55

Journal of Oral Science, Vol. 59, No. 1, 55-62, 2017

Original

Stimulated salivary flow rate and oral health status

Yoshihiro Shimazaki1,2), Bohan Fu1), Koji Yonemoto3,4), Sumio Akifusa1,5),
Yukie Shibata1), Toru Takeshita1), Toshiharu Ninomiya6), Yutaka Kiyohara3),
and Yoshihisa Yamashita1)
1)Section of Preventive and Public Health Dentistry, Division of Oral Health, Growth and Development,
Faculty of Dental Science, Kyushu University, Fukuoka, Japan
2)Department of Preventive Dentistry and Dental Public Health, School of Dentistry,

Aichi Gakuin University, Nagoya, Japan

3)Department of Environmental Medicine, Graduate School of Medical Sciences,

Kyushu University, Fukuoka, Japan

4)Biostatistics Center, Kurume University, Kurume, Japan
5)Department of Health Management, School of Oral Health Sciences, Kyushu Dental University,

Kitakyushu, Japan
6)Division of Research Management, Center for Cohort Studies, Graduate School of Medical Sciences,

Kyushu University, Fukuoka, Japan

(Received May 10, 2016; Accepted July 4, 2016)

Abstract: This study examined the relationship
between stimulated salivary flow rate and oral
health status in an adult population. Multinomial
multivariate logistic regression analysis was used to
examine the associations of salivary flow rate with
dental caries status and periodontal status at the
individual level among 2,110 Japanese adults with
10 teeth. Then, a spline model was used to examine
the nonlinear relationship between salivary flow rate
and teeth with dental caries or periodontal disease in
multilevel analysis. Odds ratios were calculated for a
1.0-mL/min reduction in salivary flow rate at a point.
After adjusting for confounding variables, partici-
pants with a flow rate 3.5 mL/min had significantly
higher odds ratios for high caries status, and partici-
pants with a flow rate 1.4 mL/min had a higher odds
Correspondence to Dr. Yoshihisa Yamashita, Section of Preventive
and Public Health Dentistry, Division of Oral Health, Growth and
Development, Faculty of Dental Science, Kyushu University,
3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
Fax: +92-642-6354 E-mail: yoshi@dent.kyushu-u.ac.jp
J-STAGE Advance Publication: December 28, 2016
Color figures can be viewed in the online issue at J-STAGE.
doi.org/10.2334/josnusd.16-0372
DN/JST.JSTAGE/josnusd/16-0372
ratio for broad periodontal disease, than did those
with a flow rate >3.5 mL/min. In spline models, the
odds ratio for teeth with dental caries or periodontal
disease increased with reduced saliva secretion. The
present findings suggest that decreased saliva secre-
tion affects both dental caries and general periodontal
health status.
Keywords: stimulated salivary flow; dental caries;
periodontal disease; multilevel analysis;
spline model.
Introduction
Saliva is important in oral functions such as mastication
and swallowing, the buffering function of pH, antimicro-
bial activity, and cleaning action (1-3). Thus, a decrease
in the ability to salivate likely affects various oral
health-related issues. However, information on the actual
conditions associated with saliva production in adults is
limited (4-6). Thus, we examined salivary flow rate in an
adult population.
Many previous studies reported a relationship between
the amount of saliva secretion and oral diseases such
as dental caries and periodontal disease. In particular, a
56
decline in saliva secretion increased the risk of dental caries
(7-10). However, the extent to which caries risk increases
because of decreased saliva production is unclear. A few
studies have suggested that decreased saliva secretion
affects periodontal disease (8,9,11), although others have
questioned whether such an association exists (4,12,13).
One study reported that few subjects with lower saliva
secretion had deep periodontal pockets (14). Thus, there
is no consensus regarding the association between saliva
secretion and periodontal disease.
This study collected information on the distribution of
stimulated salivary flow rates in a community-dwelling
adult population and analyzed the association of reduced
stimulated salivary flow rate with oral health status,
including dental caries and periodontal disease.
Materials and Methods
Study population
