SALIVA . BY DR. C. P. ARYA .B.Sc. B.D.S, M.D.S , P.M.S, R.N.T;C.P

1. DR.C.P.ARYA
BDS, MDS, PMS,
RNTCP.

2. What is saliva
Introduction
Composition
Daily salivary output
Functions
A. Lubricant
B. Digestion
C. Role in taste
D. Other
Nervous regulation of salivary secretions
Significance
A. Spitting
B. Glue to construct bird nests
C. Wound licking
D. Classical conditioning
Substitutes
Hypersalivation
Hyposalivation
References
Contents

3.  Suh-lahy-vuh
 Spell Syllables
Watery liquid secreted into the mouth by glands, providing lubrication for
chewing and swallowing, and aiding digestion.
 The principal glands of the salivation are the parotid , submandibular and
sublingual glands; in addition, there are many very small buccal glands. Daily
secretion of saliva normally ranges between 800 and 1500 milliliters.
 Saliva contains to major types of protein secretions: (1) a serous secretion
that contains PTYALIN (an α- amylase), which is enzyme for digestion
starches, and (2) mucus secretion that contains MUCIN for lubricating and for
surface protective purposes.
What is Saliva

4.  Saliva is a watery substance formed in the mouths of animals, secreted by
the salivary glands. Human saliva comprises 98% water, plus electrolytes,
mucus, white blood cells, epithelial cells (from which DNA can be
extracted), glycoproteins, enzymes (such as amylase and lipase),
antimicrobial agents such as secretory IgA and lysozyme.
 The enzymes found in saliva are essential in beginning the process of
digestion of dietary starches and fats. These enzymes also play a role in
breaking down food particles entrapped within dental crevices, thus
protecting teeth from bacterial decay.
Introduction

5.  Further more, saliva serves a lubricative function, wetting food and
permitting the initiation of swallowing, and protecting the mucosal
surfaces of the oral cavity from desiccation.
 Various animal species have special uses for saliva that go beyond
predigestion. Some swifts use their gummy saliva to build nests.
Aerodramus nests form the basis of bird's nest soup. Cobras, vipers,
and certain other members of the venom clade hunt with venomous
saliva injected by fangs. Some caterpillars, produce silk fiber from
salivary glands.
Introduction

6.  Produced in salivary glands, human saliva is 99.5% water, but also
contains many important substances, including electrolytes, mucus,
antibacterial compounds and various enzymes.
 Water: 99.5%
 Electrolytes:
 2–21 mmol/L sodium (lower than blood plasma)
 10–36 mmol/L potassium (higher than plasma)
 1.2–2.8 mmol/L calcium (similar to plasma)
 0.08–0.5 mmol/L magnesium
 5–40 mmol/L chloride (lower than plasma)
 25 mmol/L bicarbonate (higher than plasma)
COMPOSITION

7.  1.4–39 mmol/L phosphate
 Iodine (mmol/L concentration is usually higher than plasma, but
dependent variable according to dietary iodine intake)
 Mucus (mucus in saliva mainly consists of mucopolysaccharides and
glycoproteins)
 Antibacterial compounds (thiocyanate, hydrogen peroxide, and
secretory immunoglobulin A)
 Epidermal growth factor (EGF)
Composition

8.  There is much debate about the amount of saliva that is produced in a
healthy person per day; estimates range from 0.75 to 1.5 litres per day
while it is generally accepted that during sleep the amount drops to nearly
zero. In humans, the submandibular gland contributes around 70–75% of
secretion, while the parotid gland secretes about 20–25% and small
amounts are secreted from the other salivary glands.
Daily Salivary Output

9.  Saliva contributes to the digestion of food and to the maintenance of oral
hygiene. Without normal salivary function the frequency of dental caries, gum
disease (gingivitis and periodontitis), and other oral problems increases
significantly.
Digestion
 The digestive functions of saliva include moistening food and helping to create a
food bolus. This lubricative function of saliva allows the food bolus to be passed
easily from the mouth into the esophagus. Saliva contains the enzyme amylase,
also called ptyalin, which is capable of breaking down starch into simpler sugars
such as maltose and dextrin that can be further broken down in the small
intestine. About 30% starch digestion takes place in the mouth cavity. Salivary
glands also secrete salivary lipase (a more potent form of lipase) to begin fat
digestion. Salivary lipase plays a large role in fat digestion in newborn infants as
their pancreatic lipase still needs some time to develop.
Function

