Sialolithiasis is the medical term for salivary gland stones. These stones, or calculi, are mostly composed of calcium, but they also contain magnesium, potassium, and ammonium. Your mouth has three salivary glands that can develop stones: parotid, submandibular, sublingual, and minor salivary glands. Due to being large, long, and having slow salivary flow, you are most likely to develop a salivary gland stone in your submandibular salivary gland. Children rarely develop sialolithiasis. They are most commonly found in men between the ages of 30 to 60. Most stones only occur in one gland, however, it is possible to have multiple stones form at once. Submandibular stones account for 80 to 92 percent of all sialolithiasis, while parotid stones account for most of the remaining cases at 6 to 20 percent. The sublingual and minor glands have relatively low risk for development of a stone. Saliva is mostly made up of water but also contains small amounts of electrolytes, calcium, phosphate, important antibacterial compounds, and digestive enzymes. The antibacterial properties of saliva protect against:
The digestive enzymes in saliva begin breaking down your food before you have even swallowed it and saliva is most commonly released in response to the smell and taste of food. Additional functions of saliva include helping us to swallow and talk. Saliva is produced by several glands located in the mouth and throat. The major salivary glands then transport the saliva through tiny tubes called salivary ducts which eventually release the saliva into various places in your mouth, especially under your tongue and on the floor of your mouth. The three pairs of major salivary glands are called the parotid, submandibular, and sublingual glands. In addition to the major saliva glands, there are multiple smaller glands, called minor salivary glands, located in your lips, cheeks, and throughout the tissue lining your mouth. Conditions such as dehydration which cause thickening, or decreased water content of the saliva can cause the calcium and phosphate in saliva to form a stone. The stones often form in the salivary ducts and can either totally obstruct the salivary duct, or partially occlude it. You may develop sialolithiasis even if you are healthy, and a cause may not always be able to be pinpointed. However, conditions that may cause thick saliva and subsequent sialolithiasis include:
Small stones that do not block the flow of saliva can occur and cause no symptoms. However, when the flow of saliva becomes completely blocked it may cause the associated salivary gland to become infected. Symptoms usually occur when you try to eat (since that's when the flow of saliva is stimulated) and may subside within a few hours after eating or attempting to eat. This is important to tell your healthcare providersince it may help differentiate sialolithiasis from other conditions. Symptoms of sialolithiasis may include:
Severe infections of a salivary gland may cause profound symptoms including fever, fatigue, and sometimes noticeable swelling, pain, and redness around the affected gland. An otolaryngologist, or ENT, is a physician qualified to diagnose and treat sialolithiasis. Although healthcare providers in other specialties may also diagnose or treat this condition. Your healthcare provider will consider your medical history and examine your head and neck, including the inside of your mouth. Sometimes the stone can be felt as a lump. Historically a sialograph, where dye is injected into the salivary duct followed by an X-ray, was used, however, this is more invasive than modern MRI or CT scans which are now more likely to be used. The treatment of sialolithiasis depends on where the stone is and how large it is. Small stones may be pushed out of the duct and you may be able to facilitate this by drinking plenty of water, or massaging and applying heat to the area. Sometimes a healthcare provider can push the stone out of the duct and into the mouth by using a blunt object and gently probing the area. Large salivary duct stones may be more difficult to remove and sometimes require surgery. Sometimes a thin tube called an endoscope can be inserted into the duct. If the stone can be seen with the endoscope the healthcare provider may be able to insert another tool that is then used to pull the stone out. Sometimes removal of the stone can be achieved with a small incision, in severe cases the entire gland and the stone may have to be surgically removed. In the case of an infected gland, your healthcare provider may prescribe an oral antibiotic. Never take antibiotics without seeing a healthcare provider. Sialolithiasis (also termed salivary calculi,[1] or salivary stones)[1] is a crystallopathy where a calcified mass or sialolith forms within a salivary gland, usually in the duct of the submandibular gland (also termed "Wharton's duct"). Less commonly the parotid gland or rarely the sublingual gland or a minor salivary gland may develop salivary stones.
The usual symptoms are pain and swelling of the affected salivary gland, both of which get worse when salivary flow is stimulated, e.g. with the sight, thought, smell or taste of food, or with hunger or chewing. This is often termed "mealtime syndrome".[2] Inflammation or infection of the gland may develop as a result. Sialolithiasis may also develop because of the presence of existing chronic infection of the glands, dehydration (e.g. use of phenothiazines), Sjögren's syndrome and/or increased local levels of calcium, but in many instances the cause is idiopathic (unknown).