The study participants were recruited in 2007 in the town
of Hisayama, a suburb of the Fukuoka metropolitan
area, in southern Japan. The town registry listed 3,810
residents aged 40-79 years, 2,861 (75.1%) of whom
provided written informed consent to participate in the
study and underwent a comprehensive examination.
Dental and medical examinations were performed on
2,669 dentate and edentulous adults. All participants
with at least 10 teeth were included in the analysis; 559
participants who had fewer than 10 teeth or were unable
to provide sufficient data were excluded because of the
inherent difficulties of assessing periodontal health in
these individuals. As study of individuals with fewer
teeth indicated that they were more susceptible to poor
periodontal conditions (15). The final study sample
comprised 2,110 participants (931 men, 1,179 women).
Written informed consent was obtained from all
participants, in accordance with the World Medical Asso-
ciation Declaration of Helsinki. The Ethics Committee
of the Kyushu University Faculty of Dental Sciences,
Fukuoka Japan, approved the study design, data collec-
tion methods, and procedure for obtaining informed
consent (approval 20B-1).
Oral examination and saliva collection
Each subject received an oral health examination in a
supine position under adequate artificial light in a normal
or portable dental chair. Using the methods of the Third
National Health and Nutrition Examination Survey (16),
one of nine dentists performed a periodontal examination
with standardized probing technique. A periodontal probe
was used to examine pocket depth and clinical attach-
ment loss on the mesiobuccal and mid-buccal sites of all
retained teeth except for third molars, because partially
impacted third molars frequently have pseudopockets.
Examination reliability for the periodontal assessment
was verified by interexaminer calibration of volunteers
with characteristics similar to those of the study popula-
tion. The Cohen value exceeded 0.8, indicating very
good interexaminer agreement. Oral hygiene was evalu-
ated using the plaque index, and the mean plaque index
score for each subject was included in the analysis.
Stimulated saliva was sampled between 8:00 and
10:30 AM, during a morning fast. During sampling,
participants were asked to sit in a chair. Saliva was stimu-
lated by chewing fruit-flavored gum for 2 min and then
collected from each participant. Participants expectorated
the accumulated saliva into a sterile tube. After 2 min, the
amount of collected saliva was measured by deducting
the weight of the tube from the total weight including the
tube, and salivary flow rate was expressed in mL/min,
with the specific gravity of saliva defined as 1.0.
General examination and questionnaire
A blood sample was collected from the antecubital vein
in the morning after an overnight fast, and fasting plasma
glucose values were categorized into three groups (119,
120-125, 126 mg/dL). Body mass index was calculated
as the weight in kilograms divided by the square of the
height in meters.
Each subject completed a self-administered question-
naire in advance that included smoking habit (never,
former, current) and toothbrushing frequency. A former
smoker was defined as a subject who had quit smoking
more than 1 year before the day of the examination.
Toothbrushing frequency was divided into three catego-
ries (1, 2, 3 times/day).
Statistical analysis
A previous study showed that an appropriate cut-off value
for stimulated salivary flow rate was 1.4 mL/min when
using plum-flavored gum to diagnose Sjgren syndrome
(17). Therefore, in view of its distribution, salivary flow
rate was divided into four categories (expressed as mL/
min): 1.40, n = 282 (13.3%); 1.41-2.50, n = 554 (26.3%);
2.51-3.50, n = 621 (29.4%); and 3.51, n = 653 (30.9%).
Two cut-off points for periodontal status were used to
divide the participants into three categories. Participants
without deep periodontal pockets were classified as
having good periodontal status and those at approxi-
mately the 15th percentile were classified as having poor
periodontal status, according to the percentage of teeth
with both a pocket depth and clinical attachment loss 4
mm, as follows: 0%, n = 1,033 (49.0%); 0.1-19.9%, n =

