Saliva and salivary gland disorders

What is Saliva ? A complex bodily fluid containing organic and anorganic components, secreted by minor
and major salivary glands for certain functions

Whole saliva : A complex mixture of minor and major glands’ secretes, GCF, epithelial desquamation,
debris, blood components and microorganisms

Major saliva glands #1: Parotid glands

○ A pair, located at ramus mandibula bilateral

○ Serous acinar cells

○ Secretes product via Stensen’s ducts

○ Stimulated mechanically and chemically

○ Contributes approx. 20% of the whole saliva

Major saliva glands #2: Submandibular glands

○ Also a pair, inferior of mandible angle, bilateral

○ Secretes products via Wharton’s ducts

○ Mucoserous acinar cells

○ Stimulated and unstimulated function

○ Contributes approx. 65-70% of whole saliva

Major saliva glands #3: Sublingual glands

○ Also a pair, at the floor of mouth, bilateral

○ Secrets product by Rivinus ducts (8-20 orifices)

○ Mucoserous acinar cells

○ Stimulated and unstimulated function

○ Contributes approx. 5% of whole saliva

Minor salivary glands

• About 800 – 1,000 glands, spread beyond mucosa

>Buccal, labial, lingual, palate, floor of mouth

• Innervated by Nerve VII (Facialis)

• Slight anatomical difference from the major glands

>not encapsulated by connective tissue

von Ebner glands

• Specifically located surrounding circumvallate papillae

• Pure serous secretion

• Main function :

> Moisten the papillae continuously

> Produce digestive enzyme for lipid hydrolysis > dissolve food particles and enable them to be tasted

Mechanism of saliva secretion (2)

Autonomic nervous system

 Parasympathetic

Stimulates serous flow

secretion

 Sympathetic

Supress flow, causing protein-rich saliva

production

Normal flow rate

Stimulated : 1 – 2 mL/min

Unstimulated : 0.3 – 0.4 mL/min

Sleep : 0 – 40 mL in 7 hours

Awake: Approx. 200 mL of stimulated saliva in 54 mins

Approx. 300 mL of unstimulated saliva in 16 hours

Function-supporting Contents

1. Physical protection

● Wound healing

>Growth factors, histatins, secretory leukocyte protease inhibitor, trefoil factors, leptin

● Buffering

>Bicarbonate, phosphate, protein

● Remineralization & anti-demin

>Cystatins, histatins, proline-rich glycoprotein, statherins, Ca phosphate, mucin

● Coating & Lubrication

>Amylases, cystatins, mucins, proline-rich glycoproteins, statherins, water

2. Protection against microorganisms

● Antibacterial

>Amylases, cystatins, histatins, lactoperoxidase, lysozyme, lactoferrin, agglutinin, mucins

● Antifungal

>Histatin-5, B-defensins, cethelicidins, sIgA, mucin

● Antiviral

>sIgA, mucins, cystatins

3. Digestive system

● Breaking carbs into maltose & dextrin

>Amylase; DNAse; RNAse; Lipase; Protease

● Delivering taste to taste buds

>Zinc

● Bolus formation

>Mucin

Salivary Gland Disorders

 Obstruction
 Infection
 Neoplasm
 Dysfunction
 Autoimmune

Obstruction #1: Sialolithiasis

Sialolithiasis: definition

• Also called A salivary gland stone or salivary duct stone

• a calcified structure that may form inside a salivary gland or duct

• It can block the flow of saliva into the mouth

• Most often found in the submandibular gland’s ducts

Sialolithiasis: signs, symptoms & aetiology

• Pain and swelling of the affected salivary gland

 • Worsen when the gland is stimulated
• Pathogenesis > lithogenesis:
- precipitation of mineral salts at the orifice
- Predisposed by: calcium metabolism abnormalities, dehydration, xerostomia, altered pH,
altered solubility of crystalloids
- formation of a nidus > layered with organic and inorganic material > a calcified mass

Sialolithiasis: management

1. Locate the stone : X-ray photo, USG

2. Treatment options : Non-invasive

Consult OMFS or ENT: Minimally invasive > sialoendoscopy, Surgical, NSAID & antibiotics

Obstruction #2: Mucocele & Ranula

Mucocele & Ranula : definition & aetiology

• A mucous cyst, fluid-filled swelling, which develops when the salivary gland is plugged with
mucus
• Often occurs on minor salivary glands on labial area
• Often caused by trauma, followed by chronic irritation

