Saliva by dr brajendra singh tomar

23 June 2020 1
Saliva
&
It’s implication in prosthodontics
LECTURE BY:
Dr. BRAJENDRASINGHTOMAR
MDS
ASSOCIATEPROFESSOR
PROSTHODONTICS&IMPLANTOLOGY

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contents……………………………………………………………..
Introduction……………………………………………………………………….
Source…………………………………………………………………………….
Anatomy & physiology of salivary glands
Classification of salivary glands
-Parotid
-Submandibular
-Sublingual
-Minor salivary glands
Composition of saliva
-Cellular constitutes
-Inorganic constitutes
-Organic constitutes
Properties of saliva
Function of saliva
-Mechanical function
-Digestive function
-Excretory function

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-Sensation of taste
-Water balance
-Buffering action
-Maintenance of tooth integrity
-Antibacterial action
-Soft tissue repair
-Maintenance of ecological balance
Saliva flow rate
-Methods of measurement of flow rate
-Saliva flow and ageing
-Flow rate of un-stimulated whole saliva with age
-Flow rate of stimulated saliva with age
Mastication and saliva
Role of saliva in prosthodontics
-Pre treatment evaluation
-Saliva and impression making
-Control of saliva during complete denture impression
-Control of saliva during impression for removable partial denture using
Irreversible hydrocolloid
-Control of saliva during impression for fixed partial denture

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Role of saliva in complete denture prosthodontics
Adhesion
Cohesion
Inter facial surface tension
Capillarity
Atmospheric pressure
Denture insertion and after phase
Denture plaque
Denture stomatitis
Candida in biofilm on other biomaterials
Microbiology at healthy oral implant site
Microbiology at failing implant
Salivary gland dysfunction
Xerostomia
Causes
Management of xerostomia
General measures
Management of symptoms
Treatment of oral condition
Preventive measures
Sialagogues / saliva stimulation

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Management of underlying systemic condition
Saliva substitutes
Classification of artificial saliva
Few commercial available saliva substitutes
Prosthodontics management
Requirement of oral lubricating devices
Mandibular saliva reservoir
Maxillary saliva reservoir
Sialorrhea
Saliva as a diagnostic tools
Cross contamination
References

Saliva is a complex fluid composed of secretions from salivary
glands and gingival crevicular fluid.
The oral cavity is a moist environment; a film of fluid called
saliva constantly coats its inner surface and occupies its space
between the lining oral mucosa and teeth, whose important role
is maintaining the well being of the mouth.
Saliva plays a critical role in the maintenance of oral and dental
health.
Introduction
Knowledge of the salivary system and saliva is essential for
evaluating prosthodontic problems and for educating patients in
what to expect in this phase of denture use.
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source
Saliva is a clear and slightly alkaline
mucoserous exocrine secretion. It is a
complex mixture of fluids, with contributions
from major salivary glands ,parotid
submandibular and sublingual, the minor or
accessory glands and the gingival crevicular
fluid.
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Anatomy & Physiology of
salivary glands
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Classification of salivary
glands
According to
size
According to
location
According to
the type of
secretion
major
minor cheek
lip
mucous
mixed
serous
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Largest of all the salivary glands
Purely serous gland which produces thin,
watery, amylase rich saliva
Superficial portion lies in front of the
external ear and deeper portion lies behind
the ramus of the mandible
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Stenson’s duct:
Open out adjacent to maxillary
second molar.

.
 Weight is 14.28 g. It is
irregular, wedge shaped, and unilobular
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 It is 5.8 cm in the craniocaudal
dimension, and 3.4 cm in the
ventral-dorsal dimension.

.
Superior border – Zygoma
Posterior border – External
Auditory Canal
Inferior border – Styloid Process,
Styloid Process musculature,
Internal Carotid Artery, Jugular
Veins
Anterior border – a diagonal line
drawn from the Zygomatic to
external auditory
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.
 Stensen’s duct arises from the anterior border
of the Parotid and parallels the Zygomatic
arch, 1.5 cm inferior to the inferior margin of
the arch.
 Stensen’s duct runs superficial to the masseter
muscle, then turns medially 90 degrees to
pierce the Buccinator muscle at the level of the
second maxillary molar where it opens onto
the oral cavity.
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Sub- mandibular
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Second largest salivary gland
 Produces 65-70% of total saliva
output
The duct is called Wharton’s
duct
 Wharton’s duct exits on the
floor of the mouth opposing the
lingual surface of the tongue
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 Located in a depression on the
lingual side of the mandibular
body
 Innervated by parasympathetic
nerve endings and possesses NO
sympathetic receptors
 The parasympathetic fibers arrive
through the facial and
glossopharyngeal nerves
 Mixed secretion – mostly serous
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Smallest of the major glands
Produce less than 5% of total saliva
output
 Saliva delivered via the ducts of
Bartholin
The Bartholin ducts exit on the
base of the lingual surface of the
tongue
Innervated by parasympathetic
fibers
Little or no sympathetic influence
Mixed secretion – mostly mucous
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Minor salivary glands
 Minor salivary glands are found
throughout the mouth:
– Lips
– Buccal mucosa (cheeks)
– Alveolar mucosa (palate)
– Tongue dorsum and ventrum
– Floor of the mouth
 Together, they play a large role in
salivary production.
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What is Saliva?
“Saliva is clear, testless, odourless
slightly viscous fluid, consisting of
secretions from the parotid,
sublingual, and submandibular
salivary glands and mucous gland
of oral cavity”
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Composition
 Salivary fluid is an exocrine
secretion consisting of
approximately 99.6% of water and
0.5% of solids.
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Cellular constitutes
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 Yeast cells
 Bacteria
 Protozoa
 Polymorphonuclear leucocytes
 Desquamated epithelial cells

Inorganic constitutes
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 Sodium chloride
 Potassium chloride
 Acid and alkaline phosphatase
 Calcium carbonate
 Calcium phosphate
 Potassium thiocyanate

