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A review of saliva: Normal composition, flow, and function

Sue P. Humphrey, RDH, MSEd,a and Russell T. Williamson, DMDb


College of Dentistry, University of Kentucky, Lexington, Ky.
An adequate supply of saliva is critical to the preservation and maintenance of oral tissue.
Clinicians often do not value the many benefits of saliva until quantities are decreased. Much is
written on the subject of salivary hypofunction, but little attention is paid to normal salivary flow
and function. This article is a brief, up-to-date overview of the literature on the basics of normal
salivary composition, flow, and function. A review of the literature was conducted using MED-
LINE and Healthstar (1944 through 1999); articles were selected for inclusion on the basis of
relevance and significance to the clinician. (J Prosthet Dent 2001;85:162-9.)

S aliva is a most valuable oral fluid that often is taken


for granted. It is critical to the preservation and main-
The average daily flow of whole saliva varies in
health between 1 and 1.5 L. Percentage contributions
tenance of oral health, yet it receives little attention of the different salivary glands during unstimulated
until quantity or quality is diminished. There has been flow are as follows: 20% from parotid, 65% from sub-
much recent research on the topic of salivary dysfunc- mandibular, 7% to 8% from sublingual, and less than
tion as it relates to disease or as a side effect of certain 10% from numerous minor glands. Stimulated high
medications. Saliva also has become useful as a nonin- flow rates drastically change percentage contributions
vasive systemic sampling measure for medical diagnosis from each gland, with the parotid contributing more
and research. Consequently, it is necessary for clini- than 50% of total salivary secretions.3
cians to have a good knowledge base concerning the The types of cells found in the salivary glands are
norm of salivary flow and function. This article reviews acinar cells, various duct system cells, and myoep-
the biomedical literature on normal salivary composi- ithelial cells. Acinar cells, in which saliva is first
tion, flow, and function. A search of the literature was secreted, determine the type of secretion produced
conducted by using the MEDLINE and Healthstar from the different glands. Secretion can be classified
search engines (years 1944 through 1999). Articles as serous, mucous, or mixed; serous secretions are
from the primary, secondary, and tertiary literature produced mainly from the parotid gland, mucous
were selected for inclusion on the basis of relevance secretions from the minor glands, and mixed serous
and significance to the clinician. and mucous secretions from the sublingual and sub-
mandibular glands.2 Duct system cells found in the
ORIGIN AND ANATOMY
salivary ducts are classified as intercalated, striated,
Saliva is a clear, slightly acidic mucoserous exocrine and excretory. Intercalated duct cells are the first
secretion. Whole saliva is a complex mix of fluids from duct network connecting acinar secretions to the
major and minor salivary glands and from gingival rest of the gland. These cells are not involved in the
crevicular fluid, which contains oral bacteria and food modification of electrolytes, as are the remaining
debris.1,2 The major salivary glands include the paired duct cells. Striated cells are second in the network,
parotid glands, which are located opposite the max- functioning as electrolyte regulation in resorbing
illary first molars, and the submandibular and sublin- sodium. The final duct cells, the excretory duct cells,
gual glands, which are found in the floor of the contribute by continuing sodium resorption and
mouth. Minor glands that produce saliva are found in secreting potassium. Excretory duct cells are the last
the lower lip, tongue, palate, cheeks, and pharynx.2 part of the duct network before saliva reaches the oral
The terms major and minor refer to the anatomic size cavity. Myoepithelial cells, which are long cell
of the glands. Paradoxically, it could be argued that the processes wrapped around acinar cells, contract on
minor salivary glands are the most important because stimulation to constrict the acinar. This function,
of their protective components.3 Major glands do pro- secreting or “squeezing out” accumulating fluid, is
duce more saliva than minor glands, but the quality of the result of a purely neural process.1,2,4
content and thus the type of protection varies. Understanding the source of saliva as well as the
anatomy and location of salivary glands can impact the
aAssistant
management of diminished flow in relationship to
Professor, Department of Oral Health Practice, Chandler
Medical Center. localized disease, systemic disease, radiation therapy,
bAssociate Professor, Department of Oral Health Practice, Chandler and/or salivary duct stones (sialoliths).1,3,5
Medical Center.

