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Transcript of Saliva Fnl
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Saliva lacks the drama of blood , the emotion of
tears and toil of sweat but still remains one of the
most imp. fluids in the human body (Mandel,
1990)
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 fromnon-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,alsocontains vast amounts of epithelial cells from
the oral mucosa and millions of bacteria.
These components give whole saliva its cloudyappearance,which is different from glandular
saliva, which is transparent like water.
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Multifunctionality
SalivarySalivary
FamiliesFamilies
AntiAnti--
BacterialBacterialBufferingBuffering
DigestionDigestion
MineralMineral--
izationization
LubricatLubricat--
ion &Viscoion &Visco--
elasticityelasticity
TissueTissue
CoatingCoating
AntiAnti--
FungalFungal
AntiAnti--
ViralViral
Carbonic anhydrases,Carbonic anhydrases,
HistatinsHistatins
Amylases,Amylases,
Mucins, LipaseMucins, Lipase
Cystatins,Cystatins,
Histatins,P
rolineHistatins,P
roline--rich proteins,rich proteins,
StatherinsStatherins
Mucins, StatherinsMucins, Statherins
Amylases,Amylases,
Cystatins, Mucins,Cystatins, Mucins,
ProlineProline--rich proteins, Statherinsrich proteins, Statherins
HistatinsHistatins
Cystatins,Cystatins,
MucinsMucins
Amylases, Cystatins,Amylases, Cystatins,
Histatins, Mucins,Histatins, Mucins,PeroxidasesPeroxidases
adapted from M.J. Levine, 1993adapted from M.J. Levine, 1993
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MAJOR FUNCTIONS OF
SALIVA
Solvent
Buffering
Lubrication Remineralization
Digestion
Anti-bacterial
Anti-fungal
Temperature regulation Production of growth factors and other
regulatory peptides
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Fluid or lubricant: Saliva coats the mucosa & helps
to protect against mechanical wear ,chemical
erosion and thermal irritation.It also assists smooth
airflow,speech & swallowing.
Buffering: Saliva helps to neutralise plaque pH after
eating thus reducing time for demineralizationcaused by bacterial acids produced during sugar
metabolism
remineralization :Saliva is supersaturated withions,which facilitate remineralization of teeth
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Digestion :breakdown of starch-amylase
Fat-lingual lipaseMoistening and lubricative properties of saliva:
allow the formation & swallowing of food bolus
Antimicrobial action: Lysozyme, lactoferrin,sialoperoxidase help against pathogenic
microorganisms specifically Immunoglobulins and
secretory IgA also act against microorganisms.
Cleansing: Clears food and aids swallowing.
.
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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
Pellicle formation: Derived from salivary proteins,it
forms a protective diffusion barrier to acids fromplaque.
taste: Saliva has a low threshold concentration of
sodiumchloride , sugar, urea etc allowingperception 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
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Calcium & Phosphate :
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
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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H2 CO3
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 carbonicanhydrase
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Other ions Fluoride
Low concentration, similar to plasma
Thiocyanate
Antibacterial (oxidated to hypothiocyanite
OSCN- by active oxygen produced frombacterial peroxides by lactoperoxidase)
Higher conc. => lower incidence of caries
Smokers - increased conc.
Sodium, potassium, chloride, SO4
Lead, cadmium, copper, Mg May reflect systemic concentrations -
diagnostics
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Mucins
Proline-rich proteins
Amylase
Lipase
Peroxidase
Lysozyme
Lactoferrin
Secretory IgA
Histatins
Statherin
Blood group substances, kallikrein, sugars, steroid hormones, amino
acids, ammonia, urea, uric acid, clotting factors & lipids
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Mucins Lubrication
Hydrophillic, entraining water (resistsdehydration)
Unique rheological properties (e.g.,
viscoelasticity, adhesiveness, lowresistnce to proteolytic degradation andlow solubility)
Two majormucins (MG1 and MG2)
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Amylases Calciummetalloenzyme
Hydrolyzes E(1-4) bonds of starches suchas amylose and amylopectin
Several salivary isoenzymes
Maltose is the major end-product (20% is
glucose)
Appears to have digestive function -inactivated in stomach, provides
disaccharides for acid-producing bacteria
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Lingual Lipase Secreted by lingual glands and parotis
Involved in first phase offat digestion
Hydrolyzes medium- to long-chaintriglycerides
Important in digestion ofmilk fat innew-born
Unlike othermammalian lipases, it ishighly hydrophobic and readily entersfat globules
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Statherins
Calcium phosphate salts of dental enamel
are soluble under typical conditions of pH
and ionic strength
Supersaturation of calcium phosphates
maintain enamel integrity
Statherins prevent precipitation or
crystallization of supersaturated calcium
phosphate in ductal saliva and oral fluid
Produced by acinar cells in salivary glands
Also an effective lubricant
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Proline-rich Proteins (PRPs)
40% of AAs is proline
Inhibitors of calcium phosphate crystalgrowth
Part of pellicula dentis
Subdivided into three groups
Acidic 45%
Basic 30%
Glycosylated 25%
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Lactoferrin Iron-binding protein
Nutritional immunity (iron starvation)
Some microorganisms (e.g., E. coli) haveadapted to this mechanismby producing
enterochelins. bind iron more effectively than
lactoferrin
iron-rich enterochelins are thenreabsorbed by bacteria
Lactoferrin, with or without iron, can bedegraded by some bacterial proteases.
