At our best whenAt our best when it matters most. it matters most.
Spit is it……and it matters!
Transcript of Spit is it……and it matters!
© 2018
The Saliva Chronicles
Spit is it……and it matters!
Anne N. Guignon,RDH, MPH, CSP
[email protected] 832-971-4540
The Saliva Chronicles Copyright 2020
Complicated, real life situations
© 2020
EBM
Individual clinical expertise
Best external evidence
Patient values& expectations
Improving the patient’s outcome
h0p://med.fsu.edu/index.cfm?page=medicalinformaAcs.ebmTutorial
EBM$
Individual !clinical !expertise
Best !external !evidence
Patient values!& expectations
Improving the patient’s outcome
h"p://med.fsu.edu/index.cfm?page=medicalinforma8cs.ebmTutorial © 2020
Complex patients - complex solutions
© 2020
Who has the highest risk?
© 2020
Complicated, real life situations
‣ 70 year old female
‣ severe polypharmacy-induced
xerostomia
‣ high caries risk
‣ every 3 months - something new
‣ extremely sensiAve Assues
‣ has had severe mucosiAs to
everything I have recommended
for use in her custom fl trays
© 2020
‣ self care
‣ compliance
‣ life style
‣ dry mouth
Challenges
© 2020
‣ medically complex
‣ challenged immune systems
‣ chronic health issues © 2020
Dry mouth Prevalence and clinical presentation
© 2020
Multiple terms - quality of life
‣ dry mouth / syndrome
‣ hypo-salivaAon
‣ xerostomia
Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. © 2020
Hyposalivation
‣ clinical diagnosis
‣ decreased salivary flow
‣ insufficient in saliva
Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010.
Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45.
© 2020
Xerostomia
Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010.
Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45.
Villa, A., Connell, C., AbaA, S. (2014). Diagnosis and management of xerostomia and hyposalivaAon. Therapeutics and Clinical Risk Management, 45.
‣ subjecAve term
‣ perceived lack of moisture
‣ changes in composiAon
© 2020
Prevalence
‣ 30% populaAon
‣ more women
‣ 10% early 30s
‣ over age 50
Thomson WM, Lawrence HP, Broadbent JM, Poulton R. The impact of xerostomia on oral-health-related quality of life among younger adults. Health Qual Life Outcomes. 2006
Nov 8;4:86.
Anil S, Vellappally S, Hashem M, Preethanath RS, PaAl S, Samaranayake LP. Xerostomia in geriatric paAents: a burgeoning global concern. J InvesAg Clin Dent. 2014 Sep 1.© 2020
Insufficient flow
! subtle changes
! 50% decrease - noAceable
! pH decreases
! increased demineralizaAon
Takahashi N, Nyvad B.Caries ecology revisited: Microbial dynamics and the caries process. Caries Res. 2008;42(6):409-18.
Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology. DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012
Graham I, Mount WH. (2005). PreservaAon and restoraAon of tooth structure. 2nd EdiAon. Queensland, Australia: Knowledge Books and Solware. © 2019
Visual observations
‣ red, glossy, parched
‣ pebbled tongue
‣ cracking in commisures
‣ chapped lips
‣ thick, foamy, ropy saliva
Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. © 2020
Additional complaints
‣ difficulty talking
‣ taste alteraAons
‣ dry/sore throatSreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010.
Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45.
‣ problems chewing
‣ difficulty swallowing
‣ denAnal hypersensiAvity
© 2020
Saliva functions and benefits
Saliva - The magic fluid
Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology. DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012© 2020
Digestion
‣ chewing
‣ bolus
‣ swallowing
‣ enzymes
‣ taste
© 2020
Protection
‣ diluAon
‣ lubricaAon
‣ cleansing
‣ increase pH
de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composiAon and funcAons: A comprehensive review. J Contemp Dent Pract 2008 March; (9)3:072-080.
Hara AT, Zero DT. The caries environment: saliva, pellicle, diet, and hard Assue ultrastructure. Dent Clin North Am. 2010 Jul;54(3):455-67.
Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology. DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012© 2020
Protection
‣ buffering-neutralizes
‣ remineralizaAon
‣ anA-microbial
‣ healing
de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composiAon and funcAons: A comprehensive review. J Contemp Dent Pract 2008 March; (9)3:072-080.
Hara AT, Zero DT. The caries environment: saliva, pellicle, diet, and hard Assue ultrastructure. Dent Clin North Am. 2010 Jul;54(3):455-67.
Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology. DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012
astoundingminds.blogspot.com/2012/04/boiling-point-of-human-saliva.html
© 2020
Additional functions
Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology. DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012
‣ speech
‣ nutriAon
‣ social interacAon
‣ kissing
‣ licking
‣ excreAon
© 2020
The kiss
www.lifedaily.com/12-most-surprising-facts-about-kissing/ Accessed 10/1/15.
‣ longest - 58 hours, 35 minutes and 58 sec
‣ lowers corAsol levels
‣ heart beats faster
‣ more oxygen reaches your brain
© 2020
Saliva - production, composition, flow
Sources
90% - whole saliva
‣paroAd - 30%
‣sub-mandibular- 60%
‣sub-lingual - 5%
‣10% - minor glands - 5%
found throughout the mouth
Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology. DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012© 2020
99% water
Healthy saliva - composition
also contains
!proteins
! enzymes
!mucins
!buffering compounds
Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology. DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012© 2020
Secretions serous and mucous
!paroAd - serous and enzymes
! submandibular - 90% serous, 10% mucous
! sublingual and minor - 80% daily mucous© 2020
Salivary protein functions
! antibacterial! antifungal! antiviral! buffering ! tasting
! tissue coating! wound healing! remineralization! digestion! lubrication
© 2020
Mucins - wetness and comfort proteins with carbohydrate chains
! lubricates
! controls viscosity / elasAcity
! affects sAckiness
! saliva contact with oral cavity
© 2020
Proline-rich proteins and arginine
! PRPs - 70% of all salivary proteins
! formaAon / funcAon acquired pellicle
! arginine - ammonia producAon
!buffering compounds Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology.
DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012© 2020
Types of flow
! spontaneous
minor salivary glands - mucins
! sAmulated
paro5d - serous
!unsAmulated (resAng)
sublingual and minor - serous and mucous© 2020
Stimulated saliva
80 - 90% daily salivary producAon
" anAcipatory tongue/lip movements
" chewing
" taste
" smell
de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva ComposiAon
And FuncAons: A Comprehensive Review. J Contemp Dent Pract 2008 March; (9)3:072-080.© 2020
Stimulated saliva
‣ quality improves - proteins
‣ increased bicarbonate
‣ neutralizes acids
‣ bicarbonate reserves are limited
‣ proteins - secondary path - neutraliza=on
de Almeida PDV, Grégio AMT, et al. Saliva ComposiAon And FuncAons: A Comprehensive Review. J Contemp Dent Pract 2008 March; (9)3:072-080.
García-Godoy F, Hicks MJ. Maintaining the integrity of the enamel surface: the role of dental biofilm, saliva and prevenAve agents in enamel demineralizaAon and remineralizaAon.
J Am Dent Assoc. 2008 May;139 Suppl:25S-34S.
© 2020
Saliva – Fast facts…….
! peak flow - late aAernoon
! during sleep - near zero flow
! acid substances salivary flow rates
! paroAd gland – 50% of sAmulated salivade Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composiAon and funcAons: A comprehensive review.
J Contemp Dent Pract 2008 March; (9)3:072-080.© 2020
Healthy salivary pH
‣ resAng - pH 6.8 - 7.2
‣ favors homeostasis
‣ supports remineralizaAon
‣ suppresses pathogens
Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010.
Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2020
Quality of life
© 2020
Tasting
Neuroscience made understandable Alexander van Aken Brighton and Sussex Medical School - 2014 © 2020
Tongue papillae
‣ 1 - 200 tastebuds per papillae
‣ taste pores house taste cells
‣ 50-150 taste receptor cells per taste bud
http://www.cbsnews.com/news/worlds-first-images-of-taste-buds-in-action/© 2020
Taste buds
‣ sensiAve to - sweet, bi0er, salt, or sour
‣ taste buds - taste pores
‣ chemicals in soluAon - sAmulate receptor cells
http://www.cbsnews.com/news/worlds-first-images-of-taste-buds-in-action/ © 2020
Tasting food
Nordén J, Grönberg AM, et al. NutriAon impact symptoms and body composiAon in paAents with COPD. Eur J Clin Nutr. 2015 Feb;69(2):256-61.
Ekstrom J, Khosravani N, et al. Saliva and its control of secreAons. Dysphagia,Medical Radiology. DiagnosAc Imaging. Ed. Ekberg O. Springer-Verlag Berlin Heidelberg 2012.© 2020
‣ saliva iniAates taste
‣ poor taste - anorexia
‣ adequate nutriAon
‣ supports muscle mass
‣ immune system
Taste disturbances
‣ ageusia - complete lack of taste
‣ hypogeusia - decrease taste sensiAvity
‣ dysgeusia - metallic/foul/rancid/salty
‣ phantoguesia - phantom taste
‣ cacogeusia - revolAng tastehttp://www.webmd.com/oral-health/tc/taste-changes-topic-overview © 2020
Compromises
‣ food sAcks to teeth
‣ raw food - hard to chew
‣ increase sAcky, processed foods
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2020
Compromises
‣ sip on sweet drinks
‣ require no chewing / preparaAon
‣ high carb nutriAonal supplements
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).
Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2020
Liquid intake challenges
Compromises
‣ high fluid intake
‣ olen sweet
‣ dilutes exisAng saliva
‣ frequent bathroom breaks
‣ disturbed sleep
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2020
Aging
© 2018
Medical and environmental conditions
Medical conditions
‣ Sjögren syndrome - primary
‣ Hashimoto’s disease - thyroid
‣ rheumatoid arthriAs
‣ secondary SS - other autoimmune disordersGuignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).
© 2020
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).
Medical conditions ‣ diabetes
‣ endocrine disorders
‣ Parkinson’s disease
‣ pregnancy - nursing
‣ chronic faAgue syndrome© 2020
Medical conditions
‣ hepaAAs C
‣ Alzheimers
‣ geneAc disorders
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).
‣ HIV / AIDS
‣ eaAng disorders
‣ laxaAve abuse
© 2020
Medical conditions - complication
‣ intesAnal failure
‣ COPD
‣ anxiety
‣ depression
‣ cancer therapy
‣ liver transplantGuignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).
© 2020
Pathology and sequela
‣ salivary gland disfuncAon
‣ removal salivary glands
‣ end of life / terminal illness
‣ menopause
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2020
Treatments
‣ hemodialysis
‣ radiaAon treatment
‣ hormone imbalance
‣ bariatric surgery
© 2020
Medications - OTC and Rx
‣ HBP
‣ anxiety
‣ nausea
‣ pain
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).
‣ depression
‣ appeAte control
‣ seasonal allergies
© 2020
Conditions - lead to dehydration
‣ fever
‣ vomiAng
‣ excessive sweaAng
‣ diarrhea
‣ blood loss
‣ burns © 2020
Respiratory
‣ sleep apnea
‣ mouth breathing
‣ asthma
‣ seasonal allergies
‣ facial anatomy
‣ dust / wind
‣ nasal congesAon
‣ coughing
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2020
© 2020
Oral appliances
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).
