Saliva and Its Significance

SALIVA
AND
ITS SIGNIFICANCE
Shivangi
First yr PG
CONTENTS
• Introduction
• Salivary Glands – Classification, Development,
Structure, Nerve Supply – Secretomotor pathway
• Saliva- Formation, Composition, Properties,
Regulation of salivary secretion, Functions
• Saliva and Dental Caries
• Applied Physiology
• Diagnostic Tool
• Methods of Collection
• Saliva and Dental Restorations
• Pathology
2
INTRODUCTION
Salivary glands and saliva play a critical role in the

maintenance of oral and systemic health. Saliva is a
complex fluid, produced by the salivary glands that is
required for eating, speaking, and swallowing.
3
Classification of Salivary Glands
MAJOR MINOR
LABIAL/
LABIAL/ BUCCAL
BUCCAL
PAROTID
PAROTID
PALATINE
PALATINE
SUB
MANDIBULAR
MANDIBULAR LINGUAL
LINGUAL
GLOSSOPALATINE
SUB
SUB LINGUAL
LINGUAL
VON EBNER
4
Orban’s Oral Histology & Embryology 13th Edition
Based on type/ nature of saliva secreted:
5
DEVELOPMENT OF SALIVARY GLANDS
IUL
GLAND ORIGIN
DEVELOPMENT
PAROTID Corners of stomodeum 6th week
SUB MANDIBULAR Floor of the mouth End of 6th week
Lateral to submandibular
SUB LINGUAL 8th week
primordium
MINOR GLANDS Buccal Epithelium 12th week

6
Tucker AS. Salivary gland development. Semin Cell Dev Biol. 2007;18(2):237-244.
All ectodermal (Parotid and minor salivary gland) and endodermal tissues
(sub mandibular and sub lingual) arise from :
EPITHELIUM MESENCYHME
Secretory end pieces Capsule surrounding

Duct system the gland
Myoepithelial cells

Tucker AS. Salivary gland development. Semin Cell Dev Biol. 2007;18(2):237-244.
STRUCTURE OF SALIVARY GLANDS
1. Secretory portion : 2. Ductal portion :
• Arranged in acini – serous, mucous, Highly branched ducts
mixed
• Couched by Myoepithelial cells.
Orban’s Oral Histology & Embryology 13th

Edition 8
Tencate’s Book of Oral Histology

DUCTS
Intercalated Intralobula Interlobula
Acini Main Duct
Ducts r Ducts r Ducts
9
Secretomotor Pathway Of The Glands
PAROTID GLAND
Inferior Salivatory
Nucleus
IX Nerve
Tympanic Branch
Tympanic Plexus
Lesser Petrosal Nerve
Relay In Otic Ganglion
Postganglionic Fibres
Through Auricilotemporal
Nerve
10
Introduction: the anatomy and physiology of salivary glands, Helen Whelton, 2012
Parotid Gland
Secretomotor Pathway Of The Glands
SUBMANDIBULAR & SUBLINGUAL GLAND
Submandibular Relay
Superior
Salivatory Ganglion
Nucleus
Postganglionic
Joins Lingual Fibres
Nerves Nerve, Branch
Intermedius Of V3
Submandibular
Facial Nerve Chorda Or Sublingual
Tympani Gland
Introduction: the anatomy and physiology of salivary glands, Helen

Whelton, 2012
11
Proctor GB. The physiology of salivary secretion. Periodontol 2000. 2016 Feb;70 12
SALIVA
• The oral cavity is a moist environment; a film of fluid called saliva
constantly coats its inner surfaces and occupies the space between the
lining oral mucosa and teeth.
• Saliva is a complex fluid, produced by the salivary glands, whose
important role is in maintaining the well-being of the mouth.
13
FORMATION OF SALIVA
I. Initial formation stage:
Stimulation of parasympathetic nerves
Release of intracellular stores of Ca ions
Opening of Cl channels and intracellular movement of Cl

ions
Pulls Na ions into the lumen
Movement of water into the lumen primary secretion

that contains ptyalin
and/or mucus in a
solution of ions
Formation of isotonic saliva similar to plasma
14
II. Secondary/ Modification phase of secretion:
Saliva produced by secretory acini contain electrolytes such as Na

and Cl.
Prevention of loss of Na+ and Cl- ions from the body is necessary.
The autonomic The striated duct modifies secreted saliva from acini by
nervous system & reabsorbing Na and Cl ions & simultaneously excreting K + and
mineralocorticoids HCO3- ions.
control the
modification step.
The excretory ducts play a key role in reabsorbing Na and Cl
secreted by acini.
ionic composition
of saliva is
modified  Thus, the end product is hypotonic to plasma.
intralobular ducts
reabsorb Na+ &
Cl– excluding Tencate’s Book of Oral Histology
water 15
FORMATION OF SALIVA
Secretion
of
16
Saliva circulating in mouth at any given time is termed
“WHOLE SALIVA”.
pH 6.5 -7
17
Kaufman E, Lamster IB. The diagnostic applications of saliva--a review. Crit Rev Oral Biol Med. 2002
COMPOSITION OF SALIVA
Saliva
Organic Inorganic
Substances Substances
Other
Enzymes Proteins Organic Electrolytes Gases
Substances
18

