This document discusses saliva and its potential use as a diagnostic aid. It covers how saliva contains biomarkers related to stress, periodontal health, bone turnover, and various diseases. Specific proteins and enzymes in saliva such as MMP-8, alkaline phosphatase, and cortisol are biomarkers for conditions like periodontitis, bone resorption, and stress levels. Genetic biomarkers from saliva also show promise in diagnosing diseases. Saliva allows for non-invasive collection and analysis of biomarkers for applications in dentistry, medicine, and evaluating general health.

1. SALIVA
Dr. Nitika Jain

2. Contents
 Saliva - as a diagnostic aid (general and
perio)
 Stress biomarkers
 Salivary gland diseases
 Infections
 Tumours
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3.  Diagnostic imaging of salivary gland
 Sialography
 Contrast sialography
 Conclusion
 References
8/12/2012 Saliva 3

4. SALIVA - AS A DIAGNOSTIC
AID
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5.  Human saliva performs a wide variety of
biological functions that are critical for the
maintenance of the oral health.
 Saliva, a multi constituent oral fluid, has
high potential for the surveillance of
general health and diseases.
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6.  Non – invasive
 Limited training
Why saliva???
 No special equipment
 Potentially valuable for
children and older patients
 Cost effective
 Eliminates the risk of
infection
No  Easy, No pain, No needle
Pain
prick, Fast
 Screening of large
population
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7. What is a biomarker???
A biomarker is an objective measure that
has been evaluated and confirmed either
as an indicator of physiologic health, a
pathogenic process, or a pharmacologic
response to a therapeutic intervention.
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8.  Biomarkers, whether produced by normal
healthy individuals or by individuals
affected by specific systemic diseases, are
tell - tale molecules that could be used to
monitor health status, disease onset,
treatment response and outcome.
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9. Biomarker
Detect
disease
Response Monitor
progression Stage
to / disease
treatment recurrence
Treatment
efficacy
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10. CLASSIFICATION OF
SALIVARY BIOMARKERS
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11. Bacteria and
Locally produced Genetic ⁄
bacterial
proteins of host genomic
products, ions,
and bacterial biomarkers such
steroid
origin (enzymes, as DNA and
hormones and
immunoglobulins mRNA of host
volatile
and cytokines) origin
compounds
Salivary proteomic, genomic and
microbial biomarkers for periodontal
diagnosis
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12. 8/12/2012 Saliva 12

13. 8/12/2012 Saliva 13

14. Salivary proteomic approach as
biomarkers
Periodontopathic bacteria either cause degradation of
host tissue directly or activate a host response
initiates the release of biological mediators from host
cells and when exaggerated in nature, leads to host
tissue destruction
mediators include proteinases, cytokines and
prostaglandins. And bacteria-derived enzymes, such
as collagen-degrading enzymes, elastase- like
enzymes, trypsin-like proteases, aminopeptidases and
dipeptidylpeptidase
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15. Periodontopathic
bacteria
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16.  Specific salivary proteomic biomarkers
have been identified for three key features
of the pathogenic processes in periodontal
disease –
 inflammation,
 collagen degradation and
 bone turnover
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17. Innate host defence responses are triggered
Neutrophilic polymorphonuclear leukocytes,
monocytes and activated macrophages are
recruited to the site
release numerous cytokines, such as
prostaglandin E2, tumour necrosis factor
(TNF), interleukins IL-1 and IL-6, which
direct further inflammatory processes
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18. Host-derived MMPs
 Both MMP-1 (interstitial collagenase) and
MMP-8 (polymorphonuclear leukocyte-
derived collagenase) gets activated in
periodontitis.
 MMP-8, which is primarily derived from
polymorphonuclear leukocytes during
active stages of periodontitis, is a major
tissue destructive enzyme in periodontal
disease
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19.  An elevated level of MMP-8 was detected
in the saliva of subjects affected by
periodontitis compared with healthy
patients, but the levels of salivary MMP 1
were similar in both groups.
 Therefore, quantification of the level of
MMP-8 is a promising candidate for
diagnosing and, more importantly,
predicting the progression of this episodic
disease.
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20.  Other MMPs, including MMP-2, MMP-3
and MMP-9, were also reported in the
saliva of patients affected by periodontitis
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21.  Salivary biomarkers have been used to
examine the effect of lifestyle factors,
including smoking, on periodontal health.
 Levels of salivary markers including
prostaglandin E2, lactoferrin, albumin,
aspartate aminotransferase, lactate
dehydrogenase, alkaline phosphatase
were significantly lower in current smokers
than in non-current smokers.
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22. 8/12/2012 Saliva 22

