The document discusses salivary glands, including: 1. There are three pairs of major salivary glands - parotid, submandibular, and sublingual glands. 2. The parotid gland is the largest salivary gland located below the ear. 3. There are also hundreds of minor salivary glands throughout the mouth and tracheobronchial tree.

1. 1
1

2. SALIVARY GLAND
DEPARTMENT OF PUBLIC HEALTH DENTISTRY
GUIDED BY
DR.(PROF) VEERANNA
RAMESH
PRESENTED BY
DR. ANANT KUMAR
PG 1st YEAR
B.I.D.S.H
2
2

3. CONTENTS
 History
 Introduction
 Development Of Salivary Glands
 Classification of Salivary glands
 WHO Classification Of Salivary Gland Disorders 2017
 Diagnosis Of Salivary Gland Disorders
 Syndromes Associated With Salivary Gland Diseases
 Effects Of Aging On Salivary Glands
 Conclusion
 References
3

4. HISTORY
 The name "Salivary Gland" (in Latin Glandulae salivariae) was probably used by the first time by
Andreas Vesalius in 1543, he described in his Chapter V of Book Vol. II the three types of "throat"
glands: type I "paristhimia", that corresponds to the uvula, type II "antiades" or (acorn in Latin),
corresponding to the tonsils, and type III, with no specific name, corresponding to parotid and
submandibular glands, that were also found in other animals, "that humidifies food, and must be
regarded as important as other types".
4

5. Introduction
 The salivary glands are exocrine glands that produce
saliva through a system of ducts.
 Humans have three paired major salivary glands
(parotid, submandibular, and sublingual), as well as
hundreds of minor salivary glands.
 An average person produces between 0.5 to 1.5 liters
of saliva every day.
5

6. 6
The various developmental stages are-
i. Bud stage
ii. Cord stage
iii. Branching of cords
iv. Lobule formation
v. Canalization of cords
vi. Cytodifferentiation
Development of salivary gland
The development of the parotid
gland starts from 4-6th week, the
submandibular gland at 6th week
and the sublingual gland including
minor salivary glands develops at 8-
12 week of embryonic life.

7. I. Bud stage:- The mesenchyme underlying the oral epithelium induces
the proliferation in the epithelium which results in tissue thickening and
bud formation.
II. Cord stage:- A solid cord of cells forms from the epithelial bud through
cell proliferation. Condensation and proliferation occur in the
surrounding mesenchyme which is closely associated with the epithelial
cord.
7
Stages in the development of salivary glands

8. 8
III. Branching of cords:-
The epithelial cord proliferates rapidly and branches into terminal
bulbs.
IV. Lobule formation:-
The branching continues at the terminal portion of the cord forming
an extension treelike system of bulbs. As branching occurs, the
connective tissue differentiates eventually around the Salivary
Glands branches.

9. 9
V. Canalization of cords:-
Canalization of the epithelial cord, with the formation of a hollow tube or
duct, usually occurs by the sixth month in all the major salivary glands.
Mechanism of canalization are:
 Different rates of cell proliferation between the outer and inner layers of
the epithelial cord.
 Fluid secretion by the duct cells which increases the hydrostatic pressure
and produces a lumen within the cord.
 Further branching of the duct and structure and growth of the connective
tissue septa continues at this stage of development.

10. 10
VI. Cytodifferentiation:-
 The final stage of salivary gland development is the
histodifferentiation of the functional acini and intercalated
ducts.
 Myoepithelial cells arise from the epithelial stem cells in the
terminal tubules and develop in concert with acinar
cytodifferentiation.

11. Newly discovered salivary gland named the
Tubarial gland
11
“Now, we think there is a
fourth pair of salivary gland,”
said Dr. Matthijs Valstar, a
surgeon and researcher at the
Netherlands Cancer Institute
and an author on the study,
published in the journal of
Radiotherapy and Oncology in
23rd September 2020.

12. Classification of salivary glands
12
I. Based on Anatomy
Major salivary
gland
Minor salivary
gland
II. Based on
Secretion
Serous
Mucous
Mixed

13. 13
i. Parotid gland
ii. Submaxillary or
submandibular gland
iii. Sublingual gland.
1. Major salivary gland
I. Based on Anatomy

14. 14
1. Parotid gland
 It comes from the word para-around and otic-ear. It is the largest of all the salivary glands, weight about 15-30g
and, It is located below the external acoustic meatus between the ramus of the mandible and the
sternocleidomastoid, it is like an inverted flattened pyramid shape structure.
 It is divided by facial nerve into a superficial and deep lobe. The superficial lobe, overlying the lateral surface of
the masseter, is defined as the part of the gland lateral to the facial nerve.
 The deep lobe is medial to the facial nerve and located between the mastoid process of the temporal bone and the
ramus of the mandible. An accessory parotid gland may also be present lying anteriorly over the masseter muscle
between the parotid duct and zygomatic arch.
Facial nerve
Medial pterygoid
Ramus of mandible
Masseter
Mastoid process

15. 15
Stensen’s duct
 The parotid duct which is called as ‘Stensen’s duct is about 5 cm long and has
thick walls. It emerges from the substance of the gland to course anteriorly until it
reaches the anterior border of the masseter muscle at the point of upper and middle
thirds.
 When it crosses the masseter muscle, it receives the duct of the accessory lobe.
Around the border of the masseter muscle, the duct turns sharply medially, often
embedded in a furrow of the protruding buccal fat pad.
 In its medial course, the duct reaches the outer surface of the buccinator muscle,
where it perforates in an oblique direction anteriorly and medially.
 It then runs for a short distance obliquely forward, between the buccinator and
mucous membrane of the oral cavity and opens on the oral surface of the cheek,
opposite the upper second molar.

16. 16
Blood supply:-
• Parotid gland is
supplied by the
external carotid artery
and its branches near
the gland.
Lymphatic
drainage:-
• Drains first to the
parotid nodes and
from there to the
upper deep cervical
nodes.
Nerve supply:-
• It is supplied by
auriculotemporal
nerve, plexus around
the external carotid
artery and greater
auricular nerve.
Venous
drainage:-
• External Jugular Vein
Via Local Tributaries.

