Salivary gland diseases

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  • . Severe reduction of salivary output not only results in a rapiddeterioration in oral health but also has a detrimental impact on the quality of life for. It has been used to indicate an individual’s caries susceptibility; it has also been used to reflect systemic physiological and pathological changes which are mirrored in saliva.
  • Systemic diseases where salivary glands are involved.Clinical situations in which salivary flow and chemistry are helpful in diagnosis or monitoring patient progress.
  • since they may compromise the assay by lowering saliva pH and increasing bacterial growth. (13,14)
  • the levels of many analytes are higher in the general circulation than in saliva..
  • Instruction for collection of saliva........means method.
  • The SOS is made of a non-toxic, inert polymer shaped into a 30 x 10 mm cylinder . Not recommended for children under the age of six, due to the possibility of choking
  • Instructions for UseRemove SOS from outer packaging and place into proper mouth location as directed (see placement diagram on next page). Keep SOS in place for 1-2 minutes to ensure that it is saturated. (If collecting from the parotid glands in the cheek, saliva flow will be low, and collection time should be extended for up to 5 minutes to ensure adequate volume.) Due to location effects for certain analytes, we recommend that the SOS should not be moved around in the mouth.Place SOS into the swab storage basket insert (upper portion of the tube).Replace cap and snap securely onto tube. For samples being sent to Salimetrics, label the exterior of the tube using pre-printed, bar-coded labels provided, or write the ID number with a waterproof pen.
  • Wen the stimulated whole saliva flow rate is and stimulated wole saliva is flow rate is ,it is abnormally low and Indicative of marked salivary hypofunction.
  • Since the salivary gland are located superficially ,radiographic images may be obtained with standard dental radiographic techniques.for visualization of parotid gland plain filn radiography such oblique-lateral or rotated AP VIEW MAY BE USED.standardocclusal film may be placed intra orally adcent to the paroid duct to visualzea stone close to the orifice.
  • One of the oldest method .most remmendedmehod as it provides the cleares visualization of the branching ducts.
  • But sialography has got limitations…..
  • Flow phase represents the phase immediately after the injection when isotope is equilibrating in the blood and accumulaing in the salivary gland through active ransport.second phase that concentration phase starts after 1 min of administration of tracer.after 15 min of administration tracer begins to increase the oral cavity and decrease in the salivary gland.activity remaining in the salivary gland after stimulation is suggestive of obstruction,certainumors,and inflammation.
  • Transverse gray scale sonogram of the submandibular gland showing an echogenic focus (arrow) with posterior acoustic shadowing, diagnostic of a intraglandular ductal calculus.2- Transverse gray scale sonogram showing a welldefined, round, homogeneous, hypoechoic lesion in the left submandibular gland. These features suggest a benign salivary gland lesion. Note the posterior acoustic enhancement commonly seen with pleomorphic adenoma.
  • Due to there superficial locations, the parotid and sucmandibular gland are easily visualozed by the ultrasonography.
  • Soft Tissue Window The short arrow shows the compressed submandibular gland adjacent to the sialolith and the long arrow shows the normal gland for comparison.Abscesses have hypervascular walls evident with CT imaging. MRI usually preferred because:No radiation exposureContrast media is not always neededMinimal distortion caused by dental restoration
  • Absence of salivary gland unilaterally or bilaterally.L-LACRIMINAL GLAND aplasia,orlacriminal sac inflammaion,auricles are deformed with ear having a cup shaped appearnce,hearloss.D-peg shappedteeth,hypodontia, digital deformitites manifested by deviation of fingers medially or laterally.treacherscollins syndrome will include features of craniofacial deformities,micrognathia,conducing hearing loss,zygoma,slantingeys.
  • Small localised swelling, the cause of focal enlagement is usallyhormmonal and metabolic.1.these also said to be benign adenoma of these glands.
  • No clinical significance attached to it other than they may be site of development of a retention cyst or neoplasm.
