1. Introduction to the Salivary Glands Dennis E. Lopatin, Ph.D Dept. of Biologic & Materials Sciences

2. Even Science Fiction Has Discovered the Importance of Saliva!

3. Saliva in Oral Health: Protective Functions Lubrication Lubrication Mucins, proline-rich glycoproteins, water Mucins, proline-rich glycoproteins, water Antimicrobial Antimicrobial Amylase, complement, defensins, lysozyme, lactoferrin, lactoperoxidase, mucins, cystatins, proline-rich glycoproteins, secretory IgA, secretory leukocyte protease inhibitor, statherin, thrombospondin Amylase, complement, defensins, lysozyme, lactoferrin, lactoperoxidase, mucins, cystatins, proline-rich glycoproteins, secretory IgA, secretory leukocyte protease inhibitor, statherin, thrombospondin

4. Saliva in Oral Health: Protective Functions (cont’d) Growth Factors Growth Factors Epidermal growth factor (EGF), transforming growth factor-alpha (TGF-  ), transforming growth factor- alpha (TGF-  ), fibroblast growth factor (FGF), insulin-like growth factor (IGF-I & IGF-II), nerve growth factor (NGF) Epidermal growth factor (EGF), transforming growth factor-alpha (TGF-  ), transforming growth factor- alpha (TGF-  ), fibroblast growth factor (FGF), insulin-like growth factor (IGF-I & IGF-II), nerve growth factor (NGF) Mucosal Integrity Mucosal Integrity Mucins, electrolytes, water Mucins, electrolytes, water

5. Saliva in Oral Health: Protective Functions (cont’d) Lavage/cleansing Lavage/cleansing Water Water Buffering Buffering Bicarbonate, phosphate ions, proteins Bicarbonate, phosphate ions, proteins Remineralization Remineralization Calcium, phosphate, statherin, anionic proline- rich proteins Calcium, phosphate, statherin, anionic proline- rich proteins

6. Saliva in Oral Health: Food and Speech-related functions Food Preparation Food Preparation Water, mucins Water, mucins Digestion Digestion Amylases, lipase, ribonuclease, proteases, water mucins Amylases, lipase, ribonuclease, proteases, water mucins Taste Taste Water, gustin Water, gustin Speech Speech Water, mucins Water, mucins

7. Salivary Gland Anatomy Parotid Gland Parotid Gland Submandibular Gland Submandibular Gland Sublingual Gland Sublingual Gland Minor Glands Minor Glands

8. Major Salivary Glands Parotid Glands Submandibular Glands

9. Structure of the Ducts

10. Salivary Constituents Water & electrolytes Water & electrolytes Proteins Proteins Non-electrolytes Non-electrolytes Non-glandular proteins Non-glandular proteins

11. Components of Whole Saliva Salivary glands Salivary glands Water, proteins, electrolytes, small organic molecules Water, proteins, electrolytes, small organic molecules Blood and blood derivatives Blood and blood derivatives Intraoral bleeding, gingival crevicular fluid (serum & inflammatory cells) Intraoral bleeding, gingival crevicular fluid (serum & inflammatory cells) Extrinsic substances Extrinsic substances Food debris, toothpaste and mouth rinse Food debris, toothpaste and mouth rinse Other fluids Other fluids Bronchial and nasal secretions Bronchial and nasal secretions Lining cells Lining cells Epithelial keratins Epithelial keratins Microbiota Microbiota

12. Factors Contributing to Saliva Content Normal Human Variability Normal Human Variability Unstimulated vs. stimulated saliva Unstimulated vs. stimulated saliva Aging Aging Medications Medications Disease Disease Circadian rhythms Circadian rhythms Objective vs. subjective determinations Objective vs. subjective determinations

13. Human Variations Large range defines “normality” Large range defines “normality” A little goes a long way A little goes a long way Changes over time Changes over time

14. Normal Variations in Saliva Output

15. Unstimulated vs. Stimulated Saliva Unstimulated Unstimulated Basal production Basal production Confers most protection Confers most protection Importance of minor and submandibular output Importance of minor and submandibular output Low output during sleeping hours Low output during sleeping hours Stimulated Stimulated Protection during mastication Protection during mastication Assists in deglutition Assists in deglutition Importance of parotid output Importance of parotid output

16. Circadian Rhythm

17. Effects of Aging on Saliva Quantity Quantity No significant changes in major secretions No significant changes in major secretions No significant changes in minor secretions No significant changes in minor secretions Quality Quality No general changes No general changes

18. Stimulated Parotid Flow Over Time

19. Assessment of Salivary Flow Objective measures (Clinical tests) Objective measures (Clinical tests) Major gland secretions Major gland secretions Minor gland secretions Minor gland secretions Whole saliva Whole saliva Subjective measures (Patient perceptions) Subjective measures (Patient perceptions) Xerostomia (Do you have a dry mouth?) Xerostomia (Do you have a dry mouth?) Questionnaires (Dry mouth, trouble swallowing?) Questionnaires (Dry mouth, trouble swallowing?) Thirst (Are you often thirsty?) Thirst (Are you often thirsty?)