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COMPOSITION accepted norm increases to 0.2 mL/min. These num-


bers have been projected from research on general
Saliva is composed of a variety of electrolytes, populations. Salivary flow is, however, a very individ-
including sodium, potassium, calcium, magnesium, ualized measurement and ideally should be recorded
bicarbonate, and phosphates. Also found in saliva are as a base reference after the age of 15.3 Any unstimu-
immunoglobulins, proteins, enzymes, mucins, and lated flow rate below 0.1 mL/min is considered
nitrogenous products, such as urea and ammonia. These hypofunction.10 In a 1992 study, the critical range
components interact in related function in the following separating persons with normal gland function from
general areas: (1) bicarbonates, phosphates, and urea act those with hypofunction was more precisely identi-
to modulate pH and the buffering capacity of saliva; (2) fied as unstimulated whole salivary flow rates
macromolecule proteins and mucins serve to cleanse, between 0.12 and 0.16 mL/min.21 If individualized
aggregate, and/or attach oral microorganisms and con- base rates have been established, then a 50% reduction
tribute to dental plaque metabolism; (3) calcium, in flow should be considered hypofunction.11
phosphate, and proteins work together as an antisolu- On average, unstimulated flow rate is 0.3 mL/min,3,5
bility factor and modulate demineralization and with the average total for 16 hours of unstimulated flow
remineralization; and (4) immunoglobulins, proteins, (during waking hours) being 300 mL. Salivary flow dur-
and enzymes provide antibacterial action. ing sleep is nearly zero. Stimulated flow rate is, at
The components listed above generally occur in maximum, 7 mL/min.3 Stimulated saliva is reported to
small amounts, varying with changes in flow, yet they contribute as much as 80% to 90% of the average daily
continually provide an array of important functions. It salivary production.
is important to stress that saliva, as a unique biologic The secretion of saliva is controlled by a salivary
fluid, must be considered as a whole that is greater center composed of nuclei in the medulla,5 but there
than the sum of its parts.6 Salivary components, par- are specific triggers for this secretion. Three types of
ticularly proteins, are multifunctional (performing triggers, or stimuli, for this production are mechanical
more than 1 function), redundant (performing similar (the act of chewing), gustatory (with acid the most
functions but to different extents), and amphifunc- stimulating trigger and sweet the least stimulating),
tional (acting both for and against the host).7 Recent and olfactory (a surprisingly poor stimulus). Other fac-
research into the complex roles of salivary proteins and tors affecting secretion include psychic factors such as
mucins support this theory; this research is discussed pain, certain types of medication, and various local or
under “Function.”8 systemic diseases affecting the glands themselves.2,5,12
Saliva is a very dilute fluid, composed of more than Salivary glands are innervated by both sympathetic and
99% water. Saliva is not considered an ultrafiltrate of parasympathetic nerve fibers. Various neurotransmit-
plasma.5 Initially, saliva is isotonic, as it is formed in ters and hormones stimulate different receptors,
the acini, but it becomes hypotonic as it travels different salivary glands, and different responses.13
through the duct network. The hypotonicity of When sympathetic innervations dominate, the secre-
unstimulated saliva allows the taste buds to perceive tions contain more protein from acinar cells, whereas
different tastes without being masked by normal plas- predominant parasympathetic innervations produce a
ma sodium levels. Hypotonicity, especially during low more watery secretion.3 Stimulation of 1 receptor
flow periods, also allows for expansion and hydration often enhances and complements another receptor.
of mucin glycoproteins, which protectively blanket tis- Therefore, the separation of contributing stimuli and
sues of the mouth.9 Lower levels of glucose, resulting secretory products is not absolute.13 It must
bicarbonate, and urea in unstimulated saliva augment be emphasized that there is great individual variability
the hypotonic environment to enhance taste. in salivary stimulation and secretion from cell type to
The normal pH of saliva is 6 to 7, meaning that it cell type, thereby affecting the content of saliva region-
is slightly acidic. The pH in salivary flow can range ally and as a whole.
from 5.3 (low flow) to 7.8 (peak flow). Major salivary Having distinguished between unstimulated and
glands contribute most of the secretion volume and stimulated flow rates, it probably is more meaningful
electrolyte content to saliva, whereas minor salivary and easier to measure whole saliva flow volume. As
glands contribute little secretion volume and most of stated earlier, whole saliva refers to the complex mix of
the blood-group substances.3 salivary contents that includes stimulated and unstim-
ulated saliva, gingival crevicular fluid, nonadherent
FLOW
oral bacteria and food debris, and traces of introduced
There is great variability in individual salivary flow chemicals or medicaments. Total daily flow of whole
rates. The accepted range of normal flow for unstim- saliva measures, on average, between 500 mL and 1.5 L,
ulated saliva is anything above 0.1 mL/min. For depending on the reference. There are daily and annual
stimulated saliva, the minimum volume for the ebbs and peaks in flow. Circadian (daily) low flow occurs

