Introduction to the Introduction to the Salivary GlandsSalivary Glands

Dennis E. Lopatin, Ph.DDennis E. Lopatin, Ph.DDept. of Biologic & Materials SciencesDept. of Biologic & Materials Sciences

Even Science Even Science Fiction Has Fiction Has

Discovered the Discovered the Importance of Importance of

Saliva!Saliva!

Saliva in Oral Health: Protective Saliva in Oral Health: Protective FunctionsFunctions

LubricationLubrication

• Mucins, proline-rich glycoproteins, waterMucins, proline-rich glycoproteins, water AntimicrobialAntimicrobial

• Amylase, complement, defensins, lysozyme, Amylase, complement, defensins, lysozyme, lactoferrin, lactoperoxidase, mucins, cystatins, lactoferrin, lactoperoxidase, mucins, cystatins, proline-rich glycoproteins, secretory IgA, proline-rich glycoproteins, secretory IgA, secretory leukocyte protease inhibitor, statherin, secretory leukocyte protease inhibitor, statherin, thrombospondinthrombospondin

Saliva in Oral Health: Protective Saliva in Oral Health: Protective Functions (cont’d)Functions (cont’d)

Growth FactorsGrowth Factors

• Epidermal growth factor (EGF), transforming growth Epidermal growth factor (EGF), transforming growth factor-alpha (TGF-factor-alpha (TGF-), transforming growth factor-), transforming growth factor-alpha (TGF-alpha (TGF-), fibroblast growth factor (FGF), ), fibroblast growth factor (FGF), insulin-like growth factor (IGF-I & IGF-II), nerve insulin-like growth factor (IGF-I & IGF-II), nerve growth factor (NGF)growth factor (NGF)

Mucosal IntegrityMucosal Integrity

• Mucins, electrolytes, waterMucins, electrolytes, water

Saliva in Oral Health: Protective Saliva in Oral Health: Protective Functions (cont’d)Functions (cont’d)

Lavage/cleansingLavage/cleansing

• WaterWater BufferingBuffering

• Bicarbonate, phosphate ions, proteinsBicarbonate, phosphate ions, proteins RemineralizationRemineralization

• Calcium, phosphate, statherin, anionic proline-Calcium, phosphate, statherin, anionic proline-rich proteinsrich proteins

Saliva in Oral Health: Food and Saliva in Oral Health: Food and Speech-related functionsSpeech-related functions

Food PreparationFood Preparation• Water, mucinsWater, mucins

DigestionDigestion• Amylases, lipase, ribonuclease, proteases, water Amylases, lipase, ribonuclease, proteases, water

mucinsmucins TasteTaste

• Water, gustinWater, gustin SpeechSpeech

• Water, mucinsWater, mucins

Salivary Gland AnatomySalivary Gland Anatomy

Parotid GlandParotid Gland Submandibular GlandSubmandibular Gland Sublingual GlandSublingual Gland Minor GlandsMinor Glands

Major Salivary Major Salivary GlandsGlands

Parotid Parotid GlandsGlands

Submandibular Submandibular GlandsGlands

Structure Structure of the of the DuctsDucts

Salivary ConstituentsSalivary Constituents

Water & electrolytesWater & electrolytes ProteinsProteins Non-electrolytesNon-electrolytes Non-glandular Non-glandular

proteinsproteins

Components of Whole SalivaComponents of Whole Saliva Salivary glandsSalivary glands

• Water, proteins, electrolytes, small organic moleculesWater, proteins, electrolytes, small organic molecules Blood and blood derivativesBlood and blood derivatives

• Intraoral bleeding, gingival crevicular fluid (serum & Intraoral bleeding, gingival crevicular fluid (serum & inflammatory cells)inflammatory cells)

Extrinsic substancesExtrinsic substances• Food debris, toothpaste and mouth rinseFood debris, toothpaste and mouth rinse

Other fluidsOther fluids• Bronchial and nasal secretionsBronchial and nasal secretions

