SALIVARY GLANDS - SUBMANDIBULAR SIALOLITHIASIS     Sialolithiasis is the formation of calcium concretions within the ductal system of a major or minor salivary gland. The submandibular glandular system, when compared to the parotid complex, is more susceptible to such incursions because its intraductal saliva (1) contains greater concentrations of calcium and phosphate salts than parotid saliva, (2) is more viscous, (3) is closer to alkalinity and (4) the gland is situated at a lower level than its orifice. These four factors favor salt precipitation and salivary stagnation.   The Salivary Gland Center (SGC) has noted four different clinical manifestations of submandibular stones. First, there may be a total absence of symptoms and diagnosis is made only during routine imaging studies. More often, a history of intermittent transient painful swellings of the involved gland, initiated by eating, is elicited. The third clinical picture is an acute suppurative process, characterized by swelling, redness and pain in the mouth floor above WhartonÌs duct. The gland itself is enlarged tender and tense with pus exiting from its ductal orifice. Fourthly, a chronic sclerosing sialadenitis, mimicking a tumor (KuttnerÌs tumor), may develop.   Palpation along the intraoral course of the duct and duct probing often can testify to the presence of a stone. Radiographs, specifically occlusal films of the mouth floor, best demonstrate calcified stones. However, since many sialoliths are radiolucent, the SGC often resorts to other imaging techniques (sialography, CT scans, ultrasound) for diagnosis and localization.   Prior to surgical therapy, the status of the gland must be established. Occasionally, because of advanced glandular infection and degeneration, gland extirpation is required. The SGC utilizes sialochemistry and sialography to evaluate glandular health and aid in deciding whether to remove the gland and the stone or only the stone.   Provided the stone is extraglandular, surgical treatment involves incising into the sublingual fold in the anterior mouth floor, dissecting out WhartonÌs duct and following its path to the previously ascertained stoneÌs location. A longitudinal incision into the duct wall facilitates stone delivery. Conversely, intraglandular sialoliths demand gland removal. The Salivary Gland Center (SGC) was developed because a void existed in the diagnostic and comprehensive care of patients with salivary gland problems and/or secretory dysfunction. Since the diversity of these salivary conditions presents challenges to the clinician, the SGC is available for referrals. Louis Mandel, DDS Director, Salivary Gland Center (212) 305-9982