SALIVARY GLANDS

Guided by Dr. Shoba Presented by Dr. Anvitha

Contents

Introduction Classification of salivary glands Development Anatomy of salivary glands Structure of salivary glands Saliva Composition of saliva Formation & secretion of saliva Functions of saliva

Nervous regulation of salivary secretion Salivary flow rate Salivary function tests Salivary diagnostic markers Defense mechanism of saliva Role of saliva in acquired pellicle formation Role of saliva in calculus formation Clinical considerations Conclusion

Introduction
Salivary glands are compound, tubuloacinar, merocrine, exocrine glands whose ducts open into the oral cavity. They are composed of parenchymal elements invested in surrounding connective tissue. The production of saliva is the important function of salivary glands, which provides natural protection for the teeth & soft tissues of the oral cavity. Helps in mastication, deglutition & digestion of food.

Classification
Salivary glands are most commonly classified based on their size & location as; -Major salivary glands 1. Parotid glands 2. Submandibular glands 3. Sublingual glands -Minor salivary glands 1. Labial glands 2. Glossopalatine glands 3. Lingual glands - glands of Blandin & Nuhn - posterior lingual mucous glands - Von Ebners glands

Development
It involves interaction of the epithelium with the underlying mesenchyme. The mesenchyme plays a role both in initiation & growth of the glandular bud & cytodifferentiation of glandular cells. Stages of development; 1.Bud formation; The mesenchyme induces proliferation in the buccal epithelium, which results in tissue thickening & formation. The growing bud is separated from the condensation of mesenchyme by a basal lamina. Epithelial bud

Parotid gland- arise near the corners of stomodeum by the 6th week of prenatal life. Submandibular gland- arise from the floor of the mouth during 6-7th week in utero. Sublingual gland- arise lateral to submandibular primordium at about 8th week. Minor salivary glands- begin to develop in 12th week of prenatal life.

2.Formation & growth of epithelial cord;

A cord of cells forms from the epithelial bud by cell proliferation. Condensation & proliferation occur in the surrounding mesenchyme, which is closely associated with the epithelial cord. The basal lamina plays a role in influencing morphogenesis & differentiation of the salivary glands.
basal lamina

3.Initiation of branching in terminal parts of epithelial cord & continuation of glandular differentiation; The epithelial cord proliferates rapidly & branches into berry like terminal bulbs (acini).

4.Dichotomous branching of epithelial cord and lobule formation; The branching continues at the terminal portions of the cord, forming a tree-like branching system of bulbs. As branching occurs, mesenchyme differentiates around the branches, eventually producing extensive lobulation.

5.Canalization of presumptive ducts; Canalization of the epithelial cord, with formation of lumen. This usually occurs by 6th month in all three salivary glands.

Mechanism of canalization- Fluid secretion by the duct cells which increases the hydrostatic pressure & produces a lumen within the cord. This is followed by further branching of the duct structure & growth of connective tissue.

6. Cytodifferentiation; The final stage of salivary gland development is the differentiation of the functional acini & intercalated ducts. During this period the mitotic activity is more at the terminal bulb portions. Cells differentiate into terminal tubule & proacinar cells

The myoepithelial cells usually arise from epithelial stem cells in the terminal tubules & develop in concert with acinar cytodifferentiation. The terminal tubule cells eventually differentiate into the intercalated duct cells of the adult glands.

- A thickened basal lamina appears in the apical region of the

terminal bud at the next dichotomous branch point. - Mitotic activity is localized in the peripheral regions of the bud. - Basal lamina plays an important role in the stabilization of the epithelium & initiation and maintenance of lobular morphology.

The initiation of cytodifferentiation of gland acinar cells is dependent on the preprogrammed development occurring in early stages of morphogenesis. A period of in situ epithelial-mesenchymal contact occurs hence the exocrine cells differentiates without the continued presence of mesenchyme.

