saliva as an important source of investigation xerostomia cases nd traetment.. prosthodontic approach!!

1. SALIVARY GLAND
AND SALIVA
BY PRIYANKA MAKKAR
1ST yr PG
1

2.  It is critical to the preservation and maintenance of
oral health, yet it receives little attention until
quantity or quality is diminished.
 Saliva also has become useful as a noninvasive
systemic sampling measure for medical diagnosis
and research.
2

3.  Saliva is a clear, slightly acidic mucoserous
exocrine secretion.
 Whole saliva is a complex mix of fluids from
major and minor salivary glands and from
gingival crevicular fluid, which contains oral
bacteria and food debris.
3

4.  Its status in the oral cavity is at par with that
of blood i.e. to remove waste,supply
nutrients and protect the cells
4

5. Classification of salivary gland
 Salivary Gland is any cell or organ discharging a
secretion into the oral cavity.
• Major and minor Salivary Glands
 Major (Paired)
 Collection of secretory cells aggregated into
large bilaterally paired extra oral glands with
extended duct system through which the gland
secretions reach the mouth.
- Parotid
- Submandibular
- Sublingual 5

6.  Minor salivary glands
 Collection of secretory cells scattered
throughout the mucosa & submucosa of the
oral cavity with short ducts opening directly
onto mucosal surface.
- Serous glands of Von Ebner.
- Anterior lingual glands.
- Lingual, buccal, labial, palatal
glands, glossopalatine and retromolar
glands
6

7. 2. Based on type of secretory cells
1. Serous : Parotid
2. Mixed (seromucous): Submandibular
3. Mucous: Minor salivary glands.
7

8. 8

9. Salivary gland anatomy
Parotid gland:
 Largest of all the salivary glands
 Purely serous gland that produce thin,watery amylase rich saliva
 Superficial portion lies in front of external ear & deeper portion
lies behind the ramus of mandible
 Stensen's Duct (Parotid Papilla)
 Opens out adjacent to
maxillary second molar
9

10.  Superficial portion of gland is located
subcutaneously, in front of the external ear
& deeper portion lies behind ramus of
mandible.
 Associated with facial nerve
10

11. Submandibular gland
 Second largest salivary gland
 Mixed gland
 Located in the posterior part of floor of
mouth,adjacent to medial aspect of mandible &
wrapping around the posterior border of
mylohyoid muscle
 Wharton's Duct
 Opens beneath the tongue at sub-lingual caruncle
lateral to the lingual frenum
11

12. 12

13. Sublingual gland:
 Smallest salivary gland
 Mixed gland but mucous secretory cells predominate
 Located in anterior part of floor of mouth between the
mucosa and mylohyoid muscle
 Opens through series of small ducts (ducts of rivinus)
opening along the sub-lingual fold & often through a
larger duct(bartholin’s duct) that opens with the
wharton’s duct at the sub-lingual caruncle
13

14. Minor Salivary gland:
 No. between 600 and 1000.
 Exist as aggregates of secretory tissue
present in submucosa throughout most of
the oral cavity.
 Not seen in gingiva & anterior part of hard
plate.
14

15.  Rich in mucin, antibacterial proteins and
secretory immunoglobulin.
 Continuous slow secreting glands, thus have
a important role in protecting and
moistening oral mucosa, especially when
major salivary glands are mostly inactive.
15

16. Von Ebners’s Lingual serous gland
 Located in tongue and open into the troughs
surrounding circumvallate papillae on the
dorsum of tongue and at the foliate papillae
on the side of tongue.
 Secrete digestive enzymes & proteins that
are thought to play role in taste process
 Fluid of their secretion cleanse the trough &
prepare the taste receptors for a new
stimulus.
16

17. DEVELOPMENT OF GLANDS
 All salivary glands show a similar pattern of
development.
MESENCHYME
ORAL
EPITHELIAL
BUDS
ECTODERMAL ENDODERMAL
PAROTID GLAND AND
MINOR SALIVORY GLANDS
SUBMANDIBULAR AND
SUBLINGUAL GLAND
17

18. The Primordia of the glands of humans appear
during sixth week whereas the primordium of
sublingual glands appear after 7 to 8 weeks of fetal
life.
The minor salivary glands begin their development
during the third month. The epithelial bud grows
into an extensively branched system of cords of
cell that are first solid but gradually develop a
lumen and become ducts.
18

19. DEVELOPMENT OF SALIVARY GLANDS
Bud formation
Formation and growth of epithelial chord.
Initiation of branching in terminal parts of epithelial chord.
Branching of epithelial chord and lobule formation
Canalization
Cytodifferentiation
Stage I
Stage II
Stage III
Stage IV
Stage V
Stage VI
19

20. Epithelium protrudes into underlying
ectomesenchyme & as the epithelium invaginates
, it forms a small bud connected to the surface by
trailing cord of epithelium - Initial bud stage.
At the same time , ectomesenchyme cells
condense around this bud.
The bud undergoes branching to produce a cluster
of branches & buds, -known as Pseudoglandular
Stage 20

21.  Since salivary glands are formed from an
initially solid core of epithelial cells –for the
proper functioning of the gland the duct
needs to undergo cavitation -to allow free
access between the saliva producing acini
and oral cavity.- known as Canilicular
Stage.
21

