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“SALIVARY GLANDS DISEASES”

15 May 2019
Oleh : Dian N Agus Imam
1
DIAGNOSIS OF THE PATIENT WITH
SALIVARY GLAND DISEASES :
Symptoms of
Past & present Clinical
salivary gland
medical history examination
dysfunction

Salivary gland Saliva


Sialochemistry
imaging collection

Salivary gland Serologic


biopsy evaluation
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Past & present medical history

 Medical condition  ?
 Medication  ?
 Radiotherapy for head & neck  ?
 Symptomatic complaint ?

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Clinical examination
 Mucosal dryness
 Lips  cracked, peeling, atrophic
 Bucal mucosal  pale, corrugated
 Tongue  smooth, redness, depapilation
 Teeth  erosion, caries, ↑ food debris
 Candidiasis, angular chelitis
 Enlargement of the salivary glands (???)

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Saliva collection
 Penentuan curah saliva  membantu menegakkan diagnosis &
penilaian fungsi glandula saliva.

The individual major Carlson-Crittenden


salivary glands collector

Salivary flow
rate
Saxon test

Whole saliva

Gum test

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Saliva collection

Whole saliva

Carlson-Crittenden device

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Saliva collection

Unstimulated
whole saliva
Normal
Stimulated
whole saliva
Salivary flow
rate
Unstimulated
<0.1 mL/min
whole saliva
Abnormal
Stimulated
<0.7 mL/min
whole saliva

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Sialochemistry
 the
- diagnosis by using the saliva (Panat et al., 2013).
 Viral infections, blood alcohol, hormone levels, to screen for drugs
abuse, cancers & other significant systemic diseases

Saliva nitric test


strip (Berkeley Test) HIV test for saliva

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Salivary gland imaging

Plain-film radiography
Salivary Gland Imaging

Sialography

Ultrasonography

Radionuclide salivary imaging

Positron emission tomography

Magnetic resonance imaging

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Salivary gland imaging
Imaging Modality Indication Advantages Disadvantages

Biopsy guidance; Noninvasive; cost- Limited visibility, no


USG
mass detection effective morphologic inf.
Stone structure; R/O :
Visualize ductal Invasive, requires
Sialography autoimmune/ radiation-
induced sialadenitis anatomy/blockage iodine-dye
R/O : autoimmune Radiation exposure;
Radionuclide Quantification of
sialadenitis, sialosis, no morphologic
imaging function
tumor information
Computed R/O calcified Diff oss structures
Radiation exposure
tomography structure, tumor from soft tissue
Contraindicated 
Soft tissue
MRI R/O soft tissue lesion pacemaker/metal
resolution excellent
implant
Possitron Identify regional salivary
Highly sensitive to Radiation exposure &
emission gland functional alterations
& inflammation metabolic activity no morphologic inf.
tomography
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Salivary gland biopsy

FNA

 DD  need tissue examination  To assess the extent of


 SS  labial minor salivary changes
gland  Intraoral / extraoral

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Serologic evaluation

 Laboratory blood studies


 Nonspesific markers of autoimmunity (antinuclear AB, rheumatoid fx,
Ig, erythrocyte sedimentation rate)
 Serum amylase

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SALIVARY GLAND DISEASES

A. SPESIFIC DISEASES AND


DISORDERS OF THE SALIVARY
GLANDS

B. SALIVARY GLAND TUMORS

C. XEROSTOMIA VS SIALORRHEA

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1. Developmental abnormalities

DISORDERS OF THE SALIVARY


A. SPESIFIC DISEASE AND
2. Sialolithiasis (salivary stones)

3. Sialdenitis
GLAND

4. Sialodenosis/sialosis

5. Mucoceles & ranula

6. Inflammatory & reactive lesions

7. Systemic conditions with salivary


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glands involvement 14
1. Developmental abnormalities
1) AGENESIS OF PAROTID GLAND

• Treacher Collins Syn; cleft palate; LADD Syn; anopthalmia

2) HYPOPLASIA OF PAROTID GLAND

• Melkersson-Rosenthal Syn

3) ACCESSORY SALIVARY DUCTS

• Common & don’t required treatment  superior, anterior Stensen’s


duct

4) DIVERTICULI

• saccus menonjol dr dinding duktus ⇾ picu pengumpulan saliva ⇾


rec.sialadenitis.

5) DARIER’S DISEASE

• ditemukan abnormalitas duktus salivarius ⇾ “dilatasi”


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Anopthalmia
Cleft palate

Treacher Collins syndrome


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LADD syndrome

Darier’s disease
Melkersson-Rosenthal
syndrome
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2. Sialolithiasis (salivary stones)
• pembentukan batu di dalam duktus
Definisi
salivarius.

