Salivary gland diagnostics. Dr. Veronika Gresz Ph.D Semmelweis University Dept. Of Oral Diagnostics
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1 Salivary gland diagnostics Dr. Veronika Gresz Ph.D Semmelweis University Dept. Of Oral Diagnostics
2 Salivary glands Salivary secretion Acc. parotid Unstimulated secretion: 70% gl submandibularis, 30% gl parotis arotid Parotid duct Sublingu. Stimulated secretion: Parotid secretion (can be more than the other glands!) Sublingual and minor sal. gl. Secretion remains always at a constant low level Submand.
3 Schematic salivary secretion Na + NaCl NaCl K + Na + K + H + HCO 3 - K + HCO 3 - H 2 O AQP3 AQP1? AQP5 hypotonic
4 Immunolocalization of AQP water channels in human salivary glands AQP1 AQP1 AQP3 AQP5
5 Eating, digestion Talking Lubrication Antimicrobial Defense Clearance Remineralisation Protection of the mucosa Buffering effect
6 Diagnostic process Anamnesis Physical examination Radiography Sialometry Sialochemistry Biopsy/histology
7 General Anamnesis Metabolism diseases Medication (Antihypertensive, Antidepressive)
8 Dental anamnesis Pain? Fever, Foetor ex ore? Swelling (Symmetry)? Consistency? Xerostomia? Taste disturbance? Sialorrhoea? Periodic complaints
9 Swelling with pain Acute sialoadenitis Sialolithiasis (Stimulation!) Mild pain: TumorS (Parotid)
10 90% Parotid rarely extraglandular: orchitis, meningoencephalitis, pancreatitis
11
12 sudden Mainly in the submand. gland Complication: bakterial infektion
13 Swelling without pain Tumors!!!! (malign, bening) Iodine, lead, mercury toxicosis bilateral swelling without pain Sialadenitis chronica Sjögren-syndrom (uni oder bilateral) Superinfektion might occur at hyposalivation!
14 Xerostomia Xerostomia Subjektive sensation Hyposalivation Unstimulated <0,1 ml/min Stimulated s. <0,5 ml/min
15 Oral complaints in hyposalivation A. Chief complaints Xerostomia subjektive Dysphagia- difficulty at eating Dysphonia- difficulty at talking Dry food is hard to swallow Drinking frequently Hard to wear denture
16 Oral complaints in hyposalivation B. Other complaints glossopyrosis dysgeusia cheilitis angularis Drinking frequently at night Caries insidence is raising
17 Causes of salivary hypofunction I. Water- and electrolyte loss (sweating, vomiting, diabetes mellitus) II. Salivary gland damage (salivary gland diseases, radiotherapy, autoimmune diseases, e.g. Sjögren, SLE, RA, scleroderma, cysticus fibrosis, HIV, aging) III. Innervation problems of salivary glands (medications, Alzheimer-disease, psychiatric diseases)
18 Extraoral complaints in salivary hypofunction Eye: itching, burning, feeling of foreign body (sand); frequent use of eye-drops!! Nose, pharynx: dry mucosa Vagina: dry, itching, burning, recurrent infections Skin: dry GI tract: constipation
19 Sjögren-syndrom (SS) Chronic inflammation, limphoproliferative disease, 0,5% of the population Autoimmun exocrinopathy: xerostomia and keratoconjunctivitis sicca autoimmun epithelitis : lymphocytosis in different epithelial tissues Primer SS: independent, organspecific autoimmun process Secunder SS: associated with other autoimmune, rheumatic diseases (RA, SLE) Autoantibodies (ANA, Anti-Ro/SSA, Anti-La/SSB, RF, Anti-M3 Receptor, Anti-Carboanhydrase, Anti-Ductus, Anti-Smooth Muscle etc) Immunpathogenesis: T-cell mediated autoimmune process; unregulated apoptosis (disturbance in B-cell activation, virusinfektion, genetic background, protooncogenes, cytokines)
20
21 Other symptoms and systemic manifestation of primer SS 1. Fatigue, sleeping disorders 2. Arthralgies und myalgies 3. Organic manifestations Lungs 17% Periferic neuropathy 10-15% Stomach Pancreas Liver Skin-contactallergy, medication-allergy Thyroid gl. 29% Kidney
22 I. II. III. IV. Dry eyes European diagnostic criteria Dry mouth Keratoconjunctivitis sicca Focal sialadenitis also in the minor salivary glands V. Salivary gland infection VI. Autoantibodies Diagnosis is based on the presence of 4 criteria from above
23 Diagnosis of xerostomia based on the european criteria and on labordiagnostic/immunological background I Schirmer I test: dryness of the eyes; less than 5mm/5 perc; Rose Bengal test: dryness of the epithelium of the conjunctiva; more ore equal with 4; Sialometry: unstimulated and stimulated salivary secretion is decreased; Parotis sialography: destruction of the glandular structure Parotis scintigraphy: 99Tcm-natrium-pertechnate uptake in SS patients is decresed after stimulation of the parotid and submandibular glands
