1. Non Neoplastic Lesions Of Salivary Glands

2. CLASSIFICATION OF SALIVARY GLAND DISORDERS

3. CLASSIFICATION DEVELOPMENTAL DISORDERS
APLASIA of Salivary Gland
CLASSIFICATION
HYPOPLASIA
ACESSORY Salivary Gland And Ducts
ABERRANT Salivary Glands
DIVERTICULI

4. CLASSIFICATION OBSTRUCTIVE DISORDERS MAJOR SALIVARY GLAND
SIALOLITHIASIS
CLASSIFICATION
MINOR SALIVARY GLAND
EXTRAVASATION
MUCOCELE
RETENTION

5. OBSTRUCTIVE DISORDERS
RANULA
CLASSIFICATION
FOREIGN BODIES

6. FUNCTIONAL DISORDERS
XEROSTOMIA
CLASSIFICATION
PTYLASM

7. INFLAMMATORY & REACTIVE DISORDERS
NECROTISING SIALOMETAPLASIA
RADIATION INDUCED SIALADENITIS
ALLERGIC SIALADENITIS

8. VIRAL DISEASES MUMPS VIRAL INFECTIONS : HCV INFECTION HIV INFECTIONS
CYTOMEGALOVIRUS INFECTION

9. BACTERIAL DISEASES ACUTE BACTERIAL SIALADENITIS
CHRONIC OR RECURRENT SIALADENITIS

10. WITH SALIVARY GLAND INVOLVEMENT
SYSTEMIC CONDITIONS
WITH SALIVARY GLAND INVOLVEMENT
SYSTEMIC METABOLIC CONDITIONS :
Diabetes mellitus
anorexia
Bulimia
Alcoholism

11. AUTOIMMUNE DISEASES: SJOGREN’S SYNDROME (prim & sec)
MICKULICZ’S DISEASE

12. GRANULOMATOUS DISEASES:
TUBERCULOSIS
SARCOIDOSIS

13. Necrotising sialometaplasia
salivary gland infarction
Non neoplastic ,inlf condition
Significance
Abrams et al in 1973
Etiology
Local trauma
Surgical manipulation
local anesthesia
Radiation therapy
Vascular ischemia
local infarction

14. Predisposing factors
Traumatic injuries
Dental infections
Ill fitting dentures
Adjacent tumors
Previous surgeries
Clinical features
Minor salivary glands of palate
Others areas
Parotid, smg, minor mucous glands of lungs nasal cavity, larynx, trachea and max sinus

15. C/f
Initial lesion swelling with or with out ulceration
Crateriform ulcer of palate
1 to 3 cms
Unilateral
Erosion of the palate
Age 17 to 80 yrs
m:f 2:1

16. Histologic features
• Necrosis of acini and ducts
• Squamous metaplasia, accompanied by fibrosis, increases with evolution of the lesion
• Varying degrees of acute and chronic inflammation depending on the age of the lesion

17. • Squamous nest relatively small and fairly uniform in size
• In minor salivary gland related lesions, the overlying epithelium may show pseudoepitheliomatous hyperplasia

19. D/D:
SCC
Syphilic gumma, deep fungal infection
Wegener’s granulomatosis
Extranodal lymphomas
Treatment:
Resolves spontaneously
Periodic evaluation
Prognosis excellent

20. Obstructive SG Disorders: Sialolithiasis
A stone in the salivary duct or gland
Mechanical obstruction of the salivary duct
Major cause of unilateral diffuse parotid or submandibular gland swelling
Most frequent reason for submandibular gland resection

21. Sialolithiasis
The exact pathogenesis of sialolithiasis remains unknown.
Thought to form via….
an initial organic nidus that progressively grows by deposition of layers of inorganic and organic substances.
May eventually obstruct flow of saliva from the gland to the oral cavity.

22. Sialolithiasis
Acute ductal obstruction may occur at meal time when saliva producing is at its maximum, the resultant swelling is sudden and can be painful.
Gradually reduction of the swelling can result but it recurs repeatedly when flow is stimulated.
This process may continue until complete obstruction and/or infection occurs.

23. Etiology Hypercalcemia…in rats only Xerostomic meds Tobacco smoking
Smoking has an increased cytotoxic effect on saliva, decreases PMN phagocytic ability and reduces salivary proteins
Gout is the only systemic disease known to cause salivary calculi and these are composed of uric acid.

24. Stone Composition Organic; often predominate in the center
Glycoproteins
Mucopolysaccharides
Bacterial products
Cellular debris
Inorganic; often in the periphery
Calcium carbonates & calcium phosphates in the form of hydroxyapatite

25. Parotid (PG) vs. Submandibular Gland (SMG)….
Most authorities agree obstructive phenomemnon such as mucous plugs and sialoliths are most commonly found in the SMG
Escudier et al
Lustmann et al
Rice

26. Reasons sialolithiasis may occur more often in the SMG
Saliva more alkaline
Higher concentration of calcium and phosphate in the saliva
Higher mucus content
Longer duct
Anti-gravity flow

27. Clinical presentation
Painful swelling (60%)
Painless swelling (30%)
Sometimes described as recurrent salivary
colic and spasmodic pain upon eating

28. Diagnostics: Plain occlusal film
Effective for intraductal stones, while….
intraglandular, radiolucent or
small stones may be missed.