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during sleep, whereas peaks occur during high stimula- ration of food for digestion and taste, and (2) an
tion periods.14 Circannual (yearly) low flow occurs increased susceptibility of oral structures to dis-
during the summer, whereas peak flow is during the ease.20 A set of 4 easily collected clinical parameters
winter.3,12 Circadian flow variations affect not only flow has been described in recent research; these promote
but also the concentration level of salivary components successful identification of patients with salivary
such as salivary electrolytes and proteins.15 gland hypofunction. The parameters include evi-
Salivary flow does not occur evenly throughout the dence of dry lips; buccal mucosa dryness; lack of
mouth. Regional variation in intraoral flow is site spe- salivation on palpation; and a high total score on the
cific, with the mandibular lingual being a site of high decayed, missing, or filled teeth index (DMFT).
volume and the maxillary anteriors and interproximals When all 4 parameters are scored collectively, posi-
being sites of low volume flow.3 These areas of high- tive results may lead to further diagnostic evaluation,
er and lower volume flow regions have been referred such as salivary flow rate measurements, minor sali-
to as “salivary highways and byways.”16 The regional vary gland biopsy, and/or a sialography.21
clearance rate of acid produced from bacteria is direct- Hypofunction of stimulated salivary flow is not a
ly influenced by regional variations in flow within the normal age-related change. Although decreased con-
mouth.17 Consequently, salivary byways are areas in centrations of salivary mucins have been found with
which acid by-products may remain in longer contact age in resting and stimulated whole human sali-
with oral structures unless mechanical means of va,22,23 research points to no substantial age-related
cleansing are used.16 Moreover, with varying amounts changes in the secretory responsiveness of salivary
of components and secretions coming from different mucous cells.24,25 Many times, reduced flow in older
glands, it is suggested that saliva provides different patients is linked to side effects of prescription med-
types of protection in different locations intraorally.18 ications.3,26 Nutritional changes and deficiencies can
For example, parotid saliva contains amylase, proline- influence salivary function as well. A modest reduc-
rich proteins, and agglutinins with minute amounts of tion in daily food intake may result in increased
cystatins, lysozymes, and extraparotid glycoproteins. salivary protein, whereas severe caloric restrictions
As a result, maxillary premolars exhibit higher counts tend to reduce salivary flow, cell numbers, and sali-
of salivary agglutinins due to the proximity of the vary composition.27
parotid duct. Sublingual saliva contributes high con- A working knowledge of normal salivary flow is
centrations of both types of mucins, MG1 and MG2, necessary for the clinician discussing patient home
as well as high levels of lysozymes. Submandibular care instructions. Low flow during sleep mandates the
saliva contains the largest amount of cystitis, whereas need to carefully cleanse the mouth before going to
palatine secretions offer MG1 mucins and relatively bed and after breakfast. The use of sugarless chewing
high amylase concentrations.18 Considering that a gum or candy containing xylitol or sorbitol can be
0.1-mm-thick layer of saliva on a tooth is thinner than recommended as a means of stimulating extra salivary
a layer of plaque, it is no surprise that the task of flow to aid caries management and lubrication.3,28
cleansing oral structures cannot be completed suc- Acidic and sweet taste stimuli are better choices as
cessfully by saliva alone. A small amount of saliva, on triggers for desired extra flow. Patients with
average about 0.8 mL, remains in the mouth after decreased salivary flow also should be made aware of
swallowing.3 This is referred to as residual volume. the necessity to comply with suggested oral hygiene
Dawe19 described a model for oral clearance, compar- regimens after exposure to acid-producing food
ing it with an incomplete siphon. The smaller the sources. Recommendations for professional and
amount of residual volume, the faster the clearance home fluoride treatments should be considered care-
rate for the mouth. fully for patients with salivary dysfunction, especially
Salivary dysfunction is not discussed at length in those with high caries rates and exposed root sur-
this article, but reference to it must be made to faces. The successful use of removable prostheses by
understand the topic of normal flow and function. a patient also may be affected dramatically by
Dysfunction, more commonly called hypofunction, decreased salivary flow.
is difficult to assess, namely because of the existence
FUNCTION
of a wide range of variations accepted as normal. The
diagnosis or assessment of salivary dysfunction is rel- Salivary function can be organized into 5 major
atively subjective unless an individual base record of categories that serve to maintain oral health and cre-
salivary flow has been established. About 30% of the ate an appropriate ecologic balance: (1) lubrication
population reports some degree of dry mouth, and protection, (2) buffering action and clearance,
which indicates that it is not an infrequent complaint (3) maintenance of tooth integrity, (4) antibacterial
or patient concern. Insufficient salivary flow results activity, and (5) taste and digestion.16,29 As stated
in 2 general, oral-related effects: (1) reduced prepa- earlier, salivary components work in concert in over-

