Physiology of Saliva

Saliva
Saliva is alkaline liquid secreted by the salivary glands and the mucous membrane of the mouth. Its principal constituents are water, mucus, buffers and enzyme. Function: to keep the mouth moist, to aid swallowing of food, to minimize changes of acidity in the mouth and to digest starch.

1. Parotid Gland 2. Submandibular Gland 3. Sublingul Gland

Anatomy and Physiology of Salivary Gland

Salivary Glands
The principle glands of salivation are:
Parotid glands Submandibular glands Sublingual glands Minor salivary glands

In the salivary glands, the secretory granules containing the salivary enzymes are discharged from the acinar cells into the ducts. pH of saliva secreted : 7.0 Secretion : 1500mL per day

Parotid Gland
The largest salivary gland Located anterior and inferior to the ears in the subcutaneous regions of the cheek The Parotid has been described as having 5 processes (3 superficial and 2 deep). 80% overlies the masseter muscle. 20% on retromandibular

 The boundaries of the parotid compartment:

Superior border Zygoma Posterior border External Auditory Canal Inferior border Styloid Process, Styloid Process musculature, Internal Carotid Artery, Jugular Veins Anterior border a diagonal line drawn from the Zygomatic root to the EAC

Facial nerve enters the parotid fossa by passing between the stylohyoid muscle and the posterior belly of the digastrics muscle, then splits the gland into a superficial lobe & a deep lobe.

Nerves and Arteries

Submandibular Glands
Submandibular gland lie along the body of the mandible. Submandibular duct arise from the portion of the gland that lies between the mylohoid and the hyoglossus muscle.

 The arterial supply of the mandible glands is from the submental branch of facial artery. Innervation to the Submandibular gland derives from 2 important sources:
1. Sympathetic innervation from the Superior Cervical ganglion via the Lingual artery, and 2. Parasympathetic innervation from the Submandibular ganglion, which is fed by the Lingual nerve.

Sublingual Glands
Smallest and most deeply situated. Lies in the floor of the mouth between the mandible and the genioglossus muscle. Numerous small sublingual ducts open into the floor of the mouth along the sublingual folds.

 The arterial supply of this gland is from:

The sublingual branch of lingual artery. The submental branch of facial artery.

Innervation to the Sublingual gland derives from 2 important sources:

1. Sympathetic innervation from the cervical chain ganglia via the Facial artery. 2. Parasympathetic innervation, like the Submandibular gland, is derived from the Submandibular ganglion.

Minor Salivary Glands

The minor salivary glands lack a branching network of draining ducts. Each salivary unit has its own simple duct. The minor salivary glands are concentrated in the Buccal, Labial, Palatal, and Lingual regions. Found at the superior pole of the tonsils (Webers glands), the tonsillar pillars, the base of tongue (von Ebners glands), paranasal sinuses, larynx, trachea, and bronchi. Most of the minor glands receive parasympathetic innervation from the Lingual nerve, except for the minor glands of the palate, which receive their parasympathetic fibers from the Palatine nerves, fed by the Sphenopalatine ganglion.

Composition of Saliva
1% - ions and organic components 99% - water

Inorganic Component
Most important cations : sodium and potassium Major osmotically active anions : chloride and bicarbonate. Other electrolytes : calcium phosphate, fluoride, thiocyanate, magnesium sulfate, and iodine. Water and the ionic constituents of saliva are derived by translocation from blood plasma. But saliva is not merely an ultrafiltrate of plasma.

Organic Component
1. Amylase:
Glycosylated and nonglycosylated.

