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Sialolith with Sialadenitis: A Case Study and a Proposal of a Diagnostic Algorithm
Address for correspondence Urvashi Shetty, MDS, Reader, Nitte (Deemed to be University), Department of Oral and Maxillofacial Pathology and Oral Microbiology, AB Shetty Memorial Institute of Dental Sciences (ABSMIDS), Mangalore, Karnataka, 575018, India (e-mail: Urvashishetty10@gmail.comdrurvashishetty@nitte.edu.in)
This article was originally published by Thieme Medical and Scientific Publishers Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Sialolithiasis along with sialadenitis is one of the commonly occurring salivary gland disorders. Sialadenitis is an inflammatory disease of the salivary glands. It usually occurs insidiously causing pain to the patient and may lead to development of fibrous mass of the salivary gland. The cause of sialadenitis is most commonly due to the salivary duct caliculi which is termed as sialolith or salivary stones which causes statis of saliva in the ducts. This condition is usually accompanied by pain and tenderness of the involved site. Therefore, we report a case of a male patient aged 60 years with pain in the floor of the mouth in the submandibular region which was diagnosed as submandibular sialolithiasis along with sialadenitis and propose a diagnostic algorithm.
Keywords
salivary calculi
sialadenitis
salivary stones
salivary stasis and salivary gland pathology
Introduction
Sialolithiasis occurs in approximately 1% of the general population. About 80 to 90% of salivary stones occur in submandibular gland.1 The composition of sialolith can vary depending upon the concentrations of organic or inorganic components and the gland in which it has occurred. Submandibular gland sialoliths (SMGS) are usually composed of inorganic materials such as hydroxyapatite, brushite, and octacalcium phosphate.2 The formation of SMGS is not a single process, it is influenced by various factors such as stasis of saliva, changes occurring in the salivary biochemistry, and accumulation of calcium phosphate.2 The inflammation of the salivary gland is termed sialadenitis and it is an insidious disease usually affecting the major salivary glands and characterized by intermittent swelling, accompanied by pain and tenderness.3 The microbiology of sialadenitis is not much reported in submandibular and sublingual glands. Bacterial colonies such as staphylococcus, streptococcus, and Gram-negative bacteria are the most common etiologic factors to cause this inflammatory condition.4
Since the exact etiology is still unclear there are few theories considered for the formation of sialoliths: (1) sialomicroliths agglomerating together, (2) mucus plug getting calcified, and (3) alteration of the saliva's biochemical composition. The composition of the sialoliths can be assessed through various methods such as wet chemical techniques, X-ray powder diffraction, and/or Fourier-transform infrared spectroscopy (FTIR). The FTIR is the most commonly accepted method since it is rapid and easily reproducible. The concept of FTIR is that the IR spectrum initially begins from the vibration of molecules. These motions of molecules due to vibration produces frequencies which are unique to individual compounds similar to that of fingerprints. This can be utilized for the classification of organic and inorganic compounds present. Similarly, in wet chemical analysis the quantification of ions and organic components can be calculated.5 The most commonly accepted method for assessing the composition of lithiasis is wet chemical analysis method proposed by Larsson et al,6 he had initially performed in urinary caliculi. The wet chemical method includes various steps such as:
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(1) Drying and dissolution: Initially, the calculus must be weighed and needs to be pulverized in a mortar and to be dried over silica gel to completely desiccate at room temperature for 2 days.
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(2) Later, 1 mL of concentrated nitric acid to be added to the powder, effervescence shows the presence of carbon.
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(3) Next, the calculus needs to be completely dissolved and kept in magnetic stirring for 3 hours at room temperature for creating the sample solution to find the presence of particular component such as calcium, magnesium, ammonium, phosphate, oxalate, and urate. The sample solution shouldn't be diluted for the analysis of cysteine and protein but for rest it needs to be diluted.
