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.