SALIVA

Dr. Nitika Jain

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Contents

Saliva - as a diagnostic aid (general and perio) Stress biomarkers

Salivary gland diseases Infections Tumours

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Diagnostic imaging of salivary gland Sialography Contrast sialography

Conclusion References

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SALIVA - AS A DIAGNOSTIC AID

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Human saliva performs a wide variety of biological functions that are critical for the maintenance of the oral health.

Saliva, a multi constituent oral fluid, has high potential for the surveillance of general health and diseases.

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Why saliva???

Non – invasive Limited training No special equipment Potentially valuable for

children and older patients Cost effective Eliminates the risk of

infection Easy, No pain, No needle

prick, Fast Screening of large

population

No Pain

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What is a biomarker???

A biomarker is an objective measure that has been evaluated and confirmed either as an indicator of physiologic health, a pathogenic process, or a pharmacologic response to a therapeutic intervention.

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Biomarkers, whether produced by normal healthy individuals or by individuals affected by specific systemic diseases, are tell - tale molecules that could be used to monitor health status, disease onset, treatment response and outcome.

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Biomarker

Monitor progression / recurrence

Detect disease

Stage disease

Treatment efficacy

Response to treatment

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CLASSIFICATION OF SALIVARY BIOMARKERS

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Locally produced proteins of host and bacterial origin

(enzymes, immunoglobulins and cytokines)

Genetic ⁄ genomic biomarkers such as DNA and mRNA of

host origin

Bacteria and bacterial products, ions, steroid hormones and volatile

compounds

Salivary proteomic, genomic and microbial biomarkers for periodontal diagnosis

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Salivary proteomic approach as biomarkers

initiates the release of biological mediators from host cells and when exaggerated in nature, leads to host tissue destruction

mediators include proteinases, cytokines and prostaglandins. And bacteria-derived enzymes, such as collagen-degrading enzymes, elastase- like enzymes, trypsin-like proteases, aminopeptidases and dipeptidylpeptidase

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Periodontopathic bacteria

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Specific salivary proteomic biomarkers have been identified for three key features of the pathogenic processes in periodontal disease –

inflammation, collagen degradation and bone turnover

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Neutrophilic polymorphonuclear leukocytes, monocytes and activated macrophages are recruited to the site

release numerous cytokines, such as prostaglandin E2, tumour necrosis factor (TNF), interleukins IL-1 and IL-6, which direct further inflammatory processes

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Host-derived MMPs

Both MMP-1 (interstitial collagenase) and MMP-8 (polymorphonuclear leukocyte-derived collagenase) gets activated in periodontitis.

MMP-8, which is primarily derived from polymorphonuclear leukocytes during active stages of periodontitis, is a major tissue destructive enzyme in periodontal disease

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An elevated level of MMP-8 was detected in the saliva of subjects affected by periodontitis compared with healthy patients, but the levels of salivary MMP 1 were similar in both groups.

Therefore, quantification of the level of MMP-8 is a promising candidate for diagnosing and, more importantly, predicting the progression of this episodic disease.

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Other MMPs, including MMP-2, MMP-3 and MMP-9, were also reported in the saliva of patients affected by periodontitis

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Salivary biomarkers have been used to examine the effect of lifestyle factors, including smoking, on periodontal health.

Levels of salivary markers including prostaglandin E2, lactoferrin, albumin, aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase were significantly lower in current smokers than in non-current smokers.

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Biomarkers of bone resorption or turnover

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Alkaline phosphatase

Three main sources: the actual salivary secretions the GCF, PMNs and tissue degradation; and disposed bacterial cells from dental biofilms

and mucosal surfaces

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Alkaline phosphatase

Significant correlation between ALP and pocket depth and between ALP and inflammation.

Higher enzyme activity in individuals with periodontal disease than non diseased individuals.