10. Lubricant
 Saliva, coats the oral mucosa, mechanically protecting it from trauma during
eating, swallowing and speaking. In people with little saliva (xerostomia),
soreness of the mouth is very common, and the food (especially dry food) sticks
to the inside of the mouth.
Role in taste
 Saliva is very important in the sense of taste. It is the liquid medium in which
chemicals are carried to taste receptor cells (mostly associated with lingual
papillae). Persons with little saliva often complain of dysgeusia (i.e. disordered
taste, e.g. reduced ability to taste, or having a bad, metallic taste at all times).
Other
 Saliva maintains the pH of the mouth. Saliva is supersaturated with various ions.
Certain salivary proteins prevent precipitation, which would form salts. These
ions act as a buffer, keeping the acidity of the mouth within a certain range,
typically pH 6.2–7.4. This prevents minerals in the dental hard tissues from
dissolving.
Function

11.  Saliva secretes carbonic anhydrase (gustin), which is thought to play a role
in the development of taste buds.
 Saliva contains EGF. EGF results in cellular proliferation, differentiation,
and survival. EGF is a low-molecular-weight polypeptide first purified from
the mouse submandibular gland, but since then found in many human
tissues including submandibular gland, parotid gland. Salivary EGF, which
seems also regulated by dietary inorganic iodine, also plays an important
physiological role in the maintenance of oro-esophageal and gastric tissue
integrity. The biological effects of salivary EGF include healing of oral and
gastroesophageal ulcers, inhibition of gastric acid secretion, stimulation of
DNA synthesis as well as mucosal protection from intraluminal injurious
factors such as gastric acid, bile acids, pepsin, and trypsin and to physical,
chemical and bacterial agents.
Function

12.  The production of saliva is stimulated both by the sympathetic nervous
system and the parasympathetic.
 The saliva stimulated by sympathetic innervation is thicker, and saliva
stimulated parasympathetically is more watery.
 Sympathetic stimulation of saliva is to facilitate respiration, whereas
parasympathetic stimulation is to facilitate digestion.
 Saliva production may also be pharmacologically stimulated by so-called
sialagogues. It can also be suppressed by so-called antisialagogues.
Nervous Regulation of
Salivary Secretions

13.  Parasympathetic stimulation leads to acetylcholine (ACh) release onto the
salivary acinar cells. ACh binds to muscarinic receptors, specifically M3,
and causes an increased intracellular calcium ion concentration (through
the IP3/DAG second messenger system). Increased calcium causes vesicles
within the cells to fuse with the apical cell membrane leading to
secretion. ACh also causes the salivary gland to release kallikrein, an
enzyme that converts kininogen to lysyl-bradykinin. Lysyl-bradykinin acts
upon blood vessels and capillaries of the salivary gland to generate
vasodilation and increased capillary permeability respectively.
Nervous Regulation of Salivary Secretions

14.  The resulting increased blood flow to the acini allows production of more
saliva. In addition, Substance P can bind to Tachykinin NK-1 receptors
leading to increased intracellular calcium concentrations and subsequently
increased saliva secretion. Lastly, both parasympathetic and sympathetic
nervous stimulation can lead to myoepithelium contraction which causes
the expulsion of secretions from the secretory acinus into the ducts and
eventually to the oral cavity.
 Sympathetic stimulation results in the release of norepinephrine.
Norepinephrine binding to α-adrenergic receptors will cause an increase in
intracellular calcium levels leading to more fluid vs. protein secretion. If
norepinephrine binds β-adrenergic receptors, it will result in more protein
or enzyme secretion vs. fluid secretion. Stimulation by norepinephrine
initially decreases blood flow to the salivary glands due to constriction of
blood vessels but this effect is overtaken by vasodilation caused by various
local vasodilators.
Nervous Regulation of Salivary Secretions

