1

Salivary Glands

(Burkets Oral Medicine)

Anatomy
faculty.ksu.edu.sa/Prof.Hamam

Clinical evaluation(sign&symtoms of S.G.hypofuntion)

Diagnosis
Saliva collection
S.G. imaging modalities
S.G. biopsy
Serolgic evluation
Specific diseases & disorders of S.G.
Sialorrhea ( ptyalism)
Xerostomia
Sialolithiasis (salivary stone )

Mumps
Postopertive parotitis
Sialadenitits
Mucoceles
Ranulas
Necrotizing sialometaplasia
Sjogrens syndrome
Neoplastic S.G.
Bengin ( pleomrphic adenoma )
Malignent ( mucoepidermoid carcinoma )
Lymphoma

SALIVARY
GLANDS

Anatomic location of the 3

major
salivary glands in human

3 major S.G.have a basic anatomic

structure.They are composed of acinar & duct
cells arranged much like a cluster of grapes on
stems.
The acinar cells of the parotid gland are
serous,those of sublingual gland are mucous &
those of submandibular gland are of a mixed
(mucous & serous) type.

Clinical evaluation

(Signs & Symptoms of S.G. hypofunction )

Sings : Patients with S.G.hypofunction have

obvious signs of mucosal dryness : 1-the lips are often cracked,peeling and
may be atrophic.
2- the buccal mucosa may be pale &
corrugated in apperance.
3- the tongue is often smooth & reddend
with loss of papilation.Tongue blade

4- lips stick to the teeth(one may see shed

epithelial cells adhering to the dry
enamel.)
5- there is a marked increase in erosion &
caries ( decayed on root surface,cusp&
tip)
6- candidiasis is most commonly of the
erythematous form.
7- enlargment of salivary glands

Expressed saliva should be

clear,watery and copious,viscous or
scant secreation suggest chronically
reduced function

Symptoms :-

( due to decreased fluid in oral cavity )

1- dryness of all the mucosal surface

( throat,diffcultities chewing,swallowing &

speaking )
2- inability to swallow dry foods .
3- the mucosa may be sensitive to spicy or coarse
foods

Diagnosis
The differential diagnosis of xerostomia &
Salivary gland dysfunction is a lengthly process
Past & present M.history:- (medications&radiotherapy)
Questions helpful in evaluating patients with complaints of dry mouth
1- do you have difficulty swallowing dry foods?
2- does your mouth fell dry while eating a meal ?
3-do you sip liquid to aid in swallowing dry food ?
4-does the amount of saliva in your mouth most of the time seem to be too
little,too much or do you not , notice it ?
* Positive responses to questions 1-3 or the perception of too little saliva
( question 4 ) are significantly associated with reduced salivary gland
function .

Palpation :- should be painless

Enlarged painful glands are indicative
of infection or acute inflammation.
The consistency of the gland should
be rubbery but not hard & distinct
masses within the body of the gland
should be present.

Saliva collection
Salivary flow rates provide essentional informmation for diagnostic

& research purposes.

Saivary flow rates can be calculated from the individual major
salivary glands or from a mixed samples of the oral fluids (whole
saliva )
The suction & absorbent (swab) methods
Unstimulated whole saliva flow rates of <0.1 ml/min.and
stimulated whole saliva flow rates of <1.0 ml/min.are considered
abnormally
Low& indicative of marked salivary hypofunction.
Individual parotid gland saliva collection is performed by using
Carlson- Crittenden Collectors.

 Recent work in Sjogren syndrome is

beginning to identify changes in salivary

cytokine & other protein levels that may
have diagnostic significance .
Saliva may play a greater diagnostic role
In monitoring for the presence and
concentrations of drugs of abuse and
therapeutic agents.

Salivary gland imaging

modalities

Rule/out
=R/O

Occlusal view demonstrating a

calcified deposit in Whartons duct

Sialogram
Submandibular gland demonstrating an
uncalcified sialolithiasis in Wharton
Whartons duct

It shows puncate sialectasis

in parotid (Sjogren Syndrom )

Axial view of a CT image softtissue

window demonstrating a tumor of
the right parotid .(CT)

Scintigraphy of S.G
Parotid & submandibular glands
in this healthy individual .

The thyroid gland can visulized

at the inferior of the frame

Scintigraphy of parotid gland

Top row ; shows normal patient
Bottom row ; shows acute sialoadenitis

MRI of the head showing enlarged

parotid glands.