22. 22

23.  Minor salivary glands are the most
important because of their protective
components.
 Major glands do produce more saliva than
minor glands, but the quality of content and
thus the type of protection varies.
23

24. The parotid glands normally contribute about
25% of the total volume of unstimulated whole
saliva, while the submandibular glands contribute
60%, the sublingual 7–8%, and the minor mucous
glands 7–8%.
At very high stimulated flow rates, the parotid
becomes the dominant gland, contributing about
50% of the whole saliva. 24

25. Flow rate (ml/min)
WHOLE PAROTID SUBMANDIBULAR
RESTING 0.2-0.4 0.04 0.1
STIMULATED 2.0-5.0 1.0-2.0 0.8
pH 6.7-7.4 6.0-7.8
25

26. 0.0
0.1
0.2
0.3
0.4
0.5
20-39 yr 40-59 yr > 60 yr
ml/min
Age
Flow Rate of Saliva
unstimulated
stimulated
26

27.  The average daily flow of whole saliva
varies in health between 1 and 1.5 L.
27

28. ANATOMY OF GLANDS
Secretory units are composed of serous,
mucous and myoepithelial cells arranged into
secretory tubules called-acini.
Serous cell specialised for the synthesis,
storage and secretion produce protein &
glycoprotein ( typically N linked )
28

29.  Mucous cell produce mucin , glycoprotein (
typically O linked ) & function mainly to
lubricate & form barrier against micro-
organism.
29

30. THE SECRETORY UNIT
The basic building block of all salivary glands
 ACINI - water and
ions derived from
plasma
 Saliva formed in acini flows
down DUCTS to empty into
the oral cavity.
30

31. The Secretory Unit
31

32. SEROUS CELLS
Typically spherical in shape .
8-12 cells .
Cells are pyramidal in shape, with its broad base
resting on a thin basal lamina and its narrow apex
bordering on the lumen of end piece.
The spherical nucleus is located in the basal
region of the cell. 32

33.  secrete a watery fluid, essentially devoid of
mucous
 contain zymogen granules containing a
precursor of ptyalin enzyme for digesting
starches
33

34. MUCOUS CELLS
 Polyhedral & Contain mucinogen granules.
(1) they have little or on enzymatic activity
and serve for lubrication and protection of the
oral tissues
(2) the ratio of carbohydrate to protein is
greater, and larger amounts of sialic acid and
sulphated sugar residues are present. 34

35. DUCTS
35

36. 36

37. Intercalated ducts
 The small ducts are intercalated ducts; they are
thin branching tubes of variable length that
connect to the terminal secretory units to the
next larger ducts.
Primary saliva produced by secretory end piece
passes first thorough intercalated ducts.
Diameter of these ducts are smaller 37

38. The intercalated ducts cells often contain
secretory granules in their apical cytoplasm,
and two of the antibacterial proteins in saliva,
lysozyme and lactoferrin, have been localized
to these ducts.
38

39. STRIATED DUCTS
 Constitute largest portion of ductal system
located within lobules of Salivary glands .
The striated duct cells contain kallikrein, an
enzyme found in saliva, and synthesize
secretory glycoproteins, which are stored in
the apical granules.
39

40. EXCRETORY DUCTS
 Located in connective tissue septa between
lobules of gland
Larger in diameter then striated duct .
40

41. Regulation of saliva secretion
Afferent signals from sensory receptors in mouth
Trigeminal,facial,glossopharyngeal
nerves
Salivary nuclei in the medulla oblongata of brain
Parasympathetic nerve bundle sympathetic nerve bundle
salivary glands
41

42.  Innervation
o Parasympathetic innervation to major salivary
glands
• Otic ganglion fibers supply Parotid Gland
• Submandibular ganglion supplies other major glands
o Sympathetic innervation promotes saliva flow
• Stimulates muscle contractions at salivary ducts
42

43.  Saliva secretion is also controlled by the conditioned
reflexes(by sight,smell or thought of food).
 Besides receiving impulses from the afferents,the salivary
nuclei also receives impulses from higher centers of brain
which leads to release of variety of neurotransmitters resulting
in facilatory or inhibitory effects
 As a result of such control,unstimulated salivation is inhibited
during sleep,fear & mental depression
 Stress may increase or decrease salivary flow
43

44. Salivary secretion:two step model
 Formation of primary saliva:
• Initiated by binding of neurotransmitters in the acinar cell
membranes
• Acinar cell loses K⁺ to the interstitium & Cl⁻ to the lumen
• Gain of Cl⁻ creates negative potential in the lumen,driving
interstitial Na⁺ into lumen thereby restoring
electroneutrality
• Water flux follws the movement of salt into the lumen for
osmotic reasons,resulting in acinar cell shrinkage
• Outcome is the formation of isotonic primary saliva
44

45. • At high flow rates,saliva is in
contact with the ductal
epithelium for shorter time &
Na⁺ & Cl⁻ concentration
increase & K⁺ concentration
decrease
• At low flow rates,the
electrolyte concentration
change in the opposite
direction
• The HCO₃⁻ concentration
increases with increased flow
rates,reflecting the increased
secretion of HCO₃⁻ by the
acinar cells to drive fluid
secretion acini
ducts
Na+
K+
Cl-
HCO3
-
45

