Transcribed

by Ana Sangadala

July 10, 2014

Diagnosis of Oral Diseases Lecture 7 and 8-Assessment, Diagnosis

andTreatment of Salivary Gland Disorders by Dr. Phelan

1-Title Slide
Okay those of you in the back row, can you hear me? Yes? Wave or something. Ok!
For those of who just listened to me for two hours, Im sorry. I wish I could change
my voice or something so that you get to hear somebody different. Anyway, this is a
different course, and what were going to do today is talk about salivary glands. And
as part of, as part of this course, um, what were doing is trying to introduce you to
kinda a lot of stuff so that you get an overview first. Most everything that we talk
about in this section of your course this year, were going to go into a lot more detail
next year. But I think its important that you really get a sense of the range of oral
pathology that is out there for us and get some sense of where it fits into your, into
your future careers. So Dr. Shah put into a nice package of just about kind of a broad
range of oral pathology. Ok?

2-Salivary Gland Disorders
So salivary gland disorders will involve both the minor glands and the major glands.
We probably spend, not always, but a lot more time, we see a lot more minor gland
abnormalities than major glands. And sometimes the etiology or our cause of
salivary gland diseases is a local cause, something thats happening within the oral
cavity, and sometimes the cause is a systemic cause and so were going one step at a
time to try to figure out whats happening. We might make our diagnosis on the
basis of subjective findings which are the patients symptoms and usually what the
patient will tell us, and then we will often continue with our objective findings in
order to come up with our final diagnosis. The objective findings start with our
examination findings and then usually our laboratory findings will give us the final
diagnosis. They dont always. Sometimes coming to a final diagnosis is much more
complex than we would like. It would be nice if it was a slam dunk but it just doesnt
happen that way all the time and sometimes making a final diagnosis can be a long
term process until we find out exactly whats going on.

3-Subjective Findings
The kinds of subjective findings that the patient might be telling us is that he or she
has a swelling any place that the major or minor salivary glands might be.
Sometimes the subjective findings give pain, which is gonna give us a lot of
information because a lot of salivary gland diseases dont cause any pain at all. And
then a very common problem, probably of all of the things that Im going to tell you
today, and Im going to talk about it in another setting as well, is the issue of dry
mouth and xerostomia. And I think that is of all salivary gland problems that you
will encounter in your career, xerostomia or dry mouth is probably going to be
probably the most common.

So, when you do your extra oral exam, there and now, I hope you remember a little
bit from last year when you did exams on each other.

Transcribed by Ana Sangadala

July 10, 2014

4-Objective Findings
Youre going to be able, on an extra oral exam, to be able to identify enlargement in
the major glands. Another thing that you will be taught to look for as you look at a
patient before you ever start using a palpation type of assist on your examination is
to look for enlargements and asymmetry. They may not be salivary gland
enlargements, but youre going to have to find them and move on from there. And
then, maybe some discrete swellings or masses that you need to work with. When
you get to the intra oral exam, you have to remember where the ducts are because
theyre going to be helpful in being able to tell whether or not the patient is able to
produce saliva and what the nature of the saliva actually is. And youre going to be
looking at any kinds of swellings or masses that might have developed. Um, when
you do your intra oral exam, now, in the last 30 years since dentists have been
wearing gloves, dry mouth is much easier to appreciate because the gloves just do
not slide on dry mucosa and just kinda stick as youre trying to do your exam. The
glove just wont slide on the mucosa. Thats evidence of dry mouth, even though the
patient hasnt yet told you that the patient has dry mouth.

Wheres my next slide? There we go. Ok.

5-No Title
This is a slide that should look familiar to you even if its not the exact slide that you
looked at and thats the location of the major salivary glands. The parotid glands are
superficial to the masseter muscle so one of the, as you do your exam, one of the
things you can determine. There are people that have hyperplastic, or
hypertrophied thats better, hypertrophied masseter muscle. The masseter muscle
gets larger from people that are very vigorous clenchers because again the striated
muscle is going to get larger and youre going to get enlargement of that muscle. It
can look similar to the enlargement of the parotid gland. However, since the parotid
gland is superficial to the masseter muscle, masseter hypertrophy is something you
can feel. You dont feel any parotid, you dont feel any enlargement on the muscle.
And if you feel the muscle, you can feel it clench, and you can feel that the
enlargement that you are seeing is actually the muscle. When its the parotid, you
can clench, and the enlargement that you are seeing from the parotid gland does not
really change in relationship to the clenching of the muscle. For the submandibular
and sublingual glands, there you will have to do the technique that you were taught
last year. Maybe you remember? Youre going to learn it again so it will become part
of your world. Its the bimanual palpation. And one, the reason that we do this, is if
we didnt use a hand outside on the outside of the chin, that area, when you palpate
the salivary glands, it actually depresses them and you really wouldnt be able to feel
them. So you use another hand to support that tissue, so when you feel that
submandibular gland that is way posterior in the floor of the mouth and when you
feel the sublingual gland which is anterior, you can actually feel those glands
because youre supporting the tissue with your hand on the outside. The
submandibular gland is a gland that is encapsulated, so you need to be somewhat
careful. If you remember doing this on each other, if youre too vigorous, its painful,
if you stick your finger way back in the floor of your mouth. And so we usually do

Transcribed by Ana Sangadala

July 10, 2014

this walking the fingers from the anterior of the mouth to the posterior part to
actually feel that encapsulated gland. The more you feel it, the more youre focusing
on it, the more you will recognize if its enlarged. When you start out in your exams,
youre probably not going to recognize an enlarged gland from a non-enlarged gland
because you havent felt a lot of them. But when you feel them more, youre going to
recognize what a normal submandibular gland and sublingual gland. The sublingual
gland is not an encapsulated gland. It is a complex of multiple smaller salivary
glands that are located in the anterior part of the floor of the mouth. So you kind of
feel a nodular feeling when you feel the sublingual gland.

