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SIALOLITHIASIS 
Dr ARJUN SHENOY 
PG STUDENT 
DEPT OF OMFS
INTRODUCTION 
 Sialoliths are calcified structures that develop within the 
salivary gland or the ductal system. 
 Men >...
GLAND WISE DISTRIBUTION 
80-92% - submandibular gland. 
6-20% - parotid. 
1-2% - sublingual and the minor salivary 
glands...
SUBMANDIBULAR GLAND OCCURENCE 
 Abundant calcium concentration 
 Alkaline Ph 
 Anatomic factors 
 Wharton’s duct - lon...
Composition 
organic Inorganic 
Organic substances 
MUCOPOLYSACCHARIDES 
GLYCOPROTEINS 
CELLULAR DEBRIS
INORGANIC 
CALCIUM 
PHOSPHATE 
Fe 
Cu 
CALCIUM 
CARBONATE 
Mn
CHEMICAL COMPOSITION 
 Chemical composition 
Microcrystalline apatite (Ca5[PO4]3OH) or 
Whitlockite (Ca3[PO4]) 
Brushite ...
RECENT DISCOVERIES 
 Scanning electron microscopy has demonstrated oval, 
elongated shapes, 
 suggesting the presence of...
PATHOGENESIS 
 Multifactorial event 
 Secretory disturbances & precipitation – inflammatory 
process 
 Specific changes...
MICROLITHS 
 Concrements detectable only microscopically 
 Contain – calcium and phosphorus 
hydroxyl apatite 
organic s...
 Dyschylia - Disturbed salivary secretion & change in the 
composition 
 Accumulation of organic substances & mineralisa...
PROGRESSION 
 Secretory disturbances viscous secretions 
 Microlith formation ductal obstruction 
 Coaction of factors ...
OTHER FACTORS 
 Infection 
 Salivary dysfunction 
 Ductal anamolies 
 Foreign bodies 
 Ductal epithelium metaplasia
SYMPTOMS 
 Pain, swelling & discomfort 
 Pain - meal time – severe with sour or acidic food 
 Unusual taste 
 Associat...
CHARACTERISTICS 
 The annual growth rate - 1 mm per year 
 Shape - round or irregular 
 Size - 2 mm to 2 cm
GIANT SIALOLITH 
 72 mm in length and weighing 45.8 g 
 The ability of a calculus to grow and become a giant sialolith 
...
TREATMENT MODALITIES 
 Newer treatment modalities - extracorporeal short-wave 
lithotripsy and sialoendoscopy are effecti...
HISTOLOGIC FEATURES 
 Stratified & mineralized with metaplastic excretory duct 
cells 
 Concentric laminated structures ...
DIAGNOSIS 
 History 
 Clinical examination 
Bi-manual palpation 
 Imaging
BIMANUAL
IMAGING 
Conventional radiography 
Sialography 
Ultrasonography 
Computed tomography (CT) 
Magnetic resonance 
imaging (MR...
Conventional radiography 
 Intra oral radiographs 
IOPA , Occlusal radiographs 
 Extra oral radiographs 
Panaromic , PA ...
Sialography 
 "Gold Standard” 
 Retrograde infusion of oil or water based contrast & the 
architecture of the salivary d...
LIMITATIONS 
Advantage 
detects 
radiolucent 
stones 
Therapeutic 
Disadvantage 
• invasive 
• bleeding & 
perforations 
c...
Ultrasonography 
 Non invasive, alternative method 
 Stones > 2mm detected as echo-dense spots with a 
characteristic ac...
MR Sialography 
 Non invasive 
 Acute infections 
 Canulation not possible
COMPUTED TOMOGRAPHY 
 Posterior of the duct 
 Hilum of the gland 
 Substance of the gland 
 Radiation exposure 
 Non ...
SIALOENDOSCOPY 
 Minimally invasive 
 Diagnostic & therapeutic 
 Small endoscope – light at end of flexible cannula
Differential diagnosis 
 Phleboliths – radiolucent center 
 Dystrophic calcification of lymph nodes – Cauliflower 
shape...
TREATMENT 
Symptomatic Surgical
• Opening of wharton’s duct 
Trans oral 
Ductotomy 
( sialolithotomy) 
• Deep intra glandular 
• Multiple stones 
• Preven...
Sialoendoscopy 
 Small endoscope – optical fibres 
- irrigation or working ports 
 Special devices – guide wire 
- ballo...
Sialoendoscopy – assisted Sialolithectomy 
 Large sialolith 
Lithotripsy 
 Fragmentation 
 Types – intracorporeal 
- ex...
Intracorporeal techniques 
 Mechanical fragmentation 
 Intracorpreal laser lithotripsy 
- Er: YAG 
- Ho: YAG 
 Pneumati...