15.  Sympathetic stimulation results in the release of norepinephrine.
Norepinephrine binding to α-adrenergic receptors will cause an increase in
intracellular calcium levels leading to more fluid vs. protein secretion. If
norepinephrine binds β-adrenergic receptors, it will result in more protein
or enzyme secretion vs. fluid secretion. Stimulation by norepinephrine
initially decreases blood flow to the salivary glands due to constriction of
blood vessels but this effect is overtaken by vasodilation caused by various
local vasodilators.
Nervous Regulation of Salivary Secretions

16. Spitting
 Spitting is the act of forcibly ejecting saliva or other substances from the
mouth. It is often considered rude and a social taboo in many parts of the
world, including Western countries, where it is frequently forbidden by
local laws (as it was thought to facilitate the spread of disease). These laws
are generally not strictly enforced. In Singapore, the fine for spitting may
be as high as SGD$2,000 for multiple offenses, and one can even be
arrested. In some other parts of the world, expectoration is more socially
acceptable (even if officially disapproved of or illegal), and spittoons are
still a common appearance in some cultures. Some animals, including
humans in some cases, use spitting as an automatic defensive move. Camels
are well known for doing this, though most domestic camels are trained not
to.
Significance

17. Glue to construct bird nests
 Many birds in the swift family, Apodidae, produce a viscous saliva during
nesting season to glue together materials to construct a nest. Two species
of swifts in the genus Aerodramus build their nests using only their saliva,
the base for bird's nest soup.
Wound licking
 A common belief is that saliva contained in the mouth has natural
disinfectants, which leads people to believe it is beneficial to "lick their
wounds". Researchers at the University of Florida at Gainesville have
discovered a protein called nerve growth factor (NGF) in the saliva of
mice. Wounds doused with NGF healed twice as fast as untreated and
unlicked wounds; therefore, saliva can help to heal wounds in some
species.
Significance

18. NGF has not been found in human saliva; however, researchers find human
saliva contains such antibacterial agents as secretory IgA, lactoferrin, lysozyme
and peroxidase. It has not been shown that human licking of wounds disinfects
them, but licking is likely to help clean the wound by removing larger
contaminants such as dirt and may help to directly remove infective bodies by
brushing them away. Therefore, licking would be a way of wiping off pathogens,
useful if clean water is not available to the animal or person.
Classical conditioning
 In Pavlov's experiment, dogs were conditioned to salivate in response to a
ringing bell, this stimulus is associated with a meal or hunger. Salivary
secretion is also associated with nausea.
Significance

19.  Hypersalivation (also called ptyalism or sialorrhea) is excessive production
of saliva. It has also been defined as increased amount of saliva in the
mouth, which may also be caused by decreased clearance of saliva.
 Hypersalivation can contribute to drooling if there is an inability to keep the
mouth closed or difficulty in swallowing the excess saliva (dysphagia), which
can lead to excessive spitting.
 Hypersalivation also often precedes emesis (vomiting), where it
accompanies nausea (a feeling of needing to vomit).
Hypersalivation

20. Causes
 Excessive production
 Conditions that can cause saliva overproduction include:
 Rabies
 Pellagra (niacin or Vitamin B3 deficiency)
 Gastroesophageal reflux disease, in such cases specifically called a water
brash, and is characterized by a sour fluid or almost tasteless saliva in the
mouth
 Gastroparesis (main symptoms are nausea, vomiting, and reflux)
 Pregnancy
 Excessive starch intake
 Anxiety (common sign of separation anxiety in dogs)
 Pancreatitis
 Liver disease
 Serotonin syndrome
 Mouth ulcers[medical citation needed]
 Oral infections
Hypersalivation

21.  Medications that can cause overproduction of saliva include:
 aripiprazole
 clozapine
 pilocarpine
 ketamine
 potassium chlorate
 risperidone
 pyridostigmine
 rabeprazole sodium (Aciphex)
 Toxins that can cause hypersalivation include:
 mercury
 copper
 organophosphates (insecticide)
 arsenic
 nicotine
Hypersalivation