  • In exceedingly rare conditions,Wen it does occurs causes severe xerostomia,
  • It causes drooling, which produces social embarrassment ,rejection and severe impairement in the quality of a life. most of the cases of hyper salivation are secret ion clearance issue. a swallowing study should study should be obtained. saliva flow rate should be determined. unstimulated saliva flow rate is 2.0to 3.5 ml permin.where as collection of saliva using drooling technique into a pre weighed container will result in more den 5ml.0 in 5 min.in post menopausal woman or male androngen level should be determined.
  • ZYBAN which aids in smoking cessation.
  • Sialoliths are the calcified and organic matter that are formed within the secretory system of the major salivary gland.
  • .bacterial infection of the salivary gland are most commonly seen in patients with reduced salivary gland fucntion.It might not be occurring in submandibular gland more frequently as high level of mucin. Anatomically tongue movement.also referred as surgical parotitis because post surgical patients often experienced gland enlargement from ascending bacterial infection.occrs less frequetly today beccause of the prophylactic anibiotics and perioperative hydration.
  • Rapid onset,.it is a self ,limiting last approx 6 weeks and heals by secondary intention. No specific treatment is required.but debridement and saline rinses may help he healing process.
  • Lesion results from the obstruction of duct of minor salivary gland. two type extravasation n retention type.extravasation is far more common den retention type.various studies have been conducted but no predilection have been found for any age group or gender predilection.
  • It is an acute contagious viral infection characterized by the unilateral or bilateral swelling of the salivary gland usually parotid.submandibular or sub ingual salivary gland are occasionally involved.usallypreced by the feverheadache,malaise vomiting pain below the year.followed by the rubbery swelling of the salivary gland.itusally remains peak during 2-3 days and then grduallysubsides.complications of this disease include affect of other organ of body such as testes,ovaries,pancreases,mammary gland.
  • Mixed in origin because it contains both epithelial and mesenchymal elements both.most common neoplasm of children as well.stroma consist of chondroid,myoxid,fibroid.so the name given.presence of myoepithelial cells.
  • Due to its microscopic projection a wide resection is needed to be done to avoid re-occurrence.one of the characterictic of pleomorphic adenoma is that it has microscopic projections.if these projection are not removed , the lesion will re-occur.
  • Large tumours usually invloves significant amount of superficial lobe of parotid gland.
  • Is a tumour that is composed predominantly of one type of cell.tratment is same that of pleomorphic adenoma.
  • Treatment- conservative surgical excision
  • Salivary gland diseases

    1. 1. By Priyankesh 1st year post graduate Department of oral medicine and radiology
    2. 2.      Introducion Evaluation of salivary gland -clinical examination -radiological evaluation Classification of salivary gland diseases -staging of salivary gland tumour Description of salivary gland diseases References
    3. 3.  Salivary glands and saliva plays a very important role in maintaining oral and systemic health.  Saliva is constituted by the secretions of the three paired major salivary glands. It also contains the secretions of the minor salivary glands, of which there are hundreds contained within the submucosa of the oral mucosa and some gingival crevicular fluid.  Saliva aids in speech and deglutition and serves as a diagnostic fluid
    4. 4. 1. 2. 3. 4. History : Symptoms indicative of salivary gland disorders are limited in number and generally nonspecific. Patients usually complain of swelling, pain, xerostomia, foul taste, and sometimes excessive salivation. Gender : sjogrens syndrome common in menopausal women Age group : paramyxoviral infection is most common occurring in the children between age group of 4-10 yrs. Medical profile :-diabetes mellitus, arteriosclerosis, hormonal imbalances and neurologic disturbances.
    5. 5. 4. 5. 6. Drug history: xerostomia is often caused by the diuretics and antihypertensive drugs.... A careful dietary and nutrition history should be obtained. Patients who are dehydrated chronically from bulimia or anorexia or during chemotherapy are at risk for parotitis. Swelling and pain during meals followed by a reduction in symptoms after meals may indicate partial ductal stenosis. 7. Radiation history …. 8. Current medications …..
