Ebook Concise oral medicine: Part 2

(BQ) Part 2 book “Concise oral medicine” has contents: Temporomandibular joint disorders, temporomandibular joint disorders, oral cancer and precancerous lesions, immunological diseases, forensic odontology, orofacial syndromes, differential diagnosis of miscellaneous diseases,… and other contents.

The temporomandibular joint also known as

craniomandibular joint, is described as

bilateral gingylimo-arthroidal diarthrosis,

ginglymo because these joints show ‘hinge’

type of movement, bilateral because it is

present on both sides and diarthrosis because

each joint is divided into two components and

is a freely movable joint

Parafunction: It is defined as a non-functional

oral habit, that is bringing together of the jaws

for reasons other than mastication, deglution

Insoluble personal problems (bruxism): Bruxism

and clenching may be stress relieving habits,

and are associated with severe attrition,

occlusal wear facets, prominent linea alba on

the cheeks, indentations on the tongue,

hyper-trophy of masseter muscle, pain observed on

waking up in the morning

Occupational: Weight lifter, people performing

precision work, drivers, tend to clench their

jaws more often than others

Parafunction often results in MPDS.Intracapsular Disorders

• MPDS

• Iatrogenic disorders—prolonged dentalprocedures, trauma during mandibularblock

• Infections—osteomyelitis, periostitis

• Neoplasia—tumors of the condyle and theramus

Rheumatoid arthritis is an inflammatory

disease affecting periarticular tissue and

secondarily bone It starts as a vasculitis of

synovial membrane It is associated with

round cell infiltration and subsequent

forma-tion of granulaforma-tion tissue—pannus

The cellular infiltrate causes erosion of

underlying bone and flattening of convex

condylar surface which is called as ‘sharpened

pencil’ or ‘mouthpiece of flute’ type of

appearance as seen on OPG or

transpharyn-geal view

Signs and Symptoms

• Unilateral or bilateral pain

• Decreased mandibular movements

• Changes in interproximal phalanges of

Swan neck deformity

• Narrowing of joint space

• Flattening and erosions of the condylar

head

• Erosions of the condylar head and glenoid

fossa are better appreciated on HRCT

Serum: Several autoantibodies may be

detected, but not specific for rheumatoid

arthritis

RA factor: Anti-cycilc citrullinated proteins

(anti-CCP) factor present in 80% of adult RA

patients

TreatmentMethotrexate is often the initial therapy as itreduces disease activity, joint erosions and canprovide long-term reduction in mortality.Prednisolone, and azathioprine are alsogiven

Aspirin was also used in the past, can lead

to defective platelet aggregation

• Rest to joint

• Soft diet

• Reestablish occlusion—flat plane occlusalappliance may be helpful if parafunctionalhabits are present

• Ibuprofen 400 mg TDS for 5–10 days(contraindicated in asthma due tobronchospasm) Other NSAIDs are taken by

RA patients can result in gastric ulcerationsand affect kidney function

ChondrometaplasiaSynovial chondromatosis (SC) is an uncommonbenign disorder characterized by the presence

of multiple cartilaginous nodules of thesynovial membrane that break off resulting inclusters of free-floating loose calcified bodies

in the joint (Fig 10.1) Some cases appear to

be triggered by trauma whereas others are ofunknown etiology

Extension of SC from the TM joint tosurrounding tissues (including the parotidgland, middle ear, or middle cranial fossa)may occur

Clinical Features

• Slow progressive swelling in the pretragusregion

• Pain

• Limitation of mandibular movement

• TMJ clicking, locking, crepitus

• Intracranial extension may lead to

neuro-logic deficits such as facial nerve paralysis

Radiographs

• Conventional radiography may not lead to

the diagnosis, due to superimposition of

cranial bones that may obscure the calcified

loose bodies

• A CT scan should be obtained if SC is

suspected after clinical evaluation

• The lesion may appear as a single mass or

as many small loose bodies

Treatment

Treatment should be conservative and consist

of removal of the mass of loose bodies This

may be done arthroscopically when only a

small lesion is present, but arthrotomy is

required for larger lesions The synovium and

articular disc should be removed when they

are involved Lesions that extend beyond the

joint space may require extensive resection

DEGENERATIVE JOINT DISEASE

Primarily a disorder of articular cartilage and

the subchondral bone with secondary

inflammation of synovial membrane It is

localized joint disease without systemic

manifestations It begins as loaded articular

cartilage which thins and clefts (fibrillation)

and then breaks down during joint activity

leading to sclerosis of underlying bone,subcondylar cysts and osteophyte formations

It is essentially a response of the joint tochronic microtrauma or pressure Chronicmicrotrauma may be due to continuousabrasion of the articular surfaces due to agerelated natural wear or due to chronicparafunctional habits (bruxism)

Clinical FeaturesThe incidence of DJD increases with age and

is also related to the rate and extent of dentalattrition

• Unilateral pain directly over the condyle

• Limitation of mandibular opening

• Crepitus

• Feeling of stiffness after period of inactivity

• Tenderness and crepitus of the joint onpalpation through the external auditorymeatus

• Deviation of mandible to the affected side

on opening

• Presence of Ely’s cystRadiographs

• Narrowing of joint space

• Flattening of articulating surface (Fig 10.2)

• Condyle becomes irregular in outline withsharp and pointed osteophytes seen onsuperior surface in transorbital view

• Osteophyte formation seen on tomograms or

CT scans (Fig 10.3)

• Anterior lipping of condyle

Fig 10.1: (A) Coronal and (B) Sagittal CBCT showing multiple calcified bodies involving the synovium in a

case of synovial chondromatosis

Fig 10.2: TMJ OPG showing bilateral condylar flattening

• Ely’s cyst—a well-demarcated depression

or cup-like defect seen on condyle called as

Ely’s cyst (Fig 10.4), which is a misnomer

as it is just a bony defect and not a cyst

• Joint effusion detected on T2-weighted MRI

as a hyperintense signal (Fig 10.5)

Fig 10.5: T2-weighted MRI showing hyperintense

signals suggestive of joint effusion (arrows)

Fig 10.4: Coronal CBCT image showing Ely’s cyst

Treatment

• Conservative treatment: NSAIDs, heat, softdiet, rest, occlusal splints

• Intra-articular steroids injections

• Anti-inflammatory effects of doxycyclinetherapy reduces symptoms

Fig 10.3: Coronal and sagittal CT images showing osteophytes and anterior lipping

• In severe cases with significant loss of

function—arthroplasty (removal of

osteo-phytes and erosive areas) is performed

According to Juniper, the terms ‘disk’ and

‘meniscus’ are both misnomers and fail to

describe the exact shape of the intra-articular

disk According to him, the disk resembles the

cap of a jockey, which snugly fits over the head

of the condyle and is attached to the medial

and lateral poles of the condyle by strong

ligaments The disc is a concavoconvex and

anteriorly is attached to the superior head of

the lateral pterygoid muscle The inferior head

of the lateral pterygoid is attached to the

pterygoid fovea of the condyle The disk has

the following parts:

• Anterior band which is thin

• Intermediate zone which is very thin

• Posterior band which is thick

Distally the posterior band is attached to

the bilaminar zone, the superior lamina is

inserted into the squamotympanic fissure,

and the inferior lamina is inserted on to the

neck of the condyle Posterior to the disk the

retrodiscal tissue has a rich neurovascular

supply

Pathogenesis of Click

and Internal Disk Derangement

In a patient having bruxism and clenching

habits, the closing muscles

Medial pterygoid and masseter are

hyperactive The lateral pterygoid which is an

opening muscle also shows contraction to

counterbalance the closing muscles Greater

the activity of the closing muscles, greater is

the contraction of the lateral pterygoid, this

results in anterior subluxation of the disc The

disc now occupies a position such that the

posterior band is placed anterior to the head

of the condyle in closed position When patient

opens his mouth, the condyle slips over the

posterior band, producing the opening click

When the patient closes the mouth, the disk

again relocates itself anterior to the condyle and

while so doing produces the reciprocal click

In anterior disk displacement with tion, the disk recaptures its original positionwhen patient opens the mouth (Fig 10.6) andtherefore this condition is accompanied byopening and reciprocal click Midway duringopening the jaw deviates towards the affectedsite and at the terminal phase of opening, jawaligns itself in the midline

reduc-In the anterior disk displacement withoutreduction, the disk is occupying a positionwhich is anteromedial to the condyle andhence prevents complete opening so that theopening reduces from 45 to 30–35 mm Thejaw deviates towards the affected side, andbecause of the pressure of the condyle on theretrodiscal lamina, there is severe pain onchewing As in this condition, the condyledoes not glide against the posterior band, noopening or reciprocal clicks are heard.However, these patients give history ofclicking which has disappeared As the patientcannot open the mouth fully because of thephysical presence of a malformed disk, antero-medial to the condyle, this condition is alsotermed as ‘the closed lock’ The malformeddisk has been described as ‘gum ball appea-rance’ on MRI (Fig 10.7)

ARTICULAR DISK DISPLACEMENT (ADD)

It is an abnormal relationship between thedisk, the mandibular condyle, and the arti-cular eminence, resulting from the stretching

or tearing of the attachment of the disk to thecondyle and glenoid fossa

ADD may result in:

