Saliva--the defender of the oral cavity

Regulation of salivary gland function by autonomic nerves

Oral homeostasis is dependent upon saliva and its content of proteins. Reflex salivary flow occurs at a low 'resting' rate and for short periods of the day more intense taste or chewing stimuli evoke up to ten fold increases in salivation. The secretion of salivary fluid and proteins is controlled by autonomic nerves. All salivary glands are supplied by cholinergic parasympathetic nerves which release acetylcholine that binds to M3 and (to a lesser extent) M1 muscarinic receptors, evoking the secretion of saliva by acinar cells in the endpieces of the salivary gland ductal tree. Most salivary glands also receive a variable innervation from sympathetic nerves which released noradrenaline from which tends to evoke greater release of stored proteins, mostly from acinar cells but also ductal cells. There is some 'cross-talk' between the calcium and cyclic AMP intracellular pathways coupling autonomic stimulation to secretion and salivary protein secretion is augmented during combined stimulation. Other non-adrenergic, non-cholinergic neuropeptides released from autonomic nerves evoke salivary gland secretion and parasympathetically derived vasointestinal peptide, acting through endothelial cell derived nitric oxide, plays a role in the reflex vasodilatation that accompanies secretion. Neuronal type, calcium-activated, soluble nitric oxide within salivary cells appears to play a role in mediating salivary protein secretion in response to autonomimetics. Fluid secretion by salivary glands involves aquaporin 5 and the extent to which the expression of aquaporin 5 on apical acinar cell membranes is upregulated by cholinomimetics remains uncertain. Extended periods of autonomic denervation, liquid diet feeding (reduced reflex stimulation) or duct ligation cause salivary gland atrophy. The latter two are reversible, demonstrating that glands can regenerate provided that the autonomic innervation remains intact. The mechanisms by which nerves integrate with salivary cells during regeneration or during salivary gland development remain to be elucidated.

Recovery of rat submandibular salivary gland function following removal of obstruction: a sialometrical and sialochemical study

Functional recovery of the rat submandibular gland following ligation of the main excretory duct was examined. Rat submandibular glands were ligated for 1, 4 and 8 weeks using a micro-clip with a plastic tube. Micro-clips were removed and glands were allowed to recover for periods of 8, 16 and 24 weeks. Submandibular glands were stimulated with autonomimetic drugs (methacholine and isoprenaline) and salivas were collected from atrophic or de-ligated and contralateral control glands. Glands recovered almost full size (92% of control gland) following 24 weeks of de-ligation. Saliva volume secreted by ligated/de-ligated (RSM) and control (LSM) glands were similar with different doses of agonists. Protein output expressed per gram of tissue wet weight was similar from both ligated/de-ligated and control glands with all doses of agonist. Sodium and chloride levels were higher from de-ligated glands than contralateral control glands. Protein electrophoresis showed similar profiles of salivary proteins in all samples with some minor differences. Acinar cells in de-ligated glands showed a normal morphology, as indicated by light microscopy, whilst granular ductal cells were fewer and contained fewer secretory granules. Sodium potassium ATPase staining of striated ducts in de-ligated glands was similar to that of control glands. It can be concluded that rat submandibular glands can regenerate following severe atrophy and secrete normal amounts of saliva containing broadly a full profile of secretory proteins. In contrast to acinar cells, ductal cells appear not to recover full function.

Toxicity and Biodistribution of a First-Generation Recombinant Adenoviral Vector, Encoding Aquaporin-1, After Retroductal Delivery to a Single Rat Submandibular Gland

Before conducting a phase 1/2 clinical trial of a serotype 5 adenovirus encoding human aquaporin-1 (AdhAQP1) for the treatment of radiation-damaged salivary glands, we have conducted a detailed toxicity and biodistribution study in adult rats. AdhAQP1 (2x108-2x1011 particles) was delivered to a single submandibular gland by retroductal cannulation. Administration of this vector resulted in no animal mortality or morbidities, and no adverse signs of clinical toxicity. In addition, over the 92-day time course of the study, with both male and female rats, there were no consistent treatment-related changes in serum indicators of hepatic, renal, and cardiac functions. Importantly, we also observed no vector-associated effects on either water consumption by, or hematocrit levels in, study animals. However, three suggestive mild gender-related response differences were seen. Female, but not male, rats exhibited small reductions in food consumption (10-15%) and body weight gain (5-10%), and evidence of persistent inflammation, after vector treatment. These were vector, but not dose, related. Three days after delivery of 2x1011 particles of AdhAQP1, vector was detected primarily in the targeted gland; 9 of 10 samples from the targeted gland were positive, whereas only 5 of 90 nonoral samples were positive. There was no evidence of the generation of replication-competent adenovirus in saliva or blood samples. In aggregate, these findings show that localized delivery of AdhAQP1 to salivary glands appears to occur without significant toxicity.

The oral ecosystem: implications for education

We propose a model that is applicable to oral health education. The model describes the oral cavity in a complexity-based ecological context. This concept includes the premise that factors from different organisational levels (biological, individual, community, society) interact in a complex way with the potential to 'stress' the ecosystem and thereby provoke changes. This mode of action complies with the understanding of the oral cavity as a complex adaptive system. An ecological model is actively used in the undergraduate problem-based curriculum at the Faculty of Odontology, Malmö University, Sweden and has recently been applied as a conceptual basis for the new dental curriculum being established at the University of Tromsø in Northern Norway. The purpose is to encourage and promote an ecological, health-oriented view and to stimulate reflections on premises for oral health and diseases in an integrated context.