Lining cellsLining cells• Epithelial keratinsEpithelial keratins

MicrobiotaMicrobiota

Factors Contributing to Saliva ContentFactors Contributing to Saliva Content

Normal Human VariabilityNormal Human Variability Unstimulated vs. stimulated salivaUnstimulated vs. stimulated saliva AgingAging MedicationsMedications DiseaseDisease Circadian rhythmsCircadian rhythms Objective vs. subjective Objective vs. subjective

determinationsdeterminations

Human VariationsHuman Variations

Large range defines “normality”Large range defines “normality” A little goes a long wayA little goes a long way Changes over timeChanges over time

Normal Variations in Saliva OutputNormal Variations in Saliva Output

Unstimulated vs. Stimulated SalivaUnstimulated vs. Stimulated Saliva

UnstimulatedUnstimulated

• Basal productionBasal production

• Confers most protectionConfers most protection

• Importance of minor and submandibular outputImportance of minor and submandibular output

• Low output during sleeping hoursLow output during sleeping hours StimulatedStimulated

• Protection during masticationProtection during mastication

• Assists in deglutitionAssists in deglutition

• Importance of parotid outputImportance of parotid output

Circadian RhythmCircadian Rhythm

Effects of Aging on SalivaEffects of Aging on Saliva

QuantityQuantity

• No significant changes in major secretionsNo significant changes in major secretions

• No significant changes in minor secretionsNo significant changes in minor secretions QualityQuality

• No general changesNo general changes

Stimulated Parotid Flow Over TimeStimulated Parotid Flow Over Time

Assessment of Salivary FlowAssessment of Salivary Flow

Objective measures (Clinical tests)Objective measures (Clinical tests)

• Major gland secretionsMajor gland secretions

• Minor gland secretionsMinor gland secretions

• Whole salivaWhole saliva Subjective measures (Patient perceptions)Subjective measures (Patient perceptions)

• Xerostomia Xerostomia (Do you have a dry mouth?)(Do you have a dry mouth?)

• Questionnaires Questionnaires (Dry mouth, trouble swallowing?)(Dry mouth, trouble swallowing?)

• Thirst Thirst (Are you often thirsty?)(Are you often thirsty?)

Factors Affecting Salivary ProductionFactors Affecting Salivary Production

Local diseasesLocal diseases Systemic diseasesSystemic diseases MedicationsMedications Head and neck radiationHead and neck radiation ChemotherapyChemotherapy

Local Factors Affecting SalivaLocal Factors Affecting Saliva

Obstructive DiseasesObstructive Diseases

• Neoplasms, mucous plugs, calculiNeoplasms, mucous plugs, calculi Inflammatory DiseasesInflammatory Diseases

• Acute viral sialadenitis (myxovirus of mumps)Acute viral sialadenitis (myxovirus of mumps)

• Acute suppurative bacterial sialadenitisAcute suppurative bacterial sialadenitis

• Chronic recurrent sialadenitisChronic recurrent sialadenitis

• Allergic parotiditisAllergic parotiditis Head and Neck IrradiationHead and Neck Irradiation DietDiet

Sialadenitis: Inflammation of the Salivary GlandSialadenitis: Inflammation of the Salivary Gland

Bacterial Parotiditis: Inflammation of the Parotid GlandBacterial Parotiditis: Inflammation of the Parotid Gland

Medications Influence SalivaMedications Influence Saliva

Anti-cholinergicsAnti-cholinergics Anti-histaminesAnti-histamines Anti-depressants, antipsychoticsAnti-depressants, antipsychotics Sedative and hypnotic agentsSedative and hypnotic agents Anti-hypertensivesAnti-hypertensives Anti-Parkinson drugsAnti-Parkinson drugs

Oral Side-Effects of Prescribed DrugsOral Side-Effects of Prescribed Drugs

RG Smith & AP Burtner, 1994RG Smith & AP Burtner, 1994

Xerostomia - Dry mouthXerostomia - Dry mouth

Dysgeusia - Impairment of tasteDysgeusia - Impairment of taste

Stomatitis - Inflammation of oral mucous Stomatitis - Inflammation of oral mucous membranesmembranes

Glossitis - Inflammation of tongueGlossitis - Inflammation of tongue

Systemic Diseases That Influence SalivaSystemic Diseases That Influence Saliva

Sjögren’s syndromeSjögren’s syndrome Sarcoidosis Sarcoidosis (a systemic granulomatous disease, (a systemic granulomatous disease,

especially of lungs, but affecting many other organs, especially of lungs, but affecting many other organs, including parotid glands)including parotid glands)