• Abnormal joint sounds

• Limitation in mandibular range of motion

• Pain during mandibular movementLoosened disks become displaced anterior

to the mandibular condyle

Posterior Disc DisplacementWhen a portion of the disk is found posterior

to the top of the condyle

• Direct trauma to the joint from a blow to

the mandible

• Chronic low-grade microtrauma resulting

from long-term bruxism or clenching of the

teeth

• Generalized laxity of joints

• Combination of mechanisms related to the

anatomy of the joint and the facial skeleton,

connective tissue chemistry and chronic

loading of the joint increases the

suscepti-bility of certain individuals to a disturbance

of the restraining ligaments and

displace-ment of the disk

Clinical Features

Pain or dysfunction when accompanied by

capsulitis, synovitis, and joint effusions

or tearing of restraining ligaments and hasmoved from its normal position on the top ofthe condyle

Clinical Features

• Clicking is accompanied by pain

Fig 10.7: MRI image showing anteriorly displaced disk which in open position is deformed giving gum ball

appearance (s/o ADD without reduction)

Fig 10.6: MRI image showing anteriorly displaced disk in closed mouth position Disk repositioned to normal

location in open mouth (s/o ADD with reduction)

• Dysfunction due to intermittent locking

• Pain is most noticeable at the time of the

click

Palpation and auscultation of the TMJ will

reveal:

Reciprocal click: A clicking or popping sound

during both opening and closing mandibular

movements The clicking or popping sound

due to anterior disk displacement with

reduc-tion is characterized by a click that occurs at a

different point during opening and closing

Anterior Disk Displacement without

Reduction (Closed Lock)

Closed lock may be the first sign of TMD

occurring after trauma or severe long-term

nocturnal bruxism It is detected more

frequently in patients with clicking joints that

progress to intermittent brief locking and then

permanent locking

A patient with an acute closed lock will

often have a history of a long-standing TMJ

click that suddenly disappears with a sudden

restriction in mandibular opening.This limited

mandibular opening occurs when the disk

interferes with the normal translation of the

condyle along the glenoid fossa

Clinical Features

• Pain directly over the joint during

mandi-bular opening (especially at maximum

opening)

• limited lateral movement to the side away

from the ADD

• During maximum mandibular opening, the

mandible will deviate towards the side of

the displacement Palpation of the joints

will reveal decreased translation of the

condyle on the side of the disk

displace-ment

Posterior Disk Displacement

Posterior disk displacement has been described

as the condyle slipping over the anterior rim

of the disk during opening, with the disk being

caught and brought backward in an abnormal

relationship to the condyle when the mouth

is closed The disk is folded in the dorsal part

of the joint space, preventing full mouthclosure

treat-• Painful clicking or locking should initially

be treated with conservative therapy

• Recommended treatments for symptomaticADD include splint therapy, manualmanipulation and other forms of physicaltherapy, anti-inflammatory drugs, arthro-centesis, arthroscopic lysis and lavage,arthroplasty, and vertical ramus osteotomy.Many of these nonsurgical and surgicaltechniques are effective in decreasing painand in increasing the range of mandibularmotion although the abnormal position ofthe disc is not corrected

• Anterior disk displacement with reduction:

Flat-plane stabilization splints that do not changemandibular position and anterior re-positioning splints have both been used totreat painful clicking (potential side effects

of these appliances, which include toothmovement and open bite)

• Anterior disk displacement without reduction:

Treatment options should depend on thedegree of pain associated with the ADD.Management of a locked TMJ may be non-surgical or surgical The goals of successfultherapy are to eliminate pain and to restorefunction by increasing the range ofmandibular motion Replacing the disk in

a normal position is not necessary to

achieve these goals Flat-plane occlusal

stabilization appliance to decrease the

adverse effects of bruxism is advocated

Patients with severe pain on mandibular

movement may benefit from either

arthrocentesis or arthroscopy Flushing the

joint with intra-articular corticosteroids to

decrease inflammation or with sodium

hyaluronate to increase joint lubrication

and decrease adhesions has also been

repor-ted to help in decreasing the pain associarepor-ted

with nonreducing disk displacement

MYOFASCIAL PAIN DYSFUNCTION SYNDROME

(MPDS)

MPDS or Costen’s syndrome is a disease entity

that results from spasm of the muscles

supporting the jaws due to multiple causes

most important being overclosure or

over-extension of the muscles

Etiology

The various factors that have been associated

in the cause of MPDS are as follows:

• Parafunctional habits, e.g nocturnalbruxing, tooth clenching, lipor cheek biting

• Emotional distress

• Acute trauma from blows or impacts

• Trauma from hyperextension, e.g dentalprocedures, oral

• Intubation for general anesthesia, yawning,hyperextension associated with cervicaltrauma

• Instability of maxillomandibular ships

relation-• Laxity of the joint

• Comorbidity of other rheumatic or skeletal disorders

musculo-• Poor general health and an unhealthy style

life-Pathophysiology of MPDS (Laskin’s Theory)The pathophysiology of MPDS emphasizesmainly on the muscular tension caused by oralhabits and dental irritants Figure 10.8 gives alucid explanation to the mechanism involved

in MPDS

Fig 10.8: Pathogenesis of MPDS, proposed by Laskin

Clinical Features

• Patients complain of unilateral, dull pain

in the ear or preauricular region

• Pain is worse on awakening in the morning

• Tenderness of muscle of mastication is

present

• Mouth opening is limited and painful The

jaw deviates to affected side on opening the

mouth

Laskin’s four cardinal signs of MPDS

1 Unilateral pain: There must be a dull ache

in the preauricular region Pain is worse on

a Absence of radiographic findings

b Lack of tenderness in the TMJ on palpation

from the external auditory meatus

Trigger Points

These are localized deep tender areas of taut

band of skeletal muscle, tendon or ligament

that has the tendency to cause referred pain

in a definite anatomic distribution when

stimulated Presence of such trigger points are

characteristic feature of MPDS The area

perceived by the irritable trigger point is called

the zone of reference In MPDS, pain is elicited

by applying digital pressure on the trigger

point whereas in trigeminal neuralgia, even

light touch or breeze is sufficient to stimulate

the trigger zone and precipitate an attack of

pain

Jump Sign

It is the withdrawal of head, wrinkling of head

or verbal response given by the patient on

palpating the trigger points

Tanaka’s recommendations for palpation of

iii The muscles must be examined bilaterally

to compare the difference

iv The muscles must be palpated tally and vertically to the attachments.While palpating the muscles, begin palpat-ing with light pressures before proceeding

horizon-to 3–4 pounds Muscle palpation may beperformed by two methods, i.e

1 Flat palpation: When muscle can be palpatedover the bone, e.g masseter

2 Pincer palpation: When the belly of themuscle can be held between the fingers, e.g.sternocleidomastoid

Treatment ConsiderationMultiple therapeutic approach is preferred inthe management of MPDS beginning withpatient education and counseling

Pharmacotherapy

1 NSAIDs are the drug of choice for diate pain relief Ibuprofen 400 mg t.d.s ornimesulide 100 mg b.d are good choices ofanalgesics

imme-2 Diclofenac gel in pluronic lecithin gel can be rubbed over the skin followed

organo-by hot fomentation which gives relief frompain and improves mouth opening

3 Muscle relaxants such as chlorzoxazone

250 mg t.i.d., carisoprodol 350 mg t.i.d (tabsoma) are valuable in reducing musclespasm Diazepam 2–5 mg can be given for

10 days Cyclobenzaprine 10 mg beforesleep has been tried recently and foundeffective

4 Amitriptyline which is a tricyclic depressant can be given in the doses of

anti-10 or 25 mg at bed time to reduce patientanxiety and provide a good refreshingsleep

Intraoral Appliance Therapy

Hard and soft splints can be fabricated that

help to unload TMJ and establish a harmonious

relation between TMJ and muscles

Trigger Point Therapy

The spray and stretch technique provides

stimulation of cutaneous afferent nerves and

produces trigger point inhibition causing pain

relief

Fluoromethane spray is an effective choice

for the same

Alternatively injection of local anesthesia

0.5% procaine, bupivacaine into the trigger

points reduces pain However, chances of

myotoxicity and other reactions should be

considered before initiating the therapy

Relaxation Therapy

This mode of therapy decreases sympathetic

activity and arousal Brief methods such as

deep breathing and deep methods such

as meditation, progressive muscle

relaxa-tion can be performed under the supervision

of a trained master to provide muscle

relaxa-tion

Physiotherapy

Various types of treatments like moist heat,

ultrasound and shortwave diathermy help

immensely in reducing pain and dysfunction

They act by increasing the vascularity of the

muscle, resolution of inflammation and

fibrosis and increasing the flexibility of

connective tissue Isokinetic exercises of the

jaws also provide a similar effect to the

muscles Other methods such as massage,

accupressure, homeopathic and herbal

medicines, botulinum toxin are also used

widely in the treatment of MPDS Exercises

like reciprocal relaxation, active and passive

stretch are found to be effective In reciprocal

relaxation, patient is asked to open against

pressure and this method relaxes the closing

muscles which are tender in MPDS

ANKYLOSISAnkylosis in Greek terminology means ‘stiffjoint’ Hypomobility to immobility of the jointcan lead to inability to open mouth partially

