Presentation is key to diagnosing salivary gland disorders

Initial signs and symptoms offer the best guide to next steps in assessment, testing, and treatment, plus any needed referral or multidisciplinary care.

Multimodal ultrasound investigation (grey scale, Doppler and 2D-SWE) of salivary and lacrimal glands in healthy people and patients with diabetes mellitus and/or obesity, with or without sialosis

AIM

To evaluate the ultrasound (US) modifications [grey scale, Doppler, 2D-share wave elastography (2D-SWE)] ofsalivary (parotid and submandibular) and lacrimal glands in healthy people and patients with diabetes mellitus and/or obesity, with or without sialosis.

MATERIAL AND METHODS

We evaluated 170 patients (1020 glands, 1700 grey scale and Doppler images), split in two groups (group 1- healthy people, group 2- obese and/or diabetes patients, with or without sialosis). For each patient we assessed the parotid, submandibular and lacrimal glands in grey scale US (echogenicity, homogeneity, glandular contour, posterior border, lymph nodes), color Doppler US and 2D-SWE. All images were analyzed by two examiners blinded to each other or to patients.

RESULTS

The interobserver agreement was strong or moderate for all parameters. In group 2, the salivary glands had increased echogenicity, homogeneous aspect and invisible posterior border (all p<0.001). There was no significant variation of elasticity modulus in the groups analyzed (5.46±1.57 vs 5.67±1.81 in parotid, 8.63±1.84 vs 8.55±1.94 in submandibular and 9.47±2.1 vs 9.53±2.23 in lacrimal glands, all p>0.05) or according to the body mass index (BMI), sex, patient age, the aspect in grey scale/Doppler US or the presence of sialosis (all p>0.05).

CONCLUSION

The main US differences between healthy people and patients with diabetes mellitus and/or obesity are suggested by the echogenicity, homogeneity, posterior border and the size of glandular area. No significant differences of elasticity modulus were found between the analyzed groups or related to BMI, sex, patient age or other grey scale/Doppler US items analyzed.

Oral Lesions in HIV Infection in Developing Countries: an Overview

HIV infection is a major global health problem affecting developing and developed countries alike. Oral lesions that are associated with this disease are important, since they affect the quality of life of the patient and are useful markers of disease progression and immunosuppression. Oral lesions in HIV infection have been well-documented in developed countries, but there are fewer reports on oral lesions from developing countries. Oral candidiasis is the most common opportunistic infection seen in all continents. Kaposi’s sarcoma has been reported only from Africa and Latin America, while histoplasmosis and penicilliosis were reported in patients with advanced disease from Thailand. HIV-associated salivary gland disease has a high prevalence in Africa and Latin America, especially in the pediatric group. It is clear that there are considerable regional variations in the oral manifestations of HIV infection, depending both on the populations studied and on the clinical expertise available, among other factors. Well-designed and -documented studies are necessary for the correct assessment of the nature and magnitude of the problem in developing countries, if oral health measures are to be effectively formulated for the HIV-infected.

Deep neck infection in elderly patients. A single institution experience (2000–2004)

BACKGROUND AND AIMS

Immunosenescence, the age-related decline in immunologic function in healthy individuals, seems to contribute to increased susceptibility to bacterial infections in the elderly population. The present study describes elderly patients' susceptibility to deep neck infection and prognosis.

METHODS

Between January 2000 and March 2004, 103 patients were admitted to the Department of Otolaryngology, University of Padova for deep neck infection. Twenty-four patients (23%) were over 65 (elderly patients). The remaining 79 patients (77%) aged < or =65 years (adult non-elderly patients) were also studied. Presentation modalities, origin of infection, site of deep neck infection, radiological investigations, bacteriology, treatment and outcome were all studied.

RESULTS

Hypertension and diabetes mellitus were the most commonly associated systemic diseases in both elderly and non-elderly patients. The number of patients with associated systemic diseases was significantly higher in the elderly group. The most common cause of deep neck infection was dental infection in both age groups. In the elderly group, salivary gland origin had the same incidence as dental origin. Twenty-two patients (6 elderly patients) were treated only with intravenous antibiotic therapy and intravenous steroids. Overall, in 81 cases (78.6%) (18 elderly patients) medical plus surgical procedures were indicated. None of the treated patients died of deep neck infection or its complications.

CONCLUSIONS

Although the incidence of associated systemic diseases and complications of deep neck infections were higher in the elderly group, our medical or medical plus surgical approaches to deep neck infections, based on clinical and radiological evidence, were successful in all patients treated.

[Sublingual gland amyloidosis causing obstructive sleep apnea hypopnea syndrome: a case report and review of the literatures]

OBJECTIVE

To improve the understanding of sublingual gland amyloidosis causing obstructive sleep apnea hypopnea syndrome(OSAHS).

METHODS

A case of sublingual gland amyloidosis causing OSAHS diagnosed in april 2012 was reported and the related literatures were reviewed. The literature review was carried out respectively with "amyloidosis, sublingual gland, obstructive sleep apnea hypopnea syndrome", as the search terms in Wanfang Data and PubMed by November 2012.