Mucocele: clinical appearance

• Nodule, <1 cm, normal color / bluish / translucent, asymptomatic

• Common site: labial mucosa

• Easily bitten and chewed on

• Specifically occurs on sublingual salivary glands

• May grow very big > airway obstruction

Mucocele & Ranula: management

• Pain and swelling of the affected salivary gland

• Worsen when the gland is stimulated
• Pathogenesis > lithogenesis:
- precipitation of mineral salts at the orifice
- Predisposed by: calcium metabolism abnormalities, dehydration, xerostomia, altered pH,
altered solubility of crystalloids
- Formation of a nidus  layered with organic and inorganic material > a calcified mass

Mucocele: management

• Mucocele > excision and extirpation

• Ranula > marsupialisation
• Consult :Oral & Maxillofacial Surgery

Infection: Viral & Bacterial Sialadenitis

Sialadenitis

• Inflammation may involve major or minor salivary glands

• Rapid onset of pain and swelling suggest acute condition
• May also persistent for an extended period (chronic condition)
• Bacterial : Acute bacterial sialadenitis, Chronic bacterial sialadenitis
• Viral : Viral sialadenitis

Acute Bacterial Sialadenitis:

definition

• Also known as (a.k.a) : Acute parotid sialadenitis, ascending parotitis, suppurative parotitis

• Etiology : penicillin-resistant staphylococcus

• Predilection : 80% on parotid gland, unilateral

• Pathogenesis : Bacterial invasion from upper molar via Stensen’s duct orifice

Acute Bacterial Sialadenitis: signs and symptoms

• Symptoms

- Fever, chills, headache, malaise (flu-like)

- Localized pain on affected gland

• Signs

- Pain & swelling of the affected gland

- Skin appears stretched & glossy, indurated, tender on palpation
- Purulent pus from the orifice when affected gland is massaged

Acute Bacterial Sialadenitis: management

• Pus culture

- Bacterial identification & antibiotic sensitivity test

• Pus drainage is sometimes necessary

• Oral antibiotic

- Mostly used: clindamycin 300 mg t.i.d for 7 days, then changed according to sensitivity test
result

• NSAIDs

• Continuous hydration

• Oral moisturizer

• Avoid saliva-stimulating meals

• Improve oral hygiene

Chronic Bacterial Sialadenitis: definition

• Often in mentally-challenged children, elderlies, and related to chronic inflammation or obstruction

• Etiology : Mixed-bacteria infection

• Predilection : 80% on parotid gland, unilateral

• Pathogenesis : Similar to acute type, but the bacteria infection is low grade > salivary gland destruction
over time

Chronic Bacterial Sialadenitis: symptoms and signs

• Sympthoms : No fever, or unspecific Discontinued pain

• Signs : Leukocytosis, but not always Recurrent unilateral swelling (resolve spontaneously), purulent
pus from the Stensen’s duct orifice

Chronic Bacterial Sialadenitis: management

• Pus culture : Bacterial identification & antibiotic sensitivity test

• Pus drainage & ductal lavage : Ductal lavage using erythromycin/tetracyclin 150mg/5mL

• Oral antibiotic > Mostly used: clindamycin 300 mg t.i.d for 7 days, then changed according to
sensitivity test result

• NSAIDs

• Continuous hydration

• Oral moisturizer

• Avoid saliva-stimulating meals

• Improve oral hygiene

Viral Sialadenitis: definition

• A.k.a. Mumps / Epidemic parotitis

• Most often in children up to young adult

• Etiology: Paramyxovirus

• Predilection : Parotid (90%) and submandibular (10%), Bilateral, often simultaneously

Viral Sialadenitis: symptoms and signs

• Pathogenesis

- Transmitted by droplet
- Incubation period: 2-3 weeks post- exposure

• Symptoms
 - Fever, headache, malaise (flu-like)
- Periauricular pain, swelling within 3 days

• Signs

- Swollen periauricular, earlobe lifted

- Extreme pain when saliva is stimulated

Viral Sialadenitis: management

• Sympthomatic : Antipyretic, pain relief, anti-inflammatory

• Supportive : Hi-Cal Hi-Prot, roborantia, rehydration, bed rest, Avoid contact with other
people, direct/indirectly
• Antibiotic is not obligatory