Anatomy
Parotid gland;
-It is the largest gland, weighing about 15gms.
-Situated below the external acoustic meatus, between the ramus of the mandible & sternomastoid

-It overlaps Anteriorly- masseter muscle. A part of this forward extension is often detached & is called as Accessory parotid which lies between the zygomatic arch & the parotid duct. The investing layer of deep cervical fascia forms- Parotid Capsule

investing layer of deep cervical fascia

The gland is pyramidal in shape with apex directed downwards Apex- overlaps the posterior belly of digastric. The cervical branch of facial nerve & the 2nd division of retromandibular vein emerges through it.

It has 4 surfaces; 1.Superior; It is related to auriculotemporal nerve superficial temporal vessels

external acoustic meatus

posterior surface of TMJ

2.Superficial surface; It is covered by - skin, superficial fascia, parotid fascia, few deep parotid lymph nodes greater auricular nerve

posterior fibers of platysma

Parotid lymph nodes

3.Anteromedial surface; It is related to grooved by posterior border of ramus

masseter medial pterygoid

emerging branches of facial nerve

4.Posterolateral surface; It is related tostyloid process mastoid process posterior belly of digastric sternomastoid external carotid artery

It has 3 borders; 1.Anterior; Structures emerging at this border

Transverse facial vessels Parotid duct

Terminal br. Facial nerve

2.Posterior; It separates superficial surface from the posteromedial surface.

overlaps sternocleidomastoid

3.Medial; It separates anteromedial surface from posteromedial. It is related to lateral wall of pharynx.

Parotid duct (Stensens duct );

It is thick walled, about 5cm long & emerges from the middle of the anterior border of the gland. It runs forward & slightly downwards on the masseter & pierces the buccal pad of fat, buccopharyngeal fascia, buccinator. Finally it turns medially & opens into the vestibule of the opposite the crown of upper 2nd molar. parotid duct

Blood supply; external carotid artery & its branches veins: drain into external jugular vein The facial nerve enters the gland through the upper part of posteromedial surface & divides into its terminal branches within the gland

Submandibular gland;
It is situated in the anterior part of the digastric triangle. It is about the size of a walnut; it is j shaped. The posterior border of the mylohyoid divides it into1.Larger superficial 2.Small deep superficial part posterior border of mylohyoid

deep part

SUPERFICIAL PART; It fills the digastric triangle. It has 3 surfaces: 1.Inferior surface- It is covered by-skin -platysma -cervical branch of the facial nerve -facial vein -submandibular lymph nodes. -deep fascia

2.Lateral surface; It is related to - submandibular fossa on the mandible - medial pterygoid - facial artery 3.Medial surface; It is related to - mylohyoid muscle, nerve, vessel - hyoglossus, styloglossus, - lingual nerve - stylohyoid ligament

DEEP PART;

It is smaller in size. It lies deep to mylohyoid & superficial to hyoglossus, styloglossus. Anteriorly it extends up to the posterior end of the sublingual gland.

Submandibular duct (Whartons duct );

It is thin walled, about 5cm long. It emerges at the anterior end of the deep part of the gland, runs forwards on the hyoglossus & opens on the floor of the mouth, on the summit of the sublingual papilla, at the side of the lingual frenum of the tongue. submandibular duct

Blood supply:- Facial artery Veins; Drain into the common facial or lingual vein

Sublingual gland;
This is the smallest of the salivary glands. It is almond shaped & weighs about 3-4gms.It lies above the mylohyoid, below the mucosa of the floor of the mouth, medial to the sublingual fossa of the mandible.

sublingual gland

Secretions enter the oral cavity through a series of small ducts (ducts of rivinus )opening along the lingual fold & often through a large duct Bartholins duct that opens with the submandibular duct at the sublingual fold. Blood supply; Lingual & Submental artery.

Structure
Salivary glands consists of a series of branched ducts, terminating in a spherical / tubular secretory end pieces or acini. Intercalated ducts connects secretory end pieces with striated ducts. These ducts branch once or twice before joining individual end pieces.

Secretory cells
1.Serous cells;
Serous cells are spherical with 8-12 cells surrounding a central lumen. Cells are pyramidal with a broad base & a narrow apex. The lumen has fingerlike extensions located between the adjacent cells called inter cellular canaliculi: which increases the size of the luminal surface of the cells. .

