Lipids associated with mineralization of human submandibular gland sialoliths

Rapid development of a salivary calculus in submandibular gland and its potential causes in a young victim following Russell's viper bite

Russell's viper bites are known to cause a range of haemotoxic, neurotoxic, myotoxic, cytotoxic and nephrotoxic complications. However, the impact of Russell's viper bites as well as bites from other venomous snakes on sialolithiasis has not been previously reported. Here, we present an interesting case where a Russell's viper bite induced the rapid development of a calculus in submandibular gland in a 10-year-old boy. Upon admission, the victim did not show any symptoms of swelling and/or pain around his oral cavity. He received antivenom treatment to normalise his coagulation parameters, however, on day three he developed swelling and extreme pain around his right mandibular region. An ultrasound investigation revealed the presence of a calculus in his submandibular gland, which was removed using a minor surgical procedure. The histopathological examination revealed this as a poorly calcified salivary calculus, which is composed of cell debris, mucopolysaccharides and lipids. The mechanisms behind its rapid development following a snakebite are unclear although this could be linked to excessive inflammation or modifications to the composition of saliva induced by venom toxins or other unknown factors. This report reveals an unusual complication induced by a Russell's viper bite and alerts clinicians who treat snakebites to be aware of such envenomation effects. Moreover, this will lead to novel research to explore the relationship between venom toxins and functions of salivary glands.

Neutrophil Extracellular Traps Promote the Development and Growth of Human Salivary Stones

Salivary gland stones, or sialoliths, are the most common cause of the obstruction of salivary glands. The mechanism behind the formation of sialoliths has been elusive. Symptomatic sialolithiasis has a prevalence of 0.45% in the general population, is characterized by recurrent painful periprandial swelling of the affected gland, and often results in sialadenitis with the need for surgical intervention. Here, we show by the use of immunohistochemistry, immunofluorescence, computed tomography (CT) scans and reconstructions, special dye techniques, bacterial genotyping, and enzyme activity analyses that neutrophil extracellular traps (NETs) initiate the formation and growth of sialoliths in humans. The deposition of neutrophil granulocyte extracellular DNA around small crystals results in the dense aggregation of the latter, and the subsequent mineralization creates alternating layers of dense mineral, which are predominantly calcium salt deposits and DNA. The further agglomeration and appositional growth of these structures promotes the development of macroscopic sialoliths that finally occlude the efferent ducts of the salivary glands, causing clinical symptoms and salivary gland dysfunction. These findings provide an entirely novel insight into the mechanism of sialolithogenesis, in which an immune system-mediated response essentially participates in the physicochemical process of concrement formation and growth.

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.

Characterization of a submandibular gland sialolith: micromorphology, crystalline structure, and chemical compositions

OBJECTIVE

The aim of this study was to understand the mechanism of mineralization and growth of a sialolith by analyzing its micromorphology, crystalline structure, and chemical compositions.

STUDY DESIGN

A sialolith was removed along with submandibular salivary gland from a patient. After cross-cutting and polishing the sialolith, its morphology, chemical compositions, crystalline structure, and chemical states were analyzed by using optical camera, scanning electron microscopy, energy dispersive X-ray spectroscopy, X-ray diffractometer, Fourier transform infrared spectrophotometer, and transmittance electron microscopy.

RESULTS

The sialolith had a core composed of organic material, such as lipid compounds, and the surrounding mineralized shell structure mostly consisted of hydroxyapatite. In the transition zone between the organic core and mineralized shell layers, inorganic layers were arranged alternately with organic layers. Congregated globular structures were calcified with hydroxyapatite and whitlockite crystallites. Analysis of crystalline structures and chemical compositions suggested that calcium phosphate minerals containing magnesium, such as whitlockite, were developed in the initial stage and gradually transformed into crystallites composed of hydroxyapatite during the growth of crystallites.

CONCLUSIONS

Sialolith with an organic core grew as inorganic materials were deposited and calcified in alternate layers. The mineralization process might include the initial whitlockite development and successive transformation into more stable hydroxyapatite.

