Everything You Need to Know About Salivary Glands

SALIVARY GLANDS

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

CONTENTS
HISTORY
 INTRODUCTION
 CLASSIFICATION
 DEVELOPMENT
 GROSS MORPHOLOGY
 MICROSTRUCTURE
 COMPOSITION
 FUNCTIONS OF SALIVA



HISTORY


Fundamental knowledge of the salivary
glands dates back to the work of
Heidenheim, Pavlov and Langley in 19th
century.


INTRODUCTION


Saliva, one of the several fluids occurring in the
humans, is of paramount importance to the
dentist.



It has many mechanical and chemical functions
and is a fairly sensitive parameter of certain
bodily functions.



The secretions of the major and minor salivary
glands, together with gingival crevicular fluid
constitute oral fluid.



Saliva is a clear, tasteless, odorless, viscid
fluid with slightly acidic ph.



The environment of the oral cavity is to a
large degree created and regulated by
saliva.



Saliva has manifold functions in protecting
the integrity of the oral mucosa.



Hence the knowledge of salivary
glands, secretion and function is important
in diagnosis, treatment planning, and
treatment and in predicting the prognosis.


CLASSIFICATION
1. Major and minor.
 2. Serous, mucous and mixed.
 3. Exocrine and mesocrine.



MAJOR SALIVARY GLANDS


These are the large salivary glands which
are located.



Out side the oral cavity and convey their
secretions by their ductal system.



These include the Parotid gland, Sub
mandibular gland and Sub lingual gland.


MINOR SALIVARY GLANDS


These are smaller salivary glands confined to the
mucous coat of the oral cavity.



These glands usually consists of small groups of
secretary units opening via short ducts directly into
the mouth.



The main function of these glands is not to produce
saliva but to secrete minor amounts of saliva onto the
mucosal surface to keep the mucosa moist.



These include labial glands, buccal glands, palatine
glands, glosso palatine glands, Lingual glands, and
Incisive gland.

SEROUS / MUCOUS AND MIXED
GLANDS


The salivary gland which produces a thin watery
secretion are called a serous gland e.g. parotid
gland.



A mucous gland is one which secretes thick
viscous substance called as mucous e.g. minor
salivary glands.



A mixed gland is one which produces both serous
and mucous secretions e. g. sub mandibular
gland.

EXOCRINE AND MESOCRINE GLANDS


When the secretary product passes
through the cell Walls losing the
cytoplasm, it is called as a mesocrine
gland.



If the secretary product is carried away by
the ducts leading from the gland then that
gland is said to be exocrine gland.


HISTOLOGY


During fetal life, each
salivary gland is formed at
a specific location in the
oral cavity through the
growth of a bud of oral
epithelium into the under
lying mesenchyme.



Resulting in long epithelial
cords that undergo
repeated dichotomous
branching.



The mesenchyme has
condensed around the
developing glandular
epithelium.



Lumen formation has
begun in the ducts.



Branching of the distal
ends of the epithelial
cords is evident.




Connective tissue
septa which are
continuous with the
connective tissue
capsule surrounding
the gland.



They divide the gland
parenchyma into lobes
and lobules.










Ductal system of the
salivary gland.
Main excretory duct opens
into the oral cavity.
Striated are main
intralobular ductal
component.
Intercalated ducts vary in
length and connect the
secretory end pieces to
striated ducts.
Excretory end pieces divide
into smaller interlobar and
interlobular excretory
ducts that enter the lobes
and lobules of the gland.

DEVELOPMENT


The 3 major sets of salivary glandsThe parotid gland,
The submandibular gland and
The sublingual gland.


PAROTID GLANDS


The parotid glands are the first to appear
in the 6th week of intrauterine life at the
inner cheek near the angles of the mouth
and grow back towards the ear.



The duct and acinar system is embedded
in a mesenchymal stroma that is
organized into lobules and becomes
encapsulated.


SUBMANDIBULAR GLAND


The submandibular gland buds also
appear in the 6th week as a grouped
series forming epithelial ridges on either
side of the midline in the floor of the
mouth.



The mesenchymal stroma separates off
the parenchymal lobules and provides the
capsule of the gland.

