Exodontia.Info
Release of Salivary Stones
Useful Website:

European Association of Oral Medicine


Useful Articles:

British Dental Journal 2002.  Sialolithiasis. An unusually large submandibular salivary
stone.

Arch Otolaryngol Head Neck Surg 2003.  Sialolithiasis Management - The State of
the Art.

Eastman Dental Institute Oral Medicine Clinic (2004).  Obstructive Salivary Disease.

JOMS 2004.  Submandibular Salivary Stones - Current Management Modalities

Acta Otorhinolaryngol Ital 2005.  Current Opinions In Sialolithiasis - diagnosis and
treatment.

Dental Update 2006. A Revolution in the Management of Obstructive Salivary Gland
Disease.

JOMS 2007.  Sialo-endoscopy & Sialography - Strategies for Assessment &
Treatment of Salivary Gland Obstructions

Acta Oto Rhinolaryngologica Italica 2007.  Review.  Modern management of
obstructive salivary diseases

Patient UK (2008).  Salivary Gland Stones (Salivary Calculi)

ENTNews 2008.  Salivary Gland Obstruction, Changing Patterns of Practice.

BJOMS 2008.  Selective management of obstructive submandibular sialadenitis

BJOMS 2009. Recent advances in the management of salivary gland disease.

J Oral Maxillofac Surg 2009.  Giant Submandibular Sialolith of remarkable Size in
the Comma Area Wharton’s Duct. A Case Report.

J Oral Maxillofac Surg 2010.  Modern Sialography for Screening of Salivary Gland
Obstruction.

Dental Update 2011.  Incidental Finding of Sialolithiasis in the Sublingual Gland - A
Diagnostic Dilemma

NEJM 2011.  Images in Clinical Medicine.  Sialolith of the Submandibular Salivary
Gland
What are (Submandibular / Sub-lingual) Salivary Gland
Stones?

Sialolithiasis (Salivary Gland Stones) is the most common
disease of the
salivary glands.  It is affects 12 in 1000 of
the adult population; men are affected twice as much as
women; children are rarely affected.

Sialolithiasis accounts for more than 50% of diseases of
the large
salivary glands and is thus the most common
cause of acute and chronic
salivary gland infections.  
More than 80% occur in the
submandibular gland or its
duct, 6% in the
parotid gland and 2% in the sublingual
gland or minor salivary glands.
Photos of Sialoliths removed from the Submandibular Duct
Clinical Examination, Investigations & Diagnosis

Careful history and examination are important in the diagnosis of sialolithiasis (in
fact, in all aspects of medicine & dentistry).  Pain and swelling of the concerned
gland at meal-times and in response to other
salivary stimuli are especially
important.  Complete obstruction of the salivary duct by a
salivary stone causes
constant pain and swelling;
pus may be seen draining from the duct and signs of
systemic infection may be present.

Bi-manual palpation of the floor of the mouth, in a posterior (back) to anterior
(front) direction, reveals a
salivary stone in a large number of cases of
submandibular calculi formation.  Bi-manual palpation of the gland itself can be
useful, as a uniformly firm and hard gland suggests a
hypo-functional
(under-performing) or non-functional gland.

Imaging studies are very useful for diagnosing
sialolithiasis.  Occlusal radiographs
(X-rays of the floor of the mouth) are useful in showing (
radio-opaque) stones.

Sialography is useful in patients showing signs of sialadenitis related to
(
radio-lucent) stones or deep submandibular / parotid stones.  Sialography is,
however, contra-indicated in acute infection or in marked contrast allergy (ie an
allergy to the
contrast media pumped into the duct and gland).
What does the treatment involve?

There are various methods available for the management of salivary stones,
depending on the gland affected and stone location.

Patients presenting with
sialolithiasis may benefit from a trial of conservative
management especially if the stone is small.

The patient must be well hydrated (that is, drink frequently) and must apply moist
warm heat and massage the involved
salivary gland, while sialogogues are used to
promote
saliva production and flush the stone out of the duct.

With gland swelling and
sialolithiasis, infection should be assumed and antibiotics
prescribed.  Most stones will respond to such a regimen, combined with simple
sialolithotomy when required.

If the stone is sufficiently forward in the
salivary duct, it can be ‘milked’ and
manipulated through the duct opening; this can be done with the aid of
lacrimal
probes
and dilators to open the duct.

Once open, the stone can be identified, ‘milked’ forward, grasped and removed.  
The gland is then ‘milked’ to remove any other debris in the more
posterior (back)
portion of the duct.

Almost half of the
submandibular calculi lie in the distal third of the duct and are
amenable to simple surgical release through an
incision (cut) directly onto the
stone.  In this way more posterior stones, 1 – 2 cm from the
salivary duct
punctum
, can be removed by cutting directly onto the stone in the longitudinal axis
of the duct.  Care is taken as the
lingual nerve lies deep to the duct, but in close
association with the
submandibular duct posteriorly.  Subsequently, the stone can
be grasped and removed.  No closure is done leaving the duct open for drainage.

If the
submandibular gland has been damaged by recurrent infection and fibrosis
or
calculi have formed within the gland, it may require removal.

