2. Introduction
The salivary glands classified as major&
minorglands
Major glands are paired glands they are
Parotid glands
Submandibular glands
Sublingual glands
The numerous minor salivary glands , widely
distributed in the oral cavity
Salivary gland secretion contain water,
electrolytes , urea , ammonia , glucose , fats
&proteins
2
3. Parotid gland
Largest salivary gland
Pyramidal in shape
Two lobes superficial , & deep connected by
an isthmus at posterior part of gland
Apex is toward angle of mandible
Base at the external acoustic meatus
Anteriorly gland extends up to buccal pad of
fat
Posteriorly encircles posterior border of
mandible
Parotid gland secretion is serous in nature
3
4. Parotid duct (Stenson's duct )
Stenson`s duct emerges at anterior part of
gland
Stenson`s duct opening is seen as a papilla in
the buccal mucosa opposite maxillary second
molar
4
5. Submandibulargland
The gland is located submandibular space
Extending inferiorly up to digastric muscle
Superiorly mylohyoid muscle
Posteriorly up to angle of mandible
Anteriorly mid portion of body of the mandible
Submandibular gland secretion is mixed
5
6. Submandibularduct (Wharton's
duct)
The duct starts from deep part of gland
Turns sharply at the posterior border of
mylohyoid muscle anteriorly & superiorly ,
crosses hyoglossus muscle
6
7. Sublingual gland
This gland is located in sublingual space it is
present in association with sublingual fold
below tongue , & divided into anterior &
posterior part
Sublingual gland secretes both serous &
mucous
Bartholin’ s duct
The ducts of anterior part may join to form a
large main duct called Bartholin’ s duct
7
8. Minorsalivary glands
More than 800 minor salivary glands may be
present in oral cavity
Secrete mucous secretions
8
9. Functions of saliva
Digestive function
Protective function
Cleansing
Lubrication
Antibacterial action
9
14. Xerostomia
Xerostomia is a subjective sensation of a dry
mouth
It affects women more than men , are
commonly in older people
Antihistamines , decongestants ,
antidepressants , antipsychotics,
antihypertensives, & anticholinergics are
known to cause xerostomia
Other cause of xerostomia -- salivary gland
aplasia, aging , excessive smoking , mouth
breathing , local radiation therapy , Sjogren’s
syndrome & HIV infection
14
15. Cont.
Clinical features
Dry mouth with foamy , thick , & ropy saliva
Gloves stick to the mucosa
Difficulty in mastication & swallowing
More chance for candidiasis & caries
Treatment
Removal of the cause
Maintenance oral hygiene
Use of sialagogues
15
17. Sialorrhoea
Sialorrhoea is excessive salivation
Minor sialorrhea can be seen due to local
irritation like aphthous ulcers or ill- fitting
dentures
Profuse salivation is seen in rabies, heavy
metal poisoning, gastro esophageal reflux
disease or after certain medication like lithium
& cholinergic agonists
Mentally retarded children also excessive
salivation – not by excessive production of
saliva
Treatment
Removal of the cause
17
19. Sialadenitis
Inflammation of the salivary glands is known
as sialadenitis
Causes
Viral infections
Bacterial infections
Allergic reactions
Systemic diseases
19
20. Mumps
It is also called as epidemic parotitis.
It is caused by paramyxo virus and affects
major salivary glands, especially the
parotid salivary gland.
Clinical Features:
The mumps virus can be transmitted through
urine, saliva or respiratory droplets.
Incubation period-16 to 18 days.
20
21. Cont.
Patients are contagious 1 day before & 14
days after the resolution
Usually subclinical
If symptomatic prodromal symptoms of Low-
grade fever, Headache, malaise & Myalgia
Discomfort & swelling over the lower ½ of
external ear down to posterior & inferior
border of mandible
Either one or both the parotid gland are
enlarged and become tender.
21
22. Cont.
Enlargement & pain are maximum in 2-3 days
Chewing movements or saliva stimulating
foods increases pain
Enlargement begins on one side & then
extends to other side
There many also be and edema & erythema
involving the ductal orifice.