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(4) Result calculation: The molar concentrations and volume of sample solution can be used to evaluate the amount of analyte in µmol. The composition of calculus can be computed.6
The diagnosis of this disease is usually made clinically with conventional radiography such as orthopantomogram (OPG) or occlusal radiographs followed by surgical removal of the salivary stone and the gland involved.5
Case Report
Clinical Examination
A 60-year-old male patient presented with pain and swelling in the lower right side of the floor of the mouth for the past week. The history of pain was sudden in onset with moderate intensity and was continuous in nature. The patient did not state any aggravating or relieving factors. The patient also gave no relevant history about the change in the size of the mass. On extraoral examination, mild facial asymmetry was noted on the right side. On palpation of the right submandibular region, there was a diffused enlargement noted of approximately 2 cm × 2 cm in size roughly along with tender and palpable lymph nodes. There was no difficulty in mouth opening and closing along with normal jaw moments.
Radiographic Examination
An OPG was taken (Fig. 1). The OPG revealed a well-defined radiopaque mass seen superimposed in the right lower body of the mandible near the angle of the mandible of size approximately 3.5 mm × 1.7 mm in size and a provisional diagnosis of sialolith was considered. The patient was referred to the department of oral surgery for further management.
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Fig. 1 X-ray showing sialolith on right submandibular region (white arrow).
Surgical Intervention
The surgeons evaluated the patient and prepared for the removal of the sialolith along with the involved salivary gland. An excisional biopsy was performed and given for histological evaluation (Fig. 2).
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Fig. 2 (A) Preop picture of the patient with marking prior to removal of the sialolith and the involved submandibular gland. (B) Postop picture of the patient after the removal of sialolith along with submandibular gland.
Histopathological Examination
The gross specimen was received for histopathological evaluation (Fig. 3). A radiograph of the gross specimen was also taken to check for any other calcifications present within the gland (Fig. 4). On gross examination of the sialolith it roughly measured around 1.3 cm × 0.9 cm in size (Fig. 5).
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Fig. 3 (A) the gross specimen. (B) Sialolith along with submandibular gland approximately measuring 5.5 cm × 4.5 cm.
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Fig. 4 X-ray of the excisional biopsy of sialolith along with submandibular gland.
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Fig. 5 Macroscopic view of sialolith roughly measuring 1.3 cm × 0.9 cm in size.
The hematoxylin and eosin-stained section showed encapsulated lobules of the salivary gland which were seen separated by thin fibrous septa. Numerous seromucous acini were seen. One part of the section showed loss of architecture of the acini and a focal area of diffused infiltration of inflammatory cells into the gland along with numerous ducts. Periductal inflammation was also noted along with blood vessels and extravasated red blood cells (Fig. 6).
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Fig. 6 Photomicrograph of submandibular sialadenitis showing: (A) Lobules of gland with mixed seromucinous acini in lower power magnification. (B) Periductal inflammation with dense inflammatory infiltrate. (C) Infiltration of inflammatory cells into the gland. (D and F) Higher power image showing infiltration of inflammatory cells in between acini and ducts. (E) Destruction of the ducts by the inflammatory cells.
Discussion
Sialolithiasis
Sialolithiasis is formation of salivary stones in the ducts of the major salivary glands: the parotid, submandibular, and sublingual glands with a reported prevalence of 1 in 10,000 to 1 in 30,000, and it is the most common cause of salivary gland enlargement.7 Sialoliths can occasionally restrict the salivary ducts, causing inflammation and root a secondary bacterial infection, or in extremely rare circumstances form an abscess. There are many presenting signs, but the two most prevalent signs are reduced salivary flow and cyclical postprandial enlargement of the afflicted gland.8 The etiology and pathophysiology are presented as a flowchart (Fig. 7).910
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Fig. 7 Flowcharts showing the pathophysiology and etiology of sialolithiasis.
