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Non-neoplastic salivary gland diseases (including investigations for dry mouth) Q: Which glands are responsible for secreting saliva? Ans: Saliva is primarily secreted by the major salivary glands, which includes: Þ the parotid Þ submandibular Þ and subling...

Non-neoplastic salivary gland diseases (including investigations for dry mouth) Q: Which glands are responsible for secreting saliva? Ans: Saliva is primarily secreted by the major salivary glands, which includes: Þ the parotid Þ submandibular Þ and sublingual glands as well as the minor salivary glands located throughout the oral cavity. NOTE: THE SALIVARY GLAND IS UNDER THE CONTROL OF THE ANS (AUTONOMIC NERVOUS SYSTEM) Q: What is the Salivary secretion percentage in a 24-hr period? Gland Percentage Submandibular glands 70% Parotid glands 25% Sublingual and minor salivary glands 5% Q: What are the main components of normal saliva? Ans: Þ 99% water Þ Electrolytes Þ Organic compounds including protein like: amylase, albumin, immunoglobulin A, and lysozyme. Q: List some roles of saliva in the oral cavity. Ans: Þ cleansing action Þ mucosal protection (lubrication and repair) Þ antimicrobial activity Þ aiding normal speech Þ bu^ering activity (pH maintenance) Þ aiding in alimentation (gustation, bolus formation, mastication, swallowing) Mariam J Sialolithiasis (Salivary stones): Q: What is Sialolithiasis? Ans: Formation of salivary stones within the salivary ducts or glands. Q: What are the most A=ected Glands? Ans: Submandibular, Parotid. Important notes: o 2/3 inorganic: Calcium and phosphate. o 1/3 organic: Neutral lipids. o Formed due to progressive calcification of initial nidus: Mucous plugs, Desquamation of epithelium. Q: State the occurrence rates. Ans: 80% in submandibular, 20% in parotid, very rare in sublingual. Q: Explain methods of diagnosis. Ans: Þ Clinical history: Pts will present with recurrent swelling and pain especially at mealtimes, and stones are palpable in the ducts Þ Radiographs: OPG, plain or occlusal films. Þ Sialography Þ CT Þ MRI (Sialo MRI) Q: How do we treat sialolithiasis? Ans: Sialendoscopy, Lithotripsy, Surgical removal (either of the gland or the incisive duct) Q: Why is the submandibular gland considered to be more susceptible to canuli/stones? Ans: Þ its saliva is more alkaline Þ Higher concentration of calcium and phosphate Þ Submandibular duct is long and tortuous Þ Anti-gravity flow of saliva within the duct Mariam J Salivary ducts strictures: Q: State the possible anatomical, physiological and pathological reasons for salivary duct strictures. Ans: Þ Anatomical reason: As parotid duct passes through buccinator muscle “buccinator window anomaly” e.g. Windpipe players Þ Physiological reason: As parotid duct passes through the masseter muscle e.g. Hypertrophy of masseter muscle in bruxism patient Þ Pathological reason: – Tumors – Post radio-iodine therapy (Iodine131) Q: How do we treat salivary duct strictures? Ans: Sialendoscopy (Diltation) Salivary cysts: Q: What are the 2 classifications of salivary cysts? Ans: Þ Mucous retention cysts: – Mucocele – Ranula – Plunging ranula Þ Mucous extravasation cyst Q: Give a brief description, commonly a=ected areas, diagnostic methods and treatment options for the mucous retention cysts. Ans: (Check table below) Mariam J  Type Description Commonly A=ected Clinical presentation Treatment Options Areas Mucocele Þ Involves minor Þ Lower lip Þ Bluish/white dome-like Þ Surgical excision salivary Þ Buccal mucosa swelling glands. Þ Floor of the mouth Þ Can undergo intermittent Þ Lack an rupture and refill epithelial lining Ranula Þ Form of Þ Sublingual gland Þ Asymptomatic soft, fluid- Þ Marsupialization mucous filled swelling in the lateral Þ Complete excision with gland retention cyst floor of the mouth (frog’s removal involving the belly) ducts of the sublingual gland Plunging Ranula Þ Form of ranula Þ Sublingual gland Þ Present as neck mass Þ Complete excision with which extends involved sublingual gland outside the removal mucous membranes of the floor of the