Exam 4, DLA 1210

1. Salivary Glands
CHAPTER 21

2. General Information
In oral cavity, there are major and minor salivary
glands
Three pairs of major salivary glands
Parotid, submandibular, and sublingual
Minor salivary glands may be located through
the mouth

3. Major Salivary Glands
Parotid gland is the largest of the three major salivary
glands
Located on side of face
Below and in front of ear and behind ramus
The duct is known as Stensen’s duct
Covered in parotid papilla
Several structures pierce the gland
Superficial temporal artery, the retromandibular vein, and facial
nerve
Purely serous saliva (thin and watery)

4. Major
Salivary
Glands

5. Major Salivary Glands (cont’d.)
Submandibular Gland is the 2nd largest salivary
gland
About the size of a walnut
Located in front of and underneath inferior border of
mandible
Saliva is mixed: 80% serous, 20% mucous
The duct is known as Wharton’s duct
Opens into the mouth at the sublingual caruncle

6. Sublingual Caruncle

7. Major Salivary Glands- KNOW THIS PICTURE

8. Major Salivary Glands (cont’d.)
Sublingual Gland is the smallest of major salivary
glands
Located beneath sublingual mucosa in floor of mouth
Several small ducts (8-20) known as ducts of Rivinus that
empty onto the sublingual fold
Bartholin’s duct is the one major duct that opens along with the
Wharton’s duct at the sublingual caruncle.
Secretes a mixed saliva that is primarily mucosal

9. Minor Salivary Glands
Labial Glands are found in submucosa of lips
Numerous at midline and have small ducts that
open directly onto lip mucosa
Mixed glands, primarily mucous
Buccal Glands are located in cheek
Similar to labial glands

10. Minor Salivary Glands
Palatine Glands are found on posterior
3rd of palate and soft palate
Opening may be large and visible
100% mucosal (sticky) in secretion

11. Minor Salivary Glands
Lingual Glands (3 groups)
Anterior lingual glands, located at apex of tongue,
primarily mucosal, ducts empty into the ventral surface
of the tongue
Lingual glands of Von Ebner, found beneath
circumvallate papillae, ducts open into trough of
papillae, 100% serous
Posterior lingual glands, near lingual tonsils on
posterior third of tongue, 100% mucosal

12. Summary
Oral cavity supplied by major and minor salivary
glands
Major salivary glands include
 Parotid supplies serous saliva
 Submandibular supplies mixed saliva, primarily
serous
 Sublingual supplies mixed saliva, primarily mucous

13. Summary
Minor salivary glands providing mucous saliva to
the mouth include
 Labial located in lip submucosa
 Buccal located in buccal mucosa
 Palatine located in posterior third of the palate
 Lingual divided into three groups
 Anterior glands, glands of Von Ebner and posterior
glands

14. Lymphatic/Immune
System

15. Lymphatic system
Component of the immune system
An accumulation of tiny channels or tubules with
small nodular structures called Lymph Nodes
Returns fluids to the blood stream from the various
tissues
Lymph nodes act as a filter for intracellular fluids

17. Lymph nodes
Lymphocytes are produced within the
lymph nodes
Combat infections that might spread through
the lymphatic channels
Most tissues have lymph vessels in them.
The pulp of the teeth included!

18. Distribution pattern
Lymph nodes are grouped together into small
clusters, which are all interconnected by channels
Each group drains fluids from certain structures or
tissue areas
This is why lymph nodes are involved in combating
infections in areas of the body

19. Think about it…
 A sore throat can be followed by tenderness in the neck and finally a tender lump
in that area.
 This means that the infection from the throat has spread though the lymph
channels and nodes behind the throat wall known as the retropharyngeal nodes.
 From there, it travels through lymph vessels until reaching the first group of lymph
nodes in the neck known as the upper deep cervical nodes.
 The lymphocytes in the node have begun to combat the infection and also have
started to multiply, causing the node to enlarge and become tender.
 If the infection is successfully combated, then it will subside, but if the infection is
too large, it will spread through that node onto the next one….