Periodontal destruction by measurement of probing depth, gingival bleeding, and suppuration were related to higher ALP levels in saliva

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Cathepsin B

Cysteine proteinases Cathepsin B functions in proteolysis 100% sensitivity and 99.8% specificity for

cathepsin B Cathepsin B may have a potential use in

distinguishing periodontitis from gingivitis and in planning treatment and monitoring treatment outcomes

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CRP

C-reactive protein is a systemic marker released during acute phase of an inflammatory response and is produced by liver. Circulating CRP reaches saliva via GCF or salivary glands. High levels of CRP are associated with chronic and aggressive periodontal diseases.

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Osteopontin (OPN)

Noncollagenous calcium binding glycosylated phosphoprotein in bone matrix and is produced by several cells including osteoblasts, osteoclasts and macrophages.

Kido et al (2001) demonstrated that OPN level in saliva was increased with progression of periodontal disease. However, no significant difference was observed when OPN level was compared between diseased and healthy sites.

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Osteocalcin

Is synthesized mainly by osteoblasts. A number of investigators studied

relationship between saliva osteocalcin levels and periodontal diseases.

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Genomic approach as diagnostic markers

Reports of genetic polymorphisms associated with periodontal disease are increasing, and strong evidence supports the proposal that genes play a role in the predisposition to and progression of periodontal disease.

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A number of studies have examined links between polymorphisms within host response factors and aggressive periodontitis.

Examination of genes encoding inflammatory cytokines such as IL-1 and TNF α, the anti-inflammatory cytokine IL-10 and the F c- gamma receptors.

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Reactive oxygen species, participate in the pathogenesis of periodontal tissue destruction.

DNA damage, lipid peroxidation, protein disruption and stimulation of inflammatory cytokine release.

8-hydroxy-deoxyguanosine, a product of oxidative DNA damage, is a biomarker for detecting periodontitis in human subjects.

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Advantages to using genomic and transcriptomic markers to detect disease: The marker discovery process is high-

throughput, involving the use of genome-wide microarray platforms

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Till now,68 up-regulated and six down-regulated genes was identified, including lactotransferrin, MMP-1, MMP-3, interferon induced-15, keratin 2A and desmocollin-1, and this result was confirmed by real-time polymerase chain reaction.

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Stress biomarkers in saliva

Salivary α-amylase Chromogranin A Salivary cortisol

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Salivary cortisol

Its level in saliva is lower than that in blood Advantage of salivary over serum cortisol

measurement is the minimisation of stress from fear of needles during collection, which may bias the results.

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Salivary – α amylaseChromogranin A

biomarkers of acute stress and a-amylase is better

Both salivary CgA and a-amylase are considered biomarkers of the stress response by the sympatho–adreno–medullary system, unlike cortisol, which is considered a biomarker of stress response by the Hypothalamic pituitary adrenal system.

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Various other diagnosis

Candidiasis – Through the presence of candida spp in saliva

The presence of periodontal pathogenic bacteria can also be diagnosed by this method - increasing the risk of cardiovascular and cerebrovascular diseases.

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Cystic fibrosis Cystic fibrosis (CF) is a genetically

transmitted disease of children and young adults, which is considered a generalized exocrinopathy. CF is the most common lethal autosomal-recessive disorder.

The abnormal secretions present in CF caused clinicians to explore the usefulness of saliva for the diagnosis of the disease.

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CF patients contains increased calcium levels.

Resulted in a calcium-protein aggregation which caused turbidity of saliva.

Higher occurrence of calculus as compared with healthy controls.

The levels of neutral lipids,phospholipids, and glycolipids are elevated.

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21-Hydroxylase deficiency an inherited disorder of steroidogenesis which

leads to congenital adrenal hyperplasia. In non-classic 21-hydroxylase deficiency, a partial deficiency of the enzyme is present.(Carlson et al., 1999).

In 21- hydroxylase deficiency, a strong correlation has been found between 17- hydroxyprogesterone levels in saliva and serum.

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In some malignant diseases, markers can be detected in saliva, such as the presence of protein p53 in patients with oral squamous cell carcinoma.

