saliva with its applied anatomy and physiology of salivary glands including caries management and salivary substitutes

1. SALIVA WITH ANATOMY AND
PHYSIOLOGY OF SALIVARY GLANDS
Presented by
Nadeem Aashiq
MDS 1st Year
Dept Of Endodontics And Conservative Dentistry

2. CONTENTS
 Introduction
 Anatomy of Salivary Glands
 Secretion of Saliva
 Composition of Saliva
 Functions of Saliva
 Nervous Regulation of Salivary Secretion
 Saliva in the diagnosis of oral diseases
 Saliva in the diagnosis of systemic diseases
 Buffering capacity of saliva

3.  How saliva influences the carious process
 Method of collecting saliva
 How to perform the saliva ph test
 Caries activity tests
 Caries control strategies
 Salivary stimulants
 Saliva substitutes
 Lozenges
 Management of viscous or ropy saliva
 Conclusion
 References

4. INTRODUCTION
 Throughout the gastrointestinal tract, secretory
glands subserve two primary functions:
• First, digestive enzymes are secreted in most
areas of the alimentary tract, from the mouth to the
distal end of the ileum.
• Second, mucous glands, from the mouth to the
anus, provide mucus for lubrication and protection
of all parts of the alimentary tract

5.  Most digestive secretions are formed only in response
to the presence of food in the alimentary tract, and the
quantity secreted in each segment of the tract is usually
the precise amount needed for proper digestion.
 Furthermore, in some portions of the gastrointestinal
tract, even the types of enzymes and other constituents of
the secretions are varied in accordance with the types of
food present.

6. ANATOMY OF SALIVARY GLANDS
 Parotid region contains the largest serous salivary
gland the “queen of the face” the facial nerve.
 Parotid gland contains vertically disposed blood
vessels and horizontally situated facial nerve and its
various branches.
 Parotid gland gets affected by virus of mumps, which
can extend to the territory of its attack up to gonads as
well.

7.  There are three pairs of large salivary glands
1. The Parotid
2. The Submandibular
3. The Sublingual
 In addition, there are numerous small glands in
the tongue, the palate , the cheeks and the lips.
 All the above mentioned glands produce saliva
which keeps the oral cavity moist, and helps in
chewing and swallowing.
 Saliva also contains enzymes that aid in digestion

8. PAROTID GLAND
Para = around; otic = ear
 Parotid gland is the largest of the salivary glands
 Weights about 15g
 It is situated below the external acoustic meatus,
between the ramus of the mandible and the
strenocleidomastoid and overlaps them.

10.  Anteriorly it overlaps the masseter muscle.
 Capsule of Parotid Gland
• The investing layer of the deep cervical fascia forms a
capsule for the gland
• The fascia splits (between the angle of mandible and the
mastoid process) to enclose the gland. The superficial
lamina ,thick and adherent to the gland and is attached
above the zygomatic arch.
• The deep lamina is thin and is attached to the styloid
process, the angle and posterior border of the ramus of
the mandible and the tympanic plate.

11.  A portion of the deep lamina, extending between the styloid
process and the mandible, is thickened to form the
stylomandibular ligament which separates the parotid gland
from the submandibular salivary gland. The ligament is
pierced by the external carotid artery.

12.  External features
 The gland resembles a three sided pyramid
The apex of the pyramid is directed downwards.
 The gland has four surfaces
a. Superior (base of the pyramid)
b. Superficial
c. Anteromedial
d. Posteromedial
 The surfaces are separated by three borders
a. Anterior
b. Posterior
c. Medial/pharyngeal

13.  Relations
 APEX
• It projects downwards overlapping the posterior belly of digastric
muscle and the adjoining part of the carotid triangle
The structures emerging through the apex include
1. Cervical branch of facial nerve
2. Anterior and posterior divisions of retromandibular vein

15.  Superior surface or base
It is concave and related to the external acoustic meatus and
posterior aspect of TMJ
The following structures emerge through it
1. Superficial temporal vessel
2. Auricilotemporal nerve
 Superficial surface
It is the largest of the four surfaces. It is covered with
1. Skin
2. Superficial fascia containing anterior branches of greater
auricular nerve, superficial parotid (preauricular) lymph nodes
and platysma.
3. Parotid fascia
4. Deep parotid lymph nodes embedded in the gland.

16.  Anteromedial surface
It is deeply grooved by the posterior boreder of the ramus of the
mandible it is related to
1. Masseter
2. Medial pteygoid
3. Posterior border of the ramus of the mandible
4. Lateral aspect of the TMJ
 Posteromedial surface
 It is moulded to the mastoid and styloid processes and the covering
muscles thus it is related to
1. Mastoid process, strenocleidomastoid, and posterior belly of digastric
2. Styloid process and styloid group of muscles.
The styloid process and its muscles seprate the gland from internal
carotid artery, internal juglar vein,

17.  Borders
 Anterior border
it separates the superficial surface from the anteromedial
surface. It extends from the anterior part of the superior
surface of the apex. The following structures emerge at this
border:
1. Temporal branch of the facial nerve
2. Zygomatic branch of the facial nerve
3. Transverse facial vessels.
4. Upper buccal branch of the facial nerve
5. Parotid duct
6. Lower buccal branch of the facial nerve
7. Marginal mandibular branch of the facial nerve

18.  Posterior border
It separates the superficial surface from the posteromedial surface.
The following structures emerge underneath this border
1. Posterior auricular vessels.
2. Posterior auricular branch of the facial nerve.
 Medial border
seprates the anteromedial surface from the posteromedial surface. It is
related to the lateral wall of the pharynx.