Intercellular canaliculli

The luminal surface, including intercellular canaliculi, is studded with a few short microvilli. The basal surface has few regular folds, 0.5m deep, that interdigitate with folds of adjacent cells. Serous cells are joined to one another by intercellular junctionsThe tight junctions help to maintain cell surface domains & regulate the passage of ions & water from the lumen to the intercellular spaces & vice versa

holds the adjacent cells together

2.Mucous cells;
Mucous cells have tubular Configuration, with central lumen larger than that of serous cells. There is apical accumulation of large amounts of secretory products (mucus). They are unstained, giving an empty appearance to the supranuclear cytoplasm. Unlike serous cells, they lack intercellular canaliculi, except for those covered by demilune cells.

There are serous cells associated with them in the form of a demilune or crescent covering the mucous cells at the end of the tubule. Secretions from serous demilune reach the lumen of the end piece through intercellular canaliculi extending between the mucous cells at the end of the tubule.

serous demilune

3. Myoepithelial cells; These are contractile cells associated with the secretory end cells & intercalated ducts of the salivary glands. They are joined to the cells by desmosomes.

Cells are stellate shaped with numerous branching processes which extend from the cell body to surround & embrace the end pieces. These processes are filled with filaments of actin & myosin.

stellate processes

Contraction of these cells provide support to the end pieces during active secretion of saliva. Cells help to expel the primary saliva from the secretory end pieces into the ductal system. Associated with intercalated ducts, shorten & widen the duct to maintain their potency. They have numerous proteins-Proteinase inhibitors -Anti-angiogenesis factors -Cells barrier against invasive epithelial neoplasm

Salivary ducts;
The ductal system is a varied network of tubules, that begins at the secretory end pieces & extend to the oral cavity. Ducts are - Intercalated duct - Striated duct - Excretory duct

Intercalated ducts;
-The primary saliva from secretory acini passes 1st through these ducts. These ducts are lined by simple cuboidal cells & myoepithelial cells are located along the basal surface of the ducts. -The overall diameter is smaller than that of the end pieces & their lumina are larger. -The cells have centrally placed nuclei & small amount of cytoplasm. The apical cell surface has a few short microvillus projecting into the lumen.

The lateral surfaces have folded processes that interdigitate with similar processes of adjacent cells. The Secretory granules in the apical cytoplasm contain macromolecules like lysozyme, lactoferrin.

Striated ducts;
-These are main ductal components located within the lobules of the gland (intralobular). These ducts are lined by a layer of tall columnar epithelial cells with large, spherical, centrally placed nuclei. -The cytoplasm has prominent striations at the basal ends. -The overall diameter of the duct is greater than that of secretory end pieces & the lumen is large.

Important function- Modification of the primary saliva by reabsorption & secretion of electrolytes. The apical cytoplasm contain small secretory granules.- kallikrein & other secretory proteins.

Excretory ducts;
These are located in the connective tissue septa between the lobule of the gland (extra lobular / interlobular). They are larger in diameter than striated ducts & have a pseudostratified epithelium with columnar cells extending from the basal lamina to the ductal lumen. Dendritic cells / antigen presenting cells are present which are involved in immune surveillance & processing and presentation of foreign antigen to T- lymphocytes.

Connective tissue;
It includes a surrounding capsule which demarcates the gland from adjacent structures. Septa that extend inward from the capsule divide the gland into the lobes & lobules and carry the blood vessels & nerves to supply the parenchymal components. Various cells fibroblasts, macrophages, dendritic cells, adipose cells, plasma cells, collagen fibers, elastic fibers with glycoproteins, proteoglycans are present in the extra cellular matrix of connective tissue.

Minor salivary glands

These are located beneath the epithelium of the oral cavity. These glands consists of several secretory units opening via short ducts directly into the mouth. Labial & buccal glands; These are mixed glands, consisting of mucous tubules with serous demilunes. Intercellular canaliculi are present between the serous demilune cells. Labial glands Buccal glands

Glossopalatine glands:- These are mucous glands, localized to the region of the isthmus in the glossopalatine fold, extending from the posterior extension of the sublingual gland to the glands of the soft palate.