23. Biomarkers of bone resorption
or turnover
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24. Alkaline phosphatase
 Three main sources:
 the actual salivary secretions
 the GCF, PMNs and tissue degradation; and
 disposed bacterial cells from dental biofilms
and mucosal surfaces
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25. Alkaline phosphatase
 Significant correlation between ALP and
pocket depth and between ALP and
inflammation.
 Higher enzyme activity in individuals with
periodontal disease than non diseased
individuals.
 Periodontal destruction by measurement
of probing depth, gingival bleeding, and
suppuration were related to higher ALP
levels in saliva
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26. Cathepsin B
 Cysteine proteinases
 Cathepsin B functions in proteolysis
 100% sensitivity and 99.8% specificity for
cathepsin B
 Cathepsin B may have a potential use in
distinguishing periodontitis from gingivitis
and in planning treatment and monitoring
treatment outcomes
8/12/2012 Saliva 26

27. CRP
 C-reactive protein is a systemic marker
released during acute phase of an
inflammatory response and is produced by
liver. Circulating CRP reaches saliva via
GCF or salivary glands. High levels of
CRP are associated with chronic and
aggressive periodontal diseases.
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28. Osteopontin (OPN)
 Noncollagenous calcium binding glycosylated
phosphoprotein in bone matrix and is produced
by several cells including osteoblasts,
osteoclasts and macrophages.
 Kido et al (2001) demonstrated that OPN level in
saliva was increased with progression of
periodontal disease. However, no significant
difference was observed when OPN level was
compared between diseased and healthy sites.
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29. Osteocalcin
 Is synthesized mainly by osteoblasts.
 A number of investigators studied
relationship between saliva osteocalcin
levels and periodontal diseases.
8/12/2012 Saliva 29

30. Genomic approach as
diagnostic markers
 Reports of genetic polymorphisms
associated with periodontal disease are
increasing, and strong evidence supports
the proposal that genes play a role in the
predisposition to and progression of
periodontal disease.
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31. A number of studies have examined links
between polymorphisms within host
response factors and aggressive
periodontitis.
 Examination of genes encoding
inflammatory cytokines such as IL-1 and
TNF α, the anti-inflammatory cytokine IL-
10 and the F c- gamma receptors.
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32.  Reactive oxygen species, participate in the
pathogenesis of periodontal tissue
destruction.
 DNA damage, lipid peroxidation, protein
disruption and stimulation of inflammatory
cytokine release.
 8-hydroxy-deoxyguanosine, a product of
oxidative DNA damage, is a biomarker for
detecting periodontitis in human subjects.
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33.  Advantages to using genomic and
transcriptomic markers to detect disease:
 The marker discovery process is high-
throughput, involving the use of genome-wide
microarray platforms
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34.  Till now,68 up-regulated and six down-
regulated genes was identified, including
lactotransferrin, MMP-1, MMP-3, interferon
induced-15, keratin 2A and desmocollin-1,
and this result was confirmed by real-time
polymerase chain reaction.
8/12/2012 Saliva 34

