Physiology and Pathology of Salivary Glands

1. SALIVARY GLANDS AND SALIVA
DR. HADI MUNIB
ORAL AND MAXILLOFACIAL SURGERY RESIDENT

2. OUTLINE
 Functions of Saliva
 Assessment of Salivary Glands’ function
 Salivary Glands testing
 Sialadenitis
 Sialosis
 Necrotizing Sialometaplasia
 Sarcoidosis
 HIV-Associated Salivary Gland Diseases
 References

3. OUTLINE – CONT.
 Salivary Gland Stones
 Extravasation and Retention Mucoceles and Ranulas
 Salivary Gland Tumors
 Xerostomia
 Hypersalivation
 Sjögren's syndrome
 References

4. INTRODUCTION
 Saliva is a glandular secretion that is essential for the maintenance of healthy oro-dental tissues.
 The physical properties of saliva vary according to the different types of salivary glands:
 Parotid secretions having a serous (watery) consistency.
 The submandibular and sublingual glands secrete a more viscous saliva. [Glycoprotein]
 A severe reduction in salivary flow rate can have devastating consequences on oral health.

5. FUNCTIONS OF SALIVA
 Lubricant
 Cleansing effects
 Ion Reservoir
 Water Balance – Buffering Capacity
 Antimicrobials
 Digestion
 Retention to removable prosthesis
 Taste

6. MEASUREMENTS OF SALIVA
 The unstimulated flow rate is more important than the stimulated flow rate for oral comfort.
 The stimulated flow rate is important to facilitate chewing and swallowing during mastication.
 Unstimulated: approximately 0.3 mL/min with submandibular glands contributing approximately 65%,
Parotid with15–20% and the sublingual and minor glands both delivering 7–8%.
 Stimulated: up to 0.7mL/min with the parotid providing 45-50% of it.
 1500 mL of Saliva is produced on a daily basis

7. SALIVARY GLANDS

8. ASSESSMENT OF SALIVARY GLANDS’ FUNCTION - EXAMINATION
 The parotid glands are not particularly easy to palpate.
 Tenderness and swelling are best detected by standing in front of the patient and by placing two or three
fingers over the posterior border of the ascending ramus of the mandible.
 Backwards and inwards movement of the fingers with light pressure is almost always all that is needed to
detect tenderness in the superficial part of the parotid.
 Swelling of a parotid gland may also be visualized by standing behind the patient who is seated in a reclined
dental chair.
 Inflammatory signs
 TMDs.

9. SIALOMETRY
 Salivary Flow Rate
 Carlson–Crittenden collector (a small cup placed over the orifice of the parotid gland duct).
 Relatively invasive and make measurement of unstimulated flow rates unreliable for individual glands.
 Sialometry should be done under specific conditions, the time of day, the type of stimulant used, and the
pre-collection instructions.
 Sialometry is probably most beneficial for the longitudinal assessment of flow rates for individual patients
as there is considerable variation within the population.
 Changes in salivary flow are probably more important indicators of salivary function than a single flow rate
measurement.

10. SIALOMETRY
 Volunteers given atropine reported that a dry mouth developed when their resting flow fell to about 50
per cent of their normal flow rate.
 The normal rate of flow of unstimulated whole saliva is approximately 0.3 ml/minute and for stimulated
whole saliva 1–2 ml/minute.
 Stimulated saliva is mainly secreted in response to masticatory and gustatory stimuli and the flow rate
will rise significantly (4–6 ml/minute) when chewing a powerful sialogogue.

12. SALIVARY GLANDS IMAGING
 Plain Radiograph
 When investigating a suspected salivary calculus, two views should be taken at 90°.
 For the parotid gland, a panoramic or oblique lateral view can be combined with rotated anterior–
posterior or posterior–anterior view.
 For the submandibular gland, panoramic and lower occlusal views (true and oblique) are appropriate.
 Dose reduction?

