Picture this scenario. A patient walks into your clinic complaining about something a little unusual. They tell you, “Doctor, I feel a sudden pain and swelling under my jaw every time I start eating, and then, a little while after the meal, the swelling goes down on its own.”
Naturally, a thousand thoughts might cross your mind. Everything from gingivitis to an abscessed tooth. But upon examination, all the teeth appear perfectly healthy. So, what’s going on?
Many of us might overlook a very common cause for these exact symptoms, one that’s right at the core of our work as dentists: Sialolithiasis, or salivary gland stones.
Just as stones can form in the kidneys or gallbladder, similar calcifications can also develop within the salivary glands or their ducts. These can lead to incredibly painful and distressing issues for the patient. In this article, we’ll refresh your memory on everything you need to know about this condition – from its causes and symptoms, to how to accurately diagnose it in your clinic, and the various treatment options available.
What Exactly is Sialolithiasis?
In very simple terms, Sialolithiasis refers to calcifications that form either within the salivary gland tissue itself or inside its salivary ducts.
These stones are primarily composed of mineral deposits naturally present in our saliva, such as calcium phosphate and calcium carbonate. Over time, these deposits accumulate, forming a hard stone. Their size can vary dramatically—from as tiny as a grain of sand to several centimeters in diameter.
This condition is most commonly observed in middle-aged adults and stands as the leading cause of acute Sialadenitis (inflammation of the salivary glands).
Where Do These Stones Typically Form? (Common Locations)
We have several major salivary glands. However, one particular gland is the “star player” when it comes to stone formation.
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The Submandibular Gland: Approximately eighty to ninety percent of all salivary gland stones originate in this gland or its associated duct (1).
So, why this gland specifically? It all comes down to a few anatomical and physiological reasons:
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Thicker Saliva: The saliva produced by the submandibular gland is notably more viscous and mucous-rich compared to that from other glands.
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Higher Mineral Content: Its saliva tends to have a higher concentration of calcium and phosphate.
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Peculiar Duct Pathway: Its duct, known as Wharton’s Duct, is quite long and travels upwards, against gravity, before opening into the floor of the mouth beneath the tongue. This extended, tortuous path inherently slows down salivary flow, creating a prime environment for mineral precipitation and stone formation.
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The Parotid Gland: Around ten to twenty percent of stones develop in this gland.
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The Sublingual Gland and Minor Glands: Stone formation in these glands is considerably rare.
What Triggers Stone Formation? (Risk Factors)
The direct primary cause of sialolithiasis remains not fully understood (100%). However, several risk factors are known to increase its likelihood. Most of these revolve around salivary stasis (reduced flow) and increased salivary density:
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Dehydration: This is arguably the most significant and common factor. When an individual doesn’t consume enough water, their saliva becomes concentrated, and its mineral content rises, creating an ideal environment for stone formation.
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Infrequent Eating: The processes of chewing and eating stimulate salivary secretion, promoting a robust flow. Individuals who eat sparingly or fast for extended periods are more susceptible.
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Certain Medications: Many drugs cause dry mouth (xerostomia) as a side effect. These include certain antihypertensives, antihistamines, and some antidepressants.
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Trauma: Any injury or direct blow to the gland.
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Smoking.
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Gout.
Symptoms: How Do Patients Typically Complain? (Clinical Symptoms)
The hallmark symptom is the “painful swelling associated with eating.” The patient will often describe a classic scenario:
“Before or right as I start eating, I experience sudden pain and swelling under my jaw or in my cheek. The swelling becomes larger and intensely painful for about thirty minutes to an hour, and then it gradually subsides on its own.”
Why does this happen? Simply put, during meals, the brain signals the salivary glands to produce abundant saliva. If a stone is obstructing the duct, this increased saliva gets trapped behind it, generating immense pressure within the gland. This pressure is precisely what causes the sudden pain and swelling. After some time, salivary secretion diminishes, the pressure alleviates, and the swelling recedes (2).
Other symptoms you might observe include:
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Dry Mouth or Xerostomia.
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Difficulty swallowing or opening the mouth.
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If a secondary bacterial infection occurs, you might notice redness in the area, pus discharge from the duct opening, fever, and a foul taste in the mouth.
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Occasionally, there are no symptoms at all. A stone might be very small or not completely obstruct the duct, being discovered incidentally on a panoramic radiograph.
Diagnosis and Management: Your Role as a Dentist
Diagnosis
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Listen Carefully to the Patient: The classic “pain with eating” narrative alone points you 90% towards the correct diagnosis.
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Clinical Examination:
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Inspect the floor of the mouth. Pay close attention to the openings of the salivary ducts beneath the tongue. You might observe redness, swelling, or even visualize the stone if it’s very close to the opening.
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Palpate the gland and duct. Perform bimanual palpation, with one finger intraorally and another extraorally along the course of Wharton’s duct. If a significant stone is present, you should be able to feel it as a firm mass.
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Radiographs:
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Occlusal X-ray: This is often the best and simplest radiograph for visualizing stones in Wharton’s duct, as approximately 80% of these stones are radiopaque.
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Panoramic X-ray: Can reveal larger stones within the body of the gland itself.
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Ultrasound or CT Scan: These are reserved for more challenging cases or if the stone is radiolucent (not visible on conventional X-rays).
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Treatment
Treatment strategies depend on the stone’s size and location.
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Conservative Management for Small Stones:
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Plenty of Water: This is the primary and most crucial recommendation.
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Salivary Stimulation: Advise the patient to chew sugar-free gum or suck on something acidic, like lemon drops. This “flushing” action might help dislodge the stone.
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Massage and Warm Compresses: Gently massaging the gland externally combined with warm water compresses can aid in moving the stone.
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Anti-inflammatories: Medications like Ibuprofen can help alleviate pain and swelling.
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In-Office Stone Removal for Superficial Stones:
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If you can visualize the stone close to the duct opening, you might, after simple local anesthesia, gently dilate the duct orifice and help expel the stone through manual pressure (Manual Removal).
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Surgical Intervention for Larger Stones:
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Sialendoscopy: This is a modern, excellent technique. A very fine endoscope is inserted into the salivary duct, allowing the clinician to visualize the stone and remove it with micro-instruments or fragment it with a laser. Its advantage is that it’s minimally invasive and preserves the gland (3).
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Traditional Surgery: If the stone is exceptionally large or sialendoscopy fails, a surgeon might make a small incision in the floor of the mouth to remove the stone directly.
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Gland Removal: This is considered the last resort. It’s only pursued in cases where stones recur frequently and have caused permanent fibrosis within the gland.
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The Bottom Line: What to Do When This Case Walks In
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Suspect the Diagnosis: For any patient complaining of swelling and pain associated with eating, place Sialolithiasis at the top of your differential diagnosis list.
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Examine Thoroughly: Focus your examination on the floor of the mouth and the course of the submandibular gland.
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Order the Right Imaging: An occlusal X-ray is often your best diagnostic friend here.
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Start Simple: Most small stones respond well to conservative management. Advise your patient on this first.
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Know When to Refer: If the stone is large, deeply embedded, or if conservative treatment proves unsuccessful, then it’s time to refer the patient to an Oral and Maxillofacial Surgeon.
By diligently following these steps, you’ll be well-equipped to confidently manage this often-troublesome condition and provide your patient with the correct advice and solution.