Other biomarkers for OSCC: M2BP MRP14 CD59 Profilin Catalase

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The presence of the c- erb- 2 tumour marker in the saliva and blood serum of breast cancer patients and its absence in healthy women is a promising tool for the early detection of this disease.

In ovarian cancer too, the CA 125 marker can be detected in the saliva with greater specificity and less sensitivity than in serum.

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PCR detection of H. pylori in the saliva show high sensitivity.

The presence of antibodies to other infectious organisms such as Borrelia burdogferi, shigella can also be detected in saliva.

Detection of hepatitis A and hepatitis B surface antigen in the saliva has been used in epidemiological studies.

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In neonates the presence of Ig A is an excellent marker of rota virus infection

HIV antibody detection is as precise in saliva as in serum and is both applicable in clinical and epidemiological studies.

Salivary and oral fluid test: Orasure ( available in USA)

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SALIVARY GLAND DISORDERS

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Salivary gland disorders

Bacterial infections Acute bacterial parotitis Chronic bacterial parotitis Chronic recurrent juvenile parotitis Acute suppurative submandibular sialadenitis Chronic recurrent submandibular sialadenitis Acute allergic sialadenitis

Viral infections Mumps HIV/AIDS Cytomegalovirus

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Fungal infections Mycobacterial infections

Tuberculosis Atypical mycobacteria

Parasitic infections Autoimmune-related infections

Systemic lupus erythematosus Sarcoidosis Sjogren’s syndrome

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Sialolithiasis

• Sialolithiasis is the formation or presence of a calculus or calculi in a salivary gland.

• It is most commonly seen in the submandibular gland and duct (about 80% of cases), then the parotid gland and duct .

• Sialolithiasis is rare in the sublingual gland. • Most stones are solitary, but multiple stones may

be present. • The reason why a stone forms is unknown

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Symptoms:• May be asymptomatic • Dull pain from time to time over the affected

gland • Swelling of the gland• Pain with chewing or swallowing Complications• Oral infection

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Sialadenitis

• The salivary glands contain a network of ducts. Saliva flows through them into the mouth. If the flow is reduced or stopped for some reason, infection can grow. This infection called sialadenitis .

• The most common infection is bacterial.• Sialadenitis is most common in the parotid

gland and the submandibular gland.

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Symptoms:• Tender, painful lump in cheek or under chin. • Pus may drain through the gland into the mouth. • If the infection spreads, fever, chills and malaise

may occur.

Complication• Oral infection.• Upper respiratory tract infection.• Upper GIT infection.

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XEROSTOMIA

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XEROSTOMIA: Epidemiology

Medication Autoimmune disease (Sjogren’s syndrome, lupus) Systemic diseases (diabetes, asthma, kidney,

sarcoidosis, HIV) Stress/anxiety/depression Radiation therapy to the head and neck

30 Gy = glandular fibrosis (gland can still produce some saliva)

60-70 Gy = glandular destruction (gland can no longer produce saliva)

Factors that Affect Salivary Flow

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Gender (70 % female, usually postmenopausal)

Sympathomimetic medications (stimulate the sympathetic nervous system)

Parasympatholytic medications (inhibit the parasympathetic nervous system)

Antacid Antianxiety Anticholinergic Anticonvulsant Antidepressant Antiemetic Antihistamine Antihypertensive Antiparkinsonian Antipsychotic

Factors that Affect Salivary FlowXEROSTOMIA: Epidemiology

•Cholesterol reducing•Decongestant•Diet pills•Diuretic•Hormonal replacement therapy•Muscle relaxant•Narcotic analgesic•Sedative•Bronchodilator

Over 400 Medications Can Produce the Side Effect of Xerostomia

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XEROSTOMIA: Epidemiology

Factors that Affect Salivary Flow

Age

o Studies show that among non-institutionalized people not taking medication, neither the quantity or quality of saliva change significantly with age

o Studies show a positive correlation between the number of drugs taken and the incidence and severity of xerostomia

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Xerostomia is the term used for the symptom of oral dryness. While oral dryness is most commonly associated with a reduction in salivary gland output (termed salivary gland hypofunction), the symptom may be reported by patients with apparently normal salivation who have changes in saliva composition.

