DIAGNOSIS AND MANAGEMENT

OF SAIVARY GLAND DISORDERS

DR.TAHERA AYEUB
ASISSTANT PROFESSOR
ORAL AND MAXILLOFACIAL SURGERY
DEPARTMENT
 EMBRIOLOGY ANATOMY AND
PHYSIOLOGY
• Divided into two groups
minor glands
major glands
-Develop from embryonic oral cavity as buds of
epitheliumthat extend into underlying
mesenchymal tissues
-epithelium ingrowth branch to form a
primitive dental system-canalized to provide
for drainage of salivary secretion
• Development begin
-minor salivary gland-fortieth day in utero
-major salivary gland-thirty fifth day in utero
-secretory cell around the ductal system-7th
or 8th month in utero
 SALIVARY GLAND RADIOLOGY
• TO IDENTIFY SALIVARY STONES(CALCULI)
• 80% TO 85% stones are radiopaque
• Visible radiographically
• Mandibular occlusal film is use for detecting
sublingual and sub mandibular gland calculi in the floor
of the mouth
• Puffed cheek view
• Panoramic radiogra reveal stones in the parotid gland
and posteriorly located submandibular gland
• Periapical radiograph can show calculi in each salivary
gland and minor salivary gland
 PAROTID GLAND
• Largest salivary gland
• Lie superficial to the posterior aspect of
masseter muscle and assending ramus of
mandible
• Peripheral portion extend to the mastoid
process along the anterior border of the
sternocleidomastoid muscle
• Around the posterior border of the mandible
into the pterogomandibular space
• seventh cranial (facial) nerve divide the
parotid gland into
-superficial lobe
-deep lobe
• Coursing anteriorly from their exit at the
stylomastoid foramen to the innervat the
muscle of expression
• Small ducts from various regions of the gland
coalesce at the anterosuperior aspect of the
parotid to form stensen's duct
• Stensen's duct 1 to3mm in diameter and 6cm
in length
• At the anterior edge of the masseter Stensens
duct turns medial and passes through the
fibers of the buccinator muscle
• The duct opens into the oral cavity through
buccal mucosa adjacent to maxillary 1st and
2nd molar tooth
• Gland receive innervation from ninth caranial
(glossopharyngeal)nerve with
auriculotemporal nerve from the otic ganglion
 SUBMANDIBULAR GLANDS
• Located in the submandibular triangle of the neck
• Which is formed by anterior and posterior belly
of digastric muscles and inferior border of the
mandible
• Posterosuperior portion of the gland curves
upward around the posterior border of the
mylohyoid muscle
• Give rise to the major duct of the submandibular
gland known as warton's duct
• Duct passes forward along the superior
surface of the mylohyoid muscle in the
sublingual space,adjacent to the lingual nerve
• Lingual nerve loops under wartan,s duct from
lateral to medial in the posterior floor of the
mouth
• Duct is 5cm in length
• Diameter of lumen is 2 to 4 mm
• Warton's duct open into the floor of the
mouth with a punctum
• Punctum located close to the incisors at the
most anterior aspect at the lingual frenum and
the floor of the mouth
 SUBLINGUAL GLANDS
• Lie on the superior surface of the mylohyoid
muscle, in the sublingual space
• Are separated from oral cavity by a thin layer
of oral mucosa
• Acinar ducts of the sublingual glands are
bartholins duct in most instance coalesce to
form 8 to 20 ducts of rivinus
• Short and small in diameter
• open directly into the floor of the mouth on a
crest of mucosa known as plica sublingualis
• Or they open indirectly through connection to
the submandibular duct and then into the oral
cavity with warton's duct
• Submandibular and sublingual glands are
innervated by the facial nerve through the
submandibular ganglion with the chorda
tympani nerve
 FUNCTIONS OF SALIVA
• Provide lubrication for speech and mastication
• To produce enzymes for digestion
• To produce compounds with antibacterial
properties
• Produce 1000 to 1500 saliva per day with the
highest flow rates occurring during meals
 Daily saliva production by salivary
glands
• Submandibular gland 70%
• Parotid gland 25%
• Sublingual gland 3% to 4%
• Minor glands trace
 Diagnostic modalities
• HISTORY AND CLINICAL EXAMINATION
-In most cases patient will guide the doctor to
the diagnosis by relating the events that have
occurred in association with the presenting
complaint
• Must perform a thorough evaluation for
diagnosis
• Many instances diagnosis can be determined
without further diagnostic evaluation
