Oral Health for Vasculitis Patients

On Saturday, October 23rd, 2010, Dr. Thomas W. Mara, Chair for the Division of Oral Medicine and Radiology at the University of Western Ontario, delivered a presentation on oral health in Vasculitis patients.

Dr. Mara started his university education at the University of Western Ontario in London, receiving an HBSc in biochemistry in 1973.  The same year he was accepted into dental school graduating in 1977. He was in private practice in London from 1977 until 1988 as well as teaching part time at the school.  In 1988 he started a 3 year residency in oral pathology/medicine as well as an MSc, finishing in 1991.  Since then he has been at the dental school, the last 10 years as Chairman.  The Division is responsible for instruction in Oral Diagnosis, Oral Medicine and Oral Radiology.  It is closely associated with other areas such as Oral Pathology, General Medicine for dental students, Applied Psychology for Dentistry, and Forensic Dentistry. The diverse nature of the Division is reflected in the background of its faculty and the research each pursues.

Of particular interest to the audience was his discussion of Dry Mouth also known as Xerostomia.   Below are the highlights of his presentation.

XEROSTOMIA (Dry Mouth)

Abnormal reduction in Saliva

-Physiologic
-Adverse effect of medication
-Symptom of certain diseases
-Associated with psychological factors

Subjective, may be associated with normal flow rates

Saliva Consists of:

-Fluid Component
-Bicarbonate and phosphate buffers
-Minerals
-Ions
-Protein component
-Glycoproteins, mucoproteins
-IgA, IgG, IgM
-Lysozyme, lactoperoxidase
-Coagulation factors

Average person makes 1 litre, (with ranges of 240-1375 ml) of saliva/day or 81 gallons/year

Flow rates vary depending on demand or physiologic status of person

-Resting/unstimulated-0.3 ml/min
-Sleep-0.1 ml/min
-Eating/chewing-4-5 ml/min

Saliva is essential or oral health

-Lubrication
-Eases passage of food over oral tissues
-Reduces friction of tooth to tooth contact
-Physical protection of oral tissues
-Hydration of Teeth
-Allows remineralization
-Decreases staining
-Mechanical cleaning of food and bacteria
-Dilution of bacterial products
-Buffering of acidic bacteria products
-Antimicrobial actions
-Lysozyme, lactoperoxidase
-Globulins
-Solvent for taste molecules
-Important for intraoral would healing

Effects of Persistent Xerostomia

-Mucosal soreness
-Increase in intraoral ulcerations
-Burning/depapillation/fissuring of tongue
-Dry, cracked lips
-Oral mucosa pale & dry
-Difficulty eating and swallowing (Dysphagia)
-Loss of taste (Dysgeusia)
-Salivary gland infections and/or enlargement

Etiology of Xerostomia

-Drugs (commonest cause)
-50% of adult population takes 1 prescription drug
-7% take 5
-81% females older than 65 take 2
-500 commonly prescribed drugs
-Tricyclic antidepressants, antipsychotics, benzodiazapines, diuretics,  b blockers, antihistamines etc.
-Damage to salivary glands (Rare)
-Therapeutic radiation
-Chemotherapy **
-Xerostomia fourth most common symptom
-May make saliva thick
-Effect ends with end of chemo
-Surgery to salivary glands
-Diseases of salivary glands
- Sjögren's Syndrome, sarcoidosis, PBC
-HIV
-Autoimmune disease
-Ectodermal dysplasia

Management of Xerostomia

Preventive

Oral Hygiene
-Plaque control, OHI, dietary advice
-Fluoride: Gelkam, Prevident 5a000 plus and booster, rinses, trays*
-Chlorhexidine rinses (Peridex) 0.12%
-Regular frequent recalls

Dentures
-Well adapted, implant retained, OH for dentures, reservoirs for salivary substitutes

Candidiasis
-May lead to burning mouth, long term nystatin

Drug induced

-Need accurate drug log with doses, time of administration etc.
-Change in dose schedule
-Split into smaller more frequent doses
-Change in time of dose
-Substitution of drug
-Removal of drug

Symptomatic treatment

Topical agents

-Sip room-temperature water throughout the day
-Salivary substitutes, short action, lack protection but increase lubrications and hydration of oral tissues
-Sugarless drinks & watch carbonated beverages
-Watch intake of caffeine
-Sugar free candies and gum may increase saliva output
-Special products, gels, mouth rinses, lozenges and tooth paste (Biotene)
-Smoking & alcoholic beverages will dry out your mouth
-If you use a mouth rinse chose an alcohol free product
-Use a room humidifier to moisten your room air

Systemic treatment

-Pilocarpine 5 mg qid or 10 mg tid: Salagen

-Increases secretion by exocrine glands, within 15 minutes
-Muscarinergic cholinergic agonist

-Increases secretion of all exocrine glands
-Sweat, lacrimal, gastric, pancreatic & intestinal glands, mucous cells of respiratory tract

-Sialor
For patients with mild hypofunction

The Vasculitis Foundation Canada would like to thank Dr. Mara for attending and giving such an informative presentation on issues affecting many of the members.

Sharon Janushewski
Secretary
Vasculitis Foundation Canada