Sialadenitis
Sialadenitis is the inflammatory condition of salivary glands. It most commonly occurs in major salivary glands. Submandibular sialadenitis is usually caused due to stasis of saliva which in turn leads to retrograde seeding of bacteria from the oral cavity. Submandibular glands are present bilaterally in the submandibular triangle covered by the investing layer of deep cervical fascia and it drains into the oral cavity through the Wharton's duct in the floor of the mouth. The submandibular gland saliva is rich in potassium and low in sodium. There are two forms of submandibular gland sialadenitis: acute and chronic form. The acute form is characterized by insidiously occurring and the chronic form is characterized by long-standing infection due to obstruction. The usual clinical presentation will be swelling of the gland without erythema accompanied by pain. The common causes and pathophysiology are listed in Fig. 8.11121314
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Fig. 8 Common causes and pathophysiology of sialadenitis.
Since there are numerous causative factors, all differential diagnosis must be excluded by the clinician based on the clinical criteria to arrive at a diagnosis. The clinical, radiographical, laboratory, and histological tests need to be done for confirmatory diagnosis. To assist the diagnostician in reaching a diagnosis and course of treatment, we suggest a straightforward but practical diagnostic algorithm. This algorithm takes into consideration the palpable salivary stones as well15161718 (Fig. 9).
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Fig. 9 Diagnostic algorithm for sialadenitis and sialolithiasis.
The most common cause of sialadenitis is sialolithiasis, which occurs in the submandibular region and accounts for approximately 80% of cases.19 There are various theories put forth on the formation of salivary stones, but they are most likely to occur in the submandibular gland because of salivary stagnation, increased alkalinity of saliva, physical trauma, being more susceptible to infection and inflammation, and the production of saliva against gravity.20 Also, the contents of submandibular saliva contribute due to their increased levels of mucin, protein, calcium, and phosphate compared to that of other major salivary glands.19 In fact, tobacco can also contribute to the formation of sialoliths because it greatly influences the rate of salivary flow and can also cause inflammation of the gland.20 About 85% of the sialoliths occur in Wharton's duct because of its complex morphology, while the rest, 15%, occur in the gland parenchyma.2021 The obstruction of the gland can cause swelling with a subsequent risk of superinfection. Sialolith usually occurs predominantly in adult male population. In the current case report a 60-year-old male was affected which is in accordance to the literature.21 The signs and symptoms include cyclical episodes of pain accompanied by inflammation and swelling, the inflammation and swelling occur due to the obstruction of the flow of saliva, resulting in increased intraglandular pressure. In partial or incomplete ductal obstruction, the saliva can escape around the sialolith. In these types of cases, the patients will be asymptomatic and can only be diagnosed as an incidental finding in routine dental radiography.22 The imaging of the salivary gland is crucial because it aids in determining the location, kind, and extent of the lesion, assessing the ductal morphology, choosing the site of the biopsy, and formulating a treatment strategy.23 Conventional radiography, digital subtraction sialography, sonography, computed tomography, and magnetic resonance (MR) imaging sialography are imaging methods that can be used to investigate salivary calculi. Just 20% of calculi are radiopaque, and conventional radiography depends on the nature of the stone. Digital subtraction sialography has a sensitivity range of 96 to 100% and a specificity range of 88 to 91%. Because of the possibility for an infection's symptoms to worsen, it is contraindicated in the acute context. According to reports, sonography has a sensitivity range of 59.1 to 93.7% and a specificity range of 86.7 to 100%.2223 According to reports, MR imaging sialography has a 91% sensitivity rate and a 94 to 97% specificity rate.24
The choice of imaging modality should be made based on the disease and the characteristics of the patient. There are numerous therapy options that principally rely on the sialolith's size and location. Frequently performed is bimanual palpation for tiny stones which pass through the duct and are “milked out.” Surgical shock wave lithotripsy is advised for salivary stones up to 10 mm which have been found in the proximal part of the duct and it is an extremely minimal invasive procedure for removing substantial salivary stones. Sialoliths greater than 10 mm and which are not palpable are removed surgically along with the gland involved.15161718
The differentials that can be considered in case of swelling in the submandibular region and radiopacities seen in radiographs are listed out in Table 1.