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Lysozyme Present in numerous organs and most
body fluids
Also called muramidase
hydrolysis ofF(1-4) bond between N-acetylmuramic acid and N-acetylglucosamine in thepeptidoglycan layer ofbacteria.
Gram negative bacteria generally
more resistant than gram positivebecause of outer LPS layer
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Histatins
secretory Leukocyte
protease inhibitors
A group of small histidine-rich
proteins
Potent inhibitors ofCandidaalbicans growth
Have antiviral properties
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Cystatins Are inhibitors of cysteine-proteases
Are ubiquitous in many body fluids
Considered to be protective against
unwanted proteolysis bacterial proteases
lysed leukocytes
May play inhibit proteases inperiodontal tissues
Also have an effect on calcium
phosphate precipitation
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Salivary
peroxidasesystems
Sialoperoxidase (SP, salivary
peroxidase)
Produced in acinar cells of parotid
glands
Also present in submandibular saliva
Readily adsorbed to various surfaces of
mouth
enamel, salivary sediment, bacteria, dental
plaque
Myeloperoxidase (MP)
From leukocytes entering via gingivalcrevice
15-20% of total peroxidase in whole
saliva
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Functions Salivary Components Involved
(1) Protective functions
Lubrication Mucins, proline-rich glycoproteins, water
Antimicrobial
Amylase, complement, defensins,
lysozyme, lactoferrin, lactoperoxidase,
mucins, cystatins, histatins, proline-rich
glycoproteins, secretory IgA, secretory
leukocyte protease inhibitor, statherin,
thrombospondin
Growth factors
Epidermal growth factor (EGF),
transforming growth factor-alpha (TGF-
), transforming growth factor-beta
(TGF-), fibroblast growth factor (FGF),
insulin-like growth factor (IGF-I & IGF-II),
nerve growth factor (NGF)
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Mucosal integrity Mucins, electrolytes, water
Lavage/cleansing Water
Buffering
Bicarbonate, phosphate
ions, proteins
Remineralization
Calcium, phosphate,
statherin, anionic proline-
rich proteins
(2) Food- and speech-related functions
Food preparation Water,mucins
Digestion
Amylases, lipase,
ribonuclease, proteases,
water, mucins
Taste Water, gustin
Speech Water,mucins
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Each SG consists of a large no of acini
Each acinus is lined by a single layer of
epithelial cells Acinar/ end peice
cells From the acinus anintercalated duct arises opens
into the striated duct finally
several open into the excretory duct
oral cavity.
Myoepithelial cells surround the acini
& intercalated ducts ( contain actin &
myosin)
Contractions of these lead to expulsion
of secretions within acinus & duct.
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Salivon
Secretory unit of saliva
Acinus + Intercalated duct +
striated duct
The Intercalated & striated
ducts are more than passive
condiutsbu
t actively involvedin formation of final saliva.
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Production ofSaliva
The production of saliva is an activeprocess occurring in 2 phases:
1) Primary secretion occurs in the acinar
cells. This results in a product similar in
composition and osmolality to plasma.
2) Ductal secretion results in a hypotonic
salivary fluid. It also results in decreased
sodium and increased potassium in the endproduct
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THE SECRETORY UNIT
The basic building block of all salivary glands
ACINI - waterandionsderived fromplasma
Saliva formedinaciniflowsdownDUCTStoemptyintotheoralcavity.
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Primary saliva
S
ecretedby acinar cells and si
milar incomposition to plasma (isotonic)
Fluid & electrolyte secretion:
This process is drivenby transepithelial Cl-
movt.