29. DIAGNOSIS:
Radiographic examination
Plain film radiography
Sialography
Sialendoscopy
Ultrasonography
CT imaging

33. Mucocele
Mucoceles, exclusive of the irritation fibroma, are most common of the benign soft tissue masses in the oral cavity.
Muco: mucus , coele: cavity.
Consist of a circumscribed cavity in the connective tissue and submucosa producing an obvious elevation in the mucosa
When in the oral floor, they are called ranula.

34. Etiology and pathogenesis
Obstruction of minor sg duct
Traumatic severance of duct
Chronic partial obstruction
Salivary calculus
Classification
Extravasation mucocele
Retention mucocele

35. Mucocele
Extravasation is the leakage of fluid from the ducts or acini into the surrounding tissue.
Extra: outside, vasa: vessel
Retention: narrowed ductal opening that cannot adequately accommodate the exit of saliva produced, leading to ductal dilation and surface swelling.
Less common phenomenon

36. C/F
Accessory glands lower lip
Birth to ninth decade
Dome shaped mucosal swelling
1 or 2 mm to several cms
Children, young adult

37. Mucocele
The majority of the mucoceles result from an extravasation of fluid into the surrounding tissue after traumatic break in the continuity of their ducts.
Lacks a true epithelial lining.

38. H/P
Lack of epi lining
Mucous laden tissue defect
Infiltraion of infl cells
Adj sg may be atrophic or show interstitial fibrosis

40. Ranula
Is a term used for mucoceles that occur in the floor of the mouth.
The name is derived form the word rana, because the swelling may resemble the translucent underbelly of the frog.

41. Ranula Although the source is usually the sublingual gland,
may also arise from the submandibular duct
or possibly the minor salivary glands in the floor of the mouth.

42. Ranula Presents as a blue dome shaped swelling in the floor of mouth.
They tend to be larger than mucoceles & can fill the FOM & elevate tongue.
Located lateral to the midline, helping to distinguish it from a midline dermoid cyst.

43. Plunging or Cervical Ranula
Occurs when spilled mucin dissects through the mylohyoid muscle and produces swelling in the neck.
Concomitant FOM swelling may or may not be visible.

44. Treatment of Mucoceles in Lip or Buccal mucosa
Excision with strict removal of any projecting peripheral salivary glands
Avoid injury to other glands during primary wound closure

45. AUTOIMMUNE DISEASES: Keratoconjunctivits sicca Xerostomia
SJOGERNS SYNDROME
HENRIK SJOGREN : 1933
CLINICAL TRIAD :
Keratoconjunctivits sicca
Xerostomia
Rheumatoid arthritis

46. Primary Sjogren’s syndrome (Sicca complex)
Dry mouth and dry eyes
Secondary Sjogren’s syndrome
Systemic lupus erythematosus, polyarteritis nodosa, polymyositis, scleroderma

47. Etiology
Genetic
Hormonal
Infectious
Immunologic – antisalivary duct antibody
Combinations of factors

48. C/F:
Usually in females over 40yrs
Children & young adults may be affected
F:M– 10:1
Dryness of eyes and mouth
Painful, burning sensation of oral mucosa
Lymphadenopathy is more common in primary form

51. Salivary gland function test
Diagnosis :
History & Exam
Investigations:
Opthalmologic test
Salivary gland function test
Connective tissue disorder test
Opthalmologic test:
Schirmer’s test
Break up time test (BUT)
Rose Bengal Dye test

52. Salivary gland function test:
Salivary flow rate
Salivary gland biopsy
Scintigraphy & Sialography
Connective tissue disorder test:
+ve antisalivary antibody
+ve rheumatoid factor

53. Lab finding
Polyclonal hyperglobulinemia
Antisalivary duct antibodies, rheumatoid factor and antinuclear antibodies.
An increased sedimentation rate
Radiography
formation of punctate cavity defect which are filled with radio-opaque contrast media
Cherry blossom or branchless fruit laden tree appearance

55. H/P
Intense lymphocytic infiltration of the gland replacing all acinar structures although the lobular architecture is preserved.
Proliferation of ductal epithelium and myoepithelium to form 'epimyoepithelial islands'.
An atrophy of the glands sequential to the lymphocytic
infiltration.

