2018 Oregon Dental Conference Course Handout Denis Lynch, DDS, PhD

Transcription

1 2018 Oregon Dental Conference Course Handout Denis Lynch, DDS, PhD Course 9120: Spit Happens (and Sometimes it Doesn t): The Diagnosis and Treatment of Salivary Gland Disease Thursday, April 5 9 am - 12 pm

2 SPIT HAPPENS (and sometimes it doesn t) The Diagnosis and Treatment of Salivary Gland Disease Oregon Dental Conference Portland, Oregon April 5-7, 2018 Denis P. Lynch, D.D.S., Ph.D. Outline Benign Salivary Gland Neoplasms Malignant Salivary Gland Neoplasms Xerostomia Non-neoplastic Salivary Gland Disease 1

3 Synopsis Major clinical signs and symptoms Diagnostic criteria and tests Currently accepted therapeutic modalities References References 2

4 Benign Neoplasms Pleomorphic adenoma Warthin s tumor Monomorphic adenoma(s) Salivary Gland Tumor Sites Parotid (64%) Submandibular (10%) Sublingual (0.3%) Minor (23%) Parotid Tumors Pleomorphic Adenoma (53%) Warthin's Tumor (7.7%) Other Benign (7%) Mucoepidermoid (9.6%) Acinic Cell (8.6%) Other Malignant (14.1%) 3

5 Submandibular Gland Tumors Pleomorphic Adenoma (53.3%) Other Benign (5.5%) Adenoid Cystic (11.7%) Mucoepidermoid (9.1%) Other Malignant (20.4%) Minor Salivary Gland Tumors Pleomorphic Adenoma (38.1%) Other Benign (13.3%) Mucoepidermoid (21.5%) Adenoid Cystic (7.7%) Pleomorphic Adenoma 4

6 Etiology and Epidemiology benign mixed tumor Most common salivary neoplasm 53-77% of parotid tumors 44-68% of submandibular tumors 38-43% of minor salivary gland tumors More common in young adults Slightly more common in females Etiology and Epidemiology Superficial lobe (90%) in parotid Minor salivary gland Posterior lateral palate (60%) Upper lip (20%) Buccal mucosa (10%) Clinical Features Painless Slow growing Firm Occasionally traumatically ulcerated 5

7 Diagnosis Imaging Biopsy Incisional Excisional Fine needle aspiration Treatment Surgical excision Do NOT enucleate Prognosis Excellent prognosis 95% cure rate 6

8 Warthin s Tumor Etiology and Epidemiology papillary cystadenoma lymphomatosum Limited to parotid 2 nd most common parotid tumor (5-15%) From heterotopic salivary gland in parotid lymph nodes More common in smokers (8x) (?) male predominance Clinical Features Slow growing Painless Firm to fluctuant Tail of parotid (?) multicentric 5-15% bilateral, but metachronous 7

9 Diagnosis Biopsy Fine needle aspiration Intra-operative frozen section Treatment and Prognosis Surgical excision Resection versus superficial parotidectomy Excellent prognosis 10% recurrence rate Monomorphic Adenomas Canalicular adenoma Basal cell adenoma Oncocytoma 8

10 Etiology and Epidemiology Upper lip (80%) Most common tumor Older adults Females (2x) Clinical Features Slow growing, painless Rarely multifocal Diagnosis, Treatment, and Prognosis Excisional biopsy Excellent prognosis 9

11 Malignant Neoplasms Mucoepidermoid carcinoma Adenoid cystic carcinoma Malignant Salivary Gland Tumors Parotid Submandibular Sublingual Minor Malignant Intraoral Salivary Gland Tumors 10

12 Mucoepidermoid Carcinoma Etiology and Epidemiology Most common salivary gland malignancy 10% of major salivary gland malignancies Most common in parotid 15-21% of minor salivary gland malignancies Wide age range #1 salivary gland malignancy in children Slight female predominance Clinical Features Asymptomatic swelling Subsequent pain and nerve palsy (parotid) Occasionally fluctuant (minor glands) 11

13 Diagnosis Imaging Biopsy Incisional Excisional Fine needle aspiration Treatment and Prognosis Surgical excision Occasional adjunctive radiation Fair to good prognosis 90% for low-grade tumors 30% for high-grade tumors Adenoid Cystic Carcinoma 12

14 Etiology and Epidemiology 50% in minor salivary glands Palate most common site (8-15%) Rare in parotid (2-3%) #1 submandibular gland malignancy Middle-aged adults Clinical Features Slow growing mass Frequently painful Variable ulceration Invade nerves Palsy Diagnosis Imaging Biopsy Incisional Excisional Fine needle aspiration 13

