Saliva / Orthodontic Courses by Indian Dental Academy

SALIVA
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INTRODUCTION
Beginning in 1950s whole saliva was evaluated
(antimicrobial properties, role in microbial attachment,
mineralization, taste, lubrication)

In 1970s individual components were isolated and
biochemically characterized.

In mid-1980s investigators began to map functional
domains of the constituents.

Saliva has been defined as the fluid secreted by the
salivary glands that begins the digestion of foods.

Saliva, however, is hardly the simple body fluid, nor does
it have the limited function, implied in this definition.

The functions of saliva are best appreciated by
individuals having diminished salivary function, or
xerostomia (Mandel, 1987).

These individuals suffer from increased caries and
periodontal disease; their oral mucosa is constantly
irritated and sore; food is difficult to chew and swallow;
and taste acuity is impaired.

Saliva is thought to function in part by forming protective
tenacious films, or pellicles, on the available oral
surfaces.


The whole saliva that bathes the oral cavity is primarily
a mixture of secretions from the paired major (parotid,
submandibular, and sublingual) glands and the
numerous minor (labial, buccal, glossopalatine, palatine,
and lingual) glands.

While salivary glands are normally not found in the
gingival tissues, atopic salivary gland tissue has been
reported in gingiva (gingival salivary gland choristoma ;
Moskow and Baden, 1986).

Whole saliva also
contains bacteria (about
10
8
to 10
9
/ml); their
products, such as organic
acids and enzymes;
epithelial cells; food
debris; and components
from gingival cervicular
fluid.

Characteristics Of Saliva
Consistency :- slightly cloudy due to presence of
mucins and cells

Reaction :- usually slightly acidic (pH 6.02-7.05).On
standing or boiling, it loses co
2
and becomes alkaline.
This alkaline reaction causes precipitation of salivary
constituents, as tartar on teeth or calculus in salivary
duct. pH increases with flow rate

Specific gravity :- 1.002-1.012

Freezing point :- 0.07-0.34 degree Celsius
Anatomy and physiology
Salivary glands are composed of acini, ducts, and
stroma. Acini are composed of two cell types: mucous
cells, which secrete the viscous mucins, and serous
cells, which secrete a less viscous watery fluid
containing Ptyalin

The parotid glands posses exclusively serous cells; the
sublingual and minor glands contain predominantly
mucus-secreting cells; and the submandibular glands
are mixed.
Stimulation of salivary gland tissues results in the
release of components contained within the secretory
granules into the salivary ducts.

Acinar cells produce the majority of macromolecules and
water found in salivary secretions and are involved in
salt transport.

Cells that line the secretary ducts also contribute
components to the secretions and help regulate the
electrolyte content of saliva.


The secretion at this point is isotonic with respect to
electrolytes.

As the secretion travels distally, electrolytes are
readsorbed from the secretion by ductal cells, resulting
in a final secretion that is hypotonic with respect to
plasma (Martinez, 1987).
Firstly the sodium ions are actively reabsorbed from the
salivary ducts and potassium ions are actively secreted
but at a slower rate in exchange for the sodium ions.

Therefore sodium concentration of saliva becomes
greatly reduced whereas the potassium ion
concentration becomes increased.

The greater excess of sodium absorption over potassium
secretion creates negativity of about -70 mm in the
salivary ducts and this allows chloride ions to be
absorbed passively

Therefore the chloride ion concentration falls to a very
low level along with the decrease in sodium ion
concentration.

Second, bicarbonate ions are secreted by the ductal
epithelium into the lumen of the duct. This is probably an
active secretary process

The net results of these active transport processes is
that, under resting condition, the concentration of sodium
and chloride ions in the saliva are only about 1/7th to
1/10th of their concentration in plasma.

On the other hand, the concentration of potassium ions
is about seven times greater than the concentration in
plasma and concentration of bicarbonate ions is about 2-
3 times that of plasma
The secretion of saliva, or salivary flow, is primarily
influenced by unconditioned gustatory and masticatory
reflexes.

In addition, salivary flow is affected by secondary factors
such as the degree of body hydration, position of the
body, circadian rhythms (maximal flow occurring in the
afternoon, minimal flow occurring during sleep), psychic
and emotional factors, numerous diseases, hormonal
factors, and drugs (Dawes, 1987).
Stimulation Of Salivary Secretion

The secretomotor fibers of the salivary glands are
parasympathetic fibers that originate from a centre that is
known as the salivary nucleus.

The parasympathetic fibers of the parotid gland arise from the
inferior salivary nucleus and the fibers of sub mandibular and
sub lingual gland arise from the superior salivary nucleus.

The fibers of the parotid gland travels with the
glossopharyngeal nerve and that of the sub mandibular and
sub lingual gland travels with the facial nerve and then with
chorda tympani nerve.

The afferent limb which reaches the salivary nucleus arise from
the tongue or it may arise from various other areas

Control Of Salivary Secretion

Spontaneous secretion or resting secretion

Secretion after a stimulus
conditioned salivary reflex
unconditioned salivary reflex
Daily output of saliva ---- 1 to 1.5 L/day
(Mandel, 1988).

Unstimulated or resting saliva constitutes 10% to 20% of
the daily production.

Approximately 85% to 90% of stimulated saliva is
derived from the parotid and submandibular glands, 5%
from the sublingual glands, and 5% to 10% from the
minor glands.


During sleep, most of the secretion comes from the
minor glands, since the flow from the major glands is
negligible

In general, the concentration of proteins in saliva is
directly proportional to the flow rate.

In addition, there is wide variation in the concentration of
various components between individuals.
METHODS OF COLLECTING SALIVA
Stimulated whole saliva :- it can be collected after
asking the patient to chew on paraffin wax, rubber
bands, gum base and citric acid (2%).

Mixed unstimulated saliva:-

Draining or spitting method: The subject is asked to
collect saliva in the floor of the mouth and then spit into a
graduated or pre-weighted test tube.


Suction method : saliva is continuously aspirated from
the floor of the mouth into a suitable collection vessel.

Swab or absorbent method : A pre-weighted swab or
cotton roll, or a gauze sponge is used to collect saliva
and then reweighed after collection
Parotid saliva:-

Modified Carlson-Crittenden device: the device has
two chambers, an inner and outer chamber. The inner
chamber is placed over the orifice of the parotid duct and
the outer chamber is connected to a vacuum squeeze
bulb. The bulb is compressed and the inner chamber is
placed over the orifice. This chamber is attached to
tubing that carries saliva to the collection vessel
Submandibular/sublingual saliva

For combined Submandibular/sublingual saliva, custom
made collectors are fabricated. Those device contains a
central chamber for collection of submandibular saliva
and one or two side chambers for sublingual saliva

Fox et al described a simpler method for collecting
Submandibular/sublingual saliva. After blocking the
blockink the orifices of the parotid duct, the saliva is
collected from the floor of mouth with micropipette.

Minor glands:-

These can be collected by micropipette, absorbent filter
paper or strips from the inner surface of lips,palate, or
buccal mucosa and quantitated by weight differences or
using a periotron device
COMPOSITION
Each salivary gland produces a characteristic and
complex secretion consisting of electrolytes, proteins,
glycoproteins and lipids, each of which differs
significantly from plasma

In fact, an increase in the salivary concentrations of
constituents such as sodium, chloride, and serum
albumin may be diagnostic for salivary gland disorders
wherein the saliva-blood barrier is compromised (e.g.,
sialadenitis).
Water content :- 99.5%
Solids :- 0.5%
Inorganic content:- 0.2%
Organic content :- 0.3%
Gases :- 1ml oxygen/100ml
2.5ml nitrogen/100ml
50ml carbon dioxide/100ml
Cellular elements

Contents of GCF
Electrolytes
Calcium :

Content of calcium in saliva was determined by J onsgar
(1937).

