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by Ana Sangadala
4-Objective
Findings
Youre
going
to
be
able,
on
an
extra
oral
exam,
to
be
able
to
identify
enlargement
in
the
major
glands.
Another
thing
that
you
will
be
taught
to
look
for
as
you
look
at
a
patient
before
you
ever
start
using
a
palpation
type
of
assist
on
your
examination
is
to
look
for
enlargements
and
asymmetry.
They
may
not
be
salivary
gland
enlargements,
but
youre
going
to
have
to
find
them
and
move
on
from
there.
And
then,
maybe
some
discrete
swellings
or
masses
that
you
need
to
work
with.
When
you
get
to
the
intra
oral
exam,
you
have
to
remember
where
the
ducts
are
because
theyre
going
to
be
helpful
in
being
able
to
tell
whether
or
not
the
patient
is
able
to
produce
saliva
and
what
the
nature
of
the
saliva
actually
is.
And
youre
going
to
be
looking
at
any
kinds
of
swellings
or
masses
that
might
have
developed.
Um,
when
you
do
your
intra
oral
exam,
now,
in
the
last
30
years
since
dentists
have
been
wearing
gloves,
dry
mouth
is
much
easier
to
appreciate
because
the
gloves
just
do
not
slide
on
dry
mucosa
and
just
kinda
stick
as
youre
trying
to
do
your
exam.
The
glove
just
wont
slide
on
the
mucosa.
Thats
evidence
of
dry
mouth,
even
though
the
patient
hasnt
yet
told
you
that
the
patient
has
dry
mouth.
Wheres
my
next
slide?
There
we
go.
Ok.
5-No
Title
This
is
a
slide
that
should
look
familiar
to
you
even
if
its
not
the
exact
slide
that
you
looked
at
and
thats
the
location
of
the
major
salivary
glands.
The
parotid
glands
are
superficial
to
the
masseter
muscle
so
one
of
the,
as
you
do
your
exam,
one
of
the
things
you
can
determine.
There
are
people
that
have
hyperplastic,
or
hypertrophied
thats
better,
hypertrophied
masseter
muscle.
The
masseter
muscle
gets
larger
from
people
that
are
very
vigorous
clenchers
because
again
the
striated
muscle
is
going
to
get
larger
and
youre
going
to
get
enlargement
of
that
muscle.
It
can
look
similar
to
the
enlargement
of
the
parotid
gland.
However,
since
the
parotid
gland
is
superficial
to
the
masseter
muscle,
masseter
hypertrophy
is
something
you
can
feel.
You
dont
feel
any
parotid,
you
dont
feel
any
enlargement
on
the
muscle.
And
if
you
feel
the
muscle,
you
can
feel
it
clench,
and
you
can
feel
that
the
enlargement
that
you
are
seeing
is
actually
the
muscle.
When
its
the
parotid,
you
can
clench,
and
the
enlargement
that
you
are
seeing
from
the
parotid
gland
does
not
really
change
in
relationship
to
the
clenching
of
the
muscle.
For
the
submandibular
and
sublingual
glands,
there
you
will
have
to
do
the
technique
that
you
were
taught
last
year.
Maybe
you
remember?
Youre
going
to
learn
it
again
so
it
will
become
part
of
your
world.
Its
the
bimanual
palpation.
And
one,
the
reason
that
we
do
this,
is
if
we
didnt
use
a
hand
outside
on
the
outside
of
the
chin,
that
area,
when
you
palpate
the
salivary
glands,
it
actually
depresses
them
and
you
really
wouldnt
be
able
to
feel
them.
So
you
use
another
hand
to
support
that
tissue,
so
when
you
feel
that
submandibular
gland
that
is
way
posterior
in
the
floor
of
the
mouth
and
when
you
feel
the
sublingual
gland
which
is
anterior,
you
can
actually
feel
those
glands
because
youre
supporting
the
tissue
with
your
hand
on
the
outside.
The
submandibular
gland
is
a
gland
that
is
encapsulated,
so
you
need
to
be
somewhat
careful.
If
you
remember
doing
this
on
each
other,
if
youre
too
vigorous,
its
painful,
if
you
stick
your
finger
way
back
in
the
floor
of
your
mouth.
And
so
we
usually
do
this
walking
the
fingers
from
the
anterior
of
the
mouth
to
the
posterior
part
to
actually
feel
that
encapsulated
gland.
The
more
you
feel
it,
the
more
youre
focusing
on
it,
the
more
you
will
recognize
if
its
enlarged.
When
you
start
out
in
your
exams,
youre
probably
not
going
to
recognize
an
enlarged
gland
from
a
non-enlarged
gland
because
you
havent
felt
a
lot
of
them.
But
when
you
feel
them
more,
youre
going
to
recognize
what
a
normal
submandibular
gland
and
sublingual
gland.
The
sublingual
gland
is
not
an
encapsulated
gland.
It
is
a
complex
of
multiple
smaller
salivary
glands
that
are
located
in
the
anterior
part
of
the
floor
of
the
mouth.
So
you
kind
of
feel
a
nodular
feeling
when
you
feel
the
sublingual
gland.
6-No
Title
Ok.
This
is
an
example
of
2
enlargements.
The
one
on
the
left
is
your
lymph
node,
ok?
Were
learning
how
to
do
your
neck
exam
in
your
classes
where
you
palpate
along
the
sternocleidomastoid
muscle
and
youre
learning
the
technique
for
the
palpation
of
the
neck.
And
this
patient
has
an
enlarged
lymph
node.
It
looks
like
it
is
superficial
to
the
sternocleidomastoid
muscle.
This
is
a
patient
where
it
looks
like
an
enlarged
parotid
gland.
And
as
you
learn
to
do
your
extra
oral
exam,
once
youve
done
your
visual
exam,
you
will
learn
a
lot
from
doing
examinations
where
there
is
no
abnormality
because
you
get
used
to
knowing
what
the
range
of
normal
is.
So
as
soon
as
something
is
abnormal,
you
will
pick
it
up.
The
more
exams
you
do,
I
have
talked
about
this
before
to
you.
Its
not
really
intuition;
its
experience
that
will
help
you
figure
it
out.
And
very
often,
you
will
know
what
it
is
that
youre
registering
as
somethings
wrong
until
you
just
take
a
little
bit
of
time
back
and
think
about
it.
You
will
recognize
what
it
is
thats
wrong.
But
its
because
youve
done
so
many
exams
by
that
time
that
you
register
somethings
wrong
even
before
you
register
what
the
abnormality
is.
7-
No
Title
Ok!
So,
we
will
move
intra
orally
and
you
have
a
sequence
for
doing
your
intra
oral
exam
but
what
Im
really
showing
you
here
is
the
location
of
the
duct
from
Stensons
glandFrom
the
parotid
gland
rather.
Stensons
duct.
Stensons
duct
is
tucked
under
a
papilla
on
the
buccal
mucosa.
What
are
these
yellow
spots?
Fordyce
granules.
And
Fordyce
glands
are
sebaceous
glands,
not
salivary
glands.
Sometimes
called
ectopic
sebaceous
glands
but
since
90%
of
adults
have
them
its
hard
to
call
them
ectopic.
It
seems
they
are
more
normal
to
find
than
not.
Anyway,
here
is
the
papilla.
When
youre
doing
your
exams,
go
look
for
it
because
you
want
to
be
able
to
see
the
variation
in
size
of
that
papilla.
Sometimes
you
can
barely
see
it,
and
sometimes
its
as
big
as
a
fibroma.
And
every
once
in
a
while
in
the
biopsy
service,
we
get
a
Stensons
duct
papilla
that,
and
if
that
person
isnt
careful,
they
can
do
damage
to
Stensons
duct.
