Post on 17-Jan-2017
transcript
SALIVA AS DIAGNOSTIC AID FOR PERIODONTAL DISEASE
Dr Harshavardhan Patwal
• Saliva is “the aqua-vita” of the oral cavity. • the principal protector of the soft and hard oral
tissues. Diminished secretion: • oral tissues become susceptible to infection• ability to masticate, swallow, speak and taste
may be disturbed.
Saliva is a clear, slightly acidic mucoserous exocrine secretion.
• Whole saliva:“It is a complex mixture of fluids from major and
minor salivary glands and from gingival crevicular fluid, which contains oral bacteria and food debris”. Edgar,1992.
Development of salivary glands
The three major sets of glands • Parotid, submandibular,sublingual• they originate in a uniform manner by oral
ectodermal epithelial buds invading the underlying mesenchyme
Classification
It is based on• Size and location• The histochemical nature of secretory products
On basis of size
Major salivary glands
Parotid gland
Submandibular gland
Sublingual gland
Minor salivary glands
Labial and buccal glands
Glossopalatine glands or
lingual glands
On basis of secretions
• Serous –parotid• Mixed –
submaxillary glands
• Mainly mucous –sub lingual
On the basis of location
• Palatal• Buccal• Lingual
Composition of saliva
(Mandel & Wotman 1976, Core 1992)
Total amount: 500-700 ml in 24 hours. Average volume in the mouth is 1.1 ml.
Production is controlled by ANS
At rest, secretion ranges from 0.25 to 0.35 ml/min and is mostly produced by the submandibular and sublingual glands.
Sensory, electrical or mechanical stimuli can raise the secretion rate to 1.5 ml/min.
The greatest volume is produced before, during and after meals, reaching its maximum peak at around 12 a.m, and falls at night.
Consistency: slightly cloudy, due to presence of cells and mucin
Reaction: usually slightly acidic (ph 6.02-7.05)
Specific gravity:1.002-1.02
Freezing point: 0.07 –0.34 degree centigrade
99% water
1% large organic and inorganic
molecules.Large organic molecules
•protein,•glycoproteins•lipids
Small organic molecules
•glucose• urea
Electrolytes
•sodium,•calcium,•chloride•phosphates
• Organic constituents:– Protein • Comprise approx. 200mg/100ml only 3% of
the protein conc. in plasma.– Enzymes – Immunoglobulins – Antibacterial proteins – Mucous glycoproteins – Traces of albumin, polypeptides and
oligopeptides.
• Inorganic constituents: – sodium, potassium, chloride and bicarbonate
are the main contributors to the osmolarity of saliva.
– Bicarbonate is also the principal buffer in saliva.
– Thiocyanate activates antibacterial effect of sialoperoxidase.
– Fluoride content similar to plasma
The known stimulus may be • Psychological (eg. Thinking of tamarind)• Visual (eg. Seeing delicious food)• Taste (tasting good food)• Others (during vomiting) Stimulated secretion of saliva is due to reflex (salivary reflex) • Conditional• Unconditional
Factors influencing the composition of saliva
Flow Rate • The accepted range of normal flow for
unstimulated saliva is anything above 0.1ml/min.
• For stimulated saliva flow rate is approx 0.2ml / min.
• As the flow rate increases, the concentration of proteins, sodium, chloride and bicarbonate rises, while the levels of phosphate and magnesium fall.
Flow rate in salivary glands according to individual constituents
Substances whose concentration increases as the flow rate increases:
• total protein, amylase, sodium, bicarbonateSubstances whose concentration decreases with the increase in flow rate:
• phosphate, urea, aminoacid, uric acid, serum, albumin
Substances whose concentration does not change with change in flow rate:
• potassium, fluorideSubstances whose concentration decreases at first but increase as flow rate increases:
• Chlorine, calcium, protein bound carbohydrates
Differential • In unstimulated whole saliva, the parotid gland contributes only
about 10%• stimulated whole saliva contains lower levels of calciumCircadian rhythm• The levels of calcium and phosphate ions are low in early
morning. Nature of stimulus • salt stimulates higher protein content. • sugar stimuli give rise to a high amylase content in saliva. Diet • Change in phosphate and urea conc. induced by dietary
alterations may be reflected in the saliva. Duration of stimulus
Salivary function can be organized into
Mastication and deglutition Taste
Facilitation of speech Buffering action
Buffering action• bicarbonate , phosphate and amphoteric proteins: the salivary
ph is usually maintained alkaline. • If the salivary ph falls from alkaline to acidic certain
constituents of saliva get precipitated -tartar - removing calcium from the tooth - caries.
