Saliva and Oral Health Part 1 Maintaining Oral

Saliva and Oral Health Part 1 Maintaining Oral Health Preventing Dental Disease A CPD Module for Dental Professionals 1 Hour Verifiable CPD

Saliva and Oral Health Overview Saliva - Production - Composition - Function Biofilm New Insights - Composition - Activity - Fluoride resistance Chewing Gum and Saliva - Flow rate - Clearance - Buffering Caries - Plaque p. H - Demineralisation-Remineralisation Erosion - Prevalence - Causes - Aetiology- Management Clinical Assessment - Examination - Chair side Tests - Recommendations (CRA BEWE) www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Saliva Major Salivary Glands - Parotid - Sublingual - Submandibular Minor Salivary Glands - Lips, tongue, cheek, palate Saliva Secretion - Parotid Serous saliva - Sublingual Mucous saliva - Submandibular Mixed saliva www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Saliva Mixed Salivary Acinus Salivary Acini End piece Serous Cell Basic secretory units of salivary glands. Serous Cells - Stain darkly. - Wedge shaped with round nucleus. Intercalated duct -Tight spherical formation. Serous Demilune Basement membrane Mucous Cells - Stain lightly. Mucous Cell © - Tubular shaped with flattened nucleus. - Open formation larger central lumen. Re ev es 20 13 Salivary duct (secretory) www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Saliva Histology varies by gland type Serous Acini Mucous Acini Mixed Acini Parotid Sublingual www. wrigleyoralhealthcare. co. uk Submandibular

Saliva and Oral Health Saliva Formation Stage One: Primary Saliva Local Vasculature ©Reeves 2013 ACINI- water and ions derived from plasma Saliva formed in acini flows down DUCTS to empty into the oral cavity www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Saliva Formation Stage Two: Final Saliva Proteins Na+& Cl- K+ Hypotonic Concentration Gradient Final Saliva ©Reeves 2013 Water and electrolytes Isotonic H 2 O Primary Saliva www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Saliva The Composition of Saliva 99. 4 % Water 0. 2 % Soluble inorganic substances: sodium, potassium, calcium, chloride, bicarbonate, phosphate, fluoride 0. 3% Soluble organic substances: proteins, digestive enzyme (amylase), mucins, antibodies (immunoglobulins), urea, peroxidases, antioxidant enzymes (SOD catalase gluathione) 0. 1 % insoluble substances www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Saliva The Composition of Saliva Water and Electrolytes Composition Unstimulated Stimulated Water 99. 55% 99. 53% Solids 0. 45% 0. 47% Flow Rate(ml/min) 0. 32 0. 23 2. 08 0. 84 p. H 7. 04 0. 28 7. 61 0. 17 5. 76 3. 43 20. 67 11. 74 Potassium 19. 47 2. 18 13. 62 2. 70 Bicarbonate 5. 47 2. 46 16. 03 5. 06 Phosphate 5. 69 1. 91 2. 70 0. 55 Chloride 16. 40 ± 2. 08 18. 09 7. 38 Calcium 1. 32 ± 0. 24 1. 47 ± 0. 35 Sodium Na+& Cl. K+ (mmol/L) Saliva and Oral Health Edgar M, Dawes C, O’Mullane D Eds. 4 th Ed 2012 www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Saliva The Composition of Saliva Water and Electrolytes Na+& Cl. K+ Dawes, C. JADA 2008; 139: suppl 2: 18 S-24 S www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Saliva Unstimulated Stimulated Water 99. 55 % 99. 53% Solids 0. 45% 0. 47% Flow Rate 0. 32 ± 0. 23 2. 08 ± 0. 84 p. H 7. 04 ± 0. 28 7. 61 ± 0. 17 Organic Total 1630 ± 720 1350 ± 290 protein 830 ± 480 460 ± 200 MUC 5 B 440 ± 520 320 ± 330 MUC 7 317 ± 290 453 ± 390 Amylase 8. 4 ± 10. 3 5. 5 ± 4. 7 Lactoferrin 4. 93 ± 0. 61 Statherin 51. 2 ± 49. 0 60. 9 ± 53. 0 Albumin 79. 4 ± 33. 3 32. 4 ± 27. 1 Glucose 0. 20 ± 0. 24 0. 22 ± 0. 17 Lactate 3. 57 ± 1. 26 2. 65 ± 0. 92 Urea 6. 86 2. 57 ± 1. 64 Saliva and Oral Health, Edgar M. Dawes C. , O’Mullane, D. Eds. 4 th Ed, 2012 www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Saliva The Functions of Saliva Resting Saliva Oral Protection System Secretion -Submandibular - 60% -Parotid - 25% -Sublingual ~ 7 -8% - Secretion rate: 0. 3 -0. 4 mls/min -Minor glands ~ 7 -8% - Texture: Viscous (mucus) - Rich in mucins - p. H value 5. 7 -7. 1 - Functions: Coating of the teeth: salivary pellicle - Lubrication of oral mucosa Stimulated Saliva Oral Repair System Secretion -Parotid 60% -Submandibular 30% -Sublingual ~ 10% - Secretion rate: 1 -3 mls/min and minor glands - Consistency: Thin (serous) - Rich in minerals - p. H value: 7. 0 -7. 8 - Functions: Clearance, buffer system, remineralisation www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health The Multiple Functions of Saliva Anti-Vi Cystat cins al tins g n ta u is it -F : H a C Bu ral ins Mu Anandid f s l ia er es ct idas Ba ox ti- Per An Ig. A C fe an arb rin hy on g dr ic HC ase O s 3 Salivary Functions ge , am ins i D e c u as lip m Min eral g tin ue ins, es s is uc las Lu sc br Vi os ica i Mu ty E tion la St ath cins stic ity er ins Figure adapted from M. J. Levine. 1993 www. wrigleyoralhealthcare. co. uk izat Fl, P ion O 4 Ca, a Ps Co PR T M y Am onase i t s yl

