Thilanka Umesh Sugathadasa Page 1
Non-neoplastic diseases of salivary glands including dry mouth
Non- neoplastic SG disorders
Atresia of the
ducts & lobes
- Acute (Ascending)
- Chronic non-specific
- Chronic specific
syphilis/ Sarcoidosis) &
- Recurrent subacute/
- Mumps like diseases
disease/ Coxaskie A
infection/ ECHO or
- HIV induced SG
Thilanka Umesh Sugathadasa Page 2
Dry Mouth/ Xerostomia
This is significantly a patient perception.
Dry mouth & Oral dryness are general terms that encompasses 2 medical entities
- Xerostomia (This is a symptom) – subjective complaints
- Hyposalivation – Objective reduction in salivary secretion
Mainly occur due to decreased salivary flow or decrease composition of the saliva.
& there are many of other causes.
So this is a subjective clinical condition due to absolute or relative reduction in amount of saliva
Advancing of the age also increasingly associated with the dry mouth. But this is usually due to
medications & diseases.
-Antidepressants : Tricyclic(eg:
Selective serotonin reuptake
-Antihypertensive : Can also cause
the compositional changes of the
saliva as well as the changes of the
- Cytotoxic drugs
doses above 40 Gy & Iodine 131)
3.Graft versus host reaction
Physiological Diseases of Salivary
Post exercise/ mouth breathing
Mouth breathing due to nasal
When doing presentation or
Thilanka Umesh Sugathadasa Page 3
Clinical features of dry mouth
1. Sensation of burning.
2. Swallowing difficulty(Eating difficulty of dry foods “cracker sign”)
3. Stability & retention of dentures become low
4. Speaking difficulty(Clicking quality speech due to tongue sticking to
5. Sensation of taste reduction
6. Increase incidence of dental caries & periodontal disease.
8. Recurrent ulceration
9. Tongue or check getting accidental bitten frequently.
1. Dryness of the lips & oral mucosa.
2. Pale & corrugated buccal mucosa.
3. Lack of salivary pooling in floor of the mouth.
4. Atrophy/ inflammation/ fissuring/ cracking/ of tongue
5. Erythema/ Ulceration
7. Lipstick sign
8. Crackers sign
9. Tongue blade sign
10. Increase levels of dental caries & periodontal disease.
11. Mucosa tends to stick to the dental mouth mirror & dry
Complications of dry mouth
Soft tissue changes Hard tissue changes Other
The mucosal tissues may
“Burning”, dry & atrophic.
Soreness & redness due to
Tingling sensation of the
Severe & uncontrolled
Marked increase in erosions
especially in the non-
carious risk areas & the root
surfaces, & even in the cusp
Caries may be progressive
even with the excellent oral
Difficulty in speaking.
Difficulty in swallowing especially
Reduced denture retention.
Reduced taste sensation.
Painful salivary gland enlargement.
Increase uptake of the fluids when
patient can be
classified in to
in the salivary secretion
not significant enough to
suffering from xerostomia.
Those suffering from
xerostomia but with no
evident decrease in salivary
Thilanka Umesh Sugathadasa Page 4
Diagnosis & Ix
Diagnosis is mainly by the combination of the
- Clinical features.
Salivary function studies
1. Salivary flow rate
3. Salivary scintiscanning
1. Lacrimation flow – exclude sjogren's syndrome
2. Urinanalysis – exclude DM
3. Blood tests
ESR – exclude Sjorgren’s syndrome or sarcoidosis
antinuclear antibodies – exclude Sjorgren’s syndrome or sarcoidosis.
Rheumatoid factor – Exclude Sjorgren’s syndrome
Serology – Viral disease
Serum calcium & phosphate – exclude hyperparathyroidism.
CXR –exclude Sarcoidosis
Ultrasonography – exclude Sjorgren’s syndrome or Neoplasia
MRI –exclude Sjorgren’s syndrome
Biopsy is taken if there is a suspicion about the organic disease of the salivary glands. Here
always possible to take biopsy from the major salivary glands but usually perform the minor SG
Bx due to risks of nerve damage, scars. So usually preferable site is the lower labial mucosa.
