Post on 16-Apr-2017
Salivary Glands and Saliva
Presented by-Dr Arpita Dutta
CONTENTSSalivary Glands SalivaINTRODUCTIONDEFINITIONCLASSIFICATIONEMBRYOLOGYDEVELOPMENTHISTOLOGYANATOMYNEURAL REGULATIONSALIVA FORMATIONSALIVARY GLAND PATHOLOGYIMAGING MODALITIESCONCLUSIONREFERENCES
INTRODUCTION COMPOSITION PROPERTIES OF SALIVA PROSTHODONTIC
CONSIDERATIONS SALIVA AS A DIAGNOSTIC TOOL METHODS OF COLLECTION OF
SALIVA CONCLUSION REFERENCES
DEFINITION Salivary Glands-
The salivary glands are group of compound exocrine glands secreting saliva. -Orban’s Oral Histology & Embryology, 14th Edition
CLASSIFICATION
SALIVARY GLANDS BASED ON ANATOMY
MAJOR SALIVARY GLANDS• PAROTID GLAND• SUBLINGUAL GLAND• SUBMANDIBULAR GLAND
MINOR SALIVARY GLANDS• LABIAL AND BUCCAL GLANDS• GLOSSOPALATINE GLANDS• PALATINE GLANDS• LINGUAL GLANDS• -BLANDIN &NUHN• -VON EBNER’S GLAND• CARMALT’S GLANDS
SALIVARY GLANDS BASED ON SECRETION
SEROUS
MUCOUS
MIXED
(Orbans Oral Histology & Embryology, 14th edtn)
PAROTID GLAND•PURELY SEROUS
SUBLINGUAL GLAND• MIXED (mainly MUCOUS)
SUBMANDIBULAR GLAND• MIXED (mainly SEROUS)
LABIAL AND BUCCAL GLANDS
• MIXED
GLOSSOPHARYNGEAL AND PALATINE GLANDS
• MUCOUS
LINGUAL GLANDS
• MIXED
VON EBNER’S GLAND’S
. SEROUS
(Orbans Oral Histology & Embryology, 14th Edition
EMBRYOLOGY
Time of origin Gland Location Intra uterine lifeParotid gland Corners of the stomodeum as placode 6th week I.U
Submandibular gland Floor of the mouth End of 6 th week I.U
Sublingual gland Lateral to S.m.primordium 8th week I.U
Minor salivary glands Buccal Epithelium 12 th week I.U
Maturity of secretory end piece: During last 2 months of gestation.
David T. Wong Salivary Diagnostics, Wiley-Blackwell
David T. Wong Salivary Diagnostics, Wiley-Blackwell
DEVELOPMENTBUD FORMATION CORD FORMATION
BRANCHING OF CORDS
LOBULE FORMATIONCANALIZATION
CYTODIFFERENTIATION
(Orbans Oral Histology & Embryology, 13th edtn)
STAGES OF DEVELOPMENT-
•BUD FORMATION•CORD FORMATION•BRANCHING OF CORDS•LOBULE FORMATION•CANALIZATION•CYTODIFFERENTIATION
PAROTID GLANDParotid gland:-Largest salivary gland
-20-25% of total saliva.
-Pyramidal in shape.
-Weighs around 20-30g.
-Superficial portion of gland is located subcutaneously, in front of the external ear & deeper portion lies behind ramus of mandible.
-4 surfaces: superior, superficial, anteromedial, posteromedial
-3 borders- anterior, medial, posterior
-Associated with facial nerve (pes anserinus)
Stenson’s duct: -35- 40mm long
Runs forward across masseter muscle, turns inwards at the anterior border of masseter
Runs through the 3Bs-Buccal pad of fatBuccopharyngeal fasciaBuccinator Muscle
- opens at a papilla opposite the second maxillary molar.
Arterial supply-External carotid artery
Venous drainage-External jugular vein
Lymphatic drainage-Upper deep cervical lymph nodes.
Nerve supply: Greater auricular and Auriculotemporal nerve
Sympathetic- From the sympathetic plexus around the external carotid artery
Parasympathetic
SUBMANDIBULAR GLAND10 to 15 gm. Size of a Walnut
65-70% of total saliva.
Located at Posterior portion of floor of mouth, medial aspect of mandible & wrapping around posterior border of mylohyoid.