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lapping, multifunctioning roles, which can be simulta- tion of saliva through the following components:
neously beneficial and detrimental.7 bicarbonate, phosphate, urea, and amphoteric proteins
As a seromucous coating, saliva lubricates and pro- and enzymes. Bicarbonate is the most important
tects oral tissues, acting as a barrier against irritants. buffering system. It diffuses into plaque and acts as a
These irritants include, but are not limited to, proteo- buffer by neutralizing acids. Moreover, it generates
lytic and hydrolytic enzymes produced in plaque, ammonia to form amines, which also serve as a buffer
potential carcinogens from smoking and exogenous by neutralizing acids.35 More than 90% of the nonbi-
chemicals, and desiccation from mouth breathing.5 carbonate buffering ability of saliva is attributed to
The best lubricating components of saliva are mucins low-molecular-weight, histidine-rich peptides.20 Urea,
that are excreted from minor salivary glands. Mucins another buffer present in saliva, releases ammonia after
are complex protein molecules that are present pre- being metabolized by plaque and thus increases plaque
dominantly in 2 molecular weight types31,32 and pH.27 The buffering action of saliva works more effi-
formed by polypeptide chains that stick together. ciently during stimulated high flow rates but is almost
These mucins have the properties of low solubility, ineffective during periods of low flow with unstimulat-
high viscosity, high elasticity, and strong adhesiveness. ed saliva.2,3 Phosphate is likely to be important as a
Any intraoral contact between soft tissues, between buffer only during unstimulated flow.36
soft tissues and teeth, or between soft tissues and pros- The pH of saliva may not be as important a measure
theses benefits from the lubricating capability of saliva for buffering action on caries as the pH of plaque,
supplied largely by these mucins.3 Mastication, speech, which saliva modifies.2 Remaining fermentable carbo-
and swallowing all are aided by the lubricating effects hydrates and the buffering capacity of saliva affect
of mucins.32 plaque pH, unless the pH of the plaque is too low for
Mucins also perform an antibacterial function by bacterial enzymes to function. The resting pH of
selectively modulating the adhesion of microorganisms plaque (that is, the pH of plaque 2 to 2.5 hours after
to oral tissue surfaces, which contributes to the control the last intake of exogenous carbohydrates) is 6 to
of bacterial and fungal colonization. Secretions from 7.3,37 The pH rises during the first 5 minutes after the
the sublingual and submandibular glands contain a intake of most foods. The pH then falls to its lowest
high-molecular-weight, highly glycosylated mucin level, to 6.1 or lower, approximately 15 minutes after
(MG1) and a low-molecular-weight, single-glycosylated food consumption. Unless there is additional ingestion