This is a T1-weighted image and demonstrates cystic ares

and the presence of lymph nodes within the glands

Salivary Gland Biopsy

In Sjogren's Syndrome (fine- needle
sample.FNA)
In Lymphoma ( immunophenotyping of
tissue)

Serologic evaluation

blood studies ( in dry mouth )

non-specific markers of autoimmunity such as
(antinuclear antibodies,rheumatoid factors,elveted
IgG,Erythrocyte sedimentation rate

* Antibodies directed against specific

extractable nuclear antigens (ss-Alro or
ss-B/la ) in sjogren syndrome
Serum amylase

Specific diseases and

disorders of the salivery
glands

Specific diseases and disorders of the salivery

glands

(Etiologic classification of S.G.

1- Developmental
*aplasia ( absence of the gland )
*atresia ( absence of the duct )
11- infectious disorders
*Viral ;
mumps, cytomegalovirus,HIV-SGD,Hepatitis,
*Bacterial
acute;postopertive(bacterial)parotiditis,tuberculosis,
syphilis,actinomycosis,sarcoidosis

diseases)

111-Neoplastic
*Benign
Pleomorphic adenoma
Papillary cystadenoma lymphomatosum
Oxyphilic cell adenoma
*Malignant
Lymphoma
Mucoepidermoid carcinoma
Adeno cystic carcinoma
Squamous cell carcinoma

1V-Obstuctive
Mucous retention cyst
Mucous extravasation cyst
Sialadenitis
V-Metabolic disorders
Sjogrens syndrome ,Thyroid
disease,Alcoholism,malnutrition,Eating
disorders(anorexia,bulimia,uncontrolled diabetes )

1-SIALORRHEA
(PTYALISM)

( increased salivary flow )

1-Infants due to inadequate swallowing
2-Children with enlarged tongue or
pharyngitis
3-Stomatitis e.g. ANUG.erythema
multiform.metalic intoxication
4-Facial palsy
5-Epileptic & mental retard patient

 6- Parkinsonian patients
7-Oseophageal stricture
8- Drugs:
Mercurial,iodide,pilocarpine,neostigmine .
9- Voluminous lesion in the oral cavity
e.g. fungating carcinoma
10- Insertion of new denture

Treatment
1- Determine the eitologic factor and if

possible remove it
2- Atropine or belladonna ( small dose )
Propantheline 15 mg tablet one hour
before treatment ( dental clinic )
3- Antihistamine e.g 50 mg tablet
promethazine hydrochloride

Xerostomia- 2
It is a clinical manifestation of salivary gland
dysfunction and it does not represent a disease
entity .Dry mouth varies from minimal viscous
appearance of saliva to complete absence of any
salivary flow.
Etiology
Xerostomia may be due to physiologic or pathologic

* Physiologic

Excessive speaking
During sleep: No salivary secretion from parotid
Old age :Senile atrophy of salivary gland

*Pathologic :

(1)- Systemic factor

1- Endocrinal
Diabetes melitus,diabetes
insipidus,hyperthyrodism

2- Drugs
Morphine: acts on salivary
Atropine:antidepressant,traquilizers,and
antihypertensive:act on autonomic
nervous system
3- Nutritonal:
Vit. B deficiency(especially nicotinamide )

(11)-Local factors
1-salivary glands
A- obstractive calculi
B- Infection: mumps
C- Degenerative Sjogrens syndrome ,irradiation
D- Developmental : Aplasia , Atresia
2- Oral Cavity
a- Heavy smoking
B-Mouth breathing

Clinical features

A- Mild form:
the oral mucosa appears quite normal
B- Moderate
*atrophy & erythema of oral mucous membrane
*Dry,glossy easily injured mucous membrane
The tongue coating (start as increased but later
becomes atrophic
Wrinkling and fissuring of tongue

 C- sever form

*The oral epithelium is red & atrophic

Dryness and burning sensation
Dry & fissured lip
Difficulty in speaking and eating
Hyperplastic ,labial gingiva in the upper anterior region
Dry,shiny , red gingiva and often easily bleeds
Candidal infection is a common secondary infection
High rate of caries
Difficulty in wearing dentures

Treatment
1- Removal of cause wherever
possible
2-Mild cases : frequent drinks

Treatment

3- Moderate/sever
A-if the secretory activity of salivary glands is lacking
*topical application of paraffin flavoured with lemon juice
*2%methyl cellulous mouth wash
If the secretory activity of salvary glands is still present
*Pilocarpine
*Neostigmine
*Potassium iodide
B- If nutritional: Nicotinamide 300-400mg t.d.s.for 10 days, if B
complex deficiency is suspected
N.B.Denture wearers have to coat their dentures with lubricating
jelly or deture adhesive power

3- Sialolithiasis
(salivary stone )

Sialoliths are calcified(crystaline) and organic

matter(hydroxyapatite) that form within the secretory

system of the major salivary glands
Etiology :
Unknown but it may be due to :1- inflamation
2- irrgularities in the duct system
3- local irritant
4- medications ( may cause pooling of saliva within the
duct . The promote stone formation
6- abnormal serum and phosphorous level & dite