24 Diagnosis of xerostomia based on the european criteria and on labordiagnostic/immunological background II Labial gland biopsy after Daniels: at least 50 mononuclear cells/4 mm2, min. 1 focus; acinar atrophy, fibrosis Differentialdiagnostics: sarcoidosis=granulomatosus inflammation; chronic sialadenitis: there is no focal aggregation and threre are other degenerative changes Labordiagnostics: GOT, GPT, ALP, LDH, BUN, creatinin, uric acid, Na, K, Cl, Ca, P, bloodgas-analysis: po2, pco2, HCO3-, ph, osmolality of the urine Immundiagnostics: Anti Ro/SSA, anti La/SSB antibodies, ANA and RF
25 AQPs and Sjögren s syndrome While expression of AQP1 is decreased in primary SS and in nonspecific sialadenitis, Expression and localitzation of AQP5 has not been changed in primary SS. Control Sjögren Sjögren Human labial gland biopsy
26 Acid-base regulation in salivary glands H-pump Primary salivary secretion is the result of accumulation of Cl- and HCO3- in the cytosol In SS Na and Cl is increased, phosphate and ph is decreased (AE2 expression, H- ATPase Ø) NHE1
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28
29 Dysgeusia distortion of the sense of taste, bad taste in the mouth, halitosis- suppurative inflammation
30 Hypersalivation Reflex answer (Epilepsy, mercurytoxicosis, rabies) Acute inflammation (infektion: herpes,; new denture)
31 Clinical investigation Inspection Palpation Auscultation Ducts of salivary glands
32 Inspection Extraoral inspection Simmetry (uni-, bilateral, discoloration) parotid, submandibular gland Intraoral inspection Asimmetry, duct investigation
33 Extraoral palpation Palpation Sensitivity, texture, consistency, fixation to surrounding tissues Intraoral palpation Parenchyma of sal. gl, probing of sal. ducts Differencialdiagnosis: Lymph.nodes, thyreoid gl.
34 PAROTID SUBMAND. AND SUBLINGUAL GL.
35 Auscultation Haemangioma (vascular noise)
36 Duct investigation Light pressing on the salivary gland Water-like fluid
37 Radiography Radiographs (occlusal, extraoral) Sialography Scintigraphy Ultrasound CT MRI
38 Radiographs
39 Sialography Contrast medium (water soluble) is injected into the salivary gland duct Indication: Chronic inflammation, e.g. Sjögren sy. Granulomatosus disease Duct obstruction (sialolithiasis, stenosis) Malformation Contraindication: ACUTE INFLAMMATION
40 Sialogram: X-ray picture of the salivary ducts and the related glandular structures
41
42 Scintigraphy 99 Tc pertectenate i.v. Gamma-camera Isotope-enrichment Indication: Funktional investigation Chronic infections (Sjögren sy.) expensive
43 Scintigraphy(Tc 99 )
44 Ultrasound unexpensive, noninvasive Indication: Tumor cyst differencialdiagnosis Ultrasound-directed aspiration
45 Computertomography Xray-tomogram Differentiation between hard and soft tissues Indication: Tumoren Combined with angiography, sialography
46 MRI Expensive Soft tissue tumors-differenzialdiagnosis (pleomorph adenom)
47 Sialometry Measurement of salivary gland production unstimulated stimulated Standardisation: 2 hours before examination nothing relax At least 2x
48 Sialometry Collection of mixed unstimulated saliva Passive flow the patient doesn t swallow, doesn t speak, doesn t move his tongue Aspiration Absorption Collection of mixed stimulated saliva: The patient gets a small piece of paraffin for 30 sec 2% citric acid on the tongue in every 30 seconds
49 Sialometric values Unstimulated secretion Normal value: ml/min Xerostomia: less than 0.1ml/min Stimulated secretion Normal value: 1-2ml/min Xerostomia: less than 0.5ml/min
50 Sialochemistry Chemical analysis of the saliva in order to get diagnostic data Salivary gland diseases Mucoviscidosis, virus infections Medication, drugs
51 CRT=Caries Risiko Test Blue: high buffer capacity/low risk Green: moderate risk Yellow: low buffer capacity/high risk
52 It is a simple, semiquantitative investigation in order to determine the Lactobacillus and Streptococcus mutans flora in the saliva
53 Biopsy Aspiration cytology Incisional biopsy Excisional biopsy (minor salivary glands)
54
55 Labial minor salivary glands Ranula
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