19. STRUCTURES WITHIN PAROTID GLAND
 Three main structures either in part or in whole traverse the gland
and branch within it from superficial to deep these are:
 Arteries:
The external carotid artery enters the gland through its posteromedial
surface.
The maxillary artery leaves the gland through anteromedial surface.
The superficial temporal artery gives transverse facial artery and
emerges at the anterior part of the superior surface.

21.  Veins:
The retromandibular vein is formed within the gland by the union of the
superficial temporal and maxillary veins.
In the lower part of the gland, the vein divides into anterior and posterior
divisions which emerge close to the apex of the gland .
 Nerves:
Facial nerve exits from cranial cavity through stylomastoid foramen and
enters the gland through the upper part of its posteromedial surface, and
divides into its terminal branches within the gland.
The branches leave the gland through its anteromedial surface, and
appear on the surface at the anterior border

23.  Facial nerve lies in realtion to isthmus of the gland which separates
large surface part from small deep part of the gland.
 Facial nerve divides into two branches
a. Temporofacial: divides into temporal and zygomatic branches.
b. Cervicofacial: divides into buccal, marginal mandibular and cervical
branches.
The various branches(5-6) of facial nerve radiate like a goose-foot
from the curved anterior border of the parotid gland to supply the
respective muscles of facial expression. This pattern of branching is
called “pes anserinus”

25. PAROTID DUCT/ STENSON’S DUCT
 It is thick walled and is about 5 cm long.
 It emerges from the middle of the anterior border of the
gland and opens into the vestibule of the mouth opposite
the crown of upper second molar tooth.
 It runs forwards and slightly downwards on the masseter.

27. RELATIONS OF PAROTID DUCT
 Superiorly
1. Accessory parotid gland
2. The transverse facial vessels
3. Upper buccal branch of the facial nerve
 Inferiorly
The lower buccal branch of the facial nerve.
At the anterior border of the masseter, the parotid duct turns medially
and pierces:

28. a. The buccal pad of fat.
b. The buccopharyngeal fascia
c. The buccinator
Because of the oblique course of the duct through the buccinator,
inflation of the duct is prevented during blowing.
The duct runs forwards for a short distance between the buccinator
and the oral mucosa. Finally, the duct turns medially and opens into
the vestibule of the mouth opposite the crown of the upper second
molar tooth

29.  Blood supply
Parotid gland is supplied by the external carotid artery and its branches
that arise within the gland.
The veins drain into the external jugular vein and internal jugular vein.
 Nerve supply
Parasympathetic nerves (secetomotor)supply: provided through
auriclotemporal
Sympathetic nerves are vasomotor, and are derived from the plexus
around the middle meningeal artery
Sensory supply it is derived from
a. Auriculotemporal nerve.
b. Greatauricular nerve parotid fascia is innverted by great auricular
nerve.

30.  Lymphatic drainage
lymph drains first to the parotid nodes and from there to the
upper deep cervical nodes.

31. SUBMANDIBULAR GLAND

32. PARTS:-
1. Superficial part
2. Deep part
3. Submandibular duct
 SUPERFICIAL PART
Wedge shaped, extending:
 Posteriorly: to the angle of mandible.
 Superiorly: to mylohyoid line of mandible.
 Inferiorly: it overlaps the 2 bellies of digastric muscle.
 DEEP PART
• Small part lying deep to mylohyoid
• Superficial to hyoglossus
• Between lingual nerve above & hypoglossal nerve

33.  BLOOD SUPPLY
Facial artery
 VENOUS DRAINAGE
Common facial & lingual vein
 LYMPHATIC DRAINAGE:
Submandibular lymph nodes
 NERVE SUPPLY:
Supplied by branches of submandibular ganglion –
 sensory fibres from lingual nerve.
 vasomotor sympathetic fibres from the facial artery plexus

34. SUBLINGUAL GLAND
•Smallest of the 3 salivary glands
•Almond-shaped and weighs 3-4 g
•About 15 ducts emerge from this gland
•Most open directly onto the floor of the mouth while some
join the submandibular duct.