Sialolithiasis

(salivary stone )

Submandibular enlargement
associated with sialolithiasis

Occlusal radiograph showing a

sialolith in the floor of the mouth

painful, swelling ,in chronic cases ,stasis of saliva

may lead to infection,fibrosis,sinus

Sialolithiasis of
submandibular duct

Sialolith removed

 The most common site is ,the submandibular

gland (90% of cases),the parotid gland (5-15%

of cases ) ,the sublingual (2-5 % of cases )
The higher rate of sialolith formation in
submandibular gland due to : 1- the torturous course of whartons duct
2- higer calcium & phosphate levels
3- position of the submandibular glands which
leave them prone to stasis

4- Mumps

(epidemic

parotitis )

Definition

It is an acute contagious disease caused by paramyxovirus (RNA)

Age :- common in children,but may occur in young adults
Prodrome :- headache,fever,malaise.(1-2 days)
Swelling of parotid gland reaches its maximum about second or
third day. It is tender, firm,smooth , edema
Unilateral or bilateral , uplifting of the ear lobe and trismus
Inflamation of parotid duct ( without purulent discharge )
Complications:- orchitis,pancreatitis,ovaritis and encephilitis
Treatment :Symptomatic ,bed rest , general supportive therapy , oral hyigen

Mumps
Swelling associated with
mumps

Swelling associated abscessed

mandibular molars

Bilateral S.G.enlargement
often
associated with HIV

PATIENT DEMONSTRATES PAROTID

SWELLING DUE TO A BACTERIAL
INFECTION

Sialadenosis ,Asymptomatic parotid

swelling in an alcoholic patient

Herrfordts syndrome

(uveoparotid fever,rare form of Sarcoidosis )

chronic condition in which T-lymphocytes,mononuclear
phagocytes & granulomas cause destruction of involved
tissue .

Bilateral,firm,painle
ss,swelling of
parotid glands
,ocular lesions
(conjuncvitis) facial
paralysis

Multiple red nodules on the upper lip

5- Postoperative parotitis
(acute bacterial parotitis)

It is acute bacterial infection caused by staphyloccus

aureus

Clinical features

Rapid onset,sever pain,swelling , edema

Fever, headache,malaise,
Trismus
Purulent discharge ( from parotid duct )
Xerostomia , dehydration
Treatment :Antibiotic , drainage , rehydration

The expression of purulence from

stensons duct seen in this patient is one
of the signs of acute parotitis

6- Sialadentitis
It is an inflammatory disease of the major
Salivary glands characterized by gland
swelling

Etiology : Submandibular S.G.( salivary duct

obstruction)
Parotid gland
:-obstruction,hyposecretion,infection with
normal oral flora

 Clinical features: 1- recurrent sialadenitis

Recurent attacks of swelling and pain of salivary gland

at meal time
The symptoms subside between meals or if saliva is
forced out by massaging
On massaging there is mucopurulant discharge
containing pus cells.
Orifice may be inflamed
The swelling may not subside between meals if duct
obstruction is complet
Treatmeant ,remoal of obsteraction

 2- Acute sialadenitis
Swelling and pain of salivary gland with

slight trismus
On massaging there is mucopurulant
discharge from the inflamed duct
Treatment : Antibiotic , drinage ,removal of the stone

Bilateral chronic submaxillary

sialadenitis in dehydrated patient

Mucoceles- 7
It is a clinical term that describes swelling
Caused by the accumulation of saliva at the site
of a traumatized or obstructed minor salivary
gland duct .
It classified into: 1- Extravasation type
2- Retention type
A large form of mucocele located in the floor of
the mouth is known as a ranula

Clinical photograph depicting a fluctuant

mucocele

Mucus extravasation
phenomenon of the lower lip

Superfacial mucocele of the

palate

1-Extravasation
Precepitated by trauma
Lower lip, buccal mucosa,tongue,floor of the

mouth,retromolar region
Mucous retention cysts (palate or floor of mouth)

Clinically : Painless,blue hue, common than retention type

The development of a bluish lesion after trauma is highly
suggestive a mucocele , other lesions ( including
salivary gland neoplasm,soft-tissue neoplasm,vascular
malformation,vesiclobolus diseases ) should be
considered .

2- Retention type
1-obstruction of minar S.G.duct by
calculus
2- contraction of scar tissue around minor
S.G.The blockage of salivary flow causes
the accumalation of saliva & dilation of the

8- Ranulas
It is a large mucocele located on the floor of the mouths.
Ranules may be either mucous extravasation phenomena or mucous
retention cysts & are most commonly associated with the sublingual
salivary gland duct

Etiology :

Trauma
Obstructed salivary gland
Ductal aneurysm
Sarcoid- associated ranula
Clinical presentation
It resembles the swollen abdomen of a frog ( bluish hue )
Painless ,slow growing , soft, movable mass of the floor of mouth

Ranula on the floor of the

mouth

Plunging ranula

Ranula
A- blockage of Whartons
duct

B-tongue may be elevated

Drinage is achieved

Complication
A deep lesion that harniates through the mylohyoid
muscles & extends along the fascial planes is
referred to as a plugging ranula & may become
large, extending into the neck.