125
100
Number of subjects
75
50
25
0
0 2
Stimulated salivary ow rate (mL/min)
Fig. 1Distribution of stimulated salivary flow rates.
739 (35.0%); and 20%, n = 338 (16.0%). The percentage
of dental caries (decayed or filled teeth) was divided into
three categories using two cut-off points, similar to the
percentages used for periodontal status, namely <70%,
n = 1,258 (59.6%); 70-89.9%, n = 571 (27.1%); and
90%, n = 281 (13.3%). Multinomial logistic regression
analyses were used to calculate odds ratios (ORs) and
95% confidence intervals (CIs) for the effects of sali-
vary flow rate and other variables on dental caries and
periodontal status. Age, sex, smoking habit, body mass
index, toothbrushing frequency, number of teeth, mean
plaque index, and fasting plasma glucose level were
included as confounding variables in the multivariate
multinomial logistic regression analysis. Additionally,
using a spline model with a model selection method
proposed by Kawaguchi et al., we examined the possi-
bility of a nonlinear association of salivary flow rate with
teeth with dental caries and teeth with periodontal disease
(18). Stratified descriptive information was calculated
using the subject and teeth as units of analysis. Dental
caries (tooth decayed or filled) and periodontal disease
(teeth with both a pocket depth and clinical attachment
loss 4 mm) were defined as the main outcome variables.
A generalized estimating equation logistic regression
model considering tooth factors (first level) nested within
subject factors (second level) was used to explain varia-
tion in binary dependent variables. ORs and 95% CIs
for teeth with dental caries or periodontal disease were
calculated for a 1.0-mL/min reduction in salivary flow
rate at a point. In the analysis, the basic level, tooth,
was nested in the upper level, subject. Ten factors were
considered as possible risk factors (covariates) for dental
caries (decayed or filled teeth) and periodontal disease
and were always included in the model for the purpose
57
4 6 8 10
of dental health investigation. These variables were
age, sex, smoking habit (0: never, 1: former, 2: current),
body mass index (kg/m2), fasting plasma glucose (mg/
dL) (0: 109, 1: 110-125, 2: 126), mean plaque index,
frequency of toothbrushing (times/day) (0: 1, 1: 2, 2:
3), number of teeth, location of tooth (0: lower incisor
or canine, 1: upper incisor or canine, 2: lower premolar,
3: upper premolar, 4: lower molar, 5: upper molar), and
amount of stimulated saliva (mL/min). P values < 0.05
were considered to indicate statistical significance. SPSS
ver.19.0 for Macintosh (IBM SPSS Japan, Tokyo, Japan)
was used for the data analysis.
Results
Figure 1 shows the distribution of stimulated salivary
flow rate in a community-dwelling adult population (age
40-79 years). The mean (standard error, standard devia-
tion) amount of stimulated saliva was 2.94 (0.0293, 1.38)
mL/min; 282 (13.3%) participants had a flow rate of 1.4
mL/min.
Table 1 shows the associations of salivary flow rate
and other variables with dental caries. Salivary flow
rate, sex, fasting plasma glucose, age, number of teeth,
and mean plaque index were significantly associated
with dental caries. As compared with participants with
a rate of 3.51 mL/min, those with a salivary flow rate
of 1.41-3.50 mL/min had a significantly higher OR for
dental caries in 70% to 89.9% of their teeth. Moreover,
participants with a rate of 2.5 mL/min had a significantly
higher OR for having dental caries in 90% of their teeth
(Table 1). Table 2 shows the associations of salivary flow
rate and other variables with periodontal status. Salivary
flow rate, sex, smoking habit, age, number of teeth, mean
plaque index, and body mass index were significantly
58

