Salivary gland diseases

Dr. Tanmay J

Saliva
is produced by the three major paired salivary glands (parotid,
submandibular, and sublingual glands)
600 and 1000 minor salivary glands
glands
(labial, buccal, lingual, palatal, retromolar).
of Weber

3 sets of minor salivary glands of the tongue

glands of
von Ebner
glands of
Blandin &
Nuhn

Major salivary glands can also be classified

based saliva-producing acinar cell type
Serous-parotid gland
Mucous-sublingual and minor salivary glands
Mix of serous and mucous cells-submandibular gland

Parotid duct

Submandibular
duct

 Ductal cells (stems) form an extensively

branching system that modifies
Transports the saliva from the acini into
oral cavity

Whole saliva
Hypotonic fluid relative to blood plasma
Composed of secretions major & minor salivary gland
99% water & less than 1% proteins & salts
Contains GCF, microorganisms, food debris, exfoliated
mucosal cells & mucus.
Normal daily WS production- 0.5 to1.5 L
Composition of WS follows a circadian rhythm
Contributors of saliva
At night & the resting state

Upon stimulation

Submandibular & sublingual

glands

parotid & submandibular

glands

Production of saliva

Initial water transport from the serum into the terminal

portion of the acinar cell

Selective reabsorption of sodium & chloride

Secretion of potassium & bicarbonate to produce a

hypotonic solution

Salivary proteins serves functions like

Digestion (e.g., -amylase, lipase, proteinases, Dnase & RNase)
Protection (immunoglobulins, lysozyme, lactoferrin, lactoperoxidase,
mucins).

Dominant
stimulus
for fluid
secretion

Muscariniccholinergic
receptors, which
release
acetylcholine

Salivary
protein
secretion

Sympathetic
-adrenergic
receptors that
release
noradrenaline

Secretion of
salivary fluid &
salivary proteins

At Aging
Parenchymal tissue of the salivary glands replaced by fat,
connective tissue, and oncocytes.
Acinar atrophy, ductal dilatation & inflammatory infiltration
A gradual loss of reserve capacity leading to reduced saliva
production in older individuals.

DIAGNOSIS OF THE PATIENT WITH SALIVARY GLAND

DISEASe
Salivary gland hypofunction
Queries
Duration of complaint
Progressive or intermittent
Circadian association and severity
An initial evaluation
Detailed evaluation of associated symptoms,
Past and present medical history
Head/neck/oral examination,
Assessment of salivary function- quantification of unstimulated
and stimulated salivary flow.
Further techniques that may be indicated are analysis of salivary
constituents, salivary imaging, biopsy, and clinical laboratory
assessment.

Symptoms of Salivary Gland Dysfunction

Patients dryness of all the oral mucosal surfaces, lips, throat
Difficulty chewing, swallowing & speaking.
Decrease in secretory capacity
These complaints focus on oral activities that rely on stimulated salivary
function.

Past and Present Medical History

Collection of the past and present medical history may reveal
medical conditions or medications known to be associated
with salivary gland dysfunction leading to a direct diagnosis
e.g., a patient who has received radiotherapy for a head and
neck malignancy or an individual taking a tricyclic antidepressant).
More than 400 drugs with xerogenic potential

Lips

Dry with cracking, peeling, and atrophy

Buccal mucosa

Pale and corrugated

Dorsal tongue

Smooth -loss of papillation and erythematous

Teeth

Carious lesions often affect the root

surfaces and the cusp tips of teeth

Gingiva

Increased plaque indices

and bleeding on probing scores

Two additional indications of oral dryness are the lipstick

and tongue blade signs.
Candidiasis - erythematous form of candidiasis, appearing
as red patches on the mucosa
Infection,
acute inflammation, or
tumor
Enlarged
glands that are painful
on palpation
slightly rubbery

Neoplasm
Painless masses

Expressed salivaChronically reduced function

Viscous or scant secretions

Bacterial infection

A cloudy exudate

Major salivary glands

Benign tumors of the parotid gland are located within the superficial
lobe
Facial nerve paralysis is usually indicative of malignancy. Other
signs -multiple masses, a fixed mass with invasion of surrounding
tissue, and the presence of cervical lymphadenopathy.
Bilateral parotid gland
masses

