Spit is it……and it matters!

© 2018

The Saliva Chronicles

Spit is it……and it matters!

Anne N. Guignon,RDH, MPH, CSP

[email protected] 832-971-4540

The Saliva Chronicles Copyright 2020

Complicated, real life situations

© 2020

EBM

Individual clinical expertise

Best external evidence

Patient values& expectations

Improving the patient’s outcome

h0p://med.fsu.edu/index.cfm?page=medicalinformaAcs.ebmTutorial

EBM$

Individual !clinical !expertise

Best !external !evidence

Patient values!& expectations

Improving the patient’s outcome

h"p://med.fsu.edu/index.cfm?page=medicalinforma8cs.ebmTutorial © 2020

Complex patients - complex solutions

© 2020

Who has the highest risk?

© 2020

Complicated, real life situations

‣ 70 year old female

‣ severe polypharmacy-induced

xerostomia

‣ high caries risk

‣ every 3 months - something new

‣ extremely sensiAve Assues

‣ has had severe mucosiAs to

everything I have recommended

for use in her custom fl trays

© 2020

‣ self care

‣ compliance

‣ life style

‣ dry mouth

Challenges

© 2020

‣ medically complex

‣ challenged immune systems

‣ chronic health issues © 2020

Dry mouth Prevalence and clinical presentation

© 2020

Multiple terms - quality of life

‣ dry mouth / syndrome

‣ hypo-salivaAon

‣ xerostomia

Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. © 2020

Hyposalivation

‣ clinical diagnosis

‣ decreased salivary flow

‣ insufficient in saliva

Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010.

Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45.

© 2020

Xerostomia



Villa, A., Connell, C., AbaA, S. (2014). Diagnosis and management of xerostomia and hyposalivaAon. Therapeutics and Clinical Risk Management, 45.

‣ subjecAve term

‣ perceived lack of moisture

‣ changes in composiAon

© 2020

Prevalence

‣ 30% populaAon

‣ more women

‣ 10% early 30s

‣ over age 50

Thomson WM, Lawrence HP, Broadbent JM, Poulton R. The impact of xerostomia on oral-health-related quality of life among younger adults. Health Qual Life Outcomes. 2006

Nov 8;4:86.

Anil S, Vellappally S, Hashem M, Preethanath RS, PaAl S, Samaranayake LP. Xerostomia in geriatric paAents: a burgeoning global concern. J InvesAg Clin Dent. 2014 Sep 1.© 2020

Insufficient flow

! subtle changes

! 50% decrease - noAceable

! pH decreases

! increased demineralizaAon

Takahashi N, Nyvad B.Caries ecology revisited: Microbial dynamics and the caries process. Caries Res. 2008;42(6):409-18.

Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology. DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012

Graham I, Mount WH. (2005). PreservaAon and restoraAon of tooth structure. 2nd EdiAon. Queensland, Australia: Knowledge Books and Solware. © 2019

Visual observations

‣ red, glossy, parched

‣ pebbled tongue

‣ cracking in commisures

‣ chapped lips

‣ thick, foamy, ropy saliva

Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. © 2020

Additional complaints

‣ difficulty talking

‣ taste alteraAons

‣ dry/sore throatSreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010.


‣ problems chewing

‣ difficulty swallowing

‣ denAnal hypersensiAvity

© 2020

Saliva functions and benefits

Saliva - The magic fluid

Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology. DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012© 2020

Digestion

‣ chewing

‣ bolus

‣ swallowing

‣ enzymes

‣ taste

© 2020

Protection

‣ diluAon

‣ lubricaAon

‣ cleansing

‣ increase pH

de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composiAon and funcAons: A comprehensive review. J Contemp Dent Pract 2008 March; (9)3:072-080.

Hara AT, Zero DT. The caries environment: saliva, pellicle, diet, and hard Assue ultrastructure. Dent Clin North Am. 2010 Jul;54(3):455-67.