mouth inferiorly into the submental or submandibular triangle. Mariam J  Bacterial sialadenitis, Chronic Recurrent Parotitis of Childhood, Mumps, Sarcoidosis, Necrotizing Sialometaplasia (NSM) and Sialosis (Sialadenosis) Condition Description A=ected Glands Clinical Presentation Investigations Treatment Bacterial Þ Prediposing factors include: Parotid and Þ Acute/chronic Þ Rehydration/hydration sialadenitis – Ductal/gland stone submandibular Þ Sialogogues – Duct stricture glands Þ Fever and painful, di=use enlargement Þ Improved oral hygiene – Dehydration of gland Þ Antibiotics – Poor oral hygiene Þ Gland is indurated and tender Þ If no improvement: Þ Purulent discharge identified at the Þ Admit and start IV antibiotics Þ Involved bacteria are Oral streptococci duct orifice Þ I&D if no improvement in 48 hours Anaerobic bacteria Þ Treat cause accordingly Chronic Þ A=ects children Parotid gland Þ Recurrent episodes (8-9 per year) Þ Ultrasound Þ Antibiotics (e.g., Augmentin) Recurrent Þ A=ecting one gland only Þ Sialography Parotitis of Þ Symptoms often resolved by puberty Þ CT/MRI Childhood Þ Sialendoscopy Mumps Þ Most common viral infection involving the Parotid ± Þ Pain and swelling of glands Þ Clinical presentation Þ Mumps virus vaccine (MMR) salivary glands submandibular Þ Fever Þ Serology: Þ Management of complications if present Þ Peak incidence: Children aged 4 – 6 years glands (10%) Þ Malaise – Demonstrating antibodies to Þ Myalgia the mumps Þ Headache – Haemagglutination antigen Þ Complications: – Serious sequelae are uncommon – Pancreatitis, meningitis, sudden deafness – In adults :25% get Orchitis/Opharitis (with risk for sterility) Sarcoidosis Þ Chronic inflammatory condition Parotid gland Þ Uveoparotid fever (Heerfordt’s disease) Þ Biopsy revealing non-caseating Þ Systemic corticosteroids Þ Salivary glands are involved in < 10% of which is a form of sarcoidosis granulomas cases characterized by: – Uveitis – Enlargement of parotid gland – Facial palsy Necrotizing Þ Benign condition of unknown etiology Minor salivary Þ Asymptomatic mucosal Þ Histology: Þ Self-limiting and require no treatment Sialometaplasia Þ Ischemia is thought to play some role glands of the hard ulceration/nodular lesion of hard palate – Lobular necrosis with (NSM) development of NSM palate squamous metaplasia of the remaining acini and ductal elements Sialosis Þ Non-inflammatory, non-neoplastic Parotid gland Þ Usually involves parotid gland Þ Blood glucose Þ Treating any possible underlying condition (Sialadenosis) enlargement of salivary glands bilaterally bilaterally Þ GH assay Þ No specific treatment Þ Aetiology is unknown, but condition is Þ LFT associated with Þ biopsy if in doubt Þ Malnutrition Þ Histology: Þ Bulimianervosa/Anorexia – Enlargement and hypertrophy of Þ Obesity acinar structures Þ Diabetes mellitus Þ Alcohol-related Hepatic cirrhosis Þ Acromegaly Þ Hypothyroidism Þ Pregnancy Þ Drugs (Insulin and Sulphonamides, Phenothiazine) Mariam J Sjögren’s syndrome: Q: What kind of disease is Sjögren’s syndrome? Ans: An autoimmune disease (exocrinopathy) Q: What sex and age is mostly a^ected by this disease? Ans: Middle-aged women (9 F:1 M) Q: Briefly explain histological findings of Sjögren’s syndrome. Ans: Periductal lymphocytes and plasma cell infiltration of lacrimal, salivary and other exocrine glands Sjögren’s syndrome Connective tissue disorder Primary Sjögren’s syndrome Secondary Sjögren’s syndrome (Keratoconjunctivitis sicca syndrome) Xerostomia (dry mouth) Xerostomia Xerophthalmia (dry eye) Xerophthalmia Connective tissue disorder Þ Usually: – Rheumatoid arthritis Þ Less commonly: – Primary biliary cirrhosis – SLE – Scleroderma vascilitis, Raynaud's phenomenon – Thyroiditis NOTE: Unilateral or bilateral salivary gland enlargement (parotid glands): Þ Primary Sjogren's syndrome (80%) Þ Secondary Sjogren's syndrome (30 – 40%) Mariam J Q: What is Sjogren's syndrome the European-American diagnostic criteria? Ans: Grade Presentation I Ocular symptoms II Oral symptoms III Ocular signs IV Histopathology V Salivary gland involvement VI Autoantibodies