Organic constitutes
 Enzymes like:
Ptyalin, Lipase, Carbonic anhydrase,
Bacterolytic enzymes and lysozyme
 It also contains Immunoglobulin and other antimicrobial
factor, mucosal glycoproteins, traces of albumin.
 Some polypeptides and oligopeptides of importance to oral
health.
 Mucin, urea, amino acids, cholesterol and vitamins, soluble
specific blood group substances A, B, O, ranging from 10 to
20 mg/L, gases – 1 ml of oxygen, 2.5 ml of nitrogen, and 50
ml of CO2 per 100 ml. of saliva.
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Properties of
saliva
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Volume: 1000 to 1500 ml of saliva is secreted per day.
It is approximately about 1ml per minute.
• 20% by the parotid glands
• 65%-70% submandibular glands
• 7% to 8% sublingual glands
• <10% by the minor salivary glands
Reaction: mixed saliva from all the glands is slightly
acidic with PH of 6.35-6.85
Specific gravity: it ranges between 1.002 and 1.012
Osmolarity: saliva is hypotonic to plasma
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Functions
of
saliva
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Mechanical Function:
 Saliva forms a seromucosal covering that lubricates and
protects the oral tissues against irritating agents. This
occurs due to mucins (proteins with high carbohydrate
content) responsible for lubrication, protection against
dehydration, and maintenance of salivary visco-elasticity.
 In addition, they protect these tissues against proteolytic
attacks by microorganisms. Mastication, speech, and
deglutition are aided by the lubricant effects of these
proteins
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Digestive Function:
 Saliva is responsible for the initial digestion of starch,
favouring the formation of the food bolus. This action
occurs mainly by the presence of the digestive enzyme α-
amylase (ptyalin) in the composition of the saliva.
 Its biological function is to divide the starch into maltose,
maltotriose, and dextrins. This enzyme is considered to
be a good indicator of properly functioning salivary
glands, contributing 40% to 50% of the total salivary
protein produced by the glands.
Excretory Functions:
 Saliva excretes urea, heavy metals thiocyanates, certain
drug like iodide etc, alkaloids such as morphine, and
antibiotics such as penicillin etc.
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Sensation of taste:
 The salivary flow initially formed inside the acini is
isotonic with respect to plasma. However, as it runs
through the network of ducts, it becomes hypotonic.
 The hypo tonicity of saliva (low levels of glucose, sodium,
chloride, and urea) and its capacity to provide the
dissolution of substances allows the gustatory buds to
perceive different flavours.
 Gustin, a salivary protein appears to be necessary for the
growth and maturation of these buds.
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Water Balance:
 Saliva keeps the mouth moist. When moisture is reduced
in the mouth, certain nerve endings at the back of the
tongue are stimulated and the sensation of thirst arises.
The degree of individual hydration is the most important
factor that interferes in salivary secretion.
 When the body water content is reduced by 8%, salivary
flow virtually diminishes to zero, whereas hyper hydration
causes an increase in salivary flow. During dehydration,
the salivary glands cease secretion to conserve water.
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Buffering Action:
Saliva behaves as a buffer system to protect the mouth as
follows:
 It prevents colonization by potentially pathogenic
microorganisms by denying them optimization of
environmental conditions.
 Saliva buffers (neutralizes) and cleans the acids produced
by acidogenic microorganisms, thus, preventing enamel
demineralization.
 The carbonic acid-bicarbonate system is the most
important buffer in stimulated saliva, while in
unstimulated saliva it serves as the phosphate buffer
system.
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Maintenance of Tooth Integrity:
 When tooth erupts it is crystallo-graphically incomplete.
Interaction with saliva provides a post eruptive maturation
via diffusion of ions of calcium, phosphate magnesium,
and fluoride thereby results in surface hardness, decreased
permeability and caries resistance.
 Saliva plays a fundamental role in maintaining the
physical-chemical integrity of tooth enamel by modulating
re-mineralization and demineralization.
 The main factors controlling the stability of enamel
hydroxyapatite are the active concentrations of calcium,
phosphate, and fluoride in solution and the salivary pH.
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 The high concentrations of calcium and phosphate in saliva
guarantee ionic exchanges directed towards the tooth
surfaces that begin with tooth eruption resulting in post-
eruptive maturation. Re-mineralization of a carious tooth
before cavitation occurs is possible, mainly due to the
availability of calcium and phosphate ions in saliva.
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Anti-Bacterial Action:
 Saliva contains a spectrum of immunologic and non-
immunologic proteins with antibacterial properties. In
addition, some proteins are necessary for inhibiting the
spontaneous precipitation of calcium and phosphate ions
in the salivary glands and in their secretions.
Soft tissue Repair:
 Presence of nerve growth factor and epidermal growth
factor in saliva may accelerate wound healing. It speeds
blood coagulation both by affecting anticoagulants directly
in blood and by diluting the anti-thrombin.13
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Maintenance of Ecological Balance:
 Colonization on tissue surface and adherence are the
critical events for survival of many bacteria. Bacterial
clearance by mechanical, and immunological means is one
of the major function of the salivary defense system.
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Immunology
of
saliva
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 Secretory immunoglobulin A (IgA) is the largest
immunologic component of saliva. It can neutralize
viruses, bacterial, and enzyme toxins.
 It serves as an antibody for bacterial antigens and is
able to aggregate bacteria, inhibiting their adherence
to oral tissues.
 Other immunologic components, such as IgG and
IgM, occur in less quantity and probably originate
from gingival fluid.
 Among the non-immunologic salivary protein
components, there are enzymes (lysozyme,
lactoferrin, and peroxidase), mucin glycoprotein’s,
agglutinins, histatins, proline-rich proteins,
statherins, and cystatins.

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Lysozyme can hydrolyze the cellular wall of some
bacteria, and because it is strongly cationic, it can
activate the bacterial “auto-lysine’s” which are able to
destroy bacterial cell wall components.
Lactoferrin links to free iron in the saliva causing
bactericidal or bacteriostatic effects on various
microorganisms requiring iron for their survival such as
the Streptococcus mutans group.
Lactoferrin also provides fungicidal, antiviral, anti-
inflammatory, and immunomodulatory functions.