1 Scar tissue formed in muscle of mastication

• Fibrous—joint space seen

• Bony—mass of bone seen between condyleand glenoid fossa (condyle cannot bevisualized) This type is due to trauma orinfection to condyle, so that the growth ofmandible on that side comes to a standstill.Etiology

Two main factors predisposing to ankylosis

is trauma and infections:

• Trauma: Congenital, at birth (forcepsdelivery), hemarthrosis, and condylarfractures

• Infections: Otitis media, parotitis, tonsillitis,

furuncle, abscess around joint, myelitis, actinomycosis

• Inflammation: Rheumatoid arthritis,

osteo-arthritis, septic arthritis

• Systemic diseases: Smallpox, scarlet fever,

typhoid, gonococcal infections, scleroderma,Marie-Strumpell disease, ankylosingspondylitis

• Others: Bifid condyle, prolonged trismus,

prolonged immobilization, burns

Clinical Features

Unilateral Ankylosis

• Obvious facial asymmetry

• Deviation of mandible and chin on affected

side

• Receded chin and hypoplastic mandible on

affected side, with teeth appearing in the

• Prominent antegonial notch on affected side

• Some degree of mouth opening is possible

• Unilateral posterior crossbite on ipsilateral

side

Bilateral Ankylosis

• Inability to open mouth—oral opening

severely reduced

• Mandible symmetrical, but micrognathic,

“bird face” deformity due to receding chin

• Antegonial notch is well defined bilaterally

• Class II malocclusion seen

• Multiple carious teeth with poor oral hygiene

• Crowding of teeth

• Multiple impacted teeth (teeth appearing in

the ramus)

Radiographic findings: TMJ OPG, transcranial

view, CT/CBCT, MRI are indicated

• Fibrous ankylosis: Normal anatomy of the

head and glenoid fossa can be appreciated,

In advanced cases there is deformity of the

condylar head and the glenoid fossa with

irregular bony projections and depressions.These irregularities interdigitate betweenthemselves hence giving a “jigsaw puzzle”appearance (Fig 10.9)

• Bony ankylosis: Complete obliteration of

joint space noticed, normal TMJ anatomy

is distorted (Fig 10.10)

• Elongation of coronoid process tory coronoid hyperplasia) on the side ofhypomobility and prominent antegonialnotch (Fig 10.11)

(compensa-TreatmentTreatment is always surgical

• Condylectomy

• Gap arthroplasty

• Interpositional arthroplasty

Fig 10.9: Coronal CT—fibrous ankylosis showing

jig-saw puzzle appearance

Fig 10.10: CBCT image showing bony ankylosis

HYPERMOBILITY, SUBLUXATION

AND DISLOCATION

During normal or unstrained opening of the

mouth, the condylar heads translate forward

to a position under the apices of the articular

eminence

Dislocation

Excursion of the condylar head beyond these

limits and the condyle is fixed anterior and

superior to the articular eminence (infratemporal

fossa) In these cases after the condyle reaches

anterior the articular eminence, the closing

muscles (medial pterygoid, masseter) go into

spasm, thereby placing the condyle in the

anterior and superior position with respect to

the articular eminence (Fig 10.12) At this

stage, lateral pterygoid muscle also goes into

spasm Consequently patient is unable

Fig 10.11: Sagittal CBCT and 3-D image showing compensatory coronoid hyperplasia and prominent

• Difficulty in mastication and speaking

• Deviation of chin towards contralateral side

is seen

• Affected condyle cannot be palpated

• In unilateral dislocation, there is a lateralcrossbite and open bite on the contralateralside, whereas in bilateral dislocation, there

is bilateral open bite

• Definite depression will be seen and felt

in front of the tragus (pre-tragal notch)(Fig 10.13)

Fig 10.12: Axial and sagittal CBCT showing dislocation of the condyle, anterior and superior to the articular

eminence

• Blow to the chin while mouth is open

• Excessive mouth opening, prolonged dental

treatment

• Injudicious use of mouth gag

Treatment

To overcome the resistance of the severe

muscle spasm, and to reduce tension and

anxiety, the following steps are taken:

• Reassure the patient

• Tranquillizer or sedative to relax the

muscles

• Pressure and massage to the area

• Manipulation

Manipulation can be done without any

anesthesia, or with LA or under GA and

sedation, depending upon the severity and

chronicity of the case

For the procedure of manipulation, the

thumbs of the operator are covered with gauze

(to prevent accidental injury in case of sudden

closure) and continuous downward pressure

is given on the posterior teeth, by placing

the thumbs on the occlusal surface, and

supporting the chin with the other fingers

Downward pressure overcomes the spasm of

the muscles plus it brings the locked condylar

head below the level of the articular eminence

Then backward pressure is given to guide the

entire mandible posteriorly

SubluxationRepeated episodes of dislocation where there

is an abnormal anterior excursion of condylebeyond the articular eminence but the patient

is able to manipulate it back to normal position.This recurrent, incomplete, self-reducinghabitual dislocation is termed as hyper-mobility or chronic subluxation of TMJ

It occurs due to triad of:

• Ligamentous and capsular flaccidity

• Surgical procedures like capsule tighteningprocedures (capsulorrhaphy), creatingmechanical obstacle for condylar head,creation of new muscle balance and removal

of mechanical obstacle by menisectomy,high condylectomy, and eminectomy

Differences between subluxation and location

dis-Fig 10.13: Deep pre-tragal notch seen in patient with

TMJ dislocation

Subluxation Dislocation Patient can correct it Doctor has to correct it himself

Condyle anterior to arti- Condyle anterior and cular eminence superior to articular emi-

nence Posterior slope of articular Posterior slope of articular eminence is flat eminence is steepSuggested Reading

1 Burket’s Oral Medicine, 11th Edition

2 Common diseases of TMJ, Ogus and Toller

3 TMJ Disorders and Occlusion, Jeffery POkeson, 7th Edition

4 TMJ Disorder and Orofacial pain, DCNAJan 2007

The maxillary sinuses are a pair of air-filled

cavities located within the body of the maxilla

They communicate with the nasal cavity

through an ostium which drains into the

middle meatus The sinuses are lined by

pseudostratified ciliated columnar epithelium

Though the function of these sinuses is not

clear, it is proposed that they serve to

humidify and warm the inhaled air and add

resonance to the voice in addition to lightening

the skull

Classification of Diseases of Maxillary Sinus

I Inflammatory disease (sinusitis)

a Acute

b Chronic

II Traumatic lesions

a Concussion or laceration of the sinus

mucosa

b Blow out fractures of the orbit involving the

sinus

c Isolated fractures of the sinus

d Complex fractures associated with middle

third injuries

e Oroantral fistula

III Cystic lesions

a Intrinsic cyst: Mucous retention cyst, benign

mucosal cyst, surgical ciliated cyst

b Extrinsic cysts: Dentigerous cyst, radicular

cyst, OKC, etc

1 The patient must be examined for anyasymmetry, ecchymosis, deformity anderythema of the skin over the sinus Thesemay be signs of traumatic injury involvingthe sinus

2 Presence of epistaxis and epiphora are signs

of malignant tumor or space occupyinglesion within the sinus

3 Paresthesia of the infraorbital nerve may bepresent which should alert the clinician of

a fracture involving the sinus wall or amalignant tumor

4 Tenderness of teeth in the absence of any

dental pathology may be a feature of

sinusitis Such teeth are referred to as Stomp

positive, i.e they are painful when the

patient jumps or walks fast

5 Trismus may be caused due to tumors of

the maxillary sinus destroying the posterior

wall of the sinus and invading the pterygoid

muscles or locking of the coronoid process

6 Eye movements must be noted carefully

Visual disturbance is associated with blow

out fractures and also malignant tumors

involving the orbit

7 Cervical lymph nodes must be examined in

all the cases as they are enlarged in

infec-tions and malignant tumors of the sinus

Radiological Evaluation of a Patient

with Maxillary Sinus Disease

The following investigations may be performed

for a case of suspected maxillary sinus disease

1 Radiographs

Radiographic survey is the preliminary choice

of investigation for sinus disease IOPA views

can be made to study the floor of sinus,

diagnose and locate oroantral fistula and

displaced root pieces For large lesions,

lateral-occlusal views can be made to visualize the

sinus and its floor Amongst the extraoral

views, OPG and Water’s view are the most

important views to study the sinuses As a rule,

cystic lesions are better visualized on OPG

while haziness of the sinus due to sinusitis can

be studied more clearly on the Water’s view

The posterior wall of the sinus cannot be seen

on the Water’s view and an SMV view is

required to demonstrate this The normal sinus

contains air and hence appears radiolucent

Any pathology or change within the sinus

encroaches the air space and hence appears

relatively radiopaque The radiographic

appearances of sinus disease are thus not

specific owing to the fact that transudates,

exudates, blood will all produce a similar

shadow on the radiograph

2 CT Scans

CT scans are excellent choice to study variouspathologies involving the sinus includingsinusitis, cysts, tumors, fractures, etc Coronaland axial sections must be obtained to studythe entire extent of the lesions CT scans aremandatory in cases of fractures and malignanttumors involving the sinus

