Measuring Sal Flow in Xerostomia

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2008;139;35S-40SJ Am Dent Assoc

Mahvash Navazesh and Satish K.S. KumaropportunitiesMeasuring salivary flow: Challenges and

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Background. Saliva is being studied extensively

and is being used for risk assessment, diagnosis and

monitoring high-risk behavior and disease progres-

sion. A variety of medical conditions and medications

are associated with salivary gland hypofunction. The

major disadvantage in the use of saliva for health-related purposes is the

lack of standardization in saliva collection methods.Methods. The authors provide a brief overview of different methods of

saliva collection and the advantages and disadvantages associated with

each method, as well as of how to assess the salivary flow rate.

Results. The authors present the complete set up and step-by-step

guidelines for the collection of unstimulated and stimulated whole

saliva.

Conclusions. The life expectancy of people will continue to increase

with advances in medicine and therapeutic modalities, and the preva-

lence of salivary gland hypofunction in the elderly population will

increase owing to their longevity. The assessment of salivary gland hypo-

function will need to be incorporated into everyday clinical practice.

Clinical Implications. The saliva collection methods outlined in

this article can be used by dentists to assess patients at risk of devel-

oping diseases and by scientists for scholarly activities.

Key Words. Saliva; saliva collection; salivary flow rate; salivary

glands; salivary gland hypofunction; xerostomia.

JADA 2008;139(5 suppl):35S-40S.

Promoting health by pre-venting disease is a goal of

health care providers, andrisk assessment and dis-

ease prevention arecommon themes in the surgeon gen-

erals report on oral health inAmerica.1 Clinicians commonly use

health questionnaires and clinicalevaluations to identify patients at

risk of developing diseases. Hemato-logic, serologic and imaging diag-nostic modalities are used to assess

these patients further. In recentyears, saliva-based diagnostic tests

have been increasing in popularitybecause of their noninvasive

nature.2,3

Technologies are available that

use saliva to diagnose, follow andassess the risk and severity of dis-

eases, high-risk behaviors or both.

Salivary biomarkers have been usedto assess the risk of developing oral,

ovarian and breast cancers; HIVinfection; Sjgren syndrome; and

dental caries and periodontal dis-eases, as well as to detect exposure

to alcohol and illegal drugs. Nico-tine and cotinine levels also can be

measured in saliva and be used bythe life insurance industry to verify

the smoking status of applicants.Hormone levels detected in saliva

ABSTRACT

ARTICLE

4

Dr. Navazesh is a professor and the chair, Division of Diagnostic Sciences, University of Southern Cali-

fornia School of Dentistry, 925 W. 34th St., DEN 4320, Los Angeles, Calif. 90089-0641. Address

reprint requests to Dr. Navazesh.

Dr. Kumar is an assistant professor of clinical dentistry, Division of Diagnostic Sciences, University of

Southern California School of Dentistry, Los Angeles.

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Measuring salivary flowChallenges and opportunities

Mahvash Navazesh, DMD; Satish K.S. Kumar, MDSc

JADA, Vol. 139 http://jada.ada.org May 2008 35S

Copyright 2008 American Dental Association. All rights reserved.

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can be used to determine the presence of physio-logical changes (for example, pregnancy) and

emotional disorders (for example, depression).2,3

Quantitative and qualitative salivary changes

associated with local or systemic disorders are notalways easily captured or appreciated by clini-

cians and scientists owing to the lack of standard-ization in saliva collection methods.4 Different

sources (mixed versus individual glands) andmethods (unstimulated versus stimulated) of col-

lection significantly affect the desired qualitativeor quantitative changes being evaluated. In this

article, we focus on

methods of saliva collec-tion and the opportunities

and challenges associatedwith each method.

