•1 Presented by Linda M. Douglas, RDH, BSc [email protected]Innovations in Saliva-Based Diagnostics and Xerostomia Management Educational Objectives List the types of biomarker which are found in saliva Describe how biomarkers for systemic disease are transported into saliva Describe the oral and systemic conditions associated with a dry mouth Discuss the value of saliva-based diagnostics in your practice Create evidence-based clinical care plans and self-care protocols for dry mouth patients. Liquid Biopsy: Saliva-based Diagnostics for Oral and Systemic disease Image courtesy of Dr David Wong Salivaomics Knowledge Database Images reproduced with permission from Dr David Wong http://www.hspp.ucla.edu/skb.swf The UCLA Human Salivary Proteome research project Salivary Diagnostics How biomarkers for systemic disease are transported into saliva Cancer-derived exosome-like microvesicles are capable of interacting with salivary gland cells Tumor-derived RNA molecules transported through exosome vesicles from source of tumor, and re-processed into saliva as biomarkers Wang, X., Kaczor-Urbanowicz, K.E. & Wong, D.T.W. Med Oncol(2017) 34: 7. https://doi.org/10.1007/s12032-016-0863-4 Novel saliva testing Technologies (PCR, OFNASET & EFIRM) Wei, F, Patel, P, Liao, W, Chaudhry, K, Zhang, L, Arellano-Garcia, M, Hu, S, Elashoff, D, Zhou, H, Shukla, S, Shah, F, Ho, C M, and Wong, D T Electrochemical sensor for multiplex biomarkers detection. Clin Cancer Res, 2009; 15: 4446-4452.
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2018 TOWNIE MEETING INNOVATIONS IN SALIVA-BASED ...Stem cell therapy Adult Salivary Gland Stem Cells and a Potential Therapy for Xerostomia Sarah Pringle, Ronald van Os, Robert P Coppes.
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drugs are metabolised by Cytochrome P450 enzyme (CYP450)
Drugmap predicts changes in CYP450 activity.
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Saliva Drug Tests
Saliva MultiDrug Screen test kit ®
QuickScreen ®
iScreen ®
Saliva Glucose test
iQuickIt Saliva Analyzer
Xerostomia—A Growing Problem
Xerostomia affects at least
1 in 10 adults in the general
population
Images courtesy of Dr Andy Wolff
Philip C. Fox, DDS Interactive Textbook on Clinical Symptom Research
'Salivary lubrication, repair, lavage, antimicrobial and buffering properties contribute significantly to the maintenance of the integrity of the hard and soft oral tissue '.
Mandel I D. The role of saliva in maintaining oral homeostasis. J Am Dental Assoc 1989; 119: 298–304
Xerostomia
A 50% reduction in salivary flow occurs before xerostomia is noted .
Ettinger RL. Review: Age Ageing. 1996;25:409-412.Dawes C. Physiologic factors affecting salivary flow rate, oral sugar clearance,
and the sensation of dry mouth in man. J Dent Res. 1987;66(special issue):648-653
Etiology of Salivary Gland Hypofunction
Getting involved in diagnosing xerostomia can provide a window to
your patient’s overall health
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How Diseases & conditions cause Salivary Gland Hypofunction:
Local Factors
Developmental defects Abnormalities of the salivary ducts Tumours Sialoliths (salivary stones) Irradiation of the head and neck Uvulopalatoplasty (removal of uvula)
Jensen SB, Pedersen AM, Reibel J, Nauntofte B. Xerostomia and hypofunction of the salivary glands in cancer therapy. Support Care Cancer. 2003;11:207-225Vissink et al 2003: Oral sequelae of head and neck radiotherapy.
How Diseases & conditions cause Salivary Gland Hypofunction:
Systemic Factors
Dehydration Malnutrition Sympathetic response Damaged nerve supply Inflammatory response due to infection,
Cherington M. Clinical spectrum of botulism. Muscle Nerve .1998;21:701-710.Blazer T, Latzer Y, Nagler RM. Salivary and gustatory alterations among bulimia nervosa patients.Eur J Clin Nutr. 2007 Jul 11;
Moore PA, et al. Type I diabetes mellitus, xerostomia, and salivary flow rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92:281-291.
