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*For medical professionals only
The first part of the ACR conference is still hot~
The American College of Rheumatology Annual Meeting (ACR) is the world's premier annual academic meeting, which brings together the latest research results
in rheumatology.
At the ACR 2022 Annual Meeting, three professors from the United States and Canada presented "Preventionand, Diagnosis, Management.
"
The lecture of Dry Mouth Complications summarizes the key points
of prevention, diagnosis, treatment and management of xerostomia.
1.
Xerostomia prevention
Changes in saliva quality and quantity lead to xerostomia
.
Although dry mouth symptoms are common in the general population, they are usually more severe in people with Sjogren's syndrome, resulting in increased difficulty chewing and swallowing dry foods, altered sense of taste, and difficulty speaking
for long periods of time.
Decreased saliva function will further lead to decreased saliva flow, dry oral mucosa, erythema, increased infection, loss of remineralization, decreased lubrication, salivary gland infection, Complications
such as swelling, candidiasis, periodontal disease, dental caries, speech, difficulty swallowing.
Despite complaints of dry mouth, many patients have normal oral examination due to residual saliva flow
.
Figure 1: Dry oral mucosa/erythema
care for patients with dry mouth should focus on the complications of xerostomia, particularly those with
severe saliva flow deficit.
Dry mouth can easily lead to dental caries and oral problems, and seriously lead to rampant tooth decay, cracked teeth, and loose
fillings.
To prevent these problems, daily dental flossing, fluoride-containing oral preparations and remineralized solutions, mouthwash with baking soda, and close dental follow-up
are recommended.
Another common complication is oral candidiasis, which typically presents with atrophic changes characterized by erythema and atrophy of the oral mucosa and filiform papillae on the back of the tongue with angular cheilitis; Sometimes a thin, white exudate may appear on the surface
of the tongue.
Candidiasis treatment:
1.
Topical therapy - first try 2 weeks of nystatin gargle, 4 times a
day.
2.
Clutiazole is dissolved in the mouth, 5 times / day
.
3.
1 teaspoon of itraconazole liquid, twice
a day.
4.
If the local effect is not good, intravenous injection of fluconazole, itraconazole, amphotericin B, voriconazole
.
2.
Diagnosis of xerostomia
Dry mouth is the main complaint of xerostomia and is a subjective feeling
.
When the rate of saliva secretion is less than the sum of the rate of saliva absorption and evaporation by the oral mucosa, people feel dry
mouth.
Only a minority of patients with xerosterosterosis have obvious signs of mucosal dryness (e.
g.
, lack of sublingual saliva pool, thick, thick saliva) on oral examination.
Saliva flow meters are used to measure saliva flow injury and measure saliva flow through individual glands (parotus, submandibular, and sublingual glands) or the oral cavity as a whole
.
Salivary gland insufficiency refers to a decrease in saliva production, which is defined as:
1.
Saliva flow rate at rest< 0.
1ml/min (</b11>
2.
Under stimulation< 0.
7ml/min (<10.
5ml within 15 minutes</b10>
During the collection procedure, the patient keeps the head tilted forward and swallows once to clear the remaining saliva
from the mouth.
At this point, the 15-min collection process begins, and then the subject spits out saliva as needed, collecting saliva in a pre-weighed 50cm3 cryovial.
The specimen is weighed with an analytical balance and the volume of saliva is obtained (1g = 1ml).
The salivary gland contrast room is another technique used to assess xerostomia and can show the type of
image of large salivary gland duct obstruction.
The biggest role of this technique is to distinguish between inflammation and tumor.
This technique involves injecting a contrast agent into a salivary gland duct and then taking a sequence of radiographs to capture the morphology
of the contrast medium flow.
Water-soluble contrast media is recommended over oil-based contrast media, which may damage nearby salivary gland tissue
.
Salivary gland angiography is not routinely used in clinical practice because it is invasive and may have complications
such as duct rupture, pain, and infection.
3.
Xerostomia treatment
Xerostomia can be treated by direct use of salivary substitutes or stimulation of residual salivary gland secretion
.
A variety of over-the-counter artificial saliva containing hydoxymethylcellulose or methylcellulose are available
.
However, its duration of action is short, so its effectiveness is limited
in most patients.
Patients can stimulate saliva production
by chewing sugar-free candy or gum.
Two oral secretagogues are available to stimulate saliva and tear flow rates, and are also approved by the U.
S.
Food and Drug Administration: pilocarpine and cevimeline
.
(1) Piocarine: By acting on the M3 receptor of the gland, it has a strong promoting effect on the secretion of salivary glands and sweat glands
.
In controlled clinical trials, oral administration of 5-7.
5 mg of TID or QID improved both objective and subjective measures
of dry mouth and xerophthalmia.
Major adverse effects include hyperhidrosis, facial flushing, and other possible adverse effects include blurred vision, polyuria, nausea, abdominal pain, and diarrhea
.
Given the pharmacological properties, it is contraindicated
in patients with iritis, angle-closure glaucoma, moderate to severe asthma.
(2) Cevigmeline (cevimeline): is another cholinergic drug, also by stimulating M3 receptors, the pharmacological effect is similar to pilocarpine, can promote the secretion
of exocrine glands.
Figure 3: Changes in saliva and tear flow
in the treatment of xerostomia in the treatment of xerostomia in the cevimeline group versus placebo in a 12-week double-blind, randomized, placebo-controlled study evaluating two doses of severalin Safety and efficacy
in the treatment of patients with xerosterosis and keratoconjunctivitis siccosa.
• Formulation: Patients are randomly assigned to receive placebo, 15 mg or 30 mg of cevimeline three times daily
.
Patients were assessed at baseline and throughout the study to assess their dryness (oral, eye, overall), as well as their subjective assessment
of specific symptoms of dry mouth and dry eyes.
Total saliva and tear flow
were also measured.
•Results showed that the 30 mg three-p.
a.
dose of cevimeline significantly increased saliva and tear flow rate in patients with dry mouth and significantly improved the subjective symptoms of dry mouth, dry eyes, and general dryness compared with the three-p.
a.
regimen of cevimeline 15 mg three times a day.
