Salivary Gland Disease

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Salivary Gland Disease

• Dent 451
• Lecture 6
• Dr. Jumana Karasneh

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Functions of Saliva

1. Lubricant ? coat protect mucosa
2. Cleanses the teeth
3. Ion reservoir ? remineralization
4. Buffer ? neutralizes PH
5. Antimicrobial ? IgA Enzymes
6. Pellicle formation
7. Digestion ? amylase
8. Facilitates taste ? by acting as solvent
9. Water balance ? stimulate need for fluid intake

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Saliva

• Resting salivary flow
• Submandibular ? 65
• Parotid ? 15-20
• Sublingual minor ? 7-8
• Stimulated salivary flow
• Parotid (rich in amylase)? 45-50
• Diurnal variation in salivary flow
• 0.3 ml / min day time
• 0.1 ml / min sleep time
• Daily flow rate 500-600 ml /day

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Anatomy Physiology

• Parotid
• Serous
• Sublingual
• Mucous
• Submandibular
• Mixed
• Minor salivary glands
• Controlled mainly by parasympathetic

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Anatomy of parotid gland

• Largest salivary gland
• Front of ear behind
• mandibular ramus
• Apex is deepest part
• Facial nerve
• Stensons duct covered by parotid papilla
  opposite second molar

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Anatomy of submandibular gland

• ½ the size of Parotid
• Wedged between body of mandible mylohyoid
  muscle
• Whartons duct opens into sublingual papilla
  lateral to lingual frenum

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Anatomy of sublingual gland

• Smallest gland
• Below floor of the mouth beneath sublingual fold
• Numerous sublingual ducts open in the mouth

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Assessment of the salivary gland1- Examination -
Parotid

• Visual examination by standing behind the Pt
• Palpate the gland
• Stand in front of pt
• 2-3 fingers over the posterior border of
  ascending ramus
• Back word inward movement with light pressure
• Slightly rubbery
• Painless unless infected/inflamed
• Check motor function of facial nerve
• Intraoral examination to check papilla if
  inflamed
• Compress the gland to see saliva flow

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Assessment of the salivary gland1- Examination -
submandibular

• Palpate below angle body of mandible
• Bimanual palpation
• Intraoral examination to
• check papilla if inflamed
• Compress the gland to see saliva flow

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Assessment of the salivary gland 2- Sialometry

• To measure salivary flow rate (resting /
  stimulated)
• Carlson-Crittenden collector for individual gland
• Whole saliva flow rate determined under
  standardized conditions
• Changes in salivary flow rate in an individual is
  more informative than a single measure
• Unstimulated whole saliva flow rate 0.3 ml/min
• Stimulated whole saliva flow rate 1-2 ml / min

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Assessment of the salivary gland 3- Salivary
gland imaging

1. Plain-film radiography
2. Sialography
3. Ultrasonography
4. Scintigraphy (Radioisotope imaging)
5. Computed tomography (CT)
6. Magnetic resonance (MRI)

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Assessment of the salivary gland 3- Salivary
gland imaging Plain-film radiography

• Used for calculi (NOT ALL RADIO-OPAQUE)
• Two views at 90?
• Parotid
• OPG / Oblique - lateral
• Rotated anterior-posterior
• Submandibular
• Occlusal
• OPG
• Lateral oblique

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Assessment of the salivary gland 3- Salivary
gland imaging Sialography

• Radiographic visualization of the ducts by a
  retrograde injection of a water-soluble contrast
  dye.
• Provides image of stones and duct morphological
  structure
• May be therapeutic.
• Demonstrate 3 phases
• Preoperatively
• Filling phase
• Emptying phase

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Sialography continued

• Disadvantages
• Irradiation dose
• High skill is needed to conduct the procedure
• Pain with procedure
• Possible perforation
• Push stone further
• Contraindications
• Acute infection
• Calculus close to duct opening
• Allergy to contrast media

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Assessment of the salivary gland 3- Salivary
gland imaging Scintigraphy (radioisotope)

