1. Dennis E. Lopatin, Ph.D. Page no. 1 Saliva as a Diagnostic Fluid Dennis E. Lopatin, Ph.D. University of Michigan

2. Dennis E. Lopatin, Ph.D. Page no. 2 Overview of Lecture Applications of Sialochemistry Applications of Sialochemistry Collection of Saliva Collection of Saliva Examples of Clinical Conditions Examples of Clinical Conditions Gingival Crevicular Fluid (GCF) Gingival Crevicular Fluid (GCF)

3. Dennis E. Lopatin, Ph.D. Page no. 3 Historical Background: Diagnostic Testing Rice Test (anxiety=dry mouth=guilt) Rice Test (anxiety=dry mouth=guilt)

4. Dennis E. Lopatin, Ph.D. Page no. 4 Saliva as a Mirror of the Body Tissue fluid levels of natural substances, as well as molecules introduced for therapeutic, dependency or recreational purposes Tissue fluid levels of natural substances, as well as molecules introduced for therapeutic, dependency or recreational purposes Emotional status Emotional status Hormonal status Hormonal status Immunological status Immunological status Neurological status Neurological status Nutritional and metabolic influences Nutritional and metabolic influences

5. Dennis E. Lopatin, Ph.D. Page no. 5 Applications of Sialochemistry Diseases of the salivary glands Diseases of the salivary glands Systemic diseases where salivary glands are involved Systemic diseases where salivary glands are involved Clinical situations in which salivary flow and chemistry are helpful in diagnosis or monitoring patient progress Clinical situations in which salivary flow and chemistry are helpful in diagnosis or monitoring patient progress

6. Dennis E. Lopatin, Ph.D. Page no. 6 Local Diseases Obstructive- neoplastic, mucus plugs, stones Obstructive- neoplastic, mucus plugs, stones Inflammatory- acute viral or bacterial, chronic recurrent bacterial, allergic Inflammatory- acute viral or bacterial, chronic recurrent bacterial, allergic Irradiation Irradiation Functional hyper- or hypoactivity Functional hyper- or hypoactivity

7. Dennis E. Lopatin, Ph.D. Page no. 7 Systemic Diseases Sjögren’s syndrome- lymphoepithelial lesions Sjögren’s syndrome- lymphoepithelial lesions Cystic fibrosis Cystic fibrosis Hormonal dysfunction- diabetes, pancreatitis, adrenal-cortex disease, thyroid disease, acromegaly, menopause Hormonal dysfunction- diabetes, pancreatitis, adrenal-cortex disease, thyroid disease, acromegaly, menopause Hypertension Hypertension Obesity and hyperlipidemia Obesity and hyperlipidemia Alcoholic cirrhosis Alcoholic cirrhosis Malnutrition Malnutrition Neurologic diseases- Parkinson’s disease, Bell’s and cerebral Neurologic diseases- Parkinson’s disease, Bell’s and cerebral Psychogenic diseases Psychogenic diseases

8. Dennis E. Lopatin, Ph.D. Page no. 8 Access to Saliva from Blood

9. Dennis E. Lopatin, Ph.D. Page no. 9 Clinical Situations Affecting Salivary Secretions Digitalis toxicity Digitalis toxicity Drug monitoring Drug monitoring Environmental pollutants Environmental pollutants Ovulation Ovulation Immunodeficiency Immunodeficiency Pharmacological agents Pharmacological agents –“Dry mouth” side effects, drugs with parasympathetic, sympathetic and ganglionic blocking effects –Direct effects- hypersensitivity or idiosyncratic reaction

10. Dennis E. Lopatin, Ph.D. Page no. 10 Methods of Collection of Saliva Whole Saliva Whole Saliva Catheterization Catheterization Parotid Saliva Parotid Saliva Submandibular (Submaxillary) Saliva Submandibular (Submaxillary) Saliva

11. Dennis E. Lopatin, Ph.D. Page no. 11 Limitations in Use of Whole Saliva An admixture of parotid, submandibular and minor gland secretions mixed with food debris, bacteria, shed cells, leukocytes and other particulate matter. An admixture of parotid, submandibular and minor gland secretions mixed with food debris, bacteria, shed cells, leukocytes and other particulate matter. Compositional studies are affected by proportions of secretions from different glands, as well as chemistry of non-salivary elements Compositional studies are affected by proportions of secretions from different glands, as well as chemistry of non-salivary elements In studies examining non-salivary components, must take care to exclude GCF, especially where inflammation is present. In studies examining non-salivary components, must take care to exclude GCF, especially where inflammation is present.