• Belum diketahui
Etiologi • Inflamasi, ketidakteraturan sist ductus,
local irritans, anticholinergic medication

• Submandibular (80-90%); parotid (5-15%);


Prevalensi
sublingual (2-5%)

• acute, painful, intermittent swelling, gejala


tergantung perluasan obstruksi duktus salivarius
Gamb. Klinis
& infeksi sekunder, nyeri tekan, jaringan lunak
sekitarnya mengalami edema & inflamasi.
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2. Sialolithiasis (salivary stones)

Crystalline  HA, calcium


phosphate, C, Mg, potassium
chloride & ammonium.

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2. Sialolithiasis (salivary stones)

CARA DIAGNOSA :
1) occlusal radiograph : gland.
Submandibula.
2) AP radiograph : gland. Parotis
3) CT-images
4) Sialoendoscopy (+ removal)
(∅ < 1mm)
5) Ultrasonography (∅ > 2mm)
Occlusal radiograph

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1 2

sialoendoscopy ultrasonography
3

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CT images 21
2. Sialolithiasis (salivary stones)
ACUTE PHASE
Analgesik Hydration Antibiotik Antipiretik

Treatment
AFTER ACUTE PHASE
Remove Sialolitho Sialoendos Complete
transorally  Incision removal of
milking -tripsy -copy glands
Sialolithotripsy is a non-invasive method of fragmenting
salivary stones into smaller portions in order to favor their
possible flushing out from the salivary duct system
spontaneously or after salivation induced by citric acid or other
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Contoh kasus Sialolithiasis :
A 65-year-old male reported to the Dept. of Oral Medicine and Radiology, with the
chief complaint of pain and swelling in the floor of mouth on right side since eight
months. Detailed history revealed that it started as small swelling which used to
increase before meals eight months back. It gradually increased over next three
months and then it burst leaving a yellowish white mass in the right floor of mouth
which was noticed by patient. Patient experienced pain, as well as pus discharge from
that region.

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22 x 14 mm

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2. Sialadenitis

Definisi

• inflamasi glandula salivarius.

Macam

Post Minor
Viral Bacterial Alergic Radiation glands

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2a. Viral sialadenitis

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2a. Viral sialadenitis

•Beta herpes virus

CMV infection
• Infeksi virus akut krn RNA
Mumps

•Adult or children, vertical


paramyxovirus. transplacental
• Biasa tjd pd anak : 4-6 th. •Klinis : acute febrile illness,
• Inkubasi : 2-3 mgu. salivary gland enlargement.
• Klinis : inflamasi & Transplacental  premature,
pembengkakan gland., LBW, congenital
preauricular pain, demam, malformation
lemas, headache, myalgia. •Diag : ↑ CMV-AB, viral culture,
• Mayoritas pd Parotis. antigen detection, CMV DNA,
IgG
• Tanpa pengeluaran
purulent. •Histopatologi  inclusion
body
• Biasanya bilateral (70%)
• IV antiviral (ganciclovir,
• Treatment : bed rest,
foscarnet, cidofovir,
analgesik, kortikosteroid.
valganciclovir)
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2a. Viral sialadenitis

•-
• HIV salivary gland disease

Hepatitis C virus infection


HIV SGD

•Trigger  autoimmune
• CD8+ cell lymphocytosis disease
• Klinis : salivary gland •HCV DNA terdeteksi pada
swelling, dry mouth, ↓ CD4, saliva pasien
HAART (highly active •Klinis : sialadenitis, dry
antiretroviral therapy), ↑ mouth, gl. Enlargement, ≠ dry
SLPI (secretory leukocyte eye
protease inhibitor) •Diagnosis : serologic
• Diagnosis : IgA  ↑↑, mirip detection of anti-HCV AB &
dg SS  anti-SS-A & anti- HCV DNA
SS-B  (−); USG, CT, MRI •Treatment : sesuai gejala
• Treatment : sesuai gejala

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2b. Bacterial sialadenitis

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2b. Bacterial sialadenitis

1) Acute bacterial sialadenitis :


 biasanya menyerang gland. Parotis.
 bakteri yg terlibat : Staphylicoccus
aureus, Streptococcus viridans,
Streptococcus pneumonia, Escherichia
coli & Haemophilus influenzae.
 Fx predisposisi : (-) saliva.
 Klinis : onset cepat, pembengkakan &
nyeri pada facial lateral, demam,
lemah, headache. Purulent terdpt pd
orifis, kulit sekitar kelenjar kemerahan.