SUBLINGUAL GLANDS


The sublingual glands arise in the 8th
week of intrauterine, as a series of about
ten epithelial buds just lateral to the
submandibular region.



These branch and canalize to provide a
number of ducts opening independently
beneath the tongue.


MINOR SALIVARY GLANDS


A great number of smaller salivary glands arise
from the oral ectodermal and endodermal
epithelium, and remain as discrete acini and
ducts scattered throughout the mouth.


GROSS
MORPHOLOGY


PAROTID GLAND


Parotid glands provide 60-65%
of total salivary volume.



Each parotid gland is pyramidal
in shape.



Location:
Superficial portion is located
subcutaneously in front of the
external ear.
Deeper portion lies behind the
ramus of the mandible.
The base of the pyramid is
rhomboidal and lies immediately
beneath the skin.



Each gland weighs about 25g.



A dense fibrous capsule
separates the gland from other
structures.



The superficial surface of the parotid gland (The
base of the pyramid) is defined by the zygomatic
arch, external auditory meatus, and just behind
and below the angle of the mandible.



The gland extends into the groove between the
mandibular ramus and sternocleidomastoid
muscle to reach the styloid process and
associated muscles which separate the gland
from the internal carotid artery and jugular vein.




The external carotid artery enters the glands and
divides into terminal branches.



The facial nerve also passes through the
gland, dividing close to the anterior border.



The main parotid duct (Stensen’s duct) leaves
the mesial angle of the gland to traverse over the
masseter muscle and turn abruptly to enter the
buccinator muscle prior to opening into the oral
cavity in a small papilla close to the buccal
surface of the maxillary first molar tooth.

SUBMANDIBULAR GLAND


The submandibular gland
produces about 20-30% of
the total salivary volume.



The glands are
irregular, walnut in
shape, with the superficial
inferior portion in contact
with the skin and platysma
muscle.



Laterally, the gland is in
contact with the
mandibular body and
medially with the extrinsic
tongue and mylohyoid



There may be a
small, deeper portion
of the gland between
the
mylohyoid, hyoglossus
and styloglossus
muscles.



This part of the gland
extends forwards and
inwards above the
posterior edge of the
sublingual gland. www.indiandentalacademy.com



After leaving the superficial
part of the gland, the duct
(Wharton’s duct) passes
beneath the deep part,
between the mylohyoid
and hyoglossus muscles
and between the
sublingual gland and
genioglossus muscle to
end at the summit of the
sublingual papilla at the
side of the lingual
frenulum.



The tortuous duct is
approximately 5 cm long.

SUBLINGUAL GLAND


The sublingual glands are
the smallest of the major
salivary glands; the
produce 2-5% of the total
salivary volume.



Each is of the size and
shape of an almond and
weighs 3-4 Gms.



The glands lie immediately
beneath the oral mucosal
lining of the mouth
floor, raising a small fold
on either side of the www.indiandentalacademy.com
tongue.



The glands rest on the
mylohyoid muscle, being
lateral to the mandible and
medial to the genioglossus
muscle.



This gland has a series of
small ducts (Bartholin’s
ducts) that open on the
surface of the sublingual
folds on either side of the
tongue.


MINOR GLANDS (Accessory glands)


Anterior Lingual Glands:
These two irregular glandular
groups lie on either side of the
frenulum on the under-surface of
the tongue, with several ducts
piercing the overlying mucosa.



Serous glands of von Ebner:
These are small glands whose
ducts open into the sulci of the
circumvallate papillae.



Lingual, buccal, labial and
palatal glands:
They are small glands with short
ducts, producing secretions rich
in mucoproteins.They are found
scattered over the surface of the
tongue, inside of the lips and
cheeks, and in the mucosa
covering the hard and the soft
palate.

BLOOD SUPPLY


The blood supply to the parotid is derived from
the facial and external carotid arteries.



The facial and lingual arteries supply the
submandibular gland.



The sub mental and sublingual arteries supply
the sublingual gland.



Venous drainage of all the glands is mainly
through the external jugular vein.

NERVE SUPPLY


Parotid: the parasympathetic nerve supply to the
gland is mainly from the I X nerve
(Glossopharengeal nerve). The pre ganglionic
fibers synapse at otic ganglion and the post
ganglionic fibers reach the gland through the
Auriculotemporal nerve.