17. Clinical consideration
 Because of fibrous fascia is covering the parotid, its inflammatory swelling is
tense and hard. The relatively static reservoir may form obstructions and are a
ready nidus for bacterial activity.
 The close association of the facial nerve with the gland is very important
consideration, during surgical procedures. After parotidectomy ,there may be
regeneration of fibers in the auriculotemporal nerve which joins auricular nerve .
 This causes stimulation of sweat glands and hyperaemia in the area of its
distribution(redness and sweating).This clinical entity is called Frey’s syndrome.
17

18. 18
2. Submandibular gland
 It is the second largest salivary gland, also known as submaxillary salivary gland, weight about 7–16 g and is
almost the size of a walnut.
 It is situated in the submandibular triangle, which has a superior boundary formed by the inferior edge of the
mandible and inferior boundaries formed by the anterior and posterior bellies of the digastric muscle.
 The gland is approximately J-shaped being indented by the posterior border of the mylohyoid which divides into a
larger part superficial to the muscle and a smaller part lying deep to the muscle divides into a larger part
superficial to the muscle.

19. Wharton’s duct
 The submandibular gland duct, also known as Wharton’s
duct, is thin-walled, about 5 cm long, and runs forward
above the mylohyoid muscle lying just below the mucosa
of the floor of the mouth in its terminal portion.
 The duct opens on the floor of the mouth, on the summit of
the sublingual papilla also called the Caruncula
Sublingualis, lateral to the lingual frenulum.
19

20. 20
Arterial supply:-
• The arteries
supplying of the
submandibular gland
are derived from the
lingual and facial
branches of external
carotid artery..
Venous
drainage:-
• It drains into facial
and lingual vein.
Nerve supply:-
• Its nerve supply is
from the branches of
submandibular
ganglion through
which it receives
fibers from chorda
tympani.
Lymphatic
drainage:-
• Passes to the
submandibular
lymph node.

21. Clinical consideration
 The entire submandibular gland and duct system lies in a dependent position, which predisposes it to
retrograde invasion by oral flora.
 Similar to the parotid duct, the Wharton’s duct is also wider before reaching the papilla. This can
lead to strangulation of saliva and the organic matter.
 The sharp bends of Wharton’s duct at the posterior border of the mylohyoid muscle allows stasis of
the saliva favoring the formation of salivary stones.
21

22. 3. Sublingual gland
 It is the smallest of all the three major salivary glands that is
almond shaped and weighs about 3-4g.
 The gland lies above the mylohyoid, below the mucosa of
the floor of the mouth, medial to the sublingual fossa of the
mandible, and lateral to the genioglossus.
22

23. Bartholin’s duct
 It comprises of one main gland duct with
various small ducts.
 The main duct, Bartholin’s duct, opens with
or near the submandibular duct.
 Several smaller ducts, duct of Rivinus, open
independently along the sublingual fold.
23
Bartholin’s
duct

24. 24
Arterial
supply:-
• It is supplied
by sublingual
and submental
arteries.
Nerve
supply:-
• It is supplied
by lingual and
chorda
tympani
nerve.
Lymphatic
drainage:-
• It passes to the
submandibular
lymph nodes

25. 2. Minor salivary gland
25
 There are hundreds of minor salivary glands throughout the
mouth and extending down the tracheobronchial tree, which are
named for their anatomic location (labial, palatal, buccal, etc.).
 The minor salivary glands are placed below the epithelium in
almost all parts of the oral cavity. These glands comprise
numerous small groups of secretory units opening via short
ducts directly into the mouth.

26. Various minor salivary gland
26
i. Buccal glands - present between the mucous membrane and buccinator muscle, four to five of these
are larger and situated outside buccinator around terminal part of parotid duct. These glands are
also called molar glands.
ii. Labial glands -situated beneath the mucous membrane around the orifice of mouth.
iii. Palatal glands - found beneath the mucous membrane of the soft palate.
iv. Glossopalatine glands - These are located to the region of the isthmus in the glossopalatine fold but
may extend from the posterior extension of the sublingual gland to the glands of the soft palate

27. v. Lingual gland
 The glands of the tongue can be divided into various groups. The anterior lingual glands (glands of
Blandin and Nuhn) are present near the apex of the tongue. The ducts open on the ventral surface of the
tongue near the lingual frenulum.
 The posterior lingual mucous glands are present lateral and posterior to vallate papillae and in association
with lingual tonsil. The ducts of these glands open on the dorsal surface of the tongue.
 The posterior lingual serous glands (Von Ebner’s glands) are located between the muscle fibers of the
tongue below the vallate papillae, and the ducts open into the trough of circumvallate papillae and at the
rudimentary folate papillae on the sides of the tongue.
27

28. Von Ebner’s glands
 Von Ebner's glands, also called Ebner's glands or gustatory glands,
are exocrine gland found in the mouth.
 These glands are named after Victor Von Ebner, an Austrian Histologist.
 Located in tongue and open into the troughs surrounding circumvallate
papillae on the dorsum of the tongue and at the foliate papillae on the
side of the tongue.
 Secrete digestive enzymes & proteins that are thought to play role in
taste Process. Fluid of their secretion cleanse the trough & prepare the
taste receptors for a new stimuli.
28

29. 29
Glands Of Blandin And Nuhn
 Anterior lingual glands (also called apical glands) are deeply placed seromucous gland that are located near the
tip of the tongue on each side of the frenulum linguae.
 They are found on the under surface of the apex of the tongue, and are covered by a bundle of muscular fibers
derived from the styloglossus and Longitudinalis inferior.
 They are between 12-25 mm in length, and approximately 8 mm in wide, and each opens by three or four ducts
on the under surface of the tongue's apex.
 The anterior lingual glands are sometimes referred by eponymous names such as:
• Bauhin's glands: Named after Swiss anatomist Gaspard Bauhin (1560–1624).
• Blandin's glands: Named after French surgeon philippe-Frederic-Blandin(1798-1849).
• Nuhn's glands: Named after German anatomist Anton Nuhn (1815–1889).

30. Clinical consideration
 The sublingual gland and the minor salivary glands have short ducts, where the chances of
stasis are less.
 Thus, obstructive lesions do not occur in the glands.
 Since minor salivary glands are placed superficially, the traumatic lesions such as Mucoceles
commonly affect these glands.
30

31. II. Based on secretion
31

32. 32
 The acinar cells (the “grapes” in this analogy) make up the secretory end
pieces, the acinar cells of the parotid gland are serous, those of the sublingual
and minor glands are mucous, and the submandibular gland is composed of
mixed mucous and serous types.
 The duct cells (the “stems”) form an extensively branching system that carries
the saliva from the acini into the oral cavity.
 Although fluid secretion occurs only through the acini, proteins are produced
and transported into the saliva through both acinar and ductal cells.
 The secretion of saliva is controlled by sympathetic and parasympathetic
neural input. It is important to check unstimulated function when evaluating a
symptomatic dry mouth patient for salivary gland dysfunction.

