Sialometry: aspects of clinical interest

Abstracts

Whole saliva is a multiglandular secretion complex consisting of gingival fluid, desquamated epithelial cells, microorganisms, products of bacterial metabolism, food debris, leukocytes mucus from the nasal cavity and the pharynx. Saliva has many functions, including tissue repair, tamponage, protection, digestion, taste, antimicrobial action, maintaining tooth integrity and antioxidant defense system. A decrease in salivary flow (hyposalivation) is a common disorder and it is estimated that approximately 20% of the general population have this alteration. Hyposalivation may be due to diabetes mellitus, hypothyroidism, dehydration, impaired glandular parenchyma by infectious processes, granulomatous diseases or autoimmune and inflammatory conditions (such as Sjogren's syndrome and rheumatoid arthritis), radiotherapy of head and/or neck region, or it may be associated with mood disorders, adverse effects caused by the use of some medications or even be idiopathic. Conventional therapies for the treatment of reduced saliva flow with the use of chemical and gustatory secretagogues are still limited. However, new alternatives have shown great perspective in the treatment of this disorder. To diagnose a patient as having chronic hyposalivation is a challenge in clinical practice and methods of salivary flow assessment are little known by rheumatologists. The serial evaluation of salivary flow is important for the diagnosis and prognosis of certain oral and systemic conditions. This review addresses some aspects related to the role of saliva, the consequences of hyposalivation and methods of salivary flow rate measurement, useful concepts in the daily practice of rheumatology.

Saliva; Sialometry; Salivary flow; Hyposalivation; Xerostomia

A saliva total é um complexo de secreções multiglandulares composto de fluido gengival, células epiteliais descamadas, microrganismos, produtos do metabolismo bacteriano, resíduos alimentares, leucócitos, muco da cavidade nasal e da faringe. A saliva possui diversas funções, incluindo reparação tecidual, tamponamento, proteção, digestão, gustação, ação antimicrobiana, manutenção da integridade do dente e sistema de defesa antioxidante. A redução do fluxo salivar (hipossalivação) é um distúrbio comum, e estima-se que cerca de 20% da população geral tenham esta alteração. A hipossalivação pode ser decorrente de diabetes mellitus, hipotireoidismo, desidratação, comprometimento do parênquima glandular por processos infecciosos, doenças granulomatosas ou condições autoimunes e inflamatórias (como a síndrome de Sjögren e a artrite reumatoide), radioterapia da região cefálica e/ou cervical, bem como pode estar associada a distúrbios do humor, efeitos adversos ocasionados pelo uso de algumas medicações ou, ainda, ser de causa idiopática. As terapias convencionais para o tratamento da redução do fluxo salivar, com o uso de sialogogos gustatórios e químicos, ainda apresentam restrições. Contudo, novas alternativas têm mostrado grande perspectiva no tratamento deste problema. Diagnosticar um paciente como hipossalivador crônico é um desafio na prática clínica, e os métodos de avaliação do fluxo salivar são pouco conhecidos pelos reumatologistas. A avaliação seriada do fluxo salivar é importante para o correto diagnóstico e prognóstico de determinadas condições bucais e sistêmicas. Esta revisão aborda alguns aspectos relacionados à função da saliva, às consequências da hipossalivação e aos métodos de medição da taxa de fluxo salivar, conceitos úteis na prática diária do reumatologista.

Saliva; Sialometria; Fluxo Salivar; Hipossalivação; Xerostomia

REVIEW ARTICLE

^IPost-Graduation Program in Medical Sciences, Faculdade de Medicina, Universidade de Brasília (UnB), Brasília, DF, Brasil

^IIService of Rheumatology, Hospital Universitário de Brasília (UnB), Brasília, DF, Brasil

^IIIPost-Graduation Program in Health Sciences, Faculdade de Ciências da Saúde, Universidade de Brasília (UnB), Brasília, DF, Brasil

ABSTRACT

Whole saliva is a multiglandular secretion complex consisting of gingival fluid, desquamated epithelial cells, microorganisms, products of bacterial metabolism, food debris, leukocytes mucus from the nasal cavity and the pharynx. Saliva has many functions, including tissue repair, tamponage, protection, digestion, taste, antimicrobial action, maintaining tooth integrity and antioxidant defense system. A decrease in salivary flow (hyposalivation) is a common disorder and it is estimated that approximately 20% of the general population have this alteration.