35. Stress biomarkers in saliva
 Salivary α-amylase
 Chromogranin A
 Salivary cortisol
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36. Salivary cortisol
 Itslevel in saliva is lower than that in blood
 Advantage of salivary over serum cortisol
measurement is the minimisation of stress
from fear of needles during collection,
which may bias the results.
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37. Salivary – α amylase
Chromogranin A
 biomarkers of acute stress and a-amylase
is better
 Both salivary CgA and a-amylase are
considered biomarkers of the stress
response by the sympatho–adreno–
medullary system, unlike cortisol, which is
considered a biomarker of stress response
by the Hypothalamic pituitary adrenal
system.
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38. 8/12/2012 Saliva 38

39. Various other diagnosis
 Candidiasis – Through the presence of
candida spp in saliva
 The presence of periodontal pathogenic
bacteria can also be diagnosed by this
method - increasing the risk of
cardiovascular and cerebrovascular
diseases.
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40.  Cystic fibrosis
 Cystic fibrosis (CF) is a genetically transmitted
disease of children and young adults, which is
considered a generalized exocrinopathy. CF
is the most common lethal autosomal-
recessive disorder.
 The abnormal secretions present in CF
caused clinicians to explore the usefulness of
saliva for the diagnosis of the disease.
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41.  CF patients contains increased calcium
levels.
 Resulted in a calcium-protein aggregation
which caused turbidity of saliva.
 Higher occurrence of calculus as compared
with healthy controls.
 The levels of neutral lipids,phospholipids, and
glycolipids are elevated.
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42.  21-Hydroxylase deficiency
 an inherited disorder of steroidogenesis which
leads to congenital adrenal hyperplasia. In
non-classic 21-hydroxylase deficiency, a
partial deficiency of the enzyme is
present.(Carlson et al., 1999).
 In 21- hydroxylase deficiency, a strong
correlation has been found between 17-
hydroxyprogesterone levels in saliva and
serum.
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43.  Insome malignant diseases, markers can
be detected in saliva, such as the
presence of protein p53 in patients with
oral squamous cell carcinoma.
 Other biomarkers for OSCC:
 M2BP
 MRP14
 CD59
 Profilin
 Catalase
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44.  The presence of the c- erb- 2 tumour
marker in the saliva and blood serum of
breast cancer patients and its absence in
healthy women is a promising tool for the
early detection of this disease.
 In ovarian cancer too, the CA 125 marker
can be detected in the saliva with greater
specificity and less sensitivity than in
serum.
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45.  PCR detection of H. pylori in the saliva
show high sensitivity.
 The presence of antibodies to other
infectious organisms such as Borrelia
burdogferi, shigella can also be detected
in saliva.
 Detection of hepatitis A and hepatitis B
surface antigen in the saliva has been
used in epidemiological studies.
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46.  In neonates the presence of Ig A is an
excellent marker of rota virus infection
 HIV antibody detection is as precise in
saliva as in serum and is both applicable
in clinical and epidemiological studies.
 Salivary and oral fluid test:
 Orasure ( available in USA)
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47. SALIVARY GLAND
DISORDERS
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48. Salivary gland disorders
 Bacterial infections
 Acute bacterial parotitis
 Chronic bacterial parotitis
 Chronic recurrent juvenile parotitis
 Acute suppurative submandibular sialadenitis
 Chronic recurrent submandibular sialadenitis
 Acute allergic sialadenitis
 Viral infections
 Mumps
 HIV/AIDS
 Cytomegalovirus
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49.  Fungal infections
 Mycobacterial infections
 Tuberculosis
 Atypical mycobacteria
 Parasitic
infections
 Autoimmune-related infections
 Systemic lupus erythematosus
 Sarcoidosis
 Sjogren’s syndrome
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50. Sialolithiasis
• Sialolithiasis is the formation or presence of a
calculus or calculi in a salivary gland.
• It is most commonly seen in the submandibular
gland and duct (about 80% of cases), then the
parotid gland and duct .
• Sialolithiasis is rare in the sublingual gland.
• Most stones are solitary, but multiple stones may
be present.
• The reason why a stone forms is unknown
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51. Symptoms:
• May be asymptomatic
• Dull pain from time to time over the affected
gland
• Swelling of the gland
• Pain with chewing or swallowing
Complications
• Oral infection
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52. Sialadenitis
• The salivary glands contain a network of
ducts. Saliva flows through them into the
mouth. If the flow is reduced or stopped for
some reason, infection can grow. This
infection called sialadenitis .
• The most common infection is bacterial.
• Sialadenitis is most common in the parotid
gland and the submandibular gland.
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53. Symptoms:
• Tender, painful lump in cheek or under chin.
• Pus may drain through the gland into the mouth.
• If the infection spreads, fever, chills and malaise
may occur.
Complication
• Oral infection.
• Upper respiratory tract infection.
• Upper GIT infection.
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54. XEROSTOMIA
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55. XEROSTOMIA: Epidemiology
Factors that Affect Salivary Flow
 Medication
 Autoimmune disease (Sjogren’s syndrome, lupus)
 Systemic diseases (diabetes, asthma, kidney,
sarcoidosis, HIV)
 Stress/anxiety/depression
 Radiation therapy to the head and neck
 30 Gy = glandular fibrosis (gland can still produce
some saliva)
 60-70 Gy = glandular destruction (gland can no
longer produce saliva)
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56.  Gender (70 % female, usually
postmenopausal)
 Sympathomimetic medications (stimulate the
sympathetic nervous system)
 Parasympatholytic medications (inhibit the
parasympathetic nervous system)
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57. XEROSTOMIA: Epidemiology
Factors that Affect Salivary Flow
Over 400 Medications Can Produce the Side Effect of Xerostomia
 Antacid •Cholesterol reducing
 Antianxiety •Decongestant
 Anticholinergic •Diet pills
 Anticonvulsant •Diuretic
 Antidepressant •Hormonal replacement therapy
 Antiemetic
•Muscle relaxant
 Antihistamine
•Narcotic analgesic
 Antihypertensive
 Antiparkinsonian •Sedative
 Antipsychotic •Bronchodilator
Saliva 57

