Salivary Gland Diseases • Presented by: Major Features of Salivary Glands

Minor salivary Parotid Sub-mandibular Sub-lingual Gland glands

Scattered throughout Largest major Second largest major Smallest of major the tongue, palate and Feature salivary gland salivary gland salivary glands lip

Bartholin's duct, Stensen's duct Wharton's duct Small Duct Rivinus ducts

Mucous except for Serous Mucous-Serous Mucous-Serous Secretion those in tongue

Fat Yes Yes Yes Yes (tongue)

Lymphoid Yes None None None tissue

Sebaceous Yes None None None Gland

Nerve Facial nerve None None None Major Salivary Glands Salivary Glands Innervations

• Both parasympathetic and sympathetic stimuli result in an increase in salivary gland secretions.

• The sympathetic nervous system also affects salivary gland secretions indirectly by innervating the blood vessels that supply the glands. Wharton’s Duct Classification of SG Diseases 1- Functional Disorders 1) 2) Pytalism 2- Developmental 1) Aplasia 2) Atrasia 3) Aberrancy 3- Infectious (sialadenitis) 1) Viral 2) Bacterial a) Non-specific b) Specific 4- Cystic 1) Mucous retention cyst 2) Mucous extravasation cyst 3) Ranula Classification of SG Diseases

5- Obstructive • Sialolithiasis 6- Autoimmune • Sjogren`s Syndrome 7- Neoplastic 1) Benign a) Pleomorphic Adenoma b) Whartin’s tumor c) Oncyocytoma 2) Malignant a) Malignant Pleomorphic Adenoma b) Adenocystic Carcinoma c) Mucoepidermoid Ca d) Acinic Cell tumor Functional Disorders

1. Xerostomia 2. Ptyalism Xerostomia • Definition: • Means dry mouth • It may be temporary or chronic (persistent) • Temporary xerostomia is of no clinical significance • Persistent xerostomia is of grave consequences • Classification: • Primary, due to defective glands. • Secondary, due to defects outside the glands • Normal Salivary Flow: • 1 – 2 ml/minute , 1 – 2 Liters/Day The protective role of saliva

• Contains components that attack the bacteria cause decay

• Neutralizes the acids produced by plaque • Contains phosphorus and calcium. • Has anti-fungal properties

• Helps to destroy viruses • Moistens food Dry Mouth Includes Dry Skin Skin around mouth become dry and tight. Your lips may become cracked, and sores form at mouth corners. Embarrassing Side Effects NO flushing of food debris, developing persistent . Culprit for hoarseness or a tickle in the throat. Xerostomia • Causes: • Sjogren’s syndrome • Pyschogenic • Irradiation • Anxiety state • Dehydration • Depression • Fluid deprivation • Drugs • Hemorrhage • Diuretic overdose • Persistent or • , • Antidepressants • Antihistamines Anxiety

Some people may have dry mouth, while others may have excess saliva, both may occur at different times. Anxiety(cont.) • Mouth Breathing – Air has a tendency to dry out the mouth, Often this type of breathing is the response to severe anxiety symptoms • Acid Backup – Those with acid reflux problems may also be more prone to dry mouth. Acid can affect the salivary glands and lead to less saliva and the feeling of a dry mouth. It may also lead to a sticky feeling and bad taste, both of which are considered dry mouth related. Anxiety(cont.)

• Fluid Changes When your fight or fight system is activated, your body make take fluids – like saliva and water – and move them to the areas they feel need them more. That may dry out your mouth as well. • Dehydration Those that aren't drinking enough water are more prone to severe anxiety symptoms. Antihistamines • When your body comes into contact with allergic triggers, it makes chemicals called histamines. They cause the tissue in your nose to swell (making it stuffy), your nose and eyes to run, and your eyes to itch. Sometimes you may also get an itchy rash on your skin, called hives. Antihistamines(Cont.) • Antihistamines have antimuscarinic effect. This means that the drug block receptors found on the surface of certain cells, producing the side-effects associated with antihistamines, such as dry mouth, blurred vision and retention of urine. These effects are mainly caused by the older first-generation antihistamines. Antidepressant

There are three types of antidepressants that block the action of acetylcholine neurotransmitter.