6-No Title
Ok. This is an example of 2 enlargements. The one on the left is your lymph node,
ok? Were learning how to do your neck exam in your classes where you palpate
along the sternocleidomastoid muscle and youre learning the technique for the
palpation of the neck. And this patient has an enlarged lymph node. It looks like it is
superficial to the sternocleidomastoid muscle. This is a patient where it looks like an
enlarged parotid gland. And as you learn to do your extra oral exam, once youve
done your visual exam, you will learn a lot from doing examinations where there is
no abnormality because you get used to knowing what the range of normal is. So as
soon as something is abnormal, you will pick it up. The more exams you do, I have
talked about this before to you. Its not really intuition; its experience that will help
you figure it out. And very often, you will know what it is that youre registering as
somethings wrong until you just take a little bit of time back and think about it. You
will recognize what it is thats wrong. But its because youve done so many exams
by that time that you register somethings wrong even before you register what the
abnormality is.

7- No Title
Ok! So, we will move intra orally and you have a sequence for doing your intra oral
exam but what Im really showing you here is the location of the duct from Stensons
glandFrom the parotid gland rather. Stensons duct. Stensons duct is tucked under
a papilla on the buccal mucosa. What are these yellow spots? Fordyce granules. And
Fordyce glands are sebaceous glands, not salivary glands. Sometimes called ectopic
sebaceous glands but since 90% of adults have them its hard to call them ectopic. It
seems they are more normal to find than not. Anyway, here is the papilla. When
youre doing your exams, go look for it because you want to be able to see the
variation in size of that papilla. Sometimes you can barely see it, and sometimes its
as big as a fibroma. And every once in a while in the biopsy service, we get a
Stensons duct papilla that, and if that person isnt careful, they can do damage to
Stensons duct. You should be able to recognize that its one of the landmarks that
youll learn to look for as you do your examination of the buccal mucosa. The duct is
behind that papilla. So when you are learning how to milk the salivary glands to find
out if the glands are able to produce saliva and what the nature of the saliva is,
youre actually identifying this location and then trying to express saliva from the
parotid gland and it will kinda squirt out of the duct.

Transcribed by Ana Sangadala

July 10, 2014

8-No Title
Ok, on the floor of the mouth, we have another duct, Whartons duct. And here,
youve got to be somewhat careful when youre doing your exam on the floor of the
mouth because sometimes when you move your hands, its kind of nice to have your
mask and goggles on, the saliva will actually pop and squirt like a little fountain right
out of the duct and hit you in the face if youre not careful. So when youre trying to
milk the sublingual/submandibular gland, it really is important to watch out for
saliva. But heres the duct and its the duct from the submandibular gland AND the
sublingual glands actually feed into that duct.

9-No Title
Ok. On the labial mucosa, we have lots of minor salivary glands and if you want to
demonstrate them for yourself, you can do them on yourself, or you can do it on a
patient, and dry the lower lip and just wait a little bit. You will see that each one of
the minor salivary glands on the lip will form a little tiny droplet of saliva and you
will get a chance to see the location of those glands. Weve got lots and lots of them
scattered throughout the mouth and this is one location. There are also minor
salivary glands on the upper lip. When youre doing the palpation of the lower lip,
get used to feeling the nodularity of those minor salivary glands on the lower lip.
Once in a while when a patient becomes very mouth conscious, the patient will start
feeling those nodules and decide the patient has tumors in the lower lip. For you,
just get used to what they feel like when theyre normal and you will be able to
reassure the patient that theyre palpating, or feeling is probably the word you
would use, the minor salivary glands.

10-No Title
Ok? And weve talked about another location of minor salivary glands in conference.
Theres an enormous collection of minor salivary glands at the junction of the soft
and hard palate. So it is a very hot location or very common location for a number of
salivary gland lesions.

11-No Title
This we talked about in conference and I believe that Dr. Shah has talked about this
condition in your class as well. This is nicotine stomatitis. And the only reason Im
showing it to you here is it is one way of visualizing all of the minor salivary glands
and you can see them all over here. And I just showed you here, not so you would
learn nicotine stomatitis, but so you would see the distribution of minor salivary
glands.

12-Acute and Chronic Sialadenitis
And minor salivary glands are all over the mouth. Uh, salivary gland lesions can
occur intra orally wherever there are minor salivary glands. There are salivary
glands on the buccal mucosa, retromolar area, theyre on the lateral tongue
posterior, on the anterior tongue and so there are potential for intra oral salivary
gland conditions. Just about any place. And some are more common in some
locations than others and well talk about that.

Transcribed by Ana Sangadala

July 10, 2014

So lets talk about some specific diseases for a few minutes. Acute and chronic
sialadenitis. You can get this in either major or minor glands and um, we know it
best in major glands because thats where it usually causes the most symptoms so
that we have to work on this patient. And it is usually due to some kind of
obstruction of a salivary gland duct. And when you obstruct a major gland duct,
youre going to get a major gland problem. SO obviously the most visible and most
problematic major glands obstructions are going to be the parotid gland and the
submandibular gland because the sublingual glands are little glands with single,
multiple single ducts. So the problem with major glands is usually submandibular or
parotid. And infection in the gland or retrograde infection, those are the people that
have a decrease in their salivary flow. And the organisms in the oral cavity can
travel up the duct because theres no saliva washing out the duct and can actually
cause bacterial or fungal infections in the duct. Parotid gland inflammation is called
parotitis. There isnt a name that I know of for submandibular gland, except
sialadentitis.