    6. 6.  signs of mucosal dryness  Lips-cracked, peeling and atrophic  Buccal mucosa-pale and corrugated in appearance  Tongue-smooth and reddened  Marked increase in erosion and caries.  Erythematous form of candidiasis commonly occurs  Viscous,scant saliva suggest chronically reduced function
    7. 7.  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
    8. 8. •Palpate below angle & body of mandible •Bimanual palpation •Intraoral examination to check papilla if inflamed •Compress the gland to see saliva
    9. 9.  To measure salivary flow rate (resting / stimulated)  provide essential information for diagnostic and research purposes  Calculated from the individual major salivary gland or from a mixed sample of the oral fluids, termed “whole saliva”.
    10. 10. 1. Passive drool 2. salimetrics oral swab 3. Infant swab 4. Spitting method 5. Suction method
    11. 11.                             Analyte Passive Drool Aldosterone yes Alpha-amylase* yes Androstenedione yes Blood Contamination yes Chromogranin A yes Cortisol yes yes Cotinine yes yes C-Reactive Protein yes DHEA yes DHEA-S* yes Epstein-Barr Virus Antibody Estradiol yes Estriol yes Estrone yes IL-1β yes yes IL-6 yes yes Melatonin yes yes Neopterin yes NGF yes 17-OH Progesterone yes Progesterone yes Secretory IgA* yes yes Testosterone yes yes TNF-α yes Total Protein yes *Note: concentrations are affected by saliva flow rate **Note: Levels are slightly higher, but highly correlated SOS/SCS/SIS yes yes** yes yes yes
    12. 12.  Avoid having alchol,caffenine,prescribed medication 12 hours before collection of saliva.  Avoid eating major meal within 60 min of sample collection  Avoid dairy products for 20 min before sample collection .  Participants should not brush their teeth within 45 minutes prior to sample collection.
    13. 13.   Rinse mouth with water to remove food residue before sample collection. Wait at least 10 minutes after rinsing before collecting saliva to avoid sample dilution. Also while pipetting saliva, greater accuracy is obtained by aspirating slowly in order to avoid formation of bubbles.
    14. 14.      Contamination of saliva samples with blood can also be a concern Blood can leak into saliva under certain conditions. Dental work should not be performed within 24 hours prior to sample collection. Research participants should be screened for oral health problems or . Saliva samples visibly contaminated with blood should be discarded and recollected.
    15. 15.   Passive drool - highly recommended because it is both cost effective and approved for use with almost all analytes. To avoid problems with analyte retention or the introduction of contaminants, use only high quality polypropylene vials for collection . The vials used must seal tight and be able to withstand temperatures down to -80ºC.
    16. 16.   participants should allow saliva to pool in the mouth. Some find it helpful to imagine eating their favorite food. At this time, unwrap the Saliva Collection Aid (SCA) and insert it into the top of the cryovial . With head tilted forward, participants should drool down the SCA to collect saliva in the cryovial. (It is normal for saliva to foam, so we advise using a vial with twice the capacity of the desired sample volume.)
    17. 17.    an excellent alternative to passive drool . SOS also helps filter large macro molecules and other particulate matter from the sample. Not recommended for children below 6 yrs of age.
    18. 18.    Carlson-Crittenden collector method used for individual gland. Stimulated saliva is obtained by applying sialagogue as citric acid to the dorsal surface of tongue. Flow rate of the saliva is also affected by the many factors such as patient position, hydration, diurnal variations ,time stimulation  Stimulated whole saliva flow rate <1.0ml/min  Unstimulated whole saliva flow rate <0.1 ml/min
    19. 19.     To differentiate inflammatory from neoplastic diseases. To differentiate from diffuse and focal suppurative disease To identify and localise sialoliths To demonstrate ductal morphology
    20. 20. 1. Plain-film radiography 2. Sialography 3. Ultrasonography 4. Scintigraphy (Radioisotope imaging) 5. Computed tomography (CT) 6. Magnetic resonance (MRI)
    21. 21.  1. Used for calculi. Parotid 1. 2. 2. OPG / Oblique - lateral Rotated anterior-posterior Submandibular 1. Occlusal 2. OPG 3. Lateral oblique
    22. 22.  First mentioned by carpy in 1902.  Barsony and uslenghi –a diagnostic tool in 1925.    It is specialised radiographic view of salivary gland taken by introduction of soluble contrast media into the ductal system.the radiographs are called sialographs. Recommended method for intrinsic & acquired abnormalities of ductal system. Helps in viewing –ductal stricture - obstruction - dilatation - ductal rupture - stones
    23. 23.   Oil & water based contrast media is available. Demonstrate 3 phases: 1. Preoperatively 2. 3.  Filling phase Emptying phase C.I - allergy to contrast media - active infection - patient with iodine sensitive
    24. 24.  Disadvantages: Irradiation dose  High skill is needed to conduct the procedure  Pain with procedure  Possible perforation  Might force bacteria throughout the ductal structure.
