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Original Article

Determination of salivary flow rate, pH, and dental

caries during pregnancy: A study
Amruta A Karnik, Sandeep S Pagare1, Vasavi Krishnamurthy1, Sonal P Vahanwala1, Mandavi Waghmare1
Department of Oral Medicine and Radiology, Modern Dental College and Research Centre, Indore, Madhya Pradesh,
1
Department of Oral Medicine and Radiology, Dr. DY Patil Dental College and Hospital, Navi Mumbai, Maharashtra, India

ABSTRACT

Introduction: Saliva is an important diagnostic biofluid and the salivary composition is affected by various systemic
conditions including pregnancy. Aims: The study was conducted to evaluate the salivary flow rate and pH in pregnant
and non-pregnant Indian women and, consequently, to compare and correlate the salivary flow rate, pH, and prevalence
of dental caries in both groups. Settings and Design: A cross-sectional study was conducted in our institute on a sample
of 30 pregnant and 30 non-pregnant women. Materials and Methods: The clinical findings for Decayed-Missing-Filled
Teeth (DMFT) index were recorded. Unstimulated whole saliva was collected to determine the salivary flow rate and pH.
Statistical Analysis Used: Data were statistically analyzed using Students t-test. Results: Salivary flow rate was lower in
pregnant women (0.63 ml/min) as compared to that in non-pregnant women (0.81 ml/min) (P < 0.05) and the pH was also
lesser in pregnant women (6.56) than in non-pregnant women (6.86) (P < 0.05). DMFT index showed a strong negative
correlation with pH in pregnant women and non-pregnant women (P < 0.05). Conclusion: A difference was observed
between the salivary parameters of pregnant and non-pregnant women in this sample. However, all the values were within
the normal range. A significant inverse relation was found between salivary pH and dental caries for both the groups.
Key words: DMFT index, pH of saliva, pregnancy, salivary flow rate, unstimulated whole saliva

Introduction research has gained importance in the fields of dentistry

S
aliva is essential for the maintenance of oral health
and it is an important diagnostic biofluid.[1] It
plays a pivotal role in protection and lubrication
of oral mucosal tissues, remineralization of teeth, and
alimentation.[2,3] The salivary composition gives it many
important physical and biochemical properties.[4] It is
useful for diagnosis, prognosis, and management of
patients with oral and systemic diseases.[1] There is
increasing inclination toward using saliva samples for
the diagnosis of oral and systemic diseases.[1] Salivary
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and oral biology.[5]
Oral health is affected by many systemic conditions. It
is influenced by female steroid sex hormones through
different mechanisms. The composition of human
saliva is altered during pregnancy, menstruation, and
menopause due to changes in steroid hormone levels.
This is an open access article distributed under the terms of the
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How to cite this article: Karnik AA, Pagare SS, Krishnamurthy V,

DOI: Vahanwala SP, Waghmare M. Determination of salivary flow rate,
10.4103/0972-1363.170454
pH, and dental caries during pregnancy: A study. J Indian Acad
Oral Med Radiol 2015;27:372-6.

Address for correspondence: Dr. Amruta A. Karnik, 302/C, Rajendra Vihar, Evershine Nagar, Malad - (West),
Mumbai-400064, Maharashtra, India. E-mail: karnik_amruta@yahoo.in
Received: 10-03-2015 Accepted: 05-11-2015 Published: 25-11-2015