3 surfaces-Inferior, Medial, LateralThe post. Border of mylohyoid divides the gland:
Superficial lobe : situated in the digastric triangle wedged between body of mandible and
mylohyoid
Small deep lobe: lying in the floor of the mouth between mylohyoid and the hyoglossus muscle
on the lateral aspect of the tongue
RELATIONS OF THE SUBMANDIBULAR GLAND
SUBMANDIBULAR DUCT•Wharton's duct runs forward and opens into the mouth beneath the tongue,
lateral to lingual frenum i.e sublingual caruncle.
•40mm
Blood supply: Facial and lingual arteries. Veins correspond to arteries, drain into internal Jugular Vein
Lymphatic drainage: Submandibular lymph node & jugulodigastric nodes.
Nerve supply:•Parasympathetic supply: Facial nerve reaching gland through the lingual nerve & submandibular ganglion.
• Sympathetic Supply:Postganglionic fibers from plexus on facial artery
SUBLINGUAL GLAND
Smallest major salivary gland Weighs- 2gm.
2.5% of total saliva.
Located at anterior part of floor of the mouth, just between mucosa & mylohyoid muscle.
Saliva is poured into a series of small ducts (duct of Rivinus) and open through large duct- Bartholin’s duct, that opens with submandibular duct at the caruncula sublingualis.
Essentials of Medical Physiology, Sembulingam 4th Edition
Blood supply: Sublingual & submental arteries.
Lymphatic drainage: Submental lymph nodes
Nerve supply:
Parasympathetic supply: Facial nerve reaching gland through the lingual nerve & submandibular ganglion.
Sympathetic Supply: -Postganglionic fibers from plexus on facial artery.
MINOR SALIVARY GLANDS Labial and buccal glands- Lips and cheek
Glossopalatine- isthmus in glossopalatine fold
Palatine glands- lamina propria of the posterolateral region of hard palate
submucosa of the soft palate and the uvula
Lingual–• Anteriorlingual GLANDS OF BLANDIN AND NUHN -apex of the
tongue
• Posterior Lingual (mucous)- lateral and posterior to the vallate papilla
• Posterior lingual( serous) VON EBNER’S GLANDS- between the
muscle fibers of the tongue below the vallate papilla.
HISTOLOGY
ACINI- TERMINAL SECRETORY UNIT.
LEADING INTO DUCTS
OPEN TO ORAL CAVITY AND SECRETION TO ANATOMIC
LOCATION
SEROUS CELLS MUCOUS CELLS
DUCTAL SYSTEM
MYOEPITHELIAL CELLSBASKET CELLS
.
stellate or spider like cellsflattened nucleussurrounded by -
• small amount of perinuclear cytoplasm
• long branching process that embracing the secretory duct cells.
CONNECTIVE TISSUE
•Same as connective tissue in other parts of body
•Contain macrophages, plasma cells, fibroblasts, macrophages, mast cells
•Extension of connective tissue into septa lobulates the gland
serous salivary gland
serous acini, zymogen granules
intercalated ducts and striated ducts
interlobular ducts with stratified epithelium.
lobules with connective tissue septa.
nearby lymph node with capsule.
PAROTID GLAND HISTOLOGY
.mixed salivary gland
predominantly serous acini; some mucous acini with serous demilunes
short intercalated ducts.
striated ducts with simple cuboidal lining epithelium.
interlobular ducts with stratified cuboidal or stratified columnar epithelium surrounded by connective tissue.
PAROTID GLAND HISTOLOGYPAROTID GLAND HISTOLOGYSUBMANDIBULAR GLAND HISTOLOGY
.mixed salivary gland
predominantly mucous acini; some serous demilunes.
acini are composed of centrally-located mucous cells and peripheral serous demilunes.
short intercalated ducts.
striated ducts with simple columnar lining epithelium
interlobular ducts with stratified cuboidal/columnar epithelium, surrounded by connective tissue.
