A 63-year-old male presented to a dental office for evaluation of pain and swelling associated with the anterior floor of the mouth.
Joen Iannucci Haring, DDS, MS
The patient described the pain and swelling as moderate to severe and reported that episodes occurred at mealtime. When questioned about duration, the patient reported that the pain and swelling had first started several weeks earlier and had occurred intermittently since that time. The patient also stated that the size and extent of the swelling had varied throughout the day.
At the time of the dental visit, the patient appeared to be in a good state of health. The patient denied any major medical problems. The patient had a history of sporadic dental treatment and had previously seen a number of dentists for emergency dental treatment.
Examination of the head and neck areas revealed no enlarged or palpable lymph nodes. The patient`s blood pressure and other vital signs were all found to be within normal limits. Extraoral examination revealed a moderate swelling that extended below the inferior border of the mandible. When massaged intraorally, the submandibular gland only produced a small amount of saliva. Intraoral palpation of the duct area revealed a rock-hard, well-defined mass on the floor of the mouth. An occlusal radiograph of the area was exposed and revealed one well-defined, round radiopacity.
Based on the clinical information presented, which one of the following is the likely diagnosis:
* Salivary duct cyst
* Malignant salivary gland tumor
* Benign salivary gland tumor
Sialolithiasis is a condition characterized by the presence of a salivary stone or sialolith (sial is from the Greek word sialon meaning salia, and, lith is from the Greek word lithos meaning stone). A sialolith is an abnormal concretion, usually composed of calcium salts, that occurs within a salivary gland duct or within the salivary gland.
This salivary stone is thought to originate as a slow calcifying nidus of mucous or bacterial debris. The length and position of the duct, the rate of salivary flow, and the chemical composition of the saliva all influence the initiation and growth of the sialolith.
The submandibular gland is most often involved due to the viscous consistency and mineral content of the saliva, and the long length and irregular configuration of the duct. In contrast, the parotid glands are only occasionally involved.
Sialoliths typically occur in middle-aged and older adults. Sialoliths may occur singly or in multiples and may range in shape from round to ovoid or cylindrical. The size may range from several millimeters to several centimeters in diameter. As the sialolith reaches a size that partially or completely obstructs the duct, symptoms such as pain and swelling occur.
The pain is experienced during salivary stimulation and, consequently, is intensified at mealtimes. The pain results from the pressure that builds from the accumulation of the saliva that is blocked by the stone. This accumulation of saliva in the gland produces a swelling that becomes large and firm. Rarely does a stone completely obstruct the duct; as a result, the pain gradually subsides and the swelling decreases as the saliva exits the duct. Sialoliths are often palpable; the larger, more peripheral stones can be described as well-defined and rock-hard.
Diagnosis - A diagnosis of sialolithiasis is made on a clinical basis. If sialolithiasis is suspected, the following is recommended:
(1) inspect the face and note any swelling or asymmetry;
(2) palpate the gland and note enlargement and consistency;
(3) massage the gland and note the amount of salivary flow;
(4) palpate the duct area and note any rock-hard masses; and
(5) question the patient concerning the history of pain at mealtimes and swelling that comes and goes.
A radiograph is often used to confirm the diagnosis of sialolithiasis; a salivary stone appears as a well-defined radiopacity. Often, multiple concentric layers of calcification are observed. In some cases, a sialolith may not appear radiopaque; approximately 20 to 40 percent appear radiolucent because of a low mineral content.
Treatment - A sialolith should be removed. If the blockage of the duct has persisted for a long period of time, fibrosis of the gland or a chronic sialadenitis (inflammation of the gland) may occur. Small, peripherally located stones may be removed by manipulation or massaging of the gland. Larger stones or stones located within the gland require surgical removal. In extreme cases, excision of the entire gland is necessary in order to prevent multiple, recurrent episodes of sialadenitis. If the gland is infected, the infection should be eliminated with the use of antibiotics prior to surgical removal.
In general, salivary stones do not recur following removal. However, if scarring of a duct occurs subsequent to removal of a stone, there is a chance that the nidus formation of mucous or debris may occur. Such accumulations may result in the formation of another sialolith. A patient who has had a sialolith removed should be instructed to return for re-evaluation should any symptoms return.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.