Palatine glands;-These are mucous gland, consisting of glandular aggregates in the lamina propria of the posterolateral region of the hard palate. The excretory ducts have an irregular contour with large distensions as they course through the lamina propria.

Palatine glands

Lingual glands;-It is divided into - Anterior lingual: Located near the apex of the tongue. The anterior glands are mucous, while the posterior part are mixed. The duct opens on the ventral surface of the tongue near the lingual frenum.

anterior lingual glands

- Posterior lingual mucous: These are mucous , located lateral & posterior to the vallate papillae. Their ducts open onto the dorsal surface of the tongue. - Posterior lingual serous: These are serous, located b/n the muscle fibers of the tongue, below the vallate papillae. Their ducts open into the trough of the vallate papillae, and at the rudimentary foliate papillae on the side of the tongue

Saliva
Saliva plays a vital role in the integrity of the oral tissues: in the selection, ingestion & preparation of food for digestion & in our ability to communicate with one another. It is a clean, tasteless, odorless, slightly acidic viscous fluid, consisting of secretions from parotid, submandibular, sublingual salivary glands & the mucous glands of oral cavity (STEDMAN) It is considered as glandular saliva whole saliva- It is the mixed oral fluid

Quantity of saliva: 1200-1500 ml/day Submandibular- 60 to 65% of total volume of flow Parotid- 25% Sublingual- 10%. Resting flow rate of whole saliva: 0.3 to 0.4 ml/min Stimulated salivary rate: 1 to 2 ml/min Consistency: slightly cloudy pH: 6.02 to 7.05 Specific gravity: 1.002 to 1.012 Freezing point: 0.07 to 0.34 %

Composition of saliva
Water- 99.4% Solids- 0.6% Inorganic Sodium Potassium Chlorides Bicarbonates

Organic Glycoproteins Salivary amylase Lysozyme Lactoferrin Fibronectin Antibodies etc

-Secretory proteins- amylase, proline rich proteins, mucins, histatin, cystatin, peroxidase etc -Immunoglobulins- IgA, IgG, IgM -Others- cAMP, serum albumin etc.

Formation & secretion of saliva

It occurs in 2 stages: 1.Cells of secretory end pieces & intercalated ducts form primary saliva which is an Isotonic fluid organic components & water

It is regulated principally by parasympathetic innervation. Acetylcholine binds to muscarinic cholinergic receptors & activates phospholipase C - release of Ca 2+ from intracellular stores. Opening of Cl- channels in the apical cell membrane & K+ channels in the basolateral membrane. Cl-draws extracellular Na+ into the lumen. The osmotic gradient resulting from increased Na+ &Cl- causes movement of water into the lumen. The Na+/ K+/2Cl- co transporter & Na+/ K+-ATP maintains the intracellular ionic & osmotic balance.

2.Primary saliva is modified as it passes through the striated & excretory ducts, mainly by reabsoption & secretion of electrolytes. The final saliva which reaches the oral cavity is Hypotonic

Na+ & Cl- is reabsorbed by transporters in the luminal & basolateral surface. The ducts also secrete K+, HCO3- with less secretion and reabsorption of water in the ducts.

At high flow rate, saliva is in contact with ductal epithelium for a shorter time & the Na+, Cl- concentration increases and K+ concentration decreases. At low flow rate, the electrolyte concentration changes in opposite direction.

The electrolyte transport in the ducts is regulated by autonomic nervous system & by mineralocorticoids produced by adrenal cortex. The sympathetic innervations has a more important role in regulating electrolyte transport in the ducts than in the acini because of a larger number of c-AMP regulated Ca 2+ channels in the luminal cell membrane.