The principle calcium phosphate salts include :
1. Dicalcium phosphate dihydrate
2. Octacalcium phosphate dihydrate
3. Tricalcium phosphate dihydrate
4. Hydroxyapatite phosphate dihydrate

Fluoride :

The fluoride content of saliva is less than that of serum
and directly correlated to dietary intake.

The fluoride concentration of dental plaque is however
greater than that of saliva.

The additional fluoride probably being derived from
enamel surface
Organic Constituents
Carbohydrates :

Glucose is present in very low concentration in saliva.

It becomes elevated in diabetes but still appears at about
1 % of blood concentration.

In addition to glucose, submandibular saliva also
contains hexose and fructose with small amount of
hexosamine and sialic acid.

The glucose concentration is generally 0.5 mg/100 ml of
saliva.
Lipids :

Saliva contains small quantity of diglycerides,
trigycerides, cholesterol and cholesterol esters and
phospholipids in addition to corticosteroids mainly
cortisone.

These lipids may play a role in bacterial adsorption to
apatite and plaque microbial aggregation.
Proteins :

The acinar cells are the principle source of protein
secretion.

Compared to that in blood, the concentration of protein in
saliva is extremely low.

With the increasing flow rate the quantity of salivary
protein is found to increase.

The serum protein in saliva may account to 20 %,
including IgM, IgG, IgA in addition to some albumin.
Acinar cells tend to produce groups or families of
molecules, whereas ductal cells produce single species

Since a family member may exhibit functions similar to,
or different from, other constituents within the same
family, each family may therefore have multiple
functions.
Acinar Cell Proteins

Mucins
Proline-rich proteins and glycoproteins
Histatins
Statherin
Cystatins
Alpha-amylases
Carbonic anhydrases
Salivary peroxidases

Ductal And Stromal Products
Lactoferrin
Lysozyme (muramidase)
Kallikrein
Fibronectin
Secretory IgA (sIgA)

Major salivary components
Mucin 1 (MG1)
sIgA
Mucin 2 (MG2)
Lactoferrin
Peroxidases
Amylases
Carbonic anhydrases
Proline-rich proteins
Lysozyme
Statherins
Histatins
1 10 100 1000 10000
Size (kDa)
Acinar cell families
Mucins :
These are high molecular weight glycoproteins that are
more than 40% carbohydrate.

The peptide backbone of mucins contains a high number
of carbohydrate side chains, which vary in size,
composition and charge (Tabak et al., 1982).

Two chemically distinct mucins have been identified in
human submadibular sublingual saliva and have been
designated mucin-glycoprotein 1 (MG1) and mucin-
glycoprotein 2 (MG2) (Levine et al., 1987).
MG1 has a molecular weight greater than 10
3
kilodaltons, whereas MG2 is considerably smaller (150
to 200 kilodaltons).

In general, the viscoelastic properties of mucins may aid
in the formation of the food bolus for efficient mastication
and swallowing.

However, the structural differences between the two
mucins indicate that they may participate in different
functions.
MG1 may function at hard and soft tissue interfaces to
provide a permeability barrier for protection against
environment insult and desiccation.

Commensurate with this proposed function, MG1 may
also act as a glycoprotein lubricant to minimize abrasion
between occluding tooth surfaces.

By complexing with antimicrobial factors in saliva. MG1
may also act as a carrier to localize these protective
molecules at tissue-environmental interfaces.
Several studies have shown that bacterial attachment to
the tooth surface is mediated by salivary mucins that
coat the tooth surface as part of the acquired enamel
pellicle.

In contrast, the coating of unattached bacteria by
salivary molecules such as mucins may inhibit their
attachment to oral surfaces and thus facilitate microbial
clearance from the oral cavity.

These interactions appear to be selective and can be
mediated, in part, by the mucins carbohydrate chains.
Proline-rich proteins and glycoproteins:

This superfamily of some 20 members comprises acidic
and basic phosphoproteins and basic glycoproteins that
are characterized by an amino acid content containing
75% to 80% proline, glutamine, and glycine (Bennick,
1987).

These molecules also exhibit genetic polymorphism
manifested as differences in the number and structure of
porline-rich proteins between individuals.
Proline-rich phosphoproteins can bind calcium, have a
high affinity for hydroxyapatite, and make up part of
acquired enamel pellicle.

In addition, acidic proline-rich phosphoproteins can
inhibit the precipitation of calcium-phophate salts and
thus protect the tooth surface from demineralization and
calculus formation.

A negative correlation was found between the
concentration of acidic proline-rich phosphoproteins in
whole saliva and dental plaque, suggesting that bacteria
in plaque may influence the half-life of these molecules
in vivo.
The proline-rich glycoproteins provide lubricating
properties on the tooth surface, especially when
complexed to serum albumin, a major constituent of
gingival cervicular fluid (Hatton et al., 1985; Levine et al.,
1987).

The peptide backbone of these molecules may mediate
attachment of Actinomyces viscous to the enamel
surface, and the carbohydrate portion of the
glycoproteins may function to mediate attachment and/or
clearance of streptococci (Bergey et al., 1986; Gibbons
and Hay, 1988).
Histatins:
The histatins are a family of small basic peptides
characterized by a high content of histidine.

At least seven members, one of which is
phosphorylated, have been identified; these vary in size
from 3 to 5 kilodaltons.

These molecules may also form part of the acquired
enamel pellicle and inhibit the precipitation of calcium
phosphate salts.
Interestingly, these proteins have recently been shown to
display bactericidal and fungicidal activities.

Histatins can inhibit the development of candid albicans
from the noninfective vegetative state to the infective
germinating form (Pollock et al., 1984; Oppenheim et al.,
1988).

Finally, these basic peptides help to maintain a relatively
neutral pH in the oral cavity.
Statherin:

Statherin is a tyrosine-rich phosphopeptide containing 43
amino acid residues.

This molecule binds calcium, has a high affinity for
hydroxyapatite,, and plays a role in demineralization by
inhibiting the precipitation of calcium-phosphate salts
(Schlesinger and Hay, 1977).
Cystatins :

These molecules constitute a diverse group of thiol
protease inhibitors that are found in several tissues and
body fluids, including saliva.

At least seven cystatins are present in human saliva;
they differ slightly in molecular weight (14 to 15
kilodaltons), charge, and degree of phosphorylation
( Hashimi et al., 1988).

Their ability to complex with mucins may serve to target
cystatins to various oral surfaces where they may play a
role in remineralization / demineralization processes and
suppress the growth and thiol protease activity of oral
pathogens.
Alpha-amylases :

This family, which represents the most abundant enzyme
found in saliva, can be divided into either glycosylated or
nonglycosylated groups (62 or 55 kilodaltons,
respectively).

Each group comprises several isoenzymes that differ on
the basis of their charge properties (Zakowski and
Bruns, 1985).

It has long been thought that the major role of this
calcium-requiring metalloenzyme was the preparation of
starches for digestion by hydrolyzing 1,4 linkages in
glucose-containing polysaccharides to end products of
glucose and maltose.


Its ability to inhibit the growth of Neisseria gonorrhoeae,
its presence in acquired enamel pellicle, and its capacity
to bind streptococcus sanguis suggest a role in oral
microbial colonization.
Carbonic anhydrases :

These zinc metalloenzymes constitute a family of at least
six distinct isoenzymes and are responsible for the
reversible hydration of carbon dioxide.