13-Sialadenitis
This is a patient with a mass related to the submandibular gland. Try to sort out
what it is based on the patient signs and symptoms, and eventually possibly
laboratory tests if you need them. Here, this is painful, ok? And the patient has had it
for about a week with a constant and continuing increase in pain. It isnt enlarging
and deflating and were going to talk about why thats important in a little bit. Its
simply an enlargement thats very painful. And the diagnosis of this based on a
needle biopsy, which is a biopsy technique. Its where instead of a scalpel biopsy
where we go into the skin and take a big chunk of tissue, its kind of a broad needle
that can be placed into the tissue so we can get enough tissue to be able to see the
morphology of the cells and get a diagnosis. So on the basis of patient signs of
symptoms, and a fever will often accompany infection if the sialadentitis is due to
infection. And sometimes the inflammation is not due to infection, but due to
blockage.
What were looking at over here is the ducts of the salivary gland that had persisted.
The salivary glands themselves are disappearing. Theyre replaced with fibrous
tissue and then theres an inflammatory infiltrate. If the process is very new within a
day or so, we will get neutrophils. Like what were learning about in the innate
immunity as Dr. McCutcheon moves on to acquired immunity, we talk about the
different types of lymphocytes and as the process moves on longer, we see more
lymphocytes, plasma cells, in the area. But it takes time for those cells to get there.
The neutrophils get there REAL fast. Whatever the cause, the neutrophils will be
there. Ok?

14-Mucocele
A common issue you will see in practice is something called a mucocele. A mucocele
is a pool of saliva that has collected in the fibrous tissue, the fibrous connective
tissue. Because the duct of the salivary gland has been severed, the saliva has
nowhere else to go. So what it does, is it collects as a pool of fluid in the connective

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July 10, 2014

tissue. This one was a traumatized on the surface, so in addition to the swelling, we
have an ulcer and some fibrin on the surface here. This one is just a blue-ish ball, or
bluish dome shaped lesion. And you can kinda get a sense that it is fluid filled. This
one has some blood in it in addition to the saliva so it is much more of a purplish
color. And you can get mucoceles any place that there are salivary glands so it is
possible to get mucoceles in this area because there are a collection of salivary
glands there. It is possible to get some in the sublingual gland area, buccal mucosa,
you can get mucoceles on the junction of the soft and hard palate. But the most
common place you can get mucoceles is on the lower lip because the most common
cause is trauma from the cuspid tooth and theres a very high density of minor
salivary glands in the lower lip just opposite the cuspid tooth. That severing of the
salivary gland duct is what causes the mucocele to develop. When we remove a
mucocele, it is very important to take all of the minor salivary glands that are in the
area because it is very important that when you are surgically removing a mucocele
you dont form another mucocele by cutting a duct because you cannot actually see
the duct of another salivary gland. So the technique for removing a mucocele is to
remove the lesion and then also all of the minor salivary glands that you can find
surrounding that lesion. And we can do without some minor salivary glands, you
dont get xerostomia from losing a couple of minor salivary glands.

15-Mucocele
Ok? So it is a lesion that forms when a salivary duct is severed. And so mucous or
rather saliva spills into the connective tissue and the body then has a technique for
actually walling off the pool of mucous so you get some compressed inflammatory
tissue around the mucocele that makes it into something that looks like a cyst. A
true cyst is lined by epithelium. Thats the definition of a cyst. And youll get that in a
number of other places. This has no epithelial lining, just inflammatory tissue so it is
called a pseudocyst. It is not a true cyst.

16-Mucocele Microscopic Appearance
And this is the microscopic appearance of a mucocele. Here is minor mucous, minor
salivary gland. This is the duct. The duct got severed. This is the epithelial lining of
the duct. This is the lumen of the pseudocyst. This is the inflammatory tissue that
the body has built up to wall off the. Its a cystlike space in the tissue but it is not a
true cyst. And its lined with something that we are going to spend a lot of time on
called granulated tissue. Its a kind of inflammatory tissue, a reactive tissue. The
lumen is filled with mucin or saliva, thats interchangeable here.

17-Mucocele
And that is the definition of a mucocele. You see it as a swelling of the tissue. And it
is also possible that it increases and decreases in size because some of that saliva
finds its way into the surface or reaches into the surrounding connective tissues. So
the bubble doesnt always keep getting bigger. Sometimes it gets bigger and smaller.
Also, more saliva gets produce when youre eating. So theres a time when youre
eating when the lesion may swell and then there is time when the saliva can reach
into the surrounding connective tissue, it deflates a little bit. The lower lip is the

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July 10, 2014

most common site, wayyy more than any other place. But there is no site where you
have minor salivary glands where you dont have potential for mucoceles. Its upper
lip, its buccal mucosa, floor of the mouth, tip of the tongue, lateral tongue, junction
of the hard and soft palate, probably forgot some location. But if there are salivary
glands, you can get a mucocele.