|
Differential diagnosis considered for submandibular gland swelling |
|
|---|---|
|
Acute symptoms |
Chronic symptoms |
|
- Viral infections - Bacterial infections |
- Obstruction of the duct due to caliculi - Low-grade non0pyogenic bacterial infection - Lymphoepithelial disease such as sicca syndrome - Granulomatous conditions such as tuberculosis, fungal infections - Sarcoidosis - Salivary gland neoplasm |
|
Lesions with similar clinical presentations in the submandibular region are: - Space infections - Dental abscess - Thyroglossal cyst |
|
|
- Non-neoplastic, noninflammatory swelling of the salivary gland can occur due to various reasons such as metabolic and nutritional imbalances which also includes liver cirrhosis due to alcoholism, pellagra, and uremia |
|
|
Differential diagnosis to be considered for radiopacities in submandibular region |
|
|
- Sialoliths (salivary stone or caliculi) - Calcified lymph nodes - Phleboliths - Tuberculosis - Atherosclerotic plaques - Metastasis from calcified carcinoma |
|
The uniqueness of this case study is that it provides a detailed insight on sialolith in the submandibular gland; its etiology, pathogenesis, analysis and composition of salivary caliculi, and a diagnostic algorithm is proposed which can help the surgeons to manage sialoliths with sialadenitis more efficiently and contribute to the literature on the subject. The terms “sialolithiasis” and “submandibular gland sialolithiasis” were used in searches on PubMed and Google Scholar. Pertinent published articles in dentistry journals were reviewed and included in the current case report. Only English-language studies published after the year 2010 reporting cases of sialoliths with sialadenitis occurring in the submandibular gland among Indian population were chosen for the review and tabulated (Table 2).
|
Author name |
Year of publication |
Age and gender of the patient |
Feature and site of occurrence |
|---|---|---|---|
|
Chandra Mouli et al27 |
2011 |
44/M |
Pain on lower left side below the tongue |
|
Shetty and Sharma28 |
2010 |
50/M |
Left submandibular region, swelling |
|
Lokesh Babu and Jain29 |
2011 |
50/M |
Left side on the floor of the mouth, pain with swelling |
|
Parkar et al30 |
2012 |
84/F |
Left floor of the mouth, swelling |
|
Iqbal et al31 |
2012 |
55/M |
Left submandibular duct region |
|
Arunkumar et al32 |
2015 |
55/M |
Left border of the mandible, swelling |
|
Marwaha and Nanda33 |
2012 |
10/F |
Left submandibular gland region, intermittent pain |
|
Saluja et al34 |
2012 |
65/M |
Right side floor of the mouth, pain and swelling |
|
Kuruvila et al35 (6 cases) |
2013 |
1- 55/F 2- 25/F 3,4,5- F (age not mentioned) 6- 8/F |
Right mandibular region Lower left back tooth region Swelling in the floor of the mouth Swelling below the tongue |
|
Dalal et al36 |
2013 |
40/F |
Left floor of the mouth, intermittent pain |
|
Singh and Singh37 |
2013 |
55/M |
Floor of the mouth, asymptomatic |
|
Dewan et al38 (multiple sialoliths) |
2013 |
26/M |
Pus discharge from the opening of the duct |
|
Kiran et al39 (2 cases) |
2013 |
26/M 44/M |
Right submandibular region, swelling and pain Left submandibular region, swelling |
|
Divya and Sathasivasubramanian40 (2 cases) |
2013 |
22/M 69/F |
An insidious swelling appears during meals and disappears Pain below the tongue |
|
Trivedi41 |
2014 |
9/F |
Right submandibular region |
|
Sinha et al42 |
2014 |
55/M |
Right lower side of the face, swelling with intermittent pain |
|