They probably play a role in bicarbonate formation and
thus contribute to the buffering capacity of saliva.
Salivary peroxidases:
The salivary peroxidase system consists of the
peroxidase enzyme (at least two species of 78 and 80
kilodaltons), the thiocyanate ion (SCN
-
), and hydrogen
peroxide.

The enzyme catalyzes the oxidation of SCN
-
), by H
2
O
2
,
generating highly reactive, oxidized forms of thiocyanate
such as OSCN
-
(Mansson Rahemtulla et al.,1988)
These products have a direct toxicity on a variety of
microorganisms, including Streptococcus mutans.

Salivary peroxidase also neutralizes the deleterious
effects of hydrogen peroxide produced by a number of
oral microorganisms and is effective in reducing acid
production by glucose-stimulated dental plaque, and can
inhibit glucose uptake by S. mutans.
Anti oxidant capacity of saliva
From a chemical point of view, oxidation is defined as loss of
electrons from substrate

An oxidant or an oxidizing agent is a substance that accepts
electrons and causes another reactant to
be oxidized (Prior & Cao 1999)

An FR is commonly defined as an atomic or molecular species
with 1 or more unpaired electrons in its structure and can be
positively or negatively charged or electrically neutral. E.g:-
radical derivatives of oxygen like O
2
-
,OH,OOH,RO,ROO,RCOO,RCOOO, etc.

Pro-oxidant is a synonym for ROS, indicating a toxic
substance that can cause oxidative damage to biological
targets. E.g:- radical derivatives of oxygen + non radical oxygen
derivatives like H
2
O
2
, HOCL, etc.

From a biomedical point of view, an antioxidant may be
defined (Halliwell 1997) as a substance that, when
present at low concentrations compared with those of an
oxidizable substrate, significantly prevents or delays a
pro-oxidant- initiated oxidation of the substrate.

Hence the reaction is as follows:-

ENZYME
OXIDANT + SUBSTRATE FREE RADICAL OR ROS

ROS can cause direct damage to proteins, DNA
carbohydrates and lipids. It can also modulate the
expression of a variety of immune and inflammatory
molecules
Classification of antioxidant
(a) Preventive antioxidants, that suppress the formation
of FR (e.g.,superoxide dismutase, catalase, glutathione
peroxidase and S-transferase,carotenoids,
transferrin,albumin, haptoglobin, caeruloplasmin).

(b) Radical-scavenging antioxidants: that scavenge
radicals to inhibit chain initiation and break chain
propagation (e.g., albumin, bilirubin,carotenoids,
ubiquinol, uric acid, vit. A, vit. C, vit. E).

(c) Repair and de novo enzymes that repair the
damage and reconstitute membranes (DNA repair
enzymes, lipase, protease, transferase).
Pro-oxidant and antioxidant feature of
saliva
Human whole saliva contains a complex peroxidase
system, the major components of which include different
forms of lactoperoxidase secreted by the salivary glands
and myeloperoxidases from PMN.

It should also be taken into account that the GCF is
constantly mixed with saliva and its flow increases with
gingival inflammation.

Increased GCF flow relates to increased PMN levels
which, in turn, contribute to overall peroxidase
enhancement by myeloperoxidase activity.

Myeloperoxidase is a chlorine-containing enzyme that catalyzes
the oxidation of chloride and reduction of H
2
O
2
to form
hypochlorous acid (HOCl), a reactive oxygen species that can
induce formation of low molecular weight chloramines with
bactericidal potential (Miyasaki 1991).

Myeloperoxidase may accumulate during sleep, when salivary
flow is very low, with consequent slow removal of PMN
products.

It has been suggested that higher myeloperoxidase levels are
present in subjects with severe gingival inflammation, probably
owing to the enhanced numbers of PMN which enter the oral
cavity (Smith & Yang 1984).

On the other hand, saliva is also rich in antioxidants,
mainly uric acid, with lesser contributions from albumin,
ascorbate and glutathione (Moore et al. 1994)

It has also been demonstrated that saliva has a role in
suppressing the lipid peroxidation of ingested foods
(Terao & Nagao 1991).

Uric acid is the major anti-oxidant in saliva accounting for
85% of the total anti oxidant capacity of saliva from both
healthy and periodontally compromised patients.


Other antioxidants include transferrin,lactoferrin and
caeruloplasmin

In fact, in healthy humans, these compounds enable iron
and copper (the two elements involved in the FR
production.
Very few published studies investigating the antioxidant
capacity of fluids local to the oral cavity.

Moore et al investigated the antioxidant capacity in
periodontally compromised patients and found no
significant change in the antioxidant capacity between
these pts. and healthy controls.

However the authors suggested that a local decrease in
the salivary antioxidants might be compensated for by an
increased GCF flow.
In another study Chappel (JCP 2004) studied the
systemic and local antioxidant capacity in periodontitis
and health.

He found that mean levels of serum and salivary total
antioxidant capacity (TAOC) were not significantly lower
in periodontitis compared to age and sex matched
healthy control.

However GCF and plasma TAOC were significantly
reduced.
Ductal And Stromal Products
Lactoferrin :-
This 76-kilodalton glycoprotein binds two atoms of iron
per molecule, with the simultaneous binding of two
molecules of bicarbonate.

Lactoferrins probable function in the oral cavity is
antimicrobial and may be due in part to its ability to
sequester iron.

In addition, lactoferrin may also posses a direct, iron
independent, bactericidal effect on various strains of
streptococci mediated by an anionic target site for
lactoferrin on the surface of these microorganisms
(Lassiter et al., 1987).
Lysozyme (muramidase)
This 14-kilodalton basic protein can lyse the cell walls of
gram-positive bacteria by hydrolyzing the b 1,4 glucosidic
linkages between N-acetylmuramic acid and N-
acetylglucosamine peptidogly can constituents.

Lysozyme may also kill bacteria found to be insensitive to its
muramidase activity by activating endogenous bacterial
enzyme(s) (Pollock et al., 1987).

Complexing of lysozyme to mucins provides a mechanism
whereby this enzyme may implement its function at various
tissue interfaces. In addition, lysozyme may also aggregate
certain bacteria, thus effecting their clearance from the oral
cavity.
Kallikrein
Kallikrein is a glycoprotein of 27 to 40 kilodaltons,
consisting of a single polypeptide chain.

It is a serine protease that can cleave C-terminal and N-
terminal peptides from proline-rich proteins and
cystatins, respectively.

This posttranslational processing of acinar cell products
takes place in the secretory duct prior to the molecules
entry into the oral cavity. The functional significance of
these events remains to be determined.

It also causes vasodilatation. On secretion it acts on the
globulins of interstitial fluid to produce bradykinin which
is a stron vasodilator www.indiandentalacademy.com
Fibronectin
Fibronectin, a high molecular weight glycoprotein (450
kilodaltons) is found at cell surfaces, in basement
membranes, in extracellular matrices, and in connective
tissues, as well as in a wide variety of body fluids,
including serum and saliva.

Fibronectin has been identified along the interface
between the tooth and the gingival connective tissue, as
well as along the junctional epithelium-cementum
interface.


Fibronectin on the epithelial cell surfaces may preclude
attachment of potential pathogens such as
Pseudomonas aeruginosa (Woods, 1987).

In addition, complexing of cell surface fibronectin with
salivary molecules (e.g., alpha-amylases) can inhibit the
epithelial colonization of gram-negative bacteria such as
Escherichia coli (Hasty and Simpson, 1987).
Secretory IgA (sIgA):
sIgA was first demonstrated by Tomasi and
Ziegelbaum in 1963

This glycoprotein is the predominant immunoglobulin
found in all mucosal secretions, including saliva.