You
should
be
able
to
recognize
that
its
one
of
the
landmarks
that
youll
learn
to
look
for
as
you
do
your
examination
of
the
buccal
mucosa.
The
duct
is
behind
that
papilla.
So
when
you
are
learning
how
to
milk
the
salivary
glands
to
find
out
if
the
glands
are
able
to
produce
saliva
and
what
the
nature
of
the
saliva
is,
youre
actually
identifying
this
location
and
then
trying
to
express
saliva
from
the
parotid
gland
and
it
will
kinda
squirt
out
of
the
duct.
8-No
Title
Ok,
on
the
floor
of
the
mouth,
we
have
another
duct,
Whartons
duct.
And
here,
youve
got
to
be
somewhat
careful
when
youre
doing
your
exam
on
the
floor
of
the
mouth
because
sometimes
when
you
move
your
hands,
its
kind
of
nice
to
have
your
mask
and
goggles
on,
the
saliva
will
actually
pop
and
squirt
like
a
little
fountain
right
out
of
the
duct
and
hit
you
in
the
face
if
youre
not
careful.
So
when
youre
trying
to
milk
the
sublingual/submandibular
gland,
it
really
is
important
to
watch
out
for
saliva.
But
heres
the
duct
and
its
the
duct
from
the
submandibular
gland
AND
the
sublingual
glands
actually
feed
into
that
duct.
9-No
Title
Ok.
On
the
labial
mucosa,
we
have
lots
of
minor
salivary
glands
and
if
you
want
to
demonstrate
them
for
yourself,
you
can
do
them
on
yourself,
or
you
can
do
it
on
a
patient,
and
dry
the
lower
lip
and
just
wait
a
little
bit.
You
will
see
that
each
one
of
the
minor
salivary
glands
on
the
lip
will
form
a
little
tiny
droplet
of
saliva
and
you
will
get
a
chance
to
see
the
location
of
those
glands.
Weve
got
lots
and
lots
of
them
scattered
throughout
the
mouth
and
this
is
one
location.
There
are
also
minor
salivary
glands
on
the
upper
lip.
When
youre
doing
the
palpation
of
the
lower
lip,
get
used
to
feeling
the
nodularity
of
those
minor
salivary
glands
on
the
lower
lip.
Once
in
a
while
when
a
patient
becomes
very
mouth
conscious,
the
patient
will
start
feeling
those
nodules
and
decide
the
patient
has
tumors
in
the
lower
lip.
For
you,
just
get
used
to
what
they
feel
like
when
theyre
normal
and
you
will
be
able
to
reassure
the
patient
that
theyre
palpating,
or
feeling
is
probably
the
word
you
would
use,
the
minor
salivary
glands.
10-No
Title
Ok?
And
weve
talked
about
another
location
of
minor
salivary
glands
in
conference.
Theres
an
enormous
collection
of
minor
salivary
glands
at
the
junction
of
the
soft
and
hard
palate.
So
it
is
a
very
hot
location
or
very
common
location
for
a
number
of
salivary
gland
lesions.
11-No
Title
This
we
talked
about
in
conference
and
I
believe
that
Dr.
Shah
has
talked
about
this
condition
in
your
class
as
well.
This
is
nicotine
stomatitis.
And
the
only
reason
Im
showing
it
to
you
here
is
it
is
one
way
of
visualizing
all
of
the
minor
salivary
glands
and
you
can
see
them
all
over
here.
And
I
just
showed
you
here,
not
so
you
would
learn
nicotine
stomatitis,
but
so
you
would
see
the
distribution
of
minor
salivary
glands.
12-Acute
and
Chronic
Sialadenitis
And
minor
salivary
glands
are
all
over
the
mouth.
Uh,
salivary
gland
lesions
can
occur
intra
orally
wherever
there
are
minor
salivary
glands.
There
are
salivary
glands
on
the
buccal
mucosa,
retromolar
area,
theyre
on
the
lateral
tongue
posterior,
on
the
anterior
tongue
and
so
there
are
potential
for
intra
oral
salivary
gland
conditions.
Just
about
any
place.
And
some
are
more
common
in
some
locations
than
others
and
well
talk
about
that.
So
lets
talk
about
some
specific
diseases
for
a
few
minutes.
Acute
and
chronic
sialadenitis.
You
can
get
this
in
either
major
or
minor
glands
and
um,
we
know
it
best
in
major
glands
because
thats
where
it
usually
causes
the
most
symptoms
so
that
we
have
to
work
on
this
patient.
And
it
is
usually
due
to
some
kind
of
obstruction
of
a
salivary
gland
duct.
And
when
you
obstruct
a
major
gland
duct,
youre
going
to
get
a
major
gland
problem.
SO
obviously
the
most
visible
and
most
problematic
major
glands
obstructions
are
going
to
be
the
parotid
gland
and
the
submandibular
gland
because
the
sublingual
glands
are
little
glands
with
single,
multiple
single
ducts.
So
the
problem
with
major
glands
is
usually
submandibular
or
parotid.
And
infection
in
the
gland
or
retrograde
infection,
those
are
the
people
that
have
a
decrease
in
their
salivary
flow.
And
the
organisms
in
the
oral
cavity
can
travel
up
the
duct
because
theres
no
saliva
washing
out
the
duct
and
can
actually
cause
bacterial
or
fungal
infections
in
the
duct.
Parotid
gland
inflammation
is
called
parotitis.
There
isnt
a
name
that
I
know
of
for
submandibular
gland,
except
sialadentitis.
13-Sialadenitis
This
is
a
patient
with
a
mass
related
to
the
submandibular
gland.
Try
to
sort
out
what
it
is
based
on
the
patient
signs
and
symptoms,
and
eventually
possibly
laboratory
tests
if
you
need
them.
Here,
this
is
painful,
ok?
And
the
patient
has
had
it
for
about
a
week
with
a
constant
and
continuing
increase
in
pain.
It
isnt
enlarging
and
deflating
and
were
going
to
talk
about
why
thats
important
in
a
little
bit.
Its
simply
an
enlargement
thats
very
painful.
And
the
diagnosis
of
this
based
on
a
needle
biopsy,
which
is
a
biopsy
technique.
Its
where
instead
of
a
scalpel
biopsy
where
we
go
into
the
skin
and
take
a
big
chunk
of
tissue,
its
kind
of
a
broad
needle
that
can
be
placed
into
the
tissue
so
we
can
get
enough
tissue
to
be
able
to
see
the
morphology
of
the
cells
and
get
a
diagnosis.
So
on
the
basis
of
patient
signs
of
symptoms,
and
a
fever
will
often
accompany
infection
if
the
sialadentitis
is
due
to
infection.
And
sometimes
the
inflammation
is
not
due
to
infection,
but
due
to
blockage.
What
were
looking
at
over
here
is
the
ducts
of
the
salivary
gland
that
had
persisted.
The
salivary
glands
themselves
are
disappearing.
Theyre
replaced
with
fibrous
tissue
and
then
theres
an
inflammatory
infiltrate.
If
the
process
is
very
new
within
a
day
or
so,
we
will
get
neutrophils.
Like
what
were
learning
about
in
the
innate
immunity
as
Dr.
McCutcheon
moves
on
to
acquired
immunity,
we
talk
about
the
different
types
of
lymphocytes
and
as
the
process
moves
on
longer,
we
see
more
lymphocytes,
plasma
cells,
in
the
area.
But
it
takes
time
for
those
cells
to
get
there.
The
neutrophils
get
there
REAL
fast.
Whatever
the
cause,
the
neutrophils
will
be
there.
Ok?
14-Mucocele
A
common
issue
you
will
see
in
practice
is
something
called
a
mucocele.
A
mucocele
is
a
pool
of
saliva
that
has
collected
in
the
fibrous
tissue,
the
fibrous
connective
tissue.