Table 1 Associations of salivary flow rate and other variables with dental caries
DF teeth (%) Dependent variable: DF teeth (%)
<70 70-89.9 90 70-89.9 vs. <70 90 vs. <70
Independent variable (n = 1,258) (n = 571) (n = 281) Adjusted OR (95% CI) Adjusted OR (95% CI)
n (%)
Stimulated salivary flow rate
3.51 mL/min 455 (36.2) 139 (24.3) 59 (21.0) 1 1
2.51-3.50 mL/min 357 (28.4) 193 (33.8) 71 (25.3) 1.53 (1.16-2.00)** 1.21 (0.78-1.86)
1.41-2.50 mL/min 296 (23.5) 169 (29.6) 89 (31.7) 1.46 (1.10-1.94)** 1.80 (1.18-2.75)**
1.40 mL/min 150 (11.9) 70 (12.3) 62 (22.1) 1.12 (0.78-1.61) 1.79 (1.11-2.90)*
Sex
Male 627 (49.8) 202 (35.4) 102 (36.3) 1 1
Female 631 (50.2) 369 (64.6) 179 (63.7) 1.82 (1.35-2.45)*** 1.72 (1.09-2.70)*
Smoking habit
Never smoker 671 (53.3) 357 (62.5) 182 (64.8) 1 1
Former smoker 283 (22.5) 129 (22.6) 50 (17.8) 1.28 (0.93-1.76) 0.79 (0.48-1.31)
Current smoker 304 (24.2) 85 (14.9) 49 (17.4) 0.83 (0.59-1.17) 1.02 (0.62-1.69)
Toothbrushing frequency
3 times/day 208 (16.5) 92 (16.1) 50 (17.8) 1 1
2 times/day 649 (51.6) 316 (55.3) 137 (48.8) 1.21 (0.90-1.62) 1.04 (0.68-1.59)
1 times/day 401 (31.9) 163 (28.5) 94 (33.5) 1.13 (0.81-1.58) 1.00 (0.62-1.60)
Fasting plasma glucose
119 mg/dL 961 (76.4) 444 (77.8) 219 (77.9) 1 1
120-125 mg/dL 179 (14.2) 81 (14.2) 32 (11.4) 0.93 (0.68-1.27) 0.54 (0.34-0.87)*
126 mg/dL 118 (9.4) 46 (8.1) 30 (10.7) 0.75 (0.51-1.10) 0.69 (0.41-1.16)
Mean (SD)
Age (years) 57.1 (9.4) 60.6 (10.1) 66.0 (9.1) 1.02 (1.01-1.03)*** 1.06 (1.04-1.08)***
Number of teeth present 25.8 (4.0) 23.9 (4.1) 19.4 (5.5) 0.91 (0.89-0.94)*** 0.80 (0.77-0.82)***
Mean plaque index 0.6 (0.6) 0.7 (0.6) 1.0 (0.7) 1.21 (1.01-1.46)* 1.85 (1.44-2.38)***
BMI (kg/m2) 23.4 (3.4) 23.1 (3.5) 23.1 (3.4) 0.98 (0.95-1.01) 0.97 (0.92-1.01)
n = 2,110. DF: decayed or filled, OR: odds ratio, CI: confidence interval, BMI: body mass index, SD: standard deviation, *: P < 0.05, **: P < 0.01,
***: P < 0.001.