RESULTS

A case of 74 year-old male patient was admitted to the hospital because of snoring for 5 years, sleep apnea for 1 year and arousal for 1 month. After admission, polysomnography showed severe OSAHS, physical examination showed redundant the sublingual gland. Enhanced CT scanning showed soft tissue masses at the sublingual gland. Abdominal B ultrasonic and CT also showed a spaces-occupying lesion in the left retroperitoneal. B-guided core needle biopsy was performed in the left retroperitoneal. Pathology report showed amyloidosis. Subsequently, sublingual gland mass resection was performed. Pathology report after operation showed amyloid deposits staining with Congo red, which gives it a characteristic green birefringence in polarised light. Accordingly, it was diagnosed as sublingual gland amyloidosis. The symptoms of snore and sleep apnea were disappeared after operation.So far, there was no local recurrence with 10 months follow-up. A total of 3 literatures were received in Wanfang Data, including 2 of macroglossia amyloidosis causeing OSAHS case report and one of retrospective study. There were no reports about sublingual gland amyloidosis in Wanfang Data. A total of 5 literatures were received in Pubmed, including 2 of sublingual gland amyloidosis case report, 2 of macroglossia amyloidosis causeing OSAHS case report and one of retrospective study. However, there were no reports about sublingual gland amyloidosis causing OSAHS.

CONCLUSIONS

Amyloidosis rarely occurred in the sublingual gland and is easy to be misdiagnosed and missed diagnosed, which can causing severe OSAHS. To make a definite diagnosis, histopathology and staining with Congo red are needed and a characteristic green birefringence in polarised light is a reliable marker for diagnosis. After sublingual gland mass resection, the patient had good prognosis.

Oral health of Chinese people with systemic sclerosis

The aim was to study oral health status, salivary function, and oral features of Chinese people with Systemic Sclerosis (SSc). Chinese people with SSc attending a university specialist clinic were invited for a questionnaire survey and a clinical examination. Ethics approval was sought (UW 08-305). Gender- and age-matched individuals without SSc who attended a university dental hospital were recruited for comparison. Forty-two SSc patients with a mean age of 54.0 ± 12.2 were examined. This study found no Chinese people with systemic sclerosis were periodontally healthy and many (76%) had periodontal pockets despite most of them (93%) practiced daily tooth-brushing. They all had caries experience (DMFT = 10.5) and many (65%) had untreated decay. Mucosal telangiectasia was a common oral feature (80%). They had lower resting salivary flow rates (0.18 ± 0.17 ml/min vs. 0.31 ± 0.21 ml/min; p = 0.003) and pH values (6.90 ± 0.40 vs. 7.28 ± 0.31; p < 0.001) and reduced maximal mouth opening (40.1 ± 6.5 mm vs. 43.6 ± 7.0 mm) than people without SSc.

Diagnosis and treatment of dry mouth

For effective management of dry mouth, early diagnosis and aggressive, symptom-based treatment are necessary to help alleviate much of the discomfort and to retard progression of the disorder. Many effective strategies are available to help patients manage their symptoms. Routine follow-up care with physicians and dentists is essential. With early intervention and proper individualized care, people with dry mouth should be able to lead full and comfortable lives.

[Reactive-dystrophic processes in salivary glands (sialoadenoses) running on the background of metabolic syndrome]

Basing upon comprehensive checkup of 82 patients with metabolic syndrome authors made diagnostics of different forms of sialoadenosis in them. The disease proceeded on the background of abdominal adiposity, lipid metabolism derangements, glucose toleration disturbances and diabetes mellitus of the 2nd type with reduction of tissue sensitivity to insulin (insulin resistivity). Results of the fulfilled patient treatment showed that it was necessary to include in the complex of therapeutic measures metformine (glukofagee) producing positive effect upon carbohydrate metabolism and also to normalize the work of glands increasing their secretory activity.

Primary sclerosing cholangitis associated with fibrosis of the submandibular glands and the pancreas

A new syndrome of primary sclerosing cholangitis associated with fibrosis of the submandibular glands and the pancreas is described in a 43-year-old male. The sclerosing cholangitis was diagnosed at laparotomy because of cholestasis and the fibrosis of the submandibular glands and pancreas confirmed at microscopical investigation of biopsy specimens. The cholangitis responded well to treatment with a low dose of prednisolone (7.5--10 mg) and an endoscopic retrograde cholangiopancreaticographic examination 10 months after the operation revealed normal bile ducts.

Coexistence of mucous retention cyst and basal cell adenoma arising from the lining epithelium of the cyst. Report of two cases

OBJECTIVE

To report 2 cases of coexisting mucous retention cyst and basal cell adenoma arising from the lining epithelium of the cyst.

