Salivary Gland Diseases PDF

Salivary Gland Diseases (1) Dr. Omar Soliman Lecturer of Oral medicine and Periodontology,South Vally University  SALIVARY GLAND ANATOMY AND PHYSIOLOGY The most common presenting complaints of a patient with salivary gland dis...

Salivary Gland Diseases (1) Dr. Omar Soliman Lecturer of Oral medicine and Periodontology,South Vally University  SALIVARY GLAND ANATOMY AND PHYSIOLOGY The most common presenting complaints of a patient with salivary gland disease are oral dryness (xerostomia) or a glandular swelling or mass. 2 Dr. Omar Soliman Dr. Omar Soliman  Saliva is produced by the three major paired salivary glands (parotid, submandibular, and sublingual glands) and numerous (600 and 1000) minor salivary glands distributed throughout the mouth. The major salivary glands can also be classified based on the dominant saliva-producing acinar cell type: serous, mucous, or a mix of serous and mucous cells. The parotid gland is composed primarily of serous cells; those of the submandibular gland are a mix of mucous and serous types, while those of the sublingual and minor salivary glands are of the mucous type. 4 Dr. Omar Soliman  Parotid saliva is secreted through Stensen’s ducts, the orifices of which are visible on the buccal mucosa in the vicinity of the maxillary first or second molar. Submandibular gland saliva is secreted through the submandibular duct (Wharton’s duct), which drains saliva from each submandibular gland and exits at the sublingual caruncles on either side of the lingual frenulum. Sublingual saliva may enter the floor of the mouth directly via the short, independent ducts of Rivinus. One or more of these ductules may converge to form the major duct of the sublingual salivary gland (also known as Bartholin’s duct), which opens into the submandibular duct. The minor glands secrete their mucinous product onto the mucosa through short ducts. 5 Dr. Omar Soliman  6 Dr. Omar Soliman  Histologically, the major salivary glands are composed of acinar (secretory cells) and ductal cells. The clustered acinar cells (the “grapes”) make up the secretory end pieces, while the ductal cells (the “stems”) form an extensively branching system that modifies and transports the saliva from the acini into the oral cavity. There are three types of ductal cells: intercalated, striated, and interlobular. 7 Dr. Omar Soliman  Whole saliva (WS; the mixed fluid contents of the oral cavity) is composed of greater than 99% water and less than 1% proteins and salts. WS may also contain variable amounts of gingival crevicular fluid, microorganisms, food debris, exfoliated mucosal cells, and mucus. Normal daily production of WS ranges from 0.5 to1.5 L. Factors that may increase salivary flow include taste and olfactory stimuli, mechanical stimulation, pain, pregnancy- related hormonal changes, sympathomimetic and parasympathomimetic drugs. Menopause-related hormonal changes, stress, anti adrenergic, and anticholinergic drugs will decrease salivary flow rate. A loss of acini, seen in a number of clinical conditions, particularly the autoimmune exocrinopathy Sjögren’s syndrome (SS), results in a decreased production of saliva. 8 Dr. Omar Soliman  DIAGNOSIS OF THE PATIENT WITH SALIVARY GLAND DISEASE The most common presentation of salivary gland disease is: Xerostomia denoting a subjective complaint of dry mouth. Hyposalivation refers to reduced salivary flow rate and may or may not be accompanied by xerostomia. Hypersalivation (ptyalism) refers to an increase in production of saliva and/or a decrease in oral clearance of saliva. 9 Dr. Omar Soliman  1. Symptoms of Salivary Gland Dysfunction. Patients may complain of dryness of all the oral mucosal surfaces, including the lips and throat, and difficulty chewing, swallowing, and speaking. Other associated complaints may include oral pain, oral burning sensation, chronic sore throat and pain with swallowing. The mucosa may be sensitive to spicy or coarse foods, limiting the patient’s enjoyment of meals, which may compromise nutrition. Often, patients experiencing chronic salivary gland hypofunction will carry water with them at all times and sip frequently to relieve their oral dryness. 10 Dr. Omar Soliman  2. Clinical Examination. The lips are often dry with cracking, peeling, and atrophy. The buccal mucosa may be pale and corrugated. The dorsal tongue may appear smooth due to a loss of papillation and erythematous or may appear fissured. Due to the absence of the buffering capacity of saliva, there is increase in erosive lesions and dental caries which affect the root surfaces and the cusp tips of teeth. Patients with xerostomia may have increased plaque indices and bleeding on probing scores. The presence of lipstick or shed epithelial cells on the labial surfaces of the anterior maxillary teeth is indicative of reduced saliva ( saliva normally wet the mucosa and aid in cleansing the teeth). A positive “tongue blade” sign results when a tongue blade, pressed gently and then lifted away from the buccal mucosa, adheres to the tissue. 11 Dr. Omar Soliman  Candidiasis is often associated with salivary gland dysfunction. The erythematous form of candidiasis, appearing as red patches on the mucosa, is more prevalent than the more familiar white, curd-like pseudomembranous (thrush) form. Angular cheilitis, seen as persistent cracking or fissuring of the oral commissures, is also common. Salivary gland dysfunction can also be associated with enlargement of the salivary glands. Enlarged glands that are painful on palpation are indicative of infection, acute inflammation, or tumor. Normally, saliva can be expressed from each major gland orifice by gently compressing the glands and by drawing pressure toward the orifice. The expressed saliva should be colorless and transparent, watery, and copious. Viscous or scant secretions suggest chronically reduced function. A cloudy exudate may be a sign of bacterial infection. The exudate should be cultured if it does not appear clinically normal, particularly in the case of an enlarged gland. 12 Dr. Omar Soliman  3. Sialometry. Gland function can be determined by objective measurement techniques. Since unstimulated salivary gland function is the predominant state, this greatly influences overall oral comfort and protection of the oral cavity. Normal subjects are found to complain of a dry mouth when unstimulated whole salivary flow is reduced 40%–50%. Examination of stimulated salivary flow can allow for assessment of the relative functional capacity of the salivary glands and help determine whether sialagogues are likely to be beneficial. Therefore, it is important to assess both unstimulated and stimulated salivary flow when investigating a complaint of xerostomia. The main methods of WS collection include spitting and absorbent (sponge) methods. In the spitting method, the patient allows saliva to accumulate in the mouth and then expectorates into a pre-weighed tube, usually once every 60 seconds for 5–15 minutes. The absorbent method uses a pre-weighed gauze sponge placed in the patient’s mouth for a predetermined amount of time. 13 Dr. Omar Soliman  3. Sialometry. 14 Dr. Omar Soliman  3. Sialometry. 15 Dr. Omar Soliman  Unstimulated sample, the patient is instructed to refrain from eating, drinking, smoking, chewing gum, and oral hygiene practices or any other oral stimulation for at least 90 minutes prior to the test session. For a general assessment of salivary function, unstimulated WS collection is recommended. It is quick and easy to perform, accurate and reproducible, and does not require expensive or labor-intensive equipment. If a stimulated WS collection is desired, chewing an unflavored gum base or an inert material such as paraffin wax or a rubber band is a reliable means of inducing saliva secretion. Or 2% citric acid may be placed on the tongue at 30-second intervals. Unstimulated WS flow rates of