56. Treatment:
Symptomatic treatment
Salivary substitutes
Ocular lubricants
Complication– Development of lymphomas

57. Mikulicz’s disease
Condition characterized by an abnormal enlargement of the SG and lacrimal glands
Johan Mikuliczs in 1888
Etiology
Autoimmune
Viral
genetic

58. Mikulicz disease
If the cause is unknown
Mikulicz’s syndrome
If enlargement of the glands are associated with known dieseases – tuberculosis, sarcoidosis or lymphoma

59. C/F
Often affects females
Middle age
Occurs with SS
Sudden onset of xerostomia, difficulty in swallowing
Tooth decay
Eyes - Enlarged lacrimal glands , decreased lacrimation
Fever

60. H/P
Variable replacement of the parenchyma, particularly acini, by lymphocytic infiltrate, but the lobular architecture is retained
• Infiltrate composed mainly of small lymphocytes and germinal centers may or may not be present •

61. Embedded within the infiltrate are varying numbers of residual ducts and epimyoepithelial islands
• Epimyoepithelial islands consist of round to irregularly shaped groups of epithelial cells or branching duct-like structures

62. Treatment:
Symptomatic

63. FUNCTIONAL DISORDERS
XEROSTOMIA
SIALORRHEA

64. XEROSTOMIA Risk factors: Developmental : Salivary gland aplasia
Iatrogenic :
Medications
Radiation therapy
Water metabolite loss:
Impaired fluid intake
Vomiting /diarrohea

65. XEROSTOMIA Local factors : Smoking Mouth breathing Systemic diseases :
Sjogerns syndrome
Diabetes mellitus
Sarcoidosis & HIV

66. XEROSTOMIA Causes; Depression / chronic anxiety Dehydration Drugs
Diseases

67. XEROSTOMIA Diagnosis : Clinical features : Dry mucosa
Residual saliva : thick and ropey
PT c/o diff in mastication & swallowing
Diagnosis :
Diseases :
Oral candidiasis
radiation induced caries
History
Clinical examination
Investigations

68. XEROSTOMIA MANAGEMENT Preventive therapy Symptomatic treatment
Local or topical salivary stimulation
Systemic salivary stimulation

69. XEROSTOMIA Treatment : Hydration Discontinue the drugs Symptomatic :
Artificial saliva
Chewing gums
Sialogogues: pilocarpine

70. SIALORRHEA Risk factors: Medications Ill fitting dentures
Excess saliva production
Risk factors:
Medications
Ill fitting dentures
Rabies clinical sign
Heavy metal poisoning
New complete dentures
Local irritations
Mentally retarded pts
Gastrointestinal reflux disease

71. SIALORRHEA Diagnosis : Past medical history
Clinical features :
Constant soiling of clothes
Diagnosis :
Past medical history
Diagnostic tests – salivary flow rate .

72. SIALORRHEA Treatment: Medications : Antihistamine Anti cholinergics
Injection : BOTULINUM TOXIN- PAROTID
Surgical intervention:
salivary gland excision (permanent relief)
salivary duct ligation

73. Sialoadenosis Non neoplastic non infl enlargement of parotid gland
Bilaterally and may manisfest recurrence or pain or both
Assos with systemic d/o; this forms the basis for classification
Hormonal sex hormone
diabetic
thyroid
adreno cortical d/o
Neurohormonal
peripheral
central
Dysenymatic
Hepatogenic
Pancreotogenic
Nephrogenic
dysprotienimic
Malnutrional sialadenois
Drug induced sialoadenosis

74.  Left submandibular sialogram demonstrates “leafless-tree” pattern (arrow) with compression of finer ducts suggestive of sialadenosis

75. Salivary gland cyst Cystic neoplasm 2 to 5 percent of parotid gland
Rare in other major glands
3 types
Lympho epi cyst
Salivary duct cyst , two types acquired and congenital
Dysgenic cyst

76. Clinical features
Parotid gland ,unilateral painless swellings with no involvement of facial nerve and no fixation to the overlying skin.
Patients are over 40 years of age.
cm with an average size of approximately 1-3 cms .

77. H/P
Unilocular cysts are lined by single or multilayered cuboidal or columnar epithelium.
Mucus containing goblet cells and areas of
Oncocytic differentiation may be seen.
Completely or partially lined by squamous epithelium.
Lymphocytic infiltration in the cyst wall.

78. Chronic sclerosing sialadenitis of SMG
Benign inflammatory condition of the submandibular gland that mimics a malignant neoplasm clinically because of presentation as a hard mass.
H/P
preserved lobular architecture, thickening of interlobular septa by sclerotic tissue, dense lymphoplasmacytic infiltrate,
preservation of ducts with periductal fibrosis, and variable loss of acini

79. References Salivary gland Pathlogy. Irving Dardick
Surgical Pathology of salivary glands. Gary L. Ellis
Textbook of Oral Pathology. Shafer 6th edition
Oral and Maxillofacial pathology. Neville, 3rd edition
Essentials of oral medicine and oral pathology. Cawson, 7th edition.

80. Thank you