PRINT POST NO. 100003758 THE COMPLETE MAGAZINE FOR THE DENTAL TEAM VOL24NO.1 JANUARY/FEBRUARY 2014 tepesmiles.com.au FIND A PHARMACY STOCKISTclinical | EXCELLENCE Applied aspects of salivary biology in clinical dental practice By Laurence J. Walsh aliva enters the mouth from major and minor gland ducts distributed across several locations. The sceretions from different glands are not that well-mixed, meaning that the properties of saliva vary considerably according to the region of the mouth being considered. Saliva forms a thin film which moves constantly, but the speed of this movement varies greatly between different sites, being slowest around labial aspects of maxillary incisor teeth. This variation explains the predilection of these sites for erosion and cervical smooth-surface caries.!* Inthe summer months in what promises to be a hotter summer thaa usual, itis timely to ook again at how prob- ems with salivary defence can develop - even in those free of ‘medical conditions und xerostomia-inducing medicines (Table 1), Body fluid balance has a major impact on resting flow. Antidiuretic hormone is released from the pituitary gland when the body moves into negative fluid balance, typically because ‘the individual has not ingested enough water, or has come under the systemic influence of alcohol or caffeine. This potent Ihormone, that increases water reabsorption in the distal tubule inthe kidney, has the same action on salivary gland ducts, causing water saving, The lower flow tate means less bicarbo: pate ion and this lowers pH and lowers buifer capacity. Nega- tive fluid balance and subclinical dehydration are among the ‘most common reasons why patients may have decreased resting, salivary flow, but normal stimulated flow. They typically are not thirsty, because thirst is somewhat surprisingly not a good Indicator of body Mud balance. Debunking misperceptions [Negative fluid balance fom subclinical dehydration can occur ‘when fluid intake does not compensate fr ud loss, causing the ‘release of ant-diuretic hormone and a consequential reduction in resting salivary flow rate, pH and buffer capacity. Ths explains the need to avoid diuretic drinks and to maintain suficient water ‘intake, as the elimate becomes Warmer. 24 auxiliary Patients who have a new denture, retainer, oclusal split or fixed orthodontic appliance inserted will generally experience a transient increase in resting salivary flow. This effect docs not, however, fully compensate for the inerease in cares risk from ‘microbial changes which accompany such interventions. Patients may have defective testing salivary output without having symptoms of oral dryness. Under such condition, the Tower pH ofthe mouth promotes a higher risk of both dental caries and dental erosion. Clinicians shouldbe alert tothe prob tems pse by an ii or environment nd consider esting ‘Table 1. Commonly encountered factors which may depress salivary flow rate * inadequate fi intake or fi loss from strenuous physical activity ‘High intakes of caffeine, nicotine or alcoho! « llogal and recreational drugs + Paychological stress «+ Proscription and over-the-counter medications $+ Uncontroled clabetes melitus “+ Salvary gland inflammation or destruction (HEN radiation, hepatits C, HIM) ‘Sjogren's syndrome and connective tissue autommane diseases talivary parameter sper ofthe diagnostic work of ew patients as well as prior to commencing expensive and complex treatments A measurement of resting flow which is below 0.7 ‘mL per minute is indicative of abnormal salivary gland function. ‘Simply looking atthe lingual aspects ofthe lower ineisor teeth and te floor of mouth forthe presence and appearance of ‘pooled saliva can be informative. Visual assessment of resting saliva should include screening patients for droplet formation ‘on the lower lip, as well s pooling an frothing of saliva inthe sublingual regions and the appearance of white mucinous strands of saliva residues onthe oral mucosa (Figures I and 2). Saliva ‘becomes more viscous and mucinous in nature as the resting flow reduces and this can be assessed visually by the appearance of January/February 2014Figure 1. The frst phase of visual assessment of resting salivary ‘output, By examining droplet formation inside the labial mucosa ofthe lower lip region. At the same time one can also assess the ‘appearance of saliva in the vestibule (watery, bubbly, or frothy) This example shows no droplets being formed and bubbly saliva a Figure 2. Bubbly, frothy sativa tx he lingual and posterior man Die regions signifies depressed water conten in he saliva at rest. the saliva, These visual tess ean then be combined with messuie ‘ments of resting and stimulated pH and buffer capacity (Figure 3) {o provide a pathway for assessing the nature ofthe problems. (One can also ook in the lingual region of the mandibular ante- rior teeth forthe presence of supragingival cleulus, however its presence isnot a diect indicator of adequate salivary param. ers. In this region, the salivary pH is least likely to fall blow the critical level, as plague here is normaly thin, sugar concen: tration after sugar intake are lowest here and its clearance rate js fastest and a high salivary film velocity