SALIVARY GLANDS DISEASES

Introduction There are 3 pairs of major salivary glands

(Parotid, Submandibular & Sublingual) and hundreds of
minor salivary glands scattered throughout the oral cavity.
All these glands secrete saliva which is either serous or
.mucous or mixed
Saliva composed mainly of water, in addition to organic
components including enzymes, proteins, human and
microorganisms products (such as Mucin, α-Amylase,
immuno-globulins "antibodies", desquamated cells, RBCs,
WBCs, and others), as well as, inorganic components
.including minerals and ions (such as Na ,K, Ca)

Functions of Saliva

Digestive (Amylase digests starch) .1

Antibacterial (Enzymes & Secretory IgA) .2

Mechanical washing action .3

Hydrating and lubricating oral mucosa .4

Facilitate proper speech and swallowing (mucin) .5

.Control thirst .6

Helps in taste (represent sapped solution in which food .7

dissolves)

Buffers pH .8

Excretion of different bodily and bacterial produced products .9

Aids in teeth re-mineralization through its’ minerals contents .10

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Anatomy There are two higher centers in the brain control
saliva secretion (superior and inferior salivatory center or
.nucleus)

Parotid gland (Stensen’s duct): Parasympathetic secretomotor

nerve fibers come from Glossopharyngeal (IX) nerve with the
Auriculotemporal nerve (branch of the Mandibular nerve V3)
.(general sensation) to reach the parotid gland

Submandibular (Wharton’s duct) & Sublingual (Bartholin’s duct).

Parasympathetic secretomotor nerve fibers come from the
.Chorda Tympani of the VII cranial nerve (Facial)

Sympathetic innervation of the S.Gs via preganglionic nerves in

the Thoracic segments (T1-T3) which synapse in the superior
.cervical ganglion with post ganglionic neurons

Investigations

Sialometry (salivary flow rate): Normal whole unstimulated .1

saliva =0.3-0.5 ml/min, less than 0.1 ml/min considered
abnormal

Sialochemistry (investigate the composition of saliva) .2

:Salivary glands imaging .3

a. Plain radiography such as occlusal radiographs for

Submandibular glands stone

b. Sialography (example in salivary gland stone or calculi)

c. CT scan, MRI & sonography

d. Scintigraphy (example in Sjogren’s syndrome)

Biopsy ( example in Sjogren's syndrome & malignancies) .4

Curry’s test : Administration of Pilocarpine HCl and measure .5

saliva rate after 2-3hs to check the neural & non-neural cause
of dry-mouth/ Xerostomia

Serological tests (to check for autoantibodies as in Sjogren’s .6

syndrome)

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Classification of Salivary Gland Diseases

I. Developmental

II. Obstructive/Traumatic

III. Functional

IV. Infectious/ Inflammatory

V. Tumors (Neoplasms)

Developmental

Aplasia (or Agenesis): Absence of 1 or more S.G, it’s rare but .1

may occur as congenital defect in the offspring of patients taking
.drugs with teratogenic effects such as Thalidomide

Atrasia: Very rare characterized by congenital absence of S.G .2

.duct which may result in retention cyst & xerostomia

Aberrancy or Stafne’s idiopathic bone cavity or bone cyst: .3

Type of aberrancy characterized by the presence of S.G in an
abnormal anatomical position such as the mandible, it is
asymptomatic and might be discovered accidently by routine
.radiographic examination (OPG)

Obstructive/Traumatic

Sialolithiasis (Salivary Stone, calculi): Sialolith is a calcified .1

organic matter that forms within the secretory system of the major
salivary glands. 90% in the submandibular S.G. Dehydration &
sialadenitis (S.G inflammation) enhance the detachment of
epithelial cells from the S.G acini or ductal lining forming a nidus
.which later on undergo calcification forming a stone or calculi

Diagnosis: Signs & symptoms including pain, sialadenitis & sudden

enlargement or swelling of the S.G during eating (diagnostic
feature) due to obstruction of the gland or duct. On clinical
examination clinician may palpate the stone when it’s in the S.G

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duct or near the orifice, whereas deeply seated stones needs
.radiograph or sialography

Treatment: When there is acute inflammation, therapy is primarily

supportive or standard care including analgesics, hydration &
antibiotics as necessary. Removal of the stone manually by milking
action, while deeply seated stones need Sialolithotripsy,
.Sialoendoscopy or Surgical removal

Stensen’s duct Stenosis: Stricture of the Stensen’s duct as a .2

result of chronic trauma from a dental prosthesis (ex. clasp) may
lead to fibrosis of the parotid gland duct due to the continuous
inflammation and healing, or inflammation around calculus or
foreign body entered within the duct orifice, or failed surgery/ or
.Sialoendoscopy

.Diagnosis by history, clinical examination and sialography

Treatment: Remove the cause with ductal dilation, along with

.supportive treatment (analgesics & antibiotics)

Salivary Gland Fistula: Communication between the S.G. or its .3

.duct with the skin or mucosa

:There are 2 types

Internal fistula: Saliva drains into the oral cavity (asymptomatic)

External fistula: Saliva drains out to the skin resulting in

persistent inflammation

Cause: Trauma or as a surgical complication or even congenital.