14. SIALOGRAPHY
 Imaging technique used to demonstrate the ductal system of the parotid or submandibular gland.
 A water-soluble, non-ionic, radio-opaque contrast medium is injected into the duct orifice and ‘post
contrast’ radiographs are then taken in two different planes.
 Structural abnormalities of the duct system.
 Sialectasis; Contrast medium sent into the body of the gland.
 Sjögren's syndrome; a characteristic ‘snowstorm’ appearance (punctate sialectasis).
 Contraindicated in the presence of acute infection or when a calculus is close to the duct opening.
 Risk of displacing calculus further into the gland by the contrast medium.

15. SIALOGRAPHY
 Suspected ‘mass’ lesions within the salivary glands should not be investigated with
Sialography – Ball in hand appearance.
 Patients with discrete masses within the salivary glands should be sent for ultrasound or (MRI)
scan
 Phases:
 Preoperative.
 The filling phase.
 The emptying phase

16. ADVERSE EFFECTS OF SIALOGRAPHY
 Pain on injection,
 Post procedural infection,
 Ductal rupture,
 Extravasation of contrast media,
 Allergic reaction to iodine

17. SIALOGRAPHY
 Ductal phase; immediately after injection of contrast material and allows
visualization of the major ducts.
 Acinar phase; within minutes after the ductal system has become fully
opacified with contrast medium and the gland parenchyma becomes
subsequently filled with contrast.
 Evacuation phase; assesses normal secretory clearance function of the gland
to determine whether any evidence remains of retention of contrast medium
in the gland or ductal system during a period greater than 5 minutes after the
contrast has been injected into the ductal system.

19. SCINTIGRAPHY (RADIOISOTOPE IMAGING)
 Salivary glands have the ability to concentrate certain radioisotopes (Technetium pertechnetate)
 An intravenous injection of the radioisotope is followed by scanning of the salivary glands at intervals of 30
seconds.
 Salivary secretory activity is stimulated by dropping citric acid solution on the tongue.
 Time–activity profiles of the glands are thereby produced and can build up a full picture of salivary
secretory Facticity.
 This procedure measures gland uptake of the radioisotope and gives an indication of its clearance.
 Scintigraphy is therefore beneficial for comparing the function of a diseased gland (as in a localized
chronic sialadenitis) with the remaining healthy glands or to detect a generalized loss of glandular function
(as seen in Sjögren's syndrome).

20. ULTRASOUND AND MRI
 Ultrasound may be used for superficial soft-tissue swellings and the initial investigation of suspected
mass lesions.
 Ultrasound is useful for differentiating between solid and cystic lesions. [Bone?]
 Ultrasound may be used in cases of chronic infection where sialography is contraindicated and may
identify sialectasis or calculus, though subtle changes are difficult to see.
 Magnetic resonance imaging is used to investigate space-occupying lesions such as salivary gland
tumors, only limited information is given on adjacent hard tissues.
 This technique provides good soft-tissue detail and localization of masses—the facial nerve is usually
identifiable.

21. SIALO-CHEMISTRY
 The measurement of the biochemical constituents of saliva has been undertaken for many diseases of the
salivary glands; the results are frequently misleading or difficult to interpret.
 Not routinely used for diagnostic purposes but it remains a potentially useful research tool.
 It can also be of value in measuring drug, antibody, and hormone levels.

23. SIALADENITIS
 Inflammation of salivary glands.
 Most commonly viral or bacterial infection, but occasionally due to other causes (allergic reactions,
irradiation).
 Affecting the major salivary glands.
 It may also occur in minor salivary glands, as a primary phenomenon (as in Sjögren's syndrome) or as a
secondary feature of some other condition such as pipe-smoker's palate.
 Bacterial sialadenitis is usually a secondary consequence of a localized or systemic cause of reduced
salivary flow and is rarely the primary pathological process.
 Viral infections frequently affect previously normal salivary glands, an example is mumps most commonly it
affects the parotid glands but may involve the other major glands.

24. SIALADENITIS
 The reduced salivary flow predisposes the gland to an ascending infection from bacteria within the oral
cavity.
 Painful, tender, and swollen, and pain is radiated to the ear and the temporal area.
 Intraorally, the duct of the affected gland may be seen to be swollen and reddened.
 In the absence of sensitivity to Penicillin, Flucloxacillin is the antimicrobial of choice.
 Nonsurgical treatment, being dependent on:
 Antibiotic therapy
 Maintenance of a correct fluid balance
 Resolution of the predisposing condition. – if possible.

