Obstructive salivary gland disease

This paper provides an overview of the most common cause of salivary gland complaints presenting to the general dental practitioner, obstructive salivary gland disease (OSGD). It is important to be aware of the characteristic signs and symptoms to allow for appropriate management and onward referral.

Treatment of Sialolithiasis: What Has Changed? An Update of the Treatment Algorithms and a Review of the Literature

Treatment for sialolithiasis has undergone significant changes since the 1990s. Following the development of new minimally invasive and gland-preserving treatment modalities, a 40-50% rate of gland resection was reduced to less than 5%. Extracorporeal shock-wave lithotripsy (ESWL), refinement and extension of methods of transoral duct surgery (TDS), and in particular diagnostic and interventional sialendoscopy (intSE) are substantial parts of the new treatment regimen. It has also become evident that combining the different treatment modalities further increases the effectiveness of therapy, as has been especially evident with the combined endoscopic-transcutaneous approach. In the wake of these remarkable developments, a treatment algorithm was published in 2009 including all the known relevant therapeutic tools. However, new developments have also taken place during the last 10 years. Intraductal shock-wave lithotripsy (ISWL) has led to remarkable improvements thanks to the introduction of new devices, instruments, materials, and techniques, after earlier applications had not been sufficiently effective. Techniques involving combined approaches have been refined and modified. TDS methods have been modified through the introduction of sialendoscopy-assisted TDS in submandibular stones and a retropapillary approach for distal parotid sialolithiasis. Recent trends have revealed a potential for significant changes in therapeutic strategies for both major salivary glands. For the submandibular gland, ISWL has replaced ESWL and TDS to some extent. For parotid stones, ISWL and modifications of TDS have led to reduced use of ESWL and the combined transcutaneous-sialendoscopic approach. To illustrate these changes, we are here providing an updated treatment algorithm, including tried and tested techniques as well as promising new treatment modalities. Prognostic factors (e.g., the size or location of the stones), which are well recognized as having a strong impact on the prognosis, are taken into account and supplemented by additional factors associated with the new applications (e.g., the visibility or accessibility of the stones relative to the anatomy of the duct system).

Intraductal Fragmentation in Sialolithiasis Using Pneumatic Lithotripsy: Initial Experience and Results

OBJECTIVE

To report initial experience in using a pneumatic lithotripter to treat salivary stones.

STUDY DESIGN

Level IV retrospective study.

SETTING

University hospital and tertiary referral center.

METHODS

A pneumatic lithotripter was used to treat salivary stones after these were diagnosed. Probes with diameters of 0.7 mm were used. Total fragmentation was intended in all stones. Stone fragments were removed using several instruments in serial sialendoscopies to achieve complete stone clearance.

RESULTS

A total of 62 patients with 77 stones were treated. Forty-three submandibular stones were treated in 34 patients, and 34 parotid stones were treated in 28 patients. An operating pressure of 2.5 bar and a single frequency mode were used. Complete fragmentation was achieved in all but one of the treated stones in both glands (98.7%). Among the patients, 90.32% became stone free and 100% symptom free. Multiple stones were treated in 24.19% of the patients, and multimodal therapy was also carried out in 24.19%. All of the glands were preserved.

CONCLUSIONS

The pneumatic lithotripter proved to be effective in the treatment of sialolithiasis. Stone size, location, and the gland involved were important clinical factors. The device was sufficient to achieve success without any increased risk for complications in the patients or damage to the sialendoscopes.

Intraductal Lithotripsy in Sialolithiasis Using the Calculase III™ Ho:YAG Laser: First Experiences

BACKGROUND AND OBJECTIVES

To report the first experiences with a newly available Ho:YAG laser system for the treatment of salivary stones.