3 MRI Scans

MRI scans produce an excellent soft tissuecontrast and valuable in studying cysts andtumors involving the sinus Mucosalthickening of the sinus wall and accumulation

of fluid within the sinus can be studied withMRI scans

4 Radionuclide Scanning

Scans obtained after injection of a radioisotopesuch as 99mTc demonstrate the physiologicalchanges taking place within the sinus.Scintigraphic studies are useful in thediagnosis of malignant tumors of the sinus tostudy the complete extent of the tumor.MAXILLARY SINUSITIS

i Sinusitis can be due to bacterial or allergic

cause Haemophilus influenzae, Streptococcus

pneumoniae are the common causative

organisms of maxillary sinusitis A rarecause can be due to fungal infection such

as aspergillosis which is usually seen inimmune-compromised patients

ii Conditions such as deviated nasal septum(DNS) predispose to sinusitis Spread ofinfection from the oral cavity from aninfected root apex or displaced root-piececan also lead to sinusitis

iii Nasal congestion or obstructions panied with headache and secretion fromthe nose are considered as the triad ofsinusitis

accom-Acute Maxillary Sinusitis

It may be suppurative or non-suppurativeinflammation of the antral mucosa

Clinical Features

• Tenderness, paresthesia, feeling of

heavi-ness on the affected side

• Mild swelling of cheek in severe cases

• Tenderness on percussion of maxillary teeth

• Patient gives a recent history of attack of cold

and rhinitis (3–4 days)

• Heaviness of the head

• Constant throbbing pain exacerbated by

lowering or bending down

• Pain which is more severe in morning and

evening

• Unilateral foul nasal discharge that becomes

more profuse on lowering of head

• Fever, chills, sweating, nausea, difficulty in

breathing

Radiographic Features

a The thickening of the mucosa and

accumula-tion of secreaccumula-tion during sinusitis reduces

the air content of the sinus and causes the

sinus to appear increasingly radiopaque

(Fig 11.1) The thickened mucosa appears

nearly parallel to the walls of the sinus It

may be of uniform thickness or polypoid

b In chronic sinusitis, opacification of sinus

takes place which may be accompanied by

sclerosis of the bony walls

c The presence of fluid within the sinus can

be ascertained if the line of demarcation

between the opacity and the sinus is straightand horizontal Fluid level indicates pus orblood in the sinus The radiograph must bemade in a standing position to confirm thisfeature (Fig 11.2)

Treatment

1 In early stages, antibiotic therapy withsteam inhalation is a good method oftreating sinusitis Amoxycillin and cephalo-sporin provide good coverage against theorganisms involved in acute maxillarysinusitis Use of nasal decongestants likeephedrine sulfate 0.5–1%, xylometazolinhydrochloride 0.1% helps shrink theswollen and inflamed mucosa, and helpsminimize mucosal discharge Steaminhalation with mucolytic agents like tinc.Benzoin, camphor and menthol improvesthe drainage by the ciliary pathways of theantral lining through the ostium

2 In severe cases, surgical drainage may have

to be established to relieve the patient

3 Chronic maxillary sinusitis cases mayrequire a Caldwell-Luc operation to curettethe sinus contents or correction of DNS toavoid recurrence

Chronic Maxillary Sinusitis

It may be due to persistent dental focus,chronic rhinitis, chronic infection in frontal orethmoidal sinuses, allergic conditions, etc

Fig 11.2: Maxillary sinusitis case showing fluid level

in Water’s view (Source: Internet)

Fig 11.1: Opacification of the right maxillary sinus

suggestive of sinusitis

Clinical Features

• Sometimes asymptomatic condition

• Pain and tenderness in the area of antrum

Sometimes the ostium of the sinus gets blocked

by thickened mucosa or other pathologic

conditions Suppurative infection results in

such cases and the pus accumulates inside the

sinus Such an accumulation of pus within a

cavity is known as empyema

Radiographically, the sinus appears to be

completely opacified Such opacity must be

differentiated from simple mucosal

thicken-ing Accumulation of pus inside the sinus may

lead to osteomyelitis

Mucous Retention Cyst of the Antrum

This is a common sequelae of an inflamed or

hyperplastic lining of the maxillary sinus

Retention cysts are formed when the duct of a

seromucinous gland is blocked or damaged

due to inflammatory reaction The lesion is

usually unilateral, asymptomatic and

acciden-tally discovered during a routine radiographic

survey

Radiographic Features

The cyst appears as a dome-shaped radiopacity

attached to the floor or lateral wall of the sinus

An OPG is a clear view to identify such cyst

(Fig 11.3) If the cyst is large, it may fill up the

entire maxillary sinus and appear as uniform

cloudiness Sometimes a large cyst may

pro-trude through the ostium into the nasal cavity

The differential diagnosis for such cystic

lesions inside the sinus includes odontogenic

cysts The presence of a hyperostotic border

around the cyst that appears as a white line

serves to identify odontogenic cysts which are

extrinsic in origin Antral polyps must also be

Fig 11.3: Bilateral dome-shaped radiopacities in

maxillary antral suggestive of benign mucosal cystdifferentiated where mucosal thickening of theentire antral lining is present

Contusions of the Sinus

A blow on the face may transmit the forcethrough the bone of the anterior wall of thesinus causing a tear in the mucosal lining Theanterolateral wall may suffer a green stickfracture but sometimes since this bone isrelatively elastic; it gives rise to laceration ofthe sinus mucosa and bleeding within thesinus

Radiographic Features

Contusions of the maxillary sinus appear ashaziness of the sinus due to bleeding Fluidlevel can be demonstrated on a radiographmade in a standing position

Blow out FracturesWhen the globe of the eye sustains a bluntinjury due to an object larger than its size, thekinetic energy is converted into hydraulicenergy and the orbital contents break the floorand the medial wall Thus, it causes herniation

of the orbital contents into the sinus

Clinical features of blow out fracturesinclude periorbital edema, subconjunctivalecchymosis, hooding of eye/enophthalmosand diplopia

Radiographic Signs

i Soft tissue swelling over the orbital rim

ii Trap door sign or bright light sign on the

CT (Fig 11.4)

iii Polypoid density in the roof of the sinus.

iv Teardrop herniation of the orbital contents

into the sinus

v If the distance between infraorbital margin

and floor of orbit appears more than 2 mm

on PA Water’s view, it is suggestive of

fracture of the floor of orbit

Oroantral Fistula/Communication

Oroantral fistula (OAF) is an unnatural

communication between the oral cavity and

the maxillary sinus The term fistula is used

to denote communication between the oral

cavity and the antrum which is chronic and

lined by the epithelium The most important

cause for the formation of an OAF is iatrogenic

perforation of the floor of sinus during

extraction of an upper molar with the root

piece displaced into the sinus Other causes

include, traumatic injuries to the maxilla such

as gun shot injuries, infections such as syphilis

causing perforation of the palate

Clinical Features

i Sudden disappearance of a root piece

during extraction into the socket is a sign

of an oroantral communication

ii Presence of bubble formation in the blood

present within the socket when the patient

blows his nose also suggests a newly

formed fistula

iii Regurgitation of fluids, nasal twang in the

voice and features of chronic sinusitis may

be seen in long-standing cases

iv A mouth mirror held near the orifice turnsmoist when the patient blows with hisnostrils closed Similarly a wisp of cottonwill flutter when it is held near theperforation when the patient blows hisnose

v In late stage, symptoms of established

oroantral fistula consist of 4 Ps:

• Pain—previously a dominant feature,

is now negligible as the fistula allowsfree escape of fluids

• Persistent, purulent or mucopurulent

foul unilateral nasal discharge whenhead is lowered

b The displaced root piece may be presentinside the sinus and appears as a radio-paque mass with a radiolucent root canalinside it

c In chronic cases, there may be generalizedhaziness of the sinus due to chronicinflammation (Fig 11.5)

Differential diagnosis: Must include a foreignbody in the sinus, antrolith, normal bonyprojections within the sinus, etc

Fig 11.4: (A) Subconjunctival ecchymosis of right eye; (B) Trap door sign suggestive of blow out fracture

Treatment of OAF

An OAF must be closed as soon as it is

identi-fied The root piece can be retrieved through

the socket or by a Caldwell-Luc surgery The

fistula can be closed by various surgical

procedures like buccal advancement flap,

palatal advancement flap or a combination

flap can be performed to close the fistula

Antrolith

An antrolith is a calcified mass within the

sinus Antroliths form around endogenous

foci such as inspissated pus, mucous plug,

blood clot, etc or around exogenous foci such

as a foreign body, a piece of paper Antroliths

are often asymptomatic but occasional large

stones may perforate the medial wall of the

sinus and protrude into the nasal cavity

Radiographically, they appear as round-,

oval-or irregular-shaped calcified masses within

the sinus It may also show alternate

radio-lucent and radiopaque lamellae

Extrinsic Cysts

Extrinsic cysts are those that arise outside the

sinus and invade the sinus The common

extrinsic cysts include radicular cysts,

denti-gerous cysts, fissural cysts such as

globulo-maxillary cysts They may be odontogenic or

non-odontogenic in origin Radicular cysts

appear as periapical radiolucency in relation

Fig 11.5: Cropped image of OPG and coronal section CT showing oroantral fistula and sinusitis of left

antrum on CT image

to the apex of a non-vital tooth They have acorticated border that separates them from thesinus