Hyposalivation may be due to diabetes mellitus, hypothyroidism, dehydration, impaired glandular parenchyma by infectious processes, granulomatous diseases or autoimmune and inflammatory conditions (such as Sjögren's syndrome and rheumatoid arthritis), radiotherapy of head and/or neck region, or it may be associated with mood disorders, adverse effects caused by the use of some medications or even be idiopathic. Conventional therapies for the treatment of reduced saliva flow with the use of chemical and gustatory secretagogues are still limited.

However, new alternatives have shown great perspective in the treatment of this disorder. To diagnose a patient as having chronic hyposalivation is a challenge in clinical practice and methods of salivary flow assessment are little known by rheumatologists. The serial evaluation of salivary flow is important for the diagnosis and prognosis of certain oral and systemic conditions. This review addresses some aspects related to the role of saliva, the consequences of hyposalivation and methods of salivary flow rate measurement, useful concepts in the daily practice of rheumatology.

Keywords: Saliva; Sialometry; Salivary flow; Hyposalivation; Xerostomia

Introduction

Saliva is a mixture of fluids secreted mainly by the three pairs of major salivary glands: parotid, submandibular, and sublingual. The 400 to 500 small salivary glands distributed over the buccal mucosa (except in the gums and anterior half of the hard palate), lips, and along the mucosa of the upper aerodigestive tract, present in the nasal cavity to the larynx and pharynx, also participate in this secretion.^1,2 Together, they are responsible for the remaining 5% of saliva secreted by humans.³ The saliva secreted by the major glands differs in composition; it is considered that humans secrete approximately 0.5 liters of saliva per day in response to stimulation of the sympathetic and parasympathetic autonomic nervous system.⁴

A reduction in salivary flow (hyposalivation) is a common disorder: it is estimated that approximately 20% of the general population have this alteration.⁵ It is natural for humans to go through short periods of hyposalivation, and its occurrence is frequent when individuals are under psychological stress.^6,7 Changes of fluids and electrolytes, as occurring in diabetes mellitus, hypothyroidism, and low hydration can also cause reduced salivary flow. However, hyposalivation may be due to multiple causes, which may include involvement of the glandular parenchyma by infectious, inflammatory processes, whether associated or not with granulomatous diseases or autoimmune conditions (such as Sjögren's syndrome and rheumatoid arthritis);^2,8 radiotherapy of the head and/or cervical region;^9,10 or it may be associated with mood disorders;⁶ adverse effects caused by the use of some medications;⁶ or it can also be idiopathic.¹¹ The decrease in flow and alterations in salivary composition affects 25% of the elderly population, and complaints of oral and systemic discomfort due to these alterations are common.¹²

Conventional therapies for the treatment of reduced salivary flow using chemical and gustatory secretagogues are still limited. However, new alternatives have shown great perspective for the treatment of this disorder.^13,14

To diagnose a patient with chronic hyposalivation is a challenge in clinical practice,¹⁵ due to lack of medical records indicating the patient's salivary pattern.¹⁶ However, the serial assessment of salivary flow is important for the diagnosis and prognosis of certain oral and systemic conditions.^17,18 It has been stated that health professionals have not yet adopted this practice due to the lack of availability of simple evaluation procedures.^18-20 As a result, hyposalivation goes undiagnosed in asymptomatic patients. Conversely, some patients may be misdiagnosed as having dry mouth when xerostomia (dry mouth sensation) is not accompanied by a decrease in the salivary secretion rate.²¹

This review aimed to address some issues related to the role of saliva, the consequences of hyposalivation, and methods of salivary flow rate measurement, which are useful concepts in the daily practice of rheumatology.

Functions of saliva

Saliva has many functions (Table 1) related to the maintenance of oral and systemic integrity,²² and it is critical for the first line of oral defense.

