SALIVARY GLANDS AND IT’S PROSTHODONTIC IMPLICATIONS

1. SALIVARY GLANDS AND IT’S
PROSTHODONTIC IMPLICATIONS
DR.ARATI
1ST YEAR PG

2. CONTENTS
1.Introduction
2.Types of salivary glands
3.Anatomy of salivary glands
4.Physiology of saliva
4.Salivary gland disorders
5.Xerostomia and its management
6.Dental implications of xerostomia
7.Prosthodontic considerations
8. COVID-19 relation with salivary gland
9. Conclusion
10.References 2

3. • The salivary glands are a group of compound exocrine glands secreting saliva.
• Saliva plays a vital role in maintaining the integrity of the oral tissues.
• Saliva forms a film of fluid coating the teeth and mucosa , creating and
regulating a healthy environment in the oral cavity.
• The importance of saliva is best demonstrated by patients in whom salivary
volume is reduced significantly.
3
INTRODUCTION

4.  MAJOR SALIVARY GLANDS (PAIRED STRUCTURES):
Parotid
Submandibular (Submaxillary)
Sublingual
MINOR SALIVARY GLANDS (DIFFUSELY SCATTERED IN
ORAL CAVITY):
Buccal (Cheek)
Palatine (Palate)
Labial (Lip)
Lingual (Tongue)
4
SALIVARY GLANDS

5. 5
TYPES OF SALIVARY GLANDS

6. 6
PAROTID GLAND

7. MACROSCOPIC
ANATOMY
• Largest major salivary gland, Pyramidal, irregular wedge- shaped, unilobular with a dense
fibrous capsule
• Secretes 60-65% of salivary volume
TYPE OF SECRETION Purely serous
DUCT • Stenson’s duct, approx. 5mm long,
• Transverses over masseter and turns abruptly to enter buccinator prior to opening opposite the
buccal surface of maxillary second molar
STRUCTURES
PASSING THROUGH
• Facial nerve, Auriculotemporal nerve, Chorda tympani nerve, Retromandibular vein
• External carotid artery, Superior temporal artery, Maxillary artery
RELATIONS • Inferiorly – border of mandible,
• Anteriorly – Masseter muscle
• Posteriorly – Mastoid process, ramus, SCM and styloid process of temporal bone
• Postero-superiorly - Zygomatic arch, external auditory meatus
BLOOD SUPPLY Facial artery, branch of external carotid artery
NERVE SUPPLY Secretomotor – Glossopharyngeal nerve - otic ganglion Sensory – Auriculotemporal nerve -
Greater auricular nerve
7
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8

8. Largest serous salivary gland
Weighs around 14-25 gms
Resembles a 3 sided pyramid with apex directed downwards
4 surfaces:
separated by 3 borders:
8
superior
superficial
anteromedial
posteromedial
anterior
posterior
medial
B D Chaurasia; Human Anatomy; 6th edition Volume 3;

9. 9
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
PAROTID GLAND - RELATIONS

10.  Thick walled. 4-6 cm in length and 5 mm
in diameter.
 Emerges - middle of anterior border of
the gland.
 Runs forward and slightly downwards on
the masseter.
 Turns deeply into buccal pad of fat &
pierces buccinator muscle.
 Opens into gingivo-buccal vestibule
opposite the crown of upper 2nd molar
tooth. 10
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
PAROTID DUCT [STENSON’S DUCT]

11. 11
• Arterial supply: External carotid artery and its branches
• Venous drainage: External jugular vein
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
BLOOD SUPPLY

12. • PARASYMPATHETIC SUPPLY
Inferior salivatory nucleus
9th cranial nerve
Otic ganglion
Auriculotemporal nerve
Gland
• SYMPATHETIC SUPPLY
Vasomotor
Plexus around the external carotid
artery
• SENSORY SUPPLY
Auriculotemporal nerve
12
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
NERVE SUPPLY

13. Drains first to the parotid lymph nodes then to the upper deep cervical lymph
nodes.
13
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
LYMPHATIC DRAINAGE

14. 14

15. • Also called submaxillary gland
• The submandibular gland is the second
largest salivary gland and is located in the
floor of the mouth adjacent to the posterior
body of mandible along the free edge of the
mylohyoid muscle.
• In submandibular triangle formed by anterior
and posterior bellies of digastric muscle and
inferior margin of mandible
• Weighs 50% of parotid gland 15
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
SUBMANDIBULAR GLAND

16. 16
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
SUPERFICIAL PART
Inferiorly:
– skin
– platysma
– cervical branch of facial
nerve
– Deep fascia
– facial vein
– submandibular lymph
nodes
Laterally:
– Submandibular fossa on the
mandible
– Insertion of medial
pterygoid
– Facial Artery
Medially:
– Mylohyoid
– Hyoglossus
–Styloglossus

