Sialadenitis

Sialadenosis is a non-inflammatory disease of the salivary glands, leading to enlargement and/or disruption of their function. The lesion is dystrophic in nature and is not associated with the appearance of tumors. Structural changes in gland tissue usually appear against the background of other systemic pathologies. Dentists quite often encounter this phenomenon: 1 case out of 10 pathologies of the salivary glands is represented by sialadenosis.

The disease usually occurs in middle-aged people. Since it often accompanies endocrine, allergic, dysmetabolic and other systemic diseases, the approach to treatment should be carried out not only from the dental side.

Types of sialadenoses

Based on the location of pathological changes, the following types of sialadenoses are distinguished:

• interstitial;
• parenchymal;
• ductal

Pathological areas can be located both in the tissues of the gland itself and in the ducts.

There are several stages based on severity:

• First. The salivary glands are of normal size and are faintly palpable.
• Second. There is a slight enlargement of the glands, which is not noticeable during visual inspection, but is palpable.
• Third. Enlargement of the glands, which is noticeable both during visual inspection and palpation.

According to the nature of origin, neurogenic, allergic, endocrine sialadenoses are distinguished, as well as nutritional ones - associated with dietary habits.

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Material and methods

In the specialized department of the Department of Maxillofacial Surgery (MCS) at the Dentistry Center (DC) of the Moscow State Medical and Dental University (MGMSU) named after. A.I. Evdokimov examined and treated 25 people aged 25 to 50 years with chronic parenchymal sialadenitis. The criterion for inclusion in the study was the presence of chronic parenchymal sialadenitis. The criterion for non-inclusion was the presence of concomitant pathology in the acute or exacerbation stage. The exclusion criterion was the refusal of patients to further participate in the studies. To make a diagnosis, all patients underwent a clinical examination, which included examination and palpation of the altered salivary gland, determination of its size and amount of secretion, and collection of anamnesis about concomitant diseases.

All patients also underwent high-resolution ultrasound (US) in B-mode and color Doppler mapping mode on a Philips iU-22 ultrasound scanner using linear scanning sensors with a frequency of 5-17 MHz. Additionally, mixed saliva was collected from patients for 5 minutes into a sterile plastic tube with a tightly screwed cap. The samples were centrifuged and the content of albumin protein (in mg/ml) was determined in the supernatant of saliva using the spectrophotometric method and the amount of immunoglobulin (Ig) G using the enzyme-linked immunosorbent method. The initial data of ultrasound Dopplerography and mixed saliva were compared with the results of the study on the 7th day and 1 month from the beginning treating patients.

According to the method of the proposed treatment, the patients were divided into two groups. Patients of group 1 ( n

=11) carried out standard antibacterial and antispasmodic therapy
per os
for 5 days with the following drugs: enhanced amoxicillin 625 mg, 1 tablet 3 times a day, drotaverine 1 tablet 2 times a day.
Patients of the 2nd group ( n
= 14), along with standard therapy, were prescribed
per os
complex antihomotoxic therapy with Traumeel S, 1 granule 3 times a day and lymphomyosot, 15 drops 3 times a day for 24 days, spascuprel, 1 tablet 2 times a day for a course of 5 days. All manipulations were carried out only after the informed consent of the patient, signed by him and the attending physician in duplicate. The rationale for the use of these homeopathic drugs was that Traumeel S is a highly effective remedy for inflammatory processes, the drug spascuprel has an antispasmodic, analgesic, sedative and anticonvulsant effect, the drug lymphomyosot improves the microcirculation of peripheral vessels. All obtained digital values ​​were processed by the method of variation statistics using the Statistica 8.0 program.

Why does sialadenosis occur?

Sialosis can develop against the background of underlying diseases or be caused by certain physiological reasons. For example, pathology occurs in women during pregnancy and lactation. Pathological changes are often provoked by autoimmune diseases - systemic scleroderma, rheumatism, psoriasis, etc., as well as metabolic and endocrine disorders.

