Mucosal Diseases, Saliva and Halitosis PDF

MUCOSAL DISEASES Dr. Dt. Erim TANDOĞDU [email protected] MUCOSAL DISEASES Developmental (Fordyce Granules) Hyperkeratosis Leukoplakia Lichen Planus Candidiasis Aphthous Ulcers Herpes Denture Sore Mouth Tumors  Fordyce Granules It is a developmental anomaly affecting the...

MUCOSAL DISEASES Dr. Dt. Erim TANDOĞDU [email protected] MUCOSAL DISEASES Developmental (Fordyce Granules) Hyperkeratosis Leukoplakia Lichen Planus Candidiasis Aphthous Ulcers Herpes Denture Sore Mouth Tumors  Fordyce Granules It is a developmental anomaly affecting the oral mucosa, characterized by the presence of numerous small yellowish-white granules. It is observed in 80% of the population. Fordyce Granules The most common sites are the buccal mucosa at the occlusal plane level, the lips, and the retromolar area. The incidence of Fordyce disease increases with age. The use of oral contraceptives can lead to an increase in these granules in women. The lesions are firm and do not require any treatment. Hyperkeratosis It is the most common white lesion observed in the oral cavity, occurring more frequently in men. It is most likely to appear in the 5th and 6th decades of life. The most common sites are, in order, the mandibular mucosa, cheeks, lips, palate, floor of the mouth, maxillary mucosa, and tongue. The lesion may be raised or flat and cannot be scraped off from the mucosa. Hyperkeratosis Irritation factors such as lip biting, chronic cheek biting, tobacco chewing, and smoking are among the causes of this lesion. To the side, hyperkeratosis on the tongue due to excessive smoking can be observed. If the lesions do not resolve after eliminating the irritation factors, a biopsy should be taken. Leukoplakia It is a white lesion of the oral mucosa. The lesions may sometimes be fissured, located on an ulcerated base, or erythematous (reddened). They are more commonly seen in the 5th and 6th decades of life. The lesions most frequently appear, in order, on the cheeks, lips, mandibular mucosa, floor of the mouth, tongue, palate, and maxillary mucosa. Leukoplakia is a premalignant lesion. Lichen Planus This lesion occurs both on the skin and in the oral cavity. Although the exact cause of the lesion is unknown, it is believed that emotional stress plays a role in its onset. Lichen Planus Lichen planus is more commonly seen in the oral cavity than on the skin. In the oral cavity, lesions are most frequently found in the following order: Buccal mucosa, palate, tongue, lips, alveolar mucosa, gingiva, and floor of the mouth. Lichen Planus Clinically, oral lesions appear white or yellowish in color, with white streaks on their surface. Patients often experience a burning sensation.  On the skin, there are numerous red or purplish, scaly, itchy lesions. They are commonly found on the inner wrists or legs. The lesions are symmetrical. Candidiasis (Thrush) Candidiasis is a fungal infection caused by Candida albicans. It most commonly affects the oral mucosa, gastrointestinal tract, and vaginal mucosa. The oral lesions are referred to as 'thrush'. Oral lesions are more frequently observed during two important life stages: infancy and old age. Candidiasis can be caused by various factors, including: Local tissue trauma Endocrine disorders Malnutrition Prolonged antibiotic therapy Blood disorders Individuals weakened by malignant diseases Individuals with weakened immune systems due to certain medications. Treatment Controlling underlying conditions that weaken the body, such as diabetes, is important. Nystatin and Amphotericin B in forms like creams, ointments, lozenges, or suspensions are recommended. These preparations are typically administered three times a day. In infants, the oral mucosa is cleaned with a cotton swab soaked in sodium bicarbonate three times a day. Denture sore mouth (Denture Stomatitis) Denture sore mouth is the most common form of oral candidiasis. It occurs in about 24% of patients who wear dentures continuously, resulting from secondary Candida infection due to trauma caused by the denture. This condition affects women more frequently, possibly due to hormonal factors. Denture sore mouth Denture sore mouth can be confused with an allergic reaction to acrylic due to its limitation to the area where the denture is worn. Candida can be isolated from the tissue under the denture through direct inoculation, or it can be identified via biopsy. This condition can be caused not only by poorly fitting dentures but also by old dentures. In fact, the presence of dentures is not essential, as orthodontic appliances can also lead to this issue.  