Mathew Cherian et al43 |
2014 |
36/M |
Floor of the mouth, pain and swelling |
|
Shruthi Hegde et al44 |
2014 |
55/M |
Left submandibular region, swelling |
|
Baliah et al45 (2 cases) |
2014 |
10/M 55/M |
Right submandibular region, swelling Lower border of mandible, swelling |
|
Krishnan et al46 |
2014 |
43/M |
Left side on the floor of the mouth, swelling |
|
Mohapatra et al.47 |
2015 |
18/F |
Right submandibular region, swelling |
|
Kiran et al48 |
2015 |
65/M |
Floor of the mouth, swelling |
|
Gopinath49 |
2015 |
35/M |
Intraoral swelling with chronic pain |
|
Thopte et al50 |
2016 |
23/M |
Lower right back tooth region, pain |
|
Singh et al51 |
2016 |
35/M |
Floor of the mouth, pain and swelling |
|
Sabu et al52 |
2017 |
55/M |
Bilateral swelling noted on the lower jaw |
|
Rana and Arya53 (3 cases) |
2017 |
22/M 35/M 48/F |
Right side of the face, pain and swelling Left side of the face, pain and mild swelling Right submandibular region |
|
Sakthivel et al54 |
2017 |
42/M |
Right submandibular region, swelling |
|
Monika et al55 |
2017 |
52/F |
Floor of the mouth, swelling |
|
Ujjwal et al56 (2 cases) |
2018 |
58/F Young female (age not mentioned) |
Left submandibular region, swelling Right submandibular region, intermittent pain and swelling |
|
Sengupta and Bose57 |
2018 |
35/M |
Pain on mastication |
|
Neeraj et al58 |
2018 |
37/M |
Left submandibular region, pain |
|
Wadhawan et al59 |
2019 |
19/M |
Right back jaw region, swelling |
|
Kumar et al60 |
2021 |
29/M |
Left angle of mandible |
|
Nirola et al61 (2 cases) |
2020 |
37/M 35/F |
Right side floor of the mouth Left side floor of the mouth, swelling |
|
Khorate and Vaidya62 |
2020 |
39/M |
Left submandibular region, swelling |
|
Chandak and Chandu63 |
2020 |
23/M |
Left submandibular region, pain and swelling |
|
Anand et al64 |
2020 |
69/M |
Floor of the mouth, pain |
|
Mathew et al65 |
2022 |
50/M |
Right submandibular region, swelling |
|
Present case |
2023 |
60/M |
Right lower side in floor of the mouth, pain and swelling |
Abbreviations: F, female; M, male.
Conclusion
Sialoliths need to be assessed and managed properly prior to the involvement of the gland because sialadenitis can cause detrimental effects. A meticulous history collection and appropriate imaging techniques would preserve time. This case report adds to the literature, it illustrates a case of sialolithiasis occurring along with sialadenitis that was diagnosed clinically and interpreted using a simple radiograph and treated with no complications. A diagnostic algorithm has been proposed to arrive at a quick diagnosis and initiate a prompt treatment.
Acknowledgment
None.
Conflict of Interest
None declared.
Conflict of Interest
None declared.
References
- Salivary stones: symptoms, aetiology, biochemical composition and treatment. Br Dent J. 2014;217(11):E23.
- [Google Scholar]
- Sialadenitis associated with sialolith- a case report. Arch Dent Res. 2021;11(02):130-132.
- [Google Scholar]
- Acute viral and bacterial infections of the salivary glands. Otolaryngol Clin North Am. 1999;32(05):793-811.
- [Google Scholar]
- Biochemical composition of salivary stones in relation to stone- and patient-related factors. Med Oral Patol Oral Cir Bucal. 2018;23(05):e540-e544.
- [Google Scholar]
- A method for quantitative wet chemical analysis of urinary calculi. Clin Chim Acta. 1984;140(01):9-20.
- [Google Scholar]
- Chronic bacterial sialadenitis—a case report. Oral Surg Oral Med Oral Radiol. 2013;1(01):1-3.