19

SALIVARY PROTEINS
Proline Rich Acidic PRPs will bind Ca with a strength  may be

Proteins important in maintaining concentration of ionic Ca in
saliva.
(PRPs)
Chitinase
it is derived from the
parotid, submandibular,
sublingual and palatine
glands
Chitin - constituent of yeast

cell walls  chitinase may
Pateel et al. Correlation of Salivary Statherin and Calcium Levels with Dental play a role in protection
Calculus Formation: A Preliminary Study. International Journal of Dentistry, 2017;
Bennick A. Salivary proline-rich proteins. Mol Cell Biochem, 1982.
against colonization of oral
epithelium by yeast.
Iron binding protein :
Multifunctional - bacteriostatic,
removes free Fe from
saliva – depletes
bactericidal, fungicidal, antiviral, Lactoferrin
anti-inflammatory and
supply of Fe required
immunomodulatory properties
for bacterial growth
Beta- Broad May serve to link

defensins have spectrum innate immunity
Defensins been antibacterial with the acquired
demonstrated & antifungal immune system.
in saliva activity
21
Pateel et al. Correlation of Salivary Statherin and Calcium Levels with Dental Calculus Formation: A Preliminary Study. International Journal of
Dentistry, 2017; Bennick A. Salivary proline-rich proteins. Mol Cell Biochem, 1982.
Agglutinin
responsible for S. mutans

mediates binding between S.
aggregating properties of
mutans & S. sanguis
parotid saliva
detectable as a component of
salivary pellicle on tooth
surface
Proteinase inhibiting properties
Cystatins
Play a role in controlling proteolytic activity :
from host (released during inflammation) or
from microorganisms majorly by Cystatin C
22
Amerongen, A. N., & Veerman, E. Saliva the defender of the oral cavity. Oral Diseases. 2002.
Peroxidase
Peroxidase activity in saliva is derived from two sources:
 human salivary lactoperoxidase (HS-LPO)  synthesized & secreted by
salivary glands
 myeloperoxidase (MPO)  PMN leucocytes, which migrate to oral cavity
Salivary peroxidases: catalyse the formation of bactericidic compounds, e.g.
hypothiocyanate, by peroxidation of thiocyanate.
 inhibits growth of bacteria
 inhibits the adherence of S. mutans to saliva coated
hydroxyapatite
Due to the antimicrobial effects of the lactoperoxidase

system, dentifrices & mouth rinses which enhance the
endogenous activity of salivary peroxidase by
supplementing H2O2- generating enzyme systems have
been marketed.
23
Amerongen, A. N., & Veerman, E. Saliva the defender of the oral cavity. Oral
Diseases. 2002.
Potent fungicidal properties
Killing of bacteria, such as S. mutans
Plays a role in pellicle formation
Neutralization of potentially noxious substances :

Histatins polyphenols
Chelation of metal ions
Inhibition of inflammatory cytokine induction
Inhibition of host & bacterial proteinases : MMPs &

cysteine proteinases
24
Catalyses the hydrolysis of cell wall
polysaccharides  lytic action  anti-microbial
activity
Lysozyme
Non-enzymatic bactericidal activity – by
activation of bacterial autolysins (Laible &
Germaine, 1985).
Chromogranin A
 a prompt elevation of salivary chromogranin A-like
immunoreactivity is found in psychosomatic stresses
 Vasostatin-1: chromogranin A-derived fragment 
displays antibacterial activity against Gram-positive
bacteria at micromolar concentrations and is also
able to kill a large variety of filamentous fungi and
yeast cells
25
Amerongen, A. N., & Veerman, E. (2002). Saliva the defender of the oral cavity. Oral Diseases.
Mucins
Protects the mouth by Mucin coated bacteria may be
lubricating the mucous unable to attach to teeth
membrane of the mouth. surface.
function as barriers and

protects the underlying
epithelium against mechanical
damage
Only salivary protein that

maintaining a high Ca level
in saliva available for inhibits spontaneous Statherin
remineralisation of toothprecipitation of calcium
enamel and high phosphatephosphate salts from
levels for buffering supersaturated saliva.
26
Ca & Zn-binding protein derived mainly from
granulocytes, monocytes, macrophages.
Inhibit microbial growth through competition

for Zn
Calprotectin
Main sources of salivary calprotectin : GCF &
oral surface epithelium.
Calprotectin rises markedly in some inflammatory

diseases  used as a marker
27
hCAP18
Inhibitor Of
Serine
IB-367
Proteinases
(SLPI)
ANTI
MICROBIAL
ACTIVITY
Von Ebner
glands
P113D
protein
(VEGh)
Cathelicidins
28
Amerongen, A. N., & Veerman, E. Saliva the defender of the oral
cavity. Oral Diseases. 2002.
HEALING AND
REPAIR
Inhibitor Of Serine
Proteinases (SLPI) wound healing
Tissue Inhibitors of
Metalloproteinases
turnover and remodelling of the
(TIMP) extracellular matrix.
Extra-parotid
glycoprotein (EP-
turnover of mucous tissues by facilitating
GP) the detachment of epithelial cells
29
Amerongen, A. N., & Veerman, E. Saliva the defender of the oral cavity. Oral
Diseases. 2002.
Battino M, Ferreiro MS, Gallardo I, Newman
HN, Bullon P: The antioxidant capacity of
saliva. J Clin Periodontol 2002; 29: 189–194.
C Munksgaard, 2002
Preventive
antioxidants:glutathione
, albumin
Antioxidant
Radical-scavenging
antioxidants: albumin,
uric acid, transferrin,
lactoferrin and
caeruloplasmin
Repair and ‘‘de novo’’

enzymes
30
INORGANIC CONSTITUENTS
• Contributes to
osmolarity of saliva
(osmolarity is ½-3/4th of • Principal buffer in saliva
blood). {resist change in salivary
• Concentration may be pH}
altered in pathological
conditions
SODIUM,
POTASSIUM, BICARBONATE
CHLORIDE
31
Proctor GB. The physiology of salivary secretion. Periodontol 2000. 2016 Feb;70
ROLE OF CALCIUM & PHOSPHATE
Calcium and phosphate neutralize