Blocking acetylcholine reduces the production of mucus and saliva secretions causing dry mouth. Nerve damage • Smoking make it worse cause dry mouth Atropine

• Drug working by blocking the effect of acetylcholine in N.S, stomach, sgl • Decrease saliva production and secretion of airway prior to surgery • Treatment of stomach spasm • Contra Indication (allergy, asthma, difficulty in swallowing) Sleep Apnea Dry mouth • With aging, or with the progression of obesity, many adults begin to experience sleep apnea. Often, the development of sleep apnea is attributed to a complication known as obstructive sleep apnea, OSA. • With the development of a sleep disorder, such as that involving obstructive sleep apnea, you may notice a variety of health complications, aside from the poor quality of sleep. Sleep Apnea Dry mouth(Cont.)

• Dry mouth is attributed to the abnormal movement of your facial muscles and mouth during sleep when apnea is present. Xerostomia - Management

qSalivary Stimulants

qSalivary substitutions Xerostomia – Management (cont.)

• Petroleum jelly - which can be applied to the lips to prevent drying and cracking. • Control caries with fluoride application • Monitor for candidosis (antifungal drugs) • Treat difficulties with dentures Xerostomia – Management (cont.)

• Limit your caffeine intake. Caffeine can make your mouth drier. • Don't use mouthwashes that contain alcohol because they can be drying. • Breath through your nose, not your mouth. • Add moisture to the air at night with a room humidifier. Xerostomia Oral Manifestations: 1. Sever dental caries 2. Sever periodontal diseases 3. Atrophied and ulcerated oral mucosa and tongue 4. Superimposed infection, particularly candida albicnans fungus due to changes in oral flora 5. Difficulty in speech, mastication and swallowing 6. Loss of taste 7. Inability to wear dentures Xerostomia - Management 1. Remove the cause if possible 2. Check for any associated drug contributing to xerostomia 3. Frequent small sips of water 4. Prescribe saliva substitutes (artificial saliva) 5. Suggest sugar-free gum 6. Maintain good oral hygiene 7. Chlorohexidine (0.2%) rinses 8. Control caries with fluoride application 9. Monitor for candidosis (antifungal drugs) 10. Treat difficulties with dentures 11. Observe regularly for possible ascending parotitis or chronic sialoadenitis Hypersalivation (Ptyalism) • Definition: Is the condition of excess salivation • Types: 1. True ptyalism In which there is actual increase in the salivary flow and the swallowing mechanism is intact 2. False ptyalism In which the salivary flow is normal while the swallowing mechanism is defective resulting in saliva from the mouth Hypersalivation (Ptyalism)

• True ptyalism: Increased salivary flow + Normal swallowing à à no significant effect • False ptyalism: Normal salivary flow + Defective swallowing à à saliva drooling Hypersalivation (Ptyalism)

1. True ptyalism • Not a problem as any excess saliva can be swallowed • Causes: 1) Local reflexes 1.Oral infections e.g. ANUG 2.Oral wounds and ulcers 3.Dental procedures 4.New dentures 2) Systemic e.g. 3) Toxic e.g. iodine and heavy metal poisoning Hypersalivation (Ptyalism)

2.False ptyalism (drooling) • Is more common and causes annoyance to the patient • Causes: 1) Psychogenic 2) Bell’s palsy (facial paralysis or paresis) 3) Parkinson’s disease 4) Stroke Hypersalivation (Ptyalism)

Treatment: • Removal of the cause, if possible • Antihistamine as it act as a sedative and can produce dry mouth Acute suppurative parotitis (Acute Bacterial Sialadenitis), (Acute ascending parotitis) • Definition: Acute suppurative inflammation of the parotid • Cause and pathogenesis:

• Predisposing factors are xerostomia resulting from postoperative dehydration, irradiation or Sjogren’s syndrome • The causative organisms are staphylococci, streptococci and pneumococci • The mode of infection is ascending i.e. via the duct and rarely blood born. • The disease is now very rare due to the invention of antibiotics and proper post-operative care Acute suppurative parotitis (Acute Bacterial Sialadenitis), (Acute ascending parotitis) • Clinically: • Mainly affect the . • Painful swelling of the gland with uplifting of the ear lobe • The overlying skin is red, shiny and tense • In severe cases edema and difficulty in opening the mouth • Purulent discharge or pus from the affected duct • Fever and malaise • Treatment: • Correction of the cause • Antibiotics Acute suppurative parotitis (Acute Bacterial Sialadenitis), (Acute ascending parotitis) Acute suppurative parotitis (Acute Bacterial Sialadenitis), (Acute ascending parotitis) Chronic Sialadenitis • Definition: This is a chronic inflammation of the salivary glands • Cause and pathogenesis: • Usually results form chronic obstruction due to stones • Clinically: • Painless or painful swelling of the affected gland which become worse at mealtime • Histologically: • Atrophy of the acini • Ductal hyperplasia and dilatation. • Lymphocytic infiltration. • Fibrosis of the stroma (Epidemic Parotitis) • Definition: Acute viral infection of the parotid • Cause and pathogenesis: • The causative virus is paramyxovirus which is RNA. • The mode of infection is droplet infection. • The virus reaches the gland through the duct or more commonly via blood. • One attack produces permanent immunity. • The incubation period is 2 - 3 weeks. • The virus could be detected in saliva and blood (viraemia) prior to the appearance of the disease by 2 - 3 days using complement fixing antibodies Mumps (Epidemic Parotitis)

