drugs affecting the salivary function / dental implant courses

By:-
INDIAN DENTAL
ACADEMY
Leader in continuing
Dental Education
www.indiandentalacademy.com

Contents
 Introduction
 Formation of saliva
 Salivary secretion control
 Functions of saliva
 Affect of drugs on salivary function
 Mechanism of action
 References

 Salivary glands are specialized secretory
apparatus.
 They show varying differentiation, structure
& arrangement in different species.
 In human beings, all salivary glands arise
from the ectoderm of the oral cavity.

 Based on size; salivary glands divided into 2
types
1. Major salivary glands
2. Minor salivary glands: 600-1000 minor salivary
glands present throughout oral cavity and
oropharynx.
 Salivary glands produce 1-1.5 lit. of saliva per day.
 In total saliva 60% by submandibular, 35% by
parotid, 4% by sublingual, 1% by minor salivary
glands

1. Parotid
Gland
2.
Submandibular
3.Sublingual
Gland
Anatomical location of major salivary
glands

 Based on type of secretion; – 2 types
1. Serous
2. Mucous
 Parotid is pure serous.
 Submandibular is mixed but predominately
serous.
 Sublingual also mixed but predominately mucous.

 Minor salivary glands classified according to
their anatomical location.
 Labial & Buccal glands — mixed in nature
 Glassopalatine — pure mucous in nature
 Palatine — pure mucous in nature
 Lingual – Anterior — chiefly mucous in
nature
Posterior — pure mucous in nature
Post. Lingual serous — pure serous

Definition
Saliva is complex fluid composed of a wide
variety of organic and inorganic constituents
that collectively act to modulate the oral
environment
Edger WM 1992

Formation of saliva occurs in 2 stages
 The basic functional unit of salivary gland is terminal
secretory unit called “acini” / “secretory end piece”
 First stage – Primary saliva – produced by cells of
secretory end pieces & intercalated ducts
 It is isotonic fluid containing most of the organic
components & water.
 Second stage – primary saliva is modified as it
passes through the striated & excretory ducts,
mainly by reabsorption & secretion of electrolytes
 The final saliva that reaches the oral cavity is
hypotonic.

Formation of
saliva

Saliva secretion control
 The physiologic control is mediated through
ANS; particularly parasympathetic nervous
system.
 The control of secretion is also linked to
changing taste & smell.
 Each of these is capable of modifying the
amount & consistency of saliva though
gustatory stimulus is more important than
masticatory stimulus.www.indiandentalacademy.com

 Postganglionic fibers of both sympathetic
and parasympathetic divisions innervate
the secretory cells.
 Myoepithelial, arteriolar smooth muscle cells,
intercalated & striated duct cells also receive
direct innervation.
 Unmylinated nerve invested by cytoplasmic
processes of Schwann, forms a plexus in the
connective tissue surrounding the terminal
secretory units.

Cortex
Fear Anticipation of feeding
Hypothalamu
s
Salivary Nuclei
Superior Inferior
(Pons ) (Medulla)
Vomiting
Center
(Medulla
)
Trigeminal
Nuclei
TMJ
Periodontiu
m Muscles
Mastication
Submandibul
ar
Sublingual
Parotid
Gland
Smel
l
Nu.of
Tractus
Solitarius
Taste
-
-
VII IX
IXVII
+ +
+
+

Composition
 Saliva is made up of approximately 99% water
& 1% inorganic ions, secretory proteins & other
components
 Secretory proteins- α-Amylase, ribonulease,
kallikrein, histatin, cystatin, sialoperoxidase,
lysozyme, lactoferin, mucins.
 Organic components like glucose, amino acids,
urea, uric acid & lipid molecules

 Immunoglobulins - secretory IgA, IgG, IgM
 Electrolytes are sodium, potassium, chlorine,
bicarbonate, phosphate, calcium,
magnesium, thiocynate, & flouride ions.
 Other components like epidermal growth
factor, insulin, cyclic AMP, binding proteins &
serum albumin.