Structure and growth of sialoliths: computed microtomography and electron microscopy investigation of 30 specimens

Theories have been put forward on the etiology of sialoliths; however, a comprehensive understanding of their growth mechanisms is lacking. In an attempt to fill this gap, the current study has evaluated the internal architecture and growth patterns of a set of 30 independent specimens of sialoliths characterized at different scales by computed microtomography and electron microscopy. Tomography reconstructions showed cores in most of the sialoliths. The cores were surrounded by concentric or irregular patterns with variable degrees of mineralization. Regardless of the patterns, at finer scales the sialoliths consisted of banded and globular structures. The distribution of precipitates in the banded structures is compatible with a Liesegang-Ostwald phenomenon. On the other hand, the globular structures appear to arise from surface tension effects and to develop self-similar features as a result of a viscous fingering process. Electron diffraction patterns demonstrated that Ca- and P-based electrolytes crystallize in a structure close to that of hydroxyapatite. The organic matter contained sulfur with apparent origin from sulfated components of secretory material. These results cast new light on the mechanisms involved in the formation of sialoliths.

Proteomic and scanning electron microscopic analysis of submandibular sialoliths

OBJECTIVES

Several theories have been proposed regarding the genesis of sialoliths, including the organic core theory, which suggests epithelial or bacterial etiology originating in the central core. Our aim was to use novel methodologies to analyze central areas (the core) of calculi from sialolithiasis patients.

MATERIALS AND METHODS

The structures of the halves of six submandibular salivary stones were analyzed by scanning electron microscopy (SEM). After structural analysis, from the other six halves, samples from the central parts of the core and peripheral parts of the core were digested with trypsin and analyzed by matrix-assisted laser desorption ionization-time of flight mass spectrometry. The peptide mass fingerprints were compared with the results of in silico digestion.

RESULTS

SEM analysis of the sialoliths showed that organic structures (collagen/fibrous-like structures, bacterial fragments) were visible only outside of the core in the concentric layers of external areas, but not in the core area. The mass spectrometry (MS)/MS post-source decay experiments were completed from the four, most intense signals observed in the MS spectrum and human defensin was proven to be present in three of the examined samples, originated from the peripheral region of three cores.

CONCLUSIONS

Although proteomic analysis demonstrated defensin protein in the peripheral region of the core in three sialoliths, SEM failed to prove organic structures in the core.

CLINICAL RELEVANCE

New investigation modalities still cannot prove organic structures in the core, henceforward challenging the organic core theory.

Lithogenesis: induction of renal calcifications by nanobacteria

Nanobacteria have been isolated from kidney stones and it has been suggested that they may act as a nucleus for the initiation of the renal stones. In the present study, we examine their role in biocrystallization and their in vivo effects on kidney pathology. Calcium oxalate monohydrate (COM) assay was carried out in the presence of nanobacteria to study biocrystallization. Wistar rats were given an intravenous injection of nanobacteria and the kidneys were examined for pathological changes. The COM assay showed accelerated biocrystallization of (14)C-oxalate in the presence of nanobacteria, indicating them to be efficient candidates for biomineralization. Histopathological studies revealed bacteria induced renal tubular calcifications and various manifestations of infection. Our studies confirm that nanobacteria may be involved in the pathogenesis of renal tubular calcification.

Possible etiology of calculi formation in salivary glands: biophysical analysis of calculus

Sialolithiasis is one of the common diseases of the salivary glands. It was speculated that, in the process of calculi formation, degenerative substances are emitted by saliva and calcification then occurs around these substances, and finally calculi are formed. However, the exact mechanism of the formation of calculi is still unclear. In this study, we identify some possible etiologies of calculi formation in salivary glands through biophysical analysis. Calculi from 13 patients with submandibular sialolithiasis were investigated by transmission electron microscopy, scanning electron microscopy, X-ray microanalyzer, and electron diffraction. Transmission electron microscopic observation of calculi was performed in the submandibular gland (n = 13). In 3 of the 13 cases, a number of mitochondria-like structures and lysosomes were found near calcified materials. Scanning electron microscopic examination of these materials revealed that there were lamellar and concentric structures and that the degree of calcification was different among the calculi. X-ray microanalysis disclosed the component elements in the calculi to be Ca, P, S, Na, etc., and the main constituents were Ca and P. The calcium-to-phosphorus ratio was 1.60-1.89. Analysis of the area including mitochondria-like structures, lysosomes, and the fibrous structures by electron diffraction revealed the presence of hydroxyapatite and calcified materials. It is speculated that mitochondria and lysosomal bodies from the ductal system of the submandibular gland are an etiological source for calcification in the salivary gland.

Presence of lipids in urine, crystals and stones: implications for the formation of kidney stones

BACKGROUND

Cell membranes and their lipids play critical roles in calcification. Specific membrane phospholipids promote the formation of calcium phosphate and become a part of the organic matrix of growing calcification. We propose that membrane lipids also promote the formation of calcium oxalate (CaOx) and calcium phosphate (CaP) containing kidney stones, and become a part of their stone matrix.