372 2015 Journal of Indian Academy of Oral Medicine and Radiology | Published by Wolters Kluwer - Medknow
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Karnik AA et al.: Salivary flow rate, pH and caries in pregnancy
Many human studies indicate that during ovulation
time, hormonal change influences the composition of
human saliva.[6] During pregnancy, there are profound
physiologic changes due to complex hormonal
interactions.[7] Pregnancy brings changes in the salivary
flow rate, pH of saliva, and biochemical composition.[8]
Salivary composition is of great importance for preventing
caries incidence.[9] The present study aims to evaluate the
effect of pregnancy on salivary flow rate and pH of saliva
and to compare and correlate the salivary flow rate, pH
of saliva, and prevalence of dental caries in pregnant and
non-pregnant Indian women. The a priori hypothesis
was there are differences in the salivary flow rate and pH
of saliva between pregnant and non-pregnant women.
Materials and Methods
A cross-sectional study was conducted in the Department
of Oral Medicine and Radiology of Dr. DY Patil Dental
College and Hospital, Navi Mumbai, Maharashtra,
India. A total convenience sample of 60 women aged
between 18 and 37 years was selected. Subjects willing to
participate and aged 18 years and above were included in
the study. Subjects with any systemic diseases, complaint
of xerostomia, and smoking habit were excluded from
the study. Thirty consecutive healthy pregnant women
between the third and the ninth months of gestation
comprised the pregnant group and 30 non-pregnant
women consecutively sampled in the same department
composed the comparison group. None of the healthy,
non-pregnant women were taking oral contraceptive
pills.
The study protocol was in compliance with the Helsinki
Declaration and an approval was obtained from the
institutions ethical committee. A written informed
consent was obtained from all participants prior to
the study procedure. A questionnaire was structured
to acquire data on oral hygiene habits (tooth brushing
frequency and method, use of interproximal brushes,
dental floss, tongue cleaning habit). Information
regarding pregnancy trimester and use of medication
was procured from the subjects medical charts. The
intraoral examination was conducted by a single
examiner under favorable lighting conditions using a
sterile mouth mirror, diagnostic probe, and explorer. The
clinical findings were recorded in the study proforma.
The Decayed-Missing-Filled Teeth (DMFT) index,
an irreversible index, was obtained to determine the
prevalence of dental caries.
The saliva sample collection procedure was standardized
prior to the study. The collection of unstimulated whole
saliva was performed under resting conditions between
9.00 am and 11.00 am. The participants refrained from
eating and drinking for a minimum of 1 h prior to saliva
Journal of Indian Academy of Oral Medicine & Radiology | Jul-Sep 2015 | Vol 27 | Issue 3
collection. The subjects were advised to rinse their
mouth several times with deionized (distilled) water and
then relax for 5 min before the procedure. The subjects
were asked to sit comfortably with head tilted slightly
forward and expectorate the saliva accumulated in the
floor of the mouth into disposable plastic containers for
duration of 5 min. Each saliva sample was collected on
ice. The salivary samples were quantified volumetrically
using graduated measuring cylinder. The salivary flow
rate was expressed as ml/min. The saliva samples were
centrifuged (centrifugal force: 1000 rpm) for the removal
of bacteria and extraneous material. The resulting
supernatant fluid was used to measure salivary pH using
a bench type pH meter.
Statistical analysis was done using SPSS software
version 15.0 using Students t-test. All the dependent
variables in the study were measured using ratio-scale
parametric statistical tests and were appropriate for
comparison with respect to the independent variable, i.e.
the pregnant and non-pregnant groups. Comparison of
all the variables between the pregnant and non-pregnant
groups was performed using Students t-test for
independent samples. The correlations between DMFT
index and saliva parameters were measured using
Pearsons correlation coefficients. P value <0.05 was
considered statistically significant.
Results
Data of all 60 subjects were available and statistically
analyzed. The mean age of women belonging to
the pregnant group was 24.57 years and that of the
non-pregnant group was 22.27 years. In the pregnant
group, 11 (36.6%) subjects belonged to the age group
of 18-22 years, 12 (40%) subjects to 23-27 years, 6 (20%)
subjects to 28-32 years, and 1 (3.33%) to 33-37 years. In
the non-pregnant group, 20 (66.67%) belonged to the
age group of 18-22 years followed by 6 (20%) subjects
to 23-27 years, 4 (13.33%) subjects to 28-32 years, and no
subject belonged to the age range of 33-37 years. Among
the pregnant women, 1 (4%) was in the first trimester,
7 (23%) were in the second trimester, and 22 (73%) were
in the third trimester [Graph 1].
The pregnant women had lower salivary flow rate
(0.63 0.24 ml/min) as compared to the non-pregnant
women (0.81 0.15 ml/min) (P = 0.001). On comparison,
the pH of saliva was also lesser in pregnant women
(6.56 0.35) than in non-pregnant women (6.86 0.42)
(P=0.004). There was a statistically significant difference
in the salivary flow rate and pH between pregnant
and non-pregnant women [Tables 1 and 2]. The DMFT
index was higher in non-pregnant group (8.23) than in
the pregnant group (7.97) [Table 1]. However, this was
statistically insignificant (P > 0.05) [Table 2].
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Karnik AA et al.: Salivary flow rate, pH and caries in pregnancy