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 The Cystatins are also related to acquired film
formation and to hydroxyapatite crystal equilibrium.
Due to its proteinase inhibiting properties,
 it is surmised they act in controlling proteolytic
activity.
 Salivary Agglutinin, a highly glycosylated protein
frequently associated with other salivary proteins and
with secretory IgA, is responsible for bacteria
agglutination.

Salivary flow rate
 Spontaneous (asleep): 8 hr at 0.05/ml/min = 25 ml
 Unstimulated (awake): 12 hr at 0.7/ml/min = 504
ml
 Stimulated ( eating, talking): 4 hr at 2.0ml/min =
480 ml
 24 hour total = 1009 ml
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Salivary flow rate
 Flow rate= volume (milli litres) of saliva
minute
 There is great variability in individual salivary flow rate.
The accepted range of normal flow ml/min is as follows:
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Methods of measurment of flow rate
Techniques for collecting
un-stimulated whole saliva
Techniques for collecting
stimulated whole saliva
 Masticatory method
(standardized piece of
paraffin used)
 Gustatory method
(1% to 6% citric acid
used )
 Draining method
 Spitting method
 Suction method
 Swab method
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Salivary flow
&
Ageing
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Flow rate of unstimulated whole
saliva with age
 Since 70% of whole resting saliva comes from submandibular
and sublingual glands , the decrease in its flow with age must
largely be due to decrease in production.
 Histological findings demonstrate that there is 20 to 30%
decrease in volume of salivary acini with age.
 On the other hand numerous functional studies have failed to
show any age related decrease in the flow of parotid saliva as
the normal resting flow rates of parotid saliva are extremely
small 0.04 to 0.06 ml/min .Therefore often no saliva can be
obtained and the frequency of not obtaining it increases with
age .
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Flow rate of stimulated whole
saliva:
 The relationship – SFR and ageing- of whole saliva is mixed.
Most studies show no change or only a modest decrease in flow
rate even though the histological findings show a significant
decline in the volume of salivary acini. The fact that this acinar
reduction does not affect the stimulated flow rate of saliva
should not be surprising- most organs when stimulated,
compensate for the loss of parenchyma.
Other factors influencing salivary flow rate:
 Diurnal variation, drugs, source of saliva, diet, duration and
type of stimuli, hormones
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Mastication & Saliva
Decreased mastication and saliva
 Mastication is the exercise of the oral apparatus. Chewing
increases ,function and lack of chewing induces disuse atrophy.
 Indeed impaired mastication is associated with a reduction in
the mass of salivary gland and a decrease in the synthesis &
secretion of saliva.
 Findings indicate that the partial or total loss of teeth, the
presence of dentures , the decrease in bite force, TMJ
dysfunction , extensive caries , pdl disease , pain ,
immobilization of jaws and other clinical conditions contribute
to in flow of saliva and salivary gland hypofunction.
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Increased mastication and saliva
 Chewing induces an increase in the flow of stimulated whole
saliva.
 This facilitates taste, swallowing and alimentation, enhances
clearance, buffers harmful oral and oesophageal acids and aids
in the remineralisation of teeth .
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ROLE OF SALIVA
IN
PROSTHODONTICS
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Pre-Treatment Evalution
 All major salivary gland orifice should be examined for
potency and the viscosity of saliva should be determined.
 Saliva can be classified as :
1. Normal quantity and quality of saliva. Cohesive and adhesive
properties are ideal
2. Excessive saliva. Contains much mucous.
3. Xerostomia . Remaining saliva is mucinous.
 The flow rate and viscosity of saliva will affect the denture
construction process and the quality of the final product
itself.
 A flow of medium viscosity at normal resting salivary flow
rate lubricates the mucosa and assists retention of complete
dentures.
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 Many factors can affect the flow rate. Medications that can reduce
salivary flow, radiation therapy in the region of the salivary
glands. The glands themselves may be diseased or ducts can be
blocked.
 Dryness of the mouth affects the retention of the dentures and
increases the potential for soreness. Often the palatal glands are
destroyed in patients who have worn a complete maxillary
denture for many years. The cause is pressure atrophy resulting
from lost residual alveolar ridge support of the denture.
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 An excess of saliva complicates denture construction, especially
impression making. When new dentures are first inserted, it is
common for the patient to experience a temporary increase in
salivary flow .
 The consistency of saliva can range from a thin, serous type to a
thick, ropy consistency. It is best to work with a serous type. Thick
saliva makes dentures more difficult to wear.
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Saliva & impression making
Control of saliva during complete denture impression:
 The amount and consistency of saliva affects the
impression making procedure.
 Excessive salivation, particularly by the submandibular
and sublingual glands, presents a problem in impression
making. When this problem exists, appropriate drugs (e.g.-
atropine sulfate) can be administered orally before making
the impression.
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 Excessive secretion of mucous from the palatal glands
may distort the impression material in the posterior two
thirds of the palate.
To counteract this problem:
a. The palate may be massaged to encourage the glands
to empty.
b. The mouth may be irrigated with an astringent mouth
wash prior to inserting the impression material.
c. The palate may be wiped with a gauge.
d. warm gauze pads may be used to milk palatal glands,
followed by cold pads to constrict gland opening.
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In patients with xerostomia:
1. A very careful gentle approach is essential for patients
with dry mouth as the mucosa and lips are easily
traumatized.
2. The lips should be coated with petroleum jelly to help
with retraction and access to the oral cavity.
3. The operator‟s gloved fingers should be wetted to
prevent them from sticking to the soft tissues.
4. A mirror should be used to facilitate insertion of the
tray as it is less bulky than the fingers.
 Silicone impression materials are the best tolerated and
least traumatic to the mucosa. Zinc oxide eugenol paste
will adhere to and burn the mouth and materials such
as impression plaster will adhere to the mucosa and
abrade it.
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Control of Saliva during Impression for Removable Partial
Denture Using Irreversible Hydrocolloid:
 Excessive amounts of saliva can displace alginate impression
material and contribute to an inaccurate impression.
 In most cases, saliva can be controlled by having the patient
rinse the mouth with an astringent mouthwash and then with
cold water.
 In the maxillary arch, one gauze strip should extend from the
posterior portion of the right buccal vestibule to the posterior
portion of the left buccal vestibule. The patient should be
instructed to hold a second strip against the tissues of the
palate. In the mandibular arch, one gauze strip should extend
from the right buccal vestibule to the left buccal vestibule. A
second gauze strip should be positioned in the lingual sulcus by
having the patient raise the tongue, placing the gauze, and then
having the patient relax the tongue. The gauze should be gently
removed immediately before the impression is made.
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 Some patients secrete excessive amounts of thick mucinous
saliva from the palatal salivary glands. This saliva displaces the
alginate and results in inaccurate impressions. These patients
should be instructed to rinse with an astringent mouthwash. If
a mouthwash is not handy, the problem may be overcome by
employing the “ Tandem” impression technique, in which one
impression is made to “soak up” the bubbles and mucinous
saliva, followed immediately by a second impression which will
record the tissues in a relatively saliva-free state.
 In turn, gauze sponges dampened in warm water should be
used to place pressure over the posterior palate, causing the
palatal glands to empty. Patients should then be directed to
rinse mouth with ice water. At this point maxillary impressions
can be made.
 In rare instances, a patient will secrete so much saliva that it
becomes extremely difficult to make accurate impressions. The
use of an anti sialagogue in combination with mouth rinses and
gauze packs may be used to control salivary flow in such
instances.
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 Anti sialagogues should not be prescribed in the presence of
medical contraindications such as glaucoma, prostatic
hypertrophy, or cardiac conditions in which any increase in
heart rate is to be avoided.
 Alginate has a tendency to stick to teeth if the teeth are too dry.
Sticking of alginate to the teeth occurs when alginate radicals
within the impression material form chemical bonds with
hydroxyapatite crystals of the enamel. As the impression is
removed, tearing of the alginate occurs. This produces surface
inaccuracies in the impression and the resultant cast.
 Adequate moisture control should be accomplished by packing
the mouth with gauze pads before making an impression.
Gauze pads must be gently removed before the impression
material is placed in the oral cavity. Drying with compressed
air is contraindicated, because this minimizes the moisture
content of tooth surfaces and contributes to sticking of
alginate.
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Cleaning the Alginate Impression :
 Failure to remove saliva from the impression will result in an
inaccurate cast. Therefore saliva should be carefully removed
from the impression surface before the associated cast is
poured. Most patients have thin, serous saliva. This type of
saliva can be removed by briefly holding the impression under
a gentle stream of cool tap water. If running tap water is not
effective, the saliva can be removed using a soft camel hair
brush and a mild detergent.
 On the other hand, some patients have thick, ropy saliva that is
difficult to remove. Therefore it is recommended that a thin
layer of dental stone be sprinkled on the surface of the
impression. The stone adheres to the saliva and acts as a
disclosing agent. When the impression is placed under running
tap water, the saliva can be removed by light brushing with a
wet camel hair brush . If saliva is retained on impression and
cast is poured, this results in a cast with rough surfaces.
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Control of Saliva during Impression for Fixed Partial
Denture :
 When an impression is made or a restoration is cemented,
great degree of dryness is required. It can be achieved by using
a rubber dam, high-volume vacuum, saliva ejector, svedopter
and anti-sialagouges.
 Drugs used to control flow of saliva include Methantheline
bromide (Banthine) and Propantheline bromide (Pro-
Banthine).
 Usually one 50-mg tablet of Banthine or 15-mg tablet of Pro-
Banthine taken 1 hour before appointment will provide
necessary control.
 Another drug that has been shown to be effective as an anti-
sialagogue is Clonidine hydrochloride.
23 June 2020 62