Multiple painless masses

within asingle parotid gland

Lymphadenopathy

Warthins tumors

Warthins tumors

Lymph nodes

Lymphoepithelial cysts

Metastatic disease

Enlarged lymph nodes in the

setting of HIV

Other benign and malignant

tumors

Acinic cell adenocarcinoma

Tumors in the submandibular or sublingual glands

Painless, solitary, slow-growing mobile masses.
Tumors of the minor salivary glands
Smooth masses
Hard or soft palate
HIV Patients may develop cystic lymphoepithelial
lesions (LELs) that may be confused with tumors
Melanoma and squamous cell carcinoma can metastasize to
the parotid gland and appear similar to a primary salivary
tumor

Sialometry
Stimulated salivary flow -relative functional capacity of the
salivary glands & help determine whether sialagogues are
likely to be beneficial
WS collection include the draining, suction, spitting &
absorbent (sponge) methods
Salivary function, unstimulated WS collection is recommended

Chewing an unflavored gum base at a controlled rate (usually 60

times/min which can be paced using a metronome) is a reliable &
reproducible means of inducing saliva secretion.

For research investigations, 2% citric acid may be placed on the

tongue at 30-second intervals

Parotid gland saliva collection

Submandibular & sublingual

glands saliva collection
Saliva from individual
submandibular
& sublingual glands

Carlson-Crittenden collectors or a modified

Lashley cup

Custom-made collectors Wolff collector

Aspirating device
or an alginate-held collector called a segregator

Unstimulated WS flow rates of <0.1 mL/min

Stimulated WS flow rates of <0.7 mL/min are abnormally
low & indicative of marked salivary gland hypofunction

Salivary Diagnostics
OraQuick ADVANCE Rapid HIV-1/2 Antibody Test
Saliva-based assay are available to detect & quantify specific
periodontal disease- associated bacteria & high-risk human
papilloma virus

Salivary Gland Imaging

Plain Film Radiography
Initial imaging modality
Visualization of radiopaque sialoliths ,bony destruction,
background for interpretation of the sialogram.
Parotid glands
Panoramic or lateral
oblique and
anteroposterior
Standard occlusal film
close to the gland orifice

Submandibular gland
Panoramic, occlusal, or
lateral oblique views

Sialography

Radiographic visualization of the salivary

glands and ducts following retrograde
instillation of soluble contrast material into
ducts

Indications
Ductal stricture, obstruction, dilatation&
ruptures
Identifying and localizing sialoliths
Pre-surgical planning for removal of salivary
masses
Normal ductal architecture has a leafless tree
appearance
Radiopaque sialoliths may appear as voids.
Focal collections of contrast medium within the
gland sialadenitis & SS

Oil-based contrast
material
Maximum opacification
of the ductal & acinar
structures

Water-based dyes
Diffuse into the
glandular tissue

High-viscosity water-soluble contrast agents that allow better

visualization of the ductal structures
Patient should-massage the gland and/or to suck on lemon drops to
promote the flow of saliva & contrast material out of the gland.
A post procedure radiograph is performed after approximately one
hour.
Incomplete clearing obstruction of salivary outflow, extraductal or
extravasated contrast medium, collection of contrast material in
abscess cavities, or impaired secretory function.

Digital subtraction sialography

Whereby the image taken, before contrast is injected is subtracted
from the image taken after injection for high-resolution (enhanced
contrast)imaging of the extraglandular & intraglandular salivary ductal
system.
Calculi or ductal stricture
Functional information can also be obtained after sialagogue
administration
Swelling or palpable mass in the submandibular or parotid regions or
gradual or chronic enlargement of a salivary gland where sialolithiasis or
sialadenitis
Two contraindications to sialography are active infection & allergy to
contrast media

Ultrasound
Assessment of superficial masses of the parotid & submandibular glands
Resolution & characterization of tissue without exposure to radiation
Method of choice for the initial evaluation of -in children and pregnant
women
suspected sialolithiasis and salivary gland abscesses

Distinguish focal from diffuse disease

Assess adjacent vascular structures & vascularity
Distinguish solid from cystic lesions
Guide fine needle aspiration biopsy (FNAB) & perform nodal staging
Distinguish glandular from extraglandular masses