35. CLINICAL IMPLICATIONS OF
SALIVARY GLANDS
Salivary glands are subjected to no. of pathologic conditions,
these include inflammatory infective diseases such as:
 Viral like mumps
 Bacterial
 Allergic sialadenitis
 Variety of benign and malignant tumors
Autoimmune diseases
 Sjögren’s syndrome
Genetic diseases
 Cystic fibrosis

36.  Mucocele (most common surface lesion)
 Systemic and metabolic diseases
 Xerostomia
Drugs causing dry mouth
 Anti cholinergics
 Antidepressants
 Antipsychotics
 Anti hypertensives
 Anoretics
 Drugs used in treatment of parkinsonism

37.  Pathologic conditions
 Suppurative parotitis: most common in young children or
weakened infant or child
 Purulent parotitis is seen in premature infants, chronically
ill children with cerebral palsy or neoplastic diseases, and
in poorly nourished children

38.  Neoplasms:
 Vascular neoplasms : most common in children
 Benign tumors: pleomorphic adenoma
Neurofibromas are rare but may involve the parotid and
submandibular glands in children with neurofibromatosis
Hemangioma :Most common pediatric parotid mass
Sialorrhea

39. SECRETION OF SALIVA
 Saliva Contains a Serous Secretion and a Mucus Secretion.
 The principal glands of salivation are the parotid, submandibular, and
sublingual glands; in addition, there are many tiny buccal glands.
 Daily secretion of saliva normally ranges between 800 and 1500
milliliters.
 Saliva contains two major types of protein secretion:
(1) a serous secretion that contains ptyalin (an α-amylase), which is an
enzyme for digesting starches.
(1) mucus secretion that contains mucin for lubricating and for surface
protective purposes.

40.  The parotid glands secrete almost entirely the serous type of secretion,
whereas the submandibular and sublingual glands secrete both serous
secretion and mucus. The buccal glands secrete only mucus.
 Saliva has a pH between 6.0 and 7.0, a favorable range for the digestive
action of ptyalin.
 Secretion of Ions in Saliva.
 saliva contains especially large quantities of potassium and bicarbonate
ions. Conversely, the concentrations of both sodium and chloride ions
are several times less in saliva than in plasma.
 The submandibular gland, a typical compound gland that contains acini
and salivary ducts.

41.  Salivary secretion is a two-stage operation: The first stage
involves the acini, and the second, the salivary ducts.
 The acini secrete a primary secretion that contains ptyalin
and/or mucin in a solution of ions in concentrations not
greatly different from those of typical extracellular fluid. As
the primary secretion flows through the ducts, two major
active transport processes take place that markedly modify
the ionic composition of the fluid in the saliva.

42.  First, sodium ions are actively reabsorbed from all the
salivary ducts and potassium ions are actively secreted
in exchange for the sodium. Therefore, the sodium ion
concentration of the saliva becomes greatly reduced,
whereas the potassium ion concentration becomes
increased.
 However,there is excess sodium reabsorption over
potassium secretion,and this creates electrical negativity
of about −70 millivolts in the salivary ducts; this in turn
causes chloride ions to be reabsorbed passively.
Therefore, the chloride ion concentration in the salivary
fluid falls to a very low level, matching the ductal
decrease in sodium ion concentration.

43.  Second, bicarbonate ions are secreted by the ductal
epithelium into the lumen of the duct. This is at least partly
caused by passive exchange of bicarbonate for chloride
ions, but it may also result partly from an active secretory
process.
 The net result of these transport processes is that under
resting conditions, the concentrations of sodium and
chloride ions in the saliva are only about 15 mEq/L each,
about one-seventh to one-tenth their concentrations in
plasma. Conversely, the concentration of potassium ions is
about 30 mEq/L, seven times as great as in plasma, and
the concentration of bicarbonate ions is 50 to 70 mEq/L,
about two to three times that of plasma.

44. FUNCTION OF SALIVA FOR ORAL HYGIENE
 Under basal awake conditions, about 0.5 milliliter of
saliva, almost entirely of the mucous type, is secreted
each minute; but during sleep, little secretion occurs. This
secretion plays an exceedingly important role for
maintaining healthy oral tissues. The mouth is loaded with
pathogenic bacteria that can easily destroy tissues and
cause dental caries. Saliva helps prevent the deteriorative
processes in several ways.
 First, the flow of saliva itself helps wash away pathogenic
bacteria, as well as food particles that provide their
metabolic support.

45.  Second, saliva contains several factors that destroy bacteria. One
of these is thiocyanate ions and another is several proteolytic
enzymes—most important, lysozyme—that
(a) attack the bacteria,
(b) aid the thiocyanate ions in entering the bacteria where these ions
in turn become bactericidal,
(c) digest food particles, thus helping further to remove the bacterial
metabolic support.
 Third, saliva often contains significant amounts of protein
antibodies that can destroy oral bacteria, including some that
cause dental caries. In the absence of salivation, oral tissues
often become ulcerated and otherwise infected, and caries of
the teeth can become rampant

46. COMPOSITION OF SALIVA

47. FUNCTIONS OF SALIVA
FUNCTIONS OF
SALIVA
Taste and
digestion
Lubrication
and
protection
Buffering
action and
clearance
Maintenance
of tooth
integrity
Antibacterial
activity

48. 1.the hypotonicity of saliva enhances the tasting capacity of
salty foods and nutrients. Various proteins, such as carbonic
anhydrase (gustin), which bind zinc, enhance the sensation
of taste. Saliva is also involved in early digestion by breaking
down various food products. For example, amylase, the most
abundant parotid protein, breaks down starch and dissolves
sugar. Other enzymes in saliva initiate fat digestion. Another
important digestive function provided by saliva is the
lubrication of the food bolus, which is provided by salivary
mucins.
2. The second category of saliva function is that of lubrication
and protection of oral cavity surfaces. The seromucous
coating secreted from the minor glands contains a high
abundance of mucin. This coating aids in mastication,
speech, and swallowing and provides protection from irritants
such as proteolytic enzymes, chemicals, and dessication