and note that for Primary Sjogren's syndrome -Any 4 out of 6, and for Secondary Sjögren’s syndrome – CT disease and any 2 items of III, IV and V Q: How do we take biopsies from salivary glands? Ans: Þ Usually taken from lower lip – minor salivary glands Þ Shows lymphocytic infiltrate with acinar atrophy Þ Specimen is graded on the basis of lymphocytic infiltrate with focus scores of greater than l focus/4 square mm proposed as diagnostic Q: What antibodies are associated with Sjogren's syndrome? Ans: Þ Anti SS-A (Ro) 80-90% Þ Anti SS-B (La) 90% Þ Others: – Rheumatoid factor 75% – ANF 75% Mariam J  – AMA 40-70% Q: How do we treat and manage patients with Sjogren’s syndrome? Ans: Þ Symptomatic approach with open access for help Þ Referral to Ophthalmologist for assessment: – Lubricating eye drops – Prompt treatment of eye infections Þ Artificial saliva: – Have neutral PH – Contains electrolytes to correspond to composition of normal saliva – Some contain mucin of porcine origin (Saliva orthana) – Available as oral spray or lozenges – e.g. Saliva orthana, Oral balance, Luborant, Glandosane Þ Sialogogues: – Sugar free chewing gum – Glycerin and lemon – Frequent sips of water Þ Prevention and treatment of dental caries Þ Monitoring and treatment of infections – Candidiasis – Mucositis/angular cheilitis – Parotitis Þ Regular review with palpation of all salivary glands o 45% risk of B-cell lymphoma o More common risk in primary Sjogren's syndrome Þ Pilocarpine hydrochloride Q: What is Pilocarpine hydrochloride? Ans: Þ Group of Parasympathomimetics Þ Used as systemic therapy Þ Contraindicated in: – Asthma – COPD – Glaucoma – Cardiovascular disease – Liver disease Þ Dose 5 mg TDS (max 30 mg) Þ Consider stopping if no improvement in 3 months Mariam J Sialorrhoea (Rare): Q: What is Sialorrhoea? Ans: Symptom of excessive production of saliva Q: What causes Sialorrhoea? Ans: Þ Acute infections e.g. sore throat, viral infection Þ Children with cerebral palsy and mentally subnormal Þ Psychogenic patients Þ Can be related to drugs: – Anticholinesterases e.g. neostigmine – Clozapine – Atropine – Ketamine Q: How do we treat patients with Sialorrhoea? Ans: Þ Physiotherapy and speech therapy Þ Surgical: – Relocating submandibular gland ducts into the posterior position Þ Antidepressant e.g. Tricyclic agents Þ Stop causative drugs Xerostomia (Dry mouth): Q: What causes Xerostomia? Ans: Þ Stress and anxiety Þ Tobacco smoking Þ Alcohol use (including in mouthwashes) Þ Ca^eine containing drinks e.g. co^ee and soft drinks Þ Specific disease e.g. Sjogren's syndrome Þ Drugs: – Tricyclic antidepressant – Antipsychotic – Alpha receptors antagonist for urinary retention Þ Radiation-induced injury of salivary glands: – Radiation to head & neck area may cause injury to salivary gland tissue – Serous acini are extremely sensitive radiation (damage and atrophy) Mariam J  Investigations for dry mouth Investigation Description Values Salivary flow rates (sialometry) Can demonstrate the presence and degree of xerostomia but are nonspecific Þ Unstimulated whole saliva: – Pt to dribble into sterile container over a measured period of time – Value < 1.5 ml/15 mins is abnormal Þ Parotid output: – Carlsson-Crittenden cups by suction to parotid duct papillae – Stimulated with 1 ml of 10% citric acid – Normal value >1 ml/min Lacrimal flow rates (Schirmer test) Filter paper strips to lateral canthus of eye for 5 mins Þ Normal: > 15 mm wetting/5 mins Þ Defective: < 5 mm wetting/5 mins Scintiscanning Þ IV Technetium Þ Decreased function of glands Þ Decreased uptake of Technetium by salivary gland Labial gland biopsy Þ Usually taken from lower lip Þ Graded on the basis of lymphocytic infiltrate with focus scores of Þ Shows lymphocytic infiltrate with acinar atrophy greater than 1 focus/4 square mm proposed as diagnostic Serology Þ Autoantibodies: Anti-Ro/La, RF, ANF, AMA Sialography Þ Show snow-storm appearance (punctate sialectasis) Mariam J  Pictures for reference Disease Picture Bacterial Sialadenitis Chronic recurring parotitis of childhood Mumps Sarcoidosis NSM Sialosis Mariam J