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2. Contents
Introduction
Formation of saliva
Salivary secretion control
Functions of saliva
Affect of drugs on salivary function
Mechanism of action
References
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3. 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.
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4. 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
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6. 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.
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7. 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
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8. 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
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9. 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.
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11. 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
12. 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.
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13. 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
+ +
+
+
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14. 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
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23. 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
24. 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
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25. 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.
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26. 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
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27. 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.
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28. 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
29. 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
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30. 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
34. XEROSTOMIA
Xerostomia is defined as subjective
feeling of oral dryness resulting
from decreased salivary flow.
BURKET’S
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35. 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
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36. 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
37. 3. Therapeutic irradiation
4. Dehydration:
Decreased water intake
Water loss thro’ skin (Burns)
Diarrhoea
Blood loss
Emesis
5. Ageing
6. Diabetes
7. Vitamin deficiency
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38. 8. Interference with Neural
transmission:
Psychological disorders
Alzheimer’s disease
Paralysis of facial nerve
9. Decrease in mastication
10. Depression
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43. 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
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44. 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
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45. 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
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46. 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
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47. 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
49. 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
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51. 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
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52. 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)
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53. 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
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55. 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
57. 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
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58. Management
Depending upon etiology of sialorrhea 3
treatment modalities are present;
1. Physical therapy
2. Medications
3. Surgical intervention
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59. 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.
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60. 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
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61. 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
62. 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
63. 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
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64. 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
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65. 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
66. 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
67. 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
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68. 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
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69. 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
70. 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.
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71. References
The pharmacological Basis of Therapeutics
Goodman & Gilman 10th Edition
Pharmacology & Pharmacotherapeutics
Satoskar 20th
Edition
Essentials of Medical Pharmacology
KD Tripathi 6th
Edition
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72. 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
73. 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
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