49. 3. Buffering and clearance are the third function of saliva. Components
involved in this function include bicarbonate, histidine-rich peptides,
urea, and phosphate. Bicarbonate is the most important buffering
system in saliva. It diffuses into plaque to neutralize acidic assaults on
tooth structure, and also generates ammonia to form amines which add
to the buffering capacity. The majority of the nonbicarbonate buffering is
provided by histidine-rich proteins and peptides. Additional buffering is
provided by ammonia release from urea and by phosphate, which is
likely to be important as a buffer only during unstimulated flow.

50.  4. The fourth functional category of saliva is the
maintenance of tooth integrity, or regulation of the
demineralization and remineralization process. Saliva
contains supersaturated concentrations of calcium and
phosphate ions which provide a reservoir for
remineralization forming salivary components, such as
statherins, cystatins, histatins, and proline-rich proteins
(Vitorino et al. 2006), aid in controlling crystalline growth of
the enamel by allowing the penetration of minerals into the
enamel for remineralization and by limiting the egress of
minerals. Finally, fluoride in saliva forms caries-resistant
flouroapetite crystals on the tooth surface, inhibiting
demineralization.
 5. The fifth category of saliva function is to form the first
line of defense against bacterial and viral attack. Saliva
contains secretory IgA, IgM, and IgG immunoglobulin
complexes

51. NERVOUS REGULATION OF SALIVARY
SECRETION
 The salivary glands are controlled mainly by parasympathetic
nervous signals all the way from the superior and inferior salivatory
nuclei in the brain stem.
 The salivatory nuclei are located approximately at the juncture of
the medulla and pons and are excited by both taste and tactile
stimuli from the tongue and other areas of the mouth and pharynx.
 Many taste stimuli, especially the sour taste (caused by acids), elicit
copious secretion of saliva—often 8 to 20 times the basal rate of
secretion. Also, certain tactile stimuli, such as the presence of
smooth objects in the mouth (e.g., a pebble), cause marked
salivation, whereas rough objects cause less salivation and
occasionally even inhibit salivation.

52.  Salivation can also be stimulated or inhibited by nervous signals arriving
in the salivatory nuclei from higher centers of the central nervous
system.
 For instance, when a person smells or eats favorite foods, salivation is
greater than when disliked food is smelled or eaten.
 The appetite area of the brain, which partially regulates these effects, is
located in proximity to the parasympathetic centers of the anterior
hypothalamus, and it functions to a great extent in response to signals
from the taste and smell areas of the cerebral cortex or amygdala.
 Salivation also occurs in response to reflexes originating in the stomach
and upper small intestines—particularly when irritating foods are
swallowed or when a person is nauseated because of some
gastrointestinal abnormality.

53.  The saliva, when swallowed, helps to remove the irritating factor in the
gastrointestinal tract by diluting or neutralizing the irritant substances.
 Sympathetic stimulation can also increase salivation a slight amount,
much less so than does parasympathetic stimulation.
 The sympathetic nerves originate from the superior cervical ganglia
and travel along the surfaces of the blood vessel walls to the salivary
glands.
 A secondary factor that also affects salivary secretion is the blood
supply to the glands because secretion always requires adequate
nutrients from the blood.
 The parasympathetic nerve signals that induce copious salivation also
moderately dilate the blood vessels.

54.  In addition, salivation itself directly dilates the blood vessels,
thus providing increased salivatory gland nutrition as needed
by the secreting cells.
 Part of this additional vasodilator effect is caused by
kallikrein secreted by the activated salivary cells, which in
turn acts as an enzyme to split one of the blood proteins, an
alpha2-globulin, to form bradykinin, a strong vasodilator

55. SALIVA IN THE DIAGNOSIS OF ORAL DISEASES
 Caries
 The prevalence of dental caries is positively correlated with the
microbial load of Streptococcus mutans and Lactobacillus in the
saliva.
 Samaranayake used paraffin wax to stimulate the production of the
salivary samples, which were then incubated in a selective growth
media for up to 24 h.
 The structures and functions of salivary bacteria have been studied
as potential predictive markers for caries onset

56.  Yang et al. analysed adult saliva microbiomes in 19 caries-active and 26
healthy human hosts by whole-genome-based deep sequencing and
cross-validated 16S rRNA amplicon-based technologies.
 They observed an overabundance of the Prevotella genus in the caries
microbiota compared with healthy ones. In addition, Prevotella species
differed in caries-active and normal individuals, indicating the predictive
role of Prevotella in the onset of dental caries.
 Another study from the same group established the first model, known as
Microbial Indicators of Caries, to diagnose caries and predict potential
caries onset for samples clinically considered healthy. The accuracy of
the prediction using the Prevotella genus and microbiota is similar,
validating the idea that the Prevotella genus is of great significance for
the timely prediction of caries

57.  Periodontal diseases
 Porphyromonas gingivalis is a ‘red complex’ bacteria that is closely
associated with periodontitis. Recently, some researchers developed an
enzyme-linked immunosorbent assay-based P. gingivalis saliva kit to
specifically detect this bacterium in saliva.
 The kit can detect both laboratory and clinical isolate strains of P.
gingivalis at concentrations of 5× 104 to 5 ×105 CFU·mL− 1 and yields
results within 90 s. Compared with real-time polymerase chain reaction
technology, the P. gingivalis saliva kit is rapid and has a sensitivity of
92% and a specificity of 96%.
 Therefore, the P. gingivalis saliva kit is expected to be an easy and time-
efficient chair-side diagnostic tool for the detection of P. gingivalis.