The acinar tight jns provide a cation-selective
pathway for Na+ flux down its electrical
gradient into the acinar lumen
The resultant osmotic gradient for NaCl causes
watermovt., via water channels & across
tight jns, to produce an isotonic, plasma lke
primary fluid.
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Fliud secretion in major salivary glnds is
largely initiated in response to
stimulation ofmuscarinic receptors on
the cell surface
ACh associated with its receptors G
protein activation & consequently, an
elevation of intracellular [Ca+] through a
PLC/IP3- dependent pathway
Inturn, this increase in intracellular [Ca+]
triggers the opening of apical Ci-
channels.
Na & then water follow Cl- into the
acinar lumen
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Water/electrolyte
secretion
Water secretion is driven by osmotic
changes
Mediated by ionic fluxes
Frombasolateral surfaces to the
apex (lumen)
Involves ion pumps and channels
Basolateral
Na+-K+-ATPase
Ca2+ activated K+ channel
Na+-K+-2Cl--cotransporter (NKCCl)
Na+-H+ exchanger
Cl-- HCO3- exchanger, plus
Carbonic anhydrase
Lumenal Ca2+ activated Cl- channel
HCO3- channel (Ca2+ activated?) ,
plus Carbonic anhydrase
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Alternative mechanisms
Na+-K+-ATPase
Ca2+ activated K+
channel
Na+-K+-2Cl--
cotransporter
Ca2+ activated Cl-
channel
Na+-H+ exchanger
Cl-- HCO3- exchanger
Carbonic anhydrase
Na+-H+ exchanger
HCO3- channel
Carbonic anhydrase
Adapted from Turner and Sugiya, Oral Dis. 2:3-11, 2002
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Ductal modification
S
aliva entering the lum
en is isotonic Saliva entering the mouth is hypotonic
Reabsorption of Na+ and Cl- by striated duct cells
Similar to distal tubules of kidneys
Ion pumps and channels
Lum
enal Na+-H+ exchanger
Cl-- HCO3- exchanger
HCO3- channel
Na+-K+ exchanger
Na
+
-Cl
-
-cotransporter Basolateral
Na+-K+-ATPase
Cl- channel
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Striated duct cell
Cl-
3 Na+
2 K+ATP
Cl-
Na+
Na+
Na+
K+
H+
Cl-
HCO3-
HCO3-
Lumen Interstitium
Nucleus
Mitochondria
Basolateral
membrane folds
Carbonic
anhydrase
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The final electrolyte composition of saliva
varies depending on the salivary flow rate
At high flow rates,saliva is in contact with
the ductal epithelium for shorter time &
Na & Cl conc increase & K conc
decrease
At low flow rates,the electrolyte conc.
change in the opposite direction
The HCO conc. increases with increased
flow rates,reflecting the increased
secretion of HCO by the acinar cells to
drive fluid secretion
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Protein secretion
A parallel process to water/ion secretion
Both occur side by side in the same secretory
cell
Multiple methods of secretion coexist in the
same acinar cells
There is complex cross-talk between
pathways
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Classic exocytosis pathway(stored granule
exocytosis)
Endoplasmic reticulum - translation,glycosylation
Golgi - more extensive glycosylation
Condensing vacuole - packaging, condensation
Immature granule - sorting, major branchingpoint
Secretory granule - protein storage
F-adrenergic stimulation
D
ocking, membrane fusion, exocytosis Time taken from synthesis to exocytosis is
about 3-5 hrs
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Classic exocytosis
Immediate response to NA:
Docking and fusion of preformed
granulesRelease of contents
Long-term response to NA:Transcription
Translation
Glycosylation
New granules
http://www.liv.ac.uk/~petesmif/teaching/1bds_mb/p4/14.gif
(Noradrenaline)
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Secretory granules
Complex internal structure
Multiple types of proteins, compacted and
folded
Membrane proteins that mediate docking and
fusion
V(esicle)-SNARES on granule membranes
T(arget)-SNARES on inner side of cell
apical membrane
A Ca2+ -dependent process
Example of cross talk between pathways
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The other protein pathways Constitutive-like pathway
Branches off from immature granules/golgicomplex
Proteins carried in vesicles to apex - fuseand open
Always active - no stimu
lation required Minor regulated pathway
Branches off from immature granules
Proteins carried in vesicles to apex - fuseand open
Triggered by low levels of M3 cholinergicagonists
Vesicle membranes contain t-SNARES forgranules
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Both are sources of proteins in basal and restingsecretions
Vesicle contents are different from granulecontents
Explains different protein composition afterstimulation
In ths mechanism some proteins travel inopposite direction; to the interstitium
In addition; transcytosis is also seen whichindicates passage of substances through acinarcells; like IgA; from interstitial tissue throughthe cell from BL to the apical cell membrane
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The flow of saliva is regulated predominantly
by the ANS
Although both sympathetic & prasympathetic
stimulation produces saliva, the
parasympathetic is dominant.
