OBSTRUCTIVE SALIVARY GLAND DISEASE Medical Assignment Help

OBSTRUCTIVE SALIVARY GLAND DISEASE

Sialolithiasis
The formation of stories, or calculi, may occur throughaut the body, including the gallbladder, urinary tract, and salivary glands. The occurrence af salivary gland stories is twice as common in men, with a, peak incidence between ages .30 and SO. Multiple stone formation Occurs in approximately 25’VcIof patients. The pathogenesis of salivary calculi progresses through a seriesof stages beginning with an abnormality In calcium metabolism and salt precipitation, with formation of a nidus that subsequent ly becomes layered with organic and inorganic material,
to. farm a calci fied mass.
‘The incidence of stone formation varies. depending o,n the specific gland involved (Box 20-31. The submandibular gland is involved in 85% of cases, which is more cornman than all other glands cornbinecl.A varietv of factors contribute to the higher incidence ot submandibular calculi.
Salivary gland secretions contain water, electrolytes, urea, ammoma, glucose, fats, proteins, and other substances; in general. parotid secretions are more concentrated than those of the other salivary glands, The main
exception is the concen ration of calcium, which is about twice as abundant, in su bmandibular saliva as in parotid

Sialolithiasis

Sialolithiasis

sallva (see Table 20-2), In addition, the alkaline pH ofsubmandibular saliva may further support stone formation, In addition to salivary composition, several anatomicIactors of the submandibular gland and duct are important, Wharton’s ‘duct is the longest salivary duct; therefore saliva
has a greater distance to travel before being emptied into the oral cavity. In addition, the duct of the submandibular gland has two sharp curves in its course: The first otcurs at the posterior border of the mylohyoid mus-
. de, and the second is near the ductal opening in the anterior floor of the mouth. Finally, the punctum of the submandibular duct is smaller than the opening of Stensen’s duct. These features contribute to a slowed salivarv flow and provide potential areas of stasis 01 salivarv flow, or obstruction. that is not found in the parotid or sublingual ductal systems, Precipitated material, mucus, and cellular debris are more easily trapped in the tortuous and lengthy submandibular duct, especially when its
small orifice is its most elevated location, and its flow the-refore occurs against the force of gravity. The precipitated material forms the nidus of mucous plugs and either radiopaque or radiolucent sialoliths that may eventually  enlarge to-the point of obstructing the flow of saliva
from the gland to the oral cavity.

The clinical, manifestations of the presence of sub:
mandibular stones become apparent when acute ductal

FIG, 20- 13 A, Labial salivary gland biopsy, Thelower lip is everted and controlled v.ith a Chalazion clump. An incision throuqh mucosa permits visualization of the minor salivary glands (attcws). B, The minor salivary glands are -removed and subnl'+-' nr{ fnr histoo.u! tno;c aSSPSCimpnt

FIG, 20- 13 A, Labial salivary gland biopsy, Thelower lip is everted and controlled
v.ith a Chalazion clump. An incision throuqh mucosa permits visualization of the
minor salivary glands (attcws). B, The minor salivary glands are -removed and subnl’+-‘
nr{ fnr histoo.u! tno;c aSSPSCimpnt

FIG. 20-14 Clinical photograph demonstrates a right submandibular swelling (arrow) secondary to' obstruction from a submandibular sialolith.

FIG. 20-14 Clinical photograph demonstrates a right submandibular
swelling (arrow) secondary to’ obstruction from a submandibular
sialolith.

BOX 20-4
Sialolithiasis for the General Dentist
Classic signs and symptoms of sialolithiasis’
• Exacerbation of pain and swelling at mealtimes
• Check for flow from Wharton’s duct
• Check for tenderness of submandibular gland
• Palpate for stone in floor of mouth
• Check mandibular occlusal radiograph
.Treatment
Anterior stone
• Attempt to dilate Wharton’s duct with lacrimal probes
• Careful to not dislodge stone .posteriorly
• “Milk” the gland to express stone
• If successful, prescribe salivary stimulants
Posterior stone or no stone visualized
I: Refer to oral surgeon

obstruction occurs at mealtime, when saliva production is at its maximum and salivary flow is stimulated against a fixed obstruction. The resultant swelling-is sudden and is usually very painful (Box 20-4; Fig. 20-14). Gradual reduc- . tion of the swelling follows, but swelling reoccurs repeatedly when salivary flow is stimulated. This process may
continue until complete obstruction, infection, or both occurs. Obstruction, with or without infection, causes atrophy of the secretory cells of the involved gland. Infection . of the gland manifests itself by swelling in, the floor of the mouth, erythema, and an associated lymphader.opathy, Palpation of the gland and simultaneous examination of
the duct and its opening may reveal the total absence of salivary flow or the presence of purulent material.

The management of submandibular gland calculi depends on the duration of symptoms, the numbe of repeated episodes, the size of the stone, and, perhaps most importantly, _toe location of the stone. Submandibular
stones a  e classified. as either anterior or posterior stones, in relation to a transverse line between the mandibular first molars. Stones that occur anterior to this line are generally well visualized on a mandibular occlusal radiograph and may be amenable to intraoral removal. Small anteriorly located stones may be retrieved through the ductal opening after dilation of the orifice.