25. CHRONIC SIALADENITIS
 Parotid or the submandibular glands.
 May follow the resolution of an acute infection or may occur without any evident primary acute phase.
 Symptoms are relatively low-grade with tenderness and a minor degree of swelling of the affected
gland, and occasionally with some degree of swelling and redness of the duct.
 Frequently minor dilatations of the ductal system may be detected on Sialography and presumably
provide foci of infection and stagnation.
 Such a recurrent chronic sialadenitis may occur following radiotherapy affecting the glands or may
follow the minor damage due to the presence of a calculus.
 The treatment is exactly the same as of acute sialadenitis.

28. SIALOSIS (SIALADENOSIS)
 A painless, non-inflammatory, non-neoplastic swelling of the salivary glands.
 There are many precipitating factors including Hormonal abnormalities, Nutritional Deficiency states, the
effect of anti-rheumatic drugs, drugs containing iodine and adrenergic drugs.
 Drug-Induced enlargements are reversible.
 The parotid glands are most frequently affected, and the swelling is commonly bilateral.
 Histologically, there is hypertrophy of serous acini.
 Investigation of patients should include the identification of predisposing causes (liver function, blood
glucose and growth hormone tests).
 A detailed drug history should be recorded and the possibility of eating disorders considered.

30. NECROTIZING SIALOMETAPLASIA
 Relatively uncommon.
 Tumor-like condition occurs more frequently in males, especially smokers and is of unknown aetiology.
 It appears to be a result of an ischemic phenomenon that occurs in minor salivary glands, usually in the
palate.
 Painless ulceration of rapid onset, the margins are often everted and may be indurated, resembling a
carcinoma.
 Histologically, the squamous metaplasia found in the salivary ducts, together with pseudo-
epitheliomatous hyperplasia of the surrounding palatal epithelium, may give an incorrect impression of
malignancy.
 This is a self-limiting condition that resolves in about 8 weeks time without anything other than
symptomatic treatment.
 Lesions are often excised for diagnostic purposes.

32. SARCOIDOSIS
 Chronic granulomatous disorder that may rarely present as painless, persistent enlargement of the major
salivary glands.
 There is often an associated reduction in salivary flow and there may be an accompanying ‘Sjögren's-
like’ condition.

35. HIV-ASSOCIATED SALIVARY GLAND DISEASES
 Patients with HIV infection can develop salivary gland problems and xerostomia.
 The salivary gland swelling may be due to a ‘Sjögren's-like’ condition with lymphocytic infiltration and a
dry mouth. However, there may be other pathology present in the salivary gland such as Kaposi's
sarcoma or a lymphoma.
 It is also possible that salivary gland swelling may be a consequence of other viral infections such as
cytomegalovirus or Epstein–Barr.
 Chronic parotitis in children is highly suggestive of HIV infection.

36. SALIVARY GLAND TUMORS
 Salivary gland tumors compromise about 3% of all tumors.
 The majority occur in the parotid glands and only 10% affect the minor salivary glands.
 The greatest concentration of the minor salivary glands is in the junction of the hard and soft palates.
 About 20% of minor salivary gland tumors occur in the upper lip.
 The majority of these lesions are pleomorphic adenomas but more aggressive lesions such as
adenocystic carcinomas may occur.

37. SALIVARY GLAND TUMORS

38. SIALOLITHIASIS (SALIVARY STONES)
 Sialoliths are calcified organic matter that forms within the secretory system of the major salivary
glands.
 Several factors that cause pooling of saliva within the duct are known to contribute to stone formation:
inflammation, irregularities in the duct system, local irritants, and anticholinergic medications.
 The recurrence rate is approximately 20%.
 Sialoliths are composed primarily of hydroxyapatite.