33. Saliva
 It is defined as , “A clear, tasteless, odourless, slightly alkaline, viscous fluid, consisting of the secretion from
the parotid, submandibular and sublingual salivary glands and the mucous glands of the oral cavity.
 The saliva forms a film of fluid coating the teeth and mucosa thereby creating and regulating a healthy
environment in the oral cavity.
 At rest (basal or unstimulated function), it is estimated that the minor glands may produce up to half of the
saliva in the oral cavity. Saliva is the product of the major and minor salivary glands dispersed throughout the
oral cavity.
 It is a highly complex mixture of water and organic and nonorganic components. They are composed of acinar
and ductal cells arranged much like a cluster of grapes on stems.
33

34. Composition of saliva
34

35. 35
Function of saliva

36. 36
Classification Of Salivary Gland Disorders
(1) Developmental- Aplasia, Atresia, Aberrancy
(2) Functional Disorders- Xerostomia, Sialorrhea
(3) Inflammatory- infectious conditions,
 acute and chronic bacterial infection- Sialadenitis,
 Viral infection- Mumps, Human immunodeficiency
virus associated salivary gland disorder,
 Post irradiation Sialadenitis, chronic sclerosing
Sialadenitis, Cheilitis glandularis
(4) Traumatic/Obstructive- Mucocele, salivary duct
cyst (mucose retention cyst, Ranula), Nicotinic
stomatitis
(5) Autoimmune- Sarcoidosis, Sjogrens syndrome,
Mikulicz’s disease
(6) Neurological- Frey’s syndrome
(7) Degenerative- idiopathic Sialolithiasis
(8) Non inflammatory non neoplastic-Sialadenosis
(9) Vascular-Necrotizing sialometaplasis

37. 37
o Pleomorphic Adenoma, Papillary Cystadenoma,
o Basal Cell Adenomas, Oncocytoma, Canalicular
Adenoma,
o Myoepithelioma, Sebaceous Adenoma,
o Ductal Papilloma, etc
Benign neoplasm Malignant neoplasm
o Mucoepidermoid Carcinoma
o Adenoid Cystic Carcinoma
o Acinic Cell Carcinoma
o Hyalinising Clear Cell Carcinoma
o Adeno carcinoma, etc
10. Neoplasm:-
The tumors can arise in about 80% in parotid gland, 15% in submandibular gland and 5% in the
sublingual and minor salivary gland.

38. 38
WHO classification 2017

39. 39
1. Atresia:- it is the congenital occlusion or absence of salivary ducts which leads to xerostomia or mucous retention
cyst.
2. Aplasia:- it is the complete absence of one or more salivary gland which leads to xerostomia, and affected patients
are more susceptible to dental caries.
3. Aberrancy:- it is an anatomic variant wherein the normal salivary gland develops at an abnormal position.
Sometimes they are found adjacent to lingual surface of the mandible within a depression.
Ex:- Staphne’s bone cyst or Staphne’s bone cavity, It is thought to be created by an ectopic portion of salivary gland
tissue which causes remodelling of the mandibular bone. This creates an apparent cyst like radiolucent area seen on
the radiographs.
1. Developmental

40. 40
 Xerostomia:- It is defined as the subjective sensation of oral dryness that may or may not be associated with
a reduction in salivary output. The condition may be transient, prolonged or permanent depending upon the
duration of the condition.
2. Functional disorders
(2) Drug therapy- Drugs that decrease the
volume of serous saliva are
Anticholinergic drugs Atropine
Anti-hypertensive drugs Reserpine , Methyldopa
Antihistamine drugs Diphenhydramine
Antidepressant drugs Amitryptiline
Antipsyschotics drugs Diazepam
Anti parkinsonian drugs Procyclidine
Anti-emetics drugs Hyoscine
Antispasmodics drugs Tizandine
 Etiology:-
a. Temporary causes-
(1) Psychological causes due to anxiety and depression
(3) Duct calculi- a blockage of the duct of a major salivary
gland can produce dryness on the affected side with pain
and swelling in the gland on stimulation.
(4) Infections-
Sialadenitis, acute infections like mumps and post
operative parotitis, chronic conditions like swellings related
to nutritional deficiency, and iodine hypersensitivity,
wherein in all these conditions causes hypo salivation.

41. 41
(5) Salivary gland aplasia, Sjogrens syndrome and Other systemic disorders like
diabetes mellitus, Parkinson’s disease, Cystic fibrosis, Sarcoidosis, Vitamin A
deficiencies and in Anaemia.
(6) Surgery or trauma to the ducts may also impair secretion
(7) Due to Radiotherapy:
 Hypo salivation occurs on exposure of major salivary glands to radiation
bilaterally in head and neck cancer.
 At radiation doses > 3000 cGy, the patient is at risk if all major glands are in
the field of radiation.
 The degree of salivary gland alteration depends on dose volume factor,
patient age, and time of exposure to radiation.
b. Permanent causes:-

42. 42
(1) Tongue may be smooth and reddened, cracked or fissured,
with loss of papillation.
(2) Increase in erosion and caries, particularly decay on root
surfaces and even cusp tip involvement.
(3) Erythematous form of candidiasis is frequent.
(4) Lipstick sign: occurrence of shed epithelial cells on the
labial surfaces of maxillary anterior teeth as the mucosa
adheres to the teeth due to reduced saliva.
(5) Tongue blade sign: when held against buccal mucosa, the
tissue adheres to the tongue blade as it is lifted away.
(7) Viscous sticky saliva with difficulty in speaking
and swallowing, Halitosis, altered taste and
smell, gingivitis.
(8) Complaint of burning mucosa, lips or tongue.
(9) Ulceration of oral mucosa.
(10) No accumulation of saliva in the floor of the
mouth.
(11) Poorly fitting prosthesis.
(12) Enlargement of salivary glands.
Signs and symptoms of xerostomia:-
 Lips are often cracked, peeling and atrophic and Buccal mucosa may be corrugated and pale.