Maltodextrin utilization plays a key role in the ability of group A Streptococcus to colonize the oropharynx

Analysis of multiple group A Streptococcus (GAS) genomes shows that genes encoding proteins involved in carbohydrate utilization comprise some 15% of the core GAS genome. Yet there is a limited understanding of how carbohydrate utilization contributes to GAS pathogenesis. Previous genome-wide GAS studies led us to a focused investigation of MalE, a putative maltodextrin-binding protein. Analysis of 28 strains of 22 distinct M protein serotypes showed that MalE is highly conserved among diverse GAS strains. malE transcript levels were significantly increased during growth in human saliva compared to growth in a chemically defined glucose-containing medium or a nutrient-rich medium. MalE was accessible to antibody binding, indicating that it is expressed on the GAS cell surface. Moreover, growth in human saliva appeared to increase MalE surface expression compared to growth in a nutrient-rich medium. Analysis of a delta malE isogenic mutant strain revealed decreased growth in human saliva compared to wild-type GAS. Radiolabeled carbohydrate binding assays showed that MalE was required for the binding of maltose but not glucose. The delta malE isogenic mutant strain colonized a lower percentage of GAS-challenged mice compared to wild-type and genetically complemented strains. Furthermore, decreased numbers of CFU were recovered from mice infected with the delta malE strain compared to those infected with wild-type GAS. These data demonstrate that maltodextrin acquisition is likely to be a key factor in the ability of GAS to successfully infect the oropharynx. Further investigation into carbohydrate transport and metabolism pathways may yield novel insights into GAS pathogenesis.

Effect of serotype 5 adenoviral and serotype 2 adeno- associated viral vector-mediated gene transfer to salivary glands on the composition of saliva

Key to the development of a useful clinical therapy is the minimization of side effects. Routine safety testing, however, does not provide information about the physiological status of many potentially useful gene transfer target sites. In this study, we evaluated the longitudinal effects of intrasalivary duct delivery of recombinant serotype 5 adenoviral (rAd5; 10(9)-10(10) particles/gland in rats) and recombinant serotype 2 adeno-associated viral (rAAV2; 10(8)-10(9) particles/gland in mice) vectors on salivary composition. Both vectors led to modest, transient alterations in several salivary components that thereafter returned to normal. The changes suggested two initial specific consequences of rAd5 and rAAV2 vector administration: (1) a modest breach of the mucosal barrier in the targeted glands, indicated by elevations in salivary albumin, total protein, and Na+ levels, and (2) an innate host response, indicated by transient elevations in either salivary lactoferrin and IgA levels (rAd5) or mucin (rAAV2). These studies are consistent with the notion that administration of modest doses of rAd5 and rAAV2 vectors to salivary glands for a therapeutic purpose can be accomplished without severe or permanent injury to the target tissue, or compromise to its essential exocrine physiological function.

Salivary gland gene therapy

Salivary glands have proven to be unusual but valuable target sites for multiple clinical gene transfer applications. Access to salivary glands for gene transfer is easy. Multiple studies in animal models have yielded proofs of concept for novel treatments for damaged salivary glands following therapeutic irraditation, in Sjögren's syndrome, and for gene therapeutics systemically by way of the blood-stream and locally in the oral cavity and upper gastrointestinal tract.

Radiation-related damage to dentition

Because of typical tissue reactions to ionising radiation, radiotherapy in the head and neck region usually results in complex oral complications affecting the salivary glands, oral mucosa, bone, masticatory musculature, and dentition. When the oral cavity and salivary glands are exposed to high doses of radiation, clinical consequences including hyposalivation, mucositis, taste loss, trismus, and osteoradionecrosis should be regarded as the most common side-effects. Mucositis and taste loss are reversible consequences, usually subsiding early post-irradiation, whereas hyposalivation is commonly irreversible. Additionally, the risk of rampant tooth decay with its sudden onset and osteonecrosis is a lifelong threat. Thus, early, active participation of the dental profession in the development of preventive and therapeutic strategies, and in the education and rehabilitation of patients is paramount in consideration of quality-of-life issues during and after radiotherapy. This Review focuses on the multifactorial causes of so-called radiation caries and presents possible treatment strategies to avoid loss of dentition.

Toward a genome-wide systems biology analysis of host-pathogen interactions in group A Streptococcus

Genome-wide analysis of microbial pathogens and molecular pathogenesis processes has become an area of considerable activity in the last 5 years. These studies have been made possible by several advances, including completion of the human genome sequence, publication of genome sequences for many human pathogens, development of microarray technology and high-throughput proteomics, and maturation of bioinformatics. Despite these advances, relatively little effort has been expended in the bacterial pathogenesis arena to develop and use integrated research platforms in a systems biology approach to enhance our understanding of disease processes. This review discusses progress made in exploiting an integrated genome-wide research platform to gain new knowledge about how the human bacterial pathogen group A Streptococcus causes disease. Results of these studies have provided many new avenues for basic pathogenesis research and translational research focused on development of an efficacious human vaccine and novel therapeutics. One goal in summarizing this line of study is to bring exciting new findings to the attention of the investigative pathology community. In addition, we hope the review will stimulate investigators to consider using analogous approaches for analysis of the molecular pathogenesis of other microbes.

Medications: a risk factor for periodontal disease diagnosis and treatment

Among the aging U.S. population, patients are taking significantly more medications than in the past. In view of this, dentists should take careful medical histories, including use of herbal agents, and be aware of medication-related problems and their potential effect on the diagnosis and treatment of periodontal disease. This review highlights major concerns about medications as a risk factor for periodontal therapy. Medications and their impact on periodontal disease can be categorized as those which affect oral hygiene, diagnosis, gingival and oral mucosa, and alveolar bone.