39. SALIVARY STONES
 Submandibular glands (80–90%) – 20% are poorly calcified
 Parotid (5–15%) – 50% are poorly calcified.
 Sublingual (2–5%) glands.
 Why the highest rate of stones is in the Submandibular gland?
1. The torturous course of Wharton's duct
2. Higher calcium and phosphate levels
3. Dependent position of the submandibular glands.

40. CLINICAL FEATURES
 History of acute, painful, and intermittent swelling of the affected major salivary gland.
 Swelling increases with eating.
 Stasis of the saliva may lead to infection, fibrosis, and gland atrophy.
 Fistulae, a sinus tract, or ulceration may occur over the stone in chronic cases.
 Soft tissue surrounding the duct may be edematous and inflamed.
 Bi-digital palpation along the pathway of the duct may confirm the presence of a stone.

41. DIAGNOSIS AND TREATMENT
 An occlusal radiograph is recommended for submandibular glands.
 Stones in the parotid gland request an AP view.
 Standard care includes analgesics, hydration, antibiotics, and antipyretics.
 Stones at or near the orifice of the duct can often be removed by milking the gland, but deeper stones
require removal with surgery or sialoendoscopy.

44. EXTRAVASATION AND RETENTION MUCOCELES AND RANULAS
 Mucocele is a clinical term that describes swelling caused by the accumulation of saliva at the site of a
traumatized or obstructed minor salivary gland duct.
 Mucoceles are classified as extravasation types and retention types.
 Mucocele located in the floor of the mouth is known as a Ranula.
 The extravasation type of mucocele is more common than the retention form.

45. MUCOCELES
 The extravasation mucocele is often termed as a cyst but…. Epithelium
 Retention mucocele is caused by obstruction of a minor salivary gland duct by calculus or possibly by
the contraction of scar tissue around an injured minor salivary gland duct, eventually, an aneurysm-like
lesion forms.

46. CLINICAL FEATURES
 Extravasation mucoceles most frequently occur on the lower lip [the buccal mucosa, tongue, floor of the
mouth, and retromolar region]
 Mucous retention cysts are more commonly located on the palate or the floor of the mouth.
 Mucoceles often present as discrete, painless, smooth-surfaced swellings that can range from a few
millimeters to a few centimeters in diameter.
 Superficial lesions frequently have a characteristic blue hue while deeper lesions can be covered by
normal-appearing mucosa.
 Although the development of a bluish lesion after trauma is highly suggestive of a mucocele, other
lesions (including salivary gland neoplasms, soft tissue neoplasms, vascular malformation, and
vesiculobullous diseases) should be considered.

47. TREATMENT
 Surgical excision is the primary treatment for mucoceles
 Aspiration of the fluid from the mucocele can be an alternative.
 Surgical management is challenging since it could cause trauma to other adjacent minor salivary glands
and lead to the development of a new mucocele.
 Intralesional injections of corticosteroids have been used successfully to treat mucoceles.

48. MUCOCELE OF LOWER LIP

49. RANULA
 Large mucocele located on the floor of the mouth.
 May present as either a mucous extravasation phenomenon or a sessile firm mass with a normal mucous
membrane.
 The most common cause is trauma, other causes include an obstructed salivary gland or a ductal
aneurysm.
 They are most common in the second decade of life and in females.
 Painless, slow-growing, soft, and movable mass located in the floor of the mouth.
 The lesion forms to one side of the lingual frenum; if the lesion extends deep into the soft tissue, it can
cross the midline.
 A deep lesion that herniates through the mylohyoid muscle and extends along the fascial planes is
referred to as a plunging Ranula.

50. TREATMENT
 Radiographs help in the diagnosis
 Surgical intervention is the treatment of choice for ranulas.
 A marsupialization procedure that unroofs the lesion is the initial treatment.
 Postsurgical complications include lesion recurrence, sensory deficits of the tongue, and damage to
Wharton's duct.
 Frequency of recurrence for marsupialization: 67%
 Ranula excision: 58%.
 Sublingual gland excision: 1%.