Functions
Protection & Lubrication:
 Pellicle formation,
 Bolus formation,
 Forms a barrier against proteolytic & hydrolytic
enzymes in plaque, potential carcinogen from smoking
& desiccation from mouth breathing.
Buffering action:
 PH
maintenance – Bicarbonate, Phosphate, basic
proteins.
 Neutralization of acids

Maintenance of tooth integrity:
 Calcium & Phosphate ions – post-eruptive
remineralization, increasing surface hardness and
resistance to demineralization.
 Remineralization of initial caries lesions; enhanced
by presence of flouride ion in the saliva.
Antimicrobial property:
 Physical barrier – Mucins,
 Immune defense – Secretory IgA,
 Non immune defense – Sialoperoxidase, lysozyme,
lactoferin, mucins,www.indiandentalacademy.com

Digestion:
 Bolus formation – water, mucin,
 Starch, triglyceride – Amylase, lipase.
Taste:
 Solubilization of food –water, lipocalins,
 Maintenance of taste buds –epidermal growth
factor & carbonic anhydrase VI.
Tissue repair: Wound healing, epithelial
regeneration – growth factors, biologically active
peptides and amines.

Sulfonamides
Ranitidine
Nifedipine
Clonidine
Clozapine
Methyldopa
Phenytoin
Iodine
Warfarin

Anti Cholinergics Atropine, Scopolamine
Anti-Depressants
TCA– Imipramine, Amitryptilline
SSRI– Fluoxetine, Setraline
Anti-Histamines Diphenhydramine Pheniramine
Cinnarizine Cetrizine, Loratadine
Anti Neoplastic drugs
Cyclophosphamide,
Methotrexate,
Radioiodine, Vinblastine
Anti Microbial agent Ofloxacinwww.indiandentalacademy.com

Antiparkinsonian drugs Levodopa
Proton pump inhibitors Omeprazole
CNS Stimulant Amphetamine
Codiene derivatives Tramadol
Anti Helminthic Thiabendazole
Anti HIV Protease
Inhibitors
Amprenavir,
Indinavir
N.R.T.I. Didanosinewww.indiandentalacademy.com

Cholinergic drugs Pilocarpine, Cevimeline
Anti-cholinesterase drugs Tacrine, Rivastigmine,
Edrophonium
Antibiotics Kanamycin, Imipenem
Gentamicin, Tobramicin
Analgesics Mefenamic acid
Muscle relaxants Succinylcholine
General anesthetics Ketamine
Thiazide derivative Diazoxidewww.indiandentalacademy.com

Benzodiazepine Alprazolam
Anti-Arrhythmic drug Amiodarone
Anti -Anxiety drugs Buspirone
Anti-Depressants Venlafaxine
Anti-Epileptic drug Lamotrigine
Anti-Psychotic drugs Risperidone
Mood stabilizers Lithium
Demulcents Methylcellulose,
Propylene glycolwww.indiandentalacademy.com

 Ofloxacin inhibits rat salivary gland
functions, which might be observed as a
side-effect in humans.
 Properties of fluoroquinolones to alter
intracellular cAMP & calcium levels and their
ability to suppress DNA, RNA and protein
synthesis of acinar cells might be possible
reasons for the observed changes
Fundam Clin Pharmacol. 2001;15:307-11

 Atropine competitively blocks the
acetylcholine action ( M3 blockade) thereby
decrease the salivary flow.
 Anti Histamines – Antagonize muscarinic
actions of acetylcholine; which decrease the
salivary flow.
 Anti Cholinesterases like Tacrine,
Edrophonium increases the salivary flow by
increasing brain acetylcholine levels.

 Omeprazole causes reduction of plasma
secretin and cholecystokinin levels
recognised inhibitors of salivation
 Omeprazole may convert acidic
gastro- esophageal reflux into alkaline reflux
thus reducing the volume of saliva stimulated
by the esophago -salivary reflex

 The mechanism of hyposalivation by
psychotrophic drugs is not yet clear.
 They have many endogenous substance
receptors in the salivary glands that mediate
the salivary flow rate, such as substance P &
vasoactive intestinal peptide receptors.
 The blocking of α-adrenergic receptors can also
lead to decrease in salivary flow rate and
alterations in the saliva composition.