Adsorption behavior of antimicrobial peptide histatin 5 on PMMA

Adsorption of antimicrobial peptide histatin 5 on a poly(methyl methacrylate) denture base may serve to prevent biofilm formation, leading to a reduction of denture-induced stomatitis. This study focused on adsorption behavior of histatin 5 onto PMMA surfaces modified using a cold plasma technique and the effectiveness of histatin 5 adsorption for reducing Candida albicans biofilm formation by the quartz crystal microbalance-dissipation (QCM-D) technique. PMMA spin-coated specimens were treated with oxygen (O(2)) plasma using a plasma surface modification apparatus. The amount of histatin 5 adsorbed onto the PMMA treated with O(2) plasma is more than six times greater than that adsorbed onto untreated PMMA. The degree of histatin 5 adsorption had a negative correlation with the contact angle, whereas that of zeta-potential showed no significant correlation. XPS analysis revealed that the introduction of the carboxyl and O(2) functional groups were observable on the O(2) plasma-treated PMMA. Increased surface hydrophilicity and the formation of the carboxyl could be responsible for histatin 5 adsorption on plasma-treated PMMA. There is no significant difference between histatin-adsorbed PMMA and control PMMA for C. albicans initially attached. On the contrary, the amount of C. albicans colonization on histatin-adsorbed PMMA was significantly less than the control.

A statherin and calcium enriched layer at the air interface of human parotid saliva

Parotid saliva placed in 35-mm-diameter tissue culture dishes developed increasing surface viscoelasticity at the interface with air. A surface layer became visible with time, and was collected and analysed by protein electrophoresis which indicated that a single protein (pI 4.2; molecular mass approx. 6 kDa) predominated. Western blot analysis demonstrated that the major protein band reacted with an antiserum directed against the C-terminal of the calcium-binding salivary protein statherin. Matrix-assisted laser-desorption ionization-time-of-flight MS analysis gave a molecular mass of 5380 Da for the protein, corresponding to the molecular mass of statherin. Staining of film protein in electrophoresis gels was compared with statherin synthesized on a solid phase, and the mean statherin content of film formed from 1 ml of parotid saliva was measured as 7 nmol. The mean calcium content of the surface layer was 250 nmol. Surface rheology was greatly decreased in the presence of EDTA, whereas surface tension of saliva was unaffected by calcium chelation, suggesting that protein accumulated at the surface was unaffected. The results suggest that a layer rich in statherin forms at the interface of saliva and air, and that the surface rheology developed is dependent upon protein interactions mediated by calcium. The surface layer may enhance the function of saliva as a protective layer on the mucosal surfaces and teeth.

Transfer of the AQP1 cDNA for the correction of radiation-induced salivary hypofunction

The treatment of most patients with head and neck cancer includes ionizing radiation (IR). Salivary glands in the IR field suffer significant and irreversible damage, leading to considerable morbidity. Previously, we reported that adenoviral (Ad)-mediated transfer of the human aquaporin-1 (hAQP1) cDNA to rat [C. Delporte, B.C. O'Connell, X. He, H.E. Lancaster, A.C. O'Connell, P. Agre, B.J. Baum, Increased fluid secretion after adenoviral-mediated transfer of the aquaporin-1 cDNA to irradiated rat salivary glands. Proc. Natl. Acad. Sci. U S A. 94 (1997) 3268-3273] and miniature pig [Z. Shan, J. Li, C. Zheng, X. Liu, Z. Fan, C. Zhang, C.M. Goldsmith, R.B. Wellner, B.J Baum, S. Wang. Increased fluid secretion after adenoviral-mediated transfer of the human aquaporin-1 cDNA to irradiated miniature pig parotid glands. Mol. Ther. 11 (2005) 444-451] salivary glands approximately 16 weeks following IR resulted in a dose-dependent increase in salivary flow to > or =80% control levels on day 3. A control Ad vector was without any significant effect on salivary flow. Additionally, after administration of Ad vectors to salivary glands, no significant lasting effects were observed in multiple measured clinical chemistry and hematology values. Taken together, the findings show that localized delivery of AdhAQP1 to IR-damaged salivary glands is useful in transiently increasing salivary secretion in both small and large animal models, without significant general adverse events. Based on these results, we are developing a clinical trial to test if the hAQP1 cDNA transfer strategy will be clinically effective in restoring salivary flow in patients with IR-induced parotid hypofunction.

A mouse caries model and evaluation of aqp5-/- knockout mice

Current techniques to alter gene expression in mice allow direct analysis of the net role of a host factor in caries development. Towards this goal we first established protocols to induce and score caries in NFS/N mice and determined caries susceptibility in mice with targeted deletion of the gene encoding aquaporin-5 (Aqp5-/-), a water channel involved in the production of saliva. In the NFS/N strain of mice total sulcal caries and severity scores were consistent between experiments, whereas smooth surface caries scores were lower, more variable but distributed fairly evenly among the buccal, lingual and sulcal surfaces. In Black Swiss/129SvJ mice (genetic background of Aqp5-/- mice) caries scores were 50-75% lower compared to NFS/N mice, suggesting strain variation in caries susceptibility under our experimental conditions. In Aqp5-/- mice, in which the volume of total salivary secretion is reduced by 60-65%, there was a significant increase in caries, primarily on the buccal and sulcal surfaces. Results indicate that caries susceptibility increases with a reduced salivary flow that is associated with decreased water content of saliva.