XEROSTOMIA: Etiology

“Dry Mouth”

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Xerostomia affects 25% of the population and is becoming one of the fastest-growing oral health Medications are the cause of more than 90% of xerostomia cases 32 million Americans today take three or more medications daily Xerostomia was not a great problem in the past because people did not take as many medications as they do today

XEROSTOMIA: Etiology

Prevalence

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The reported prevalence of dry mouth varies widely due to the methodological and population differences in various studies.

Prevalence has been estimated to range from 10% to 38%, with 20% the most commonly reported figure

Xerostomia is becoming increasingly common in developed countries

where adults are living longer and poly-pharmacy is very common.

XEROSTOMIA: Etiology

Global Prevalence

Viscous saliva Sticky saliva Difficulty speaking Difficulty swallowing Halitosis Altered taste Complaint of dryness Complaint of burning mouth, lips, or tongue Altered sense of smell

XEROSTOMIA: Diagnosis

Symptoms

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Increased caries Food sticking to the oral structures Frothy saliva Gingivitis Absence of saliva Cracking and fissuring of the tongue Ulceration of oral mucosa No pooling of saliva in the floor of the mouth Recurrent candidal infections A toothbrush, mouth mirror, or instrument that sticks to the soft

tissues Poorly fitting prostheses

XEROSTOMIA: Diagnosis

Signs

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Perform oral hygiene at least 4 times daily, after each meal and before bedtimes Use fluoride toothpaste Rinse with a salt and baking soda solution 4 to 6 times daily Avoid citrus juices (oranges, grapefruit, tomatoes) Rinse and wipe oral cavity immediately after meals Keep water handy to moisten the mouth at all times Avoid liquids and foods with high sugar content Avoid rinses containing alcohol and salty foods Brush and rinse dentures after meals Apply prescription-strength fluoride get at bedtime as prescribed Use moisturizers regularly on the lips Try salivary substitutes or artificial saliva preparations

XEROSTOMIA: Diagnosis Simple Management Strategies for Patients

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Saliva substitutes - contents Xanthan gum Sodium carboxymethylcellulose Potassium chloride Sodium chloride Magnesium chloride Calcium chloride Di-potassium hydrogen orthophosphate Potassium di-hydrogen orthophosphate Sodium fluoride Sorbitol Methyl p-hydroxybenzoate Spirit of lemon

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Commercially available: Orabalance XERO – Lube Salivart Optimoist

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Some patients are predisposed to candidiasis because of the lack of salivary histatins

Recommendation: o Antifungal medication can be recommended to control fungal growth

XEROSTOMIA: Management

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XEROSTOMIA: Management

Treatment of Xerostomia-Associated Problems

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XEROSTOMIA: Management

Treatment of Xerostomia-Associated Problems

GETTING INVOLVED IN DIAGNOSING XEROSTOMIA CAN BE A

WINDOW TO PATIENTS’ OVERALL HEALTH

Diagnosing xerostomia is an important diagnostic tool for other systemic diseases. The signs and symptoms of xerostomia are often associated with

and/or result from other conditions.

XEROSTOMIA

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Salivary gland Neoplasia

Tumors of the salivary glands are uncommon and represent 2-4% of head and neck neoplasms.

80 % of tumors occur within the parotid glands & most of the others in the submandibular glands.

Males and females are affected equally. 70% to 80% of these tumors are benign.

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Salivary gland neoplasia

Benign Warthin's tumor (benign papillary cystadenoma) Benign mixed tumors Monomorphic adenoma Benign lymphoepithelial lesions

Malignant Mucoepidermoid carcinoma Adenoid cystic carcinoma Adenocarcinoma Malignant mixed tumor

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Benign tumors

Benign mixed tumors Is the most common tumor of the major salivary

glands. Pathologically, it is characterized by slow growth and few symptoms.