Sub mandibular: the parasympathetics derived
from the facial (VII) nerve reach the gland
through lingual nerve and submandibular
ganglion.




Sub lingual: facial nerve provides
parasympathetics via lingual nerve & sub
mandibular ganglion.


MICROSTRUCTURE


The structure of the salivary glands is similar to other
exocrine glands, comprising a series of secretory units
(acinar cells) clustered around a central lumen.



These acini comprise the terminal or secretory end-piece of
the gland, situated farthest from the oral cavity.



They are supported by the myoepithelial cells and a
basement membrane.



From each acinus, secretions pass to a series of
interconnected ducts before passing out through the major
salivary duct into the oral cavity.




Each acinus comprises a series of
polygonal cells on a basement membrane
central around a central ductal lumen.



The acinar cells are classified histologically
into two types – serous cells and mucous
cells according to their appearance after
staining with eosin and hematoxylin i.e.
this in a histochemical term rather than a
functional description.

SEROUS CELLS


They stain blue.



These cells make up most of the acini of the parotid gland and of von
ebner.



They are large and polygonal in shape.



They are characterized by a nucleus lying towards the basement
membrane.



These cells contain extensive endoplasmic reticulum and many
mitochondria.



In the luminal portion of the cells are granules and vacuoles which fill up
during resting periods but discharge by exocytosis on stimulation.



Some of these can be shown to contain amylase.




In the luminal portion of the cells are granules
and vacuoles which fill up during resting periods
but discharge by exocytosis on stimulation.



Some of these can be shown to contain amylase.



These cells produce a secretion much less viscous
or more serous than the secretion of the other
glands.



Hence the term serous cells.

MUCOUS CELLS


Predominantly pink staining cells.



Since their staining properties resemble
those of other cells elsewhere which
produce mucoid substances and since the
secretions of these cells are viscous and
rich in protein – carbohydrate
complex, they have been referred to as
mucous cells.



The acinar cells of the submandibular and
sublingual glands are said to comprise mucous
cells.



The general form and appearance of mucous cells
is not dissimilar to that of serous cells.



Mucous cells show more areas of smooth parallel
cisternae and have larger secretory vacuoles.


INTERCALATED DUCT CELLS


The secretions pass from the acinus to a
short intercalated duct.



These cells tend to be cuboidal, with large
central nucleus.



The duct lining cells are closely
interdigitated.


STRIATED DUCT CELLS


The intercalated duct then pass abrupt
into another short but wide striated duct.



The striated duct is lined by cells which
are much more columnar than the cells of
the intercalated duct.



These cells have marked cellular
membrane interdigitations projecting
towards the lumen.



These striated ducts then pass abruptly
into two epithelial cell layered excretory
ducts and finally to the stratified
squamous epithelial cell lined terminal
duct.


MYOEPITHELIAL CELLS


These cells constrict the acini and ducts to
felicitate the salivary secretory flow.



In myoepithelial cells the nucleus lies in a
broader part of the cell and is surrounded by
mitochondria and strands of endoplasmic
reticulum.



The remainder of the cells consists of
longitudinally arranged myofibrils.


SALIVA


Saliva is clean, tasteless, odorless, slightly
acidic vicious fluid, consisting of secretions
from the parotid, sublingual,
submandibular salivary glands and the
mucous glands of the oral cavity.


COMPOSITION


Total amount: 1,200 – 1500 ml in 24
hrs.



Consistency: slightly cloudy, due to
presence of cells and mucin.



Ph: usually slightly acidic (ph 6.02 – 7.05)


SALIVA
Solids (0.5%)

Water (99.5%)
Organic (0.3%)

Inorganic (0.3%)

-globulin
Ptyalin
Mucin
Kallikrein
Bradykynin
Lysosome
Immunoglobulin IgG
Blood group antigen
Nerve growth factor
Vit C and vit K.
Urea and uric acid.
Cellular components


Cat ions

Na+
K+
Ca++
Mg++
Fluoride

ClHCO3PO4Thiocyanate

ORGANIC COMPONENTS


1) Salivary proteins: mucins, statherins, histatins, immunoglobulin



2) Digestive enzymes: α – amylase, lipase, peroxidase,
lactoferrins, cystatins.