STUDY DESIGN/MATERIALS AND METHODS

A retrospective study in a tertiary referral center was conducted. Patients diagnosed with sialolithiasis were treated in Erlangen using the Calculase III™ Ho:YAG laser (Karl Storz, Tuttlingen, Germany). Preset parameters had a frequency of 4 Hz and energy of 0.8-1.2 J, resulting in 3.2-4.8 W. Following total fragmentation, one to two serial sialendoscopies were performed to achieve complete fragment clearance.

RESULTS

A total of 55 stones in 49 patients were treated; 17 stones in 15 submandibular glands and 38 in 34 parotids. In total, 61 laser lithotripsies (range 1-3 per stone) were performed using various modes (long, short, and burst) and with preset parameters of 4 Hz and energy of 0.8-1.2 J, resulting in effective power of 3.2-4.8 W. Complete fragmentation was achieved in all the accessible stones. Sialendoscopes, fibers, or the mode used had no significant influence on success rates. A multimodal therapy concept was employed to treat stones in 12.24% of the cases; 95.92% of the patients were ultimately stone-free, and all became symptom-free. All glands were preserved.

CONCLUSIONS

The new Calculase III™ Ho:YAG laser was effective in the treatment of sialolithiasis with no increased risk of complications in the patients or damage to the sialendoscopes. Clinical factors such as the type of gland involved, or the location and size of stones had a greater impact on success rates than the technical or preset parameters. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Success rate and complications of sialendoscopy and sialolithotripsy in patients with parotid sialolithiasis: a systematic review

PURPOSE

To assess the success rate and complications of sialendoscopy and sialolithotripsy for parotid sialolithiasis.

MATERIALS AND METHODS

A total of 228 articles were identified by the electronic database search regarding the topics sialendoscopy and sialolithotripsy. Following independent then joint review of titles and abstracts, 109 articles were selected for the full review. Thirteen of these were chosen for data extraction from which 1285 patients with parotid salivary stones were identified. Extracted data included number of patients, age, gender, location, management, and outcomes.

RESULTS

All articles combined, 1285 patients with parotid salivary stones were included with a successful treatment in 1139 patients. The success rated ranged from 71.4 to 100% with a mean of 88.7%. Both partial as complete success was achieved. Although minor complications were frequent, no major complications occurred.

CONCLUSIONS

Sialendoscopy and sialolithotripsy are best suited as first choice treatment-if conservative therapy failed-for the management of parotid gland sialolithiasis. It is a valuable and feasible treatment option with no major complications. Selection of cases will ensure the best prognosis. Although there is no indefinite stone size, the smaller the calculus, the greater the probability of a symptom-free patient.

Mineralization of Sialoliths Investigated by Ex Vivo and In Vivo X-ray Computed Tomography

The fraction of organic matter present affects the fragmentation behavior of sialoliths; thus, pretherapeutic information on the degree of mineralization is relevant for a correct selection of lithotripsy procedures. This work proposes a methodology for in vivo characterization of salivary calculi in the pretherapeutic context. Sialoliths were characterized in detail by X-ray computed microtomography (μCT) in combination with atomic emission spectroscopy, Fourier transform infrared spectroscopy, X-ray diffraction, scanning electron microscopy, and transmission electron microscopy. Correlative analysis of the same specimens was performed by in vivo and ex vivo helical computed tomography (HCT) and ex vivo μCT. The mineral matter in the sialoliths consisted essentially of apatite (89 vol%) and whitlockite (11 vol%) with average density of 1.8 g/cm3. In hydrated conditions, the mineral mass prevailed with 53 ± 13 wt%, whereas the organic matter, with a density of 1.2 g/cm3, occupied 65 ± 10% of the sialoliths' volume. A quantitative relation between sialoliths mineral density and X-ray attenuation is proposed for both HCT and μCT.

Intraductal Pneumatic Lithotripsy after Extended Transoral Duct Surgery in Submandibular Sialolithiasis

Objective

Persistent, residual, or recurrent stones after transoral duct surgery are always associated with hilar to intraparenchymal and/or multiple sialolithiasis, causing difficulties in the treatment. This study was performed to assess the value of intraductal lithotripsy in the treatment of persistent, residual, or recurrent sialolithiasis after extended duct surgery in the submandibular gland.