43. Diagnostic test for Xerostomia
 simple screening technique for the diagnosis of hypo salivation
by oral moisture checking device can be done.
 Five spots containing starch and potassium iodide on filter
paper with or without capsaicin.
 The study suggested that this test would be useful for
evaluating the retained functional ability of salivary glands and
screening of hypo salivation with dry mouth.
43
(a) oral moisture-checking device,
(b)measurement points , (c) buccal mucosa

44. 44
• Treatment of xerostomia
associated problems:-
 Dental caries:- use of fluorinated
dentifrice (0.05% NaF)/fluoride gel in
the concentration of 1% NaF, 0.4%
Stannous fluoride application of 0.5%
sodium fluoride varnish to teeth,
regular use of re-mineralising tooth
paste.
Dental caries
Dry
mouth
Dysphagia
Oral
candidiasis
Xerostomia associated problems are-

45. 45
 Dental examination every 6 month and bitewing radiograph once a year for early diagnosis of
dental caries.
 The recent advances in chair side diagnostics test kits are GC Salivary check-Buffer Kit that
identifies, measures, and assesses patient for caries risk based on saliva conditions like
hydration, consistency, pH of resting saliva and flow, and buffering capacity of stimulated saliva.
GC Saliva Check Mutans Kit is used for
rapid detection of high levels of S.mutans
without the need for incubation is possible
within 15 min.
In a study, Gopinath et al evaluated the effect
of salivary testing in dental caries assessment
using salivary testing kit (GC Asia Dental Pvt
Ltd, Japan) and recommended adopting this
test in patients with high caries risk.

46. 46
Management approach Examples
Preventive therapies Supplemental fluoride, remineralizing solution,
optimum oral hygiene, non-cariogenic diet
Symptomatic treatment Water oral rinses, gels, mouthwash, increased
humidification, minimize caffeine
Local or topical salivary
stimulation
Sugar free gums and mints
Systemic salivary stimulation Parasympathomimetic secretogogues- pilocarpine 5
mg 3 times a day, cevimeline 30 mg 3 times a day
Therapy of underlying disorders Anti-inflammatory therapies to treat the autoimmune
exocrinopathy of Sjogren’s syndrome
Management of xerostomia

47. 47
Sialadenitis :-
Inflammation of the salivary glands is known as Sialadenitis. Parotid salivary glands are most commonly affected in
adolescents and in children, debilitated adults, or patients with medication on tricyclic antidepressants and
tranquilizers.
Etiology :-
 Staphylococcus aureus is the most common etiologic agent for acute bacterial parotitis in addition
Staph.Pyogenes, Strep. Viridians and other microorganisms can also cause sialadenitis.
 Viruses causing sialadenitis include paromyxo viruses (mumps-most common), Coxsackie virus, cytomegalo
virus, etc. The patient may present with fever and dehydration.
 Decreased salivary flow can be secondary to medications, dehydration or debilitating conditions.
 Ductal obstruction can be due to sialolithiasis, due to pressure effect from adjacent tumors.
3. Inflammatory

48. 48
• Clinical features:-
 clinically there is sudden pain at the angle of the jaw which is
unilateral with glandular enlargement and tender to palpation
with purulent discharge over Stensen’s duct.
• Treatment :-
 It includes administration of salivary stimulants, antibiotics and
surgical drainage.

49. Hepatitis C virus associated sialadenitis
Hepatitis C virus (HCV) is found to affect the salivary glands and cause the glandular inflammation.
Clinical feature:
The affected patients may present with mild swelling of the parotid gland with minimum or no symptoms
of dry eyes and dry mouth.
The diagnosis of HCV is by the detection of HCV DNA and anti HCV antibodies.
Treatment- Hepatitis associated sialadenitis is treated symptomatically.
49

50. 50
Sialadenosis
Sialadenosis also known as sialosis is an enlargement of salivary glands which is non-inflammatory
and non-neoplastic more commonly affecting the parotid salivary glands.
Etiology:- This condition can be associated with
S.
NO
Endocrine
disorders
Nutritional status Medication
induced
Sialadenosis
1. Diabetes mellitus
and insipidus
Anorexia nervosa Psychotropic
medications
2. Accromegaly Bulimia Antihypertensive
drugs
3. Hypothyroidism Chronic
alchoholism
Sympathomimetic
drugs.
4. Pregnancy General
malnutrition.
Clinical features:- Patient presents
with a slowly progressing bilateral
(rarely unilateral) swelling of parotid
salivary glands which may be
asymptomatic. Rarely patients may
complain of reduced salivary flow.
Treatment:- Management of
underlying systemic condition may
help in reversing the sialdenosis.

51. 51
MUMPS
 Mumps is normally a mild illness, but in a minority of cases, there can be
severe complications, such as deafness and meningitis.
 This is why children are vaccinated against mumps. It is most common in
children who are not immunized, It occurs in adults also.
Etiology:- paramyxovirus that infects the parotid glands.
Clinical feature:- are puffiness of cheeks (due to swelling of parotid glands),
fever, sore throat and weakness.
Treatment:- warm salt water rinses, antibiotics and anti-inflammatory
medications

52. 52
4. Traumatic
Mucocele:- It is a benign, mucus-containing
cystic lesion of the minor salivary gland. This
type of lesion is most commonly referred to
as mucocele.
Etiology:-
It is caused due to rupture of a salivary gland
duct mostly due to trauma resulting in spillage
of mucin into the surrounding tissues.
Clinical features:-
Clinically a mucoceles appear as bluish thin
walled lesion which is fluctuant, and the most
common site of occurrence is on the lower lip.
Treatment:-
Surgical excision is the primary
treatment and Intralesional injections
of corticosteroids.

53. 53
RANULA
 Ranula:- is a type of large mucocele which grows in the floor of the mouth, usually unilateral
and is called due to its similar appearance to enlarged abdomen region of a frog.
 Etiology:- Trauma , obstructed salivary gland or ductal aneurysm.