Acinar cells of the parotid and submandibular gland
produce glycoprotein known as secretary component or
secretary piece.
This, together with IgA, forms specific structural entity,
the secretory IgA, which is active on the mucosal
surfaces.

IgA leaves the plasma cells as a dimeric molecule.

The two halves of the dimmer are held together by a
polypeptide known as the J piece.

The dimer then enters the epithelial cells of the striated
duct or possibly the acinar cells.

There it joins with these secretory component which
acts to stabilize molecule and aids in its release into the
lumen of the duct.

Over 90% of IgA in saliva is of secretory variety
It acts as a first line of defense

The ability of SIgA to bind to an antigen is a beneficial
process since local aggregation of microorganisms
inhibits their adherence to hard and soft tissue and thus
hinders subsurface microbial invasion in deeper host
tissue.

The presence of local antibody can play a role in viral
neutralization, attenuation of viral growth and replication
on the oral surfaces and neutralization and disposal of
toxins and food antigens.
Cells in the parotid gland are responsible for the majority
of the IgA found in saliva (Bienenstock et al. 1980, Nair
1986).

There are two subclasses of IgA: IgA1 and IgA2. IgA1
predominates in serum while IgA2 is found in higher
concentrations in external secretions (i.e., tears, saliva
and milk; Delacroix et al. 1982).
sIgA levels, which are undetectable in newborns,
increase progressively and reach adult values in
stimulated saliva by 24 years of age, and in
unstimulated saliva by 68 years of age (Burgio et al.
1980).

The reported concentration of salivary IgA varies with the
analytical method, and is influenced by the method of
saliva collection and rate of salivary flow
FUNCTIONS OF SALIVA
Lubrication and protection
Maintenance of tooth integrity
Helps water balance
Helps heat loss
Taste
Digestive function
Buffering action
Antibacterial activity
Tissue repair
Speech
Excretory functions
Role of saliva in pellicle and plaque formation,
calculus formation and development of caries

Lubrication and protection :

The glycoproteins and mucoids produced by the major and
minor salivary glands form a protective covering for the
mucous membrane .

This coating is barrier against irritants acting directly on the
membrane.

It is also a barrier against proteolytic enzymes and hydrolytic
enzymes produced in plaque, potential carcinogens and
dessication.

It also has mechanical cleansing action

Maintenance of tooth integrity :
It is rich in calcium and phosphate and hence ensures
that ion exchange on the tooth surface

It provides minerals for post eruptive maturation, thus
there is increased surface hardness, decreased
permeability, increased resistance to caries.

It provides ion such as calcium and phosphate in
sufficient amount to counteract tooth dissolution

It forms a film of glycoprotein on the teeth, that may act
as a diffusion barrier, thus preventing loss of tooth
mineral
Helps water balance
When moisture is reduced in the mouth, certain nerve
endings at the back of the tongue are stimulated and
sensation of thirst arises.

When body water is lost (sweating, diarrhoea, etc),
saliva is reduced and thirst is felt. The subject feels the
necessity to drink water and thus water balance is
restored

Loss of 8 % of body weight results in cessation of
salivary flow
Helps heat loss

This is mainly found in animals.

When they become hot or excited more saliva is
secreted causing greater loss of heat.
Taste
Taste is a chemical sensation.

Unless the substances be in solution, the taste buds are
not stimulated

Saliva acts as a solvent and hence essential for taste
Digestive function:-
Saliva contains two enzymes ptyalin and maltase.

Ptyalin or amylase acts on boiled starch breaking down
the big polysaccharide into maltose and triose.

Its optimum pH is about 7.0.

Maltase converts maltose into glucose.
Buffering action
Primarily due to carbonate and secondarily because of
phosphate and amphoteric proteins, saliva has
considerable buffer capacity. Metabolism of proteins
and peptides by bacteria releases ammonia and urea
which helps to increase the pH

This proteolytic function occurs in plaque, directed
against acidogenic microorganisms and occasionally
on the mucous membrane surface, where acids from
foods may occur.

Many bacteria require specific pH and hence saliva
prevents the pathogens from colonizing by denying the
optimal environmental condition, thus preventing
caries and periodontal diseases.

Antibacterial activity :
Secretory IgA is effective against a number of viruses
and bacteria.

Bacterial cells gets coated with secretory IgA, which
have reduced tendency to adhere to teeth and mucous
membrane surfaces, hence they may be clumped and be
swallowed.

Lysozymes hydrolysis the cell wall of some bacteria.
Lactoferrin has also been found to exhibit a bactericidal
effect on cariogenIc streptococci.

Lactoperoxidase- thiocyanate- hydrogen peroxide
system have potential of reducing plaque accumulation.

Salivary glycoproteins inhibit the adsorption of some
bacterial to the tooth surface and to the epithelial cells of
the oral mucosa.
Tissue repair :-

When saliva is mixed with blood then clotting time is
accelerated.

A variety of growth factors and other biologically active
peptides which are present in small quantities in saliva
help in tissue growth and differentiation, wound healing
and other beneficial effects

Speech :

It also helps in pronunciation of proper words

Saliva may also lead to :-

Pellicle and plaque deposition

Plaque mineralization and calculus formation

Dental caries

Excretory functions:-
Saliva excretes urea, heavy metals, thiocynates certain
drugs like iodine,etc.

Alkaloids, such as morphine antibiotics like penicillins,
streptomycin are also excreted in saliva.

The secretion of ethyl alcohol by salivary gland has
prompted the recommendation that such a test be used
in medico-legal cases.
SALIVA AS A

DIAGNOSTIC FLUID
Enzymes
Enzymes present in saliva can be produced by cells in
the salivary glands, oral microorganisms,
polymorphonuclear leucocytes (PMNs), epithelial cells,
and can be derived from GCF entering the oral cavity
(Chauncey 1961).

Studies have examined enzyme activity in saliva in
relation to periodontal status and in response to
periodontal treatment

In a study by Nakamura & Slots (1983), enzyme activity
in mixed whole saliva and parotid saliva was examined
in 10 individuals with a healthy periodontium,
10 adult periodontitis (AP) patients and 4 localized
juvenile periodontitis (LJP/JP) patients.

Mixed whole saliva from AP patients demonstrated the
highest enzyme activity, while mixed whole saliva from
the healthy controls demonstrated the lowest.

No significant differences in enzyme activity were found
between the AP and the LJP groups
Higher enzyme activities were found in the AP patients
compared to the healthy controls for alkaline
phosphatase, esterase,-glucuronidase, -glucosidase,
and other aminopeptidases.

Saliva from patients with LJP contained the highest
levels of butyrate esterase and cysteine aminopeptidase.
Their data suggested that
oral microorganisms contributed to the enzyme pool in
saliva.
Zambon et al. (1985) evaluated changes in the levels of
enzymes in whole mixed saliva of AP patients before
and after treatment which included scaling, root planing
(Sc/Rp) and tetracycline therapy.

Treatment resulted in reduced salivary levels of
caprylate esteraselipase, leucine, valine and cysteine
aminopeptidases, trypsin, galactosidase,
glucuronidase and -glucosidase.
Furthermore, a decrease in proportions of subgingival
black pigmented bacteroides and motile organisms were
noted after treatment, suggesting that these
microorganisms are one potential source of enzyme.

The authors proposed that the effectiveness of
periodontal treatment might be monitored by changes in
levels of specific bacterial enzymes in whole saliva

Gregory et al. (1992) reported that whole saliva from
LJP patients had significantly higher levels of
immunoglobulin degrading enzymes than age, gender
and race-matched healthy controls.