22.  Decreased clearance
 Causes of decreased clearance of saliva include:
 Infections such as tonsillitis, retropharyngeal and peritonsillar abscesses,
epiglottitis and mumps.
 Problems with the jaw, e.g., fracture or dislocation
 Radiation therapy
 Neurologic disorders such as myasthenia gravis, Parkinson's disease,
multiple system atrophy, rabies, bulbar paralysis, bilateral facial nerve
palsy, and hypoglossal nerve palsy
Hypersalivation

23.  Treatment
 Hypersalivation is optimally treated by treating or avoiding the underlying
cause. Mouthwash and tooth brushing may have drying effects.
 In the palliative care setting, anticholinergics and similar drugs that would
normally reduce the production of saliva causing a dry mouth could be
considered for symptom management: scopolamine, atropine,
propantheline, hyoscine, amitriptyline, glycopyrrolate.
Hypersalivation

24.  Xerostomia, also known as dry mouth and dry mouth syndrome, is dryness
in the mouth, which may be associated with a change in the composition
of saliva, or reduced salivary flow, or have no identifiable cause.
 This symptom is very common and is often seen as a side effect of many
types of medication. It is more common in older people (mostly because
this group tend to take several medications) and in persons who breathe
through their mouths (mouthbreathing). Dehydration, radiotherapy
involving the salivary glands, chemotherapy and several diseases can cause
hyposalivation or a change in saliva consistency and hence a complaint of
xerostomia. Sometimes there is no identifiable cause, and there may be a
psychogenic reason for the complaint.
Hyposalivation

25. Definition
 Xerostomia is the subjective sensation of dry mouth, which is often (but not
always) associated with hypofunction of the salivary glands. The term is
derived from the Greek words ξηρός (xeros) meaning "dry" and στόμα
(stoma) meaning "mouth". A drug or substance that increases the rate of
salivary flow is termed a sialogogue.
 Hyposalivation is a clinical diagnosis that is made based on the history and
examination, but reduced salivary flow rates have been given objective
definitions. Salivary gland hypofunction has been defined as any objectively
demonstrable reduction in whole and/or individual gland flow rates. An
unstimulated whole saliva flow rate in a normal person is 0.3–0.4 ml per
minute, and below 0.1 ml per minute is significantly abnormal. A
stimulated saliva flow rate less than 0.5 ml per gland in 5 minutes or less
than 1 ml per gland in 10 minutes is decreased.
Hyposalivation

26. The term subjective xerostomia is sometimes used to describe the symptom
in the absence of any clinical evidence of dryness . Xerostomia may also
result from a change in composition of saliva (from serous to mucous).
Salivary gland dysfunction is an umbrella term for the presence of either
xerostomia or salivary gland hypofunction.
Signs and symptoms
 Diagram depicting mouth acidity changes after consuming food high in
carbohydrates. Within 5 minutes the acidity in the mouth increases as the
pH drops. In persons with normal salivary flow rate, acid will be
neutralized in about 20 minutes. People with dry mouth often will take
twice as long to neutralize mouth acid, leaving them at higher risk of tooth
decay and acid erosion
 True hyposalivation may give the following signs and symptoms:
 Dental caries (xerostomia related caries) – Without the anticariogenic
actions of saliva, tooth decay is a common feature and may progress much
more aggressively than it would otherwise ("rampant caries").
Hyposalivation

27.  It may affect tooth surfaces that are normally spared, e.g., cervical caries
and root surface caries. This is often seen in patients who have had
radiotherapy involving the major salivary glands, termed radiation-induced
caries. Therefore it's important that any products used in managing dry
mouth symptoms are sugar-free, as the presence of sugars in the mouth
support the growth of oral bacteria, resulting in acid production and
development of dental caries.
 Acid erosion. Saliva acts as a buffer and helps to prevent demineralization
of teeth.
 Oral candidiasis – A loss of the antimicrobial actions of saliva may also lead
to opportunistic infection with Candida species.
Hyposalivation

