AUTOIMMUNE DISORDERS

1. DR DAVIS NADAKKAVUKARAN
READER
MALABAR DENTAL COLLEGE

2. Introduction
Classification
Autoimmune diseases of salivary gland
Sjogren’s syndrome
Mickulick’s disease
Reference

3. Oral cavity depicts many pathological
processes from the ubiquitous collection of
tissues
Proper understanding of these disease
process is must for a precise diagnosis of
these conditions

4. Salivary gland
diseases
Developmental
Enlargement of
the gland
Inflammatory
Non-
infalmmatory
Salivary gland
dysfunction
Cysts
Tumors of
salivary gland
Benign tumors Malignant

5. DEVELOPMENTAL
Aplasia
Atresia
Aberrancy

6. ENLARGEMNT
OF THE
GLAND
Inflammatory
Viral
Bacterial
Allergic
Sarcoidosis
Obstructive
Non-
inflammatory
autoimmune
alcoholic
cirrhosis
Diabetes
mellitus
Nutritional
deficiency
HIV associated

7. Cysts
Extravasation
cyst
Retention
cysts
Ranula

8. Tumors of
salivary gland
Benign
Pleomorphic
adenpoma
Warthin’s tumor
Basal cell
adenoma
Myoepithelioma
Canalicular
adenoma
Ductal
pappiloma
Malignant
Mucorpidermoid
carcinoma
Adenoid cystic
carcinoma
Malignant
pleomorphic
adenoma

9. Salivary
gland
dysfunction
Xerostomia Sialorrhea

10. SJOGREN’S SYNDROME
MICKULICK’S DISEASE

11.  Condition originally described as triad;
1. Dry eyes
2. Dry mouth
3. Rheumatoid arthritis
 CLASSIFICATION
1. Primary Sjogren’s syndrome
2. Secondary Sjogren’s syndrome

12.  Unknown
 Suggested causes;
1. Genetic
2. Hormonal
3. Infection
4. Immunologic

13.  Predominant in women
 >40 years of age
 Although seen in children and adults
 F:M-10:1
 Dry eyes and dry mouth due to hypofunction of
lacrimal and salivary glands

14.  Leads to pain, burning sensation and ulceration on
oral/conjuctival mucosa
 Nasal, bronchial, vaginal glands show hyposecretion
 Rheumatoid arthritis accompanies above symptoms in
secondary Sjogren’s syndrome
 Primary Sjogren’s syndrome patients also manifests
parotid gland enlargement, purpura, lymphadenopathy

15.  Lab findings are important and distinct
 Polyclonal hyperglobulinemia and many develop
cryoglobulinemia
 Multiple organ or tissue specific antibodies are
found

16.  Schirmer test: placing a strip of filter paper in the lower
conjuctival sac. Normal patients will wet 15mm in 5
minutes & patient with Sjogren’s syndrome will wet less
than 5mm of filter paper

17.  Rose-Bengal dye test: used to detect the damaged and
denuded areas of the cornea
 The break up time (BUT) is performed using a slit lamp
and noting the interval between an complete blink and
the appearance of dry spot on the cornea

18.  If two of the above three tests are abnormal the
patient is said to have dry eyes
 Salivary gland function in suspected cases can
be measured by parotid flow rate, biopsy, and
salivary scintigraphy
 Sialochemistry studies have shown elevated
levels of IgA, K, Na, etc

19.  Sialography demonstrates the cavitary defects which are
filled with radiopaque contrast media, producing the
“BRANCHLESS FRUIT LADEN TREE” or “CHERRY
BLOSSOM” appearance

20.  No satisfactory treatment
 Keratoconjuctivitis is treated by instillation of occular
lubricants such as artificial tears containing methyl
cellulose
 Xerostomia is treated by saliva substitutes
 No specific treatment for the enlargement of the salivary
gland

21.  Surgery is employed but is recommended for
those patients with discomfort
 Radiotherapy has been advocated but it is not
advocated currently
 A major complicating factor is development of
pseudo lymphoma and malignant lymphoma

22.  Also called as benign lymphoepithelial lesion, and
Mickulickz syndrome, Mickulicks-Sjogren’s syndrome,
Von Mickulickz syndrome
 Chronic condition characterized by abnormal
enlargement of salivary and lacrimal gland
 Tonsils and other glands in the soft tissue of the face and
neck may also be affected

23. Unknown etiology
Suspected to be an autoimmune disorder
Symptoms of Mickulickz disease may
occur due to the excessive accumulation
of lymphocytes in to the involved glands

24.  Females are more affected
 Combination with Sjogren’s syndrome
 Characterized by sudden onset of xerostomia that may
lead to difficulty in swallowing and result in tooth decay
 Other symptoms: enlarged lacrimal glands, leading to
absent or decreased tears, painless swelling of salivary
glands
 Patients experience recurring fever
 Fever may be accompanied by dry eyes, diminished
lacrimation and uveitis

25.  CLASSIC SIGNS:
1. Lacrimal gland enlargement
2. Parotid gland enlargement
3. Dry mouth
4. Dry eyes

26.  Lymphocytic infiltration of the salivary gland tissue
destroying or replacing the acini, with the persistence of
islands of epithelial cells which probably represents
residua of gland ducts
 The epithelium may consists of duct showing cellular
proliferation and loss of polarity , or as the disease
persists solid nests or clumps of poorly defined epithelial
cells which Morgan and Castleman termed
‘MYOEPITHELIAL ISLANDS”

27. Biopsy of one of the swollen glands is a
key to diagnosis
Ultrasound examination to rule out other
reasons for gland swelling
Artificial tears and saliva may be used
Patients instructed to follow moist diet
It helps to reduce the pain caused by
chewing and swallowing

28. Textbook of Oral & Maxiilofacial Surgery-
Neelima Anil Malik
Shafer’s textbook of Oral Pathology