Control of Saliva during Impression for Fixed Partial
Denture :
 When an impression is made or a restoration is cemented,
great degree of dryness is required. It can be achieved by using
a rubber dam, high-volume vacuum, saliva ejector, svedopter
and anti-sialagouges.
 Drugs used to control flow of saliva include Methantheline
bromide (Banthine) and Propantheline bromide (Pro-
Banthine).
 Usually one 50-mg tablet of Banthine or 15-mg tablet of Pro-
Banthine taken 1 hour before appointment will provide
necessary control.
 Another drug that has been shown to be effective as an anti-
sialagogue is Clonidine hydrochloride.
23 June 2020 63

ROLE OF SALIVA IN COMPLETE DENTURE
PROSTHODONTICS
Saliva is one of the physiological factors which plays
an important role in the retention of the denture
The various physical factors which affects retention
are
 Adhesion
 Cohesion
 Interfacial surface tension
 Capillarity
 Atmospheric pressure
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Adhesion:
“The property of remaining in close proximity, as that
resulting from the physical attraction of molecules to a
substance or molecular attraction existing between
the surfaces of bodies in contact’’(GPT8)
 It is the physical force involved in the attraction between
unlike molecules. A drop of water introduced on the
surface of a solid glass plate will resist movement away
from the glass in proportion to the adhesion between the
unlike molecules.
 A layer of saliva between the denture base and the
mucosa of the basal seat acts in the same way. The
effectiveness of adhesion depends on close adaptation of
the denture base to the supporting tissue and is also
directly proportional to the area covered by the denture.
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Serous or watery saliva is quite efficient provided the
denture base can be wetted. Some denture base materials
allow saliva to stick to them and spread out in a thin layer.
These materials have greater potential for being retained by
adhesion than materials that cause drops to form over their
surface.
Cohesion:
1. “the act or state of sticking together tightly.
2. the force whereby molecules of matter adhere to one
another; the attraction of aggregation.
3. molecular attraction by which the particles of a body
are united throughout their mass.” (GPT 8)

