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Year : 2017  |  Volume : 8  |  Issue : 4  |  Page : 187-190

Mealtime syndrome: A report of two cases and review of literature

1 Department of Oral Pathology, SRM Dental College, Chennai, Tamil Nadu, India
2 Department of Oral Medicine and Radiology, SRM Dental College, Chennai, Tamil Nadu, India

Date of Web Publication14-Dec-2017

Correspondence Address:
AH Harini Priya Sundar
No 178, 4th Cross Street, Baba Nagar, Villivakam, Chennai - 600 049, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_56_17

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Sialolithiasis is the utmost common obstructive disorder affecting the salivary gland. The frequently involved gland is the submandibular gland, and the innumerable whys and wherefores have been cited in the literature hitherto. It consistently affects male paralleled to that of female and customarily the sialolith measures about 1 mm to <1 cm and seldom measures more than 1 cm. So far, cases as large as 7 cm have been reported. In this article, we had reported two cases of submandibular gland sialolithiasis with a brief review of the literature.

Keywords: Meal time syndrome, sialolithiasis, sialomicroliths, submandibular gland

How to cite this article:
Sundar AH, Priyadarshini N, Joy R, Anandi M S. Mealtime syndrome: A report of two cases and review of literature. SRM J Res Dent Sci 2017;8:187-90

How to cite this URL:
Sundar AH, Priyadarshini N, Joy R, Anandi M S. Mealtime syndrome: A report of two cases and review of literature. SRM J Res Dent Sci [serial online] 2017 [cited 2022 May 25];8:187-90. Available from:

  Introduction Top

Sialolithiasis is the most common salivary gland disorder which fetches about obstruction of the gland, and it accounts for 1.2% of unilateral major salivary gland swelling.[1] By whole of major salivary gland, submandibular gland is most commonly afflicted and it ranges from 80% to 90% while 5%–10% in the parotid gland and 0%–5% in salivary gland and other minor salivary glands.[2] The degree to which this obstruction can befall show a discrepancy from one to another and also in the course of diagnosis. Thus, it can be partial or complete. Sialolithiasis is most common in the fourth to fifth decade of life. Men are more affected compared to women while minor salivary gland sialolithiasis be likely to come about in the fifth to eighth decades.[3]

  Case Reports Top

Case 1

A 22-year-old male patient reported with the chief complaint of swelling in the floor of the mouth which gradually increased in size. The patient met with an accident and sustained fracture in the left parasymphysis and was treated with open reduction and internal fixation under general anesthesia following which he started developing swelling in the floor of the mouth. The patient also gave a history of increase in the size of swelling during eating which reduces gradually thereafter. Intraoral examination revealed a swelling in relation to the submandibular ductal orifice measuring about 0.5 cm × 1 cm. On palpation, the swelling was firm to hard, nontender, and well defined. The sialolith was removed under local anesthesia by placing direct incision of the duct, the sialolith was then removed, and sutures were placed. On follow-up, no recurrence was noted, and the salivary flow resumed to normal. Ground section of the sialolith was done for further examination [Figure 1] and [Figure 2].
Figure 1: Sialolith measuring 1 cm × 2.5 cm

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Figure 2: Ground section showing concentric lamellated structures around a central nidus

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Case 2

A 24-year-old male came with the chief complaint of pain and swelling in the right submandibular region. History reveals that swelling increased in size during meal time and gradually decreased thereafter. On intraoral examination, inflammation is evident in relation to the right submandibular ductal orifice, on palpation, there was pus and blood discharge from the ductal orifice.[Figure 3] On occlusal radiograph examination, a radiopaque mass was evident in relation to 31, 41, and 42 region [Figure 4]. On further exploration, there was slight compression of the swelling distally, the orifice widened. As patient has pain on palpation, the entire procedure was carried out under local anesthesia. Following which the mass was gently removed by means of distal compression [Figure 5]. On follow-up, no recurrence was noted and the salivary flow returned to normal.
Figure 3: Inflammation and pus discharge evident along the ductal orifice

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Figure 4: Occlusal radiograph showing a radio opaque mass

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Figure 5: Stereomicroscopic image of sialolith