METHODS

Human urine, crystals of CaOx and CaP produced in the urine of healthy individuals, and urinary stones containing struvite, uric acid, CaOx and CaP crystals for the presence of membrane lipids were analyzed. Crystallization of CaOx monohydrate at Langmuir monolayers of dipalmitoylphosphatidylglycerol (DPPG), dipalmitoylphosphatidylcholine (DPPC), dipalmitoylphosphatidylserine (DPPS), dioleoylphosphatidylglycerol (DOPG), palmitoyloleoylphosphatidylglycerol (POPG) and dimyristoylphosphatidylglycerol (DMPG) was investigated to directly demonstrate that phospholipid assemblies can catalyze CaOx nucleation.

RESULTS

Urine as well as CaOx and CaP crystals made in the urine and various types of urinary stones investigated contained some lipids. Urine of both CaOx and uric acid stone formers contained significantly more cholesterol, cholesterol ester and triglycerides than urine of healthy subjects. However, urine of CaOx stone formers contained more acidic phospholipids. The organic matrix of calcific stones contained significantly more acidic and complexed phospholipids than uric acid and struvite stones. For each Langmuir monolayer precipitation was heterogeneous and selective with respect to the orientation and morphology of the CaOx crystals. Crystals were predominantly monohydrate, and most often grew singly with the calcium rich (10-1) face toward the monolayer. The number of crystals/mm2 decreased in the order DPPG> DPPC and was inversely proportional to surface pressure and mean molecular area/molecule.

CONCLUSIONS

Stone forming conditions in the kidneys greatly impact their epithelial cells producing significant differences in the urinary lipids between healthy and stone forming individuals. Altered membrane lipids promote face selective nucleation and retention of calcium oxalate crystals, and in the process become a part of the growing crystals and stones.

Analytical ultrastructural investigation of microliths in salivary glands of cat

Microliths in Araldite-embedded pieces of submandibular and sublingual glands of cat were stained in semithin sections by Methylene Blue and Azure II followed by Basic Fuchsin, and were examined in ultrathin sections by electron-microscopical X-ray microanalysis. Calcium and phosphorus were detected in substantial aggregates of crystals that were stained by Basic Fuchsin and appeared to be hydroxyapatite, but were not detected in granular material that was stained by Methylene Blue and Azure II and appeared to be organic. The polychromatic stain thus appears to be a useful indicator of calcified material. The majority of microliths in acini contained substantial aggregates of crystals, whereas the majority of those in ducts did not. This corresponds to the distribution of the glandular calcium, and suggests that microliths are variously enriched with calcium according to its local level.

The presence of microcalculi in normal human submandibular and parotid salivary glands

A search for microcalculi in 10 submandibular and 10 parotid glands obtained from autopsies revealed them in 8 submandibular glands in all decades from the third to the seventh, and in one parotid gland in the fourth decade. They were found in serous acinar cells, striated ductal cells, lumina and interstitium. They may form in autophagosomes in parenchymal cells and usually pass into lumina to be expelled in the saliva.

In vitro precipitation of calcium oxalate in the presence of whole matrix or lipid components of the urinary stones

Organic matrix of human calcium oxalate urinary stones was obtained by demineralizing with EDTA. Lipids were extracted from the EDTA-insoluble matrix by chloroform methanol treatment. The whole matrix and its total lipid extract were then incubated in a metastable solution of calcium oxalate and depletion of calcium and oxalate ions from the calcifying solution was determined. Results of our studies described here show that urinary calcium oxalate stone matrix and its total lipid contents were capable of binding calcium and oxalate ions and of catalysing calcium oxalate crystal formation from a metastable calcium oxalate solution.

Presence of lipids in urinary stones: results of preliminary studies

The presence of lipids in urinary stones was determined by histochemical and biochemical methods. When crystals of calcium oxalate, made by mixing calcium chloride and potassium oxalate solutions and sections of human calcium oxalate urinary stones, were exposed to osmium vapors, there was no staining of the pure crystals whereas the stone sections were stained. De-paraffinized sections of demineralized calcium oxalate stones showed positive sudanophilia on staining with Sudan black B. Both these experiments indicate the presence of lipids in calcium oxalate stones. Lipids were extracted from uric acid, struvite, and calcium oxalate stones using standard techniques. Phospholipids were separated by one-dimensional thin layer chromatography. All the stones studied contained lipids. In calcium oxalate stones they accounted for 10.15% of the matrix. Calcium oxalate and struvite stones contained more phospholipids than uric acid stones. Cardiolipin, sphingomyelin, phosphatidyl choline, phosphatidyl inositol, phosphatidyl ethanolamine, phosphatidyl serine, and phosphatidyl glycerol were identified in lipid extracts. Demineralization by ethylenediaminetetra-acetate (EDTA) treatment increased lipid output from calcium oxalate stones by 15.5%.