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 Cohesion is the physical factor of electromagnetic force
acting between molecules of the same material or
otherwise called like molecules.
 Cohesion occurs in the layer of saliva between the
denture base and the mucosa and is effective in direct
proportion to the area covered by the denture.
Interfacial surface tension:
Surface tension: “A property of liquids in
which the exposed surface tends to contract to the
smallest possible area, as in the spherical formation
of drops. This is a phenomenon attributed to the
attractive forces, or cohesion, between the
molecules of the liquid”(GPT 8)
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 The phenomenon of surface tension is the force that
maintains the surface continuity of a fluid. This results
from an imbalance in cohesive forces present at the
surface of the layer or column of the fluid.
 All denture base materials have higher surface tension
than oral mucosa, but once coated by salivary pellicle,
their surface tension is reduced, which promotes
maximizing the surface area between saliva and base.
 The thin fluid film between the denture base and the
mucosa of the basal seat therefore furnishes a retentive
force by virtue of the tendency of the saliva to maximize
its contact with both surfaces.
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Capillarity:
“That quality or state which, because of surface
tension, causes elevation or depression of the
surface of a liquid that is in contact with the solid
walls of a vessel” (GPT 8)
 Capillary attraction or capillarity is a force developed
because of surface tension that causes the surface of a
liquid to become elevated or depressed when it is in
contact with a solid.
 When the adaptation of the denture base to the mucosa is
sufficiently close the space between the denture base and
mucosa usually about 0.1mm or less – filled with a thin
film of saliva acts as
23 June 2020 70

Atmospheric pressure:
 The atmospheric pressure acts as a retentive force when
dislodging forces are applied to the denture. Atmospheric
pressure itself is supplied by the weight of the atmosphere
and amounts to 14.7 lb/inch2.
 This means that the retentive force supplied by the
atmospheric pressure is directly proportional to the area
covered by the denture base.
 A perfect border seal is essential all around the denture
base for this force to be effective.
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 Atmospheric pressure is an emergency retentive force
which comes into play when the denture is being pulled
away from the basal seat and the negative pressure
created between the denture and the basal seat helps in
retention.
 Even if the other retentive forces are being over powered
the atmospheric pressure may be able to keep the denture
in position.
23 June 2020 72

Denture insertion and after phase
 New dentures are often interpreted as foreign objects by the
oral system. This leads to stimulation of salivary glands to
produce saliva. On excessive salivation patient may complain
of floating dentures. But this decreases over the weeks after
denture insertion.
 Also it is generally recognized that dentures have some effect
on taste sensation. But the exact nature of sensory alteration
and the role of saliva are not well understood.
 If good denture hygiene is not maintained, in the long run,
saliva modulates the colonization of micro organisms in the
pellicle leading to plaque formation which in turn leads to
denture stomatitis.
23 June 2020 73

Taste alteration:
 Apart from alteration in sensory mechanisms, other factors
which have been explored in relationship to effect on taste
sensation are age and saliva. Recent controlled studies show
only a small decrease in ability to taste salt and bitter and no
significant impairment of taste function to sweet and sour
with human aging.
 Since a substance or tastants must be present at the taste
receptor in a solution, the role of saliva in taste function may
be that of a tastants solute.
23 June 2020 74

 Many xerostomic patients exhibit altered taste abilities.
However, irradiated patients and Sjogren‟s syndrome
patients have been shown to have damage to the taste cells.
 Salivary composition may also be related to taste acuity.
Sodium levels in saliva have been positively correlated with
salt taste threshold levels although levels of salivary glucose
apparently have no effect on sweet taste threshold. Henkin
et al demonstrated that a patient population with idiopathic
hypogeusia (decreased taste acuity) was deficient in zinc
concentrations in parotid saliva, which could be restored
with dietary zinc supplements.
23 June 2020 75

 In summary, no single factor, whether prosthesis use or
salivary quantity or composition, has been correlated with
altered taste perception. It is more likely that dentures may
mediate some change in salivary characteristics that may
subsequently alter the perception of taste.
23 June 2020 76

Pellicle as a Mediator of Plaque Formation:
 When denture prosthesis is placed in the oral cavity, a layer
of saliva is rapidly adsorbed to the surface. This is termed
the acquired denture pellicle (ADP).
 The presence of ADP is described in ultrastructural studies
as a thin (2 to 4 μm) electron dense layer that may appear
organized as a striated lamellar palisade.
 Microorganisms are then observed in contact with this
pellicle layer instead of becoming attached directly to the
denture surface.
23 June 2020 77

 ADP has been shown to differ in composition between the
tissue and polished surfaces of complete dentures.
Therefore, it may be expected that microbial adherence is
specific for the individual denture surface.
 The minor salivary glands of the palatal mucosa must be
considered a major source of ADP on the tissue side of the
maxillary denture.
 This is not only because of their close opposition to the
denture base, but also to the isolating effect of the maxillary
palatal surface, which is designed to create a border seal.
23 June 2020 78

Denture Plaque, Denture
Stomatitis and the Adhesion of
Candida albicans to Inert
Materials
23 June 2020 79

Denture Plaque
 The plaque microflora varies between sites in the mouth.
On the denture, differences between the buccal flange,
the smooth denture tooth surface, the denture „tooth
gum interface‟ and the denture fitting surface have been
identified.
 Yeasts were present on external surfaces less often than
on the fitting surfaces. The environment enclosed by the
fitting surface is more stagnant and this would facilitate
plaque accumulation and hence enhance the yeast cells‟
chances of being retained; it also has a more acidogenic
plaque population than those of the more exposed
denture surfaces .
23 June 2020 80

 A complete or partial denture surface in contact with the
palatal mucosa can provide an environment highly
susceptible to plaque mediated disease called denture
induced stomatitis (DIS).
 Denture stomatitis is usually graded clinically in 3 types
Type 1 – localized inflammation or pinpoint hyperemia
Type 2 – diffuse erythema
Type 3 – inflammatory papillary hyperplasia.
 Types 2 and 3 have been associated with infection by
Candida albicans.
Denture Stomatitis: A Plaque Mediated Disease
23 June 2020 81

 Trauma to the underlying tissues by a poorly fitting
prosthesis with occlusal disharmony is one contributing
factor in denture stomatitis.
 Occlusal adjustment or refitting of the dentures can result
in complete resolution of denture stomatitis. Although
allergic response to the denture base material has been
suggested as an etiology, no instance of true allergic
sensitization has been reported.
23 June 2020 82