46. saliva
Water -99% solids 1%
Organic substance Inorganic substance
Gases
Enzymes Other org. substance
1.amylase 2maltase
3lingual lipase
4lysozyme
5phosphatase
6carbonic
anhydrase
7kalikrein
1.Proteins- mucin & albumin
2.Blood group antigen
3.Free amino acids
4.Non protein nitrogenous
substances-urea,uric
acid,creatinine,xanthine
hypoxanthine
1.Sodium
2.Calcium
3.Potassium
4.Biocarbonate
5.Bromide
6.Chlorine
7.Fluoride
8.phosphate
1.Oxygen
2.Carbon
dioxide
3.Nitrogen
46

47. COMPOSITION OF
SALIVA
47

48. Inorganic components
Saliva compositon
48

49.  Calcium and Phosphate
 Hydrogen bicarbonate
 Other ions are:-
Fluoride
Thiocynate
Sodium,Potassium,Chloride
Lead,Cadmium,Copper
49

50. Organic components
Saliva composition
50

51. Organic components of saliva Mucins
 Proline-rich proteins
 Amylase
 Lipase
 Peroxidase
 Lysozyme
 Lactoferrin
 Secretory IgA
 Histatins
 Statherin
 Blood group substances, sugars, steroid hormones, amino
acids, ammonia, urea
51

52. Multifunctionality
Salivary
Functions
Anti-
Bacterial
Buffering
Digestion
Mineral-
ization
Lubricat-
ion &Visco-
elasticity
Tissue
Coating
Anti-
Fungal
Anti-
Viral
Carbonic anhydrases,
Histatins
Amylases,
Mucins, Lipase
Cystatins,
Histatins, Proline-
rich proteins,
Statherins
Mucins, Statherins
Amylases,
Cystatins, Mucins,
Proline-rich proteins, Statherins
Histatins
Cystatins,
Mucins
Amylases, Cystatins,
Histatins, Mucins,
Peroxidases
52

53. MAJOR FUNCTIONS OF SALIVA
1.PROTECTION:
 Mechanical washing action:
- Flushes away non-adherent bacterial and acellular debris
from the mouth.
-Clearance of sugars from the mouth limits their
availability to acidogenic plaque microorganisms.
 Lubricant: (mucin)
- Protects the lining mucosa by forming a barrier against
noxious stimuli, microbial toxins and minor trauma.
- Allows the oral surface to move one another with minimal
friction during function.
2.BUFFERING:
 Bicarbonate ,phosphate, some salivary proteins.
Metabolism of salivary proteins and peptides produce
ammonia and urea which help in increase of pH.
 Buffers the acid produced by plaque microorganism. 53

54. 3.Pellicle formation:
 Salivary proteins bind to surface of the teeth and oral
mucosa, thus forming salivary pellicle which behaves
as a protective membrane .
 Binding site for bacteria – plaque.
4.MAINTAINENCE OF TOOTH INTEGRITY:
 Saliva is saturated with Ca+ & PO4- : acidic prolein rich
proteins & statherin
 High concentration of these ions ensures that ionic
exchange with the tooth surface results in post eruptive
enamel maturation, increase in surface hardness,
decrease in permeability and increase in resistance to
demineralization.
 Remineralization of initial caries.
54

55. 5.ANTIMICROBIAL ACTION:
 Lysozyme is an enzyme that can hydrolyse the
cell wall of some bacteria.
 Lactoferrin binds free iron & in doing so
deprives bacteria of this essential element.
 Antibodies present in saliva (IgA)
-has the capacity to agglutinate
microorganisms that are swallowed.
-prevent their agglutination to oral tissue.
 Mucin and specific agglutins: aggregate
microorganisms.
 Histatin and peroxidase 55

56. 6.ROLE OF SALIVA IN TISSUE REPAIR:
 Bleeding time of oral tissues is shorter than other tissues.
 Experiment have shown that wound healing is faster &
wound contraction is also increased in the presence of
saliva.
7.DIGESTION:
 Forms the food bolus-preparation of the ingested food for
deglutition.
 Breaks down starch (Amylase).
 Lipase
 Dilutes gastric chyme.
8.TASTE:
 Saliva is required to dissolve substance to be tasted &
carry them to the taste buds.
 It also contains a protein called gustin that is thought to
be necessary for growth & maturation of the taste buds. It
is thought to be secreted by circumvallate papillae.
56

57. 8.Salivary anticaries activity:
 Carbohydrate & microbial clearance from the oral
cavity.
 Buffering action - Salivary bicarbonates.
 Remineralization of incipient carious lesion-Ca+,
PO4
+, Fl-
 Increase enamel resistance to acid decalcification-
Fl-
 Salivary urea and bicarbonate can increase rate of
glycolysis, thus leading to faster carbohydrate
metabolization, which inturn leads to reduced
duration of the enamel exposure to critical pH
levels.
57