• Indications To assess salivary gland function
• Pass through 3 stages
• Flow phase 15-20 sec
• Concentration phase up to 10-15 min
• Symmetrical distribution in parotid,
  submandibular
• Washout phase
• Pt is given a lemon juice drop
• Prompt, uniform symmetric emptying

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Assessment of the salivary gland 3- Salivary
gland imaging Ultrasonography

• Shows superficial part of gland
• Indications
• Differentiate between extra intra glandular
  mass
• Differentiate between cystic solid lesion

Hypoechoic benign tumor
Echogenic sialolith
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Assessment of the salivary gland 3- Salivary
gland imaging Magnetic resonance imaging (MRI)

• Indications
• Suspected salivary gland tumour
• Proximity of the lesion to facial nerve
• Contraindications
• Paediatric cases
• Claustrophobic
• Mentally physically challenged

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Assessment of the salivary gland 3- Salivary
gland imaging Computed tomography (CT)

• Indications
• Sialolith
• Osseous erosions sclerosis
• To differentiate cysts from abscess
• CT Vs MRI

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Assessment of the salivary gland 4- Salivary
gland biopsy

1. Labial minor salivary gland biopsy
2. Sjögrens syndrome
3. Amyloidosis
4. FNA
5. Major salivary gland mass
6. Major salivary gland biopsy
7. Extra-oral
8. High morbidity

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Assessment of the salivary gland 5-
Sialochemistry
Monitoring Condition
Blood groups Forensic medicine
Drug levels Lithium, methadone, digoxin
Detection of drugs Alcohol, amphetamines, benzodiazipine, opioid
Hormones Cortisol, testosterone
Antibody detection HIV infection, measles, mumps,
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Salivary Gland Disease

• Dent 451
• Lecture 7
• Dr. Jumana Karasneh

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Specific diseases disorders of salivary glands

1. Sialadenitis
2. Sialosis
3. Necrotizing sialometaplasia
4. Sarcoidosis
5. HIV- associated salivary gland disease
6. Salivary gland tumours
7. Disturbance of salivary flow
8. Xerostomia
9. Sjögrens Syndrome

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Sialadenitis

• Inflammation of salivary gland
• Bacterial
• Viral (Mumps)
• Allergic
• irradiation
• Usually affect major salivary glands but minor
  might be affected
• Sjögrens
• Necotenic stomatitis

Infective
Non-infective
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Bacterial sialadenitis

• Usually secondary to localized or systemic
  predisposing factors
• Reduction in salivary flow due to localized
  (calculus) or systemic casus (Sjögrens)
• Low immunity
• Clinical picture
• Sudden onset (acute)
• Gland is painful , swollen indurated
• Erythematous overlying skin
• Purulent discharge from orifice
• Chronic form might follow resolution of acute
  infection or start as chronic
• Recurrence if inadequately treated or persistent
  predisposing factor

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Bacterial sialadenitis

• Treatment
• Antibiotics after culture and sensitivity, if not
  possible use flucloxacillin 500mg (1x4x5-7d)
• Milk the gland several times a day (not during
  acute phase)
• Increase hydration use of Sialogogue
• Improve oral hygiene
• Remove predisposing factor if possible (calculus)
• Excision of severely damaged gland (chronic/
  recurrent)

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Allergic sialadenitis

• Caused by drugs or allergens
• Clinical presentation
• Acute salivary gland enlargement
• Itching over the gland
• With/without rash
• Treatment
• Self-limiting
• Avoid allergen
• hydration

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Sialosis

• Painless non-inflammatory, non-neoplastic
  swelling of salivary glands
• Parotid is most commonly affected and commonly
  bilateral
• Unknown mechanism
• Histologically presented as hypertrophy of serous
  acini

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Sialosis

• Predisposing factors
• Drug induced (antirheumatic, idoine containing
  drugs, adrenergic)
• Hormonal (Diabetes, acromegaly)
• Nutritional deficiency induced by anorexia
  nervosa
• Chronic alcoholism
• Medication induced salivary dysfunction