Mastication and deglutition• This helps to convert food into a soft bolus which is coated
with a layer of mucous which acts as a lubricant and facilitates swallowing (deglutition)
Taste• has to be in solution. • Saliva provides the water for this purpose and helps in the
appreciation of taste.
Starch digestion• This is the only digestive function of saliva and is
due to ptyalin, which is a weak amylolytic enzyme
Boiled starch
Soluble starch
Erythrodextrin and maltose
Achrodextrin and maltose
Isomaltose and maltose (Maltase converts maltose into glucose)
Facilitation of speech• Saliva lubricates the oral cavity of proper activation
of speechExcretory function• Helps in excreting certain heavy metals like lead
and iodineMaintenance of the tooth integrity Saliva is supersaturated with calcium and phosphate
ions that provides minerals for• post eruptive maturation.• to counteract tooth dissolution by saliva (solubility
product principle)• forms a film of glycoprotein on the teeth (the
pellicle) that may act as a diffusion barrier
Antibacterial factors: that influence bacteria.
Specific
Immunoglobulins
aggregate specific bacteria
Non-specific
Lactoferrin
Lysozymes
Sialoperoxidase
Histidine
Role in oral disease
The role of saliva in oral disease is most apparent when salivary flow is markedly reduced• Pellicle and plaque deposition• Plaque mineralisation to form calculus• Dental caries
Pellicle and plaque deposition• It is partly cellular, fundamentally bacterial, and partly
acellular, from bacterial, salivary and dietary sources.
It initiates plaque deposition by pellicle formation (or cuticle) which occurs in stages
• Bathing of tooth surfaces by salivary fluid, which contains numerous protein constituents
• Selective adsorption of certain negatively and positively charged glycoproteins (electrostatic attraction of charged molecules is a factor)
• Loss of solubility of the adsorbed proteins by surface denaturation and acid precipitation
• Alteration of the glycoproteins by enzymes from bacteria and the oral secretions
pellicle formation ( made up of salivary proteins and other macromolecules)
The amino-terminal segment of Proline-rich proteins adheres to the tooth, leaving the carboxy-terminal region free to bind to the
bacteria.
saliva continues to provide agglutinating substances to the intercellular matrix and bacterial intercellular adhesion results.
Secondary colonization. Salivary proteins and carbohydrates serve as a substrate for metabolic activity of the bacteria.
Salivary urea and ammonia have a profound effect on bacterial activity and final plaque ph
Plaque mineralization and calculus formation
• Salivary calcium, phosphorus, magnesium, sodium, and potassium become part of the gel like interstices of the plaque and influence mineralization.
• Esterase, pyrophosphatase and possibly acid phosphatase may play a role in plaque mineralization
• Persons who are heavy calculus formers have higher levels of salivary glycoproteins than non-calculus formers.
Dental caries
Saliva can affect caries in five general ways• To mechanically cleanse and thus lessen plaque
accumulation• To reduce enamel solubility by plaque modification
through calcium, phosphate and fluoride• To buffer and neutralize the acids either produced by
cariogenic organisms or introduced directly through diet
• By direct anti bacterial activity• By aggregation or clumping bacteria and reducing
adherence to tooth surface
SALIVA AS A DIAGNOSTIC TOOL
Analysis of saliva may be useful for the diagnosis of
• hereditary disorders • autoimmune diseases • malignant and endocrinal disorders• assessment of therapeutic levels of drugs• monitoring of illicit drug use
Collection of saliva
Aspects to be considered to collect saliva
Whether resting or stimulated saliva will be detected, and if stimulated, how will it be stimulated?
The amount of saliva needed to complete the analysis
Pre-treatment of saliva before assaying and storage until assay.