58. Functions in detail according to
its composition
Calcium and phosphate
 Help to prevent dissolution of dental enamel
 Calcium
• 1.4 mmol/lt. (1.7 mmol/lt. in stimulated saliva)
• 50% in ionic form
• sublingual > submandibular > parotid
 Phosphate
• 6 mmol/lt. (4 mmol/lt. in stimulated saliva)
• 90% in ionic form
 pH around 6 - hydroxyapatite is unlikely to dissolve
 Increase of pH - precipitation of calcium salts =>
dental calculus 58

59. Hydrogen Bicarbonate
 Buffer
 Low in unstimulated saliva, increases with
flow rate
 Pushes pH of stimulated saliva up to 8
 pH 5.6 critical for dissolution of enamel
 Defence against acids produced by cariogenic
bacteria
 Derived actively from CO2 by carbonic
anhydrase Helps to protect the teeth from
demineralization caused by bacterial acids
produced during sugar metabolism. 59

60. Mucins
 Products of acinar cells from submandibular,sublingual and
some minor salivary glands.
 Asymmetrical molecule with open, randomly organized
structure
 Glycoproteins - protein core with many oligosaccharide side
chains attached by glycosidic bond
 Hydrophillic
 Unique rheological properties (e.g., high elasticity,
adhesiveness, and low solubility)
60

61. Major salivary mucins are:
 MG1-adsorbs tightly to the tooth surface contributing
to the enamel pellicle formation, thereby protecting
the tooth surface from chemical & physical attack
including acidic challenges
 MG2-also binds to the tooth surface but is easily
displaced, however it promotes clearance of oral
bacteria by aggregation
61

62. Amylases
 Produced by acinar cells of major salivary glands
 Metabolizes starch and other polysaccharides into glucose &
maltose
 Calcium metalloenzyme
 Parotid; 30% of total protein in parotid saliva
 “Appears” to have digestive function - inactivated in stomach,
provides disaccharides for acid-producing bacteria
 It is also present in tears, serum, bronchial, and male and
female urogenital secretions
 A role in modulating bacterial adherence
62

63. Lingual Lipase
 Secreted by sublingual gland and parotid
gland
 Involved in first phase of fat digestion
 Hydrolyzes medium to long chain
triglycerides
 Important in digestion of milk fat in
newborn
 Unlike other mammalian lipases, it is
highly hydrophobic and readily enters fat
globules
63

64. Statherins
 Produced by acinar cells in salivary glands
 Acidic peptide containing relatively high levels of
proline,tyrosine and phosphoserine
 Inhibits spontaneous precipitation of calcium
phosphate salts from supersaturated saliva & favours
remineralization
 Calcium phosphate salts of dental enamel are soluble
under typical conditions of pH and ionic strength
64

65.  Supersaturation of calcium phosphates maintain
enamel integrity
 Also an effective lubricant for the tooth surface thus
protecting it from physical forces
65

66. Proline-rich Proteins (PRPs)
 Like statherin, PRPs are also highly
asymmetrical
 Present in the initially formed enamel
pellicle and in “mature” pellicles
 2 types:
 Basic
 Acidic
 Both are secretory products of major
salivary glands 66

67. Lactoferrin
 Iron-binding protein
 Prevents iron from being used by microorganism that
require it for metabolism
 Nutritional immunity (iron starvation)
 Some microorganisms (e.g., E. coli) have adapted to
this mechanism by producing enterochelins.
• bind iron more effectively than lactoferrin
• iron-rich enterochelins are then reabsorbed by
bacteria
 Lactoferrin, with or without iron, can be degraded by
some bacterial proteases.
67

68.  CHEMICAL BENEFITS OF SALIVA
STIMULATION
• Stimulating the flow of saliva alters its
composition. Increases the concentration of
protein, sodium, chloride and bicarbonate and
decreases the concentration of magnesium and
phosphorus.
• Perhaps of greatest importance is the increase in
the concentration of bicarbonate, which increases
progressively with the duration of stimulation.
The increased concentration of bicarbonate
diffuses into the plaque, neutralizes plaque acids,
increases the pH of the plaque and favors the
remineralization of damaged enamel and dentin
68

69.  Studies have shown that chewing sugar-free
gum after meals results in a significant
decrease in the incidence of dental caries and
that the benefit is due to stimulating salivary
flow rather than any chewing gum ingredient.
 Stimulating salivary flow after meals reduces
the incidence of dental caries
so,its practical measures should be considered
in caries prevention programs
69

70. Saliva:A Diagnostic Fluid
 ADVANTAGES:
• non-invasive
• limited training
• no special equipment
• potentially valuable for children and older
adults
• cost-effective
• eliminates the risk of infection
• screening of large populations
70

71. Testing of saliva production
 Unstimulated production – collection of saliva into
container during 15 min
 Stimulated production – collection of saliva during 5
min of chewing 1g paraffin
 Unstimulated whole saliva flow rates of <0.1
ml/min. and stimulated whole saliva flow rate’s of
<1.0 ml/min. are considered abnormally low&
indicative of marked salivary hypofunction.
71

72.  Recent work in Sjogren syndrome is beginning
to identify changes in salivary cytokine &
other protein levels that may have diagnostic
significance .
 Saliva may play a greater diagnostic role
in monitoring for the presence and
concentrations of drugs of abuse and
therapeutic agents.
72