Viral Sialadenitis: prevention and prognosis

• Prevention: MMR vaccine > not available in ID

• Self-imiting disease, resolve spontaneously within 2 weeks > in immunocompetent individuals

• Complication

Meningitis, encephalitis, Deafness, Myocarditis, Thyroiditis, Oophoritis, Infertility

Neoplasm: Benign & Malignant

Salivary gland neoplasm

Benign

● Pleomorphic

Adenoma

● Warthin’s tumor

Malignant

● Mucoepidermoid carcinoma

● Adenoid cystic carcinoma

● Acinic cell carcinoma

● Adenocarcinoma

Dysfunction: Xerostomia

Xerostomia: definition

• Dry mouth syndrome

• Subjective xerostomia : No sign of hyposalivation & other clinical signs > pure psychological > consult
psychiatry
• Objective xerostomia : Confirmed by hyposalivation & other clinical signs

• May be reversible or irreversible

Objective Xerostomia: symptoms and signs

Symptoms

• Bad taste

• Burning mouth

• Chewing & swallowing difficulty

• Denture wearing problems

• Hypogeusia

• Halitosis

Signs

• Dry-looking, sticky mucosa

• Stringy saliva

• Depapilated, mucositis-like

• Oral candidiasis

• Gingivitis & periodontitis

• Cervical caries

• Halitosis

Reversible Xerostomia: definition

• Temporary gland dysfunction/hypofunction

• Symptoms reduce when the causing agent is withdrawn
• Therapy focused on stimulating glands to increase saliva production and flow
• May progress to irreversible when failure to withdraw Causing agent

Reversible Xerostomia: common cause

• Dehydration > physical activity, fever, diarrhoea

• Psychologic > depression, anxiety, stress

• Alcohol > drinks, mouthwash

• Drugs > antidepressants,antipsychotic, antihistamin, decongestan, antihypertension, anti-appetite,

diuretics

• Infection & obstruction > sialadenitis, mucocele

• Neuro disorder > autonomic nervous system disorder

Reversible Xerostomia: management

• Elimination of cause

• Stimulate gland’s production : sour / sweet / mint candy or chewing gum

• Cholinergic drugs : pilocarpine, cevimeline

• Maintain mucosal hydration : Continuous water intake > frequent sips of water, Avoid dry meals

• Improve and maintain oral hygiense : Treat caries and other mucositis

irreversible Xerostomia: definition

• Irreversible gland damage

• Acinar cells degeneration

• Glandular atrophy

• Irreversible damage on innervation and vascularization

irreversible Xerostomia: common cause

• Degenerative diseases > HT, DM, HIV, CKD

• Autoimmune diseases > Sjögren’s syndrome

• Radiotherapy > involving head-neck regio

• Neoplasma > salivary gland tumor

• Persistent neuro disorder

irreversible Xerostomia: management

• Elimination of cause > very hard, mostly impossible

• Gland’s production stimulation > only works when not all glands are affected by irreversible condition

• Cholinergic drugs > only works when no neurological disorder is present

• Maintain mucosal hydration : Continuous water intake > frequent sips of water, Avoid dry meals, Use
oral moisturizers > saliva substitutes

• Improve and maintain oral hygiense : Treat caries and other mucositis

Autoimmune: Sjögren’s syndrome

Sjögren’s syndrome: definition

• Autoimmune disease involving salivary and lacrimal glands, causing sicca syndrome (dry mouth and
dry eyes)
• 2 types:

- Primary SS : pure SS without other autoimmune disease

- Secondary SS : Secondary to other autoimmune diseases, i.e. Systemic Lupus
Erythematosus, Rheumatoid Arthritis, Scleroderma

Sjögren’s syndrome: aetiology and predisposing factors

• Immune regulatory dysfunction causing auto-antibody production against acinar cells

• Trigger factors:

- Genetic
- Glandotrophic viruses
- Immune-complex response

Sjögren’s syndrome: diagnostic procedures

Subjective complaints : suggesting dry mouth & dry eyes >3 months

Clinical findings

• Sialometry to confirm hyposalivation

• Other prolonged xerostomia signs
• Schirmer’s test to confirm decreased tear flow

Sjögren’s syndrome: management

• Follow treatment principle of irreversible xerostomia

• Continuous steroid to lessen the hyper-reactivity of the immune system, to stop attacking the acinar
cells

• Routine follow up and tests to rule out other autoimmune disease and catch the worst possible
prognosis: Lymphoma maligna, as early as possible