20. Factors Affecting Salivary Production Local diseases Local diseases Systemic diseases Systemic diseases Medications Medications Head and neck radiation Head and neck radiation Chemotherapy Chemotherapy

21. Local Factors Affecting Saliva Obstructive Diseases Obstructive Diseases Neoplasms, mucous plugs, calculi Neoplasms, mucous plugs, calculi Inflammatory Diseases Inflammatory Diseases Acute viral sialadenitis (myxovirus of mumps) Acute viral sialadenitis (myxovirus of mumps) Acute suppurative bacterial sialadenitis Acute suppurative bacterial sialadenitis Chronic recurrent sialadenitis Chronic recurrent sialadenitis Allergic parotiditis Allergic parotiditis Head and Neck Irradiation Head and Neck Irradiation Diet Diet

22. Sialadenitis: Inflammation of the Salivary Gland

23. Bacterial Parotiditis: Inflammation of the Parotid Gland

24. Medications Influence Saliva Anti-cholinergics Anti-cholinergics Anti-histamines Anti-histamines Anti-depressants, antipsychotics Anti-depressants, antipsychotics Sedative and hypnotic agents Sedative and hypnotic agents Anti-hypertensives Anti-hypertensives Anti-Parkinson drugs Anti-Parkinson drugs

25. Oral Side-Effects of Prescribed Drugs RG Smith & AP Burtner, 1994 Xerostomia - Dry mouth Dysgeusia - Impairment of taste Stomatitis - Inflammation of oral mucous membranes Glossitis - Inflammation of tongue

26. Systemic Diseases That Influence Saliva Sjögren’s syndrome Sjögren’s syndrome Sarcoidosis (a systemic granulomatous disease, especially of lungs, but affecting many other organs, including parotid glands) Sarcoidosis (a systemic granulomatous disease, especially of lungs, but affecting many other organs, including parotid glands) Cystic fibrosis Cystic fibrosis Diabetes Diabetes Alzheimer’s disease Alzheimer’s disease AIDS AIDS Dehydration Dehydration

27. Submandibular Duct Obstruction 2° to Infection

28. Head and Neck Radiation Parotid vs. Submandibular Parotid vs. Submandibular Dysfunction is dose- and field-dependent Dysfunction is dose- and field-dependent Threshold of permanent destruction: 2100- 4000 cGy Threshold of permanent destruction: 2100- 4000 cGy

29. Salivary Flow Following Radiation Therapy

30. Chemotherapy Alters salivary constituents Alters salivary constituents Normal function returns Normal function returns Bone marrow transplantation: graft vs. host disease Bone marrow transplantation: graft vs. host disease

31. Salivary Dysfunction and Oral Sequelae Caries Caries Mucositis Mucositis Oral ulceration Oral ulceration Taste Taste Swallowing Swallowing Dentures Dentures Infections Infections

32. Salivary Dysfunction and Oral Sequelae: Caries Incipient decay Incipient decay Recurrent decay Recurrent decay Root vs. coronal decay Root vs. coronal decay

33. Extensive Caries in a post-radiation patient

34. Caries in a xerostomic individual Glossitis Mucositis Caries

35. Salivary Dysfunction and Oral Sequelae: Mucositis Pain Pain Infections Infections Dysphagia Dysphagia Impaired nutrition Impaired nutrition Dehydration Dehydration

36. Mucositis

37. Salivary Dysfunction and Oral Sequelae: Oral Ulceration Wound healing Wound healing Lichen planus Lichen planus Recurrent aphthous ulcers Recurrent aphthous ulcers Pain Pain Secondary infection (Candidiasis) Secondary infection (Candidiasis)

38. Xerostomia: Dry Fissured Tongue

39. Salivary Dysfunction and Oral Sequelae: Taste Reduced enjoyment of eating Reduced enjoyment of eating Altered supra-threshold and threshold performance Altered supra-threshold and threshold performance Sucrose, sodium chloride Sucrose, sodium chloride Citric acid, quinine sulfate Citric acid, quinine sulfate

40. Salivary Dysfunction and Oral Sequelae: Swallowing Subjective complaints of dysphagia Subjective complaints of dysphagia Increased duration in oral swallow times Increased duration in oral swallow times Dry swallows Dry swallows Wet swallows Wet swallows

41. Salivary Dysfunction and Oral Sequelae: Dentures Decreased retention and stability Decreased retention and stability Increased complaints Increased complaints Greater likelihood for Candida infections Greater likelihood for Candida infections

42. Salivary Dysfunction and Oral Sequelae: Infections Candidiasis Candidiasis Caries Caries Gingivitis Gingivitis Viral infections Viral infections Bacteremias Bacteremias Aspiration pneumonia Aspiration pneumonia

43. Candida 7th Week Following Tonsil Radiation Treatment

44. Candida/Denture Stomatitis

45. Saliva and Oral health: Conclusions Saliva in health Saliva in health Saliva in disease Saliva in disease Prevention of disease Prevention of disease Treatment of disease Treatment of disease

46. Saliva deficient