However, the complexity of the molecular composition of saliva has shown its importance in the systemic context. Saliva acts in the maintenance of the upper gastrointestinal tract pH.²³ Additionally, it has defense factors such as antibodies, cytokines, and growth factors that are associated with defense mechanisms and healing of inflammatory and infectious processes not restricted to the mouth, but also including the oropharynx, esophagus, and stomach.^24-28

Salivary components interact with microorganisms and are important to control the composition of the oral microbiota.²⁶ In this context, it is noteworthy that patients sedated in intensive care units often have alterations in salivary patterns within just two weeks of hospitalization. It is observed that most of these patients have elevated Gram-negative oral microbiota, and that there is also a high occurrence of nosocomial pneumonia. Thus, a correlation between salivary alterations and the manifestation of nosocomial pneumonia has been established.²⁹

Consequences of hyposalivation

In a systematic review of the subject, it was concluded that the flow rate of stimulated whole saliva below the normal range (< 1.0 mL/min of stimulated saliva) can be considered a predictor of caries.³⁰ Regarding the degree of formation of dental calculus, it is known that it depends on the rate of salivary gland secretion, and a low salivary flow, associated with high salivary viscosity, would be a risk factor for periodontal disease in the elderly.³¹

Saliva also reflects the control of water consumption by the body, since when the body is dehydrated, the mouth becomes dry, and thirst is felt.^32,33 It was observed that patients with severe hyposalivation tend to ingest more fluids during the day and night. Thus, they are likely to wake up at night more often to drink water and urinate. These frequent interruptions in nighttime sleep may favor insomnia, depression, and decreased memory, which affect the individual's quality of life.³⁴

Moreover, it appears that severe hyposalivation is associated with increased occurrence of opportunistic fungal infections in the mouth and oropharynx, stomatitis, diffi culty to eat dry solids, dysphagia, burning sensation in the tongue and other parts of the oral mucosa, rampant caries, dental biofilm, instability of total dentures, dysgeusia, and halitosis.^24,35-38 Another important aspect is also related to changes in eating habits, since the lack of saliva can reduce the pleasure of eating due to reduced sense of taste.^38,39 Therefore, hyposalivation can result in physical, functional, and social impairment, affecting the quality of life of patients.^10,40

Regarding social and quality of life impairment, it is known that halitosis results in severe emotional disorders for patients.^41,42 Fisher (1915) stated that bad breath can be sexually disgusting by indicating a variety of diseases.⁴³ Saliva represents a systemic body fluid that contains, among others, volatile organic compounds (VOCs). These compounds are considered to be excellent indicators of environmental and occupational exposure to chemicals, resulting from transdermal absorption, inhalation, or through food intake.⁴⁴ VOCs from the saliva have been used in physiological, metabolomic, pharmacokinetic, toxicological, and forensic studies.⁴⁴ Moreover, classic^45,46 and current studies^47,48 state that halitosis, in most cases, originates in the mouth and results from the metabolism of proteolytic anaerobic bacteria that release volatile sulfur compounds (VSCs).

Saliva is essential not only for the dilution of these compounds, but also to provide the washing of the oropharynx, thus hindering the stagnation of organic matter and consequent formation of disagreeable gaseous compounds. It is worth noting that, depending on the capacity of volatilization of these compounds, they may or may not stimulate the human sense of smell. In this context, it is important to emphasize that halitosis is a perceived change in the quality of the expiratory flow odor. Therefore, it can manifest as a signal, clinical halitosis, noticeable by the examiner and the people living with the individual that has halitosis, or as a symptom, i.e., subclinical halitosis, perceptible only by the patient.³⁷

Subclinical halitosis represents a major challenge in routine clinical care, and causes major behavioral changes due to the patient's belief that he/she has bad breath and the difficulty in establishing an accurate diagnosis.⁴⁷ This situation may occur due to the low concentration of volatile compounds that excite the retronasal endings of the individual, the sense of bad taste, or due to psychiatric disorders such as olfactory reference syndrome. Nevertheless, it appears that individuals with severe hyposalivation and asialia are vulnerable to gustatory sense-perceptive disorders that cause an unpleasant taste.⁴⁹

Salivary flow assessment methods

Tests used in the screening of a risk factor in the diagnosis of disease and in estimating the prognosis of a patient are important and costly phases of healthcare, and thus, they are noteworthy in clinical research.⁵⁰

Several methods have been proposed for salivary flow assessment. The choice of technique can be made by collecting whole saliva or saliva from a specific salivary gland. In addition, a sample can be obtained to evaluate salivary flow with and without stimulus.

