Salivary Gland Disease Notes

Dentistry Notes

Notes for Dental Board Examinations and MCQs

The salivary glands play a vital role in oral and systemic health by producing saliva, which facilitates digestion, protects oral tissues, and maintains a balanced oral microbiome. Understanding the anatomy, physiology, and pathologies of these glands is essential for dental practitioners and other healthcare providers. These notes are meticulously structured to cover key concepts, clinical presentations, diagnostic criteria, and management strategies, all tailored for high-yield exam preparation. Active recall techniques and board-relevant questions are embedded throughout to enhance retention and understanding.

By reviewing these comprehensive notes, you will build a strong foundation in salivary gland disorders and be well-prepared for dental board examinations.

Keywords

salivary glands, parotid gland, submandibular gland, sublingual gland, saliva, xerostomia, sialolithiasis, sialadenitis, viral sialadenitis, bacterial sialadenitis, pleomorphic adenoma, Warthin tumor, mucoepidermoid carcinoma, Sjögren’s syndrome, mumps, salivary gland tumors, salivary gland function, ductal anatomy, obstructive sialadenopathy, glandular swelling, facial nerve, saliva secretion, sialendoscopy, salivary gland imaging, FNA biopsy, malignant transformation, surgical excision, sialagogues, salivary gland pathologies.

Salivary Gland Disease

Core Concepts

  • Salivary glands are exocrine glands in the oral cavity that produce and secrete saliva to aid in digestion, lubrication, and antimicrobial protection.
    • Major salivary glands: Parotid, submandibular, sublingual.
    • Minor salivary glands: Scattered throughout the oral mucosa (e.g., lips, palate); between 800-1000 minor salivary glands.
  • How are salivary glands classified?
    • By secretion type:
      • Serous (parotid)
      • Mixed (submandibular)
      • Mucous (sublingual)
    • Mnemonic: PS: A Man Mixed Up the Limos
    • Parotid → Serous.
    • Mandibular → Mixed.
    • SubLingual → Mucous.

Key Anatomical & Physiological Relationships

Anatomy

  • Parotid gland:
    • Largest gland, located anterior to the ear.
    • Duct (Stensen’s): Opens near the maxillary second molar.
  • Submandibular gland:
    • Located in the submandibular triangle.
    • Duct (Wharton’s): Opens at the floor of the mouth near the lingual frenulum.
  • Sublingual gland:
    • Smallest, found under the tongue.
    • Opens into the floor of the mouth via multiple ducts (Rivinus’ ducts).

Innervation

  • Parotid: Glossopharyngeal nerve (CN IX) via otic ganglion.
  • Submandibular & Sublingual: Facial nerve (CN VII) via chorda tympani and submandibular ganglion.

Vascular Supply

  • Parotid: External carotid artery branches.
  • Submandibular & Sublingual: Facial and lingual arteries.

Clinical Considerations

  • Why is saliva important?
    • Maintains oral pH.
    • Facilitates lubrication and aids in digestion (contains amylase and lipase).
    • Provides antimicrobial activity (lysozyme, IgA).
  • What are the normal components of saliva?
    • Electrolytes (Na+, K+, Cl-, bicarbonate).
    • Enzymes (amylase, lipase).
    • Mucins for lubrication.

Key Salivary Gland Disease Pathologies

Sialadenitis

  • Etiology: Bacterial (Staphylococcus aureus), viral (mumps).
  • Presentation: Pain, swelling, fever, pus from duct orifice.
  • Treatment: Antibiotics, hydration, warm compress. Antibiotics: Dicloxacillin or cephalexin.

Sialolithiasis (Salivary Stones)

  • Common site: Submandibular gland (Wharton’s duct).
  • Presentation: Postprandial pain, swelling, visible duct obstruction.
  • Diagnosis: Sialography, ultrasonography.
  • Treatment: Stone removal, hydration, gland massage. Sialendoscopy for obstruction removal; glandular massage; sialagogues (e.g., pilocarpine).
  • Note: The submandibular gland is most susceptible to stone formation due to the upward angle of Wharton’s duct and high mucin content.