SGUS may also represent a promising tool for earlier disease

detection and for monitoring disease activity and progression in
established SS patients.
SGUS has been shown to be effective in identifying SS patients with
changes indicative of lymphoma development

Radionuclide Salivary Imaging

Scintigraphy with technetium (Tc) 99m pertechnetate is
a dynamic and minimally invasive diagnostic test to assess
salivary gland function and to determine abnormalities in
gland uptake and excretion
Technetium is a pure gamma rayemitting radionuclide
that is taken up by the salivary glands (following intravenous
injection), transported through the glands, and then secreted
into the oral cavity.
The parotid and submandibular glands can be visusalized
distinctly in similar way as thyroid gland

CT scan
Inflammatory diseases of the salivary gland
Mandibular cortical bone erosion & destruction,
cutaneous changes & submandibular duct
calculi
Define characteristic hypervascular wall & &
distinguish fluid-filled masses (i.e., cyst) from
abscesses
Detects sialoliths, masses, glandular
enlargement or asymmetry, nodal involvement
& loss of tissue planes

Tumors, abscesses, and inflamed lymph nodes will show abnormal

enhancement when compared with normal structures

Enhanced CT can also help in staging malignant disease of the salivary

glands and in assessing lymphadenopathy of the pharynx and neck.
Coronal & sagittal reconstructions can be used in the evaluation of
perineural spread.
Conventional CT can be combined with sialography to examine salivary
gland ductal systems and detect sialoliths

Magnetic resonance imaging

Preoperative evaluation of salivary gland

tumors
Assess the extracranial extent
Assessing perineural & intracranial spread of
malignancies

MRI with sailography :-finer evaluation of ductal

alterations & any filling defects

SS-inhomogeneous internal pattern in both T1- &

T2-weighted images; appearing as a salt-andpepperor honeycomb-like appearance
Head and neck MRI
Useful tool for the detection of CNS involvement
in SS

Positron Emission Tomography

Measuring regional salivary gland function & recognizing
inflammatory changes
Incidental detection of salivary gland tumors
SGS & fluorodeoxyglucose (FDG) PET is favored for the
differentiation of various parotid gland tumors
Increased FDG uptake may be observed in the salivary glands,
lymph nodes, and lungs of SS patients.

Salivary gland biopsy

Minor salivary gland biopsy
Labial minor salivary glands
Diagnose amyloidosis, sarcoidosis & cGVHD
6-10minor gland lobules from just below the mucosal surface
In SS-presence of focal lymphocytic sialadenitis

Major salivary gland biopsy

Parotid gland biopsy
Diagnose sarcoidosis & lymphomas
Advantages
Repeat specimens can be obtained from the same gland in combination
with saliva samples from the gland

FNAB
Useful for elderly patients who cannot tolerate an
excisional biopsy because of medical considerations

Core Needle Biopsy

Employing a larger-bore needle than in the FNAB to remove cylinders
of tissue
Preoperative evaluation of salivary gland lesions
Reduced risk of tumor seeding
Preserve histologic architecture
Evaluation of extracapsular tumor invasion

Immunohistochemical
stains are also more likely
to be reliable with core
biopsy specimens

Ultrasound-guided core needle aspiration

Salivary gland masses of the major salivary glands
Evaluation of pathology involving the submandibular space
Investigate associated cervical lymphadenopathy
Differentaites -benign or malignant
Awareness of the biologic aggressiveness of the tumor prior to
definitive surgery is helpful in planning optimal treatment

Serological evaluation
Sjogrens syndrome

Individuals serum amylase levels

increased salivary gland
inflammation & where there is
pancreatic involvement in SS

Determination of amylase
isoenzymes (pancreatic & salivary)
will allow the recognition of salivary
contributions to the total serum
amylase concentration

Elevated ESR
Mild normochromic normocytic anemia

Leukopenia
Polyclonal hypergammaglobulinemia
Rheumatoid factor (RF), antinuclear
antibodies (ANAs), and anti-SSA/Ro &anti-SSB/La
Autoantibodies

 Developmental abnormalities
Sialolithiasis
Mucoceles
Inflammatory & Reactive lesions
Sialadenitis
1. Allergic
2. Viral
3. Bacterial
Systemic conditions with salivary gland
involvement
Salivary gland tumors

Developmental Abnormalities
Complete absence (aplasia or agenesis) of salivary
glands
Clinical features

Xerostomia
Rampant caries
Enamel hypoplasia
Congenital absence of teeth
Extensive occlusal wear

Associated with

Hemifacial microstomia
Mandibulofacial dysostosis
Cleft palate
Lacrimo-auriculodento-digital syndrome
Anophthalmia observed
Ectodermal dysplasia.