    25. 25.     dynamic & minimal invasive diagnostic technique. Technetium is a pure gamma ray-emitting radionuclide taken up by the salivary gland, transported through the glands and then secreted into oral cavity. Uptake of Tc 99m indicated presence of epithelial tissue present. Serves as a measurement of fluid movement in salivary acinar cells.
    26. 26.  Pass through 3 stages: 1. Flow phase 15-20 sec 2. Concentration phase up to 10-15 min Symmetrical distribution in parotid, submandibular 3. Washout phase Pt is given a lemon juice drop Prompt, uniform & symmetric emptying
    27. 27.    Non-invasive & cost effective imaging modality used in the evaluation of masses occurring in superficial lobe of parotid gland. Indicated :intra & extra glandular masses. solid & cystic lesion. Recent studies have established sonographic diagnostic criteria for sjogren‟s syndrome.
    28. 28.  Shows superficial part of gland Echogenic sialolith Hypoechoic benign tumour
    29. 29.  Indications: 1. 2.  Osseous erosions & sclerosis 3.  Sialolith To differentiate cysts from abscess Retromandibular vein,carotid artery & deep lymph nodes are identified. Especially useful in inflammatory condtions associated with sialoliths.
    30. 30.  Advantages :- 1. excellent ability to differentiate soft tissue . 2. Provide multiplanar imaging. 3. No exposure to radiation 4. No intravenous contrast media required. 5. Minimal artifact from dental restorations.
    31. 31. Imaging Modality Indications Advantages Disadvantages Ultrasonography Biopsy guidance; mass detection Noninvasive; costeffective limited visibility of deeper portions of gland; no morphologic information Sialography Stone, stricture; R/O autoimmune orradiationinduced sialadenitis Visualizes ductal anatomy/blockage Invasive; requires iodine dye; no quantification Radionuclide imaging R/O autoimmune sialadenitis; sialosis, tumor Quantification of function Radiation exposure; no morphologic information Computed tomography R/O calcified structure; tumor Differentiates osseous structures from soft tissue No quantification; contrast dye injection; radiation exposure Magnetic resonance imaging R/O soft-tissue lesion Soft-tissue resolution excellent, with ability to differentiate osseousstructures from soft tissue; Dental scatter; contraindicated with por metal implant; no quantificationace maker
    32. 32. • • • • • Developmental disturbances Saliva and salivary flow Inflammatory condition Non inflammatory condition Tumors
    33. 33. • Aplasia/Agenesis • Hyperplasia of minor salivary glands
    34. 34. • • • • • Saliva Hypofunction Xerostomia & salivary gland hypofunction due to medicaions/radiations Sjogren syndrome Benign lymphoepithelial lesion
    35. 35.          Mucocele Ranula Sialolithiasis Sialadenstis Non specific sialadenitis Bacterial sialadenitis Sub acute necrotizing sialadenitis Necrostizing sialometaplasia Mumps
    36. 36.      Sialadenosis Anorexia-related sialadnosis Sialadenosis associated with alcoholic cirrhosis diabetes mellitus Medication –induced sialadenosis sarcoidosis
    37. 37.     Plemorphic adenoma Canalicular adenoma Basal cell adenoma Papillary cystadenoma lumphomatosum (warthin‟s tumour)
    38. 38.      Mucoepidermoid carcinoma Acinic cell mucoepidermoid carcinoma Acinic cell carcinoma Malignant mixed tumor Metasizing mixed tumor
    39. 39. Congenital absence of salivary gland  Aplasia occurs in combination with congnital anomalies such as LADD SYNDROME,TREACHERS COLLINS  Hypoplasia in patient with melkerson rosenthal syndrome. Clinical feature  one or group of gland missing unilaterally or bilaterally  Xerostomia  Dental caries  Dry n smooth oral mucosa 
    40. 40. Causes:    hormonal & metabolic Usually occurs at minor salivary gland of he palate Asymptomatic surface firm, sessile & normal in colour.
