Salivary markers of systemic disease: noninvasive diagnosis of disease and monitoring of general health

Because of interest in the link between oral and general health, clinicians are increasingly using salivary analyses to diagnose systemic disease and to monitor general health. The reason for this interest lies in the ability of new diagnostic tools, such as sensitive enzyme-linked immunosorbent assays, as well as other technologies, to distinguish a range of salivary components that are biomarkers for changes in the body's health. The noninvasive nature of salivary testing has made it an attractive and effective alternative to blood and urine testing, and home testing kits have made it possible for people to monitor their own health using this diagnostic medium. This paper explores what saliva can reveal about general health, drawing examples from recent research on salivary biomarkers of systemic illness and highlighting the current use, and potential clinical and research applications, of diagnostics based on oral fluids.     

Stimulating the discussion on saliva substitutes: a clinical perspective

Xerostomia is a significant problem commonly faced by patients and oral health practitioners. There is no cure for this condition, which commonly manifests as a side effect of medications, head and neck irradiation and other systemic conditions, such as Sjögren's syndrome and type 2 diabetes. It may also arise idiopathically. Therefore, treatment is palliative and takes the form of oral lubricants and saliva substitutes which aim to reduce symptoms associated with xerostomia as well as prevent oral disease secondary to it. Recently there has been an expansion of the number and range of products available in Australia for the palliative management of xerostomia. It is imperative then that oral health professionals have a sound understanding of the advantages and disadvantages of using such products as patients tend to be well informed about new products which are commercially available. This article discusses some of the most commonly available products used for the symptomatic relief and preventive management of xerostomia. Amongst the plethora of products available to the patient suffering from xerostomia, no single product or product range adequately reproduces the properties of natural saliva and therefore consideration of patients' concerns, needs and oral health state should be taken into account when formulating a home care regime. With Australia's ageing population and its heavier reliance on medications and treatments which may induce xerostomia, oral health professionals are likely to encounter this condition more than ever before and therefore an understanding of xerostomia and its management is essential to patient care.     

Diagnosis and treatment of salivary gland disorders.

The keystone of the architecture of the oral cavity is saliva; however, it is rarely acknowledged as a vital physiologic secretion. Saliva plays three major roles in oral and systemic health. It provides host protection, assists in the initiation of food and fluid intake, and enables communication through speech. Without adequate salivary output augmented by a rich assortment of salivary proteins and electrolytes, oral and pharyngeal health declines as well as a person's quality of life. This article will provide a brief summary of the function of saliva, oral and systemic etiologies of salivary dysfunction, and methods to treat and prevent salivary disorders. Oral health care professionals can play a vital role in identifying patients at risk for developing salivary dysfunction and should provide appropriate preventive and interventive techniques that will help preserve oral health and function.     

Who cares for the oral health of dependent elderly and disabled persons living at home? A qualitative study of case managers' knowledge, attitudes and initiatives

In 1999 a new law in Sweden granted people receiving a certain level of supportive care from the community the right to receive a free, in-home oral health assessment. Subsequent appraisal has disclosed that far from all eligible people, especially those living at home, have undergone such an assessment. Of fundamental importance to the success of this scheme is the active involvement of case managers in identifying those who are eligible for assessment. The aim of this study was to investigate case managers' knowledge of and attitudes to the oral health of their clients and the initiatives they take to ensure that dependent elderly and disabled persons living at home have access to oral health care. In qualitative in-depth interviews, 24 case managers from three Swedish counties were questioned about their perceptions of oral health care for their clients.The transcribed text was analysed by manifest and latent qualitative content analysis. The manifest analysis was based on the three content areas knowledge, attitudes and initiatives. During this process a theme emerged which disclosed the case managers' perceptions of their role in oral health care among elderly and disabled persons, a latent analysis. The case managers' age, education, experience and breadth of responsibilities varied. Their knowledge of the 1999 law was limited. In general there were no procedures in place to ensure that the oral assessments were undertaken and that records were kept. The case managers considered that they should not be responsible, although they could not suggest a more appropriate instance. The potential role of regular oral health assessment in prevention of oral diseases was not discussed at all in the interviews. The current systems for monitoring oral health are tailored primarily to institutionalised care. In future many more dependent people will continue to live at home with support from community home care assistants and relatives. It is important that oral health care activities, as well as research, are modified accordingly.     