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Sialosis

• Management
• Detailed drug history
• Liver function test
• Blood glucose level
• Growth hormone level
• CBC and full blood investigation

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Necrotizing sialometaplasia

• Benign changes in form of the cells taking a more
  squamous morphology
• More common in males and smokers
• Results from vasculitic phenomenon (ischaemia)
  leading to necrosis of minor salivary glands
• Unknown etiology with reports of LA role
• Self-limiting

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Necrotizing sialometaplasia

• Clinical presentation
• Red nodule
• Deep ulcer with rolled margin
• Necrosis
• Moderate dull pain
• 6-8 weeks

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Sarcoidosis

• Chronic granulomatous disorder affecting several
  organs
• Lungs
• Skin
• Eyes
• Parotid glands
• Severity and duration of disease varies
• Saliva flow would be affected
• Mild improvement noticed with steroid therapy

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HIV-associated salivary gland disease

• HIV patient usually develop salivary gland
  problems and xerostomia
• Swelling of parotid might be caused by
• Sjogren-like condition
• Kaposis sarcoma
• Lymphoma
• Viral infection
• Chronic parotitis

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Salivary gland tumors

• Majority of tumors occur in the parotid, 10 in
  minor salivary gland
• Most minor salivary gland tumors occur in the
  junction between hard and soft palate, 20 in the
  lip
• WHO classification of salivary gland tumours
• Benign Tumors
• Pleomorphic adenoma
• Malignant Tumors
• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma

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Salivary gland tumors

• Pleomorphic adenoma
• Slowly growing
• Firm consistency
• Normal overlying mucosa
• Painless and doesnt ulcerate unless traumatized
• Signs of malignancy
• Rapid aggressive growing
• Ulceration
• Usually nature of tumor is unpredictable ? biopsy
  ? diagnosis achieved by histological examination
• Adenomas of minor salivary gland should be
  excised with safety margin

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Disturbance of salivary flowXerostomia

• Subjective feeling of oral dryness
• Not associated with salivary hypofunction
• Sensory or cognitive disorders
• Pt usually complains of bad taste, abnormal
  sensation, burning mouth
• Associated with salivary hypofunction
• Need to investigate causes of hypofunction

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Disturbance of salivary flowXerostomia - Causes
of hypofunction

1. Loss of secretory tissue (Sjogrens, sarcoidosis)
2. Disturbance of secretory innervation
3. Xerogenic drugs
4. Neurological disease
5. Systemic factors
6. Renal disturbances
7. Endocrine disturbances (diabetes)
8. Sjogrens syndrome
9. Radiation to head neck
10. Radioactive iodine for thyroid cancer
11. Cognitive disorders (depression, anxiety)
12. Aging

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Disturbance of salivary flowXerostomia

• Examples of Xerogenic drugs
• Antidepressants
• Antihistamines
• Decongestant
• Antiparkinsonian agents
• Tranquillizers and hypnotics
• Anticholinergic
• Antihypertensive drugs (Diuretics)
• Appetite suppressants

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Disturbance of salivary flowXerostomia -
investigation

• History
• Does the amount of saliva in your mouth feel too
  little? Too much? Not notice it?
• Does your mouth feel dry while eating?
• Do you frequently sip liquids while eating?
• Do you have difficulties swallowing food?
• Symptoms
• Thirst
• Difficulty eating, speaking, wearing denture
• Need sips of water while eating
• Burning sensation of mouth
• Abnormal taste halitosis
• Cracked lips and soreness of corners of mouth

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Disturbance of salivary flowXerostomia -
investigation

• Signs
• Dryness of oral mucosa
• Tongue fissuring lobulation
• Oral candidosis angular chelitis
• Thick stringy saliva
• Difficulty milking saliva
• Dental caries and periodontal problems
• Swollen salivary glands (infection / autoimmune
  sialadenitis)