‣ dentures / parAal dentures
‣ bite guards
‣ orthodonAc aligners
‣ sports mouth guards
‣ whitening trays
© 2020
Lifestyle
© 2018
Lifestyle
‣ smoking / vaping
‣ recreaAonal drugs
‣ C-Pap machine
‣ prolonged speaking / singing
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2020
Lifestyle
‣ stress
‣ anxiety/fear
‣ caffeine
‣ alcohol
‣ heavy exercise
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2020
Climate
‣ air condiAoning
‣ central heat
‣ desert climates
‣ cold temperatures
‣ airplanes / hotel rooms
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2020
cdc.gov/VitalSigns/AdultSmoking/index.html#StateInfo - Behavioral Risk Factor Surveillance System, 2010 Accessed 7/25/15
Smoking prevalence by state
© 2020
Lifestyle - sodium intake
© 2020
Lifestyle - diet94% from food!
‣high sodium intake
‣processed foods
Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2020
Understand sodium intake levels
© 2020
Who has the highest risk?
© 2020
Gateway - the rest of the body
‣ oral disease is complex
‣ changing hormone levels
‣ medicaAons causing dry mouth
‣ geneAcs
‣ immune system
‣ lifestyle / environmental factors
‣ natural aging process© 2020
The Saliva Chronicles Muddy flooding and sinkholes
Anne N. Guignon,RDH, MPH, CSP
[email protected] 832-971-4540 Copyright 2020
Erosion vs caries
© 2020
Erosion is different from caries?© 2020
Hanning M and Hanning C. Nature Nanotechnology 5, 565–569 (2010)
Biofilm attachment
© 2020
Caries — infection that involves microbes
Hanning M and Hanning C. Nature Nanotechnology 5, 565–569 (2010) © 2020
What is erosion?
Erosion
‣ progressive loss of hard Assue
‣ chemical loss - not bacterial
‣ most important factor - hypersensi3vity
‣ erosive lesions – generally sensiAve
Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion—an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45 Suppl 1:2-12.
Ren, YF. Dental erosion: EAology, diagnosis and prevenAon. Acad of Dent Thera Stoma. April 2011.
Carvalho TS, Colon P, et al. . Consensus report of the European FederaAon of ConservaAve DenAstry: Erosive tooth wear diagnosis and management. Swiss Dent J. 2016;126(4):342-346.
© 2020
How does erosion happen?© 2020
Hanning M and Hanning C. Nature Nanotechnology 5, 565–569 (2010)
Acid erosion
© 2020
Erosion - surface softening
• citric acid pH 2.3
• 6 X 5 min/day
• 10 days
• stored in salt soluAon
Lussi A, Schlueter N, et al. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45 Suppl 1:2-12. © 2020
Erosion - a multifactorial condition
Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2020
Erosion vs. caries
‣ surface-solening lesion
‣ extrinsic / intrinsic acid
‣ add a0riAon / abrasion
Ren, YF. Dental erosion: EAology, diagnosis and prevenAon. Acad of Dent Thera Stoma. April 2011.
Zero DT, Lussi A. Erosion--chemical and biological factors of importance to the dental pracAAoner. Int Dent J. 2005;55(4 Suppl 1):285
Carvalho TS, Lussi A. SuscepAbility of enamel to iniAal erosion in relaAon to tooth type, tooth surface and enamel depth. Caries Res. 2015;49(2):109-15.
‣ remineralizaAon difficult
‣ prevalence - increases with age
© 2020
Caries - SinkholeErosion - Flooding
Communication tools
© 2020
www.wonderhowto.com/how-to-explore-atomic-structure-tooth-160130/© 2020
Intrinsic and extrinsic factors
Erosion – complicating medical conditions
GERD – gastric esophageal reflux
•7% adults - daily episodes
•36% monthly
•children also experience GERD
Anorexia
•47 % - binge/purge subcategory
•refuse to maintain normal weight
Bulimia
•typically normal weight
•self induced vomiAng aler eaAng
Aranha ACC, Eduardo CP, Cordás TA. EaAng Disorders Part I: Psychiatric Diagnosis and Dental ImplicaAons. J Contemp Dent Pract 2008 September; (9)6:073-081.