Because
the
duct
of
the
salivary
gland
has
been
severed,
the
saliva
has
nowhere
else
to
go.
So
what
it
does,
is
it
collects
as
a
pool
of
fluid
in
the
connective
tissue.
This
one
was
a
traumatized
on
the
surface,
so
in
addition
to
the
swelling,
we
have
an
ulcer
and
some
fibrin
on
the
surface
here.
This
one
is
just
a
blue-ish
ball,
or
bluish
dome
shaped
lesion.
And
you
can
kinda
get
a
sense
that
it
is
fluid
filled.
This
one
has
some
blood
in
it
in
addition
to
the
saliva
so
it
is
much
more
of
a
purplish
color.
And
you
can
get
mucoceles
any
place
that
there
are
salivary
glands
so
it
is
possible
to
get
mucoceles
in
this
area
because
there
are
a
collection
of
salivary
glands
there.
It
is
possible
to
get
some
in
the
sublingual
gland
area,
buccal
mucosa,
you
can
get
mucoceles
on
the
junction
of
the
soft
and
hard
palate.
But
the
most
common
place
you
can
get
mucoceles
is
on
the
lower
lip
because
the
most
common
cause
is
trauma
from
the
cuspid
tooth
and
theres
a
very
high
density
of
minor
salivary
glands
in
the
lower
lip
just
opposite
the
cuspid
tooth.
That
severing
of
the
salivary
gland
duct
is
what
causes
the
mucocele
to
develop.
When
we
remove
a
mucocele,
it
is
very
important
to
take
all
of
the
minor
salivary
glands
that
are
in
the
area
because
it
is
very
important
that
when
you
are
surgically
removing
a
mucocele
you
dont
form
another
mucocele
by
cutting
a
duct
because
you
cannot
actually
see
the
duct
of
another
salivary
gland.
So
the
technique
for
removing
a
mucocele
is
to
remove
the
lesion
and
then
also
all
of
the
minor
salivary
glands
that
you
can
find
surrounding
that
lesion.
And
we
can
do
without
some
minor
salivary
glands,
you
dont
get
xerostomia
from
losing
a
couple
of
minor
salivary
glands.
15-Mucocele
Ok?
So
it
is
a
lesion
that
forms
when
a
salivary
duct
is
severed.
And
so
mucous
or
rather
saliva
spills
into
the
connective
tissue
and
the
body
then
has
a
technique
for
actually
walling
off
the
pool
of
mucous
so
you
get
some
compressed
inflammatory
tissue
around
the
mucocele
that
makes
it
into
something
that
looks
like
a
cyst.
A
true
cyst
is
lined
by
epithelium.
Thats
the
definition
of
a
cyst.
And
youll
get
that
in
a
number
of
other
places.
This
has
no
epithelial
lining,
just
inflammatory
tissue
so
it
is
called
a
pseudocyst.
It
is
not
a
true
cyst.
16-Mucocele
Microscopic
Appearance
And
this
is
the
microscopic
appearance
of
a
mucocele.
Here
is
minor
mucous,
minor
salivary
gland.
This
is
the
duct.
The
duct
got
severed.
This
is
the
epithelial
lining
of
the
duct.
This
is
the
lumen
of
the
pseudocyst.
This
is
the
inflammatory
tissue
that
the
body
has
built
up
to
wall
off
the.
Its
a
cystlike
space
in
the
tissue
but
it
is
not
a
true
cyst.
And
its
lined
with
something
that
we
are
going
to
spend
a
lot
of
time
on
called
granulated
tissue.
Its
a
kind
of
inflammatory
tissue,
a
reactive
tissue.
The
lumen
is
filled
with
mucin
or
saliva,
thats
interchangeable
here.
17-Mucocele
And
that
is
the
definition
of
a
mucocele.
You
see
it
as
a
swelling
of
the
tissue.
And
it
is
also
possible
that
it
increases
and
decreases
in
size
because
some
of
that
saliva
finds
its
way
into
the
surface
or
reaches
into
the
surrounding
connective
tissues.
So
the
bubble
doesnt
always
keep
getting
bigger.
Sometimes
it
gets
bigger
and
smaller.
Also,
more
saliva
gets
produce
when
youre
eating.
So
theres
a
time
when
youre
eating
when
the
lesion
may
swell
and
then
there
is
time
when
the
saliva
can
reach
into
the
surrounding
connective
tissue,
it
deflates
a
little
bit.
The
lower
lip
is
the
most
common
site,
wayyy
more
than
any
other
place.
But
there
is
no
site
where
you
have
minor
salivary
glands
where
you
dont
have
potential
for
mucoceles.
Its
upper
lip,
its
buccal
mucosa,
floor
of
the
mouth,
tip
of
the
tongue,
lateral
tongue,
junction
of
the
hard
and
soft
palate,
probably
forgot
some
location.
But
if
there
are
salivary
glands,
you
can
get
a
mucocele.
18-Ranula
Then,
there
is
another
lesion
called
the
ranula.
The
ranula
is
named
for
the
Latin
word
for
frog.
It
is
named
for
this
out
pouching
when
the
frog
croaks.
Many
textbooks
said
it
is
named
because
it
looks
like
the
belly
of
a
frog.
But
it
doesnt
look
like
a
belly
of
a
frog,
because
a
belly
of
a
frog
doesnt
look
like
this.
It
looks
like
the
out
pouching.
This
is
a
ranula.
This
ranula
happens
to
be
blood
filled
as
well
as
saliva.
This
is
another
one.
Your
textbook
will
call
any
fluid
filled
peudocyst
on
the
floor
of
the
mouth
a
ranula,
so
even
the
ones
that
come
from
the
sublingual
glands,
which
are
much
more
like
mucoceles
everywhere
place
else,
are
sometimes
interchanged
for
ranula.
I
dont
like
that.
Thats
a
personal
thing
but
I
dont
think
that
when
there
are
small
mucoceles
on
the
floor
of
the
mouth
that
dont
look
anything
like
the
outpouching
of
a
frog
and
so
I
just
dont
know
why
that
has
stayed
in
the
literature
but
again
I
will
try
not
to
ask
you
a
question
that
mixes
you
up.
But
you
will
see
in
the
literature
that
a
ranula
is
this
phenomena
where
there
is
a
severed
duct
and
you
get
this
phenomena
on
the
floor
of
the
mouth.
Which
is
true,
but
when
you
get
little
tiny
ones
from
the
sublingual
glands,
they
dont
look
anything
like
this
outpouching.
19-Ranula
Be
that
as
it
may,
it
is
a
mucocele-like
lesion
that
forms
unilaterally.
It
is
really
pretty
impossible,
unless
the
patient
has
some
kind
of
habit
that
would
sever
salivary
gland
ducts
bilaterally,
it
is
a
unilateral
lesion.
And
it
is
associated
with
the
large
duct
of
the
submandibular
gland
and
if
it
is
caused
by
an
obstruction
of
the
duct
instead
of
the
severing
of
the
duct,
what
will
happen,
and
this
is
true
in
the
small
minor
glands
as
well.
When
the
biopsy
is
done,
the
duct
has
been
obstructed
and
instead
of
the
saliva
spilling
into
the
connective
tissue,
the
duct
expands.
Now,
the
duct
is
an
elongated
structure,
but
if
you
expand
the
duct
and
you
take
a
biopsy,
what
you
get
is
a
circular
lesion
that
is
lined
by
epithelium.
Even
though
it
is
not
a
true
cyst,
it
looks
like
a
cyst.
So
it
is
sometimes
called
a
mucocyst
when
you
get
that
phenomenon
because
it
has
an
epithelial
lining
but
its
just
another
form
of
a
mucocele.