73. SALIVA COLLECTION
METHODS
73

74. 74

75. SUBMANDIBULR /SUBLINGUAL
Alternatively , for et al have described a
simpler method for the collection of
submandibular-sublingual.
After blocking the parotid saliva secretion
by placing a gauze pad at the orifice of the
parotid ducts. Saliva can be collected from
the floor of the mouth with a micropipette.
75

76. MINOR GLANDS
Minor gland secretions 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 Peritron
device.
76

77. Pathology related to salivary glands
77

78. Hypofunction of salivary glands
Clinical evaluation
 Patient’s complaints:
• Oral dryness and soreness
• Burning sensation of oral mucosa and tongue
• Difficulties in speech
• Difficulty in chewing dry food
• Taste impairment and disturbances
• Difficulties in wearing removable dentures
• Dry lips
• Acid reflux,nausea,heart burn
• Sensation of thirst
• The oral symptoms are often associated with other symptoms
such as dry skin,dry nose,dry eyes,dry vaginal mucosa,dry
throat,dry cough and constipation 78

79.  Signs:
• Mucosal dryness:dry glazed and red oral mucosa
• Lobulation and fissuring of the dorsal part of
tongue
• Atrophy of filiform papillae
• Dry lips,angular cheilitis
• Increased caries experience
• Oral candidiasis
79

80. Xerostomia
It is a clinical manifestation of salivary gland dysfunction
and it does not represent a disease entity .Dry mouth varies
from minimal viscous appearance of saliva to complete
absence of any salivary flow.
 More prevalent in women.
 Can cause significant morbidity and a reduction in a
patient’s perception of quality of life.
 When unstimulated salivary flow is less than 0.12 to 0.16
ml/minute, a diagnosis of hypofunction is established.
80

81. Etiology
 Aging
 Foods:alcohol, coffee, coco cola, smoke
 Drugs:
• Anti-depressants
• Anti-histamine
 Cimitidine
• Anti-cholinergic
• Anti-HTN (sympathomimetic drugs)
• Anti-inflammatory
 Systemic factors
• Emotions: nervousness , excitation, depression, stress..
• Encephalitis, brain tumors, stroke, Parkinson’s disease
• Dehydration: diarrhea, vomiting, polyuria of diabetes …
• Anemia, nutrition deficiency.
81

82. Etiology
 Radiotherapy
• Acini atrophy fibrosis or replaced by fatty tissue
• Serous acini: more sensitive to R/T
• Saliva: thickened, altered electrolytes, pH↓,
secretion of immunoglobulins↓
• >1000rad (2-3wk): felt oral dryness
• >4000rad: irreversible change
 Sjogren’s syndrome
 Other salivary gland diseases
82

83. Antidepressants
 As used to treat depression but blocked
histaminic,cholinergic and alpha-1-
adrenergic receptors sites,causes the
unwanted side effects called dry mouth.
Eg:-citalopram (celexa)
escitalopram (laxapro)
83

84. Antipsychotics
 Relative anticholinergic potential of
selected antipsychotics:
 Eg:- Promazine,triflupromazine,clozapine.
Chlorpromazine,pimozide.
84

85. Antihistaminic drugs
 Relative potencies for anticholinergic
effects of these drugs are:
 Eg:-Diphenhydramine,promethazine
 Chlorphenarimine,hydroxyzin
85

86. Analgesics
 Immediate release of oxycodone
causes more oral dryness
than sustained release.
86

87.  Radiotherapy
 chemotherapy
87

88. Trauma or surgery
 Trauma to the mouth
or throat
 Nerve damage to the
head and neck
88

89. Need of sialogogues
 Required in case of reduced salivary
secretion,commonly that condition is known as
dry mouth or xerostomia.
 Seen in all age groups but common in
elders,30%of people beyond 60 yrs experience
this disorder.
89

90. Symptoms & Signs
 Symptoms:
• Oral dryness (most common)
• Halitosis
• Burning sensation
• Loss of sense of taste or bizarre taste
• Difficulty in swallowing
• Tongue tends to stick to the palate
• Decreased retention of denture
90

91.  Signs:
• Saliva pool disappear
• Mucosa: dry or glossy
• Duct orifices: viscous and opaque saliva
• Tongue:
glossitis  fissured  red with papilla atrophy
• Angular cheilitis
• Rampant caries: cervical or cusp tip
• Periodontitis
• Candidiasis
91

92.  Clinical Appearance:
• Oral mucosa appears dry, pale, or atrophic.
• Tongue may be devoid of papillae with fissured
and inflamed appearance.
• New and recurrent dental caries.
• Difficulty with chewing, swallowing, and tasting
may occur.
• Fungal infections are common.
92

93. Pale Fisured Tongue Due To
Severe Dry Mouth
93

94. Moderate Xerostomia
94

95. Severe Dry Mouth
(Strawberry Tongue)
95

96.  One of the major problems associated with
xerostomic patients is the poor tolerance
and retention of removable dental
prostheses because of thin dry atrophic
mucosa and lack of a saliva film.
 Combined with oral discomfort and loss of
taste acuity it causes increase caries
incidence, burning sensation and problem
during speech
Problem
96