Tumors

  • Benign: Pleomorphic adenoma (most common).
    • Painless, slow-growing mass.
  • Malignant: Mucoepidermoid carcinoma.
    • Painful, rapidly growing mass with possible facial nerve involvement.

Differential Diagnoses

ConditionEtiologyKey FeaturesDiagnostic Tools
SialadenitisBacterial (S. aureus)Pain, swelling, fever, Radiopaque structures in soft tissues of the floor of the mouth (Wharton’s duct).Ultrasound, culture
SialolithiasisSalivary stonePostprandial swellingSialography, ultrasound
Pleomorphic adenomaBenign tumorPainless, slow-growing, Pleomorphic adenoma: Smooth, well-defined radiolucent area.Fine-needle aspiration

Expanded High-Yield Board Exam Points

Anatomy and Physiology High-Yield Points

  • Gland Location Mnemonic:
    • PMS: Parotid → Serous; Submandibular → Mixed; Sublingual → Mucous.
    • Exam Tip: Remember Stensen’s duct for the parotid gland, Wharton’s duct for the submandibular gland.
  • Innervation Key Facts:
    • Parotid: Glossopharyngeal nerve (CN IX) → Otic ganglion → Auriculotemporal nerve.
    • Submandibular/Sublingual: Chorda tympani (branch of CN VII) → Submandibular ganglion.
  • Vascular Supply Reminder:
    • Parotid: Superficial temporal artery (branch of external carotid).
    • Submandibular/Sublingual: Facial and lingual arteries.

Sialadenitis (Inflammation)

  • Board-relevant fact:
    • Acute bacterial sialadenitis is most commonly caused by Staphylococcus aureus and typically affects the parotid gland.
    • Exam Tip: Look for predisposing factors like dehydration or Sjögren syndrome in questions.
  • Clinical Point:
    • Viral sialadenitis (e.g., mumps) typically presents bilaterally in the parotid glands with systemic symptoms like fever and malaise.
  • Commonly Tested Pathophysiology:
    • Decreased salivary flow → Retrograde bacterial invasion → Inflammation.
  • Diagnostic Clue for Exams:
    • Tender, swollen gland with purulent discharge expressed from the duct orifice.

Sialolithiasis (Salivary Gland Stones)

  • Key Board Concept:
    • The submandibular gland is the most common site for salivary stones due to the higher mucin content and upward angle of Wharton’s duct.
  • Mnemonic for Symptoms:
    • PISS:
      • Pain.
      • Intermittent swelling.
      • Stimulated by meals.
      • Submandibular location.
  • Radiographic Findings: Radiopaque stones in the floor of the mouth visible on occlusal or panoramic X-rays.
  • Exam Pitfall: Failing to differentiate between sialolithiasis and other causes of swelling, such as tumors or infections.

Salivary Gland Tumors

  • High-Yield Tumor Facts:
    • Pleomorphic adenoma (benign): Most common salivary gland tumor. Painless, slow-growing, firm mass.
    • Mucoepidermoid carcinoma (malignant): Most common malignant tumor. Painful, rapidly enlarging mass, often involving the facial nerve.
  • Key Diagnostic Mnemonic for Tumor Types:
    • BPM | Benign → Pleomorphic adenoma. Malignant → Mucoepidermoid carcinoma.
  • Clinical tip: Facial nerve paralysis is a red flag for malignancy in parotid gland tumors.
  • Pitfall: Confusing Warthin’s tumor (benign, associated with smoking) with malignant neoplasms.

Autoimmune and Systemic Disorders

  • Sjӧgren Syndrome:
    • Key association: Dry eyes, dry mouth (xerostomia).
    • Minor Salivary gland biopsy is the definitive diagnosis: Lymphocytic infiltration of minor salivary glands.
    • Positive anti-SSA (Ro) and/or anti-SSB (La).
    • Evidence of decreased salivary flow.
    • Cases mention a middle-aged woman with complaints of dryness and bilateral gland swelling.

