Transcript saliva - shabeelpn

Introduction
 Salivary gland anatomy
 Functions of saliva
 Secretion of saliva
 Composition of saliva
 Organic components
 Inorganic components
 Hypofunction of salivary glands
 Xerostomia
 Ptyalism
 Burning mouth syndrome
 Saliva:A diagnostic fluid
 Diagnostic imaging of salivary glands
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Saliva lacks the drama of blood,the emotion
of tears and toil of sweat but it still remains
one of the most important fluids in the
human body.
Its status in the oral cavity is at par with that
of blood i.e. to remove waste,supply nutrients
and protect the cells
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Saliva is composed of more than 99% water
and less than 1% solids,mostly electrolytes
and proteins,the latter giving saliva its
characteristic viscosity
The term saliva refers to the mixed fluid in
the mouth in contact with the teeth and oral
mucosa,which is often called ‘whole saliva’
Normally the daily production of whole saliva
ranges from 0.5 to 1.0 litres
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90% of the whole saliva is produced by three
paired major salivary glands
 Parotid Gland
 Submandibular gland
 Sublingual gland
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Secretions from many minor salivary glands
in the oral mucosa
(labial,lingual,palatal,buccal,glossopalatine
and retromolar glands) also contribute (less
than 10%) to the saliva secretion
In addition,whole saliva contains
contributions from non-glandular sources
such as gingival crevicular fluid in an
amount that depends on the periodontal
status of the patient
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Whole saliva,in contrast to glandular
saliva,also contains vast amounts of epithelial
cells from the oral mucosa and millions of
bacteria.
These components give whole saliva its
cloudy appearance,which is different from
glandular saliva, which is transparent like
water.
Parotid gland:
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Largest of all the salivary glands
Purely serous gland that produce thin,watery amylase
rich saliva
Superficial portion lies in front of external ear & deeper
portion lies behind the ramus of mandible
Stensen's Duct (Parotid Papilla)
 Opens out adjacent to maxillary second molar
Submandibular gland
 Second largest salivary gland
 Mixed gland
 Located in the posterior part of floor of
mouth,adjacent to medial aspect of mandible &
wrapping around the posterior border of
mylohyoid muscle
 Wharton's Duct
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Opens beneath the tongue at sub-lingual caruncle
lateral to the lingual frenum
Sublingual gland:
 Smallest salivary gland
 Mixed gland but mucous secretory cells
predominate
 Located in anterior part of floor of mouth
between the mucosa and mylohyoid muscle
 Opens through series of small ducts (ducts of
rivinus) opening along the sub-lingual fold &
often through a larger duct(bartholin’s duct)
that opens with the wharton’s duct at the
sub-lingual caruncle
Amylases, Cystatins,
Carbonic anhydrases,
Histatins, Mucins,
Histatins
AntiPeroxidases
Buffering
Bacterial
Amylases,
Cystatins,
Mucins, Lipase
AntiMucins
Digestion
Viral
Salivary
Functions MineralAntiization
Fungal
Cystatins,
Histatins
Histatins, ProlineLubricatTissue ion &Viscorich proteins,
Coating elasticity
Statherins
Amylases,
Cystatins, Mucins,
Mucins, Statherins
Proline-rich proteins, Statherins
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Fluid or Lubricant
Saliva coats the mucosa & helps to protect against
mechanical,chemical and thermal irritation.
It also assists smooth airflow,speech & swallowing.
Buffering
Saliva helps to neutralise plaque pH after eating
thus reducing time for demineralization caused by
bacterial acids produced during sugar metabolism
Remineralization
Saliva is supersaturated with ions,which facilitate
remineralization of teeth
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Digestion
Breakdown of starch-amylase
Fat-lingual lipase
Moistening and lubricative properties of
saliva:allow the formation & swallowing of
food bolus
Anti-microbial action
Lysozyme,lactoferrin,sialoperoxidase help
against pathogenic microorganisms
specifically
Immunoglobulins and secretory IgA also
act against microorganisms.
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Cleansing
Clears food and aids swallowing.
Agglutination
immunoglobulins and secretory IgA cause
agglutination of specific microorganisms,
preventing their adherence to oral tissues.
Mucins as well as specific agglutinins also
aggregate microorganisms.
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Pellicle formation
Derived from salivary proteins,it forms a
protective diffusion barrier to acids from
plaque.
Taste
Saliva has a low threshold concentration of
sodium chloride,sugar,urea etc allowing
perception of taste to occur. It acts as a
solvent allowing mixing and interaction of
food with taste buds
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Water balance
Osmoreceptors act as per state of
hydration of the body to transmit
information to the hypothalamus
Tissue repair
A variety of growth factors & other
biologically active peptides and proteins are
present in small quantities in saliva.under
experimental conditions,many of these
promote tissue growth &
differentiation,wound healing and other
beneficial effects.
Afferent signals from sensory receptors in mouth
Trigeminal,facial,glossopharyngeal
nerves
Salivary nuclei in the medulla oblongata of brain
Parasympathetic nerve bundle
sympathetic nerve bundle
salivary glands
 Innervation
o Parasympathetic innervation to major salivary
glands
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Otic ganglion fibers supply Parotid Gland
Submandibular ganglion supplies other major glands
o Sympathetic innervation promotes saliva flow
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Stimulates muscle contractions at salivary ducts
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Saliva secretion is also controlled by the
conditioned reflexes.