acids that would otherwise
compromise tooth mineral integrity
Depending on the pH, calcium is

distributed in saliva as free, ionized
and bound forms
Free ionized form is important in caries

process as it maintains equilibrium
between dental tissue and surrounding
Greabu M, Battino M, Mohora M, et al. Saliva--a diagnostic window to the body, both in health and in disease. Journal of Medicine and Life. 2009
Usha, & Sathyanarayanan. (2009). Dental caries-A complete changeover (Part I).
32
ROLE OF CALCIUM &
PHOSPHATE
supersaturated prevents facilitates

with calcium & dissolution of enamel
phosphate enamel mineralization
Greabu M, Battino M, Mohora M, et al. Saliva--a diagnostic window to the body, both in health and in disease. Journal of Medicine and 33
Life. 2009
Usha, & Sathyanarayanan. (2009). Dental caries-A complete changeover (Part I).
Demineralization
Remineralization
Both occur on the tooth surface, and a substantial number of mineral ions can
be lost from HA without destroying its integrity.
34
Usha, & Sathyanarayanan, Usha. (2009). Dental caries-A complete changeover (Part I).
Abou Neel EA, Aljabo A, Strange A, et al. Demineralization-remineralization dynamics in teeth and bone. Int J Nanomedicine. 2016
Fermentable carbohydrate
Acidic condition,
Loss of and ions
Undersaturated saliva
Release of minerals from bacteria,

calculus, tooth, Ca-F formulation 35
Once plaque fluid stabilizes,
mineral loss is stopped
Supersaturated saliva, , ,
Precipitation of minerals
36
ROLE OF FLOURIDE
Role of Fluoride
anti-cariogenic
property
Sources
drinking water
toothpaste
topical fluoride
products
37
Yao, K., & Grøn, P. (1970). Fluoride Concentrations in Duct Saliva and in Whole Saliva. Caries Research, 4(4), 321-331.
During
remineralization
Fluoride gets
Acidogenic challenge adsorbed onto the Fluorapatite crystals
tooth surface
Making the subsequent

acidic challenge more Lower critical ph
difficult to bring about (from 5.5 to 4.5)
demineralization
38
GENOMIC, TRANSCRIPTOMIC AND
PROTEOMIC CONSTITUENTS OF
SALIVA
Genome (Human Transcriptome
Salivary Proteome
DNA) (Human mRNA)
• total DNA in • The total RNA in • The total amount
whole saliva = cell free of proteins in
1.8 – 128.4 (centrifuged) whole saliva is
μg/mL whole saliva is 0.5 to 3 mg/mL.
• quality of 0.108 ± 0.023 • 22.8% to 28.7%
salivary DNA μg/mL to 6.6 ± have an
yield is good ie, 3.6 μg/mL unknown
72% to 96% of • majority of function
can be RNAs present in
genotyped cell free whole
saliva is mRNA
39
SALIVARY DNA, RNA AND
PROTEOME IN THE DIAGNOSIS
OF DISEASES
• Early Cancer Diagnosis
• mutated salivary DNA at p53 gene was found in 62.5% of oral
cancer patients
• HPV (human papilloma virus) DNA in saliva HPV-related head
and neck cancers
• tumor-inducing viruses like HIV (human immunodeficiency
virus) and HHV-8 (human herpesvirus 8)
• interleukin-1- (IL1), interleukin-8 (IL8), ornithine decarboxylase
antizyme-1 (OAZ1) and spermidine/spermine N1-
acetyltransferase (SAT). Regression tree (CART) analysis of these
four, elevated biomarkers T1 and T2 oral cancer
40
PROPERTIES OF SALIVA
Total amount : 1,200 – 1,500 ml in 24 hrs.
Total amount : 1,200 – 1,500 ml in 24 hrs.
(A large
(A large proportion
proportion is secreted
is secreted atwhen
at meal time, mealthetime, when
secretory the
rate is secretory rate is
highest.)
highest.)
Theseproportions
These proportions vary
vary with withand
intensity intensity and type
type of stimulation. of stimulation.
• Spontaneous (asleep): 8 hr at 0.05 – 0.1 ml/ min = 25 ml

• Unstimulated (awake): 12 hr at 0.7 ml/ min = 504 ml
• Stimulated (eating, talking) 4 hr at 1.67-2 ml/ min = 480 ml
• 24 hour total = 1009 ml
Consistency : slightly cloudy, due to presence of cells and mucin.

41

PROPERTIES OF
SALIVA
usually slightly acidic (pH

pH
6.35 – 6.85)
Specific gravity 1.002 – 1.012
Freezing point 0.07 – 0.34ºC.
42

REGULATION OF SALIVARY
SECRETION
Salivary secretion is regulated by nervous mechanism through
reflex action. Salivary reflexes are of two types:-
UNCONDITIONED REFLEX CONDITIONED REFLEX