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2b. Bacterial sialadenitis
2) Chronic bacterial sialadenitis :
Mrpkan inflamasi non spesifik, biasanya akibat penyumbatan
duktus  sering : gland. Submandibula.
Pada keadaan tdk ada sumbatan, penyebabnya  penurunan
saliva.
Biasanya unilateral, pembengkakan lunak.
Sel2 acinar atrofi, terdapat penggantian oleh jarg. Fibrosis.

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2c. Allergic sialadenitis

Definisi : pembesaran glandula salivarius akibat terpapar


bahan farmasetik atau alergen.

Contoh : ethambutol, logam berat, iodine compound,


isoproterenol, phenobarbital, phenotiazine, sulfisoxazole.

Klinis : akut, rasa gatal pada kelenjar. Biasanya tidak


diikuti rash/gejala alergi lainnya.

Treatment : self-limiting, hindari alergen.

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2d. Post radiation sialadenitis

Merupakan komplikasi radioterapi.

Keparahan terkait dosis paparan


radiasi.

Serous acini lbh sensitif dibanding


mucous acini.

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2e. Sialadenitis of Minor Glands

Disebut juga stomatitis glandularis

Sangat jarang

Merupakan pembengkakan mukosa multipel

Biasanya menyertai kelainan lain seperti


sarcoidosis maupun sjogren syndrome.

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2e. Sialadenitis of Minor Glands

Ekstraoral Intraoral

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4. Sialodenosis/ Sialosis
Pembengkakan gland salivarius (tersering parotis); sering
bilateral; yang bukan inflamasi, bukan tumor/neoplasma;
kadang kambuhan.

Terkait dengan kelainan kontrol neurosecretory dan


berkaitan dengan gangguan hormonal, malnutrisi, sirosis
hepatis, alkoholis kronis.

Treatment : terapi kelainan sistemik pasien.

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5a. Mucoceles

Extravasation type Retention type


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5a. Mucoceles

Tidak
sakit

Bibir
bawah,
mukosa Permukaan
RM, lesi = licin
palatum,
dsr mulut Gamb.
klinis

Permukaan
Ø = mm-
lesi
cm
kebiruan

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5a. Mucoceles

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5b. Ranula

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5b. Ranula

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6. Inflammatory and Reactive Lesions

Inflammatory and Reactive Lesions


6a. Necrotizing sialometaplasia

6b. External beam radiation-


induced pathology

6c. Internal radiation-induced


pathology

6d. Chronic sclerosing sialadenitis

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6a. Necrotizing sialometaplasia

Benign, self-limiting, reactive inflammatory disorder of the


salivary tissue

Etiologi  unkown,  (?) immune respone

Gb.klinis : rapid onset, predominantly on palate, lips,


trigonum retromolar, ada kaitannya dg bulimia (?)

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6a. Necrotizing sialometaplasia
Tender erytematous nodule

The mucosa break down

Deep ulceration with yellowish base


forms

 Necrosis
 Epitel mucosa  hyperplasia
pseudoepitheliomatous
 Epitel ductus  metaplasia
squamous
 Infiltrasi  limfosit, histiosit,
PMN, eosinophil
 NO MALIGNAT cell

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6a. Necrotizing sialometaplasia

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6b. External beam radiation-induced pathology

Pd pasien dg kanker kepala & leher

Gb.klinis : acute effect  oral dryness,


viscous saliva.

Prevention & treatment : radiation planning 


IMRT (intensity-modulated radiotherapy)

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6c. Internal radiation-induced pathology

Pada pasien kanker tiroid

Pengambilan gl tiroid & (post-op)


radioaktif iodine

Dapat memicu fibrosis glandula,


hipofungsi glandula saliva secara
permanen

Gamb. Klinis: parotid swelling, pain,


xerostomia, ↓salivary gl. function

Diag  riwayat pemakaian radioaktif


Iodine
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6d. Chronic Sclerosing Sialadenitis

Nama lain : Küttner's Tumour

Sebuah penyakit inflamasi kronis langka kelenjar ludah submandibular


(<< parotid/ minor salivary glands)

Etiopatogenesis : blm diketahui, immune process triggered by


intraductal agent

Gb.klinis : biopsy  progressive periductal fibrosis, dilated duct 


lymphocyte infiltration & lymphoid follicle formation, acinar atrophy

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7. Systemic conditions with salivary glands
involvement
Diabetes

Anorexia
7a. Metabolic condition
Chronic
alcoholism
Systemic condition

Dehydration

7b. Medication-induced salivary


disfunction
Mikulicz’s
disease
7c. Immune condition
Sjogren
7d. Granulomatous syndrome
condition
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7a. Metabolic conditions