Hypoplasia of the parotid Gland

MelkerssonRosenthal syndrome

Congenital fistula formation within the ductal system

Brachial cleft abnormalities
Accessory parotid ducts
Diverticuli

Stafne bone defect

Asymptomatic depression of the lingual surface of the mandible
Associated with ectopic salivary gland tissue
Third molar inferior to the mandibular canal
Caused -result from pressure exerted by adjacent glandular tissue.
R/F-unilocular, well-circumscribed radiolucency

Accessory salivary ducts

Frequent location-superior & anterior to the normal location of
Stensens duct

Diverticula
is a pouch or sac protruding from the wall of a duct
pooling of saliva & recurrent sialadenitis

Dariers Disease
Sialography of parotid glands -duct dilation, with periodic stricture
affecting the main ducts.

Sialolithiasis (Salivary Stones)

Calcified organic masses - secretory system of the major salivary
glands
They form secondarily to chronic obstructive sialadenitis.
Factors favoring salivary stone formation
Factors favoring saliva
retention

Saliva composition

Irregularities in the duct

system

Calcium saturation

Local inflammation

Deficit of crystallization
inhibitors such as phytate

Dehydration
Anticholinergics,diuretics

 Sialolithiasis can occur in a wide age range of patients & has been
reported in children.
Commonly in the -Submandibular(80%90%)
-Parotid(5%15%)
-Sublingual (2%5%)
Higher rate of sialolith formation in the submandibular gland

Tortuous
course

Higher
Ca& K
levels

Position of
gland

Mucoid
nature

 Silaolith formation

Microcalculi are intermittently formed in salivary

ducts due to secretory inactivity
Food debris & bacteria from the oral cavity may
then migrate into the main ducts
Impacted sialomicrolith in a small intraglandular
duct results in focal obstructive atrophy
Bacteria may proliferate resulting in local
inflammation,then spread to involve adjacent
lobules resulting in swelling & fibrosis of the
large intraglandular ducts.

Partial obstruction leads to ductal dilatation &

stagnation of calcium-rich secretory material
resulting in further lamellar calcification

Sialolith
Calcium carbonates & phosphates,cellular debris,
glycoproteins & mucopolysaccharides
Core-Purely organic to heavily calcified material
surrounded by less-calcified or purely organic lamellae
Hydroxyapatite is the most common mineral
Magnesium, potassium chloride, and ammonium salts

Patients with hyperparathyroidism- increased incidence of

sialolithiasis
Hyperparathyroidism & sialolithiasis show a greater incidence of
nephrolithiasis than those without sialolithiasis indicating
that hypercalcemia may be a contributing factor

Clinical presentation
Acute, colicky, periprandial pain & intermittent swelling of the affected major salivary
gland
Salivary gland swelling will be evident upon
eating, enlargement -causes pain
Stasis of the saliva may lead to infection,
fibrosis & gland atrophy
Concurrent infection - suppurative or
nonsuppurative drainage, erythema or warmth
in the overlying skin
Bimanual palpation directed in a posterior to
anterior fashion along the course of the involved
duct - detect a stone.
Chronic case-Fistulae, a sinus tract, or ulceration may occur in the tissue covering
the stone

Complications -acute sialadenitis, ductal stricture & ductal

dilatation.
Diagnosis
Plain film radiographs

Submandibular sialolith

AP view of the face or an occlusal film placed

intraorally adjacent to the duct

Stones in the parotid gland

Sialography using panoramic, occlusal,& periapical

radiographs

Inflammation or salivary stone

disease

Contrast sialography using iodinated contrast media

Parotid & submandibular ductal

systems

Ultrasound
Transoral sonographyusing an intraoral approach

Radiolucent calculi

CT scan

Small calculi

CBCT imaging in sialography, more

Complex cases of salivary duct

obstruction

MRI sialography

Iodine or contrast media allergies or

acute infection.