SUBLINGUAL GLAND HISTOLOGY
PHYSIOLOGICAL FACTORS AFFECTING SALIVATION
TASTE OF EATABLES
SURFACE OF OBJECT
DEHYDRATIONAGE
EMOTIONS AND PSYCHOLOGICAL
EFFECTS
INCREASED SALIVATION
DECREASED SALIVATION
Syllabus of Complete Dentures, Charles M. Heartwell and Arthur O. Rahn, 4th edtn
PHASE OF SALIVATION
• SMELLS• VIEW
CEPHALIC
Syllabus of Complete Dentures, Charles M. Heartwell and Arthur O. Rahn, 4th edtn
FORMATION OF SALIVA• TWO STAGE MODEL of saliva secretion
Physiology, Robert M. Berne and Matthew N. Levy, 3rd edth
NEURAL REGULATION OF SALIVARY SECRETION
PATHOLOGIES OF SALIVARY GLANDSDEVELOPMENTAL
DISORDERS• ABERRANT GLANDS• APLASIA AND HYPERPLASIA• ATRESIA
OBSTRUCTIVE DISORDERS
• SIALOLITHIASIS• MUCOCELE• NECROTIZING SIALOMETAPLASIA
NEOPLASTIC DISORDERS
• BENIGN• MALIGNANT
• SJOGREN’S SYNDROME• RADIATION• XEROSTOMIA
INFLAMMATORY DISORDERS
• VIRAL• BACTERIAL
Textbook of Oral Medicine, A.V.Ghom, 3rd edtn
DEGENERATIVE CONDITION- SJOGREN’S SYNDROME
• A.k.a Gougerot Sjogren’s Syndrome/ Sicca Syndome
• It is an autoimmune disorder described as a triad of : -Keratoconjuctivitis sicca -Xerostomia -Rheumatoid arthritis
Two types: -Primary -Secondary
Keratoconjunctivitis sicca
Xerostomi
a
Rheumato
id arthri
tis
Sjogren’s syndrom
e
Clinical freatures:•Dry mouth and dry eyes
•Dry and fissured tongue
•Primary sjogren’s syndrome are associated with parotid gland enlargment, purpura, lymphadenopathy.
Treatment: 1. Ocular lubricants and salivary
substitutes,2. maintenance of oral hygiene3. Frequent fluoride application,4. sialogogues.
Fig- DRY AND FISSURED TONGUE
SALIVARY GLAND IMAGING MODALITIES
1. PLAIN FILM RADIOGRAPHY• OCCLUSAL VIEW• ORTHOPANTOGRAPH• LATERAL OBLIQUE• POSTERIOR ANTERIOR SKULL PROJECTION 2. SIALOGRAPHY
3. ULTRASONOGRAPHY
4. SCINTIGRAPHY
5. COMPUTED TOMOGRAPHY
6. MAGNETIC RESONANCE IMAGINGFig:- MANDIBULAR OCCLUAL VIEW OF A CALCIFIED STONE IN THE WHARTON’S DUCT
SCINTIGRAPHY
AXIAL CT
SIALOGRAPHY
SIALOGRAPHY• Retrograde injection of a iodinated
contrast agent into the ductal system of a salivary gland.
• Oldest imaging modality.
• First sialogram performed by CARPY 1904 on an isolated parotid using mercury as a contrast agent.
• Simple, quick and painless procedure
AMAMENTARIUMSialography cathetersLacrimal probesIodinated contrast agentCotton rolls
Maxillofacial Imaging, Angelo. M DelBalso
CONTRAST AGENTS
INJECTION TECHNIQUES
HYDROSTATIC INJECTION
DISTENTION INJECTION
HAND INJECTION
FAT SOLUBLE
•ETHIODOL•LIPIODOL•PANTOPAQUE
WATER SOLUBLE
•ANGIOGRAPHIC DYES•SINOGRAFIN
PHASES OF SIALOGRAPHY
DUCTAL PHASE ACINAR PHASE EVACUATION AND POST-EVACUATION PHASE
Maxillofacial Imaging, Angelo. M DelBalso
Saliva
INTRODUCTIONSaliva is a viscous, transparent liquid secreted by cells of the salivary glands.
Salivary flow facilitates-1. Speech2. Mastication3. Food Bolus Formation And Its
Swallowing4. General Oral Health And
Function.
It plays a critical role in retention of dentures due to its lubricating function and, thus, dry mucosa often leads to compromise in the retention of prosthesis.
