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	Tuesday 2nd February 2010 Hospital pioneers new salivary stone techniques Guy's Dental Hospital is leading the NHS in pioneering new techniques to tackle the increasingly recognised problem of salivary stones. Instead of traditional surgery to remove the gland where the stones form, which carries a high risk of side affects, the expert team is now offering a range of techniques that include breaking up the stones using controlled acoustic shockwaves, collecting the stones using miniature forceps or baskets that are passed down the salivary duct, and finally minimally invasive controlled surgery. Salivary stones can be as large as three centimetres in diameter and form in ducts leading into the mouth where they obstruct the normal flow of saliva. At mealtimes extra saliva is produced which becomes stuck causing significant swelling around the glands and pain. If the problem is left untreated for long periods the backed up saliva can become infected. No one fully understands why the stones form, only that they are made from calcium and the other minerals that are found in saliva. Awareness of the problem is not widespread and so sufferers often go undiagnosed or have limited treatment options at their nearest hospital. The traditional treatment involved an invasive operation under general anaesthetic in which a surgeon would cut through the cheek and open the gland or duct to remove the stone or, frequently, the whole gland. As well as being uncomfortable for the patient, and causing scarring, it also carried a significant risk of damaging important nerves that give the face its movement and expression. At Guy's the specialist team has grouped the talents of an oral and maxillofacial surgeon, a radiologist and an expert in oral medicine and lithotripsy to tackle this problem together. The work has been so successful that patients now travel from as far away as Northern Ireland, Cornwall, Wales and Scotland for their care. Professor Mark McGurk, consultant oral and maxillofacial surgeon, said: "We started specialising in this area 12 years ago, collaborating with partners in Europe, and have now built up a knowledge and level of expertise that isn't found elsewhere in the NHS. That is reflected by the fact that patients are referred from so far away for treatment here. Other centres prefer to send their patients to us as we deal with salivary stones on such a regular basis, whereas they only come across it from time to time." Dr Michael Escudier reports that the clinic is now seeing approximately 600 patients a year for the various forms of treatment and our results show that 80 per cent of stones can be successfully treated this way. Currently Guy's is the only centre in the UK offering this treatment. Small stones can be retrieved using either X-ray guidance or a tiny endoscope tube with a camera and light at the tip which is passed into the blocked duct. If a stone is seen then a tiny 'basket' either attached to the tube or directed by the moving X-ray image is used to grab the stone and pull it out. Medium size stones in the parotid are successfully treated by lithotripsy (60 per cent stone clearance). For larger stones that are too big for the aforementioned approaches, the fallback option is a small operation â€“ this may involve an endoscope passed to where the stone is located in the cheek. The light emitted from the tube is visible through the cheek and allows the surgeon to see exactly where he needs to operate in order to remove the stone with a much smaller incision. Larger stones under the tongue can also be removed by more conservative surgery in the mouth. Dr Jackie Brown added: "Salivary stones affect about 4,000 thousand people per year in the UK but are not widely understood or recognised. We do a lot of work to educate GPs about how to spot the symptoms, and also try and teach other surgeons and radiologists how best to treat them. That said in many cases the patients are referred on to us for treatment as we have the experience in dealing with them. The treatment options are becoming more and more advanced and we are at the forefront of international research into this area." One patient to benefit was Seanne Brearley, 30, of High Barnet, who began experiencing problems a year and a half ago. The social work student said: "It wasn't all the time but frequently I'd sit down to eat a meal, or smell something cooking or even just think about eating and suddenly my saliva glands would swell up. The longer this went undiagnosed the more painful it became, and there were times when I could hardly open my mouth because the glands under my tongue became so swollen. If I was out at a restaurant and looking forward to enjoying a meal, it would become quite frustrating as I couldn't eat anything because it was too painful. "Neither my GP nor my dentist knew what the problem was and my GP eventually referred me to an Ear Nose and Throat specialist. They took an X-ray that suggested it might be salivary stones and referred me on to Guy's because they'd heard about the unit's methods to avoid high-risk surgery. I was pleased about that because the side effects of the traditional surgery such as facial nerve damage and loss of taste sounded scary. Dr Brown examined me at Guy's and decided I was a suitable candidate for the X-ray guided stone extraction treatment which I had in November. "It was all done under local anaesthetic and only took about 45 minutes, but because it is still quite new there were six other consultants from around the country watching the procedure. I was given the two calcium stones that they successfully removed to keep â€“ they are roughly half the size of tic-tacs, and are more substantial than you'd imagine. The night of the procedure I treated myself to a tikka massala curry because I was advised to eat as much tasty food as possible to stimulate my saliva. I was prescribed antibiotics, but my mouth was totally fine within a couple days of days. I've had no ill effects since, which is fantastic."