58.  Oral cancer
 The onset and development of malignancy are related to somatic mutations
of tumour-specific DNA, which can be found in the saliva, plasma or other
body fluids.
 These somatic mutations can be used as biomarkers to diagnose oral or
other tumours. In saliva, tumour specific DNA was positive in 100% of
patients with oral tumours.
 However, only 47%–70% of patients with tumours in the other parts of the
human body carry tumour-specific DNA in the saliva. In contrast, tumour-
specific DNA was found in 80% of plasma samples from patients with oral
tumours and in 86%–100% of patients with tumours in other sites.
 Salivary proteins can also be used for cancer detection. It was reported that
the increase in tumour antigen CA15-3 and antibodies for tumour protein
markers c-erbB2, CA-125 and P53 in saliva can also be considered salivary
biomarkers for cancers of the oral cavity and other sites.

59.  Sjögren’s syndrome
 Sjögren’s syndrome (SS) is a chronic systemic autoimmune disease
characterized by keratoconjunctivitis sicca and xerostomia. With further
development of SS, the salivary flow rate is decreased and the salivary
constituents change.
 There are also significant changes in the proteome and transcriptome in
patients with SS.

60. DIAGNOSIS OF SYSTEMATIC DISEASES BY
SALIVA
 Diabetes mellitus
 Diabetes is a metabolic disease caused by insufficient insulin secretion,
insulin action or insulin resistance, which leads to a glucose metabolism
disorder.
 A positive correlation was found between α-2-macroglobulin and HbA1c,
which demonstrated that levels of α-2-macroglobulin in the saliva could
reflect the glycaemic control in patients with type 2 diabetes mellitus.
 However, the concentration of salivary melatonin decreased in patients
with type 2 diabetes and patients with periodontitis. This indicates that
salivary melatonin has an important role in the pathogenesis of diabetes
and periodontal diseases, and might become a key biomarker in the
diagnosis and treatment of these two diseases

61.  Cardiovascular disease
 Cardiovascular disease (CVD) is related to the circulatory system and
includes atherosclerosis, myocardial infarction and coronary heart
disease.
 Kosaka et al. found that levels of salivary inflammatory cytokines
including IL-1β, IL-6, TNF-α and prostaglandin E2 increased
significantly in both atherosclerosis and periodontal diseases. These
cytokines might be potential biomarkers for the diagnosis of periodontal
disease and atherosclerosis.
 Miller et al. identified that the C-reactive protein (CRP) was the most
predictive biomarker of acute myocardial infarction. Acute myocardial
infarction was predicted by a combination of electrocardiogram and
CRP levels with 80.0% sensitivity and 100% specificity.

62.  These data demonstrated the potential use of salivary biomarkers with
electrocardiogram for the diagnosis of acute myocardial infarction.
Moreover, the levels of α-2-HS-glycoprotein in saliva decreased in
patients with CVD, which indicates that the peptidome might provide a
potential way for the early diagnosis of patients with CVD.

63.  Viral infections
 Diagnostic tests for viral infections currently rely on salivary
biomarkers, such as viral DNA and RNA, antigens and antibodies.
 At the proteomic level, there are saliva-based antibody tests to detect
viruses, including hepatitis A virus, hepatitis B virus, hepatitis C virus,
HIV-1, measles virus, rubella virus and vesicular stomatitis virus
mumps virus, among others.
 The Raffaele Scientific Institute in Milan used a new salivary test
named OraQuick hepatitis C virus rapid antibody test, to detect the
hepatitis C virus in an easier and faster way.
 Moreover, the dengue virus (DENV) RNA and non-structural protein 1
antigens are detectable from saliva, which might provide a more
effective way to diagnose dengue.
 In the research of Nefzi et al. the saliva appears to be more sensitive
than the blood in the detection of HHV-6 or human cytomegalovirus.

