SALIVA

Introduction
Saliva is a glandular secretion present in the oral cavity. The principle glands of salivation are the
three-paired major salivary glands, the minor salivary buccal glands and the gingival crevicular
fluid.1,11

Its importance is clearly illustrated in individuals suffering abnormalities with salivary output. For
example, decreased salivation may manifest as deterioration in oral health, such as: oral pain, increased
susceptibility to dental caries and infections by opportunistic microorganisms. 2,1 More specifically,
saliva plays a crucial role in treatment planning and the effects upon the denture-making process.
Unfortunately saliva does not receive enough consideration as its flow rate and viscosity are important
to denture success.3 Thus, an understanding of saliva and its role in oral health is required to identify,
prevent and/or treat the patient to achieve the most optimal outcome.1

Functions of Saliva
The complexity of this oral fluid is best appreciated by the consideration of its many and varied
functions. The functions of saliva are largely protective; however, it also has other functions.1

Table 1.1 Functions of saliva.

Fluid/Lubricant Moistens and lubricates the soft tissues of the oral cavity, keeping them pliable and dry; thus,
helping protect against mechanical, thermal and chemical irritation. Assists smooth air flow,
speech and swallowing.1,4
Ion reservoir Solution supersaturated with ions facilitates remineralisation of the teeth.
Buffer Helps to neutralize plaque pH after eating, thus reducing time for demineralisation.
Cleansing Clears food particles, desquamated epithelial cells and aids swallowing.1,4
Antimicrobial Specific and non-specific anti-microbial mechanisms help control the oral microflora.
Agglutination Aggregation and accelerated clearance of bacterial cells.
Pellicle formation Protective diffusion barrier formed on enamel from salivary proteins
Digestion Due to the presence of the enzyme amylase, starchy food debris on the teeth is broken down.
Taste Saliva acts as a solvent thus allowing interaction of foodstuff with taste buds to facilitate taste.
Excretion As the oral cavity is technically outside the body, substances which are secreted in saliva are
excreted. This is a very inefficient excretory pathway as reabsorption may occur further down
the intestinal tract.1 Such substances include: drugs, metals and alcohol.4
Water balance Under conditions of dehydration, salivary flow is reduced, dryness of the mouth and information
from osmoreceptors evoke decreased urine production and thirst.1,4
Solvent action Saliva dissolves many solid foods, thus aiding in appreciation of the food and stimulation of the
taste buds with resultant reflex secretion.4

The Salivary Glands

Parotid Gland
The parotids are the largest of the three paired salivary glands enclosed within the parotid sheath
contributing to 25% of the total saliva secretion.1,5 The gland is situated anteroinferior to the external
acoustic meatus and behind the ramus of the mandible. 1,5 The parotid duct is thick walled, formed from
the union of the ductules which drain the lobules of the glands; it passes horizontally turning medially
at the anterior border of the masseter to piece the buccinator and enters the oral cavity in a papilla
opposite the second upper molar.1,5 Of importance to the parotid gland is its innervation, derived from
parasympathetics and sympathetics. The parasympathetic component originates from the
glossopharyngeal nerve which supplies secretory fibers to the parotid gland; Sympathetic fibers are
derived from the cervical ganglia.5 Both nervous innervations cause secretion of the parotid gland, but
vary in the secretory product.6

Timothy Van
Submandibular Gland
The submandibular gland is variable in size but approximately half the size of the parotid gland yet
contributes to 70% of the total saliva secretion.5,1 Its thin walled duct runs parallel to the side of the
tongue, opening into the floor of the mouth underneath the anterior part of the tongue through the
sublingual papilla to the lingual frenum.1 Parasympathetic innervation of the submandibular gland is
derived from the salivary nucleus via the facial nerve which synapses in the submandibular ganglion.7

Sublingual Gland
The sublingual glands are the smallest and most deeply situated of the salivary glands contributing to
only 5% of the total saliva secretion.1,5 One fifth the size of the submandibular gland, its numerous
ducts open into the floor of the mouth beneath the sublingual folds of mucous membrane.1,5 Its
innervation is alike to the submandibular glands.7

Fig. 1 The three major salivary glands and associated ducts.8

Structure of Salivary Glands

Timothy Van
Salivary glands involve clustered secreting acini end pieces attached to freely branching ductal
system.1,9 The walls of the acini surround a central cavity known as an alveolus; the intercellular spaces
between the cells in the end piece open into the alveolus which is the beginning of the ductal system.9
Three types of ducts are present in the branched ductal system of all salivary glands: the intercalated
ducts contain low cuboidal epithelium and a narrow lumen; striated ducts which contain more
columnar cells and the excretory ducts which have cuboidal epithelium with stratified squamous
epithelium lining the terminus.1