Besides receiving impulses from the afferents,the
salivary nuclei also receives impulses from higher
centers of brain which leads to release of variety of
neurotransmitters resulting in facilatory or
inhibitory effects
As a result of such control,unstimulated salivation
is inhibited during sleep,fear & mental depression
Stress may increase or decrease salivary flow
THE SECRETORY UNIT
The basic building block of all salivary glands
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ACINI - water and
ions derived from
plasma
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Saliva formed in acini
flows down DUCTS to
empty into the oral
cavity.
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Formation of primary saliva:
Initiated by binding of neurotransmitters in the
acinar cell membranes
Acinar cell loses K⁺ to the interstitium & Cl⁻ to the
lumen
Gain of Cl⁻ creates negative potential in the
lumen,driving interstitial Na⁺ into lumen thereby
restoring electroneutrality
Water flux follws the movement of salt into the
lumen for osmotic reasons,resulting in acinar cell
shrinkage
Outcome is the formation of isotonic primary saliva
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Ductal modification of primary saliva:
Occurs principally through reabsorption &
secretion of electrolytes
The luminal & basolateral membrane have
abundant transporters that function to
produce a net reabsorption of Na⁺ & Cl⁻
resulting in formation of hypotonic final
saliva
The final electrolyte composition of saliva
varies depending on the salivary flow rate
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At high flow rates,saliva is in contact with
the ductal epithelium for shorter time & Na⁺
& Cl⁻ concentration increase & K⁺
concentration decrease
At low flow rates,the electrolyte
concentration change in the opposite
direction
The HCO₃⁻ concentration increases with
increased flow rates,reflecting the increased
secretion of HCO₃⁻ by the acinar cells to
drive fluid secretion
TWO STAGE HYPOTHESIS
OF SALIVA FORMATION
Most proteins
Water &
electrolytes
Na+ Cl- resorbed
Some proteins
Isotonic
primary saliva
electrolytes
K+ secreted
Hypotonic
final saliva
into mouth
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Differential saliva production by glands
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Unstimulated salivation (Salivary gland at rest)
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1.5 Liters produced per day (basal rate)
Major salivary glands: 90% of saliva produced
Submandibular and sublingual glands: 70% of saliva
Stimulated salivation
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Saliva production increases 5 fold
Parotid gland produces majority of saliva
WHOLE
PAROTID
SUBMANDIBULAR
RESTING
0.2-0.4
0.04
0.1
STIMULATED
2.0-5.0
1.0-2.0
0.8
pH
6.7-7.4
6.0-7.8
Flow Rate of Saliva
unstimulated
stimulated
ml / min
0.5
0.4
0.3
0.2
0.1
0.0
20-39 yr
40-59 yr
Age
> 60 yr
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Unstimulated production – collection of
saliva into container during 15 min
Stimulated production – collection of saliva
during 5 min of chewing 1g paraffin
Unstimulated whole saliva flow rates of
<0.1 ml/min. and stimulated whole saliva
flow rate’s of <1.0 ml/min. are considered
abnormally low& indicative of marked
salivary hypofunction.
Recent work in Sjogren syndrome is
beginning to identify changes in salivary
cytokine & other protein levels that may have
diagnostic significance .
 Saliva may play a greater diagnostic role
in monitoring for the presence and
concentrations of drugs of abuse and
therapeutic agents.
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Saliva compositon
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Help to prevent dissolution of dental
enamel
Calcium
◦ 1.4 mmol/lt. (1.7 mmol/lt. in stimulated saliva)
◦ 50% in ionic form
◦ sublingual > submandibular > parotid
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Phosphate
◦ 6 mmol/lt. (4 mmol/lt. in stimulated saliva)
◦ 90% in ionic form
pH around 6 - hydroxyapatite is unlikely to
dissolve
Increase of pH - precipitation of calcium
salts => dental calculus
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Buffer
Low in unstimulated saliva, increases with
flow rate
Pushes pH of stimulated saliva up to 8
pH 5.6 critical for dissolution of enamel
Defence against acids produced by cariogenic
bacteria
Derived actively from CO2 by carbonic
anhydrase
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Fluoride
◦ Low concentration, similar to plasma
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Thiocyanate
◦ Antibacterial (oxidated to hypothiocyanite OSCNby active oxygen produced from bacterial
peroxides by lactoperoxidase)
◦ Higher conc. => lower incidence of caries
◦ Smokers - increased conc.
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Sodium, potassium, chloride
Lead, cadmium, copper
◦ May reflect systemic concentrations - diagnostics
Saliva composition
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Mucins
Proline-rich proteins
Amylase
Lipase
Peroxidase
Lysozyme
Lactoferrin
Secretory IgA
Histatins
Statherin
Blood group substances, sugars, steroid hormones,
amino acids, ammonia, urea
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Products of acinar cells from
submandibular,sublingual and some minor salivary
glands.