Treatment: Surgical but take in consideration the danger to
traumatize vital structures (Parotid gland and Facial nerve)

Mucocele: Is a soft, painless, recurrent swelling of 1mm-several .4

cms in size, pink or blush in color depending on its type (retention
cyst or extravasated cyst). 75% of mucoceles occur in the lower
.lip

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If burst result in a painful ulcer. Mucoceles mostly occur due to
.trauma to a minor S.G or its duct

Mucoceles are self-limited (heal spontaneously); however, as they

recur frequently they will need surgical excision (excisional
.biopsy)

D.D Hemangioma, Hematoma. Diascopy test is useful in the

.diagnosis

Ranula: It is an uncommon type of S.G mucocele or cyst arises .5

from the Sublingual S.G. (more) or Submandibular S.G. (less).
Ranula lies in the floor of the mouth usually unilaterally, around 2-
3cm in diameter. It’s slowly growing, bluish, soft, painless &
fluctuant swelling which may reach a larger size extending across
the whole floor of the mouth leading to herniation of the Mylohyoid
muscle (plunging ranula) and elevation of the tongue interfering
.with speech and mastication

As it increases in size it may become painful and result in

dysphagia. In rare cases it may reach the base of the skull which is
dangerous and life threatening condition

D.D:1. Dermoid cyst 2. Cystic Hygroma

Treatment: Surgery (marsupialization or excision)

D.D: Hemangioma, S.G malignancy

:Functional

Sialorrhea or Hypersalivation or Ptyalism may occur .1

physiologically: Food smell or sensation, an object in the mouth
.such as a denture, erupting tooth or teeth, dental procedure…etc

It may also occur pathologically: Oral infections, drugs

.(cholinergic), metal poisoning, Rabies, & GIT diseases

,Treatment: Na-Bicarbonate gargle

Drugs with anticholinergic and similar effects such Probantheline

15 mg Tab 3 times daily (q8h) before meal. Other drugs Atropine,
.Hyoscine, Amitriptyline

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Some cases may need surgery (duct relocation)

Dry mouth or Xerostomia: Hyposalivation or reduced salivary .2

secretion which may result in dryness & cracking of oral mucosa,
or even ulcerations, white & red lesions of the oral mucosa,
tongue, lips & angle of the mouth. Candidiasis, atrophy of the
tongue papillae (depapillation), dental caries especially cervical,
periodontitis & burning sensation are common findings in patients
with diminished saliva

There are 2 types of causes: First Physiologic such as during

sleep, fasting and mouth breather

Second Pathologic including local S.G diseases such as infections,

aplasia, atresia, Sialolithiasis, & Sjogren’s system. Systemic,
psychoneural, side effects of drugs (anticholinergic,
antihypertensive, sedative, antidepressants), body fluid loss
(dehydration), irradiation, Iron and vitamins deficiency anemia.
.Diabetes Mellitus, Diabetes Insipidus, & aging

Note. Transient hyposalivation Dry mouth whereas permanent

known as xerostomia

:Treatment of Dry mouth or Xerostomia

a. Remove the causes and give artificial saliva (xero lube)

b. Sialogogues (Pilocarpine Hcl 5mg tab3-4 times daily but dose

should not exceed 30mg/day)

c. Topical Fluoride application for dental caries

d. For candidiasis: Nystatin drops or suspension or Nizoral®

(ketoconazole) (200 mg tab once daily at meal up to 2 tab 400
mg daily)

e. Chlorhexidine mouth wash to control plaque and periodontal

diseases

f. Advice the patient to sip water throughout the day

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:Infectious/Inflammatory

A. Sialadenitis (Acute & Chronic): Inflammation of the S.Gs

mostly caused by Staphylococcus aureus or Streptococci and
.Anaerobes

Predisposing factors include: Xerostomia and salivary stone

Clinically: Parotid gland most commonly affected, characterized by

painful swelling of the gland which worsens at meal time, redden
skin, Facial nerve maybe affected, fever, headache, malaise,
lymphadenopathy, limited mouth opening (trismus) & dysphagia.
On examination the affected gland is tender with pus discharging
.from the duct orifice

Investigations: Sialography in some chronic cases may show

.Sialectasis (Snow storm appearance)

Treatment: Milking or drainage of pus if possible. Subscribe

antibiotics with analgesics & antipyretics (or NSAIDs). Rehydration
and gum chewing to stimulate salivation. Surgery or
sialoendoscopy may be needed in some cases especially when
.there is a salivary stone that should be removed

B. Mumps: One of the common acute sialadenitis affecting mainly

the Parotid gland. Caused by RNA Paramyxo Mumps virus. It is
contagious from the day 1before its appearance to 14 days after
resolution. Mumps affects young aged children (4-6 years old or
less than 10 years). Mostly one Parotid gland affected and less
.commonly both glands

Clinical features include: Following an incubation period of 21 days

(2-3 weeks), starts painful swelling which lasts for 10 days (with
raised ear lobe), headache, malaise, fever, myalgia, lymphadenitis,
.and anorexia

Usually history and clinical examination are enough for diagnosis;

however, If necessary, the diagnosis can be confirmed by a rise in
.titer of IgM antibodies in the unvaccinated patients

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If mumps occurs in adults, they are more prone for complications
including involvement of the gonads (orchitis & oophoritis leading
to sterility), deafness, pancreatitis, arthritis, mastitis, nephritis,
.pericarditis or meningitis

Treatment of mumps: Supportive including Analgesics,

Antipyretics, fluids and soft diet, bed rest and isolation to prevent
.spread of infection

Prevention by MMR (measles-mumps-rubella) vaccine (live

.attenuated virus)