54. 54

55. Nicotinic stomatitis
Etiology:- The long standing habits of tobacco and alcohol/hot liquid
consumption.
Clinical feature:-
Exhibits whitened areas of the hard palate due to hyperkeratosis caused
by the thermal irritation. This irritation also causes inflammation and
dilatation of the duct openings of the minor salivary glands of the
palate manifesting as red patches or spots on a white background.
Treatment:- discontinuation of the habits reverses the condition back
to normal.
55

56. 5. Autoimmune
Sarcoidosis:- It is an autoimmune chronic granulomatous inflammatory
condition which causes destruction of the tissue by T lymphocytic,
mononuclear phagocytic infiltration and granuloma formation. The parotid
salivary glands are affected in 10%-30% of cases.
Clinical feature:- The patient presents with a hard, bilateral enlargement of
the parotid gland usually asymptomatic in nature. Sarcoidosis of parotid
glands along with uveitis and facial nerve paralysis is termed as Heerfordt’s
syndrome or uveo parotid fever. The patient may complain of dry mouth and
minor salivary gland biopsy confirms the diagnosis.
56

57. Treatment:-
 Palliative treatment primarily relieving of the symptoms of
salivary component of sarcoidosis is advised.
 Corticosteroid or with Chloroquine has been recommended.
 Immunosuppressive and immune modulatory medications
are administered in patients who do not respond the
corticosteroids.
57

58. 58
Sjogren’s syndrome
It is an autoimmune disorder associated with HLA-DR3 AND HLA-B8.
The disease was described by Henric Sjogren in 1933.
Clinical feature:-
 The primary Sjogren syndrome/sicca complex exhibit dry eyes and dry
mouth.
 The secondary Sjogren syndrome develops SLE, polyarteritis nodosa,
polymyositis, rheumatoid arthritis and in scleroderma.
 This condition is most commonly seen in women over 40 years with
male: female ratio is 1: 10.

59. 59
Laboratory findings:-
 Anti salivary duct antibodies, anti-nuclear
antibodies, rheumatoid factor increased ESR,
Lip biopsy-lymphocytes around salivary glands.
 The other tests are Rose Bengal dye test,
Sialography and sialochemistry, etc.
Sialography (also termed radiosialography):-
It is the radiographic examination of the salivary
glands. It usually involves the injection of a small
amount of contrast medium into the salivary duct of
a single gland, followed by routine X-ray
projections. The resulting image is called
a sialogram
Rose Bengal dye test

60. 60
There is no permanent treatment and to limit the
harmful effect of disease treat symptomatic
condition.
 Dry mouth
 Saliva substitutes:- sprays, rinses
 Saliva stimulation:- Cevimeline, oral gels
 Dry eyes
 Lubricants:- artificial tears, ointments
 Punctal plugs:-
(small medical device that is inserted into the tear
duct(puncta) of an eye to block the duct)
 Lateral tarsorrhaphy:-
(Surgical closure of a portion of the eyelids)
 Dry nasal mucosa
 Saline nasal spray lavage:-
(moistening the mucus membranes)
 Active dental care suggested
Punctal
plug
Treatment

61. Mikulicz’s disease
Mikulicz’s disease of unknown aetiology was first reported by Johann von
Mikulicz-Radecki in 1888.
It also known as benign lymphoepithelial lesion/myoepithelial sialadenitis.
Clinical feature:-
Patients suffering from Mikulicz’s disease present with asymptomatic, bilateral
swelling of the parotid, and submandibular salivary glands along with lacrimal
glands. This disease closely resembles Sjogren’s syndrome. However the lacrimal
and salivary secretion depletion is very minimal in Mikulicz’s disease.
61

62.  Histologically the disease resembles Sjogren’s syndrome, but lacks the
characteristic anti-SS-A and anti-SS-B antibodies of Sjogren’s syndrome.
 Studies have found increased levels of IgG4 antibodies in the serum of
patients with Mikulicz’s disease.
 However, it has been demonstrated that autoimmune, viral, and genetic
factors may contribute to the pathogenesis of the disease
Treatment-
 Mikulicz’s disease is very much responsive for steroid therapy
particularly to methylprednisolone.
62

63. 6. Neurological
Frey’s syndrome also known as Auriculo temporal
syndrome which is characterized by sweating in the pre
auricular and temporal areas after gustatory stimulation.
Etiology-
the condition most commonly caused due to faulty
regeneration of sympathetic and parasympathetic nerve
fibres which were injured during parotid tumor surgery or
ramus resection.
63

64. 64
Clinical feature:-
Post-surgery the parasympathetic fibres start innervating the sweat glands and
vasculature of the skin around the parotid area. The symptoms usually appear
within few minutes of the start of mastication or during stimulation of saliva
and may remain up to 30 min after discontinuing mastication. The diagnosis of
the syndrome can be confirmed by starch iodine test.
Treatment:-
Reassurance to the patient is advocated in most of the cases. Intra cutaneous
injection of botulin toxin is found to be effective in severe condition and
Tympanotomy may be the treatment of choice with severe symptoms.
starch iodine test

65. 7. Degenerative
Sialolithiasis:-
It is a condition of unknown aetiology. However, there could be several coexisting
causes leading to the salivary stone formation. Some of these cofactors may be related
to disturbed pH of saliva, abnormalities in the sphincter mechanism related to salivary
duct opening and abnormal calcium metabolism.
Clinical Feature:-
This condition most often will not produce any signs and symptoms. Rarely, it may
cause complete ductal obstruction, pain and swelling of the salivary glands.
Treatment:- Large salivary stone are managed by extracorporeal or intracorporeal
lithotripsy procedure.
65

66. 66
8. Non inflammatory non neoplastic:-
 Sialadenosis is a non-infectious, non-inflammatory gland enlargement usually affecting the
parotid bilaterally. This condition is most often seen in women causing salivary hypo salivation
which can occur due to systemic disorders.
9. Vascular:-
Necrotizing sialometaplasia:-
Etiology-
 The probable cause could be due to vascular infarction of the salivary gland lobules and is often
mistaken for oral cancer.
 Vascular compression is caused by a necrotic myocutaneous reconstruction of the flap used in palatal
surgeries and embolization from carotid endarterectomises, Berger’s disease, Raynaud’s
phenomenon.
 Predisposing factors are dental injections, ill-fitting denture, traumatic injury, previous surgery and
upper respiratory tract infections.

67. 67
Clinical feature:-
 Appears as a non-neoplastic lesion that usually arises from a minor salivary gland in the lips,
posterior part of the palate, and retro molar regions.
Treatment:-
 It is considered to be a self-limiting disease, and takes about 3-12 weeks to resolve. Majority of the
case resolves itself or by supportive and symptomatic treatment. Surgical intervention is rarely
required.