Table 1: Minimum, maximum, mean, standard deviation, and 95%

confidence interval for salivary flow rate, pH, and DMFT index
for the pregnant and non-pregnant groups
Variables Minimum Maximum Mean SD 95% confidence
interval
Pregnant (n = 30)
Salivary flow rate 0.3 1.1 0.63 0.24 0.54
pH of saliva 5.85 7.36 6.56 0.35 6.43
DMFT index 0 19 7.97 4.82 6.1679
Non-pregnant (n = 30)
Salivary flow rate 0.5 1.5 0.81 0.15 0.76
pH of saliva 5.63 7.62 6.86 0.42 6.70
DMFT index 0 20 8.23 5.52 6.1725

Table 2: Comparison of variables for pregnant and non-pregnant

Graph 1: Distribution of subjects in pregnant group groups
Variables Pregnant group Non-pregnant t-value P value
Mean (SD) group Mean (SD)
DMFT index showed a strong correlation with pH in Salivary flow rate 0.63 (0.24) 0.81 (0.15) 3.575 0.001*
pregnant women (P = 0.002) and non-pregnant women pH of saliva 6.56 (0.35) 6.86 (0.42) 2.983 0.004*
(P = 0.01). The regression coefficients were negative DMFT index 7.97 (4.82) 8.23 (5.52) 0.199 0.843
for both the groups, suggesting a significant inverse *P value is statistically significant at <0.05
relationship in the pH of saliva and caries prevalence.
No correlation was found in DMFT index and salivary
Table 3: Correlation between DMFT index and salivary flow rate
flow rate for both the groups [Table 3]. Data regarding and pH of saliva for pregnant and non-pregnant groups
the oral hygiene habits were recorded, which showed that Variables Group Pearsons Regression
21 pregnant patients (70%) and 19 non-pregnant patients correlation (P value) coefficient
(63.34%) brushed their teeth twice daily. Eight pregnant Salivary Pregnant 0.23 0.23
patients (26.67%) and five non-pregnant patients (16.67%) flow rate Non-pregnant 0.07 0.34
used dental floss. Seventeen (56.67%) pregnant patients pH Pregnant 0.002* 0.54
and 14 (46.67%) non-pregnant patients had received Non-pregnant 0.01* 0.46
professional guidance for oral hygiene care previously. *P value is significant at <0.05

an increased level of salivary pH because the bicarbonate

Discussion
In the present study, the salivary flow rate and pH of saliva
were lower in pregnant women than in non-pregnant
women. An inverse relation was found between pH of
saliva and caries prevalence, but no relation was present
between salivary flow rate and caries prevalence for both
the groups. For the purpose of this study, unstimulated
whole saliva was collected for evaluation of salivary
flow rate and pH of saliva, as unstimulated whole saliva
plays a major role in maintenance of oral health and it
is predominantly secreted through the day and at night
time.[6] The salivary composition and flow rate are altered
during pregnancy, menstruation, and menopause due
to changes in steroid hormone levels. [6] However, no
direct influence of age is seen on the salivary flow rate of
unstimulated whole saliva.[10,11]
We found that there was numerically lesser salivary flow
rate in pregnant women than in non-pregnant women.
Studies conducted by Hugoson[12] and Gonzlez et al.[13]
showed similar findings of decreased salivary flow rate
in pregnant women. Salivary flow rate has a definitive
influence on the pH of saliva. At higher flow rate, there is
concentration increases with elevated flow rate.[4,9] It
was found in our study that the salivary pH was lower
in pregnant women than in non-pregnant women. The
pH of saliva for both the groups was within the normal
range of 5.5-7.4, according to the international reference
values.[14] At a pH lower than the critical level of 5.5,
the hydroxyapatite crystals begin to dissolve causing
demineralization of teeth.[15] In this study, the salivary
pH levels for both the groups were above the critical
level of 5.5. Rosenthal et al.[8] compared the pH of saliva
in pregnant and non-pregnant women; they reported
that the mean pH value of saliva of pregnant women was
6.5 and that of non-pregnant women was 7.0. Decreased
salivary pH in pregnant women was also reported in a
previous study conducted by Kullander and Soneson.[16]
Laine et al.[17] reported that the salivary pH decreased
toward late pregnancy, followed by a rapid increase after
childbirth. Rockenbach et al.[18] reported that pregnant
women had reduced level of salivary pH (6.7) than
non-pregnant women (7.5).
During pregnancy, the levels of progesterone and
estrogen (estradiol, estriol, and estrone) increase

