Salivary gland disorders and its management.pptx

salivary glands disorders and its management

1. Salivary gland disorders Dr Sinitha Sreedhar Dept of Oral Medicine & Radiology

2. Classification Neoplastic Non- neoplastic Congenital / developmental Inflammatory / traumatic/ ischemic Infective Endocrine Autoimmune Obstructive Drug induced

3. Non- neoplastic SG disorders Developmental Aplasia Agenesis Atresia Abberancy Hemangiomas Inflammatory Stomatitis Nicotina Necrotizing sialometaplasia Chelitis glandularis Mucocele

4. Infective Bacterial Acute sialadenitis Chronic non specific and specific sialadenitis Viral Mumps Mumps like diseases HIV induced SG diseases Obstructive Sialolithiasis Strictures

5. Endocrine Alcoholic cirrhosis DM Acromegaly Malnutrition Chronic renal failure Cystic fibrosis Autoimmune Sjogren’s syndrome Drug induced Chlorhexidine , Isoprenaline , Iodine, Phenyl butazone

6. Neoplastic Malignant epithelial tumors Adenoid cystic carcinoma Mucoepidermoid carcinoma Acinic cell carcinoma Cystadenocarcinoma Benign epithelial tumors Pleomorphic adenoma Warthin’s tumour Lymphadenoma Oncocytoma

7. Xerostomia Definition Due to decreased salivary flow or decrease composition of the saliva and there are many of other causes Subjective feeling of oral dryness and it is the result of salivary hypofunction

8. Causes Iatrogenic Drugs- atropine, antidepressants, antihypertensives Irradiation Graft versus host reaction Chemotherapy Developmental – Salivary glandAgenesis / Atresia Dehydration- controlled diabetes, chronic renal failure Diseases of salivary gland- sjogren’s syndrome , cystic fibrosis , parotidectomy , infections Infection – Hepetitis C ,HIV Physiological – post exercise, mouth breathing Psychogenic – stress, depression

9. Drugs Anticholinergic agents Antidepressants , antipsycotics Antihypertensives Diuretic agents Muscle relaxants Sedatives Analgesics NSAIDS Antihistamines

10. Clinical features Symptoms Sensation of burning Swallowing difficulty, Speaking difficulty Sensation of taste reduction Infection, recurrent ulceration, dental caries Signs Dryness , lack of salivary pooling in the floor of the mouth Erythema , ulceration, infections Increased dental caries and periodontic diseases Lipstick sign Tongue blade sign Crackers sign Mucosa stick to mouth mirror

11. Complications

12. Diagnosis Salivary flow rate Sialography Salivary scintiscanning Lacrimation flow Urinanalysis Blood tests ESR Antinuclear antibodies Rheumatoid factor Serology Serum calcium Imaging- USG, MRI Biopsy

13. Management Symptomatic Preventive Curative

14. Symptomatic Non-sugar containing fluids Humidifiers Lip moisturizers and emolients Avoid Dry foods, spicy foods Mouth rinses with high alcohol content Local saliva stimulants – rinses, gums, candies Systemic sialogogues Cevimeline hydrochloride 30mg tid Pilocarpine 5mg tid Interferon alpha

15. Composition of artificial saliva Carboxy methyl cellulose Sorbitol Sodium chloride Magnesium chloride Calcium chloride Dipotassium hydrogen phosphate

16. Preventive Increase oral hygiene measures Topical fluoride application If bacterial infection , antibiotics Candidal infection , systemic or topical antifungals

17. Curative If due to drugs, stopping or changing drugs in physician’s consultation Identify the cause by history and examination

18. Sjogren’s syndrome Chronic autoimmune disease characterised by symptoms of oral and ocular dryness, exocrine dysfunction and lymphocytic infiltration and dystruction of the exocrine glands 1-3% of general population Females > males (9:1) Peri and post menopausal women 4-5 th decades Described by Henrick Sjogren Primary Sjogren’s syndrome Secondary Sjogren’s syndrome Classification

19. Etiology Genetic predisposition A link between MHC genes and development of autoimmune diseases Association with HLA system Viruses Cytomegalovirus EBV HCV HTLV-1 HRV-S Sex hormones Oestrogen Prolactin

20. Pathogenesis

21. SS-1 ( Sicca complex)

22. SS-2

23. Clinical features Symptoms Xerostomia with unpleasant taste Angular cheilitis Pus discharge Unilateral/bilateral intermittent enlargement of salivary glands Thick, frothy saliva Glazed, dry mucosa , redness or soreness Partial/ complete depapillated tongue with reduced number of taste buds Severe dental caries, periodontal diseases Enlarged tender regional lymph nodes