64.  Pancreatic cancer
 Pancreatic cancer has a low incidence rate but a high mortality rate.
Worldwide, more than 200 000 patients with pancreatic cancer are
registered annually and the disease results in the death of 98% of
patients.
 It has been predicted that pancreatic cancer will become the second
cause of death worldwide by 2030.Therefore, it is important to diagnose
and classify patients with pancreatic cancer at earlier stages, to give
them timely treatment.
 In rodent models of pancreatic cancer, vesicles similar to exosomes
can carry and transport tumour specific biomarkers into the saliva.
 It was also found that hsa-miR-210 and let-7c were over expressed in
the saliva of patients with pancreatitis. In addition, significantly
increased levels of hsa-miR-21, hsa-miR-23a, hsa-miR-23b, miR-29c
and hsa-miR-216 were identified in the saliva of patients with
pancreatic cancer;

65.  There are also correlations between periodontitis and pancreatic
cancer onset. Patients with periodontitis had a 64% higher risk of
pancreatic cancer. There was an increase in 31 bacterial species
and a decrease in 25 bacterial species in the saliva of pancreatic
cancer patients.
 Moreover, two bacterial biomarkers, Neisseria elongata and
Streptococcus mitis, have a high sensitivity and specificity for the
diagnosis of patients with pancreatic cancer

66.  Breast cancer
 Breast cancer is one of the most common cancers in females.
ATP6AP1 is an ATPase that is expressed in normal tissues such as the
brain marrow, blood, nerves and skin, and it is also correlated with
several tumours such as head and neck carcinomas, lung tumours,
adrenal tumours and various other cancers.
 Zhang et al.found eight mRNA biomarkers and one protein biomarker
that could be used to detect breast cancer with an 83% sensitivity and
97% specificity. In another study, it was found that the levels of vascular
endothelial growth factor, epidermal growth factor (EGF) and carcino
embryonic antigen in the saliva were significantly increased in patients
with breast cancer.
 The levels of CA15-3 and c-erB-2 were also found to be increased in
the saliva, which has positive correlations with the serum of patients
with breast cancer. Based on these studies, potential salivary
biomarkers can be applied to the early diagnosis of breast cancer.

67.  Lung cancer
 Lung cancer has a high incidence rate. Mutations identified in the EGF
receptor (EGFR) are the tumour-specific biomarkers for non-small cell
lung carcinoma (NSCLC).
 A novel core technology known as electric field-induced release and
measurement relies on a multiplexible electrochemical sensor that can
detect EGFR mutations in bodily fluids was shown to be effective,
accurate, rapid and cost effective for the detection of EGFR mutations in
the saliva of patients with NSCLC.

68.  Prostate cancer
 MiR-141 and miR-21 are two tumour biomarkers; the former is
significantly elevated in patients with advanced-stage prostate cancer,
whereas the latter is over expressed in early-stage prostate cancer.
 It has been demonstrated that the expression of miR-21 and miR-141 in
the saliva can be detected by nano-graphene oxide. This is expected to
be a non- or minimally invasive approach to diagnose early-stage
prostate cancer.
 Other diseases
 In the saliva of patients with gastric ulcer and chronic gastritis,
Helicobacter pylori DNA can be detected to identify H. pylori infection.

69.  Significant correlations were found between salivary caffeine clearance
and liver diseases. Thus, saliva can be used as an effective biochemical
parameter for the diagnosis of chronic liver diseases (CLDs) and
assessment of residual liver function in CLD.
 The saliva of patients with chronic renal failure presented significantly
higher levels of NO. After haemodialysis treatment, the saliva showed
significantly higher levels of immunoglobulin (Ig)A, IgG and CRP. Thus,
this demonstrated that salivary levels of IgA, IgG, NO and CRP might
have an important role in monitoring renal disease

70. BUFFERING CAPACITY OF SALIVA
 After intake of sugar-containing foodstuffs the pH in plaque will drop
and remain lowered until the sugar is cleared from the mouth and
the bacterial produced acid is buffered .
 Tooth demineralization can occur when the actual pH drops below
the critical pH.
 The magnitude of the pH drop is determined by the amount of acid
that is produced by bacteria and by the saliva buffer capacity, the
latter working at counteracting the pH drop, it is crucial to reduce
the time that the actual pH stays below this value.

71. BICARBONATE BUFFER SYSTEM
3–5 mmol/l to 25–28 mmol/l in highly stimulated saliva.
Overall buffer capacity varies from a little less than half in
resting saliva to more than 90% in stimulated saliva.
HCl + NaHCO3 → H2CO3 + NaCl
CO2 + H2O ↔H2CO3↔HCO3- + H+

72. PROTEIN BUFFER SYSTEM
Buffering effect of the proteins is far less than bicarbonate and
phosphate in human saliva.
Saliva proteins increase the viscosity of the saliva & physically
protect the teeth against acid load by forming a diffusion barrier.

75. HOW SALIVA INFLUENCES THE
CARIOUS PROCESS
The flow of saliva can reduce plaque accumulation on the tooth
surface and also increase the rate of carbohydrate clearance
from the oral cavity.
The diffusion of salivary components such as calcium,
phosphate, hydroxyl, and fluoride ions into the plaque can
reduce the solubility of enamel and promote remineralization of
early carious lesions.
The carbonic acid–bicarbonate buffering system, as well as
ammonia and urea constituents of the saliva, can buffer and
neutralize the pH fall which occurs when plaque bacteria
metabolize sugar. The pH and buffering capacity of saliva is
related to its secretion rate.