28.  Ascending (suppurative) sialadenitis – an infection of the major salivary
glands (usually the parotid gland) that may be recurrent. It is associated with
hyposalivation, as bacteria are able to enter the ductal system against the
diminished flow of saliva. There may be swollen salivary glands even without
acute infection, possibly caused by autoimmune involvement.
 Dysgeusia – altered taste sensation (e.g., a metallic taste) and dysosmia,
altered sense of smell.
 Intraoral halitosis – possibly due to increased activity of halitogenic biofilm
on the posterior dorsal tongue (although dysgeusia may cause a complaint of
nongenuine halitosis in the absence of hyposalivation).
 Oral dysesthesia – a burning or tingling sensation in the mouth.
 Saliva that appears thick or ropey.
 Mucosa that appears dry.
 A lack of saliva pooling in the floor of the mouth during examination.
Hyposalivation

29.  Dysphagia – difficulty swallowing and chewing, especially when eating dry
foods. Food may stick to the tissues during eating.
 The tongue may stick to the palate, causing a clicking noise during speech,
or the lips may stick together.
 Gloves or a dental mirror may stick to the tissues.
 Fissured tongue with atrophy of the filiform papillae and a lobulated,
erythematous appearance of the tongue.
 Saliva cannot be "milked" (expressed) from the parotid duct.
 Difficulty wearing dentures, e.g., when swallowing or speaking. There may
be generalized mucosal soreness and ulceration of the areas covered by the
denture.
 Mouth soreness and oral mucositis.
 Lipstick or food may stick to the teeth.
Hyposalivation

30.  A need to sip drinks frequently while talking or eating.
 Dry, sore, and cracked lips and angles of mouth.
 Thirst.
 However, sometimes the clinical findings do not correlate with the
symptoms experienced. E.g., a person with signs of hyposalivation may not
complain of xerostomia. Conversely a person who reports experiencing
xerostomia may not show signs of reduced salivary secretions (subjective
xerostomia). In the latter scenario, there are often other oral symptoms
suggestive of oral dysesthesia ("burning mouth syndrome"). Some
symptoms outside the mouth may occur together with xerostomia.
 These include:
 Xerophthalmia (dry eyes).
 Inability to cry.
 Blurred vision.
 Photophobia (light intolerance).
 Dryness of other mucosae, e.g., nasal, laryngeal, and/or genital.
Hyposalivation

31.  Burning sensation.
 Itching or grittiness.
 Dysphonia (voice changes).
 There may also be other systemic signs and symptoms if there is an
underlying cause such as Sjögren's syndrome, for example, joint pain due to
associated rheumatoid arthritis.
Differential diagnosis
 The differential of hyposalivation significantly overlaps with that of
xerostomia. A reduction in saliva production to about 50% of the normal
unstimulated level will usually result in the sensation of dry mouth. Altered
saliva composition may also be responsible for xerostomia.
Hyposalivation

32. Physiologic
 Salivary flow rate is decreased during sleep, which may lead to a
transient sensation of dry mouth upon waking. This disappears with
eating or drinking or with oral hygiene. When associated with
halitosis, this is sometimes termed "morning breath". Dry mouth is
also a common sensation during periods of anxiety, probably owing to
enhanced sympathetic drive. Dehydration is known to cause
hyposalivation, the result of the body trying to conserve fluid.
Physiologic age-related changes in salivary gland tissues may lead to
a modest reduction in salivary output and partially explain the
increased prevalence of xerostomia in older people. However,
polypharmacy is thought to be the major cause in this group, with no
significant decreases in salivary flow rate being likely to occur
through aging alone.
Hyposalivation

33. Medications associated with xerostomia
 Antidepressants
 Antihypertensives
 Opiates
 Bronchodilators
 Proton pump inhibitors
 Antipsychotics
 Antihistamines
 Diuretics
 Antineoplastics
Hyposalivation