Dentigerous cysts are associated with thecrown of an unerupted tooth They appear asperi coronal radiolucency attached to the neck

of the tooth The associated impacted toothmay be pushed deep into the sinus at timesreaching the floor of the orbit or the posteriorwall of the sinus (Fig 11.6) A corticated wallseparates the cyst from the sinus CT scansmust be obtained to confirm the location ofthe tooth inside the sinus

Globulomaxillary cyst (so-called) wasconsidered to be a fissural cyst that arises fromthe epithelial remnants at the site of fusion ofthe maxilla and pre-maxilla but now believed

to be an odontogenic cyst It appears on theradiograph as inverted pear-shaped radio-lucency between the canine and lateral incisor

A large expanding cyst may cause ment of the walls of nasal cavity The inverted

displace-‘Y’ line of Ennis may be obliterated when suchlarge cysts encroach the sinus

Benign TumorsBenign tumors, such as papilloma and osteoma,arise within the sinus Epithelial papilloma is

a soft tissue mass arising from the lining ofthe walls of the sinus Radiographically, itappears haziness within the sinus Osteomas

are the most common mesenchymal tumors

of the PNS It is a slowly growing expansile

lesion causing nasal obstruction The frontal

sinus is the most common sinus to be affected

On the radiographs, osteomas appear as

lobulated sharply defined, rounded

homo-geneous mass of much greater opacity

Extrinsic tumors involving the sinus include

ameloblastoma, AOT

The most common extrinsic tumor affecting

the sinus is ameloblastoma It is an aggressive

tumor when it occurs in the maxilla and grows

rapidly causing loosening of the teeth and

nasal obstruction It also causes painless

deformity of the middle-third of the face

Radiographically, it appears as unilocular or

multilocular radiolucency involving the sinus

The complete extension of ameloblastoma can

be studied on a CT scan

AOT is a benign odontogenic tumor chiefly

affecting the anterior part of the maxilla It

may extend posteriorly to involve the sinus

The lesion present as an expansile radiolucent

mass having an impacted tooth or areas of

calcification with a Milky Way appearance of

the lumen

Squamous Cell Carcinoma of the Sinus

It accounts to about 3% of malignant tumors

affecting the sinus The clinical features

depend upon the walls of the sinus that are

affected

i When the medial wall is affected, it causesnasal symptoms such as nasal obstruction,discharge, epistaxis and pain

ii When the floor is affected, it causesnumbness of the palate, unusual mobility

of the teeth and swelling of the palate.iii When the lateral wall is affected, it causesswelling on the face and vestibule alongwith pain and hyperesthesia of themaxillary teeth

iv When the roof of the sinus is affected, eyesymptoms such as diplopia, proptosis,pain in the cheeks and upper teeth are thepresenting features and sometimessudden loss of vision may take place

v When the tumor spreads posteriorly, thepterygoid muscles are affected and thisalong with locking of the coronoid processcauses trismus and obstruction to theeustachian tube Radiographically, thetumor appears as haziness of the sinus.The affected walls of the sinus aredestroyed and appear discontinuous(Fig 11.7A to C)

Treatment involves surgical removal of themaxilla followed by radiotherapy and re-habilitation with a suitable prosthesis.Fibrous Dysplasia of Bone

It is a benign fibro-osseous lesion thatfrequently affects the maxillary sinus It isbelieved to be a hamartoma that has limited

Fig 11.6: Axial and coronal CT showing dentigerous cyst involving the left maxillary sinus

Fig 11.7C: Coronal CT showing extensive osteolytic lesion destroying the walls of the left maxilla suggestive

of CA maxillary antrum

Fig 11.7A: Growth involving left maxilla

Fig 11.7B: OPG showing osteolytic lesion of the left

maxilla with discontinuity of the floor of the antrum and floating 27

Fig 11.8A: Patient presenting with expansile lesion in the left maxilla

growth potential Fibrous dysplasias commonly

affect young individuals and presents as

expansile dense radiopaque mass filling the

sinus It may have a characteristic groundglass,

stippled or a granular appearance (Fig 11.8Aand B) It is treated by surgical recontouring

of the excess bone which is best performed afterthe growth has stopped to avoid recurrence

Fig 11.8B: Axial and coronal CT showing groundglass appearance of fibrous dysplasia

Even if normally FD stops growing after

adolescence, pregnancy and hormonal factors

are reported to trigger sudden spurt in the

Implica-DISEASES OF SALIVARY GLAND

• Diverticuli—small pouches in which

saliva can stagnate

II Debilitating diseases

2 Secondary to blockage of salivary

In the diagnosis of salivary gland pathology

history plays an important role For example,

patients with sialolithiasis give history of

unilateral pain and swelling related to food

intake

Mumps patients give history of fever with

tender enlargement of parotid gland

Sjögren’s syndrome patients will give history

of severe dryness of oral cavity and eyes

2 Clinical Examination

Clinical examination is carried out to locate

and study clinical characteristics the salivary

gland pathology, e.g unilateral or bilateral

tender swelling of parotid gland with elevated

ear lobules and inflamed ductal orifices in

mumps, milking of the gland to study the

diminished secretion in sialolithiasis,

bi-manual palpation for locating the calculus

3 X-rays

True occlusal of mandible to study calculus

in the Wharton’s duct, Donovan’s technique

to study calculus in deeper portion of the duct

Cheek blow out AP view and intrabuccal

view (IOPA) to study parotid calculi

Sialography: Radiographic procedure to

study ductal pattern of salivary gland This

involves introduction of dye in the ductal

system of salivary gland Parenchymal

abnormality, however, cannot be appreciated

6 CT Scan and CT Sialography

It is useful in studying the salivary gland andductal pathology

7 MRI

Considered the best imaging modality tostudy various parenchymal pathologies, e.g.tumors, infections

8 Sialoendoscopy

It can be performed to study obstruction inthe ducts and its removal

Sialography(Neglected step child of radiology)

Indications

1 Diagnostic

a Detection of a calculus or calculi or foreignbodies whether they are radiopaque orradiolucent (mucus plugs)

b Determination of extent of destruction ofgland secondary to obstructing calculi orforeign body so as to decide whether totalexcision of gland is required or simplelithotomy will suffice

c Detection of fistula, diverticula or strictures

d Detection and diagnosis of recurrentswellings and inflammatory process

e Demonstration of tumour and tion of its location, size and origin whetherradiograph suggests benign or malignanttumour

determina-f Selection of a site for biopsy

g Detection of residual stones, residual

tumor, fistula, stenosis or retention cyst

following surgical procedures

h Outline plane of facial nerve as guide in

biopsy or surgery

2 Therapeutic

Introduction of dye causes dilatation of ductal

system during study may aid in drainage of a

ductal contents, e.g flushing out of small

mucus plugs

Limitations

Useful primarily for the study of diseases

involving ductal system

d History of urticaria and hypotension

e Sialography performed during a period

acute inflammation of gland, may lead to

leakage of dye into the parenchyma and

connective tissue, causing severe foreign

body reaction, as in acute inflammation

ductal epithelium becomes thin and gets

disrupted

f Administration and retention of iodine

contrast medium may interfere with

subsequent thyroid function test Such

studies should be performed prior to

sialography

Complications

i Chronic inflammatory process may be

aggravated by this procedure

ii Overdistention of gland may cause

temporary swelling and discomfort for a

few hours or a few days

iii Extravasation of contrast medium may

lead to foreign body reaction

iv It should be radiopaque

v Low surface tension and low viscosity toallow the filling of the smaller ductules

vi It should be easily eliminated

vii It should be detoxified by liver andexcreted through kidney

Procedure

a X-rays: Pre-procedure radiographic

evaluation to localize calculus if any and tostudy any bony defects

b Procedure: In case of diminished secretion

it becomes difficult to localize the ductalorifice in such cases a piece of lemon can beused to increase secretion Cotton rolls areused to dry the area, the gland is massaged,appearance of a drop of saliva helps tolocalise ductal orifice

Lacrimal dilator is used to cannulate anddilate the ductal orifice Thereafter a cannulaattached to a plastic catheter is gentlyintroduced into the ductal orifice and thenradiopaque dye is injected gradually with thehelp of a syringe attached to the catheter.Around 2–3 ml of radiopaque dye is injected,radiographs are obtained when the patientstarts getting a sensation of fullness in thesalivary gland under study

• For Wharton’s duct occlusal and lateral

oblique view are taken

• For Stenson’s duct transpharyngeal and AP

view are taken

• Same views are again taken at evacuation

phase

• Normal salivary gland appear as leafless

tree pattern in sialography

• Sialoadenitis appears as apple tree in

blossom

• Sjögren’s syndrome presents with elongated

delicate ducts and punctate, globular and

cavitory sialectasis—branchless tree with

fruit-laden appearance

• Benign tumor presents as ball in hand

appearance

Scintigraphy

Scintigraphy is carried out with Tc pertectanate

99m which is injected intravenously and after

specified period with the help of gamma

camera images are made

Indications

1 Study of parenchyma for morphology of

salivary gland and to diagnose space

4 Prevent tooth disintegration

a Provides minerals for post-eruptive

maturation, e.g calcium and phosphate

b Forms a pellicle to protect enamel

c Prevent tooth dissolution

d Forms a glycoprotein and prevents

attrition and abrasion

5 Antibacterial properties especially IgA and

lysosomes break up bacterial wall

6 Antiviral activity—HIV infection

7 Digestive properties, e.g amylase helps indigestion of carbohydrates

Aberrant/Ectopic Salivary GlandSalivary glands may be developed at anunusual site such glands are referred to asaberrant