promotes loss of any acids formed in plague from fermentation. OF great importance is the fact thatthe high salivary film velocity there also brings more urea tothe ste, which facilitates plague alkalinisation, siving a shallow Stephan curve of short duration after a sucrose challenge. As a resul, there is a prevailing tendency for ealculus {o deposit fom the supersaturated fluid phase of dental plaque." To boost salivary flow, sugar-free chewing gums provide a safe, proven and effective stimulant. Studies of healthy subjects ‘who chewed one tablet of Wrigley's Extra peppermint o fruit. January/February 2014 Sita WATERLINE. | MAINTENANCE New Addec ICX"offers you a unique and effective way to maintain clean dental unit, waterlines. First of all, it's incredibiy easy to use. Simply add one ICX self-contained water bott filing, As the effervescent tablet dissolves, ingredients are released into the water to help prevent contamination and the build-up of deposits. + Convenient single tablet dispensing packet + Continuously present; eliminates need to purge waterlines + ICX is suitable for all self contained water bottle systems. ICX is available for both 0,7-litre & 24itre bottles, 22k grdee 45 0 a watering protocol, aciewingavaltyresuts requis | bahetence tothe apufecturers | reconmendes recess, ale rellablecroative tablet to an empty tle before each auxiliary 25EXCELLENCE clinical Bn Sis Figure 3 Assessment of salivary pH using the GC Saliva-Check Bagjer test kit. From let, minimal volume and acidic saliva at rest onthe labial aspect ofthe maxillary anterior teth; acidic saliva at rest in the sublingual region; normal salivary pH after chewing for 3 minutes: anu a bufer capacity atthe lower end of ‘he normal range. This pattern of results is consistent with effects om lifestyle or medicines, rather than salivary gland disease flavoured (peach) gum continuously over 2 hours have shown ‘that the flow rato increases initially and then, after 35-40 min, falls a baseline value which remains significantly elevated from the resting flow rate, With both gums, the salivary pH from. 2 minutes to 2 hours of chewing is significantly higher than that ‘of unstimulated saliva” This means in practical termi that ever ‘when a single gum is chewed beyond the point that any flavour remains, there is ill a worthwhile benefit. Moreover, there is no evidence tht the resting oc unstimulated salivary flow rates are reduced after prolonged gum chewing. ‘A number of medicated gums now exist onthe market and chewing urea-containing gum after exposure to sucrose can reduce the extent of pH reductions in the Stephan curve. On the other band, suger-containing gums provide a cariogenic chal- Tenge and cause an extended drop in plaque pH from the fact that virtually al the sucrose in these gums will be released into the saliva during the 20 minutes of chewing, with a peak con- centration at 1-2 minutes. Conversely, sugar-free gum chewed References Wah. Sat Tsing: Good practic, good sense. 2nd Bn, GC 2010 Dawes C Satvary ow pater an the eth oF Hara sael sns. ‘AmDen Asse, 2008139 Sup 185248, (Chang HS, Walsh Li, Fee TH Bes of orosooic neatmaat oa stacy om, pl tr apy and eel of mutans enepeoocl nd acto. ABS (Oro 1599 154, 239234, Wali. Clinical apect svar Wot forte dent cnn, Iter 4 Daa SA (Austals Ean), 2007.23) 1630 lh. Cll semen of ivan pres, Ay 2010202). wes C. why docs sapalagval als fora peel c th Ingo ec ofthe ler atnioes I Can Det Asse 20057210} 9286 26 auxiliary | Table 2. Ensuring optimal salivary defence 4 Salva coats and protects the hard and sot oral tissues, enables us to prepare our food for cigestion, and assists cur speech. Depressed fow of salva may profoundly affect oral haath, disturb digestion and speech, and seri ‘ously impair patient's quality of Fe. ‘Screen patients for salivary problems when they have high cari rates, candidosis, swallowing problems or com plaints of orl dryness. Remember that mouth breathers ‘are more likey to experience dness bacaues of the evan: Craton of residue salva from the hard palate. Prominent causes of ow salvary gland output arelitestyle factors, medicines, iracaton, organic diseases, psycho- ‘genic factors and decreased mastication i ‘Avoid swishing ecie dinks, patiouary crate containing links which sequester avalabie calcium ions. Keep food and liquids in the mouth es bvity as possible, “ Salvary flow is negigble during sleep and the protective ffcts of salva are los, 80 brush just before bed. (Chewing sugar-free gum stimulates salivary flow, which benefits herd and sof oral tssues in many weys. Using ‘a rango of favours helps to prevent accommodation responees to any one particular favour. Localy acing stimuants of salvar flow or saliva substi- ‘utes may aleviate symptoms or oral dryness. Use ioe as stimulant whenaver practicable, during a cariogeni challenge causes a rapid rise in plague pEL. ‘This emphasizes both the choice of gum and the timing of gum chewing as important factors to provide advice to patients on. Prolonged use of xylitol or xylitol containing chewing gum reduces levels of Steptococcus mutans both in dental plague and saliva, thereby limiting the seidogenic potential of plague and its adhesiveness. No adaptive