17.  Small sized, lies deep to Mylohyoid, superficial
to hyoglossus and styloglossus
 Relations:
17
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
DEEP PART

18. • Thin walled, 5cm long.
• Emerges at the anterior end of the deep part of the gland.
• Runs forward on the hyoglossus between lingual and hypoglossal nerves.
• It opens on the floor of the mouth, on the summit of the sublingual papilla at the
side of the frenulum of the tongue.
18
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
SUBMANDIBULAR DUCT

19. • Arterial supply: Facial artery.
• Venous drainage: Common facial or Lingual vein.
• Lymph Nodes: Passes to the submandibular lymph nodes.
19
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
BLOOD SUPPLY AND LYMPHATIC DRAINAGE

20. • PARASYMPATHETIC SUPPLY
Superior salivatory nucleus
7th cranial nerve
Submandibular ganglion
Gland
• SYMPATHETIC SUPPLY
VASOMOTOR
Plexus around the facial artery
20
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
NERVE SUPPLY

21. 21

22. • Smallest of the three major glands.
• Almond shaped and weighs about 3-4 g.
• Lies above the mylohyoid muscle and below the mucosa of the floor of the
mouth.
• Medial to the sublingual fossa and lateral to genioglossus.
22
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8
SUBLINGUAL GLAND

23. • 15 ducts emerge from the gland, most of which open directly into
the floor of the mouth.
• A few join the submandibular duct.
• Blood supply: from lingual and submental arteries.
• Nerve supply is same as that for submandibular gland.
23
B D Chaurasia; Human Anatomy; 6th edition Volume 3; 106-112 , 133-8

24. SALIVA
• SALIVA is a clear, alkaline, somewhat viscid secretion from the
parotid, submandibular, sublingual and smaller mucous glands of the
mouth. - DORLAND’S MEDICAL DICTIONARY
• SALIVA Is a clear taste less, odorless, slightly acidic, viscous fluid
consisting of secretions from the parotid, submandibular & mucous glands
of oral cavity. - STEDMAN’S MEDICAL DICTIONARY
24
SALIVA

25. 25
COMPOSITION OF SALIVA

26. 26

27. 27
PROPERTIES OF SALIVA
Volume : 500-1500 ml/day
pH : 6.7 – 7.4 (whole saliva)
Sp gravity : 1.002-1.008
Tonicity : Hypotonic to plasma

28. PROPERTY FEATURE
ADHESION
Physical attraction between two unlike
molecules for each other
It acts when saliva sticks to and wets the
basal surface of the dentures & at the
same time to the mucous membrane of the
basal seat
COHESION
Physical attraction between two like
molecules for each other
Occurs between layer of saliva and the
denture base and mucosa, in order to be
effective thin film of saliva is essential
28
SALIVA & COMPLETE DENTURE RETENTION
ADHESION
COHESION

29. 29
PROPERTY FEATURE
INTERFACIAL SURFACE TENSION
Phenomenon that maintains the surface
continuity of a fluid
Is the resistance to separation posed by
a film of liquid between two well
adapted surfaces. Found in the thin
film of saliva – similar in its action to
cohesion and to capillary attraction
CAPILLARITY Is a force that causes the surface of a
liquid to become elevated or depressed
when it is in contact with a solid
ATMOSPHERIC PRESSURE The atmospheric pressure acts as a
retentive force when dislodging forces
are applied to the denture.
VISCOSITY It is the resistance experienced by one
part of liquid in moving over another
part.

30. 30
Burket’s oral medicine; Michael glick; 12th edition
SALIVARY GLAND
DISORDERS

31. • It is a state of hypersalivation often experienced by the patient due to
hyperfunction of the glands.
• Causes –
• pregnancy
• irritation of mucosa
• new denture
• severe oral ulcerations/injuries
• psychic stress
31
Burket’s oral medicine; Michael glick; 12th edition
SIALORRHEA/ HYPERSALIVATION

32. FEATURES
• Thick ropy saliva.
PROBLEMS ENCOUNTERED
• Complicates impression by forming voids on surface while it sets.
• Causes patient to gag during impression making and denture delivery.
• Any thickening of the interposed salivary film by excessive mucin destroys the
intimacy of the contacting surface, thereby reducing friction and causing
skidding.
32
Burket’s oral medicine; Michael glick; 12th edition

33. • IMPRESSION MAKING
• Palatal surface should be wiped free of saliva before impression making.
• massaging glands to empty.
• Mouth washed prior to investing impression material.
• Fast setting impression material is used.
• Anti-sialagogues administered immediately or 1 to 2 days before treatment.
33
Burket’s oral medicine; Michael glick; 12th edition

