Journal of Dental Research

Nature's demands on salivary glands are extensive and diverse and range from the reptilian need for a venomous drop to incapacitate its prey to the 100 quarts that ruminants require to digest a day's grazing. Other species depend on saliva not for survival, but for improving the quality of life, using the fluid for functions varying from grooming and cleansing to nest-building. Humans can manage without saliva; its loss is not life-threatening in any immediate sense, but it results in a variety of difficulties and miseries. Oral digestion per se is only of marginal importance in humans, but saliva is important in preparing food for mastication, for swallowing, and far normal taste perception. Without saliva, mealtimes are difficult, uncomfortable, and embarrassing. The complex mix of salivary constituents provides an effective set of systems for lubricating and protecting the soft and hard tissues. Protection of soft tissues is afforded against desiccation, penetration, ulceration, and potential carcinogens by mucin and anti-proteases. Saliva can encourage soft tissue repair by reducing clotting time and accelerating wound contraction. A major protective function results from the salivary role in maintenance of the ecological balance in the oral cavity via; (1) debridement/lavage; (2) aggregation and reduced adherence by both immunological and nan-immunological means; and (3) direct antibacterial activity. Saliva also possesses antifungal and anti-viral systems. Saliva is effective in maintaining pH in the oral cavity, contributes to the regulation of plaque pH, and helps neutralize reflux acids in the esophagus. Salivary maintenance of tooth integrity is dependent on: (1) mechanical cleansing and carbohydrate clearance; (2) post-eruptive maturation of enamel; (3) regulation of the ionic environment to provide a remineralizing potential without spontaneous precipitation; and (4) pellicle deposition and limitation of acid diffusion. Saliva also plays a role in water balance, can serve in a limited way in excretion, and has possible hormonal function in the gastro-intestinal tract.

It is very well established that the principal control of salivary secretion is derived from autonomic innervation. Transmission of a neural signal to a salivary gland acinar cell occurs chemically via neurotransmitters, the first messengers of a secretory response. Neurotransmitters bind to specific cell surface receptor proteins, an event which activates precise transduction mechanisms which then transfer the neural signal to the inside of the cell. There are two major transduction mechanisms operative in salivary gland acinar cells. One involves the generation of cAMP, the other involves the breakdown of plasma membrane polyphosphoinositides. For both mechanisms, the appropriate stimulated receptor activates a second plasma membrane protein, termed an N (or G) protein. The N protein requires GTP to activate an enzyme (adenylate cyclase or phospholipase C), which then catalyzes the formation of a second messenger (cAMP and inositol trisphosphate/diacylglycerol, respectively). This action provides the intracellular signal for secretory events (protein, fluid, electrolyte secretion) to begin.

Acinar cells of exocrine glands are highly specialized for producing, storing, and discharging secretory proteins for use on surfaces that represent interfaces between the organism and the surrounding environment. These functions are achieved through the secretory pathway that includes a series of functionally distinct intracellular compartments — the endoplasmic reticulum, subcompartments of the Golgi complex, and the secretion granule in which exportable macromolecules are stored at high concentrations. Most secretion occurs by granule exocytosis in response to external hormonal or neural stimuli. Although these processes have been traced in a variety of morphological and biochemical studies, very Utile is known about the mechanisms involved in facilitating and maintaining secretory storage, orchestrating discharge at the apical cell surface, and in ensuring conservation and re-internalization of the granule membrane. Recent studies initiated on cell fractions obtained from the rat parotid gland have provided significant insight into the protein storage conditions that prevail in the granule interior and the components of the granule membrane that are likely to be involved in general secretory function such as exocytosis.

Secretion of water and electrolytes in salivary glands occurs by a dual process involving the formation of a plasma-like, isotonic primary-secretion in salivary acini and its subsequent modification in salivary-ducts by the removal and addition of specific ions. The mechanisms underlying the formation of primary acinar secretion have been investigated with a number of experimental approaches such as electrophysiology, the measurement of ion transport in gland fragments and dispersed acinar cells, and the evaluation of the ionic requirements for secretion in isolated, perfused gland preparations. The ac-cumulated evidence suggests that salivary secretion is formed by a complex interaction between passive and active ion movements across acinar cell membranes, resulting in the trans-acinar movement of Cl and Na* and, by the osmotic gradient which develops, of water. A major consequence of stimulation is the release of K+ through Ca++ -and voltage-sensitive channels and its subsequent recycling back into the cells by ouabain- and furosemide-sensitive transport systems. This results in NaCl uptake across the basolateral cell membrane and the subsequent efflux of Cl through luminal membrane channels, which also appear to be sensitive to cellular Ca++. The rates of these various ion movements appear to be, therefore, closely linked and interdependent. Ductal modification of the primary secretion has been studied in microperfused duct preparations. The evidence likewise indicates that it involves interactions between complex conductance pathways in the luminal cell membrane and a Na, K pump present in the basolateral cell membrane and that it is under autonomic and hormonal control. Activation of ductal transport mechanisms results in NaCl reabsorption and KHCO3 secretion. Final saliva thus differs from primary secretion in electrolyte composition and, because water permeability is low in the duct epithelium, becomes hypotonic. Alterations in fluid and electrolyte secretion such as those observed in disease can result, therefore, from disturbances in one or more of these complex transport processes in acinar or duct cells.