Can divide in to 3 categories
1. Symptomatic Rx
2. Preventive Rx
3. Curative Rx
Salivary flow over a 24-hour period
40 ml saliva will be produced over 7 hours
300 ml of unstimulated saliva over 16 hours
200 ml of stimulated saliva during meals over 54 minutes
Thilanka Umesh Sugathadasa Page 5
Symptomatic Rx Preventive Rx Curative Rx
(- Directed at alleviating or minimizing complaints associated
with decreased salivation. Range from simple methods of
hydration & lubrication to systemic secretagogues to stimulate
the salivary function)
Non sugar containing fluids & frequent small
sips of them. Helps to hydrate the mucosa &
removal of retained debris
Avoids fluids containing sugars.
Humidifiers specially closer to bed at night
(Can use jug of water)
Lip moisturizers & emollients.
Penetrating creams are preferred over the
petroleum based products.
Avoid dry foods.
Avoiding spicy foods, alcohol & strong
flavoring may reduce oral mucosal sensitivity.
Avoid mouth rinses with high alcohol content.
(Listerine), which can induce mucosal
irritation & sensitivity.
Mechanical, local saliva induce with sugarless
candy, gums or rinses.
disadvantages of local stimulants
- short lived
- Frequent application can be inconvenient.
- Citric acid may irritate the oral mucosa.
- continue use may contribute to
- Only use for the patients who have salivary
tissues that can be stimulated.
- Pilorcarpine hydrochloride-
parasympathomimetic agonist that increase
- Most widely tested sialagogue.
- Recommended dose = 5mg tds
- Cevimeline hydrochloride – similar to
Pilorcarpine. (This product can’t use in high in
high conc as it containing metals.)
Salivary replacement products (Substitute)
commonly containing Carboxymethylcellulose
or hydroxycellulose as lubricants, artificial
sweeteners, preservatives, chloride &
(- To limit the consequences of
salivary gland hypofunction on oral
& dental tissues)
Increase oral hygiene
Oral application of topical
fluorides to minimize the
dental caries risk.
If bacterial infection is
antibiotics should be
identified. It may require
If swelling which is not
due to infection a short
course of steroids are
NSAIDs are not helpful
If candidal infection
presents use topical or
those antifungals should
not contain sugars.
Composition of the
10g/L(Keep the watery
content of saliva)
- Sorbitol 30mg/L
- Sodium chloride
- Magnesium chloride
- Calcium chloride
- Dipotasium hydrogen
- Regular use is
- More viscous than the
natural saliva so feel odd.
- No antimicrobial & other
(Managing underlying cause
If dry mouth is due
drugs if possible, in
Identify the cause
investigations & Rx
- Secretagogues can
relief but will not
- Patients may leave
decline in function
over time &
symptoms & signs.
Thilanka Umesh Sugathadasa Page 6
Mx of the Xerostomia can be presents as
1. Replacement of saliva
2. Avoidance of harmful effects.
3. Prevention of oral disease
4. Stimulation of the residual secretory capacity.
5. Curative Rx.
Replacement of saliva
Frequent sips of water
Glycerol & Thymol or Glycerol & lemon
Luborant- Methyl cellulose based products
Glandosane - ;;
Above having enough hydration but not enough lubrication
Saliva orthana is having (Mucin- based products) better
Avoidance of harmful effects
Dry and cariogenic foods.
Tobacco smoking and alcohol intake
Alter treatment with medicaments if there are any medicines
which cause dry mouth.
Avoid wearing dentures at night
Prevention of oral disease
Meticulous (careful) oral hygiene.
Chlorhexidine mouth wash 0.2%
Stimulation of the residual secretory capacity
Sugar free chewing gums
Saliva orthana lozenges(release Mucin)
Pilorcarpine tablets 5mg tds
Pilorcarpine eye drops 0.5- 1% also can be swallowed (2-4 drops)
every 4 hours.
Other drugs (Anethole trithione, yohimbine, neostigmine)
Thilanka Umesh Sugathadasa Page 7
Condition Features & etiology Clinical features/ Ix &
An autoimmune inflammatory
Immunologically mediated chronic
inflammatory disorder of exocrine
glands mainly affecting salivary,
Common in the middle aged Females.
Two types present
- Primary SS (sicca syndrome)-:
Dry eyes (Keratoconjunctivitis/
xerophthalmia) & dry mouth.