Saliva and Oral Health Saliva Digestion & Taste The Major Functions of Saliva Protection Manipulation • Dissolve solids • Starch digestion • Buffer - plaque acids • Attachment - (foods) extrinsic acids (amylase) (reflux) intrinsic acids • Gustatory sensation • Facilitate chewing • Swallowing • Bolus formation • Antibacterial Saliva proteins coat enamel surface and allow specific absorption of primary colonisers Oral ecology balance • Food - Pathogen defence Saliva may act as a carbon source and select for healthy bacterial balance • Mouth clearance/rinsing Food and bacteria • Prevent demineralisation • Aid remineralisation • Hydrates mucous membrane www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Biofilm Bacterial Microcolonies Streamers Fluid Channels Flow Pellicle ©Reeves 2013 Biofilm: a well organized, cooperating community of microorganisms. - A complex community of highly organised bacterial colonies. - Each community contains a mix of microorganisms. - Arranged in micro-colonies surrounded by a protective matrix. - With a communication system of fluid channels: Quorum sensing www. wrigleyoralhealthcare. co. uk Tooth Surface

Saliva and Oral Health Biofilm 1 st Phase: immediately to approximately 4 hours Formation of aquired pellicle from salivary glycoproteins and maturation. Early colonisation from initial bacteria mainly Streptococcus strains. 2 nd Phase: 4 to 48 hours Colonisation of predilection sites, i. e. fissures, iatrogenic retention factors (restorations/overhangs/ortho brackets) and white spots. 3 rd Phase: 3 to 7 days Aerobic bacterial metabolic products compromise the hard dental tissues; anaerobic bacterial metabolic products compromise the soft tissues. (König 1987) 4 th Phase: 7 to 14 days Mature plaque biofilm is established that consists of sessile bacteria firmly attached to the hard dental tissues and planktonic (floating) bacteria. www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Biofilm co ti en d T. Quorum sensing The Formation of Biofilm la AA Fl- PG s or f T. ea Strep. oralis s C. A. na es lu uis p. sang Stre -amylase ge ti pu C. gingivalis A. oris Flresistance Late Colonizers na C. achrac Statherin ia h yt lii e ra is A. nd ii Strep . gord Strep. mitis Proline-rich protein ry a Saliva in gglutin Salivary Pellicle Enamel Surface www. wrigleyoralhealthcare. co. uk onii Sialylated mucins Early Colonizers