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  Discussion Top

Salivary gland plays a vivacious role in sustaining homeostasis in oral microenvironment by secreting saliva, which in turn encompasses various components comprehensive of antimicrobial modules.[4] In some patients these types of obstruction can cause swelling of the salivary gland as such. Sialolith is one such common cause which brings about impasse of duct leading to enlargement of the gland.[5] The scrupulous etiology for the progress of sialolith is not vibrant while innumerable reasons have been hypothesized for the same which includes as follows:

  1. The agglomeration of sialomicroliths
  2. Anatomical variations of the salivary ducts
  3. A transformed biochemical composition of saliva
  4. Salivary stasis or decreased salivary flow can contribute to the precipitation of calcium
  5. A nidus of salivary organic material comes to be calcified and gradually forms a sialolith.

Studies have shown that sialolithiasis can be related to primary hyperparathyroidism, as the latter can lead to altered electrolytic imbalance which in turn can lead to the formation of salivary calculi. In a retrospective analysis done in US, it has been shown that approximately 8100 salivary stone cases could have coexisting hyperparathyroidism, in which 2700 cases, sialolith might be the only presenting symptom.[6] In a study done by Rakesh et al., comparison between sialolith and nephrolith was done in an ultrastructural level, which demonstrated that nephrolith is related to electrolytic imbalance in urine whereas in sialolith it is related to electrolytic imbalance in saliva. Sialolith is predominantly composed of hydroxyapatite crystals whereas in nephrolith, it is calcium oxalate and phosphate. Approximately, 10% of the patients showed a possible link between sialolith and nephrolith.[7],[8] Sialomicroliths are microscopic concretions perceived in normal salivary gland, and it contains calcium and phosphorus as well as organic secretory material in granular form and necrotic cell residues. These are found in the serous acinar cells, striated ductal cells, luminal and interstitial component in more or less all submandibular gland and in 10%–20% of parotid gland. Typically, these structures form in autophagosome and pass by means of the lumen in the saliva disregarded, on the odd occasion, these can coalesce leading to formation of large sialolith.[9] Microorganism does not play a vital role in the initiation of sialolith while few studies have reported the manifestation of oral commensals such as streptococcus or peptostreptococcus species in the peripheral parts of the sialolith.[10]

Ultrastructural examination publicized that sialolith is made up of small spherules of amorphous material concreted together called “aspidinic” hydroxyapatite layers. These particles consist of appropriate amount of organic matter mutually on outer and inner surface, which supplementary undergoes calcification by hydroxyapatite crystallization which is preferential by high level of salivary calcium phosphate (thermodynamic factor) and lower level of crystallization inhibitors (kinetic factors). All these mechanisms are found to be analogous with that of renal calculi.[11]

The submandibular gland is commonly affected. The higher rate of giant sialolith formation in this gland may be attributed to:

  1. The tortuous course of Wharton's duct
  2. Higher calcium and phosphate levels
  3. Dependent position of submandibular glands, which leaves them prone to stasis
  4. The saliva so secreted by the submandibular gland is more alkaline in nature
  5. The secretion has a high mucin content.[4],[9]

Sialolithiasis is commonly known as “Meal Time Syndrome.” This term has been given based on the clinical finding that patient complains of escalation in the size of the swelling during meal time (on intake of food) and steadily decreases thereafter.[12]

Appropriate clinical examination is of extreme importance to avoid misdiagnosis.[13] Bimanual palpation is expedient in detecting submandibular sialolith which are usually plain in the floor of the mouth and parotid sialolith are usually evident around the orifice of stensen's duct or along its course, however, minor salivary sialoliths are usually found in the buccal mucosa or upper lip.[14] Other investigative methods are inclusive of standard mandibular occlusal radiograph, sialography, ultrasound, computed tomography, and scintigraphy.[15] Sialoendoscopy can be performed to visualize the lumen of the salivary ductal system.[16] Color Doppler Sonography has also been useful in patients with sialolithiasis.[17]