Central role of a bacterial two-component gene regulatory system of previously unknown function in pathogen persistence in human saliva

The molecular genetic mechanisms used by bacteria to persist in humans are poorly understood. Group A Streptococcus (GAS) causes the majority of bacterial pharyngitis cases in humans and is prone to persistently inhabit the upper respiratory tract. To gain information about how GAS survives in and infects the oropharynx, we analyzed the transcriptome of a serotype M1 strain grown in saliva. The dynamic pattern of changes in transcripts of genes [spy0874/0875, herein named sptR and sptS (sptR/S), for saliva persistence] encoding a two-component gene regulatory system of unknown function suggested that SptR/S contributed to persistence of GAS in saliva. Consistent with this idea, an isogenic nonpolar mutant strain (DeltasptR) was dramatically less able to survive in saliva compared with the parental strain. Iterative expression microarray analysis of bacteria grown in saliva revealed that transcripts of several known and putative GAS virulence factor genes were decreased significantly in the DeltasptR mutant strain. Compared with the parental strain, the isogenic mutant strain also had altered transcripts of multiple genes encoding proteins involved in complex carbohydrate acquisition and utilization pathways. Western immunoblot analysis and real-time PCR analysis of GAS in throat swabs taken from humans with pharyngitis confirmed the findings. We conclude that SptR/S optimizes persistence of GAS in human saliva, apparently by strategically influencing metabolic pathways and virulence factor production. The discovery of a genetic program that significantly increased persistence of a major human pathogen in saliva enhances understanding of how bacteria survive in the host and suggests new therapeutic strategies.

Antimicrobial peptides in the oral environment: expression and function in health and disease

The oral cavity is a unique environment in which antimicrobial peptides play a key role in maintaining health and may have future therapeutic applications. Present evidence suggests that alpha-defensins, beta-defensins, LL-37, histatin, and other antimicrobial peptides and proteins have distinct but overlapping roles in maintaining oral health and preventing bacterial, fungal, and viral adherence and infection. The expression of the inducible hBD-2 in normal oral epithelium, in contrast to other epithelia, and the apparent differential signaling in response to commensal and pathogenic organisms, provides new insights into innate immunity in this body site. Commensal bacteria are excellent inducers of hBD-2 in oral epithelial cells, suggesting that the commensal bacterial community acts in a manner to benefit the overall innate immune readiness of oral epithelia. This may have major significance for understanding host defense in the complex oral environment.

Growth characteristics of and virulence factor production by group A Streptococcus during cultivation in human saliva

Group A Streptococcus (GAS) commonly infects the human oropharynx, but the initial molecular events governing this process are poorly understood. Saliva is a major component of the innate and acquired immune defense in this anatomic site. Although landmark studies were done more than 60 years ago, investigation of GAS-saliva interaction has not been addressed extensively in recent years. Serotype M1 GAS strain MGAS5005 cultured in human saliva grew to approximately 10(7) CFU/ml and, remarkably, maintained this density for up to 28 days. Strains of several other M-protein serotypes had similar initial growth patterns but did not maintain as high a CFU count during prolonged culture. As revealed by analysis of the growth of isogenic mutant strains, the ability of GAS to maintain high numbers of CFU/ml during the prolonged stationary phase in saliva was dependent on production of streptococcal inhibitor of complement (Sic) and streptococcal pyrogenic exotoxin B (SpeB). During cultivation in human saliva, GAS had growth-phase-dependent production of multiple proven and putative extracellular virulence factors, including Sic, SpeB, streptococcal pyrogenic exotoxin A, Mac protein, and streptococcal phospholipase A(2). Our results clearly show that GAS responds in a complex fashion to growth in human saliva, suggesting that the molecular processes that enhance colonization and survival in the upper respiratory tract of humans are well under way before the organism reaches the epithelial cell surface.

Increased fluid secretion after adenoviral-mediated transfer of the human aquaporin-1 cDNA to irradiated miniature pig parotid glands

The treatment of most head and neck cancer patients includes ionizing radiation (IR). Salivary glands in the IR field suffer irreversible damage. Previously, we reported that adenoviral (Ad)-mediated transfer of the human aquaporin-1 (hAQP1) cDNA to rat submandibular glands following IR restored salivary flow to near normal levels. It is unclear if this strategy is useful in larger animals. Herein, we evaluated AdhAQP1-mediated gene transfer after parotid gland IR (20 Gy) in the miniature pig. Sixteen weeks following IR, salivation from the targeted gland was decreased by >80%. AdhAQP1 administration resulted in a dose-dependent increase in parotid salivary flow to approximately 80% of pre-IR levels on day 3. A control Ad vector was without significant effect. The effective AdhAQP1 dose was 2.5 x 10(5) pfu/microl infusate, a dose that leads to comparable transgene expression in murine and minipig salivary glands. Three days after Ad vector administration little change was observed in clinical chemistry and hematology values. These findings demonstrate that localized delivery of AdhAQP1 to IR-damaged salivary glands increases salivary secretion, without significant general adverse events, in a large animal model.

Obstructive sleep apnea and head and neck neoplasms

OBJECTIVE

To elaborate the relationship between obstructive sleep apnea (OSA) and head and neck neoplasms (HNN).

STUDY DESIGN AND SETTING

A systematic review of the MEDLINE literature.

RESULTS

Thirty of 34 articles indexed under OSA and HNN were about neoplasms that presented first as OSA. Four of the articles were about treatment of HNN causing OSA and gave incidences varying from 8% to 92%. Quality of life surveys confirm that patients with malignant HNN have sleep problems. Xerostomia may contribute to these sleep problems, and the role of salivary mucins deserves consideration.

CONCLUSIONS

This review of the literature raises several new research questions about the clinical and biological relationships between OSA and HNN.

Statherin levels in saliva of patients with precancerous and cancerous lesions of the oral cavity: a preliminary report

OBJECTIVE

The aim of this study was to measure concentration of human salivary statherin in patients with oral cavity pathologies and salivary gland diseases.