- Secondary SS-:
Dry eyes, Dry mouth & connective
tissue disorder (RA, SLE, Systemic
sclerosis, mixed CT disease, primary
- Genetic predisposition
- Inflammatory events
- Auto antibodies
- Liver disease
- Processes mediating salivary gland
A benign autoimmune inflammatory
exocrinopathy (epithelitis) directed
against alpha fodrin, a cytoskeletal
protein involved in actin binding, with
lymphocyte-mediated destruction of
salivary, lacrimal and other exocrine
glands. Tumor necrosis factor (TNF),
interferon (IFN) and B cell activating
factor (BAFF) are implicated. A viral
etiology, possibly human retrovirus 5
(HRV-5), and a genetic predisposition
May be implicated. A SS type of
disease may follow HIV, EBV, HCV, or
Helicobacter pylori infection, or graft-
Xerostomia is the main
problem. But only some
have unpleasant taste.
Pus discharge from the
of salivary glands mainly
Thick frothy saliva, later
stage with loss of saliva
Glazed, dry mucosa that
tend to form wrinkles.
Redness/soreness of the
mucosa due to candida
depapillated tongue with
reduced no of taste buds
Gross accumulation of
Several dental caries
including root caries.
Recurrent attacks of the
sialadenitis: SS is the most
common cause for the
Enlarged tender regional
Difficulty in eating
Soreness of the mouth.
Difficulty in speech.
are treated with
Mx of dry mouth
Mx of dry eyes
As curative Rx
most of the time
Thilanka Umesh Sugathadasa Page 8
Rheumatic Diseases associated with
- Progressive systemic sclerosis
- Mixed CT disease.
- Polyarteritis nodosa.
- Reynaud’s phenomenon.
Immunologically related diseases
associated with SS
- 1ry biliary cirrhosis
- Chronic active hepatitis
- Autoimmune thyroid disease
- Pemphigus vulgaris
- Coeliac disease
- Myasthenia gravis
- Graft versus host disease
Sensation of dryness
Also dryness of pharynx,
larynx, and genital areas
also may present.
CT disorders clinical
features also can present
in the 2ry SS.
1. Multiple sialectasias
(snow storm app) in
sialogram with atrophy
of ductal system
delayed emptying of
2. Impaired salivary
activity seen in salivary
Reduced sialometry &
Positive ose Bengal staining
test & schirmer test
Thilanka Umesh Sugathadasa Page 9
Reduced salivary flow (measured by sialometry)
with dry eyes (measured by Schirmer test)
Biopsy of labial salivary glands
(> 1 focus of lymphocytes in 4 mm2
ANA, ENA ,SS-A and SS-B
If biopsy of labial salivary
glands – positive(> 1 focus
in 4 mm2)
review some months later
syndrome and ask for
laboratory test in a
Consider an incomplete
form of Sjogren’s
Thilanka Umesh Sugathadasa Page 10
Diagnostic criteria (American-European) for Sjögren’s syndrome.
A positive response to at
of the following questions:
(1) Have you had daily ocular symptoms or
persistent, troublesome dry eyes
For more than three months?
(2) Do you have a recurrent sensation of
sand or gravel in the eyes?
(3) Do you use tear substitutes more than 3
times a day?
A positive response to at
of the following questions
(1) Have you had a daily feeling of dry mouth
for more than 3 months?
(2) Have you had recurrently or persistently
swollen salivary glands as an adult?
(3) Do you frequently drink liquids to aid in
swallowing dry food?
That is, objective evidence
involvement defined as a
result for at least one of:
In minor salivary glands
(1) Schirmer test, performed without
anesthesia (< 5 mm in 5 minutes).
(2) Rose-Bengal score or other ocular dye
score (> 4 according to van
Bijsterveld’s scoring system).
Focal lymphocytic sialadenitis evaluated
by an expert histopathologist, with
a focus score > 1, defined as a number
of lymphocytic foci (which are adjacent
normal-appearing mucous acini and
contain more than 50 lymphocytes)
per 4 mm2 of glandular tissue.
Objective evidence of
involvement, defined by a
result for one of the
(1) Unstimulated whole salivary flow ≤
1.5 ml in 15 minutes.