24. Signs Unpleasant taste Difficulty in eating Soreness of the mouth Difficulty in speech SS affects nose, throat, trachea, vagina and skin and also thyroid, lung, kidney. Dryness of pharynx, larynx and genital areas Patient may experience arthralgia , myalgia , rashes, peripheral neuropathy

25. Eye Sensation of dryness Burning sensation Redness Frequent conjunctival infections Ulceration

26. Diagnosis

27. Sialochemistry Elevated levels of IgA , K and Na in saliva of patients with sicca complex Increased phospholipids and glycolipids Sialometry Salivary flow rate < 1.5 ml/ 15mts Sensitive indication of salivary gland function Sialography Shows sialectasis – Snow storm appearence

28. Schirmers test A standardised strip of filter paper is applied over margin of the lower eyelid After 5 mts with eyes lightly closed, paper is removed and length of moistened part is measured. Cut off value is 5mm/5mts In SS very low reading <5mm

29. Rose Bengal test 2.5 micro L 1% Rose Bengal dye isinstalled in eyes Stains any breaks or dessicated epithelial cells in the corneal epithelial surface Amount of stain is expressed as van Bijsterveld score 0-3 , 0 is normal and 3 is the highest level of staining

30. Sialolithiasis Formation of sialolith in the SG or duct , resulting in the obstruction of salivary flow Sialoliths are calcified and organic matter that are developed in the parenchyma or ducts of SG Precipitating factors Salivary stagnation Increased alkalinity of saliva Infection or inflammation of SG or duct Physical trauma to salivary duct Anticholinergic medication Recurrence rate is 20 %

31. Diagnostic criteria Focal lymphocytic sialadenitis with focus score 1 per 4 mm square Unstimulated salivary flow <1.5 mL /15 mt Abnormal parotid sialography Abnormal salivary scintigraphy Presence of Ro(SSA) or La(SSB) or both in serum

32. For SS1 Any 4 of the 6 criteria, must include IV OR VI Any 3 of the 4 criteria III, IV, V, VI For SS2 Presence of 1 symptom (I or II) + 2 of the 3 criteria(III,IV,V)

33. Management Required multispecialists General physician Ophthalmologist Oral medicine specialist Rheumatologist Oral physician Treatment of xerostomia Treat caries, candidiasis Maintenance of oral hygiene First drug of choice– corticosteroids

34. Mikulicz disease Abnormal persistent enlargement of salivary and lacrimal glands with dry mouth, dry eyes 50-60 yrs of age Infiltration of IgG-4 positive plasma cells Biopsy and USG

35. Sialadenitis Inflammation of SGs which is characterised by a painful swelling of the affected glands Sialodochitis – inflammation of the duct system of a SG Sialectasis - dialatation of the ducts within salivary glands , associated with infections and gland destruction

36. Types Bacterial Viral Allergic Immune sialadenitis Radiation induced Sarcoid sialadenitis

37. Bacterial sialadenitis In patients with reduced SG function Acute Bacterial sialadenitis Age : older adults Males> females Etiopathogenesis : Streptococcus viridans and staphylococcus aureus Parotid glands most commonly affected Acute Chronic

38. Causes Decreased host resistance Salivary secretion and bacterial effects Composition of the saliva Calculi, mucus plugs, duct strictures Clinical features Symptoms Painful, tender enlargement in the gland Trimus pain in TMJ region Fever Taste disturbances

39. Signs The overlying skin can be reddened Pus Tender on percussion; hot and indurated Spread to surrounding tissues also Leucocytosis Malaise

40. Treatment Hydration and improved oral hygiene Maintain electrolyte balance Soft diet as chewing is painful to the patient Stimulate salivation to facilitate drainage of pus Lemon juice suction to promote salivary flow Analgesics High dose of parentral antibiotics against staphylococcus

41. Chronic bacterial sialadenitits Sialolith with bacterial infection – S tr Viridans Duct obstruction due to tumors, foreign bodies, scar formation Features Periodic swelling and pain ,mainly at meal time D/D Calculus , neoplasm Investigations Plain radiographs, USG, MRI, sialography

42. Viral sialadenitis Cause acute non- suppurative sialadenitis Causative viruses are Paramyxovirus (Mumps) Cytomegalovirus HIV HCV Epstein-Barr virus

43. Mumps Acute contagiousmviral infection characterised chiefly by unilateral orm bilateral swelling of the salivary glands usually parotid 2-3 weeks Clinical features : 4-6 yrs Parotid>SM Usually bilateral

44. Initial symptoms : headache, chills,myalgia , fever, vomiting, preauricular pain Skin over swelling will be edematous Firm, rubbery or elastic in consistency Ducts inflamed without purulent discharge Swelling elevate the ears Swelling lasts for 7 days