Whole saliva is a multiglandular secretion complex consisting of gingival fluid, desquamated epithelial cells, microorganisms, products of bacterial metabolism, food debris, leukocytes, and mucus from the nasal cavity and the pharynx.²⁶ Its main advantage as part of the clinical evaluation is its ease-of-collection, and it is more often used than the individualized sample.

Regarding the absence or presence of stimulation in the evaluation of salivary flow, the former will primarily reflect the functional status of the submandibular and sublingual glands, as these are mainly responsible for basal secretion. However, the nature of the stimulus will influence the type of response. Mechanical stimulation promotes a marked response of the parotid gland, while gustatory stimulus activates the three pairs of major salivary glands. Table 2 shows different methods used to evaluate the rate of whole saliva flow.

The passive flow method has been frequently used for the assessment of unstimulated saliva in clinical practice. With regard to stimulation, the mechanical stimulus has been more often used. A five-minute collection time has been widely used to evaluate the flow rate of unstimulated and stimulated saliva.

Table 3 shows the values found for the flow rate of unstimulated whole saliva and under different types of stimuli, demonstrating the inter- and intra-patient variability. In addition to the technique, other factors may influence the results obtained, such as ambient temperature, relative air humidity, noises in the environment, time of sampling, duration of collection, type of gustatory stimulation, consistency and size of the mechanical stimulus, fasting period, environment brightness, and even the season of the year.^17,51,52 These factors should be controlled as much as possible, and a test standardization should be used so as not to impair test result reliability.

Table 4 shows the reference values to classify patients as having severe or mild hyposalivation, or normosialia. Prior to collection, the patient should be instructed not to smoke, eat, drink, or perform any oral hygiene procedures in the two hours prior to the measurement. In addition, the patient should drink 300 mL of water two hours prior to collection of saliva to prevent the variability in body hydration from affecting the results. Another important aspect concerns the standardization of time, i.e., flow monitoring should always be performed at the same time at which the fi rst collection was performed, in order to avoid circadian variations. It is important that the clinical environment should be peaceful and that the patient should turn the phone off, because otherwise the ring or other sound from the device can generate anxiety and alter the results. Regarding the evaluation sequence, the unstimulated saliva flow should be assessed fi rst, and then the salivary flow rate in response to stimulation.

The professional must strive to include this assessment as part of routine care in cases where the patient will be submitted to treatments that can promote changes in salivary flow. As examples, prior to prescribing xerogenic medications in addition to chemo- and radioiodine therapy, in cases where patients will undergo radiation therapy in the cervical-encephalic region, when suspecting and monitoring the progression of autoimmune diseases, and in other situations of dental interest.

Conclusions

Saliva has many functions, including tissue repair, tamponage, mechanical protection, digestion, taste, antimicrobial action, and maintenance of tooth integrity and the antioxidant defense system. Hyposalivation can result in physical, functional, and social impairment, causing a negative impact on quality of life of patients.

As an organic fluid, which varies according to a number of factors and circumstances, the use of the assessment of salivary flow in clinical practice requires standardization of its performance.

Therefore, it is important for the rheumatologist to know the functions of saliva, the consequences of hyposalivation, and the methods of salivary flow assessment, since diagnosing a patient with chronic hyposalivation is a challenge in clinical practice and serial evaluation of salivary flow is important for the diagnosis, prognosis, and monitoring of certain systemic and oral conditions.

Conflicts of interest

The authors declare no conflicts of interest.