    41. 41. aberrant salivary gland  an aberrant or ectopic salivary gland is a salivary gland tissue that develops at a site where it is not normally found. Clinical feature  Site- cervical region near parotid gland or he body of mandible  No clinical signifiance  Usually its site for development of retention cyst or neoplasm.
    42. 42.    Congenital occlusion or absence of one or two major salivary gland Site-submandibular duct in the floor of the mouth. Causes severe xerostomia
    43. 43. Sialorrhea  Increase in salivary secretion.  Stimulation of parasympathetic causes profuse secretion of saliva. Clinical feature  Drooling from mouth  Occurs with various neurologic disorder  Traumatic ulceration.  Heavy metal poisiong.  Drug induced as anti-pshycotic.  Gastroesophagel reflux  pregnancy
    44. 44. Medications that can cause overproduction of saliva include:  clozapine  pilocarpine  ketamine  potassium chlorate  Risperidone. Metals that can cause hypersalivation include:  iron  lead  Mercury  Arsenic  Thallium Neurologic diseases  Parkinson‟s diseases  Wilson‟s diseases  Down syndrome  Cerebral palsy  Fragile Xsyndrome  autism
    45. 45.                   Pharmaceuticals External beam irradiation to the head and neck and internal radionuclides (eg, 131I) Systemic diseases Sjögren syndrome, primary and secondary Granulomatous diseases (sarcoidosis, tuberculosis) Graft-versus-host disease Cystic fibrosis Bell palsy Diabetes (uncontrolled) Amyloidosis Human immunodeficiency virus infection Thyroid disease (hypo- and hyperthyroidism) Late-stage liver disease Salivary gland disease (tumors) Psychologic factors (anxiety,depression) Malnutrition (anorexia, bulemia, dehydration) Idiopathic
    46. 46.  Dryness of the mouth .  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
    47. 47. History: 1. Does the amount of saliva in your mouth feel too little? Too much? Not notice it? 1. Does your mouth feel dry while eating? 2. Do you frequently sip liquids while eating? 3. Do you have difficulties swallowing food?
    48. 48. Symptoms  Thirst  Difficulty eating, speaking, wearing denture  Need sips of water while eating  Soreness and Burning sensation of mouth  Abnormal taste & halitosis  Cracked lips and soreness of corners of mouth  Dry, atrophic, pale and translucent mucosa
    49. 49. Preventive therapy 1. 1. 2. Flouride rinses & gel Oral hygiene Symptomatic treatment 2. 1. 2.     Water Artificial saliva Avoid products containing sugar, alcohol Vaseline ointment to relief cracking Topical antifungal Regular check ups Salivary stimulation 3. 1. Local / topical stimulation (detectable salivary gland function) 1. 2. Chewing (flavoured, sugar free, xylitol) Systemic stimulation (Pilocarpine).
    50. 50. Submandibular salivary gland is common site of calculus formation mainly because of the saliva flowing against gravity. Stone composition:  Organic- glycoproteins., Inorganic - Calcium carbonate, Mucopolysaccarides calcium phosphates in the bacteria, form of hydroxyapatite cellular debris .
    51. 51. The exact mechanism of stone formation is unclear, but it appears to be related to the following conditions:  Salivary stagnation-inflammation,irregularities in the duct system,local irritants and anticholinergic medications   Epithelial injury along the duct- sialolith formation, which acts as a nidus for further stone formation Precipitation of calcium salts, altered salivary hydrogen ion concentraion.