20-Sialolith
Ok
and
then
we
get
calcifications
that
will
form
in
salivary
glands.
These
are
called
sialoliths.
Lith
is
the
Latin
name
for
stone.
When
they
form
in
the
submandibular
gland
in
the
submandibular
duct,
they
have
a
specific
type
of
presentation
that
starts
with
a
swelling
in
the
neck
and
possibly
in
the
floor
of
the
mouth.
Its
primary
in
the
neck
though.
And
the
patient
will
usually
have
a
distinct
history
of
a
swelling
in
the
neck
that
enlarges
and
deflates
that
is
related
to
eating.
When
the
patient
is
eating
and
more
saliva
is
produced,
the
swelling
gets
larger.
Between
meals,
when
the
saliva
seems
to
be
able
to
get
around
the
connective
tissue
of
the
duct,
it
seems
to
slowly,
it
will
be
able
to
get
out
of
the
gland
and
then
the
next
time
the
patient
eats,
it
swells
up
again.
So
this
swelling
and
deflating
is
a
characteristic
of
a
sialolith.
The
same
the
thing
will
happen
in
the
parotid
gland
but
its
usually
not
as
dramatic.
The
patient
will
again
be
able
to
describe
a
swelling
or
enlargement
and
a
resolution
related
to
eating.
When
you
get
that
kind
of
history,
there
isnt
much
else
that
will
do
it
unless
its
a
blockage,
some
kind
of
blockage
of
the
gland
that
prevents
saliva
from
flowing.
And
with
time
the
saliva
will
flow
out
of
the
gland
and
the
swelling
will
deflate.
21-No
Title
Ok?
And
heres
an
x-ray
and
a
part
of
the
panoramic
x-ray.
A
panoramic
radiograph
is
a
very
useful
radiograph
in
identifying
sialoliths
when
they
are
in
the
submandibular
gland
duct.
And
here
is
the
sialolith.
Its
long,
but
there
are
all
kinds
of
sizes
and
shapes.
Ok?
And
here
it
is
after
its
been
removed.
You
can
see
this?
This
is
this.
And
it
is
a
mineralized
structure
and
so
on
the
radiograph
it
comes
out
and
you
can
actually
see
the
mineralized
structure.
22-No
Title
It
is
also
possible
to
get
sialoliths
in
the
minor
glands
and
usually
when
they
are
submitted
to
the
biopsy
service,
the
clinician
will
say
it
feels
as
it
there
is
a
foreign
body
in
the
mucosa
of
the
patient
because
its
so
hard.
And
theyre
round
and
pea
shaped
and
here
we
were
lucky
enough
to
be
able
to
see
the
mineralized
structure
on
the
radiograph.
We
are
not
always
so
lucky.
But
here
is
the
lesion
clinically,
and
here
it
is
radiologically.
23-Sialolith
Histologically,
it
would
look
something
like
this.
Here
is
the
overlying
mucosa.
This
is
the
duct.
And
we
dont
see
the
salivary
gland,
its
down
here
some
place.
And
heres
the
calcified
lith,
the
mineralized
stone.
24-Bilateral
Salivary
Gland
Enlargement
Ok?
Thats
mucoceles,
granulas,
and
sialoliths.
Um,
now
we
get
into
a
bit
more
complex
salivary
gland
disease.
And
thats
the
whole
group
of
bilateral
salivary
gland
enlargements.
And
in
general
pathology
and
systems
pathology,
were
going
to
bump
into
a
number
of
these
conditions
as
we
move
through
those
courses,
but
there
are
a
number
of
different
problems
that
can
all
cause
a
very
similar
enlargement
of
the
salivary
glands
and
its
almost
always
the
parotid
gland.
So,
our
job
is
to
sort
out.
Its
very
helpful
to
have
a
list.
Sort
out
the
list
on
the
basis
of
what
we
can
find
in
subjective
and
objective
findings.
Were
probably
going
to
spend
more
time
than
we
ought
to
since
there
are
so
many
times
that
we
do
talk
about
it.
Its
an
autoimmune
disease
called
Sjorgens
syndrome.
The
hallmark
characteristic
of
Sjorgens
syndrome
is
that
the
patient
gets
a
progressive
dry
mouth
and
has
enlarging
parotid
glands,
but
it
can
also
happen
in
submandibular
glands.
But
parotid
glands
are
the
characteristic
enlargement.
The
patient
also
gets
enlargement
in
the
lacrimal
glands
and
dry
eyes
and
this
one
is
an
autoimmune
disease
where
the
body
is
producing
antibodies
to
the
patients
salivary
glands
and
destroying
the
patients
salivary
glands
in
the
process.
Were
going
to
spend
more
time
on
Sjorgens
syndrome
as
we
move
along.
Patients
who
are
long-term
alcoholics
can
sometimes
present
with
bilateral
salivary
enlargement.
It
may
very
well
be
that
we
are
looking
at
here,
not
at
the
alcoholism,
but
many
patients
with
alcoholism
have
chronic
malnutrition.
Because
depending
on
how
severe
the
alcoholism
is,
they
are
missing
major
nutrients
and
this
is
a
nutritional
enlargement
rather
than
just
due
to
the
alcoholism.
Malnutrition,
depending
on
its
severity
is
known
to
be
associated
with
salivary
gland
enlargement.
Diabetes
mellitus
here,
the
mechanism
isnt
clear,
but
some
patients
with
diabetes
for
a
long
time
all
start
developing
enlargement
of
their
salivary
glands.
And
again
malnutrition
is
a
separate
category
here,
but
the
malnutrition
in
alcoholism
is
probably
whats
causing
it
in
that
one.
And
again,
in
trying
to
sort
out
what
the
patient
is
getting
at,
you
go
through
all
those
questions
to
help.
HIV
infection
is
also
one
of
the
things
that
causes
bilateral
salivary
gland
enlargement.
We
will
talk
a
lot
more
about
the
pathological
and
histological
features
of
these
as
we
move
along.
There
are
a
number
of
drugs
that
have
the
ability
to
cause
salivary
gland
enlargement.
Mumps
can
do
it
as
well.
But
mumps
is
an
acute
problem.
And
usually
when
the
patient
has
mumps,
youre
going
to
be
able
to
know
the
patients
salivary
glands
are
enlarged.
The
patient
has
a
fever,
the
patient
didnt
have
it
yesterday,
and
its
usually
mumps
in
the
area
and
other
people
have
had
the
problem.
So
mumps
usually,
of
all
of
these,
is
one
of
the
easiest
forms
to
be
able
to
diagnose
on
the
basis
of
preliminary
features.
There
is
a
granuloma
disease,
called
sarcoidosis
that
does
this.
And
then
to
make
our
lives
really
pleasant,
there
are
sometimes,
you
just
cant
figure
it
out.
You
go
through
all
the
possibilities
and
the
patient
has
none
of
those
and
you
just
cant
figure
it
out.
Or
you
didnt
get
the
right
answer
to
the
right
question,
which
is
certainly
something
that
once
in
a
while
happens.
25-Mumps
This
is
a
patient
with
mumps.
26-Anorexia
Nervosa
And
this
patient
is
a
patient
with
malnutrition
thats
related
to
anorexia
nervosa.
I
will
tell
you
the
story
once
and
try
not
to
repeat
it
as
we
get
into
bilateral
salivary
gland
enlargement
in
general
pathology.
Say
you
told
us
this
one
already,
dont
tell
us
again.
This
is
a
patient
that
I
saw
when
I
was
a
resident
with
very
experienced
oral
pathologists
and
she
has
as
you
can
see,
bilateral
salivary
gland
enlargement.
Shes
16
years
old
and
she
is
thin,
ok?