• Occasionally the clinician may find it necessary
to use any of several diagnostic modalities

- salivary gland radiology

- salivary gland endoscopy(sialoendoscopy)
- sialochemistry
- fine-needle aspiration biopsy
- salivary gland biopsy
 SALIVARY GLAND RADIOLOGY
• PLAIN FILM RADIOGRAPHS
- in the assessment of salivary gland disease is
to identify salivary stones(calculi)
- 80% to 85% stones are radio opaque
- mandibular occlusal film is most useful for
submandibular and sublingual gland calculi in
the anterior floor of the mouth
 SIALOGRPHY
Indications
• in the detection of radio opaque stones
• Detect 15% to 20% radiolucent stones
• In the assessment of the extent of destruction
of salivary duct or gland as a result of
-obstructive , inflammatory, traumatic and
neoplastic diseases
 COMPUTER TOMOGRAPHY
• For the assessment of mass lesions of the
salivary glands
• Less invasive than sialography
• Does not require the use of contrast material
• Demonstrate salivary gland calculi
• Especially submandibular stones that are
located posteriorly in the duct or in the
substance of the gland itself
Magnetic resonance imaging(MRI)
• Superior to CT scanning in delineating the soft
tissue detail of salivary gland lesions
• Specifically tumors , with no radiation
exposure to the patient
 ULTRASONOGRAPHY
• Simple , noninvasive imaging modality
• Poor detail resolution
• Role is in the assessment of superficial
structures
• To determine whether a mass lesion is solid or
cyst(fluid-filled) in nature
 SALIVARY SCINTIGRAPHY
(RADIOGRAPHIC ISOTOPE SCANNING)
• Use of nuclear imaging in the form of radioactive
isotope scanning
• Allows a thorough evaluation of the salivary
gland parenchyma
• Presence of mass lesions
• Function of the gland itself
• Demonstrate increased uptake of radioactive
isotope in an acutely inflamed gland
• Decrease uptake in chronically inflamed gland
• Presence of a mass lesion(benign or malignant)
 SALIVARY GLAND
ENDOSCOPY(SIALOENDOSCOPY)
• Minimally invasive modalities of diagnosis and treatment
• Applied to the major salivary glands
• Is a specialized procedure that uses a small video
camera(endoscope)
• With a light at the end of a flexible canula
• Introduced into the ductal orifice
• Can be used diagnostically and therapeutically
• Used to dilate small strictures
• Flush clear small mucous plugs in the salivary gland ducts
• Specialized devices such as small balloon catheters used to dilate
sites of ductal constriction
• Small baskets may be used to retrieve stones in the ductal system
 SIALOCHEMISTRY
• An examination of the electrolyte
composition of the saliva of each gland
• May indicate a variety of salivary gland
disorders
• Concentration of sodium and potassium
change with salivary flow rate
• Elevated sodium concentration with
decreased potassium concentration may
indicate an inflammatory sialadenitis
 FINE NEEDLE ASPIRATION BIOPSY
• Use in the diagnosis of salivary gland tumors'
• Has a high accuracy rate for distinguishing
between benign and malignant lesion in the
superficial location
• Is performed using a syringe with a20-guage
or smaller needle
 PROCEDURE
• local anesthesia
• Needle is advanced into the mass lesion
• The plunger is activated to create a vacuum in the
syringe
• The needle is moved back and forth throughout the
mass with pressure maintained on the plunger
• The pressure is then released the needle is withdrawn
• The cellular material and fluid is expelled onto a slide
and fixed on histologic examination
•
 SALIVARY GLAND BIOPSY
• Either incisional excisional biopsy can be used to
diagnosed tumor of one of the major salivary
glands
• The lower lip labial salivary gland biopsy has been
shown to demonstrate certain characteristic
histopathologic changes that are seen in the
major glands in ss
• The procedure is performed using local
anesthesia
• Approximately 10 minor salivary glands are
removed for histologic examination
 OBSTRUCTIVE SALIVARY GLAND
DISEASE
Sialolithiasis
• formation of stones or calculi may occur
throughout the body
• Including gallbladder, urinary tract and
salivary glands
• Common in men
• Age between 30 and 50
• Multiple stone formation in 25% of patients
• The pathogenesis of salivary calculi progresses
through a series of stages beginning with an
abnormality in calcium metabolism and salt
precipitation