Ultrastructural and histochemical observations on microcalculi in chronic submandibular sialadenitis

A search for microcalculi was made in 14 cases of chronic submandibular sialadenitis. Microcalculi were found in all cases. They were within serous acinar cells and ductal cells, within lumina, and interstitially. They were stained variably by periodic-acid/Schiff and Alcian Blue at pH 2.5. Ultrastructural analytical examination showed them to consist of crystals containing calcium and phosphorus. The observations support the possibility that microcalculi form in autophagosomes, enter lumina and occasionally become impacted to produce sialolithiasis and sialadenitis.

Giant sialolithiasis appearing as odontogenic infection

The dentist frequently is called on to diagnose pathoses of the head and neck region. Two reports of giant submandibular sialoliths that were originally diagnosed as submandibular space odontogenic infections are presented. Careful history, and physical and radiographic examinations are necessary to assure proper diagnosis and treatment of this condition.

Ultrastructural and histochemical observations on intracellular and luminal microcalculi in the feline sublingual salivary gland

As the genesis of salivary calculi in man has not been established, the fortuitous observation of microcalculi in sublingual glands of cats prompted this study. Microcalculi were seen occasionally within acinar cells and lumina and macrophages, and rarely interstitially. Microcalculi were stained with the periodic-acid/Schiff technique, and acid-phosphatase activity was associated with intracellular microcalculi. Intracellular microcalculi were seen ultrastructurally in acinar cells in membrane-bound vacuoles that also contained debris and sometimes what appeared to be secretory material. X-ray microanalysis showed the microcalculi to consist of crystals containing calcium and phosphorus. The observations suggest that the microcalculi form within autophagosomes in acinar cells by a precipitation of calcium and phosphorus present in degenerate material, and that the microcalculi eventually enter lumina, where they may be discharged in the saliva or retained and enlarge.

Improved lipid preservation by malachite green-glutaraldehyde fixation in rat incisor predentine and dentine

A network of granules and filaments stained with malachite green-aldehyde (MGA) was observed in predentine in the spaces between the collagen fibres and many small granules were associated with these fibres in peripheral and circumpulpal-dentine. The granules were present throughout the entire thickness of the dentine, especially at the periphery of the calcospherites, although scarce or absent at their centre. This MGA-stainable material (i) resisted demineralization in acetic acid and EDTA solutions, and (ii) differed from non-collagenous material and crystal ghosts which stained on control sections after prior demineralization. In predentine, transport and diffusion of MGA-stainable material occurred in the direction of the dentine in which this material was associated with periodical striation of mineralized collagen fibres. This suggests that true matrix-associated lipids might play a role in dentine mineralization.

Brain calcification in severely stressed neonates receiving parenteral calcium

Morphologic evidence for calcium salts within the brains of severely stressed neonates at autopsy correlated to the mean daily parenteral dose of calcium gluconate (P less than 0.01). Survival analysis indicated that parenteral administration of calcium contributed a negative effect to predicted survival (P less than 0.05).

Calcium redistribution, calcification and stone formation in the parotid gland during experimental stimulation and hypercalcaemia. Cytochemical and X-ray microanalytical investigations

Distribution and redistribution of intra- and pericellular calcium was investigated in the parotid gland of rats under secretory stimulation and hypercalcaemia. The effects of hypercalcaemia and secretory stimulation and of the combination of both were compared. Calcium content was determined by atomic absorption spectrometry. Calcium distribution within the tissue was demonstrated by light microscopical ( GBHA ) staining and electron microscopical (pyroantimonate method) cytochemistry in combination with X-ray microanalysis. Typical calcium depot sites were the basal and cellular membranes, the calcium buffer organelles (i.e. mitochondria) the secretory granules and the acinar lumina. After stimulation (by isoprenalin ) a decrease of calcium-enriched secretory granules and a depletion of intracellular calcium buffer organelles occurred. During hypercalcaemia (induced by dihydrotachysterol), a calcium overloading of the cell membrane and intracellular buffer organelles without calcification was observed. Combined stimulation and hypercalcaemia induced an excessive calcium overloading of all intra- and extracellular calcium depots with excessive calcium release into the acinar lumina resulting in calcium phosphate aggregates and stone formation. Secretory stimulation and simultaneous hypercalcaemia exert potentiating effects on intracellular and intraluminal calcification proposing an importance for pathogenesis of human sialolithiasis.