34.  Drug induced
 Aside from physiologic causes of xerostomia, iatrogenic effects of
medications are the most common cause. A medication which is
known to cause xerostomia may be termed xerogenic. Over 400
medications are associated with xerostomia, some of these are listed
in table 1. Although drug induced xerostomia is commonly reversible,
the conditions for which these medications are prescribed are
frequently chronic. The likelihood of xerostomia increases in relation
to the total number of medications taken, whether the individual
medications are xerogenic or not. The sensation of dryness usually
starts shortly after starting the offending medication or after
increasing the dose. Anticholinergic, sympathomimetic, or diuretic
drugs are usually responsible.
Hyposalivation

35. Sjögren's syndrome
 Xerostomia may be caused by autoimmune conditions which damage saliva
producing cells . Sjögren's syndrome is one such disease, and it's associated
with symptoms including fatigue, myalgia and arthralgia . The disease is
characterised by inflammatory changes in the moisture producing glands
throughout the body, leading to reduced secretions from glands that produce
saliva, tears and other secretions throughout the body . Primary Sjögren's
syndrome is the combination of dry eyes and xerostomia. Secondary Sjögren's
syndrome is identical to primary form but with the addition of a combination
of other connective tissue disorders such as systemic lupus erythematosus or
rheumatoid arthritis.
Hyposalivation

36. Radiation Therapy
 Radiation therapy for cancers of the head and neck (including
brachytherapy for thyroid cancers) where the salivary glands are
close to or within the field irradiated is another major cause of
xerostomia . A radiation dose of 52 Gy is sufficient to cause severe
salivary dysfunction. Radiotherapy for oral cancers usually involves
up to 70 Gy of radiation, often given alongside with chemotherapy
which may also have a damaging effect on saliva production .
Hyposalivation

37. Sicca syndrome
 "Sicca" simply means dryness. Sicca syndrome is not a specific condition,
and there are varying definitions, but the term can describe oral and eye
dryness that is not caused by autoimmune diseases (e.g. Sjogren
Syndrome).
 Other causes
 Oral dryness may also be caused by mouth breathing, usually caused by
partial obstruction of the upper respiratory tract. Examples include
hemorrhage, vomiting, diarrhea, and fever.
 Alcohol may be involved in the cause of salivary gland disease, liver
disease, or dehydration.
 Smoking is another possible cause. Other recreational drugs such as
methamphetamine, cannabis, hallucinogens, or heroin, may be implicated.
Hyposalivation

38.  Hormonal disorders, such as poorly controlled diabetes, chronic graft versus
host disease or low fluid intake in people undergoing haemodialysis for
renal impairment may also result in xerostomia, due to dehydration .
 Xerostomia may be a consequence of infection with hepatitis C virus (HCV)
and a rare cause of salivary gland dysfunction may be sarcoidosis
 Infection with Human Immunodeficiency Virus/Acquired immunodeficiency
Syndrome (AIDS) can cause a related salivary gland disease known as
Diffuse Infiltrative Lymphocytosis Syndrome (DILS)
Hyposalivation

39. Diagnostic approach
 A diagnosis of hyposalivation is based predominantly on the clinical signs and
symptoms. There is little correlation between symptoms and objective tests
of salivary flow, such as sialometry. This test is simple and noninvasive, and
involves measurement of all the saliva a patient can produce during a
certain time, achieved by dribbling into a container. Sialometery can yield
measures of stimulated salivary flow or unstimulated salivary flow.
Stimulated salivary flow rate is calculated using a stimulant such as 10%
citric acid dropped onto the tongue, and collection of all the saliva that
flows from one of the parotid papillae over five or ten minutes.
Unstimulated whole saliva flow rate more closely correlates with symptoms
of xerostomia than stimulated salivary flow rate.
Hyposalivation

40.  Sialography involves introduction of radio-opaque dye such as iodine
into the duct of a salivary gland. It may show blockage of a duct due
to a calculus. Salivary scintiscanning using technetium is rarely used.
Other medical imaging that may be involved in the investigation
include chest x-ray (to exclude sarcoidosis), ultrasonography and
magnetic resonance imaging (to exclude Sjögren's syndrome or
neoplasia). A minor salivary gland biopsy, usually taken from the lip,
may be carried out if there is a suspicion of organic disease of the
salivary glands. Blood tests and urinalysis may be involved to exclude
a number of possible causes. To investigate xerophthalmia, the
Schirmer test of lacrimal flow may be indicated. Slit-lamp
examination may also be carried out.
Hyposalivation