changes in plaque metabolism occur, making these gum suitable for long tenn, regular use, Gums containing xylitol and CPP-ACP can exer aditional preventive ‘benefits to optimise remineralization and lower caries risk. Patients should be free to choose a flavour of gum whieh ‘matches their personal preferences, realizing tht during gum chewing te flavour drives aigher salivary secretion rate forthe first 4 minutes of chewing, after which point the most important factor isthe gum base and the mechanical act of chewing itself. Said another way, the inital effect ofthe gustatory stimulation of foods is muuch more important in stimulating salivary Row than the mechanical stimulation from chewing 1 Dawes Kubin: K The effet of prtanged gm ewig oa lay se an ompeston Arch Or Bo. 2004496859, 5 Dawes C. The nsnmlsed ary Sow rat ale prolonged gu chewing ‘Arch Ott Biol. 2015506) 361-8. 5 Dawes, Osan 0, Slvr sin pts eed fire and eck cance Cua Dent Asc. 2008;40):397 400. 1M, Dawer ©. How mach va enough fr svoidnce of serxamia? Cis ex 20038(3):25640 1, Dawes C. O"Comor AM, Aspen IM The ffx ox ham ser ow rate of the tomperatare of ¢gurtary sinus. Arch Ota Bll. 2000: Ciyssrsi January/February 2014The relevance of oral dryness Patents who complain of mouth dryness after proonged gum chewing may have become accustomed to the larger volume of saliva present inthe mouth during the period of gum chewing* Infect, patients who report that thee mouths dry may not havea complete lack of uid in the mouth: rather, there may be localized eas of dryness, notably onthe hare palate where the salivary Glen is particularly thin and subject to fluid absorption oF evaporation because of mouth breathing. This as been documented i ptints Who have received radiation eatimet or who have undergone removal of the salivary glands (or both) for head and neck eancer and who have depressed resting and stimulated flow rates? ‘There is good evidence that xerostomia, the subjective sense tion of dry moath, occurs whenever the salivary Hw rate i es ‘than te rate of fluid loss from the mouth by evaporation and by absorption of water dhyough the oral mucosa. Evaporation during rmouth-beathing may each a maximum rae of about 0.21 mL mi, while water absorption trough the mucosa has @ maximum absorption rate of 019 mfx thus a total of 4 mimi for te maximal rate ofthese losses. Unstimulated salivary low rates 30.1-0.3 mbmin may be necessary to overcome such Tass. ‘The work of Calin Dawes has shown tha the volume of saliva Jeftin the mouth ater swallowing isa key factor i the sensations ‘of oral wetness and dryness and that the dynamics ofthe salivary film are vey similar in children and adults. The volume of saliva remaining after swallowing is lower (71% of normal) in pationts ‘with depressed salivary output and whose mouths fel very dy Saliva remaining ftr swallowing i present as thin film. On the Ir palate, the film isthe thinnest (ess than 10 microns thick) and thus is prone to evaporation during mouth-breathing andor ‘uid absorption, resulting in xerstomia. This is aggravated when hore are reduced rates of secretion from the soft palate mine lands, which may be due to effects of iestyle or medicines. Boosting salivary outputs Prompted by the sensation of mucosal dryness, patients will sek fluids to drink, particulary heverages for “hirsquenching” which ‘are cold and acidic. As the mouth becomes drier, gustatory sensi- tivity declines and higher concentrations are needed to sustain the same level of stimolation. If patients wish to use a sweet-tasting product, these should be based on xylitol, sorbitol or Isomalt®, as these are non-catiogenic and have a low glycaemic index. A spocial word of caution must be sounded regarding the ten- dency of patients to use citrus lavoured confectioneries and other product fo boost salivary output. Patents with salivary gland dys funtion must nt use etic ucid-based products to stimulate their salivary flow. The citrate contained within these products will, impair subsequent remineralization and the effect will be most noted atthe sites with greatest cares risk because oftheir inher: ently lower clearance. A much better alternative is to have the patient suck ice, which is not only dentally safe but a more effec tive stimulant of salivary low than a sourlitec acid stirs. A summary of practical advice for management of dry mouth problems is presented in Table 2 About the author Professor Laurence J. Walsh is the technology editor of Ausiralasian Dental Practice magazine and a regular contrib: ior to Aucitiay. He is also a noted commentator on and user (of new technologies and the jormer Head of The University of Queensland School of Dentsey. January/February 2014 assistina. What are the key factors for instrument maintenance? Correct cleaning and regular lubrication and your instrument will operate The Assistina 301 plus is an air-driven maintenance unit for straight and contra- angle handpieces, turbines, air motors and air driven scalers from all major instrument perfectly and give a good working life. | | manufacturers. The Assistina operates on the principle of rotational lubrication. The result: ‘minimal friction, low wear and long working life. avdec I auxliary 27