Asymmetrical molecule with open, randomly
organized structure
Glycoproteins - protein core with many
oligosaccharide side chains attached by glycosidic
bond
Hydrophillic
Unique rheological properties (e.g., high elasticity,
adhesiveness, and low solubility)
Major salivary mucins are:
 MG1-adsorbs tightly to the tooth surface
contributing to the enamel pellicle
formation, thereby protecting the tooth
surface from chemical & physical attack
including acidic challenges
 MG2-also binds to the tooth surface but is
easily displaced, however it promotes
clearance of oral bacteria by aggregation
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Tissue Coating
◦ Protective coating about hard and soft tissues
◦ Primary role in formation of acquired pellicle
◦ Concentrates anti-microbial molecules at mucosal
interface
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Lubrication
◦ Align themselves with direction of flow (characteristic
of asymmetric molecules)
◦ Increases lubricating qualities (film strength)
◦ Film strength determines how effectively opposed
moving surfaces are kept apart
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Aggregation of bacterial cells
◦ Bacteria adhere to mucins-result in surface
attachment, or
◦ Mucin-coated bacteria may be unable to attach to
surface
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Bacterial adhesion
◦ Mucin oligosaccharides mimic those on mucosal
cell surface
◦ React with bacterial adhesins, thereby blocking
them
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Produced by acinar cells of major salivary glands
Metabolizes starch and other polysaccharides into
glucose & maltose
Calcium metalloenzyme
Parotid; 30% of total protein in parotid saliva
“Appears” to have digestive function - inactivated
in stomach, provides disaccharides for acidproducing bacteria
It is also present in tears, serum, bronchial, and
male and female urogenital secretions
A role in modulating bacterial adherence
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Secreted by sublingual gland and parotid
gland
Involved in first phase of fat digestion
Hydrolyzes medium to long chain
triglycerides
Important in digestion of milk fat in
newborn
Unlike other mammalian lipases, it is
highly hydrophobic and readily enters fat
globules
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Produced by acinar cells in salivary glands
Acidic peptide containing relatively high
levels of proline,tyrosine and phosphoserine
Inhibits spontaneous precipitation of
calcium phosphate salts from
supersaturated saliva & favours
remineralization
Calcium phosphate salts of dental enamel
are soluble under typical conditions of pH
and ionic strength
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Supersaturation of calcium phosphates
maintain enamel integrity
Also an effective lubricant for the tooth
surface thus protecting it from physical
forces
Like statherin, PRPs are also highly
asymmetrical
 Present in the initially formed enamel pellicle
and in “mature” pellicles
 2 types:
 Basic
 Acidic
 Both are secretory products of major salivary
glands
 Acidic proline-rich protein binds tightly to
hydroxyapatite and prevents precipitation of
calcium phosphate and thereby protecting the
enamel surface & preventing demineralization
 Also bind to oral bacteria including mutans
streptococcci
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Acquired enamel pellicle is 0.1-1.0 µm thick
layer of macromolecular material on the dental
mineral surface
Pellicle is formed by selective adsorption of
hydroxyapatite-reactive salivary proteins, serum
proteins and microbial products such as glucans
and glucosyl-transferase
Pellicle acts as a diffusion barrier, slowing both
attacks by bacterial acids and loss of dissolved
calcium and phosphate ions
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Early caries are repaired despite presence of
mineralization inhibitors in saliva
Sound surface layer of early carious lesion
forms impermeable barrier to diffusion of high
mol.wt. inhibitors.
Still permeable to calcium and phosphate ions
Inhibitors may encourage mineralization by
preventing crystal growth on the surface of
lesion by keeping pores open
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Calculus forms in plaque despite inhibitory
action of statherin and PRPs in saliva
May be due to failure to diffuse into
calcifying plaque
Proteolytic enzymes of oral bacteria or lysed
leukocytes may destroy inhibitory proteins
Plaque bacteria may produce their own
inhibitors
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Several salivary proteins appear to be involved in
preventing or promoting bacterial adhesion to
oral soft and hard tissues
PRPs are strong promoters of bacterial adhesion
◦ Amino terminal: control calcium phosphate chemistry
◦ Carboxy terminal: interaction with oral bacteria
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Interactions are highly specific
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Iron-binding protein
Prevents iron from being used by
microorganism that require it for metabolism
Nutritional immunity (iron starvation)
Some microorganisms (e.g., E. coli) have
adapted to this mechanism by producing
enterochelins.
◦ bind iron more effectively than lactoferrin
◦ iron-rich enterochelins are then reabsorbed by
bacteria
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Lactoferrin, with or without iron, can be
degraded by some bacterial proteases.