Fig. 2 The structure of the salivary glands.10

These secreting cells of the acini end pieces may be either of serous or the mucous type. The cell
arrangement in the acini differs can be classed into two types; serous secreting cells are arranged in a
rough spherical form while mucous secreting cells are arranged in a tubular configuration with a larger
lumen.1,9 Salivary gland end pieces may have different cell arrangements; secreting cells of the parotid
glands are of the serous type; submandibular glands are both serous and mucous types and the acini of
the sublingual glands are composed primarily of mucous cells.1

Physiology of Saliva

Timothy Van
 Characteristics
Saliva contains two major types of protein secretion: ptyalin-containing serous secretion and a mucin-
containing mucous secretion. Ptyalin is a minor α-amylase enzyme that begins starch digestion whilst
mucin assists in lubrication and servers to protect oral surfaces.11 The parotid glands secrete entirely
the serous type of secretion, whilst the submandibular and sublingual glands secrete both serous and
mucus type secretions; however, the sublingual gland secretes higher concentration of mucin in
comparison to the submandibular glands.11 Saliva has a pH between 6.0 and 7.0, which is a favourable
range for the digestive action of ptyalin.11
Acinar cells are also responsible for the secretion of most of the proteins found in saliva (>85%),
although duct cells secrete numerous proteins with important biological activities, e.g., nerve growth
factor, epidermal growth factor, immunoglobin A, and kallikrein.1

Saliva contains high concentrations of potassium and biocarbonate and lower concentrations of sodium
and chloride with respect to plasma.11 This difference can be explained by the mechanism of saliva
secretion below.

Formation and Modification of Saliva

Salivary secretion is a two-stage process process: initial stage involves acini to secrete a primary
secretion that contains ptyalin and/or mucin in a solution of ions similar in plasma. As the primary
secretion flows through the ducts, two major active transport processes take place that markedly
modify the ionic composition in the saliva.1,11

Under normal resting conditions, Na+ and Cl- are transported to the lumen of the acinus through acinar
cells; thus, water movement follows the electrolyte secretion producing an isotonic fluid in the lumen.1
This NaCl-rich secretion is then subsequently modified as it passes through branched ductal system;
most modification occurs in the striated ducts where ion exchange takes place with NaCl being
reabsorbed, while K+ and HCO3 being excreted.1,2 Additionally, its composition is further modified in
the excretory ducts before its final secretion into the oral cavity proper.1 Under maximal salivary
production, salivary ionic concentrations in the mouth change considerably because the rate of
formation of primary secretion flows through the ducts so rapidly that ductal modification is
ineffective. Therefore, NaCl concentration is increased and K+ falls respectively in the mouth.

Table 1.2 Factors affecting composition of Saliva

 Contribution of different glands Nature of the stimulus

 Flow rate Circadian rhythms
 Duration of stimulation

Flow rate

Timothy Van
 Salivary flow rates exhibit diurnal and seasonal variation with peaks in mid afternoon and higher flow
rates in the Spring than in the Autumn. Normal salivary rates are in the region of 0.3ml/min when
unstimulated and 1.5-2.0ml/min when stimulated, although both rates have wide normal ranges.1 The
volume of saliva secreted can vary dramatically from 1-2L per day in the adult with various
contributions from the three major paired salivary glands.1,4,11,12 During sleep, flow rate is negligible.1

Table 1.3 Factors affecting salivary flow rate

Unstimulated Saliva Gland size

 Degree of hydration Stimulated Saliva
 Body posture and lighting conditions Mechanical stimuli
 Biological rhythms Vomiting
 Psychic stimuli Gustatory and olfactory stimuli
 Drugs Unilateral stimulus

Adhesion and Cohesion

Adhesion
Adhesion is the physical attraction of unlike molecules and works to enhance further the retentive
force of interfacial surface tension. Adhesion of saliva to the mucous membrane and denture base is
achieved through ionic forces between charged salivary glycoproteins and surface epithelium or acrylic
resin. It is also observed between the denture bases and the mucous membranes themselves, seen often
in patients with xerostomia. The denture base material sticks to the dry mucous membrane and other
oral surfaces. Such adhesion is ineffective for retaining dentures and is a precursor to mucosal
abrasions and ulcerations because of the lack of salivary lubrication.