SUBJECTS AND METHODS

Levels of statherin were analysed with High Performance Liquid Chromatography (HPLC) in following groups of subjects: group A: 24 patients with neoplastic diseases of salivary glands, group B: 13 patients with inflammatory lesions of salivary glands, group C: 13 patients with precancerous and cancerous lesions of the oral cavity excluding salivary gland tumors, group D: 20 healthy volunteers (control group).

RESULTS

Our preliminary data indicated a sensible reduction of the statherin level in the saliva of patients with precancerous and cancerous lesions of the oral cavity (group C) compared with the healthy subjects (group D). The statherin levels are not significantly reduced either in the inflammatory (group B) or in the salivary glands tumours (group A), compared with the healthy subjects (group D).

CONCLUSION

Statherin could play a protective effect in oral cavity in association with its other functions.

Toward defining the human parotid gland salivary proteome and peptidome: identification and characterization using 2D SDS-PAGE, ultrafiltration, HPLC, and mass spectrometry

Saliva plays many biological roles, from lubrication and digestion to regulating bacterial and leukocyte adhesion. To understand the functions of individual components and families of molecules, it is important to identify as many salivary proteins as possible. Toward this goal, we used a proteomic approach as the first step in a global analysis of this important body fluid. We collected parotid saliva as the ductal secretion from three human donors and separated the protein components by two-dimensional SDS-polyacrylamide gel electrophoresis (2D SDS-PAGE). Proteins in gel spots were identified by peptide mass fingerprinting, and the results were confirmed by tandem mass spectrometry of selected peptides. Complementing this approach we used ultrafiltration to prepare a low-molecular-weight fraction of parotid saliva, which was analyzed directly or after reversed phase high-performance liquid chromatography separation by using mass spectrometric approaches. MS analyses of 2D SDS-PAGE spots revealed known components of saliva, including cystatins, histatins, lysozyme, and isoforms and/or fragments of alpha-amylase, albumin, and proline-rich proteins. We also discovered novel proteins, such as several isoforms of Zn-alpha-2-glycoprotein and secretory actin-binding protein. MS analyses of the ultrafiltrate showed that the low-molecular-weight fraction of parotid saliva was peptide-rich, with novel fragments of proline-rich proteins and histatins in abundance. Experiments using Candida albicans as the test organism showed that at least one of the novel peptides had antifungal activity. Our results show that saliva is a rich source of proteins and peptides that are potential diagnostic and therapeutic targets.

Using the modified Schirmer test to measure mouth dryness: a preliminary study

BACKGROUND

Current methods of measuring saliva volume often are difficult to perform in a general dental or medical office setting. This study seeks to determine whether the Schirmer test for measuring eye dryness can be modified to measure mouth dryness.

METHODS

The authors performed a modified Schirmer test (MST) on a control group composed of 41 healthy adult volunteers and a study group composed of 10 patients who had received head and neck radiation and 10 patients who had oral chronic graft-versus-host disease (CGVHD). The authors placed the strip on the floor of each subject's mouth and took readings at one minute, two minutes and three minutes. Fourteen control subjects also spat into a container over a five-minute interval, and the authors weighed the collected saliva.

RESULTS

The mean reading for the control subjects at three minutes was 29.5 millimeters, while the mean reading for the test subjects was 6.9 mm (P < .00005).

CONCLUSIONS

The results of the MST were able to distinguish between healthy adult volunteers and subjects who experienced profound xerostomia and hyposalivation.

CLINICAL IMPLICATIONS

The MST as used in this preliminary study is an objective, inexpensive, easy-to-perform and well-tolerated test for measuring mouth dryness. It readily distinguishes between patients who are healthy and asymptomatic and those who experienced profound xerostomia and hyposalivation.

Randomized controlled trial of pilocarpine hydrochloride for the moderation of oral mucositis during autologous blood stem cell transplantation

Pilocarpine hydrochloride has been reported to increase salivation and decrease oral mucositis in patients receiving head and neck radiotherapy, but there is only one report of its use in a cancer chemotherapy patient population. This prospective, double-blinded, randomized, placebo-controlled trial was undertaken to determine the efficacy of pilocarpine for the moderation of oral mucositis during autologous blood stem cell transplantation. Subjects were randomized to receive a 5 mg tablet of pilocarpine, or a placebo, during and following chemotherapy. Subjects were seen every other day and evaluated for gingival, oral, and oropharyngeal mucositis; nutrition; oral hygiene; eating; speaking; sleeping; pain at rest and/or with swallowing; and mouth dryness. We recorded the mean and highest scores and duration of problems, along with white blood cell counts and differentials, and the use of systemic narcotics for oral mucosal pain. We enrolled and randomized 36 subjects, and there were no statistically or clinically significant differences for the primary outcome of severity of mucositis and no clinically significant differences in any of the other outcome measures. Pilocarpine has no benefit for the moderation of the incidence, severity, or duration of mucositis in patients receiving autologous blood stem cell transplantation.

An Approach to Oral Infections and Their Management

Oral infections can be odontogenic or nonodontogenic in origin. Odontogenic infections are most prevalent and include dental caries, periodontal disease, and suppurative deep space infections. Nonodontogenic infections include sialadenitis and parotitis, vesiculobullous gingivostomatitis, aphthous ulcers, oropharyngeal candidiasis, and severe oral mucositis in the immunocompromised host. Clinical presentations can be variable. An understanding of the underlying anatomic structures, the oral microflora, and associated medical conditions of the host is critical to guide appropriate diagnosis and management. In this paper, preventative strategies to reduce dental plaque formation and promote oral health are emphasized.