3) Carbonic anhydrase.



4) Intrinsic growth factors: EGF (epidermal growth factors)
TGF α β (transforming growth factor).



5) Circulating adrenal glucocorticoids: Coritsol.



6) Sex hormones in blood: Estriol.



7) Blood glucose in lower levels.



8) Blood group substances from A B O groups.



9) Buffering action of saliva.


etc.

INORGANIC COMPONENTS









Sodium (Na +)
Potassium (K +)
Hydroxyapatite & calcium phosphate salts.
Chloride (Cl -)
Magnesium (Mg 2+)
Thiocynate (SCN -)
Fluoride and
Carbonic acid (Hco 3 - )


FUNCTIONS OF SALIVA


Saliva protects the teeth & esophageal mucosa through a
number of mechanisms; it maintains the integrity of these
tissues.



Saliva functions in relation to digestion in the upper GIT.



It facilitates food intake by dissolving food taste
substances.



It clears and dilutes the food detritus and bacterial matter.



It rinses the mouth and lubricates soft tissues.



Finally it facilitates mastication, swallowing and speech.

PROTECTIVE FUNCTION


Water in saliva mechanically cleanses the mouth and
clears the food and microbes.



Water, mucins, glycoproteins helps in lubrication of
oral surfaces.



Epidermal growth factors and nerve growth factors
help in maintaining mucosal integrity and coating.



Cystatin, histatin, proline rich proteins, statherins
calcium and phosphate salts all are helpful in tooth
mineralization.



Bicarbonates, phosphates and proteins helps in
buffering properties of saliva.

ANTI MICROBIAL FUNCTION


Amylases, cystatins, hystatins, mucins, lysozym
e, lactoferrin, calprotectin, I g, chromognanin A
etc serves as ANTI BACTERIAL substances.



Histatines, immunoglobulin, chromognannin A
has ANTI FUNGAL properties.



Secretary leukocyte protein ease inhibitor, cyst
tines, mucins etc. serves as ANTI VIRAL
substances.

DIGESTION AND SPEECH


Formation of bolus, mastication &
swallowing is done by water and mucins.



Water, mucins, lipases, ribonucleases, pro
teases help in initial digestion.



Gustine, zinc and water helps in taste.



Water and mucin helps in speech.

Thank

SALIVARY GLAND DYSFUNCTION /
HYPERSALIVATION / HYPOSALIVATION AND
XERSTOMIA:


A salivary gland is said to be dysfunctional when
there is qualitative and quantitative change in the
output of saliva secretion.



This dysfunction may cause either hyper
salivation or excess of salivation and hypo
salivation or less salivary out put.



Xerostomia is a condition resulting due to
hyposalivation and change in saliva composition
which is a subjective feeling of dry mouth.

HYPERFUNCTIONAL SALIVARY GLAND
(OR) HYPERSALIVATION


This is relatively uncommon in adults and is also known as
“SIALORRHEA”.



This may be idiopathetic or caused by mucosal irritation.



Clinically drooling of saliva occurs as a result of under lying
neurological disorder.



Problem lies in decrease swallowing efficiency and
frequency and is rarely related to a genuine salivary hyper
function.



Drooling causes severe problem to patients, like it can
cause maceration of the skin at the angle of the mouth and
chin followed by colonization of opportunistic infections.






Drooling may also be seen in mentally handicapped patients and
also as a side effect to neuroleptic drugs.
Examples : Cerebral palsy,
Myotropic lateral sclerosis,
Parkinson’s disease.
Other causes for sialorrhea are:
Acute inflammation of oral mucosa
Fractures of jaw bones
During eruption of teeth in infants
Schizophrenia
Epilepsy
Acrodynia (mercury poisoning)
Rabies
Familial dystonias.


HYPOFUNCTIONAL SALIVARY GLAND
(OR) HYPOSALIVATION


Hypo functional salivary gland results in
decreased salivary flow rate and also a change in
the composition of formed saliva.



This results in a subjective feeling of dryness in
the mouth which is referred as `XEROSTOMIA’ or
`DRY MOUTH’.