 ARCH OTOLARYNGOL HEAD NECK SURG/VOL 129, SEP 2003
Extracorporeal Lithotripsy 
 Shock waves – focused, multiple high intensity acoustic 
pulses 
 Kinetic energy – compress...
Complications 
-Inability to remove 
fragment 
-Postoperative 
infections 
-Neural damage 
-Intraductal 
adhesion 
-Subglo...
 paediatric patients 
 Relatively small and distal 
 Bimanual careful palpation is mandatory to diagnostic 
approach fo...
MIGRATING SALIVARY STONES
Conclusion 
 Sialolithiasis is the main cause of unilateral diffuse parotid or 
submandibular gland swelling. 
 Mechanic...
References 
 Contemporary OMFS – Perterson 
 Oral Radiology – principles & interpretation – White & Pharoah 
 Sialoendo...
Sialolithiasis and its management in oral and maxillofacial surgery
Sialolithiasis and its management in oral and maxillofacial surgery
Sialolithiasis and its management in oral and maxillofacial surgery
Sialolithiasis and its management in oral and maxillofacial surgery
Sialolithiasis and its management in oral and maxillofacial surgery
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Sialolithiasis and its management in oral and maxillofacial surgery

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sialolithiasis in oral and maxillofacial surgery.

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Sialolithiasis and its management in oral and maxillofacial surgery

  1. 1. SIALOLITHIASIS Dr ARJUN SHENOY PG STUDENT DEPT OF OMFS
  2. 2. INTRODUCTION  Sialoliths are calcified structures that develop within the salivary gland or the ductal system.  Men > women  Rare in children  75% - single  3% - bilateral  1.2% -autopsy
  3. 3. GLAND WISE DISTRIBUTION 80-92% - submandibular gland. 6-20% - parotid. 1-2% - sublingual and the minor salivary glands.  Submanibular – larger & intraductal  Parotid – multiple, within the gland
  4. 4. SUBMANDIBULAR GLAND OCCURENCE  Abundant calcium concentration  Alkaline Ph  Anatomic factors  Wharton’s duct - longest - two sharp curves - small punctum
  5. 5. Composition organic Inorganic Organic substances MUCOPOLYSACCHARIDES GLYCOPROTEINS CELLULAR DEBRIS
  6. 6. INORGANIC CALCIUM PHOSPHATE Fe Cu CALCIUM CARBONATE Mn
  7. 7. CHEMICAL COMPOSITION  Chemical composition Microcrystalline apatite (Ca5[PO4]3OH) or Whitlockite (Ca3[PO4]) Brushite and weddellite BRUSHITE WEDDELLITE
  8. 8. RECENT DISCOVERIES  Scanning electron microscopy has demonstrated oval, elongated shapes,  suggesting the presence of bacilli in sialoliths.  A recent polymerase chain reaction study found bacterial DNA, mainly belonging to the Streptococcus genus ARCH OTOLARYNGOL HEAD NECK SURG/VOL 129, SEP 2003
  9. 9. PATHOGENESIS  Multifactorial event  Secretory disturbances & precipitation – inflammatory process  Specific changes in structure of organic molecules – supportive frame formation  Metabolic disturbances – alkalinity & precipitation
  10. 10. MICROLITHS  Concrements detectable only microscopically  Contain – calcium and phosphorus hydroxyl apatite organic secretory material necrotic cellular residues  Generated - autophagocytosis of organelles that are rich in calcium.
  11. 11.  Dyschylia - Disturbed salivary secretion & change in the composition  Accumulation of organic substances & mineralisation of organic matrix Accumulation of calcium Increase in pH Decreases the solubility of calcium phosphates
  12. 12. PROGRESSION  Secretory disturbances viscous secretions  Microlith formation ductal obstruction  Coaction of factors + participation of bacteria sialoliths  Dyschylia & increasing microlith formation ascent of bacteria lead to a focal obstructive atrophy of the acinar cells secretory disturbances Journal of Oral Science, Vol. 45, No. 4, , 2003
  13. 13. OTHER FACTORS  Infection  Salivary dysfunction  Ductal anamolies  Foreign bodies  Ductal epithelium metaplasia
  14. 14. SYMPTOMS  Pain, swelling & discomfort  Pain - meal time – severe with sour or acidic food  Unusual taste  Associated with infection – fever , purulent discharge & lymphadenopathy
  15. 15. CHARACTERISTICS  The annual growth rate - 1 mm per year  Shape - round or irregular  Size - 2 mm to 2 cm
  16. 16. GIANT SIALOLITH  72 mm in length and weighing 45.8 g  The ability of a calculus to grow and become a giant sialolith depends mainly on the reaction of the affected duct. Rai and Burman. Giant Submandibular Sialolith. J Oral Maxillofac Surg 2009.