Functions of saliva; Function

1. Lubrication 2. Physical protection 3. Cleansing 4. Buffering

Salivary components
-glycoprotein, mucoids -glycoprotein, mucoids -physical flow -bicarbonates, - phosphate -minerals glycoprotein pellicle -Ig A, lactoperoxidase

5. Tooth integrity maintenance 6.Anti bacterial

Nervous regulation of saliva

Salivary glands are innervated by both sympathetic & parasympathetic divisions of autonomic nervous system. - Parotid gland - Inferior salivary nucleus - Submandibular & Sublingual gland Superior salivary nucleus

They act through the medium of acetylcholine- cholinergic fibres. On stimulation, enzyme kallikrein is liberated & forms a polypeptide bradykinin, which causes vasodilatation more secretion of thin saliva

On stimulation of these fibers - secretion of viscous saliva with high solid content - vasoconstriction less amount of saliva & is thick They act through the medium of adrenaline like substances Adrenergic fibers

Reflexes involved in salivary secretion - Conditioned / Acquired reflex - Unconditioned /Inborn reflex - Conditioned-; Sight or smell of the food stimulates salivary secretion although no food is actually given. - Unconditioned-; Presence of food is necessary to stimulate salivary secretion

Defense mechanism of saliva

-Saliva has major influence on plaque by mechanically cleansing the exposed oral surface, by buffering acids produced by bacteria & by controlling bacterial activity Antibacterial factors; - Various organic & inorganic factors are toxic to many bacterial cells. LYSOZYME:- Cleaves the linkage between structural components of the glycopeptides muramic acid - Acts in both gram +ve & gram ve organisms e.g: Aa, veillonella

LACTOPEROXIDASE- THIOCYANATE SYSTEM:It is bactericidal to some strains of Lactobacillus, Streptococcus. LACTOFERRIN:It is effective against Actinobacillus. MYELOPEROXIDASE:It is bactericidal for Actinobacillus Inhibits attachment of Actinomyces strains to hydroxyapatite.

SALIVARY ANTIBODIES; IMMUNOGLOBULINS:Inhibits the adhesion of oral Streptococcus to epithelial Surface. ANTIPROTEASES:Inhibits the action of proteolytic enzymes cathepsins. TIMP:- Inhibits the action of collagen degrading enzyme. SALIVARY BUFFERS & COAGULATION FACTORS; Bicarbonate- Carbonic acid system-maintains pH

Role of saliva in acquired pellicle formation

- Saliva plays an important role in formation of plaque - The organic & inorganic content of intercellular matrix of plaque is derived from saliva. - Glycoprotein from saliva form an important component of the pellicle which initially coats a clean tooth surface - The inorganic components are derived from saliva. As the mineral content increases, plaque undergoes calcification to form calculus

- Glycoprotein pellicle on the surface of tooth helps in accumulation of plaque forming bacteria like streptococcus sanguis, actinomyces viscosus etc. - The hydoxyapatite surface has vely charged phasphate groups that interact with +vely charged components of saliva. - It also aids in maintaining the integrity of dental plaque on tooth, tissue surfaces & fixed and removable prosthesis.

Role of saliva in calculus formation

- As mineral concentration in plaque mass increases, it gets calcified to form calculus. - Supra gingival calculus is more i.r.t buccal surfaces of maxillary molars & lingual surfaces of mandibular anterior corresponding to ductal orifices of respective glands-reflecting high concentration of minerals available from saliva. - Supra gingival calculus is also called as Salivary calculus

Mechanism involved in calculus formation- An increase in the pH of the saliva causes precipitation of calcium phosphate salts by lowering the precipitation constant. pH is elevated by the loss of CO2 & due to formation of Ammonia by plaque bacteria. - The colloidal proteins in saliva bind Ca 2+ & phosphate ions and maintain a supersaturated solution with respect to calcium phosphate salts. With stagnation of saliva, causes precipitation of calcium phosphate salts

Salivary flow rates

It is secreted in response to neurotransmitter stimuli. During most of the day its release is low & resting flow occurs. During food consumption, in response to gustatory & masticatory stimuli, there is marked release of neurotransmitter and increased secretion of saliva. The rate of flow of whole saliva -In unstimulated condition.0.08-1.83ml/min - In stimulated condition.0.2-5.7ml/min

Salivary function tests

Various techniques employed to measure the functions of salivary glands are Sialometry; It is the quantitative measurement of salivary output. Salivary scintigraphy: It measures the uptake, concentration & secretion by the salivary glands of an intravenously injected radioactive substance technetium-99m Helpful in measuring the functional activity of salivary glands. Sialography; It is the retrograde injection of a radio opaque dye into the salivary glands. It is useful in cases of salivary gland obstruction.

