Salivary Gland Diseases.pdf

Salivary Gland Diseases Importance of Saliva - Protects oral tissues —> Provides lubrication for hard + soft oral tissues - Essential for daily activities: - Speech - Swallowing - Mastication - Taste - Importan...

Salivary Gland Diseases Importance of Saliva - Protects oral tissues —> Provides lubrication for hard + soft oral tissues - Essential for daily activities: - Speech - Swallowing - Mastication - Taste - Important part of mucosal immune system: - Keeps bacterial + fungal populations under normal limits Salivary Gland Dysfunction Changes in salivary output - Quantity or Changes in salivary composition -Quality Changes in salivary output - Quantity: Salivary hyperfunction – ↑ salivary output = hypersalivation (sialorrhea) Salivary hypofunction – ↓ salivary output = dry mouth Hypersalivation - Excess saliva production or Decrease in saliva clearance. - Causes of hypersalivation: Medications - e.g. pilocarpine and cevimeline Heavy metals - e.g. iron, lead, mercury etc. Neurologic de cit/changes (e.g. CVA, cerebral palsy) → swallowing di culties → drooling Neuromuscular diseases e.g. Parkinson’s disease 1 of 8 fi ffi  Medication-Induced Salivary Gland Dysfunction - > 400 medications associated with xerostomia - Common problem among elderly patients due to multiple medication use - ↓Salivary volume or compositional changes - Unstimulated salivary output a ected - Drug withdrawal → normal salivary function Most common medications that causes hyposalivation: Anticholinergics Anti-histamines Anti-depressants Some sedatives and tranquilizers Anti-anxiety Some muscle relaxants Anti-hypertensives including diuretics Anti-seizures Anti-re ux (↓ gastric hyperacidity) Some Causes Of Salivary Gland Hypofunction: 1 Developmental: Salivary gland agenesis, aplasia 2 Infections/In ammatory: - Bacterial - Viral - CMV, HIV, Hepatitis C - Granulomatous- Tuberculosis - IgG4-related disease (Mikulicz’s disease) 3 Medication-associated oral dryness ( > 400 medications) 4 Reactive: Sialometaplasia 5 Iatrogenic: Radiation therapy (external beam; internal beam), Post-surgical adenectomy, ductal ligation, Botox injection 6 Neoplastic: Benign and malignant salivary gland tumors 7 Non-neoplastic: Sialolithiasis, Mucocele, Sialosis/sialadenitis 8 Systemic: Anorexia nervosa/bulimia, Diabetes mellitus, Chronic alcoholism, Sarcoidosis 9 Autoimmune: Sjogren’s syndrome, Chronic GVHD Symptoms of Salivary Gland Hypofunction Oral mucosa and throat dryness Di culty chewing, swallowing and speaking Inability to swallow dry foods Drinks uids while eating to help swallowing Carry uids at all times/chew on ice-aid in speaking and swallowing Mucosal pain 2 of 8 ffi fl fl fl fl ff  Mucosa sensitive to spicy or coarse foods Signs of Salivary Gland Hypofunction ‘Lipstick sign’: lipstick and epithelial cells on labial surfaces of anterior maxillary teeth Tongue: Red, ssured, with papillary atrophy ‘Tongue blade sign’: dry buccal mucosa sticky to mouth mirror or tongue blade Candidal infections -labial commissures, mucosa and beneath dentures Dental caries: ↑DMFT score, root, cervical and cuspal caries Caries a ecting the cusp tips is a characteristic , multiple cervical caries lesions. Infections/In ammations of Salivary Glands Bacterial Sialadenitis May occur in patients with dry mouth Erythema of overlying skin Pain, induration, tenderness Purulent discharge from ductal ori ce Bacterial Sialadenitis Treatment Culture and sensitivity of exudate Imaging may be needed Broad spectrum antibiotics “Milk” the involved gland several times throughout the day. Increase patient hydration (sipping uids) Meticulous oral hygiene required. I & D may be required (incision and drainage) Viral Infections of the Salivary Glands Common Viral Infections: Epidemic parotitis; mumps (Paramyxovirus), Hepatitis C virus infection (HCV) Cytomegalovirus infection (CMV) Human immunode ciency virus (HIV) COVID-19-Associated Sialadenitis Ear pain Pain-associated chewing Retromandibular edema Parotid gland enlargement Sticky saliva Intraparotid lymphadenitis Granulomatous Disorders of the Salivary Glands Tuberculosis Sarcoidosis: painless bilateral enlargement of the parotid gland Neoplasms of the Salivary Glands Salivary Gland Tumors Majority (80%) occur in the parotid gland Probability of a malignant salivary gland tumor is greater the smaller the gland Most common benign tumor: pleomorphic adenoma Most common malignant tumor: mucoepidermoid carcinoma 3 of 8 ff fl fi fi fi fl  Reactive, Metabolic, Trauma Reactive lesion – Necrotizing Sialometaplasia Etiology Reactive in ammatory disorder Pathogenesis: local ischemic event Precipitating factors: L.A injection; Restorative dental procedures Repeated vomiting associated with bulimia Clinical Presentation Rapid onset Commonest location: Palate (also lips, retromolar pad region) - minor salivary glands Erythematous nodule → deep ulcer →yellowish base and