peptide chain mucin (MG2).31,32 The importance of of fermentable carbohydrates, the pH of plaque grad-
these 2 major mucins has been the focus of much ually returns to its resting pH of 6 to 7.38-40 Thus,
research in the last 2 decades. MG1 adsorbs tightly to salivary buffering, clearance, and flow rate work in
the tooth and thereby contributes to the enamel pelli- concert to influence intraoral pH.39 As stated earlier,
cle, which protects the tooth from acid challenges. salivary flow can be augmented by the stimulus of
MG1 forms heterotypic complexes with other salivary chewing as well as by the muscular activity of the lips
proteins such as amylase, proline-rich proteins, and tongue.29,35 With stimulated additional flow,
statherin, and histatins, simultaneously attracting the chewing products (such as gum) that contain no fer-
attachment of certain bacteria and providing a short- mentable carbohydrates can aid in the modulation of
term nutrient source for bacteria.30 MG2 binds to plaque pH. Sugar-free sweeteners such as xylitol and
enamel but is displaced easily. It promotes the aggre- sorbitol should be recommended for use without fear
gation and clearance of oral bacteria, including of promoting caries. Indeed, research has shown that
streptococci mutans.33,34 In the saliva of caries-resis- the use of gum containing xylitol or sorbitol reduces
tant patients, MG2 predominates, whereas the level of plaque accumulation and gingival inflammation and
MG1 is higher in caries-susceptible patients.31 An enhances remineralization potential.41 Taking into
important part of the multifunctional role of salivary account the time frame for changes in plaque pH relat-
mucins in preserving mucosal integrity is their ability ed to the ingestion of fermentable carbohydrates,
to regulate intercellular calcium levels.31 As a part of dentists should recommend that patients, especially
the enamel pellicle, mucins help initiate bacterial colo- those who are caries-prone, brush soon after the intake
nization by promoting the growth of benign of cariogenic meals and snacks.
commensal oral flora, forming a protective barrier and Maintaining tooth integrity is a third function of
lubrication against excessive wear, providing a diffu- saliva, one that facilitates the demineralization and
sion barrier against acid penetration, and limiting remineralization process. Demineralization occurs
mineral egress from the tooth surface.9 The results of when acids diffuse through plaque and the pellicle
research clearly indicate that salivary mucins perform a into the liquid phase of enamel between enamel crys-
variety of functions essential to maintaining a stable tals. Resulting crystalline dissolution occurs at a pH of
oral defense.32 5 to 5.5, which is the critical pH range for the devel-
Buffering action and clearance are a second func- opment of caries.3 Dissolved minerals subsequently