97.  The use of salivary substitutes can improve lubrication,
provide irrigation for dry mucosa, provide significant relief
from symptoms, and also improve the retention of removable
prostheses. They are three types-glycerine and lemon based,
carboxymethylcellulose, based on mucin even milk can be
used as saliva substitute.
 Management should be directed toward relief of symptoms.
 These substitutes can be delivered over prolonged periods by
using saliva reservoirs in the prosthesis itself as it is difficult
to carry salivary substitutes all the time.
Intervention
97

98. Implications
in
Prosthodontics
98

99. Retention Of Denture
 Salivary wetting mechanics are necessary to
create adhesion,cohesion and surface
tension that helps in retention of denture
 ADHESION:is the bond created by saliva
between oral mucosal epithelium and
denture base.Thin film of saliva hold the
denture to mucosa.
 Amount of adhesion present is directly
proportional to denture base area.
99

100.  COHESION is the bond between salivary
components that helps in retention of
prosthesis.Watery serous saliva forms a
thinner film and is more cohesive than thick
serous saliva.
100

101. Viscosity of saliva
 It also determines denture retention.
 Serous saliva has a moderate flow favorably
contributes to retention.
 Thick ropy saliva often forces the denture
out of their position thus providing a
detrimental factor for retention.
101

102.  Saliva allows for the vaccum pressure
formation that contributes to the fit of
prosthesis.
 Adequate amount,flow and consistency of
saliva ensures the optimal denture
functioning by providing the fit,support and
stabilization of the denture
102

103. In CD patients
 Saliva is required to make a intimate surface
between denture and soft tissues
 Keeps the denture in stable position
 Helps in providing the retention
 Tissue contacting denture will become irritated in
absence of adequate amount of saliva.
 Denture sores can occur in case of
hyposalivation
103

104. Dry mouth is managed in
following ways
 By treating the drug induced xerostomia.
 Salivary substitutes.
 Sialagogue herbs.
104

105. How to treat drug induced
xerostomia
 Following ways can be used to modify
patient intake of xerogenic drugs:
1.elimination and reduction of select drugs.
2.modification of drug intake schedule.
3.substitution of one drug with another with
less noxious effects.
105

106.  For antidepressants:
Newer multiple receptors antidepressants
are less xerogenic than tricyclics:
Eg.nefazodone,mirtazapine.
 Anticholinergics/antispasmodics:
Tolterodine tartarate is less xerogenic than
oxybutynin chloride.
106

107. When drug therapies are not
enough….
 When it is impossible to determine or
eliminate the cause of oral dryness or drugs
will do minimally help,then attempts are
made to stimulate the patient saliva by Use
of SIALAGOGUES or
 to moisturize the oral mucosa by
Use of SALIVARY SUBSTITUTES/
ORAL MOISTURIZERS.
107

108. Salivary stimulants….
 A) mechanical
 B) electrical
 C) pharmacological
 D) chemical
108

109. a) Mechanical stimulants…
Sugarless Gums
like Biotene,Eclipse,Extra,Orbit has
Xylitol,Sorbitol,mannitol
Acesulfame,Aspartame etc…
109

110. b) Electrical stimulants..
 Salitron:- Proponents of electro stimulation
as a treatment option postulate that
stimulating the tongue and the roof of the
mouth simultaneously will result in
impulses to all residual salivary tissues,
major and minor, in the oral and pharyngeal
regions, thus causing salivation.
110

111. Pharmacological stimulants…
 Cholinergic drugs like PILOCARPINE
HCL(salagen) and CEVIMELINE HCL
(evoxac)
111

112.  Pilocarpine is also used to treat
xerostomia which can occur, for
example, as a side effect
of radiationtherapy for head and neck
cancers, and in Sjogren's syndrome.
Pilocarpine stimulates the secretion of
large amounts of saliva and sweat.
 Dose : 5 mg four times a day
112

113.  Pilocarpine has been known to cause excessive
sweating, excessive salivation, bronchospasm,
increased
bronchial mucus secretion, bradycardia, vasodilati
on, and diarrhea.
113

114. Oral moisturizer…
•Like:- WATER, Salivart ,Oralube,
Xerolube, Plax
114

115.  To fabricate maxillary prosthesis using
resilient liner in the floor of reservoir for
management of hyposalivation problem in
xerostomic patients
PURPOSE OF STUDY
115

116. Complete all the steps for complete
denture fabrication in a
conventional manner up to the trial
placement appointment
 At the trial placement
appointment, add modeling wax to
the palatal surface of the denture
base and evaluate speech, adjusting
palatal contours as necessary. If
needed make a palatogram .
Technique
116

117. 117

118.  After the addition of wax,
make an index of the palatal
surface with Type III dental
stone . Note that this index
serves as a guide when
fabricating the floor of the
reservoir.
 Remove the modeling wax
and process the dentures.
118

119.  Adapt a sheet of modeling wax over the surface
of the stone index. Flask and process it in clear
heat-polymerized acrylic resin to form the floor
of the reservoir .
119

120.  To make it functional, make a hole with
roughened borders in the anterior part of the floor
and line it with a resilient liner . This completes
the fabrication of the floor of the reservoir.
120