If the patient may be taking medication or have a disease causing dry mouth
Whether quantitative or qualitative assays will be seen on the specimens
The main methods of whole saliva collection
Draining
Spitting
Suction
absorbent
methods
In it preweighed sponge is placed in the pt’s mouth for a set amount of time. After collection the sponge is weighed again and the volume of saliva is determined.
It requires the pt. to allow saliva to flow from the mouth into a pre weighed test tube or graduated cylinder for a time period.
Pt. allows the saliva to accumulate in the mouth and then expectorates into a pre weighed graduated cylinder usually every 60 sec for 2 to 5 min It uses an saliva ejector to draw saliva from the mouth into a test tube for defined time period.
Commercially available kits are Sialometer, Salivette, Omnisal, Orasure are used for collection of saliva.
Paper indicator strips to measure the pH of saliva.
Strip test to measure the buffer capacity of saliva
Dip slide test for oral bacteria. Lab on chip Oral fluid
nanosensor test
Testing of saliva
Advantages
• Can be collected non invasively• more accurate reflection of the active hormone in the
body specially steroid hormones• can be collected with devices that will be stable at
room temperature for extended periods• the health hazards associated with blood collection
such as cross contamination among patient do not apply to saliva
• secretory leucocyte protease inhibitor (SLPI) may be another factor contributing to the safety of saliva as a diagnostic specimen. SLPI expresses anti virus activity against free HIV-1 and lymphocyte derived tumor cell lines.
Disadvantages • Direct spitting into a tube or absorption in cotton balls
performs most saliva collections. samples not sterile and subjected to bacterial degradation over time
• Interpretation of saliva assays is still difficult although diurnal and monthly patterns generally parallel serum values
• Polar hormones such as thyroxin and the peptide hormones are subjected to variations by flow rate, so reliable levels cannot be obtained in saliva
• Proficiency testing programmes are not yet available for saliva, which makes validation of laboratory tests for certified laboratories difficult.
Clinical problems in which saliva contributes to diagnosis.
• Digitalis toxicity.• Stomatitis in cancer chemotherapy• Immuno deficiency of secretory IgA• Cigarette usages• Dietary nitrates, nitrites and gastric cancer• Ovulation time
Salivary assays in diagnosis
Sialadenitis
• Raised Na+,K+,Ca2+ and PO4-levels
Radiation damage
• Raised Na+,Ca2+,Mg2+ and Cl-levels
Sjogren’s syndrome• Raised Na+,Cl-and PO4
- in parotid gland saliva• Raise total protein and 2-microglobulin levels in parotid
gland salivaCystic fibrosis• Raised Na+,K+,Ca2+ and PO4
-levels.• Raised total proteins ,amylase ,lysozyme in
submandibular gland saliva and glycoproteins in parotid gland saliva .
The findings of Mandel (1980) include the following
Alcoholic cirrhosis• Raised K+ levels• Raised total protein and amylase in parotid gland saliva
Hyperparathyroidism• Raised Ca2+ levels • Raised total protein
Diabetes mellitus• Raised Ca2+ levels• Raised total protein, IgA, IgG, IgM, and raised glucose levels
Chronic pancreatitis• Depressed HCO3
-levels Psychiatric illness (not other wise specified)
• Possibly raised Na+ levelsDigitalis intoxication
• Raised Na+ and K+levelsSarcoidosis
• Depressed amylase and lysozyme levels
Drug monitoring
• Drug levels in saliva reflect the free non protein bound portion in plasma
• therapeutic drug monitoring is most effectively used when the saliva to plasma concentration ratio is constant
The determination of drugs in saliva depends on their• concentration in the blood • diffusion capacity• liposolubility and molecular size. Examplesanti convulsant drugs such as phenytoin, primidone, ethosuximide, carbamazepinetheophylline monitoring for asthmatic children salivary lithium in manic depressive patienthigh correlation between ethanol concentrations in saliva and in
serum.
Screening for antiviral and viral antigens
complete concordance between salivary and
serum finding for HIV positive peoplethe proportion of specific to total
immunoglobulins is similar in the saliva and serum of each individuals
Hormones monitoring
• the liposoluble hormones with lower molecular weights can be detected reliably (Kaufman E, 2002).
• The steroid hormones assayed in saliva includes cortisol, testosterone, 5α dihydro testosterone, 17 beta hydroxy progesterone, progesterone, 17beta estradiol, sterol, estrone.