The retention provided by adhesion is proportionate to the area covered by the denture; thus, dentures
should be extended to the limits of the health and function of the oral tissues, and efforts should be
made at all times to preserve the alveolar height to maximise retention.3

Cohesion
Cohesion is the physical attraction of like molecules. It is a retentive force that occurs within the fluid
layer present between the denture base and the mucosa to maintain the integrity of the interposed fluid.
Normal saliva is not very cohesive so that most of the retentive force of the denture-mucosa interface
comes from adhesive and interfacial factors unless the interposed saliva is modified. Despite thick,
high-mucin saliva being more viscous than serous saliva, thick secretions usually do not increased
retention of the denture base because serous saliva can be interposed in a thinner film to its thicker
counterpart. 3

Saliva and its effects on the denture-making process

Timothy Van
Saliva affects the denture making process especially during the impression-taking procedures.
Elastomeric impression materials do not tolerate or displace moisture which can cause voids in the
impression. Therefore, salivary flow should be minimised. Before even beginning impression taking,
we must ensure that the patient’s oral cavity is cool and dry to enable to knock off saliva stimulatory
receptors as saliva will affect our impression. This can be achieved by instructing the patient to rinse
vigourously with a mouthwash to remove ropey saliva and possible debris from the mouth.

The dentist must ensure that the denture is not ill fitting, as the minor salivary glands of the palate,
which are vital for retention, may come under excess pressure. As a result, the salivary ducts may
become blocked or the glands may themselves cause atrophy, reducing the salivary flow.

Oral Pathology
Treatment planning as discussed in another chapter is important in assessing whether any medications
or underlying conditions will affect the denture-making process or the final retention and stability of
the denture. The dentist must be wary of any conditions and what steps may be taken to resolve these
issues. Discussed below are two categories of saliva hypo and hypersalivation.

Hyposalivation/Xerostomia
In healthy adults the total quantity of saliva produced in 24 hours is between 1-2L, and decreased
production will cause xerostomia. The cause of salivary gland hypofunction/xerostomia can be
contributed to either: water/metabolite loss; damage to salivary glands and interference with neural
transmission. Common reasons for its occurrence include: chronic inflammation of the salivary glands,
Sjogren’s syndrome, irradiation treatment, dehydration, psychological factors and medication. And as
mentioned, denture patients with xerostomia will often have adhesion that occurs between the denture
base and the dry mucous membrane; thus, which will give rise to other complications.12

Hypersalivation
Hypersalivation has unknown origin; however, it has been noted in patients who initially wear artificial
dentures complain of hypersalivation for the first few weeks as the oral cavity adjusts to the new
appliance. However, pain-causing lesions may also cause hypersalivation for example: herpetic
stomatitis, aphthous stomatitis or ulcerative gingivitis.

Artificial alternatives to Saliva

There are several artificial alternatives to Saliva: an ethanol-free rinse containing aloe and lanolin, a
water-soluble lubricating jelly, or a saliva substitute containing carboxymethlcellulose or mammalian
mucin.3

Patients suffering from xerostomia due to irradiation or an autoimmune disorder such as Sjogren’s
syndrome may use medication such as oral pilocarpine to assist in salivary stimulation.

Summary
Saliva plays a crucial role in treatment planning and the effects upon the denture-making process.
Thus, an understanding of saliva and its role in oral health is required to identify, prevent and/or treat
the patient to achieve the most optimal outcome.

References (incomplete)
Timothy Van
1: Saliva and Oral Health / W.M. Edgar
2: http://arjournals.annualreviews.org/doi/full/10.1146/annurev.physiol.67.041703.084745
3. Boucher
4: Saliva and its relation to oral health / 4sky
5: clinically oriented anatomy
6: http://www.umanitoba.ca/faculties/dentistry/oral_biology/tutorials/parotid_facial.pdf
7: http://www.med.mun.ca/anatomyts/head/parotid.htm
8: http://www.mercksource.com/ppdocs/us/common/dorlands/dorland/images/fig_g_0011.jpg
9: http://www.becomehealthynow.com/article/bodydigestive/945
10:
http://mcb.berkeley.edu/courses/mcb136/topic/Gastrointestinal/SlideSet2/GI2_files/slide0002_image0
02.gif
11: Medical Physiology
12: Diseases of the oral cavity and Salivary glands / Dr. G. boering

Timothy Van