15 Treatment and Prognosis Surgical excision Adjunctive radiation Poor prognosis 70% 5-year survival 20% 20-year survival SPIT HAPPENS AND SOMETIMES IT DOESN T Saliva lacks the drama of blood, the sincerity of sweat and the emotional appeal of tears. Mandel (1990) 14

16 Xerostomia Etiology Sjögren's syndrome Iatrogenic Clinical Features Subjective objective Thick / ropey or foamy saliva Mucosal "tackiness Fissured, atrophic tongue Dysgeusia and dysphagia Increased incidence of candidiasis Increased Class V and root caries 15

17 Sjögren's Syndrome Etiology Autoimmune disorder Genetic predisposition (?) Relationship to EBV Epidemiology 0.5% of USA population Middle-aged adults Women > men (9:1) 16

18 Clinical Features Primary Sjögren's syndrome Xerostomia Xerophthalmia Secondary Sjögren's syndrome Xerostomia Xerophthalmia Other disorder, e.g., RA, LE Clinical Features Salivary gland enlargement Firm, diffuse, asymptomatic Abnormal sialography Reduced lacrimation Mucoid discharge Gritty" sensation Corneal abrasion Differential Diagnosis Mumps Salivary gland neoplasm Drug-induced xerostomia 17

19 Diagnosis Minor salivary gland biopsy Schirmer test Serology Slit lamp examination Treatment Artificial saliva / moisturizers Salivary stimulants Topical fluoride Prognosis Good Increased lymphoma risk (40x) 18

20 Iatrogenic Xerostomia Etiology Drug side-effect Prescription medications Antidepressants Antihypertensives Psychotherapeutic agents OTC medications Antihistamines Head and neck radiation therapy Antidepressants DRUG RANK Prozac (fluoxitine) 9 Zoloft (sertraline) 13 Paxil (paroxetine) 33 Elavil (amitryptyline) 47 Pamelor (nortriptyline) 163 Effexor (venlaxafine)

21 Antihypertensives DRUG RANK Dyazide (triamterene/hctz) 17 Lasix (furosemide) 23 Esidrix (hydrochlorothiazide) 94 Tenormin (atenolol) 116 Psychotherapeutic Agents DRUG RANK Xanax (alprazolam) 38 Klonopin (clonazepam) 48 Ativan (lorazepam) 79 Valium (diazepam) 133 Restoril (temazepam) 149 Epidemiology One of the most common drug side effects 20

22 Clinical Features Identical to Sjögren's syndrome Temporal relationship to medication use Resolution when medication changed or dosage regimen altered Differential Diagnosis Sjögren's syndrome Diagnosis By exclusion 21

23 Treatment Change medication Alter dosage regimen Sialogogues Artificial saliva Salivary Stimulants OTC sialogogues Sugarless candy Sugarless gum Treatment Water Artificial saliva / moisturizers MedOral Salivart Oasis Glandosane Mouthkote Oral Balance gel 22

24 Treatment Ethyol (amifostine) IV before XRT Salivary stimulants Salagen (pilocarpine) Evoxac (cevimeline) Urecholine (bethanechol) Topical fluoride Prevident (1.1% neutral NaF) NeutraCare (1.1% neutral NaF) Side Effects Sweating Lacrimation Urinary frequency Dental Caries Aggressive therapy Scrupulous oral hygiene Dietary alterations Chlorhexidine mouth rinses Topical fluoride Salivary stimulation 23

25 Prognosis Variable Excellent if medication can be changed or dosage altered Poor if permanent damage (radiation) Non-Neoplastic Salivary Gland Disease Mucocele Ranula Sialolithiasis Necrotizing sialometaplasia Mucocele 24

26 Etiology and Epidemiology Trauma to minor salivary gland duct More common in lateral lower lip (75%) More common in children Clinical Features Dome-shaped Fluctuant Transleucent Occasional rupture and reformation Diagnosis and Treatment Clinical signs and symptoms Excisional biopsy Remove adjacent minor salivary glands 25

27 Prognosis Excellent Occasional recurrence Ranula Etiology and Epidemiology Occlusion of submandibular gland Sialolith Trauma More common in adults 26

28 Clinical Features Floor of mouth Unilateral Transleucent ( frog belly ) Occasional pain during eating Occasional rupture Diagnosis, Treatment, Prognosis Clinical signs and symptoms Marsupialization Sialadenectomy Excellent prognosis Sialolithiasis 27