• Secretion of saliva when any substance • Secretion of saliva by the sight,
is placed in the mouth. smell, hearing or thought of food
• Present since birth & hence also called is called conditioned reflex.
inborn reflex – does not need any • Presence of food in the mouth is
previous experience. not necessary to elicit this.
• Due to stimulation of nerve endings in • It is due to the impulses arising
the mucuos membrane of oral cavity. from the eyes, ear, etc.
• Eg : When food is taken, any • It is an acquired reflex & needs
unpleasant or unpalatable substance previous experience.
enters mouth, when oral cavity is
handled with instruments by dentists.
43
SECRETION
Cytoplasmic
Ach from activates Ca2+ released
parasympathetic muscarinic M3 from the
nerves receptors endoplasmic
reticulum (ER)
activation of Cl-
Fluid secretion
release
44
Proctor GB, Carpenter GH. Salivary secretion: mechanism and neural
regulation. Monogr Oral Sci. 2014;24:14-29
SECRETION
noradrenaline activation of
from (b1-Adr) and Intracellular cyclic AMP
sympathetic vasointestinal signaling (cAMP)
nerves peptide (VIP)
release of exocytosis of activates

protein into protein storage protein kinase
saliva. granules A (PKA)
45
FUNCTIONS OF SALIVA
Amerongen, A. N., & Veerman, E. (2002). Saliva the defender of the oral cavity. Oral Diseases
Tencate’s Book of Oral Histology. 46
Preparation Of Food For Swallowing
Lubrication
Formation of
of food by Swallowing
bolus
MUCIN
Saliva
dissolves
food APPRECIATION
substance
OF TASTE
Stimulation
of taste buds
Taste
perception
47
Digestive Function
Role in
Speech
• Moistens & lubricates the soft
parts of the mouth and lips
• Mouth is dry- articulation and
pronunciation become difficult.
48

REGULATION OF EXCRETORY FUNCTION
• Excretes substances like mercury,
WATER BALANCE potassium iodide, lead, and
• Body water content ↓ : thiocyanate
salivary secretion ↓ Pathological conditions: saliva
• activation of receptors in the excretes substances like glucose in
diabetes mellitus, calcium in
oral cavity  dryness of hyperparathyroidism.
mouth  induces thirst Many drugs, as well as alcohol, are
• When the water is taken excreted into the saliva
→restores the body water
content.
49
CLEANSING AND PROTECTIVE
FUNCTIONS
constant prevents
mouth & free of debris,
saliva bacterial
teeth rinsed foreign particles
secretion growth
Lysozyme saliva kills some bacteria such as Staphylococcus,

Streptococcus and Brucella.
PRPs, Lacto
ferrin antimicrobial property, protect teeth integrity by
stimulating enamel mineralization.
Secretory IgA
antibacterial & antiviral actions
50
Van Nieuw Amerongen A, Bolscher JG, Veerman EC. Salivary proteins: Protective and diagnostic value in cariology? Caries Res 2004.
MAINTENANCE OF TOOTH
INTEGRITY
through this maturation
diffusion of ↑ surface
protective ions such as hardness, ↓
interaction
function begins permeability,
with saliva  Ca, PO4, Mg, F,
immediately &
post-eruptive & other trace
after tooth experimentally
maturation components,
eruption shown to ↑
into surface resistance to
enamel caries.
51
REMINERALIZATION
Protect
Maintains Prevent
Proline rich enamel
Ca in saliva precipitation
protein; Effectively surface by
in a of Calcium
Statherin; binds to Ca preventing
supersaturat phosphate
Cystatins demineraliza
ed state salts
tion
These proteins  too large to penetrate enamel pores  remain on

surface, bound to HA  aid in controlling crystalline growth by
allowing penetration of minerals into enamel for remineralization
& limiting mineral egress.
52
Brij Kumar, Nilotpol Kashyap, Alok Avinash, Ramakrishna Chevvuri, Mylavarapu Krishna Sagar, Kumar Shrikant, “The composition, function
and role of saliva in maintaining oral health: A review,” Int J Contemp Dent Med Rev 2017.
PELLICLE FORMATION
Plaque maturation
bacterial colonization
Predominantly  saliva continues
 adherence of
involved in 1st step of to provide
bacteria to salivary-
plaque formation – agglutinating
pellicle-coated tooth
deposition of a pellicle substances
surface
Bathing of tooth Alteration of Salivary proteins

surfaces by salivary glycoproteins by & carbohydrates
fluids which contain bacterial & oral - substrate for
abundant proteins. enzymes. metabolic activity
of bacteria.
Selective adsorption Salivary Ca, PO4, Mg,

Loss of solubility of
of certain negative & Na, K become part of
adsorbed proteins by
positively charged the gel-like plaque 
surface denaturation
glycoproteins - act as influence plaque
& acid precipitation.
an agglutinating base. mineralization.
53
REPAIR
Presence of nerve growth factor (NGF) & epidermal growth factor (EGF)
in submandibular saliva  may accelerate wound-healing.
ORAL SALIVARY CLEARANCE

Most important caries-preventive functions of saliva are the flushing and
neutralizing effects : referred to as salivary clearance/ oral clearance
capacity.
• Physical flow of saliva + muscular activity of lips & tongue  effectively
removes many potentially harmful bacteria from teeth & mucosal
surfaces.
• Similar to tearing and blinking in the eye, blowing the nose, and coughing
and expectorating to clear the lungs.
Higher the flow rate  the faster the clearance and higher the buffer
capacity
54
MAINTENANCE OF
ECOLOGICAL BALANCE
Colonization of tissue surfaces & adherence :
critical event for survival of many bacteria
Interference with this process : bacterial

clearance by mechanical, immunological &
non-immunological means is one of the major
functions of the salivary defense mechanism.
55
SALIVA AND DENTAL CARIES
56
Critical pH Consistency
Enamel: 5.5 Low risk: serous

Fluorapatite: 4.5 consistency
Dentin: 6.2-6.7 High caries: viscous

consistency
González-Cabezas C. The chemistry of caries:

remineralization and demineralization events
with direct clinical relevance. Dent Clin North 57
Am. 2010 Jul;54(3):469-78

• High risk • High risk

caries: caries:
• Low risk • Low risk
caries: caries:
Flow Buffering
Rate Capacity
González-Cabezas C. The chemistry of caries: remineralization and
58
demineralization events with direct clinical relevance. Dent Clin North Am.
2010 Jul;54(3):469-78
White Spot Lesion
White spot lesions are opacities that occur by
demineralization of enamel under the surface and cause
esthetic problems.
• Brackets in orthodontic treatment
Etiology
• Areas difficult to access by tooth brush
• Proper brushing
Management • Application of fluoride on affected lesion
• Pits and fissures sealants
Temel SS, Kaya B (2019) Diagnosis,