68. 10. Neoplasm
Pleomorphic Adenoma:-
 The pleomorphic adenoma is the most common tumor of the salivary
glands, overall, it accounts for about 60% of all salivary gland tumors. It is
often called a mixed tumor because it consists of both epithelial and
mesenchymal elements.
 The majority of these tumors are found in the parotid glands, with less than
10% in the submandibular, sublingual, and minor salivary glands.
 Pleomorphic adenomas may occur at any age, but the highest incidence is in
the fourth to sixth decades of life. It also represents the most common
salivary neoplasm in children.
68
Figure(A) A 64-year-old patient
with a right-sided preauricular
mass. (B) Magnetic resonance
image showing the characteristic
mixed composition of the benign
salivary gland tumor

69. 69
Clinical feature:-
 These tumors appear as painless, firm, and mobile masses that rarely ulcerate the overlying skin or mucosa. In the
parotid gland, these neoplasms are slow growing and usually occur in the posterior inferior aspect of the
superficial lobe.
 In the submandibular glands, they present as well-defined palpable masses. It is difficult to distinguish these
tumors from malignant neoplasms and indurated lymph nodes. Intraorally, pleomorphic adenomas most often
occur on the palate, followed by the upper lip and buccal mucosa.
 Pleomorphic adenomas can vary in size, depending on the gland in which they are located. One case series
reported an infrequent yet clinically significant malignant transformation to carcinoma of 8.5%.
 In the parotid gland, the tumors are usually several centimeters in diameter but can reach much larger sizes if left
untreated.

70. 70
Pathology:-
 The gross appearance of pleomorphic adenoma is that of a firm smooth
mass within a pseudocapsule. Histologically, the lesion demonstrates
both epithelial and mesenchymal elements.
 The epithelial cells make up a trabecular pattern that is contained within
a stroma. The stroma may be chondroid, myxoid, osteoid, or fibroid. The
presence of these different elements accounts for the name pleomorphic
tumor or mixed tumor.
 Myoepithelial cells are also present in this tumor and add to its
histopathologic complexity. One characteristic of a pleomorphic
adenoma is the presence of microscopic projections of tumor outside of
the capsule.
 If these projections are not removed with the tumor, the lesion will recur.

71. Treatment
 Surgical removal with adequate margins is the principal treatment. Because of its
microscopic projections, this tumor requires a wide resection to avoid recurrence.
 A superficial parotidectomy is sufficient for the majority of these lesions. A small
tumor in the tail of the parotid gland may be removed with a wide margin of
normal tissue, sparing the remainder of the superficial lobe.
 Lesions that occur in the submandibular gland are treated by the removal of the
entire gland.
71

72. Papillary Cystadenoma Lymphomatosum
 Papillary cystadenoma lymphomatosum, also known as Warthin’s
tumor, is the second most common benign tumor of the parotid
gland. It represents ≈6 to 10% of all parotid tumors and is most
commonly located in the inferior pole of the gland, posterior to the
angle of the mandible.
 The tumor demonstrates a slight predilection toward males, and it
usually occurs between the fifth and eighth decades of life. These
tumors occur bilaterally in about 6 to 12% of patients.
72

73. 73
This tumor presents as a well-defined, slow-growing mass in the tail of the
parotid gland. It is usually painless unless it becomes superinfected. Because
this tumor contains oncocytes, it will take up technetium and will be visible on
Tc 99m scintiscans.
Clinical feature
The gross appearance of this tumor is smooth, with a well-defined capsule.
Cutting a specimen reveals cystic spaces filled with thick mucinous material.
Histologically, the tumor consists of papillary projections lined with
eosinophilic cells that project into cystic spaces. The projections are
characterized by a lymphocytic infiltrate.
Pathology

74. Treatment
 Papillary cystadenoma lymphomatosum is easily removed with a margin
of normal tissue.
 Larger tumor that involve a significant amount of the superficial lobe of
the parotid gland are best treated by a superficial parotidectomy.
 Recurrences and malignant degeneration of this tumor are rare.
74

75. 75
 Basal cell adenomas are slow-growing and painless masses that account for approximately 1 to
2% of salivary gland adenomas. This lesion has a male predilection (male-to-female ratio is 5:1).
 Seventy percent of basal cell adenomas occur in the parotid gland, and the upper lip is the most
common site for basal cell adenomas of the minor salivary glands.
Basal Cell Adenomas
 Histologically, three varieties of basal cell adenomas exist: solid,
trabecular-tubular, and membranous. The solid form consists of islands
or sheets of basaloid cells. Nuclei have a normal size and are basophilic,
with minimal cytoplasmic material.
 The trabecular-tubular form consists of trabecular cords of epithelium.
The membranous form is multilocular, and 50% of the lesions are
encapsulated. The membranous form tends to grow in clusters
interspersed between normal salivary tissue.
Pathology:-

76. Treatment
 Lesions are removed, with conservative surgical
excision extending to normal tissue.
 In general, lesions do not recur, however, the
membranous form has a higher recurrence rate.
76

77. Oncocytoma
 Oncocytomas are less common benign tumors that make up less than 1%
of all salivary gland neoplasms.
 The name of the tumor is derived from the presence of oncocytes, which
are large granular acidophilic cells.
 This tumor occurs almost exclusively in the parotid glands and is equally
distributed in both men and women.
 The sixth decade of life is the most common time of presentation.
77

78. 78
 Oncocytomas are usually solid round tumors that can be seen in any
of the major salivary glands but are extremely rare intraorally.
 Bilateral presentation of this tumor can occur, and it is the second
most common salivary gland tumor that occurs bilaterally (after
Warthin’s tumor).
Clinical feature:-
 On gross examination, these tumors appear noncystic and firm.
Histologically, they consist of brown granular eosinophilic cells.
 The oncocytes within this tumor concentrate technetium, and
this tumor can be visualized by Tc 99m scintigraphy.
Pathology:-

79. Treatment
 Oncocytomas undergo a benign course, grow very slowly, and are
unlikely to undergo recurrences. The treatment of choice for
parotid oncocytomas is superficial parotidectomy with
preservation of the facial nerve.
 Removal of the gland is the treatment of choice for tumors in the
submandibular gland, and gland removal with a normal cuff of
tissue is the treatment of choice for oncocytomas of the minor
salivary glands.
79