    52. 52. sialolithiasis more often in submandibular gland saliva a.more alkaline. b.Higher concentration of calcium and phosphate in the saliva c.Higher mucous content d.Longer duct e.Anti gravity flow Treatment:  Acute infections-antibiotics. Stones in the distal portion of duct can often be removed manually.  Deeper stones require surgery. Lithotripsy has been described as a non-invasive method of disintegrating sialoliths
    53. 53.        Reduced salivary gland function. Also referred as surgical parotitis. More frequently occurrence involving parotid gland. clinical feature Unilateral or bilateral salivary gland enlargement Indurated, painful and tender to palpation. Overlying skin-erythematous Purulent discharge may be expressed from duct orifice.
    54. 54.  Treatment   Antibiotics after culture and sensitivity, 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) 
    55. 55.     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
    56. 56.  Predisposing factors: 1. Drug induced (antirheumatic, idoine containing drugs, adrenergic) 2. Hormonal (Diabetes, acromegaly) 3. Nutritional deficiency induced by anorexia nervosa 4. Chronic alcoholism 5. Medication induced salivary dysfunction
    57. 57.  Management: 1. Detailed drug history 2. Liver function test 3. Blood glucose level 4. Growth hormone level 5. CBC and full blood investigation
    58. 58.    Non neoplastic inflammatory self healing reaction of salivary gland tissue, which both clinically and histologically mimics a salivary gland malignancy. Etiology: trauma radiation vascular ischemia tobacco use. C/F: The lesion generally presents as an ulcer Seen- Posterior hardpalate, is due to necrosis of minor saliary glands.
    59. 59. 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
    60. 60. Swelling caused by the pooling of saliva at the site of injuries salivary gland.  Mucus extravasation cyst-spillage of mucin into the surrounding tissues. Clinical feature  Site inner aspect of lower lip,floor of the mouth,tongue  Painless swelling which frequently reoccurs.   Fluctuant,dome shaped,non ulcerated.
    61. 61.         Latin rana means frog, and a ranula- a frog's underbelly. Term used for mucocele for the floor of the mouth. Associated with ducts from the submandibular or sublingul gland. Spherical or dome shaped. Translucent blue colour in apperance . Can cause elevation of the tongue. Slow enlarging swelling on the floor of the mouth can cause difficulty in speech or eating. When deep lesion tat herniates through mylohyoid muscle and extend along the fascial planes it is referred plunging ranula.
    62. 62. Contagious viral infection caused by para myxo virus.  The more common symptoms of mumps are:Parotid inflammation in 60–70% of infections.  The incubation period(time until symptoms begin) can be from 14–25 days  Parotitis causes swelling and local pain, particularly when chewing Clinical feature  Unilateral or bilateral parotid enlargement gland.  Fever ,headache, malaise or anorexia  Pain below the ear.  Glands are tender on percussion. 
    63. 63.   Chronic autoimmune disease affecting exocrine glands,primarily salivary and lacrimal glands. It can exist as a disorder in its own right (Primary Sjögren's syndrome) or it may develop years after and associated rheumatic disorder such as rheumatoid arthritis,SLE, scleroderma, primary biliary cirrhosis etc (Secondary Sjögren's syndrome).
    64. 64. Clinical feature  Persistent xerostomia & keratoconjunctivits sicca.  Hyposalivation or reduced salivary flow rate.  Thick or frothy saliva  Difficulty in chewing and swallowing, wearing denture  Dryness of eyes.