Lipids of supragingival calculus

The matrix of supragingival calculus constitutes 15.7% of the calculus dry weight and contains 54.9% protein and 10.2% lipids. Of the total lipids, 61.8% are represented by neutral lipids, 28% by glycolipids, and 10.2% by phospholipids. The neutral lipids exhibit a high content of free fatty acids (63.9%) and triglycerides (15.8%). The glycolipids are comprised of simple glycosphingolipids (17.2%), mainly lactosyl- and glucosylceramides, and of neutral and sulfated glyceroglucolipids (82.8%). The phospholipids contain large quantities of phosphatidylethanolamine (34.2%) and diphosphatidylglycerol (25.5%). Comparison with salivary and submandibular stone lipids indicates that both saliva and bacteria contribute to the lipid content of supragingival calculus.

Lipid composition of human parotid salivary gland stones

The parotid gland stone matrix constitutes 20.2% of the stone dry weight and contains 8.5% of lipids. Of the total lipids, 74% are represented by neutral lipids, 17% by glycolipids, and 9% by phospholipids. The neutral lipids exhibit a high content of free fatty acids (52.7%) and cholesteryl esters (31.1%). The glycolipids are composed of simple glycosphingolipids (7.1%), and of neutral and sulfated glyceroglucolipids (92.9%). Phosphatidylethanolamine and diphosphatidylglycerol are the principal constituents of the phospholipid fraction.

Association of lipids with proteins and glycoproteins in human saliva

The distribution of lipids in the fractions of parotid and submandibular saliva following Bio-Gel A-50 column chromatography was measured. Over 50% of the total lipids of submandibular saliva was found in the fraction which contained mainly the high-molecular-weight glycoprotein. This fraction also contained most of the glycolipids, free fatty acids, phospholipids, and cholesterol. In the parotid saliva, the fraction containing the basic glycoprotein (the major glycoprotein fraction of parotid saliva) contained 35% of the total saliva lipids and was enriched in phospholipids ana cholesterol esters.

Phospholipids associated with human parotid gland sialoliths

Ca-acidic phospholipid-phosphate complexes (CPLX) were isolated from 6 whole and 2 pooled human parotid sialoliths containing the mineral phases hydroxyapatite, whitlockite and octacalcium phosphate (ash 78 +/- 16 per cent, n = 7). Total lipids accounted for 25 per cent of the demineralized dry weight of these sialoliths. CPLX was 39 +/- 18 per cent of the lipid phosphorous pool, while diphosphatidyl glycerol, phosphatidyl ethanolamine and phosphatidyl choline were the principal non-complexed phospholipids. The high cholesterol:phospholipid molar ratio (1.0 +/- 0.3) observed in the sialolith lipids suggests a plasma membrane origin for these lipids.

Lipid composition of the matrix of human submandibular salivary gland stones

The lyophilized stone matrix, prepared by exhaustive dialysis of pulverized stones against 10 per cent EDTA and water, yielded 9.6 +/- 0.9 mg per cent of lipids. Following fractionation of the lipid extract on silicic acid columns, 57 per cent of lipids were found in the neutral lipid fraction, 40 per cent in the glycolipid fraction and 3 per cent in the phospholipid fraction. Of the total neutral lipids, 77.3 per cent were represented by free fatty acids, 14.7 per cent by cholesterol, 4.1 per cent by triglycerides and 3.2 per cent by cholesterol esters. The glycolipid fraction was comprised of simple glycosphingolipids (11.3 per cent), mainly lactosyl- and glucosylceramides, and of neutral and sulphated glyceroglucolipids (88.7 per cent). The sulphated glyceroglucolipids consisted of tri- and tetraglucosyl glyceroglucolipids, whereas hexa- and octaglucosyl glyceroglucolipids were the predominant constituents of the neutral glyceroglucolipid fraction. The phospholipids exhibited a high content of sphingomyelin (22.3 per cent), phosphatidylcholine (12.1 per cent), phosphatidylethanolamine (11.4 per cent), phosphatidylserine (10.5 per cent) and lysophosphatidylcholine (13.3 per cent). The major fatty acids of the neutral lipid fraction were hexadecanoate, octadecanoate and octadecenoate. The glycolipids contained large quantities of hexadecanoate and tetracosanoate, while the hexadecanoate, octadecanoate and tetracosanoate were the principal fatty acids of the phospholipid fraction.