Study Design

Retrospective study covering February 2015 to June 2018.

Study Setting

Tertiary referral center for salivary gland diseases.

Subjects and Methods

After extended ductal surgery, 39 patients presenting with persistent, residual, or recurrent stones were treated. Four patients had persistent stones; 16 had residual stones; and 19 presented with recurrent stones. Among these patients, 50 stones were treated with intraductal pneumatic lithotripsy. Fragmentation rate, stone-free rate, and symptom-free rate after treatment with intraductal lithotripsy were outcome measures.

Results

Of the 39 patients, 97.4% became stone-free, and all were symptom-free. Ninety-eight percent of the stones were completely fragmented. For 23.1% of the patients, >1 stone was treated with intraductal lithotripsy. All patients with persistent stones, 93.7% of those with residual stones, and all with recurrent stones became stone-free and symptom-free. No severe complications developed.

Conclusions

This study shows that patients presenting with difficult and/or multiple sialolithiasis after extended transoral submandibular duct surgery can be treated with success rates >97%. For multiple sialolithiasis in particular, a multimodal treatment approach with interventional sialendoscopy and intraductal lithotripsy as a central element is a prerequisite for success, as this enables the most difficult part to be performed with high success rates.

Salivary lithotripsy in the era of sialendoscopy

The traditional management of obstructive salivary disorders has been replaced by minimally-invasive gland-preserving techniques including shock-wave lithotripsy, sialendoscopy, interventional radiology and endoscopically video-assisted trans-oral and cervical stone retrieval, of which sialendoscopy is considered to be the method of first choice. Primary endoscopically controlled stone extraction without prior fragmentation is only possible in 15-20% of cases; in more than 80%, fragmentation is necessary because of the size, impactation and location of the stone, or an alternative treatment such as transoral duct surgery or combined approaches are required. Moreover, about 10-20% of all stones cannot be adequately accessed by means of a sialendoscope or any alternative surgical method and, in such cases, extra-corporeal shock wave lithotripsy (ESWL) is the treatment of choice. However, in endoscopically accessible stones, ESWL is being gradually replaced by endoscopically assisted intra-corporeal techniques, including endoscopically guided laser and pneumatic intracorporeal lithotripsy. We describe the currently most widely used techniques for salivary lithotripsy, including ESWL, and endoscopically guided laser, electrohydraulic, electrokinetic and pneumatic intra-corporeal lithotripsy, and discuss their indications given the widespread use of advanced rehabilitative sialendoscopy and combined therapeutic approaches.

Cost-effectiveness of transfacial gland-preserving removal of parotid sialoliths

OBJECTIVE

Examine outcomes of transfacial gland-preserving removal of difficult parotid stones and compare the cost and operative time to traditional parotidectomy.

STUDY DESIGN

Cost-effectiveness analysis and retrospective chart review.

METHODS

Patients who underwent transfacial removal of symptomatic parotid sialoliths at a tertiary medical center from June 2010 to July 2015 were evaluated. Outcomes included operative technique, stone size, stone location, complications, and symptom relief. In addition, patients who underwent traditional parotidectomy for chronic sialadenitis were identified. The charges and times for both procedures were reviewed and compared.

RESULTS

Forty-four patients underwent transfacial resection for symptomatic parotid sialolithiasis. Stones were most often located in the main duct and hilum (53.3%), with fewer intraglandular stones (46.7%). No facial nerve weakness was observed. Of those with follow-up, 33 (87%) patients reported at least partial resolution of symptoms. Overall transfacial technique charges were significantly less expensive (U.S.$) than parotidectomy (mean difference -8,064.09; 95% confidence interval [CI] -13,472.78 to -2,655.40; P = 0.033). Anesthesia charges (mean difference -2,997.85; 95% CI, -5,748.81 to -246.89; P = 0.035) and operating room charges (mean difference -4,793.91; 95% CI, -8,958.09 to -629.72; P = 0.028) were also less expensive for the transfacial technique. Finally, mean procedure time for transfacial removal of parotid stones was shorter than for parotidectomy (120.2 ± 49.9 vs. 178.4 ± 41.3 minutes, respectively; P = 0.002).