Xerogenic Diseases & Conditions
Dialysis Chronic
Mouthbreathing Cystic fibrosis Hepatitis C
HIV Sarcoidosis Thyroid disease Scleroderma Thalassemia major
Bots CP et al. The management of xerostomia in patients on haemodialysis: Palliative Medicine, Vol. 19, No. 3, 202-207 (2005) Albilia JB et al. Small mouths ... Big problems? A review of scleroderma and its oral health implications. J Can Dent Assoc. 2007 Nov;73(9):831-6. Review. PMID: 18028759
How Drugs cause Salivary Gland Hypofunction
Tissue damage
Altering fluid and electrolyte balance
Effect on neural pathways
Anticholinergic
Sympathomimetic
Vasoconstriction
ADA Council on Scientific AffairsConclusions and
Practice Implications
Health history Comprehensive
evaluation Corrective
actions
Interdisciplinary patient care
Patient education Palliative and
preventive measures
10.14219/jada.2014.44 The Journal of the American Dental Association August 1, 2014 vol. 145 no. 8 867-873
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Risk Assessment: A Xerostomia Screening Questionnaire
1. Does the amount of saliva in your mouth seem too little?
2. Do you have any difficulties swallowing?
3. Does your mouth feel dry when eating a meal?
4. Do you sip liquids to aid in swallowing dry food?
Fox PC, Busch KA, Baum BJ. Subjective reports of xerostomia and objective measures of salivary gland performance. JADA 1987;115(4):581–584
Images reproduced with permission from Professor
Stephen Challacombe
Chronic Salivary Gland Enlargement
Image courtesy of Sjögren’s Syndrome Foundation
Sjögren’s Syndrome Sarcoidosis HIV infection Hepatitis C Bulimia Nervosa Mucoepidermoid Ca Lymphoma
Your text here
Images reproduced with permission from
Eileen McQuade, RDH, BS
Your text here
Other Diagnostic Techniques
Blood testing
Immunologic testing
Biopsy-incisional, or
aspiration cytology
Endoscopy
Diagnostic imaging
Fox PC. Differentiation of dry mouth etiology. AdvDent Res. 1996;10:13-16.
Image reprinted with permission from Medscape
Reference http://emedicine.medscape.com/, 2013,
available at: http://reference.medscape.com/features/slideshow/neck-masses
Hands-On Saliva Testing
Image courtesy of Dr Steven Steinberg
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Saliva-Check BUFFER
Test for Saliva Quality, pH & Buffering Capacity
Image courtesy of http://www.gcamerica.com
Checking Hydration
Image courtesy of http://www.gcamerica.com
Test 1: Unstimulated (resting) saliva
•Collect unstimulated saliva-refrain from swallowing for 30 seconds, then spit into the cup
•Assess colour and consistency of saliva•Test resting salivary pH
Testing pH
Ideal saliva pH 6.8 to 7.5
Images courtesy of http://www.gcamerica.com/
Test 2: Collect Stimulated Saliva-Chew & Spit 5 min
Chew unflavored paraffin wax
Chew and spit saliva into cup every 15-20 seconds for 5 minutes
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The Salivary Flow Index:Salivary Flow Rates
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Unstimulated Stimulated
0.3 to 0.4mL/min
1 to 2mL/min
<0.1 mL/min
<0.7 mL/min
Normal Abnormal
mL/
min
Assessment of Saliva Saliva: The Movie
Hands-On Saliva Testing
Now Playing“Saliva” by Mew
Test 2 Continued: Testing Stimulated Saliva
Measure volume of Stimulated Saliva collected
Test Stimulated salivary pH
Keep this saliva for Buffer testing
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Test 3: Test Buffering capacity of stimulated saliva
Use pipette to drop saliva onto the three parts of the buffer test pad
Turn pad sideways on a tissue to remove excess saliva
Check the score with the colour chart after two minutes
Buffer Test
Testing capacity to buffer an acid
challenge
Images courtesy of http://www.gcamerica.com/
Testing for Cariogenic Bacteria
Image courtesy of .gcamerica.
Stimulate saliva
Saliva Substitution
Conserve functional salivary gland tissue
Multifaceted Management of Xerostomia and SGH
Prevent Caries, remineralize
Protect soft tissue
Palliation
Hydration
Sjögren’s Syndrome Foundation’s Clinical Practice
Guidelines: Caries Prevention
Fluoride Non-fluoride remineralizing
agents Salivary stimulation Antimicrobials
JADA April 2016,Volume 147, Issue 4, Pages 295–305 Clinical practice guidelines for oral management of Sjögren disease Domenick T. Zero et alwww.sjogren’s.org
Quinn et al. Efficacy of a supersaturated calcium p hosphate oral rinse for the prevention and treatment of oral mucositis in patie nts receiving high-dose cancer therapy: a review of current data. Eur J Canc er Care. 22:564-579;2013 .
Supersaturated Calcium phosphate rinse
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Images courtesy of Biotene, AS. Saliva Orthana and Lubricity