Sialochemistry assay; It assays the concentration of various salivary constituents like levels of electrolytes, proteins, presence of drugs, hormones etc Microbiologic tests; To identify Streptococcus mutans, Lactobacillus acidophilus, Candida in xerostomia conditions Biopsy: Of minor mucous glands e.g: Sjogrens syndrome

Diagnostic markers of saliva

Saliva is a fluid that is readily available & contains locally produced microbial and host response mediators, as well as systemic markers that aid in diagnosis of periodontal disease. The markers1.Enzymes- alkaline phosphatase, alpha,betaglucoronidase, collagenase, esterase, kallikrein, kininase, myeloperoxidase, trypsin. 2.Immunoglobulins- Ig-A, Ig-G, Ig-M 3.Phenotypic markers-epithelial keratins

4.Hormones-cortisol 5.Proteins- cystatins, fibronectin, lactoferrin, platelet activating factor, VEGF etc. 6. Ions-calcium 7. Bacteria & its products etc. By Nakamura & Slots (1983), enzyme activity in whole saliva & parotid saliva in patients adult periodontitis, -increased levels of alkaline phosphatase, elastase, -glucoronidase & other aminopeptides.

The activity of salivary elastase correlated significantly with the number of deep pockets & the % of bleeding sites. It helps to assess disease severity & the response to treatment. There is increased collagenase, protease & elastase activity in patients with adult periodontitis. Hayakawa et. al (1994)reported decreased concentration of TIMP-1 in patients with periodontitis, with increased levels of Collagenase. Salivary peroxidase activity-marker for gingival inflammation in IDDM patients.

Immunoglobulins; The predominant Ig in saliva is Ig-A which is derived from the cells of parotid gland. Salivary Ig levels were increased in patients with juvenile periodontitis as compared with healthy controls. Proteins; Various proteins like cystatins, epidermal growth factors, lactoferrin, platelet activating factors were increased in patient with periodontitis. Hormones; Elevated levels of cortisols were detected in patients with severe periodontitis with high levels of financial strain & emotional stress.

Salivary ions; Salivary calcium & saliva calcium to phosphate ratio were higher in periodontitis affected subjects. Phenotypic markers; To study epithelial cell function in disease & diagnosis, specific keratins antigens in saliva are evaluated. There is increased keratin concentration in GCF in patients with gingivitis & periodontitis

Clinical considerations
Age changes;
As age advances there is decreased production of saliva and this is mainly due to loss of salivary gland parenchymal tissue. The lost cells are replaced by adipose tissue cells. The resting salivary secretion is in the normal range, the volume of saliva produced during stimulated condition is less than normal.

Xerostomia;
It refers to subjective sensation of a dry mouth; causes; -Developmental Salivary gland aplasia -Water / metabolite loss Impaired fluid intake, hemorrhage, diarrhea -Iatrogenic Medications, radiation therapy -Systemic diseases Sjogrens syndrome, diabetes mellitus, HIV infection

Medication that causes Xerostomia; 1.AntihistaminesDiphenhydramine Clorpheniramine 2.DecongestantsPseudoephedrine 3.Antidepressants4.AntipsychoticsPhenothiazine derivatives 5.Antihypertensives- Methyldopa Chlorthiazide Calcium channel blockers 6.Anticholinergics- Atropine

Clinical features; -There is decreased salivary secretion & residual saliva is thick & ropey -Mucosa appears dry, Patient c/o difficulty in swallowing -Dorsal surface of tongue is fissured with atrophy of filiform papillae -Dental caries, oral candidiasis- due to decreased antimicrobial activity