    65. 65. Revised International Classification Criteria for Sjogren’s syndrome: Criteria I Ocular symptoms: at least one of the following  1. Daily dry eyes for >3 months  2. Persistent sensation of sand or gravel  3. Use of tear substitutes >3 times daily II Oral symptoms: at least one of the following  1. Dry mouth daily >3 months  2. Recurrent salivary gland swellings  3. Use of liquid to aid in swallowing food II Ocular signs: at least one of the following  I1. Schirmer‟s I test (5 mm in 5 min)  2. Rose Bengal score (4) IV Histopathology: focal lymphocytic sialoadenitis with focus  score 1 per 4 mm2 of tissue V Salivary gland involvement: at least one of the following  1. Unstimulated salivary flow 1.5 ml ⁄ 15 min  2. Abnormal parotid sialography  3. Abnormal salivary scintigraphy VI Autoantibodies
    66. 66. Testing for opthalmic involvement  Schirmer‟s I test: quantitative measure of tear production over a specific period of time Rose Bengal eye stain: reveals breaks in the corneal-epithelial surface  to evaluate ocular surface irritation  Patient history of opthalmic symptoms Testing for oral involvement  Salivary sialometry: low salivary flow is defined as less than 1.5 ml of saliva per 15 minutes  Labial minor salivary gland biopsy: showing lymphocytic sialoadenitis with a focus score of ‡1 per 4 mm2 of tissue  Examination for salivary gland enlargement: parotid and ⁄ or submandibular  Patient history of oral symptoms Systemic tests  Presence of auto antibodies.  Presence of rheumatoid factor in patients serum BK ayetto, RM Logan,Sjogren‟s syndrome: a review of aetiology, pathogenesis,diagnosis and management, Australian Dental Journal 2010; 55:(1 Suppl): 39–47
    67. 67. Treatment: - Treat recurrent infection - Salivary substitutes/sprays - cholinergic drugs (Pilocarpine) - Avoid alcohol, tobacco. - Immunosuppressive therapy; corticosteroids or cytotoxic drug have been proven effective.
    68. 68.    uveitis, parotid swelling, and facial nerve paralysis. It usually begins with a prodrome of constitutional symptoms and involvement of the submandibular, sublingual, and lacrimal glands may occur. last months to years and resolves spontaneously. Treatment is usually symptomatic with steroids being most beneficial when administered in the acute phase of the illness
    69. 69. Benign tumors with low propensity for recurrence Oncocytoma Papillary cystadenoma lymphomatosum Basal cell adenoma Canalicular adenoma Benign tumors with a propensity for recurrence Pleomorphic adenoma (major glands) Malignant tumors with high-grade behavior Adenoid cystic carcinoma Salivary duct carcinoma Epithelial-myoepithelial carcinoma of intercalated ducts High-grade mucoepidermoid carcinoma Squamous cell carcinoma of salivary origin Malignant tumors with low-grade behavior Polymorphous low-grade adenocarcinomas Low- and intermediate-grade mucoepidermoid carcinoma Cystadenocarcinomas
    70. 70.                 Tx To T1 T2 T3 T4 Primary tumor can not be assessed No evidence of primary tumor Tumor < 2 cm in greatest dimension Tumor 2–4 cm in greatest dimension Tumor 4–6 cm in greatest dimension Tumor >6 cm in greatest dimension T= N= tumour size well as extension into adjacent tissue Nodal involvement Nx Regional nodes cannot be assessed M= Metastases N0 No regional lymph node metastases N1 Single ipsilateral node < 3 cm in diameter N2a Single ipsilateral node 3–6 cm in diameter N2b Multiple ipsilateral node, none > 6 cm N2C Bilateral or contralateral nodes, none > 6 cm N3 Metastasis in a lymph node > 6 cm Mx Presence of distant metastases cannot be assessed M0 No distant metastases M1 Distant metastases
    71. 71.     Stage I T1a T2a T1b T2b T3a T3b T4a N0 M0 N0 M0 Stage II N0 M0 N0 M0 N0 M0 Stage III N0 M0 N0 M0 Any T (except T4b) Nl M0 Stage IV T4b Any N M0 Any T N2N3 M0 Any T Any N M1 Adapted from the American Joint Committee for Cancer Staging and End Results
    72. 72. Also called benign mixed tumour  Most common salivary neoplasm. can involve any major or minor salivary gland Clinical feature  Seen 4th-6th decade of life.  Slight female predilection.  Slow- growing, painless, firm n non –tender  Mobile in early stages. with increases in size irregular n nodular upon palpation.  Intermittent growth period.  Histologically epithelial cells make up a Trabecular patterncalled stroma 
    73. 73. Treatment: The treatment for salivary gland tumor is surgical resection. Benign tumors of the parotid gland are treated with superficial or total parotidectomy
    74. 74.        PAPILLARY CYSTADENOMA LYMPHOMATOISM/adenolymphoma Type of benign tumor of the parotid gland. etiology is unknown, but there is a strong association with cigarette smoking. clinical feature: Parotid gland. (age 50–70years), male predilection. slow growing, painless, and usually appears in the tail of the parotid gland near the angle of the mandible. Painless until superinfected. Visible on Tc 99m scintiscans.