If sublingual gland is involved – bilateral
enlargement of floor of mouth
22
25. Bacterial infection
Bacterial infection can inflammation of major
salivary glands
Bacterial sialadenitis affects parotid gland
more commonly
Submandibular glands are rarely affected
25
26. Acute bacterial sialadenitis
Organisms - staph ;aureus , strep ; pyogenes,
strep; viridans etc
Some drugs like tranquilizers; antiparkinson
drug ; diuretics; & antihistamines drugs etc
decrease salivary flow with increased chance
of infection of salivary glands
Clinical features
Sudden onset of pain at angle of the jaw
which is unilateral
26
27. Cont.
Affected gland is enlarged & tender &
extremely painful
Inflammatory swelling is very tense & does not
show much fluctuation
Skin is warm & red
Associated fever & trismus may be there
Purulent discharge from the affected duct
orifice
Histopathologic features
Accumulation of neutrophils is observed
with in ductal system & acini
27
28. Cont.
Treatment
Antibiotics
Hydrating the pt
Stimulate the salivation by chewing
sialagogues
Improve oral hygiene by debridement &
irrigation
Surgical drainage if abscess is there
28
29. Chronic bacterial siladenitis
It may be idiopathic or with factors like
Duct obstruction ,
Congenital stenosis,
Sjogren ’s syndrome
The microorganisms may be strep; viridans, e-
coli
Clinical features
Unilateral periodic pain & swelling at the angle
of jaw usually during mealtime
Gland may undergo atrophy , which results in
decreased salivary flow
29
30. Cont.
Histopathologic features
Patchy infiltration of salivary parenchyma
by lympocytes & plasma cells
Atrophy of acini & ductal dialatation &
sometimes fibrosis
Sialography – ductal dialatation proximal to
area of obstruction
Treatment
Antibiotics
30
31. Cont.
Intra ductal infusion of erythromycin or
tetracycline
Excision of the gland
31
33. Sjogren syndrome
Characterized by dry eyes , xerostomia &
rheumatoid arthritis
Clinical features
Occurs predominantly in women
Dry eyes & dry mouth
Pain & burning sensation
Red & tender mucosa with Ulceration
Difficulty in swallowing
Altered taste sensation
Denture sore mouth
33
34. Cont.
Angular cheilitis
There may have diffuse firm enlargement of
major salivary glands usually bilateral
Sialography- demonstrates cavitary defects
are filled with radiopaque contrast media
producing ‘ branchless fruit laden tree’ or
“cherry blossom appearance”
Histopathologic features
Lymphocytic infiltration with destruction of
acinar cells
34
37. Sialadenosis
It is non- inflammatory , non - neoplastic
swelling of the salivary gland
Sialadenosis can occur in the following
conditions;
Hormonal disorders(pregnancy, hypothyroidism)
Diabetes mellitus
Alcoholic cirrhosis
Malnutrition
Caused by dysregulation of autonomic
innervation of salivary acini causing aberrent
intracellular secretory cycle leading to
excessive secretion of secretory granules
37
38. Cont.
Clinical features
Enlargement is usually painless
Usually bilateral
More common in women
Commonly affects parotid
Histopathologic features
Hypertrophy of acinar cells
Nuclei are displaced to the base
Cytoplasm is engorged with zymogen
granules
38
39. Cont.
In DM & alcoholism – acinar atrophy & fatty
infiltration
Treatment
Control underlying cause
Pilocarpine
39
40. Sialolithiasis
Sialolithiasis is the formation of sialolith
( salivary calculi, salivary stone ) in the salivary
duct or gland resulting in the obstruction of the
salivary flow
Sialolith
Sialolith is a calcified mass with laminated
layers of inorganic material from crystallization
of salivary solutes
The sialolith is yellowish white in colour ;