Cystic fibrosisCystic fibrosis DiabetesDiabetes Alzheimer’s diseaseAlzheimer’s disease AIDSAIDS DehydrationDehydration

Submandibular Duct Obstruction 2° to InfectionSubmandibular Duct Obstruction 2° to Infection

Head and Neck RadiationHead and Neck Radiation

Parotid vs. SubmandibularParotid vs. Submandibular Dysfunction is dose- and field-dependentDysfunction is dose- and field-dependent Threshold of permanent destruction: 2100-Threshold of permanent destruction: 2100-

4000 cGy4000 cGy

Salivary Flow Following Radiation Salivary Flow Following Radiation TherapyTherapy

ChemotherapyChemotherapy

Alters salivary constituentsAlters salivary constituents Normal function returnsNormal function returns Bone marrow transplantation: graft vs. host Bone marrow transplantation: graft vs. host

diseasedisease

Salivary Dysfunction and Oral SequelaeSalivary Dysfunction and Oral Sequelae

CariesCaries MucositisMucositis Oral ulcerationOral ulceration TasteTaste SwallowingSwallowing DenturesDentures InfectionsInfections

Salivary Dysfunction and Oral Sequelae: Salivary Dysfunction and Oral Sequelae: CariesCaries

Incipient decayIncipient decay Recurrent decayRecurrent decay Root vs. coronal decayRoot vs. coronal decay

Extensive Caries in a post-radiation patientExtensive Caries in a post-radiation patient

Caries in a xerostomic individualCaries in a xerostomic individual

GlossitisGlossitis

MucositisMucositis

CariesCaries

Salivary Dysfunction and Oral Sequelae: Salivary Dysfunction and Oral Sequelae: MucositisMucositis

PainPain InfectionsInfections DysphagiaDysphagia Impaired nutritionImpaired nutrition DehydrationDehydration

MucositisMucositis

Salivary Dysfunction and Oral Sequelae: Salivary Dysfunction and Oral Sequelae: Oral UlcerationOral Ulceration

Wound healingWound healing Lichen planusLichen planus Recurrent aphthous ulcers Recurrent aphthous ulcers PainPain Secondary infection (Candidiasis)Secondary infection (Candidiasis)

Xerostomia: Dry Fissured TongueXerostomia: Dry Fissured Tongue

Salivary Dysfunction and Oral Sequelae: Salivary Dysfunction and Oral Sequelae: TasteTaste

Reduced enjoyment of eatingReduced enjoyment of eating Altered supra-threshold and threshold Altered supra-threshold and threshold

performanceperformance

• Sucrose, sodium chlorideSucrose, sodium chloride

• Citric acid, quinine sulfateCitric acid, quinine sulfate

Salivary Dysfunction and Oral Sequelae: Salivary Dysfunction and Oral Sequelae: SwallowingSwallowing

Subjective complaints of dysphagiaSubjective complaints of dysphagia Increased duration in oral swallow Increased duration in oral swallow

timestimes

• Dry swallowsDry swallows

• Wet swallowsWet swallows

Salivary Dysfunction and Oral Sequelae: Salivary Dysfunction and Oral Sequelae: DenturesDentures

Decreased retention and stabilityDecreased retention and stability Increased complaintsIncreased complaints Greater likelihood for Greater likelihood for CandidaCandida infections infections

Salivary Dysfunction and Oral Salivary Dysfunction and Oral Sequelae: InfectionsSequelae: Infections

CandidiasisCandidiasis CariesCaries GingivitisGingivitis Viral infectionsViral infections BacteremiasBacteremias Aspiration Aspiration

pneumoniapneumonia

Candida 7th Week Following Tonsil Candida 7th Week Following Tonsil Radiation TreatmentRadiation Treatment

Candida/Denture StomatitisCandida/Denture Stomatitis

Saliva and Oral health: ConclusionsSaliva and Oral health: Conclusions

Saliva in healthSaliva in health Saliva in diseaseSaliva in disease Prevention of diseasePrevention of disease Treatment of diseaseTreatment of disease

Saliva deficientSaliva deficient