• estriol measurement during pregnancy for detecting fetal growth retardation and the estriol progesterone ratios for preterm labor.
• significant correlation between salivary and plasma insulin and melatonin
• Higher salivary cortisol levels detected in severe periodontitis, a high financial strain, and high emotion-focused coping(Genco et al. 1998).
Application of salivary analysis of medicine inorganic ions
• thiocyanate ion excellent indicator of smokers • High levels of nitrate in the saliva associated with
carcinoma of the digestive tract
Saliva for periodontal diagnosis
• Probing depth• Clinical attachment level• Bleeding on probing (BOP) • Plaque index (PI) • Radiographic loss of alveolar bone (Polson & Goodson
1985) • Monitoring of the microbial infection (Listgarten 1992) • Analysis of the host response in GCF (Lamster 1997)• Genetic analysis (Kornman 1997)
information primarily about disease severity, and are not useful measures of disease activity.
Limitations of traditional methods
• Insufficient for determining site of active disease
• Insufficient for quantitative measurement of response to therapy
• Insufficient for measuring susceptibility to future disease progression.
• Time consuming• Subject to measurement error
Why Saliva
• Contains biomarkers for unique physiological aspects of periodontal/peri-implant disease.
• Quantitative changes in the biomarkers can identify patients with enhanced disease susceptibility
• Identify sites with active disease.• Identifying sites that will have active disease in
future.• Simple and non-invasive method of collection
Proposed markers for disease include• proteins of host origin (i.e. enzymes,
immunoglobulins)• phenotypic markers (epithelial keratins)• host cells, hormones (cortisol)• bacteria and bacterial products• volatile compounds and ions (Mandel 1991)
Markers affecting the dental biofilm
marker Relationship with periodontal disease
periodontal disease
Specific ImmunoglobinsIgA,IgM,IgG
Interfere in adherence and bacterial metabolism, increased conc. in saliva of periodontal patients
Chronic and Aggressive
Non specific
Mucin Interfere with colonization of Aa Aggressive
Lysozyme Regulates biofilm accumulation ChronicLactoferrin Inhibits microbial growth,
increased correlation with AaAggressive
Histatin Neutralizes LPs and enzymes known to affect periodontium
Chronic and Aggressive
Peroxidase Interfere with biofilm accumulation, increased correlation with periodontal patients
Chronic
Systemic C reactive protein Increased conc found in serum and saliva of periodontal patients
Chronic and Aggressive
Specific markers:• Ig are important specific defense factors of saliva.• the preponderant immunoglobulin found is IgA. • Major and minor salivary glands contribute all of
the secretory IgA (sIgA) and lesser amounts of IgG and IgM.
sIgA • forms specific immune defense mechanism in
saliva • parotid gland responsible for the majority of the IgA
(Nair 1986). • important in maintaining homeostasis in the oral
cavity. • control the oral micro biota by reducing the
adherence of bacterial cells to the oral mucosa and teeth (Morcotte and Lovice.1998)
• two subclasses IgA1 and IgA2. • sIgA levels, undetectable in newborns, increase
progressively and reach adult values in stimulated saliva by 2–4 years of age, and in unstimulated saliva by 6–8 years of age (Burgio1980).
IgGpresent in low concentration.concentration increases during inflammation of
the periodontal tissues (Wilton,1989, Shapiro, 1979).
Immunoglobulin isotypes in saliva• Basu (1976) increased IgG concentration in saliva
and decreased IgA concentration before periodontal therapy as compared to post-treatment levels. Salivary levels of IgG and IgA found to be higher in a group of NIDDM patients with periodontitis.
• Guven (1982) positive correlation between the severity of inflammation and IgA concentration.
• Sandholm (1984) Salivary IgA, IgG, and IgM levels were higher in the JP patients
• Harding (1980) found decreased levels of IgA and IgG, but elevated sIgA concentration, in saliva of the patients with NUG.
Specific immunoglobulins in saliva
• Eggert (1987) saliva from treated periodontitis patients had higher IgA and IgG for periodontal pathogens (P.g and T.d).
• Sandholm (1987) The level of salivary IgG antibody to A.a was significantly elevated in 55% of the patients with untreated JP and in 28% of the treated patients and 57% in AP.
