more than 80% occur in the submandibular gland or its duct , probably because of its more viscous saliva , longer duct , and higher mineral content in the saliva , 4 - 10% have been reported in the parotid gland and 1 - 7% in the sublingual gland or minor salivary glands . the etiological factors of the sialoliths are unknown , but inflammation is the widely accepted causative condition . hypotheses regarding the pathogenesis suggest that , there is an initial organic nidus which progressively grows by the deposition of inorganic and organic substances or that intracellular microcalculi are excreted in the canal and act as a nidus for further calcification . in some cases , the existence of mucosal plugs acting as a nidus in the ductal system was reported . a possibility of debris , bacteria or substances migrating in the salivary ducts from oral cavity has also been suggested . bilateral or multiple - gland sialolithiasis occurs in fewer than 3% of cases . in patients with multiple stones submandibular stones close to the hilum of the gland tend to become large before they become symptomatic . giant salivary gland stones are those stones measuring over 1.5 cm and have been rarely reported in the medical literature . giant salivary gland stones measuring over 3 cm are extremely rare , with only scanty reported cases . although , sialolith may occur at any age from 6 up to 70 years old but , most cases occurs under the age of 40 years . a 51 year old male patient reported to the department of oral medicine and radiology with complaint of pain and swelling on left side of floor of the mouth . patient noticed the swelling for past three months , pain aggravated while eating . the tongue was slightly elevated . on clinical examination a hard mass was palpable on the floor of the mouth on left side with a small ulceration towards midline . through the ulceration a yellowish white stone like material was seen [ figure 1 ] . on radiographic examination occlusalview revealed radio - opaque mass in relation to mandibular left canine and premolars [ figures 2a and b ] . the size of the stone was approximately 15 mm and it was fragmented [ figure 3 ] . the patency of the duct was maintained by inserting a drain and area was sutured . the patient was followed - up two weeks post operatively to check salivary function of the gland . on review the left submandibular gland was palpable but clear saliva could be expressed from the duct . sialolith visible on the left side of floor of the mouth ( a , b ) opg and mandibular anterior occlusa l view showing radio opaque sialolith in the region of mandibular left canine and premolar surgically extracted sialolith a 40 year old male patient reported to the department of oral medicine and radiology with complaint of ulceration on the floor of the mouth left side [ figure 4 ] . patient also reported with a stone like thing in his hand which exfoliated from the ulcerated area that morning . patient had history of pain and swelling one year back which relieved on taking analgesics . the pain again started after 10 days on the left side of floor of the mouth . this was gradual in onset and increased on taking meal and relieved on taking analgesic . on clinical examination the ulceration was seen on the left side of the floor of the mouth of size approximately 2 cm [ figure 5 ] . a 51 year old male patient reported to the department of oral medicine and radiology with complaint of pain and swelling on left side of floor of the mouth . patient noticed the swelling for past three months , pain aggravated while eating . the tongue was slightly elevated . on clinical examination a hard mass was palpable on the floor of the mouth on left side with a small ulceration towards midline . through the ulceration a yellowish white stone like material was seen [ figure 1 ] . on radiographic examination occlusalview revealed radio - opaque mass in relation to mandibular left canine and premolars [ figures 2a and b ] . the size of the stone was approximately 15 mm and it was fragmented [ figure 3 ] . the patency of the duct was maintained by inserting a drain and area was sutured . the patient was followed - up two weeks post operatively to check salivary function of the gland . on review the left submandibular gland was palpable but clear saliva could be expressed from the duct . sialolith visible on the left side of floor of the mouth ( a , b ) opg and mandibular anterior occlusa l view showing radio opaque sialolith in the region of mandibular left canine and premolar surgically extracted sialolith a 40 year old male patient reported to the department of oral medicine and radiology with complaint of ulceration on the floor of the mouth left side [ figure 4 ] . patient also reported with a stone like thing in his hand which exfoliated from the ulcerated area that morning . patient had history of pain and swelling one year back which relieved on taking analgesics . the pain again started after 10 days on the left side of floor of the mouth . this was gradual in onset and increased on taking meal and relieved on taking analgesic . on clinical examination the ulceration was seen on the left side of the floor of the mouth of size approximately 2 cm [ figure 5 ] . salivary calculi are usually small and measure from 1 mm to less than 1 cm . giant sialoliths are rare and are defined as the size of 3.5 cm or larger . large and giant calculi may perforate the floor of the mouth by ulcerating the duct or may result in a skin fistula by causing a suppurative infection . however , large sialoliths have been frequently reported in the body of salivary glands , they have rarely been described in the salivary ducts , particularly without any complaints from the patients . some unusual large salivary calculi may be seen without a long history , because of the lesions were generally asymptomatic . it is believed that a calculus may enlarge at the rate of approximately 1 to 1.5 mm per year . the key step in diagnosis of sialolithiasis is the elucidation of a thorough history and careful clinical examination . submandibular gland calculi have been reported to be radio opaque in 80% to 94.7% of cases . in the anterior floor of the mouth sialoendoscopic system was developed in the 1990 's as an endoscopic technique , which examine the ductal system completely due to the small size of scopes . , clinical and radiological features of two large sialoliths which were in the size of 1.8 and 2.1 centimeters were presented . they were located in wharton 's ducts and the patients complained of pain and occasional swellings . in both cases the treatment of sialolithiasis depends upon the location and size of thesialolith . in case of small sialoliths , conservative methods such as proper hydration of the patient , application of moist warm heat and massaging the gland in conjunction with sialogogues may be considered . sialodochoplasty can be performed to remove the submandibular sialoliths which are located close to the orifice of wharton 's duct . to remove the stones distal to the punctum , a transverse incision can be made distally on the stone taking care not to injure the lingual nerve . in the management of large sialoliths which are located in the close proximal duct , extracorporeal shock wave lithotripsy can be considered . endoscopic intracorporeal shock wave lithotripsy is also gaining importance because of less damage to the adjacent tissues during the procedure . sialadenoscopy , which is a non - invasive technique , can be used to manage large sialolithsas well as ductal obliteration . co2 laser , because of its advantages of minimal bleeding , less scarring , clear vision and minimal post - operative complications , is gaining its popularity in the treatment of sialolithiasis .