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diffuse out of the tooth structure and into the saliva food material tenaciously cling to hard and soft tissue
surrounding the tooth. The buffering capacity of sali- surfaces in relatively dry environments. Even profes-
va greatly influences the pH of plaque surrounding sional therapy for patients with extreme salivary
the enamel, thereby inhibiting caries progression.37 dysfunction is a challenge because of tissue desiccation
Plaque thickness and the number of bacteria present and subsequent lack of ease in manipulating instru-
determine the effectiveness of salivary buffers. ments and materials under such conditions. Clinicians
Remineralization is the process of replacing lost should resist the temptation to “overexplore” white
minerals through the organic matrix of the enamel to spot lesions. Excessive manipulation of the crystalline
the crystals. Supersaturation of minerals in saliva is crit- structure may interfere with further remineralization
ical to this process. The high salivary concentrations of of the area.3
calcium and phosphate, which are maintained by sali- A fourth function of saliva is its antibacterial activity.
vary proteins, may account for the maturation and Salivary glands are exocrine glands, and, as such, secrete
remineralization of enamel.2 Statherin, a salivary pep- fluid containing immunologic and nonimmunologic
tide, contributes to the stabilization of calcium and agents for the protection of teeth and mucosal surfaces.
phosphate salts solution, serves as a lubricant to protect Immunologic contents of saliva include secretory IgA,
the tooth from wear, and may initiate the formation of IgG, and IgM. Nonimmunologic salivary contents are
the protective pellicle by binding to hydroxyapatite.3,6 selected proteins, mucins, peptides, and enzymes.
Proteins in the protective pellicle, such as statherin, Secretory IgA, the largest immunologic component of
histatins, cystatins, and proline-rich proteins, are too saliva, is an immunoglobulin produced by plasma cells
large to penetrate enamel pores. Therefore, they in connective tissues and translocated through the duct
remain on the surface, bound to hydroxyapatite, to aid cells of major and minor salivary glands. IgA, while
in controlling crystalline growth of the enamel by active on mucosal surfaces, also acts to neutralize virus-
allowing the penetration of minerals into the enamel es, serves as an antibody to bacterial antigens, and works
for remineralization and by limiting mineral egress.6,34 to aggregate or clump bacteria, thus inhibiting bacterial
This control of precipitation and mineral egress attachment to host tissues.6,45 Other immunoglobulins
enhances the stability of hydroxyapatite in the outer present in saliva are in low quantities and probably come
tooth structure.42 Low-molecular-weight protein frac- from gingival crevicular fluid.2 It seems unlikely that
tions, thought to be derived from the proteolytic host complement response could act generally in the
processing of larger proteins, are likely to be in oral fluid.3 IgA itself does not activate complement,5
exchange with dental plaque fluid. These protein frac- but oral fluids can be augmented by gingival crevicular
tions help adjust and augment remineralization, fluid host complement components when gingivitis is
microbial attachment, and plaque metabolism at the present around existing teeth.1,29
tooth-saliva interface.43,44 Immunologic and nonimmunologic antibacterial
The presence of fluoride in saliva speeds up crystal salivary content come from 2 different sources—
precipitation, forming a fluorapatite-like coating more namely, plasma and ductal cells—with different
resistant to caries than the original tooth structure. In responses to stimulation and different content levels.
that sense, small amounts of demineralization have Nonimmunologic antibacterial salivary contents such
been suggested as advantageous for the tooth because as proteins, mucins, peptides, and enzymes (lactofer-
enamel components of magnesium and carbonate are rin, lysozyme, and peroxidase), all products of acinar
replaced with the stronger, more caries-resistant fluor- gland cells, help protect teeth against physical,
apatite crystals.3 Fluoride in salivary solution works to chemical, and microbial insults. 15 MG2, the low-
inhibit dissolution of apatite crystals. molecular-weight mucin, and IgA complex bind
The contribution of saliva to the demineralization- mucosal pathogens with greater affinity than either
remineralization process points to the importance of MG2 or IgA alone.46 Lactoferrin, produced in inter-
monitoring salivary flow, especially in patients taking calated ductal cells, binds ferric iron in saliva. This
multiple medications or having systemic entities that process makes ferric iron unavailable as a food source
decrease salivary flow. For patients with exposed root for microbes, such as cariogenic streptococci, that
surfaces or with recurrent or incipient carious lesions, need iron to remain viable.2 This process of starving
fluoride supplementation can promote remineraliza- bacteria of vital nutrients is called nutritional immu-
tion. Salivary stimulants and substitutes also should be nity. 47 Lactoferrin exhibits another antimicrobial
encouraged for patients with salivary hypofunction. effect not related to its iron-binding ability via the
Researchers currently are investigating a method to sensitivity of Streptococcus mutans to lactoferrin.48
genetically engineer salivary proteins and other salivary Lysozymes, derived from the basal cells of striated
components for use in future artificial salivas.7 Home ducts in parotid glands, split bacterial cell walls, lead-
care for persons with decreased salivary flow becomes ing to the destruction and inhibition of bacterial
a time-consuming process because plaque and any growth.5,49 Moreover, lysozymes promote the clear-