52. SALIVARY GLAND TUMORS

53. PLEOMORPHIC ADENOMA
 The most common tumor of the salivary glands; it accounts for about 60% of all salivary gland tumors.
 Majority in Parotid, less than 10% in Submandibular, Sublingual and Minor salivary glands.
 Mixed tumor.
 The highest incidence is in the fourth to sixth decades of life.

54. CLINICAL FEATURES
 Painless, firm, and mobile masses that rarely ulcerate the overlying skin or mucosa.
 In the parotid gland, they’re 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.
 Intraorally, they most often occur on the palate, followed by the upper lip and buccal mucosa.

55. PATHOLOGY
 A firm smooth mass within a pseudo-capsule.
 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 and occasionally myoepithelial cells.
 One characteristic is the presence of microscopic projections of tumor outside of the capsule.

56. TREATMENT
 Surgical removal with adequate margins is the principal treatment.
 Superficial parotidectomy is sufficient for the majority of these lesions.
 Lesions that occur in the submandibular gland are treated by the removal of the entire gland.

57. PLEOMORPHIC ADENOMA

58. PAPILLARY CYSTADENOMA LYMPHOMATOSUM
 Warthin’s tumor. the second most common benign tumor of the parotid gland.
 6 to 10% of all parotid tumors and is most commonly located in the inferior pole of the gland,
 Slight predilection toward males, between the fifth and eighth decades of life.
 Bilaterally in about 6 to 12% of patients.
 Well-defined, painless, slowly-growing mass in the tail of the parotid gland and visible on tc99m scintiscans.
 Cystic spaces filled with thick mucinous material. The tumor consists of papillary projections lined with
eosinophilic cells that project into cystic spaces.
 Treatment; Surgical or Superficial parotidectomy.
 Recurrences and malignant degeneration of this tumor are rare.

60. BASAL CELL ADENOMA
 Slow-growing and painless masses.
 1 to 2% of salivary gland adenomas.
 Male: Female ratio is 5:1
 70% occur in the parotid gland, and the upper lip is the most common site for basal cell adenomas of the
minor salivary glands.
 Histologically, three varieties exist: solid, trabecular-tubular, and membranous.
 Solid; consists of islands of basaloid cells, nuclei have a normal size and basophilic.
 Trabecular-tubular; consists of trabecular cords of epithelium.
 Membranous; Multilocular, and 50% are encapsulated.
 Treatment; Conservative surgical excision, lesions do not recur; however, the membranous form has a higher
recurrence rate.

62. MUCOEPIDERMOID CARCINOMA
 The most common malignant tumor of the salivary glands.
 Most common malignant tumor of the parotid gland
 Second most common malignant tumor of the submandibular gland, after adenoid cystic carcinoma.
 Approximately 60 to 90% occur in the parotid gland; the palate is the second most common site.
 F = M, 3rd to 5th decade of life.
 Epidermoid: Mucous cells Ratio; High-Grade or Low-Grade.
 Low-Grade has a higher ratio and less aggressive, the high-grade form is a more malignant tumor and
has a poorer prognosis.

63. CLINICAL FEATURES
 The clinical course depends on the grade.
 Low-Grade: Painless enlargement.
 High-grade often demonstrate rapid growth and a higher likelihood for metastasis.
 Pain and ulceration of overlying tissue are occasionally associated.
 If the facial nerve is involved, the patient may exhibit a facial palsy.

64. PATHOLOGY
 Low-grade tumors are usually small and partially encapsulated, usually demonstrate a mucinous fluid,
usually consist of regions of mucoid cells with interspersed epithelial strands.
 High-grade tumors are less likely to demonstrate a capsule, usually demonstrate solid content, usually
consist primarily of epithelial cells, with very few mucinous cells.
 Special stains are necessary to differentiate between these high-grade tumors and squamous cell
carcinoma.
 An unusual form of the tumor is the sclerosing variant, characterized by an intense central sclerosis with
an inflammatory infiltrate of plasma cells, eosinophils, and lymphocytes in the peripheral regions.