12. Dennis E. Lopatin, Ph.D. Page no. 12 Standardization of Collection Resting secretions Resting secretions –need an accommodation period of at least 5 minutes. (Influence of collection procedure as stimulus) Stimulated saliva Stimulated saliva –Consistent gustatory stimulant throughout the study Flow rate Flow rate –Timed, focus on specific gland Time of day Time of day –Circadian rhythm, time of collection is important

13. Dennis E. Lopatin, Ph.D. Page no. 13 Salivary Studies in Cystic Fibrosis (CF) CF gene cloned in 1991 CF gene cloned in 1991 The gene product is a cyclic AMP-regulated chloride ion channel named CFTR The gene product is a cyclic AMP-regulated chloride ion channel named CFTR Cystic Fibrosis Transmembrane Conductance Regulator Cystic Fibrosis Transmembrane Conductance Regulator Most investigators felt that chloride and water secretion was the unifying key to explain the abnormalities and consequences of CF. Most investigators felt that chloride and water secretion was the unifying key to explain the abnormalities and consequences of CF. A disease of all exocrine glands. A disease of all exocrine glands.

14. Dennis E. Lopatin, Ph.D. Page no. 14 Sialochemistry Studies of CF Marked increase in calcium, proteins and phosphate, most evident in submandibular glands Marked increase in calcium, proteins and phosphate, most evident in submandibular glands Turbidity of the submandibular saliva probably due to precipitation of calcium-binding proteins Turbidity of the submandibular saliva probably due to precipitation of calcium-binding proteins Too much overlap in calcium levels between CF and asthmatics to serve as screening test Too much overlap in calcium levels between CF and asthmatics to serve as screening test Flow rate of saliva from labial salivary glands virtually absent in 90% of CF children, probably due to turbidity and blockage of duct Flow rate of saliva from labial salivary glands virtually absent in 90% of CF children, probably due to turbidity and blockage of duct

15. Dennis E. Lopatin, Ph.D. Page no. 15 Diagnostic Aids in Clinical Situations Digitalis toxicity (calcium and potassium) Digitalis toxicity (calcium and potassium) Affective disorders (prostaglandin) Affective disorders (prostaglandin) Immunodeficiency (sIgA) Immunodeficiency (sIgA) Stomatitis in chemotherapy (albumin) Stomatitis in chemotherapy (albumin) Cigarette usage (cotinine) Cigarette usage (cotinine) Gastric cancer (nitrates and nitrites) Gastric cancer (nitrates and nitrites) Forensic medicine (blood group substance) Forensic medicine (blood group substance) Coeliac disease (anti-IgA gliadin) Coeliac disease (anti-IgA gliadin) Liver function (caffeine clearance) Liver function (caffeine clearance)

16. Dennis E. Lopatin, Ph.D. Page no. 16 Malignancy P53 Tumor suppressor antigen P53 Tumor suppressor antigen –inactivation in certain cancers leads to accumulation. Oral squamous cell carcinoma leads to anti-p53 antibodies in saliva Salivary Defensin-1 levels elevated in oral SCC (made by PMN’s). Salivary Defensin-1 levels elevated in oral SCC (made by PMN’s). C-erbB-2 (erb) Tumor marker associated with breast carcinoma. C-erbB-2 (erb) Tumor marker associated with breast carcinoma. CA 125 (ovarian cancer marker) associated with elevated salivary levels CA 125 (ovarian cancer marker) associated with elevated salivary levels

17. Dennis E. Lopatin, Ph.D. Page no. 17 Drug and Hormone Monitoring Psychiatrists studying methadone: advantages using saliva Psychiatrists studying methadone: advantages using saliva –humanitarian- less discomfort –clinical- patient acceptance of repeated testing –children and patients with limiting coping abilities –economic (do it yourself tests) HIV therapy HIV therapy Epilepsy Epilepsy

18. Dennis E. Lopatin, Ph.D. Page no. 18 Drugs

19. Dennis E. Lopatin, Ph.D. Page no. 19 Salivary Antibodies and Antigens Advantages in large scale studies Advantages in large scale studies Viral Screening Viral Screening Antigen Detection Antigen Detection –H. pylori (PCR of saliva) Antibody Screening Antibody Screening –rubella –hepatitis A and B –Shigella

20. Dennis E. Lopatin, Ph.D. Page no. 20 Gingival Crevicular Fluid (GCF) (E) Cervical enamel (OSE) Oral sulcular epithelium (JE) Junctional epithelium (OE) Keratinized oral epithelium

21. Dennis E. Lopatin, Ph.D. Page no. 21 Collection of GCF Static fluid Static fluid Timed crevicular fluid flow Timed crevicular fluid flow

22. Dennis E. Lopatin, Ph.D. Page no. 22 GCF Flow and Inflammation

23. Dennis E. Lopatin, Ph.D. Page no. 23 GCF Flow and Probing Depth

24. Dennis E. Lopatin, Ph.D. Page no. 24 GCF Flow and Menstrual Cycle GCF flow highest at ovulation GCF flow highest at ovulation

25. Dennis E. Lopatin, Ph.D. Page no. 25 GCF and Tetracycline Levels Blood by finger puncture Maximum GCF Minimum GCF

26. Dennis E. Lopatin, Ph.D. Page no. 26 Conclusions Sialochemistry provides important information in a variety of clinical and disease states Sialochemistry provides important information in a variety of clinical and disease states Greater acceptance by patients Greater acceptance by patients Non-invasive in most cases Non-invasive in most cases