121.  Attach the floor to
the palatal surface
of the reservoir
with
autopolymerizing
acrylic resin .
121

122.  Drill a 1 mm diameter hole in
the most anterior part of the
floor. This will be the lowest
point of the reservoir floor.
Demonstrate to the patient
how to inject saliva substitute
through the hole by using a 5
mL disposable syringe and
needle. Select a needle with a
diameter slightly smaller than
that of the hole. Have the
patient practice this procedure
until they are able to inject the
saliva substitute easily.
122

123.  artificial salivas normally contain a mixture
of buffering agents, cellulose derivatives (to
increase stickiness and moistening ability)
and flavoring agents (such as sorbitol).
123

124. The technique given for the construction of
reservoir using resilient liner the tongue
presses against the liner during swallowing
,resulting in flow of saliva substitute
through a hole in the anterior part of floor of
the reservoir.
Discussion
124

125. Advantages of this functional saliva reservoir
design include the swallowing cycle
controlling the flow of saliva, less outlet
clogging, ease of fabrication, and low cost.
The reservoir does not contain any metal
components, which could increase
prosthesis weight .
Advantages
125

126.  Limitations
 It cannot be used for patients with shallow
palatal forms, there is a loss of resiliency of
liner over the period of time
 Increased weight of the denture is also an
issue
Disadvantages
126

127.  Remove all acrylic resin undercuts from the internal
surface of the denture, reestablish the borders and the
posterior palatal seal with impression compound, and
place an impression adhesive on the appropriate surfaces.
 Make a final impression with a material of choice. Zinc
oxide-eugenol impression pastes should not be used in
patients with xerostomia because of its irritating effect on
the dry, vulnerable oral mucosa
Construction of an artificial saliva
reservoir in an existing denture
V. ink, M. C. HuismanConstruction of an artificial saliva reservoir in an
existing maxillary denture, j Pros dent.1986;5:56;1:70-75
127

128.  Thicken the palatal surface of the denture with soft
beeswax by approximately 9 mm. Mold the wax so
that oral function, especially speech, is not
disturbed. Normal speech should be acceptable,
although rapid speech will be difficult .
128

129.  Cover the beeswax with a thin
film of modeling wax to
prevent it from sticking to the
mold.
 Pour a cast in plaster and key
it
 Lightly lubricate the superior
surface of the cast with
waterglass and cover it with a
layer of plaster to form the
nonfitting surface of the mold
.
 Separate the nonfitting
surface of the mold and
remove the beeswax.
129

130.  Fill the space created by the
beeswax with Optosil and
replace the nonfitting surface
of the mold. Remove the
excess Optosil .
130

131.  Shorten the borders of the denture and
remove the palatal part .
 With sticky wax secure the teeth and the
remaining base material to the nonfitting
surface of the mold .
131

132.  Construct a chrome-cobalt palatal
plate on a duplicate cast. The metal
base should cover the palate and
terminate 5 mm anterior to the
posterior extension.The metal base
should be 0.45 mm thick at the center
and 1 mm thick where it joins the
acrylic resin base
 Leakage at the junction does not occur
because of the border seal and the
rheological properties of the saliva
substitute. Place two filling holes (1.5
mm in diameter) in the metal base,
one anterior and one posterior at the
midline.
 Adapt a shellac baseplate to the upper
half of the flask that holds the teeth
and glue the metal palate to the
flasked cast.
132

133.  Cover both halves of the flask with
polythene foil and fill the remaining space
with Optosil . The amount of Optosil is
less than that used because the shellac
baseplate allows for the acrylic resin
covering of the oral side of the reservoir.
 Remove excess Optosil so that 2 mm of
the outline of the chrome-cobalt baseplate
is free.
 Glue the Optosil to the metal base and
glue a small round piece of tinfoil to the
Optosil and
 The tinfoil creates an area for the valve.
Pack acrylic resin into the flask and cure
in the usual manner.
133

134.  Unsnap the metal base and
remove the filler and the
tinfoil from the denture
 Place a hole in the middle of
the acrylic resin that covered
the tinfoil. Cover the opening
with a latex membrane . The
membrane is secured to the
acrylic resin with
cyanoacrylate glue. Punch a
hole in the membrane.
 Snap the metal base to
position .
 The reservoir can be filled
with a syringe. The patient
can moisten the oral cavity by
sucking some artificial saliva
out of the reservoir.
134

135. 135

136. 136

137. Burning Mouth Syndrome
 Painful,frustating condition often described as
a scalding sensation in tongue,lips,palate or
throughout the mouth
 Can affect anyone but occurs most commonly
in middle-aged or older women
 occurs with a range of medical and dental
conditions, from nutritional deficiencies and
menopause to dry mouth and allergies
 the exact cause of burning mouth syndrome
cannot always be identified with certainty.
137

138. SIGNS AND SYMPTOMS
 Moderate to severe burning in the mouth is the main
symptom of BMS and can persist for months or
years
 the burning sensation begins in late morning, builds
to a peak by evening, and often subsides at night
 Some feel constant pain; for others, pain comes and
goes
 Anxiety and depression are common in people with
burning mouth syndrome and may result from their
chronic pain.
138