And
um,
there
was
at
that
point,
an
attempt
to
try
to
figure
out
what
was
going
wrong
with
the
salivary
glands
and
one
of
the
things
you
will
learn
is
if
you
even
suspect
that
the
patient
has
an
eating
disorder,
it
isnt
particularly
wise
to
try
to
get
information
when
the
mother
is
in
the
room.
Youre
just
not
going
to
get,
unless
its
a
previously
diagnosed
problem,
not
really
going
to
get
the
answers
that
you
want.
And
so
a
number
of
diagnostic
procedures
were
done,
but
no
biopsy
was
done
to
figure
out
what
was
going
on
with
this
young
women.
It
was
at
this
point
that
we
considered
it
idiopathic.
It
was
thought
it
may
be
autoimmune
or
very
early
Sjorgens
syndrome.
But
Sjorgens
syndrome
does
not
emerge
in
16
year
olds
usually.
So
she
went
to
college
in
Maryland
and
she
was
referred
to
a
group
of
oral
pathologists
in
Maryland
and
they
actually
did
a
needle
biopsy
of
the
salivary
glands.
On
the
needle
biopsy
of
the
salivary
glands,
it
was
clearly
not
Sjorgens
syndrome
because
Sjorgens
syndrome
is
where
the
salivary
glands
are
replaced
with
lymphocytes.
Her
salivary
glands
were
just
very
very
enlarged.
HYPERTROPHIC
salivary
gland
acini.
So
the
condition
that
is
known
to
cause
hypertrophic
salivary
glands
is
malnutrition
and
it
was
at
that
point
they
were
able
to
recognize
and
diagnose
the
anorexia
nervosa
that
was
causing
the
enlarged
salivary
glands
that
hadnt
been
diagnosed
before.
You
will
find
and
I
will
show
you
a
couple
of
conditions
later
where
there
are
facial
and
oral
characteristics
and
complications
that
occur
from
eating
disorders.
It
may
be
a
condition
where
you
may
be
the
first
one
to
talk
to
the
patient
about
the
problem
that
is
a
secret.
You
suddenly
know
a
secret
and
trying
to
find
ways
to
talk
to
the
patient
is
something
that
takes
some
skill
and
I
would
be
very
very
careful
the
first
time
that
you
think
about
doing
it,
before
you
approach
the
patient,
because
you
are
suddenly
discovering
a
secret
that
the
patient
didnt
want
you
to
know.
27-Alcoholic
Sialadenosis
This
patient
is
a
long
term
alcoholic
and
here
is
related
to
malnutrition
as
well.
28-Sjorgens
Syndrome
Sjorgens
syndrome.
Were
not
going
to
spend
a
lot
of
time
in
this
course
on
Sjorgens
syndrome
because
I
will
spend
time
on
it
later.
So
what
I
want
you
to
know
is
that
Sjorgens
syndrome
is
on
the
categories
of
salivary
gland
disorders.
On
here,
we
are
looking
at
an
autoimmune
disease.
And
it
is
an
autoimmune
disease
where
the
body
is
producing
antibodies
that
are
destroying
the
salivary
glands.
So
over
time,
the
salivary
glands
become
more
and
more
severely
affected
and
over
time
the
patient
has
a
dryer
and
dryer
mouth
because
the
patient
is
not
able
to
produce
saliva.
So
it
is
one
of
the
conditions
where
you
get
bilateral
salivary
gland
enlargement
and
well
talk
about
it
more
later.
Sjorgens
syndrome
is
a
combination
of
dry
eyes
and
dry
mouth.
29-No
Title
And
this
is
a
patient
with
Sjorgens
syndrome.
She
also
has
dry
skin.
Its
a
very
complex
case,
and
she
has
an
increased
risk
fo
developing
lymphoma
and
well
talk
about
that
later
but
this
is
her
parotid
gland
enlargement.
Ok?
30-Autoimmune
Disease:
Sjorgens
Syndrome
Heres
another
patient
with
parotid
gland
enlargement.
And
very
dry
mouth
and
Ill
show
you
pictures
like
this.
These
are
the
driest
mouth
pictures
I
have
so
youll
see
them
a
couple
of
times.
Remember
I
told
you
in
conference
that
people
with
severe
xerostomia
get
atrophic
or
depapillated
tongue?
So
this
is
an
example
where
that
is
happening.
And
then
the
other
thing
that
happens
when
you
have
no
saliva
is
that
the
risk
of
caries
is
very
high
and
well
talk
about
that
a
little
bit
more
later.
31-Laboratory
Values
in
Sjorgens
Syndrome
And
this
is
one
disease
where
laboratory
values
are
very
helpful
in
making
the
diagnosis.
I
am
not
going
to
ask
you
to
know
the
laboratory
values
in
Sjorgens
syndrome
in
this
course,
because
I
will
ask
you
to
know
them
later.
But
there
are
laboratory
values
and
I
think
that
much
you
should
know.
So
I
think
you
should
know
the
definition
of
Sjorgens
syndrome
that
it
is
a
combination
of
dry
eyes
and
dry
mouth.
I
think
you
should
know
patients
with
Sjorgens
syndrome
have
very
dry
mucosa
and
they
have
an
increased
risk
of
developing
rampant
caries
and
we
can
use
laboratory
values
to
help
make
the
diagnosis.
Ok?
32-HIV
Associated
Salivary
Gland
Disease
This
is
an
HIV
patient
with
bilateral
salivary
gland
enlargement
and
here
are
his
salivary
glands.
Parotid
glands.
33-HIV
Associated
Salivary
Gland
Disease
And
here,
the
laboratory
findings
actually
rule
out
Sjorgens
syndrome.
So
the
laboratory
values
can
be
helpful
because
they
are
negative
and
the
disease
itself
is
very
similar
to
Sjorgens
syndrome
in
presentation.
So
the
fact
that
the
patient
doesnt
have
the
laboratory
values
is
helpful.
Also,
patients
with
HIV
or
HIV
serum
positive,
which
is
another
laboratory
value
which
is
helpful.
The
histology
is
very
similar.
One
difference
from
Sjorgens
syndrome
is
patients
with
HIV
salivary
gland
disease
get
very
large
cystic
spaces
in
the
salivary
gland.
34-No
Title
And
you
can
see
some
of
them
here.
And
we
dont
see
them
in
Sjorgens
syndrome.
35-No
Title
If
we
look
at
it
under
a
microscope,
we
can
get
to
see
some
of
the
large
cystic
spaces
that
are
present
in
this
salivary
gland.
Ok?
36-Salivary
Gland
Tumors
Thats
bilateral
salivary
gland
enlargement.
And
we
will
talk
about
that
a
lot
more
as
your
curriculum
proceeds.
I
do
think
that
at
this
point,
it
is
a
good
idea
to
learn
the
list.
Youre
going
to
have
to
learn
it
anyway
and
you
might
as
well
learn
it
now
since
it
is
summertime
and
you
dont
have
quite
as
many
things
to
work
on.
So,
work
on
the
list,
but
I
think
that
actually
making
the
distinction
between
all
of
the
parts
of
the
list,
we
will
try
to
keep
that
to
the
kinds
of
things
we
will
cover
in
this
course
and
this
lecture.
And
from
here,
we
move
onto
salivary
gland
tumors.
There
are
benign
tumors.
And
benign
salivary
gland
tumors,
they
are
called..there
are
a
variety
of
different
names,
but
they
are
called
adenomas.
So
we
have
a
pleomorphic
adenoma
and
we
have
a
canalicular
adenoma
but
if
you
see
salivary
gland
tumor
and
the
suffix
or
second
part
is
adenoma,
that
means
its
a
benign
one.
For
the
malignant
ones,
they
are
adenocarcinomas.
But
carcinoma
is
the
end
part
of
the
malignant
salivary
gland
tumors.