CLINICAL PRESENTATION AND INTERVENTION

Two cases of painless swellings, well-demarcated, soft to palpation, and located in the submucosa of the upper lip were clinically examined with the provisional diagnosis of mucocele or salivary gland tumor. Histological examination showed the presence of a large unilocular cystic cavity in many parts surrounded by single or bilayered lining epithelium composed of flattened to cuboidal cells, and in other parts surrounded by projections of cells arranged in a trabecular pattern far into the cystic cavity. The trabeculae were composed of basal and low columnar cells that sometimes formed small duct-like structures. Immunohistochemistry showed that the lining epithelium of the cystic cavity and the cells of the projections expressed cytokeratin 7 and high-molecular-weight cytokeratins. The cells of the projections were weakly positive for S-100 protein and negative for vimentin and alpha-smooth muscle actin. Based on the results, a diagnosis of coexisting mucous retention cysts and basal cell adenomas arising from the lining epithelium of cysts was made.

CONCLUSION

The coexistence of mucous retention cysts and basal cell adenomas arising from the lining epithelium of the cyst is reported.

[Salivary and lacrymal gland disorders and HTLV-1 infection]

INTRODUCTION

The frequency and severity of salivary and lacrymal gland human T-cell lymphotropic virus type 1 (HTLV-1) infection were assessed in HTLV-1 plus patients, presenting with neurological deficit (tropical spastic paraparesis/HTLV-1 associated myelopathy [TSP/HAM]) or not. The mechanism of this deficit was investigated.

MATERIAL AND METHODS

A case-control study was made from April 2002 to December 2005, in an area strongly endemic for HTLV-1. The patients were classified in three groups: group 1 with 16 patients presenting with TSP/HAM; group 2 with 67 HTLV-1 carriers and group 3 with 29 healthy volunteers. The dry syndrome was investigated by history taking and by oral and ophthalmological clinical examination. Immunological and biological screening for rhumatoid factors, antinuclear antibodies, and antibodies against soluble nuclear antigens (SSA, SSB). Peripheral blood was separated by density gradient and mononuclear cells were recovered to dose interferon-gamma and tumor necrosis factor-alpha. Patients in the three groups were assessed for salivary flow by stimulated weighing using Saxon's test. A Chi-2 test, a variance analysis (Anova), and the Spearman rank correlation test were used for the statistical analysis.

RESULTS

The dry syndrome was mild and more common in group 1 patients (75%). In group 2, 22% of the patients presented with functional signs of buccal mucosa dryness comparable to those observed in group 1. No correlation was found between salivary flow and screened pro-inflammatory cytokines.

DISCUSSION

Our results show that hyposialia is an important part of the disease induced by HTLV-1, even in virus carriers without neurological deficit. Its mechanism seems different than that of the Gougerot-Sjögren syndrome.

Plunging ranula in young HIV patient

The case of a 15-year-old African-American male with congenital HIV on highly active antiretroviral therapy (HAART) therapy with a plunging ranula who was treated with surgical removal of the offending sublingual gland and suffered no complications. This case may serve as an example that young HIV patients with this pathologic condition should be expected to have a similar course as a non-HIV patient.

Oral lesions in HIV-positive dental patients--one more argument for tobacco smoking cessation

OBJECTIVE

To determine the prevalence of oral lesions associated with human immunodeficiency virus (HIV) in a population of dental patients and analyze its association with psycho-social variables and biological markers.

STUDY DESIGN

The dental charts of 415 dental patients consecutively treated between May and July 2005 in a dedicated HIV dental clinic were reviewed. Oral soft tissue examinations, psycho-social and medical variables were extracted and recorded for each patient. Ethnicity, gender, HIV treatment, peripheral CD(4) counts and tobacco usage were analyzed in correlation with oral lesions associated with HIV.

RESULTS

Fifty-five percent of all subjects had at least one oral lesion associated with HIV, with oral candidiasis, salivary gland enlargement and oral hairy leukoplakia being the most commonly observed conditions. Gender and ethnicity did not correlate with a higher prevalence in lesions. However, tobacco smoking correlated significantly with a higher prevalence of oral lesions, independent of CD(4) counts.

CONCLUSIONS

These findings suggest that oral lesions remain commonly observed morbidities among HIV-infected dental patients independent of gender and ethnicity and that tobacco usage is a major and often underestimated risk factor for those lesions.

Coexistence of Sjögren's syndrome and sarcoidosis: a report of five cases

BACKGROUND

Sjögren's syndrome (SS) and sarcoidosis are diseases that can affect the salivary glands and result in the loss of salivary gland function. Most of the criteria used for the diagnosis of SS exclude sarcoidosis before establishing the diagnosis of SS. However, several reports have suggested the coexistence of both SS and sarcoidosis in the same patient.

OBJECTIVE

The purpose of this study was to present five cases that support a true coexistence of sarcoidosis and SS.

METHODS

Clinical and laboratory findings of patients with evidence of having both SS and sarcoidosis were reviewed. The diagnosis of SS was based on the European community criteria; the diagnosis of sarcoidosis was based on the presence of serological, radiographic and/or histopathologic findings that are consistent with sarcoidosis.

RESULTS

All patients fulfilled the criteria for the diagnosis of both diseases.

CONCLUSION

Our findings appear to support a true coexistence of sarcoidosis with SS. Therefore, it is reasonable to suggest removing the exclusion of sarcoidosis from the diagnostic criteria for SS.