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Positively charged enzymatic protein which
binds to salivary anions of various types
(bicarbonate,fluoride,iodide,nitrate) and
forms a complex which binds to cell wall of
bacteria & destabilizes the cell wall
Present in numerous organs and most body
fluids
Also called muramidase
Alters glucose metabolism in sensitive
bacteria
Causes aggregation,contributing to
clearance of bacteria from the oral cavity
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A group of histidine-rich proteins
The major form in the oral cavity are
histatin 1,histatin 3 and histatin 5
Binds to hydroxyapatite and prevent
calcium phosphate precipitation from a
supersaturated saliva and favour
remineralization
Potent inhibitors of Candida albicans
growth
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Are inhibitors of cysteine-proteases
Are present in many body fluids
Prevent the action of potentially harmful
proteases on the soft tissue of oral cavity
Considered to be protective against
unwanted proteolysis
◦ bacterial proteases
◦ lysed leukocytes
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Also inhibits calcium phosphate
precipitation
Promotes supersaturation of saliva with
calcium and phosphate,thus protecting
the tooth surface
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Sialoperoxidase (SP, salivary peroxidase)
◦ Produced in acinar cells of parotid glands
◦ Also present in submandibular saliva
◦ Readily adsorbed to various surfaces of
mouth
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Myeloperoxidase (MP)
◦ From leukocytes entering via gingival crevice
◦ 15-20% of total peroxidase in whole saliva
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Patient’s complaints:
Oral dryness and soreness
Burning sensation of oral mucosa and tongue
Difficulties in speech
Difficulty in chewing dry food
Taste impairment and disturbances
Difficulties in wearing removable dentures
Dry lips
Acid reflux,nausea,heart burn
Sensation of thirst
The oral symptoms are often associated with other
symptoms such as dry skin,dry nose,dry eyes,dry
vaginal mucosa,dry throat,dry cough and constipation
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Signs:
Mucosal dryness:dry glazed and red oral mucosa
Lobulation and fissuring of the dorsal part of
tongue
Atrophy of filiform papillae
Dry lips,angular cheilitis
Increased caries experience
Oral candidiasis
It is a clinical manifestation of salivary gland
dysfunction and it does not represent a disease
entity .Dry mouth varies from minimal viscous
appearance of saliva to complete absence of any
salivary flow.
 More prevalent in women.
 Can cause significant morbidity and a
reduction in a patient’s perception of quality of
life.
 When unstimulated salivary flow is less than
0.12 to 0.16 ml/minute, a diagnosis of
hypofunction is established.
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Aging
Foods:alcohol, coffee, coco cola, smoke
Drugs:
◦ Anti-depressants
◦ Anti-histamine
 Cimitidine
◦ Anti-cholinergic
◦ Anti-HTN (sympathomimetic drugs)
◦ Anti-inflammatory
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Systemic factors
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Emotions: nervousness , excitation, depression, stress..
Encephalitis, brain tumors, stroke, Parkinson’s disease
Dehydration: diarrhea, vomiting, polyuria of diabetes …
Anemia, nutrition deficiency.
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Radiotherapy
◦ Acini atrophy fibrosis or replaced by fatty
tissue
◦ Serous acini: more sensitive to R/T
◦ Saliva: thickened, altered electrolytes, pH↓,
secretion of immunoglobulins↓
◦ >1000rad (2-3wk): felt oral dryness
◦ >4000rad: irreversible change
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Sjogren’s syndrome
Other salivary gland diseases
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Symptoms:
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Oral dryness (most common)
Halitosis
Burning sensation
Loss of sense of taste or bizarre taste
Difficulty in swallowing
Tongue tends to stick to the palate
Decreased retention of denture
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Signs:
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Saliva pool disappear
Mucosa: dry or glossy
Duct orifices: viscous and opaque saliva
Tongue:
glossitis  fissured  red with papilla
atrophy
Angular cheilitis
Rampant caries: cervical or cusp tip
Periodontitis
Candidiasis
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Clinical Appearance:
◦ Oral mucosa appears dry, pale, or atrophic.
◦ Tongue may be devoid of papillae with fissured and
inflamed appearance.
◦ New and recurrent dental caries.
◦ Difficulty with chewing, swallowing, and tasting
may occur.
◦ Fungal infections are common.
Pale Fisured Tongue Due To
Severe Dry Mouth
Moderate Xerostomia
Severe Dry Mouth
(Strawberry Tongue)
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History taking
Symptoms & clinical examination
Special investigations
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Salivary flow rate, SFR
Salivary scintiscanning
Sialochemical analysis & laboratory values
Labial biopsy
Sialography
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Dietary & environmental considerations
Preventive Dental Care Measures
Saliva stimulants
Saliva substitutes
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Dietary:
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Avoid drugs that may produce xerostomia
Avoid dry & bulky foods
High fluid intake & rinsing with water
Avoid alcohol, smoking and sugar
Take protein and vitamin supplements
Environment:
◦ Maintain optimal air humidity in the home
◦ Use Vaseline to protect the lips
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Smooth sharp cusps, occlusal grooves or fissures,
irregular fillings.
Check and adjust the denture.
Fluoride rinses & chlorhexidine rinses.
Antifungal medications:
◦ Denture: Miconazole gel,amphotericin or nystatin ointment
◦ Topical: Nystatin, amphotercin suspension or fluconazole..
Saliva Substitutes:
•Sodium carboxymethyl cellulose:0.5%
aqueous solution
•Commercial oral moisturizing gels (OTC)
includes:
OralBalance.
XERO-Lube
Salivart
Optimoist
Saliva Stimulants:
The use of sugar free gum, lemon drops or
mints are conservative methods to temporarily
stimulate salivary flow in patients with
medication xerostomia or with salivary gland
dysfunction.
•Biotine chewing gum
•Pilocarpine HCl
May need 2-3 months to determine effectiveness.