18-Ranula
Then, there is another lesion called the ranula. The ranula is named for the Latin
word for frog. It is named for this out pouching when the frog croaks. Many
textbooks said it is named because it looks like the belly of a frog. But it doesnt look
like a belly of a frog, because a belly of a frog doesnt look like this. It looks like the
out pouching. This is a ranula. This ranula happens to be blood filled as well as
saliva. This is another one. Your textbook will call any fluid filled peudocyst on the
floor of the mouth a ranula, so even the ones that come from the sublingual glands,
which are much more like mucoceles everywhere place else, are sometimes
interchanged for ranula. I dont like that. Thats a personal thing but I dont think
that when there are small mucoceles on the floor of the mouth that dont look
anything like the outpouching of a frog and so I just dont know why that has stayed
in the literature but again I will try not to ask you a question that mixes you up. But
you will see in the literature that a ranula is this phenomena where there is a
severed duct and you get this phenomena on the floor of the mouth. Which is true,
but when you get little tiny ones from the sublingual glands, they dont look
anything like this outpouching.

19-Ranula
Be that as it may, it is a mucocele-like lesion that forms unilaterally. It is really
pretty impossible, unless the patient has some kind of habit that would sever
salivary gland ducts bilaterally, it is a unilateral lesion. And it is associated with the
large duct of the submandibular gland and if it is caused by an obstruction of the
duct instead of the severing of the duct, what will happen, and this is true in the
small minor glands as well. When the biopsy is done, the duct has been obstructed
and instead of the saliva spilling into the connective tissue, the duct expands. Now,
the duct is an elongated structure, but if you expand the duct and you take a biopsy,
what you get is a circular lesion that is lined by epithelium. Even though it is not a
true cyst, it looks like a cyst. So it is sometimes called a mucocyst when you get that
phenomenon because it has an epithelial lining but its just another form of a
mucocele.

20-Sialolith
Ok and then we get calcifications that will form in salivary glands. These are called
sialoliths. Lith is the Latin name for stone. When they form in the submandibular
gland in the submandibular duct, they have a specific type of presentation that
starts with a swelling in the neck and possibly in the floor of the mouth. Its primary
in the neck though. And the patient will usually have a distinct history of a swelling
in the neck that enlarges and deflates that is related to eating. When the patient is
eating and more saliva is produced, the swelling gets larger. Between meals, when

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July 10, 2014

the saliva seems to be able to get around the connective tissue of the duct, it seems
to slowly, it will be able to get out of the gland and then the next time the patient
eats, it swells up again. So this swelling and deflating is a characteristic of a sialolith.
The same the thing will happen in the parotid gland but its usually not as dramatic.
The patient will again be able to describe a swelling or enlargement and a resolution
related to eating. When you get that kind of history, there isnt much else that will do
it unless its a blockage, some kind of blockage of the gland that prevents saliva from
flowing. And with time the saliva will flow out of the gland and the swelling will
deflate.

21-No Title
Ok? And heres an x-ray and a part of the panoramic x-ray. A panoramic radiograph
is a very useful radiograph in identifying sialoliths when they are in the
submandibular gland duct. And here is the sialolith. Its long, but there are all kinds
of sizes and shapes.
Ok? And here it is after its been removed. You can see this? This is this. And it is a
mineralized structure and so on the radiograph it comes out and you can actually
see the mineralized structure.

22-No Title
It is also possible to get sialoliths in the minor glands and usually when they are
submitted to the biopsy service, the clinician will say it feels as it there is a foreign
body in the mucosa of the patient because its so hard. And theyre round and pea
shaped and here we were lucky enough to be able to see the mineralized structure
on the radiograph. We are not always so lucky. But here is the lesion clinically, and
here it is radiologically.

23-Sialolith
Histologically, it would look something like this. Here is the overlying mucosa. This
is the duct. And we dont see the salivary gland, its down here some place. And
heres the calcified lith, the mineralized stone.

24-Bilateral Salivary Gland Enlargement
Ok? Thats mucoceles, granulas, and sialoliths. Um, now we get into a bit more
complex salivary gland disease. And thats the whole group of bilateral salivary
gland enlargements. And in general pathology and systems pathology, were going
to bump into a number of these conditions as we move through those courses, but
there are a number of different problems that can all cause a very similar
enlargement of the salivary glands and its almost always the parotid gland. So, our
job is to sort out. Its very helpful to have a list. Sort out the list on the basis of what
we can find in subjective and objective findings. Were probably going to spend
more time than we ought to since there are so many times that we do talk about it.
Its an autoimmune disease called Sjorgens syndrome. The hallmark characteristic
of Sjorgens syndrome is that the patient gets a progressive dry mouth and has
enlarging parotid glands, but it can also happen in submandibular glands. But
parotid glands are the characteristic enlargement. The patient also gets enlargement

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in the lacrimal glands and dry eyes and this one is an autoimmune disease where
the body is producing antibodies to the patients salivary glands and destroying the
patients salivary glands in the process. Were going to spend more time on Sjorgens
syndrome as we move along.

Patients who are long-term alcoholics can sometimes present with bilateral salivary
enlargement. It may very well be that we are looking at here, not at the alcoholism,
but many patients with alcoholism have chronic malnutrition. Because depending
on how severe the alcoholism is, they are missing major nutrients and this is a
nutritional enlargement rather than just due to the alcoholism. Malnutrition,
depending on its severity is known to be associated with salivary gland
enlargement. Diabetes mellitus here, the mechanism isnt clear, but some patients
with diabetes for a long time all start developing enlargement of their salivary
glands. And again malnutrition is a separate category here, but the malnutrition in
alcoholism is probably whats causing it in that one. And again, in trying to sort out
what the patient is getting at, you go through all those questions to help. HIV
infection is also one of the things that causes bilateral salivary gland enlargement.
We will talk a lot more about the pathological and histological features of these as
we move along. There are a number of drugs that have the ability to cause salivary
gland enlargement. Mumps can do it as well. But mumps is an acute problem. And
usually when the patient has mumps, youre going to be able to know the patients
salivary glands are enlarged. The patient has a fever, the patient didnt have it
yesterday, and its usually mumps in the area and other people have had the
problem. So mumps usually, of all of these, is one of the easiest forms to be able to
diagnose on the basis of preliminary features. There is a granuloma disease, called
sarcoidosis that does this. And then to make our lives really pleasant, there are
sometimes, you just cant figure it out. You go through all the possibilities and the
patient has none of those and you just cant figure it out. Or you didnt get the right
answer to the right question, which is certainly something that once in a while
happens.