21. Retropharyngeal nodes
A group of nodes behind the throat
wall and involved in throat infections
These nodes drain to the upper
deep cervical lymph nodes

22. Submental nodes
 A very small accumulation of nodes found beneath the chin
 The lymphatic channels from the mandibular incisors, the tip of
the tongue, and the midline of the lower lip and chin drain into
these nodes
 Any infection in these areas would cause some tenderness and
enlargement of these nodes
 Submental nodes tend to drain into the submandibular nodes
or directly down and across the neck to the lower deep cervical
nodes

23. Submandibular nodes
 Found grouped around the submandibular gland near the
angle of the mandible
 Locate the glands by taking a finger on the inferior border
of the mandible near the angle, run finger back and forth
until you feel the depression in the inferior border of the
mandible
This is the point where the facial artery and vein cross the inferior
border
 Just medial to this depression is the submandibular gland,
and the submandibular lymph nodes that are grouped
around it.

24. Submandibular nodes
 The areas that drain into the submandibular nodes are:
 All of the maxillary teeth and maxillary sinus, with the exception of the
maxillary 3rd molars
 The mandibular canines and all mandibular posterior teeth, with the
possibility that the mandibular third molars may not drain there
 The floor of the mouth and most of the tongue
 The cheek area
 Hard palate
 Anterior nasal cavity
 As mentioned before, the Submental nodes also drain here…

25. Submandibular nodes
Infection in any of the previously mentioned areas
will cause enlargement and tenderness of the
submandibular nodes.
This condition is called lymphadenopathy
Enlarged lymph glands or nodes, may be seen or
felt when one has a sore throat, infected ears,
and so on…

26. Upper deep cervical nodes (anterior)
 Located on the lateral surface of the internal jugular vein, and
lie just beneath the anterior border of the sternomastoid
muscle, about 2” below the ear.
 A number of other nodes drain into the upper deep cervical
nodes
Submandibular nodes, retropharyngeal nodes, parotid nodes, etc.
 Also drains the maxillary 3rd molars, base of the tongue,
tonsillar area, soft palate and the posterior nasal cavity

27. Upper deep cervical nodes
 This is the group affected when you have a REALLY BAD sore
throat
 When a throat infection begins, the first group of nodes
involved are the retropharyngeal (behind the throat), but its
impractical to palpate these nodes…
 So the next group that are generally involved are the upper
deep cervical, where you finally are able to notice them (i.e.
First group noticed with severe throat infection)

28. Lower deep cervical nodes (posterior)
 Found on the lateral surface of the internal jugular beneath the anterior
border of the sternomastoid muscle
 2” above the clavicle
 They drain the upper deep cervical nodes and many of the nodes at the
back of the neck
 Frequently referred to as the occipital nodes
 They also drain some glands in the anterior neck region
 From the lower deep cervical nodes, the lymphatic fluid drains into the
junction of the Subclavian and Internal jugular veins

29. Node groups affected by disease
Primary nodes
Secondary nodes
Tertiary nodes
If its not stopped by the first, it drains to the second, if
not stopped at second, it drains to the third…

30. Upper deep cervical nodes in disease
 Infection of the third molars may involve the upper deep cervical
nodes first
 The primary group involved
 If the infection were in a first molar, the initial sign of infection
would be in the submandibular nodes
 If it were not successfully combated there, it would spread secondarily to
the upper deep cervical (secondary nodes)
 Infections in the middle of the lower lip would first (primary node)
spread to the Submental nodes, secondarily to the submandibular
nodes, and then to the upper deep cervical nodes (tertiary)

31. Spread of disease/infection
In infections, any group of nodes may overcome the
infection if it is not too severe
Then the infection may not go any further
You must understand this concept to comprehend the
spread of oral cancer…

32. Spread of oral cancer
 Each group of nodes acts as a resistance barrier against the spread of
cancer
 The nodes slow the speed, and if the cancer is detected early enough,
it can be treated more successfully.
 Once the infection or cancer reaches the lower deep cervical nodes
and passes through them, it enters the blood stream, moving directly
to the heart and then throughout the body…
 Keeping this in mind its easier to understand why cancer on the tip of
the tongue does not result in as high of a mortality rate as does
cancer that begins further back on the tongue or in the throat.

33. Spread of oral cancer
 The tip of the tongue must drain into four different groups of
nodes before it enters the blood stream, whereas cancer in
the posterior portion or in the throat goes directly into the
deep cervical nodes, to the lower cervical nodes to the
bloodstream…
Two areas to try to stop or slow infection
 When cancer is detected, knowing the location of the cancer
and having a knowledge of the nodes involved allows the
surgeon to do a biopsy of the next group of nodes in the
chain to see if the cancer has spread to them..