Eating disorders that lead to sialosis include strict long-term diets and restrictions, and anorexia. In general, the most common causes are diabetes mellitus, menstrual dysfunction and thyroid dysfunction, chronic pancreatitis and other gastrointestinal pathologies.

The allergic nature of the disease may be associated with drug allergies. In some cases, sialosis of the salivary glands develops after surgery or trauma in the area of ​​the dental system.

Classification of sialadenoses

According to the state of the salivary gland, sialadenoses are defined as interstitial, parenchymal and ductal (depending on the predominant changes detected using private and special examination methods). This disease has three stages of development:

• initial (I degree), in which the salivary glands are not enlarged and have normal sizes;
• the stage of pronounced clinical changes (II degree) is accompanied by a slight increase in the size of the salivary glands, which is determined by palpation;
• late (III degree) is characterized by an increase in the size of the salivary glands, which is diagnosed both visually and by palpation.

In addition, sialadenoses are divided into endocrine, neurogenic, allergic and associated with nutritional disorders. In order to determine the degree of development of sialadenosis, a specialist assesses the size of the major salivary glands, taking into account examination and palpation data.

Symptoms of the disease

Sialosis most often affects the parotid glands, rarely - the submandibular and sublingual glands. Usually we are talking about a bilateral pathological process. The picture of the disease is nonspecific - painful swelling appears in the area of ​​the affected glands, their increase in the 2nd and 3rd stages. The increase persists over time.

One of the manifestations of the disease is dry mouth. This is due to the fact that salivation during illness may be insufficient.

During the examination, the doctor will determine the characteristic swelling of the soft tissues. Palpation does not cause severe pain; sometimes discomfort or mild pain appears. The nearby lymph nodes are not changed, and there are no restrictions in opening the mouth. During a massage of the salivary gland, clear saliva is released without external features.

It is worth noting that specific symptoms may accompany sialosis, occurring with decreased or increased salivation without an increase in the glands themselves. For example, this is observed with stomatitis, duodenal ulcers, parasitosis, neurasthenia, etc.

Results and discussion

At the time of treatment, patients complained of pain and swelling in the area of ​​the causative salivary gland. In the case of inflammation of the submandibular salivary gland, patients indicated pain when swallowing. From the anamnesis it follows that the day before all patients were exposed to hypothermia. Objectively: in the area of ​​the causative salivary gland, symptoms of edema and hyperemia of the skin were noted, with bimanual palpation - severe pain. Body temperature ranged on average from 37.5 to 38.5 °C. When examined from the oral cavity, swelling and hyperemia were revealed; a small amount of saliva was released from the mouth of Wharton's duct, and in some cases pus mixed with blood; probing was difficult. According to the results of Doppler ultrasound: the gland is enlarged in size, decreased echogenicity, the parenchyma is heterogeneous, the duct is dilated, stones are not detected. Color Doppler mode: diffuse enhancement of parenchymal vascularization. Examination of mixed saliva showed the presence of albumin in an amount of 15.3 ± 6.87 mg/ml and an increase in IgG to 16.5 ± 3.44 mg/ml.

Repeated examination of all patients after the prescribed treatment on the 7th day showed a decrease in pain. This coincided with a decrease in local inflammatory phenomena and a decrease in the size of the salivary gland. The Doppler ultrasound also confirmed the results of the clinical examination in both groups of patients, i.e., a decrease in the size of the examined salivary glands, the excretory ducts are not dilated. During these periods, the echogenicity and heterogeneity of the parenchyma of the inflamed salivary gland remained reduced compared to the contralateral side. In the mixed saliva of patients of both groups on the 7th day after treatment, a significant decrease in albumin level was observed ( p

<0.05). The greatest decrease in the content of this protein in saliva occurred in patients of the 2nd group, for whom antihomotoxic therapy was included in complex treatment (4.24±0.67 mg/ml versus 5.67±0.32 mg/ml in patients of the 1st group ). At the same time, a decrease in the IgG content in saliva was determined to 8.90 ± 2.40 mg/ml in patients of the 1st group and to 9.23 ± 1.23 mg/ml in the 2nd group.