Prevention and Treatment of White Spot 59
Lesions Related to Orthodontics. Int J Oral

60
Maintains pH and has Calcium and

Tooth dissolution:
buffering capacity by phosphate: tooth
prevented or retarded
increasing secretion integrity
calcium, phosphate,
Reduces plaque hydroxyl and fluoride
accumulation by ions enhances re-
increasing flow rate mineralization of
early carious lesions
61
Carbonic acid-
bicarbonate buffering
Total concentration of IgA
system, ammonia and urea–
in saliva inversely related
act as buffer  regulate
to caries experience
pH over developing
lesions
Lysozyme,
lactoperoxidase and
lactoferrin – have
antibacterial action
Brij Kumar, Nilotpol Kashyap, Alok Avinash, Ramakrishna Chevvuri, Mylavarapu Krishna Sagar, Kumar Shrikant, “The composition, function 62
APPLIED PHYSIOLOGY
Saliva quantity and quality can be affected by multiple diseases and medical treatments.
HYPOSALIVATION Reduction in the secretion of saliva
CONSEQUENCE 
Temporary Permanent ++ Dental Caries
Age Changes – With Emotional Obstruction of

age a generalized loss conditions - fear salivary duct (sialo
of gland parenchymal lithiasis)
tissue occurs. The lost
salivary cells often are
Fever Congenital absence/
replaced by adipose hypoplasia of glands
tissue.
Paralysis of facial
Dehydration nerve (Bell’s 63
palsy)
Chronic Conditions Associated with Salivary Gland Hypofunction in Adults:
Medication
Anti Anti Anti Antiretrovir Appetite

Antiemetics al therapy Decongestants
depressants psychotics histamines suppressants
(protease
inhibitors)
Medical conditions
Sjögren’s syndrome
Viral infections (HIV, HCV)
Uncontrolled diabetes
Chemo
Diuretics
therapy
Irradiation
Alzheimer’s disease
Hypertension
Depression
64
Iorgulescu G. Saliva between normal and pathological. Important factors in
determining systemic and oral health. J Med Life. 2009;2(3):303-307.
Hyposalivation due to Irradiation
Irradiation at low prone to remineralization is

dose of 20 Gy demineralization hampered
changes in the
amount of saliva
and its pH falls from 7·0
Dental caries
consistency: to 5·0, cariogenic
sparse, thick and
ropy
food sticking to the

Loss of lubrication
teeth
65
EFFECT OF SALIVARY
CHARACTERISTICS IN DIABETES
MELLITUS
Significant decrease seen in patients with
neuropathic diabetes melitus
Salivary (0.06 vs. 0.53 mL/min),
flow rate
Salivary It is higher in diabetes

Amylase
Levels
Salivary higher in diabetic patients(1.26 to 11 mg/dL), than in

Glucose non diabetic patients, ranging from 0.5 to 4.8
Levels mg/dL.
66
EFFECT OF SALIVARY
CHARACTERISTICS IN STRESS
Stress
Cortisol Levels
Salivary flow
67
Hypersalivation Excess secretion of saliva
(Sialorrhea)
Physiological Pathological
Pregnancy Ptyalism
Nausea, Heavy metal

Vomiting poisoning
Neurological
Disorders : Cerebral
Palsy, Mental
DROOLING Retardation
 Uncontrolled flow of saliva outside the mouth is called drooling.

 Often called ptyalism.
 Drooling occurs because of excess production of saliva in association + inability

to retain it within the mouth.
 Hinderance during placement of a restoration
68
Management
Anti-Sialogogues
The use of drugs to control salivation is rarely indicated in

restorative dentistry.
Atropine Sulfate
Methantheline Bromide (Banthine)
Propantheline Bromide (Pro-Banthine)
Belladonna Tincture
69
Burning Mouth Syndrome
• It is a psychosomatic condition of the oral area. It is a set of painful and burning

sensations in the mouth experienced even when the clinical investigation of the
mucosa proves to be normal.
Etiology
- Local (e.g., dental materials used to restore teeth)
- Systemic (including lack of minerals, vitamins, etc.).
- Stressful life events.
- Mental health problems.
- Psycho-social difficulties
70
Burket’s ORAL MEDICINE Eleventh Edition

71
ISOLATION
Isolation of operating field from saliva forms a
part of moisture control.
Dental restorations may also be affected by

salivary contamination.
It is also helps in infection control during root

canal procedures
72
COHEN 10th Edition

Eating Disorders
Bulimia nervosa Anorexia nervosa

• resting and stimulated salivary • mucosal atrophy, and swelling
flow rates are reduced of the salivary glands
• dental erosion
• Malnourishment
• Sialadenosis
• Bilateral parotid gland
enlargement
73

CHORDA TYMPANI SYNDROME
(or) FREY’s SYNDROME
74
SALIVA AS A DIAGNOSTIC TOOL
Reflective of the status of health , salivary samples can be analyzed for:
Tissue fluid levels of

naturally,
therapeutically, Emotional status
recreationally
introduced substances
Hormonal status Immunologic status
Nutritional/metabolic
Neurologic status
influences
75
Mandel ID. Salivary diagnosis: promises, promises. Ann NY Acad Sci 1993;694:1-10.
SALIVA AS A DIAGNOSTIC
TOOL
ADVANTAGES OVER BLOOD SERUM/ URINE IN DIAGNOSIS
Non-invasive Relatively Less risk of

collection safer for exposure to
techniques : Inexpensive, health care needles and
reduce easy to use worker than possibly AIDS
anxiety in serum or hepatitis
subject. analysis viruses
Most molecules found in blood & urine are found in saliva, although
at concentration of 1/10th to 1/100th of their concentration in blood.
76

