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Case 2: Xerostomia

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John Tankersley

on 28 August 2014

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Transcript of Case 2: Xerostomia

Alternatives for Managing Dry Mouth
Mild Case
5. How many different tooth wear processes are occurring?
List them and their most frequent causes.
Profile: Mrs. Greenacre has been a patient of the practice for 30 years. She is in her late 70's and has most of her own teeth, but does wear a RPD. She enjoys dental visits and chatting with Gabby, the receptionist.
Health History: Chief complaint - dry mouth, some teeth occasionally sensitive, especially close to denture.
Medical History: Complicated with incontinence, type 2 diabetes, frequent asthma attacks, hypertension and depression medication.
Dental History: Noticeable wear facets on occlusal surfaces of some teeth, wedge shaped lesions on facial and lingual surfaces, dentin exposed in some areas, sticky oral mucosa with matte appearance, tongue fissured, butterfly shaped rash on face (across cheeks and bridge of nose), eyes reddened with very dry granular or gritty accumulation in corners (keratoconjunctivitis), and non productive cough.
Dental Caries
How to manage tooth sensitivity and protect teeth
and oral cavity from further damage?

Biotene mouth rinse
Sugarless gum with xylitol
Oral moisturizers
Sip water (2,3)

-Attrition: Tooth against tooth friction. Examples would be clenching or grinding
Use of fluoridated dentifrice
-mouth rinses
-fluoride varnish
Severe Case
Prescription Salagen (4)
Prescription Evoxac (5)

Medical History
Effects on Oral Health
- Sign of Diabetes, could result from Microvascular damage. (AA)
Type 2 Diabetes - Increases dry mouth and risks of periodontitits and caries (BB)
Asthma - medication includes: an anticholinergic which could increase dry mouth and a bronchodilator. (CC)
Hypertension - could result in cardiovascular event from procedural stress or epinephrine exposure. Medications can cause dry mouth (DD)
Depression medication - Can cause Xerostomia, Bruxism, gingivitis, glossitis, and sialadenitis. (EE)
-Abrasion: Wear/tear on the tooth from biting on hard objects, brushing too hard, etc.
-Erosion: Chemically related to acidic content and/or acidic environments (1)
Erosion is defined as partial demineralization of enamel or dentine by intrinsic or extrinsic acids (6).
Dental Erosion
Medical Prognosis and Recommendations
-Attrition: Tooth against tooth friction. Examples would include clenching or grinding
-Mrs. Greenacre's Medical History:
-Type 2 Diabetes
-Asthma Attacks
Lupus Erythematosus
Autoimmune disorder without a cure
Unpredictable course of disease with flares followed by periods of remission
Mainly affects the heart, lungs, skin, joints and nervous system
Health effects include heart attacks, strokes, seizures and organ failure
90% of individuals live more than 10 years after being diagnosed [7]
-Mrs. Greenacre's Dental History
-Notable wear facets on occlusal surfaces
-Small, removable, partial denture
-Wedge shaped lesions on facial surfaces
-Exposed dentin on many sites

Medical Conditions
Cancer - Damage to salivary glands (ex. Radiation or Chemotherapy) - Direct (CC)
Sjogren's Syndrome - Neither
Alzheimer's Disease - Indirect (GG)
Stroke - Indirect (GG)
Dehydration - Neither
Sarcoidosis & Amyloidosis - Indirect (GG)
Asthma - Direct (FF)
Depression - Direct (BB)
Hypertension - Direct (HH)
Diabetes Type 2 - Indirect (DD)
-Abfraction: Stress marks on the tooth from flexing or bending
Biological roles of Saliva
Minimizes contact of acids to tooth
Acts as a buffer and diluting agent
Contains water, mucins, PRP, glycoproteins
Pellicle formation
Dentin Exposed

Areas of the body affected by Lupus
Recap: What is Dentin?
Sjögren's Syndrome
-Notable wear facets on occlusal surfaces
-Abrasion: Wear/tear on the tooth from biting on hard objects, brushing too hard, etc.
-Small, removable, partial denture