• Clinically: • Fever and malaise. • Enlargement of one parotid followed by enlargement of the other one within 2 - 3 days - rarely enlargement of both parotids occurs • The enlargement is firm - painful - elevate the lobule of the ear and causing trismus • No pus formation unless secondary infection occurs • The disease is self limiting and spontaneous regression occurs after 2 - 3 weeks • Histologically: • Degeneration of the acini. • Acute inflammatory cell infiltration • Despite the classic correlation of mumps and parotitis, mumps is no longer the most common cause of parotid swelling. Other viral causes include cytomegalovirus, parainfluenza virus 1 and 3, influenza A, and HIV. • Bacterial infections, drug reactions, and metabolic disorders can also cause parotitis. Mumps (Epidemic Parotitis) • Complications (rare, usually in adults): • Extension to other salivary glands. • Hepatitis. • • C.N.S. affection • Orchitis and ovaritis which may lead to sterility • Prevention: • Vaccination with MMR • Treatment: • Supportive treatment (analgesics & antipyretics) • Plenty of fluids and soft diet • Maintain good oral hygiene Mumps Cytomegallic Inclusion Disease Definition: • A viral infection in which salivary glands may be affected Etiology: • A virus known as cytomegallovirus which is a DNA. Clinically: • Usually occurs in infants. infection occurs transplacentally from carrier mothers. • Rarely in adults which are immunocompromised. • - – thrombocytopenia - Enlargement of salivary gland - parotid is affected in infants and submandibular in adults Sialolithiasis, Sialolith (Salivary Calculus) • Occurs usually in adults. • Usually in submandibular more than parotid because the duct of the submandibular is more tortuous and the secretion is more viscous. • The stone occurs in the duct or in the salivary gland. • Calcification occurs around a foreign body, bacteria or desquamated epithelial cell • Calculus consists mainly of calcium carbonate and phosphate in addition to some trace minerals. • They could be detected in X-ray as a radiopaque mass. • The stone causes obstruction and secondary infection of the involved gland. • Clinically there is tender enlargement of the gland and the duct become visible in the floor of the mouth.

Sialolithiasis – Salivary Stones

Wharton's duct is much more commonly involved by a sialolith than is Stensen's duct. In many cases, the stone is difficult to see and often no intraoral manifestations are evident Sialolithiasis – Salivary Stones

• Radiographs are helpful in detecting the stone, or stones, as in this good example. • However, some stones are not radiopaque in X-ray films and hence need sialography Sialolithiasis – Salivary Stones Sialolithiasis – Salivary Stones

The usual result of duct obstruction is inflammation of the gland. The changes consist of ductal dilatation, acinar degeneration, chronic inflammation and fibrosis Cysts of Salivary Glands

1. Mucous Retention Cyst Mucocele 2. Mucous Extravasation Cyst 3. Ranula Mucous Retention Versus Mucous Extravasation Mucous retention cyst • Definition: • A cyst affecting minor salivary gland due to retention of mucous • Etiology: • Partial obstruction of the duct by a stone or stenosis due to inflammation which will lead to slow build up of pressure behind the obstruction • Clinically: • Usually occurs in the lip, tongue or buccal mucosa. • appears as a bluish small swelling which is flactuant • Histologically: • A pool of mucous surrounded by the acinar ductal cells Mucous Extravasation cyst • Definition: • A psuedocyst of salivary gland resulting from extravasation of mucous into the connective tissue due to torn duct • Etiology: • Trauma to the duct • Clinically: • Usually occurs in the lip, tongue or buccal mucosa. • appears as a bluish small swelling which is flactuant • Histologically: • A pool of mucous surrounded by compressed connective tissue with no epithelial lining (psuedocyst) Mucocele