76. The pH of parotid saliva increases from about 5.5 for
unstimulated saliva to about 7.4 when the flow rate is high. The
respective pH values for submandibular saliva are 6.4 and 7.1.
An increase in the secretion rate of saliva also results in a
greater buffering capacity. In both cases this is due to the
increase in sodium and bicarbonate concentrations.
Several non-immunological components of saliva such as
lysozyme, lactoperoxidase, and lactoferrin have a direct
antibacterial action on plaque microflora or may affect their
metabolism so that they become less acidogenic

77. Immunoglobulin A (IgA) molecules are secreted by plasma cells
within the salivary glands, while another protein component is
produced in the epithelial cells lining the ducts. The total
concentration of IgA in saliva may be inversely related to caries
experience.
Salivary proteins could increase the thickness of the acquired
pellicle and so help to retard the movement of calcium and
phosphate ions out of enamel.

78. GENERAL CONSEQUENCES OF
REDUCED SALIVARY FLOW
The oral mucosa, without the lubricating and protective action of
saliva, is more prone to traumatic ulceration and infection.
Mucositis presents as tenderness, pain, or a burning sensation
and is exacerbated by spicy foods, fruits, alcoholic and
carbonated beverages, hot drinks, and tobacco.
Taste sensation is altered, and chewing and swallowing present
difficulties, particularly if the food is bulky or dry.

79. When salivary flow is diminished, foods requiring a great deal of
chewing are not well tolerated. This makes matters worse
because chewing itself helps to stimulate salivary flow, provided
there is some glandular activity left.
Speaking may become difficult because of lack of lubrication.
These individuals also suffer from extreme sensitivity of teeth to
heat and cold, especially if any dentine is exposed.

80. Edentulous patients may have problems tolerating dentures,
probably because of reduction in surface tension between the
dry mucosa and the fitting surface of the denture.
There is an increase in dental plaque accumulation, which
makes gingivitis more likely. However, there is no evidence that
periodontitis, which involves loss of bone support, is affected.
There is also modification of the plaque flora in favour of
Candida, mutans streptococci, and lactobaccilli.
Consequently, in patients with dry mouths, candidal infections
are frequent and rampant caries is common if no preventive
measures are taken.

81. METHOD OF COLLECTING SALIVA
Spitting method
Suction method
Swab method

82. Avoid eating major meal 60 minutes & dairy products for 20
minutes before sample collection.
Avoid foods with high sugar or acidity, or high caffeine content,
immediately before sample collection
Rinse mouth with water to remove food residue and wait at
least 10 minutes after rinsing to avoid sample dilution.

83. SALIVA COLLECTION METHODS

85. SUBMANDIBULR
/SUBLINGUAL
After blocking the parotid
saliva secretion by placing a
gauze pad at the orifice of the
parotid ducts. Saliva can be
collected from the floor of the
mouth with a micropipette.

86.  MINOR GLANDS
 Minor gland secretions can
be collected by
micropipette,absorbent
filter paper or strips from
the inner surface of
lips,palate,or buccal
mucosa and quantitated by
weight differences or using
a Peritron device.

87. HOW TO PERFORM THE SALIVA PH TEST
First, fill your mouth with saliva and then swallow it. Repeat
this step to help ensure that your saliva is clean. Then the
third time, put some of your saliva onto the pH paper
The pH paper should turn blue. This indicates that your
saliva is slightly alkaline at a healthy pH of 7.4. If it is not
blue, compare the color with the chart that comes with the
pH paper.

88. The saliva pH of the non-deficient and healthy person
is in the 7.5 to 7.1 slightly alkaline range.
The range from 6.5 (weakly acidic) to 4.5 (strongly
acidic) represents states from mildly deficient to
strongly deficient, respectively.
Most children are dark blue, a pH of 7.5. Over half of
adults are green-yellow, a pH of 6.5 or lower, reflecting
the calcium deficiency of aging and lifestyle defects.

89. CARIES ACTIVITY TESTS
Definition:
Increment of active lesions (new and recurrent lesions) over a stated
period of time.
Caries susceptibility:
Susceptibility (or resistance) of a tooth to a caries producing environment.

90. Principle: Estimation of the number of acidogenic and aciduric
bacteria in the saliva by counting the number of colonies appearing
on Tomato peptone agar plates (pH 5.0) after inoculation with a
sample of saliva.
No of
organisms
1-1000
1000-5000
5000-10,000
More than
10,000
Symbolic
designation
+
+
++
+++/++++
Degree of caries
activity suggested
Little or none
Slight
Moderate
Marked
LACTOBACILLUS COLONY COUNT TEST

91. • This test measures the ability of salivary
microorganisms to form organic acid from a
carbohydrate medium.
• The medium contains an indicator dye
“Bromocresol green”, changes colour from
green to yellow when pH changes from 5.4
to 3.8. Indirectly measures the number of
both aciduric and acidogenic organisms in
saliva.
SNYDER TEST
24 hrs 48 hrs 72hrs
Color : yellow yellow yellow
Caries activity: marked definite limited
Color : green green green
Caries activity: continue to continue to caries inactive
incubate incubate

92. This test measures the activity of reductase enzyme present in
salivary bacteria
 The sample is mixed with fixed amount of diazo-resorcinol
 The change in color after 15 min is taken as a measure of caries
activity
REDUCTASE TEST
color Time score Caries activity
Blue
Orchid
Red
Red
pink
15min 1
15 min 2
15 min 3
Immediately 4
Immediately 5
Non conductive
Slightly conductive
Moderately conductive
Highly conductive
Extremely conductive