Side effects include sweating and diarrhea.
Avoid in patients with narrow angle glaucoma, severe
asthma, pulmonary diseases.
Pathophysiology
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Normal Submandibular Saliva production 0.10-0.15
ml/min
Ptyalism may result in 1-2 L/day of Saliva loss
Mechanisms of excessive Saliva
Decreased Saliva swallowing and clearance
Excessive Saliva production
Neuromuscular disease
Anatomic abnormalities
Saliva Overproduction
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Pregnancy (Ptyalism Gravidarum)
Excessive starch intake
Gastrointestinal causes
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Gastric distention or irritation
Gastroesophageal Reflux
Acute Gastritis or Gastric Ulcer
Pancreatitis
Liver disease
◦ Medications and toxins
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Clozapine(Clozaril)
Potassium Chlorate
Pilocarpine
Mercury Poisoning
Copper
Arsenic poisoning
Antimony (used to treat parasitic infections)
Iodide
Bromide
Aconite (derived from Aconitum napellus
root)
Cantharides
◦ Stomatitis and localized oral
lesions
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Aphthous Ulcers
Oral chemical burns
Oral suppurative lesions
Alveolar abscess
Epulis
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Dental Caries
Diphtheria
Syphilis
Tuberculosis
Small Pox
◦ Oral infectious Lesions
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Difficulty Swallowing Saliva
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Infections
Tonsillitis
Retropharyngeal Abscess
Peritonsillar Abscess
Epiglottitis
Mumps
Chancre
Actinomycosis
Bone Lesions
Jaw fracture or dislocation
Ankylosis of the temporomandibular joint
Sarcoma of the jaw
◦ Neuromuscular disorders
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Cerebral Palsy
Mental retardation
Bulbar Paralysis
Pseudobulbar paralysis
Bilateral Facial Nerve Palsy
Cerebrovascular Accident
Myasthenia Gravis
Hypoglossal Nerve palsy
Rabies
Botulism
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Radiation therapy
Macroglossia
Dental malocclusion
◦ Miscellaneous Causes
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Non-specific
Treat specific causes as below
General measures to reduce Saliva
 Tooth brushing and mouthwash has
drying effect
 Reduce starch intake from diet
Orthodontic appliances that aid
swallowing
 Upper plate to cover palate with
movable beads
 Aids lip closure
 Directs Saliva toward pharynx
Anticholinergic Medications
 Glycopyrrolate
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Advanced procedures in severe and
refractory cases
 Botulinum toxin A Salivary Gland
injection
 Performed under ultrasound
guidance
 Radiation therapy
 Surgery
 Submandibular Gland excision or
duct relocation
 Parotid duct relocation or ligation
 Salivary denervation
(transtympanic neurectomy)
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Specific measures
Treat Nausea with Antiemetics
Treat Gastroesophageal Reflux
Neuromuscular causes
 Speech pathology (e.g.
swallowing mechanism)
 Neurology consultation
Oral diseases including dental
malocclusion
 Dentist or orthodontist
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Painful,frustating condition often described
as a scalding sensation in tongue,lips,palate
or throughout the mouth
Can affect anyone but occurs most commonly
in middle-aged or older women
occurs with a range of medical and dental
conditions, from nutritional deficiencies and
menopause to dry mouth and allergies
the exact cause of burning mouth syndrome
cannot always be identified with certainty.
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Moderate to severe burning in the mouth is
the main symptom of BMS and can persist for
months or years
the burning sensation begins in late morning,
builds to a peak by evening, and often
subsides at night
Some feel constant pain; for others, pain
comes and goes
Anxiety and depression are common in
people with burning mouth syndrome and
may result from their chronic pain.
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Other symptoms of BMS include:
tingling or numbness on the tip of the tongue
or in the mouth
bitter or metallic changes in taste
dry or sore mouth
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damage to nerves that control pain and taste
hormonal changes
dry mouth, which can be caused by many medicines
and disorders such as Sjögren’s syndrome or
diabetes
nutritional deficiencies
oral candidiasis, a fungal infection in the mouth
acid reflux
poorly-fitting dentures or allergies to denture
materials
anxiety and depression.
In some people, burning mouth syndrome may have
more than one cause. But for many, the exact cause
of their symptoms cannot be found
A review of medical history, a thorough oral
examination, and a general medical
examination may help identify the source of
burning mouth. Tests may include:
• blood work to look for infection, nutritional
deficiencies, and disorders associated with
BMS such as diabetes or thyroid problems
• oral swab to check for oral candidiasis
• allergy testing for denture materials, certain
foods, or other substances that may be
causing symptoms.
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Treatment should be tailored to individual
needs. Depending on the cause of BMS
symptoms, possible treatments may include:
adjusting or replacing irritating dentures
treating existing disorders such as diabetes,
Sjögren’s syndrome, or a thyroid problem to
improve burning mouth symptoms
recommending supplements for nutritional
deficiencies
switching medicine, where possible, if a drug
is causing burning mouth
• prescribing medications to
— relieve dry mouth
— treat oral candidiasis
— help control pain from nerve damage
— relieve anxiety and depression.
 When no underlying cause can be found,
treatment is aimed at the symptoms to try to
reduce the pain associated with burning
mouth syndrome.