Salivary gland calculi occur much less commonly in the parotid gland. In general, parotid gland infection usually leads to stone formation; the opposite, however, is the case for the submandibular gland. The parotid gtand is examined by inspection and palpation of the gland extraorally
over the ascending mandibular ramus. Stenscu’s duct and its orifice can be examined intraorally. Palpation of the gland and simultaneous observation of the duct allow observation of salivary flow or the production of other
.matcrial, such a  purulence, from the punctum reproduct. Parotid sialoliths found in thedistal third of Stensen’s duct that can be palpated intraorally may be removed after

FIG. 19- 1~cont' d 0, Large oroantral communication in left maxilla that developed after removal of second molar tooth. E, Palatal flap outlined. Flap is posteriorly based and receives its blood supply from anterior palatine neurovascular bundle. Width of flap is much larger than clinical oroantral communication. F, Palatal flap is elevated and readied for transposition laterally to cover osseous oroantral defect. Buccal mucosa has also been elevated to facilitate suturing of flap. Larye size ot"osseous defect is demonstrated

FIG. 19- 1~cont’ d 0, Large oroantral communication in left maxilla that developed after removal
of second molar tooth. E, Palatal flap outlined. Flap is posteriorly based and receives its
blood supply from anterior palatine neurovascular bundle. Width of flap is much larger than
clinical oroantral communication. F, Palatal flap is elevated and readied for transposition laterally
to cover osseous oroantral defect. Buccal mucosa has also been elevated to facilitate suturing
of flap. Larye size ot”osseous defect is demonstrated

FIG. 19-14-cont'd G, Palatal flap has been 'rotated laterally and sutured in place. Osseous defect is well covered. Small area of exposed bone near palatal midline will heai by secondary intention. H, Well-closed oroantral communication 4 weeks after rotation of palatal flap. Vestibular depth is maintained with this procedure. Metallic-foil closure of oroantral communications

FIG. 19-14-cont’d G, Palatal flap has been ‘rotated laterally and sutured in place. Osseous
defect is well covered. Small area of exposed bone near palatal midline will heai by secondary
intention. H, Well-closed oroantral communication 4 weeks after rotation of palatal flap. Vestibular
depth is maintained with this procedure. Metallic-foil closure of oroantral communications

. ,~, 19· i:; Metallic-foil closure of oroantral communications. A, Diagrammatic illustration of. oroantral fistula in right maxillary alveolar process in region of missing first molar tooth, which is to be closed with subperiosteal placement of metallic-foil "patch." 8, Botl') facial and palatal mucoperiosteal" flaps are developed. When elevated, these provide ample exposure of underlying atveolar process and fistulous tract. Fistulous tract is excised. Osseous margins must be exposed 360 degrees ,around bony defect to allow placement of metallic-foil patch beneath, mucoperiosteal flaps. Flap is supported on all sides by underlying bone. C, Metallic-foil patch has been adapted to cover osseous defect and positioned between alveolar process and overlying buccal and palatal mucoperiosteal flaps. Foil should be supported on all its margins by sound underlying bone. Mucoperiosteal flaps have been repositioned , and sutured over foil. D, Cross-sectional diagram of metallic-foil closure technique. Both buccal and palatal mucoperiosteal flaps are elevated to expose osseous defect and large area of underlying alveolar borie around oroantral communication.

FIG 20-19· i:; Metallic-foil closure of oroantral communications. A, Diagrammatic illustration of.
oroantral fistula in right maxillary alveolar process in region of missing first molar tooth, which is to be
closed with subperiosteal placement of metallic-foil “patch.” 8, Botl’) facial and palatal mucoperiosteal”
flaps are developed. When elevated, these provide ample exposure of underlying atveolar process and
fistulous tract. Fistulous tract is excised. Osseous margins must be exposed 360 degrees ,around bony
defect to allow placement of metallic-foil patch beneath, mucoperiosteal flaps. Flap is supported on all
sides by underlying bone. C, Metallic-foil patch has been adapted to cover osseous defect and positioned
between alveolar process and overlying buccal and palatal mucoperiosteal flaps. Foil should be
supported on all its margins by sound underlying bone. Mucoperiosteal flaps have been repositioned
, and sutured over foil. D, Cross-sectional diagram of metallic-foil closure technique. Both buccal and
palatal mucoperiosteal flaps are elevated to expose osseous defect and large area of underlying alveolar
borie around oroantral communication.

FIG 19-15

FIG 19-15

F!G. 19-15-cont'd I, Palatal and buccal mucosal flaps are sutured in plac.e over metallic-foil patch. Flaps are minimally advanced, and no real attempt is made to close mucosa primarily over foil. J, Four weeks after closure of right maxillary oroantral defect with the foil patch procedure. Area is well healed. Normal vestibular depth and palatal anatomy are maintained.

F!G. 19-15-cont’d I, Palatal and buccal mucosal flaps are sutured in plac.e over metallic-foil
patch. Flaps are minimally advanced, and no real attempt is made to close mucosa primarily
over foil. J, Four weeks after closure of right maxillary oroantral defect with the foil patch procedure.
Area is well healed. Normal vestibular depth and palatal anatomy are maintained.

 BIBIOLOGY


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Sieher H, editor: Orbllll:\ oral Ilistolog), and elllbr)’l1loS.I; St Louis,
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