• Schenk(1993)patients with a low mean number of bleeding gingival units demonstrated significantly higher levels of salivary IgA antibody reactive with S.mutans, A.a, and Eubacterium.
Non specific markers:
Mucins• glycoproteins produced by salivary glands• mucins(MG1 and MG2) • cytoprotection• Lubrication• protection against dehydration • maintenance of viscoelasticity in secretions.• The mucin MG2 affects the aggregation and
adherence of bacteria (A.a) and decreased conc of MG2 in saliva may increase colonization with Aa.
EnzymesEnzymes found in whole saliva originate from three main sources:
(1)the actual salivary secretions per se(2)the GCF, stemming from PMNs and tissue
degradation(3)bacterial cells from dental biofilms and
mucosal surfaces. (Chauncey 1961).
Ingman et al. 1993 enzyme activity in whole saliva appears to reflect the severity of periodontal disease
• salivary enzymes reported in increased conc in periodontal disease are hyaluronidase, lipase, β-glucuronidase and chondritin sulfatase, amino acid decarboxylases, catalase, peroxidase and collagenase.
• proteolytic enzymes in the saliva contribute to the initiation and progression of periodontal disease
• saliva contains antiproteases that inhibit cysteine proteases such as cathepsins, antileucoproteases that inhibit elastase and (TIMP) to inhibit the activity of collagen – degrading enzyme
• Nakamura and Slots (1983) noted higher enzyme activity in AP patients for alkaline phosphatase, esterase, β-glucuronidase, β-glucosidase, and cysteine aminopeptidases in JP.
• Gibert et al. relationship between attachment loss in the periodontal group and a drop in ALP activity in serum.
• Zambon et al. (1985) reduced salivary levels of caprylate esteraselipase, leucine, valine and cysteine aminopeptidases, trypsin, b-galactosidase, b glucuronidase and b-glucosidasedecrease in proportions of subgingival black pigmented bacteroides and motile organisms noted after treatment, suggesting them as potential source.
Lysozyme
• hydrolytic enzyme cleaves the linkage between the glycopeptide (muramic acid) – found in the cell wall of certain bacteria’s.
• cause lysis of bacterial cells by interacting with monovalent anions and with proteases found in saliva. leads to destabilization of the cell membrane as a result of the activation and degranulation of endogenous bacterial autolysins.
• Lysozyme targets Veillonella species and A.a.• It probably repels certain transient bacterial invaders of the
mouth (Pullock et al 1985)Jalil et al. (1993) patients with low levels in saliva are
more susceptible to plaque accumulation which is considered as risk factor for periodontal disease.
Lactoperioxidase
• Peroxidase activity is derived from 2 sources.– Human lactoperoxidase (HS-LPO) is synthesized
and secreted by salivary glands.– Myeloperoxidase (MPO) is found in PMN leucocytes
& migrate in to oral cavity by gingival crevice.
Salivary peroxide
• removes toxic hydrogen peroxide produced by oral microorganisms and reduces acid production in the dental biofilm, thereby decreasing plaque accumulation.
• Guven et al. (1996)higher activity in the diabetes patients, serve as a marker for gingival inflammation
The lactoperoxidase-thiocynate system in salivacatalyses the formation of bactericidal compounds e.g. hypothiocyanate, by peroxidation of thiocyanatebactericidal to certain strains of lactobacillus and streptococcus prevents the accumulation of lysine and glutamic acid, both of which are essential for bacterial growth.
Myeloperoxidase• released by leukocytes and is bactericidal for
Actinobacillus• inhibits the attachment of Actinomyces to hydroxyapatite.• Increased MPO activity was found in saliva of RPP and AP.
Histatin • salivary protein with antimicrobial properties • secreted from parotid and submandibular glands. • neutralizes the LPS located in membrane of gram
negative bacteria. • inhibitor of host and bacterial enzymes involved
in the destruction of the periodontium• involved in the inhibition of release of histamine.
Other proteins
Cysteine proteinases • proteolytic enzymes originated from pathogenic
bacteria, inflammatory cells, osteoclasts and fibroblasts.
• collagenolytic activity, which may cause tissue destruction. (Cutler et al. 1995).