Parental perceptions of their preschool-aged children's oral health

BACKGROUND: Parents have an important role in making decisions about their children's oral health. The purpose of the authors' study was to determine parental perceptions of their children's oral health status and factors correlated with these perceptions of health. METHODS: The authors analyzed data for 3,424 children (2-5 years of age) from the Third National Health and Nutrition Examination Survey. They based the dependent variable on a question asked of primary caregivers: "How would you describe the condition of [child's name]'s natural teeth?" Explanatory variables included demographic variables, dental visits, perception of child's general health, need for dental care and presence of tooth caries. RESULTS: Eighty-nine percent of parents rated their child's oral health as excellent, very good or good, and 11 percent rated it as fair or poor (mean = 2.7 on a five-point scale, with 1 being excellent and 5 being poor). Tooth caries, perceived need for dental cleaning and treatment, lower income and poorer general health perceptions were associated with poorer parental ratings. CONCLUSIONS: Actual disease and perceived need are associated significantly with parents' perceptions of their children's oral health. PRACTICE IMPLICATIONS: Understanding parents' perceptions of their children's oral health and factors that motivate these perceptions can help dentistry overcome barriers that parents encounter in accessing dental care for their children.     

Saliva secretion rate and acidity in a group of physically disabled older care home residents

A growing number of older people have teeth, which are vulnerable to oral diseases. To maintain good oral health, an adequate amount of saliva should be secreted and the saliva should possess adequate buffer capacity. The study aim was to investigate the associations of saliva secretion rate and acidity with gender, age, and some medical characteristics in a convenience sample of physically disabled older care home residents. In 20 male and 30 female physically disabled older care home residents with a mean age of 78.1 ± 9.7 years, the resting, chewing-stimulated, and acid-stimulated whole saliva secretion rate and acidity, as well as the main medical diagnosis and the number of medications used, were registered. Resting, chewing-stimulated and acid-stimulated whole saliva secretion rates were lower in women than in men and negatively associated with age and the number of medications used. In female residents, the acidity of acid-stimulated whole saliva was negatively associated with the acid-stimulated whole saliva secretion rate. In residents aged >70 years, the acidity of resting whole saliva was positively associated with age. The acidity of acid-stimulated whole saliva of all residents was positively associated with the number of medications used.     

Salivary lactobacillus counts as a diagnostic and didactic tool in caries prevention

The usefulness of salivary lactobacillus counts in regular dental care was investigated in 236 13 1/2-yr-old Swedish children for 2 1/2 yr. The average individual preventive care was at least as extensive as the restorative care and the dental health of these children must be considered good with a mean DFS-value of 6.8 at baseline. Nevertheless, it proved possible to reduce caries increment by more than 50%, simply by replacing one NaF-rinsing in school once every 6 months by a saliva sampling session together with subsequent presentation and information of an inoculated and incubated Dentocult dip-slide. The way of determining salivary lactobacillus counts in schoolchildren, as performed in this study, could easily be adopted as a routine part of general care. It proved to be useful for early diagnosis of caries and motivation to home care, and as a supplement to clinical examination it would be a valuable aid in the early selection of high-risk cases as well as identification of low-risk cases, who do not require extensive prevention.     

Factors influencing whether low-income mothers have a usual source of dental care

Mothers are both the source of dental caries and the managers of children's use of dental care. This is particularly important for the low-income population. The objective of this research was to explore predictors of having a usual source of dental care among low-income women. Eight-hundred-ten mothers (82 percent white, mean age twenty-seven years), drawn from among participants in an ABCD program in one Washington State County completed a study questionnaire. The study examined predisposing, enabling and illness level variables in relation to whether the mother reported a usual source of dental care for herself. Fifty-two percent of the subjects gave positive answers to the dependent variable Do you now have a dentist you can go to if you have a problem? The analysis suggests that mothers that report good oral health and believe in care for their children are five times as likely to have a usual source of care for themselves than mothers who report both poor oral health and more negative attitudes about dental care for children. The results suggest that interventions aimed at child health that ignore the welfare of the mother are likely to be less successful than those that also address the mothers' needs.     