So
we
have
adenoid
cystic
carcinomas
and
we
have
acinic
cell
carcinomas,
and
mucodermic
carcinomas,
and
we
have
many
different
salivary
gland
tumors.
Each
one
of
the
salivary
gland
tumors
is
diagnosed
on
the
basis
of
its
histopathological
appearance.
So
in
order
to
differentiate
between
benign
and
a
malignant
salivary
gland
tumor,
you
have
to
take
a
biopsy
because
clinically
they
both
present
very
similarly.
Ok,
so
there
might
be
some
slight
changes.
A
malignant
one
might
get
larger
faster
than
a
benign
one,
but
some
of
the
malignant
ones
are
very
slow
growing
tumors
and
so
they
enlarge
very
slowly.
So
really
there
are
no
characteristics
clinically
that
differentiate
a
benign
salivary
gland
tumor
from
a
malignant
salivary
gland
tumor.
Thats
something
that
I
expect
you
to
know
for
this
course.
When
we
get
later
on
in
the
course,
you
are
going
to
have
to
learn
some
names.
When
you
get
to
oral
pathology
net
year,
youre
going
to
have
to
know
a
lot
about
salivary
gland
tumors.
But
right
now,
what
I
want
you
to
know
is
that
there
are
benign
ones
and
there
are
malignant
ones.
The
benign
ones
end
in
adenoma
and
the
malignant
ones
end
in
carcinoma
and
they
are
all
types
of
adenocarcinoma.
You
cant
tell
what
they
are
clinically.
37-No
Title
There
are
different
distributions
of
salivary
glands.
If
you
look
at
the
parotid
gland,
the
parotid
gland
accounts
for
78%
of
all
salivary
gland
tumors
and
75%
of
all
of
one
type
of
benign
salivary
gland
tumor
called
a
pleomorphic
adenoma.
And
it
doesnt
matter
all
the
statistics,
but
about
15%
are
malignant.
Submandibular
gland,
there
is
a
higher
prevalence
of
malignant
salivary
gland
tumors
than
the
parotid
gland.
Sublingual
glands,
again
there
are
at
least
in
the
study
that
these
statistics
came
from,
theres
a
high
prevalence
of
malignancy
in
the
sublingual.
Think
of
the
submandibular
gland.
And
then
intra
oral,
these
are
relatively
old
statistics
because
at
this
point
Im
not
even
sure
we
go
here,
but
lots
of
them
are
malignant,
but
also
lots
of
them
are
benign.
At
this
point
what
I
would
like
you
to
know
here
is
that
salivary
gland
tumors
can
occur
anywhere
you
have
salivary
glands.
They
occur
both
in
major
glands
and
minor
glands
and
there
are
some
differences
in
the
prevalence
of
malignant
tumors
versus
benign
tumors.
I
will
not
ask
you
percentages.
I
cant
remember
percentages.
But
I
would
like
you
to
know
where,
which
one
has
a
higher
percentage
or
a
higher
prevalence
of
malignant
ones
such
as
the
sublingual
and
submandibular
glands
are
more
malignant
in
prevalence
than
the
parotid
glands.
38-Salivary
Gland
Tumors
Ok,
so
they
occur
in
major
and
minor
glands.
And
most
intra-orally.
Another
thing
you
should
know
is
that
they
occur
anywhere
there
are
salivary
glands
but
the
most
common
location
BY
FAR
is
the
junction
of
the
hard
and
soft
palate.
The
hard
and
soft
palate
is
greater
than
the
lips,
greater
than
the
buccal
mucosa,
and
the
upper
lip
is
more
prevalent
than
the
lower
lip.
And
remember
that
a
little
bit
ago
I
told
you
where
is
the
most
common
location
for
mucoceles?
The
lower
lip.
So
salivary
gland
tumors
are
more
prevalent
on
the
upper
lip.
Does
that
mean
you
cant
get
a
mucocele?
No.
And
mucoceles
are
more
common
or
prevalent
on
the
lower
lip.
Does
that
mean
you
cant
get
a
salivary
gland
tumor?
No.
Its
just
that
if
youre
doing
a
differential
diagnosis
and
you
want
to
put
something
on
top,
for
the
lower
lip,
you
put
mucoele
on
top
and
for
the
upper
lip,
you
put
salivary
gland
tumor
on
top.
Some
salivary
gland
tumors
form
mucous
and
can
form
a
cystic
structure
that
can
mimic
a
mucocele.
Ok?
39-Pleomorphic
Adenoma
Pleomorphic
adenomas,
benign
salivary
gland
tumors,
are
benign.
They
are
slow
growing
and
they
will
continue
to
enlarge,
as
every
tumor
will.
Characteristics
of
a
tumor
are
that
it
has
unlimited
growth
potential.
Weve
been
taking
about
epithelial
hyperplasia
and
hyperplasia,
thats
a
reactive
condition.
So
it
will
continue
as
long
as
the
source
thats
causing
the
reaction
is
there.
If
you
remove
the
irritant,
you
will
stop
the
process.
With
tumors
thats
not
true.
With
tumors,
they
are
programmed
to
enlarge
and
keep
going
until
you
have
done
something
to
remove
them.
So
pleomorphic
adenoma
is
the
most
common
of
the
benign
salivary
gland
tumors
and
this
is
just
an
illustration
of
just
how
large
a
pleomorphic
adenoma
can
get.
40-No
Title
Here
we
have
3
or
4
different
types
of
salivary
gland
tumors.
Adenoid
cystic
carcinoma-malignant.
Pleomorphic
adenoma-benign.
Pleomorphic
adenomas
are
worrisome
if
you
dont
remove
them
because
there
are
a
lot
of
illustrations
or
instances
where
a
carcinoma
has
formed
in
the
pleomorphic
adenoma.
So
there
is
a
concern
of
potential
malignant
transformation
in
a
pleomorphic
adenoma.
Mucoepidermic
carcinoma-another
carcinoma.
All
we
have
here,
this
one
is
benign.
This
one
is
malignant.
The
only
reason
you
see
what
looks
like
an
ulceration
here
is
because
thats
where
the
biopsy
was
done.
But
all
of
these
look
very
similar
to
you
clinically
even
though
this
one
is
benign
and
the
other
3
are
malignant.
You
cant
tell
the
difference.
So
the
way
to
make
a
diagnosis
of
a
salivary
gland
tumor
is
through
a
biopsy
and
there
really
isnt
another
way
to
do
it.
41-No
Title
Salivary
gland
tumors
can
occur
anywhere
there
are
salivary
glands
and
if
we
look
here,
we
have
an
enlargement
from
the
salivary
glands
on
the
tip
of
the
tongue.
This
happens
to
be
a
malignant
one.
This
is
an
adenocystic
carcinoma.
Im
not
going
to
take
a
break
because
Im
not
going
to
go
to
4:50
and
I
dont
want
to
take
a
15
minute
break
and
come
back
for
10
minutes.
That
doesnt
make
any
sense.
Ok?
42-Assessment
of
Salivary
Flow
So,
then
we
have
to
go
to
an
assessment
of
salivary
flow.
And
I
will
cover
this
here
and
I
will
mention
it
again
as
we
go
on
later.
There
are
2
terms
and
they
are
used
very
very
carefully
within
research
but
they
are
mixed
up
constantly
in
clinical
practice.
The
term
xerostomia
means
the
patient
is
complaining
of
dry
mouth.
It
can
be
all
the
way
through
to
your
clinical
assessment
where
the
tissue
is
dry.
You
can
still
call
it
xerostomia.
Hyposalivation
means
we
have
measured
the
salivary
flow
and
the
salivary
flow
measures
low.
So
xerostomia
is
a
term
for
the
patient
complained
and
the
clinical
presence
of
the
characteristics
of
dry
mouth.
Hyposalivation
means
you
measured
it.