A well circumscribed blue compressible enlargement of the commissure area. The lesion does not blanch upon pressure Mucocele Mucocele

Mucous retention phenomenon. Low- power photomicrograph showing a lobule of normal salivary gland tissue adjacent to a circumscribed pool of mucus. Hematoxylin and eosin stain Ranula • Definition: • A mucous retention or mucous extravasation cyst of major salivary gland usually submandibular or rarely sublingual • Etiology: • Stone, stenosis or trauma of the duct • Clinically: • Large flactuant, bluish swelling similar to frogs belly found in the floor of the mouth at one side of lingual frenum • May cause difficulty in eating, swallowing or speech • Histologically: • A pool of mucous surrounded by acinar or ductal cells if it was a retention cyst or surrounded by compressed connective tissue if it was extravasation cyst Ranula

Ranula (salivary extravasation phenomenon; mucous retention phenomenon; mucocele): A large compressible bluish soft tissue enlargement of the floor of the mouth Ranula

Large mucocele of the left sublingual gland with extension across the midline. Sjogren’s Syndrome Sjogren’s Syndrome

• Definition: An autoimmune disease affecting salivary gland Sjogren’s Syndrome Types: 1. Primary Sjogren`s syndrome, (Sicca Syndrome, Benign Lymphoepithelial Lesion), characterized by: • Dryness of the mouth “Xerostomia” • Dryness of the eyes “Xerophthalmia” 2. Secondary Sjogren`s Syndrome characterized by: • Dryness of the mouth • Dryness of the eyes • Rheumatoid arithritis • Other systemic diseases such as lupus erythematosis, scleroderma Sjogren’s Syndrome

• Etiology: • Autoimmune • Retroviral infection, suspected but not proven yet Sjogren’s Syndrome Clinically: • Age: over 40 years. • Sex: usually females (10 – 1). • Features: • Enlargement of lacrimal glands with keratoconguctivitis sicca • Enlargement of salivary glands (particularly parotid) with xerostomia. • Any other autoimmune disease e. g. rheumatoid arthritis, lupus erythematosus Sjogren’s Syndrome

• Oral Manifestations: Are those of xerostomia: 1. Sever dental caries. 2. Sever periodontal diseases. 3. Atrophied and ulcerated oral mucosa. 4. Superimposed infection. 5. Difficulty in speech, mastication and swallowing. 6. Inability to wear dentures. 7. Loss of taste Sjogren’s Syndrome Histopathology: 1. Atrophy of the acini. 2. Ductal hyperplasia forming masses of epithelial and myoepithelial cells called epimyoepithelial islands 3. Dense lymphocytic infiltration with or without germinal centers, thus the disease is described as a lymphoepithelial lesion. 4. 85 % of minor salivary gland show the same picture particularly those of the lip 5. The oral mucosa show signs of atrophy + parakeratosis + lymphocytic infiltration Sjogren’s Syndrome Lymphocytic infiltrate destroying salivary gland in Sjogren’s syndrome. Sjogren’s Syndrome Lymphocytic infiltrate destroying salivary gland in Sjogren’s syndrome. Sjogren’s Syndrome Differential Diagnosis:

1) Malignant lymphoma: there is:

1. Absence of epimyoepithelial islands

2. Atypical lymphocytes

3. Invasion of the connective tissue septa and the capsule

2) Papillary cystadenoma lymphomatosum Sjogren’s Syndrome Serologic Abnormalities:

1. Antisalivary duct antibodies.

2. Rheumatoid factor

3. Complement fixing antibodies.

4. Increased sedimentation rate Sjogren’s Syndrome

Sialography:

• The injected material will escape from the ducts and produce radiopaque mass scattered within the gland

• This picture is called

• sialoectasis or

• snow storm appearance or

• branchless fruit laden tree Sjogren’s Syndorme – Sialography

This picture is called sialoectasis or snow storm appearance or branchless fruit laden tree Sjogren’s Syndrome • Diagnosis: 1. Labial gland biopsy. 2. Sialography. 3. Serological tests. • Treatment: • No available treatment • However management of xerostomia and xerophthalmia is essential • treatment with immunosuppressive drugs Sjogren’s Syndrome

• Complications:

• Malignant lymphoma in 6% of patients.

• Squamous cell carcinoma is rare.

• For these reasons treatment with immunosuppressive drugs e.g. corticosteroids is contraindicated