2. Lipase
Secreted by the lingual (von Ebners)salivary glands.

3. Mucosa glycoprotein
Consist of multiple oligosaccharide chain attached to a peptide core.

4. Proline-rich glycoprotein
I. II. Basic glycoprotein : binds lipids and may preferentially absorb to membranes Acidic protein : comprises calcium binding proteins and attaches to the tooth surface

5. Tyrosine-rich protein (statherin)

Prevent calcium precipitating from saliva

6. Histadine-rich protein
Forms pellicle

7. Lysozyme
Important in oral protective functions

8. Secretory immunoglobulin A
Synthesized by plasma cell

9. Growth factors and kallikrein

Factors Affecting Salivary Secretion

 Secretion of saliva is under nervous control and to date no hormones directly affecting the rate of salivary secretion have been identified. Increase secretion my result from conditional reflex. Increased secretion when:
The noise of food being prepared Talking about food Sight of food

Secretion decrease when:

Though about disliked food

 Unconditional reflex and increase secretion may be caused by:

Taste. Smell. Mechanical stimulation of the oral mucosa Mechanical irritation of the gingiva Mastication of food Chemical irritation of the oral mucosa Distention or irritation of esophagus Chronic irritation of the esophagus Chemical irritation of the stomach Pregnancy

Function of saliva
Play essential role during mastication in bolus formation. Act as a lubricant in swallowing. Speech production. Digestion Salivary amylase is a digestive enzyme- breakdown of starch and glycogen. Salivary lipase-secreted by lingual salivary glands(von Ebners gland)-fat digestion. Temperature regulation Buffering action Maintenance of oral health by limiting the formation of acid from bacterial fermentation

 Maintaining the integrity of oral and dental tissue by controling the oral pH Bicarbonate -major factor to control the pH. Reduction in salivary flowpH etching & dissolution of crowns of teeth. Antibacterial action & Antifungal action Lysozyme,lactoferrin,sialoperoxidase help against pathogenic microorganisms Immunoglobulins and secretory IgA also act against microorganisms. Production of growth factors & other regulatory peptides. Remineralization Saliva is supersaturated with ions,which facilitate remineralization of teeth

 Agglutination immunoglobulins and secretory IgA cause agglutination of specific microorganisms- prevent their adherence to oral tissues. Mucins as-specific agglutinins to aggregate microorganisms. Taste Saliva has a low threshold concentration of sodium chloride,sugar,urea etc allowing perception of taste to occur. It acts as a solvent allowing mixing and interaction of food with taste buds

Mechanism of saliva secretion

is controlled by the autonomic nervous system. Salivary glands have both parasympathetic and sympathetic secretomotor innervation. A)Parotid gland i)Parasympathetic control otic ganglion is a parasympathetic ganglion located just below the foramen ovale and medial to the mandibular nerve to which it is connected. The lesser superficial petrosal nerve(branch of glossopharngeal nerve), carries preganglionic parasympathetic fibers from the inferior salivatory nucleus synapse in the otic ganglion.

 Postganglionic fibers reach the gland via the auriculotemporal branch of the mandibular nerve.

ii)Sympathetic control Arises in the 1st 2 thoracic segment(T1 and T2) & synapse in the sympathetic superior cervical ganglion. Postganglionic fibersotic ganglion via middle meningeal artery. Sympathetic fibers pass through the otic ganglion without synapsing and accompany parasympathetic fibers gland

B) Submandibular & sublingual glands i)Parasympathetic control

Submandibular ganglion is a small parasympathetic ganglion located in the floor of the mouth& is connected to lingual nerve. Preganglionic fiber from superior salivatory nucleus ganglion via facial nerve. Postganglionic fibers from this ganglion are secretomotor to both glands.

ii)Sympathetic control similar route to the parotid gland Postganglionic fiberssubmandibular ganglion via facial and lingual arteries. And pass through the ganglion without synapsing to supply the submandibular & sublingual glands C) Minor salivary glands i)Parasympathetic control Most of the palate are supplied by parasympathetic fibers arising in superior salivatory nucleus.

 Preganglionic fiberparasympathetic sphenopalatine ganglion, situated in pterygopalatine fossa and connected to the maxillary nerve. Postganglionic fibers from the sphenopalatine ganglion reach the glands of the palate via palatine branches of maxillary nerve.