-mouth guard
-dental sealants to prevent future cavities
-saliva substitutes
-Abfraction: Stress marks on the tooth from flexing or bending
-Wedge shaped lesions on facial surfaces
-Erosion: Chemically related to acidic content and/or acidic environments
-Exposed dentin on many sites
AA. Brown, J. S. (2006). Prevalence And Risk Factors For Urinary Incontinence In Women With Type 2 Diabetes And Impaired Fasting Glucose: Findings From The National Health And Nutrition Examination Survey (NHANES) 2001-2002 . Diabetes Care, 29(6), 1307-1312.
BB. Oral Health Fact Sheet for Dental Professionals. (n.d.). Washington Department of Health. Retrieved August 23, 2013, from depts.washington.edu/sodent2/wordpress/wp-content/media/sp_need_pdfs/Depression-Adult.pdf
CC. Sandberg, G. E., Sundberg, H. E., Fjellstrom, C. A., & Wikblad, K. F. (2000). Type 2 diabetes and oral health A comparison between diabetic and non-diabetic subjects. Diabetes Research and Clinical Practice, 50, 27-34.
DD. Soell, M., Hassan, M., Miliauskaite, A., Haïkel, Y., & Selimovic, D. (2007). The Oral Cavity Of Elderly Patients In Diabetes. Diabetes & Metabolism, 33, S10-S18.
EE. Standaert, D. G., Lee, V. M., Greenberg, B. D., Lowery, D. E., & Trojanowski, J. Q. (1991). Molecular Features of Hypothalamic Plaques in Alzheimer's Disease. American Journal of Pathology, 139(No. 3). Retrieved August 26, 2013, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1886221/
FF. Turner, M. D., & Ship, J. A. (2007). Dry mouth and its effects on the oral health of elderly people. The Journal of the American Dental Association, 138, 15S - 20S.
GG. Witt, R. L. (2005). Salivary gland diseases: surgical and medical management. New York: Thieme.
HH. The Hypertensive Patient. (n.d.). Oral Health Journal - Canada's Leading Dental Journal. Retrieved August 27, 2013, from http://www.oralhealthgroup.com/news/the-hypertensive-patient/1000880285/
(1): http://www.webmd.com/oral-health/guide/tooth-enamel-erosion-restoration
(2): GS Chandu, MN Hombesh. Management of Xerostomia and Hyposalivation in Complete Denture Patients. Indian J Stomatol 2011; 2(4): 263-66.
(3): http://www.sjogrens.org/home/about-sjogrens-syndrome/symptoms/dry-mouth
(4): Vivino FB, Al-Hashimi I, Khan Z, et al. Pilocarpine Tablets for the Treatment of Dry Mouth and Dry Eye Symptoms in Patients With Sjögren Syndrome: A Randomized, Placebo-Controlled, Fixed-Dose, Multicenter Trial. Arch Intern Med. 1999;159(2):174-181. doi:10.1001/archinte.159.2.174.
(5): Fife RS, Chase WF, Dore RK, et al. Cevimeline for the Treatment of Xerostomia in Patients With Sjögren Syndrome: A Randomized Trial. Arch Intern Med. 2002;162(11):1293-1300. doi:10.1001/archinte.162.11.1293.
(6). 1. Zwier, N. Saliva Parameters and Erosive Wear in Adolescents. Caries Research. College of Dental Sciences, Radboud University Nijmegen Medical Centre. 2013. June 15. Pg 1-5.
7)^ "Prognosis and a Hopeful Future". Lupus Foundation of America website. Retrieved 14 December 2010.
8) National Institue of Neurological Disorders and Strokes. http://www.ninds.nih.gov/disorders/sjogrens/sjogrens.htm. accessed august 28, 2013.
9)Type 2 diabetes. Medline plus. National Institute of Health. http://www.nlm.nih.gov/medlineplus/ency/article/000313.htm
10) Grunow. J. Weber State University. http://webcache.googleusercontent.com/search?q=cache:0kkijnMUqEcJ:faculty.weber.edu/jgrunow/documents/sympathetic%2520-%2520parasympathetic%2520lecture%2520outline.rtf+&cd=3&hl=en&ct=clnk&gl=us&client=firefox-a
11)ADA (2007, September). Dry mouth and ts effects on the oral health of elderly people. Retrieved August 28, 2013, from http://jada.ada.org/content/138/suppl_1/15S.long#ref-29
12.)Jones, J. A. (2011). Dentin hypersensitivity: Etiology, risk factors, and prevention strategies. Dentistry Today, 14(45). Retrieved from http://www.dentistrytoday.com/articles-hygiene/6454-dentin-hypersensitivity-etiology-risk-factors-and-prevention-strategies
13.)Sensodyne (2013). About sensitivity. Retrieved August 28, 2013, from us.sensodyne.com/about-sensitivity.aspx
14. )WebMD (2013). Dry mouth causes and treatments. Retrieved August 28, 2013, from http://www.webmd.com/oral-health/guide/dental-health-dry-mouth
15.Journal of Conservative Dentistry (2010). Dentin hypersensitivity: Recent trends in management. Journal of Conservative Dentistry, 4(13). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3010026/
16. )Ferreira, Joao. Interactions between developing nerves and salivary glands. Landes Bioscience.Oranogenesis 9:3, 152-158; July 2013
17. )Ned Tijdschr Tandheelkd. Saliva and Dentures. 1992 Mar;99(3):97-9.
Sjögren’s Syndrome
Butterfly Rash is a hallmark sign of Lupus
Possible secondary diagnosis of Sjogren's Syndrome
Dry mouth may increase incidence of caries
Glycoproteins and mucins in pellicle protect the tissue from injury caused by the base of the denture (17).
Retention of dentures dependent on saliva layer (17).