 Infection of the palatal mucosa by Candida albicans as a
cause of DIS was first demonstrated by Lyon and Chick.
 Cultures from direct smears of the palatal mucosa of
patients with DIS demonstrated significantly higher
percentages positive for Candida species compared with
those from patients with a healthy palatal mucosa.
 Further evidence of the involvement of Candida albicans
in denture stomatitis is the effectiveness of short term
topical treatment with antifungal oral rinses, such as
nystatin and amphotericin B.
23 June 2020 83

Candida in Biofilm on Other Biomaterials
 Dentures are most commonly constructed of
polymethylmethacrylate, which most authors believe resist
penetration by the biofilm on its surface.
 In maxillofacial prostheses, silicones are used heavily, with
different structural parts being exposed to different environments.
Contamination may lead to aesthetic spoilage as well as providing
a focus of infection.
 Denture soft linings/tissue conditioners are used to improve the fit
and comfort, being softer than denture acrylic. The surface is
more prone to penetration by microorganisms and the surface
texture and chemistry hamper effective mechanical cleaning.
 Silicone rubbers are particularly prone to colonization.
23 June 2020 84

 Thus in the oral environment and in other parts of the
body, biofilms accumulate on a variety of inert foreign
surfaces which have a relatively extended stay particularly
those surfaces which are more penetrable.
 Denture fabricated from metal are less common but are
much less frequently associated with denture stomatitis.
This may be due to different properties of the substratum
and to the different prosthesis design.
23 June 2020 85

Microbiology at Healthy Oral Implants Sites
 The primary colonizers on oral implants are Streptococcus and
Actinomyces species bound through receptors mediated by
salivary glycoproteins in the oral biofilm.
 Successfully osseointegrated implants are characterized by little
plaque and no marginal inflammation.
 Plaque microbial composition at well maintained implant sites
shows many similarities with that of the tooth at gingival health.
 The subgingival plaque of stable osseointegrated implants is
dominated by coccoid cells and predominantly gram positive
organisms. Streptococcus sanguis, Streptococcus oralis,
Streptococcus mitis, Actinomyces naeslundii, Veillonella parvula
and Fusobacterium nucleatum are dominating species while black
pigmented gram negative rods, Prevotella and Campylobacter are
present at less than 1% of the total.
23 June 2020 86

 Despite the fact that plaque development on implants
and on teeth shows a microbiologically similar pattern,
there might be differences in the very early phases of
microbial establishment. Several factors can be
involved in bacterial establishment to foreign materials
e.g.: material toxicity, the surface biofilm and material
roughness.
23 June 2020 87

Microbiology at Failing Implants
 Despite the high success rate of dental implants failures do exist
and a significant number of implants are lost due to peri-
implantitis.
 Tissue breakdown can be even more substantial around implants
compared to the natural tooth and there is a high failure rate in
patients with persisting own teeth and in those with previous
history of periodontitis.
23 June 2020 88

 A combination of a periodontitis associated microflora and a
susceptible host may thus predispose towards implant failure.
Implant failure are characterized by a complex peri-implant
microbiota resembling that of adult periodontitis.
 Thus the subgingival flora of failing implants is dominated by
Prevotella and Porphyromonas species, spirochetes, fusobacteria
and campylobacter, while Streptococci and Actinomyces although
present are proportionally lower in number than in healthy
situations.
23 June 2020 89

SALIVARY GLAND
DYSFUNCTION
23 June 2020 90

 Salivary gland dysfunction is defined as
any quantitative and / or qualitative
change in the output of saliva.
 Thus salivary gland dysfunction includes
either an increase in salivary output
(hyperfunction) or a decrease
(hypofunction).
23 June 2020 91

“Xerostomia is a clinical condition caused by a
decrease in the production of saliva which may
present itself as a local symptom, as part of a
systemic disease such as sjogren’s syndrome,
diabetes,alcoholism or as side effect of
medications or following therapeutic radiation
to the head and neck regions”.
23 June 2020 93

Iatrogenic - Medications (Antidepressant,
Diuretics, Antihypertensives, Antipsychotics),
Chemotherapy, Radiotherapy to head and neck
region, Surgical trauma
Autoimmune disease - Rheumatoid arthritis,
Sjogrens syndrome
Neurological disorders - Mental depression,
Cerebral palsy
Causes
23 June 2020 94

Harmonal disorders - Diabetes mellitus, Hyper
& hypothyroidism
Hereditary disorders - Cystic fibrosis,
Ectodermal dysplasia
Metabolic disturbance – Malnutrition,
Dehydration, Vitamin deficiency
Local salivary diseases - Sialoliths, Sialadenitis,
Carcinoma
23 June 2020 95

Management
of
xerostomia
23 June 2020 96

A. General measures (etiological treatment)
- management of symptoms
- treatment of oral condition
A. Preventive measures
B. Increased salivary flow or salivary stimulations (
sialogogues)
C. Management of underlying systemic condition
D. Use of saliva substitutes
E. Use of oral lubricating devices
23 June 2020 97

 Among the general measures to be taken into account when
treating patient with dry mouth, consideration should first
focus on the control of any systemic disorders that may be
responsible for the oral problem.
 Aminofostine, a selective cytoprotector that acts upon the
salivay gland, kidneys, liver, heart or bone marrow can be
used to limit the undesirable effects of radiotherapy for
head and neck cancer.
 The drug has side effects such as nausea, vomiting, and
hypotension and hypocalcemia may also result.
General measures (etiological treatment)
23 June 2020 98

Management of symptoms
SYMPTOMS MANAGEMENT
1. Dry mouth
2. Difficulty with speech
3. Difficulty with swallowing
4. Disturbed taste sensations
5. Increased caries rate and
periodontal diseases
6. Oral infections
1. Improve oral hygiene/ saliva
substitutes
2. Chlorhexidine (CHX) gel or
mouth rinse
3. Avoid sugar- sweetened
drinks/ cofectionery
4. Suck chips of ice
5. Restoration of caries, fluoride
mouth rinse and CHX mouth
rinse
6. Prescribe as appropriate
23 June 2020 99