34. • It is the condition of dry mouth resulting from reduced or absent salivary flow.
• Subjective feeling of oral dryness.
• Symptom, not a disease.
• Common complaint among older adults and according to a study, 30% of population
aged above 65+ years experience this disorder. (Ship 2002)
34Hallikerimath RB, Kumar VS, Arora A, Ruttonji Z. Xerostomia-Current
Concepts Of Aetiology And Its Management.
Burket’s oral medicine; Michael glick; 12th edition.
XEROSTOMIA (DRY MOUTH, PASTIES,
COTTON MOUTH)

35. 35
Burket’s oral medicine; Michael glick; 12th edition

36. • Dry, or burning feeling in the mouth.
• Dental caries, Tooth loss.
• Trouble chewing, swallowing, tasting, or speaking.
• Altered taste or intolerance for spicy, salty, or sour foods or drinks.
• Increased need to drink water while swallowing/eating dry crumbly food.
• Increased susceptibility to PDL disease.
• Reduced denture retention and generalized denture intolerance.
• Decreased buffering capacity with risk of opportunistic infections.
• A dry or sore throat, cracked, peeling, or atrophic lips, a dry, rough tongue, mouth sores, halitosis
(bad breath) .
• Inability to retain dentures or otherwise poorly fitting removable prostheses. 36
Burket’s oral medicine; Michael glick; 12th edition
SIGNS AND SYMPTOMS

37. • Medical history, H/o radiation, chemotherapy.
• Dry mouth questionnaire.
• Sialography, salivary scintigraphy, gland biopsy.
• 4 reliable predictors of gland hypofunction –
1. Dryness of lips,
2. Buccal mucosa,
3. Absence of saliva production during gland palpation and
4. Increased DMFT index score. 37
Dugal R. Xerostomia: Dental Implications And Management. Ann Essences Dent. 2010 Jul 13;3:13740
CLINICAL DIAGNOSIS

38. 38
MANAGMENT

39. SYMPTOMATIC TREATMENT
• Hydration
• Avoid smoking, caffeine, alcohol/strong flavor (mucosal irritation)
• Avoid sugar products
• Artificial salivary substitutes
• Salivary stimulants : sugar-free candies
• Systemic stimulation : cholinergic drugs like pilocarpine
39
Dugal R. Xerostomia: Dental Implications And Management. Ann Essences Dent. 2010 Jul 13;3:13740

40. ADDRESS UNDERLYING CAUSES
• Physician consultation
- Alter drug dosages
- Substitute medication causing xerostomia
• Control of systemic disorder
40
Hallikerimath RB, Kumar VS, Arora A, Ruttonji Z. Xerostomia-
Current Concepts Of Aetiology And Its Management.

41. STIMULATE RESIDUAL GLAND FUNCTION
• Sugarless gums (xylitol / sorbitol) and candies
• Cholinergic agonists :
- Pilocarpine
- Cevimeline
41
Hallikerimath RB, Kumar VS, Arora A, Ruttonji Z. Xerostomia-
Current Concepts Of Aetiology And Its Management.

42. • Pilocarpine HCL
Dose : 5mg tid up to 90 days
• Cevimeline HCL
Dose- 30mg tid up to 6 weeks
In the study done, 44% of patients reported improved salivation while on a dose of
5.0 mg Pilocarpine tid day. 42
Johnson J T, Ferretti G A, Nethery W J, et al. Oral pilocarpine for post-irradiation xerostomia in patients with
head and neck cancer. New Eng J Med 1993; 329: 390-395

43. SALIVA SUBSTITUTES
• Carboxymethyl cellulose
• Mucin
Commercial Salivary Substitute
Xerostom
• Basic ingredient - xylitol
• Available as toothpaste, mouthwash, pastilles, oral spray and gum
43
Hallikerimath RB, Kumar VS, Arora A, Ruttonji Z. Xerostomia-Current Concepts Of Aetiology
And Its Management.

44. • Dry mouth GC
• Basic ingredients:
Polyglycerol
Sodium citrate
WET MOUTH
Basic Ingredients:
Glycerin
Cellulose Gum
44
Hallikerimath RB, Kumar VS, Arora A, Ruttonji Z. Xerostomia-Current Concepts Of Aetiology
And Its Management.