THE SALIVARYGLANDS

The three major salivaryglands (parotid, sub-

mandibular and sublin-gual) contribute to 90 per-

cent of the mixed fluid inthe mouth that is known

as whole saliva; minorsalivary glands that are

scattered throughout the

mouth contribute to theremaining 10 percent ofthe mixed fluid. Fooddebris, microorganisms

and gingival crevicularfluid are other compo-

nents of whole saliva.Saliva is composed of

approximately 99 percentwater and 1 percent pro-

teins and salts. Thenormal daily production of

saliva is between 0.5 and1.5 liters. The subman-dibular glands are the

major contributors toresting (unstimulated)

saliva, and the parotidglands are the major con-

tributors to stimulatedsaliva. The contribution of

sublingual glands to un-stimulated and stimulated

whole saliva is low.5,6

Although the minor salivary glands are notmajor contributors to the whole-saliva volume,

they play a significant role in the lubrication andprotection of the oral mucosa because of their

mucous secretions. Parotid gland secretion ispurely serous, and submandibular and sublingual

gland secretions are mixed (mucous and serous).The primary saliva, formed by the acinar cells,

36S JADA, Vol. 139 http://jada.ada.org May 2008

BOX

University of Southern California School of Dentistryguidelines for saliva collection.*

A. COLLECTION OF UNSTIMULATED WHOLE SALIVAThe patient is advised to refrain from intake of any food or beverage (waterexempted) one hour before the test session. Smoking, chewing gum and intake ofcoffee also are prohibited during this hour. The subject is advised to rinse his or hermouth several times with deionized (distilled) water and then to relax for five min-utes. The patient is then told the following: I will first obtain measures of salivaflow while you are at rest. This means that before and during the collection youshould make every effort to minimize movement, particularly movements of yourmouth. To begin a collection trial, I will ask you to swallow to void the mouth ofsaliva. Then you should lean your head forward over the test tube and funnel(demonstrate). Keep your mouth slightly open and allow saliva to drain into thetube. Keep your eyes open. At the end of the collection period, I will ask you to col-lect any remaining saliva in your mouth and spit it into the test tube. This move-ment should be done very quickly and should be done in the same manner from trialto trial. This is very important. Do you understand the procedures?

When you start a trial, tell the subject:1. Swallow to begin a trial (begin timing).2. Make as little movement as possible. Do not swallow, and keep your eyes openduring collection periods.3. At the conclusion of the trial, collect the remaining saliva and spit it out.For each subject, collect saliva for one minute of practice trial and discard it. Aplastic or paper cup may be used for this trial. The actual trial should last for fiveminutes, and the sample should be saved for further analysis if indicated.

B. COLLECTION OF STIMULATED WHOLE SALIVAGUM1. Instruct the subject to sit motionless.2. Instruct the subject to lean the head forward over the funnel.3. Instruct the subject to swallow to void the mouth of saliva (starting time).4. Instruct the subject to chew the inert gum base according to the pace of themetronome (approximately 70 strokes per minute).5. Every one minute, ask subject to spit saliva into the tube without swallowing. Tellsubject, Spit out, keep chewing (after first minute), Spit out, keep chewing (aftersecond minute), etc. Discard the first two-minute collection. A plastic or paper cupmay be used for this collection. Proceed with another three-minute collection. Savethis sample for further analysis if indicated.

6. Ask the patient to spit everything (that is, both saliva and gum base) into thetube.7. Remove the gum base from the funnel before weighing the tube and funnel withsaliva.8. If the patient is too dry (that is, has dry mouth), it is possible to add the weight ofthe gum base to the preweight measure with the gum base in the funnel of the testtube of saliva.

C. COLLECTION OF STIMULATED WHOLE SALIVACANDYRepeat steps one through eight as in B. Substitute chewing gum base with suckingon sugar-free, lemon-flavored candy.Remember, unstimulated whole saliva collection always should precede stimulatedwhole saliva collection.

* Adapted with permission of Mahvash Navazesh, DMD.

ABBREVIATION KEY. SWS-Candy: Stimulated wholesalivacandy. SWS-Gum: Stimulated whole salivagum. UWS: Unstimulated whole saliva.