Bilateral Parotid Enlargement

  • Bilateral Parotid Enlargement: Swelling of both parotid glands, which can result from inflammatory, infectious, autoimmune, or neoplastic causes. Systemic Associations: Often linked to conditions like Sjögren’s syndrome, sarcoidosis, or viral infections (e.g., mumps).

Common Pathologies and Their Presentations

  • Viral Sialadenitis (e.g., Mumps)
    • Presents with fever, malaise, bilateral swelling, and tenderness.
    • Predominantly seen in children and unvaccinated individuals.
  • Autoimmune Diseases (e.g., Sjögren’s Syndrome)
    • Associated with xerostomia and keratoconjunctivitis sicca (dry eyes).
    • Often involves bilateral, painless swelling.
  • Sarcoidosis
    • Non-painful, firm bilateral swelling, possibly with systemic granulomatous symptoms (e.g., lung or lymph node involvement).
  • Chronic Sialadenitis
    • Recurrent inflammation leading to fibrosis and gland enlargement.
  • Benign Lymphoepithelial Lesions
    • Associated with HIV; presents as painless, persistent swelling.
  • Warthin Tumor
    • Typically unilateral but can present bilaterally in smokers.
CauseKey FeatureDiagnostic Modality
Viral (Mumps)Fever, parotid tenderness, unvaccinatedSerology (IgM antibodies)Viral (e.g., mumps): Supportive care (hydration, analgesics, antipyretics).
Sjögren’s SyndromeDry eyes, dry mouth, parotid swellingMinor salivary gland biopsy; Autoantibody panel (SSA/SSB)Sjögren’s: Artificial saliva, systemic immunomodulators (e.g., hydroxychloroquine).
SarcoidosisSystemic granulomas, non-tender swellingChest X-ray, ACE levelsManaging symptoms
Warthin TumorBilateral in up to 10% ; most commonly smokers, appears as a mobile massUltrasound, FNASialendoscopy for obstruction removal; glandular massage; sialagogues (e.g., pilocarpine).

Clinical Vigenttes For Board Questions

  • Scenario 1
    A 45-year-old male presents with recurrent post-meal swelling under the jaw. Imaging shows a radiopaque lesion in the floor of the mouth.
    Diagnosis: Sialolithiasis (salivary gland stone).
    Insight: Most common in the submandibular gland due to its long, tortuous duct and the upward flow of saliva.
    Risk factors include dehydration, reduced salivary flow, and high calcium concentrations.
    Pain and swelling typically occur during meals as saliva production increases, causing obstruction.
    Treatment: Conservative management: Hydration, gland massage, sialagogues (lemon drops), and warm compresses.
    Interventional: Removal of the stone via sialendoscopy or surgical excision for larger stones.

    Scenario 2
    A 12-year-old child presents with bilateral parotid gland swelling, fever, and malaise. No purulent discharge is observed.
    Diagnosis:Viral sialadenitis (mumps).
    Insight: Caused by the mumps virus (a paramyxovirus), typically in children. Characterized by painful gland enlargement, systemic symptoms like fever, and malaise. Complications include orchitis, oophoritis, meningitis, and pancreatitis.
    Treatment: Supportive care: Hydration, analgesics (acetaminophen or ibuprofen), and rest.
    Prevention: MMR vaccine.

    Scenario 3
    A 55-year-old smoker presents with a painless, slow-growing mass near the angle of the jaw.
    Diagnosis: Pleomorphic adenoma.
    Insight: Most common benign salivary gland tumor, typically found in the parotid gland.
    Presents as a painless, firm, and mobile mass. Long-term presence increases the risk of malignant transformation (e.g., carcinoma ex pleomorphic adenoma). Smoking is not a direct risk factor for pleomorphic adenoma, but it raises suspicion for other salivary tumours, such as Warthin’s Tumor.
    Treatment: Surgical excision: Superficial parotidectomy with facial nerve preservation.
    Monitoring: Regular follow-up to assess for recurrence or malignant transformation.

