Saliva and Dental Caries

Dr.Ghada Maghaireh BDS,MS,ABOD

Anatomy

Major salivary glands Minor salivary glands

The Oral Cavity and Saliva

Whole saliva is the mixed fluid in the mouth in contact with the teeth and mucosa which derived from the major salivary glands, minor salivary gland and certain gingival cervicular fluid. The daily production of saliva ranges between 0.5 and 1.0 liter and it is composed of more than 99% water and less than 1% solids (proteins and electrolytes).

Functions of Saliva

Rinsing effect. Solubilization of food taste-substances. Bolus formation. Food and bacterial clearance.

Dilution of debris. Lubrication of oral soft tissue. Facilitation of mastication, swallowing and speech. Protection of the teeth by neutralization of acid by buffering action and by maintaining supersaturated calcium phosphate concentrations and by participating in pellicle formation.

Salivary Clearance

Salivary clearance or oral clearance is a physiological process in which saliva dilute and eliminate substances to the oral cavity. Bacteria: Bacteria is removed from the mouth to the stomach by saliva. Food debris: Saliva clears the mouth from food debris.

Salivary Gland Hypofunction

Salivary gland hypofunction can result in hyposalivation (reduced salivary flow rate or xerostomia). Normal salivary flow: unstimulated whole saliva flow rate (0.3 ml/min) and stimulated saliva flow rate (1.5 ml/min).

In hyposalivation: unstimulated whole saliva flow rate ( 0.1 ml/min) and stimulated saliva flow rate ( 0.5 0.7 ml/min).

Symptoms of Xerostomia
1.

The oral mucosa is thin and pale and without the usual glistening appearance. The saliva appears thick and foamy, and form whitish threads on mucosa.

2.

3.

Xerostomic patients suffer from symptoms of burning mouth, taste disturbances and dry eyes.

Causes of Salivary Gland Hypofunction

1.

Medication with a side effect of decline in salivary secretion rate (e.g. antidepressants, diuretics, antihistamines, antihypertensive, antiemetics and narcotics).

2.
3.

Radiation therapy to the head and neck area.

Autoimmune diseases (e.g. rheumatoid arthritis, Sjogrens syndrom, sarcoidosis).

Effect of Age on Salivary flow Rate

Age dose not notably affect salivary flow in a clinical situation. The flow rate of stimulated whole saliva dose not decline with age. Decrease in secretion of submandibular and minor salivary glands which may explain the feel of dry mouth in elderly even when the stimulated whole salivary flow rate shows normal values.

Components of Saliva

Water Organic Components Inorganic Components

Inorganic Components of Saliva

Hydrogen ion Calcium Inorganic phosphate Fluoride

Hydrogen ion

Sources of hydrogen ions: secreted from the gland in the form of organic and inorganic acids, produced by the oral microorganisms, or taken to the oral cavity. The acid-base balance of the oral cavity is very complicated and variable.

After an intake of fermentable carbohydrate: Locations of the oral cavity with very high concentrations of hydrogen ions will present low pH, while other locations may have lower hydrogen ions concentration due may be to access to saliva will have high pH.

Hydrogen ion

The pH of saliva depends on secreted acids and bases mostly the bicarbonate ion. The bicarbonate ion concentration in unstimulated saliva is one-tenth of the plasma level. The more the salivary flow is stimulated the closer the salivary bicarbonate to the plasma concentration.

Therefore, the pH of stimulated and unstimulated saliva can differ up to 2 pH units.

The Buffering Ability of Saliva

The most important buffering system in saliva is the carbonic acid/bicarbonate system. The bicarbonate has the ability to take up the hydrogen ions to form carbonic acid.

The enzyme carbonic anhydrase, which is present in saliva, catalyze the reaction forming carbon dioxide from carbonic acid.

The Buffering Ability of Saliva

After a certain amount of acid has been added to saliva, the pH starts to fall rapidly. This rapid decrease is caused by a depletion of the bicarbonate and inorganic phosphate ions.

Around pH 4, the buffering ability of saliva is mainly caused by macromolecules such as proteins.
The buffering of saliva is complicated by transport of buffer substances between the many compartments of the oral cavity.

Calcium

Salivary calcium is distributed as free, ionized calcium and bound calcium depending on the salivary pH value. The free, ionized calcium is important in caries (establish the equilibrium between the calcium phosphate of the dental hard tissue and the surrounding). In normal saliva, ionized calcium is about 50%, as pH decrease, the ionized form increase. At pH value below 4 most of the salivary calcium is in ionized form. The amount of calcium in the pellicle layer is higher than that in the saliva.

Calcium

Calcium caries two positive charges which can bind by chelation to certain chelating agents (e.g. citrate in citric acid found in citrus fruits or juices).
This may result in the dissolution of the calcium phosphate of the tooth surface.

Inorganic Phosphate

The inorganic phosphate found in saliva consists of phosphoric acid, primary, secondary and tertiary phosphate ions. The concentrations of total inorganic phosphate decreases with increasing flow rate. The most important function of inorganic phosphate is participating in the maintenance of the tooth structure.

Buffering of the saliva.

Phosphate is a nutrient to the oral microflora.

Fluoride

The Fluoride concentration in saliva ranged 0.01-0.03 ppm, which considered negligible. Fluoride concentration in saliva depend on fluoride in the environment (drinking water, dentifrices and other products). Fluoride diffuse from the saliva into the plaque causing elevation of fluoride level in plaque.

Organic Components

Mucins and other glycoproteins.: Lubricating and maintaining a moist mucosal surface. Help protecting the mucosa from infection and prevent bacterial adhesion to tooth structure. Statherin and acidic proline-rich proteins: Theses are calcium-binding proteins that inhibit spontaneous precipitation of calcium phosphate salts on tooth. Amylase : Amylase split starch into maltose, maltotrios and dextrin. Clear food debris containing starch in the mouth by which acids can form, so starch has some cariogenic potential. Other antimicrobial proteins: The most of these proteins can inhibit the metabolism, adherence, and the variability of cariogenic microorganisms.

Dental Caries and the Quantity of Saliva

Reduced ability to produce saliva is associated with increased caries experience. In patients with reduced quantity of saliva the mechanistic and clearing properties of saliva are impaired. The unstimulated flow rate has been found to be more important than the stimulated. The buffering capacity of saliva depends on the concatenation of bicarbonate which is strongly dependent on the secretion rate (the lowest concentrations are found at low secretion rates).

High lactobacillus counts are marks of low saliva production and number of lactobacilli in saliva has been found to correlate positively with caries activity.

Effect of Salivary Gland Hypofunction

The lack of saliva leads to rapidly developing caries in atypical places such as lingual, incisal, and cuspal tooth surfaces. Patients with impaired salivary secretion should receive an individual prophylactic dental program including intensive caries preventive care.

Saliva and Caries

Chewing Action:
- Stimulate saliva flow. - Stimulated saliva has higher buffer capacity. - Food (fermentable carbohydrates) is more rapidly cleared. - Acids are neutralized and cleared more rapidly.