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Disturbance of salivary flowXerostomia -
Management

• Preventive therapy
• Florid rinses gel
• Oral hygiene
• Symptomatic treatment
• Water
• Artificial saliva
• Avoid products containing sugar, alcohol
• Vaseline ointment to relief cracking
• Topical antifungal
• Regular check ups
• Salivary stimulation
• Local / topical stimulation (detectable salivary
  gland function)
• Chewing (flavoured, sugar free, xylitol)
• Systemic stimulation (Pilocrpine HCl)

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Sjögrens syndrome

• Chronic autoimmune disease destructing exocrine
  glands
• Unknown etiology
• 1?SS lacrimal salivary gland dysfunction
• 2?SS 1?SS connective tissue disease
• More common in female (91)
• Middle - Old age group

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Primary SS - Clinical picture

• Mostly parotid gland is affected
• Persistent / intermittent gland enlargement
• bilateral, non-tender, firm, and diffuse swelling
• ? saliva and altered saliva composition
• Check of any recent changes to the character of
  the glands (nodularity)
• significantly increased risk of developing B-cell
  lymphoma
• Keratoconjunctivitis sicca

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Secondary SS - Clinical picture

• Dryness of the skin pruritis
• Dry and persistent cough
• gt50 have arthralgia with or without arthritis
• Dysphagia, nausea, dyspepsia, and epigastric pain
• Peripheral cranial neuropathy

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Diagnostic Criteria

1. Ocular Symptoms (at least one)
2. Dry eyes gt3 months?
3. Foreign body sensation in the eyes?
4. Oral Symptoms (at least one)
5. Dry mouth gt3 months?
6. Recurrent or persistently swollen salivary
   glands?
7. Need liquids to swallow dry foods?
8. Ocular Signs (Schirmer test)
9. Oral Signs (at least one)
10. Unstimulated whole salivary flow (1.5 mL in 15
    minutes)
11. Abnormal parotid sialography
12. Abnormal salivary scintigraphy
13. Histopathology (Lip biopsy showing focal
    lymphocytic sialoadenitis)
14. Autoantibodies (at least one)
15. Anti-SSA (Ro)
16. Anti-SSB (La)

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Serologic evaluation for Sjögrens syndrome

1. Antinuclear antibodies (80)
2. Anti SS-A, anti SS-B (60)
3. RF (Rheumatoid factor)
4. ESR

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For a primary Sjögrens syndrome diagnosis

• Any 4 of the 6 criteria, must include either item
  4 (Histopathology) or 5 (Autoantibodies)
• Any 3 of the 4 objective criteria (3, 4, 5, 6)

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Sjögrens syndrome - Management

• Symptomatic
• Systemic cholinergic (Pilocarpine)
• 5mg TID/QID (should not exceed 30mg/day)
• Follow up
• If tumor is suspected
• MRI CT
• Major gland biopsy
• Referral

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Sialorrhea (ptyalism)

• Rare complaint caused by
• Hypersecretion
• New intraoral prosthesis
• Infected or ulcerative lesions
• Neuromuscular dysfunction
• Cerebral palsy, Parkinsons disease epilepsy
• Decrease swallowing induces drooling
• Infants
• Pt with neuromuscular disease

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Sialorrhea (ptyalism)

• Treatment
• Remove underlying cause if possible
• Anticholinergic drugs used for pt with cerebral
  palsy
• Redirect major salivary gland duct to oropharynx
• Reassurance
• Speech therapy

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Sialolithiasis

• Etiology is unknown
• Contributing factors
• Inflammation
• Irregular duct system
• Local irritants
• Anticholinergic medication
• 50 of parotid 20 of submandibular are not
  calcified
• 80-90 of sialoliths occurs in submandibular

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Sialolithiasis

• Clinical picture
• Acute painful intermittent swelling
• Eating will initiate swelling
• Infection fibrosis of chronic cases
• Diagnosis
• Treatment
• Acute symptoms ? surgical
• Long term treatment ? remove predisposing factor