45. Diagnosis Isolation – saliva or throat swabs Serum amylase elevated Complement fixation test ELISA PCR

46. Treatment Conservative management MMR vaccine –prevention Overall prognosis are good Death occurs due to CNS or cardiac involvement

47. Sialolithiasis Formation of sialolith in the SG or duct , resulting in the obstruction of salivary flow Sialoliths are calcified and organic matter that are developed in the parenchyma or ducts of SG Precipitating factors Salivary stagnation Increased alkalinity of saliva Infection or inflammation of SG or duct Physical trauma to salivary duct Anticholinergic medication Recurrence rate is 20 %

48. Mechanism More often in submandibular gland ?

49. Clinical features Middle aged most affected Males>females 90% in submandibular > 6% parotid >sublingual Size few mms to several cms Symptoms Presents usually unilateral Meal time swelling Moderate pain Fever and malaise Signs Pus discharge through orifices Severe inflammation in the soft tissues Overlying mucosa ma ybe ulcerated Sialoliths may be palpated if present in the extraglandular portion Enlargement of the glands

50. Investigations Conventional radiographic views Rotated PA or oblique lateral IOPAR Occlusal OPG Advanced radiography Sialography – ductal dialatation proximal to the calculus causing filling defect in the main duct Ultrasound – stones as hyperechoic mass CT scan – stones as hyperdense mass

51. Complications Long duration- bacterial infection of the gland Sialoangiectasis Mucoceles Atrophy of the gland

52. Management Several techniques – depends on size, number , site of stone and age of the patient Small sialolith - milking of the gland Large- surgically Stones which are not deeper – intubation of the duct and application of suction to the tube Multiple stones in gland – removal of gland Other techniques- piezo electric shock wave Lithotripsy

53. Oral Mucocele Most common SG disorder and 2 nd most common benign ST tumour in the oral cavity Mucocele is defined as mucous filled cavities that can appear in the oral cavity, appendix, gall bladder, paranasal sinuses or lacrimal sac

54. Types Based on involvement Superficial Deep Based on mechanism Extravasation Retention

55. Extravasation

56. Retention type

57. Aetiopathogenesis Trauma Habit of lip biting and tongue thrusting Obstruction of salivary gland duct

58. Phases of the extravasation type

59. Clinical features Well-circumscribed transparent, dome-shaped, soft and fluctuant nontender swellings, with intact epithelium over it . Size may vary from few mms to cms Lower lip, BM, tongue Asymptomatic with rapid onset , frequently resolves spontaneously. Patient may give history of increase and decrease in size of swelling

60. Superficial – bluish Deep – normal mucosal colour Bluish discoloration – due to vascular congestion and cyanosis of the tissue above and fluid accumulation below

61. Differential diagnosis Benign or malignant SG neoplasms Soft irritation fibroma Oral haemangioma Venous varix Lipoma

62. Investigaions Excisional biopsy

63. Treatment Conventional surgical removal Other CO2 laser ablation Cryosurgery Micro marsupiaization Marsupiaization Electrocautery Intralesional corticosteroid injection

64. Ranula Mucoceles that occur in the floor of the mouth Associated with submandibular or sublingual SG It resemblesappearence of a frog’s translucent under belly

65. Etiopathogenesis Trauma Obstruction

66. Clinical features A unilateral, fluctuant, soft tissue mass in the floor of the mouth Size varies. Large– medial and superior deviation of tongue Crosses midline Appearance of overlying mucosa varies upon location Superficial – bluish transluscency Deep seated – normal

67. Plunging or cervical ranula – spilled mucin passes through the mylohyoid muscle and along the facial planes of the neck producing the swelling rare occassions – progress into mediastenum

68. Differential diagnosis Sialadentitis Sialolithiasis SG tumours Thymic cyst and cystic hygroma

69. Treatment Surgical excision Marsupialization before excision

70. Necrotizing sialometaplasia Reactive necrotizing inflammatory process Benign self-limiting inflammatory condition Pathogenesis Trauma—injury on the blood vessels– ischaemic changes—necrosis of glandular tissue—sequestration—ulceration— metaplastic changes occurs in ducts—normal glandular structure replaced by fibrous connective tissue—heals

71. Etiology Trauma Infectious processes Radiotherapy Use of tobacco or cocaine

72. Clinical features More commonly in men 5 th -6 th decades Palate, BM, lips, retromolar pad Extraoral sites – nasopharynx Swelling, feeling of fullness Pain only in large ulcers

73. Treatment Self-limiting Debridement and saline rinses- aid in healing process Recurrence is rare