DEFINITION “Saliva is clean, tasteless, odourless, slightly acidic viscous fluid,
consisting of secretions from the parotid, sublingual, submandibular salivary glands and the mucous glands of the oral cavity.” - Stedmans medical dictionary 26th edition
• Saliva is a clear, alkaline, somewhat viscid secretion from the parotid, submandibular, sublingual & smaller mucous glands of the mouth. – Dorland Medical dictionary
• Saliva is a complex fluid produced by the salivary glands , the most important function of which is to maintain the well being of the oral cavity . – Tencate’s Book of Oral Histology
WHOLE / TOTAL SALIVA
FLOW RATE(ML/MIN)
WHOLE SALIVA PAROTID GLAND SALIVA SUBLINGUAL GLAND AND SUBMANDIBULAR GLAND SALIVA
RESTING STATE 0.2-0.4 0.04 0.1
STIMULATED STATE
2.0-5.0 1.0-2.0 0.8
pH 6.7-7.4 6.0-7.8 6.0-7.4
Ten Cate’s Oral Histology, Development, Structure, and Function, Seventh Edition
COMPOSITION
WATER-99.5%
SOLID -0.5%
SOLID COMPOSITION OF SALIVA
ORGANIC• SECRETORY PROTEINS:• ENZYMES AMYLASE,RIBONUCLEASE,KALLIKREIN ESTERASE,CYSTATIN,PEROXIDE LYSOZYMES,LACTOFERRIN ACID PHOSPHATASE PROLINE RICH PROTEINS GLYCOPROTIENS• IMMUNOGLOBULINS IgG, IgM, IgA• BLOOD CLOTTING FACTORS• DESQUAMATED EPITHELIAL CELLS• MICROORGANISMS PRODUCTS• LEUKOCYTES• SERUM REMNANTS
INORGANIC
• ELECTROLYTES SODIUM POTASSIUM CALCIUM CHLORINE BICARBONATE PHOSPHATE MAGNESIUM SULPHATE IRON IODINE
FUNCTIONS
ANTI BACTERIAL• LYSOZYMES+LACTOFERRIN+LACTOPERO
XIDASE+IMMUNOGLOBULINS+CYSTATINS
ANTIFUNGAL • IMMUNOGLOBULINS+CHROMOGRAINS
ANTI VIRAL • CYSTATINS+MUCINS+IMMUNOGLOBULINS+SECRETORY LEUKOCYTE
BUFFER• BICARBON
ATE• PHOSPHA
TE• PROTEINS
PROTECTION AGAINST DEMINERALIZATION• MUCINS• CALCIUM• PHOSPHATE
LUBRICATION
GLYCOPROTEINS
MUCINS
REMINERALIZATIONSTATHERIN
PHOSPHATECALICUM
Bolus formationMUCINS+WATER
Taste of eatablesGUSTIN+WATER
Digestion of foodAMYLASE+PROTEASE+LIPASE
PROPERTIES
• Total amount : 1,200 – 1500 ml in 24 hrs. A large proportion of this volume is secreted at meal time, when the secretory rate is highest.
• Consistency : slightly cloudy, due to presence of cells and mucin.
• pH : usually slightly acidic (ph 6.35 – 6.85)
• Specific gravity : 1.002 – 1.012
• Freezing point : 0.07 – 0.340c.
Total volume secreted 1200ml to 1500ml/day
PAROTID GLAND
SUBLINGUAL GLANDMINOR GLANDS
SUBMANDIBULAR GLAND
20%
7- 8% <10%
65-70%
Saliva composition and functions: A comprehensive Review, The Journal of Contemporary Dental Practice vol(9),no 3,2008
FACTORS AFFECTING COMPOSITION OF SALIVA
Time of the day
Source of secretion
Pathology
Flow rate
Differential gland contribution
Circadian rhythm
Nature of stimuli
Diet and hydration
David T. Wong Salivary Diagnostics, Wiley-Blackwell
SALIVA: A DIAGNOSTIC TOOL
SALIVA
BACTERIA
VIRUSES
NEOPLASTIC
CONDITIONS
SYSTEMIC DISEASE
BIOMARKERS
DRUG ABUSE
CONDITIONS
David T. Wong Salivary Diagnostics, Wiley-Blackwell
Salivary testing is becoming more common as clinicians have begun to appreciate its
advantages & investigators defined its worth. Saliva proves to be a reflection of
the body.