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Sip water frequently.
Suck on ice chips.
Avoid irritating substances like hot, spicy
foods; mouthwashes that contain alcohol;
and products high in acid, like citrus fruits
and juices.
Chew sugarless gum.
Brush teeth/dentures with baking soda and
water.
Avoid alcohol and tobacco products.
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Difficulties in chewing
tasting
swallowing
speaking
Increased chances of developing dental decay &
other infections in mouth
Mouth sores
Difficult for operator to work when saliva pools in
mouth (in case of sialorrhea)
uncoordinated swallowing
poorly synchronized lip closure
abnormal increase in tone of the muscles that
open the mouth
 Acute
bacterial sialadenitis
 Chronic
sialadenitis
 Recurrent
sialadenitis
 Mumps
 Post
operative usually parotid
 Autoimmune
diseases
Tumors of the salivary glands are
commonest in the parotid much less
common in the submandibular gland and
very rare in the sublingual and minor
salivary glands.
I. Benign:
a) Mixed salivary tumor or pleomorphic
adenoma
b) Adenolymphoma or warthin’s tumor
c) Oncocytoma
d) Monomorphic adenoma
II. Malignant:
a) Primary carcinoma
b) Secondary carcinoma – direct invasion
from skin or from secondarily involved lymph
nodes
Typical Features of Benign & Malignant
Salivary Gland Tumours
BENIGN
MALIGNANT
• Slow growing
• At times Fast growing
• Soft or Rubbery Consistency
• May be Hard Consistency
• Usually Encapsulated
• Is not encapsulated.
• Does not ulcerate
• May ulcerate; invades bone
• No associated nerve palsies
• May cause cranial nerve
palsies depending on the site of
involvement.
• Mainly affects the parotid
gland.
• Usually affects minor salivary
glands.
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Present as swelling
unilateral or bilateral
painless or painful
Slow growing or fast growing
Associated symptoms:
Trismus
Pyrexia
Tachycardia
Purulent discharge from duct
Difficulty in mastication
Facial muscle weakness
Nerve palsies-malignat tumours
lymphadenopathy
THE CARIOGENIC CHALLENGE
 Although the etiology of dental caries is
reasonably well established,the chemicalphysical process that results in the
demineralization of enamel and dentin often
is less appreciated.
 The stage is set for the oral flora to
metabolize the ingested carbohydrates
leading to the production of acids that are
capable of demineralizing enamel and dentin
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The production of acids by microorganisms
within the dental plaque continues until the
carbohydrate substrate is metabolized
The plaque’s pH goes from acidic to normal
(or the resting level) within a few minutes
This is due to the carbonate and phosphate
pH buffering agents in saliva
Saliva also serves as the host’s defense
mechanism by repairing the demineralization
that occurs when the plaque pH is below 5.5
to 6.0
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CHEMICAL BENEFITS OF SALIVA STIMULATION
Stimulating the flow of saliva alters its
composition. Increases the concentration of
protein, sodium, chloride and bicarbonate
and decreases the concentration of
magnesium and phosphorus.
Perhaps of greatest importance is the
increase in the concentration of bicarbonate,
which increases progressively with the
duration of stimulation. The increased
concentration of bicarbonate diffuses into the
plaque, neutralizes plaque acids, increases
the pH of the plaque and favors the
remineralization of damaged enamel and
dentin
Studies have shown that chewing sugar-free
gum after meals results in a significant
decrease in the incidence of dental caries and
that the benefit is due to stimulating salivary
flow rather than any chewing gum ingredient.
 Stimulating salivary flow after meals reduces
the incidence of dental caries
so,its practical measures should be
considered in caries prevention programs
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With age, a generalized loss of salivary gland
parenchymal tissue occurs. The lost salivary cells
often are replaced by adipose tissue. Although
decreased production of saliva often is produced
in older persons,whether this is related directly
to the decrease in parenchymal tissue is not
clear. Some studies of healthy older individuals,in
which the use of medication were carefully
controlled,revealed little or no loss of salivary
function. Other studies suggest that although
resting salivary secretion is in the normal
range,the volume of saliva produced during
stimulated secretion is less than normal.
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ADVANTAGES:
non-invasive
limited training
no special equipment
potentially valuable for children and older
adults
cost-effective
eliminates the risk of infection
screening of large populations
SALIVA COLLECTION:
• with or without stimulation
• Stimulated saliva-collected by masticatory action (i.e.,
from a subject chewing on paraffin) or by gustatory
stimulation (i.e., application of citric acid on the
subject's tongue)
• Unstimulated saliva is collected without exogenous
gustatory, masticatory, or mechanical stimulation
Unstimulated salivary flow rate is most affected by
the degree of hydration,but also by olfactory
stimulation, exposure to light, body positioning, and
seasonal and diurnal factors
Two ways:
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Draining method, in which saliva is allowed to drip
off the lower lip
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Spitting method, in which the subject expectorates
saliva into a test tube
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Serum components may also reach the saliva
through the crevicular fluid. This raises the
prospect of using saliva in the diagnosis of
certain pathologies
The use of saliva in diagnosing caries risk is
well-known, particularly in monitoring chemical
treatments to control the disease,owing to the
possibility of detecting the presence of S. mutans
and Lactobacillus spp, as well as lactic acid which
causes the sub-surface demineralisation that
causes the onset of the caries lesion
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Candidiasis-through the presence of Candida
spp in the saliva
The presence of periodontal pathogenic bacteria
can also be diagnosed by this method-increasing
the risk of cardiovascular and cerebrovascular
diseases
Cystic fibrosis-raised sodium chloride, calcium,
phosphate, lipid and protein contents in the
submaxillary saliva.