Host defense in oral and airway epithelia: chromosome 20 contributes a new protein family

The innate immune response is of pivotal importance in defending the mucosal barriers of the body against pathogenic attack. The list of proteins that contribute to this defense mechanism is constantly being updated. In this review we introduce a novel family of secreted proteins, palate, lung, and nasal epithelium clones (PLUNCs), that are expressed in the mouth, nose and upper airways of humans, mice, rats and cows. In humans, PLUNC genes are located in a compact cluster on chromosome 20, with similar loci being found in synteneic locations in other species. The protein products of this gene cluster are predicted to be structural homologues of the human lipopolysaccharide binding proteins, lipopolysaccharide binding-protein (LBP) and bacterial permeability-increasing protein (BPI), which are known mediators of host defense against Gram-negative bacteria. On the basis of these observations we outline why we believe PLUNC proteins mediate host defense functions in the oral, nasal and respiratory epithelia.

Effect of Saliva Composition on Experimental Root Caries

The aim of this study was to determine the effect of saliva composition on caries lesion development independently of the flow rate of unstimulated whole saliva (UWS) and other caries-related variables such as lesion progression time, oral hygiene level, and fluoride exposure. We hypothesized that this could be done by developing experimental root caries under carefully controlled conditions in situ in test subjects with UWS flow rates within a narrow window of normalcy. Fifteen female and 5 male subjects (66 +/- 6 years) were selected for the study according to their UWS flow rates between 0.2 and 0.4 ml/min. All subjects developed experimental root caries lesions during a 62-day period in which UWS as well as stimulated whole saliva (SWS) were repeatedly collected and analysed for flow rate, pH, buffer capacity, inorganic, and organic composition. Caries lesion development was determined by quantitative microradiography. The mean UWS flow rate was 0.30 +/- 0.05 ml/min. Significant negative correlations were obtained between UWS total phosphate concentration and mineral loss (DeltaZ; r(s) = -0.72, p < 0.001) and UWS total protein concentration and DeltaZ (r(s) = -0.70, p < 0.01). SWS and its constituents had only limited or no effect on DeltaZ. Qualitative UWS protein analysis (SDS-PAGE) revealed that subjects with low DeltaZ values had broader and more stained amylase bands than subjects with high DeltaZ values. These findings were confirmed quantitatively by HPLC. We conclude that, within a group of subjects with normal UWS flow rates, the UWS composition was more important for caries lesion development than the SWS composition. Furthermore, high UWS concentrations of phosphate, protein, and amylase were caries-protective.

Medications' impact on oral health

BACKGROUND

Over-the-counter and prescription drugs are used frequently, in large quantities and by many adults, particularly by those older than 65 years of age. A number of medications (prescription, over-the-counter, vitamins and minerals, herbal preparations) can affect oral health. With the population's aging, and as more drugs become available, dentists can expect to encounter medication-related oral side effects among their patients.

TYPES OF STUDIES REVIEWED

The author reviewed studies that ranged from case reports to randomly controlled, double-blinded studies. However, in view of the subject matter, the majority of findings are based on case reports.

CONCLUSIONS

Since many patients regularly take medications, both prescribed and nonprescribed, dentists always must take a thorough medical history so that they can be aware of medication-related problems and the impact of medications on diagnosis and treatment planning.

CLINICAL IMPLICATIONS

Dentists must be aware of the potential oral tissue complications that medications can create and develop appropriate treatment plans for their patients that consider the oral health impact of the medications they take.

Salivary glands: novel target sites for gene therapeutics

Directing the local or systemic expression of therapeutic proteins is a potentially important clinical application of gene transfer technology. Gene-based therapeutics theoretically offer many advantages over protein therapeutics. Numerous tissues have been evaluated for this purpose in animal models, most commonly the liver and skeletal muscle. Based on pre-clinical studies, we suggest that salivary glands are a valuable, yet under-appreciated, target tissue for both systemic and upper gastrointestinal tract gene therapeutic applications.

The role of oral microbial colonization in ventilator-associated pneumonia

The present article reviews the association between microbial colonization of the oral cavity and the lungs in critically ill patients that develop ventilator-associated pneumonia (VAP) in the intensive care unit (ICU) setting. The risk factors and microorganisms associated with VAP are presented. The role of oral colonization of VAP-associated pathogens (VAP-AP) in the development of VAP is examined. We explore the potential factors involved in oral colonization of VAP-AP, which are atypical bacteria for the oral cavity. Strategies for the prevention or moderation of oral colonization of VAP-AP have had limited success. We need a deeper understanding of the pathophysiology of VAP in order to reduce the morbidity, mortality, and cost from this common complication in ICU medicine and surgery.

Neuroendocrine regulation of salivary IgA synthesis and secretion: implications for oral health

Secretory immunoglobulin A (S-IgA) represents the main adaptive immune mechanism in the oral cavity. The regulation of secretion and synthesis of S-IgA is not only dependent on prior antigenic stimulation, but is also under strong neuroendocrine control. Thus, alterations in neuroendocrine functioning (such as induced by stress, exercise, pregnancy, menstrual cycle, and pharmacological interventions) may affect salivary IgA levels. This review deals with the neuroendocrine regulation of synthesis and secretion of salivary IgA and its potential role in the maintenance of oral health.

Correlation of peri-implant health and myeloperoxidase levels: a cross-sectional clinical study

OBJECTIVES

At present, there are no diagnostic tools that permit early detection of peri-implantitis. The purpose of this cross-sectional study was to evaluate the correlation of myeloperoxidase (MPO) levels with traditional periodontal clinical parameters around dental implants including peri-implant pocket probing depth (PPD), gingival index (GI) and bleeding on probing (BOP), since MPO has been associated with destruction of periodontal tissues.

