsDrugscommonlyassociatedwithoralcomplicationsMethotrexateDoxorubicin5-Fluorouracil(5-FU)BusulfanBleomycinPlatinumcoordinationcomp