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ance of bacteria through aggregation. Gingival crevic- digestion by beginning the breakdown of starch with
ular fluid also contributes lysozymes from plasma.6 amylase, a major component of parotid saliva that ini-
Peroxidase, also known as sialoperoxidase or lactoper- tially dissolves sugar.16,29 The contribution of saliva to
oxidase, catalyzes bacterial metabolic by-products with starch breakdown is limited because most of the diges-
thiocynate, which is highly toxic to bacterial sys- tion of starch results from pancreatic amylase, not
tems.1,3 Secreted by acinar cells, peroxidase salivary amylase.5 Salivary enzymes also initiate fat
additionally protects mucosa from the strong oxidiz- digestion.53 More importantly, saliva serves to lubri-
ing effects of hydrogen peroxide produced by oral cate the food bolus, which aids in swallowing.1,27,54
bacteria.6 Cystatins, a family of cysteine-containing When one considers the contribution of saliva to taste
proteins, have a minor role in the regulation of salivary and early digestion, it becomes clear that artificial sup-
calcium. But the main action of cystatins may be to plements would be difficult to develop.
inhibit cysteine-proteinase involved in the pathogene-
RESEARCH APPLICATIONS
sis of periodontal disease.31
Finally, proteins such as glycoproteins, statherins, Many areas of research involving salivary compo-
agglutinins, histadine-rich proteins, and proline-rich nents and functions are in progress for local and
proteins work to aggregate bacteria. This “clumping” systemic disease diagnosis, treatment, and prevention.
process, as described earlier, reduces the ability of bac- The value of saliva undoubtedly will continue to
teria to adhere to hard or soft tissue intraoral surfaces increase because it serves as an easily collected, nonin-
and thereby controls bacterial, fungal, and viral colo- vasive source of information. Reflective of the status of
nization.35 As a whole, protein content increases health in the body, salivary samples can be analyzed
proportionally with increasing flow rate.2 But salivary for: (1) tissue fluid levels of naturally, therapeutically,
protein concentrations, like other salivary compo- and recreationally introduced substances; (2) emotion-
nents, may also be subject to circadian variations and al status; (3) hormonal status; (4) immunologic status;
affected by stress, inflammation, infection, and hor- (5) neurologic status; and (6) nutritional/metabolic
monal changes. In addition, protein content varies influences.55
among persons, exhibits different polymorphic pheno- Saliva already is used to aid in the diagnosis of den-
types, and can exhibit strain-species differences in tal disease. Examples include caries risk assessment,
protein-microbial interactions.15 periodontal disease genotypes, and identification
It is a paradox that, although saliva has numerous markers for periodontal disease, salivary gland disease
antibacterial functions, it also supports the selective and dysfunction, and candida infections. Salivary col-
bacterial growth of noncariogenic microflora.50 lections are used for diagnostic determinants for viral
Glucose levels in saliva are too low to explain this phe- diseases, sarcoidosis, tuberculosis, lymphoma, gastric
nomenon.1,3 Just as the content of saliva varies in ulcers and cancers, liver dysfunction, and Sjogren’s
different parts of the mouth, so varies the composition syndrome.55-58 Saliva also is being used to monitor
of pellicle formed in different parts of the mouth. This levels of polypeptides, steroids, antibodies, alcohol,
may be important in the establishment of bacteria and and various other drugs. Research currently is being
tooth-related disease patterns from one area of the conducted to determine the value of saliva as a diag-
mouth to another.51 nostic aid for cancer and preterm labor.56,57 Another
The concept of saliva’s antibacterial activity high- area of research involves the possible regenerative
lights the clinical value of stimulating natural saliva, properties and functions of growth factors found in
especially in patients with decreased function. Saliva saliva, such as epidermal growth factor and transform-
substitutes are extremely important for lubrication and ing growth factor. Evidence suggests that these growth
helpful for oral clearance and tooth integrity, but they factors play a role in wound healing and the mainte-
offer little that can compare with the protection given nance of oral and systemic health.20,59
by natural salivary components. Because salivary com- The multifunctional roles of salivary components con-
ponents are considered multifunctional (that is, having tinue to represent a very focused area of dental research.
“built-in” compensatory redundant antibacterial prop- Can the redundant and synergistic effects of salivary pro-
erties) and amphifunctional, depending on the teins be used to further enhance remineralization? Could
intraoral environment or the molecule, the develop- the salivary antibacterial factors be targeted to positively
ment of an effective artificial saliva is a difficult task.7,52 alter the biofilm community in plaque? Can salivary con-
A fifth and final function of saliva is to enhance taste stituents more selectively control bacterial adherence and
and begin the digestive process. The hypotonicity of aggregation? Can the buffering system of saliva effective-
saliva enhances the tasting capacity of salty foods and ly and selectively be enhanced? Can salivary components
nutrient sources. This enhanced tasting capability be reproduced or replaced by new developments in arti-
depends on the presence of protein and gustin, which ficial saliva? Questions such as these are being addressed
bind zinc.2 Saliva has an early, limited role in total through continuing research efforts.