Alternative methods of treatment have emerged such as the use of
Extracorporeal
Shock Wave Lithotripsy
(ESWL) and more recently the use of Endoscopic
Intracorporeal Shockwave Lithotripsy
(EISWL), in which shockwaves are delivered
directly to the surface of the stone lodged within the duct without damaging
adjacent tissue (
piezoelectric principle).  Both extra and intra-corporeal lithotripsy
are gaining increasing importance in the treatment of
salivary stone disease.

Submandibular gland removal may be indicated following failure of lithotripsy or if
the size of an
intra-glandular stone is > 12 mm as the success of lithotripsy may
be < 20% in such cases.

In the case of small
calculi, the treatment of choice should be medical, instead of
surgical.  The patient can be administered natural
sialogogues such as small slices
of lemon or
sialogogue medication (such as pilocarpine).

Surgical removal of the
calculus (or even of the whole gland) has traditionally been
used as an alternative to medical therapy, whenever the latter was not possible or
when it proved ineffective.

How long will the operation take?

It can be very quick (a few minutes).  If the stone is big or difficult to access, it can
take that much longer.

What can I expect after the operation?

It is unlikely to be very sore but regular painkillers will be arranged for you.  There
is relatively little swelling following salivary stone removal.

Do I need any time off work?

Possibly only for the day of the operation.

Will I have a scar?

No.

What are the possible problems?

Bleeding from the wound is unlikely to be a problem.  If it occurs it usually does so
within the first 12 hours of surgery which is why you need to stay in hospital
overnight.

Infection is uncommon but if your surgeon thinks it may happen to you a short
course of antibiotics will be arranged.

What are the possible complications?

There are potential complications with any operation.  Fortunately with this type of
surgery complications are rare and may not happen to you.

This list of warnings might seem excessive to some however the legal ruling in
the case of
Chester vs Afshar (2004) would suggest that it is quite prudent /
necessary to list them.  Others might say that there isn't enough information but
where do you stop?

The following list of warnings regarding
sialolith release is neither exhaustive nor
is it predictive.  The most pertinent warnings have been included here.


Pain.  As it is a surgical procedure, there will be soreness at the operation site.  
This can last for several days.  Painkillers such as
Ibuprofen, Paracetamol,
Solpadeine or Nurofen Plus are very effective.  Obviously, the painkiller you use is
dependent on your medical history and the ease with which the stone was released.

Swelling.  There will be swelling afterwards though it will not be obvious from the
outside.  Sucking an ice-cube at the op site will help to decrease the swelling.  
Avoidance in the first few hours post-op of alcohol, exercise or hot foods / drinks
will decrease the degree of swelling that can develop.

Sutures.  The op site will often be closed with stitches.  These dissolve and ‘fall out’
within 10 – 14 days.

Limitation of Mouth Opening.  Often the chewing muscles and the jaw joints are
sore after the op so that mouth opening can be limited for the next few days.

Scarring / Lumpiness at Op Site.  Any cut to soft tissues produces a scar.  Initially,
after the release of a stone, a scar may be produced.  This softens and disappears
(i.e. improves) with time.  The scarring can also be dependent on the size of the
stone, how long it had been present for, how many infections had been associated
with it and the individuals’ tendency to scarring.

Floor of Mouth Complications.  When stitching up the operation site, sometimes,
the stitches can tie off the
Submandibular Duct.  If this happens, saliva produced
by the
Submandibular Gland can not escape into the mouth and back pressure into
the gland happens.  This causes the
Submandibular Gland to swell and become
painful.  The floor of the mouth may even rise.

If any of this happens, you will need to contact the
OMFS department or A&E as
soon as possible.  Because of the potential of this to happen, stitches are
sometimes not used or if used, are very loose.

Repeat Op.  Sometimes not all of the stone is removed or there were more stones
than originally thought (and not obvious on the X-ray) or the conditions that created
the salivary stone in the first place haven’t changed and a new stone has formed;
hence, the need to repeat the op.

Numbness of the Tongue.  The lingual nerve which supplies feeling to the side of
the tongue can become bruised as a result of surgery.  If this occurs you will
experience a tingly or numb feeling in the tongue, similar to the sensation after
having an injection at the dentist.  This numbness may take several months to
disappear and in a minority of patients may last for ever.

Damage to the Submandibular Duct.  The submandibular duct is the name of the
tube which carries
saliva from the submandibular gland into the mouth.  The duct
runs close to the
sublingual gland before opening on the inside of the mouth under
the tongue immediately behind the lower front teeth.  If this duct is damaged,
saliva
may not drain properly from the submandibular gland and the gland may therefore
swell in the upper part of the neck.  The majority of these swellings settle down on
their own.

Need for Gland Excision.  If the stone has caused multiple infections in the
Submandibular Gland, this may have damaged the gland so much that removal of
the stone will have no beneficial effects.  If this is the case, the
Submandibular
Gland
may need to be removed.


Are there are any long-term effects of having my (submandibular / sub-
lingual) salivary stones removed?

No.

Will I need further appointments?

Not necessarily.  If the stone has been removed and it is thought that all the stone
has been removed and that the procedure was straightforward, then there is no
need for review.  If there are any queries, then a review is most likely.
Last Updated 10th February 2012