- [Google Scholar]
- Etiologic factors in sialolithiasis. Otolaryngol Head Neck Surg. 2011;145(06):935-939.
- [Google Scholar]
- Salivary gland calculi - contemporary methods of imaging. Pol J Radiol. 2010;75(03):25-37.
- [Google Scholar]
- Lack of correlation between water hardness and salivary calculi in England. Br J Oral Maxillofac Surg. 2000;38(01):50-53.
- [Google Scholar]
- Retrograde theory in sialolithiasis formation. Arch Otolaryngol Head Neck Surg. 2001;127(01):66-68.
- [Google Scholar]
- Primary tubercular sialadenitis - a diagnostic dilemma. Iran J Otorhinolaryngol. 2019;31(102):45-50.
- [Google Scholar]
- Iodinated contrast-induced sialadenitis: a review of the literature and sonographic findings in a clinical case. J Ultrason. 2018;18(75):359-364.
- [Google Scholar]
- Immunoglobulin G4-related chronic sclerosing sialadenitis: an emerging entity. J Oral Maxillofac Pathol. 2020;24(01):S135-S138.
- [Google Scholar]
- Algorithms for treatment of salivary gland obstructions. Otolaryngol Clin North Am. 2009;42(06):1173-1192.
- [Google Scholar]
- The role of adenectomy for salivary gland obstructions in the era of sialendoscopy and lithotripsy. Otolaryngol Clin North Am. 2009;42(06):1161-1171.
- [Google Scholar]
- Diagnostic utility of submandibular and labial salivary gland biopsy in IgG4-related sialadenitis. Clin Rheumatol. 2020;39(12):3715-3721.
- [Google Scholar]
- Sialolithiasis. A survey on 245 patients and a review of the literature. Int J Oral Maxillofac Surg. 1990;19(03):135-138.
- [Google Scholar]
- Association of serum electrolytes and smoking with salivary gland stone formation. Int J Oral Maxillofac Implants. 2016;45(06):764-768.
- [Google Scholar]
- Disease of the salivary glands In: Gorlin J R, Goldmann M H, eds. Thomas' Oral Pathology. St Louis, MO: Mosby-Year Book Inc.; 1970. p. :997-1003.
- [Google Scholar]
- Incidental finding of sialolithiasis in the sublingual gland: a diagnostic dilemma. Dent Update. 2011;38(10):704-705.
- [Google Scholar]
- Imaging the major salivary glands: a review. Adv Dent & Oral Health. 2018;8(04):555745.
- [Google Scholar]
- The diagnostic accuracy of contrast-enhanced CT of the neck for the investigation of sialolithiasis. AJNR Am J Neuroradiol. 2017;38(11):2161-2166.
- [Google Scholar]
- Inflammatory and obstructive disorders of salivary glands. J Dent Res. 1987;66:675-679. (Spec No):
- [Google Scholar]
- Sialolith: a case report with review of literature. Indian J Multidiscip Dent. 2011;2:377-379.
- [Google Scholar]
- Unusual case of a projecting intraoral giant sialolith. Indian J Surg. 2010;72(02):155-157.
- [Google Scholar]
- Giant submandibular sialolith: a case report and review of literature. Int J Head Neck Surg. 2011;2(03):154-157.
- [Google Scholar]
- A large sialolith perforating the Wharton's duct: review of literature and a case report. J Maxillofac Oral Surg. 2012;11(04):477-482.
- [Google Scholar]
- Unusually large sialolith of Wharton's duct. Ann Maxillofac Surg. 2012;2(01):70-73.
- [Google Scholar]
- Oversized submandibular gland sialolith: a report of two cases. J Maxillofac Oral Surg. 2015;14(01):116-119.
- [Google Scholar]
- Giant Sialolith in the Wharton's duct causing sialo-oral fistula: a case report and review of literature. J Orofac Sci. 2012;4:137-142.
- [Google Scholar]
- Submandibular sialolithiasis: report of six cases. J Pharm Bioallied Sci. 2013;5(03):240-242.