Clinically, the mucosa covered by the appliance appears bright red, and the tissue is translucent, resembling glass. There is a sensation of burning and pain in the mucosa under the denture. Since the development of denture sore mouth requires two main factors (tissue trauma and infection), treatment should focus on eliminating these two factors to ensure rapid resolution of the symptoms. When encountering such a patient, the first step is to have the patient discontinue the use of the denture, apply antifungal creams to the affected tissue twice daily, and once the clinical symptoms have completely resolved, a new denture should be made. ORAL ULCERS Aphthous ulcers are round lesions ranging from 3-5 mm in diameter, with a yellowish-gray appearance, typically found on the oral mucosa. They are usually painful. They can occur as solitary ulcers or in multiples, which is referred to as aphthous stomatitis.  ORAL APHTHOUS ULCERS Patients experience significant pain during speaking, chewing, and swallowing, especially if the ulcer is located on the tongue. While the exact cause is not fully understood, some people attribute the condition to psychological factors. Others believe that allergic reactions to certain foods (such as nuts, chocolate, certain toothpaste, or mustard) play a role in the development of aphthous ulcers. Treatment There is no known effective treatment for aphthous ulcers. They typically heal within 10 days without leaving scars. Patients are advised to take B vitamins and rest. Additionally, rinsing the mouth twice daily with chlorhexidine may be recommended, and if there is significant pain, using Tamtum Verde mouthwash can help alleviate the discomfort. Treatment Kenacort A Orabase ointment can be applied three times a day on the lesions. Sometimes, aphthous ulcers may recur, which is referred to as 'recurrent aphthous stomatitis.' Recurrence is less commonly seen in smokers. TUMORS FIBROMA This lesion is a growth of fibrous tissue, which can develop as a result of prolonged irritation. Most Common Locations: Buccal mucosa Lateral borders of the tongue Vestibular mucosa Lips Treatment: The treatment for fibroma is surgical excision. HEMANGIOMA A hemangioma is a benign tumor of blood vessels. In the oral cavity, it is most commonly found on the buccal mucosa and the tongue. Hemangiomas are blue or purple in color, and their color fades when pressed. Squamous Cell Carcinoma Squamous cell carcinoma in its early stage is asymptomatic and may appear as atypical red patches. Clinically, it resembles erythroplakia, erythematous candidiasis, or a contact reaction to dental materials. In such cases, a biopsy is necessary for a definitive diagnosis. SALIVA Salivary Glands Functions of Saliva Properties of Saliva Control of Saliva Secretion Salivary Secretion Disorders Salivary Gland Diseases Saliva They are secretions discharged from the salivary glands into the oral cavity. In humans, three major and around 400-500 minor salivary glands release their secretions into the oral cavity. Our Salivary Glands (Parotid Gland) It is the largest salivary gland. Duct: Stensen's duct The saliva from the parotid gland is abundant and watery, helping to moisten food and diluting acids and alkalis to neutralize them. For this reason, it is called "protective or diluting saliva.  Parotid Gland It is located behind the ramus of the mandible, in front of and below the ear, in a depression called the *fossa retromandibularis*. This duct opens into the oral cavity at the level of the upper second molar's anterior surface. The Stensen's Duct The duct of the parotid gland (Stensen's duct) opens into the oral cavity in the vestibular area near the upper second molar tooth.  