Single or multiple, may be round & ovoid or
elongated having size of 2cm or more
diameter
40
41. Cont.
The minerals are various forms of calcium
phosphate like hydroxyapatite, octacalcium
phosphate etc
Calcium & phosphorus ions are deposited on
the organic nidus, may be desquamated
epithelial cell, bacteria, foreign particle or
product of bacterial decomposition
It may be related to sialadenitis or ductal
obstruction
Clinical features
Commonly seen in middle -age persons
41
43. Cont.
More common in submandibular salivary ductal
system
Pain & swelling during & after eating food
Stone can be palpated if it is in the peripheral
aspect of the duct
Minor salivary stones are seen as
asymptomayic hard nodule commonly in upper
lip
Histopathologic features
Sialoliths appear as round , & oval calcified
mass exhibits concentric laminations surround
a nidus of amorphous debris43
44. Cont.
Investigations
Radiographs –PA view , lateral oblique or
occlusal view – shows radiopaque mass
Sialography
Treatment
Smaller sialoliths, are located peripherally
near ductal opening may be removed by
manipulation called milking the gland
Larger sialoliths are surgically removed
44
45. Cont.
Stones which are not impacted , may be
extracted through the intubation of the duct
with fine soft plastic catheter& application of
the suction to the tube
Piezoelectric shock wave lithotripsy
Multiple stones or stone in gland require
removal of the gland
Transoral sialolithotomyof thesubmandibular
duct
Local anaesthesia
Position of the stone is located by x-rays &
palpation
45
46. Cont.
Suture is placed behind the stone
Tongue is lifted & held with help of a gauze
Incision is made in the mucosa parallel to the duct
Duct is located by blunt dissection
Longitudinal incision is made over the stone
Stone removed using small forceps, in case the
stone is large, it is crushed with help of the
forceps
Cannula may be passed to aspirate the pieces of
stone, mucin etc
Sutures are placed at the level of the mucosa
46
47. Mucocele
Lower lip is commonly affected
Other common sites are buccal mucosa,
ventral tongue, floor of mouth
It can be superficial or deep
Superficial – elevated well circumscribed
vesicle with bluish hue
Deep – nodule with no change in color
Cystic contents – thick mucous material
Usually covered by mucous membrane
There may have periodic rupture of the
swelling releasing the contents47
49. Cont.
After rupture it may leave shallow painful
ulcers
Some lesions resolve by itself
Histopathologic features
Area of spilled mucin surrounded by granulation
tissue
Adjacent minor salivary glands contain c/c
inflammatory infiltrate
Treated by excision along with adjacent minor
salivary glands to prevent recurrence
49
50. Salivary duct cyst
Mucus retention cyst or sialocyst
Epithelium lined cavity that arises from salivary
gland tissue
True cyst
May be caused by ductal dilatation or
secondary to ductal obstruction
It can be seen in major or minor salivary
glands
Cysts of major glands are common in parotid
gland
Intraoral cyst are common in buccal mucosa,
floor of mouth & lips
50
51. Cont.
They are soft, fluctuant, asymptomatic swelling
& may appear bluish depending on the depth
Histopathologically – cyst may be lined by
cuboidal, columnar or squamous epithelium
surrounding the mucoid secretion in lumen
Treated by local excision for minor salivary
gland ducts
For major salivary glands total or partial
removal of gland can be done
Sialgogues can stimulate salivation & prevent
accumulation of mucus
51
53. Ranula
Extravasation cyst usually arises from ducts of
sublingual gland
Bluish, dome shaped, fluctuant swelling in
floor of mouth
May enlarge raise the tongue
Usually seen lateral to midline
May extend to the neck behind the posterior
border of mylohyoid (plunging ranula)