Sialendoscopy : Allowing for access to deeper segments of a duct and potentially the
inner areas of the gland
Feasible, simultaneous visualization and removal of sialoliths
Dilation of the ductal opening or papillotomy -introduction of surgical
instruments-Dormia basket, graspers, or laser fibers Irrigation with saline or steroid instillation is then performed to flush out
debris and treat ductal inflammation
Removal of the stone, the endoscope -stent is placed to maintain
patency of the duct

Treatment

Acute phase of
sialolithiasis

Analgesics, hydration, antibiotics &

antipyretics
Sialogogues, massage & heat
Application of the duct can often be removed
transorally by, but require intervention with.
Stones at or near the orifice-milking the gland
Deeper stones-conventional surgery or sialendoscopy

Multiple calculi ,45 mm,

lie freely in the duct lumen

Interventional sialendoscopy

Larger sialoliths

Mechanical or laser fragmentation

Extracorporeal shock wave lithotripsy
high-energy shock waves to pulverize stones so that
they may be flushed out by physiologic saliva flow

Fixed
intraparenchymal stones

Sialoadenectomy

Large stones and a longstanding history

of recurrent sialadenitis

Gland removal-superficial parotidectomy &

transcervical submandibulectomy.

Extravasation and Retention MucocelesRanulas

Swelling caused by the accumulation of saliva at the site of a
traumatized or obstructed minor salivary gland duct.
Extravasation
Retention

Extravasation mucocele does not have an epithelial

lining or a distinct border.

Extravasation

Result of trauma
to a minor
salivary gland
excretory duct

Pooling of saliva
in the adjacent
submucosal
tissue & swelling

Retention
Obstruction of a
minor salivary
gland duct

Accumulation of
saliva and
dilation of
the duct

Clinical Presentation

Discrete, painless, smooth-surfaced swellings

Superficial lesions -blue hue. Deeper lesions -diffuse, covered by
normal-appearing mucosa.
Extravasation
mucoceles

Lower lip, buccal mucosa, tongue, floor of

the mouth, and retromolar region
Children and teenagers
Soft fluctuant polypoid mass

Upper lip, palate, buccal mucosa, floor of the

mouth
Mucous retention cysts
older patients

Treatment
Removal of the entire lesion along with the feeder salivary glands and
duct
Electrosurgery

Cryosurgery

Laser
surgery

Micromarsu
pialization

Intralesional
injections of
corticosteroi
ds

Sclerotherapy

Ranula

Glands continuous
salivary secretion

Located in the floor of the mouth

Underbelly of a frog (Latin rna[frog])
Arise from the sublingual gland -mechanical
trauma to its ducts of Rivinus,-extravasation of saliva.
second decade of life & in females
Oral ranula

Plunging ranula

only in sublingual space

Dissects along facial planes

beyond the sublingual
space inferior to the
mylohyoid muscle

one side of the lingual

frenulum

swelling involving the

submandibular
triangle or other cervical
space

Sublingual gland
adenectomy with intraoral
excision of the ranula

Intraoral excision of the

sublingual gland with cervical
incision and drainage

Inflammatory and Reactive Lesions

Necrotizing Sialometaplasia
Benign, self-limiting, reactive inflammatory
disorder of salivary tissue
Development of NS has been associated
with smoking, local injury, blunt force
trauma, denture wear, and surgical
procedures.
Higher in male patients
Age -older than 40 years
clinical presentation
Painful, rapidly progressing swelling of the
hard palate with central ulceration &
peripheral erythema
Rapid onset -1 to 3 cm
Predominantly on the palate

Histopathological features
Necrosis of the salivary gland
Granulation tissue, and a mixed inflammatory cell infiltrate
Pseudoepitheliomatous hyperplasia of the mucosal epithelium &
squamous metaplasia of the salivary ducts
Treatment
Self-limiting condition typically resolving within 312 weeks
Appropriate analgesics with antiseptic mouthwash -0.12%
chlorhexidine gluconate

Cheilitis Glandularis
Chronic inflammatory disorder affecting the
minor salivary glands & their ducts in which
thick saliva is secreted from dilated ductal
openings.
Function of
aquaporin
proteins