• Formation of a nidus that subsequently
becomes layered with organic and inorganic
material,to form a calcified mass
• Submandibular gland involve 85%
• Concentration of calcium is about twice as
abundant in submandibular saliva as in
parotid saliva
• Alkaline Ph of submandibular saliva may further
support stone formation
• Warton,s duct is longest salivary duct –has a
greater distance to travel before being emptied
into the oral cavity
• The punctum of submandibular gland is smaller
-provide potential areas of stasis of salivary flow
or obstruction
-precipitated material mucous and cellular debris
are more easily trapped in the tortuous and
submandibular duct
• Obstruction occurs at meal time because salivary
production maximum
SIALOLITHIASIS FOR GENERAL DENTIST
• Classic signs and symptoms of sialolithiasis
- exacerbation of pain and swelling at
mealtimes
- check for flow from warton,s duct
- check for tenderness of submandibular
gland
- Palpate for stone in floor of mouth
- check mandibular occlusal radiograph
 MANAGEMENT
• the management of submandinbular gland
calculi depends on
- the duration of symptoms
- the number of repeated episodes
- the size of the stone
- the location of the stone
 SIALODOCHOPLASTY
(revision of the salivary duct)
• An incision made floor of the mouth
• Expose the duct and stone
• A longitudinal incision is then made in the
duct ,the stone is retrieved
• The ductal lining is sutured to the mucosa of
the floor of the mouth
• Saliva will then flow out the revised duct
• In many inctences of repeated stone
formation
• The submandibular gland and the stone
should be removed by an extraoral approach
 Counciling of the patient
• Patients are encourage to maintain ample
salivary flow by using salivary stimulants
- citrus fruits
- flavored candies
- glycerin swabs
 EXTRACORPOREAL SHOCK WAVE
LITHOTRIPSY
• Successful in treating small salivary gland
stones
• This technology uses transcutaneous
electromagnetic waves to break the calculus
into small calcified debris particles
• Flushed from the ductal system by the normal
flow of saliva
• This procedure is limited by
- the size of stone(usually less than 3mm)
- the number of stones(usually less than three)
- the location of the stone(intraglandular
stones may be less amenable to ecswl)
 MUCOUS RETENTION AND
EXTRAVASATION PHENOMENA
• MUCOCELE
what is mucocele?
. Salivary duct, especially those of the minor
salivary glands ,are occasionally traumatized
commonly by lip biting, and severed beneath the
surface mucosa.
. Subsequently saliva production may then
extravsate beneath the surface mucosa into the
soft tissues
. Over time ,secretions accumulate within the
tissues and produce a pseudocyst that contains
thick viscous saliva common in mucosa of upper
lip known as mucoceles
 second common site is buccal mucosa
Mucocele formation results in an
elevated,thinned, stretched overlying mucosa
that appears as a vesicle filled with a clear or
blue-gray mucus.
The patient frequently relates a history of the
lesion filling with fluid, rupture of the fluid
collection, and refilling of these lesion
Mostly mucocele formation regress
spontaneously without surgery
Persistent oror recurrent lesions – treatment
consist of exicision of the mucocele and
associated minor salivary glands
Recurrence rates may be as high as 15% to
30% after surgical removal
• RANULA
Ranulas results from either mucous retention
in the sublingual gland ductal system or
mucous extravasation as a result of ductal
disruption
Most common lesion of sublingual gland
Two types of ranulas are
- simple ranula
- plunging ranula
First recurrence of ranula
Third recurrance of ranula
Fifth recurrance of ranula
• Simple ranula is confined to the area occupied by
the sublingual gland in the sublingual space,
superior to the mylohyoid muscle
• Plunging ranula occures when the lesion extends
beyond the level of the mylohyoid muscle into
the submandibular space
- plunging ranula has the potential to extend into
the neck and compromise the airway, resulting in
medical emergency
• Ranulas may reach a larger size than mucoceles
because their overlying mucosa is thicker and
because trauma that would cause their rupture is
less likely in the floor of the mouth
 Treatment of ranula
• Is marsupilization
• In which a portion of the oral mucosa of the
floor of the mouth is excised along with the