Saliva and Oral Health Sugar-Free Gum Salivary Flow Rate Saliva flow rates under stimulation Saliva flow (ml in 20 min) - Chewing gum increases the saliva flow rate up to 10 times. - “Empty” chewing, without flavor additive (e. g. , paraffin), only stimulates up to 5 times. Un-stimulated saliva Stimulated saliva after chewing sugarparaffin free gum - Chewing sugar-free gum with flavor additive improves flushing and accelerates the removal of soluble compounds. (Edgar 1993) www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Sugar-Free Gum Salivary Flow Rate Polyol-sweetened gum stimulates the production of saliva by two mechanisms: - Gustatory stimulation (taste buds) - Masticatory action (periodontal mechanoreceptors) (Dawes and Macpherson. 1992) www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Sugar-Free Gum Salivary Flow Rate - Salivary stimulation lasts more than 2 hours with SF gum. - Flavour and chewing increase salivary flow. Unstimulated flow rates of less than 0. 1 m. L/minute are considered evidence of hypo-salivation (Dawes, C. , et al. Arch Oral Biol 2004, 49, 665 -669. ) www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Sugar-Free Gum Salivary Flow Rate and Xerostomia* Sugar-free gum may have benefits in older and medically-compromised patients - Chewing sorbitol gum increased saliva flow rates and neutralized plaque p. H drop from sucrose in subjects with xerostomia. 1, 2 - 69% of cancer patients with xerostomia preferred chewing gum to artificial saliva 3; 60% of hemodialysis patients preferred gum to saliva substitutes. 4 - Gum chewing (12 months, 2 x/day) increased stimulated saliva flow rates in 111 frail older people. 5 - 1. 2. 3. 4. 5. 6. A 6 month study in 186 older (community-dwelling) adults showed significant improvements in plaque and gingival indices, but not saliva flow 6; self-perceived oral health status improved significantly in the gum group. Markovic N; Abelson DC; Mandel ID (1988): Gerodont. 7: 71 -75 Abelson DC, Barton J, Mandel ID (1990): J Clin Dent 2: 3 -5 Davies AN (2000): Palliat Med 14: 197 -203 Bots CP, Brand HS, et al (2005): Palliat Med 19: 202 -207 Simons D, Brailsford SR, Kidd EAM, Beighton D (2002): J Am Geriatr Soc 50: 1348 -1354 Al-Haboubi M, Zoitopoulos L, Beighton D, Gallagher JE (2012): Community Dent Oral Epidemiol 40: 415 -424 www. wrigleyoralhealthcare. co. uk * Module Two

Saliva and Oral Health Sugar-Free Gum Oral Clearance - Relies on swallowing and flow rate. Halftime(min) 15 - Higher salivary flow rate = increased clearance. 10 - Unstimulated flow rate < 0. 2 ml/min = prolonged clearance. 5 - Prolonged clearance = greater risk of caries. 0 0. 2 0. 4 0. 6 0. 8 0 1. 0 - Greater risk of acid erosion. Unstimulated Flow Rate UNSTFR(ml/min) Effect of changes in the UNSTFR on the clearance halftime of sucrose Saliva and Oral Health, Edgar M. Dawes C. , O’Mullane, D. Eds. 4 th Ed, 2012 www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Sugar-Free Gum Buffering Capacity Fast flowing saliva neutralises plaque (p. H value increases). Saliva stimulation and buffering of acids by chewing gum Chewing gum with sugar substitute Buffer capacity is the ability to neutralise acids (buffering). - The p. H value is raised due to the increased concentration of bicarbonate in stimulated saliva. (Bicarbonate increases from 5. 47 unstimulated to 16. 03 mmol/L in stimulated saliva). - Increased flow rate exposes hard tissues to low p. H for a shorter period. (Flow rate increases from 0. 32 ml/min unstimulated to 2. 08 ml/min in stimulated saliva). p. H value 10% sugar solution - Time in minutes (Stoesser 1996) www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Caries Plaque p. H Saliva stimulation from chewing gum helps to neutralise plaque acids Factors affecting plaque acids - Fermentable carbohydrates. - Oral bacteria produce: Plaque p. H - Extracellular polysaccharides in the presence of excess sucrose. - Glucans increase plaque adhesion and thickness. - Fructans produce acid metabolites. - Intracellular polysaccharide stores provide ongoing acid production in resting plaque. Time (min) Manning RH, Edgar WM (1993) Brit Dent J 174: 241 -4 www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Caries Plaque p. H Plaque buffering systems Bicarbonate diffuses from saliva and neutralises plaque acids Plaque acids diffuse out and are neutralised by bicarbonate in saliva - Bicarbonate is the most important buffering system. - Bicarbonate concentration increases with salivary flow. - Directly increases plaque p. H. Urea from saliva diffuses into plaque Ammonia increases plaque p. H - Urea from saliva is converted to ammonia by bacteria in plaque with urease activity. - Ammonia is highly alkaline and neutralises plaque p. H. Plaque bacteria convert urea to ammonia Calcium phosphate in plaque - The intrinsic buffering capacity of plaque. Increases buffering capacity in plaque - Calcium phosphate crystals in plaque dissolve in acid conditions. - Increasing buffering capacity. ©Reeves 2013 Dissolves in acid conditions www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Caries Demineralisation-Remineralisation - A dynamic equilibrium exists between demineralization and remineralisation. - A neutral p. H value promotes remineralisation. - When the p. H value is <5. 5 Demineralisation - Calcium (Ca 2+) and Phosphate H+ Low p. H (PO 43 -) are withdrawn from the dental enamel. Demineralisation Ca ++ H+ Ca++ P O 4 - F- H+ Remineralisation Increased p. H - When the p. H value is >6. 5 - Calcium (Ca 2+) and Phosphate (PO 43 -) migrate back into the dental enamel. PO 4 - H+ Ca ++ F- FCa++ PO 4 - Remineralisation www. wrigleyoralhealthcare. co. uk F- FPO 4©Reeves 2014