34. Spread of infection through fascial spaces
 Potential spaces between layers of muscle or layers of
connective tissue
 Much less common, but when it happens it is much more
dramatic
 You may see a patient with a large swollen jaw or with
swollen area beneath the eye…
This means it has broken out of the bone around the tooth and is
spreading between the tissue or muscle layers
Not spreading through small lymphatic channels..

35. Spread of infection in fascial spaces
 This type of infection spread will follow certain predictable
pathways, depending on its location
 In general, dental infections start in the maxillae or mandible
at the apex of a tooth or in the periodontal space around a
tooth
 Most periodontal infections cause a swelling of the gingival
or mucosal tissue within the oral cavity
 Infections at the apices of the teeth cause swelling in one of
two directions
Buccal or lingual

36. Spread of infection in fascial spaces
 Most buccal swellings also lead to a swelling in the vestibule of the
oral cavity
 Sometimes referred to as gumboil
 The infection comes to a pointed head, breaks through the mucosa,
and drains into the oral cavity
 If a mandibular infection spreads not in the buccal but in the lingual
direction, it will travel to the tissue spaces in two specific areas
depending on its point of origin
 Above the Mylohyoid muscle in the floor of the mouth
 Beneath the Mylohyoid muscle in the tissue beneath the chin

37. • Picture the lengths of the
roots of the teeth.
• Look at the Mylohyoid line
on the mandible and notice
its location relative to the
apices of the roots
• You can see that, in general,
the apices of the mandibular
molar teeth are inferior to
the Mylohyoid line, whereas
the apices of the roots of
the premolars and molars
and the anterior teeth are
above the Mylohyoid line

38. Therefore, a molar infection will
tend to break out of the bone
below the Mylohyoid line and
spread to the space beneath the
chin, referred to as the Submental
space
Infections in the premolars and
anterior teeth will tend to break
out of the bone above the
Mylohyoid line, and spread to the
spaces in the floor of the mouth,
referred to as the Sublingual
space

39. Spread of infection in fascial spaces
 Infection spreading into the sublingual spaces causes swelling into the floor of the
mouth
 Infection spreading into the Submental space causes swelling beneath the chin
 Sometimes referred to as Ludwig’s angina.
 These infections will spread due to gravity if not treated
 Whether above or below the Mylohyoid line, they spread down and back, they
reach the posterior end of the Mylohyoid muscle
 They eventually reach the side of the neck, next to the pharyx
 Referred to as the lateral pharyngeal or parapharyngeal space
 This causes swelling on the side of the neck if left untreated
 From there, it may spread around the pharynx and to its posterior border
 Known as the retropharyngeal space

40. Spread of infection in fascial spaces
From the retropharyngeal space, the infection will
spread to the posterior mediastinum
Back of the chest or thoracic cavity
If the infection reaches this point, the person may die
within a short period of time

41. Maxillary infections
Maxillary infections react slightly different
If the infection does not open up into the maxillary
buccal vestibule, or onto the palate, it may spread
toward three areas
Nasal cavity
Maxillary sinus
Soft-tissue spaces f the cheek or the area below the eye

42. Maxillary infections
 A swelling below the eye is usually related to infection from
an anterior tooth, usually the maxillary canine
 Swelling in the cheek is usually related to infection in a
posterior tooth
 Although its possible for infection to spread to maxillary
sinus or nasal cavity, its rare
 Infections around the eye or cheek can also spread to the
lateral pharyngeal space and from there to other areas

43. Major groups of nodes in the head and neck
Submental
Submandibular
Upper deep cervical
Lower deep cervical
Retropharyngeal
Parotid or perauricular
Occipital

45. The structures
that drain primarily
into groups are….

46. Submental nodes
Mandibular incisors
Tip of tongue
Lower lip
Chin

47. Submandibular nodes
 All mandibular teeth, except the incisors and 3rd
molars
 Maxillary teeth, except 3rd molars
 The face
 Maxillary sinus
 Most of the tongue, except the tip and root
 Anterior nasal cavity
 Submental nodes

48. Upper deep cervical
Third molars
Posterior nasal cavity
Root of the tongue
Retropharyngeal nodes
Parotid nodes
Submandibular nodes

49. Lower deep cervical
Upper deep cervical nodes
Occipital nodes

50. Retropharyngeal nodes
Posterior throat wall
Possibly some of the posterior nasal cavity

51. Parotid or preauricular nodes
Parotid gland
Anterior area of the ear

52. Occipital nodes
Behind the ear
Occipital region