41. Treatment
 The successful treatment of xerostomia is difficult to achieve and often
unsatisfactory. This involves finding any correctable cause and removing it if
possible, but in many cases it is not possible to correct the xerostomia
itself, and treatment is symptomatic, and also focuses on preventing tooth
decay through improving oral hygiene. Where the symptom is caused by
hyposalivation secondary to underlying chronic disease, xerostomia can be
considered permanent or even progressive. The management of salivary
gland dysfunction may involve the use of saliva substitutes and/or saliva
stimulants:
Hyposalivation

42. Saliva substitutes
 These are viscous products which are applied to the oral mucosa, which
can be found in the form of sprays, gels, oils, mouthwashes, mouthrinses,
pastilles or viscous liquids. This includes SalivaMAX, water, artificial
salivas (mucin-based, carboxymethylcellulose-based), and other
substances (milk, vegetable oil)
 Mucin Spray: 4 Trials have been completed on the effects of Mucin
Spray on Xerostomia, overall there is no strong evidence showing that
Mucin Spray is more effective than a placebo in reducing the
symptoms of dry mouth.
Saliva Substitutes

43.  Mucin Lozenge: Only 1 trial (Gravenmade 1993) has been completed
regarding the effectiveness of Mucin Lozenges. Whilst it was assessed as
being at high risk of bias, it showed that Mucin Lozenges were ineffective
when compared to a placebo.
 Mucoadhesive Disk: These disks are stuck to the palate and they contain
lubricating agents, flavouring agents and some antimicrobial agents. One
trail (Kerr 2010) assessed their effectiveness against a placebo disk.
Strangely, patients from both groups (placebo and the real disk) reported
an increase in subjective oral moistness. No adverse effects were
reported. More research is needed in this area before conclusions are
drawn.
Saliva substitutes

44.  Biotene oral Balance Gel & toothpaste: One trial has been completed
(Epstein 1999) regarding the effectiveness of Biotene Oral Balance
gel & toothpaste. The results showed that Biotene products were
"more effective than control and reduced dry mouth on waking".
 Saliva stimulants – organic acids (ascorbic acid, malic acid), chewing
gum, parasympathomimetic drugs (choline esters, e.g. pilocarpine
hydrochloride, cholinesterase inhibitors), and other substances
(sugar-free mints, nicotinamide). Medications which stimulate saliva
production traditionally have been administered through oral tablets,
which the patient goes on to swallow, although some saliva
stimulants can also be found in the form of toothpastes. Lozenges,
which are retained in the mouth and then swallowed are becoming
more and more popular. Lozenges are soft and gentle on the mouth
and there is a belief that prolonged contact with the oral mucosa
mechanically stimulates saliva production.
Saliva substitutes

45.  Pilocarpine: A study by Taweechaisupapong in 2006 showed no
'statistical significant improvement in oral dryness and saliva
production compared to placebo' when administering pilocarpine
lozenges.
 Physostigmine Gel: A study by Knosravini in 2009 showed a reduction
in the oral dryness and a 5 times increase in saliva following
physostigmine treatment.
 Chewing gum increases saliva production but there is no strong
evidence that it improves dry mouth symptoms.
 The Cochrane oral health group concluded 'there is insufficient
evidence to determine whether pilocarpine or physostigmine' are
effective treatments for Xerostomia. More research is needed.
Saliva substitutes

46.  Dentirol chewing gum (xylitol): A study by Risheim in 1993 showed that
when subjects had 2 sticks of gum up to 5 x daily, the gum gave
subjective dry mouth symptom relief in approximately 1/3 of
participants but no change in SWS (stimulated whole saliva).
 Profylin lozenge (xylitol/sorbitol):A study by Risheim in 1993 showed
that when subjects had 1 lozenge 4 to 8 x daily, profylin lozenges gave
subjective dry mouth symptom relief in approximately 1/3 of
participants but no change in SWS (stimulated whole saliva).
Saliva substitutes