Home care workers' oral health awareness and practice for disabled elderly]

The purpose of this study was to investigate the level of oral health awareness, and to explore the needs for home care workers to provide oral health care for disabled elderly. We conducted a questionnaire survey at two home-help service centers and a social welfare council. Subjects for this investigation were 63 home care workers. The results were as follows: 1. Ninety-six percent of home care workers thought it was necessary to provide oral health care for disabled elderly, but only 11 percent of them put oral care into practice on a daily basis. 2. From the results of a cause and effect diagram, necessities of oral care were summarized as six major causes: 1) Disabled elderly are often unable to brush their teeth, 2) The oral hygiene level may affect physical condition, 3) Disabled elderly should be protected from oral diseases, 4) Disabled elderly should have their mouths kept clean, 5) Eating and swallowing may become increasingly difficult, 6) Disabled elderly should take in adequate nutrition. 3. Sixty-eight percent of home care workers took part in a training course of nursing care including oral care. 4. Home care workers, dentists, dental hygienists, and nurses taught oral health care to home care workers. 5. From the results of a cause and effect diagram, there were three major items that home care workers want to know: 1) denture management, 2) the routine of oral care, 3) infection control. 6. Home care workers recognized that oral care should be provided by family members of disabled elderly or home care workers.     

Atraumatic dental treatment among Finnish elderly persons

There is an increase in elderly dentate adults who will retain more of their natural teeth, and thus the demand for restorative dental services among them will be high. In Finland, systematic dental care for old people has not been organized. Health centres have mainly targeted the development of dental care for children, adolescents and young adults. With this background, atraumatic restorative treatment (ART) was seen as a complementary procedure in oral health services for the elderly. It was tested in 1997-1999 in Helsinki among 119 old people (mean age 72.5 years) living in their homes and receiving community-based support services. Patients were satisfied with having dental examination and oral health education at home. The ART fillings (n=33) were provided for 21 persons and depuration for 56. After 1 year, 25 fillings (58%) could be evaluated: 68% of the fillings were assessed as being good, 11% as having a slight marginal detect and 16% as having unacceptable marginal defect, and one filling was totally lost. In conclusion, ART is an appropriate approach in dental care for the elderly. However, more testing should be completed to find out how the screening could be organized to make the dental home visits more cost-effective and less time consuming.     

Prevention and dental health services

There has been, and still is a firm belief that regular use of dental services is beneficial for all. Thus governments in most European countries have shown some interest in training oral health care professionals, distributing the dental workforce and cost sharing. Constantly evolving treatment options and the introduction of new methods make dental clinicians feel uncertain as to which treatments are most useful, who would benefit from them, and which treatments will achieve cost-effective health gain. Although there is a considerable quantity of scientific literature showing that most available preventive measures are effective, and the number of sensible best-practice guidelines in prevention is growing, there are few studies on cost-efficiency of different methods and, secondly, the prevention and treatment guidelines are poorly known among general practitioners. In the eyes of the public, it is obvious that preventive methods practised by patients at home have been eclipsed by clinical procedures performed in dental clinics. Reliance on an increasingly individualistic approach to health care leads to the medicalisation of issues that are not originally health or medical problems. It is important to move general oral disease prevention back to the people who must integrate this in their daily routines. Prevention primarily based on healthy lifestyles, highlighted in the new public health strategy of the European Union (EU), is the key to future health policy.     

The value of dentures

Dentures may be boring, but they are a major part of dentistry, and will be for the foreseeable future. While implants are growing in popularity, there will always be patients who opt for dentures. It is your duty to inform patients of the need to have their dentures remade periodically, to ensure excellent oral care. Be sure to manage patient expectation and to create an effective system for prompt payment. This will enable you to help patients achieve good oral health, while maximizing your profit.     