25-Mumps
This is a patient with mumps.

26-Anorexia Nervosa
And this patient is a patient with malnutrition thats related to anorexia nervosa. I
will tell you the story once and try not to repeat it as we get into bilateral salivary
gland enlargement in general pathology. Say you told us this one already, dont tell
us again. This is a patient that I saw when I was a resident with very experienced
oral pathologists and she has as you can see, bilateral salivary gland enlargement.
Shes 16 years old and she is thin, ok? And um, there was at that point, an attempt to
try to figure out what was going wrong with the salivary glands and one of the
things you will learn is if you even suspect that the patient has an eating disorder, it
isnt particularly wise to try to get information when the mother is in the room.
Youre just not going to get, unless its a previously diagnosed problem, not really
going to get the answers that you want. And so a number of diagnostic procedures

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were done, but no biopsy was done to figure out what was going on with this young
women. It was at this point that we considered it idiopathic. It was thought it may be
autoimmune or very early Sjorgens syndrome. But Sjorgens syndrome does not
emerge in 16 year olds usually. So she went to college in Maryland and she was
referred to a group of oral pathologists in Maryland and they actually did a needle
biopsy of the salivary glands. On the needle biopsy of the salivary glands, it was
clearly not Sjorgens syndrome because Sjorgens syndrome is where the salivary
glands are replaced with lymphocytes. Her salivary glands were just very very
enlarged. HYPERTROPHIC salivary gland acini. So the condition that is known to
cause hypertrophic salivary glands is malnutrition and it was at that point they were
able to recognize and diagnose the anorexia nervosa that was causing the enlarged
salivary glands that hadnt been diagnosed before. You will find and I will show you
a couple of conditions later where there are facial and oral characteristics and
complications that occur from eating disorders. It may be a condition where you
may be the first one to talk to the patient about the problem that is a secret. You
suddenly know a secret and trying to find ways to talk to the patient is something
that takes some skill and I would be very very careful the first time that you think
about doing it, before you approach the patient, because you are suddenly
discovering a secret that the patient didnt want you to know.

27-Alcoholic Sialadenosis
This patient is a long term alcoholic and here is related to malnutrition as well.

28-Sjorgens Syndrome
Sjorgens syndrome. Were not going to spend a lot of time in this course on
Sjorgens syndrome because I will spend time on it later. So what I want you to
know is that Sjorgens syndrome is on the categories of salivary gland disorders. On
here, we are looking at an autoimmune disease. And it is an autoimmune disease
where the body is producing antibodies that are destroying the salivary glands. So
over time, the salivary glands become more and more severely affected and over
time the patient has a dryer and dryer mouth because the patient is not able to
produce saliva. So it is one of the conditions where you get bilateral salivary gland
enlargement and well talk about it more later.
Sjorgens syndrome is a combination of dry eyes and dry mouth.

29-No Title
And this is a patient with Sjorgens syndrome. She also has dry skin. Its a very
complex case, and she has an increased risk fo developing lymphoma and well talk
about that later but this is her parotid gland enlargement. Ok?

30-Autoimmune Disease: Sjorgens Syndrome
Heres another patient with parotid gland enlargement. And very dry mouth and Ill
show you pictures like this. These are the driest mouth pictures I have so youll see
them a couple of times. Remember I told you in conference that people with severe
xerostomia get atrophic or depapillated tongue? So this is an example where that is

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happening. And then the other thing that happens when you have no saliva is that
the risk of caries is very high and well talk about that a little bit more later.

31-Laboratory Values in Sjorgens Syndrome
And this is one disease where laboratory values are very helpful in making the
diagnosis. I am not going to ask you to know the laboratory values in Sjorgens
syndrome in this course, because I will ask you to know them later. But there are
laboratory values and I think that much you should know. So I think you should
know the definition of Sjorgens syndrome that it is a combination of dry eyes and
dry mouth. I think you should know patients with Sjorgens syndrome have very dry
mucosa and they have an increased risk of developing rampant caries and we can
use laboratory values to help make the diagnosis. Ok?

32-HIV Associated Salivary Gland Disease
This is an HIV patient with bilateral salivary gland enlargement and here are his
salivary glands. Parotid glands.

33-HIV Associated Salivary Gland Disease
And here, the laboratory findings actually rule out Sjorgens syndrome. So the
laboratory values can be helpful because they are negative and the disease itself is
very similar to Sjorgens syndrome in presentation. So the fact that the patient
doesnt have the laboratory values is helpful. Also, patients with HIV or HIV serum
positive, which is another laboratory value which is helpful. The histology is very
similar.
One difference from Sjorgens syndrome is patients with HIV salivary gland disease
get very large cystic spaces in the salivary gland.

34-No Title
And you can see some of them here. And we dont see them in Sjorgens syndrome.

35-No Title
If we look at it under a microscope, we can get to see some of the large cystic spaces
that are present in this salivary gland. Ok?