Warthin's tumor (benign papillary cystadenoma) A slow-growing, cystic tumor that almost always

occurs in older men.

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Benign tumors

Monomorphic adenoma Are a group of benign lesions with a variety of growth patterns. These

lesions usually are found in the parotid glands.

Benign lymphoepithelial lesions Include a wide range of cystic changes that share the common

denominator in atypical lymphoid hyperplasia. These changes are found often in patients infected with HIV.

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Malignant tumors

Mucoepidermoid carcinoma • Is unique in that the tumors it produces can vary

in aggressiveness from low-grade and slow growing to high-grade and rapidly growing.

• It occurs more frequently than any other malignancy of the major salivary glands.

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Malignant tumours

Adenoid cystic carcinoma• Account for 25% of malignant salivary gland

tumors and 15% of all parotid gland tumors. • Occur most often in the minor, rather than major,

salivary glands. • The disease is unique in that its tumors grow

slowly, but metastasize readily.

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Malignant tumours Adenocarcinoma

• Are most frequently found in the minor salivary glands of the nose and paranasal sinuses.

• Account for 15% of malignancies of the parotid and 10% of malignancies of the submandibular glands.

Malignant mixed tumor• Make up approximately 15% and 12% of parotid

and submandibular neoplasms respectively. • The disease typically is characterized by slow,

protracted growth.

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Drug monitoring in saliva

molecular size, lipid solubility, and the degree of ionization of the drug

molecule, as well as the effect of salivary pH and the

degree of protein binding of the drug

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Therapeutic Drugs

Antipyrine Caffeine Carbamazepine Cisplatin Cyclosporine Diazepam Digoxin Ethosuximide

Irinotecan Lithium Methadone Metoprolol Oxprenolol Paracetamol Phenytoin Primidone

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Saliva and age

With age, a generalized loss of salivary gland parenchymal tissue loss.

Salivary acini are replaced by adipose tissue.

Decreased production of saliva

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DIAGNOSTIC IMAGING FOR SALIVARY GLAND

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Diagnostic imaging for salivary gland

To differentiate inflammatory from neoplastic diseases

Differentiate diffuse from focal suppurative disease

Identify and localize sialoliths Demonstrate ductal morphology

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Methods

Plain film radiography Intra oral radiography Extra oral radiography Conventional sialography Computed tomography ( CT) Magnetic resonance imaging Scintigraphy Ultrasonography

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Conventional Sialography

A radiographic technique wherein a radiopaque contrast agent is infused into the ductal system of a salivary gland before imaging.

Imaging is done with plain films, fluoroscopy, panoramic radiography, CT.

Mainly submandibular and parotid

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Technique

A lacrimal or periodontal probe is used to dilate the sphincter at the ductal orifice before the passage of a cannula, blunt needle or catheter, which is connected to a syringe containing contrast agent.

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Indications

Contraindications

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Phases of sialography Ductal phase Acinar phase Post – evacuation phase

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Contrast sialography

Lipid soluble agents 37% iodine e.g.: ethiadol

Water soluble agents 28 to 38 % iodine e.g.: hypaque 50%,

hypaque M 75%, renografin 60, isopaque, triosol, dionosil.

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Computed tomography

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Magnetic resonance imaging

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Sialoendoscopy

Specialized procedure that uses a small video camera at the end of a flexible cannula, which is introduced into the ductal orifice.

Both diagnostically and therapeutic Can demonstrate the strictures and kinks

in the ductal system, as well as mucous plugs.

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Conclusion

Biomarkers of disease in succession play an important role in life sciences and have begun to assume a greater role in diagnosis, monitoring and therapy outcomes and drug discovery.

The challenge for biomarkers is to allow earlier detection of disease evolution and more robust therapy efficacy measurements.

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References