Diagnostic imaging for chronic orofacial pain, maxillofacial osseous and soft tissue pathology and temporomandibular disorders

Since dentists can be faced by unusual cases during their professional life, this article reviews the common orofacial disorders that are of concern to a dentist trying to diagnose the source of pain or dysfunction symptoms, providing an overview of the essential knowledge and usage of nowadays available advanced diagnostic imaging modalities. In addition to symptom-driven diagnostic dilemmas, where such imaging is utilized, occasionally there are asymptomatic anomalies discovered by routine clinical care and/or on dental or panoramic images that need more discussion. The correct selection criteria of an image exam should be based on the individual characteristics of the patient, and the type of imaging technique should be selected depending on the specific clinical problem, the kind of tissue to be visualized, the information obtained from the imaging modality, radiation exposure, and the cost of the examination. The usage of more specialized imaging modalities such as magnetic resonance imaging, computed tomography, ultrasound, as well as single photon computed tomography, positron electron tomography, and their hybrid machines, SPECT/ CT and PET/CT, are discussed.

Salivary gland gene therapy

Salivary glands have proven to be unusual but valuable target sites for multiple clinical gene transfer applications. Access to salivary glands for gene transfer is easy. Multiple studies in animal models have yielded proofs of concept for novel treatments for damaged salivary glands following therapeutic irraditation, in Sjögren's syndrome, and for gene therapeutics systemically by way of the blood-stream and locally in the oral cavity and upper gastrointestinal tract.

Sclerosing polycystic adenosis of the salivary gland: a report of 16 cases

Sclerosing polycystic adenosis is a recently described, extremely rare, reactive, sclerosing, inflammatory process somewhat similar to fibrocystic changes and adenosis tumor of the breast. To date, there have been 22 cases described in the literature. Because of the infrequency of this lesion, we describe our combined experience with 16 cases, 1 of which has been previously reported. Thirteen tumors arose in the parotid gland, two involved the submandibular gland, and one arose in the buccal mucosa. There were 9 men and 7 women. Patients ranged in age from 9 to 75 years. Fourteen patients presented with a primary mass. Two were incidental findings in patients with a mixed tumor and an oncocytoma. Tumors ranged in size from 0.3 to 6 cm in greatest dimension. They are typically well circumscribed and are composed of densely sclerotic lobules with prominent cystic change. Hyperplasia of ductal and acinar elements and areas of apocrine-like metaplasia are frequent. Foci with mild ductal epithelial atypia were frequent with >50% of cases demonstrating at least focal areas of duct epithelial hyperplasia with atypia. Follow-up ranged from 1.5 to 40 years. One tumor recurred twice; no patient has developed metastases or died of disease.

Atypical facial pain--a diagnostic challenge

BACKGROUND

Facial pain is a relatively frequent cause of presentation to both general medical and dental practitioners. Although in the vast majority of cases the cause is dental disease or tempero-mandibular joint dysfunction, the remaining patients are often difficult to diagnose and treat.

OBJECTIVE

This article discusses the differential diagnosis of facial pain and presents three cases of atypical facial pain.

DISCUSSION

A detailed history, clinical examination, imaging and laboratory investigations may be required to establish the cause of atypical facial pain. An assessment of the patient's mental state is mandatory, as depression or psychological overlay is common. In a small number of cases, the diagnosis remains unclear despite detailed investigation. These patients may have their symptoms ameliorated by empirical pharmacological therapy.

A Stafne's cavity with unusual location in the mandibular anterior area

The typical Stafne's cavity, located on the posterior portion of the mandible, is a relatively uncommon entity. However, when the defect is located in the anterior region of the mandible, it is quite rare, having thus far been described in only 36 cases in the scientific literature. Most of these defects appear in the fifth and sixth decades of life, are localized to the area of the canines and premolars, and have a predilection for males. The inferior dental canal, one of the anatomical-radiographic landmarks that aid in the diagnosis of Stafne's cavity in the posterior region, is rarely present anterior the mental foramen. For this reason, because of its more variable radiographic appearance compared to the posterior defect, its tendency to be superimposed over the apices of the teeth, and the rarity of its localisation to the anterior mandible, it is much more difficult to establish a definitive diagnosis of a Stafne's cavity in this location. It is therefore more likely that a diagnostic error can occur, especially early on. We present a new case in a 68-year-old male in which the diagnosis was serendipitous, and we review in particular the aetiology and pathogenesis, clinical aspects, and differential diagnoses for this condition.

Unsuspected systemic amyloidosis diagnosed by fine-needle aspiration of the salivary gland: case report

Amyloidosis of the head and neck region may represent a local amyloidoma or a manifestation of systemic disease. Involvement of major salivary glands by either primary or secondary forms of amyloidosis is very rare. We describe a case of systemic amyloidosis that initially presented as submandibular gland mass and was diagnosed by fine-needle aspiration (FNA). A 69-year-old male presented with submandibular mass. His past medical history was significant for left forearm melanoma that was excised 6 years ago and tricuspid valve endocarditis after valvular replacement 3 months prior to FNA of the submandibular gland. The patient had no symptoms or clinical and laboratory data suggestive of amyloidosis. FNA specimen showed salivary gland tissue and abundant amorphous material, which stained positive for amyloid with Congo red stain and showed typical birefringence when examined by polarized microscopy. Further workup of the patient revealed generalized amyloidosis with multiorgan involvement by the disease. This case demonstrates that FNA can be a useful technique in the diagnosis of unsuspected amyloidosis.