36-Salivary Gland Tumors
Thats bilateral salivary gland enlargement. And we will talk about that a lot more as
your curriculum proceeds. I do think that at this point, it is a good idea to learn the
list. Youre going to have to learn it anyway and you might as well learn it now since
it is summertime and you dont have quite as many things to work on. So, work on
the list, but I think that actually making the distinction between all of the parts of
the list, we will try to keep that to the kinds of things we will cover in this course
and this lecture.
And from here, we move onto salivary gland tumors. There are benign tumors. And
benign salivary gland tumors, they are called..there are a variety of different names,
but they are called adenomas. So we have a pleomorphic adenoma and we have a
canalicular adenoma but if you see salivary gland tumor and the suffix or second

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July 10, 2014

part is adenoma, that means its a benign one. For the malignant ones, they are
adenocarcinomas. But carcinoma is the end part of the malignant salivary gland
tumors. So we have adenoid cystic carcinomas and we have acinic cell carcinomas,
and mucodermic carcinomas, and we have many different salivary gland tumors.
Each one of the salivary gland tumors is diagnosed on the basis of its
histopathological appearance. So in order to differentiate between benign and a
malignant salivary gland tumor, you have to take a biopsy because clinically they
both present very similarly. Ok, so there might be some slight changes. A malignant
one might get larger faster than a benign one, but some of the malignant ones are
very slow growing tumors and so they enlarge very slowly. So really there are no
characteristics clinically that differentiate a benign salivary gland tumor from a
malignant salivary gland tumor. Thats something that I expect you to know for this
course. When we get later on in the course, you are going to have to learn some
names. When you get to oral pathology net year, youre going to have to know a lot
about salivary gland tumors. But right now, what I want you to know is that there
are benign ones and there are malignant ones. The benign ones end in adenoma and
the malignant ones end in carcinoma and they are all types of adenocarcinoma. You
cant tell what they are clinically.

37-No Title
There are different distributions of salivary glands. If you look at the parotid gland,
the parotid gland accounts for 78% of all salivary gland tumors and 75% of all of
one type of benign salivary gland tumor called a pleomorphic adenoma. And it
doesnt matter all the statistics, but about 15% are malignant. Submandibular gland,
there is a higher prevalence of malignant salivary gland tumors than the parotid
gland. Sublingual glands, again there are at least in the study that these statistics
came from, theres a high prevalence of malignancy in the sublingual. Think of the
submandibular gland. And then intra oral, these are relatively old statistics because
at this point Im not even sure we go here, but lots of them are malignant, but also
lots of them are benign. At this point what I would like you to know here is that
salivary gland tumors can occur anywhere you have salivary glands. They occur
both in major glands and minor glands and there are some differences in the
prevalence of malignant tumors versus benign tumors. I will not ask you
percentages. I cant remember percentages. But I would like you to know where,
which one has a higher percentage or a higher prevalence of malignant ones such as
the sublingual and submandibular glands are more malignant in prevalence than the
parotid glands.

38-Salivary Gland Tumors
Ok, so they occur in major and minor glands. And most intra-orally. Another thing
you should know is that they occur anywhere there are salivary glands but the most
common location BY FAR is the junction of the hard and soft palate. The hard and
soft palate is greater than the lips, greater than the buccal mucosa, and the upper lip
is more prevalent than the lower lip. And remember that a little bit ago I told you
where is the most common location for mucoceles? The lower lip. So salivary gland
tumors are more prevalent on the upper lip. Does that mean you cant get a

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July 10, 2014

mucocele? No. And mucoceles are more common or prevalent on the lower lip. Does
that mean you cant get a salivary gland tumor? No. Its just that if youre doing a
differential diagnosis and you want to put something on top, for the lower lip, you
put mucoele on top and for the upper lip, you put salivary gland tumor on top. Some
salivary gland tumors form mucous and can form a cystic structure that can mimic a
mucocele. Ok?

39-Pleomorphic Adenoma
Pleomorphic adenomas, benign salivary gland tumors, are benign. They are slow
growing and they will continue to enlarge, as every tumor will. Characteristics of a
tumor are that it has unlimited growth potential. Weve been taking about epithelial
hyperplasia and hyperplasia, thats a reactive condition. So it will continue as long as
the source thats causing the reaction is there. If you remove the irritant, you will
stop the process. With tumors thats not true. With tumors, they are programmed to
enlarge and keep going until you have done something to remove them. So
pleomorphic adenoma is the most common of the benign salivary gland tumors and
this is just an illustration of just how large a pleomorphic adenoma can get.

40-No Title
Here we have 3 or 4 different types of salivary gland tumors. Adenoid cystic
carcinoma-malignant. Pleomorphic adenoma-benign. Pleomorphic adenomas are
worrisome if you dont remove them because there are a lot of illustrations or
instances where a carcinoma has formed in the pleomorphic adenoma. So there is a
concern of potential malignant transformation in a pleomorphic adenoma.
Mucoepidermic carcinoma-another carcinoma. All we have here, this one is benign.
This one is malignant. The only reason you see what looks like an ulceration here is
because thats where the biopsy was done. But all of these look very similar to you
clinically even though this one is benign and the other 3 are malignant. You cant tell
the difference. So the way to make a diagnosis of a salivary gland tumor is through a
biopsy and there really isnt another way to do it.

41-No Title
Salivary gland tumors can occur anywhere there are salivary glands and if we look
here, we have an enlargement from the salivary glands on the tip of the tongue. This
happens to be a malignant one. This is an adenocystic carcinoma.
Im not going to take a break because Im not going to go to 4:50 and I dont want to
take a 15 minute break and come back for 10 minutes. That doesnt make any sense.
Ok?