    75. 75. TREATMENT  Most of these tumors are treated with surgical removal.  Superficial parotidectomy in case of large tumours.
    76. 76.    Differentiated from mixed tumour: monophasic histology composed of cells of one type. absence of connective tissue changes. But in cases where background stroma contains myxoid, chondroid, or mesenchymal derivatives, the term „monomorphic‟ should not be applied rather „mixed tumor‟ should be used.
    77. 77.       Clinical features: Male predilection. primarily in major salivary gland – parotid. painless, slow growing, firm swelling which may be cystic and compressable. Upper lip -the most common site Neoplasm of uniform population of basaloid epithelial cells arranged in soild, tubular,or trabecular patterns.
    78. 78.  Cannot be distinguished from mixed tumor. Although, BCA may be found in all salivary gland preferably parotid, and minor salivary glands of upper lip Histological features:  1)Solid type  2)Tubular  3)Trabecular type  4)Membranous type  Consist of island or sheets of basaloid sheets. TREATMENT: Excision. Recurrence is seldom seen.
    79. 79.          most common type of malignant salivary gland tumour. clinical feature painful and ulceration of overlying tissue. Female predilection. Extra orally – parotid gland is affected. Intra orally - palate Presents as painless, slow-growing mass that is firm or hard. Metastasis is seen in high grade tumour. Poor prognosis. Tumour is composed of mucus – secreting cells and epidermoid type of cells in varying proportions
    80. 80. TREATMENT: Malignant salivary tumors usually require wide local resection of the primary tumor.An adjuvant radiotherapy should be added to improve local control.
    81. 81. Second most common malignant salivary gland tumor o occur in children. Clinical feature:  90-95%locted in parotid gland  Encapsulated  Female predilecion.  Superficial lobe and inferior lobe of parotid gland are common site of occurrence.  Slow growing, mobile / fixed mass, asymptomatic.  Facial muscle weakness reported.  Characterized by the late distant metastasis and local reoccurences. h/f: Cells – acinar differentiation ie, duct formation. 
    82. 82. Treatment: Surgical excision. Poor prognosis include gross invasion,painor fixation, atypia.
    83. 83.     Rare type of CANCER that can exist in many different body sites. It most often occurs in the areas of the head and neck, in particular the salivary glands. Patients may survive for years with metastases because this tumor is generally well-differentiated and slow growing. It is the second most common malignant salivary gland tumor overall (after mucoepidermoid carcinoma)
    84. 84. TREATMENT Primary treatment -surgical removal with clean margins. Paliative radiotherapy is commonly given following surgery.
    85. 85.        Malignant epithelial neoplasm of major salivary gland, composed of squamous cells. C/f Mostly occurs in parotid gland. Previous exposure to ionizing radiation, increases the risk present as a firm enlarging mass that is not uncommonly fixed to the surrounding tissue. Pain , facial weakness present. Tumor most commonly seen in plummer vision syn. Histological findings:  presence of neoplastic squamous cells. Metaplastic changes, with varying degree of nuclear a typia. Treatment :  Surgical resection.  Prognosis poor. 
    86. 86.  General anatomy of head and neck Chaurasia  Oral medicine Burkits  Oral medicine ravikiran ongole  Oral pathology shafers  ANATOMY AND PHYSIOLOGY OF THE SALIVARY GLANDS Resident Physician: Frederick S. Rosen, MD Faculty Physician: Byron J. Bailey, MD , January 24, 2001  The Pathology of the Salivary GlandsR. A. Cawson, M. J. Gleeson, J. W. Eveson  The Journal of Contemporary Dental Practice, Volume 9, No. 3, March 1, 2008  The anatomy and physiology of salivary glands by Helen Whelton

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