CONCLUSION

Transfacial gland-preserving removal of difficult parotid stones is a well tolerated and effective alternative to parotidectomy. Moreover, it is faster and less expensive than parotidectomy, maximizing both surgeon time and hospital resources.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1080-1086, 2017.

Growth Factors in Bone Marrow Blood of the Mandible With Application of Extracorporeal Shock Wave Therapy

INTRODUCTION

Enhancement of bone regeneration is crucial to dental implantology. Growth factors play a significant role during osteogenesis and angiogenesis. Extracorporeal shock wave therapy (ESWT) enhances bone healing; however, no studies have yet been performed in oral implantology.

MATERIALS AND METHODS

Twenty patients who underwent bilateral mandibular wisdom tooth removal were included. ESWT was applied to 1 side of the jaw. Blood samples were collected from the peripheral vein (PB), mandibular bone marrow without and with ESWT (BM-/+SW). Quantity and quality of the growth factors bone morphogenetic protein (BMP)-2, BMP-4, insulin-like growth factor 1 (IGF-1), vascular endothelial growth factor (VEGF), and transforming growth factor-beta (TGF-β) were investigated via ELISA and cell proliferation assay.

RESULTS

ELISA revealed superior amounts of IGF-1 and VEGF in BM-/+SW compared to PB (P < 0.05). TGF-β demonstrated no variance. Levels of BMP-2 and BMP-4 were too low for adequate detection in the ELISA. No difference was noticed upon ESWT. The cell proliferation assay did not identify any changes comparing PB versus BM-SW versus BM + SW.

CONCLUSION

IGF-1 and VEGF are present at higher levels in mandibular bone marrow than in peripheral blood (PB). This study did not identify any benefits of extracorporeal shock wave therapy to increase the investigated growth factors.

Ultrasound: A Revenant Therapeutic Modality in Dentistry

An ultrasound (US) gives a visible image of the organs that are present inside the body. In medicine it serves for diagnosing and also its therapeutic benefits are well established for bone healing, osteointegration and soft tissue healing. In dentistry it is widely used for diagnostic purposes. When it was discovered it was introduced for therapeutic purposes, but due to lack of clinical studies its use as therapy was remittent in dentistry. The aim of the present paper was to establish the efficiency of therapeutic US in maxillofacial region for alleviating the pain and to see the other applications. Our search included the English terms like ultrasonography, applications, dentistry in Google search engine, PubMed and Medline from 1980 to 2015. We found very few articles showing the effects of therapeutic Ultrasound (US) in treatment of pain and healing in dentistry. We concluded that clinical benefits of in vivo studies were very little and demands further rigorous research to strive for the therapeutic success of US.

Does drinking water influence hospital-admitted sialolithiasis on an epidemiological level in Denmark?

OBJECTIVES

Sialolithiasis, or salivary stones, is not a rare disease of the major salivary glands. However, the aetiology and incidence remain largely unknown. Since sialoliths are comprised mainly of calcium phosphate salts, we hypothesise that drinking water calcium levels and other elements in drinking water could play a role in sialolithiasis. Owing to substantial intermunicipality differences in drinking water composition, Denmark constitutes a unique environment for testing such relations.

DESIGN

An epidemiological study based on patient data extracted from the National Patient Registry and drinking water data from the Geological Survey of Denmark and Greenland retrieved as weighted data on all major drinking water constituents for each of the 3364 waterworks in Denmark. All patient cases with International Statistical Classification of Diseases 10th Revision (ICD-10) codes for sialolithiasis registered between the years 2000 and 2010 were included in the study (n=3014) and related to the drinking water composition on a municipality level (n=98).