• Cystatins are physiological inhibitors of cysteine proteinases
• Henskens,1996 After periodontal treatment, total cystatin and cystatin C concentration decreased to control levels.
• Evren, 2008 total saliva cystatin C levels were higher in health
Lactoferrin •is a iron binding glycoprotein produced by salivary glands•inhibits microbial growth by sequestering iron from the environment thus depriving bacteria. •strongly upregulated in mucosal secretions during gingival inflammation and is detected at high conc. in saliva of patients with periodontal disease.•effective against Actinobacillus species (Arnold, 1980)
Platelet activating factor (PAF)• a potent phospholipid mediator of inflammation• Garito,1995 A significant positive correlation was
observed between the level of PAF in saliva and measures of periodontal inflammation
Serine proteinases
Elastase
• Produced by PMN leukocytes.• Elastase is held in inactive state within cell, by
inhibitors (α1proteinase inhibitor and α2 macroglobulin).
• Elastase is able to degrade proteoglycans and can also activate latent collagenase
• Nieminen,1993 levels correlate with bleeding sites
• significantly higher in patients group from gingivitis to periodontitis.
• Ingman,1993 higher in untreated AP patients.
Fibronectin • is a glycoprotein, promotes selective adhesion
and colonization of certain bacterial species, while inhibiting others.
• Gibbons et al. (1986) Higher proteolytic activity observed in saliva collected immediately after awakening, and the levels of enzyme activity correlated with the state of cleanliness.
• Lamberts et al. (1989) salivary fibronectin levels (used as an index of GCF flow into the oral cavity), did not differ significantly between individuals with or without periodontal disease.
Defensins• These are antimicrobial peptides which are
induced in epithelial tissues upon inflammation.• These peptides are part of the innate immune
system, have broad spectrum antibacterial and antifungal activity.
Calprotectin• Main source of salivary calprotectin are GCF and
oral surface epithelium.• Salivary calprotectin levels are raised in patients
with oral candidiasis.
Epidermal growth factor (EGF) • involved in oral wound healing and stimulates
epithelial cells. • Oxford(1998) found a transient increase in salivary
EGF levels in response to periodontal surgery.
Vascular endothelial growth factor (VEGF)
a multifunctional angiogenic cytokine important in inflammation and wound healing. Taichman 1998 Higher levels of VEGF were detected
in whole saliva from periodontitis patients
Epithelial keratins
• Epithelial cells from the lining of the oral cavity found in saliva
• McLaughlin (1996) higher conc of keratin in GCF at sites exhibiting gingivitis and periodontitis
• not observed in saliva.
Inflammatory cells• leukocytes in saliva varies from person to person,
and vary for an individual during the course of the day.
• Klinkhammer (1968) standardized collection and counting of leukocytes in saliva
• developed the orogranulocytic migratory rate (OMR). The OMR was found to be correlated with gingival index
• Raeste(1978) the OMR reflects the presence of oral inflammation
Salivary ionsCalcium(Ca) • A high concentration of salivary Ca was correlated
with good dental health • no relationship detected with periodontal bone
loss as measured from radiographs (Sewon & Makela 1990).
• Sewon et al. 1990 salivary Ca, and the saliva Ca to phosphate ratio were higher in periodontitis- affected subjects
Volatiles• Salivary volatiles suggested as possible
diagnostic markers and contributory factors in periodontal disease.
• primarily hydrogen sulfide and methylmercaptan(Rosenberg & McCulloch 1992).
• pyridine and picolines were found only in subjects with moderate to severe periodontitis (Kostelc et al. 1980).
Vitaminsthiamine, riboflavin, niacin, pyridoxine, pantothenic
acid, biotin, folic acid and vitamin C and B12, and vitamin K
Coagulation factorscoagulation factors VIII, IX, X, plasma
thromboplastin antecedent (PTA) and the Hageman factors
hasten blood coagulation and protect the wounds from bacterial invasion.
Bacteria
• De Jong,1984 serve as a growth medium for oral Streptococus species and A. viscous.
• Bowden ,1997 number of bacterial cells for a in unstimulated saliva may show active growth in plaque.
Oral microbial rinse test (Oratest) • described by Rosenberg,1989• for estimating oral microbial levels. • provides a reliable estimate of gingival
inflammation
• Asikainen,1991 A.a when recovered from subgingival sites was also found in 69.9% and 35.9% of the samples of stimulated and unstimulated saliva.