The authors proposed that production of such enzymes
by periodontal pathogens may provide these organisms
an ecological advantage.
Fibronectin is a glycoprotein that promotes selective
adhesion and colonization of certain bacterial species,
while inhibiting others.

Therefore, the production of fibronectin-degrading
enzymes by certain bacteria present in dental plaque
may promote their adhesion and colonization.

This was investigated by Gibbons et al. (1986) who
examined fibronectin-degrading enzymes in saliva from
periodontally healthy adults.
Whole unstimulated saliva collected immediately after
awakening (representing the absence of oral hygiene
measures for 6 to 8 h), and samples which were
collected after toothbrushing, were evaluated.

Higher proteolytic activity was observed in saliva
collected immediately after awakening, and the levels of
enzyme activity correlated with the state of cleanliness.

It was concluded that changes in oral cleanliness may
contribute to the rapid fluctuations in salivary proteases
and epithelial cell fibronectin.
Nieminen et al. (1993) measured enzyme activity in
whole saliva from 24 adults with advanced periodontitis
and 25 subjects with a healthy periodontium.

Patients received periodontal treatment and were
evaluated longitudinally for 20 months.

After treatment, a decrease was noted in protease
levels in saliva.

Using saliva samples collected prior to treatment and
after non-surgical therapy, the activity of salivary
elastase correlated significantly with the number of deep
pockets and the % of bleeding sites

The authors stated that the enzyme activity in whole
saliva appears to reflect the severity of periodontal
disease, and that salivary elastase has potential as an
adjunctive measure to assess periodontal inflammation
and the response to periodontal treatment.
General proteolytic activity in saliva, as well as
collagenase, elastase-like and trypsin-like activity has
been examined in patient with LJP, AP, and healthy
controls (Ingman et al. 1993).

Saliva of AP patients demonstrated higher levels of
protease, collagenase and elastase like activity in
comparison to the LJP patients and the healthy controls.

In the AP patients, Sc/Rp reduced the levels of protease
and elastase-like activities.

No significant response to treatment was detected in the
LJP patients.

The data suggest that elastase-like activity in saliva
would be a simple and accurate indicator of the
effectiveness of treatment.
Comparable results were reported by Uitto et al. (1990),
who collected saliva from subjects with a healthy or
diseased periodontium. Samples were assayed for
collagenase activity.

Vertebrate collagenase was detected in whole saliva
from all subjects, but not in parotid, sublingual or
submandibular saliva.

Collagenase activity was higher in the periodontitis
patients than the controls. Very little collagenase activity
was detected in whole saliva of edentulous subjects.
For the periodontitis patients, treatment resulted in a
significant reduction in collagenase activity.

In those patients the collagenase was mainly in the
active form, while in the healthy subjects the enzyme
was in the latent form.

The authors stated that while bacterial collagenase may
have been present in small quantities, most of the
collagenase in the saliva samples originated from PMNs
entering the oral cavity through the gingival sulcus.

Sorsa et al. (1990) supported these finding and reported
that interstitial collagenases isolated from extracts of
inflamed human gingiva, GCF and saliva were derived
from PMNs, and not fibroblasts.

Children with Downs Syndrome have an increased
prevalence and severity of periodontal disease (Orner
1976).

Activity of salivary collagenase in 9 affected children, 9
17 years of age, was higher than controls.

It was suggested that the presence of activated matrix
metalloproteinase activity derived from PMNs and/or
cytokine-activated fibroblasts, may in part be responsible
for the early periodontal tissue and alveolar bone
destruction seen in patients with Downs Syndrome
(Halinen et al. 1996).

Hayakawa et al. (1994) reported that the concentration
of tissue inhibitor of metalloproteinases 1 (TIMP-1) in
whole saliva of patients with periodontal disease was
lower, and total collagenase activity was higher, as
compared to healthy controls.

Most of the collagenase in whole saliva from the healthy
subjects consisted of procollagenase, while active
collagenase predominated in saliva from patients with
periodontal disease.

Increased TIMP-1 and decreased collagenase activity
were observed after initial therapy was provided to the
periodontitis patients.
Similarly, Ganbar et al. (1990) evaluated salivary levels
of collagenase and gelatinase in 23 patients with AP,
and 7 patients with LJP. Active collagenase levels were
found to be significantly higher in AP and LJP patients
compared with controls.

Following treatment, levels of active collagenase and
gelatinase were reduced.

No significant correlations were observed between the
clinical indexes (gingival index, plaque index and pocket
depth) and enzyme activity, but positive trends were
observed.

The authors concluded that measurement of active
collagenase and gelatinase in mouthrinse samples is
potentiallyuseful in the diagnosis and assessment of
Levels of salivary gelatinase in relation to periodontal
status were also evaluated by Makela et al. (1994).

They determined that the concentration of MMP-9 (92
kDa gelatinase) was significantly higher in whole saliva
of periodontitis patients compared with healthy subjects,
and that conventional periodontal treatment (Sc/Rp and
surgery if needed) reduced the levels of these enzymes.
Ingman et al. (1994) studied the presence and
molecular forms of gelatinase in saliva and GCF
collected from AP, LJP and patients with type II diabetes
melitus and periodontitis.

The gelatinase isolated from saliva and GCF was similar
to gelatinase isolated from PMNs and fibroblasts.

It was suggested that multiple forms of gelatinase
present in saliva may be involved in tissue destruction
Several studies have evaluated the presence of host-
derived non-immune antimicrobial factors in saliva.

The concentration of lysozyme in mixed saliva was
examined in 28 patients with severe periodontitis (6-mm
probing depths and generalized bone loss) and 28
healthy controls.

Patients with periodontitis demonstrated decreased
lysozyme concentration compared to controls
(Markkanen et al. 1986).

But the significance was not maintained if secretion rates
were analyzed
In contrast, Soumalainen et al. (1996) evaluated
myeloperoxidase (MPO), lysozyme an lactoferrin activity
in relationship to periodontal disease.

7 patients with LJP and 7 periodontally healthy controls
were studied.

The concentrations of lysozyme, lactoferrin and MPO
were significantly elevated in peripheral blood PMNs,
and in GCF from the LJP patients.
Following periodontal therapy, these values declined and
approached those observed in healthy controls.

In a study by J alil et al. (1993), resting and stimulated
whole saliva samples were collected from 94 children
(aged 1214 years), and analyzed for concentrations of
thiocyanate, lyzozyme and lactoferrin in relation to
plaque accumulation and gingivitis.

An inverse relationship was observed between the
salivary thiocyanate concentration in both resting and
stimulated saliva and the amount of plaque and gingival
inflammation.

The lactoferin concentration in stimulated saliva was
directly related to the amount of plaque and severity of
gingivitis.

Lysozyme concentration in stimulated saliva was
directly related to the amount of plaque.
In an experimental gingivitis study in 8 patients, Smith et
al. (1984) demonstrated an increase in peroxidase
activity with the onset of inflammation, which declined
after normal oral hygiene measures were resumed.

Similarly, salivary peroxidase activity in whole saliva was
also measured in a group of 10 patients with insulin
dependent (type I) diabetes mellitus (IDDM) with gingival
inflammation, and in 10 healthy subjects (Guven et al.
1996).

Salivary peroxidase activity was higher in the diabetes
patients, and the authors suggested that salivary
peroxidase activity might serve as a marker for gingival
inflammation in IDDM patients.