65. TREATMENT
 Low-grade can be treated with a superficial parotidectomy if it involves only the superficial lobe.
 High-grade lesions should be treated aggressively, a total parotidectomy is performed, with facial nerve
preservation if possible.
 If there is any possibility that the tumor involves the facial nerve, the nerve is resected with the tumor.
 Immediate nerve reconstruction can be performed at the time of tumor extirpation
 Postoperative radiation therapy is a useful adjunct in treating the high-grade tumor.
 5-year (79%) and 10-year (65%) survival rates depend upon grade, stage, and margin status.
 High-grade lesions, recurrence with metastases can occur in up to 60% of patients.
 Survival rate for low-grade lesions is about 95% at 5 years; as for high-grade lesions, it drops to 40%.

67. ADENOID CYSTIC CARCINOMA
 6 to 10% of all salivary gland tumors
 Most common malignant tumors of the submandibular and minor salivary glands.
 15 to 30% of submandibular gland tumors and 30% of minor salivary gland tumors, and 2 to 15% of
parotid gland tumors.
 50% of all adenoid cystic carcinomas occur in the minor salivary glands.
 5th decade, F = M
 Frequent late distant metastases and local recurrences.

68. CLINICAL FEATURES
 Firm unilobular mass in the gland.
 Occasional pain
 Parotid tumors may cause facial nerve paralysis
 Peri-Neural invasion.
 Slow growth.
 Intraoral tumors may exhibit mucosal ulceration
 Metastases into the lung are more common than regional lymph node metastasis.

69. TREATMENT
 Radical surgical excision of the lesion is the appropriate treatment.
 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.
 Factors affecting the long-term prognosis are the size of the primary lesion, its anatomic location, the
presence of metastases at the time of surgery, and facial nerve involvement.

71. ACINIC CELL CARCINOMA
 1% of all salivary gland tumors.
 90 and 95% of these tumors are found in the parotid gland; almost all of the remaining tumors are
located in the submandibular gland.
 3% Bilateral involvement
 Higher frequency in women and 5th decade.
 Second most common malignant salivary gland tumor in children, second only to mucoepidermoid
carcinoma.
 Present as slow-growing masses with occasional pain.
 Well-defined mass that is often encapsulated, two types of cells are present; similar to acinar cells
adjacent to cells with a clear cytoplasm. these cells are positive on PAS.
 20-year survival rate is about 50%.
 Superficial parotidectomy, with facial nerve preservation if possible. when these tumors are found in
the submandibular gland, total gland removal is the treatment of choice.

73. SALIVARY GLAND HYPOFUNCTION
 Xerostomia: the subjective feeling of oral dryness, which may or may not be associated with hypofunction.
1. May be due to either:
2. Loss of secretory tissue in the salivary glands.
3. Disturbance in the secretory innervation mechanism.
 Xerostomia is frequently reported by patients with burning mouth syndrome.
 Conflicting reports on the effect of age on salivary gland function.
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74. CAUSES OF XEROSTOMIA
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75. DRUG-INDUCED SALIVARY GLAND HYPOFUNCTION
 There are over 400 medications that are listed as having dry mouth as an adverse effect.
 High incidence of salivary disorders in the elderly.
 Some drugs may not actually cause impaired salivary output but may produce alterations in saliva
composition that lead to the perception of oral dryness.
 Medication-induced salivary hypofunction usually affects the unstimulated output.
 Substitution with similar types of medications with fewer xerostomic side effects is preferred.
 SSRIS vs. TCA.
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76. DRUG- INDUCED SALIVARY GLAND HYPOFUNCTION
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77. INVESTIGATIONS OF SALIVARY GLAND HYPOFUNCTION
 Oral dryness
 Burning, tingling sensation of tongue
 The need for frequent drinks to be taken
 Difficulty in swallowing dry foods
 Altered taste (dysguesia)
 Smell Recurrent salivary gland swellings/infections
 Increase in rate of dental decay
 Dry, sore, cracked lips and angles of mouth
 Difficulty in talking (dysphonia)
 Generalized mucosal soreness and ulceration of denture-bearing areas
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78. INVESTIGATIONS OF SALIVARY GLAND HYPOFUNCTION
 Oral examination reveals:
 Swollen salivary glands
 Absence of salivary film over oral mucosa
 Dry, paper-thin ‘parchment’ appearance of oral mucosa
 Fissuring and lobulation of the tongue
 Dry, cracked lips
 Angular cheilitis
 Evidence of chronic oral candidosis
 Development of new carious lesions, especially on incisal or cuspal surfaces
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79. 79