Abnormality
in water
flow
mechanism

Alteration in
salivary
composition

Clinical features
Middle-aged & elderly men
Lower lip, upper lip &palatal involvement
Thick saliva adheres to lip-discomfort
Edema and focal ulceration

poor
oral
hygiene
smokin
g

chronic
exposur
e to
sunlight
and wind
immunoc
ompromi
sed

CG

Simple CG
Multiple painless
lesions, dilated
ductal openings, and
numerous small
nodules

Superficial suppurative
CG
Infection of the simple
type lesions
Superficial ulceration,
painless
crusting, swelling, and
induration of the lip

Deep suppurative CG
Infection of the deeper
tissues is associated
with abscess formation
and fistulae

Histopathologic features
Dilated & tortuous minor salivary gland ducts
Accumulation of mucus in the ductal lumina
Chronic sialadenitis

Treatment
Use of lip balms, emollients & sunscreens
Conservative
treatment

Refractory cases

Topical, intralesional or systemic steroids, systemic

anticholinergics, systemic antihistamines, and/or antibiotics
Cryosurgery, vermillionectomy, and/or labial mucosal stripping

Deep suppurative Surgical excision

type

Acute & Chronic Allergic Sialadenitis

Acute Allergic Sialadenitis
Allergic effects of allergens on the salivary glands
Enlargement of the salivary glands has been
associated with exposure to various
pharmaceutical agents
Histopathologically
Mixed inflammatory infiltrate affecting the
Periductal & perivascular tissues
Partial destruction of the acinar cells

Ethambutol
Heavy metals
Iodine compounds
Isoproterenol
Phenobarbital
Phenothiazine
Sulfisoxazole

Chronic allergic sialadenitis

is seen with sarcoidosis, Crohns disease, cheilitis granulomatosa, &
granulomatosis with polyangiitis
Allergic sialadenitis is acute salivary gland enlargement, often
accompanied by itching over the gland.

treatment
Avoidance of the allergen, maintaining hydration & monitoring

 Eosinophilic Granulomatosis wth polyangitis

EGPA

Sialodochitis
Fibrinosa

Vasculitis small & mediumsized vessels

Paroxysmal recurrent
salivary
gland swelling

Asthma, allergic rhinitis, and

eosinophilia

Asthma, allergic rhinitis,

urticaria& food allergy

Eosinophilic & necrotizing

granulomas in the vessel
walls & perivascular tissue

Duct thickening and/or

periductal lymphocytic
and eosinophilic
infiltration

Glucocorticoids &
immunosuppressants

Systemic
antihistamines and
steroids, irrigation &
parotidectomy

Mepolizumab, rituximab

Montelukast

Massage to
encourage
removal of
obstructing
mucous plugs

Mumps (Paramyxovirus or Epidemic Parotitis)

Age- 4 and 6 years.
Incubation period-2-3 weeks
2 days malaise,
anorexia, & lowgrade pyrexia with
headache

Nonpurulent
gland
enlargement
1 week

Unilateral
salivary gland
swelling to
bilateral

95% of symptomatic cases - parotid gland

10% of cases- the bilateral submandibular& sublingual glands
concomitant with the parotid swelling.
If partial duct obstruction occurs, the patient may experience pain while
eating.

Complications
Meningitis and encephalitis
Deafness, myocarditis, thyroiditis, pancreatitis, hepatitis, & oophoritis

Males epididymitis orchitis, resulting in testicular atrophy &

infertility if the disease occurs in adolescence or late

Diagnosis
Unilateral or bilateral salivary gland swelling lasting two or more days
Positive mumps IgM antibody
Isolation of mumps virus
Detection of mumps RNA in saliva, urine, CSF

treatment
Analgesics & antipyretics.

Prevention
Live-attenuated mumps vaccines -30 years ,with MMR & varicella
vaccine
CDC recommends mumps patients be isolated and standard and
droplet precautions be followed for 5 days after parotitis onset.