How is
Case 2: Xerostomia Clinical Application
Group 12
Rubi Perez
Jose Gonzales
Michael Chilton

Jonathan Tankersley
Megan Bender
Courtney Kiel

Saliva secretion is controlled by both the sympathetic and parasympathetic nervous systems
Saliva is secreted from major and minor salivary glands
Facial nerve (VII) innervates the sublingual and submandibular glands
Glossopharyngeal nerve (IX) innervates the parotid gland
ACh stimulates an increase in NaCl and water into the acinar cells
NA stimulates an increase in proteins in the acinar cells.
Water and proteins are pushed through the striated duct
A systemic autoimmune disease in which immune cells attack and destroy the exocrine glands that produce tears and saliva
There is not a cure for individuals with Sjögren's
Treatment is symptomatic
There currently is not a treatment that will reverse the keratoconjunctivitis or xerostomia
Damages organs of the body then, like Lupus Erythamatosus, may go into remission for a period of time before returning
Associated with increased risk of B-cell lymphoma.
Patients who have primary Sjögren's syndrome can expect to have a normal life expectancy. However, there is an increased mortality rate for secondary Sjögren's mainly due to associated disorders such as Lupus Erythematosus [8]
Type 2 Diabetes
Body doesn't use insulin properly "insulin resistance"
Life-long disease in which individual has elevated blood sugar
Main treatment is diet and exercising
Risk of heart attack is the same as an individual who has already had a heart attack
I would suggest that Mrs. Greenacre manage her weight, diet, and blood pressure in order to decrease her risk of heart attack stroke, and death [9]
Unfortunately, the medical prognosis for Mrs. Greenacre is poor. The three diseases I mentioned earlier do not have a cure and will affect her throughout the rest of her life. Individually, each of these diseases is manageable and she could expect to have a relatively normal life expectancy. However, I believe that Mrs. Greenacre has an incredibly high risk of having a heart attack. Sjogren's, Lupus, and Diabetes have a common health risk of heart attacks. Furthermore, she is affected by many diseases including depression, hypertension, asthma, and incontinence. Due to the volume of medications she is taking it is likely that her Xerostomia will be exacerbated. Each individual ailment seems to affect the next. For example, the incontinence most likely makes her very self-conscience which could increase the severity of depression and hypertension. The increased hypertension puts her at an even greater risk for heart attack.
Medical Recommendation
Enjoy life. In her late 70's and afflicted with so many ailments, I think her best option would be to increase her happiness by any means as long as her health allows. Perhaps vacationing will minimize her depression and indirectly or directly reduce the hypertension.
As mentioned before, I suggest watching her weight, blood pressure, and diet. Keeping control of these things will be key to her increasing her life span.
Finally, I'd suggest that she meet with her doctor and review the medication she is taking for the different ailments. A drug to alleviate one symptom may aggravate another. For example, a drug that functions to increase salivation in the mouth would stimulate the parasympathetic nervous system. Stimulation of the parasympathetic nervous system will also lead to bronchial constriction and perhaps induce one of Mrs. Greenacres asthma attacks.
Dentin is composed of microscopic channels known as dentinal tubules which transmit pain stimuli. This tubules radiate from the pulp outward through the dentin to the exterior cementum or enamel border.

Dentin is covered by a smear layer of 70% inorganic matter (calcium and phosphorus predominately) and 30% organic matter.
Removal of this material and exposure to the dentinal tubules will induce hypersensitivity. (12)

-Sensodyne/ Crest Sensitive toothpaste
-Sensodyne Pronamel toothpaste
-Fluoride therapy (14)
-Use a soft-bristled toothbrush
-Use night guard to avoid grinding teeth (11)
Majority of the toothpastes contain potassium salts. Potassium salts act by diffusion along the dentinal tubules and decreasing the excitability of the intradental nerve fibers by blocking the axonic action. (15)
Brännström's hydrodynamic theory :
The hypersensitivity of dentin is based on that stimuli create a pressure change or disturbance within the fluid that fills the dentinal tubules. The movement of the fluid in the open tubules is then transmitted to the nerve fibers in the pulp-dentine complex.

Heat, cold, air, and pressure may cause this rapid movement of fluid in open dentin tubules.

Cold stimuli will cause the fluid in the tubules to contract while heat stimuli will expand the fluid, which cause a notable pressure change within the tubule (12)
Why Should a dentist be concerned?
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