1 month after treatment, 3 (27.3%) patients of group 1 were treated for exacerbation of chronic sialadenitis, which required surgical intervention. In the remaining patients, there was an improvement in the function of the salivary glands over time, and there were no complaints of pain. An ultrasound examination showed that in 5 patients of this group there was still a slight increase in the size of the damaged gland and there was echogenicity and heterogeneity of the parenchyma. Traces of albumin were detected in the mixed saliva of these patients.

Patients of group 2, who took antihomotoxic drugs, had no complaints after 1 month, clinically no changes were detected in the inflamed gland, functional activity was normal, which was confirmed by ultrasound data. Albumin was not detected in mixed saliva, and IgG was detected in trace amounts.

We present a clinical case.

To the specialized department of the Department of Maxillary Surgery of the CS MGMSU named after. A.E. Evdokimov was contacted by patient K.

, 35 years old, with complaints of pain in the submandibular region on the right, the presence of edema and slight pain when swallowing. From the anamnesis: the day before the patient became hypothermic. Objectively: in the submandibular region on the right there were signs of swelling and hyperemia of the skin, with bimanual palpation - severe pain. Body temperature 38.5 °C. Local status: Wharton's duct on the right is swollen and hyperemic, a small amount of saliva was released from the mouth, probing is difficult. The albumin content in mixed saliva is 12.3 mg/ml, IgG 9.47 mg/ml. The patient underwent an ultrasound scan, which resulted in a diagnosis of parenchymal sialadenitis of the submandibular salivary gland on the right (Fig. 1).

Rice.
1. Doppler ultrasound before treatment. Sialadenitis of the right submandibular salivary gland. a — B-mode: the gland is enlarged in size, decreased echogenicity, the parenchyma is heterogeneous, the duct is dilated, stones are not detected; b — color Doppler mode: diffuse enhancement of parenchymal vascularization; c — B-mode: the left submandibular gland is not changed. Treatment: the patient was prescribed standard antibacterial and antispasmodic therapy (enhanced amoxicillin at a dose of 625 mg, 1 tablet 3 times a day, 5 days; drotaverine, 1 tablet 2 times a day, 5 days). On the 7th day after the course of treatment with allopathic drugs, no improvement was noted. The ultrasound results did not reveal positive echographic dynamics in the condition of the right submandibular salivary gland.

In this regard, the patient was additionally prescribed antihomotoxic therapy according to the following regimen: Traumeel C, 1 granule 3 times a day and lymphomyosot, 15 drops 3 times a day for 24 days; spascuprel 1 tablet 2 times a day, 5 days. 7 days after the prescription of antihomotoxic drugs, the patient noted a significant improvement in her health in the form of a decrease in pain and inflammation. Albumin and IgG were detected in trace amounts in mixed saliva. It was recommended to continue antihomotoxic therapy with dynamic ultrasound monitoring, which showed positive echographic dynamics (Fig. 2).

Rice. 2. Ultrasound results after 14 days (a) and 60 days (b) from the start of treatment. B-mode: a — the size of the right submandibular salivary gland has decreased, the duct is not dilated; there remains a decrease in echogenicity and heterogeneity of the gland parenchyma; b — right submandibular gland of normal echogenicity and structure, the duct is not dilated; a slight increase in size remains compared to the contralateral side.

Diagnostic features

Examination of a person with suspected sialadenosis may include the following methods:

• survey, examination, palpation of the glands;
• laboratory tests - general and biochemical blood tests, clinical urine tests, assessment of carbohydrate metabolism (glucose test);
• Ultrasound of the salivary glands and soft tissues is necessary to confirm the non-inflammatory nature of the disease and exclude tumors.

It is important for the doctor to exclude other possible pathologies characterized by enlargement of the salivary glands: inflammatory diseases, infectious diseases, cysts and tumors, the formation of calculi (stones).

Sialography is prescribed to determine dilated or narrowed salivary ducts; it involves the administration of a contrast agent. A radiosialogram may also be required to assess the secretory capacity of the glands. Using a CT scan, the doctor can see a bilateral increase in tissue size and density and rule out malignant and benign formations.