- [Google Scholar]
- Surgical management of an unusually large sialolith of the Wharton's duct: a case report. King Saud Univ J Dental Sci. 2013;4(01):33-35.
- [Google Scholar]
- Submandibular gland megalith eroding the floor of the mouth: a case report. Ear Nose Throat J. 2013;92(12):e17-e19.
- [Google Scholar]
- Unusaual presentation of submandibular duct and gland calcui: case report. Online J Otolaryngol. 2013;3(01):56.
- [Google Scholar]
- Surgical removal of submandibular gland sialolithiasis in a 9-year-old girl: A case report. Pediatr Dent J. 2014;24(02):111-114.
- [Google Scholar]
- Submandibular gland sialolithiasis with chronic sialadenitis: a case report. Intl J Med Dental Case Rep. 2014;1(01):1-4.
- [Google Scholar]
- Wharton's duct sialolith of unusual size: a case report with a review of the literature. Case Reports Dentist 2014;2014;
- [Google Scholar]
- Sialadenitis of left submandibular salivary gland associated with giant sialolith-a case report. Ind J of Med Res and Pharm Sci 2014;1(01)
- [Google Scholar]
- Giant sialolith in Wharton's duct with perforation in oral cavity: case report. Indian J Contemp Dentist. 2015;3(02):44.
- [Google Scholar]
- A megalith (giant sialolith) in Wharton's duct: a case report and review of the literature. Egyptian J Oral Maxillofacial Surg. 2015;6(03):102-106.
- [Google Scholar]
- A rare case report of large submandibular duct calculus. Intl J Curr Innovat Res. 2015;1:225-227.
- [Google Scholar]
- Sialolithiasis of submandibular gland with acute suppurative sialadenitis: A Case Report. World J Pharm Pharm Sci. 2016;5(04):1677-1682.
- [Google Scholar]
- Giant sialolith of Wharton's duct treated economically in a poor patient. J Clin Diagn Res. 2016;10(06):ZJ03-ZJ04.
- [Google Scholar]
- Submandibular sialolithiasis with sialadenitis presenting as Ludwigs angina-a case report. J Adv Med Dental Sci Res. 2017;5(06):10-12.
- [Google Scholar]
- Sialolithiasis of the Wharton's duct-report of 3 cases. J Adv Med Dental Sci Res. 2017;5(11):108-111.
- [Google Scholar]
- Giant sialolith of submandibular duct. JNMA J Nepal Med Assoc. 2017;56(206):262-264.
- [Google Scholar]
- Submandibular sialolith of an unusual size: a clinical review. Ann Dental Special. 2017;5(04):198.
- [Google Scholar]
- Submandibular sialolithiasis: a brief overview and report of two cases. Mod Res Dent. 2018;1(05):1-7.
- [Google Scholar]
- Sialolithiasis of right submandibular duct of unusual size. Indian J Surg. 2018;80(02):190-191.
- [Google Scholar]
- Sialolithiasis of the submandibular salivary duct-a case report. J Oral Med Oral Surg Oral Pathol Oral Radiol. 2018;4(01):58-60.
- [Google Scholar]
- Sialolithiasis: an unusually large salivary stone. J Maxillofac Oral Surg. 2021;20(02):227-229.
- [Google Scholar]
- Submandibular duct sialoliths of unusual sizes-two case reports. J Dent Health Oral Disord Ther. 2020;11(01):33-35.
- [Google Scholar]
- Submandibular sialolithiasis case report with 10 years follow up. Intl J Appl Dental Sci. 2020;6:446-449.
- [Google Scholar]
- Submandibular gland Wharton's duct phlegomous calculus sialoadenitis: A rare case report. J Datta Meghe Inst Med Sci Univ. 2020;15(02):292-294.
- [Google Scholar]
- Extremely large submandibular sialolith removal - a case report. Ann Maxillofac Surg. 2022;12(02):237-239.
- [Google Scholar]