80. MANAGEMENT OF XEROSTOMIA AND HYPOFUNCTION
 Local stimulation; chewing sugar-free gum
 Xylitol; Antibacterial and may have a significant anti-caries effect.
 Systemic medication to stimulate salivary flow; pilocarpine the most effective drug tested.
BUT…..
 Sialagogues.
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81. CHEWING SUGAR-FREE GUM
 Increases the flow of stimulated saliva to levels about 3 to 10 times resting values.
 Stimulated saliva has enhanced buffering capacity and a greater remineralizing potential than resting saliva.
 Increase the resting salivary flow rate for up to 30 minutes beyond the period of chewing.
 Has an antimicrobial activity if it contains xylitol.
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82. HYPER-SALIVATION
 Sialorrhoea or ptyalism
 An uncommon complaint.
 Hypersecretion and neuromuscular dysfunction.
 Intraoral prosthesis for the first time.
 It can be difficult to distinguish between hyper-salivation and Drooling
 Hyper-Salivation; saliva is normally cleared from the mouth by swallowing.
 Drooling; due to a failure to swallow saliva and is common in infants and also in those with poor
neuromuscular coordination.
 Anticholinesterases, which enhance neuromuscular transmission can cause hyper-salivation.
 The antipsychotic drug clozapine has been implicated in causing a dry mouth and hyper-salivation.
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83. TREATMENT
 The use of drugs to suppress salivary flow is rarely indicated.
 Anticholinergic drug therapy is sometimes used in patients with cerebral palsy who drool excessively.
BUT Caries.
 Alternatively, the major salivary gland ducts can be redirected to the oropharynx to treat drooling.
 In a minority of patients, behavioral therapy may be beneficial
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84. SJÖGREN'S SYNDROME
 Autoimmune disease of the exocrine glands that particularly involves the salivary and lacrimal
glands.
 Traditionally, the symptoms of Sjögren's syndrome were thought to result from the destruction of
salivary and lacrimal gland tissue.
 More recently, it has become clear that many Sjögren's syndrome sufferers have substantial reserves
of histologically normal acinar tissue that simply does not function properly.
 Primary vs. Secondary
 1–3% of the UK population.
 Middle-aged and elderly women F:M Ratio 9:1
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85. CLINICAL FEATURES
 Oral dryness.
 The mucosa may be painful and sensitive to spices and heat.
 Dry, cracked lips and angular Cheilitis.
 The mucosa is pale and dry, friable, or furrowed.
 The tongue is often smooth (depapillated) and painful.
 Mucocutaneous Candidal infections are common, particularly of the erythematous form.
85

86. CLINICAL FEATURES
 Xerophthalmia; Keratoconjuntivitis sicca; Blindness
 Prominent serologic signs of autoimmunity, including hypergammaglobulinemia, autoantibodies, an
elevated sedimentation rate, decreased white blood cells, monoclonal gammopathies, and
hypocomplementemia.
 Intermittent or chronic salivary gland enlargement.
 Sjögren’s syndrome patients have a 20- to 40-fold increased risk of lymphoma
86

87. 87

88. AETIOLOGY
 Multifactorial.
 Suggested scenario:
1. Initiation by an exogenous factor;
2. Disruption of salivary gland epithelial cells;
3. T lymphocyte migration and lymphocytic infiltration ofexocrine glands;
4. B lymphocyte hyper-reactivity and production of rheumatoid factor and antibodies to Ro(SS-A) and
La(SS-B).
88

89. RISK FACTORS
 Genetic predisposition, members of the same family, twins, MHC genes and the development of
autoimmune disorders.
 Viruses, cytomegalovirus infections, EBV, HCV.
 HIV and HCV are capable of producing SS-like symptoms, reduced salivary flow.
 Sex hormones, suggested by the high F:M ratio.
89