MATERIAL AND METHODS

Twenty-four healthy adult volunteers (9 men and 15 women) with 64 Ankylos Biofunctional implants (DentsplyFriadent, Mannheim, Germany) were recruited from Tallinn Dental Clinic. Biochemical and clinical parameters evaluated were the following ones: the level of MPO in the peri-implant sulcus fluid (PISF) (an analog for gingival crevicular fluid in natural teeth), PPD (mm), GI (0,1,2 or 3), and BOP (0 or 1).

RESULTS AND CONCLUSION

In comparison to the clinically healthy implants, total amounts of MPO were significantly higher in PISF collected around implants with inflammatory lesions. In addition, the levels of MPO were correlated with the clinical parameters. The results confirm the similarity of the inflammatory response of tissues surrounding implants and natural teeth, and suggest that MPO could be promising marker of inflammation around dental implants.

Two-Dimensional Liquid Chromatography Study of the Human Whole Saliva Proteome

The human whole saliva proteome was investigated using two-dimensional liquid chromatography (2-DLC). The 2-DLC study was able to identify, with high confidence, 102 proteins including most known salivary proteins (35), and a large number of common serum proteins (67). Peptides from proline-rich proteins, abundant in saliva, had unusual cleavage sites and were frequently only partially tryptic. Three proteins not previously observed in human saliva were also detected. Significantly greater numbers of identified proteins, including high molecular weight, low molecular weight, and proline-rich proteins, were found with 2-DLC compared to previously reported two-dimensional gel electrophoresis studies.

Four reasons to consider a novel class of innate immune molecules in the oral epithelium

An expanding number of innate immune molecules occupy the "epithelial frontier". This review introduces a recently recognized class of mammalian proteins with similarity to PLUNC (palate, lung and nasal epithelium clone), which is itself related to the host defense protein BPI (bactericidal/permeability-increasing protein). Four emerging lines of evidence unite the PLUNC-like proteins: conserved genetic structure, epithelial expression, three-dimensional protein similarity, and a physiological response to injury or inflammation. By analogy to known proteins of the innate immune system, an emerging hypothesis for this family is that they act as sensors of Gram-negative bacteria in the oral cavity, among other areas.

Salivary proteins: protective and diagnostic value in cariology?

Saliva is essential for a lifelong conservation of the dentition. Various functions of saliva are implicated in the maintenance of oral health and the protection of our teeth: (i) The tooth surface is continuously protected against wear by a film of salivary mucins and proline-rich glycoprotein. (ii) The early pellicle proteins, proline-rich proteins and statherin, promote remineralization of the enamel by attracting calcium ions. (iii) Demineralization is retarded by the pellicle proteins, in concert with calcium and phosphate ions in saliva and in the plaque fluid. (iv) Several salivary (glyco)proteins prevent the adherence of oral microorganisms to the enamel pellicle and inhibit their growth. (v) The salivary bicarbonate/carbonate buffer system is responsible for rapid neutralization of acids. An overview is presented on the major antimicrobial systems in human saliva. Not only the well-known major salivary glycoproteins, including mucins, proline-rich glycoprotein and immunoglobulins, but also a number of minor salivary (glyco)proteins, including agglutinin, lactoferrin, cystatins and lysozyme, are involved in the first line of defense in the oral cavity. Besides, small cationic antimicrobial peptides, e.g. defensins, cathelicidin and the histatins, have come into focus. These are potentially suited as templates for the design of a new generation of antibiotics, since they kill a broad spectrum of microorganisms, while hardly evoking resistance, in contrast to the classical antibiotics.

Utilizing endocrine secretory pathways in salivary glands for systemic gene therapeutics

Mammalian salivary glands are commonly used models of exocrine secretion. However, there is substantial experimental evidence showing the physiological existence of endocrine secretory pathways in these tissues. The use of gene transfer technology in vivo has allowed the unambiguous demonstration of these endocrine pathways. We and others have exploited such findings and evaluated salivary glands as possible target tissues for systemic applications of gene therapeutics. Salivary glands present numerous advantages for this purpose, including being well encapsulated, which limits extra-glandular vector dissemination, and having the luminal membranes of almost all parenchymal cells accessible via intraoral delivery of vectors through the main excretory ducts. Existing studies suggest that clinical benefits will result from salivary gland targeted systemic gene therapeutics.

Involvement of periodontopathic biofilm in vascular diseases

Oral bacteria inhabit biofilms, which are firm clusters adhering in layers to surfaces and are not easily eliminated by immune responses and are resistant to antimicrobial agents. Dental plaque is one such biofilm. In the past 10 years, subgingival plaque bacteria forming biofilms have been increasingly reported to be involved in systemic diseases. A close relationship between microbial infections and vascular disease has also been reported in the past two decades. The present review discusses the significance of the ecologic characteristics of biofilms formed by periodontopathic bacteria in order to further clarify the associations between periodontal disease and systemic disease. We focus on the relationships between periodontal disease-associated bacteria forming biofilms and vascular diseases including atherosclerosis and carotid coronary stenotic artery disease, and we discuss the direct and indirect effects on vascular diseases of lipopolysaccharides as well as heat shock proteins produced by periodontopathic bacteria.

Prevention and treatment of the consequences of head and neck radiotherapy

The location of the primary tumor or lymph node metastases dictates the inclusion of the oral cavity, salivary glands, and jaws in the radiation treatment portals for patients who have head and neck cancer. The clinical sequelae of the radiation treatment include mucositis, hyposalivation, loss of taste, osteoradionecrosis, radiation caries, and trismus. These sequelae may be dose-limiting and have a tremendous effect on the patient's quality of life. Most treatment protocols to prevent these sequelae are still based on clinical experience, but alternatives based on fundamental basic and clinical research are becoming more and more available. Many of these alternatives either need further study before they can be incorporated into the protocols commonly used to prevent and treat the radiation-related oral sequelae or await implementation of these protocols. In this review, the various possibilities for prevention and/or treatment of radiation-induced changes in healthy oral tissues and their consequences are discussed.