Protection

‣ buffering-neutralizes

‣ remineralizaAon

‣ anA-microbial

‣ healing

de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composiAon and funcAons: A comprehensive review. J Contemp Dent Pract 2008 March; (9)3:072-080.

Hara AT, Zero DT. The caries environment: saliva, pellicle, diet, and hard Assue ultrastructure. Dent Clin North Am. 2010 Jul;54(3):455-67.


astoundingminds.blogspot.com/2012/04/boiling-point-of-human-saliva.html

© 2020

Additional functions


‣ speech

‣ nutriAon

‣ social interacAon

‣ kissing

‣ licking

‣ excreAon

© 2020

The kiss

www.lifedaily.com/12-most-surprising-facts-about-kissing/ Accessed 10/1/15.

‣ longest - 58 hours, 35 minutes and 58 sec

‣ lowers corAsol levels

‣ heart beats faster

‣ more oxygen reaches your brain

© 2020

Saliva - production, composition, flow

Sources

90% - whole saliva

‣paroAd - 30%

‣sub-mandibular- 60%

‣sub-lingual - 5%

‣10% - minor glands - 5%

found throughout the mouth


99% water

Healthy saliva - composition

also contains

!proteins

! enzymes

!mucins

!buffering compounds


Secretions serous and mucous

!paroAd - serous and enzymes

! submandibular - 90% serous, 10% mucous

! sublingual and minor - 80% daily mucous© 2020

Salivary protein functions

! antibacterial! antifungal! antiviral! buffering ! tasting

! tissue coating! wound healing! remineralization! digestion! lubrication

© 2020

Mucins - wetness and comfort proteins with carbohydrate chains

! lubricates

! controls viscosity / elasAcity

! affects sAckiness

! saliva contact with oral cavity

© 2020

Proline-rich proteins and arginine

! PRPs - 70% of all salivary proteins

! formaAon / funcAon acquired pellicle

! arginine - ammonia producAon

!buffering compounds Saliva and the Control of Its SecreAon. Ekberg (ed.), Dysphagia, Medical Radiology.

DiagnosAc Imaging, Springer-Verlag Berlin Heidelberg 2012© 2020

Types of flow

! spontaneous

minor salivary glands - mucins

! sAmulated

paro5d - serous

!unsAmulated (resAng)

sublingual and minor - serous and mucous© 2020

Stimulated saliva

80 - 90% daily salivary producAon

" anAcipatory tongue/lip movements

" chewing

" taste

" smell

de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva ComposiAon

And FuncAons: A Comprehensive Review. J Contemp Dent Pract 2008 March; (9)3:072-080.© 2020

Stimulated saliva

‣ quality improves - proteins

‣ increased bicarbonate

‣ neutralizes acids

‣ bicarbonate reserves are limited

‣ proteins - secondary path - neutraliza=on

de Almeida PDV, Grégio AMT, et al. Saliva ComposiAon And FuncAons: A Comprehensive Review. J Contemp Dent Pract 2008 March; (9)3:072-080.

García-Godoy F, Hicks MJ. Maintaining the integrity of the enamel surface: the role of dental biofilm, saliva and prevenAve agents in enamel demineralizaAon and remineralizaAon.

J Am Dent Assoc. 2008 May;139 Suppl:25S-34S.

© 2020

Saliva – Fast facts…….

! peak flow - late aAernoon

! during sleep - near zero flow

! acid substances salivary flow rates

! paroAd gland – 50% of sAmulated salivade Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composiAon and funcAons: A comprehensive review.