XEROSTOMIA


This condition may occur due to reduced salivary
flow or a change in salivary composition.



Xerostomia is sometimes colloquially called
PASTIES or COTTONMOUTH (this referred
especially when occur as a side effect of smoking
marijuana or during hangover.


CAUSES


It may be a sign of underlying disease such as
Sjogrens syndrome,
Poorly controlled diabetes,
Eaton- Lambert syndrome.



Other causes may include side effects of drugs,
medications, or alcohol, trauma to the salivary
glands or their ducts or nerves.



Dehydration, excessive mouth breathing and
previous radiation therapy.

Etiology


Iatrogenic causes: Drugs & Medicines such as Atropine.



Auto immune diseases: Rheumatoid arthritis, sjogrens
syndrome, sarcoidosis.



Neurological disorders: Mental depression, Cerebral palsy, Bell’s
palsy.



Infections: like HIV, Hepatitis C infection, Epidemic parotitis etc.



Other conditions involving:
Parotidectomy procedures,
Impaired mastacatory
performance,
Menopause and
Aplasia of gland.

SIGNS AND SYMPTOMS
Patient usually experiences the following signs and symptoms
they are as follows.


Oral mucosal dryness and soreness.



Burning oral sensation.



Dysphonia ( difficulty in speech ).



Dysphagia ( difficulty in swallowing ).



Difficulty in chewing the food.



Dysgeusia or Hypogeusia ( impairment of taste ).

ORAL COMPLICATIONS ARISING DUE
TO XEROSTOMIA


Dental caries which involves smooth surfaces &
root surface of teeth which are difficult to
control and are parallel to rampant form of
caries.



Candidial super infections which causes
Burning, taste changes, intolerance to
spices, mucosal errythema and angular
stomatitis.



Ascending sialdenitis present with pain and
swelling of major salivary gland and sometimes
present with purulent discharge from the duct.

DIAGNOSIS


SIALOMETRY: Deals with estimation of salivary flow rates
by draining method.



SIALOGRAPHY : Non specific test, in which a radio opaque
dye is injected into the duct (such as iodine based dye).
And a radiograph is taken which shows if the duct is
constricted, dilated or there is any calculus formation.



SALIVARY SCINTISCANNING:
Non invasive procedure, examines all major salivary glands
Technetium-99 is used which emits gamma radiation, and
is associated with small amount of radiation hazard and is
expensive procedure, not always used.




IMAGING:
Chest radiography to rule out sarcoidosis.
Ultrasonography to exclude sjogrens
and neoplasm
MRI scanning to exclude sjogrens.



SALIVARY GLAND BIOPSY:
To rule out suspicion of organic disease of
salivary glands
If the dry mouth condition has no evidence of
reduced flow or salivary gland disorder, then
there may be a Psychological reason for the
complaint.

MANAGEMENT OF XEROSTOMIA AND
HYPOSALIVATION


The prevalence of xerostomia and its negative
effect on the patient’s quality of life make it likely
that the practitioner will encounter this condition
on regular basis.



General approach for management is directed at
palliative treatment for relief of symptoms and
prevention of oral complications.


PALLIATIVE TREATMENT






Any under lying cause of xerostomia should if possible, be
rectified such as diabetes, drugs etc.
Avoiding factors that may increase dryness such as,
Hot dry environment
Dry food such as biscuits
Drugs like tricyclic anti depressants
Alcohol including mouth washes with alcohol
Smoking etc.
Use of humidifiers at nights, application of lip balms, olive
oil, and vit E to keep the mucosa moist.




Application of petroleum derived lubricants like Vaseline should be
avoided.



Saliva substitutes may help symptomatically such as
water sipping frequently
Application of ice chips
Use of synthetic substitute



Home made preparation of saliva substitute consists of using a
teaspoon of



Glycerin in 8 ounce of water.



Use of salivary flow stimulants like chewing a sugarless chewing
gum, biotin dry mouth gum, xylifresh and sugar less candies,
Salix lozenges and simply application of citric acid on the lateral
borders of tongue.

SALIVA SUSTITUTES AND ORAL
LUBRICANTS


Over the counter formulations like
solutions, sprays or gels are useful.