An infection is observed at the opening of Stensen's duct. The Stensen’s Duct The Stensen's duct exits from the front surface of the parotid gland and crosses over the masseter muscle. The duct is approximately 6 cm long. The branches of the facial nerve (n. facialis), which is responsible for motor control of the face, run underneath the duct. Glandula Submandibularis (Submaxillary Gland) It is the second largest salivary gland and is paired. It fills the middle and posterior portions of the triangular area between the body of the mandible and the two bellies of the digastric muscle. Submandibular Gland The duct of the gland is the ductus submandibularis (Warton's duct). Warton's duct opens into the oral cavity at a small elevation called the caruncula sublingualis, which is located on the inner side of the plica sublingualis on the floor of the mouth. Submandibular Gland The saliva from this gland dissolves substances that are ingested, making them soluble in water, which helps in tasting food. For this reason, the saliva of the submandibular gland is also referred to as taste saliva. Sublingual Gland It is the smallest of the salivary glands. This gland is located on both sides, above the mylohyoid muscle, beneath the mucosa, and extends parallel to the axis of the mandible. Sublingual Gland The Glandula Sublingualis is formed by the union of many small glands, each with its own separate duct. These ducts, which open onto the plica sublingualis, number between 8 and 15 and are called Rivinus ducts. Sublingual Gland The largest of these ducts, located at the front, is called the Bartholin duct. The saliva from the sublingual gland is called swallowing saliva because it helps to lubricate the food boluses, making them smooth and easier to swallow.  Minor Salivary Glands These are glands located beneath the mucosa of the pharynx, oral cavity, nasal cavity, sinuses, larynx, and trachea, as well as in the root of the tongue, hard palate, and the inner surfaces of the lips and cheeks. They are numerous and contribute to the secretion of mucous. Salivary Glands: Secretion Types Parotis (Parotid Gland) Secretion Type: Serous (watery, enzyme-rich saliva) Submandibular Gland Secretion Type: Mixed (primarily serous, with some mucous components) Sublingual Gland Secretion Type: Mixed (primarily mucous, with some serous components) Dudak Bezleri (Labial Glands) Secretion Type: Mucous Yanak Bezleri (Buccal Glands) Secretion Type: Mucous Dil Kökündeki Bezler (Glands of the Tongue Root) Secretion Type: Mucous Sert Damak Arka Kısmı (Glands of the Hard Palate) Secretion Type: Mucous Minor Salivary Glands Glandula labialis Glandula buccalis Glandula molaris Glandula palatini Glandula lingualis Properties of Saliva: Saliva contains mucin, globulins, albumin, amino acids, creatinine, uric acid, urea, and inorganic salts. The consistency of saliva secreted by the salivary glands varies depending on the amount of mucin present. Mucin makes saliva slippery and helps keep the mucosa constantly moist, which facilitates the easy swallowing of food. The following are inorganic salts found in saliva: 1. Sodium Chloride (NaCl) ○ Helps maintain osmotic balance and contributes to the salty taste of saliva. 2. Calcium Chloride (CaCl₂) ○ Plays a role in maintaining the integrity of the oral tissues and assists in the formation of dental enamel. 3. Sodium Bicarbonate (NaHCO₃) ○ Acts as a buffering agent, helping to neutralize acids in the mouth and maintain a stable pH environment. 4. Calcium Carbonate (CaCO₃) ○ Contributes to the formation of enamel and helps buffer acids. 5. Calcium Phosphate (Ca₃(PO₄)₂) ○ Important for remineralization of teeth and maintaining oral health by helping to repair enamel. 6. Sodium Phosphate (Na₃PO₄) ○ Serves as a buffer and aids in maintaining the pH balance in saliva. Control of Saliva Secretion: The medullary salivation center consists of two main components: 1. Sympathetic Pathway ○ The sympathetic nervous system influences the secretion of saliva, particularly when there is a need for a rapid response, such as during stress. This pathway generally leads to the secretion of a thicker, more mucous saliva. 2. Parasympathetic Pathway ○ The parasympathetic system is primarily responsible for the continuous, abundant production of watery and enzyme-rich saliva, particularly during activities like eating. ○ Parasympathetic Innervation of the Parotid Gland: The parasympathetic innervation to the parotid gland is provided by the glossopharyngeal nerve (cranial nerve IX), which carries secretory fibers that stimulate the gland to produce saliva. ○ Parasympathetic Innervation of the Submandibular and Sublingual Glands: The submandibular and sublingual glands receive parasympathetic secretory fibers from the chorda tympani, a branch of the facial nerve (cranial nerve VII). These fibers help stimulate the secretion of saliva from these glands, which is generally more mucous in nature. Control of Saliva Secretion: Sympathetic Innervation of the Salivary Glands: The sympathetic innervation of the salivary glands originates from the sympathetic plexus surrounding the facial nerve (cranial