The condition is usually managed by removing the stone, and several different techniques are available. Rarely, removal of the submandibular gland may become necessary in cases of recurrent stone formation. Sialolithiasis is common, accounting for about 50% of all disease occurring in the major salivary glands and causing symptoms in about 0.45% of the general population. Persons aged 30–60 and males are more likely to develop sialolithiasis.[2] The term is derived from the Greek words sialon (saliva) and lithos (stone), and the Greek -iasis meaning "process" or "morbid condition". A calculus (plural calculi) is a hard, stone-like concretion that forms within an organ or duct inside the body. They are usually made from mineral salts, and other types of calculi include tonsiloliths (tonsil stones) and renal calculi (kidney stones). Sialolithiasis refers to the formation of calculi within a salivary gland. If a calculus forms in the duct that drains the saliva from a salivary gland into the mouth, then saliva will be trapped in the gland. This may cause painful swelling and inflammation of the gland. Inflammation of a salivary gland is termed sialadenitis. Inflammation associated with blockage of the duct is sometimes termed "obstructive sialadenitis". Because saliva is stimulated to flow more with the thought, sight or smell of food, or with chewing, pain and swelling will often get suddenly worse just before and during a meal ("peri-prandial"), and then slowly decrease after eating, this is termed meal time syndrome. However, calculi are not the only reasons that a salivary gland may become blocked and give rise to the meal time syndrome. Obstructive salivary gland disease, or obstructive sialadenitis, may also occur due to fibromucinous plugs, duct stenosis, foreign bodies, anatomic variations, or malformations of the duct system leading to a mechanical obstruction associated with stasis of saliva in the duct.[2] Salivary stones may be divided according to which gland they form in. About 85% of stones occur in the submandibular gland,[3] and 5–10% occur in the parotid gland.[2] In about 0–5% of cases, the sublingual gland or a minor salivary gland is affected.[2] When minor glands are rarely involved, caliculi are more likely in the minor glands of the buccal mucosa and the maxillary labial mucosa.[4] Submandibular stones are further classified as anterior or posterior in relation to an imaginary transverse line drawn between the mandibular first molar teeth. Stones may be radiopaque, i.e. they will show up on conventional radiographs, or radiolucent, where they not be visible on radiographs (although some of their effects on the gland may still be visible). They may also symptomatic or asymptomatic, according to whether they cause any problems or not.
The stone seen in the submandibular duct on the person's right side Signs and symptoms are variable and depend largely upon whether the obstruction of the duct is complete or partial, and how much resultant pressure is created within the gland.[1] The development of infection in the gland also influences the signs and symptoms.
Rarely, when stones form in the minor salivary glands, there is usually only slight local swelling in the form of a small nodule and tenderness.[1] The major salivary glands (paired on each side). 1. Parotid gland, 2. Submandibular gland, 3. Sublingual gland. There are thought to be a series of stages that lead to the formation of a calculus (lithogenesis). Initially, factors such as abnormalities in calcium metabolism,[3] dehydration,[2] reduced salivary flow rate,[2] altered acidity (pH) of saliva caused by oropharyngeal infections,[2] and altered solubility of crystalloids,[2] leading to precipitation of mineral salts, are involved. Other sources state that no systemic abnormality of calcium or phosphate metabolism is responsible.[1] The next stage involves the formation of a nidus which is successively layered with organic and inorganic material, eventually forming a calcified mass.[2][3] In about 15-20% of cases the sialolith will not be sufficiently calcified to appear radiopaque on a radiograph,[3] and will therefore be difficult to detect. Other sources suggest a retrograde theory of lithogenesis, where food debris, bacteria or foreign bodies from the mouth enter the ducts of a salivary gland and are trapped by abnormalities in the sphincter mechanism of the duct opening (the papilla), which are reported in 90% of cases. Fragments of bacteria from salivary calculi were reported to be Streptococci species which are part of the normal oral microbiota and are present in dental plaque.[2] Stone formation occurs most commonly in the submandibular gland for several reasons. The concentration of calcium in saliva produced by the submandibular gland is twice that of the saliva produced by the parotid gland.[3] The submandibular gland saliva is also relatively alkaline and mucous. The submandibular duct (Wharton's duct) is long, meaning that saliva secretions must travel further before being discharged into the mouth.[3] The duct possesses two bends, the first at the posterior border of the mylohyoid muscle and the second near the duct orifice.[3] The flow of saliva from the submandibular gland is often against gravity due to variations in the location of the duct orifice.[3] The orifice itself is smaller than that of the parotid.[3] These factors all promote slowing and stasis of saliva in the submandibular duct, making the formation of an obstruction with subsequent calcification more likely. Salivary calculi sometimes are associated with other salivary diseases, e.g. sialoliths occur in two thirds of cases of chronic sialadenitis,[4] although obstructive sialadenitis is often a consequence of sialolithiasis. Gout may also cause salivary stones,[4] although in this case they are composed of uric acid crystals rather than the normal composition of salivary stones. Ultrasound image of sialolithiasis Stone resulting in inflammation and dilation of the duct[5] Diagnosis is usually made by characteristic history and physical examination. Diagnosis can be confirmed by x-ray (80% of salivary gland calculi are visible on x-ray), by sialogram, or by ultrasound.
Some current treatment options are:
The prevalence of salivary stones in the general population is about 1.2% according to post mortem studies, but the prevalence of salivary stones which cause symptoms is about 0.45% in the general population.[2] Sialolithiasis accounts for about 50% of all disease occurring in major salivary glands, and for about 66% of all obstructive salivary gland diseases. Salivary gland stones are twice as common in males as in females. The most common age range in which they occur is between 30 and 60, and they are uncommon in children.[2]
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