associated with periodontal status. Participants with a
flow rate 1.40 mL/min had a significantly higher OR for
having 20% teeth with periodontal disease, as compared
with participants with a flow rate of 3.51 mL/min (Table
2).
Next, we evaluated the nonlinear effect of salivary flow
rate on teeth with dental caries or teeth with periodontal
disease using the ORs from the spline model. For illus-
tration, we focused on the variable salivary flow rate
because of its nonlinear effect. Figure 2 shows the ORs
for decayed or filled teeth, and Fig. 3 shows the ORs for
teeth with a pocket depth and clinical attachment loss 4
mm, for a 1.0-mL/min reduction in salivary flow rate, as
computed from the spline model, assuming all other vari-
ables remained constant. Figure 2 shows that, down to 2.15
mL/min, caries risk for an individual tooth continued to
increase gradually as salivary flow decreased, but the OR
became nonsignificant when salivary flow rate was less
than approximately 2.15 mL/min. A rate less than about
2.15 mL/min did not further increase the risk of dental
caries, although the risk of dental caries remained high.
Figure 3 shows that a salivary flow rate >2.7 mL/min was
not associated with the risk of a tooth having periodontal
disease, but the OR increased and was significant when
salivary flow rate was less than approximately 2.7 mL/
min.
Discussion
Because information on hyposalivation in the general
adult population is limited, this study examined the
distribution of stimulated salivary flow in Japanese adults
participating in a community-based health examination.
A gum test is often used to evaluate oral dryness, and
a value of 1.0 mL/min has been used as a cutoff value
for stimulated salivary flow in the diagnosis of Sjgren
syndrome (19). If flavored gum is used, a salivary flow
cut-off value of 1.4 mL/min is recommended for iden-
tification of hyposalivation. According to that criterion,
about 13.3% of adults 40 years or older have a stimulated
salivary flow equal to or lower than that value. Using a
modification of the Saxon test, a previous study (6) of
a community-dwelling Japanese population aged 20-90
years reported that about 14% of participants had low
stimulated salivary flow (2.04 g/2 min); this proportion
 59

Table 2 Associations of salivary flow rate and other variables with periodontal status
PD and CAL 4 mm (%) Dependent variable: PD and CAL 4 mm (%)
0 0.1-19.9 20 0.1-19.9 vs. 0 20 vs. 0
Independent variable (n = 1,033) (n = 739) (n = 338) Adjusted OR (95% CI) Adjusted OR (95% CI)
n (%)
Stimulated salivary flow rate
3.51 mL/min 323 (31.3) 229 (31.0) 101 (29.9) 1 1
2.51-3.50 mL/min 326 (31.6) 203 (27.5) 92 (27.2) 0.93 (0.71-1.21) 1.04 (0.72-1.50)
1.41-2.50 mL/min 263 (25.5) 213 (28.8) 78 (23.1) 1.18 (0.90-1.55) 1.18 (0.80-1.73)
1.40 mL/min 121 (11.7) 94 (12.7) 67 (19.8) 1.14 (0.80-1.61) 1.98 (1.23-3.06)**
Sex
Male 371 (35.9) 356 (48.2) 204 (60.4) 1 1
Female 662 (64.1) 383 (51.8) 134 (39.6) 1.00 (0.75-1.33) 0.64 (0.43-0.93)*
Smoking habit
Never smoker 685 (66.3) 384 (52.0) 141 (41.7) 1 1
Former smoker 211 (20.4) 179 (24.2) 72 (21.3) 1.33 (0.97-1.81) 1.11 (0.72-1.71)
Current smoker 137 (13.3) 176 (23.8) 125 (37.0) 2.67 (1.93-3.70)*** 4.14 (2.73-6.29)***
Toothbrushing frequency
3 times/day 194 (18.8) 103 (13.9) 53 (15.7) 1 1
2 times/day 577 (55.9) 370 (50.1) 155 (45.9) 1.08 (0.81-1.44) 0.85 (0.58-1.26)
1 times/day 130 (25.4) 266 (36.0) 130 (38.5) 1.26 (0.91-1.73) 0.83 (0.54-1.28)
Fasting plasma glucose
119 mg/dL 854 (82.7) 533 (72.1) 237 (70.1) 1 1
120-125 mg/dL 111 (10.7) 126 (17.1) 55 (16.3) 1.30 (0.97-1.75) 1.20 (0.81-1.79)
126 mg/dL 68 (6.6) 80 (10.8) 46 (13.6) 1.32 (0.92-1.91) 1.57 (0.99-2.48)
Mean (SD)
Age (years) 57.3 (9.9) 61.4 (10.0) 60.6 (9.5) 1.04 (1.03-1.05)*** 1.01 (1.00-1.03)
Number of teeth present 25.5 (4.2) 24.1 (4.6) 21.9 (5.4) 0.97 (0.94-0.99)** 0.89 (0.86-0.92)***
Mean plaque index 0.5 (0.5) 0.7 (0.6) 1.0 (0.7) 1.86 (1.53-2.25)*** 3.29 (2.60-4.16)***
BMI (kg/m2) 22.9 (3.4) 23.6 (3.6) 23.6 (3.2) 1.04 (1.01-1.08)** 1.04 (1.00-1.09)
n = 2,110. PD: pocket depth, CAL: clinical attachment loss, OR: odds ratio, CI: confidence interval, BMI: body mass index, SD: standard deviation,
*: P < 0.05, **: P < 0.01, ***: P < 0.001.