SYSTEMIC DISEASES-
• HEREDITARY DISEASES- CYSTIC FIBROSIS
• AUTOIMMUNE DISEASES- SJOGREN’S SYNDROME
• MALIGNANCIES- ADENOCARCINOMA, BREAST CARCINOMA, OVARIAN
CANCER (MARKERS)
VIRAL INFECTION MARKERS-
• HIV
• OTHER VIRAL DISEASES (due to immunoglobulins present in saliva)
SALIVA AS A DIAGNOSTIC TOOL
DRUG MONITORING-• THERAPEUTIC- Carbamazepine, Diazepam, Ethosuximide,
Lithium, Tolbutamide, etc• RECREATIONAL- Nicotine, Cocaine, Barbiturates,
Benzodiapines, Marijuana, etc
MONITORING OF HORMONE LEVELS
DIAGNOSIS OF ORAL CONDITIONS ASSOCIATED WITH DEEPER SYSTEMIC CONDITIONS
• Forensic odontology- serological and cellular analysis of saliva aids in identification of accused
-Saxena S, Kumar S. Saliva in forensic odontology: A comprehensive update. J Oral Maxillofac Pathol [serial online] 2015 [cited 2016 Apr 24];19:263-5.
• Salivary pH assessment using telemetry:
Device called telemetry system is incorporated in the denture which has a radiosensitive diode, oscillator, ph sensor, and a computer analyzer
METHODS OF COLLECTION OF SALIVA
• Draining method- funnel placed near lip and patient asked to expectorate saliva into the funnel to collect in a pre-weighed test tube
• Spitting method- saliva allowed to accumulate in the floor of the mouth and then spat into a pre-weighed tube. For stimulated saliva patient is asked to chew on paraffin.
• Suction method- saliva is aspirated into a pre-weighed container using a saliva ejector.
• Absorbent method- preweighed swab, cotton roll, gauze sponge.
APPLICATION IN PROSTHODONTICS
62
• Adhesion• Cohesion • Surface Tension• Capillary Attraction• Atmospheric
Pressure• Viscosity of Saliva
ROLE OF SALIVA IN COMPLETE DENTURE RETENTION
Adhesion: It is achieved through ionic forces between charged salivary glycoproteins and surface epithelium or acrylic resin.
According to Bernard Levin– the most adhesive saliva is thin but containing some mucous component
Cohesion: It is a retentive force because it occurs within the layer of fluid (saliva) that is present between the denture base and the mucosa and works to maintain the integrity of the interposed fluid.
Interfacial force/ Surface tension• It is the resistance to separation of two
parallel surfaces that is imparted by a film of liquid between them.
• It is dependent on the ability of the fluid to ‘ wet’ the rigid surrounding material (WETTABILITY).
Capillary Action
• Capillarity is what causes a liquid to rise in capillary tube
• • When adaptation of denture base to mucosa on
which it rests is sufficiently close, the space filled with thin film of saliva acts like capillary tube in that liquid ,seeks to increase contact with both denture and mucosal surface.
Atmospheric pressure
•The cohesive forces result in the formation of a concave meniscus at the surface of the saliva in the border region of the denture.
•When a fluid film is bounded by a concave meniscus the pressure within the fluid is less than that of the surrounding medium;
•Thus a pressure differential will exist between saliva film and air and thereby aids in the retention of the denture
XEROSTOMIA AND HYPERSALIVATIONXEROSTOMIA• Dry mouth/ pasties/ cotton mouth• Hyposalivation or Aptyalism
Causes-• Dehydration or Renal Failure• Sjogren’s Syndrome• Radiotherapy• Trauma to Salivary gland or duct• Drugs• Smoking of marijuana/cannabis• Shock
HYPERSALIVATION• Excess saliva secretion• Physiological- Pregnancy• Pathological is called Ptyalism,
Sialorrhea, Sialosis
Causes-• Decay of tooth or a neoplasm• Disease of foregut, stomach or
intestine• Cerebral Palsy• Parkinsonism
DID YOU KNOW?In ancient China, a suspect would be made to chew dry rice while being questioned. When the suspect spat out the rice, they were assumed to be guilty if the grains remained stuck to their tongue. The reason was that the stress caused slow saliva flow and induced a dry mouth (activation of the sympathetic nervous system).