• uncontrolled • Possibly due to

NERVOSA/BULIMUA
DIABETES

ANOREXIA
diabetes = dry nutritional
mouth & salivary deficiencies and the
hypofunction habit of repeated
• perubahan pd induced vomiting
memb. basalis sel2 • Histopatologi 
Gl. acinar enlargement
• IO : enamel erosion,
dry mouth, salivary
gl. Enlargement,
mucosal erythema,
cheilitis
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7a. Metabolic conditions

• Salivary gland • Sekresi saliva

DEHYDRATION
CHRONIC ALCOHOLISM

disfunction & terkait dg system


bilateral salivary sirkulasi cairan pd
(parotid) gland sel2 acinar
enlargement • Kurang cairan 
• Histopalotogi : sekresi saliva ↓↓↓
hipertrofi acinar,
perubahan struktur
ductus striata

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7b. Medication-induced salivary disfunction

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7c. Immune condition

Benign lymphoepithelial lesion

Karakteristik : pembesaran gl. Lacrimal, parotis,


submandibular secara simetris disertai infiltrasi limfosit

Etiologi : tdk diketahui, kemungkinan terkait autoimun,


virus atau fx genetic.

Systemic disease rather than a localized lacrimal &


salivary gland disorder.

Treatment : corticosteroid

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7c. Immune condition

Penyakit autoimun kronis, dg karakteristik gejala


xerostomia & xeropthalmia, disfungsi eksokrin,
infiltrasi limfosit, destruksi kelenjar eksokrin.

Etiologi : unknow  no cure

Primary SS : penyakit sistemik melibatkan gl.


Lakrimal & saliva tanpa kondisi autoimun lainnya.

Secondary SS : disfungsi gl. Lakrimal &/ saliva


disertai kondisi autoimun lainnya (SLE, RA,
scleroderma, dll)
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7d. Granulomatous condition

• Kelainan

Sarcoidosis
TB

• Disebabkan olh :
Mycobacterium granulomatosa
tuberculosis multisystem ditandai
dg kondisi patologis 
• Tanda & gejala : infiltrasi limfosit-T,
pembengkakan gl dg fagosit mononuclear yg
disertai granuloma atau menyebabkan
kista, dry mouth kerusakan jrg yg
• Dg PCR  98% pasien terlibat
terdpt Mycobacterium • Treatment : perawatan
tuberculosis paliatif
• Treatment : anti-TB

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B. SALIVARY
GLAND TUMORS

Benign tumors Malignant tumors

Pleomorfic adenoma,
monomorfic adenoma, papillary Mucoepidermoid carcinoma,
cystadenoma lymphomatosum, adenoid cyst carcinoma, acinic
oncocytoma, basal cell cell carcinoma, carcinoma ex
adenomas, canalicular pleomorphic adenoma,
adenoma, myoepithelioma, adenocarcinoma, lymphoma,
sebaceous adenoma, ductal myoepithelial carcinoma
papilloma
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C. XEROSTOMIA -
SIALORRHEA

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Definisi: kekeringan mulut akibat disfungsi glandula
salivarius (kurang/tdk ada aliran saliva).

GEJALA atau efek samping dari : (anxiety, autoimmune


disease, DM, chemoteraphy, radioteraphy, obat-obatan
dll).

Klinis : mucosa kering, fissured tongue, atropi papila


filiformis, pasien kesulitan, berbicara, mengunyah &
menelan dll.
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Managemen utk pasien xerostomia :

1. Terapi paliatif ⇾ meredakan gejala.


• eliminasi konsumsi alkohol & kopi
• hindari bahan kumur yg mengandung alkohol
• sugarless candy
• berkumur dg sodium carboxymethyl cellulose.
2. Stimulan saliva :
• pilocarpine
• cevimiline
• bethanechol

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Def : kelebihan saliva/hipersalivasi,
disebabkan o/ berbagai macam penyebab
antara lain :

Minor sialorrhea ⇾ krn iritasi lokal


(apthous ulcers atau ill-fitting denture).

Dapat merupakan sistem buffering (utk


menetralisir asam lambung) pasien
gastroesophageal reflux disease.

Rabies & keracunan logam berat (besi,


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timah, arsen, merkuri, thallium). 60
Obat-obatan : clozapine, pilocarpine,
cevimeline, lithium, bethanecol,
physostigmine, nitrazepam, risperidon.

Neurologic disease, cth : Parkinson


disease., wilson’s disease, cerebral palsy
dll.

infant teething.

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