(2) Parotid sialography showing the presence
of ductal sialectasis (punctate,
cavitary or destructive pattern) without
evidence of obstruction in the major
(3) Salivary scintigraphy showing delayed
uptake, reduced concentration and/or
delayed excretion of tracer.
Presence in the serum of the
Antibodies to Ro (SS-A) or La (SS-B) antigens,
Thilanka Umesh Sugathadasa Page 11
For the diagnosis of primary SS:
In patients without any potentially associated disease, primary SS may be defined as follows:
The presence of any 4 of the 6 items is indicative of primary SS, as long as either item IV
(histopathology) or VI (serology) is positive
The presence of any 3 of the 4 objective criteria items (that, is items III, IV, V, VI)
The classification tree procedure represents a valid alternative method of classification,
although it should be more properly used in clinical “epidemiological survey
For the diagnosis of secondary SS:
In patients with a potentially associated disease (for instance, another well-defined connective
tissue disease), the presence of item I or item II plus any 2 from among items III, IV, and V may
be considered as indicative of secondary SS
1. Past head and neck radiation treatment
2. Hepatitis C infection
3. Acquired immunodeficiency disease (AIDS)
4. Pre-existing lymphoma
6. Graft versus host disease
7. Use of anticholinergic drugs (since a time shorter than 3-fold the half-life of the drug).
Thilanka Umesh Sugathadasa Page 12
Condition Features & etiology Clinical features/ Ix & Diagnosis
Calculi composed of
laminated layers of
organic materials covered
with concentric shells of
Etiology & pathogenesis
of existing inflammation)
Common in the
10% in the parotid gland.
Reasons for higher
prevalence of sialoliths in
- Saliva more alkaline
- Presence higher conc of
Calcium & Phosphate
- Higher mucus content
- Richness in phosphatase
- Low content of Co2
- Longer duct
- anti gravity flow(position
of the gland)
- Smaller orifice than the
- Irregular course of duct.
Middle aged people with slight male predilection
Size can vary from few mm to several cm.
Intraglandular sialoliths cause less problems to the
patients than extraglandular/ ductal sialoliths.
- Sometimes there are no any symptoms
- Meal time swelling (due to increase demands)
- Moderate pain(due to increase pressure)
- fever & malaise due to infections (If untreated)
- Pus discharge through the orifice
- Severe inflammation in the soft tissues.
- Overlying mucosa may be ulcerated.
- Sialoliths may be palpated if it presents in the
- Reduce salivary flow
- Enlargement of the glands.
- Radiolucent calculi(Here 80-90% of SMG calculi are
radio-opaque & 50-80% of parotid calculi are
- Solitary or Multiple(30% of the SMG stones are
multiple & 60% of the parotid stones are multiple)
- Usually oval shape & is cylindrical with multiple layers
Sialography is indicated when sialoliths are radiolucent,
Here we can see easily the ductal dilatation & the
- Hyoid bone
- Myositis ossificans
- Calcific submandibular lymph nodes
- Gas bubble in sialography
Plain radiographic views
- Oblique lateral/ Rotated PA or AP
Intraoral view of the cheek to show the duct using an
-DPT/ Oblique lateral
- Lower 900
- Lower oblique occlusal(to show the gland)
Thilanka Umesh Sugathadasa Page 13
Diagram of submandibular sialogram.
The subsidiary duct descending from the angle of the
jaw to join the angle of the main duct is very
Diagram of parotid sialogram. There are usually
three ascending ducts as well as the duct of the
socia, if present, and one or two descending ducts
depending on the size of the gland. Several small
retromandibular ducts drain the deep, part
of the gland.
Sialadenitis showing pus from Stensen duct
Tiny apparatus consisting of four
wires that can be advanced
through an endoscope to the body
cavity or tube, manipulated to trap
a calculus or other object,&
Used in the bile duct & the ureter
Thilanka Umesh Sugathadasa Page 14
Management of the sialolithiasis
Traditional Mx of the
Non-surgical Mx of the sialolithiasis
Incision & dissection
when the gland has
Side effects of the
1. Transient glandular
2. Ductal strictures
4. Basket block
6. Temporary parasthesia
8. Ranula formation
Various techniques are using
- coronary angioplasty
- Wire loop
- Embolectomy catheter
Under fluoroscopy guidance
Best method is the
fluoroscopically guided stone
retrieval (success rate 40-100%)
Main complications are
Main limitation is the
administration of ionizing
Antibiotics if acute infection is present
Increase salivation & allow stone to come out through
E/O & I/O palpation behind the calculi in to the orifice.