 Antidepressants block the effects of
acetylcholine on the muscarinic M3
receptors, resulting in a decreased salivary
flow rate.
 Antidepressants mainly TCAs modify the
salivary component concentration, e.g. total
proteins, α -amylase, glycoproteins,
calcium & potassium.
 The benzodiazepines [BZD] decreases the
salivary flow rate through the BZD receptors
in the salivary glands & by indirect action on
the salivary glands through the central BZD
receptors. www.indiandentalacademy.com

 Clozapine is have potent anticholinergic
effects
 Development of transient salivary gland
swelling on clozapine therapy
 Salivary gland swelling may be a possible
cause for the inhibition saliva flow
J clinical psychiatry 1995, vol. 56;11:511-
513

 Theophylline, a phosphodiesterase inhibitor,
is known to induce enlargement of the
salivary glands.
 This enlargement has been thought to be
associated with enhanced cellular levels of
cyclic AMP as a result of inhibition of
phosphodiesterase, finally increase the
saliva flow
J Toxicologic Pathology Vol. 16 (2003)
;4: 215 www.indiandentalacademy.com

THANK
YOU

Good Morning

Management of
Xerostomia &
Sialorrhea

XEROSTOMIA
Xerostomia is defined as subjective
feeling of oral dryness resulting
from decreased salivary flow.
BURKET’S

1. Iatrogenic causes:
Drugs;
 Anti Cholinergics ( Atropine, Hyoscine)
 Anti Depressants (TCA’s, SSRI, Lithium. )
 Anti Hypertensives
 Anti Histamines
 Anti Emetics
 Phenothiazines
 Proton pump inhibitors
 Cytotoxic drugs
 Opioids
 BZD s
 Diuretics
 Decongestants

2. Salivary Gland Disorders
A. Damage to salivary glands
Auto immune diseases
a. SjŐgren’s syndrome
b. SLE
c. Scleroderma
d. Sarcoidosis
B. Infections ( HIV, HCV, HTLV-1)
C. Obstructive salivary glandwww.indiandentalacademy.com

3. Therapeutic irradiation
4. Dehydration:
Decreased water intake
Water loss thro’ skin (Burns)
Diarrhoea
Blood loss
Emesis
5. Ageing
6. Diabetes
7. Vitamin deficiency

8. Interference with Neural
transmission:
 Psychological disorders
 Alzheimer’s disease
 Paralysis of facial nerve
9. Decrease in mastication
10. Depression

TREATMENT OPTIONS
1. Preventive therapy
( Topical Fluorides, Regular dental visits )
2. Symptomatic treatment
(sipping water frequently, room humidifiers,
oral rinses & gels, artificial saliva)
3. Salivary stimulation
Topical
Systemic
4. Treatment of underlying systemic disorders

Mechanical stimulants
 Eating foods which require Mastication
 Artificial Sweeteners
Chemical stimulants
 Mucopolysaccharide solutions containing
Citric Acid
Electrical stimulants (TENS)

Artificial Salivary Substitutes
 Aqueous Ionic solutions
Carboxy methyl cellulose
Mucin containing sol
Glycoprotein containing solutions
 Gel based substitutes
Pharmacological stimulants

Proposed systemic
sialogogues
 Pilocarpine
 Cevimeline
 Bethanechol
 Anetholetrithion
e
 Guaifensin
 Bromhexine
 Neostigmine
 Yohimbine
 Potassium
iodide
 Nicotinic acid
 Malic acid
 Vit A

Pilocarpine Hydrochloride
 Obtained from Pilocarpus Jaborandi plant
 Fox et al (1998), reported a clinical trial in
primary Sjögren’s syndrome patients with
pilocarpine
1. Subjective improvement of xerostomia
2. Improvement of parotid & submandibular flow
rates
 First medication approved by Food & Drug
Administration for the treatment of xerostomia in
patients with SS

 Parasympathetic Agent
 Muscarinic Agonist
 Causes pharmacological stimulation of
Exocrine glands
 Acts by stimulating functional salivary gland
tissue
 Hence not much effective in patients with
little remaining functional gland tissue

Indications:
 Mainly causes pupillary constriction & reduction of
IOP
Hence used in:
 Primary open angle glaucoma
 Angle closure glaucoma
 Oral dose: 5-10 mg 1 hr before eating
 Onset of action is 30 min
 Duration of action: 2-3 hrs

Contraindicated in patients:
 Gall bladder disease
 Narrow angle glaucoma
 Acute iritis
 Renal colic
SIDE EFFECTS
 Sweating
 GI upset
 Bradycardia
 Increased pulmonary secretions
 Increased smooth muscle tone
 Blurred vision
Risk to individuals
with:
 Heart disease
 Asthma
 Angina pectoris
 Chronic bronchitis
 COPD
 History of MI