Common sites are parabuccal and molar regions and such glands do not haveducts or secretory orifices Aberrant glandshave also been found at the base of the neck,

retro-at level of TMJ articulretro-ation, in the middle earand at the surface or within the mandible.Aplasia or Hypoplasia

Absence of major salivary gland is rare and isassociated with cleft palate, mandibular facialdysostosis

Hypoplasia of parotid gland is frequentlyobserved in Melkersson-Rosenthal syndrome:Fissured tongue, facial palsy, salivary glandhypoplasia, cheilitis glandularis’

Pouches or out pockets of ductal system Itmay lead to stagnation of saliva and repeatedepisodes of parotitis

Diagnosis—sialographySialorrhea

Increased salivation

Causes

a Infancy

b Before eruption of deciduous teeth (because

of lack of swallowing capacity)

c Insertion of a new complete denture

g Metallic poisoning, e.g mercury, lead, iron

h Medications such as pilocarpine, cevimeline,

clonazepam, mercuric salts, etc

Clinical Features

1 Drooling saliva can cause social

embarrass-ment and rejection

2 Angular cheilitis and skin infection (because

of perioral irritation)

3 In severe cases, partial or total blockage of

air space can occur and can give rise to

aspiration pneumonia

Treatment

Depends upon etiology of sialorrhea:

1 Physical method: Speech and swallowing

therapy to increase neuromuscular control

2 Medications: Such as scopolamine,

propan-thelene, diphenhydramine

• Amisulpride 400 mg/day produce

signi-ficant improvement

• The underlying causes like GERD, GI tract

disturbances should be treated

• Intraglandular botulinum toxin injection

can be used to improve sialorrhea in

Parkinson’s disease and cerebral palsy

3 Surgical: Redirection of submandibular and

parotid ducts

Duct ligation has been tried for major

salivary glands but can cause complications

like ranula formation, pain, swelling, etc

Xerostomia (Dry Mouth, Asialorrhea)

1 Diseases of salivary gland like aplasia,hypoplasia, ductal obstruction, severesialoadenitis

4 Psychologic factors: Fear, anxiety

5 Physiologic: Menopausal

6 Irradiation of salivary gland

7 Uncontrolled diabetes, hyperthyroidism

8 Vitamin A and B complex deficiency

Topical application of paraffin, almond oil,

Aloe vera and vitamin E products and cold

cream or silicone fluid or petroleum jelly

(Pilocarpine and cevimeline are

contra-indicated in pulmonary and

cardio-vascular diseases and glaucoma)

d Neostigmine bromide 7.5 mg t.d.s

(Side effect increased peristalsis)

SIALOLITHIASIS

It is the formation of calcified organic matter,

developed in the secretory system of major

and minor salivary glands

Composition

Organic matter or nidus covered with shells

of calcified material The structure of sialoliths

is crystalline primarily composed of

hydroxy-apatite Chemical composition is calcium

phosphate, traces of carbon, magnesium, KCl,

NH3

Exact cause not known

Factors leading to sialolithiasis:

Single or multiple calculi may be formed

Sialoliths are more common in

submandi-bular duct and gland because:

• Submandibular gland saliva contains more

of calcium and phosphorus

• Saliva is more viscous, mucinous andalkaline compared to parotid secretions

• The Wharton’s duct is longer and hastortuous course

• Ductal orifice is small and lumen is largerpossibly leading to stasis of saliva

• Ductal orifice is at higher level and gland

is at lower level possibly leading to salivarypooling due to gravity

• The Wharton’s duct takes right-angled bendposterior to mylohyoid muscle, this area

is termed as coma area (Fig 12.1) andsialoliths occur more commonly seen in thisregion

Parotid GlandStenson’s duct opening is at higher levelcompared to the gland and also it pierces thebuccinator and takes a right-angled turn toopen into parotid papilla Despite these pointssimiliar to Wharton’s duct, sialoliths are not

so common in the Stenson’s duct becausemainly salivary secretions are serous

Clinical Features

a The patients may have no symptoms andsialolith may be detected during routineradiographic examinations

Fig 12.1: Sialogram showing sharp bend in the

Wharton’s duct (coma area)

b Xerostomia is absent in patients with small

calculi

c If sialolith causes partial or total blockage

of the affected duct, pooling of salivary

secretions takes place just before meals

leading to transient pain and swelling of the

affected gland which reduces itself after

meals

d Clinical examination shows diminished

secretion on the affected side and at times

frank pus is expressed on applying digital

pressure on the gland

e Complete blockage often gives rise to

recurrent/chronic swelling which is tender

Chronic stagnation of the salivary secretion

can give rise to progressive pressure

atrophy leading to destruction of the gland

f In certain cases a fistula, sinus tract or ulcer

may occur over the calculus

g The presence of calculus can be ascertained

with digital palpation

h Other complications from sialolith includes

acute sialoadenitis and strictures

• Donovan’s technique (Fig 12.3)

d Sialography may show filling defect

• If large surgically removed

• Complete removal of gland may be

advocated in cases where there is complete

destruction

Fig 12.3: Deeply located sialolith visualized on

occlusal view taken by Donovan’s technique

Fig 12.4: Sialogram showing filling defect caused

by sialolith

Fig 12.2: Occlusal view showing multiple sialoliths

in Wharton’s duct

• Lithotripsy and sialoendoscopy may be

helpful and non-invasive treatment for

sialolithiasis

Chronic Necrotizing Sialometaplasia

Benign, self-limiting, reactive inflammatory

disorder of salivary tissue of unknown

etiology Could be related to local ischemia

3 It has a rapid onset and starts as a tender

erythematous nodule which breaks down

to form a deep ulcer with yellow base

4 Compared to the large size pain is moderate

or dull

5 These lesions occur shortly after surgical

procedures and also have been reported to

be connected to vomiting episodes in bulimia

Diagnosis requires biopsy and

histo-pathology of the lesion The lesion does not

shows any evidence of malignancy

Differential Diagnosis

Major aphthae (associated with history of

recurrence and severe pain)

Malignancy (mucoepidermoid carcinoma,

adenoid cystic carcinoma or squamous cell

carcinoma)

Treatment

This is a self-limiting condition and healing

takes place within 6–8 weeks

Debridement of the lesion and saline rinses

helps in the healing process

Recurrence is rare

Mumps/Non-suppurative Parotitis

• Caused by paramyxovirus

• Most common in children 4–6 years

• Adults may be affected

• After the incubation of 2–3 weeks salivarygland inflammation and enlargementoccurs with preauricular pain

• Associated with malaise, fever andanorexia

• Enlargement of salivary gland which aretender and present difficulty in eating, ifpartial ductal obstruction occurs

• The ductal orifices are inflamed but there

involve-to raised ear lobules

• All glandular structures may be affected

c Recurrent parotid swelling of inflammation due to sialoadenosis is non-tender, soft and of long duration

non-Treatment

Prevention with live attenuated vaccine (MMR).Systemic corticosteroid for painful testicularinvolvement

Acute Bacterial SialoadenitisBacterial infections of the salivary glands arecommonly seen in patients with decreased

salivary flow in debilitated and dehydrated

patients

In the past, retrograde bacterial infection

were seen in the patients who have undergone

general anesthesia as a result of xerostomia

and dehydration secondary to administration

of anticholinergic drugs (as preanesthetic

medication)

In recent times, majority of bacterial

infec-tions occurs in patients with reduced salivary

flow as there is diminished mechanical

flushing of bacteria which tend to colonise the

oral cavity and then colonise the duct

Although, sialoliths occcur more often in

submandibular gland, bacterial sialoadenitis

occurs more frequently in parotid gland It is

believed that submandibular salivary gland

secretion has high level of mucin which has

potent anti-microbial activity, tongue

move-ments tend to clear the floor of mouth and

protect the Wharton’s duct Parotid papilla is

located adjacent to molars where heavy

bacterial colonization occurs

Clinical Features

Fever with sudden onset of unilateral or

bilateral salivary gland enlargement

• Intense pain in salivary gland region

• Tender, warm, enlarged gland with red skin

• Purulent discharge from orifice of Stenson’s

duct

• Leukocytosis

Diagnosis

Purulent discharge expressed can be cultured

for various organisms mainly Staphylococcus

aureus, H influenzae, S viridans, Prevotella and

• Culture antibiotic sensitivity test

• Patients are instructed to milk the glandseveral times throughout the day

• Stimulation of salivary secretion by sucking

on candy

• Surgical drainage in acute condition

• Improvement of oral hygiene

• IV fluid and electrolytes

• Intraductal instillation of penicillin orsaline

Allergic Sialoadenitis

History of allergy, asthmatic attack

• Asymptomatic enlargement or with itchingover the gland

• History of change in or new intake of drug

• Most common drugs associated are butol, phenobarbital, iodine compoundsand heavy metals

• Avoiding the allergens

• Monitoring the patient and prevention ofsecondary infection

 Infection and swelling of parotid glandwith fever

 Inflammation of uveal tract of eye

 Facial palsy

Diagnosis

Biopsy of the minor salivary gland can confirmthe diagnosis of sarcoidosis with non-caseating granuloma