Lithotripsy(shock wave)- sialolithotripsy
- Introduced in 1989
- Noninvasive method of fragmenting the stones in to
smaller portions to allow possible flushing out
- stone fracture by producing a compressive wave that
spread through calculus & expansive wave that pit stone &
- shock wave can be generated
Extra-corporeally using piezoelectric or
Intra-corporeally using electro-hydrolic, pneumatic or
laser endoscopic techniques
- First used to diagnosis but now also used for the calculi
- First describe in 1991
- Rigid, semi rigid, or moderately flexible endoscopes
presents with different diametres.
- Equipped with working channels & irrigation ports
- Main problem is the entering through orifice
- this problems are overcome by
Dilatation with lacrimal probes/ guiding wires
Papillotomy with CO2 laser
Microsurgical dissection of anterior duct(ductal cut
Graspers, miniforceps, dormaia baskets & balloons to
- Not indicated if the calculi is located deeply inside the
gland or embedded in wall.
- Success rate is around 89% for submandibular & 83-86%
for parotid calculi
- Also effective in removing mucus plugs, foreign bodies,
polyps & granulation tissue.
- Contraindicated if there is complete distal obliteration of
- insertion of the sialostent averts recurrences
Thilanka Umesh Sugathadasa Page 15
Condition Features & etiology Mx & Diagnosis
Sialadenitis due to bacterial infection
ascending from the oral cavity.
Prevalence (approximate): Rare.
Age mainly affected: Older adults.
Gender mainly affected: M = F.
Etiopathogenesis: The organisms most.
commonly isolated in ascending sialadenitis
are Streptococcus viridans and
(often penicillin-resistant). The parotid glands
are most commonly affected
- Decreased host resistance
- salivary secretion & bacterial effects
- Composition of the saliva
- Calculi, Mucus plugs, duct strictures
Other predisposing factors
- After radiotherapy to the head & neck.
- In Sjogren’s syndrome
- Occasionally in the GI surgery due to
dehydration & dry mouth.
- Painful & tender enlargement in the gland
- Pain in TMJ region.
- Taste disturbances
- The overlying skin can be redded.
- Pus exuding from, or in milked form through
the parotid duct orifice
- Become hot, indurated & tender on
- Can spread to the surrounding tissues also.
Pus should be sent for a
culture & ABST
Deep parotid abcess vs Otitis
- Must treat aggressively as
it can cause death in
debilitated patient, even
- Improvement of oral
- Pus for culture & ABST
- High dose of parental
amoxicillin/ clavulanate if
staphylococcus and not
allergic to penicillin;
azithromycin in penicillin
- Improve hydration
- Maintain electrolyte
- soft diet as chewing is
painful to the patient.
- Stimulate salivation to
facilitate drainage of pus
- If there is no improvement
drainage of the affected
- Lemon juice suction for
promote salivary flow.
Thilanka Umesh Sugathadasa Page 16
Definition: Chronic salivary gland infection.
Prevalence (approximate): Rare.
Age mainly affected: Older adults.
Gender mainly affected: M = F.
Etiopathogenesis: May develop after salivary
calculus formation or acute sialadenitis,
particularly if inappropriate antibiotics are
used, or predisposing factors not eliminated.
Serous acini atrophy when salivary outflow is
chronically obstructed, further reducing saliva
Usually caused by streptococcus viridans
Recurrent forms are due to duct obstruction,
congenital stenosis, Sjogren’s
syndrome,Allergy or previous viral infection
Salivary flow is accompanied by the flecks of
Fibrosis of gland after several recurrences
causing reduced salivary flow
-Single, swollen, firm , non-tender salivary
Diagnosis is from clinical
features, and imaging
- Intraductal injection of
- Ligation of duct to induce
- Radiotherapy to induce
fibrosis but this increase the
risk of head & neck cancers.
- Total removal of the gland
- Multiple ectasias &
dilatations of main excretory
duct in sialogram
- Multiple cavitations in the
Repeated parotitis &sialectasis in a child,
associated with a sialographic pattern of
Prevalence (approximate): Uncommon.