90. PATHOGENESIS
 Autoantibodies are found in the serum of both primary and secondary SS patients.
 Most common are Ro⁄ SS-A and La ⁄SS-B autoantibodies which are found in the serum of 60–70% of
patients with primary SS.
90

91. PATHOGENESIS OLD THEORY
 Chronic lymphocytic infiltration and subsequent damage of salivary gland acini.
 Exocrine glands display acinar atrophy, ductal hyperplasia and replacement of acinar
cells with fibrosis and ⁄ or fatty infiltration which results in these areas of the gland
being nonfunctional.
 The lymphocytic infiltrate contains T cells and B cells at a ratio of 4:1 as well as plasma
cells.
91

92. 92

93. PATHOGENESIS (NEW THEORY)
 Autoantibodies to muscarinic M3 receptors.
 Autoantibodies to lacrimal and salivary gland muscarinic M3 acetylcholine receptors are produced in SS.
This prevents the synapse between the efferent nerves and the gland cells resulting in decreased saliva
production.
 The remaining gland must be inactive via ‘‘paralysis’’ of either the release of neurotransmitters from
cholinergic nerve fibers or post-signalling response of the glandular cells.
93

94. DIFFERENTIAL DIAGNOSIS
 Drug therapy (Anticholinergic drugs)
 Past treatments; Past head and neck radiation
 Systemic disease :
 Sarcoidosis
 Hepatitis C
 HIV ⁄ AIDS
 Graft-versus-host disease
 Pre-existing lymphoma
 Rheumatoid arthritis
 Systemic lupus erythematosus
 Primary biliary cirrhosis
 Diabetes mellitus
 Cytomegalovirus and other herpes viruses
94

95. DIAGNOSIS
 Not straightforward, the estimated interval between initial symptoms and diagnosis of the disease is
approximately 6 to 10 years.
 Common initial (vague) symptoms include, arthralgia, fatigue and extra-glandular complications.
95

96. DIAGNOSIS
 Exclusion criteria:
 Past head and neck radiation treatment
 Hepatitis C, HIV⁄ AIDS
 Pre-existing Lymphoma.
 Sarcoidosis.
 Graft-Versus-Host Disease
 The use of anticholinergic drugs.
96

97. DIAGNOSIS
 Measurement of salivary gland flow should be determined by sialometry, Sialography, using a water-
based dye, may be indicated where there is a history or clinical signs indicating possible structural
damage of the salivary glands.
 Labial gland biopsy for patients with suspected Sjögren's syndrome.
 Anti – SS-A and Anti – SS-B tests
 American European Consensus Group (AECG) Six criteria.
97

98. AECG
98

99. COMPLICATIONS
 Increased incidence of malignant lymphoma, non-Hodgkin’s lymphoma, lymphoproliferative disease.
 The risk of lymphoma is equivalent for both primary and secondary (44 times greater than the risk in the
general population).
 Nose and skin dryness.
 Recurrent sinusitis, chronic cough due to dryness of the trachea
 Chronic Keratoconjuntivitis sicca causes an irregular surface of the cornea which leads to deteriorating
vision and increased risk of recurrent infections.
 Psychological disorders and depression are high in patients with SS, xerostomia is a major contributing
factor.
99

100. ORAL COMPLICATIONS
 Decreased salivary flow.
 Higher caries rate, smooth surface caries.
 Mucosal dryness, mucositis, sloughing and ulceration.
 Atrophic glossitis.
 Aggressive forms of gingivitis and periodontitis.
 Candidosis.
 Dysphagia and dysguesia.
100

101. MANAGEMENT
 Systemic corticosteroid therapy (prednisolone) has been suggested to
 improve symptoms and histological features (conflicting results).
 Newly introduced treatments; Rituximab and interferon-α.
 There is a spontaneous improvement in symptoms in approximately 12% of patients, indicating that the
disease does not always have a progressive nature.
101

102. REFERENCES
 Burket’s: Chapter 8: Salivary Glands and Saliva
 Tyldesley’s: Chapter 8: Salivary Gland Diseases

103. THANK YOU