dental disorders
Xerostomia
Evaluation of Xerostomia
History of present illnessshould include acuity of onset, temporal patterns (eg, constant vs intermittent, presence only on awakening), provoking factors, including situational or psychogenic factors (eg, whether xerostomia occurs only during periods of psychological stress or certain activities), assessment of fluid status (eg, fluid intake habits, recurrent vomiting or diarrhea), and sleeping habits. A history of use of recreational and illicit drugs should be taken. should seek symptoms of causative disorders, including dry eyes, dry skin, rashes, and joint pain ( Sjögren Syndrome ). should inquire about conditions associated with xerostomia, including Sjögren syndrome, history of radiation treatment, head and neck trauma, and a diagnosis of or risk factors for Human Immunodeficiency Virus (HIV) Infection . Drug profiles should be reviewed for potential offending medications (see table Physical examination is focused on the oral cavity, specifically any apparent dryness (eg, whether the mucosa is dry, sticky, or moist; whether saliva is foamy, thick, stringy, or normal in appearance), the presence of any lesions caused byCandida albicans,and the condition of the teeth. The presence and severity of xerostomia can be assessed in several ways. For example, a tongue blade can be held against the buccal mucosa for 10 seconds. If the tongue blade falls off immediately when released, salivary flow is considered normal. The more difficulty encountered removing the tongue blade, the more severe the xerostomia. The lipstick sign, where lipstick adheres to the front teeth, may be a useful indicator of xerostomia. If there appears to be dryness, the submandibular, sublingual, and parotid glands should be palpated while observing the ductal openings for saliva flow. The openings are at the base of the tongue anteriorly for the submandibular and sublingual glands and on the middle of the inside of the cheek for the parotid glands. Drying the duct openings with a gauze square before palpation aids observation. If a graduated container is available, the patient can expectorate once to empty the mouth and then expectorate all saliva into the container. Normal production is 0.3 to 0.4 mL/min. Significant xerostomia is 0.1 mL/min. Dental Caries may be observed at the margins of restorations or in unusual places (eg, at the gum line, incisal edges, or cusp tips of the teeth). A common manifestation ofC. albicansinfection is areas of erythema and atrophy (eg, loss of papillae on the dorsum of the tongue). Less common is the better-known white, cheesy curd that bleeds when wiped off. The following findings are of particular concern: Extensive tooth decay Concomitant dry eyes, dry skin, rash, or joint pain Risk factors for HIV Xerostomia is diagnosed by symptoms, appearance, and absence of salivary flow when massaging the salivary glands. No further assessment is required when xerostomia occurs after initiation of a new medication and stops after cessation of that medication or when symptoms appear within several weeks of irradiation of the head and neck. Xerostomia that occurs with abrupt onset after head and neck trauma may be caused by nerve damage. Concomitant presence of dry eyes, dry skin, rash, or joint pain, particularly in a female patient, suggests a diagnosis of Sjögren Syndrome . Severe tooth discoloration and decay, out of proportion to expected findings, may be indicative of illicit drug use, particularly Sialometry Salivary gland biopsy For patients in whom the presence of xerostomia is unclear, sialometry can be conducted by placing collection devices over the major duct orifices and then stimulating salivary production with citric acid or by chewing paraffin. Normal parotid flow is 0.4 to 1.5 mL/min/gland. Flow monitoring can also help determine response to therapy. The cause of xerostomia is often apparent, but if the etiology is unclear and systemic disease is considered possible, further assessment should be pursued with biopsy of a minor salivary gland (for detection of Sjögren Syndrome , 