• Umeda,1998 bacterial detection in whole saliva had a sensitivity of 42.6% for A. a, 68.4% for T.f, 97.8% for P. g, and 88.7% for P. i. The specificity of bacterial detection for these microorganisms in saliva was 88.5%, 71.2%, 77.9% and 77.1%.
• Von Troil-Linden,1995 salivary levels of the periodontal pathogens reflected the periodontal status.
• Christoph A,2009 Elevated salivary MMP-8 and T. denticola biofilm levels in periodontal disease
Systemic markers related to periodontal infection
C-reactive protein • released during the acute phase of an
inflammatory response• produced by liver and stimulated by
circulating cytokines such as TNFa,IL1 • may reach saliva via gcf or salivary glands. • High levels associated with chronic and
aggressive periodontal diseases • measurable from saliva using lab on chip
method.
Markers of periodontal soft tissue inflammation
• During the initiation of an inflammatory response PGE2,IL1β,IL6,TNFa are released from the cells of junctional epithelium and from ct fibroblasts, macrophages and pmn leckocytes.
• Subsequently enzymes such as MMP8,9,13 are produced by pmn and osteoclasts leading to degradation of ct collagen and alveolar bone.
• Bradon,2008 increase in TNF in periodontitis
Markers of alveolar bone loss
MMP Host proteinases responsible for both tissue degradation
and remodeling. MMP-8 most prevalent in diseased tissues and gcffound in elevated level in saliva from patients with
periodontal diseaseelevated in peri-implant sulcular fluid in peri-imlantitis
lesions.Integrated Microfluidic Platform for Oral Diagnostics
(IMPOD) mean MMP-8 concentration in the saliva of the periodontally healthy individuals was 10-fold less than that of the periodontally diseased patients Herr AE,2007
MMP-9,is produced by neutrophils and degrades collagen, intercellular ground substance.
2 fold increase found in patients with progressive attachment loss.
Makela et al. (1994) higher concentration of MMP-9 in whole saliva of periodontitis patients
MMP-13 has been implicated in peri-implantitisfound in elevated level corresponding to the vertical bone
loss around loosening dental implants.Hayakawa et al. (1994) reported lower conc of TIMP-1 in whole
saliva of patients with periodontal disease with higher collagenase activity
Increased TIMP-1 and decreased collagenase activity observed after initial therapy
Uitto et al. (1990) Collagenase originated from PMNs entering the oral
cavity through the gingival sulcus. activity was in higher and active form in the
periodontitis patients. Very little collagenase activity detected in saliva of
edentulous subjects.
Pyridinoline Cross-Linked Carboxyterminal Telopeptide of Type I Collagen (ICTP)
• to detect bone resorption in periodontitis and periimplantitis
• Palys et al. strongly correlated with whole subject levels of several periodontal pathogens including T.f, P. g, P. i, and T. d.
• Golub et al. 70% reduction in GCF ICTP levels after treatment.
Osteonectin polypeptide that binds strongly to hydroxyapatite
and other extracellular matrix proteins including collagens.
has been implicated in the early phases of tissue mineralization.
Osteopontin• highly concentrated at sites where osteoclasts are attached to
the underlying mineral surface• conc increased proportionally with the progression of disease
CONCLUSIONThe knowledge of normal salivary composition, flow and function is extremely important on a
daily basis when treating the patients.Recognition should be given to saliva for the many
contribution it makes to the preservation and maintenance of oral and systemic health
Saliva as a diagnostic specimen can give not only the same information as serum testing but also
additional or new information that cannot be obtained from serum.
• The device performs rapid microfluidic chip-based immunoassays (<3–10 min) with low sample volume requirements (10 μL) and appreciable sensitivity (nM–pM). Our microfluidic method facilitates hands-free saliva analysis by integrating sample pretreatment (filtering, enrichment, mixing) with electrophoretic immunoassays to quickly measure analyte concentrations in minimally pretreated saliva samples. The microfluidic chip has been integrated with miniaturized electronics, optical elements, such as diode lasers, fluid-handling components, and data acquisition software to develop a portable, self-contained device.