We
dont
use
the
term
hyposalviation
unless
you
actually
measured
salivary
flow.
Do
you
have
your
hand
up?
No?
I
cant
see
so
it
looks
like..your
hand
it
front
of
her
and
shes
in
front
of
you
so
it
looks
like
her
hand
is
up.
Ok,
we
measure
both
stimulated
and
unstimulated
flow
and
we
get
a
lot
of
information
out
of
the
measurement
of
salivary
flow.
43-Diagnosis
What
we
can
do
to
find
out
about
dry
mouth.
There
are
different
reasons
patients
have
dry
mouth.
And
we
looked
at
Sjorgens
syndrome
as
a
condition
where
you
have
dry
mouth.
And
there
are
multiple
medications
that
dry
up
saliva.
There
are
salivary
gland
diseases
that
will
cause
xerostomia.
And
so
one
of
the
things
we
need
to
figure
out
and
its
not
very
difficult
to
figure
out,
is
whether
or
not
the
patients
dryness
is
due
to
a
salivary
gland
disease
or
due
to
a
medication
that
is
drying
up
saliva.
Also
stress
can
also
do
it.
If
any
of
you
have
ever
been
in
a
stressful
situation
you
will
recognize
that
your
mouth
gets
really
dried
out
and
you
can
barely
move
your
tongue
around
your
mouth
because
your
salivary
glands
have
just
dried
up.
In
salivary
gland
diseases,
the
salivary
gland
acini
are
being
destroyed
more
than
they
are
being
replaced.
So
you
can
try
to
measure
unstimulated
and
stimulated
saliva,
you
dont
get
either.
You
can
stimulate,
but
over
time
the
worse
the
salivary
gland
disease
is,
the
stimulated
saliva
will
not
flow.
So
the
patient
will
have
very
low
unstimulated
salivary
flow
and
a
VERY
low
stimulated
salivary
flow.
If
the
problem
is
due
to
a
medication,
usually,
the
only
medication
that
really
destroyes
salivary
glands
is
lithium.
Most
of
the
others
are
just
interfering
with
the
innervation
that
allows
salivary
flow.
So
what
will
happen
is
as
soon
as
you
stimulate,
the
saliva
will
flow
so
you
may
get
a
very
low
unstimulated
flow,
but
you
get
plenty
of
saliva
as
soon
as
you
give
your
patients
something
to
chew
on
and
stimulate
the
flow.
And
you
can
tell
the
difference
between
a
patient
who
has
salivary
gland
disease
destroying
the
salivary
glands
and
a
patient
who
has
a
medication
that
results
in
xerostomia
by
using
the
technique.
You
dont
have
to
do
it
as
sophisticated
as
we
do
in
research,
in
a
research
program.
In
your
own
practice
you
can
just
have
patients
spit
in
a
cup
and
you
can
tell
the
difference
between
stimulated
and
unstimualted
saliva
which
kind
of
helps
figure
out
which
direction
you
are
going.
Also,
a
patient
with
salivary
gland
disease
is
going
to
need
some
kind
of
lubrication
in
order
to
eat
during
meals.
A
patient
that
has
no
problem
with
salivary
flow
and
salivary
gland
structure
is
going
to
be
fine
at
meals
because
that
will
trigger
the
flow
of
saliva.
So
the
questions
about
meals
and
about
needing
to
drink.
A
patient
with
Sjorgens
syndrome
has
to
drink.
*Cough.
Excuse
me,
let
me
drink.
Has
to
drink
liquid
in
order
to
be
able
to
get
the
force
to
swallow
it.
*Cough
Cough
Cough.
This
is
what
happens
after
three
hours.
And
so
you
need
to
tell
the
difference.
Patients
who
got
a
dry
mouth..*cough
Okay.
I
think.
A
person
who
has
a
dry
mouth
because
of
medication
should
not
have
any
problems
during
meals
at
all.
When
a
patient
has
dry
mouth
a
lot,
you
need
saliva
to
retain
dentures.
There
are
some
techniques
to
help,
but
again
the
dentures
will
not
stay
in
the
way
they
are
supposed
to.
And
then
we
talked
about
facial
and
oral
swellings
during
meal
time.
44-Objective
Findings
Other
things
you
can
look
for:
patients
with
dry
mouth
have
very
dry
chapped
lips
usually.
There
is
an
increase
in
dental
caries
and
increased
risk
in
developing
candida.
Saliva
has
antifungal
properties
that
are
very
very
sophisticated.
And
patients
who
have
decreased
saliva
are
more
vulnerable
to
candidiasis.
When
you
do
your
exam,
you
can
see
the
very
dry,
dessicated
mucosal
surfaces.
And
often
they
are
so
dry
that
the
patient
has
ulceration
because
the
friction
and
the
disruption
of
the
oral
mucosa.
Patients
lips
will
adhere
to
the
patients
teeth.
We
talked
about,
in
the
conferences
this
week,
changes
in
tongue
papillae
that
we
dont
really
understand.
And
of
course,
objectifying
salivary
gland
development
is
usually
very
helpful.
45
This
is
a
larger
picture
of
very
dry
mucosa.
This
is
a
patient
who
I
think
had
cancer
and
radiation
therapy
dryness.
46
The
saliva
thats
there
is
very
thick
and
ropy
and
this
is
an
example
of
this.
47
This
is
a
patient
with
a
type
of
candidiasis.
And
we
have
talked
a
little
bit
in
conference
about
wiping
it
off.
All
that
white
stuff
wipes
off.
The
patient
is
wearing
dentures,
but
the
candida
is
way
outside
the
dentures
and
not
just
the
denture
thats
a
problem.
48
Here,
its
a
patient
with
very
dry
mouth
and
an
atrophic
bald
tongue.
Angular
chilitis
is
one
of
the
clues
to
intra
oral
candidiasis
and
here
she
has
angular
chilitis.
This
is
a
patient
that
was
taking
multiple
medications.
She
was
taking
a
blood
pressure
medication
and
then
she
added
an
anti
allergy
medication
and
then
she
added
another
one
for
sleep.
By
the
time
she
added
a
third
one,
she
really
had
a
very
very
dry
mouth.
49
This
is
a
patient
with
cervical
caries.
You
guys
will
get
very
used
to
a
variety
of
different
caries,
but
most
patients,
particularly
younger
patients
do
not
get
cervical
caries.
The
extensive
cervical
caries
should
give
you
a
clue
that
this
patient
has
dry
mouth.
50
Again,
very
extensive
caries
in
patients
with
Sjorgens
syndromes
and
other
chronic
conditions
with
dry
mouth
will
just
have
a
very
difficult
maintaining
their
teeth,
maintaining
their
restorations
that
you
have
put
in
the
teeth
because
the
teeth
are
decaying.
The
caries
is
just
affecting
the
teeth
right
around
the
restorations.
51
Then,
incisal
caries
is
really
really
really
rare.
We
dont
see
incisal
caries
very
often.
Incisal
caries
just
by
definition-this
patient
has
a
very
dry
mouth.
Unless
the
patient
is
doing
some
VERY
unusual
stuff
with
sugar,
you
would
expect
the
incisal
caries
is
going
to
be
xerostomia.
52-Measurement
of
Salivary
Flow
Measuring
salivary
flow-unstimulated
and
stimulated
are
both
measurements
that
we
use.
They
are
important
because
the
difference
between
the
two
can
give
us
the
clue
as
to
whether
the
patients
salivary
gland
problem
is
salivary
gland
disease
or
might
be
related
to
medications.
53
Another
thing
you
can
look
for
is
pooling
of
saliva
in
the
floor
of
the
mouth.
Normally,
your
patient
will
just
pool
saliva
in
the
floor
of
the
mouth.