93. Principle: Measurement of amount of powdered enamel dissolved,
when the patient’s saliva is mixed with glucose and powdered
enamel.
• It is based on the fact that when glucose is added to saliva
containing powdered enamel, organic acids are formed.
• Organic acid decalcifies the enamel, resulting in an increase in
the amount of soluble calcium.
• The extent of increase of calcium is a direct measure of caries
activity.
FOSDICK CALCIUM DISSOLUTION TEST

94. CARIES CONTROL STRATEGIES
Visit the dentist every 3 months. Plaque control needs to be
excellent, and professional plaque control should be considered.
The risk of caries is high. Stimulated flow rates should be
measured every 3–4 months
Rigid dietary control is impractical. However, each time the
patient is seen, the opportunity should be taken to reinforce the
importance of avoiding sweet drinks and snacks. The bedtime
sweet drink is particularly dangerous.
Chewing a sugar-free gum containing xylitol will be safer and
more effective. The use of a saliva substitute until salivary flow
returns will also be helpful.

95. 0.05% NaF mouthrinse daily for several years to help arrest any
initial carious lesions.
A 1% chlorhexidine gel should be applied by the patient in
custom-made applicator trays for 5 minutes every night for 14
days. Repeated every 3–4 months.
Avoid smoking, alcohol, and caffeine based drinks
Without constant vigilance and regular monitoring by the dentist,
a short lapse by the patient may have disastrous results.

96. SALIVARY STIMULANTS
Sugar-free gum containing xylitol
and or chlorhexidine
SST (sinclair) increases
salivation through physiological
stimulation of the taste buds.
The tablet containing sorbitol,
citric acid, citric acid salts, and a
phosphate buffer.

97. Salivix is a lozenge containing malic acid,
gum arabic, calcium lactate, sodium
phosphate, lycasin, and sorbitol.
Stimulates salivary flow and because of
the calcium lactate buffer present & does
not demineralize enamel in spite of a pH
of 4.0.
Pilocarpine HCL.
Causes sweating, flushing, nausea, and
diarrhoea, bradycardia, hypotension and
reflex narrowing of airways.
Contraindicated in patients with cardiac
or chest problems.
The recommended dose is one 5 mg
tablet daily. May be increased up to
three 5 mg tablets daily.

98. SALIVA SUBSTITUTES
Saliva substitutes have
been produced in the form
of sprays, lozenges, or
mouthwashes.
 Luborant
 Saliva Orthana
 Glandosane
 Saliveze
98
They all contain calcium,
phosphate, sodium, magnesium,
and potassium ions.

99. Luborant, Glandosane and Saliveze contain
carboxymethylcellulose to provide viscosity, Saliva Orthana
contains mucin prepared from the gastric mucosa of the pig.
Luborant and Saliva Orthana both contain fluoride, have a pH
between 6 and 7 and have been shown to have a significant
remineralizing capacity Saliveze and Glandosane do not contain
fluoride
Glandosane has a somewhat lower pH at 5.1 and should,
therefore, be used only for edentulous patients. The sprays
should be directed towards the inside of the cheeks and not
down the throat.
99

100. LOZENGES
Lozenges are only helpful if there is
enough saliva present to dissolve
them.
Saliva Orthana is also available in the
form of a lozenge. It does not contain
fluoride but is quite palatable.
10
0
Dentifrices, mouthrinses & gels
with antimicrobial proteins such as
peroxidose, lysozyme, and
lactoferrins. Biotene and bioXtra

101. MANAGEMENT OF VISCOUS OR ROPY
SALIVA
When saliva is present but is ropy, rinsing or gargling with a
mouthwash made up by mixing half a teaspoonful of baking
powder with one litre of warm water will break up the mucous in
the mouth and throat. This can help patients with mild mucositis
due to radiotherapy.
Any preparation with an unbuffered, low pH should never be
used for dentate patients. Ideally, the saliva substitute should
contain fluoride and be supplemented by a daily fluoride
mouthwash.
10
1

102. CONCLUSION
 Saliva has numerous effects like protection against caries by inhibition of
bacteria, dilution and elimination of bacteria & their substrates, buffering
bacterial acids & by offering a reparative environment after bacteria-induced
demineralization of teeth.
 Patients suffering from salivary gland hypofunction are therefore at risk of
developing caries and should receive an individually tailored prophylactic
dental program including intensive caries preventive care.
 This includes instructions to improve the patient’s oral hygiene, appropriate
dietary advice, and targeted use of antimicrobials and regular topical fluoride
treatments to help preserve dentition when the natural protection from saliva
is reduced.

103. REFERENCES
1. Human anatomy by B.D chaurasia 4th edition
2. Guyton and Hall Text Book of Medical physiology 12th Edition.
3. Saliva in the diagnosis of diseases International Journal of Oral
Science (2016) 8, 133–137
4. Oral histology and embryology – Orban’s. 12th edition
5. Shafer’s textbook of oral pathology

104. THANK YOU