C-pterygopalatine fossa

ii)Sympathetic control Sympathetic fibers pass to the glands of palate from the1st 2 thoracic segments(T1&T2). Preganglionic fiber synapse in the superior cervical ganglion from where postganglionic fibers parasympathetic sphenopalatine ganglion via maxillary nerve.

sphenopalatine ganglion

 Both the superior(associated with facial nerve) & inferior salivatory nuclei(associated with glossopharyngeal nerve) are found in medulla oblongata. Parasympathetic innervation is secretory & vasodilatory; Sympathetic innervation is vasoconstrictive. Secretory activity of gland cells is mediated by cholinergic(parasympthetic) and adrenergic(sympathetic)agents.

Following statement can be made with regard to autonomic secretory innervation of salivary glands 1. Secretory cells are supplied by both parasympathetic & sympathetic nerves 2. Impulses conducted via parasympathetic system are more regular than impulses along sympathetic nerves. 3. The effect of stimulation by nerves of these 2 systems is not necessarily antagonistic. 4. Both stimulation causes contraction of myoepithelial cells- promote salivary flow.

5. Blood capillaries receive stimuli from both systems,

but parasympatheticvasodilation; sympathetic vasoconstriction Parasympathetic stimulation is mainly responsible for secretion of larger volume of saliva by secretory cells;Sympathetic has greater influence on the composition of saliva.

Types of salivary gland

Major salivary gland Minor salivary gland

Major salivary glands

Parotid gland:
Pure serous gland Found in adult human, although mucous cells present in children.

Submandibular gland:
Mixed. Predominantly serous. Serous mucous ratio is 12:1.

Sublingual gland:
Mixed. Predominantly mucous. A few pure serous acini and the serous cells present are arranged in demilunes.

Minor salivary glands

1.

Lingual glands
Found bilaterally.

Anterior lingual gland Inferior surface of tongue tip

Anterior mucous Posterior mixed

Posterior lingual gland Found in lingual tonsil and lateral margin of the tongue Pure mucous gland

2.

Buccal and labial glands

Found in cheeks and lips. May contain both mucous and serous.

3.

Palatine gland 4. Pure mucous gland Found in: Soft palate Uvula Posterolateral of hard palate

Glossopalatine glands Pure mucous glands Found in glossopalatine fold.

Salivary gland radiography

Submandibular gland
Seen in posterior part of submandibular triangle Triangular in shape May be connected with parotid or sublingual gland by glandular processes Wharton duct runs from hilum at the level of mylohyoid muscle, bends around free part of mylohyoid, extends to its orifice at sublingual caruncle along the medial part of the sublingual gland

Wharton duct: Efferent duct of submandibular gland

Parotid gland
Located in retromandibular fossa, anterior to ear and SCM Located at mandibular angle wrapping it Majority is superficial to masseter Drained by Stenson duct - exits above upper 2nd molar tooth; usually not seen on USG

Stensens duct: Efferent duct of parotid gland

Sublingual glands
Lies between muscles of floor of oral cavity Lies adjacent to mandible Oval on cross section and lentiform on long axis Medially there is Wharton duct

Duct calculi

Parotid gland Calculus in the distal segment of the partoid duct (arrow). Sialography

Duct calculi
Submandibular gland Axial CT demonstrating two closely apposed calculi at the hilus of the right submandibular gland(arrow).

Lateral oblique plain film demonstrating a radiopaque calculus(arrow).