  17. 17. TREATMENT MODALITIES  Newer treatment modalities - extracorporeal short-wave lithotripsy and sialoendoscopy are effective alternatives to conventional surgical excision for smaller sialoliths.  However, for giant sialoliths, transoral sialolithotomy with sialodochoplasty or sialadenectomy remains the mainstay of management.
  18. 18. HISTOLOGIC FEATURES  Stratified & mineralized with metaplastic excretory duct cells  Concentric laminated structures  Acini infiltrated by lymphocytes  Dialatation of duct  Epithelium exfoliation
  19. 19. DIAGNOSIS  History  Clinical examination Bi-manual palpation  Imaging
  20. 20. BIMANUAL
  21. 21. IMAGING Conventional radiography Sialography Ultrasonography Computed tomography (CT) Magnetic resonance imaging (MRI) Sialoendoscopy Imaging
  22. 22. Conventional radiography  Intra oral radiographs IOPA , Occlusal radiographs  Extra oral radiographs Panaromic , PA skull projection  Intraglandular and small stones can be missed.  20% of sialoliths are radiolucent
  23. 23. Sialography  "Gold Standard”  Retrograde infusion of oil or water based contrast & the architecture of the salivary duct system is visualized radio graphically .
  24. 24. LIMITATIONS Advantage detects radiolucent stones Therapeutic Disadvantage • invasive • bleeding & perforations contraindicated • acute infections • allergic to contrast
  25. 25. Ultrasonography  Non invasive, alternative method  Stones > 2mm detected as echo-dense spots with a characteristic acoustic shadow.
  26. 26. MR Sialography  Non invasive  Acute infections  Canulation not possible
  27. 27. COMPUTED TOMOGRAPHY  Posterior of the duct  Hilum of the gland  Substance of the gland  Radiation exposure  Non invasive & do not require contrast media
  28. 28. SIALOENDOSCOPY  Minimally invasive  Diagnostic & therapeutic  Small endoscope – light at end of flexible cannula
  29. 29. Differential diagnosis  Phleboliths – radiolucent center  Dystrophic calcification of lymph nodes – Cauliflower shaped  Palatine tonsiliths- multiple & punctate  Haemangiomas with calcifications
  30. 30. TREATMENT Symptomatic Surgical
  31. 31. • Opening of wharton’s duct Trans oral Ductotomy ( sialolithotomy) • Deep intra glandular • Multiple stones • Prevent recurrence Sialoadenectomy
  32. 32. Sialoendoscopy  Small endoscope – optical fibres - irrigation or working ports  Special devices – guide wire - balloon catheters - metal baskets - laser fibres  Ductal dialation – lacrimal probe - balloon dialator
  33. 33. Sialoendoscopy – assisted Sialolithectomy  Large sialolith Lithotripsy  Fragmentation  Types – intracorporeal - extracorporeal
  34. 34. Intracorporeal techniques  Mechanical fragmentation  Intracorpreal laser lithotripsy - Er: YAG - Ho: YAG  Pneumatic lithotripsy
  35. 35.  ARCH OTOLARYNGOL HEAD NECK SURG/VOL 129, SEP 2003
  36. 36. Extracorporeal Lithotripsy  Shock waves – focused, multiple high intensity acoustic pulses  Kinetic energy – compressive & tensile forces
  37. 37. Complications -Inability to remove fragment -Postoperative infections -Neural damage -Intraductal adhesion -Subglossal scar band formation -Sialocele & Ranula formation
  38. 38.  paediatric patients  Relatively small and distal  Bimanual careful palpation is mandatory to diagnostic approach for children suspicious of sialolithiasis.  These findings also suggest that intra-oral approach is effective treatment procedure for most of sialolithiasis in children. Int J Pediatr Otorhinolaryngol 2007 May;71(5)
  39. 39. MIGRATING SALIVARY STONES
  40. 40. Conclusion  Sialolithiasis is the main cause of unilateral diffuse parotid or submandibular gland swelling.  Mechanical obstruction of the salivary duct, causing repetitive swelling during meals, & often complicated by bacterial infections.  Common in submandibular gland , 10 – 20% are radiolucent  Newer minimally invasive diagnostic & therapeutic modalities
  41. 41. References  Contemporary OMFS – Perterson  Oral Radiology – principles & interpretation – White & Pharoah  Sialoendoscopy & salivary gland sparing surgery - Oral Maxillofaccial Surg Clin N Am 21 (2009)  Pathogenesis & diverse histologic findings of sialolithiasis – J Oral Maxillofac Surg 68: 2010  Imaging the major salivary glands – British Journal of Oral & Maxillofacial Surgery 49 (2011)  Oral & maxillofacial pathology – Neville  Text book of OMFS – Neelima Mallik

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