Age mainly affected: Usually begins in pre-
Gender mainly affected: M > F.
Etiopathogenesis: Congenital or autoimmune
- Intermittent pain,
- Unilateral parotid swelling which lasts
< 3weeks with spontaneous regression.
- It may occur simultaneously or alternately
- parotid swelling
Diagnosis is mainly on
clinical grounds but serum
anti-SS-A and SS-B
antibodies are indicated to
exclude Sjögren's syndrome,
with ultrasonography and CT
scan or sialography showing
sialectasis is confirmatory
In- patients hospital
admission if condition
Culture & ABST(from salivary
High fluid intake.
Lemon juice suction to
promote salivary flow
Thilanka Umesh Sugathadasa Page 17
Commonly seen in SMG
Is a chronic inflammatory disease of major
salivary glands causing fibrosis & firm tumor
like enlargement of the gland.
Due to ductal calculi causing subsequent
bacterial infection resulting chronic
inflammation, acinar destruction &
- Multiple globular
sialectasias in sialogram.
- Sialodochitis (sausage like
appearance of ducts) in
- Absence of terminal
branches & presence of
constricted ductal lumens.
- Multiple cavitations with
reduced echogenicity in USS.
Main one is Sarcoidosis which produce Heerfordt’s syndrome
Features of the Heerfordt’s syndrome are
- Uveitis of the eye
- Salivary gland swelling
- Facial palsy
This is the most commonest & important
Acute contagious viral infection
Characterized by bilateral/ unilateral gland
Mainly affects the major salivary glands but
also can affects testis, meninges, pancreas,
heart & mammary glands.
Also called endemic parotitis
Caused by paramyxovirus
Endemic in most urban population
- more common in boys & often between 5-15
years of age.
- Incubation period is 2-3 weeks
- Prodromal symptoms(Onset of headache,
chills, moderate fever, vomiting, pain below
ear & last about 1 week)
- Parotids are usually affected & mostly
- SMG is less commonly involved & when
affected have less swelling & pain.
Symptoms – Prodromal symptoms followed by
sudden onset of painful salivary gland swelling
without purulent discharge from duct.
Signs- Elevation of ear lobe, Firm/ rubbery/
elastic gland enlargement., Puffy & reddened
No antiviral therapy or
Bed rest & isolation
Hydration with plenty of
for children’s: Ibuprofen
Thilanka Umesh Sugathadasa Page 18
Non- neoplastic, non- inflammatory enlargement of the salivary glands
Usually bilateral & may presents as recurrent painless enlargements.
Commonly in parotids in males.
Associated with systemic conditions such as cirrhosis, diabetes, thyroid
insufficiency, alcoholism & malnutrition
Alteration occurs in the chemical composition of saliva.
Significant elevation of salivary potassium & decrease in sodium.
Increase salivary secretions occurs.
- True Sialorrhea: Rare, may be due to rabies,
metal poisoning, inflammatory lesion in the
- Pseudo Sialorrhea: Common in
infants(drooling), Neuromuscular problems,
Down’s syndrome, paralysis, Mental handicaps
- Local factors such as stomatitis, erythema
multeforme & ANUG
- Systemic disease such as rabies, paralysis,
alcoholic neuritis, epilepsy, Down’s syndrome,
- Miscellaneous causes such as psychic
factors, metal poisoning & facial paralysis
- Excessive production or inadequate
swallowing due to neuromuscular in-
- Affected individuals may need several cloths
- Emotional & physical impairment.
- Infections due to chronic exposure to saliva
- Ulceration & cheek scarring due to recurrent
infections & necrosis of tissues.
Botulinum toxin injection is
an effective method
Cause selective chemical
denervation by blocking
neurotransmitter release at
terminals of the salivary
glands. So secretory
capacity of the gland is
Botulinum toxin therapy is
also used to treat sialocele
& chronic & recurrent
Diseases of minor salivary
Thilanka Umesh Sugathadasa Page 19
Tree in winter appearance(normal appearance of the parotid gland)
Thilanka Umesh Sugathadasa Page 20
Brush in winter appearance (SMG)
Sialadochitis(Sausage link appearance)