In addition, increased MPO activity was found in saliva of
patients with rapidly progressive periodontitis (RPP) and
AP patients as compared to controls (Over et al. 1993).

The highest MPO activity was found in the RPP group,
suggesting a relationship between MPO activity and the
severity of periodontal breakdown.

The increased MPO activity was attributed to increased
infiltration and degranulation of PMNs.

In contrast, the concentration of salivary peroxidase was
significantly reduced in both whole and parotid saliva
from 28 JP patients in comparison with age and gender-
matched controls (Saxen et al. 1990).

Furthermore, leukocyte-derived MPO was present in
significantly lower amounts in whole saliva from the JP
patients.

Based on these findings it was concluded that reduced
peroxidase mediated host defense mechanisms could be
characteristic of JP.
Levels of the enzyme kallikrein have been studied in
saliva.

This enzyme hydrolyzes kininogen to release vasoactive
kinin peptides such as bradykinin (Fuji-moto et al. 1973).

These peptides are important mediators of inflammation

Kininogen levels in saliva from patients with periodontal
disease were higher than what was observed in saliva
from periodontally healthy patients.


In another study, an increase in salivary kallikrein and a
decrease in salivary kininase activity were found in
association with increased severity of periodontal
disease (Picarelli et al. 1986).
Immunoglobulins

Guven et al. (1982) reported that in comparison to
healthy controls, higher levels of IgA were present in
whole saliva collected from patients with gingivitis and
periodontitis.

There was a positive correlation between the severity of
inflammation and IgA concentration

Sandholm et al. (1984) evaluated salivary IgA, IgG, and
IgM in whole saliva from 21 patients with JP, 27 healthy
siblings and 17 age-matched healthy controls.

Salivary IgA, IgG, and IgM levels were higher in the JP
patients as compared with the healthy controls

In contrast, Bokor (1997) reported that the concentration
of IgA in mixed unstimulated saliva was lower in subjects
with more gingival inflammation.
Changes in the concentration of immunoglobulins in
saliva following treatment were examined by Reiff
(1984).

The salivary (and serum) levels of IgG and IgA were
determined in healthy adult patients, and patients with
periodontal disease before and following initial
periodontal therapy.

A decrease in salivary levels of both IgA and IgG
was observed after treatment.

In a study of whole saliva collected from 12 patients with
periodontal disease, the IgG concentration in saliva was
found to be increased and IgA concentration decreased
before periodontal therapy as compared to post-
treatment levels (Basu et al. 1976).

Salivary levels of IgG and IgA were found to be higher
in a group of 50 NIDDM patients with periodontitis, as
compared with 50 non-diabetic periodontitis patients,
and 50 age and gender matched healthy controls.

The authors proposed that the altered immune
response observed in patients with diabetes may be due
to a greater antigenic challenge in the diabetic patients
(Anil et al. 1995).
Summary
While sIgA is the predominant immunoglobulin in saliva
and is secreted actively, IgG in saliva is primarily derived
from GCF and analysis of this isotype holds promise as
an indicator of periodontal disease.

Contradictory results were found, however, when levels
of salivary immunoglobulins were studied in relation to
periodontal status and the response to treatment.
Some studies reported an increase in levels of
immunoglobulins with more pronounced periodontal
disease (Guven & De Visscher 1982, Sandholm &
Gronblad 1984, Sandholm et al. 1987)

while other studies demonstrated decreased levels
(Bokor 1997, Schenck et al. 1993).

For IgA, many studies did not differentiate between sIgA
and serum derived IgA.

This may explain the contradictory results. Furthermore,
the method of collection can affect the results (Aufricht
et al. 1992).
Specific immunoglobulins in saliva

Specific immunoglobulins in saliva directed towards
periodontal pathogens have also been examined for the
diagnostic potential.

Mansheim et al. (1980) evaluated salivary IgA levels to
Porphyromonas gingivalis in 8 patients with RPP and 3
patients with JP, and found that antibody levels in saliva
samples from patients were not significantly different
from those of age matched controls.
Eggert et al. (1987) reported that saliva from treated
periodontitis patients had higher IgA and IgG levels than
did saliva from control subjects.

These higher antibody levels were observed for
periodontal pathogens (P. gingivalis and Treponema
denticola), but also for the normal inhabitant of the oral
cavity Streptococus
Sandholm et al. (1987) measured specific salivary
antibody to Actinobacillus actinomycetemcomitans Y4 in-
patients with JP and AP and in healthy controls.

Compared to the concentration observed in subjects with
a healthy periodontium, a significantly increased
concentration of salivary IgG was found in 34% of the
patients with moderate AP, and in 57% of the patients
with severe AP.

The level of salivary IgG antibody to A.
actinomycetemcomitans was significantly elevated in
55% of the patients with untreated JP and in 28% of the
treated patients
In a study by Schenk et al. (1993), salivary IgA levels
against oral bacteria were measured in an experimental
gingivitis protocol.

As compared to patients with a high bleeding score,
patients with a low mean number of bleeding gingival
units demonstrated significantly higher levels of salivary
IgA antibody reactive with Streptococcus mutans, A.
actinomycetemcomitans, and Eubacterium saburreum.
The authors stated that high levels of salivary IgA
directed against bacteria in dental plaque might protect
against the development of gingivitis.

Similar trends were found by Tynelius-Barthall & Ellen
(1985) who measured changes in salivary antibodies to
Actinomyces viscosus and Actinomyces naeslundii in 6
patients with gingivitis prior to and after treatment.
Nieminen et al. (1993) reported that the concentration of
specific IgG and IgA antibodies to A.
actinomycetemcomitans in saliva of patients with
advanced periodontitis correlated significantly with
corresponding antibody titers in the serum of those
patients.

It was concluded that for severe AP patients, saliva
samples could be used diagnostically to assess the
serum antibody response to A.actinomycetemcomitans.
Proteins
Fibronectin is a glycoprotein which mediates adhesion
between cells and is also involved in chemotaxis,
migration, inflammation, and wound healing and tissue
repair.

In a study by Lamberts et al. (1989), salivary
fibronectin levels did not differ significantly between
individuals with or without periodontal disease .

Fibronectin concentration in stimulated whole saliva,
unstimulated whole saliva and GCF was not affected by
treatment in a group of 10 subjects with gingivitis
(Tynelius-Bratthall1988).

Thus, fibronectin levels in saliva do not differentiate
between periodontal health and disease.

Blankenvoorde et al. (1997) analyzed cystatin activity
in GCF and saliva of 9 periodontitis patients.

The mean cystatin concentration was lower in GCF than
in saliva.

While cystatin C, S and SN were present in saliva, they
could not be detected in any of the GCF samples, where
cystatin A was present.

It was concluded that GCF is not a major contributor of
cystatin C, S, or SN to saliva
Henskens et al. (1996) evaluated the change in
concentration and activity of salivary cystatins in whole
and parotid saliva from 20 periodontitis patients
undergoing treatment.

After periodontal treatment, total cystatin and cystatin C
concentration decreased to control levels.

The changes occurred in whole saliva but not in parotid
saliva.

These results suggest that salivary glands other than the
parotid gland are responsible for cystatin activity in
saliva.
Henskens et al. (1996) demonstrated that levels of total
protein and cystatin activity, as well as the levels of
glandular-derived amylase and cystatin C, were
significantly higher in whole and parotid saliva of
subjects with periodontitis versus healthy controls.

The authors concluded that the salivary glands may
respond to periodontitis by enhanced synthesis of some
acinar proteins
In contrast, no significant differences in the levels and
activity of salivary comparing periodontally healthy and
diseased individuals (Aguirre et al. 1992).