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The knowledge of normal salivary composition, flow, mandibular salivary flow rates in healthy, different-aged adults. J Gerontol
and function is extremely important on a daily basis A Biol Sci Med Sci 1995;50:M285-9.
27. Johnson DA. Regulation of salivary glands and their secretions by mastica-
when treating patients. Dental health professionals spend tory, nutritional and hormonal factors. In: Scribney LM, editor. The salivary
untold hours removing this precious natural resource to system. Boca Raton, FL: CBC Press; 1987. p.136-55.
perform therapy with little regard to its value until flow 28. Isokangas P, Tiekso J, Alanen P, Makinen KK. Long-term effect of xyli-
tol chewing gum on dental caries. Community Dent Oral Epidemiol
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HUMPHREY AND WILLIAMSON THE JOURNAL OF PROSTHETIC DENTISTRY

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Reprint requests to:


DR SUE P. HUMPHREY, RDH,MSED
DEPARTMENT OF ORAL HEALTH PRACTICE, ROOM D-440
COLLEGE OF DENTISTRY, UNIVERSITY OF KENTUCKY
CHANDLER MEDICAL CENTER
LEXINGTON, KY 40536-0297
FAX: (606)257-1847
E-MAIL: sphrdh@pop.uky.edu doi:10.1067/mpr.2001.113778

Passivity of fit and marginal opening in screw- or cement-


Noteworthy Abstracts retained implant fixed partial denture designs
of the Guichet DL, Caputo AA, Choi H, Sorensen JA. Int J Oral
Current Literature Maxillofac Implants 2000;15:239-46.

Purpose. Early designs of implant-supported restorations called for screw retention of the pros-
thesis to allow for its retrieval. With increasing predictability of the osseointegration process, there
has been an increase in the usage of nonretrievable prosthesis designs that use cement retention
of the final restoration. This study compared the marginal fit of prostheses to support abutments
when restorations were cemented versus screw-retained. In addition, the study evaluated the
stress patterns in a photoelastic model of the implants with the 2 different methods of prosthesis
retention.
Material and methods. A simulated mandibular model was created with 10 mm implants
(Branemark System, Noble Biocare, Yorba Linda, Calif.) in the positions of the left first and sec-
ond premolar and first molar teeth. Five prostheses were fabricated to fit to EP Conical
Abutments (Implant Innovations Inc, Palm Beach Gardens, Fla.) for the screw-retained design,
and 5 prostheses were fabricated to fit to EP 2-piece abutment posts (Implant Innovations Inc,
Palm Beach Gardens, Fla.) for the cement-retained design. Marginal integrity was assessed using
a traveling microscope (Gaertner, Chicago, Ill.) before cementation or screw tightening and again
after cementation and screw tightening. Photoelastic models were assessed for both types of pros-
thetic restorations with stress concentration ranked for comparison purposes.
Results. There were no significant differences in marginal openings before cementation, before
screw tightening, or after cementation. Marginal closure did occur when the retaining screws
were tightened, resulting in a significant improvement of fit (P<.05). Photoelastic analysis showed
higher stress concentration with the screw-retained restorations.
Discussion. Both methods of prosthesis connection have advantages and disadvantages. Passivity
of fit has been described as an important factor for maintenance of osseointegration, but this con-
cept recently has been questioned. Ongoing research on this topic and on methods to improve
fit was suggested. 35 References. —SE Eckert

FEBRUARY 2001 169

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