Saliva can be used as a diagnostic tool for :
ORAL MICROBIAL / SUBSTANCE

INFECTIONS
DISEASES HUMAN DNA ABUSE
Caries activity HIV-1 /HIV-2 Biomarker Alcohol
tests Hepatitis-A Profiling Amphetamines
Periodontitis Hepatitis-B Forensic Barbiturates
Candidiasis Measles Identification Cocaine
Oral Squamous Mumps Tobacco
Cell
Carcinoma
Greabu M, Battino M, Mohora M, et al. Saliva--a diagnostic window to the body, both in health and in disease. Journal of Medicine and Life. 2009 77

Saliva can be used as a diagnostic tool for:
ENDOCRINE AUTOIMMUNE NEOPLASTIC

DISORDERS DISORDERS DISORDERS
Cushing’s Sjogren’s Ovarian Tumors
Sydrome Syndrome Breast Cancer
Diabetes Systemic Lupus
(Type1) Erythematosus

Saliva can be used as a diagnostic tool for
Greabu M, Battino M, Mohora M, et al. Saliva--a diagnostic window to the

body, both in health and in disease. Journal of Medicine and Life. 2009
Kaufman E, Lamster IB. The diagnostic applications of saliva--a review. Crit
Rev Oral Biol Med. 2002
79
Some Salivary Markers for disease
PRP, Salivary
albumin, Superoxide Dental caries
dismutase (SOD)
Salivary AST, ALT

periodontitis
and ALP
Total antioxidant lower in periodontal disease,

capacity (TAC) diabetics, smokers, oral cancer
lower in smokers, due to the

Salivary peroxidase cyanide ions present in
cigarette smoke.
80
Greabu M, Battino M, Mohora M, et al. Saliva--a diagnostic window to the body, both in health and in disease. Journal of Medicine and Life. 2009
Hegde MN, Attavar SH, Shetty N, Hegde ND, Hegde NN. Saliva as a biomarker for dental caries: A systematic review. J Conserv Dent. 2019.
Alzheimer disease
Salivary
AChE
activity
lower in smokers - caused by the oxidative stress

Salivary
GGT
lower in saliva from heavy smokers, oral cancer,

periodontitis and diabetic patients + periodontitis
Uric acid
levels
Saliva As a Diagnostic Tool for
Caries Risk Assessment
Saliva also finds its role in diagnosing and assessing caries.
Clinical examination of carious lesions with a probe and mirror, coupled with
radiographs, neither predicts caries activity nor a patient's susceptibility to dental
caries.
A reliable laboratory test for measuring caries activity offers a valuable adjunct
for patient motivation in a caries prevention programme.
82
Shafer's Textbook of ORAL PATHOLOGY Eighth Edition
Lactobacillus Colony Test
Patient
Lactobacillu
saliva +
Incubation s colony
Rogosa' s
assessment
medium
83
Colorimetric Snyder Test
Patient saliva + Change in colour

medium at: 24, 48, 72 hr
Media:
glucose+agar+bromocresol
green
pH=4.7-5.0
84
Swab Test
Swab from Result

buccal Incubation analysis
surfaces of for 48 hr using pH
teeth+ media indicator
pH Caries Activity
4.1 and Below Marked Caries Activity
4.2-4.4 Active
4.5-4.6 Slightly Active
4.6 and Above Inactive
85
Salivary Reductase Test
patient
saliva+indicator: Colour change
diazoresorcinol
86
Chair Side Caries Assessment
Saliva and bacterial plaque tests are conducted in order to

assess: Streptococcus mutans, Lactobacilli, saliva volume,
pH and buffer capacity. The results may predict future caries
experience and design suitable preventive protocol.
MEDICINE AND PHARMACY REPORTS 2019 87
VOL. 92 - Supplement No. 3 / S33 - S38

Testing the Level of Hydration
Values higher than 60 seconds indicate a low resting flow.
MEDICINE AND
PHARMACY REPORTS
2019 VOL. 92 -
Supplement No. 3 /
88
S33 - S38
pH Measurement
Collection of pH strip is Colour change

saliva placed is noted
Value Interpretation
5-5.8 Highly Acidic
6-6.6 Moderately Acidic
6.8-7.8 Healthy Saliva

Quantity of Saliva
Patient is asked Saliva is Amount of saliva

to chew wax collected collected in 5min

Buffering Capacity
Collection of
One drop in 3 Colour change
saliva via
test pad after 2 min
micropipette
MEDICINE AND PHARMACY

REPORTS 2019 VOL. 92 - 91
Supplement No. 3 / S33 - S38
SALIVA & COVID-19
Source of COVID-19 in Saliva  salivary

glands (via the ducts) or from the GCF
(gingiva) or secretions of the lower & upper
respiratory tract that combines with the
saliva
Vinayachandran D, Saravanakarthikeyan B. Salivary diagnostics in COVID-19: Future research implications. J Dent Sci. 2020;
Sabino-Silva R. et al. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clin Oral Invest. 2020
Before lung lesions emerge, SARS-CoV RNA can be found

in saliva  could account for asymptomatic infections &
associated COVID-19 spread  source of asymptomatic
infection could be salivary glands
Xu J. et al. Salivary glands: potential reservoirs for COVID-19 asymptomatic infection. J Dent Res. 2020
92
SALIVA & COVID-19
Epithelial oral cavity cells : ample expression of Angiotensin-
Converting Enzyme 2 (ACE2) receptor  plays a critical role in
allowing SARS-CoV-2 to enter the cells.
salivary glands – elevated ACE-2 expression : indicating that a target