As an additional method, sialometry, cytological studies of secretions (salivary fluid), as well as biochemical studies of saliva can be used. The final diagnosis can be made after aspiration or another type of gland biopsy. Histological study allows us to establish dystrophic changes.

To find out the exact cause of the disease, it is important to assess your overall health. Therefore, the patient often needs to be examined by another specialist: an endocrinologist, gynecologist, urologist, allergist, etc. In some cases, the involvement of a rheumatologist is required.

Symptoms of sialadenoses

Typically, during the development of sialadenosis, patients experience swelling in the area of ​​the salivary glands, which is not accompanied by pain. The enlargement of the salivary glands persists for a long time; their size does not change when eating. With sialadenosis, salivation is often reduced. When examining the patient, a moderate amount of squamous epithelium is observed in the secretion and a change in the configuration of the face, which is caused by symmetrical swelling of the soft tissues. In this case, the enlarged glands have a dense shape to the touch, with a smooth surface. In turn, the manifestation of parenchymal sialadenosis is accompanied by dilation of the excretory ducts. A relative sign of interstitial sialadenosis is narrowing of the excretory ducts. Ductal sialadenosis is accompanied by a stricture of dilated ducts. Sometimes disturbances in the excretory and secretory functions of the salivary glands occur without their visible increase. These conditions are also classified as sialadenoses as a reaction of the parenchyma to various changes in the body: they are manifested by increased or decreased salivation. An increase in the secretion of the salivary glands (hypersalivation) is associated with diseases such as stomatitis, gastric and duodenal ulcers, helminthiasis and even toxicosis during pregnancy. Reduced secretion (hyposalivation) leads to dry mouth, or more precisely to xerostomia. The symptom of dry mouth is often observed in patients with various diseases of the salivary glands and body systems.

Treatment methods

Treatment of sialadenosis is a multi-step process. The main condition is effective therapy for the underlying or concomitant disease, although this will not help solve the problem completely. Symptomatic therapy is possible using novocaine blockades. Physiotherapy will help cope with unpleasant symptoms; electrophoresis, galvanization, magnetic and laser therapy are widely used. The impact is carried out on the area of ​​​​the cervical nerve tissue in order to improve the conductivity of impulses.

Drug therapy consists of the use of vitamin E, drugs to stimulate salivation, as well as colloidal solutions to correct blood viscosity and improve blood flow in small blood vessels. Surgical treatment may be indicated in the absence of a positive response to conservative therapy. It consists of partial or complete removal of the salivary gland or its duct.

Reasons for the development of sialadenoses

Sialadenosis can be caused by both physiological reasons and the pathological condition of the patient, namely:

• pregnancy;
• breastfeeding;
• alcohol abuse;
• endocrine system disorders;
• diabetes mellitus;
• menstrual irregularities (hypermenstrual syndrome);
• prostatitis;
• chronic pancreatitis;
• autoimmune diseases (rheumatoid arthritis, systemic lupus erythematosus, scleroderma, psoriasis, Sjogren's disease, Mikulicz's disease, etc.);
• decreased nutrition due to anorexia nervosa.

Patients may also develop allergic sialadenoses when taking certain medications. Sialadenosis may occur after surgery on the salivary gland or after injury to it. The main and most common cause of sialadenosis in patients who suffer from alcoholism is liver cirrhosis. There are also frequent cases of the development of sialadenoses of unknown origin in patients who do not have any systemic diseases. In this case, the patient undergoes an examination to identify a general disease. The mechanism of development of this pathology in medical practice is not entirely clear. But in medicine there are such factors for the manifestation of this disease as:

• neuropathy, which is accompanied by the destruction of nerve fibers;
• disturbances in the microcirculatory system and lipid oxidation, which leads to damage to cell tissue;
• congenital expansion and violation of the architectonics of the ductal system.

These processes cause functional failure and replacement of glandular tissue with adipose tissue.