Saliva and Oral Health Caries Demineralisation- Remineralisation - Demineralisation shifts to remineralisation by the use of fluoridation and saliva activation. Saliva provides the medium for remineralisation. - Supersaturation of saliva with ionic Ca and Pi, can effectively help remineralise incipient caries lesions. - Fluoride inhibits demineralisation by penetrating and coating enamel crystals to prevent dissolution. - Enhancing remineralization resulting in enamel with a higher Fl content and lower acid solubility. www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Caries Demineralisation - Remineralisation At a p. H value < 5. 5 -5. 7 demineralisation begins. Reversible caries = early enamel lesions - Plaque-coated. - Frequent fall in p. H value below 5. 5 -5. 7. - Beginning of demineralisation of the enamel. - White spots; surface “pseudo-intact” Image Courtesy Dr F Goulbourn Irreversible caries = dentine caries - Prolonged acid attack. - No remineralisation. - Established lesion (manifest caries). - Breach of the enamel surface. www. wrigleyoralhealthcare. co. uk ©Goulbourn 2012

Saliva and Oral Health Caries THE CARIES BALANCE PATHOLOGi. CAL FACTORS - Acid producing bacteria - Frequent eating/drinking of fermentable carbohydrates - Subnormal saliva flow and function PROTECTIVE FACTORS - Saliva flow and components- Fluoride-remineralisation with calcium and phosphate - Antibacterials: chlorhexidine, xylitol CARIES NO CARIES Redrawn from Featherstone BMC Oral Health 2006 6(Suppl 1): S 8 www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Caries Reduction Studies Chewing SF gum reduces caries in prospective 2 -3 year clinical trials. - Three year study in children with high caries prevalence showed caries-protective benefit of sugar-free gum (Beiswanger et al. 1998) Ø Three year study, Puerto Rico Ø N = 1402 subjects, age 8 -13 Ø Chewed gum 3 x/day for 20 min after meals Ø 7. 9% fewer DMFS in all subjects and 11. 0 fewer in high-caries subjects. - Another two year study confirmed caries-protective benefit in lower-caries prevalence population (Szöke et al, 2001) Ø Two year study, Hungary Ø n = 547 subjects, age 8 -13 Ø Chewed gum 3 x/day for 20 min after meals or no gum Ø Results show 38. 7% reduction in DMFS increment after 2 years INCREMENTAL DMFS Clinical Caries Studies www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Caries Reduction Studies Tabulated Summary of Data from Pertinent Human Intervention Studies Study Intervention (n/N) Control (n/N) Reduction of Caries Incidence (%) Möller 1973 Sorbitol gum 3 x/day after meals. 161/313 No gum. 152/313 10% Glass 1983 Sorbitol gum 2 x/day. 269/540 No gum. 271/540 2% Kandelman 1990 15% Xylitol gum 90/274 No gum. 97/274 61% Kandelman 1990 65% Xylitol gum 87/274 No gum. 97/274 66% Mäkinen 1995 a Sorbitol gum pellets 2 x 1. 3 g, 5 x/day 129/1135 No gum. 121/1135 17% Mäkinen 1995 a 3: 2 xylitol/sorbitol pellets, 5 x/day 120/1135 No gum. 121/1135 44% Mäkinen 1996 Sorbitol stick, 1, 5 x/day. 63/471 No gum. 86/471 28% Beiswanger 1998 Sorbitol gum, 3 x/day after meals. High risk subjects, intention to treat, 607/1256 No gum. 649/1256 12% Szöke 2001 Sorbitol stick, 3 x/day after meals. Including white spots, 269/547 No gum. 278/547 33% Peng 2004 Sorbitol/xylitol/carbamide gum, 4 x/day. 363/733 No gum. 370/733 42% Machiulskiene 2001 Sorbitol gum, 5 x/day after meals. 68/432 No gum. 80/320 25% www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Caries Reduction Studies Caries Reduction and Gum - Conclusions -Multiple studies support the anti-caries benefits of sugar-free gum chewed after eating. -The majority showed reductions in the range 20 -60%. -Systematic reviews have also supported this position. (eg Mickenautsch et al, 2007; Deshpande and Jadad , 2008) - Studies have been reviewed by expert panels resulting in supporting reviews and statements from regulatory and authoritative bodies (FDA, FDI, ADA, EFSA, etc). www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Erosion The loss of hard tissue as a result of direct decalcification from acids of non bacterial origin. ©Image Courtesy Dr F Goulbourn www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Erosion Sources Extrinsic - Acidic foods (p. H < 5)* Intrinsic - Acidic medications (p. H < 5) -Gastroesophageal reflux (GERD: backflow of gastric acid into the oral cavity). - Diet (e. g. , frequent acidic food/drink intake. -Vomiting due to: - Particularly in the presence lower saliva flow. -Chronic alcohol abuse - Environmental factors (e. g. , occupational exposure to acids) * Exception: Yogurt (p. H = 4) is not erosive. www. wrigleyoralhealthcare. co. uk -Bulimia - Central nervous disorders