45. Biotene
- gums, mouthwash and toothpaste
Oralbalance
- moisturizing gel
• Compared use of oralbalance gel and biotene toothpaste against control of
carboxymethylcellulose gel and commercial toothpaste.
Patients using Oralbalance and Biotene reported to be more effective than the controls
45
Epstein J B, Emerton S, Stevenson-Moore P. A double-blind crossover trial of Oral Balance gel and Biotene toothpaste versus placebo in patients with
xerostomia following radiation therapy. Oral Oncol 1999; 35: 132-137

46. Dental and oral health-specific recommendations from the National Institute For Dental
And Craniofacial Research and others, include the following for patients with dry mouth:
• Brush teeth gently at least twice a day with fluoridated toothpaste.
• Floss teeth every day.
• Schedule dental visits at least twice a year (with yearly bitewing radiographs).
• Prompt treatment of oral fungal or bacterial infections.
• Application of 0.5% fluoride varnish to teeth.
• Dental soft- and hard-tissue relines of poorly fitting prostheses and use of denture
adhesives.
46
Department of Scientific Information, ADA Science institute; july 8, 2019
DENTAL IMPLICATIONS OF XEROSTOMIA

47. • COMPLETE DENTURE
• Procedures -aim at optimizing retention and stability
• Use dentures with metal bases
• Use of soft liners to improve comfort
• Use of denture adhesives to augment retention
• Frequent recall – As more prone to candida infections
47
Hallikerimath RB, Kumar VS, Arora A, Ruttonji Z. Xerostomia-Current Concepts Of Aetiology
And Its Management.
PROSTHODONTIC MANAGEMENT

48. SALIVA RESERVOIR-TECHNIQUE
Angel Mary Joseph, Suja Joseph, Nicholas Mathew, Fabrication Of A Functional salivary reservoir in maxillary complete denture –
technique redefined,2016;108:332-335
48

49. • REMOVABLE PARTIAL DENTURE
• Health of residual teeth and periodontal tissues.
• Use of gingivally approching clasp avoided.
• Tooth supported denture with minimal tissue coverage.
• Metal denture bases are preferred.
49

50. • FIXED PROSTHODONTICS
• In dry environment, fixed non tissue bearing prosthesis are preferred where
indicated.
• FPDs should have full coverage retainers and easily cleaned pontics and
connectors.
• Margins of retainers should be supragingival.
50

51. 51
COVID-19 relation with salivary gland

52. 52

53. 53

54. • Knowledge of anatomy and physiology of salivary glands is essential to
distinctly identify various associated conditions and salivary gland pathologies.
• Precise anatomical knowledge is also essential to plan out our treatment
strategies and alter the patient’s lifestyle for the better.
• Clinicians should be aware of the signs and symptoms, diagnostic procedures,
etiologies, sequelae and appropriate therapeutic regimens.
• Effective evaluation and appropriate treatment will promote acceptable levels of
comfort and function.
54
CONCLUSION

55. • B D Chaurasia; Human Anatomy; 6th Edition Volume 3; 106-112 , 133-8.
• Burket’s Oral Medicine; Michael Glick; 12th Edition.
• Hallikerimath Rb, Kumar Vs, Arora A, Ruttonji Z. Xerostomia-current Concepts Of Aetiology And Its
Management.
• Dugal R. Xerostomia: Dental Implications And Management. Ann Essences Dent. 2010 Jul 13;3:13740.
• Johnson J T, Ferretti G A, Nethery W J, Et Al. Oral Pilocarpine For Post-irradiation Xerostomia In Patients With
Head And Neck Cancer. New Eng J Med 1993; 329: 390-395.
• Epstein J B, Emerton S, Stevenson-moore P. A Double-blind Crossover Trial Of Oral Balance Gel And Biotene
Toothpaste Versus Placebo In Patients With Xerostomia Following Radiation Therapy. Oral Oncol 1999; 35: 132-
137.
• Department Of Scientific Information, ADA Science Institute; July 8, 2019.
• Upadhyay R, Kumar L, And Rao J, Fabrication Of A Functional Palatal Saliva Reservoir By Using A Resilient
Liner During Processing Of A Complete Denture, JPD 2012;108:332-335. 55
REFERENCES

56. • K sembulingam; essentials of medical physiology; 4th edition; 197-203
• A K jain ; textbook of physiology; 4th edition volume 1; 201-4
• Blahova zora et al: physical factors in retention of complete dentures. J prosthet dent 1971; 25:
230-235.
• Boucher o. Carl : Boucher's prosthodontic treatment for edentulous patients, ed. 9.
• Edgar w.M. : Saliva : its secretion, composition and functions. British dental journal april 1992;
25: 305-312.
• Fdi working group 10, core, saliva : its role in health and disease. International dental journal
1992; 42: 291-304.
• Heartwell m. Charles et al : syllabus of complete dentures ed. 4, philadelphia 1992, lea and
febiger. 56

57. 57
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