Salivary glands /certified fixed orthodontic courses by Indian dental academy


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Salivary glands /certified fixed orthodontic courses by Indian dental academy

  1. 1. SALIVARY GLANDS INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. HISTORY  Fundamental knowledge of the salivary glands dates back to the work of Heidenheim, Pavlov and Langley in 19th century.
  4. 4. 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.
  5. 5.  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.
  6. 6.  Hence the knowledge of salivary glands, secretion and function is important in diagnosis, treatment planning, and treatment and in predicting the prognosis.
  7. 7. CLASSIFICATION 1. Major and minor.  2. Serous, mucous and mixed.  3. Exocrine and mesocrine. 
  8. 8. 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.
  9. 9. 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.
  10. 10. 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.
  11. 11. 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.
  12. 12. 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.
  13. 13.  Lumen formation has begun in the ducts.  Branching of the distal ends of the epithelial cords is evident.
  14. 14.  Connective tissue septa which are continuous with the connective tissue capsule surrounding the gland.  They divide the gland parenchyma into lobes and lobules.
  15. 15.      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.
  16. 16. DEVELOPMENT  The 3 major sets of salivary glandsThe parotid gland, The submandibular gland and The sublingual gland.
  17. 17. 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.
  18. 18. 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.
  19. 19. 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.
  20. 20. 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.
  22. 22. 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.
  23. 23.
  24. 24.  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.
  25. 25.  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.
  26. 26. 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
  27. 27.  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.
  28. 28.  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.
  29. 29. 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 tongue.
  30. 30.  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.
  31. 31. 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.
  32. 32. 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.
  33. 33. 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.
  34. 34.  Sub lingual: facial nerve provides parasympathetics via lingual nerve & sub mandibular ganglion.
  35. 35. 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.
  36. 36.  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.
  37. 37. 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.
  38. 38.  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.
  39. 39. 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.
  40. 40.  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.
  41. 41. 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.
  42. 42. 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.
  43. 43.  These striated ducts then pass abruptly into two epithelial cell layered excretory ducts and finally to the stratified squamous epithelial cell lined terminal duct.
  44. 44. 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.
  45. 45. 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.
  46. 46. 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)
  47. 47. 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
  48. 48. 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.
  49. 49. INORGANIC COMPONENTS         Sodium (Na +) Potassium (K +) Hydroxyapatite & calcium phosphate salts. Chloride (Cl -) Magnesium (Mg 2+) Thiocynate (SCN -) Fluoride and Carbonic acid (Hco 3 - )
  50. 50. 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.
  51. 51. 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.
  52. 52. 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.
  53. 53. 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.
  54. 54. Thank
  55. 55. 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.
  56. 56. 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.
  57. 57.    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.
  58. 58. 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’.
  59. 59. 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.
  60. 60. 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.
  61. 61. 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.
  62. 62. 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 ).
  63. 63. 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.
  64. 64. 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.
  65. 65.  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.
  66. 66. 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.
  67. 67. 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.
  68. 68.  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.
  69. 69. 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.
  70. 70.  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.
  71. 71.  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.
  72. 72. 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.
  73. 73. 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.
  74. 74. 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.
  75. 75. 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.
  76. 76. 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
  77. 77. 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
  78. 78. 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.
  79. 79. 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.
  80. 80. 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.
  81. 81. 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.
  82. 82. 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.
  83. 83.
  84. 84. 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.
  85. 85. 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.
  86. 86. 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.
  87. 87. 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.
  88. 88. 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.
  89. 89.  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.
  90. 90. 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.
  91. 91. 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.
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  95. 95. Thank you Leader in continuing dental education