These findings suggest that salivary levels of cystatins
may not provide a reliable measure of periodontal
disease status.
Levels of platelet activating factor (PAF), a potent
phospholipid mediator of inflammation, were studied in
whole saliva collected from 69 subjects (Garito et al.
1995).

A significant positive correlation was observed between
the level of PAF in saliva and measures of periodontal
inflammation, i.e., the % of sites with probing depths
greater than 4 mm, the number of bleeding sites, and the
number of histologically identified PMNs in saliva.
Rasch et al. (1995) conducted a longitudinal evaluation
of the effect of periodontal therapy (oral hygiene
instruction, prophylaxis and Sc/ Rp) on salivary PAF
levels in 15 chronic AP patients.

A reduction in pre-treatment levels of salivary PAF was
observed in response to supra gingival plaque control.
These levels declined further following Sc/Rp.

The authors stated that PAF might participate in
inflammatory events during periodontal tissue injury and
disease.
Epidermal growth factor (EGF) is involved in oral
wound healing and functions with hormone-like
properties to stimulate epithelial cells.

In humans, the parotid gland is the major source of EGF
(Thesleff et al. 1988).

Oxford et al. (1998) found a transient increase in
salivary EGF levels in response to periodontal surgery

In a study by Hormia et al. (1993), higher EGF
secretion rates in unstimulated and stimulated saliva
were observed in 17 JP patients as compared with
healthy age and gender matched controls.
Vascular endothelial growth factor (VEGF), also
known as vascular permeability factor or vasculotropin,
is a multifunctional angiogenic cytokine important in
inflammation and wound healing.

Higher levels of VEGF were detected in whole saliva
from periodontitis patients, in comparison to whole saliva
from healthy controls. Taichman et al. 1998

However, VEGF was present in all saliva samples
(Booth et al. 1998).

Several studies have examined the levels of free amino
acids in saliva in relation to periodontal status

It appears that in some patients, elevated levels of
certain amino acids, especially proline, may be detected
Syrjanen et al. 1984.

These amino acids probably appear in whole saliva as a
result of bacterial metabolism or degradation of salivary
proteins rich in proline.
In another study by the same investigators (Syrjanen et
al. 1990) no differences in amino acid concentrations in
saliva were found between patients with progressive
periodontitis and controls.

The authors concluded that levels of amino acids in oral
fluids (including GCF) has no diagnostic significance for
Epithelial keratins
To study epithelial cell function in periodontal disease
and periodontal diagnosis, specific keratin antigens in
saliva may be evaluated.

It has been suggested that phenotypic markers for
junctional and oral sulcular epithelia might eventually be
used as indicators of periodontal disease.

However there are no studies that demonstrate an
association between number or type of epithelial cells or
specific types of keratins in saliva and progression of
periodontitis.


GCF keratin concentration may serve as a marker of
gingival damage.

Considering the various types of immunologically-
identified keratins, further studies may be warranted.
Inflammatory cells
The majority of salivary leukocytes enter the oral cavity
via the gingival crevice (Schiott & Loe 1970).

Studies in the late 1960s and the early 1970s
examined the presence of leukocytes (orogranulocytes)
in saliva.

Klinkhammer et al. (1968) standardized collection and
counting of leukocytes in saliva and developed the
orogranulocytic migratory rate (OMR).

The OMR was found to be correlated with gingival index
(Klinkhammer & Zimmerman 1969).

In an experimental gingivitis model, the number of
granulocytes in saliva increased before the appearance
of clinical gingivitis (Friedman & Klinkhammer 1971,
Skougaard et al. 1969).

In a study by Raeste et al. (1978), the OMR was
determined with sequentional mouthrinse sampling in
periodontitis patients and controls.

The results indicated that the OMR reflects the
presence of oral inflammation, and the authors
suggested that this measure can be used as a laboratory
test
However conflicting results were reported by Cox et al.
(1974).

In that study, no significant correlation was found
between the number of oral leukocytes and the degree
of gingival inflammation.
Salivary ions
Calcium(Ca)is the ion that has been most Intensely
studied as a potential marker for periodontal disease in
saliva.

A high concentration of salivary Ca was correlated with
good dental health in young adults, but no relationship
was detected with periodontal bone loss as measured
from dental radiographs (Sewon & Makela 1990).
In another study (Sewon et al. 1990), salivary Ca, and
the saliva Ca to phosphate ratio were higher in
periodontitis affected subjects

No differences between groups were found for flow rate
and buffering capacity of saliva.

Another study from the same investigators examined
differences in salivary calcium levels in a group of 20
periodontitis patients in comparison to a group of 15
periodontally healthy subjects (Sewon et al. 1995).

A higher concentration of Ca was detected in whole
stimulated saliva from the periodontitis patients.

The authors concluded that an elevated Ca
concentration in saliva was characteristic of patients with
periodontitis.

Considering the distribution of Ca, this ion appear to hold
only limited promise as a marker for periodontal disease.
Serum markers in saliva with
potential importance for periodontal
disease: cortisol
Recent studies have suggested that emotional stress is
a risk factor for periodontitis (Breivik et al. 1996, Genco
1996, Linden et al. 1996, Axtelius et al. 1998).

One mechanism proposed to account for the
relationship is that elevated serum cortisol levels
associated with emotional stress exert a strong
inhibitory effect on the inflammatory process and
immune response (Chrousos & Gold 1992,
J ohnson et al. 1992, Fantuzzi & Ghezzi 1993
Recently, salivary cortisol levels were used to evaluate
the role of emotional stress in periodontal disease.

Higher salivary cortisol levels were detected in
individuals exhibiting severe periodontitis, a high level of
financial strain, and high emotion-focused coping, as
compared to individuals with little or no periodontal
disease, low financial strain, and low levels of emotion-
focused coping (Genco et al. 1998).
While it appears that emotional stress, as reflected by
salivary cortisol levels, is a risk factor for periodontal
disease, attempts to diagnose periodontal disease
severity or activity based on salivary cortisol levels are
premature.

It can be argued that in addition to changes in the host
response, stress also leads to behavioral changes (i.e.,
smoking, poor oral hygiene and poor compliance) which
could also have a significant effect on the periodontium

Nitric oxide
There is evidence that NOS-II production by resident
inflammatory cells is increased in periodontitis (Kendall
HK)

Increase in NOS-II production causes increases in
production of nitric oxide.

In a study carried out by Dr.Supriya Koshti nitric oxide
increases in patients with periodontitis with stress.

NO can inhibit collagen synthesis inducing MMP activity
In contrast Aleksic et al showed that NO in saliva of
patients affected with periodontitis was lower than
healthy controls.

This was in agreement with Kankanian 1996 who
showed that PMNs isolated from periodontal pockets
were found to have a suppressive effect in the
production of NO than PMNs from venous blood.
Bacteria
It has been suggested that microorganisms in dental
plaque can survive in saliva, and can utilize salivary
components as a substrate.

It was shown that saliva could serve as a growth
medium for oral Streptococus species and A. viscous
(De J ong et al. 1984).

Bowden (1997) suggested that the number of bacterial
cells for a given species in unstimulated saliva may
indicate whether that microorganism is actively growing
in plaque.
In a study by De J ong et al. (1986), micro-organisms
from supragingival plaque were grown on saliva agar.
When supragingival plaque was plated on saliva and
blood agar plates, the composition of the microflora
isolated from the plates were similar.

The authors concluded that the supragingival microflora
could utilize saliva as a complete nutrient source.
Asikainen et al. (1991) compared the recovery of A.
actinomycetemcomitans from subgingival sites, the
dorsum of the tongue and saliva.