for COVID-19 may possibly be salivary glands ~ significant
reservoir of virus
Baghizadeh Fini,
Maryam. “Oral saliva
and COVID-19.” Oral
oncology vol. 108
(2020):
The Rutgers Clinical Genomics
Laboratory TaqPath SARS-CoV-2 Assay
For Emergency Use Authorization (EUA) Only
• rT-PCR intended for the qualitative detection of nucleic acid from SARS-CoV-2 in
 oropharyngeal (throat) swab
 nasopharyngeal swab
 anterior nasal swab
 mid-turbinate nasal swab
 saliva specimens
• Collection of saliva specimens is limited to patients with symptoms of COVID-19 
should be performed in a healthcare setting under the supervision of a trained
healthcare provider using the Spectrum Solutions LLC SDNA-1000 Saliva Collection
Device.
94
METHODS OF COLLECTING SALIVA
WHOLE SALIVA PAROTID SALIVA
Suction Method Swabbing Method

MINOR GLAND SALIVA
SUBMANDIBULAR/
SUBLINGUAL SALIVA
• Suction method
• Cannulation
• Segregator method
95
Yamuna Priya K et al. Methods of collection of saliva - A Review. International Journal of Oral Health Dentistry; July-September 2017;3(3):149-153
Recent Techniques of Collection of Saliva
• most sophisticated technique, where preservatives are added to
Oragene protect sample integrity; used in genetic analysis/testing.
• uses collection tubes into which saliva is expectorated for a

Saligene predetermined volume, following which a plunger is placed to cap
the tube.
• collection through absorbent foam swab :picks up 1 mL of

saliva
• Micro tube incorporated - saliva is centrifuged directly into
Oracol final container  reduces risk of aerosol contamination
• beneficial where lab facilities not available  measles, HIV,
hepatitis A and B, mumps and rubella.
• utilises high quality immuno- chromatographic strips for delivery

Verofy
of immediate results. 96
Yamuna Priya K et al. Methods of collection of saliva - A Review. International Journal of Oral Health Dentistry; July-September 2017;3(3):149-153
SALIVA  interaction  RESTORATION
• Zinc Oxide Eugenol
Saliva  water  accelerates the setting of cement
Eugenolate rapidly hydrolyzes into free eugenol + Zn(OH)2 : hence it is

water-soluble
• Zinc Phosphate
Contamination should be avoided as it dissolves the cement
• Glass Ionomer
Initially water sensitivity – desiccation of cement
Saliva may act as a source of fluoride supply for GIC.

97
Phillips science of dental material, 12 th edition

AMALGAM: EFFECT OF MOISTURE CONTAMINATION
DELAYED EXPANSION
• When a zinc-containing low-copper or high-
Zn H2O copper amalgam is contaminated by moisture
during trituration or condensation, a large
expansion can take place.
Electrolytic
action • This expansion usually starts after 24 hrs,
reaches a peak within 3-5 days & may
continue for months reaching values >
400µm/cm.
Hydrogen
• Poor isolation of operative field  saliva 
main source of contamination
H2 does not combine with amalgam. It

collects within the filling
Internal pressure within filling

increases to high levels.
Creep  observed expansion

98
Phillips science of dental material, 12th edition

RESIN-BASED RESTORATION : EFFECT OF
SALIVARY CONTAMINATION
Isolation is very important for composite restorations.

Etching  loss of microporosities created: clogging with saliva,
ineffective action of acid on substrate  need to isolate, wash, retch
Bonding  prevents resin tag formation: re-etch, re-apply bonding
agent.
Salivary esterases : increase/ decrease internal and external
discoloration. The formation of acquired pellicle on the surface of a
material varies by the properties of the material, and the pellicle
interacts with denaturation agents, such as tannin and chlorhexidine,
to form stains and also adsorbs staining substances.
Lee, Y.-K., & Powers, J. M. (2006). Influence of salivary organic substances on the discoloration of esthetic dental materials—A review.
Journal of Biomedical Materials Research Part B: Applied Biomaterials. 99
XEROSTOMIA
- Dry mouth or pasties or cottonmouth
- Due to hyposalivation or absence of salivary secretion
Drugs : antihistamines, antidepressants, monoamine oxidase

inhibitors, anti-parkinsonian drugs and sympathomimetic/
anticholinergic drugs.
E
T Renal failure
I
Sjogren’s syndrome
O
L Severe dehydration
O
Radiotheraphy
G
Y Trauma to salivary glands or their ducts. 100
Signs and Symptoms Associated with Chronic Salivary Gland Hypofunction:
SIGNS SYMPTOMS
Dry, chapped lips; desiccated, dry and None (often may be asymptomatic)
fissured tongue
Difficulties in swallowing, chewing,
speaking
Angular cheilitis / pseudomembranous
and erythematous candidiasis Bad taste, breath
Dental caries (cervical & root caries Sore mouth, lips, tongue
particularly)
Burning sensations in mouth, lips, tongue
Gingivitis
Difficulty wearing removable prostheses
Frequent need to sip water for food
Frequent awakenings at night with dry mouth
Dry mouth, nose, and throat
101
Iorgulescu G. Saliva between normal and pathological. Important factors in
determining systemic and oral health. J Med Life. 2009;2(3):303-307.
Management
102
Villa, Alessandro et al. “Diagnosis and management of xerostomia and hyposalivation.” Therapeutics and clinical risk
management vol. 11 45-51.
SJOGREN’S SYNDROME
• Sjogren’s syndrome is a chronic autoimmune disorder characterized by xerostomia
(dry mouth), xerophthalmia (dry eyes), and lymphocytic infiltration of the exocrine
glands.
• Primary Sjogren’s syndrome – Sicca syndrome. It is an autoimmune disorder in