Radiographic projection
Lateral Oblique Projection: Lateral Projection:
To delineate the submandibular gland Image is projected below the ramus of the mandible Shows ductal projection

Occlusal Projection:
Useful for sialolith located in the anterior part of the whartons duct

Anterior-posterior projection:
Demonstrates medial and lateral gland structures

Panaromic Projection
Made during the filling phase. Easier to expose Low radiation Satisfactory bony details

Applied diagnostic imaging of salivary gland

1. 2. 3. 4. 5. 6. 7. Plain film radiography Intraoral radiography Extraoral radiography Conventional sialography Computed tomography (CT) Magnetic resonance imaging (MRI) Ultrasonography (US)

1. Plain Film Radiography

Provide sufficient information to preclude the use of more sophisticated and expensive imaging techniques. To identify inrelated pathoses in the areas of the salivary glands To suggest present of sialoliths :
20% in submandibular 40% in parotid Rarely found in sublingual not well calcified, radiolucent, not visible.

A large proportion of salivary calculi are radiopaque

 Patients presenting with obstructive symptoms of acute intermittent swelling require routine radiographs to determine the presence and position of the stone (s).

2. Intraoral radiography
In submandibular gland:
Anterior 2/3: Sialoliths are imaged with a cross sectional mandibular projection Posterior: posterior oblique view. Central ray is directed parallel with mandible.

In parotid gland:
More difficult to demonstrate Stensen duct Only sialoliths in anterior part can be imaged. To demonstrate:
Held intraoral film packet inside the cheek as high as posible in buccal sulcus and over parotid papilla. Central ray is perpendicular to the film centre.

3. Extraoral radiography
In submandibular gland:
Demonstrate:
Posterior duct sialoliths Intraglandular sialoliths

To demonstrate, lateral projection:

Open mouth, extend chin, depress tongue: sialolith move inferior to mandibular border

Parotid gland:
Demonstrate:
Interglandular sialoliths

To demonstrate: Cheek puffed out: sialolith move out of bone Sialoliths superimposed over the ramus and body of mandible: limited value of lateral radiograph Sialoliths in distal portion of stensen duct: difficult to demonstrate by intraoral and lateral

4. Conventional saliography
Definition: Radiographic demonstration of the major salivary glands by introducing a radiopaque contrast medium into their ductal system. Radiopaque contrast agent is used before imaging. Most detailed way to image ductal system Scout film: used before infusion of contrast solution
Verifying optimal exposure factors Patient positioning parameters Detect radiopaque sialoliths Extraglandular pathosis

 Contrast agent:
Lipid-soluble: ethiodol Non-lipid-soluble: sinografin

To opacify the salivary duct of interest and associated glandular tissues to demonstrate potential pathological processes. The administration of contrast fills the salivary duct and flows distal to the intraglandular ducts to outline the salivary gland. Due to the close proximity of the three pair of salivary glands, only one of the salivary ducts and its gland can be imaged at a time.

Normal saliographic appearance

Parotid gland The main duct is of even diameter (1-2 mm wide) and should be filled completely and uniformly. The duct structure within the gland branches regularly and tapers gradually towards the periphery of the gland. Tree in winter appearance.

Submandibular gland The main duct is of even diameter (3-4 mm wide) and should be filled completely and uniformly. Smaller than parotid, but the overall appearance is similar with the branching duct structure tapering gradually towards the periphery. Bush in winter appearance

Sialography Procedure
1. Localization of the orifice of the selected duct. Palpate the salivary gland or ask the patient to suck on a lemon slice. 2. The duct may be accessed with a lacrimal probe for cannulization. 3. The selected cannula should be filled with the contrast to ensure that no air is injected into the duct. 4. The cannula should be immobilized through the placement of sterile gauze between the cannulated sites and the tongue. 5. The extension tubing and contrast-filled syringe may then be secured to the chest by adhesive tape. 6. The contrast medium is then introduced.

The Contrast Medium A radiopaque iodinated substance. 1. Lipid soluble

37% iodine ADVANTAGES: It is not diluted by saliva It is not absorbed across glandular mucosa Highly opaque Provides optimal visualization of ducts.

DISADVANTAGES: More viscous , higher injection pressure is required More pain & discomfort Not to be used if the calculi are suspected since it may inhibit the visualization of stone.