58. XEROSTOMIA: Epidemiology
Factors that Affect Salivary Flow
Age
o Studies show that among non-institutionalized
people not taking medication, neither the
quantity or quality of saliva change significantly
with age
o Studies show a positive correlation between the
number of drugs taken and the incidence and
severity of xerostomia
Saliva 58

59. XEROSTOMIA: Etiology
“Dry Mouth”
Xerostomia is the term used for the symptom
of oral dryness. While oral dryness is most
commonly associated with a reduction in
salivary gland output (termed salivary gland
hypofunction), the symptom may be reported
by patients with apparently normal salivation
who have changes in saliva composition.
Saliva 59

60. XEROSTOMIA: Etiology
Prevalence
Xerostomia affects 25% of the population and is
becoming one of the fastest-growing oral health
 Medications are the cause of more than 90% of
xerostomia cases
 32 million Americans today take three or more
medications daily
 Xerostomia was not a great problem in the past
because people did not take as many medications as they
do today
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61. XEROSTOMIA: Etiology
Global Prevalence
The reported prevalence of dry mouth varies widely due to
the methodological and population differences in various studies.
Prevalence has been estimated to range from 10% to 38%,
with 20% the most commonly reported figure
Xerostomia is becoming increasingly common in developed countries
where adults are living longer and poly-pharmacy is very common.
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62. XEROSTOMIA: Diagnosis
Symptoms
 Viscous saliva
 Sticky saliva
 Difficulty speaking
 Difficulty swallowing
 Halitosis
 Altered taste
 Complaint of dryness
 Complaint of burning mouth, lips, or tongue
 Altered sense of smell
Saliva 62