2.0

1.5
Odds ratio

1.0

0.5

0.0
1 2 3 4 5
Stimulated salivary ow rate (mL/min)
Fig. 2Odds ratio for a tooth being decayed or filled for a 1.0-mL/min reduction in salivary flow rate at
a point. Odds ratios were adjusted for age, sex, smoking habit, body mass index, fasting plasma glucose,
mean plaque index, frequency of toothbrushing, number of teeth present, and location of teeth. The solid
line shows the odds ratio based on a spline model and the shaded band shows the 95% confidence interval.

was close to that in the present study. In Sweden, the aged 65 years had a stimulated salivary flow rate of 1.0
prevalence of a low (<1.0 mL/min) stimulated salivary mL/min or less (20). Salivary flow rate may be affected
flow rate was about 9% among dental patients aged 40 by differences in population characteristics and ethnicity.
years or older (5). In the United States, 35% of adults Although the present participants were residents of a
60

1.8

1.6

Odds ratio 1.4

1.2

1.0

0.8

1 2 3 4 5
Stimulated salivary ow rate (mL/min)
Fig. 3Odds ratio for a tooth having a pocket depth and clinical attachment loss 4 mm for a 1.0-mL/min reduction
in salivary flow rate at a point. Odds ratios were adjusted for age, sex, smoking habit, body mass index, fasting
plasma glucose, mean plaque index, frequency of toothbrushing, number of teeth present, and location of teeth. The
solid line shows the odds ratio based on a spline model and the shaded band shows the 95% confidence interval.

single town in Japan, the participation rate was high.
Thus, our data are relevant to the distribution of stimu-
lated salivary flow in the Japanese adult population.
Decreased saliva secretion increases the risk of dental
caries (7-10). Our study suggests that saliva volume
is inversely associated with the risk of dental caries.
Although the study participants were aged 40 years and
many had missing teeth, we were unable to identify the
cause of tooth loss. We then defined dental caries status
as the proportion of decayed or filled teeth among teeth
present in participants having 10 teeth. Multivariate
analysis adjusted for number of present teeth and other
variables showed that lower stimulated salivary flow was
significantly associated with a higher rate of dental caries.
Although dental caries risk was not significantly higher
(70% to 89.9% vs. <70% DF teeth) in participants with
the lowest saliva secretion (1.4 mL/min), we hypothe-
size that this risk explains why many of these participants
were in the highest dental caries category (90% DF
teeth). In the multilevel spline model, caries risk for each
tooth increased with reduced saliva secretion; however,
when salivary flow was less than approximately 1.15
mL/min (2.15-1.0 mL/min), the OR for dental caries did
not further increase.
Both subject-level and multilevel analyses suggested
that high salivary flow prevents dental caries and that a
decrease in saliva production might have a cariogenic
effect. Sjgren syndrome is a systemic autoimmune
disease associated with hyposalivation (21), and patients
with this disease have many teeth with dental caries
(22,23). A previous study showed that levels of Lactoba-
cillus acidophilus in saliva and supragingival plaque were
significantly higher in patients with Sjgren syndrome
than in control subjects and suggested that changes in
the microbial composition may affect individual risk
of dental caries (24). Future microbial studies should
attempt to clarify the mechanism underlying the relation
between salivary flow rate and dental caries.
Although several studies have examined the relation
between salivary flow and periodontal disease, a few
reports have suggested that individuals with lower sali-
vary flow rates have higher risks for periodontal disease
(8,9,11). The present participants with a salivary flow rate
1.4 mL/min had a higher risk for extensive periodontal
disease. The spline model for analysis at the tooth level
showed that the inflection point for the risk of teeth with
periodontal disease due to a 1.0-mL/min decrease in
saliva secretion was about 2.7 mL/min. A decrease of
1.0 mL/min from this value (i.e., 1.7 mL/min) was close
to the high-risk value (about 1.4 mL/min) for extensive
periodontal disease in the present subject-level analysis.
These findings suggest that periodontal conditions are
unchanged in persons with average stimulated salivary
flow. Although low salivary flow increased the risk of
dental caries over a wide range of salivary flow rates,
the risk of periodontal disease due to low salivary secre-
tion was higher only in the lower range of salivary flow.
Therefore, adverse periodontal effects may only occur at
a stimulated salivary flow rate below approximately 1.4
mL/min for flavored gum chewing, which corresponds to
a rate of 1.0 mL/min for paraffin gum chewing-stimulated
salivary flow. One study showed that low stimulated