J Contemp Dent Pract 2008 March; (9)3:072-080.© 2020

Healthy salivary pH

‣ resAng - pH 6.8 - 7.2

‣ favors homeostasis

‣ supports remineralizaAon

‣ suppresses pathogens


Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2020

Quality of life

© 2020

Tasting

Neuroscience made understandable Alexander van Aken Brighton and Sussex Medical School - 2014 © 2020

Tongue papillae

‣ 1 - 200 tastebuds per papillae

‣ taste pores house taste cells

‣ 50-150 taste receptor cells per taste bud

http://www.cbsnews.com/news/worlds-first-images-of-taste-buds-in-action/© 2020

Taste buds

‣ sensiAve to - sweet, bi0er, salt, or sour

‣ taste buds - taste pores

‣ chemicals in soluAon - sAmulate receptor cells

http://www.cbsnews.com/news/worlds-first-images-of-taste-buds-in-action/ © 2020

Tasting food

Nordén J, Grönberg AM, et al. NutriAon impact symptoms and body composiAon in paAents with COPD. Eur J Clin Nutr. 2015 Feb;69(2):256-61.

Ekstrom J, Khosravani N, et al. Saliva and its control of secreAons. Dysphagia,Medical Radiology. DiagnosAc Imaging. Ed. Ekberg O. Springer-Verlag Berlin Heidelberg 2012.© 2020

‣ saliva iniAates taste

‣ poor taste - anorexia

‣ adequate nutriAon

‣ supports muscle mass

‣ immune system

Taste disturbances

‣ ageusia - complete lack of taste

‣ hypogeusia - decrease taste sensiAvity

‣ dysgeusia - metallic/foul/rancid/salty

‣ phantoguesia - phantom taste

‣ cacogeusia - revolAng tastehttp://www.webmd.com/oral-health/tc/taste-changes-topic-overview © 2020

Compromises

‣ food sAcks to teeth

‣ raw food - hard to chew

‣ increase sAcky, processed foods

Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2020

Compromises

‣ sip on sweet drinks

‣ require no chewing / preparaAon

‣ high carb nutriAonal supplements

Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).


Liquid intake challenges

Compromises

‣ high fluid intake

‣ olen sweet

‣ dilutes exisAng saliva

‣ frequent bathroom breaks

‣ disturbed sleep


Aging

© 2018

Medical and environmental conditions

Medical conditions

‣ Sjögren syndrome - primary

‣ Hashimoto’s disease - thyroid

‣ rheumatoid arthriAs

‣ secondary SS - other autoimmune disordersGuignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).

© 2020


Medical conditions ‣ diabetes

‣ endocrine disorders

‣ Parkinson’s disease

‣ pregnancy - nursing

‣ chronic faAgue syndrome© 2020

Medical conditions

‣ hepaAAs C

‣ Alzheimers

‣ geneAc disorders


‣ HIV / AIDS

‣ eaAng disorders

‣ laxaAve abuse

© 2020

Medical conditions - complication

‣ intesAnal failure

‣ COPD

‣ anxiety

‣ depression

‣ cancer therapy

‣ liver transplantGuignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).

© 2020

Pathology and sequela

‣ salivary gland disfuncAon

‣ removal salivary glands

‣ end of life / terminal illness

‣ menopause


Treatments

‣ hemodialysis

‣ radiaAon treatment

‣ hormone imbalance

‣ bariatric surgery

© 2020

Medications - OTC and Rx

‣ HBP

‣ anxiety

‣ nausea

‣ pain


‣ depression

‣ appeAte control

‣ seasonal allergies

© 2020

Conditions - lead to dehydration

‣ fever

‣ vomiAng

‣ excessive sweaAng

‣ diarrhea

‣ blood loss

‣ burns © 2020

Respiratory

‣ sleep apnea

‣ mouth breathing

‣ asthma

‣ seasonal allergies

‣ facial anatomy

‣ dust / wind

‣ nasal congesAon

‣ coughing


© 2020

Oral appliances


‣ dentures / parAal dentures

‣ bite guards

‣ orthodonAc aligners

‣ sports mouth guards

‣ whitening trays

© 2020

Lifestyle

© 2018

Lifestyle

‣ smoking / vaping

‣ recreaAonal drugs

‣ C-Pap machine

‣ prolonged speaking / singing


Lifestyle

‣ stress

‣ anxiety/fear

‣ caffeine

‣ alcohol

‣ heavy exercise


Climate

‣ air condiAoning

‣ central heat

‣ desert climates

‣ cold temperatures

‣ airplanes / hotel rooms


cdc.gov/VitalSigns/AdultSmoking/index.html#StateInfo - Behavioral Risk Factor Surveillance System, 2010 Accessed 7/25/15

Smoking prevalence by state

© 2020

Lifestyle - sodium intake

© 2020

Lifestyle - diet94% from food!