63. XEROSTOMIA: Diagnosis
Signs
 Increased caries
 Food sticking to the oral structures
 Frothy saliva
 Gingivitis
 Absence of saliva
 Cracking and fissuring of the tongue
 Ulceration of oral mucosa
 No pooling of saliva in the floor of the mouth
 Recurrent candidal infections
 A toothbrush, mouth mirror, or instrument that sticks to the soft
tissues
 Poorly fitting prostheses
Saliva 63

64. XEROSTOMIA: Diagnosis
Simple Management Strategies for Patients
 Perform oral hygiene at least 4 times daily, after each meal and before bedtimes
 Use fluoride toothpaste
 Rinse with a salt and baking soda solution 4 to 6 times daily
 Avoid citrus juices (oranges, grapefruit, tomatoes)
 Rinse and wipe oral cavity immediately after meals
 Keep water handy to moisten the mouth at all times
 Avoid liquids and foods with high sugar content
 Avoid rinses containing alcohol and salty foods
 Brush and rinse dentures after meals
 Apply prescription-strength fluoride get at bedtime as prescribed
 Use moisturizers regularly on the lips
 Try salivary substitutes or artificial saliva preparations
8/12/2012 Saliva 64

65. Saliva substitutes - contents
 Xanthan gum
 Sodium carboxymethylcellulose
 Potassium chloride
 Sodium chloride
 Magnesium chloride
 Calcium chloride
 Di-potassium hydrogen orthophosphate
 Potassium di-hydrogen orthophosphate
 Sodium fluoride
 Sorbitol
 Methyl p-hydroxybenzoate
 Spirit of lemon
8/12/2012 Saliva 65

66.  Commercially available:
 Orabalance
 XERO – Lube
 Salivart
 Optimoist
8/12/2012 Saliva 66

67. XEROSTOMIA: Management
Some patients are predisposed to candidiasis because of the lack of salivary
histatins
 Recommendation:
o Antifungal medication can be recommended to control fungal growth
8/12/2012 Saliva 67

68. XEROSTOMIA: Management
Treatment of Xerostomia-Associated Problems
8/12/2012 Saliva 68

69. XEROSTOMIA: Management
Treatment of Xerostomia-Associated Problems
8/12/2012 Saliva 69

70. XEROSTOMIA
GETTING INVOLVED IN DIAGNOSING XEROSTOMIA
CAN BE A
WINDOW TO PATIENTS’ OVERALL HEALTH
Diagnosing xerostomia is an important diagnostic tool for other
systemic diseases. The signs and symptoms of xerostomia are often associated with
and/or result from other conditions.
Saliva 70

71. Salivary gland Neoplasia
 Tumors of the salivary glands are uncommon
and represent 2-4% of head and neck
neoplasms.
 80 % of tumors occur within the parotid
glands & most of the others in the
submandibular glands.
 Males and females are affected equally.
 70% to 80% of these tumors are benign.
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72. Salivary gland neoplasia
 Benign
 Warthin's tumor (benign papillary cystadenoma)
 Benign mixed tumors
 Monomorphic adenoma
 Benign lymphoepithelial lesions
 Malignant
 Mucoepidermoid carcinoma
 Adenoid cystic carcinoma
 Adenocarcinoma
 Malignant mixed tumor
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73. Benign tumors
 Benign mixed tumors
 Is the most common tumor of the major salivary
glands. Pathologically, it is characterized by slow
growth and few symptoms.
 Warthin's tumor (benign papillary
cystadenoma)
 A slow-growing, cystic tumor that almost always
occurs in older men.
8/12/2012 Saliva 73