nerve VII). This sympathetic input generally modulates the secretion of saliva by the glands, often producing a thicker, mucous type of saliva, especially during stress. Evidence of Reflex Salivation: If the sensory nerves of the oral cavity or the secretory sympathetic or parasympathetic nerves to the salivary glands are severed, salivation does not occur when food or foreign objects are placed in the mouth. This highlights the reflexive nature of salivation, where the stimulation of sensory receptors in the oral cavity triggers a neural response leading to saliva secretion. The reflex mechanism is evidence that salivation is not just a direct result of conscious thought but also involves automatic, involuntary reflex pathways. Sympathetic and parasympathetic innervation have opposite effects on the same organ! Parasympathetic Sympathetic innervation results innervation in the production results in the of large amounts production of a of watery saliva. small amount of thick, viscous saliva.  Saliva Secretion Disorders: Xerostomia (Dry Mouth) Xerostomia (dry mouth) is not a disease but a symptom. It negatively affects the patient's quality of life and occurs due to reduced saliva production caused by various factors. Saliva is essential for oral health, and its deficiency can affect several functions such as speech, chewing, swallowing, and taste perception. Reduced saliva can also lead to problems like difficulty swallowing, oral infections, and increased tooth decay, as saliva plays a critical role in cleansing the mouth, neutralizing acids, and protecting against harmful bacteria. Causes of Dry Mouth (Xerostomia): Various Medications: Many drugs, such as antihistamines, antidepressants, diuretics, and certain pain relievers, can cause dry mouth as a side effect. Radiotherapy: Radiation therapy, particularly for head and neck cancers, can damage the salivary glands, leading to reduced saliva production. Chemotherapy: Chemotherapy can affect the salivary glands, causing a temporary or permanent reduction in saliva production. Chronic Inflammation of Salivary Glands: Conditions like sialadenitis (inflammation of the salivary glands) can impair saliva production. Obstruction of Salivary Gland Ducts: Salivary gland ducts can be blocked by stones or other obstructions, limiting the flow of saliva. Psychological Factors: Stress, anxiety, and other psychological factors can reduce the production of saliva. Dehydration: Conditions leading to dehydration, such as vomiting, diarrhea, high fever, or bleeding, can cause dry mouth. Sjögren’s Syndrome: An autoimmune disorder where the body's immune system attacks the salivary and tear glands, leading to dry mouth and dry eyes. Diabetes: High blood sugar levels in diabetes can lead to reduced saliva production, contributing to dry mouth. Smoking: Smoking can worsen dry mouth by reducing saliva flow and irritating the salivary glands. Medications that Cause Dry Mouth (Xerostomia): 1. Antihistamines 2. Antidepressants 3. Antihypertensives (High Blood Pressure Medications) 4. Antipsychotics 5. Pain Relievers and Analgesics 6. Diuretics (Water Pills) 7. Chemotherapy Drugs 8. Anticholinergic Medications 9. Anti-Epileptic Drugs 10. Hormones 11. Bipolar Disorder Medications Oral and General Complications of Dry Mouth (Xerostomia): Increased Risk of Dental Cavities Cracking of the Lips Difficulty in Functions such as Speaking, Swallowing, Chewing, and Tasting Halitosis (Bad Breath) Candidal Infections Burning Sensation in the Mouth  The treatment for salivary gland dysfunction, such as xerostomia (dry mouth), is often cause-specific, but in many cases, where the cause is unknown, palliative treatment is applied. Treatment Approaches: Chewing sugar-free gum containing xylitol can help increase saliva flow over time. Increased fluid intake is recommended to help with hydration. Acidic, sweet beverages (like lemonade) may stimulate saliva production. Sucking on ice chips can provide temporary relief. The diet should include soft foods such as: ○ Ice cream, milkshakes, mashed potatoes, bananas, soft-cooked eggs, and yogurt. Alcoholic beverages should be avoided as they can further dry out the mouth. Mouth breathing is discouraged as it can worsen the condition.  