superior wall of the ranula
• The ranula wall is sutured to the oral mucosa
of the floor of the mouth and allowed to heal
by secondary intention
• The preferred treatment for recurrent or
persistant ranulas is excision oh the ranula and
sublingual gland
 SALIVARY GLAND INFECTIONS
• Related to obstructive disease, especially in
submandibular gland
• Cause of acute suppurative sialadenitis of the parotid
gland usually involves a change in fluid balance that is
likely to occur in patients who are
-elderly
-debilitated
-malnourished
-dehydrated
-plagued with chronic illness
• In these cases,gland infections are usually bilateral
• Mean age of infection iss is 60 years
• Organisms including aerobic and anaerobic
,bacteria,viruses,fungal organisms and
mycobacteria
• In most cases mixed bacterial flora is
responsible for sialadenitis
• The most common organism implicated in
salivary gland infection is staphylococcus
aureus
• This organism normally colonizes around
ductal orifices
Clinical chracteristics of acute bacterial
salivary gland infections
• Is rapid onset of swelling in the
preauricular(parotid gland)or submandibular
regions
• Associated erythema and pain
• On palpation gland will reveal no flow or elicit
a thick purulent discharge from the orifice of
the duct
 TREATMENT 0F BACTERIAL SALIVARY
GLAND INFECTIONS
• Includes symptomatic and supporative care
• Including IV fluid hydration, antibiotics ,and
analgesics
• Initial empiric antibiotics should be aimed at the
most likely causative organism s. aureus
• Should include a cephalosporin or
antistaphylococcal semisynthetic penicillin
• Culture and sensitivity studies of purulent
material should be obtained to aid in selecting
the most appropriate antibiotic for each patient
• In most cases,surgery consist of incision and
drainage
• Untreated infection may progress rapidly and
can cause
-respiratory obstruction
-septicemia and eventually death
• In recurrent infections , excision of the gland
may be indicated
 Viral parotitis or mumps
• Is an acute ,nonsuppurative communicable
disease
• Occurred in epidemics during winter and
spring
• Viral infections are not the result of
obstructive disease
• Not require different treatment ,not including
antibiotics
• Mumps is characterized by a
painful,nonerythematous swelling of one or both
parotid glands
• Begins 2 to 3 weeks after exposure to the virus
• Common in children between ages 6 and 8
• Signs and symptoms
pain
swelling
fever
chills
headache
• Usually resolves in 5 to 12 days after its onset
• Supportive and symptomatic care for
-fever
-headache
-malaise with antipyretics
-analgesics
-adequate hydration treats viral partitas
• Complications in 20% of young males
-meningitis
-pancreatitis
-nephritis
-orchitis
-testicular atrophy
-sterility
 NECROTIZING SIALOMETAPLASIA
• Is a reactive nonneoplastic inflammatory process
that usually affects the minor salivary glands of
the palate
• Unclear origin but is thought to be secondary to
vascular infarction of the salivary gland lobules
• Potential causes of diminished blood flow to the
affected area including
trauma, local anesthetic injection
smoking, diabetes mellitus, vascular disease
pressure from denture prosthesis
• Age range is 23 and 66 years
• Lesions usually 1 to 4 cm large
• Painless or painful
• Deeply ulcerated areas lateral to the palatal midline
and near the junction of the hard and soft palate
• Unilateral or bilateral involvement may occur
• Patient may report a prodromal flulike illness before
the onset of the ulceration
• It resembles a malignant carcinoma(squamous cell or
mucoepdermoid carcinoma)
• The ulceration of necrotizing sialometaplasia usually
heal spontaneously within 6 to 10 weeks after their
onset
• No surgical management
 SJOGRENS SYNDROME
• Is a multisystem disease process with a variable
presentation
• Two types of ss are
1- primary ss or sicca syndrome
. Charecterized by xerostomia(dry mouth)
. Keratocunjuctivitis sicca(dry eyes)
2- secondary ss
. Composed of primary ss and an associated
connective tissue most commonly rheumatoid
arthritis
• Cause of ss is unknown
• There appears to be a strong autoimmune
influence
• The first symptoms to appear are
arthritic complaints
followed by occular symptoms
late in the disease proses
Salivary gland symptoms
• Xerostomia results from a decreased function