Formulations containing carboxymethyl or
hydroxymethyl cellulose, electrolytes and
flavoring agents are used. These substitutes
provide relief for only limited time. And are most
useful when used immediately before bed time or
speaking.




Salivary replacements or artificial saliva substitutes
available as,

1. Gladosane & luborant ----sodium carboxyl methylcellose
base available as spray.
2. Oral balance & wet mouth ----- lactoperoxidase, glucose
oxidase and xylitol.
3. Saliva orthana ------- mucin spray containing fluoride.
4. Salivase ------ sodium carboxyl methyl cellulose base as
spray.
5 Others like Moi-stir, mouth kote, xero- lube Etc.



Cholinergic drugs and Sialogogues: these may
alter the cardiac conduction and should be
avoided in patients who have heart disease. Also
contraindicated in patients with asthma, narrow
angle glaucoma and acute iritis.
Examples include, CEVIMELINE and
PILOCARPINE 5 -10 mg 3 to 4 times/day.



Pilocarpine available as SALGEN 5mg given 3
times /day with food. This has potential side
effects as, reduces eye sight, and contraindicated
in pregnancy, asthma, and glaucoma.

DISEASES AND DISORDERS OF
SALIVARY GLANDS
1. DEVELOPMENTAL ABNORMALITES: Aplasia
Agenesis
Hypoplasia
Aberrant glands
Accessory ducts
Diverticuli
Dariers disease
2. SALIVARY RETENTION DISORDERS:
Silolithiasis
Mucoceles
Ranula
3. INFLAMMATORY AND REACTIVE LESIONS:
Necrotizing silometaplasia
Radiation induced pathology.
Allergic sialadenitis
4. VIRAL AND BACTERIAL DISEASES:
Mumps (Epidemic parotitis)
Cytomegalovirus infection
HIV infection
Hepatitis C virus infection
Bacterial sialadenitis
5. SYSTEMIC CONDITIONS WITH SALIVARY GLAND
INVOLVEMENT:
Granulomatous conditions like
Tuberculosis
Sarcoidosis.
Neoplasms

7. SALIVARY GLAND TUMORS;
BENIGN TUMORS – Pleomorphic adenoma
Monomorphic adenoma
Oncocytoma
Basal cell adenoma
Myoepithelioma
Ductal papilloma
Papillary cystadenoma
Lymphomatosum
MALIGNANT TUMORS – Mucoepidermoid carcinoma
Adenocystic carcinoma
Acinic cell carcinoma
Adenocarcinoma
Lymphoma

8. ABSENCE OF GLAND TISSUE DUE TO SURGERY /
TRAUMA:
Parotidectomy procedure
Sub mandibular, sublingual and minor gland surgery
9. METABOLIC CONDITIONS:
Diabetes
Anorexia nervosa
Bulimia
Chronic alcoholism

6. IMMUNE CONDITIONS:
Benign lymphoepithelial lesion MIKULICZ’S DISEASE
Sjogrens syndrome.

DEVELOPEMENTAL
DISORDERS
APLASIA : Refers to lack of origin or development of salivary gland.
AGENISIS: Is the defective or incomplete development of gland (or)
congenital absence of parts of an organ.
HYPOPLASIA: Refers to defective or incomplete development of any tissue or
structure.
ABBRENCY: Refers to deviation from usual or normal course, location, or
action.
ACESSORY DUCTS: These are very common finding and usually do not
require any treatment.
DIVERTICULI: By definition, diverticula’s is a pouch or sac protruding from
the wall of the duct.
DARIERS DISEASE: It is also called as Keratitis follicularis or Darier white
disease.

II. SALIVA RETENTION DISORDERS
A) SIALOLITHIASIS:
Sialoliths are calcified and organic matter that develops in the
parenchyma or ducts of major and minor salivary glands.
Etiology: is unknown, but several factors contribute to the stone
formation such as inflammation, irregularities of duct
system, local irritants and anti cholinergic medications which
cause pooling of saliva within the duct and promotes stone
formation.
Structure and composition: Sialoliths are crystalline in structure and
composed of primarily Hydroxyapatite, calcium phosphate and
carbon, with traces of magnesium, potassium chloride and
ammonium.