If
you
have
a
patient
with
dry
mouth,
the
pooling
of
saliva
is
not
going
to
happen.
54
There
are
a
number
of
different
ways
to
collect
saliva.
When
we
collect
saliva
in
our
studies,
we
are
actually
using
it
on
ice
and
thats
the
cup
here
with
a
graduated
cylinder
and
a
funnel.
So
we
have
a
nifty
system
for
collecting
saliva.
You
really
dont
need
that
in
clinical
practice
unless
you
really
are
doing
a
study.
You
do
need
to
measure
the
saliva
sometimes.
Sometimes
you
dont
even
need
to
measure
it
because
what
youre
really
looking
for
is
how
dry
is
the
patient.
Whether
or
not
you
can
use
stimulation
to
get
the
patient
more
comfortable.
Just
the
difference
between
stimulated
and
stimulated.
Sometimes
you
can
see
it
just
visually.
Sometimes
you
just
get
them
to
spit
in
a
cup
for
about
5
minutes
and
then
with
stimulation.
If
youre
not
doing
a
study,
you
can
use
chewing
gum
for
stimulation
or
you
can
use
anything.
And
for
our
purposes,
you
wont
use
anything
sugarless
but
you
can
use
a
sugarless
lozenge
as
well.
You
are
not
looking
at
the
nature
of
saliva
at
this
point.
You
are
really
looking
at
the
ability
of
the
patient
to
respond
to
stimulation.
The
best
stimulation
is
chewing
gum,
but
not
all
patients
can
chew
gum.
It
depends
and
certainly
patients
with
prosthetic
dentistry
sometimes
cant
chew
gum
because
the
gum
sticks.
You
really
dont
have
to
get
fancy
about
this.
When
you
get
to
clinic,
we
are
able
to
give
you
graduate
cylinders.
I
might
need
to
get
some
more
because
you
might
take
me
up
on
this
more
than
other
classes.
We
do
have
graduated
cylinders
and
we
do
have
funnels,
so
some
of
the
students
have
done
a
measured
technique
for
measuring
salivary
flow
and
I
think
you
will
learn
a
lot
about
xerostomia
if
you
use
that
while
you
are
here
in
school.
55-
Measurement
of
Salivary
Flow
Unstimulated-what
you
do
is
you
drool.
You
sit
quietly
and
let
whatever.
The
easy
way
to
do
it
is
to
let
patients
sit
quietly
and
let
whatever
forms
collect
in
the
floor
of
their
mouth
and
if
they
think
they
can
spit,
they
can
spit.
Actually
drooling
is
very
uncomfortable
because
you
feel
like
you
have
to
let
the
saliva
drip
out
of
your
lip.
Its
usually
the
research
way
of
doing
it,
but
it
really.
In
your
own
practice,
you
can
just
let
the
saliva
collect
in
the
floor
of
the
mouth
and
when
its
enough
to
spit,
spit.
Patients
with
a
real
xerostomia,
you
are
probably
not
going
to
get
any
unstimulated
saliva.
Nothing
is
going
to
be
there
so
you
dont
even
have
anything
to
spit.
With
stimulated,
you
can
sit
there
for
5
minutes
and
get
nothing.
Then
you
give
the
patient
a
lozenge
and
suddenly
the
saliva
starts
flowing.
You
can
tell
immediately
that
the
patient
has
functioning
salivary
glands
and
you
can
make
the
patient
comfortable
with
mechanisms
to
stimulate
salivary
flow.
We
have
to
be
really
careful
because
our
patients
are
going
to
learn
that
too.
If
they
are
going
to
use
a
sugar
lozenge
to
try
to
make
saliva
flow,
they
are
going
to
end
up
with
a
xerostomia
and
an
increase
in
their
caries
experience,
which
isnt
just
because
of
their
dry
mouth.
Its
because
of
what
they
are
doing
to
try
to
stimulate
their
dry
mouth.
We
try
to
intervene
with
fluoride
and
advice
when
we
try
to
get
patients
to
do
what
they
can
about
xerostomia.
Xerostomia
is
that
much
more
subjective
term
for
decreased
salivary
flow
and
hyposalivation
is
when
we
have
measured
it.
I
think
you
will
find
in
your
practice-I
tend
to
talk
about
xerostomia
a
lot.
If
you
dont
identify
a
dry
mouth
before
you
start
a
dental
treatment,
your
dental
treatment
is
going
to
fail.
It
is
really
important
for
your
relationship
with
your
patient
for
you
to
recognize
that
problem
before
you
start.
That
patient
is
going
to
have
increased
caries-caries
around
your
restorations.
Your
gorgeous
dentistry
is
going
to
fail
because
your
patient
has
xerostomia.
56-Etiology
There
are
a
number
of
different
medications
that
are
known
to
cause
dry
mouth.
The
number
is
over
500.
There
are
just
a
number
of
medications
that
will
do
this.
These
are
just
the
categories
of
medications
you
will
learn
much
more
about
medications
as
you
move
through
the
curriculum
but
you
will
also
learn
that
there
are
great
ways
of
looking
medications
and
identifying
those
that
are
likely
to
be
the
culprits.
Sometimes
you
can
work
with
the
patients
physician
to
change
the
medication
to
something
that
is
not
xerostomic.
But
sometimes
you
cant,
and
need
to
work
around
the
medication
isnsteas
of
changing
the
medication.
It
depends
on
what
the
medications.
Very
often
the
alternatives
are
just
as
bad
as
the
one
the
patient
is
using
so
changing
the
medication
unless
there
is
a
category
that
works
for
that
patients
disease
that
is
not
xerostomic,
were
usually
stuck
with
the
medication.
The
more
you
add,
the
worse
it
gets.
A
patient
with
1
medication
that
is
potentially
xerostomic,
the
patient
may
not
have
a
problem.
The
patient
adds
another
medication,
and
the
patient
may
still
not
have
a
problem
but
you
will
see.
With
our
patients
the
older
our
patients
get,
the
more
medications
theyre
taking.
Sometimes
they
are
taking
3
or
4
medications
that
all
have
the
potential
to
decrease
salivary
flow.
57-Etiology
Again,
there
are
systemic
diseases
that
will
decrease
salivary
flow.
Usually
these
are
conditions
that
do
not
respond
well
to
stimulation.
Autoimmune
disease,
the
most
well
known
one
is
Sjorgens
syndrome.
Cystic
fibrosis
actually
affects
salivary
glands
as
well
as
other
glands.
Diabetes,
only
when
it
is
uncontrolled.
Controlled
diabetes
usually
doesnt
give
us
dry
mouth.
HIV
infection,
even
without
the
salivary
gland
problem
can
sometimes
cause
dry
mouth.
It
is
very
often,
we
think
it
is,
and
we
will
talk
about
this
in
another
lecture
we
give
you.
But
we
think
the
problem
is
probably
the
medications.
Whether
or
not
the
HIV
disease
is
really
doing
this
outside
of
identified
salivary
gland
disease
is
not
clear.
And
dehydration.
Dehydration
is
episodic.
Dehydration
will
cause
dry
mouth
but
not
something
that
will
cause
long
term,
chronic,
dry
mouth
unless
you
have
a
dehydration
that
is
really
life
threatening.
Then
we
are
talking
about
a
different
problem
all
together.
58-Etiology
Head
and
neck
radiotherapy
is
notorious.
The
problem
here
is
that
it
destroys
the
salivary
glands
and
there
are
techniques
out
now
for
shielding
the
salivary
glands
so
that
the
salivary
glands
dont
get
destroyed
the
way
they
used
to.
This
is
still
a
problem
if
the
salivary
glands
are
affected,
but
there
some
ways
to
protect
them.
So
thats
our
story
about
salivary
gland
assessment.
There
is
more
to
come,
but
thats
enough
for
today.