of both the major and minor salivary glands
 DIAGNOSIS
• By the patient complaints complaints
• By immunological laboratory tests
• By using salivary flow rate studies
• Sialography
• Labial minor Salivary gland biopsy
 Treatment
• SYMPTAMATIC
- artificial tears for dry eyes
- salivary substitute for dry eyes
• MWDICATION
- pilocarpine(salagen)
- biotene products to stimulate salivary
flow from the remaining functional salivary
gland tissue
 TRAUMATIC SALIVARY GLAND
INJURIES
• Occur in close proximity to one of the major
salivary glands or ducts
• Due to trauma, fractures,
• Repair may include ductal anastomoses
• In which the proximal and distal portions of the
duct are identified
• A plastic or metal catheter is placed as a stent
• The duct is sutured over the stent
• Catheter leave for 10 to 14 days for
epithelialization of the duct
• Trauma involve the major salivary glands
include infection-facial paralysis-cutaneous
salivary gland fistula –sialocele formation and
duct obstruction as a result of scar formation-
evantually glandular atrophy-require surgical
removal
 NEOPLASTIC SALIVARY GLAND
DISORDERS
• Salivary gland tumor distribution
Major salivary gland
parotid glands 85% to 90%
submandibular gland 5% to 10%
sublingual gland rare
Minor salivary gland
palatal 55%
lips 15%
remainder rare
BENIGN SALIVARY GLAND TUMORS
• pleomorphic adenoma or benign mixed
tumor
• warthin,s tumor or papillary cytadenoma
lymphomatosum
• Monomorphic adenoma
 Pleomorphic adenoma
• Most common salivary gland tumor
• Occurrence age is 45 years
• Male to female ratio 3:2
• In major glands parotid gland is involved 80%
• Minor glands intraoral sit is the palate
• Slow growing painless masses
• Histopathology shows two types of cell
1- ductal epithelial cell
2-myoepithelial cell
• Treatment
- complete surgical excision with a margin
of normal uninvolved tissue
- parotid lesion-removal of involved lobe
along with tumor
- recurrene is possible in rare cases
- small risk 5% of malignant transformation
 Warthans tumor or papillary
cystadenomatosum
• Affect the parotid gland
• Specifically the tail of the parotid gland
• Peak incidence is sixth decade of life
• Male to female ratio 7:1
• Slow growing soft and painless mass
• Caused by entraped salivary epithelial rests
within developing lymph nodees
• Histopathology
 epithelial component in a papillary pattern
 Slymphoid component with germinal centers

• Treatment
 surgical excision
Recurrence is rare
 Malignant salivary gland tumors

• Mucoepidermoid carcinoma
• Polymorphous low grade adenocarcinoma
• Adenoid cystic carcinoma
 Mucoepidermoid carcinoma
• most common malignant salivary gland tumor
• 10% major gland tumor(mostly parotid)
• 20% minor gland tumors(mostly palate)
• Mean age is 45 years
• Male to female ratio is 3:2
• Clinical presentation –submucosal mass-
painful or ulcerated
• Histopathology show three cell types
-mucous cells
-epidermoid cells
-intermediate (clear) cells
• Treatment
- low grade lesion –wide surgical removal with
margins of uninvolved normal tissue
-95% 5-year survival rate
-high grade lesions require more aggressive
surgical removal with margins
-local radiation therapy
- less than 40% 5-year survival rate
 Polymorphous low-grade
adenocarcinoma
• Second most common malignant tumor
• Most common sit is the junction of hard and
soft palate
• Mean age 56-year
• Male to female ratio is 3:1
• Slow growing asymptomatic masses
• May be ulcertaed
Polymorphous low grade
adenocarcinoma
• Histopathology shows many cell shapes and
patterns(polymorphous)
• Patient experienced an infiltrative
proliferation of ductal epithelial cells in an
indian file pattern
• Invasion of surrounding nerves
• Treatment-WIDE SURGICAL EXCISION
• Recurrence rate is 14%
 ADENOID CYSTIC CARCINOMA
• Third most common intraoral salivary gland
malignancy
• Mean age 53 years
• Male to female ratio 3:2
• 50% in parotid gland
• 50% occur in minor salivary gland
• Slow growing nonulcerated masses
• Associated chronic dull pain
• Parotid lesion may result in facial paralysis as a
result of facial nerve involvment
• Histopathology – infiltrative proliferation of
basaloid cells arranged in a cribriform (swiss
cheese) pattern
• Treatment
- wide surgical excision
- in some cases radiation therapy
- Prognosis is poor
Necrotizing sialometaplasia