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Diagnosis of submandibular sialolithiasis Occlusal radiograph taken at 90° from the floor of the mouth

Complications from sialoliths Acute sialadenitis ductal Stricture ductal Dilatation Fistula and a sinus tract Ulceration in the tissue covering the stone in chronic cases

Infection occurs Suppurative or nonsuppurative drainage and erythema or warmth in the overlying skin

Stasis of saliva May lead to infection, fibrosis, and gland atrophy

Acute pain Glands are encapsulated and there is little space for expansion

Swelling Subsides when salivary stimulation ceases

Salivary flow Salivary pooling within the gland ductal system

Diagnosis of sialolithiasis 1. Radiography (occlusal view for submandibular, AP view for parotid) 2. Contrast sialography (to differentiate from phleboliths, contraindicated in acute sialadenitis) 3. Ultrasound (to visualize radiolucent calculi)

Complications from sialoliths Acute sialadenitis Ductal stricture Ductal dilatation Fistula and sinus tract Ulceration in tissue covering the stone

Clinical presentation of sialolithiasis 1. Swelling upon eating (due to salivary pooling from blocked duct) 2. Acute pain (due to gland encapsulation and little space for expansion) 3. Infection, fibrosis, and gland atrophy from saliva stasis

Reasons for higher rate of sialolith formation in submandibular gland Tortuous duct course, higher calcium and phosphate levels in secretion, dependent gland position, increased mucoid nature of secretion, lack of nervous stimulation leading to secretory inactivity

Sialoliths Most commonly occur in the submandibular glands (80-90%), followed by parotid (5-15%) and sublingual (2-5%) glands, rarely in minor salivary glands

No relationship between tobacco smoking and increased risk of sialolithiasis, but smoking adversely affects saliva cytotoxicity and amylase

Etiologic factors for sialoliths Factors favoring saliva retention (irregularities in duct system, local inflammation, dehydration, medications) Saliva composition (calcium saturation, deficit of crystallization inhibitors, bacterial infection increasing salivary pH)

Salivary duct diverticulum A sac protruding from the duct wall, leading to pooling of saliva and recurrent sialadenitis

Stafne bone cyst Asymptomatic depression of the lingual surface of the mandible, not a true cyst

Darier's disease Sialography shows duct dilation with periodic stricture affecting the main ducts

Complete absence of salivary gland is rare, but aberrant salivary glands can develop at unusual anatomic sites

Diagnostic imaging of salivary glands 1. Radiography (lateral oblique and anteroposterior projections) 2. Sialography (radiographic visualization of ducts following contrast injection) 3. Radioactive iodine (for ductal stricture, obstruction, dilatation, ruptures, sialoliths) 4. Ultrasonography (initial evaluation, detect sialolithiasis and abscesses, differentiate lesions) 5. CT (superior to radiographs and US for sialolithiasis, tumor detection and differentiation) 6. CBCT (high spatial resolution of osseous structures at lower radiation) 7. MRI (non-invasive, no contrast or radiation, but limitations with small calculi)

The smaller the salivary gland, the greater the likelihood of a malignant neoplasm