which the immune cells destroy exocrine glands such as lacrimal glands & salivary
glands .
• Secondary Sjogren’s syndrome –connective tissue disorders like SLE, scleroderma,

etc… are seen in addition.
103
Textbook of Oral Medicine, Oral Diagnosis and Oral Radiology Second Edition
Editors Ravikiran Ongole BDS, MDS
Diagnosis
• Conventional Sialography
• Biopsy
Textbook of Oral Medicine, Oral Diagnosis
and Oral Radiology Second Edition Editors
Ravikiran Ongole BDS, MDS
104
Management
• Frequent intake of water carried in small bottles and sipped through the day.
• Avoid alcoholic/ caffeinated beverages, fluids containing sugar and alcoholic

mouth rinses as these worsen the xerostomic symptoms.
SIALOGOGUES/ ARTIFICIAL SALIVA

• It is made up of carboxy methylcellulose/ hydroxyethyl cellulose.
• Designed to mimic natural saliva both chemically and physically.
• Acts by moistening and lubricating the oral cavity
• More effective and long lasting than simple rinses.
• Used before bed time and as desired throughout the day.
105
Sialorrhea
Sialorrhea or ptyalism is a condition characterized by increased salivary flow.
Etiology
Pathological Physiological
Neurological: Secretory phase of

Parkinson’s disease the menstrual cycle
Older aged
Infections: Rabies
individuals
Heavy metal
poisoning: Wilson
disease, mercury
poisoning
drugs: clozapine,
risperidone, lithium 106
and digoxin.
Clinical Features
episodes of increased salivary flow occurring 1 or 2 times
per week at 2–5 minutes in duration.
Management
 Botulism toxin injected into the
parotid gland
 Surgical techniques
107
Sialolithiasis, Salivary Duct Stone,
Salivary Calculi
Sialoliths are calcified bodies that develop within the
salivary gland or ductal system.
Etiology
These develop from the deposition of calcium salts around a
focus of material within the duct lumen.
108
 Age: young and middle-aged adults
 Site: submandibular gland (80–90%)
 Signs and symptoms:
Clinical o intermittent postprandial salivary gland
swelling
Features o persistent enlargement of gland
o size: 2 mm to 2 or more cm in diameter
 Occlusal Films
 Non-contrast CT
Diagnosis  Sialographs
 Ultrasound
109
Conclusion
• It is a reflection of the overall health status be it physical
or mental.
• Saliva plays a vital role in oral maintaining oral health.
• It is used as a diagnostic tool to diagnose not only the oral
pathologies but also for various systemic disorders and
infectious diseases that can be helpful in diagnosis,
prevention of diseases and monitoring the diseases
110

Saliva and Its Significance

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SALIVA

Salivary glands and saliva play a critical role in the

Orban’s Oral Histology & Embryology 13th Edition

Secretory end pieces Capsule surrounding

Orban’s Oral Histology & Embryology 13th Edition

Orban’s Oral Histology & Embryology 13th

Tencate’s Book of Oral Histology

Lesser Petrosal Nerve

Relay In Otic Ganglion

Introduction: the anatomy and physiology of salivary glands, Helen

Stimulation of parasympathetic nerves

Release of intracellular stores of Ca ions

Opening of Cl channels and intracellular movement of Cl

Pulls Na ions into the lumen

Movement of water into the lumen primary secretion

Saliva produced by secretory acini contain electrolytes such as Na

Orban’s Oral Histology & Embryology 13th Edition

Tencate’s Book of Oral Histology

Proline Rich Acidic PRPs will bind Ca with a strength  may be

Chitin - constituent of yeast

Beta- Broad May serve to link

responsible for S. mutans

Proteinase inhibiting properties

Due to the antimicrobial effects of the lactoperoxidase

Killing of bacteria, such as S. mutans

Plays a role in pellicle formation

Neutralization of potentially noxious substances :

Chelation of metal ions

Inhibition of inflammatory cytokine induction

Inhibition of host & bacterial proteinases : MMPs &

function as barriers and

Only salivary protein that

Inhibit microbial growth through competition

Calprotectin rises markedly in some inflammatory

Repair and ‘‘de novo’’

Calcium and phosphate neutralize

Depending on the pH, calcium is

Free ionized form is important in caries

supersaturated prevents facilitates

Loss of and ions

Release of minerals from bacteria,

Making the subsequent

• Spontaneous (asleep): 8 hr at 0.05 – 0.1 ml/ min = 25 ml

Consistency : slightly cloudy, due to presence of cells and mucin.

Orban’s Oral Histology & Embryology 13th Edition

usually slightly acidic (pH

Specific gravity 1.002 – 1.012

Freezing point 0.07 – 0.34ºC.

Orban’s Oral Histology & Embryology 13th Edition

UNCONDITIONED REFLEX CONDITIONED REFLEX

release of exocytosis of activates

Orban’s Oral Histology & Embryology 13th Edition

Lysozyme saliva kills some bacteria such as Staphylococcus,

These proteins  too large to penetrate enamel pores  remain on

Bathing of tooth Alteration of Salivary proteins

Selective adsorption Salivary Ca, PO4, Mg,

ORAL SALIVARY CLEARANCE

Interference with this process : bacterial

Enamel: 5.5 Low risk: serous

Dentin: 6.2-6.7 High caries: viscous

González-Cabezas C. The chemistry of caries:

Am. 2010 Jul;54(3):469-78

• High risk • High risk

Temel SS, Kaya B (2019) Diagnosis,