Site: 80 to 90 % involved in sub mandibular glands followed by 5 to
15 % in parotid and 2 to 5 %in sub lingual or minor salivary
glands.

CLINICAL MANIFESTATIONS


Patient presents with the history of painful, intermittent
swelling of gland depending on extent of ductal obstruction
and presence of secondary infection.



Typically eating will initiates the swelling of gland. The
stone totally or partially blocks the duct thus causing poling
of saliva in ducts and the body of glands.



Involved gland is usually enlarged and tender. Stasis of
saliva will lead to infection, fibrosis, and gland atrophy.



Fistulas, sinus tracts or ulcerations may occur over the
stone in chronic cases



Palpation along the pathway of duct may confirm the
presence of stone.

DIAGNOSIS


Diagnosis is confirmed by radiological
examination, bimanual palpation, and clinical signs and
symptoms.



An occlusal view of sub mandibular gland is recommended
for diagnosing stones and is difficult in cases of parotid due
to super impositions of other anatomic structures so for
parotid an anteroposterior view of face is useful.



CT has 10 times the sensitivity of plain film radiography for
detection of calcifications



Calcified phelboliths are stones that lie within blood vessels
can be mistaken for sialoliths radiologically, but the fact is
phelboliths occur outside the ductal structure, and
sialography can therefore aid in differentiating these
lesions.



FNAC of gland help as diagnostic tool for those who donot

TREATMENT


During acute phase; ------- supportive therapy with
analgesics, hydration, antibiotics & antipyretics are necessary.



In pronounced exacerbations ----- surgical intervention of drainage is some times
required; stones at orifices of ducts are removed intraorally by milking the gland.



Deeper stones require surgery after acute phase subsides surgery should be planned
depending on location of stone.



If stone is seen in glandular tissue, then total gland is removed. If removed from
ductal approach 75% of patients recover with normal functioning gland.



A non invasive treatment for sialoliths called as LITHOTRIPSY is gaining popularity
nowadays.



Currently ultrasonography is used to locate the stone and extra corporeal lithotripsy
to fragment the stone is used.



Stone with > 2mm diameter is only visible by ultrasonography.



Complications with this treatment include, transient hearing loss, hematoma at site &
pain

B) MUCOCELES


Mucocele is clinical term that
describes swelling caused by
the accumulation of saliva at
the site of a traumatized or
obstructed minor salivary
gland duct or it can be due to
simply due to obstructed
salivary gland duct.



Mucoceles can be classified as
EXTRAVASATION type and
RETENTION type.



A large mucocele in the floor
of the mouth is called as
RANULA.

ETIOLOGY


Extravasation type of mucocele is believed to be the result
of trauma to a minor salivary gland excretory duct.



Laceration of duct results in pooling of saliva in the
adjacent sub mucosal tissue and consequent swelling.



Retention type is caused by obstruction of minor gland duct
by calculus or contraction of scar around an injured duct



The blockage of salivary flow causes the accumulation of
saliva and dilation of the duct, so eventually an aneurysm
like lesion forms which is lined by epithelium of the dilated
duct.


CLINICAL FEATURES


Extravasation type commonly occur in lower lip where trauma is
common followed by buccal mucosa, tongue, floor of the
mouth, retro molar area etc.



Mucous retention cysts are commonly found on the palate or floor
of the mouth.



Mucoceles often present as discrete pain less smooth surfaced
swellings that can range from a few mm to a few cm in diameter.



Superficial lesions have a characteristic blue hue.



Deeper lesions may be more diffuse and covered by normal
mucosa with out blue hue.



The lesions may vary in size over time.


TREATMENT


Surgical excision, to prevent recurrence removal
of associated minor salivary gland is essential.



Aspiration of fluid does not provide long term
benefit.



Intra lesional injections with corticosteroids are
helpful to treat mucocele.


C) RANULA




May be extravasation or retention types.
Seen in floor of the mouth as a large mucocele.
Associated with sub lingual salivary gland duct.

Etiology:
 Considered due to trauma, commonly and less
commonly due to retention of saliva due to
obstruction or aneurysm.
 A sarcoid associated ranula is also reported.


CLINICAL FEATURES


As name suggests it resembles the swollen belly of a frog.