    Scenario 4
    A 68-year-old female with a history of dehydration and poor oral hygiene presents with unilateral swelling of the parotid gland, fever, and pain that worsens with eating. Purulent discharge is expressed from Stensen’s duct.
    Diagnosis: Acute bacterial sialadenitis.
    Insight: Look for risk factors such as dehydration or recent surgery.
    Treatment: Empiric antibiotics (e.g., dicloxacillin) and increased hydration.

    Scenario 5
    A 50-year-old man complains of recurrent swelling and pain in the submandibular gland for months, especially after meals. He reports occasional resolution but frequent flare-ups. Imaging shows ductal dilation without obstruction.
    Diagnosis: Chronic sialadenitis due to reduced salivary flow or duct stenosis.
    Treatment: Sialagogues, gland massage, and potentially surgical ductal dilation.

    Scenario 6
    A 40-year-old male presents with sudden swelling and intense pain under the jaw, accompanied by fever and erythema over the submandibular region. Palpation reveals a hard structure near the duct opening, expressing purulent discharge.
    Diagnosis: Obstructive sialolithiasis complicated by infection.
    Key Tip: Distinguish between uncomplicated sialolithiasis (no infection) and this presentation.
    Treatment: Antibiotics followed by removal of the stone.

    Scenario 7
    A 25-year-old patient presents with a painless, bluish, fluctuant swelling on the lower lip that has gradually increased in size over the past month. History reveals frequent lip biting.
    Diagnosis: Mucocele.
    Key Insight: History of trauma (e.g., lip biting) is often present.
    Treatment: Surgical excision of the lesion and involved minor salivary gland.

    Scenario 8
    A 60-year-old female presents with a firm, painless, slow-growing mass near the angle of the jaw. No facial nerve deficits are noted. Imaging shows a well-demarcated lesion within the parotid gland.
    Diagnosis: Pleomorphic adenoma.
    High-Yield Point: Most common benign tumor of the salivary glands, frequently tested.
    Treatment: Surgical excision with preservation of the facial nerve.

    Scenario 9
    A 48-year-old male reports a rapidly growing, painful mass in the parotid gland region, along with recent onset of facial nerve weakness. Biopsy reveals a high-grade tumor.
    Diagnosis: Mucoepidermoid carcinoma.
    Key Exam Insight: Facial nerve involvement often indicates malignancy in salivary gland tumors.
    Treatment: Surgical resection with adjuvant radiation therapy.

    Scenario 10
    A 50-year-old woman presents with dry eyes, dry mouth, and bilateral, non-tender parotid gland enlargement. She also reports joint pain and fatigue. Blood tests reveal positive anti-SSA/Ro antibodies.
    Diagnosis: Sjögren syndrome.
    High-Yield Fact: Biopsy of minor salivary glands often shows lymphocytic infiltration.
    Treatment: Artificial tears, salivary stimulants (e.g., pilocarpine), and symptomatic management.

    Scenario 11
    A 70-year-old male smoker presents with a painless, slow-growing mass in the parotid gland. Imaging shows a well-circumscribed cystic lesion.
    Diagnosis: Warthin tumor (Papillary Cystadenoma Lymphomatosum)
    Key Board Pearl: Strongly associated with smoking and predominantly occurs in males.
    Treatment: Surgical excision; often benign.

    Scenario 12
    A 10-year-old child presents with bilateral parotid gland swelling, fever, and malaise. The parents report no history of vaccination.
    Diagnosis: Viral sialadenitis (mumps).
    Insight: Do not confuse this presentation with bacterial causes; Mumps typically lacks purulent discharge.
    Treatment: Supportive care (hydration, analgesics).

    Scenario 13
    A 75-year-old female with a history of hypertension and depression presents with complaints of dry mouth, difficulty swallowing, and dental caries. She is on lisinopril and amitriptyline.
    Diagnosis: Medication-induced xerostomia.
    Insight: Anticholinergic medications like amitriptyline frequently cause xerostomia.
    Treatment: Reduce or switch medications, prescribe salivary stimulants or artificial saliva.

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