42-Assessment of Salivary Flow
So, then we have to go to an assessment of salivary flow. And I will cover this here
and I will mention it again as we go on later. There are 2 terms and they are used
very very carefully within research but they are mixed up constantly in clinical
practice. The term xerostomia means the patient is complaining of dry mouth. It can
be all the way through to your clinical assessment where the tissue is dry. You can
still call it xerostomia. Hyposalivation means we have measured the salivary flow

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July 10, 2014

and the salivary flow measures low. So xerostomia is a term for the patient
complained and the clinical presence of the characteristics of dry mouth.
Hyposalivation means you measured it. We dont use the term hyposalviation unless
you actually measured salivary flow.
Do you have your hand up? No? I cant see so it looks like..your hand it front of her
and shes in front of you so it looks like her hand is up.
Ok, we measure both stimulated and unstimulated flow and we get a lot of
information out of the measurement of salivary flow.

43-Diagnosis
What we can do to find out about dry mouth. There are different reasons patients
have dry mouth. And we looked at Sjorgens syndrome as a condition where you
have dry mouth. And there are multiple medications that dry up saliva. There are
salivary gland diseases that will cause xerostomia. And so one of the things we need
to figure out and its not very difficult to figure out, is whether or not the patients
dryness is due to a salivary gland disease or due to a medication that is drying up
saliva. Also stress can also do it. If any of you have ever been in a stressful situation
you will recognize that your mouth gets really dried out and you can barely move
your tongue around your mouth because your salivary glands have just dried up.

In salivary gland diseases, the salivary gland acini are being destroyed more than
they are being replaced. So you can try to measure unstimulated and stimulated
saliva, you dont get either. You can stimulate, but over time the worse the salivary
gland disease is, the stimulated saliva will not flow. So the patient will have very low
unstimulated salivary flow and a VERY low stimulated salivary flow. If the problem
is due to a medication, usually, the only medication that really destroyes salivary
glands is lithium. Most of the others are just interfering with the innervation that
allows salivary flow. So what will happen is as soon as you stimulate, the saliva will
flow so you may get a very low unstimulated flow, but you get plenty of saliva as
soon as you give your patients something to chew on and stimulate the flow. And
you can tell the difference between a patient who has salivary gland disease
destroying the salivary glands and a patient who has a medication that results in
xerostomia by using the technique. You dont have to do it as sophisticated as we do
in research, in a research program. In your own practice you can just have patients
spit in a cup and you can tell the difference between stimulated and unstimualted
saliva which kind of helps figure out which direction you are going. Also, a patient
with salivary gland disease is going to need some kind of lubrication in order to eat
during meals. A patient that has no problem with salivary flow and salivary gland
structure is going to be fine at meals because that will trigger the flow of saliva. So
the questions about meals and about needing to drink. A patient with Sjorgens
syndrome has to drink. *Cough. Excuse me, let me drink. Has to drink liquid in order
to be able to get the force to swallow it. *Cough Cough Cough. This is what happens
after three hours. And so you need to tell the difference. Patients who got a dry
mouth..*cough Okay. I think. A person who has a dry mouth because of medication
should not have any problems during meals at all. When a patient has dry mouth a
lot, you need saliva to retain dentures. There are some techniques to help, but again

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July 10, 2014

the dentures will not stay in the way they are supposed to. And then we talked about
facial and oral swellings during meal time.

44-Objective Findings
Other things you can look for: patients with dry mouth have very dry chapped lips
usually. There is an increase in dental caries and increased risk in developing
candida. Saliva has antifungal properties that are very very sophisticated. And
patients who have decreased saliva are more vulnerable to candidiasis. When you
do your exam, you can see the very dry, dessicated mucosal surfaces. And often they
are so dry that the patient has ulceration because the friction and the disruption of
the oral mucosa. Patients lips will adhere to the patients teeth. We talked about, in
the conferences this week, changes in tongue papillae that we dont really
understand. And of course, objectifying salivary gland development is usually very
helpful.

45
This is a larger picture of very dry mucosa. This is a patient who I think had cancer
and radiation therapy dryness.

46
The saliva thats there is very thick and ropy and this is an example of this.

47
This is a patient with a type of candidiasis. And we have talked a little bit in
conference about wiping it off. All that white stuff wipes off. The patient is wearing
dentures, but the candida is way outside the dentures and not just the denture thats
a problem.

48
Here, its a patient with very dry mouth and an atrophic bald tongue. Angular chilitis
is one of the clues to intra oral candidiasis and here she has angular chilitis. This is a
patient that was taking multiple medications. She was taking a blood pressure
medication and then she added an anti allergy medication and then she added
another one for sleep. By the time she added a third one, she really had a very very
dry mouth.

49
This is a patient with cervical caries. You guys will get very used to a variety of
different caries, but most patients, particularly younger patients do not get cervical
caries. The extensive cervical caries should give you a clue that this patient has dry
mouth.

50
Again, very extensive caries in patients with Sjorgens syndromes and other chronic
conditions with dry mouth will just have a very difficult maintaining their teeth,

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July 10, 2014

maintaining their restorations that you have put in the teeth because the teeth are
decaying. The caries is just affecting the teeth right around the restorations.

51
Then, incisal caries is really really really rare. We dont see incisal caries very often.
Incisal caries just by definition-this patient has a very dry mouth. Unless the patient
is doing some VERY unusual stuff with sugar, you would expect the incisal caries is
going to be xerostomia.