Dual ectopic thyroid gland with Graves' disease and unilateral ophthalmopathy: a case report and review of the literature

Ectopic thyroid gland (ETG) is a rare entity and can be seen anywhere in the route of descending gland. It is much rarer when encountered away from the midline. Dual ETG is such a rare entity that only a few have been reported in the literature. ETGs not only cause thyroid dysfunction, most commonly hypothyroidism and rarely hyperthyroidism, but also frequent local symptoms. Therapeutic options change according to patients' co-morbid diseases, age, size of goiter and presence of local symptoms. Graves' disease is very rarely detected in a patient with ectopic thyroid. There is no report in literature concerning ectopic thyroid presenting with Graves' disease and unilateral ophthalmopathy. We describe a case with dual ETG and Graves' disease and unilateral ophthalmopathy: it is the first reported in literature.

Herniation of the mylohyoid muscle

During ultrasound examinations in patients with dysphagia, deficiencies in the mylohyoid muscle with herniation of the sublingual gland were found, which may be mistaken as soft tissue tumors. Between the years 2001 and 2003, 205 half-heads used in dissection courses were examined to determine the location and contents of these gaps. In 25 of these cadaveric specimens, the hiatus (of variable size) appeared as small fissures between the divided fibers of the mylohyoid. In 18 cases (72%), the sublingual gland slipped through these deficiencies and occurred in the front part of the submandibular triangle. From the inferior surface of the muscle, the submental artery also coursed through the separated muscle fibers. The herniations of 7 specimens (28%) were found without any contents, neither with gland perforation nor with a submental artery. The following study points out the spatial relation of the salivary glands to the floor of the mouth and the clinical significance, and some factors referred to the development of herniations are discussed.

Adenoid cystic carcinoma associated with salivary duct cyst in the sublingual gland

We described an extremely rare case of adenoid cystic carcinoma associated with salivary duct cyst in the sublingual gland of a 40-year-old Japanese woman. The tumor was growing from the cyst wall and almost occluded the cyst lumen. The epithelium lining the cyst lumen contained both keratin 19-positive cells and alpha-smooth muscle actin-positive cells, indicating the cyst being derived from the acinus/intercalated duct of the sublingual gland. Therefore, our case has presented for the first time a direct evidence that adenoid cystic carcinoma arises from acinus/intercalated duct.

An update of the etiology and management of xerostomia

Salivary gland disease gives rise to salivary gland enlargement, pain, and prolonged xerostomia (dry mouth). Xerostomia is the most common long-standing problem for the majority of affected patients. There are many causes of dry mouth, with long-standing xerostomia being a particular problem in Sjögren's syndrome and after radiation to the head and neck region. Xerostomia is usually managed with saliva substitutes, but a large number of potential systemic therapies of long-standing xerostomia now exist. Some-particularly immunosuppressants-are of fundamental interest for the potential reduction of gland damage in Sjögren's syndrome but as yet are of limited clinical usefulness. Others, particularly pilocarpine and cevimeline, are, or have the potential to be, clinically useful in stimulating salivation by virtue of their action on cholinergic receptors.

Salivary gland disease in pediatric HIV patients: an update

Oral manifestations are one of the earliest clinical indicators of HIV infection and progression in children. Prompt recognition of these signs and symptoms by dental providers can help in the diagnosis and intervention of delaying the progression of HIV disease to AIDS. Salivary gland disease is a common manifestation of HIV infection in pediatric patients, presenting either as gland enlargement and/or xerostomia. The parotid glands by far are most frequently affected, though the other major glands are commonly involved. Diseases of the salivary glands and the corresponding quantitative changes in saliva affect the homeostasis of the oral cavity and account for significant morbidity during the progression of HIV disease. This paper summarizes the research on HIV-related salivary gland disease and outlines treatment and management considerations.

Progressive transformation of germinal centers: a clinicopathological study of 42 Japanese patients

To clarify the clinicopathological features of progressive transformation of germinal center (PTGC) unrelated to nodular lymphocyte predominant Hodgkin's lymphoma in Japanese patients, we reviewed 42 cases and compared the results with those of the United States and Germany. Our results were similar to theirs, with male predominance (M/F ratio, 3:1) and the presentation of a solitary asymptomatic enlarged lymph node in the head and neck area as the common features. However, in Japan, PTGC occurs more frequently in elderly patients. In this study, 12 (29%) of the patients with PTGC were aged 60 years or more. Thirteen patients (31%) with lymphadenopathy in the neck and head area had developed localized chronic inflammation (chronic sialoadenitis=4, chronic tonsillitis=3, infectious epidermal cyst=2) or an autoimmune disorder (hyperthyroidism=2 and bronchial asthma=2). None of the patients developed a malignant lymphoma during the follow-up period of 5 to 238 months (median 27 months). Histologically, in a single longitudinal section of the lymph node, the PTGC occupied up to 5% of the total follicles in 22 patients, 5-10% in 10, 10-20% in 7, and more than 20% in 3. In 5 (12%) patients, an association with prominent marginal zone hyperplasia was also noted. This study also indicates that nodal involvement by various low-grade B-cell lymphomas exhibiting marginal zone distribution patterns should be considered as a differential diagnosis of PTGC. Moreover, in Japan, PTGC is thought to be involved in the etiology of florid reactive follicular hyperplasia in elderly patients.