Photo - Courtesy of Richard Erlich, DDS - Ontario, Canada elmtreedental.com
© 2020
Eating disorders – behaviors and findings
• vomiAng - palatal surfaces - maxillary teeth
• eroded surfaces - smooth/glossy
• erosion – 2+ years of self-induced vomiAng
• acAve lesions - smooth/unstained
• inacAve lesions - stain over Ame
::
Aranha ACC, Eduardo CP, Cordás TA. EaAng Disorders Part I: Psychiatric Diagnosis and Dental ImplicaAons. J Contemp Dent Pract 2008 September; (9)6:073-081.
© 2020
Eating disorders – Common behaviors and findings
! erosion – 2+ years - self-induced vomiAng
! excessive - acidic beverages and fresh fruits
! anAdepressants - cause dry mouth
! binge/purge – high carbohydrate intake
! anorexia - olen poor oral hygiene
Aranha ACC, Eduardo CP, Cordás TA. EaAng Disorders Part I: Psychiatric Diagnosis and Dental ImplicaAons. J Contemp Dent Pract 2008 September; (9)6:073-081. © 2020
Early erosion…….one year later
Photos - Courtesy of Richard Erlich, DDS - Ontario, Canada elmtreedental.com© 2018
Erosion – factors
Regurgita=on
! reflux
! bulimia
! chemotherapy
! pregnancy
! alcoholism
! pepAc ulcers
! gastriAs
! drug side effects
Gandara BK and Trulove EL. Diagnosis and management of dental erosion. J Cont Dent Prac. 1999;1(1):1-17 © 2020
OTC supplements
medica=ons
! chewable vitamin C
! cough drops
! fizzy liquid medicaAons
! gummy bear supplements
Erosion – Extrinsic factors
!diet
drinks, fruits, candies, pickled foods
!environmental
occupaAonal (acid vapors from industrial electrolyAc processes / wine
tasAng)
recreaAonal (swimming pools)*
Gandara BK and Trulove EL. Diagnosis and management of dental erosion. J Cont Dent Prac. 1999;1(1):1-17
Erosion of Dental Enamel among CompeAAve Swimmers – Virginia h0p://www.cdc.gov/mmwr/preview/mmwrhtml/00000109.htm Pedrão AMN, Andrews Portes L, et al. Erosive tooth wear and dietary pa0erns: A clinical study. Oral Health Prev Dent. 2018;16(2):145-151.
Staufenbiel I, Adam K, et al. Influence of fruit consumpAon and fluoride applicaAon on the prevalence of caries and erosion in vegetarians--a controlled clinical trial. Eur J Clin Nutr. 2015 Oct;69(10):1156-60.
vegetarian / lacto - ovo
‣ more erosion than omnivores
‣ eat more fruit
‣ higher erosion risk
© 2020
Sensitivity and fungal infections
Dentinal hypersensitivity
two condi3ons are necessary
• exposed den5n via loss of enamel or periodontal Assues
• open den5n tubules - patent to the pulp – loss of smear layer
Bamise CT, Olusile AO, Oginni AO. An Analysis of the EAological and Predisposing Factors Related to DenAn HypersensiAvity. J Contemp Dent Pract 2008 July; (9)5:052-059.
© 2020
*Absi et al, J Clin Periodont 1987; Images. thejcdp.com, Sept 2006
Non-sensiAve
No of open tubules x 8 x
Diameter of tubules 0.43 0.83
Fluid Flow (Poisseuille’s law) y 16 y
Structural differences between sensitive and non-sensitive dentin*
Sensitive
© 2020
Candidiasis
• tongue
• commisures
• buccal mucosa
• palate
Jenkinson HF and Douglas LJ. InteracAons between Candida species and bacteria in mixed infecAons. www.ncbi.nlm.nih.gov/bookshelf/
br.fcgi?book=pmd&part=A2773#A Accessed 7/25/2009 © 2020
‣ taking or using?‣ then… what
are you doing? ‣ partner for clues
Health history - Questions
© 2020
Thank you!……..and best wishesfor a healthier career!
832-971-4540 © 2020