52-Measurement of Salivary Flow
Measuring salivary flow-unstimulated and stimulated are both measurements that
we use. They are important because the difference between the two can give us the
clue as to whether the patients salivary gland problem is salivary gland disease or
might be related to medications.

53
Another thing you can look for is pooling of saliva in the floor of the mouth.
Normally, your patient will just pool saliva in the floor of the mouth. If you have a
patient with dry mouth, the pooling of saliva is not going to happen.

54
There are a number of different ways to collect saliva. When we collect saliva in our
studies, we are actually using it on ice and thats the cup here with a graduated
cylinder and a funnel. So we have a nifty system for collecting saliva. You really dont
need that in clinical practice unless you really are doing a study. You do need to
measure the saliva sometimes. Sometimes you dont even need to measure it
because what youre really looking for is how dry is the patient. Whether or not you
can use stimulation to get the patient more comfortable. Just the difference between
stimulated and stimulated. Sometimes you can see it just visually. Sometimes you
just get them to spit in a cup for about 5 minutes and then with stimulation. If youre
not doing a study, you can use chewing gum for stimulation or you can use anything.
And for our purposes, you wont use anything sugarless but you can use a sugarless
lozenge as well. You are not looking at the nature of saliva at this point. You are
really looking at the ability of the patient to respond to stimulation. The best
stimulation is chewing gum, but not all patients can chew gum. It depends and
certainly patients with prosthetic dentistry sometimes cant chew gum because the
gum sticks. You really dont have to get fancy about this. When you get to clinic, we
are able to give you graduate cylinders. I might need to get some more because you
might take me up on this more than other classes. We do have graduated cylinders
and we do have funnels, so some of the students have done a measured technique
for measuring salivary flow and I think you will learn a lot about xerostomia if you
use that while you are here in school.

55- Measurement of Salivary Flow
Unstimulated-what you do is you drool. You sit quietly and let whatever. The easy
way to do it is to let patients sit quietly and let whatever forms collect in the floor of

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July 10, 2014

their mouth and if they think they can spit, they can spit. Actually drooling is very
uncomfortable because you feel like you have to let the saliva drip out of your lip.
Its usually the research way of doing it, but it really. In your own practice, you can
just let the saliva collect in the floor of the mouth and when its enough to spit, spit.
Patients with a real xerostomia, you are probably not going to get any unstimulated
saliva. Nothing is going to be there so you dont even have anything to spit. With
stimulated, you can sit there for 5 minutes and get nothing. Then you give the
patient a lozenge and suddenly the saliva starts flowing. You can tell immediately
that the patient has functioning salivary glands and you can make the patient
comfortable with mechanisms to stimulate salivary flow. We have to be really
careful because our patients are going to learn that too. If they are going to use a
sugar lozenge to try to make saliva flow, they are going to end up with a xerostomia
and an increase in their caries experience, which isnt just because of their dry
mouth. Its because of what they are doing to try to stimulate their dry mouth. We
try to intervene with fluoride and advice when we try to get patients to do what they
can about xerostomia. Xerostomia is that much more subjective term for decreased
salivary flow and hyposalivation is when we have measured it. I think you will find
in your practice-I tend to talk about xerostomia a lot. If you dont identify a dry
mouth before you start a dental treatment, your dental treatment is going to fail. It is
really important for your relationship with your patient for you to recognize that
problem before you start. That patient is going to have increased caries-caries
around your restorations. Your gorgeous dentistry is going to fail because your
patient has xerostomia.

56-Etiology
There are a number of different medications that are known to cause dry mouth.
The number is over 500. There are just a number of medications that will do this.
These are just the categories of medications you will learn much more about
medications as you move through the curriculum but you will also learn that there
are great ways of looking medications and identifying those that are likely to be the
culprits. Sometimes you can work with the patients physician to change the
medication to something that is not xerostomic. But sometimes you cant, and need
to work around the medication isnsteas of changing the medication. It depends on
what the medications. Very often the alternatives are just as bad as the one the
patient is using so changing the medication unless there is a category that works for
that patients disease that is not xerostomic, were usually stuck with the medication.
The more you add, the worse it gets. A patient with 1 medication that is potentially
xerostomic, the patient may not have a problem. The patient adds another
medication, and the patient may still not have a problem but you will see. With our
patients the older our patients get, the more medications theyre taking. Sometimes
they are taking 3 or 4 medications that all have the potential to decrease salivary
flow.

57-Etiology
Again, there are systemic diseases that will decrease salivary flow. Usually these are
conditions that do not respond well to stimulation. Autoimmune disease, the most

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well known one is Sjorgens syndrome. Cystic fibrosis actually affects salivary glands
as well as other glands. Diabetes, only when it is uncontrolled. Controlled diabetes
usually doesnt give us dry mouth. HIV infection, even without the salivary gland
problem can sometimes cause dry mouth. It is very often, we think it is, and we will
talk about this in another lecture we give you. But we think the problem is probably
the medications. Whether or not the HIV disease is really doing this outside of
identified salivary gland disease is not clear. And dehydration. Dehydration is
episodic. Dehydration will cause dry mouth but not something that will cause long
term, chronic, dry mouth unless you have a dehydration that is really life
threatening. Then we are talking about a different problem all together.

58-Etiology
Head and neck radiotherapy is notorious. The problem here is that it destroys the
salivary glands and there are techniques out now for shielding the salivary glands so
that the salivary glands dont get destroyed the way they used to. This is still a
problem if the salivary glands are affected, but there some ways to protect them.

So thats our story about salivary gland assessment. There is more to come, but
thats enough for today.