80. 80
 Canalicular adenomas predominantly occur in persons older than
50 years of age and occur mostly in women.
 Eighty percent of cases occur in the upper lip. The lesions are slow
growing, movable, and asymptomatic.
Canalicular Adenoma
 Treatment is surgical excision with a margin of normal tissue.
 Recurrence is rare but has been reported; thus, patients should
be monitored periodically.
Treatment
 This lesion is composed of long strands of basaloid tissue, usually
arranged in a double row. The supporting stroma is loose, fibrillar,
and highly vascular.
Pathology

81. 81
Most myoepitheliomas occur in the parotid gland and in the minor salivary glands of the palate.
No gender predilection exists, and lesions tend to occur in adults, with the average age in the sixth decade of life.
Myoepithelioma
 Clinical features include a well-circumscribed, asymptomatic, slow-growing mass.
 Myoepitheliomas consist of spindle-shaped cells, plasmacytoid cells, or a combination of the two. Diagnosis is
based on the identification of myoepithelial cells and must be differentiated from other benign and malignant
epithelial and mesenchymal tumors for treatment planning purposes.
 Growth patterns vary from a solid to a loose stroma formation with myoepithelial cells. This tumor is epithelial in
origin; however, it functionally resembles smooth muscle and is demonstrated by immune histochemical staining
for actin, cytokeratin, and S-100 protein.
Pathology :-
 Surgical excision, including a border of normal tissue, is
recommended. (Recurrence is uncommon)
Treatment :-

82. Sebaceous Adenoma
Sebaceous adenomas are rare. These lesions are derived from sebaceous glands located
within salivary gland tissue. The parotid gland is the most commonly involved gland.
Pathology :-
Cells derived from sebaceous glands are present. Benign forms contain well-
differentiated sebaceous cells, whereas malignant forms consist of more poorly
differentiated cells.
Treatment :-
Removal of the involved gland is the treatment of choice. Intraoral lesions are surgically
removed with a border of normal tissue.
82

83. Ductal Papilloma
 Ductal papillomas form a subset of benign salivary gland tumors that arise from the excretory ducts,
predominantly of the minor salivary glands.
 The three forms of ductal papillomas are simple ductal papilloma (intraductal papilloma), inverted ductal
papilloma, and sialadenoma papilliferum.
a. Simple Ductal Papilloma:-
The simple ductal papilloma presents as an exophytic lesion with a pedunculated base. The lesion often has a reddish
color. Microscopic examination reveals epithelium-lined papillary fronds projecting into a cystic cavity without
proliferating into the wall of the cyst.
Treatment :- Local surgical excision is the recommended. (A minimal recurrence rate is reported)
83

84. b. Inverted Ductal Papilloma
 The inverted ductal papilloma occurs in the minor salivary glands.
It presents clinically as a submucosal nodule that is similar to a
fibroma or lipoma.
 The inverted ductal papilloma histologically resembles the
sialadenoma. This form of ductal papilloma also consists of
projections of ductal epithelium that proliferate into surrounding
stromal tissue, forming clefts.
 The lesion is treated by surgical excision. A low recurrence rate is
reported
84

85. c. Sialadenoma Papilliferum
 The sialadenoma papilliferum form of ductal papilloma is analogous to the
syringocystadenoma papilliferum of the skin. An adult male predilection exists,
and most lesions occur between the fifth to eighth decades of life. This lesion
occurs primarily on the palate and buccal mucosa and presents as a painless
exophytic mass.
 Clinically, the lesion resembles a papilloma. Microscopic examination shows
epithelium-lined papillary projections supported by fibrovascular connective
tissue, forming a series of clefts within the lesion.
 Local surgical excision is the recommended treatment, and recurrences are rare.
85

86. 86
Malignant Tumors
Mucoepidermoid Carcinoma:- Mucoepidermoid carcinoma is the most common
malignant tumor of the salivary glands. It is the most common malignant tumor of
the parotid gland and the second most common malignant tumor of the
submandibular gland, after adenoid cystic carcinoma. Approximately 60 to 90% of
these lesions occur in the parotid gland. Men and women are affected equally by this
tumor and the highest incidence occurs in the third to fifth decades of life.
Clinical Presentation:-
The clinical course depends on the grade. It is not uncommon for low-grade tumors
to undergo a long period of painless enlargement. In contrast, high-grade
mucoepidermoid carcinomas often demonstrate rapid growth and a higher likelihood
for metastasis. Pain and ulceration of overlying tissue are occasionally associated
with this tumor. If the facial nerve is involved, the patient may exhibit a facial palsy.

87. 87
Pathology:-
Macroscopically, low-grade mucoepidermoid carcinomas are usually small and partially
encapsulated. The high-grade tumors are less likely to demonstrate a capsule because of
the more rapid growth and local tissue invasion.
Treatment:-
 A low-grade mucoepidermoid carcinoma can be treated with a superficial
parotidectomy if it involves only the superficial lobe. High-grade lesions should be
treated aggressively to avoid recurrence. A total parotidectomy is performed, with facial
nerve preservation.
 Postoperative radiation therapy is a useful adjunct in treating the high-grade tumor.
Overall, 5-year (79%) and 10-year (65%) survival rates depend upon grade, stage, and
margin status.

88. Adenoid Cystic Carcinoma
 Adenoid cystic carcinomas account for approximately 6 to 10% of all salivary
gland tumors and are the most common malignant tumors of the submandibular
and minor salivary glands.
 They comprise 15 to 30% of submandibular gland tumors, 30% of minor
salivary gland tumors, and 2 to 15% of parotid gland tumors.
 Approximately 50% of all adenoid cystic carcinomas occur in the minor salivary
glands. The tumor affects men and women equally and usually occurs in the
fifth decade of life.
88

89. 89
Clinical feature:-
 Adenoid cystic carcinoma usually presents as a firm unilobular mass in the
gland. Occasionally, the tumor is painful, and parotid tumors may cause facial
nerve paralysis in a small number of patients.
 This tumor has a propensity for perineural invasion; thus, tumor tissue often can
extend far beyond the obvious tumor margin.
Pathology:-
 On gross examination, the tumor is unilobular and either partially encapsulated
or nonencapsulated. There is often evidence of invasion into adjacent normal
tissue.
 Microscopic evidence of perineural or intraneural invasion is the distinguishing
feature of adenoid cystic carcinoma. The individual cells are small and
cuboidal.