Treatment :- surgically

9- Necrotizing
sialometaplasia

It is(Inflammatory
a benign self-limiting
& reactive reactive
lesions ) inflammatory disorder of
the salivary tissue .(mimics malignancy,initiated by a local ischemic
event )

Etiology :
After oral surgical procedures
Restorative dentistery
Administration of local anesthesia
Induced vomiting practiced by patient sufferring from bulimia

Treatment :
Biopsy
Self- limiting ( lasts 6- weeks )
Heal by secondary intention

Necrotizing sialometaplasia of the

hard palte

10-Sjogrens syndrome

It is a symptoms complex marked by

keratoconjuctiva sicca. Xerostomia and

enlargement of salivary gland
Etiology
Unknown ,immunologic ,virus
Clinical features
Primary SSSica syndrome with no clinical
features of the C.T.disease
Secandary SS:- there are C.T. disease e.g.
rheumatoid arthritis ,systemic lupus
erythematous, or other autoimmune diseases.

 Glandular involvement : 1- Ocular symptoms , itching , redness &

xerophthalmia
2- parotid gland
Early stage, induration without enlargement ,
Late stage , diffuse , non tender or slightly tender
swelling
Complication, protid lymphoma is a lethal
complication of primary SS

 3- Oral features
Dry,sticky,erythematous mucous membrane
Difficulty in speaking or denture wearing
Atrophic lobulated tongue
Increased susceptibility to : Candidal infection
Caries
Periodontal disease
Acute sialadenitis

Extra-glandular involvement
Respiratory tract: recurrent respiratory infection
Vaginal glands, dry vaginal mucosa with candidal infection
Diagnosis
1-Diminished salivary flow rate (normal;1-5ml/min.with
10%citric acid )
2- Sialography : punctate sialctasis .
3- Biopsy:
4- hypergammaglobulinemia
5-Raised ESR
6- Salivary scintigraphy ( decreased function )
7- MRI ( being non invasive ,great help ) it give salt &
paper

A patient with Sjogrens

Syndrome

The tongue of a patient with Sjogren

syndrom and salivery hypofunction .

Enlarged major S.G.This was

found to be a benign condition

Depappillation tongue,dry,
Corrugated appearance

dry,labulated tongue

Sjogrens Syndrome
Sever ocular lesions

Bilateral enlargement of
submandibular glands

Bilateral parotid enlargement secondary

to Sjogrens Syndrome
D.D. Mikuliczs disease ( benign lymphoepithelial lesion )
Autoimmune,viral,genetic factors,
Swelling of S.G. due to a benign lymphoid infiltration
Reduced salivary flow ,lead to infection

Treatment

1-Mangement of xerostomia
2- antifungal
3- antibacterial
4- caries ( topical flouride application ,good oral
hygiene , 2% chlorhexidine mouth rinse )

Neopastic salivary gland-11

*Benign

Pleomorphic adenoma
Papillary cystadenoma lymphomatosum
Oxyphilic cell adenoma

*Malignant

Carcinoma pleomorphic adenoma

Mucoepidermoid carcinoma
Adeno cystic carcinoma
Epidermoid carcinoma

Pleomorphic adenoma
It is a mixed tumour(epithelial&mesenchymal
elements,
parotid,submandibular,sublingual
intra-orally ( palate,upper lip, buccal mucosa )
painless,firm,mobile masses,indurated lymph
nodes

Treatment

;surgical removal with adequate

margins

Pleomorphic adenoma
Clinical photograph of benign
adenoma of the palate

MRI,T2-weighted image,lesions that

recur after inadequate surgery

It is characterized by ductal
structuers,spindled
myoepithelial cells&a diverse
myxoidstroma

Malignant tumors
(muco-epidermoid
carcinoma
Most common) malignant tumor of
parotid gland
High-grade (poor prognosis )
Low-grade (like benign tumor )
Pain,ulceration , facial palsy

Mucoepidermoid carcinoma
M.E.C. of the palate

M.E.C. of the retromolar area

Lymphoma
Lymphoid tissue within the glands
Major forms of lymphoma are non-

hodgkins lymphoma (NHL) & Hodgkin s

disease
Parotid , submandibular gland
Painless,enlargement S.G.
Tretment ;
Radiation, chemotherapy

Hodgkins disease , swelling of the

cervical lymphnodes

Non-Hodgkins Lymphoma