29 Etiology and Epidemiology Intralumenal calcification Submandibular gland most common Highest salivary calcium content Usually adults Clinical Features Variable symptoms Pain and swelling at mealtime Occasionally evident radiographically Occasionally palpable near duct orifice Diagnosis, Treatment, and Prognosis Clinical signs and symptoms Sialogogues Milking the gland Surgical stone removal Sialadenectomy Excellent prognosis 28

30 Necrotizing Sialometaplasia Etiology Trauma Dental injection Ill-fitting denture Upper respiratory infection Adjacent tumors Prior surgery Ischemia -> infarct -> necrosis -> ulcer Epidemiology Usually minor salivary glands Usually adults More common in males (2x) More common in posterior palate (75%) Usually unilateral (65%) 29

31 Clinical Features Localized swelling Often asymptomatic Occasional pain or paresthesia Tissue slough in 2-3 weeks Diagnosis, Treatment, and Prognosis Incisional biopsy Microscopic similarities Squamous cell carcinoma Mucoepidermoid carcinoma No treatment necessary Heal by secondary intention in 4-6 weeks 30

32 Spit Happens Post-Test In what specific salivary gland are most salivary gland neoplasms found? 1. Parotid gland 2. Submandibular gland 3. Sublingual gland 4. Minor salivary gland What is the most common parotid gland neoplasm? 1. Pleomorphic adenoma 2. Warthin tumor 3. Mucoepidermoid carcinoma 4. Adenoid cystic carcinoma What is the most common malignant submandibular gland neoplasm? 1. Pleomorphic adenoma 2. Warthin tumor 3. Mucoepidermoid carcinoma 4. Adenoid cystic carcinoma Which salivary gland neoplasm can occur bilaterally? 1. Pleomorphic adenoma 2. Warthin tumor 3. Mucoepidermoid carcinoma 4. Adenoid cystic carcinoma Where are monomorphic adenomas most commonly found? 1. Parotid gland 2. Submandibular gland 3. Sublingual gland 4. Minor salivary gland of the upper lip 5. Minor salivary gland of the lower lip

33 Which salivary gland has the highest percentage of malignant neoplasms? 1. Parotid gland 2. Submandibular gland 3. Sublingual gland 4. Minor salivary gland What is the most common salivary gland malignancy in children? 1. Mucoepidermoid carcinoma 2. Adenoid cystic carcinoma In which major salivary gland is an adenoid cystic carcinoma most likely found? 1. Parotid gland 2. Submandibular gland 3. Sublingual gland When adenoid cystic carcinomas occur in minor salivary glands, what is the most common anatomic site? 1. Lower lip 2. Upper lip 3. Retromolar pad 4. Palate Which malignant salivary gland neoplasm has a propensity to invade peripheral nerves and perineural lymphatics? 1. Mucoepidermoid carcinoma 2. Adenoid cystic carcinoma In which of the following groups is Sjögren syndrome more common? 1. Infants and children of both sexes 2. Middle-aged men 3. Middle-aged women 4. Geriatric men and women

34 Which of the following is not a component of secondary Sjögren syndrome? 1. Xerostomia 2. Xeropthalmia 3. Other autoimmune diseases 4. All of the above are components of secondary Sjögren syndrome. Patients with Sjögren syndrome are at increased risk for what salivary gland malignancy? 1. Mucoepidermoid carcinoma 2. Adenoid cystic carcinoma 3. lymphoma Which of the following classes of medications commonly cause xerostomia? 1. Antidepressants 2. Antihypertensives 3. Psychotherapeutic agents 4. Antihistamines 5. All of the above medications commonly cause xerostomia. What is often the most effective initial therapy for xerostomia? 1. Using artificial saliva 2. Sucking on sugar-free tart candies 3. Chewing sugarless gum 4. Sipping water 5. Taking prescription salivary stimulants Which of the following are characteristic of mucoceles? 1. Most commonly found in the lateral lower lip 2. More common in children 3. Due to trauma to the salivary gland duct 4. Must be removed surgically 5. All of the above are characteristic of mucoceles.

35 Sialoliths are most likely to occur in which salivary gland? 1. Parotid gland 2. Submandibular gland 3. Sublingual gland 4. Minor salivary gland Which of the following statements regarding necrotizing necrotizing sialometaplasia is correct? 1. It is due to an infarction of the salivary gland. 2. It is most commonly found on the posterior palate. 3. It may be confused microscopically with squamous cell carcinoma. 4. It may be confused microscopically with mucoepidermoid carcinoma. 5. All of the above statements are correct.