When A. actinomycetemcomitans was recovered from
subgingival sites it was also found in 69.9% and 35.9%
of the samples of stimulated and unstimulated saliva,
respectively.

Detection of A. actinomycetemcomitans from saliva of
subjects with healthy or diseased periodontium was
equally effective

The authors stated that the recovery of this
microorganism from stimulated saliva may provide a
non-invasive, inexpensive and simple sampling method
for detection of this bacterial species

Recently, Umeda et al. (1998) examined the presence
of periodontopathic bacteria in whole saliva in relation to
occurrence of the microorganisms in subgingival plaque.

Using polymerase chain reaction, a fair agreement was
found between the presence of P. gingivalis, Prevotella
intermedia and T. denticola in whole saliva and in
periodontal pocket samples.

These 3 micro-organisms, in addition to Prevotella
nigrescens, were detected more often in saliva than in
the subgingival samples.
The effect of plaque accumulation on the salivary counts
of some dental plaque microorganisms was examined in
20 subjects who refrained from oral hygiene for 7 days
(Schaeken et al. 1987).

The large increase in the number of bacteria on the teeth
was reflected by an increase in salivary counts of
Actinomyces species.

A highly significant correlation was found between S.
mutans level in dental plaque and the salivary level of
this microorganism
A study of 60 children aged 59 years, isolation,
frequency and numbers of Mycoplasma species in saliva
were consistently related to gingivitis scores, which
supports an association of Mycoplasmas and gingivitis in
children (Holt et al. 1996).

Salivary levels of periodontal pathogens were found to
vary with periodontal status and as a result of treatment
Salivary levels of A.a, P. gingivalis, P. intermedia,
Campylobacter rectus, and Peptostreptococus micros
were determined by bacterial culture and related to
clinical periodontal status in 40 subjects with varying
degrees of periodontitis (Von Troil-Linden et al. 1995).

The salivary levels of the periodontal pathogens
reflected the periodontal status of the patient.
Furthermore, in 10 patients with advanced periodontitis
that received mechanical debridment and adjunctive
systemic metronidazole, periodontal treatment
eradicated or significantly reduced the levels of
periodontal pathogens in saliva.

No data were provided on the relationship between the
salivary bacterial count and the subgingival levels of
bacteria.
Similarly, in a study of 15 patients with moderate to
severe periodontitis, a decrease in the number of
patients harbouring A. actinomycetemcomitans and
P. gingivalis in saliva was noted after Sc/Rp and surgery
(Danser et al. 1996).

An oral microbial rinse test (Oratest) was described by
Rosenberg et al. (1989).

In this study Oratest was found to be a simple method
for estimating oral microbial levels. In a companion study
(Tal & Rosenberg 1990),

Oratest results were correlated with plaque index and
gingival index scores, and the authors stated that this
test provides a reliable estimate of gingival inflammation.
Volatiles
Volatile sulphur compounds, primarily hydrogen sulfide
and methylmercaptan, are associated with oral malodor
(Rosenberg et al)

Salivary volatiles have been suggested as possible
diagnostic markers and contributory factors in

For example, pyridine and picolines were found only in
subjects with moderate to severe peroidontitis (Kostelc
et al. 1980, Kostelc et al. 1981).
Furthermore, saliva seems to be a useful medium to
evaluate oral malodor.

A significant association between the BANA scores from
saliva and oral malodor was found (Kozlovsky et al.
1994).

However, no specific association between levels of
volatiles and periodontal status has been reported.

CLINICAL SIGNIFICANCE

Downs syndrome :

Greater collagenase activity that are derived from PMNs or
cytokine-activated fibroblasts are in part responsible for
the early periodontal tissue and alveolar destruction
-- Halinen et al
Papillon-Lefevre syndrome:

Salivary secretion, both stimulated and unstimulated is
reduced by 50% in patients with Papillon-Leferve
syndrome.

There is decrease in the amount of peroxidase activity in
saliva of patients suffering from Papillon-Leferve
syndrome
Diabetes mellitus :

There is increase in the amount of MMP-8 MMP-9 in
saliva of patients with type II diabetes and these are
related to advanced periodontitis seen in these patients
-- Colin et al

There is increase in the glucose level which is taken up by
plaque bacteria, and hence promote plaque formation.

There increase in the amount of myeloperoxidase activity in
saliva of patients with type I diabetes mellitus
HIV infection:

Increased activity of interstitial collagenase in saliva of
patients that are HIV+ve.

Also there is increase in the amount of fibroblast-type
matrix or MMP-1, stromelysin-1 (MMP-3) and neutrophil
collagenases (MMP-8)

There is also increased amount of myeloperoxidase activity
--Mellanen et al
Smoking:
There is decrease in the amount of proteolytic enzymes
and MMP-8 levels in saliva of patients who smoke.

There is also decrease in the amount of elastase level in
saliva of patients who smoke.

Hence it was suggested that care must be taken while
interpreting results suggesting that the levels of elastase,
proteolytic enzymes and MMP-8 might be diagnostic
markers for periodontal disease activity.


Also there is decrease in the amount of cystatins in patients
who smoke and decrease output of cystatin C during
inflammation.
Agranulocytosis:

There is increased salivation in patients suffering from
agranulocytosis

Oral contraceptives:
There is decrease in the concentration of proteins, sialic
acid, hydrogen ions and total electrolytes.
Increased salivary flow --- Ericson et al
Decreased salivary flow -- El-Ashiry et al
Radiotherapy:

If the dose is delivered to the salivary glands then there
might be xerostomia.

Parotid gland is most radiosensitive.

Saliva may become extremely viscous or nonexistent
depending on the dose.
Drugs:

Increase in salivary flow :

Acetylcholine
Methacholine
Carbachol
Bethanechol
Muscarine
Pilocarpine
Arecoline
Decrease in salivary flow:
Antidepressants
Antihistaminics
Antihypertensives
Oxyphenonium
Clidinium
Atropine
Isopropamide
Propantheline

Xerostomia
Decrease in the flow of saliva or complete absence of
saliva is termed as xerostomia.

It may result from a variety of factors like sialolithiasis,
sarcoidosis, Sjogrens syndrome, Mikulicz;s disease,
irradiation, surgical removal of salivary gland, pregnancy
and old age.

Xerostomia results in increased caries and periodontal
disease; oral mucosa is constantly irritated and sore;
food is difficult to chew and swallow; and taste acuity is
impaired; speech is altered

Saliva substitute:

They are intended to match the chemical and physical traits of
saliva.

They are used to relieve symptoms of dry mouth.

They usually contain salt ions, flavoring agent, paraben
(preservative), cellulose derivative or animal musins and
fluoride.

ADA approval has been granted to products like saliva
substitute and salivart

They are available as spray bottle, rinse, or oral swab sticks

In addition, products such as dry mouth toothpaste and
moisturizing gels are also available for treatment of dry
mouth.
References
Clinical periodontology-------- Caranza
Text book of physiology ------- Chaudhary
Human physiology ------- Chatterjee
Oral histology -------- Tencate
Contemporary periodontics--- Genco
Outline of periodontics --Eley and Manson
Oral diseases------- 2002;8:117-129
PNAC1986;83:6103-6106
Periodontology2000,34,2004:57-83
JCP 2002;29:189-194
JCP2004;31:515-521
Essentials of medical pharmacology ---- Tripathi


JCP 1996;23:1068-1072
JCP 2001;28:979-984

JCP 2002;29:189-194
JCP2004;31:515-521
Essentials of medical pharmacology ---- Tripathi
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