‣high sodium intake

‣processed foods


Understand sodium intake levels

© 2020

Who has the highest risk?

© 2020

Gateway - the rest of the body

‣ oral disease is complex

‣ changing hormone levels

‣ medicaAons causing dry mouth

‣ geneAcs

‣ immune system

‣ lifestyle / environmental factors

‣ natural aging process© 2020

The Saliva Chronicles Muddy flooding and sinkholes

Anne N. Guignon,RDH, MPH, CSP

[email protected] 832-971-4540 Copyright 2020

Erosion vs caries

© 2020

Erosion is different from caries?© 2020

Hanning M and Hanning C. Nature Nanotechnology 5, 565–569 (2010)

Biofilm attachment

© 2020

Caries — infection that involves microbes

Hanning M and Hanning C. Nature Nanotechnology 5, 565–569 (2010) © 2020

What is erosion?

Erosion

‣ progressive loss of hard Assue

‣ chemical loss - not bacterial

‣ most important factor - hypersensi3vity

‣ erosive lesions – generally sensiAve

Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion—an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45 Suppl 1:2-12.

Ren, YF. Dental erosion: EAology, diagnosis and prevenAon. Acad of Dent Thera Stoma. April 2011.

Carvalho TS, Colon P, et al. . Consensus report of the European FederaAon of ConservaAve DenAstry: Erosive tooth wear diagnosis and management. Swiss Dent J. 2016;126(4):342-346.

© 2020

How does erosion happen?© 2020

Hanning M and Hanning C. Nature Nanotechnology 5, 565–569 (2010)

Acid erosion

© 2020

Erosion - surface softening

• citric acid pH 2.3

• 6 X 5 min/day

• 10 days

• stored in salt soluAon

Lussi A, Schlueter N, et al. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45 Suppl 1:2-12. © 2020

Erosion - a multifactorial condition


Erosion vs. caries

‣ surface-solening lesion

‣ extrinsic / intrinsic acid

‣ add a0riAon / abrasion

Ren, YF. Dental erosion: EAology, diagnosis and prevenAon. Acad of Dent Thera Stoma. April 2011.

Zero DT, Lussi A. Erosion--chemical and biological factors of importance to the dental pracAAoner. Int Dent J. 2005;55(4 Suppl 1):285

Carvalho TS, Lussi A. SuscepAbility of enamel to iniAal erosion in relaAon to tooth type, tooth surface and enamel depth. Caries Res. 2015;49(2):109-15.

‣ remineralizaAon difficult

‣ prevalence - increases with age

© 2020

Caries - SinkholeErosion - Flooding

Communication tools

© 2020

www.wonderhowto.com/how-to-explore-atomic-structure-tooth-160130/© 2020

Intrinsic and extrinsic factors

Erosion – complicating medical conditions

GERD – gastric esophageal reflux

•7% adults - daily episodes

•36% monthly

•children also experience GERD

Anorexia

•47 % - binge/purge subcategory

•refuse to maintain normal weight

Bulimia

•typically normal weight

•self induced vomiAng aler eaAng

Aranha ACC, Eduardo CP, Cordás TA. EaAng Disorders Part I: Psychiatric Diagnosis and Dental ImplicaAons. J Contemp Dent Pract 2008 September; (9)6:073-081.