Cevimeline hydrochloride
 Cholinergic agonist
 Binds to Muscarinic receptors
 Stimulates remaining functional salivary
gland tissue
 Binds more specifically to M3 receptors than
to M1 & M2
 Because it specifically targets the salivary
glands, side effects are less severe
 Hence better tolerated than Pilocarpine
 Approved by FDA for treatment of
xerostomia in SS patientswww.indiandentalacademy.com

 Dose: 30 mg t.i.d
 Reported peak blood conc. is 1.5-2 hrs
Contraindications:
 Uncontrolled Asthma
 Narrow angle glaucoma
 Cardiac diseases
( alters cardiac conduction & heart rate)

Bethanechol chloride
 Cholinergic drug
 Used for: Urinary retention
Neurogenic atony of bladder
 Stimulates Parasympathetic nervous
system
 Everett (1975), published a study in which
Bethanechol was given to alleviate the
Anticholinergic side effects of TCA &
reported symptomatic improvement

Contraindications:
 Bronchial asthma
 Hyperthyroidism
 Peptic ulcer disease
 Bradycardia
 Hypotension
 Mechanical obstruction of GI / Urinary tract

 Dose: 10-25 mg 3-4 times daily
 Onset of action of GI effects is 30 min
 Duration of action is 1hr
Tab. Urotone – 25mg
Tab. Urotonin - 25mg
Common cholinergic side effects:
 Sweating, GI upset, Miosis
 Decreased BP & reflex tachycardia
 Bronchial obstruction & Asthmatic attacks

Bromhexine
 Alkaloid derived from Adhatoda vasica
 Mucolytic agent
 Used for treatment of chronic bronchitis & COPD
 Acts by increasing quantity of secretions while
decreasing their viscosity
 Does not appear to be an effective treatment for
xerostomia (In clinical trials)

Mucolytic Agents
 Guaifensin & Potassium iodide
 Used to treat respiratory infections
 Decrease the viscosity of saliva
 Improve the symptoms of oral dryness by
improving flow through salivary ducts
 No controlled clinical trials have been
demonstrated
 Dosage; Acolyt syrup, Acocotin-7.5mg

 Alpha Interferon
 Hydroxychloroquine
 NSAIDS
 Corticosteroids
 Methotrexate
ALTERNATIVE MEDICINES
 Herbal medications
 Acupuncture therapy

Alpha interferon
 Alteration in salivary cytokines are seen in
SS
 These abnormal salivary cytokine levels
may contribute to progressive destruction
of salivary gland tissue in SS
 Recombinant human alpha interferon may
function as a Biological response modifier
 Improves salivary gland function in Auto
immune related xerostomia
 Clinical trials with weekly IM injections of
alpha interferon demonstratedwww.indiandentalacademy.com

Sialorrhea
Sialorrhea is defined as an excessive
secretion of saliva
BURKET’S

Causes for sialorrhea
1. Medication
2. Infant teething
3. The secretory phase of menstruation
4. Heavy metal poisoning
5. Oraganophosphorous poisoning
6. Nausea
7. Gastro Esophageal Reflux Disease
8. Obstructive esophagitis
9. Neurologic & neuromuscular diseases

Management
 Depending upon etiology of sialorrhea 3
treatment modalities are present;
1. Physical therapy
2. Medications
3. Surgical intervention

Physical therapy
 It can be used to improve neuromuscular
control.
 Speech & swallowing therapy should be
attempted prior to medical & surgical
intervention.
 Patient cooperation is essential, so this
therapy reported very low success rate.

Medications
 If patient is experienced sialorrhea
secondary to pharmaceutical treatment,
alternative medications should be evaluated,
 If therapeutic regimen cannot be altered,
compatible xerostomic agents should be
considered.
 Cholinergic muscarinic receptor antagonists
can be used

 Drugs like atropine, scopolamine can be
advised.
 These drugs are contraindicated when there
is H/o cardiac problem,
closure glaucoma,
prostate hypertrophy,
paralytic ileus / pyloric obstruction.
Preparations & Dosages:
 Atropine sulfate – 0.6 – 2mg i.m., i.v.
( Children 10µg/ kg )www.indiandentalacademy.com