irregular border Pain mild c/w size of ulceration Necrotizing Sialometaplasia Diagnosis: Clinical history Biopsy Treatment: No Tx needed Self limiting –about 6 weeks Recurrence: Rare Metabolic lesions - Sialolithiasis Formation of calci ed and organic matter within the secretory system of the major salivary glands Sialolith = salivary stone Sialolithiasis Occurrence: Submandibular- 80-90% Parotid- 5-15% Sublingual or minor- 2-5% Why high occurrence in submandibular gland? Torturous course of Wharton’s duct High calcium and phosphate levels Sialolithiasis Treatment Dependent anatomic position → salivary stasis. Reassurance Diagnosis Hydration and sialogogues (? Washout effect) History: Acute, painful, and intermittent swelling of the Surgical removal of stone a ected major salivary gland initiated by eating Lithotripsy-stone fragmentation without Glands are encapsulated so swelling causes pain entering the body of the gland Clinical examination: Swelling of the a ected gland May be able to visualize stone if close to ori ce Imaging 4 of 8 ff fl ff fi fi Traumatic lesions - Mucocele - A clinical term for a swelling caused by accumulation of saliva at the site of a traumatized or obstructed minor salivary gland duct Types Mucous extravasations Mucous retention Ranula- a large mucocele located on the oor of the mouth 5 of 8 fl  Sialosis Asymptomatic Non-in ammatory Bilateral salivary gland enlargement Parotid gland mostly a ected Associated with underlying systemic disorder Resolves when the systemic disorder is corrected Commonly associated with: Anorexia nervosa, bulimia —> Glandular acinar cell hypertrophy Alcoholism, cirrhosis, obesity, uncontrolled diabetes mellitus Fatty in ltration of glandular tissue Sialosis Treatment Reassurance (non-neoplastic enlargement) Bulimia-behavioral modi cation, antidepressants Tx of Type 2 diabetes (control glucose level) Surgery-super cial parotidectomy (if painful or to improve appearance) Immunological causes of Salivary Gland Disease Sjögren’s Syndrome (SS) - F > M (9:1) - Age: mid 50ʼs (Post menopausal women) - Approx. 1 million people a ected in USA - 44% increased risk of developing lymphoma Primary SS: systemic disorder that includes both lacrimal and salivary gland dysfunctions without another autoimmune condition. Secondary SS: salivary and/or lacrimal gland dysfunction in the setting of another connective-tissue disease e.g. SLE, RA, scleroderma, polymyositis, dermatomyositis,. Diagnosis I. Ocular signs and symptoms II. Oral signs and symptoms III. Histopathology IV. Serology (Autoantibodies) *Exclusions: no history of H&N radiation Tx, HCV, HIV, GVHD, pre-existing lymphoma, use of anti- cholinergic drugs Blood test 6 of 8 fi fl fi ff fi ff 2012 Sjögren International Collaborative Clinical Alliance (SICCA) Diagnostic Criteria: Primary SS: Positive for 2 out of the 3 objective tests 1. Serology:Anti-SS-A/B blood test: +Anti-SSA and/or Anti-SSB and/or + RFA and elevated ANA 2. Ocular surface staining —> ≥4 3. Histopathology (salivary gland biopsy) —> Focus Score > 1 (per 4mm2) Questions to Ask 1. Does the amount of saliva in your mouth seem to be too little, too much, or you don't notice it? 2. Do you have any di culties swallowing? 3. Does your mouth feel dry when eating a meal? 4. Do you sip liquids to aid in swallowing dry foods? Evaluation of Salivary Gland Dysfunction Measuring Saliva A. Unstimulated saliva: Basal secretion; saliva secreted in the absence of exogenous gustatory, masticatory or mechanical stimulation. OR B. Stimulated saliva: Saliva secreted in response to mechanical, pharmacologic or gustatory stimulation Hyposalivation: - Unstimulated whole saliva: < 0.1 ml/min - Stimulated whole saliva: < 1.0 ml/min 7 of 8 ffi  Treatment of Salivary Gland Dysfunction A. Palliative Therapy 1. Hydration Increase water intake/forced uids, humidi ed air Reduce ca eine, alcohol 2. Lubrication/substitution of oral care products Oral rinses/gels/mucin-based products Saliva substitutes/Biotene® products, OralBalance® 3. Mechanical/Gustatory stimulation ‘Milking’ of salivary gland Salivary gland massage Sugar-free gums/mints/candies B. Preventive Therapy 1. Caries and candidiasis prevention Good oral hygiene + freq recalls Topical uoride (trays) Antimicrobial rinses/Eludril® (↓ opportunistic infections) 2. Alternate medication regimen Substitution, elimination Change in dose or time of day taken 3. Pre-radiotherapy planning IMRT –Intensity modulated radiotherapy Amifostine (cyto- and radioprotective; O2 scavenger) Surgical gland repositioning - movement of salivary gland to submental region C. Pharmacologic Therapy Pharmacologic stimulation Pilocarpine HCl(Salagen®) —> non-selective muscarinic agonist Cevimeline HCl (Evoxac®)—> selective for M1/M3 muscarinic receptors Bethanechol Chloride (Urecholine®) (not available anymore) similar to acetyl choline (Parasymp.N.S) ↑ smooth muscle tone - ↑ emptying 8 of 8 fl ff fl fi