Oral sequelae of head and neck radiotherapy

In addition to anti-tumor effects, ionizing radiation causes damage in normal tissues located in the radiation portals. Oral complications of radiotherapy in the head and neck region are the result of the deleterious effects of radiation on, e.g., salivary glands, oral mucosa, bone, dentition, masticatory musculature, and temporomandibular joints. The clinical consequences of radiotherapy include mucositis, hyposalivation, taste loss, osteoradionecrosis, radiation caries, and trismus. Mucositis and taste loss are reversible consequences that usually subside early post-irradiation, while hyposalivation is normally irreversible. Furthermore, the risk of developing radiation caries and osteoradionecrosis is a life-long threat. All these consequences form a heavy burden for the patients and have a tremendous impact on their quality of life during and after radiotherapy. In this review, the radiation-induced changes in healthy oral tissues and the resulting clinical consequences are discussed.

How can oral health care providers determine if patients have dry mouth?

BACKGROUND

Dentists recognize the importance of saliva in maintaining oral health and often are familiar with the clinical effects an insufficient salivary flow can have on oral tissues. A variety of medical conditions and medications can alter salivary secretion and composition. Typically, diagnosis of hyposalivation is made only after damage has occurred to the oral tissues.

OVERVIEW

The author describes a series of clinical steps that, if followed properly, may help in the early detection of salivary gland hypofunction and prevention of its severe complications. This four-step approach includes identifying a patient's chief complaint and the symptoms and duration of illness that brought the patient to the dentist, as well as any approaches the patient took to relieve symptoms; obtaining a medical history that includes a review of the body systems; performing a clinical evaluation that notes the patient's overall condition in addition to the health and functioning of the salivary glands and oral soft and hard tissues; and, when needed, conducting further diagnostic evaluations.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Oral health care providers will continue to face the challenges of treating new and recurrent carious lesions if the profession's approach to salivary hypofunction remains reactive rather than proactive. The recommendations in this article may enhance clinicians' awareness of the objective methods used to identify patients with salivary gland hypofunction or those at risk of developing it. It is hoped that early identification of asymptomatic patients at risk of developing hyposalivation, as well as symptomatic patients will lower the incidence and prevalence of dental caries and fungal infection in this population and ultimately enhance their quality of life.

Mineralized tissue and vertebrate evolution: the secretory calcium-binding phosphoprotein gene cluster

Gene duplication creates evolutionary novelties by using older tools in new ways. We have identified evidence that the genes for enamel matrix proteins (EMPs), milk caseins, and salivary proteins comprise a family descended from a common ancestor by tandem gene duplication. These genes remain linked, except for one EMP gene, amelogenin. These genes show common structural features and are expressed in ontogenetically similar tissues. Many of these genes encode secretory Ca-binding phosphoproteins, which regulate the Ca-phosphate concentration of the extracellular environment. By exploiting this fundamental property, these genes have subsequently diversified to serve specialized adaptive functions. Casein makes milk supersaturated with Ca-phosphate, which was critical to the successive mammalian divergence. The innovation of enamel led to mineralized feeding apparatus, which enabled active predation of early vertebrates. The EMP genes comprise a subfamily not identified previously. A set of genes for dentine and bone extracellular matrix proteins constitutes an additional cluster distal to the EMP gene cluster, with similar structural features to EMP genes. The duplication and diversification of the primordial genes for enameldentinebone extracellular matrix may have been important in core vertebrate feeding adaptations, the mineralized skeleton, the evolution of saliva, and, eventually, lactation. The order of duplication events may help delineate early events in mineralized skeletal formation, which is a major characteristic of vertebrates.

Morphological alterations of the parotid gland of rats maintained on a liquid diet

The purpose of this study was to analyze the morphological alterations that occurred in the parotid glands of rats maintained on a liquid diet compared to a solid diet. Thirty-six animals were randomly divided into two groups. The control group received a solid diet, and the experimental group received a liquid diet. The animals were killed after 8, 15 and 30 days. The glands were prepared for inclusion in paraffin and analyzed with a light microscope. The results showed a statistically significant reduction of the parotid gland weight of the animals from the experimental group compared to the control group at 15 and 30 days. The strongest morphological alteration displayed was the presence of cytoplasm vacuoles on the parotid glands of the animals maintained on the liquid diet. Specific stain techniques for glycoproteins and mucopolysaccarides could not identify the substances inside the vacuoles observed in the experimental animals. We conclude that a liquid diet caused atrophy of the parotid gland after 15 and 30 days.

Impact of lysozyme and lactoferrin on oral Candida isolates exposed to polyene antimycotics and fluconazole

OBJECTIVE

To assess the antifungal activity of lysozyme and lactoferrin on 10 oral isolates each of Candida albicans and Candida tropicalis following their brief exposure (I h) to subtherapeutic concentrations of two polyene drugs - nystatin, amphotericin B, and an azole -fluconazole.

METHODS

Yeasts were sequentially exposed to subtherapeutic concentrations of antifungals and then to either lysozyme or lactoferrin and the viability evaluated by quantifying colony-forming units.

RESULTS

The exposure of both C. albicans and C. tropicalis isolates to all three antifungal agents significantly increased their susceptibility to lysozyme (P < 0.05) but not to lactoferrin. Exposure to the two polyene drugs had a lesser impact on the lysozyme susceptibility of both Candida species compared with the azole drug. Both interspecies and intraspecies sensitivity to lysozyme was noted and C. albicans was less susceptible than C. tropicalis.

CONCLUSIONS

Lysozyme, in addition to being a potent natural antifungal agent, may act synergistically with the studied antimycotics.