47.  Saliva substitutes can improve xerostomia, but tend not to improve the
other problems associated with salivary gland dysfunction.[citation needed]
Parasympathomimitic drugs (saliva stimulants) such as pilocarpine may
improve xerostomia symptoms and other problems associated with salivary
gland dysfunction, but the evidence for treatment of radiation-induced
xerostomia is limited. Both stimulants and substitutes relieve symptoms to
some extent. Salivary stimulants are probably only useful in people with
some remaining detectable salivary function. A systematic review
compromising of 36 randomised controlled trials for the treatment of dry
mouth found that there was no strong evidence to suggest that a specific
topical therapy is effective.
Saliva substitutes

48.  This review also states that topical therapies can be expected to
provide only short-term effects, which are reversible. The review
reported limited evidence that oxygenated glycerol triester spray
was more effective than electrolyte sprays. Sugar free chewing gum
increases saliva production but there is no strong evidence that it
improves symptoms. Plus, there is no clear evidence to suggest
whether chewing gum is more or less effective as a treatment. There
is a suggestion that intraoral devices and integrated mouthcare
systems may be effective in reducing symptoms, but there was a lack
of strong evidence.
Saliva substitutes

49.  A systematic review of the management of radiotherapy induced
xerostomia with parasympathomimetic drugs found that there was limited
evidence to support the use of pilocarpine in the treatment of radiation-
induced salivary gland dysfunction. It was suggested that, barring any
contraindications, a trial of the drug be offered in the above group (at a
dose of five mg three times per day to minimize side effects).
Improvements can take up to twelve weeks. However, pilocarpine is not
always successful in improving xerostomia symptoms. The review also
concluded that there was little evidence to support the use of other
parasympathomimetics in this group. Another systematic review showed,
that there is some low-quality evidence to suggest that amifostine prevents
the feeling of dry mouth or reduce the risk of moderate to severe
xerostomia in people receiving radiotherapy to the head and neck (with or
without chemotherapy) in the short- (end of radiotherapy) to medium-term
(three months postradiotherapy). But, it is less clear whether or not this
effect is sustained to 12 months postradiotherapy.
Saliva substitutes

50.  Physiology: 6/6ch4/s6ch4_6 - Essentials of Human Physiology
 Fejerskov, O.; Kidd, E. (2007). Dental Caries: The Disease and Its
Clinical Management (2nd ed.). Wiley-Blackwell. ISBN 978-1-4051-
3889-5.
 Edgar, M.; Dawes, C.; O'Mullane, D. (2004). Saliva and Oral Health
(3rd ed.). British Dental Association. ISBN 0-904588-87-4.
 ptyalism : Dorland's Medical Dictionary for Health Consumers. 2007
 Mosby's Medical Dictionary, 8th edition. 2009
 Saunders Comprehensive Veterinary Dictionary, 3 ed. 2007
 sialorrhea :The American Heritage Dictionary of the English
Language, Fourth Edition, Updated in 2009.
 Hypersalivation By Erica Brownfield. Posted: 05/19/2004
References

51.  Crispian (2008). Oral and maxillofacial medicine : the basis of
diagnosis and treatment (2nd ed.). Edinburgh: Churchill Livingstone.
pp. 17, 31, 41, 79–85. ISBN 9780443068188.
 Wijers OB, Levendag PC, Braaksma MM, Boonzaaijer M, Visch LL,
Schmitz PI (2002), "Patients with head and neck cancer cured by
radiation therapy: a survey of the dry mouth syndrome in long-term
survivors", Head Neck, 24 (8): 737–747,
 Tyldesley, Anne Field, Lesley Longman in collaboration with William
R. (2003). Tyldesley's Oral medicine (5th ed.). Oxford: Oxford
University Press. pp. 19, 90–93. ISBN 0192631470.
 Guyton & Hall ,textbook of medical physiology, 11/e; CHAPTER 64 p-
793-95. ISBN: 978-0-7216-0240-0,2006.
References