Bacterial Sialadenitis
Acute -sudden onset of a swollen & painful infected salivary gland
Chronic -repeated bacterial glandular Infection
Seen in salivary gland hypofunction
Age -50-60years
Retrograde bacterial parotitis
Due to Decreased salivary flow during anesthesia
Within two weeks of the surgery
Mostly seen in parotid glands

Clinical Presentation
Sudden onset of unilateral or bilateral salivary
gland enlargement
Fevers, chills, malaise, trismus, & dysphagia

Risk factors
Dehydration
Xerogenic drugs
Salivary gland diseases,
Nerve damage
Ductal obstruction,
Irradiation, Diabetes mellitus
SS

On palpation
Enlarged, warm, painful, indurated gland
Purulent discharge may be expressed from the orifice
Diagnosis
One specimen -Cultured for aerobes, anaerobes, fungi &
mycobacteria
Second specimen-Gram stain
Staphylococcus aureus is most commonly isolated.
CT with intravenous contrast is used tool for
detecting an abscess.
Haemophilus
influenzae, Streptococcus viridans,
Streptococcus pneumoniae,
and Escherichia coli. Prevotella
and Porphyromonas,
Fusobacterium species,
Peptostreptococcus species

Treatment
Anti-inflammatory agents & steroids- reduce pain & swelling

Massage the gland several times a day

After 24-48hours,incision and drainage-if there is no

improvement

Chronic sialadentits-Intraductal instillation of penicillin or saline

Anti-Staphylococcal penicillin, a combination -lactamase inhibitor,

or a first-generation cephalosporin

Systemic Conditions With Salivary Gland

Involvement
Diabetes Mellitus
Uncontrolled diabetes-dry mouth
Children with diabetes-impaired salivary flow rates & salivary
compositional changes
Etiology
Polyuria, poor hydration, or underlying salivary gland pathology,
including alterations in the basement membranes of salivary
glands

Anorexia Nervosa/Bulimia
Salivary gland enlargement and dysfunction
Due to nutritional deficiencies & habit or
repeated induced vomiting.
In bulimia- total & salivary specific amylase
levels are increased.
Treatment
Salivary gland enlargement resolves when patients return to normal
weight and discontinue unhealthy dietary habits
Benign hypertrophy may persist and be of cosmetic concern.
Dentists should be aware oral findings (i.e., erosion, xerostomia,
salivary gland enlargement, mucosal erythema & cheilitis).
Patients should be questioned directly when an eating disorder is
suspected & an appropriate medical referral should be made.

Chronic alcoholism
Salivary gland dysfunction & bilateral parotid gland
enlargement
Etiology
Dehydration & poor nutrition

Dehydration
Normal salivary
output

Requires movement of
water from

the systemic circulation

through acinar cells

Salivary
ductal
system

Mouth

Dehydration has been demonstrated to result in diminished

salivary output
Greater &more prolonged period of salivary hypofunction in
older-age-associated diminished secretory reserve capacity in
older adults

Medication-Induced Salivary Dysfunction

More than 500 medications are associated with xerostomia.

Some drugs may produce alterations in saliva composition
that lead to the perception of oral dryness
Salivary hypofunction

Medication-induced salivary hypofunction -affects the

unstimulated output

Anticholinergic drugs
Inhibit acetylcholine binding to
muscarinic receptors on salivary
gland acinar cells preventing water
movement -ductal system to mouth

Analgesics
Anticholinergics
Antidepressants
Antihistamines
Antihypertensive
Antiparkinsonian
Antipsychotics
Antiseizure
Cytotoxic agents
Diuretics
Muscle relaxants
Sedatives and
anxiolytics

Antihistamines, alpha & betablocker, antihypertensives

Inhibit neurotransmitter binding to
the salivary gland acinar cells
changes in the quality
and quantity of salivary secretion

Treatment
In theses patients
Serotonin-specific reuptake inhibitors cause less dry mouth than
tricyclic antidepressants
Taking xerogenic drugs earlier during the day may diminish
nocturnal xerostomia since salivary output is lowest at night
Drug dosages can be divided-side effects are minimized
In case of polypharmacy-Review of their current medications
& medical history & coordination with a patients primary care
provider may help to eliminate drug-induced hyposalivation