PROSTHODONTIC MANAGEMENT OF PATIENT WITH XEROSTOMIA
In dry environment, fixed non tissue bearing prosthesis are preferred where indicated
FPDs should have full coverage retainers and easily cleaned pontics and connectors
Margins of retainers should be supragingival
Health of residual teeth and periodontal tissues
Use of gingivally approching clasp avoided
Tooth supported denture with minimal tissue coverage
Metal denture bases are preferred
FIXED PARTIAL DENTURE PROSTHESIS
REMOVABLE PARTIAL DENTURE PROSTHESIS
Procedures -aim at optimizing retention and stability
Use dentures with metal bases
Use of soft liners to improve comfort
Use of denture adhesives to augment retention
Frequent recall – As more prone to candidal infections
COMPLETE DENTURE PROSTHESIS
TREATMENT OPTIONS
•Use of sialogogues•Saliva reservoirs•Flexible dentures
SALIVA RESERVOIS
Pattanaik B, Pattanaik S. Prosthetic rehabilitation of a xerostomia patient with a mandibular split salivary reservoir denture. Annals and Essences of dentistry 2010;3:32–5
SPLIT DENTURES
Mendoza AR, Tomlinson MJ. The split denture: a new technique for artificial saliva reservoirs in mandibular dentures. Aust Dent J 2003;48:190–4
Flexible denturesSaliva substitutes are contraindicated in • asthma• iritis• Glaucoma
limitations of the split dentures • Require adequate vertical dimension• Structure weakened• repair and relining are difficult• Too bulky
Flexible dentures-• Long lasting• do not warp or become brittle• exhibit better accuracy• softer material locks into the undercuts of the ridges
thereby adapting to the constant movement• Can retain a small percentage of water- more
compatibility and softer than acrylic
• Dental restorations are affected by saliva. They have ability to dissolve silicates.
• Changes physical properties of various impression materials.
• Causes electro-galvanisation between silver and gold discolors the restoration, causes pain.
• Hampers clinicians view and contaminates working area.
ISOLATION:
METHODS OF FLUID CONTROL
SALIVA EJECTORS RUBBER DAMSVEDOPTER
ANTI-SIALOGOGUES RETRACTION CORDS GAUZE AND COTTON ROLLS
IMPLANTS
• Failure of Implants is seen due to microbiota present in saliva.
• Bacterial species from human saliva may penetrate along the implant-abutment interface
• Essentials of Human Anatomy- Head and Neck, 4th Edition- A K Datta• Orbans Oral Histology & Embryology, 14th Edition• David T. Wong Salivary Diagnostics, Wiley-Blackwell• Ten Cate’s Oral Histology, Development, Structure, and Function, Seventh Edition• Oral Radiology Principles And Interpretation Sixth Edition,Stuart C. White and
Michael J. Pharoah• Textbook of Oral Medicine, A.V.Ghom, Third Edition• Physiology, Robert M. Berne and Matthew N. Levy, Third Edition• Syllabus of Complete Dentures, Charles M. Heartwell and Arthur O. Rahn, Fourth
Edition• A contemporary review of the factors involved in complete denture retention,
stability, and support. Part I: retention. Jacobson TE, Krol AJ. J Prosthet Dent. 1983 Jan;49(1):5-15.
REFERENCES
•Essentials Of Medical Physiology K. Sembulingam 4th Edition
•Syllabus of Complete Dentures, Charles M. Heartwell and Arthur O. Rahn, 4th edtn
• Ten Cate’s Oral Histology, Development, Structure, and Function, Seventh Edition
•Mendoza AR, Tomlinson MJ. The split denture: a new technique for artificial saliva reservoirs in mandibular dentures. Aust Dent J 2003;48:190–4
•Pattanaik B, Pattanaik S. Prosthetic rehabilitation of a xerostomia patient with a mandibular split salivary reservoir denture. Annals and Essences of dentistry 2010;3:32–5
•Saliva composition and functions: A comprehensive Review, The Journal of Contemporary Dental Practice vol(9),no 3,2008
•Kaufman E, Lamster IB. The diagnostic applications of saliva--a review. Crit Rev Oral Biol Med. 2002;13(2):197-212.
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