An epidermal growth factor with low biological
activity compared to that of healthy persons and
raised prostaglandin E2 levels are also found in
the saliva of these patients
In 21-hydroxylase deficiency, a strong
correlation has been found between 17hydroxyprogesterone levels in saliva and in
serum.
In Sjögren’s syndrome, minor salivary gland
biopsy is an accepted diagnostic procedure. A
predominant inflammatory infiltrate composed of
CD4 lymphocytes is found, together with lowered
at rest and stimulated salivary flow rates.
Quantitatively, there are raised concentrations of
sodium, chloride, IgA, IgG, lactoferrin, albumin,
microglobulin, cystatin C and S, lipids and
inflammation mediators such as prostaglandin
E2, thromboxane B2 and interleukin-6
 In some malignant diseases, markers can be
detected in the saliva, such as the presence of
protein p53 antibodies in patients with oral
squamous cell carcinoma
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The presence of the c-erbB-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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PCR detection of Helicobacter pylori in the
saliva shows high sensitivity
The presence of antibodies to other
infectious organisms such as Borrelia
burdogferi, Shigella or Tenia Solium can also
be detected through the saliva
detection of hepatitis A antigen and hepatitis
B surface antigen in the saliva has been used
in epidemiological studies
saliva has also been used to detect antibodies
to the rubella, parotitis and rubeola viruses
In neonates, the presence of IgA is an
excellent marker of rotavirus infection
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HIV antibody detection is as precise in saliva as in
serum and is applicable in both clinical and
epidemiological studies
Salivary IgA levels to HIV decline as infected
patients become symptomatic. It was suggested
that detection of IgA antibody to HIV in saliva
may, therefore, be a prognostic indicator for the
progression of HIV infection
Several salivary and oral fluid tests have been
developed for HIV diagnosis
Orasure® is a testing system that is
commercially available in the United States and
can be used for the diagnosis of HIV
The test relies on the collection of an oral
mucosal transudate (and therefore IgG antibody).
IgG antibody to the virus is the predominant type
of anti-HIV immunoglobulin
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Certain drugslithium,carbamazepine, barbiturates, benzodiazepines, phenytoin, theophylline and
cyclosporine
High correlation between ethanol
concentrations in saliva and in serum. The
presence of thiocyanate in the saliva is an
excellent indicator of active or passive
smoking
Other drugs such as cocaine or opiates can
also be detected in saliva
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Consequently, the use of saliva as an
alternative method of diagnosis or as a
means to monitor the evolution of certain
illnesses or the dosage of certain medicines is
a promising path
The earlier the diagnosis, the better the
prognosis
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This procedure is done to differentiate
inflammatory from neoplastic disease; diffuse
from focal suppurative disease, identify and
localize sialoliths, & demonstrate ductal
morphology.
The methods employed are:
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Plain Film Radiography
IntraOral Radiography
ExtraOral Radiography
Conventional Sialography
Computed Tomography (CT)
Magnetic Resonance Imaging
Scintigraphy
UltraSonography
CONVENTIONAL SIALOGRAPHY
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It is 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,
flouoroscopy, panoramic radiography, CT.
This technique is mainly used to study
Parotid and SubMandibular glands.
In this 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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INDICATIONS:Detection of calculi or foreign bodies
Determination of extent of destruction of
salivary gland tissue
Detection of fistulae, diverticuli & strictures
Detection & diagnosis of recurrent swelling &
inflammatory processes
Demonstration of tumour, its size, location &
origin
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Selection of the site for biopsy
Outline the plane of facial nerve as a guide in
planning a biopsy or a dissection
Detection of residual stones, residual tumour
or a retention cyst
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CONTRAINDICATIONS:Patients with a known allergy or
hypersenstivity to iodine compounds
During the period of acute inflammation of
salivary glands because:1. contrast media cause irritation
2. there is increased chance of rupture of
duct & extravasation of contrast media into
already inflamed gland
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Patient scheduled for thyroid function tests in
near future. absorption of iodine present in
the contrast material, across the glandular
mucosa may interfere with these studies.