Saliva and Oral Health Erosion Sources Often seen in those striving for a healthy lifestyle ©Goulbourn 2012 www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Erosion Prevalence ESCARCEL Study - Prevalence growing steadily. - Europe has a prevalence rate of 29. 4% of young adults having erosive tooth wear. - 41. 9% demonstrating dentine hypersensitivity. - The increasing prevalence of dentine hypersensitivity due to: - The longevity of healthy dentition. - More frequent daily dietary acid challenges to the tooth surface. - Tooth wear risk factors: - Associated with frequent acidic food with increased levels of damage. ©Goulbourn 2012 Image courtesy Dr F Goulbourn Bourgeois D, et al ; FDI Annual World Dental Congress, 28 -31 August 2013, Istanbul, Turkey. www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Erosion Aetiology Appearance of erosions: - Dish-shaped, shallow, rounded edges. - Molar cupping. - On buccal, palatal or incisal dental surfaces. Progress of erosions: ©Goulbourn 2012 - Pain-free onset. - Initially in dental enamel. - Leads to exposed dentine. - Hypersensitivities. - Erosive wear, abfraction. - Opacity to incisal edges. Image Courtesy Dr F Goulbourn ©Goulbourn 2012 www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Erosion Remineralisation Sugar free gum may help prevent erosion and erosive tooth wear* - Exogenous dietary acids occur at much lower p. H values in comparison to plaque acids. - Saliva stimulation from chewing gum: - Increases the rate of mouth clearance from acidic food or drink 1. - Stimulates saliva production 2. - Increases levels of bicarbonate and calcium ions in saliva 3. - Aids in more rapid remineralisation of the enamel surface following an acid challenge 4. *Initial study suggests salivary stimulation may help 5. *Direct clinical evidence pending 1. Trlolo P et al: J Dent Res 1990: 69(1 Suppl); 136 2. Dawes C et al: Arch Oral Biol 2004; 49(8): 665 -669. 3. Dawes C et al: Arch Oral Biol. 1995; 40: 699 -705. 4. Wefel JS et al: J Dent Res 1989; 68(1 supp): 214. 5. Rios D et al: Caries Res 2006; 40: 218 -23. www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Clinical Assessment Examination Review Medical History - Drugs, medicines. - Conditions: Acid reflux, diabetes, vomiting, heartburn, hiatus hernia, - Autoimmune diseases (e. g. Sjögren’s syndrome), radiotherapy Soft Tissue Examination - Oral hygiene. - Periodontal conditions: BOP, pocketing. - Soft tissue loss: previous periodontal therapy, surgical/non surgical. - Dry/ friable mucus membrane. - Lack of saliva pooling. Hard Tissue Examination - Exposed root surfaces. - Attrition - Erosion - Abfraction - Abrasion - Loss of enamel characteristics : shiny, flat surfaces. - Caries rate: root surface, proximal. - Demineralisation bands. www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Clinical Assessment Examination Diet - Acids : Food, drinks and frequency. - Sugars: Added, hidden and frequency. - Timing: Avoid before bed time - reduced salivary flow. Oral Hygiene - Tooth brushing technique, bristle type. - Toothpaste