TUMORS OF SALIVARY GLANDS

Parotid 80%
Submandibular 10% to 15%
Sublingual and minor salivary glands
80% of parotid , 50% of submandibular and minor salivary gland
tumors are benign
More than 60% of sublingual gland tumors are malignant
Minor salivary gland Pleomorphic adenoma (benign)
Mucoepidermoid carcinoma (malignant)
Most common tumors in children are Mucoepidermoid carcinoma
and Acinic cell carcinoma
Treatment surgical excision of tumor along with afffected gland
followed by radiotherapy for advanced lesions

Benign tumors

Pleomorphic adenoma
Warthins tumor
Oncocytoma
Basal cell adenomas
Canalicular adenoma
Myoepithelioma
Sebaceous adenoma
Ductal papilloma

Malignant tumors
Mucoepidermoid
carcinoma
Acinic cell carcinoma
Adenoid cystic
carcinoma
Carcinoma ex
pleomorphic adenoma
adenocarcinoma

Pleomorphic adenoma
A benign neoplasm consisting of cells exhibiting
the ability to differentiate to epithelial cells ( ductal
& non ductal ) and mesenchymal cells (chondroid,
myxoid, osseous)
Mixed tumour
Most common tumor
Majorly found in parotid
4th 6th decade
Also the most common tumor in children

Clinical features :
Painless , firm and mobile mass rarely ulcerating the skin or
mucosa
In parotid , slow growing tumors affect the postero inferior
aspect of superficial lobe
In submandibular glands, they present as well defined
palpable masses
Intraorally, commonly found in palate, upper lip and buccal
mucosa
Histopathology :
Firm smooth mass with pseudocapsule
Demonstrates both epithelial and mesenchymal components
Epithelial trabecular pattern within the stroma (chondroid,
myxoid, osteoid, fibroid)
Characteristic microscopic projections of tumour outside of
the capsule

Treatment :
Surgical excision with adequate margins
Superficial parotidectomy for majority of the lesions
In case of submandibular gland, complete removal
of the gland,

Warthins tumor ( Papillary cystadenoma

lymphomatosum)
2nd most common tumor of parotid gland
Mostly located in the inferior pole of the gland, posterior to the angle of
mandible
Male predilection ; 5th 6th decade

Clinical features :
Well defined , slow growing mass in the tail of the parotid gland
Painless unless with an added superinfection
Visible on Tc 99m Scintiscan as it contains oncocytes

Histopathology :
Grossly it appears smooth with a well defined capsule
with the cavity filled with thick mucinous material
Tumor consists of papillary projections line with
eosinophilic cells projecting into cystic spaces
characterised by lymphocytic infiltrate

Treatment :
Surgical excision along with the margins
Involvement with the superficial lobe is best treated with
superficial parotidectomy

Mucoepidermoid Carcinoma
Most common malignant tumor of the salivary glands ; especially
parotid
Palate is the second most common site
3rd decade; equal predilection for males and females
Has both mucous & epidermal cells ; classified as High & Low grade
depending on the ratio of these cells
Clinical features :
Depends on the grade of the tumor
Low grade painless enlargement
High grade rapid growth and high risk of metastasis
Associated with ulceration and pain

Histopathology :
May or may not be capsulated ; containing solid to mucinous fluid
Low grade consists Regions of mucoid cells interspersed with epithelial
strands
High grade consists of primarily epithelial cells and very few mucoid
cells
Treatment :
Low grade can be treated with superficial parotidectomy while sparing
the facial nerve
High grade lesions are treated aggressively with neck node dissection
followed by postoperative radiotherapy

Adenoid cystic carcinoma

6 to 10 % of all salivary gland tumors
Most common malignant tumor of submandibular and minor salivary
glands
4th- 5th decade of life; equal sex predilection
Characterised by frequent late metastases and recurrences

Clinical features :
Firm, unilobular mass in the gland, occasionally painful and may
cause facial paralysis
Has propensity for perineural invasion and thus extends beyond the
tumor margin
May exhibit mucosal ulceration and metastases is more common to
lungs than regional lymph nodes

Histopathological :
Gross examination reveals a unilobular mass , partially
encapsulated or without capsule
Microscopic evidence of perineural invasion
Cells are small , cuboidal arranged in sheets or strands with
pseudocystic spaces filled with acellular material

Treatment :
Radical surgical excision
Postoperative radiotherapy
Patients should be kept under observation for future
recurrences and metastases