Caffeine-containing beverages such as coffee and similar drinks should be avoided, as they can worsen dry mouth. It is important to keep the mouth as moist as possible. Using a saliva substitute or sipping water frequently can help. Rinsing the mouth twice a day with chlorhexidine solution is recommended to help prevent infections and maintain oral hygiene. Dentures should be removed at night and soaked in a hypochlorite solution to ensure they are clean and free of bacteria. Pilocarpine is often recommended to stimulate salivation in individuals with dry mouth (xerostomia). How to Use: The typical prescription is a mixture of 25 parts pilocarpine with 10 parts distilled water. On the first day, take 5 drops diluted in a small amount of water. Increase the dosage by 1 drop per day as tolerated. Potential Side Effects: Sweating (diaphoresis) Nausea and vomiting Diarrhea Convulsions (seizures) in rare cases If any of these side effects occur, the antidote is atropine sulfate, which can counteract the effects of pilocarpine. Note: Currently, no other preparations are known to continuously stimulate salivation as effectively as pilocarpine. Always consult a healthcare provider before using pilocarpine to ensure it is suitable for your specific condition. In addition to the specific treatments, efforts should be made to eliminate the underlying causes of dry mouth (xerostomia): Diabetes should be controlled, as it is a common contributor to dry mouth. For patients who have undergone radiotherapy, the condition may improve and return to normal after 2-3 years. For medications that cause dry mouth, it may be beneficial to take them after meals instead of before, as this can allow for greater saliva production during meal times. Hypersalivation Hypersalivation (excessive salivation) can occur due to a variety of factors, and in many cases, the cause is unknown. Some known causes include: Patients using dentures may experience hypersalivation, especially during the first few weeks, as they may have a tendency to suck on the prosthetics. Lesions causing pain in the oral cavity, such as herpetic stomatitis, aphthous stomatitis, or ulcerative gingivitis, can lead to excessive salivation. Neurological disorders, such as Parkinson's disease, can result in hypersalivation. Rauwolfia alkaloids (e.g., reserpine), which are used for managing high blood pressure, can cause excessive salivation. Pregnancy and teething may also trigger hypersalivation, likely due to hormonal changes or the physical process of tooth eruption. Gastrointestinal disorders, such as those affecting the stomach and intestines, may also lead to hypersalivation. Treatment: The treatment for hypersalivation involves addressing the underlying cause. In addition, medications may be used to manage excessive salivation: Atropine sulfate (0.25-0.5 mg) taken three times a day can help reduce saliva production. However, care must be taken to monitor for tachycardia (increased heart rate) as a potential side effect. In severe cases, if conservative treatments are ineffective, atrophy of the affected gland may be induced. This can be done by ligating one side of the parotid duct, which effectively reduces saliva secretion from that gland. There are many issues that can affect the salivary glands, including: Cysts: Fluid-filled sacs that can form within or around the salivary glands. Neoplasms: Tumors (either benign or malignant) that can develop in the salivary glands. Obstruction of the gland or duct: This can occur due to various causes, such as stones (sialolithiasis), tumors, or infections that block the normal flow of saliva. Syndromes: Certain conditions can affect the salivary glands, including: ○ Sjögren's syndrome: An autoimmune disease that primarily affects moisture-producing glands, leading to dry mouth and eyes. ○ Uveoparotitis: A condition that involves both salivary gland inflammation and uveitis (inflammation of the eye's uveal tract). ○ Mikulicz’s disease: A rare condition that causes the swelling of the salivary and lacrimal glands, often associated with other autoimmune disorders. Parotid Gland To diagnose tenderness and swelling in the parotid gland, the examiner should stand in front of the patient and place two or three fingers on the posterior edge of the mandibular ramus. By gently applying pressure towards the back and inward, the examiner can assess the tenderness of the superficial part of the parotid gland. During this examination, it is important to be mindful of painful conditions arising from the temporomandibular joint (TMJ) or muscle dysfunction, as these can cause pain that might be felt in the parotid region due to their close anatomical relationship.  