Mainly palliative corticosteroids and other

immunosuppressive and immunomodulator

drugs are used

Sjögren’s syndrome

Autoimmune disorder of exocrine glands first

described by Henrick Sjögren in 1933

• Primary Sjögren’s syndrome (SS) is

associated with salivary and lacrimal

glands dysfunction without any

–Salivary gland involvement causing

decreased salivation (xerostomia)

–Along with autoimmune disorders such

as: Rheumatoid arthritis, SLE

Clinical Features

Post-menopausal women are most commonly

affected (40–60 years)

a Lacrimal gland involvement gives rise to

dryness of the eyes and continuous feeling

of dirt or foreign body in the eye

Conjunctivitis and corneal ulceration also

a common feature

b Dryness of pharynx, larynx and nasal cavity

may lead to pneumonia

c Xerostomia—severe dryness of the oral

cavity causing difficulty in speech,

mastica-tion and deglutimastica-tion

d Minimum salivation in the oral cavity, if

present saliva is thick and ropy Mirror

head, tongue blade gets stuck to the mucosa

during examination

e Dry and cracked lips with angular cheilitis

f Oral mucosa is dry and glistening, tongue

appear depapillated and at times lobulated

g Candidiasis and increased dental caries are

SS only 5 mm

2 Rose Bengal dye test: Denuded and damagedareas of the cornea can be visualized clearlywith this dye

3 Break up time test: A slit-lamp is used andinterval between complete blink andappearance of dry spot on the cornea isnoted

Salivary gland function is assessed by:

1 Salivary flow rate is diminished in SS

2 Minor salivary gland biopsy taken fromlower labial mucosa

3 Scintigraphy: Technetium pertechnate 99m,

in SS diminished uptake and excretion ofisotope in the saliva

4 Sialography shows thinning of the ductsand decrease in the number of ductules Thetypical sialography appearance is described

as punctate, globular and cavitory sialectasis It is termed as pseudosialectasisbecause the appearance is due to thepooling of the dye in periductal area andnot because of the dilation of the ductules.Overall description is given by the termbranchless tree with fruit-laden appearance(Rankow) (Fig 12.5A)

pseudo-5 MRI shows salt and pepper appearances ofthe enlarged salivary glands (Fig 12.5B)

b Pilocarpine 5 mg 1 tab t.d.s.

c Cevimeline 30 mg 1 tab t.d.s

d Bromhexine

4 Dental considerations

a Daily use of topical fluoride rinse

b Topical application of nystatin and

clotrimazole to control candidiasis

c Patients of SS may be on steroids or

immunosupressants for the treatment of

SLE or rheumatoid arthritis, therefore

one must take precaution against

infec-tion preceding oral surgical procedures

5 Additional drugs

a Methotrexate

b Oral interferon α: 150 IU daily

c Antimalarial drugs: Hydroxychloroquine

d Rituximab (rituxan), an anti-CD20

mono-clonal antibody

HIV Associated Salivary Gland Disease

Patients with HIV infection may experience

salivary gland disease either from AIDS related

tumours, i.e lymphoma, or because of

Sjögren’s syndrome like condition of unknown

etiology

Such patients on labial biopsy shows

similar changes like Sjögren’s but with

pre-ponderance of CD8lymphocytes

On CT and MRI, large multicentric cysts are

detected within the enlarged parotid glands

This enlargement is due to:

a Hyperplastic lymph nodes

Parotid glands are more often involved thanthe submandibular glands Swelling of pre-auricular portion is more common than theretroauricular

Fig 12.6: CT scan multicentric cyst in parotid gland

Fig 12.5: (A) Sialogram showing branchless fruit-laden tree appearance in Sjögren’s syndrome, (B) MRI

showing salt and pepper appearances of parotid glands

Sialochemistry shows increased salivary

potassium and decreased salivary sodium

levels

Sialoadenosis may occur in a variety of

conditions:

1 Hormonal sialoadenosis associated with

menarche, pregnancy, menopause, etc

2 Diabetic sialosis

3 Associated with alcoholism

4 Associated with malnutrition specially with

protein deprivation

5 May be because of drug administration like

iodine containing drugs, phenylbutazone

On sialographic examination, the ducts and

ductules appear to be splayed

Treatment

Treatment is symptomatic and is related to the

management of causative factors

Mucocele

This is a term used to describe swelling caused

by pooling of saliva at the site of injured minor

salivary gland duct

It is of two types:

1 Mucus extravasation: It is the common

mucocele caused by trauma to the minor

salivary duct giving rise to extravasation of

saliva/mucus in the adjacent connective

tissue This is surrounded by an area of

inflammation and formation of granulation

tissue but does not have any epithelial cyst

wall, even if it is termed as a cyst

2 Mucus retention cyst: It is less common and

caused by the obstruction of minor salivary

duct The continuous pressure of

accumu-lated salivary secretion forms a cyst-like

lesion which can be lined by epithelium of

dilated duct

Clinical Features

a More common in lower lip because it is

more prone to trauma, other sites are buccal

mucosa, floor of the mouth, etc

b Typical mucocele appears as a thin-walled

bluish, rounded swelling on the lower lip

(Fig 12.7) that ruptures easily giving rise

to salty discharge following which thelesion deflates, but recurrence is common

c Size varies from 4 mm to 1 cm

Treatment

1 Surgical excision helps to prevent currence, however, adjacent minor salivarygland ducts can get traumatized and lead

re-to new mucoceles

2 Intralesional steroid injections have beentried

RanulaRanula is large mucocele located in the floor

of mouth It may be because of mucus vasation or mucus retention

Fig 12.8: Bluish swelling in the floor of the mouth Fig 12.7: Dome-shaped bluish swelling on the lower

lip—mucocele

Fig 12.9: Nodular swelling on the right parotid

elevating the ear lobule (s/o pleomorphic adenoma)

c Superficial may appear blue in color and

deeper ranulas may have normal

appea-rance

d Deep ranula which herniates through the

mylohyoid muscle and extends along the

fascial planes to the neck region is called

plunging ranula

Diagnosis

a Radiography helps to rule out sialolith

b Injecting radiopaque dye to delineate

borders and full extent of the lesion

c MRI will show cystic lesion giving

hyper-intense signal on T2-weighted image

Treatment

a Surgical intervention: Marsupialization and

excision

b Intralesional injection of corticosteroids

Salivary Gland Tumors

They may be classified as:

1 Benign

2 Malignant

Majority of the salivary gland tumors (80%)

occur in the parotid gland 10–20% occur in

submandibular gland and the remaining in

sublingual and minor salivary glands

80% of parotid and 50% of submandibular

and minor salivary gland tumors are benign

in contrast 60% of the tumors in sublingual

gland are malignant

Pleomorphic Adenoma

Most common tumor of salivary glands and

majority of these are found in parotid glands

• It is called mixed tumor because it consists

of epithelial and mesenchymal elements

• It accounts for 60% of tumors

• 4–6th decade

Clinical Features

Slow growing, painless and firm mass which

elevates the ear lobule, if present in parotid

gland (Fig 12.9)

In parotid gland, these neoplasms are most

commonly seen in posterior-inferior aspect of

the superficial lobe The size of the tumorvaries from several centimetres to very large,

Treatment

• Superficial parotidectomy

–Lesions in submandibular gland aretreated by complete removal of the entiregland

Mucoepidermoid Carcinoma

• Most common malignant salivary glandtumor

–60–90% occur in parotid gland and palate

is the second most common site

–3–5th decade

Clinical Features

• Low grade tumor shows a long period ofslow and painless growth may resemblepleomorphic adenoma

–High grade tumor grows rapidly, produce

pain and ulceration of overlying tissue and

shows early metastasis

–Facial nerve palsy may be seen

Treatment

• Treated by superficial parotidectomy or

total parotidectomy depending upon the

extent of the lesion

–Postoperative radiation therapy is useful

adjunct

Adenoid Cystic Carcinoma (Cylindroma)

• 6–10% of salivary gland tumors

–Most common tumor of submandibular

and minor salivary glands

Clinical Features

• It is usually presents as firm, slow growing

and unilobular mass in the gland

–Occasionally the tumor is painful

–If parotid gland is involved facial nerve

palsy can occur

–It spreads by perineural invasion

–Intraorally, adenoid cystic carcinomapresents as mucosal ulceration whichhelp it to distinguish from benign mixedtumor Metastasis into lungs is morecommon

Treatment

Radical surgical excision Because of ability ofthe lesion to spread along the nerve sheaths,remaining cells can give rise to long-termrecurrence even after aggressive surgicalexcision

Maxillo-3 Diseases of the Salivary Gland, Rankow

4 Oral and Maxillofacial Pathology byNeville, 3rd edition

5 Shafer’s Textbook of Oral Pathology, 6thedition

Fig 12.10: MRI image showing nodular tumor mass in the right parotid

Pain is by far the most common symptom with

which the patient presents to the dental

clinician

It is stated, “There was never yet a Philosopher

who could endure toothache patiently!”

Pain may be defined as an unpleasant

sensation produced by a noxious stimulus

carried as an impulse along a nerve track to

the CNS where it is interpreted as such

As per International Association for Study

of Pain (IASP), pain is—“An unpleasant

sensory and emotional experience associated

with actual or potential tissue damage or

described in terms of such damage.”