139.  Other symptoms of BMS include:
 tingling or numbness on the tip of the
tongue or in the mouth
 bitter or metallic changes in taste
 dry or sore mouth
139

140. Causes:
 damage to nerves that control pain and taste
 hormonal changes
 dry mouth, which can be caused by many medicines and
disorders such as Sjögren’s syndrome or diabetes
 nutritional deficiencies
 oral candidiasis, a fungal infection in the mouth
 acid reflux
 poorly-fitting dentures or allergies to denture materials
 anxiety and depression.
 In some people, burning mouth syndrome may have more than
one cause. But for many, the exact cause of their symptoms
cannot be found
140

141. Diagnosis:
 A review of medical history, a thorough oral
examination, and a general medical examination
may help identify the source of burning mouth.
Tests may include:
• blood work to look for infection, nutritional
deficiencies, and disorders associated with BMS
such as diabetes or thyroid problems
• oral swab to check for oral candidiasis
• allergy testing for denture materials, certain foods, or
other substances that may be causing symptoms.
141

142. Treatment:
 Treatment should be tailored to individual
needs. Depending on the cause of BMS
symptoms, possible treatments may include:
 adjusting or replacing irritating dentures
 treating existing disorders such as diabetes,
Sjögren’s syndrome, or a thyroid problem to
improve burning mouth symptoms
 recommending supplements for nutritional
deficiencies
142

143.  switching medicine, where possible, if a drug is causing
burning mouth
• prescribing medications to
— relieve dry mouth
— treat oral candidiasis
— help control pain from nerve damage
— relieve anxiety and depression.
 When no underlying cause can be found, treatment is
aimed at the symptoms to try to reduce the pain
associated with burning mouth syndrome.
143

144. Helpful tips:
 Sip water frequently.
 Suck on ice chips.
 Avoid irritating substances like hot, spicy foods;
mouthwashes that contain alcohol; and products
high in acid, like citrus fruits and juices.
 Chew sugarless gum.
 Brush teeth/dentures with baking soda and water.
 Avoid alcohol and tobacco products.
144

145. Clinical implications:
 Difficulties in chewing
tasting
swallowing
speaking
 Increased chances of developing dental decay & other infections
in mouth
 Mouth sores
 Difficult for operator to work when saliva pools in mouth (in
case of sialorrhea)
 uncoordinated swallowing
 poorly synchronized lip closure
 abnormal increase in tone of the muscles that open the mouth
145

146. 2. HYPERSALIVATION
The excess secretion of saliva is known as hypersalivation .
Hypersalivation in pathological condition is known as ptyalism ,
sialorrhea , sialism or sialosis.
Hypersalivation occurs in the following conditions :-
1) Decay of tooth or neoplasm of mouth or tongue due to
continuous irritation of nerve endings in the mouth
2) Disease of esophagus , stomach & intestine
3) Neurological disorder such as cerebral palsy & mental
retardation
4) Cerebral stroke
5) Parkinsonism
6) Some psychological & psychiatric conditions
7) Nausea & vomiting
146

147.  DROOLING
 Uncontrolled flow of saliva outside the mouth is called
drooling . It is often called ptyalism.
Drooling occurs because of excess production of saliva in
association with inability to retain saliva within the
mouth.
 Drooling in small children is a normal part of
development.
 Teeth are coming in, they put everything in their little
mouths, and they haven’t developed the habit of keeping
the lips together.
 While child is teething ,their gums will produce excessive
saliva
147

148.  The saliva which is produce during drooling
is designed to moisten and lubricate babys
tender gums.
 Drooling serves to help make teething
process more bearable for child.
148

149. Antisialogogue…
 Antisialagogues are substances that decrease
the production of saliva and their effect is
opposite to that of sialagogues. Their origin
may be both natural and synthetic. Classic
antisialagogues include:
 atropine,
 opium,
 alkalies,
 belladonna,
 tobacco in excess,
149

150.  Atropine dilates the pupils, increases heart rate, and
reduces salivation and other secretions. Atropine is
an effective salivary-secretion suppressant and,
therefore, useful in dentistry. Its value depends
upon a careful selection of proper dosage in order
to achieve maximum antisialogogic effects with a
minimum of side actions. This dose would range
between 0.4 mg. and 0.8 mg. of atropine sulfate
(total dose) for an average adult.
 Brand names : atrophen,atrisolon,diafort,lomophen
contain atropine sulphate. 150

151. Saliva & Age:
With age, a generalized loss of salivary gland
parenchymal tissue occurs. The lost salivary cells
often are replaced by adipose tissue. Although
decreased production of saliva often is produced
in older persons,whether this is related directly to
the decrease in parenchymal tissue is not clear.
Some studies of healthy older individuals,in
which the use of medication were carefully
controlled,revealed little or no loss of salivary
function. Other studies suggest that although
resting salivary secretion is in the normal
range,the volume of saliva produced during
stimulated secretion is less than normal.
151

152. DIAGNOSTIC IMAGING FOR
SALIVARY GLAND
The methods employed are:
- Plain Film Radiography
- IntraOral Radiography
- ExtraOral Radiography
- Conventional Sialography
- Computed Tomography (CT)
- Magnetic Resonance Imaging
- Scintigraphy
- UltraSonography
152

153. 153