Lesion present as painless, slow growing, soft movable
mass located in the floor of the mouth.



It is formed on one side of lingual frenum, some times
crosses the mid line.



Ranulas have typical bluish hue.



Deep lesions terminate through mylohyoid muscle and
extend along the facial planes referred to as plunging
ranula. And can become large, extending into neck.

TREATMENT


Surgical marsupilisation procedures unroof the
lesion and are the treatment of choice in smaller
lesions.



Excision in case of large lesions and also in
recurrence.



Intralesional injections of corticosteroids are
successful.


III. INFLAMMATORY REACTIVE
LESIONS
A) NECROTISING SIALOMETAPLASIA:


Begnine self limiting reactive inflammatory disorder of salivary gland
tissue.



Clinically mimics malignancy, failure to recognize leads to unnecessary
radical dissection.



The condition is initiated by local ischemic effect.



Clinically has rapid onset, occur in palate, retro molar pads and lips.



Lesions are tender, erythematous nodules with breakdown of mucosa and
formation of deep ulcerations with yellow base.



Pain is of moderate and dull aching type and reported along with inducing
vomiting as in case of bulimia.


TREATMENT


Biopsy and detail history reveals necrosis of gland, pseudo
epithelimatous hyperplasia of mucosal epithelium.



Squmaous metaplasia oe salivary ducts are seen. No
malignant cells and lobular architecture is preserved even
tough necrosis is evident.



It is usually self limiting disease lasts approximately 6
weeks, and heals by secondary intension.



No specific treatment is required, but debridment and
saline rinses may help in healing process.


B) RADIATION INDUCED PATHOLOGY
Doses of >= 50 Gy will result in permanent salivary gland
damage, and symptoms of oral dryness.
Clinical manifestations:
 Acute effects of salivary gland function can be recognized
within a week of beginning treatment at doses of
approximately 2 Gy daily and patient usually complains of
oral dryness by the end of second week.


Mucositis is very common condition. > 50 Gy results in
salivary dysfunction and severe and permanent damage.



Difficulty in speaking, dysphagia and increased incidence of
dental caries etc, will dramatically affect the quality of life.



Saliva is thick and ropy and is very minimal.



Rapidly advancing caries occurring at incisal or
cervical aspects of teeth and wrap around the
teeth in an apple core fashion is termed as
radiation induced caries due to hypo salivation.



Other complications like candidiasis and
siladenitis occur.



Risk of osteoradionecrosis and salivary gland
neoplasm do occur in patients with post
radiation.

TREATMENT


Radiation planning is key to the effective preservation of
the gland, as 3D conformal radiation therapy proposed by
Eisbrush and colleagues limits salivary exposure by 50%.



Radio protective agents limit radiation therapy induced
salivary gland damage.



Agents like AMIFOSTINE (approved by food and drug
administration) scavenge the free oxygen radical’s formed.



Daily prescription strength of topical fluoride is
recommended to help control caries.



Alternate medicine therapy like acupuncture, chi gong and
herbal medications are reported to increase the salivary
flow in xerostomic patients.

C) ALLERGIC SIALADENITIS


Enlargement of salivary gland tissue due to various
pharmaceutical agents and allergens without rash or other signs
of allergy are reported as allergic sialadenitis.



Characteristically acute salivary gland enlargement accompanied
by itching over the gland is a path gnomic feature.



Compounds which have sialadenitis as potential side effect
include,
Phenobarbital
Phenothiazine
Ethambutol
Sulfisoxasole
Iodine compounds
Isoproterenol and
Heavy metals.



It is a self limiting disease, avoiding allergens and maintaining
hydration and monetering secondary infections are recommended
treatment protocols.

SALIVARY GLAND IMAGING


I. ULTRA SONOGRAPHY.



II. SIALOGRAPHY.



III. RADIO NUCLIOTIDE SALIVARY IMAGING OR
SCINTIGRAPHY.



IV. COMPUTED TOMOGRAPHY (CT).



V. MAGENETIC RESONANCE IMAGING (MRI).



VI. PANAROMIC RADIOGRAPHY AND OCCLUSAL
RADIOGRAPHY.

Thank you
Leader in continuing dental education


Everything You Need to Know About Salivary Glands

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