Sir,- I feel I have to write in response to the letter of J. F. Sharp (BDJ2003, 195: 551) on the subject of salivary calculi. This is not because I wish to claim a further superior sized stone but to challenge the methods used by the author. I applaud the use of a distally positioned suture to prevent the calculus disappearing back down the duct into the gland; it is a shortcut one will only do once to omit this stage as you explain red-faced to the patient that the stone has 'disappeared'.
I would strongly advise against closing the resultant incision with sutures as there is a very real risk of causing occlusion of the submandibular duct. It is better practice to leave the wound without suturing and simply remove the distal suture. A new opening from an essentially shortened duct is likely to form further back in the floor of the mouth which will be of no consequence to the patient.
Additionally, I would caution readers from trying to remove calculi positioned further back in the floor of the mouth than the segment of duct that is immediately visible behind the lower incisors. Too many times I have had to intervene for 'have a go heroes' trying to remove calculi deep in the floor of the mouth in the third molar area. I would advise such cases are dealt with by experienced surgeons when a general anaesthetic is often required for their removal. If such a patient continues to suffer recurrent submandibular gland swelling after removal of a calculus, it is likely there has been glandular damage. In such instances referral is advised when a sialogram is indicated to examine the residual functional lobules and assess damage. In some cases subsequent removal of the gland is indicated.