Treatment of xerostomia: a systematic review of therapeutic trials

The results of the present systematic review of randomized controlled trials published in peer-reviewed journals demonstrate the presence of a wide variety of biases and the weakness of the existing literature of xerostomia treatment. The report of statistically significant efficacy on an outcome measure is only meaningful in the setting of a well-controlled, appropriately designed clinical trial. This points to the importance of evaluating the quality of the clinical trial closely when deciding if study results are applicable to a specific patient population. Future studies in the management of xerostomia will require an increased effort on the part of investigators to eliminate easily recognized flaws during the planning stages of a clinical trial. Minimizing bias in clinical studies will allow for easier interpretation and comparisons of different studies. Better clinical trial design is vital to provide maximal confidence in the efficacy of xerostomia interventions.

Dry mouth and nose in the older patient. What every PCP should know

Dry mouth and dry nose are common complaints among the older population. Dry mouth can be attributed to medical conditions and other underlying causes, whereas dry nose is usually associated with age-related changes in nasal physiology and structure. In both cases, medications can contribute to dryness, so a proper evaluation includes a careful drug review. Management of dry mouth includes hydration and use of mouthwash, sugarless gum, candy, and saliva substitutes. Dry nose can be managed with nasal sprays that moisten the nasal cavity.

Lingual and buccal mandibular bone depressions: a review based on 583 cases from a world-wide literature survey, including 69 new cases from Japan

OBJECTIVES

To review present knowledge of so-called lingual and buccal mandibular bone depressions (n = 583) based on studies of 247 contemporary and 267 archaeological cases from a world-wide literature survey in addition to 69 new cases from Japan.

METHODS

The 69 cases from Japan were retrieved through examination of 42,600 consecutive panoramic radiographs.

RESULTS

Bone depressions can be divided into four topographical variants: (1) lingual anterior mandibular body (incisor-canine- premolar area) above the mylohyoid muscle; (2) posterior to the mandibular angle-first permanent molar area, below the mandibular canal, and a third located to the ascending, lingual mandibular ramus, posterior to the lingual foramen, just below the neck of the condyle. An excessively rare fourth variant is located to the buccal aspects of the ascending mandibular ramus.

CONCLUSIONS

The present concept favours that all variants have a common origin: a hyperplastic/hypertrophic lobe (or aberrant lobe) of the sublingual, submandibular or parotid salivary gland, exerting pressure upon the cortex of the mandible by the respective gland, leading to focal atrophy or resorption of the bone. The bone depressions take years to develop, appearing radiographically not until the 5th to 6th decades.

Saliva and gastrointestinal functions of taste, mastication, swallowing and digestion

Saliva has multiple essential functions in relation to the digestive process taking place in the upper parts of the gastrointestinal (GI) tract. This paper reviews the role of human saliva and its compositional elements in relation to the GI functions of taste, mastication, bolus formation, enzymatic digestion, and swallowing. The indirect function of saliva in the digestive process that includes maintenance of an intact dentition and mucosa is also reviewed. Finally, pathophysiological considerations of salivary dysfunction in relation to some GI functions are considered.

Syndromes with salivary dysfunction predispose to tooth wear: Case reports of congenital dysfunction of major salivary glands, Prader-Willi, congenital rubella, and Sjögren's syndromes

Four cases-of congenital dysfunction of the major salivary glands as well as of Prader-Willi, congenital rubella, and Sjögren's syndromes-were identified in a series of 500 patients referred for excessive tooth wear. Although there was evidence of consumption of highly acidic drinks, some occlusal parafunction, and unacceptable toothbrushing habits, salivary dysfunction was the salient factor predisposing a patient to tooth wear in these syndromal cases. The 500 subjects have been characterized either as having medical conditions and medications that predispose them to xerostomia or lifestyles in which workplace- and sports-related dehydration lead to reduced salivary flow. Normal salivation, by buffering capacity, clearance by swallowing, pellicle formation, and capacity for remineralization of demineralized enamel, protects the teeth from extrinsic and intrinsic acids that initiate dental erosion. Thus, the syndromes, unrelated in many respects, underline the importance of normal salivation in the protection of teeth against tooth wear by erosion, attrition, and abrasion.

Plunging ranula as a complication of intraoral removal of a submandibular sialolith

Mucous cysts in the submandibular region--so-called 'plunging' ranula--are relatively uncommon. We report a case of a plunging ranula that complicated excision of an intraductal sialolith of the submandibular gland.