90. Treatment
 Because of the ability of this lesion to spread along the nerve sheaths, radical
surgical excision of the lesion is the appropriate treatment.
 Even with aggressive surgical margins, tumor cells can remain, leading to long-
term recurrence.
 The site of origin appears to be an important factor in survival, with better
survival in tumors originating from the parotid gland compared with minor
salivary glands.
 Postoperative radiotherapy and chemotherapy have not demonstrated consistent
benefit beyond aggressive surgery alone.
90

91. Acinic Cell Carcinoma
 Acinic cell carcinoma represents about 1% of all salivary gland tumors.
Between 90 and 95% of these tumors are found in the parotid gland;
almost all of the remaining tumors are located in the submandibular
gland.
 The distribution of acinic cell carcinoma reflects the location of acinar
cells within the different glands. This tumor occurs with a higher
frequency in women and is usually found in the fifth decade of life.
91

92. 92
Clinical feature:-
 These lesions often present as slow growing masses. Pain may be associated
with the lesion but is not indicative of the prognosis.
 The superficial lobe and the inferior pole of the parotid gland are common
sites of occurrence.
 Bilateral involvement of the parotid gland has been reported in
approximately 3% of cases.
Pathology:-
 The gross specimen is a well-defined mass that is often encapsulated.
Microscopically, two types of cells are present, cells similar to acinar cells
in the serous glands are seen adjacent to cells with a clear cytoplasm.
 These cells are positive on periodic acid–Schiff staining. Lymphocytic
infiltration is often found.

93. Treatment
 Acinic cell carcinomas initially undergo a relatively benign course.
Unfortunately, long-term survival is not as favorable, and the 20-year
survival rate is about 50%.
 Treatment consists of superficial parotidectomy, with facial nerve
preservation. When these tumors are found in the submandibular gland,
total gland removal is the treatment of choice.
93

94. Lymphoma
 Definition, the term primary lymphoma describes a situation in which a salivary
gland is the first clinical manifestation of the disease. Primary lymphoma of the
salivary glands probably arises from lymph tissue within the glands.
 The major forms of lymphoma are non- Hodgkin’s lymphoma (NHL) and
Hodgkin’s disease. NHL is less curable and is often disseminated at diagnosis.
 There is an increased incidence of NHL in patients with autoimmune disease,
including Sjögren’s syndrome. The parotid gland is the most commonly
involved gland, followed by the submandibular gland.
94

95. 95
Clinical Presentation:-
This lesion commonly presents as painless gland enlargement or
adenopathy.
Pathology:-
Histologic examination demonstrates B-cell lymphoma tissue that
originates from lymphoid tissue associated with malignant mucosa,
also referred to as lymphoma of MALT.
Since these lesions are not typically suspected, results from FNA are
often misleading, and parotidectomy is required for a definitive
diagnosis.

96. Treatment
 A staging workup is required to determine the treatment plan. For isolated asymptomatic parotid gland
masses, a superficial parotidectomy is recommended.
 For early-stage primary NHL, radiotherapy alone resulted in overall survival of 90% at 5 years and
71% survival at 10 years.
 Appropriate treatment includes radiation therapy, chemotherapy, or a combination of the two,
depending on the staging of the lymphoma.
96

97. Myoepithelial Carcinoma
Myoepithelial carcinoma or malignant myoepithelioma is
a very rare malignant salivary gland neoplasm with good
short-term survival and poor long-term survival. Mean age is
the sixth decade of life, with the parotid gland being the most
common site.
Clinical Presentation:-
This is a rapidly growing tumor with extensive local growth,
invasion of surrounding tissues, and infrequent cervical node
metastasis but high rates of distant metastasis.
97

98. 98
Pathology:-
 Due to their morphologic heterogeneity, these neoplasms can be confused
easily with other tumors.
 Aspirates of these neoplasms demonstrate primarily spindle cells, whereas
histopathology reveals infiltrative growth with a characteristic
multinodular architecture with a cellular periphery and central
necrotic/myxoid zones.
 Necrosis is frequently present with perineural and vascular invasion.
Treatment:-
 Early and aggressive surgery with close follow up is required, whereas
radiotherapy and neck dissection may not be necessary.

99. EFFECTS OF AGING ON SALIVARY GLANDS
99
 Shrinkage of cells
 Dilation of ducts
 Oncocytic transformation
 Increased adiposity
 Fibrosis
 Focal micro calcifications with obstruction
 Chronic inflammation
 Decrease in salivary flow
Changes in the salivary glands

100. 100
Conclusion
 Saliva reflects the physiologic state of the body. Salivary gland diseases may be inflammatory, non-
inflammatory, non-neoplastic or neoplastic lesions. Only when a definitive diagnosis is established, treatment
depends upon the lesion size, cause, severity, extent and other clinical considerations of the disease.
 However, a thorough knowledge of the subject including their recent advancements together with a team of
associated medical and dental specialists, it is possible to detect the diseases of salivary glands in their early
stage and manage them more efficiently.
 Salivaomics, the future of saliva-based techniques for early diagnosis of dental diseases is promising. Saliva
being readily available can be used as a diagnostic tool to help the clinicians for early detection of oral diseases
like caries, periodontal disease, oral cancer, salivary gland disorders and non-oral diseases by adapting the
advance noninvasive technique and technologies.

101. 101
1. Chaurasia BD, Human anatomy Vol. III 5th edition pg. no: 141-170
2. Singh Inderbir, Human embryology 10th edition p.g no: 96-178
3. Martin S. Greenberg, Michael Glick, Jonathan A. Ship, Burket’s oral medicine 11th edition, pg. no: 200-221
4. Sembulingam K, Sembulingam Prema, Essentials of Physiology for Dental Students 2nd edition, pg. no:164-172
5. Krishnamurthy S, Vasudeva SB, Vijayasarathy S. Salivary gland disorders: A comprehensive review. World J
Stomatol 2015; 4(2): 56-71 [DOI: 10.5321/wjs.v4.i2.56]
6. https://1587600.167.directo.fi/@Bin/8c3dcbd504bf43336877375dbf5fc723/1620614769/application/pdf/195274/L
eivo-head%26neck%20uusi%20.WHO Classification 2017pdf
7. https://www.researchgate.net/publication/344391139 The tubarial salivary glands first description of a potential
new organ at risk for head-neck radiotherapy

102. 102