Salivary Diagnostics in Dentistry

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dentistry/6

Dental CE Courses: The Richmond Institute

According to the National Cancer Institute, from 1975 to 2005, the rate of oral pharyngeal
cancer has more than doubled in the 20 to 49 age range. The increased prevalence of the
certain human papillomavirus genotypes has been a game changer in regards to oral
pharyngeal cancer. It is estimated that more than 24 million Americans are currently
infected with HPV and an estimated 6 million Americans will become infected each year. 19
To date, HPV is the most commonly sexually transmitted disease. Although there are over
120 genotypes of HPV, the primary HPV genotypes associated with oral pharyngeal cancer
are HPV 16 and 18.20
.
In general, when a virus comes in contact with a cell, it is capable of inserting its genetic
material into the host cell. The concern is when the invading virus prompts the lytic phase
whereby the virus takes over the host cell and uses it to exponentially produce more viral
cells. It has been well established in the literature that HPV 16 and 18 are some of the most
dangerous variations. These HPV genotypes can produce dysplastic changes in the tissue. A
recent study of 253 head and neck cancer patients at the Johns Hopkins Oncology Center
showed a strong correlation between HPV and oral cancer. In 25% of the cases, the tissue
taken from the tumors was HPV positive, and of that subset, HPV 16 was present in 90% of
the samples.21
.

OralRisksm HPV

Oral DNA Labs has developed a salivary diagnostic test that allows clinicians to test for the
presence of the HPV 16 and 18 genotypes. This test is able to detect the presence of the
virus with or without a clinical lesion and provides triage information for patients that are
positive or at risk to the virus. The recommended protocol is to use this test in conjunction
with the traditional oral cancer exam and advanced screening tools.
Oral Risksm HPV is recommended for the following patients:

Those that are sexually active

Family history of oral cancer

Signs and symptoms of oral canceR

Suspicious lesions

History of HPV

The test is performed in a similar manner to the other products developed by Oral DNA.
The major difference is with the sample procuring protocol. It is imperative to have the
patient gargle with the saline solution in order to gather DNA from the posterior aspects of
the oral pharyngeal cavity.

SALIVARY DIAGNOSTICS IN DENTAL CARIES

Equilibrium occurs within the oral cavity between the buffering and remineralizing benefits
of saliva and the demineralizing effects of acids that are produced by fermented
carbohydrates, acid drinks and internally derived gastric acids. Salivary risk assessment
testing can identify the imbalance in this equilibrium and hopefully prevent future
irreversible loss of tooth structure.
.

CariFree has developed a product line based on CAMBRA (CAries Management By Risk
Assessment); this comprehensive system allows clinicians to measure current decay
conditions, current bacterial challenges, decay history, dietary habits, current prescription
medications, salivary flow, medical conditions and oral hygiene habits. The system cleverly
combines a patient questionnaire with a clinical assessment tool to devise treatment
recommendations based on the findings of those assessment tools. CariFree uses the CRA
form to gather qualitative and quantitative data to derive the treatment recommendations.

CRA breaks down the caries assessment into three categories:

1. Risk Factors (Patient Questionnaire Format)

Plaque Accumulation

Medications

Dry mouth

Caries causing liquid consumption

Dietary habits

Oral appliances

Habits and medical conditions

2. Disease Indicators

New/progressing visible cavitations

New/progressing approximal radiographic radiolucencies

 New/progressing white spot lesions

History of decay

3. Biofilm Challenge

CariScreen Caries Susceptibility Test is a 1-minute, chair-side bacterial test for

assessing the patients caries risk. CariScreen uses ATP bio-luminescence to identify
the oral bacterial load that correlates with patients risks for decay. The CariScreen
uses a qualitative approach to measure risk assessment.

o 0-1500= Low Risk

o 1501- 9999= High Risk

After gathering the data, the clinician completes the risk identification portion of the
assessment, and assigns a risk category according to the patients subjective risk factors.
The clinician also determines the disease indications and biofilm challenge measured by the
CariScreen instrument. Once a risk category is assigned, CTx therapeutic recommendations
are made for the patient based on the targeted therapy (e.g. pH neutralization, antibacterial,
fluoride, xylitol and/or remineralization).

GC America manufactures the Saliva-Check BUFFER kit and the Saliva-Check

MUTANS kit. This series of chair-side tests are designed to aid clinicians in assessing how
effectively patients saliva is protecting their teeth.

Saliva-Check BUFFER consists of five steps that measure multiple aspects of resting
and stimulated saliva:22
STEP 1: Measure the flow rate of resting saliva, and assigns a risk category. The lower lip
is everted and gently blotted with a piece of gauze. The clinician observes the appearance
of the droplets of saliva as they are stimulated from the minor salivary glands. The risk
category is measured against the normal rate of salivary production: 30 to 60 seconds.
.

STEP 2: Measure the viscosity of the resting saliva. Normal, healthy, unstimulated saliva
is watery and clear. If the unstimulated saliva appears frothy, bubbly or sticky, this may be
an indication that the content of water is low due to production rate.

STEP 3: Measure the resting pH of unstimulated saliva. The patient is instructed to

expectorate pooled saliva into a collection cup. A pH test strip is then placed in the sample
for 10 seconds. Highly acidic saliva tests are between a pH of 5.0 to 5.8, while moderately
acidic saliva tests have a pH of 6.0-6.6, and healthy saliva tests have a pH of 6.8 7.8.
Acidic saliva potentially creates an acidic challenge that may result in the demineralization
of the tooth structure that the saliva cannot offset.

STEP 4: Measure the stimulated flow. Stimulated saliva is derived primarily from the
parotid gland in response to a variety of stimuli. Stimulated flow is crucial in flushing the
acids from our diet and dental plaque and gastric acids. To test the stimulated flow, the
patient is instructed to chew on a piece of wax for 30 seconds and expectorate into a
collection cup for five minutes. The quantity of the stimulated saliva is measured in
milliliters and assigned a risk category.
STEP 5: Measure the buffering capacity of stimulated saliva. The buffering capacity
provides insight of the efficacy of the salivas ability to neutralize acids derived from diet,
bacterial plaque or gastric acids. An important component of saliva is bicarbonate because
of its buffering capacity. Unstimulated saliva is very low in bicarbonate, whereas stimulated
saliva can have up to 60 times more bicarbonate. To test the buffering capacity, remove the
buffer test strip and pipette saliva from the stimulated collection cup onto the test pads
without over-saturating the pads. Allow the sample to sit for 2 minutes, then align the test
strip with the interpretive table.

Saliva-Check MUTANS specifically tests for the Streptococcus Mutans. Strep Mutans
bacteria plays a leading role in the initiation of dental caries. Strep Mutans are not the
primary cause of caries associated with root caries or early childhood caries; Strep Mutans
are usually only present in the plaque found in early carious lesions, once the lesions
cavitate, other bacteria take over and the presence of Strep Mutans declines. The Strep
Mutans test is a four step process. A positive test results yields a faint or clear red line
below the T and signifies that the sample had over 500,000 cfu/ml of Streptococcus
Mutans.