Parasympathetic: Ach & VIP
Sympathetic: NA
Postganglionic fibers ofboth the divisions
innervate the secretory cells
Myoepthelial, arteriolar smooth muscle cells,
intercalated & striated duct cells also recieve
direct innervation
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The receptors for these reside directly on
cell membrane and the NT is non synaptic
The axons can be hypolemmal or
epilemmal
The release of NT from the nerve
terminals adjacent to the parenchymal
cells stimulates them to discharge their
secretory granules, secretes water &
electrolytes & contraction ofmyoepthelial
cells.
The molecular events that occur during
this process is called Stimulus-secretion
coupling
Functions of ANS
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Functions of ANS
Parasympathetic
Fluid formation Glandularmetabolism & growth
Transport activity in acinar & ductal cells
Vasodilatation
Sympathetic
Exocytosis & protein metabolismmodulation
Constriction ofblood vessels
Dual
Stimulation of salivary flow
Constriction ofmyoepithelial cells
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Muscarinic messages
http://www.liv.ac.uk/~petesmif/teaching/1bds_mb/p4/15.gif
The Phospholipase C - IP3pathway sends the
message
Intracellular (and extracellular)
Ca2+ flux is a major effector
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Adrenergic messages
http://www.liv.ac.uk/~petesmif/teaching/1bds_mb/p4/16.gif
The adenylate cyclase - cAMP
pathway sends the message
Effectors are activated by a
phophorylation cascade
(Noradrenaline)
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There are 2 types of salivary secretions:
Spontaneous : occurs all the time w/o any
known stimulus and keeps ourmouth
moist all the time
Stimulated: can be :
Conditioned
unconditioned
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Unconditioned
Inborn
Eg: place lemon juice on the tongue of a
new born baby - there is salivation
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Conditioned
Requires previous training
Pavlovs experiment
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Salivary gland secretions:
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Salivary gland secretions:
Parotid gland:
Proteinaceous , watery serous secretion
2/3rd of salivary flow during gustatory &
olfactory stimuli
Organic (proteins inc. Enzymes; amylase) &
inorganic materials are higher
Submandibular gland:
High mucin content, viscous/ serous
secretion
High basal flow rate
Ca is higher
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Sublingual
Highermucin content
5% of salivary flow
Minor salivary gland secretion
Purely mucous glands
5% of salivary flow
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Secretion of salva is minimum at birth&
does not contain salivary amylase
The volume of saliva increases by 2-3
months & salvary amylase appears when
the infant is given complex CHO in diet
In old age the secretory reserves become
decreased though the constituents appear
to be stable
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Salivary Flow
The average volume of saliva secreted in
a 24 hour period is 1-1.5 liters (approx 1
cc/minute), most of which is secreted
during meals.
The basal salivary flow rate=0.001-0.2ml/minute/gland.
With stimulation, salivary flow rate=0.18-
1.7ml/min/gland.
Salivary flow rate from the minor salivary
glands is independent of stimulation,
constitu
ting7-8% of total salivary o
utput.
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Under normal conditions, the ph of
unstimulated saliva is about neutral(mean
value ph 6.8)
Upon stimulation the conc. Of HCO3
increases, resulting in higher ph (mean
value 7..4)
The specific gravity of saliva : 1.01-1.02
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In the UNSTIMULATED state the relative
contribution of the major salivary glands is
as follows:
1) Submandibular gland=69%
2) Parotid gland=26%
3) Sublingual gland=5%
In the STIMULATED state the relative
contribution of the major salivary glands is
as follows:
1) Parotid gland=69%
2) Submandibular gland=26%
3) Sublingual gland=5%
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Though the Sublingual glands and minor
salivary glands contribute only about 10%
of all saliva, together they produce the
majority ofmucous and are critical in
maintaining the mucin layer over the oralmucosa.