To avoid confusion, it may be necessary to conduct an intra-oral examination of the Stenson's duct opening. By applying gentle pressure with the fingers on the skin corresponding to the canal, the examiner can check whether the canal is functioning properly and if the duct is open. This can help assess the flow of saliva and detect any potential blockages or dysfunction. Submandibular Gland The submandibular gland can be palpated beneath the body and angle of the mandible. This simple palpation is supported by placing one finger inside the mouth, a technique known as bimanual palpation. In brief, the gland is examined between the lower border of the mandible (in the molar region) and the floor of the mouth. This approach helps in identifying any swelling, tenderness, or abnormalities in the submandibular gland.  When the submandibular gland becomes infected, lymphadenopathy, swelling of the floor of the mouth, and erythema(redness) are typically observed. The patient also experiences pain. If the gland is obstructed by a salivary stone (sialolith), the symptoms are usually similar. Palpation of the gland and examination of the duct may reveal reduced salivary flow or the presence of purulent material. Tumors of the submandibular gland are rare. Sublingual Gland The sublingual gland is examined by inspecting the anterior one-third of the floor of the mouth and performing a bimanual examination. Sublingual gland tumors are very rare, but when they occur, they tend to show high malignancy. Obstruction of the sublingual gland is also rare, but when it occurs, the Bartholin duct on the same side becomes blocked as well. Ranula The most common lesion of the sublingual gland is "ranula." A ranula appears on the floor of the mouth. Unlike a mucocele, it is larger in size. The lesion can also be seen in the submandibular gland. If it grows significantly, it can push the tongue to the side and upward, causing speech difficulties. Minor Salivary Glands Minor salivary glands are examined through the control and palpation of the mucosal surfaces of the lips, buccal mucosa, palate, and floor of the mouth. These smaller glands are scattered throughout the oral cavity. The image on the side shows a mucocele on the tongue. A mucocele is a lesion that appears as a vesicle filled with mucus, typically appearing as a clear or bluish-gray swelling. It occurs when a salivary gland duct becomes obstructed or ruptured, leading to the accumulation of mucus under the mucosal surface. Key features: Appearance: The lesion looks like a small, fluid-filled blister on the mucosal surface of the mouth, often on the lower lip, but it can also appear on the tongue or floor of the mouth. Symptoms: Patients often report that the lesion ruptures from time to time, causing the mucus to drain out, only to fill up again later. Mukoepidermoid Carcinoma Malignant tumors of the minor and major salivary glands are rare, and their etiology is unknown. The treatment for these tumors is typically surgical excision. Adenoid cystic carcinoma (ACC) Malignant tumors of the salivary glands can occur in both minor and major salivary glands. The etiology (cause) of these tumors is not well understood. A hard swelling may appear in the area of the affected salivary gland. These tumors are often painful and can cause discomfort. As a complication, these malignancies can metastasize to peripheral nerves and the lungs. Salivary Stones Salivary stones are most commonly found in the submandibular gland or duct, accounting for about 80% of cases. Stones in the parotid gland or duct are rare. Stones in the submandibular duct are typically round or elongated, while those localized in the gland itself tend to have an irregular shape. The exact cause of salivary stone formation is not well understood, and it is unclear whether inflammation plays a significant role in their development. There is no established link between the formation of salivary stones and stone formation in other parts of the body. The reasons behind stone formation remain complex and require further investigation, though factors such as dehydration, reduced saliva flow, or saliva composition changes may contribute. Salivary Stones Salivary stones are more commonly seen in men and are rare in children. Many patients are in the middle-aged group. The lesion typically manifests with pain attacks during or just before eating, accompanied by swelling in the affected gland, especially if the stone is lodged in the duct and causing a blockage. This blockage can lead to discomfort, as