REFERENCES

• ¹
  Ferris RL, Myers EN. Salivary gland disorders. Eur Arch Otorhinolaryngol 2008;265:735-36.
• ²
  Barcellos KSA, Andrade LEC. Histopatologia e imunopatologia de glândulas salivares menores de pacientes com síndrome de Sjögren (SSj). Bras J Rheumatol 2005;45(4):215-23.
• ³
  Melvin JE, Yule D, Shuttleworth T, Begenisich T. Regulation of fluid and electrolyte secretion in salivary gland acinar cells. Annu Rev Physiol 2005;67:445-69.
• ⁴
  Watanabe S, Dawes C. The effects of different foods and concentrations of citric acid on the flow rate of whole saliva in man. Arch Oral Biol 1988;33(1):1-5.
• ⁵
  Martinez JR. Treatment of Salivary Gland Disorders: Alternative Approaches. Available from URL: http://www.nidcr.nih.gov/OralHealth/Topics/Saliva/AlternativeApproaches.htm [accessed in september 17, 2012]
• ⁶
  Bergdahl M, Bergdahl J. Low unstimulated salivary flow and subjective oral dryness: association with medication, anxiety, depression, and stress. J Dent Res 2000;79(9):1652-8.
• ⁷
  Bosch JA, Turkenburg M, Nazmi K, Veerman EC, de Geus EJ, Nieuw Amerongen AV. Stress as a determinant of salivamediated adherence and coadherence of oral and nonoral microorganisms. Psychosom Med 2003;65(4):604-12.
• ⁸
  Mota LMHd, Cruz BA, Brenol CV, et al. Consenso da Sociedade Brasileira de Reumatologia 2011 para o diagnóstico e avaliação inicial da artrite reumatoide. Bras J Rheumatol 2011;51(3):207-19.
• ⁹
  Murdoch-Kinch CA, Russo N, Griffith S, Braun T, Eisbruch A, D'Silva NJ. Recovery of salivary epidermal growth factor in parotid saliva following parotid sparing radiation therapy: a proof-of-principle study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97(1):28-46. 2011;111(1):64-70.
• ¹⁰
  Kakoei S, Haghdoost AA, Rad M, et al. Xerostomia after radiotherapy and its effect on quality of life in head and neck cancer patients. Arch Iran Med 2012;15(4):214-18.
• ¹¹
  Porter SR, Scully C, Hegarty AM. An update of the etiology and management of xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97(1):28-46.
• ¹²
  Atkinson JC, Grisius M, Massey W. Salivary hypofunction and xerostomia: diagnosis and treatment. Dent Clin North Am 2005;49(2):309-26.
• ¹³
  Jensen S, Pedersen A, Vissink A, et al. A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: management strategies and economic impact. Support Care Cancer 2010;18(8):1061-79.
• ¹⁴
  Alajbeg I, Falcão DP, Tran SD, et al. Intraoral electrostimulator for xerostomia relief: a long-term, multicenter, open-label, uncontrolled, clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol 2004;97(1):28-46. 2012;113(6):773-81.
• ¹⁵
  Navazesh M, Christensen C, Brightman V. Clinical criteria for the diagnosis of salivary gland hypofunction. J Dent Res 1992;71(7):1363-9.
• ¹⁶
  Dawes C. Factors influencing salivary flow rate and composition. In: Edgar M, Dawes C, O'Mullane D, editors. Saliva and Oral Health. 3rd ed. London: British Dental Association; 2004:32-49.
• ¹⁷
  Sanchez-Guerrero J, Aguirre-Garcia E, Perez-Dosal MR, Kraus A, Cardiel MH, Soto-Rojas AE. The wafer test: a semiquantitative test to screen for xerostomia. Rheumatology (Oxford) 2002;41(4):381-9.
• ¹⁸
  Dawes C. Salivary flow patterns and the health of hard and soft oral tissues. J Am Dent Assoc 2008;139 Suppl: 18S-24S.
• ¹⁹
  Lopez-Jornet P, Camacho-Alonso F, Bermejo-Fenoll A. A simple test for salivary gland hypofunction using Oral Schirmer's test. J Oral Pathol Med 2006;35(4):244-8.
• ²⁰