Effect of saliva substitutes on mineral content of demineralized and sound dental enamel

The aim of this in vitro study was to evaluate the effects of commercially available saliva substitutes on the mineral content of pre-demineralized and sound enamel. From 56 bovine incisors 224 enamel specimens were prepared and hand-polished. The specimens were partially covered with nail varnish (control of sound enamel). In group 1, 112 samples were demineralized (18 days; 37 degrees C; pH 5.0) and a portion of the demineralized area was likewise covered with nail varnish. Subsequently, 16 specimens were exposed (14 days; 37 degrees C) to 10 ml of each of several different saliva substitutes (Artisial; Glandosane; Oralube; Saliva medac), or mouthwash solutions (Biotène; Meridol), respectively. Non-carbonated, fluoride-containing mineral water (Eptinger) was used as control. In group 2, the 112 sound enamel specimens were immersed directly in the solutions (without a demineralization period). After immersion, the specimens were cut perpendicular to the surface, and slabs (110 microns) were ground. Contact microradiographs were obtained and studied with a digital image-analyzing system. A dedicated software (TMR 1.24) was used to calculate the mineral content. Sound enamel (group 2) was significantly demineralized after immersion in Biotène and Glandosane (P < 0.001; Kruskal-Wallis). In group 1, mineral loss after storage in Biotène and Glandosane was significantly increased (P < 0.001), compared with the mineral content after demineralization. All other solutions revealed a significant mineral gain (P < 0.01; Wilcoxon), with the most pronounced effects after use of Oralube and mineral water (both containing calcium, phosphates, and fluorides). Therefore, administration of products similar to the last named can be recommended for dentate patients with salivary gland hypofunction.

Characteristics of salivary diffuse infiltrative lymphocytosis syndrome in West Africa

OBJECTIVE

To determine the prevalence of diffuse infiltrative lymphocytosis syndrome (DILS) in the minor salivary glands of 30 African Cameroonian adults with the acquired immunodeficiency syndrome (AIDS).

DESIGN

Salivary gland tissue was analyzed using a modified classification system that was developed to aid the diagnosis of Sjögren syndrome. The advantages and disadvantages of this approach are discussed.

MATERIALS AND METHODS

Formalin-fixed, paraffin-embedded, hematoxylin-eosin-stained biopsy sections were prepared for 30 patients with AIDS, 26 healthy individuals who declined human immunodeficiency virus (HIV) testing, and 4 seronegative healthy controls. Tissues were immunostained for CD4/CD8+ lymphocytes and cytomegalovirus (CMV), and transmission electron microscopy was performed to locate viral particles. Patients were tested for HIV-1 and HIV-2 by the HIV/Chek System 3 or CAMSTIX-HIV-1 and HIV-2 assay.

RESULTS

Severe salivary ductal atypia (96%) was the feature most strongly associated with AIDS, and the lymphocytic focus score was the second histologic feature most strongly correlated with AIDS. Forty-eight percent of patients with HIV-1 infection had more than 1 lymphocytic focus in a minor salivary gland. These lymphocytes were primarily CD8+. We report, to the best of our knowledge, the first case of multinucleated salivary duct epithelial cells in minor salivary glands also containing enveloped virus particles. All cases were negative for CMV.

CONCLUSIONS

The prevalence of DILS in West Africans with AIDS appears higher than the prevalence reported in whites from the United States and Europe and in blacks from the United States, a group that has been reported to have a greater incidence of DILS than whites. This discrepancy may be related to differences in patient selection criteria. The determination of lymphocytic focus score, as used in the diagnosis of Sjögren syndrome, with the adjunct of ductal atypia is useful for assessing DILS. The impact of patient selection, drug therapy, and parasites on salivary gland pathology is discussed.

Frequency of oral manifestations in children infected with human immunodeficiency virus

OBJECTIVE

The main objective of this study was to investigate the frequency of oral manifestations in children with acquired immunodeficiency syndrome. It also attempted to correlate the presence of lesions with the patient's degree of immunosuppression, as measured by the T4/T8 ratio.

METHOD AND MATERIALS

Oral examinations were performed in 51 children with acquired immunodeficiency syndrome for a 2-year period. A questionnaire used in this investigation was based on the children's classification proposed by the Centers for Disease Control in 1987. The children's T4/T8 ratios were obtained from their medical files.

RESULTS

Pseudomembranous candidiasis was the most common lesion, found in 21.57% of the children. Salivary gland disease was present in 19.61% of patients. Erythematous candidiasis was observed in 5.88%, and linear gingival erythema and oral hairy leukoplakia were both observed in 1.96% of children. Children with a T4/T8 ratio < 0.5 were more prone to development of pseudomembranous candidiasis.

CONCLUSION

Pseudomembranous candidiasis was the most common type of oral lesion in human immunodeficiency virus-positive children with acquired immunodeficiency syndrome. There was a relationship between the frequency of oral manifestations and the patient's T4/T8 ratio.