The Contrast Medium 2. Water soluble

28 to 38% iodine Routinely used. ADVANTAGES: Low viscosity Low surface tension More miscible with salivary secretions Residual contrast medium is absorbed and excreted through kidney

DISADVANTAGES: Opacification worst than oil based media as it is rapidly absorbed across glandular mucosa It is diluted by saliva The injection is accompanied by little pain & discomfort

5. Compured tomography (CT)

Evaluate structures in and adjacent to salivary glands. Display both soft and hard tissues. Parotid glands are more radiopaque than the fat but less opaque than muscle. Submandibular and sublingual gland are identified on the basis of shape and location.

Advantages
Less invasive than sialography Does not require the use of contrast material Used for assessment of mass lesions of the salivary glands Can demonstrate salivary gland calculi. Especially submandibular stones that are located posteriorly in the duct, at the hilum of the gland or in the substance of gland itself.

6. Magnetic resonance imaging (MRI)

MRI is superior to CT scanning in delineating the soft tissue detail of the salivary gland lesions Advantages:
Better images of soft tissue than CT Disclose the major vessels Identified as areas of no tissue signal (dark), without contrast medium. Accurately reveal ductal morphology No radiation exposure to patient

Disadvantage:
May not be sufficiently sensitive to identify small sialoliths.

7. Ultrasonography (US)
Differentiate solid masses and cystic Detect sialoliths and diagnose advanced autoimmune lessions. Advantages:
Inexpensive compare to CT and MRI Widely available Painless Easy to perform Noninvasive

Salivary gland disorders

Parotid gland
Unilateral Bacterial sialadenitis Sialodochitis Cyst Benign neoplasm Malignant neoplasm Intraglandular lymph node Masseter muscle hypertrophy Lesions of adjacent osseous structures Bilateral Bacterial sialadenitis Viral sialadenitis Sjogren syndrome Warthin hypertrophy Medicated-induced hypertrophy Accesory salivary glands TMJ-related lesions

Submandibular gland
Unilateral Bilateral

Bacterial sialadenitis Sialodochitis Cyst Benign neoplasm Malignant neoplasm Fibrosis

Bacterial sialadenitis Sjogren syndrome Lymphadenitis Branchial cleft cyst Submandibular space infection

Sialolithiasis
Synonyms: Calculus and salivary stone Definition: formation of a calcified obstruction within salivary duct Radiographic features:
May appear either radiopaque or radiolucent Vary in shapes Homogenous radiopaque internal structure Contrast agent is more radiopaque and is used to obscure small and radiolucent sialoliths

Sialolithasis

CT appearance of Sialolithasis Contrast-enhanced CT of the neck demonstrates a stone (blue arrow) in the submandibular region of a dilated Wharton's Duct (red arrow)

Sialographic appearances of sialodochitis Segmented sacculation or dilatation and stricture of the main duct Sausage link appearance Associated calculi or ductal stenosis.

Sialolithiasis May appear either radiopaque or radiolucent on radi-ographic examinations (20% to 40% of cases), depending on their degree of calcification Vary in shape from long cigar shapes to oval or round shapes. When visible, they usually have a homogeneous radiopaque internal structure. Sialography is helpful in locating obstructions that are undetectable with plain radiography, especially if the sialoliths are radiolucent.

 Widespread dots or blobs of contrast medium within the gland, an appearance known as punctate sialectasis or snowstorm. This is caused by a weakening of the epithelium lining the intercalated ducts, allowing the escape of the contrast medium out of the ducts. Considerable retention of the contrast medium during the emptying phase The main duct is usually normal.

Sjogens syndrome

Dermoid cyst or ranula

More radiopaque soft tissue of this cyst compared with surrounding soft tissue.

Mucoceles
About 90% of mucoceles occur in the ethmoidal and frontal sinuses and are rare in the maxillary and sphenoid sinuses. The normal shape of the sinus is changed into a more circular shape as the mucocele enlarges. The internal aspect of the sinus cavity is uniformly radiopaque.