Histopathologically similar to mucocele
Treated by marsupialization or removal of the
feeding sublingual gland53
55. Pleomorphic adenoma
It can affect both major & minor salivary gland
It commonly affects the parotid gland
Clinical features
More commonly in females
Small painless nodule at the angle of
mandible or beneath the ear lobe
Well circumscribed , encapsulated , firm in
consistency & may show area of cystic
degeneration
Difficulties in mastication & talking
Initially tumor is movable but later becomes55
56. Cont.
If deep lobe is affected , a swelling in the
lateral pharyngeal wall or soft palate
Minor salivary gland involvement is common in
palate & lip as smooth surfaced dome shaped
swelling
Histopathologic features
Well - circumscribed , encapsulated tumor
Tumor is composed of a mixture of glandular
epithelium & myoepithlial cells with in a
mesenchyme like background may be myxoid
or chondromatous or hyalinized56
59. Warthin tumor
Papillary cystadenoma lymphamatosum
Affects the parotid glands
Males are affected more
Clinical features
Firm or fluctuant, non- tender , circumscrided
mass in the region of angle or ramus of the
mandible or beneath ear lobe
Common in the tail of the gland
Both side parotid gland affected
59
62. Mucoepidermoid carcinoma
The low grade tumour behaves almost like a
benign tumour with very good prognosis
High grade tumour behaves very aggressively
It occurs with equal distribution between
males& females
Clinical features
More common in parotid gland
It may grow slowly or rapidly
Painless swelling
Ulceration
62
63. Cont.
Facial paralysis
Minor salivary gland tumors are common in
palate & may have bluish hue
Local destruction & metastasis to regional
lymph nodes & distant metastasis to the lung
Histopathologic features
Mucus producing cells & squamous cells
High grade tumors have cellular atypia
63
65. Cont.
Treatment
Surgical excision
For minor salivary glands excision with
surrounding normal tissues
For tumors with metastasis radical resection
with radiation
65
66. Acinic cell carcinoma
A low grade malignancy
Clinical features
Commonly occurs in parotid gland
Common in females
Usually asymptomatic
Commonly affects serous acini
In minor salivary glands it is common in buccal
mucosa, lip & palate
It may be a slow growing swelling
Sometimes pain, tenderness may be there
66
68. Cont.
Histopathologic features
Acinar cell has abundant granular basophilic
cytoplasm & round, darkly stained eccentric
nucleus
Treatment
Tumour confined to the superficial lobe is
treated by lobectomy
Tumour involving deep lobe - parotidectomy
Radiotherapy for severe cases
68
69. Adenoid cystic carcinoma
It is also called cylindroma
Clinical features
Slow growing swelling
Commonly occurs in palatal minor salivary
glands
Commonly occurs in middle aged individuals
Constant , low grade, dull aching pain
Facial nerve paralysis in parotid tumours
Histopathologic features
Islands of basaloid epithelial cells that contain
multiple cylindric , cyst like spaces
69
72. Necrotizing sialometaplasia
It is a locally destructive inflammatory lesion
affecting minor salivary glands
Cause is ischemia of salivary tissues
Clinical features
Commonly occurs in men
Minor salivary glands of the palate, lip or
retromolar pad affected
The lesion occurs as a swelling with
paresthesia then it sloughs leaving large ulcer
or ulcerated nodule
Edge of lesion presents with an inflammatory72
74. Cont.
Histopathologic features
Acinar necrosis
Squamous metaplasia of salivary ducts
Treatment
Debridement by hydrogen peroxide or saline
Application of gentian violet
The lesion is self - limiting one & heals in 6 to
8 weeks
74
75. Sialography
It is a specialized radiographic procedure
performed for detection of disorders of major
salivary glands
Mercury is used as contrast agent
It involves cannulation & filling with a
radiopaque or contrast agent to make them
visible on a radiograph
Indications
Detection of calculi or foreign bodies
75
76. Cont.
Determination of the extent of destruction of
salivary gland tissue secondary to obstruction
such as calculi or foreign bodies
Detection of fistulae , diverticuli & strictures
Detection & diagnosis of recurrent swelling &
Inflammatory processes
Demonstration of tumour ; its size location &
origin
Selection of the site for biopsy
76
77. Cont.
Contraindications
Pt with allergy or hypersensitivity to contrast
media
Acute inflammation of the salivary glands
Pt scheduled for thyroid function test
Technique
Identification of the location of duct orifices
Exploration of the duct with lacrimal probe
Cannulation of the ducts
Introduction of the radiographic dye
77
80. Superficial parotidectomy
Indications
Tumour ; common is pleomorphic adenoma
Massive enlargement secondary to
Sjogren’s syndrome
Calculus in the hilum of gland - calculus is
removed without removal of the gland
Chronic infection
80
81. Cont.
Approaches
Preauricular
Submandibular
Combination of the two
Preauricularincision
Incision is taken in the skin
Platysma & superficial fascia dissected
Duct is identified at anterior border of gland
81
82. Cont.
Duct is followed backward through substance
of gland until calculus identified & recovered
Fascial sheath encasing the gland is closed
completely
Wound is closed in layers
Pressure dressing given
82
83. Complete excision of parotid
gland
In this procedure facial nerve preservation is
difficult so this should be explained to the pt
Y-shaped incision is planned, starting from
the superior attachment of the pinna
downward & anteriorly toward angle of the
mandible & anteriorly , forward till hyoid bone
The second arm of incision is made posterior
to the pinna
Ear lobe is retracted upward & skin flap is
developed on the cheek side of the incision
83
84. Cont.
Superficial lobe is freed from its attachments
Stenson’s duct is located , ligated & cut
Deep lobe is approached
Ligation of external carotid artery & posterior
facial vein is carried out
Facial nerve is then carefully elevated from the
deep portion
Deep portion is gently dissected out of the
retromandibular space
Wound is closed in layers
84
85. Excision of submandibular
gland
An incision , 4to5 cm in length , is taken in the
skin in the submandibular region
Incision is placed in, or parallel to the skin
creases , about 2cm below submandibular
border
Wound is deepened through platysma & deep
fascia
Branches of facial nerve in the field are
identified , mobilized & retracted
Facial vein is identified & ligated
85
86. Cont.
Lower pole of the gland is exposed, grasped
with tissue holding forceps
Facial artery is ligated & divided
Gland is separated from lower border of
mandible
Lingual nerve is dissected
Ligature is passed anterior to ductal pathosis
Second ligature is passed posterior to the first
one , but still anterior to the ductal pathosis&
duct is sectioned between the ligatures
86
87. Cont.
Deep part of the gland is excised
Wound sutured in layers
87
88. Complications of surgery of
salivary glands
Damage to lingual nerve
Damage to Wharton's duct
Damage to Auriculotemporal nerve
Facial nerve paralysis
88