Utility of fine-needle aspiration in the diagnosis of salivary gland lesions in patients infected with human immunodeficiency virus

Fine-needle aspiration (FNA) has been increasingly utilized as a diagnostic tool in evaluating salivary gland masses, primarily to differentiate nonneoplastic from neoplastic lesions. Patients infected with human immunodeficiency virus (HIV) frequently present with salivary gland lesions. In this study, we reviewed the cytology of salivary gland lesions in HIV-infected patients and assessed the value of FNA in the diagnosis of salivary gland lesions in HIV-infected patients. One hundred and three FNAs of salivary gland lesions from 78 HIV-infected patients (63 males and 15 females) were included in our study. The patients' ages ranged from 7-65 yr, with a mean age of 40.9 yr. FNAs were classified into three categories: benign lymphoepithelial lesions (BLL) (77 cases or 74.8%), inflammatory processes (14 cases or 13.6%), including 3 reactive lymphoid hyperplasia, and neoplastic lesions (6 cases or 5.8%). The latter included three malignant lymphomas, a multiple myeloma, a metastatic adenocarcinoma from a lung primary, and a direct extension of basal-cell carcinoma. Six (5.8%) aspirates were nondiagnostic. No false-positive or false-negative cases were noted during follow-up of these patients. In conclusion, FNA is a simple and cost-effective procedure for the diagnosis of HIV-related salivary gland lesions. The majority of these lesions are cystic BLL and can be managed conservatively. Malignant lesions are rarely encountered and are readily recognized by FNA. Diagn. Cytopathol. 1999;21:260-264.

[Primary Sjögren's syndrome presenting as unconsciousness associated with IgA-lambda M-protein]

We describe the case of a 43-year-old woman who presented with primary Sjögren's syndrome (SS) which manifestated as unconsciousness due to M protein. A diagnosis of SS was made based on a ten-year history of dryness, a Shirmer test, and the histological findings of labial biopsy. A rouleaux formation was observed and serum protein electrophoresis revealed a monoclonal spike of 4.0 gm/dl in the gamma-region, which was characterized as IgA-lambda. Biopsy of the minor salivary glands showed marked polyclonal lymphoproliferation with lymphoid follicles, including both T cells and B cells as revealed by immunohistological staining. Therefore, the patient had a lymphoproliferative lesion of the minor salivary glands, which is also known as pseudolymphoma. We conclude that fainting associated with marked M protein may be manifestation of SS. Such cases should be followed carefully since the subsequent neoplastic transformation of pseudolymphomas have been previously reported.

[Late onset of type I familial amyloid neuropathy: results of biopsy from accessory salivary glands]

Familial amyloidotic polyneuropathy (FAP) type I is usually characterized by onset in the third decade, autonomic nervous system failure, and heart block conduction occurring after the onset of neurological symptoms. A 74-year-old woman, with past medical history of a third degree heart block treated by a pace-maker, was hospitalized because of an axonal sensory-motor polyneuropathy, without autonomic dysfunction. There was no familial history. Because she complained of mouth dryness, biopsies of the labial salivary glands were performed, showing amyloid deposits. Immuno-histochemicals studies confirmed the presence of transthyretin. We analysed the transthyretin gene of the patient and her asymptomatic son, and found in both cases, the point mutation leading to the single amino acid substitution of a methionine for valine at position 30, which is typical of type I FAP. This case revealed the clinical variation of FAP type I and the interest of biopsies of the labial salivary glands in the diagnosis of polyneuropathies.

Microlithiasis in parotid sialadenosis and chronic submandibular sialadenitis is related to the microenvironment: an ultrastructural and microanalytical investigation

AIMS

Microlithiasis was investigated in parotid sialadenosis and chronic submandibular sialadenitis to determine if it relates to the glandular microenvironment as has been found experimentally.

METHODS AND RESULTS

Semithin sections were stained by a mixture of methylene blue and Azure II followed by basic fuchsin, which stains calcified parts of microliths red and organic parts green, and ultrathin sections were examined electron microscopically and microanalytically. Microliths in sialadenosis were found in periacinar stroma, in which necrotic acinar cells were found, and in parenchyma, and consisted of consolidated organic material with little or no crystalline calcium. Microliths in sialadenitis were found in stroma, particularly around intercalary ducts, in lumina and in parenchyma, and contained much crystalline calcium. Macrophages enclosed some microliths.

CONCLUSIONS

The paucity of calcium in microliths in sialadenosis and the abundance in sialadenitis relates to the glandular calcium. The periacinar distribution of microliths in sialadenosis possibly relates to formation in periacinar necrotic debris. The distribution of microliths in sialadenitis around intercalary ducts possibly relates to formation in matrix vesicles formed from atrophic parenchyma, and in lumina to formation in stagnant secretory material. Microliths appear to be scavenged by macrophages. Thus the experimental finding that salivary microlithiasis relates to the microenvironment pertaining in humans.

Minor salivary gland hyalinisation and amyloidosis in low-grade lymphoma of MALT

Two patients with low-grade lymphoma of mucosa-associated lymphoid tissue (MALT) arising in primary Sjögren's syndrome developed solitary nodules in their lips. Histologically both lesions showed enlargement and hyalinisation of single minor salivary glands with acinar atrophy, loss of most ducts and conversion into almost acellular sclerotic eosinophilic masses. In one case the lesion was shown to contain an amyloid component. No amyloid was detected in the second case but deposition of collagen and basement membrane and sclerotic neoplasm were excluded.