saliva flow is obstructed. Salivary Stones Radiographs are helpful in visualizing salivary stones. For stones in the submandibular gland or duct, an occlusal film (a type of dental X-ray) can be used to detect the stone. Stones can also be seen in a lateral jaw radiograph, which provides a side view of the mandible and its surrounding structures, aiding in the identification of stones in the duct or gland. These imaging techniques are useful for diagnosing salivary stones and determining their location for appropriate treatment planning. Salivary Stones In cases of suspected salivary stones in the parotid gland and duct, dental radiographs of the soft tissues in the cheek area can be taken to help diagnose the condition. However, sometimes the stone may not be directly visible on standard radiographs. In such cases, a contrast agent, such as lipiodol, may be injected into the gland to provide better imaging. This procedure is called sialography and helps to visualize the stone and any blockage in the duct. If the stone is located in the duct, sialography may not be necessary, as the stone could be displaced during the injection, potentially making it more difficult to detect. In such cases, alternative imaging or methods may be used for diagnosis and treatment. Salivary Stones The treatment for salivary stones is the removal of the stone. Stones in the parotid duct are generally easier to remove. However, stones in the parotid gland are rarer and may require more extensive procedures, such as total or partial parotidectomy. When removing stones from the submandibular duct or gland through an intra-oral approach, extra caution must be taken to avoid damage to the lingual nerve. This is because the lingual nerve crosses the Wartton duct(submandibular duct), and injury to it can result in sensory or motor deficits in the tongue and floor of the mouth.  When a stone is removed from the submandibular gland duct, the general symptoms are usually mild. However, swelling (edema) at the floor of the mouth and a slight elevation in body temperature can be observed. After the stone is removed, recurrence of stones may occur. This is likely due to degenerative changes in the gland or duct, which can lead to the formation of new stones in the future. Proper management and follow-up are important to prevent recurrence and further complications. Sjögren’s Syndrome This condition is also referred to as sicca syndrome. It is characterized by: Swelling of the salivary glands Dry mouth (xerostomia) Dry eyes (xerophthalmia) Dry throat (pharyngolaryngitis sicca) Dry nose (rhinitis sicca) Arthritis-like lesions in the joints, similar to rheumatoid arthritis The exact cause of sicca syndrome is unknown, but it is likely an autoimmune disorder in which the immune system attacks moisture-producing glands, leading to dryness in various parts of the body. The treatment of this condition is challenging for the patient, as it involves managing symptoms and complications, with no cure currently available. Treatment often focuses on alleviating dryness and addressing associated symptoms. Most patients with Sjögren's syndrome are middle-aged or older. Sensitivity is present in the mouth and eyes. The oral mucosa becomes atrophic and reddened. Tongue symptoms are more prominent, and the tongue may have painful fissures. Although some patients report swelling of the salivary glands, this is not always observed. The disease can lead to blindness in the eyes if left untreated or if complications occur. Sjögren's syndrome is an autoimmune disorder that affects moisture-producing glands, leading to dryness and other symptoms that can significantly impact a person's quality of life. The treatment for Sjögren's syndrome is often symptomatic. Dry mouth can be partially alleviated with artificial saliva. Dry eyes can be treated with artificial tears, such as methylcellulose solution. If the patient has teeth, sweet foods and beverages should be avoided to prevent further damage to the oral cavity. Topical fluoride treatments can be applied as a protective measure to help prevent dental decay and protect enamel.  Rinsing with 0.2% chlorhexidine solution helps reduce plaque formation in the oral cavity. Candida infections in the oral cavity can also develop, and these infections can be treated with solutions like nystatin or amphotericin. These antifungal treatments help to control and eliminate the overgrowth of Candida species, reducing the symptoms of oral candidiasis (thrush).