  Leal SC, Falcão DP, Vieira CN, Zancheti AC, Filgueira T, Allegretti RV. Saliva e sua análise na prática clínica de um grupo de periodontistas Rev Periodontia 2008;18(2):55-59.
• ²¹
  Borges BC, Fulco GM, Souza AJ, de Lima KC. Xerostomia and hyposalivation: a preliminary report of their prevalence and associated factors in Brazilian elderly diabetic patients. Oral Health Prev Dent 2010;8(2):153-58.
• ²²
  Navazesh M, Denny P, Sobel S. Saliva: a fountain of opportunity. J Calif Dent Assoc 2002;30(10):783-8.
• ²³
  Herrera JL, Lyons MF, 2nd, Johnson LF. Saliva: its role in health and disease. J Clin Gastroenterol 1988;10(5):569-78.
• ²⁴
  von Bultzingslowen I, Brennan MT, Spijkervet FK, et al. Growth factors and cytokines in the prevention and treatment of oral and gastrointestinal mucositis. Support Care Cancer 2006;14(6):519-27.
• ²⁵
  von Bultzingslowen I, Sollecito TP, Fox PC, et al. Salivary dysfunction associated with systemic diseases: systematic review and clinical management recommendations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103 Suppl: S57 e1-15.
• ²⁶
  Costa HO, Eckley CA. Correlação do pH e volume salivares com sintomas laringofaríngeos. Rev Bras Otorrinolaringol 2004;70(1):24-28.
• ²⁷
  Eckley CA, Costa HO. Estudo comparativo do pH e do volume salivar em indivíduos com laringofaringite crônica por doença do refluxo gastroesofágica antes e após o tratamento. Rev Bras Otorrinolaringol 2006;72(1):55-60.
• ²⁸
  Oxford GE, Tayari L, Barfoot MD, Peck AB, Tanaka Y, Humphreys-Beher MG. Salivary EGF levels reduced in diabetic patients. J Diabetes Complicat 2000;14(3):140-45.
• ²⁹
  Gibson G, Barrett E. The role of salivary function on oropharyngeal colonization. Spec Care Dentist 1992;12(4):153-56.
• ³⁰
  Micenaustch S, Yengopal V, Bönecker M, Leal SC, Bezerra ACB, Oliveira LB. Minimum intervention (MI): A new approach in dentistry. A evidence-based compendium. South Africa: Midentistry corp, 2005.
• ³¹
  Hirotomi T, Yoshihara A, Ogawa H, Ito K, Igarashi A, Miyazaki H. A preliminary study on the relationship between stimulated saliva and periodontal conditions in communitydwelling elderly people. J Dent 2006;34(9):692-8.
• ³²
  Jenkins GN. The physiology of the mouth. 3rd ed. Great Britain: The Alden Press, 1970.
• ³³
  Mandel ID. The function of saliva. J Dent Res. 1987;66:623-62.
• ³⁴
  Tsuno N, Besset A, Ritchie K. Sleep and Depression. J. Clin. Psychiatry 2005;66(10):1254-69.
• ³⁵
  Ikebe K, Matsuda K, Morii K, et al. Impact of dry mouth and hyposalivation on oral health-related quality of life of elderly Japanese. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(2):216-22.
• ³⁶
  Mese H, Matsuo R. Salivary secretion, taste and hyposalivation. J Oral Rehabil 2007;34(10):711-23.
• ³⁷
  Falcão DP, Vieira CN, Batista de Amorim RF. Breaking paradigms: a new definition for halitosis in the context of pseudo-halitosis and halitophobia. J Breath Res 2012;6(1):017105-05.
• ³⁸
  Samnieng P, Ueno M, Shinada K, Zaitsu T, Wright FA, Kawaguchi Y. Association of hyposalivation with oral function, nutrition and oral health in community-dwelling elderly Thai. Community Dent Hlth 2012;29(1):117-23.
• ³⁹
  Zalewska A, Waszkiewicz N, Szajda SD, Waszkiel D. Impact of salivary flow and lysozyme content and output on the oral health of rheumatoid arthritis patients. CORD Conference Proceedings 2011;65:40-45.
• ⁴⁰
  Jensen SB, Pedersen AML, Vissink A, et al. A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: Prevalence, severity and impact on quality of life. Support Care Cancer 2010;18(8):1039-60.