74. Benign tumors
 Monomorphic adenoma
 Are a group of benign lesions with a variety of growth patterns. These
lesions usually are found in the parotid glands.
 Benign lymphoepithelial lesions
 Include a wide range of cystic changes that share the common
denominator in atypical lymphoid hyperplasia. These changes are
found often in patients infected with HIV.
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75. Malignant tumors
 Mucoepidermoid carcinoma
• Is unique in that the tumors it produces can vary
in aggressiveness from low-grade and slow
growing to high-grade and rapidly growing.
• It occurs more frequently than any other
malignancy of the major salivary glands.
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76. Malignant tumours
 Adenoid cystic carcinoma
• Account for 25% of malignant salivary gland
tumors and 15% of all parotid gland tumors.
• Occur most often in the minor, rather than major,
salivary glands.
• The disease is unique in that its tumors grow
slowly, but metastasize readily.
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77. Malignant tumours
 Adenocarcinoma
• Are most frequently found in the minor salivary
glands of the nose and paranasal sinuses.
• Account for 15% of malignancies of the parotid
and 10% of malignancies of the submandibular
glands.
 Malignant mixed tumor
• Make up approximately 15% and 12% of parotid
and submandibular neoplasms respectively.
• The disease typically is characterized by slow,
8/12/2012protracted growth. Saliva 77

78. Drug monitoring in saliva
 molecular size,
 lipid solubility,
 and the degree of ionization of the drug
molecule,
 as well as the effect of salivary pH and the
degree of protein binding of the drug
8/12/2012 Saliva 78

79. Therapeutic Drugs
 Antipyrine  Irinotecan
 Caffeine
 Lithium
 Carbamazepine
 Methadone
 Cisplatin
 Metoprolol
 Cyclosporine
 Diazepam  Oxprenolol
 Digoxin  Paracetamol
 Ethosuximide  Phenytoin
 Primidone
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80. Saliva and age
 With age, a generalized loss of salivary
gland parenchymal tissue loss.
 Salivary acini are replaced by adipose
tissue.
 Decreased production of saliva
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81. DIAGNOSTIC IMAGING FOR
SALIVARY GLAND
8/12/2012 Saliva 81

82. Diagnostic imaging for salivary
gland
 To differentiate inflammatory from
neoplastic diseases
 Differentiate diffuse from focal suppurative
disease
 Identify and localize sialoliths
 Demonstrate ductal morphology
8/12/2012 Saliva 82

83. Methods
 Plain film radiography
 Intra oral radiography
 Extra oral radiography
 Conventional sialography
 Computed tomography ( CT)
 Magnetic resonance imaging
 Scintigraphy
 Ultrasonography
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84. Conventional Sialography
A radiographic technique wherein a
radiopaque contrast agent is infused into
the ductal system of a salivary gland
before imaging.
 Imaging is done with plain films,
fluoroscopy, panoramic radiography, CT.
 Mainly submandibular and parotid
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85. Technique
A lacrimal or periodontal probe is used to
dilate the sphincter at the ductal orifice
before the passage of a cannula, blunt
needle or catheter, which is connected to
a syringe containing contrast agent.
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86.  Indications
 Contraindications
8/12/2012 Saliva 86

87.  Phases of sialography
 Ductal phase
 Acinar phase
 Post – evacuation phase
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88. Contrast sialography
 Lipid soluble agents
 37% iodine e.g.: ethiadol
 Water soluble agents
 28 to 38 % iodine e.g.: hypaque 50%,
hypaque M 75%, renografin 60, isopaque,
triosol, dionosil.
8/12/2012 Saliva 88

89. Computed tomography
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90. Magnetic resonance imaging
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91. Sialoendoscopy
 Specialized procedure that uses a small
video camera at the end of a flexible
cannula, which is introduced into the
ductal orifice.
 Both diagnostically and therapeutic
 Can demonstrate the strictures and kinks
in the ductal system, as well as mucous
plugs.
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92. Conclusion
 Biomarkers of disease in succession play
an important role in life sciences and have
begun to assume a greater role in
diagnosis, monitoring and therapy
outcomes and drug discovery.
 The challenge for biomarkers is to allow
earlier detection of disease evolution and
more robust therapy efficacy
measurements.
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93. References
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