 Sublingual administered atropine reduces
hypersalivation
 Hyson et al (2002), delivered 1 drop of
atropine (1%wt / vol solution containing 0.5
mg) sublingually twice a day.
 Transdermal Therapeutic System [ TTS]; It is
a self adhesive dermal patch delivering
scopolamine, usually applied to prevent
nausea. www.indiandentalacademy.com

 Zeppetella (1999), successfully used
scopolamine via nebulization in patients who
had not improved with transdermal patch.
 With nebulized delivery system scopolamine is
absorbed faster & can be used on “as required”
basis.
 It is helpful in patients with problematic bronchial
secretions.
 Reinish et al (1997) reported that Amisulpride
(400mg/d up-titrated from 100mg/d over week)
produced significant improvement in

Minimally invasive methods
Injection of botulinum toxin A:
 BTX/A (7.5-15 units) is injected in the
salivary gland it inhibit acetylcholine release
mainly at neurosecretory junctions.
 It binds SNAP-25 protein forming a complex
that impairs neuronal excytosis by inhibiting
fusion of the presynaptic vesicles containing
the neurotransmitter

Photocoagulation of salivary ducts
 It is aimed to minimize surgical
complications.
 Chang & Wong used Nd:YAG laser
(1064nm) for intraductal laser
photocoagulation of bilateral parotid ducts at
7/10 watts during 10 seconds.
 Concepts of laser-tissue interaction of
intraductal laser photocoagulation are based
on partial destruction of parotid gland &
occlusion of parotid ducts.
 Postoperatively transient facial swelling iswww.indiandentalacademy.com

Tongue acupuncture
 Wong et al, hypothesized that tongue
acupuncture stimulate the rich neural network in
the tongue, which is connected to salivary
glands & tongue muscles via the cranial nerve
nuclei; & improve salivary secretion and
swallowing mechanism.
 Children easily tolerated the treatment with
significant improvement of hypersalivation & no
complications
 This technique may be an alternative /
adjunctive option for children with intractablewww.indiandentalacademy.com

Surgical methods
 Neurectomy – sectioning the parasympathetic
pathway reduces the flow of saliva.
 The tympanic plexus and Chorda tympanic
nerves can be sectioned unilaterally or
bilaterally, and either alone in combination with
submandibular gland removal.
 Chorda tympani neurectomy reduces the
salivary flow rate of the submandibular /
sublingual complex but it seems to be poor

 Chorda tympani neurectomy always
produces a loss of taste in the anterior 2/3rds
of the tongue.
 Contraindicated in patients who already have
hearing problems.
 Hearing loss is the possible complication
 Despite an initially high success rate, the
long term results of neurectomies used alone
are relatively disappointing

Salivary duct and gland
procedures
 One of the earliest surgical management of
sialorrhea is;
 Bilateral parotid duct relocation from buccal
vestibule to tonsillar fossa or posterior part of
tonsillar pillar to initiate the swallowing reflex.
 Bilateral duct ligation of parotid glands combined
with submandibular gland removal gives goodwww.indiandentalacademy.com

 The purpose of duct ligation is to obtain
gland atrophy.
 Submandibular duct relocation performed
alone or in combination gives success
rate of 75% - 89%.
 Occasional post operative complications
such as ranula formation, pain &
numbness.

References
 The pharmacological Basis of Therapeutics
Goodman & Gilman 10th Edition
 Pharmacology & Pharmacotherapeutics
Satoskar 20th
Edition
 Essentials of Medical Pharmacology
KD Tripathi 6th
Edition

 Oral Histology & Embryology
Orban 12th
Edition
 J Contemp Dent Practice 2008; 9: 001-
032
 O O O E 2008;106:58-
65
 British Dental Jour 1992;172:305-
312 www.indiandentalacademy.com

 Burket's Oral Medicine 11th Edition
 Salivary gland dysfunction: A review of systemic
therapies
OOOE 2001;92:56-62
 An update of etiology and management of
xerostomia
OOOE 2004;97:28-46
 Drooling of saliva: A review of etiology and
management options
OOOE 2006;101:48-57

Thank You

drugs affecting the salivary function / dental implant courses

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Andere mochten auch

Andere mochten auch (12)

Ähnlich wie drugs affecting the salivary function / dental implant courses

Ähnlich wie drugs affecting the salivary function / dental implant courses (20)

Mehr von Indian dental academy

Mehr von Indian dental academy (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

drugs affecting the salivary function / dental implant courses