This paper discusses methods for collection of both whole saliva and individual gland secretions, the normal ranges of salivary flow rate, the effects of physiological variables which influence flow rate, and the role of saliva in oral sugar clearance. The physiological basis for the sensation of dry mouth is discussed, and a new concept is advanced which states that the sensation of dry mouth will occur when the salivary flow rate is less than the sum of the rates of water absorption and evaporation from the mouth. In a study of the effects of anticholinergic agents on salivary flow, the subjects experienced the sensation of dry mouth when the normal flow rate of unstimulated saliva was reduced by from 40 to 50%.

Previous findings from studies utilizing human labial and palatine minor salivary glands are reviewed. These studies took histopathological, biochemical, and ultrastructural approaches, and focused on control and diseased glands. Disease-oriented summarizations are used, and control results are discussed in the context of disease-related findings. Findings are reviewed separately for electrolytes, macromolecules, and ultrastructure. In control subjects, minor gland salivary electrolyte concentrations are dependent on flow rate, and this dependence may be altered by diseases such as cystic fibrosis as-well as by inflammatory situations such as graft-versus-host disease. There is also evidence that salivary electrolyte secretion processes are not similar in labial and palatine minor glands. Studies of salivary macromolecular composition are reviewed for control subjects and for patients with graft-versus-host disease and Sjögren's syndrome. The findings indicate that the macromolecular contents of labial and palatine gland saliva are similar, but that both are significantly different from that for major gland saliva. Finally, studies attempting to measure disease-related changes in intracellular composition are reviewed. It is concluded that the minor salivary glands are important models for the study of exocrine gland physiology and pathophysiology in man.

The rheology of saliva affects the coating and lubrication of oral surfaces and the consistency of ingested foods. Salivary gland dysfunction can cause tissue damage and dysphagia. Therefore, we have considered the problem of designing a synthetic saliva for medical management. Also, we have measured certain rheological properties [shear-dependent viscosity η(κ)] and the frequency-dependent moduli [G'(f) and η'(f)] of normal stimulated whole saliva. Analysis of the rheological data and consideration of requirements for using artificial saliva have resulted in a better understanding of the rheological functions of natural saliva and the desirable characteristics of synthetic saliva. In addition, we have measured rheological properties of two commercial saliva substitutes for comparison.

Cystic fibrosis (CF) is a fatal autosomal recessive disorder which affects all exocrine glands, or perhaps all epithelial surfaces. The three organs most consistently affected are the eccrine sweat gland, which produces excessively salty sweat; the lung, in which chronic obstructive pulmonary disease invariably develops and is usually the cause of mortality; and the pancreas, which fails to produce adequate bicarbonate ion and water in nearly all patients, and produces in-adequate digestive enzymes in most, giving rise to pancreatic insuf-ficiency. However, the liver, reproductive tracts, intestine, sinuses, and salivary glands are also regularly affected. In the sweat gland and in the airways, passive chloride permeability is reduced, accounting for the salty sweat and probably contributing to the dehydrated mucus in the airways. In organs apart from the sweat gland, a common feature of the disease is the plugging of glandular acini and ductules by precipitated secretions. Salivary glands have been extensively studied in CF because of both the accessibility of the glands and their products, and the mix of mucous and serous components in the salivary glands. However, there is no unanimity in the results from parotid and submandibular glands. In the labial (mucous) glands, the sodium content of secreted product and in the secretory granules is markedly elevated, and histologically the acini are plugged with eosinophilic material. Functional studies of CF salivary glands have also yielded inconsistent data. Cultured cell systems combined with molecular biologic approaches offer promise in tracing the funda-mental CF defect in salivary and other epithelial systems.

Obstructive and inflammatory diseases of the salivary glands can have a congenital, traumatic, metabolic, or infectious-inflammatory cause. The acute inflammatory conditions include bacterial and viral infections, and the chronic conditions include sialoliths, strictures, chronic sialadenitis, sialectasis, and lymphoepithelial disease. The neoplastic diseases can cause obstruction and/or infection and often make the diagnosis elusive. In addition to a working knowledge of possible etiology, one needs experience with clinical examination, salivary analysis, sialography, CT scans, MRI, and fine-needle aspiration and cytology in order successfully to evaluate and manage patients with these conditions.