Photo - Courtesy of Richard Erlich, DDS - Ontario, Canada elmtreedental.com

© 2020

Eating disorders – behaviors and findings

• vomiAng - palatal surfaces - maxillary teeth

• eroded surfaces - smooth/glossy

• erosion – 2+ years of self-induced vomiAng

• acAve lesions - smooth/unstained

• inacAve lesions - stain over Ame

::

Aranha ACC, Eduardo CP, Cordás TA. EaAng Disorders Part I: Psychiatric Diagnosis and Dental ImplicaAons. J Contemp Dent Pract 2008 September; (9)6:073-081.

© 2020

Eating disorders – Common behaviors and findings

! erosion – 2+ years - self-induced vomiAng

! excessive - acidic beverages and fresh fruits

! anAdepressants - cause dry mouth

! binge/purge – high carbohydrate intake

! anorexia - olen poor oral hygiene

Aranha ACC, Eduardo CP, Cordás TA. EaAng Disorders Part I: Psychiatric Diagnosis and Dental ImplicaAons. J Contemp Dent Pract 2008 September; (9)6:073-081. © 2020

Early erosion…….one year later

Photos - Courtesy of Richard Erlich, DDS - Ontario, Canada elmtreedental.com© 2018

Erosion – factors

Regurgita=on

! reflux

! bulimia

! chemotherapy

! pregnancy

! alcoholism

! pepAc ulcers

! gastriAs

! drug side effects

Gandara BK and Trulove EL. Diagnosis and management of dental erosion. J Cont Dent Prac. 1999;1(1):1-17 © 2020

OTC supplements

medica=ons

! chewable vitamin C

! cough drops

! fizzy liquid medicaAons

! gummy bear supplements

Erosion – Extrinsic factors

!diet

drinks, fruits, candies, pickled foods

!environmental

occupaAonal (acid vapors from industrial electrolyAc processes / wine

tasAng)

recreaAonal (swimming pools)*

Gandara BK and Trulove EL. Diagnosis and management of dental erosion. J Cont Dent Prac. 1999;1(1):1-17

Erosion of Dental Enamel among CompeAAve Swimmers – Virginia h0p://www.cdc.gov/mmwr/preview/mmwrhtml/00000109.htm Pedrão AMN, Andrews Portes L, et al. Erosive tooth wear and dietary pa0erns: A clinical study. Oral Health Prev Dent. 2018;16(2):145-151.

Staufenbiel I, Adam K, et al. Influence of fruit consumpAon and fluoride applicaAon on the prevalence of caries and erosion in vegetarians--a controlled clinical trial. Eur J Clin Nutr. 2015 Oct;69(10):1156-60.

vegetarian / lacto - ovo

‣ more erosion than omnivores

‣ eat more fruit

‣ higher erosion risk

© 2020

Sensitivity and fungal infections

Dentinal hypersensitivity

two condi3ons are necessary

• exposed den5n via loss of enamel or periodontal Assues

• open den5n tubules - patent to the pulp – loss of smear layer

Bamise CT, Olusile AO, Oginni AO. An Analysis of the EAological and Predisposing Factors Related to DenAn HypersensiAvity. J Contemp Dent Pract 2008 July; (9)5:052-059.

© 2020

*Absi et al, J Clin Periodont 1987; Images. thejcdp.com, Sept 2006

Non-sensiAve

No of open tubules x 8 x

Diameter of tubules 0.43 0.83

Fluid Flow (Poisseuille’s law) y 16 y

Structural differences between sensitive and non-sensitive dentin*

Sensitive

© 2020

Candidiasis

• tongue

• commisures

• buccal mucosa

• palate

Jenkinson HF and Douglas LJ. InteracAons between Candida species and bacteria in mixed infecAons. www.ncbi.nlm.nih.gov/bookshelf/

br.fcgi?book=pmd&part=A2773#A Accessed 7/25/2009 © 2020

‣ taking or using?‣ then… what

are you doing? ‣ partner for clues

Health history - Questions

© 2020

Thank you!……..and best wishesfor a healthier career!

[email protected]

832-971-4540 © 2020

Saliva 2020

Documents

Spit is it……and it matters!