• ⁴¹
  Suzuki N, Yoneda M, Naito T, Iwamoto T, Hirofuji T. Relationship between halitosis and psychologic status. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106(4):542-7.
• ⁴²
  Zaitsu T, Ueno M, Shinada K, Wright FA, Kawaguchi Y. Social anxiety disorder in genuine halitosis patients. Health Qual Life Outcomes 2011;9:94.
• ⁴³
  Fisher RA. The evolution of sexual preferences. Eugen. Rev 1915;7:184-92.
• ⁴⁴
  Soini HA, Klouckova I, Wiesler D, et al. Analysis of volatile organic compounds in human saliva by a static sorptive extraction method and gas chromatography-mass spectrometry. J Chem Ecol. 2010;36(9):1035-42.
• ⁴⁵
  Richter VJ, Tonzetich J. The Application of Instrumental Technique for the Evaluation of Odoriferous Volatiles from Saliva and Breath. Arch Oral Biol 1964;9:47-54.
• ⁴⁶
  Tonzetich J, Kestenbaum RC. Odour production by human salivary fractions and plaque. Arch Oral Biol 1969;14(7):815-27.
• ⁴⁷
  Fukui M, Hinode D, Yokoyama M, Yoshioka M, Kataoka K, Ito H-O. Levels of salivary stress markers in patients with anxiety about halitosis. Arch Oral Biol 2010;55(11):842-47.
• ⁴⁸
  Kim JG, Kim YJ, Yoo SH, et al. Halimeter ppb Levels as the Predictor of Erosive Gastroesophageal Reflux Disease. Gut Liver 2010;4(3):320-25.
• ⁴⁹
  Bergdahl M, Bergdahl J. Perceived taste disturbance in adults: prevalence and association with oral and psychological factors and medication. Clin Oral Investig 2002;6(3):145-9.
• ⁵⁰
  Newman TB, Browner WS, Cummings SR. Delineando estudos de testes médicos. In: Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB, editors. Delineando a Pesquisa Clínica - Uma Abordagem Epidemiológica: Artmed 2008:384.
• ⁵¹
  Shannon IL, Suddick RP. Effects of light and darkness on human parotid salivary flow rate and chemical composition. Arch Oral Biol 1973;18(5):601-08.
• ⁵²
  Navazesh M, Kumar SK. Measuring salivary flow: challenges and opportunities. J Am Dent Assoc 2008;139 Suppl: 35S-40S.
• ⁵³
  Cate ART. Oral histology: Development, structure, and function. 5a. ed. St. Louis: Mosby-year book, 1998.
• ⁵⁴
  Amerogen AVN, Veerman ECI. Salivary glands and saliva - The defender of oral cavity. Oral Dis 2002;8:12-22.
• ⁵⁵
  Vissink A, Wolff A, Veerman ECI. Saliva collectors. In: Wong DT, editor. Salivary Diagnostics. New Delhi, India: Wiley-Blackwell, 2008:320.
• ⁵⁶
  Becks H, Wainwright WW. Human Saliva XIII. Rate of flow of resting saliva in healthy individuals. J Dent Res 1943;22(5):391-96.
• ⁵⁷
  Bergdahl M. Salivary flow and oral complaints in adult dental patients. Community Dent Oral Epidemiol 2000;28(1):59-66.
• ⁵⁸
  Engelen L, de Wijk RA, Prinz JF, van der Bilt A, Bosman F. The relation between saliva flow rate after different stimulations and the perception of flavor and texture attributes in custard desserts. Physiol Behav 2003;78(1):165-69.
• ⁵⁹
  Eliasson L, Birkhed D, Osterberg T, Carlen A. Minor salivary gland secretion rates and immunoglobulin A in adults and the elderly. Eur J Oral Sci 2006;114(6):494-9.
• ⁶⁰
  Ericsson V, Hardwick L. Individual diagnosis, prognosis and counsellingfor caries prevention. Caries Res 1978;12 (Suppl 1):94-102.

Sialometry: aspects of clinical interest

Denise Pinheiro Falcão^I,*; Licia Maria Henrique da Mota^I,II; Aline Lauria Pires^III; Ana Cristina Barreto Bezerra^III

Publication Dates

• Publication in this collection
  27 Jan 2014
• Date of issue
  Dec 2013

History

• Received
  26 Sept 2012
• Accepted
  12 Mar 2013