abrasives. - Bacterial acids, plaque scores, demineralisation. Fluoride Exposure - Frequency - Age appropriate fluoridation Saliva - Quality: serous, mucoid, frothy. - Quantity: adequate and reaches all areas of the mouth. - Buffering capacity. www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Clinical Assessment Risk Assessment Tools Caries www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Clinical Assessment Risk Assessment Tools Basic Erosive Wear Examination 0 No surface loss 1 Initial loss of enamel surface texture 2* Distinct defect, hard tissue loss less than 50%of the surface area 3* Hard tissue loss more than 50% of the surface area *Dentine is often involved BEWE: a new scoring system for scientific and clinical needs. Clin Oral Investig. 2008 March; 12(Suppl 1): 65– 68. BEWE Index www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Chairside Testing Saliva 1. Measuring the saliva flow rate (ml/min) Saliva categories Normal flow rate Reduced saliva flow rate Mouth dryness (xerostomia) Saliva flow rates (ml/min) 1 - 3 0. 5 - 0. 8 <0. 5 2. Consistency Visual inspection Categories Characteristics Strongly increased viscosity Sticky frothy saliva Increased viscosity Frothy bubbly saliva Normal viscosity Watery clear saliva 3. Measuring the buffer capacity The change in color on the test strip is compared with the sample card and this indicates the buffer capacity: www. wrigleyoralhealthcare. co. uk Low Medium High

Saliva and Oral Health Recommendations - Continuous recall with oral hygiene, caries, gingivitis, bleeding index. - Regular fluoridation building up a stable fluoride reservoir. - Use a less abrasive toothpaste. H+ H+ Ca++ F- H+ PO 4 - H+ - Only take acidic medications (p. H < 5. 7) with water. F- FCa++ - Diet with a low erosive potential, e. g. , vegetables, milk, hard cheese. F- FPO 4©Reeves 2014 www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Recommendations Sugar Free Gum - Chew SFG for 20 mins after sugar or acid challenge. - Encourage regular saliva stimulation in between meals. -Chew sugar free gum, to increase the saliva flow rate. - Dental care on the go: chewing sugar free gum can: - Provide mouth clearance - Help prevent plaque accumulation. - Increase saliva buffering capacity. - Decrease plaque p. H. - Decrease caries and erosive potential. www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Conclusions Saliva is the most important part of the body’s own protective systems for maintaining oral health. Reduced saliva quantity and quality increase the risk of caries, erosion, xerostomia and interfere with the ecological balance in the mouth. Informing the patient and activating the saliva’s protective function for the mouth and teeth is the basis of a modern, preventionoriented treatment strategy. It has been scientifically proven: saliva stimulation by chewing sugar free gum helps to increase the saliva flow-rate up to tenfold, which can reduce the risk of caries by up to 40%. www. wrigleyoralhealthcare. co. uk

Saliva and Oral Health Thank you! Thank You! 47 www. wrigleyoralhealthcare. co. uk