Treatment; -Artificial saliva -Sugarless candy-to stimulate salivary flow -Systemic Pilocarpine-to increase salivary secretion

Sialolithsis (salivary gland calculi; salivary stones);

Sialoliths are calcified masses that develop with in the salivary ductal system. They arise due to deposition of ca 2+ salts around a nidus of debris within the ductal lumen. Their formation is promoted by sialadenitis & partial obstruction of duct. Clinical features; Common in duct of submandibular gland- due to long,tortuous, upward path of the duct & thick mucoid secretion. episodic pain/swelling at meal time microscopically-calcified mass exhibits concentric lamination that surround a nidus

Treatment; Small sialolith-gentle massage of the gland to milk it out Sialagogues Large sialolith- surgical removal

sialolith

Sialadenitis;
It is the inflammation of the salivary gland. Causes; Infectious- viral(mumps, coxsackie A,cytomegalovirus) -bacterial(staphylococcus aureus,strepococci) Noninfectious- Sjogrens syndrome, Sarcoidosis, radiation therapy, allergens. Clinical features; Common in parotid gland, gland is swollen & painful and the overlying skin is erythematous with low grade fever. Ductal obstruction

Sialorrhea; It is characterized by excessive salivation.

condition Causes;Local irritants-aphthous ulcers, ill fitting dentures neurologic disorder heavy metal poisoning drugs like-lithium, cholinergic agonist Clinical features; drooling. Seen in patients with neuromuscular disease Super salivation of unknown cause- Idiopathic Paroxysmal Sialorrhrea Treatment; Anti cholinergic drugs Transdermal scopolamine Ductal relocation

Mucocele;
It is mainly due to rupture of a salivary duct & spillage of
mucin into surrounding soft tissue due to trauma. It is not a true cyst It is dome shaped mucosal swelling about 1-2mm Lower lip is the common site.

Microscopically-mucin is surrounded by a granulation tissue Treatment; Small mucocele- rupture & heal themselves Large mucocele- surgical excision

Sjogrens syndrome;
It is a common, systemic autoimmune disorder which involves the salivary & lacrimal glands, resulting in xerostomia and xerophthalima -Primary sjogrens syndrome -Secondary sjogrens syndrome Clinical features; Common in females in middle aged group Xerostomia, saliva is frothy, difficulty in swallowing Bilateral swelling of gland

Sialography- There is ductal dialatation with lack of normal structure of ductal system, demonstrating fruit laden, branchless tree

Sialadenosis (sialosis); It is an unusual non inflammatory

disorder, characterized by salivary gland enlargement. ( parotid gland). It is usually associated with an underlying systemic problemsa. Endocrine: Diabetes Mellitus Diabetes Insipidus Acromegaly b. Nutritional: Malnutrition Alcoholism C. Medication: Anti-hypertensive drugs Psychotropic drugs

There is dysregulation of the autonomic innervation of the salivary gland acini, causing an aberrant intracellular secretory cycle. This leads to excessive accumulation of secretory granules, with marked enlargement of the acinar cells Clinical features: Swelling of parotid gland with or without pain. Decreased salivary secretion. Radiographic features: Sialography- leafless tree pattern- due to compression of the finer ducts by hypertrophy of acinar cells.

Mumps:-(Epidemic parotitis) - It is an acute contagious viral infection of salivary glands, characterized by unilateral / bilateral swelling of parotid glands -It is transmitted through droplet nuclei or saliva. It replicates in respiratory epithelium -There is acinar & epithelial duct cells necrosis -Pain upon mastication -It is preceded by headache, chills, fever, vomiting & pain below the ear -Papilla of the opening of the parotid duct is often puffy and reddened Treatment; prevention by vaccination

WHO classification of salivary gland tumors

1.Adenomas- Pleomorphic adenoma Myoepithelioma Basal cell adenoma Warthin tumor Oncocytoma Ductal papilloma 2.Carcinoma- Acinic cell carcinoma Mucoepidermoid carcinoma Adenoid cystic carcinoma Salivary duct carcinoma Malignant myoepithelioma Basal cell adenocarcinoma Squamous cell carcinoma

3. Nonepithelial tumors 4. Malignant lymphomas 5. Secondary tumors 6. Unclassified tumors 7. Tumor like lesionsSialadenosis Oncocytosis Necrotizing sialometaplasia Salivary gland cysts Benign lymphoepithelial lesions etc.