Treatment of oral conditions
1. Dental caries
2. Oral candidiasis
3. Denture antifungal
treatment
4. Bacterial infections
5. Ill or poor fitting
prosthesis
1. Restorative therapy, topical fluoride applicatons
2. CHX 0.12 % rinse, swish, and spit 10 ml twice
daily nystatin/triamcinolone ointment for angular
chelitis : apply topically 4 times daily.
Clotrimazole troches: 10 mg dissolves orally 4-5
times daily for 10 days. Systemic therapy for
immuno-compromised patients.
3. Soaking of denture for 30 minutes daily in
CHX or 1% sodium hypochloride.
4. Systemic antibiotics for 7-10 days
5. Denture adjustment, hard and soft reline, use of
denture adhesive, implant –borne prosthesis etc.
23 June 2020 100

 Preventive care should be addressed next. Extra measures
should be instituted to prevent oral complications from low
salivary output.
 This starts with frequent dental and oral evalutions , with
examinations every 4-6 months and radio-graphs
performed annually.
 To prevent dental caries in case of single complete denture
or overdenture, meticulous oral hygiene, a low sugar diet,
and regular use of topical fluoride are recommended.
Preventive measures
23 June 2020 101

 Daily use of neutral PH sodium fluoride is the most effective
means of preventing rampant hyposalivation induced
caries.
 Fluorides and remineralizing solutions are available as
varnishes, dentifrices, gels,and rinses, which can be used
with or without applicator trays.
23 June 2020 102

 In patient with dry mouth it is important to determine
whether functional salivary gland parenchyma remaining
can be stimulated mechanically or chemically.
 Stimulation can be achieved through simple measures such
as more frequent meals, then ingesion of lemonade or acid
drinks, the disssolving of sugar free essence candies in the
mouth , or the prescription of xylitol chewing gum.
 It is also possible to administer sialogogues that directly
stimulat the salivary glands, such as anetoltritione,
pilocalperine and cevimeline and bethanechol.
Increase salivary flow or salivary
stimulation (sialogogues)
23 June 2020 103

 The most common systemic disease is sjogren’s syndrome,
an autonomous exocrinopathy producing dry eyes and a dry
mouth.
 Other pertinent disease include rheumatoid arthritis, HIV
infection, diabetes, Alzheimer disease and smoke,
 The most common cause of salivary disorders in elderly
people is prescription and non-prescription medications,
primarily because of certain drugs, anticholinergic effects.
 These medications include tricyclic antidepressants,
sedatives and tranquilizers, anti histamines, anti
hypertensive agents, cytotoxic agents, anti parkinsonism
agents and antiseizure drugs.
Management of underlying systemic
condition
23 June 2020 104

 Radiation therapy, a common treatment modality for head
and neck cancers, causes permanent salivary hypofunction
and persistent xerostomia.
 The xerostomic side effects of medications may be
alleviated or reduced by substituting for the problem with
medications that have lesser side effects.
 Moreover, alterations in the timing or dosing schedule of
medications, such as avoidence of medication doses at
night time when salivary flow is normally at its lowest, may
minimize xerostomic effects.
 Multidiscilinary management of underlying systemic
conditions is imperative to reduce oral complications.
23 June 2020 105

Saliva
substitutes
23 June 2020 106

 In patients with extreme or prolonged dry mouth,
substances that replace lost salivary function and
components can be used.
 These options include artificial saliva which humidifies
the oral cavity, particularly protecting it from irritative
mechanical or chemical factors and infections.
 Such preparation consist of aqueous solution containing
glycoproteins or mucins, and salivary enzymes such as
peroxidase, glucose oxidase or lysozyme.
 Polymers such as carboxymethyl cellulose have also been
used with the aim of protecting the soft tissues. Or ions
such as calcium and phosphates or fluorides for
protecting the hard structures of the teeth.
23 June 2020 107

 The artificial saliva can be classified into three groups:
A. Glycerine and lemon: they are the simplest but, if natural
teeth are present, it may also cause erosion , in addition
glycerine is astringent and may sting the soft tissues.
B. Those based on carboxylmethyl cellulose.
C. Those based on mucin; based artificial saliva have best
properties.
Classification of artificial saliva
23 June 2020 108

 Milk can also be recommended as a salivary substitutes.
Milk appears to have chemical and physical properties of a
good saliva substitute.
 In addition to moistening and lubricating the oral mucosa,
milk is capable of buffering oral acids, reducing enamel
solubility and contributing to enamel remineralisation.
 These properties are attributable to calcium and phosphate
content as well as milk phosphoproteins that adsorb to
enamel because of these factors milk is regarded as a good
saliva substitute.
 Some saliva substitutes are based on pig products
( bovine/procine) and are contraindicated in vegetarians.
23 June 2020 109

 Some patients tend to use home remedies such as
margarine.
 A water soluble extract of linseed oil has been found to have
physical properties similar to glycoprotiens of saliva.
Salinum is based on this linseed oil.
23 June 2020 110

A. Luborant : contains lactose peroxidase which increases oral
defence mechanism. It can be given in any condition giving
rise to dry mouth.
B. Glandosame (fresinius) : it is indicated in denture wearers
only, because PH of glandosane is 5.0 and can cause
subsurface demineralization in dentulous patients.
C. Saliva orthona (Nycomed ): it is an oral spray containing
procine mucin. It is also available as a lozenge. It is
unsuitable for certain ethnic group and vegetarians.
Few commercial available saliva
substitutes.
23 June 2020 111

D. Oral balance/ biotene: it is available as mouth rinse ,
lozenges and toothpaste. It contains several components
such as polyglycerol methacrylate, lactoperoxidase and
glucose oxidase. It diminishes the sensation of oral dryness
and improve oral functions, Biotene can also cause
subsurface demineralization.
E. Salinum: Based on water soluble extract of linseed oil.
F. Salivix pastilles (tablets): acts locally as salivary stimulants
23 June 2020 112

 Electrical stimulation- SALITRON-.battery operated devices
which deliver an electrical stimulus to the tongue and palate
for saliva production.
 Acupuncture.
 Future aspects:
-gene therapy
-tissue engineering.
23 June 2020 113