salivary flow rate was associated with decreased risk of
having teeth with a pocket depth 4 mm among dentate
subjects aged 75 years (14). This result appears to
contradict the findings of the present study; however, the
subjects of that study were older and more likely to be
female, especially in groups with low salivary flow rates,
and these factors may affect the difference in the relation
between salivary secretion and periodontal disease.
Studies have reported that periodontal status is poor
in patients with Sjgren syndrome (22,23,25,26). In
addition, plaque index scores were higher for Sjgren
syndrome patients than for control subjects (22,25), and
stimulated salivary flow was inversely associated with
plaque index score in Sjgren syndrome patients (26).
Serum antibody levels to periodontopathogens were
significantly higher in Sjgren syndrome patients than
in control subjects (25). A case-control study suggested
a possible correlation between periodontal disease and
Sjgren syndrome, as capillary alterations in gingival
microcirculation were observed in patients with Sjgren
syndrome (27). Plaque accumulation associated with low
salivary flow rate might affect gingival inflammation and
blood circulation. However, additional evidence from
healthy adult populations and Sjgren syndrome patients
is needed in order to clarify the relation between salivary
secretion and periodontal health.
This study had several limitations. Although we evalu-
ated stimulated salivary flow rates, we did not examine
unstimulated salivary flow rates. However, a previous
study reported a significant positive correlation between
unstimulated and stimulated salivary flow rates (28).
Because the present assessment of periodontal status was
based on a partial periodontal examination, the resulting
underestimation of periodontal disease might have
affected the evaluation of the association between sali-
vary flow rate and periodontal disease (29). The results of
the present study were based on a cross-sectional design;
thus, we could not draw conclusions regarding a causal
relation between salivary secretion and oral health status.
We used the proportion of decayed or filled teeth as an
indicator of dental caries status because a large propor-
tion of the participants had many teeth with dental caries.
Longitudinal studies are needed in order to determine the
risk of incident dental caries in relation to salivary flow
rate. Longitudinal observations would help clarify this
relation, because the association between salivary flow
rate and periodontal disease is not always consistent.
In current dental practice and oral health examina-
tions, tooth and periodontal examinations are generally
conducted during the evaluation of oral health status.
However, examination of salivary secretion capacity
61
is less common, except in patients who specifically
complain of oral dryness. This study showed that low
salivary flow rate may affect both dental caries and
general periodontal health. Thus, assessment of salivary
secretion in health examinations and at dental clinics
may have an important role in evaluating patients future
risk of oral disease.
Acknowledgments
This work was supported by a Grant-in-Aid for Scientific Research
(No. 23390483, 25293428, and 25893177) from the Ministry of
Education, Culture, Sports, Science and Technology, Japan and by
the departmental budget of Kyushu University, Fukuoka, Japan.
Conflict of interest
The authors declare that they have no competing interests.
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