The affecting individual must be well hydrated and a moist warm heat and gland kneading, while sialagogues are used to stimulate saliva production and flush the stone out of the duct. However, then again, most of the submandibular calculi lie in the distal third of the duct and a simple surgical discharge through an incision in the floor of the mouth can be performed to remove the calculi. This procedure is usually less complicated.[18] While the management of parotid sialolith more counteractive methodologies is to be espoused as very less of stensen's duct is amenable. Intraglandular sialoliths entails surgical management. This approach is for patients who do not retort to conservative therapy.[19]

  Conclusion Top

Dental practitioners thus play a pivotal role in timely diagnosis and treatment of sialolithiasis. Treatment modalities should be framed considering location and size of sialolith. Other nonsurgical methods can also be adopted to avoid stricture formation along the course of the duct. Recurrence of sialoliths is uncommon and is estimated to occur in 1%–10% of the patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kuruvila VE, Bilahari N, Kumari B, James B. Submandibular sialolithiasis: Report of six cases. J Pharm Bioallied Sci 2013;5:240-2.  Back to cited text no. 1
Marwaha M, Nanda KD. Sialolithiasis in a 10 year old child. Indian J Dent Res 2012;23:546-9.  Back to cited text no. 2
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Kraaij S, Karagozoglu KH, Forouzanfar T, Veerman EC, Brand HS. Salivary stones: Symptoms, aetiology, biochemical composition and treatment. Br Dent J 2014;217:E23.  Back to cited text no. 3
Arunkumar VR, Prabhu K, Ramesh AS, Hemlatha. Giant Sialolithiasis – “Meal Time Syndrome.” Ann Dent Spec 2016;4:13-4.  Back to cited text no. 4
Oliveira Tde P, Oliveira IN, Pinheiro EC, Gomes RC, Mainenti P. Giant sialolith of submandibular gland duct treated by excision and ductal repair: A case report. Braz J Otorhinolaryngol 2016;82:112-5.  Back to cited text no. 5
Stack BC Jr., Norman JG. Sialolithiasis and primary hyperparathyroidism. ORL J Otorhinolaryngol Relat Spec 2008;70:331-4.  Back to cited text no. 6
Rakesh N, Bhoomareddy Kantharaj YD, Agarwal M, Agarwal K. Ultrastructural and elemental analysis of sialoliths and their comparison with nephroliths. J Investig Clin Dent 2014;5:32-7.  Back to cited text no. 7
Lustmann J, Regev E, Melamed Y. Sialolithiasis. A survey on 245 patients and a review of the literature. Int J Oral Maxillofac Surg 1990;19:135-8.  Back to cited text no. 8
Harrison JD, Epivatianos A, Bhatia SN. Role of microliths in the aetiology of chronic submandibular sialadenitis: A clinicopathological investigation of 154 cases. Histopathology 1997;31:237-51.  Back to cited text no. 9
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Grases F, Santiago C, Simonet BM, Costa-Bauzá A. Sialolithiasis: Mechanism of calculi formation and etiologic factors. Clin Chim Acta 2003;334:131-6.  Back to cited text no. 11
Ashwini Rani SR, Suragimath G, Bijjaragi S, Shetty PK. Case Report Mealtime Syndrome: An Enigma to Resolve. J Adv Med Dent Sci 2014;2:120-3.  Back to cited text no. 12
Kim DH, Song WS, Kim YJ, Kim WD. Parotid sialolithiasis in a two-year-old boy. Korean J Pediatr 2013;56:451-5.  Back to cited text no. 13
Gadve V, Mohite A, Bang K, Shenoi SR. Unusual giant sialolith of Wharton's duct. Indian J Dent 2016;7:162-4.  Back to cited text no. 14
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Siddiqui SJ. Sialolithiasis: An unusually large submandibular salivary stone. Br Dent J 2002;193:89-91.  Back to cited text no. 15
Al-Abri R, Marchal F. New era of endoscopic approach for sialolithiasis: Sialendoscopy. Sultan Qaboos Univ Med J 2010;10:382-7.  Back to cited text no. 16
Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro L. Modern management of obstructive salivary diseases. Acta Otorhinolaryngol Ital 2007;27:161-72.  Back to cited text no. 17
Sheikh A, Lai R, Pass B, Obayomi TA, Longwe E. Diagnosis and management challenges of sialolithiasis: Case report. Dent Today 2008;27:92, 94-6.  Back to cited text no. 18
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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