Artificial
salivary
Resorviors
Prosthodontic management
23 June 2020 114

 In order to permit the wearing of denture, artificial
saliva preparation have been recommended.
 The major drawback of artificial saliva is thar it must
be mechanically introduced into the oral cavity by
the patient at regular intervals.
 Patient object to carry a bottle of artificial saliva and
would prefer a more convenient saliva delivery
system in the form of reservoir dentures or oral
lubricating devices.
23 June 2020 115

Requirments of oral lubricating devices:
 Should provide substained release of saliva
substitutes
 Should provide slow release of artificial saliva.
 Should be easy to use.
 Should be easy to clean
 Should not interfere with normal oral function
23 June 2020 116

Mandibular saliva reservoir
23 June 2020 117

Maxillary saliva reservoir
23 June 2020 123

SIALORRHEA
 Excessive salivation often experienced by the
individual and experienced by the individual &
noticed by the operator.
Prosthodontic management:
 Impression making: mouth irrigated with an
astringent.
 Mouth washed prior to investing impression
material.
 Fast setting impression material is used.
 Anti sialagogues administered 1to 2 days before
treatment
 Dummy dentures are fabricated & given.
23 June 2020 128

Saliva as a diagnostic tools
 Saliva already is used to aid in the diagnosis of dental
disease. Examples include caries risk assessment,
periodontal disease genotypes, and identification
markers for periodontal disease, salivary gland
disease and dysfunction, and candida infections.
 Salivary collections are used for diagnostic
determinants for viral diseases, sarcoidosis,
tuberculosis, lymphoma, gastric ulcers and cancers,
liver dysfunction, and Sjogren’s syndrome.
 Saliva also is being used to monitor levels of
polypeptides, steroids, antibodies, alcohol, and
various other drugs.
 Research currently is being conducted to determine
the value of saliva as a diagnostic aid for cancer and
preterm labor.23 June 2020 129

 Saliva drug testing kits are commercially available.
Included in these are the tests for alcohol, cocaine,
HIV1 ,HIV2 ,DNA, etc.
 Salivary cortisol is an indicator of hypothalamic
pituitary adrenal axis function- used to quantify the
human stress & to determine the effect of treatment
on it.
 to detect antibodies-hepatitis A, rubella virus, etc.
 to diagnose systemic disease after salivary gland
dysfunction- sjogren’s syndrome, alzheimer’s disease,
cystic fibrosis, etc.
 Forensic odontology
23 June 2020 130

 Salivary pH assessment using telemetry: Device
called telemetry system is incorporated in the
denture which has a radiosensitive diode, oscillator,
PH sensor, and a computer analyzer.
 Another area of research involves the possible
regenerative properties and functions of growth
factors found in saliva, such as epidermal growth
factor and transforming growth factor. Evidence
suggests that these growth factors play a role in
wound healing and the maintenance of oral and
systemic health.
23 June 2020 131

Cross
Contamination
23 June 2020 132

23 June 2020 133
 Dental professionals are exposed to a wide variety of
microorganisms in the blood and saliva of the patients.
 These microorganisms may cause infectious diseases. The
use of effective infection control procedures and universal
precautions in the dental office and the dental laboratory
will prevent cross contamination that could extend to
dentists, dental office staff, dental technicians and patients.

23 June 2020 134
Direct contact
Airborne
infections
spatter
Cross-
contamination
may be due to
Infected saliva
and blood
From microorganism
containing aerosols
During lab
procedure
When using knife
and other sharp
object

23 June 2020 135
Chain of infections
Pathogens
Reservoir
Subceptible host
Indirect contact
Portal of entry
Direct contact

23 June 2020 136
Immnization
Barrier techniques
Aseptic techniques
Make dental
lab safe Minimize
potential
IC Compliance
Goals/Action

23 June 2020 137
Transmission of infection
impression
Impression
trays
prosthesis
Occlusal rims
cast
Artculators

23 June 2020 138
Infection control precautions
Appropriate personal protective
equipment
Frequent hand hygiene
Organization of clinic / lab

23 June 2020 139
Barrier systems
Hand washing
Plain or
antimicrobial
soap
Or an alcohol
based hand
rub
Personal protection
equipment
Gloves
Mask &
protective eye
wear
Chin length
face sheild
Apron /
lab coats

23 June 2020 140
Disinfection of Impresssion

23 June 2020 141
Methods of
disinfection
Same
disinfectant can
be used again
Uses less
disinfectant
Spraying
Exposure of
all surfaces
preferrable
Immersion

23 June 2020 142
Dental lab procedure
Incoming
items
Clear and
disinfect
Rinse, dilute
with mouthwash
Place in
plasttic bag
outgoing
items
Rinse to
remove blood
& saliva
disinfect
Again rinse
to remove
disinfectant

23 June 2020 143
ORALLY SOILED PROSTHESIS
Scrub with brush and anti microbial
soap.
Place in plastic bag in ultrasonic
cleaning solution
Removed Rinsed Dried
Accomplished required work.

23 June 2020 144
Dental prosthesis
 Do not exceed the
recommended
contact time to
minimize corrosion
 Do not store in
disinfection before
insertion
 Store in diluted
mouthwash untill
insertion

23 June 2020 145
References……………………………………………………………
1) Secretory functions of alimentary canal. In, Guyton AC, Hall JE (ed). Text book of
Medical Physiology. 9th edition.
2) Sembulingum’s human physiology
3) Grey’s anatomy, Anatomy of salivary glands
4) Sharry JJ (ed). Complete Denture Prosthodontics. 3rd edition.
5) The retention of complete dentures. In, Zarb GA, Bolender CL (ed). Prosthodontic
treatment for edentulous patients. 12th edition.
6) RRJDS | Vol 1 | Issue 1 | April – June, 2013

23 June 2020 146
7) Lakhyani R et al NJIRM 2012; 3(1) : 139-146
8) Indian J Stomatol 2011;2(4):263-66.
9) The Journal of Indian Prosthodontic Society / April 2009 / Vol 9 / Issue 2
10)The International journal of Prosthodontics Volume 6, Number 5,1993

Saliva by dr brajendra singh tomar

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