Developing lifetime relationships with patients: strategies to improve patient care and build your practice

AIM: The purpose of this article is to describe three strategies to build a thriving, patient-centered practice and promote oral health throughout a patient's lifetime. BACKGROUND: Compared to previous decades, more dental patients are "shopping around" for dental care and changing dental practices. This trend is due to factors such as acceptance of dental insurance, more comprehensive service offerings by other dentists, and effective marketing campaigns by other dental offices. FINDINGS: Delivering customer service exceeding patient expectations ("WOW" service), advocating patient education, and developing customized home care regimens will help lead to long-term patient retention and promote optimal patient care. DISCUSSION: A dental team making relationship-building a priority conveys respect for their patients' time and well-being. Once trust has been established patients are more likely to be receptive to oral health education and become more compliant with home care regimens. Since a patient's oral health status will likely change over time, it's important to make education and customized treatment planning an integral part of each visit. CONCLUSIONS: By demonstrating a strong commitment to customer service, education, and home care, patients recognize the care providers in a dental practice are interested in their well-being rather than simply treating problems. CLINICAL SIGNIFICANCE: If patients recognize a dental practice is focused on prevention and at-home oral health care, they are more likely to partner with that practice for a lifetime of excellent oral health care.     

Oral status, oral hygiene habits and caries risk factors in home-dwelling elderly dependent on moderate or substantial supportive care for daily living

Strömberg E, Hagman‐Gustafsson M‐L, Holmén A, Wårdh I, Gabre P. Oral status, oral hygiene habits and caries risk factors in home‐dwelling elderly dependent on moderate or substantial supportive care for daily living. Community Dent Oral Epidemiol 2011;. © 2011 John Wiley & Sons A/S Abstract – Objectives: Elderly people with disabilities have an increased risk of developing oral diseases as compared with the healthy elderly. The aim of this study was to investigate oral hygiene habits, clinical variables related to oral self‐care and caries risk in elderly individuals living at home with moderate and substantial needs of home care. Methods: A random sample of 151 elderly people with moderate needs and 151 with substantial needs of home care were examined. Data concerning general health, social conditions and oral hygiene habits were collected using a questionnaire. Data showing the prevalence of caries, plaque scores and gingival bleeding were obtained through clinical examinations. Results: Elderly subjects with substantial needs of home nursing had more active caries (P < 0.01) and more often gingival bleeding (P < 0.05), as compared with elderly people with moderate needs. Forty‐nine per cent of the elderly with moderate needs performed acceptable self‐care, as compared with 25% of the individuals with substantial needs. Good self‐care was associated with women, low plaque scores, less bleeding and less caries. Factors increasing the risk of having caries were low saliva secretion, high plaque scores and a large number of fillings, while having a dentist and good oral hygiene habits increased the chance of not developing caries. Conclusions: Good oral hygiene habits were associated with less prevalence of plaque and oral disease in the elderly irrespective of extent of needs of home nursing. However, the elderly with moderate needs more often performed good self‐care, indicating that the possibilities of strengthening self‐care and learning new routines are better when functions are less affected.     

State case studies: improving access to dental care for the underserved

Introduction: This article, a supplement to the work of the Institute of Medicine's Committee on Oral Health Access, examines dental access disparities, reviews societal strategies for reducing disparities, explores the relationship between state level public health and dental safety net efforts and utilization/oral health outcomes, and describes selected public health and safety net programs with special promise. Methods: Data were obtained from interviews with state dental directors and safety net leaders and a review of the literature. Findings: There is a two-fold difference in utilization rates between low- (<30 percent) and high- (56 percent) income families. The three societal strategies for reducing disparities - Medicaid, dental safety net system, and increasing the supply of dentists - all have significant limitations. The primary factor positively related to oral health is per capita income. Five promising programs for reducing access disparities include a dental home initiative for young children; a virtual dental home for school children and nursing home residents; a women, infants, and children early oral education and prevention intervention program; an enhanced Medicaid reimbursement program for educational institutions in North Carolina; and a school-based dental care system run by Connecticut Federally Qualified Health Centers. Conclusions: There are wide disparities in access to dental care, and current societal strategies to reduce disparities have significant limitations. At the state level, the primary determinant of oral health status is per capita income. Several states have promising programs to reduce disparities but most are still at the demonstration level and have not been adequately evaluated.     