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Sialography can be divided into 3 phases:Ductal phase
Acinar phase
Post-evacuation phase
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Ductal phase of both parotid and
submandibular sialogram starts with the
reterograde injection of contrast medium &
ends when glandular parenchyma starts to
become “hazy” reflecting onset of acinar
opacification
Visualization of ducts draining accesory
parotid gland often occur during this phase`
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It begins after the ductal system has become
fully opacified with contrast and the gland
parenchyma becomes filled subsequently
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It assesses normal secretory clearance
function of the gland to determine whether
any evidence of retention of contrast remains
in the gland or ductal system after the
sialogram
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Contrast sialography can be performed either
by :A) lipid –soluble agents
B) water –soluble agents
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These agents contain 37% iodine, e.g.
ethiadol
ADVANTAGES:It is not diluted by saliva
It is not absorbed across glandular mucosa
DISADVANTAGES:These are more viscous , hence higher
injection pressure is required
More pain & discomfort
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Any calculus encounterd in the duct may be
displaced backward
Extravasated agents can cause foreign body
reaction, & can induce inflammatory reactions
and granuloma formation
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These agents contain 28 to 38% iodine, e.g.
hypaque50%, hypaque M 75%, renografin 60,
isopaque, triosol & dionosil
ADVANTAGES:Low viscosity
Low surface tension and more miscible with
salivary secretions
Residual contrast medium is absorbed and
excreted through kidney
◦ DISADVANTAGES:◦ Opacification is generally not as good as oil –based
media as it is rapidly absorbed across glandular
mucosa
◦ It is diluted by saliva
◦ The injection is accompanied by little pain &
discomfort
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EQUIPMENT:Polythene tubing with a special blunt metallic
tip with side holes for parotid gland injection
A 5-10ml syringe
Lacrimal dilator
Contrast medium
Lemon slices or artificial lemon extract
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PROCEDURE:1) Identification of the location of duct
orifices
The parotid duct is located at the base of
the papilla in the buccal mucosa opposite
maxillary 1st and 2nd molar teeth
The area of the mucosa in the vicinity of the
orifice is dried with a small sponge
The application of gentle pressure over the
area would lead to expression of saliva
The submandibular duct orifice is situated
on the summit of papilla by side of lingual
frenum
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2)EXPLORATION OF THE DUCT WITH A
LACRIMAL PROBEIn view of torturous course of the parotid
duct, patient”s cheek must be turned outward
prior to insertion of the probe into the duct.
This eversion of cheek reduces the chances of
penetration of duct at the sharp angles in its
course.
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In case of the submandibular duct, the probe
should pass through the considerable length
of the floor of the mouth to the level of
posterior border of mylohyoid muscle, apx
5cm
In both the ducts, the probe should slide
easily back & forth and also rotate freely
without dragging.
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3) CANNULATION OF THE DUCTS:The duct orifice is slightly enlarged, & the
salivary cannula is inserted into the duct.
The cannula is held in place by taping the
tubing wrapped in sponge.
INTRODUCTION OF THE RADIOGRAPHIC DYE:The dye is slowly introduced into the duct
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The amount used is best determined by
flouroscopic observation.
The patient is instructed to inform the
operator when the gland area feels tight or
full.
The apx. Values of the dye required vary from
0.76ml to 1.0ml for parotid gland, & 0.5 to
0.75ml for submandibular gland
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1)LATERAL OBLIQUE PROJECTION:This projection is best to delineate the
submandibular gland, as the image is
projected below the ramus of the mandible
2)LATERAL PROJECTION:This projection also shows ductal projection
3)OCCLUSAL PROJECTION:This view is useful for sialolith located in the
anterior part of the wharton’s duct
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4)ANTERIOR-POSTERIOR PROJECTION:This projection demonstrates medial and
lateral gland structures
5)PANORAMIC PROJECTION:This projection is made during the filling
phase.
It has following advantages:Easier to expose
Radiation dose is relatively low
Satisfactory bony details
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Less invasive than sialography
Does not require the use of contrast material
Used for assessment of mass lesions of the
salivary glands
Can demonstrate salivary gland calculi.
Especially submandibular stones that are
located posteriorly in the duct, at the hilum of
the gland or in the substance of gland itself.
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MRI is superior to CT scanning in delineating
the soft tissue detail of the salivary gland
lesions, esp. tumours
With no radiation exposure to the patient or
the neccesity of contrast enhancement
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It is a relatively simple, non-invasive imaging
modality, with poor detail resolution.
Useful in assessment of superficial structures
to determine whether a mass lesion that is
being evaluated is solid or cystic in nature.
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It is a specialised procedure that uses a
small video camera with a light at the end
of a flexible cannula , which is introduced
into the ductal orifice
Can be used diagnostically and
therapeutically
Can demonstrate strictures and kinks in the
ductal system , as well as mucous plugs and
calcifications
May be used to dilate small stictures and
flush clear small mucous plugs
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An examination of electrolyte composition of
saliva of each gland may indicate a variety of
salivary gland disorders.
Principally, the concentrations of sodium and
potassium, which normally change with
salivary flow rate, are measured
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Textbook of medical physiology by guyton &
hall
Dental caries by Ole Fejerskov & Edwina
Kidd
Ten Cate’s Oral Histology
Textbook of Pediatric Dentistry by Shobha
Tandon
Textbook of Oral Pathology by Shafer
Preventive community dentistry by Soben
Peter
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Microbial composition of whole saliva:The Dental
Clinics of North America
Saliva:the precious body fluid:The Journal of the
American Dental Association
Burning mouth syndrome:NIDCR
The diagnostic applications of saliva a review:
published by SAGE
Dry mouth:NIDCR
The effect of saliva on dental caries:The Journal of
the American Dental Association
The role of saliva in maintaining oral health and as
an aid to diagnosis:clinical dentistry