Warthins tumor:- It is the salivary gland tumor commonly

involving parotid gland. Tumor arises in the salivary gland tissue entrapped within paraparotid lymph nodes during embryogenesis. Present in 6th&7th decades of life. It is not painful. Tumor is superficial, lying beneath the parotid capsule. It contains variable number of cysts that contains clear fluid. Local areas of hemorrhage are seen. Microscopic features; 2 components: epithelial & lymphoid tissue. It is lined by tall columnar cells with eosinophilic cytoplasm Treatment: Surgical exicision

Mikulicz Syndrome;It is a chronic condition characterized by abnormal swelling of the salivary & lacrimal glands. It is an autoimmune disease-excessive accumulation of lymphocytes in the glands with destruction of acini Clinical features; Pain less swelling of salivary glands Sudden onset of xerostomia-difficulty in swallowing & decay Enlargement of lacrimal gland-less tears Treatment: Symptomatic treatment- artificial tears, artificial saliva Soft diet-To reduce pain on chewing & swallowing

Pleomorphic Adenoma (Mixed tumor):-It is a benign neoplasm consisting of cells having the ability to differentiate to epithelial & mesenchymal cells. -Parotid gland is most commonly involved. Common among females. Patient usually gives history of small, painless, quiescent swelling which slowly increase in size. -It is not fixed to underlying structures, firm in consistency with areas of cystic degeneration. Facial nerve involvement-facial paralysis. Treatment: Surgical excision.

Acinic cell carcinoma:It is a malignant tumor in which the neoplastic cells express acinar differentiation. It is encapsulated & lobulated. Common in parotid gland Common among females( middle age group) Asymptomatic, facial muscle weakness Microscopic features: 4 growth patterns: Solid, papillary cystic, follicular & microcystic The cells have features of the acinar cells, with granular basophilic cytoplasm & a darkly stained eccentric nucleus. Treatment: Surgical excision

Mucoepidermoid Carcinoma:-It is a malignant epithelial tumor, composed of mucus secreting cells & epidermoid type cells in varying proportions. -Common neoplasm of major & minor salivary glands. Parotid is commonly involved. -It is the most common neoplasm in children. -It is slowly enlarging, painless mass, is not completely encapsulated & contains cysts which are filled with a viscoid, mucoid material Treatment; Conservative excision with preservation of facial Nerve.

Salivary duct carcinoma:It is a high grade malignant epithelial neoplasm composed of structures that resemble expanded salivary gland ducts. Parotid swelling is most common sign. Facial nerve dysfunction Microscopic features: It is composed of clusters of tumor cells that have small lumina or cribriform arrangement. The neoplastic epithelial cells are cuboidal & polygonal with eosinophilic cytoplasm and are accompanied by a dense fibrous connective tissue stroma. Treatment; Complete surgical excision with radical neck dissection & radiation therapy

Conclusion
Saliva is the most important oral fluid secreted by salivary glands and plays an important role in preservation and maintenance of oral tissues and for the metabolic health of the mouth as a whole. Saliva has also become useful as a non invasive systemic sampling measure for diagnosis and research. Consequently, it is necessary for the clinicians to have good knowledge base, regarding structure of salivary glands, salivary flow, function etc to assess treatment plan & prognosis and easier handling of clinical cases.

Tencates Oral Histology - 6th edition Chaurasias Human Anatomy - 3rd edition verys Oral Histology & embryology- 2nd edition Neville, Damm, Allens Oral & Maxillofacial pathology -2nd edition Saliva: Role in health & disease; IDJ -1992. Vol 42 Analysis of saliva for periodontal diagnosis; JCP No-27: A review Chatterjees Human Physiology - 11th edition Shafers Oral Pathology 5th edition