Classification of Orofacial Pain

– Vascular—migraine, cluster headache,etc Migrane—now believed to be neuro-vascular

– Referred

C Unknown Nature

• Atypical neuralgia

• Psychogenic painDental Pain

c Periapical pain

1 Acute apical periodontitis

2 Acute apical abscess

3 Chronic apical periodontitis

4 Suppurative apical periodontitis

5 Apical cyst

d Pericoronitis, dry socket

e Dentin and cementum exposure

f Occlusal trauma

g Eruption and exfoliation

h Impacted unerupted supernumerary (IUS)

Practical Approach Towards

Diagnosis of Orofacial Pain

Whenever a patient presents with pain to a

dental surgeon, as a first step, tooth related

causes should be ruled out, as follows:

Tooth: Enamel should be examined for

attrition, abrasion, erosion, abfraction,

hypoplasia, cracked tooth and carious lesions

Dentin exposure: In case of total wear of enamel,

or deep caries, dentin is exposed or involved

leading to hypersensitivity

Cementum: In cases where the abrasion and

other wasting diseases involve the tooth at

CEJ, cementum is lost, there by exposing root

dentin Loss of cementum also gives rise to

bone loss Cemental caries is also commonly

seen in older individuals

Pulpitis: Either caries or the wasting diseases

of the teeth, or trauma, or cracked tooth, may

lead to pulpitis which presents as excruciating

pain

A good mouth mirror, sharp explorer and

a good quality light is mandatory for detection

of caries Occlusal caries is easily detectable,marginal ridges have to be carefully observedfor the presence of opacity (lack of trans-lucency) which is associated with proximalcaries

• Upper and lower third molars buccalsurface and distal surfaces of 17, 27 are moreprone to caries, and are most likely to bemissed during clinical examination, andhence these areas should be examinedcarefully

• Periapical abscess, granuloma and cyst maypresent with pain which may vary fromsevere to mild Such teeth are tender topercussion This can be diagnosed with thehelp of clinical examination of teeth andradiographs

If the teeth are healthy then gingiva should

be examined carefully for the cause of pain

• Gingiva: Pocket, ulceration, ANUG,

periodontitis

It is also advisable to ask the patient toocclude his teeth, do side to side move-ments and look for the evidence of occlusaltrauma, e.g premature contact, plungercusp, abnormally tilted teeth, etc as thesefactors can lead to persistent pain in theteeth which otherwise look normal Teethwith periodontal abscess are tender onlateral percussion, and the painful tooth iseasily localized by the patient unlikepulpitis affected tooth

Many times the teeth and the periodontiumare quite normal At such times, othermucosal surfaces should be examined forany pathology

• Mucosa: Ulceration (aphthous, lichen

planus, traumatic ulcerations)The dental surgeon may encounter painwhich is related to the deeper structures,like the alveolar bone, e.g dry socket, osteo-myelitis

If the examination of teeth, the dontium, mucosa, and the alveolar bone

perio-reveals no cause for pain, one should suspect

MPDS or pain of muscle origin, presenting

with tender trigger points commonly in

masseter and temporalis muscles Trismus

which is due to spasm of masticatory muscles

can present with severe pain

At times, patients clearly complain of pain

in the TM joint with clicking in which case TM

joint disorders should be suspected and

investigated These would include anterior

disc displacement with or without reduction,

arthritis, etc

Patients with neuralgia have distinct acute,

paroxysmal, lancinating, electric shock-like

pain precipitated by stimulation of the ‘trigger

zone’ Despite these characteristic features,

mistaken diagnosis of pulpitis and subsequent

needless endodontic treatment or extractions

have been carried out

Patients who present with unilateral

throbbing pain with rapid pounding

pulsa-tions should be suspected to have pain of

vascular origin, e.g migraine with or without

aura, cluster headache (pain localized behind

the eye), temporal arteritis (with visible

throbbing of the artery)

Salivary gland pathologies, like sialolithiasis,

sialoadenitis, mumps, present with pain and

swelling of the affected gland with diminished

secretion

Maxillary sinusitis at times may be mistaken

for toothache, but a history of rhinitis, blocked

ostium, and unilateral heaviness, increased

pain on bending down and foul discharge can

help to pinpoint the diagnosis

Many times the pain from distant organs

such as myocardium, ENT can be referred to

the teeth In such cases, absence of positive

findings on history, clinical examination and

radiography can help to rule out dental cause

for pain However, diagnose cardiac or ENT

cause of pain is a challenging task Patients

with cardiac complaint have the pain localized

to the left angle of mandible and neck and is

relieved by nitroglycerine It is prudent to seek

expert advice in cases where the dental

surgeon is unable to reach the diagnosis

Psychogenic: Patients presenting with pain

of chronic nature, which cannot be attributed

to any of the above conditions, may becautiously considered to be of psychogenicorigin Such pains are constant, unanatomic,and can cross the midline and seen in patientswho are rigid and unyielding However, everyeffort must be made to rule out physical causefor pain before labelling this type of pain aspsychogenic

PulpalgiaPulpitis is the most common painful conditionwhich brings the patient to the dentist Caries,cracked tooth, trauma can precipitate pulpitis.Acute pulpitis pain is the most severe pain,and it is caused by the severe pressure exerted

on the apical nerve endings because ofinflammatory changes within the pulp Thepain is unbearable and increases on lyingdown Pulpitis pain is poorly localized and isrelieved after excavation of caries with/without extirpation of pulp

Reversible pulpitis: Exaggerated quick, sharpresponse to cold stimulus, followed by dullache that disappears; there is no pain onpercussion and no radiographic evidence ofperiapical abnormality Usually afterexcavation of caries or removal of the causeand restoration of lost tooth structure,symptoms abate and root canal treatment isnot required

Irreversible pulpitis: Spontaneous lingeringdull ache or constant severe unrelenting pain,aggravated by noxious stimuli, and positiveresponse to cold and heat stimuli, radio-graphically periapical widening of PDL space.Treatment is either RCT or extraction

Chronic pulpitis pain is relatively milder

In chronic open pulpitis, patient normallycomplains of pain after food impaction and

in chronic hyperplastic pulpitis, there is pulppolyp with very mild pain However, in boththese cases, patients stop chewing from thatparticular side, leading to excessive deposition

of calculus on the teeth of the affected segment

sometimes even on occlusal surfaces!

Closed suppurative pulpitis: In this condition,

inflammation leads to necrosed pulp which

further gets infected with pyogenic organisms

As the pus is accumulated, and confined to a

very limited area within the tooth, the pressure

exerted on the apical nerve endings is

tremendous so that patient is literally crying

LA injection followed by pulp extirpation

brings immediate relief to the patient

Periapical Pain

This is moderate to severe spontaneous pain

that is sharp, throbbing or aching in nature

The tooth in question is nonvital, tender to

percussion, more so, if the abscess is confined

to the bone The abscess may present in the

soft tissues presents as fluctuant pus filled

swelling extremely tender to palpation, or if

there is a fistula formation, the severity of the

pain is less

Acute apical periodontitis: There is a

complaint of spontaneous pain which is

moderate or severe, the tooth involved is

nonvital and tender to percussion Patient

complains of severe pain on biting on that

tooth, and radiographic findings include break

in lamina dura and widening of PDL space

Such type of pain is also observed at the

second seating after inadvertent

over-instrumentation during endodontic treatment

of affected teeth

Acute apical abscess: It is characterized by

rapid onset of spontaneous pain and swelling

of gingival and alveolar mucosa Sometimes

it is confined only to the bone

Radiographi-cally periapical changes may or may not be

present

Chronic apical abscess: This is due to

long-standing focus of infection, with a little or no

discomfort to the patient There is a presence

of a fistula or a sinus tract

Patients having periapical lesions have to

be treated with endodontic treatment with or

without periapical curettage and in certain

cases by extraction

Occlusal TraumaSometimes patients having occlusal abnor-malities such as premature contacts, highpoints in the restorations, plunger cusps maypresent with tenderness in the affected teeth.Such symptoms get aggravated, if patientsalso have clenching habit or bruxism

Bruxism: Pain in masticatory muscles onawakening, persistent grating soundproduced by the patient with nocturnalbruxism is more disturbing to the spouse!Such patients present with:

• Facets on teeth, unusually severe attrition

in younger individuals

• Indentations on tongue

• Prominent linea alba

• Masticatory muscle fatigue and painespecially worse on awakening

Such cases respond to occlusal adjustmentafter the detection of premature contacts andmouth guard to minimize the clenching/bruxing habit

Cracked Tooth SyndromeAssociated with incomplete fracture of toothwhich may or may not extend to the pulp.When pulp is involved, patient startscomplaining of severe pain, which is sharpand momentary and is stimulated by bitingand releasing Pain in this condition is morecommonly noted with the release of biting,owing to the fluids within the dentinaltubules moving to the pulp

Patients give history of either habituallyeating hard substances or inadvertently biting

on hard substance:

• Areca nut chewing

• Bottle opening/electricians stripping wireswith teeth

• Hard substance eaten

• More common in upper premolars withprominent cusps

• Teeth having large proximal restorationsmore susceptible to cracks