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Karnik AA et al.: Salivary flow rate, pH and caries in pregnancy
gradually to a great extent due to placental production of
these hormones. Levels of human chorionic gonadotropin
(HCG), cortisol, and beta-endorphin also increase in
pregnancy and to a greater extent in the third trimester
of pregnancy. Estradiol and estriol (biologically active
forms of estrogen) increase by 100-fold and 1000-fold,
respectively, during pregnancy. As a result, physiological
changes occur in women that lead to adaptive changes at
both systemic and oral levels.[19] In the second trimester,
there is increased HCG causing decrease in the salivary
flow rate. During pregnancy, the levels of human
chorionic somatomammotropin (HCS) and progesterone
increase markedly, which leads to reduction in the
salivary flow rate.[7,20,21] Also, the increased progesterone
decreases the plasma bicarbonate level resulting in a
decrease in the pH of saliva.[22]
During the third trimester of pregnancy, salivary pH
and buffering capacity reach their lowest levels, which
increases the risk of caries incidence with higher levels
of Streptococcus mutans.[6,17] Maternal saliva is the main
vehicle for bacterial transfer to the children.[23-25] Hence,
it is essential to evaluate the prevalence of caries in
pregnant women. We chose to use DMFT index to
evaluate the caries prevalence. We found that the
DMFT index was higher in non-pregnant women than
in pregnant women. However, these values were not
statistically significant [Tables 1 and 2]. It has been
established that the flow rate and pH of saliva are
significant in the development of caries.[5,26] Hence, we
considered evaluating the correlation between salivary
pH and flow rate with DMFT index in Indian pregnant
women.
In this study, DMFT index showed a strong negative
correlation with the pH of saliva in both pregnant and
non-pregnant women, suggesting an inverse relationship
between salivary pH and caries prevalence. Heintze
etal.[27] suggested that on a population level, an inverse
relationship exists between the buffering capacity of
saliva and caries susceptibility. In the present study, no
relation was found between salivary flow rate and caries
prevalence. Birkhed and Heintze[28] and Russell etal.[29]
suggested that no linear relationship exists between
salivary secretion rate, DMFT/DMFS index, and caries
activity. Mandel[2.30] and Russell et al.[29] reported that
only weak or no association was found between salivary
secretion rate and caries incidence.
Vadiakas and Lianos[31] studied the correlation between
pregnancy and dental caries. They noted that changes in
oral microflora and saliva, nutritional changes, vomiting,
and neglected oral hygiene are significantly important
in relation to caries during pregnancy. Conversely,
Orosz etal.[32] suggested that a positive correlation exists
between pregnancy and caries. The bacteria ferment
Journal of Indian Academy of Oral Medicine & Radiology | Jul-Sep 2015 | Vol 27 | Issue 3
carbohydrates, which leads to increased production of
organic acids that decrease the pH of saliva and plaque
resulting in caries. Thus, maintenance of oral hygiene is
essential for prevention of caries.[25] In this study, patients
in the pregnant group had better oral hygiene maintenance
than the patients belonging to the non-pregnant group.
The values of salivary variables reported in this study
group of pregnant and non-pregnant Indian women
are similar to the values reported for other populations
and are within international references of normality.
The differences detected in the saliva of pregnant and
non-pregnant women in our study and those reported
in previous studies are small in absolute values and they
do not seem to affect the oral health and prevalence of
dental caries in these individuals.
Conclusion
In conclusion, the salivary flow rate and pH of saliva were
lower in pregnant women than in non-pregnant women.
DMFT index showed a strong negative correlation with
pH in pregnant women and non-pregnant women; hence,
a significant inverse relationship was found between
pH and caries prevalence. However, further studies are
essential evaluating salivary parameters in medically
compromised women with high-risk pregnancy.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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