The preferences of adult outpatients in medical or dental care settings for giving saliva, urine or blood for clinical testing

BACKGROUND: The design of new diagnostic tests would benefit from knowing patients' preferences for the collection of bodily fluids. These preferences, however, are unknown. The authors assessed patients' preferences for the collection of saliva, urine and blood as diagnostic fluids. METHODS: The authors handed out surveys adult outpatients who sought treatment at two medical care sites and one dental care site at a medical center regarding the comfort, convenience and ease of collection of saliva, urine and blood for diagnostic testing. RESULTS: A total of 413 surveys were completed. Subjects regarded the donation of saliva as more comfortable and convenient than that of blood or urine at the doctor's (physician's or dentist's) office, and they reported that saliva and urine are easiest to collect at home compared with blood. Male subjects and subjects who had ever donated saliva were more likely to perceive saliva donation in the doctor's office favorably. Subjects at all care sites regarded the donation of saliva as more comfortable and convenient than that of blood or urine; however, subjects at the dental care site perceived saliva donation more favorably than did subjects at the medical care sites. In addition, respondents said they were more willing to participate in research and medical testing if it required saliva donation rather than urine or blood collection. CONCLUSIONS: In terms of convenience and comfort, saliva compared well with blood and urine as a diagnostic fluid for clinical and research testing. Patients who sought care at both medical and dental sites shared these perceptions. CLINICAL IMPLICATIONS: Given strong patient preferences, saliva may be the fluid of choice for the development and implementation of patient-centered diagnostic tests in research and practice.     

What does saliva represent to the dentist?

Despite the undoubtedly large impact of saliva on the patient's oral health, little is known about its exact properties and role. More research has been put into serum, when compared to saliva, although that is changing. More and more researchers are interested in the role of certain proteins or electrolytes in an oral disease process. Besides the purely laboratory research, practitioners are also interested in the bacterial colonisation of the oral fluids, especially in assessing a patient's caries risk. The use of bacterial chair-side tests illustrates this aspect of progression in oral health care. For the dental professional, saliva is an important ally in preventing dental caries and mucositis. The lubrication properties and antibacterial/antiviral function of saliva play an important role in the protection of the oral cavity. These aspects may be suppressed in some medically compromised patients. In those cases, the dental professional is faced with a challenge to solve the oral health problems.     

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近十余年来,牙酸蚀症患病率不断上升,已成为一个新的口腔健康问题。各国学者进行了大量的调查和研究,认为牙酸蚀症是一种多因素的疾病,是化学、生物、行为等多种因素相互影响、相互作用的结果。对于牙酸蚀症的易感人群,应对其饮食习惯、口腔卫生习惯、牙齿结构、唾液及获得性膜等方面进行风险评估,并综合分析各项评估结果,以利于诊断和为不同风险级别的易感者制定全面的预防策略。     

Preventing and detecting oral cancer. Oral health care providers' readiness to provide health behavior counseling and oral cancer examinations

BACKGROUND: The authors conducted a study to examine oral cancer prevention and early detection practice patterns in a population-based random sample of practicing oral health care professionals in New York state. METHODS: The authors surveyed a population-based, self-weighting, stratified random sample of dentists (n = 1,025) and dental hygienists (n = 1,025) in New York state. They assessed the subjects' readiness to offer tobacco-use cessation and alcohol-abuse counseling and oral cancer examinations. RESULTS: The effective response rates were 55 and 66 percent for dentists and dental hygienists, respectively. In terms of readiness to perform oral cancer examinations for patients aged 40 years and older, the large majority (82 percent of dentists and 72 percent of dental hygienists) were in the maintenance stage of behavior, indicating that oral cancer examinations were a routine part of their practice. In terms of readiness to offer tobacco-use cessation counseling, only 12 percent of dentists and 21 percent of dental hygienists were in the maintenance stage, and only 2 percent of dentists and 4 percent of dental hygienists were in the maintenance stage of offering alcohol-abuse counseling. CONCLUSIONS: Oral cancer examinations seem to have been adopted as a standard of practice by most oral health care providers in New York state, but cancer prevention services, such as counseling regarding cessation of tobacco use and alcohol abuse, are lacking. CLINICAL IMPLICATIONS: Oral health care providers should be trained in oral cancer prevention services such as tobacco-use cessation and alcohol-abuse counseling and encouraged to include these services, along with continued provision of oral cancer examinations, as a standard aspect of care.     

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.