Case 4 – Mrs Brown’s Dry Mouth

Body In health

What is the composition of saliva?

What is normal salivary flow rate?

Unstimulated whole saliva flow rate in a normal person is between 0.3-0.4 per minute
(below 0.1ml per minute is significantly abnormal). A stimulated saliva flow rate less than
0.5ml in 5 minutes or less or less than 1ml per gland in 10 minutes is abnormal.

How is saliva produced?

What is the function of saliva?

 Lubrication
 Buffering pH action
 Antimicrobial properties
 Partial digestion of food
 Remineralisation properties

Where are the salivary glands located?

What are the main salivary glands in the body?

Body In disease

What are the causes of dry mouth?

 Systemic (Sjogren’s Syndrome, Diabetes, Rheumatoid Arthritis)

 Prodedures (chemotherapy and radiotherapy)
 Medications (antihypertensives, antidepressants, diurectics, antihistamines)
 Dehydration
 Salivary gland stones

What is the relationship between dental caries and dry mouth?

Patients with dry mouth are at higher risk of developing caries due to the loss of saliva and its
benefits. A loss of saliva increases the acidity of the mouth, which affects many factors that
contribute to the development of caries, such as increase of acid-producing bacteria, inability to
buffer the acid produced by the bacteria, loss of minerals from tooth surfaces and inability to
replenish the lost minerals, and loss of lubrication. 

What causes gross caries to occur in a short period of time?

What are differences between radiotherapy varies and bacterial caries?

 Both are bacterial induced

 Radiation tends to onset around 3 weeks after irradiation (as rampant caries)
 Radiation caries is linked xerostomia
 Radiation caries tend affect atypical areas of the teeth (e.g. lingual surface, incisal and cusp
tips)

Why has the dryness of the mouth increased after the radiotherapy?

What is the lump on the upper jaw?

Abscess

Ulcer

Oral Cancer

Salivary Duct Blockage (Sialolithiasis)

Cysts

Clinical signs of oral cancer

 Lesion may or may not be painful (dependent on the stage of the oral cancer)
 Lesion most likely will present of the lateral borders of the tongue or floor of the mouth
 Other locations included the buccal mucosa, retromolar area, gingiva, soft palate (less
frequent location include the back of the tongue and hard palate)
 Lesion lasts more than 3 weeks
 Well demarcated red and white areas with a slight roughness (in the early stages), soft tissue
may feel harder on palpation

Types of Oral Cancers

Squamous cell carcinoma: Normally, the throat and mouth are lined with so-called
squamous cells, which are flat and arranged in a scale-like way. Squamous cell carcinoma
means that some squamous cells are abnormal.

Verrucous carcinoma: A type of very slow-growing cancer made up of squamous cells.

Minor salivary gland carcinomas: This category includes several kinds of oral cancer that can
develop on the minor salivary glands, which are found throughout the lining of the mouth
 and throat. These types include adenoid cystic carcinoma, mucoepidermoid carcinoma, and
polymorphous low-grade adenocarcinoma.

Lymphomas: Oral cancers that develop in lymph tissue, which is part of the immune system,
are known as lymphomas. The tonsils and base of the tongue both contain lymphoid tissue.

Benign oral cavity and oropharyngeal tumors: Several types of non-cancerous tumors and
tumor-like conditions can arise in the oral cavity and oropharynx. Sometimes, these
conditions may develop into cancer. The types of benign lesions include:

Leukoplakia and erythroplakia: These non-cancerous conditions mean that there are certain
types of abnormal cells in the mouth or throat. With leukoplakia, a white area can be seen,
and with erythroplakia, there is a red area, flat or slightly raised, that often bleeds when
scraped. Both conditions may be precancerous; that is, they can develop into different types
of cancer. When these conditions occur, a biopsy or other test is done to determine whether
the cells are cancerous

Why does she find it difficult to wear her acrylic dentures?

Patients with dry mouth are at higher risk of developing caries due to the loss of saliva and its
benefits. A loss of saliva increases the acidity of the mouth, which affects many factors that
contribute to the development of caries, such as increase of acid-producing bacteria, inability to
buffer the acid produced by the bacteria, loss of minerals from tooth surfaces and inability to
replenish the lost minerals, and loss of lubrication. 

Procedures, treatments and professional concerns

What are the consequences of missing a check-up?

How does radiotherapy cause dry mouth?

What are the treatments for dry mouth?

Salivary Stimulants Salivary Substitutes

Sugar sweets or chewing gum
Pilocarpine – for xerostomia caused by
irradiation of the head/neck area and
Sjögren’s Syndrome
Salivix pastilles (localised salivary stimulants
can be used to treat any condition that
causes dry mouth)
Saliva Stimulating Tablets (SST) (Medac)
systemic salivary stimulant that be used to
treat dry mouth conditions
Water or ice cubes
Saliva Orthana (neutral pH substitute that has animal
derived ingredients) - can be used to treat any
condition that causes dry mouth
BioXtra (neutral pH substitute that has animal derived
ingredients) - can be used to treat any condition that
causes dry mouth
Glandosane (acidic substitute, that hasn’t got any
animal derived ingredients) - can be used to treat any
condition that causes dry mouth
What is radiotherapy?

Radiotherapy uses high-energy rays to treat disease. It can be given both externally and
internally.

 External radiotherapy aims high-energy x-rays at the affected area using a large
machine.
 Internal radiotherapy involves having radioactive material placed inside the body.

How does radiotherapy work?

How long do you have to wait before seeing a patient after radiotherapy?

What are the different types of dentures?

Complete Dentures: Complete dentures are made of a plastic base that is coloured in order
to replicate gum tissue and supports a full set of plastic or porcelain teeth. The traditional
full denture is held in the mouth by forming a seal with the gums.

Partial Dentures: Partial dentures can either be made with a plastic base or a metal
framework that supports the number of teeth that need to be replaced. It is held in the
mouth by using clasps and rests that are carefully adapted around the natural teeth.

Immediate Dentures: typically placed on the same day as teeth extracted

Implant supported/ Overdentures: implants drilled into the alveolar bone, are used to
support the denture

Skeleton Dentures

When would a partial acrylic denture be recommended?

 Missing teeth (but some teeth available to act as the abutment)

 Cheaper than implants
 Interim solution to more permanent solution
 Patients with severe periodontitis or excessive alveolar bone loss

What are the differences between prescribed high fluoride toothpaste and non-prescribed