PRIMARY AND SECONDARY OUTCOME MEASURES

Multiple regression analysis using iterative search and testing among all demographic and drinking water variables with sialolithiasis incidence as the outcome in search of possible relations among the variables tested.

RESULTS

The nationwide incidence of hospital-admitted sialolithiasis was 5.5 cases per 100,000 citizens per year in Denmark. Strong relations were found between the incidence of sialolithiasis and the drinking water concentration of calcium, magnesium and hydrogen carbonate, however, in separate models (p<0.001). Analyses also confirmed correlations between drinking water calcium and magnesium and their concentration in saliva whereas this was not the case for hydrogen carbonate.

CONCLUSIONS

Differences in drinking water calcium and magnesium may play a role in the incidence of sialolithiasis. These findings are of interest because many countries have started large-scale desalination programmes of drinking water.

Ho:Yag Laser for Sialolithiasis of Wharton’s Duct

Objective

To assess the feasibility of intracorporeal lithotripsy with holmium YAG laser under sialoendoscopic guidance for sialolithiasis of Wharton’s duct.

Study Design

Case series with planned data collection.

Setting

Tertiary referral university hospital.

Methods

This study was conducted on 16 patients with sialolithiasis of Wharton’s duct. Diagnosis was confirmed at ultrasound examination. Patients with stones ranging from 5 to 8 mm in diameter were enrolled in the study. The selected patients underwent intracorporeal lithotripsy with holmium Yag laser under endoscopic control. Debris was removed using sialoendoscopic forceps or a wire basket during the same procedure. After a 3-month follow-up, radiological tests were rerun.

Results

Stone fragmentation was possible in all cases. All patients experienced a regular postoperative course. Postoperative ultrasound examinations revealed residual stones in 3 patients, 1 of whom was asymptomatic. Three patients complained of residual symptoms after 3 months of follow-up. These patients were treated successfully during a second sialoendoscopic procedure.

Conclusions

In our experience, endoscopic laser lithotripsy was proved to be a feasible technique for Wharton’s duct lithiasis in clinical practice.

Sialendoscopy in the Diagnosis and Treatment of Sialolithiasis

Objective

Sialendoscopy and other gland-preserving techniques such as extracorporeal shockwave lithotripsy (ESWL), transoral stone removal, and combinations of these methods have fundamentally changed the therapeutic approach to salivary stones. Since 2003, all patients presenting with sialolithiasis have been diagnosed and treated with the same algorithm and routine salivary gland endoscopy (SGE).

Study Design

Case series with chart review of patients with sialolithiasis treated between 2003 and 2008 using an algorithm for gland preservation.

Setting

Tertiary referral academic medical center.

Subjects and Methods

A total of 1154 patients with suspected sialolithiasis were identified and reviewed. Factors analyzed included stone location, size, surgical method, rate of stone clearance, complications, and rate of short- and long-term symptom resolution. Successful treatment was defined as freedom from symptoms at follow-up.

Results

Diagnostic sialendoscopy confirmed 221 parotid stones and 812 submandibular stones, of which 206 and 736, respectively, were treated. Transoral stone removal was the most frequently used method to remove submandibular stones (92%), with a smaller percentage able to be removed by SGE alone (5%) with long-term success rates ≥90%. Only 4% (29/736) required submandibular gland removal. Parotid stones were removed by SGE (22%), combined SGE and incisional technique (26%), or ESWL (52%), with long-term success rates of 98%, 89%, and 79%, respectively. Only 8 of 206 (4%) patients eventually required parotidectomy.

Conclusion

Salivary gland endoscopy is an important diagnostic and therapeutic tool in the management of sialolithiasis but must be combined with additional techniques to ensure a high rate of stone clearance, symptom resolution, and gland preservation.