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Figure 2. Three tubes with measurements, funnels, inert gum baseand sugar-free candy used for the collection of unstimulated andstimulated whole saliva.

Name of Patient: Date:

UWS

SWS-GumSWS-Candy

* Salivary gland hypofunction is considered as whole unstimulated saliva < 0.1 g/minute (that is,mL/minute), whole chewing stimulated saliva


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powered toothbrushes have beenused to stimulate salivary flow.15

UNSTIMULATED ANDSTIMULATED WHOLE SALIVACOLLECTION

Several methods for collecting salivahave been reported and tested for

validity and reproducibility.13,16 In this article, we

provide in detail the guidelines for collectingunstimulated and stimulated whole saliva (Box,

page 36S) and measuring salivary flow rate(Figure 1) as followed at the University of

Southern California School of Dentistry(Figures 2-5).

COLLECTION OF SALIVA FROM INDIVIDUALGLANDS

Saliva collection from individual glands should

not be contaminated with food debris and micro-organisms, so it is prudent to acquire saliva from

scale, an ordinal scale based on rank-ordered cat-

egories (for example, I have no/slight/severe/annoying feeling of dry mouth) or both to assess

salivary gland function.Objective measurements of qualitative or

quantitative changes in saliva are best capturedby collecting saliva from individual glands or

from all that contribute to whole saliva.13 Com-monly used stimulants include gum base,

paraffin wax, rubber bands and citric acid. Secre-tagogues such as pilocarpine and cevimeline

hydrochloride14 and mechanical stimuli such as atranscutaneous electrical nerve stimulator and


4.5

4

3.5

3

2.5

2

1.5

1

0.5

0

Unstimulated StimulatedGum StimulatedCandy

COLLECTION METHOD

FLOW

RATE(g/MINUTE)

Patient 1

Patient 2

Patient 3

Patient 4

Figure 5. Changes in salivary flow rates obtained by using three methods in fourpatients. The healthy patients (1 and 3) have increased salivary output in response to stim-ulation compared with that of the subjects with salivary dysfunction (2 and 4). g: Grams.

Figure 4. Comparison of amount of saliva col-lected (from left to right): unstimulated wholesaliva, gum-stimulated (masticatory) whole saliva(note the heavy sediment of salivary contami-nants such as food debris, microorganisms andgingival crevicular fluid) and candy-stimulated(gustatory and masticatory) whole saliva.

Figure 3. To collect unstimulated whole saliva, the patient drools passively into thecollection tube for five minutes.


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individual major glands. The techniques, how-

ever, are tedious and require custom-made collec-tion devices.17

Parotid gland. The parotid gland secretion isvoided in the oral cavity via the Stensen duct atthe vicinity of the parotid papilla opposite the

maxillary second molar. A modified Lashley cupor Carlson-Crittenden collector often is used for

collecting saliva from the parotid glands(Figure 6).

Submandibular and sublingual glands.The submandibular and sublingual gland secre-

tions are voided in the oral cavity via theWharton duct, which opens into the floor of the

mouth. Many custom-made collectors such as the

Wolff collector are used (Figure 7).

17,18

Minor salivary glands. Minor salivary glandsecretions do not have much clinical application,owing to the labor-intensive nature of collecting

them. Specific methods are used to measureminor salivary gland secretions.19

CONCLUSION

With advances in medicine and therapeuticmodalities, human life expectancy is increasing

steadily. One can expect an increase in salivarygland hypofunction, along with other more preva-

Figure 6. A modified Carlson-Crittenden devicefor collecting parotid gland saliva.

Figure 7. A custom-made Wolff saliva collector for submandibular and sublingualgland saliva collection.

lent medical conditions, in the elderly population.

In this article, we presented saliva collectionmethods that can be used by dentists in their

practices to assess patients at risk and by scien-tists for scholarly activities.

Disclosure. Drs. Navazesh and Kumar did not report anydisclosures.

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