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Saliva Collectors
Whole saliva :
1. Draining method
2. Spitting
3. Suction4. Absorbent
Parotid :
1. Cannulation2. Lashley/Carlson-
Crittenden cup
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Submandibular/sublingual
:
1. Cannulation
2. S
egregator( individu
alprosthesis)
3. Suction
4. Wolff apparatus
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Saliva as a Mirror of the Body
Tissue fluid levels of natural substances, as well asmolecules introduced for therapeutic, dependencyor recreational purposes
Emotional status
Hor monal status
Immunological status
Neurological status
Nutritional and metabolic influences
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Clinical Situations Affecting
Salivary Secretions
Digitalis toxicity
Drug monitoring
Environmental pollutants
Ovulation Immunodeficiency
Pharmacological agents Dry mouth side effects, drugs with parasympathetic,
sympathetic and ganglionic blocking effects Direct effects- hypersensitivity or idiosyncratic reaction
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Applications ofSialochemistry
Diseases of the salivary glands
Systemic diseases where salivary glands are
involved
Clinical situations in which salivary flow and
chemistry are helpful in diagnosis ormonitoring
patient progress
Diagnostic Aids in Clinical Situations
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Diagnostic Aids in Clinical Situations
Digitalis toxicity (calcium and potassium)
Affective disorders (prostaglandin)
Immunodeficiency (sIgA)
Stomatitis in chemotherapy (albumin)
Cigarette usage (cotinine)
Gastric cancer (nitrates and nitrites)
Forensic medicine (blood group substance)
Coeliac disease (anti-IgA gliadin)
Liver f unction (caffeine clearance)
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Malignancy
P53 Tumor suppressor antigen inactivation in certain cancers leads to accumulation.
Oral squamous cell carcinoma leads to anti-p53antibodies in saliva
Salivary Defensin-1 levels elevated in oral SCC (made
by PMNs). C-er bB-2 (erb) Tumormarker associated with breast
carcinoma.
CA 125 (ovarian cancermarker) associated withelevated salivary levels
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Drug and Hormone Monitoring
Psychiatrists studying methadone: advantages usingsaliva
humanitarian- less discomfort
clinical- patient acceptance of repeated testing
children and patients with limiting coping abilities economic (do it yourself tests)
HIV therapy
Epilepsy
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Drugs
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Salivary Anti
bodies and Antigens
Advantages in large scale studies
Viral Screening
Antigen Detection
H. pylori(PCR of saliva)
Antibody Screening
rubella
hepatitis A and B Shigella
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Disorders of salivary secretion
Disorders of salivary secretion &
composition can be generally termed:
Dyschylia
Hypo/hypersecretion
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Hyperfunction/ptyalism/sialorrhoe
a/hypersialia
Drugs: bethanicol, clozapine, lithium,
physostigmine, pilocarpine, risperidone
Oral conditions: teething, ill-fitting
prosthesis, mucosal ulcerations
Other conditions: CVA, GERD, heavy
metal poisoning, hyperhydration, nausea,
obstructive esophagitis, parkinsons
disease, secretory phase ofmenstrutiation
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Xerostomia/hyposecretion
Drugs: antcholinergics, antihistamines,
antihypertensives, oncological
chemotherapy, sedatives & chemotherapy
Radiation & radioisotopes
Oral conditions: sg benign& malignant
tumors, infections
Other conditions: amyloidosis, bells palsy,
cystic fibrosis, diabetes, graft Vs Host
disease, granulomatous diseases, HV, latestage liver disease, malnutrition, sjorens
syndrome, psychologcal factors, Sjogrens
syndrome, thyroid disease
References:
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References:
1. Orbans Oral Histology and Embryology
2. Salivary Diagnostics : By David T. Wong
3. Concise medical Physiology: Chaudhary
4. Otorhinolaryngology, Head and Neck Surgery :By Matti Anniko, Manuel Bernal-Sprekelsen, PATRICK BRADLEY
5. Salivary gland diseases: surgical and medical management :By Robert Lee Witt
6. ANATOMY AND PHYSIOLOGY OF THE SALIVARY GLANDSSOURCE: GrandRounds Presentation, UTMB, Dept. ofOtolaryngology DATE: January 24, 2001
Resident Physician: Frederick S. Rosen, MD Faculty Physician: Byron J. Bailey,
MD
7. Physiology of saliva: DENT 5302;Topics in Dental Biochemistry;Dr. Joel Rudney
8. Saliva as a Diagnostic Fluid: Dennis E. Lopatin, Ph.D.;University of Michigan
9. www.google.com
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