Saliva is important for maintaining oral health and function. There are instances when medical therapy is intended to decrease salivary flow, such as during general anesthesia, but most instances of iatrogenic salivary gland dysfunction represent untoward or unavoidable side-effects. The clinical expression of the salivary dysfunction can range from very minor transient alteration in saliva flow to a total loss of salivary function.

The most common forms of therapy that interfere with salivation are drug therapies, cancer therapies (radiation or chemotherapy), and surgical therapy. These therapies can affect salivation by a number of different mechanisms that include: disruption of autonomic nerve function related to salivation, interference with acinar or ductal cell functions related to salivation, cytotoxicity, indirect effects (vasoconstriction/dilation, fluid and electrolyte balance, etc.), and physical trauma to salivary glands and nerves.

A wide variety of drugs is capable of increasing or decreasing salivary flow by mimicking autonomic nervous system actions or by directly acting on cellular processes necessary for salivation; drugs can also indirectly affect salivation by altering fluid and electrolyte balance or by affecting blood flow to the glands. Ionizing radiation can cause permanent damage to salivary glands, damage that is manifest as acinar cell destruction with subsequent atrophy and fibrosis of the glands. Cancer chemotherapy can cause changes in salivation, but the changes are usually much less severe and only transient. Finally, surgical and traumatic injuries interfere with salivation because of either disruption of gland innervation or gross physical damage (or removal) of glandular tissue (including ducts).

Salivary gland hypofunction occurs most often as a consequence of numerous drug therapies, anti-neoplastic treatments, or systemic disease. There are no universally accepted means of treating gland dysfunction and the resultant subjective xerostomia. A few studies have suggested that treatment of underlying inflammatory connective tissue disease will improve salivary performance in Sjögren's syndrome. Most of these reports, however, have either been limited to a small number of patients or have failed to include objective measures of salivary gland output. A larger body of literature deals with attempts using many different sialogogues to stimulate salivary function in a variety of conditions. Again, many studies have failed to document salivary improvement objectively. Recently, interest has focused on three drugs: bromhexine, anethole-trithione, and pilocarpine hydro-chloride. Studies with these agents are reviewed, and current clinical investigations with pilocarpine are presented in detail.

Modern technology has allowed us to understand better the functions of saliva and now provides a rationale for developing: (1) diagnostic reagents for monitoring oral and systemic health status and (2) replacement therapies for individuals with salivary dysfunctions. Several areas of dental research are directed at augmenting or enhancing both the quality and quantity of saliva for individuals with dry mouth. An “intrinsic” approach is being explored which utilizes medications such as pilocarpine and bromhexine to stimulate the salivary glands to produce more saliva. An “extrinsic” approach proposes to use topically applied artificial saliva. Studies in our laboratory have been directed toward developing artificial salivas which incorporate many of the protective features of “native” saliva. An ideal artificial saliva should be “long-lasting”, provide lubrication, inhibit colonization of microflora responsible for dental caries and gingivitis, and coat the oral soft tissues for protection against environmental insult and desiccation. Studies are currently under way to determine the structural requirements of salivary molecules responsible for these protective functions. Composite salivary molecules consisting of multiple biologically active or “functional domains” could then be designed and synthesized based upon primary sequence and conformational analyses, computer-assisted structural predictions, and in vitro testing. These supersalivary substances could then be used as saliva substitutes for targeting to selected oral surfaces to promote mineralization, hydration, and/or regulate microbial-mediated disease.

The purpose of this paper is to enumerate and describe the oral complications that are associated with salivary gland dysfunction. The significance of these oral problems and their related adverse impact on the patient's quality of life are presented. Palliative and therapeutic agents and regimens are discussed, and a suggested protocol for managing the deleterious oral sequelae of salivary gland dysfunction is outlined.

A variety of immunologic mechanisms may theoretically give rise to disease in the salivary glands. Among them are abnormal antibody production, hyper-reactive T-lymphocytes, and mono- or oligoclonal expansions of B-lymphocytes, While it is not clear which, if any, of these mechanisms are of prime importance in the immunopathology of salivary gland disease, they provide a framework, within which to discuss theoretical approaches to the treatment of autoimmune salivary gland disease. Among the techniques used to decrease antibody-induced damage are non-steroidal anti-inflammatory agents, plasmapheresis, and corticosteroids. Cyclosporin, monoclonal antibodies, and biologic response-modifiers may be used to modulate T-cell function, and anti-idiotype antibodies or immunosuppressive agents may be used to treat malignant expansions of B-cells. Although the generally benign nature of autoimmune salivary gland disease precludes the use of many of the potentially toxic treatment regimens discussed here, the appreciation of these approaches to immunomodulation provides a basis upon which to develop new and innovative therapeutic strategies.