Importance of oral health to overall health
taste, smell, food enjoyment, Salivary output, Chewing and swallowing, Systemic health!
Links to systemic disease
- Cardiovascualr disease
- Preganancy (low birth weight),
- Diabetes(periodontitis, gingivitis)
- Medications (xerostomia)
- Learning in children
- Halitosis(can be from periodontal disease)
- Communication and relationships
Definition of Oral Medicine?
Dicipline of dentistry concerned with, oral health care of medically-compormised patients, and diagnosis and non-surgical management of medically-related disorders or conditions affecting the oral and maxillofacial region.
Oral medicine examples
- Systemic infection
- Bleeding gums-means unhealthy gums,medications like antiplatelet drugs ex aspriin, coumadin
- Xerostomia-dry mouth
- Radiation therapy
JADA (journal of the American Dental Assiciation)
regonizes the link between oral health and systemic disease!
Primary funciton of the Oral cavity
- speech (phonetics)
- process food (Mastication)
Know the following terms and where they are in relation to one another
- Cementum (portion of anatomical rood that covers it's dentin)
- Dentin(inside part of tooth coverd by cementum and enamle and can re-mineralize)
- Enamle(anotomical crown and covers dentin)
- Peridonal ligament (PDL- little fibers that attach the tooth to the aveolar process)
- plaque- dental biofilm
- Pulp-nerve of the tooth and supplies it's nutrients.
- Alveolar process( socket)
- Calculus (calcified Plaque that occurs duing higer pH's also called tarter)
- Caries- (cavities demineralized her tissue)
- Lymphoid tissue-
- Mucosa-involved in absorption and secretion and covered in epithelium
- Palate-roof of mouth
What is the anatomy of the oral cavity?
- Taste Receptors
- Floor of the mouth
- Blood supply
- Salavary glands(parotid, sublingual, submandibular are major glands)
- Muscles of mastication(temporialis, Masseter, medial petrygoid, lateral petrygoid.)
- Muscles of facial expression
- Temporomandibular joint (TMJ)(joining of temporal bone and mandible)
What are Carries
Cavities (caused by introducing acidity or sugar in to oral cavity and then this causes an acidic environment which demineralizes enamel)
Gingivitis, and periodontitis
other diseases that can occur in oral cavity
what are snacks that cause caries and what are snacks that don't?
infection, cancer, (aging)
- sugary snacks, acidic snacks,
- ones that don't are peanuts, or cheese, these are low risk snacks
Abnormalities of the Oral cavity are?
- Cleft palate-cranio facial defect at birth
- Aphthous ulcer( canker sore, caused by trauma, and immunologic abnormality
- Leukoplakia-white patch in oral cavity, usually in users of chronic irritans like smoking
- Edentulism(no teeth)
Pulp Replenishment of Dentin
The pulp can replenish the dentin but it does so at a slower rate than a carie spreads.
permanant dentition 1-32
diciduous dentition or primary dentition A-T
- key numbers to know
Define the peridontium and its parts.
- made up of Gingiva and attachment apparatus.
- Periodontal ligament PDL
- Alveolar bone
Define the following terms of the periodontium...
- Gingival sulcus-healthy when 1-3 mm
- Gingival line
- Attached Gingiva
- Mucogingival Junction
- Alveolar Mucosa
- Epithelial Attachment
- Lamina Dura
- Spongy Bone
- Lingual Corticl plate
Examination and diagnosis of oral (and systemic) disease begins with knowledge of?
Anatomy and function
Condition of the oral cavity is an important sign in?
The condition of the oral cavity, especially the teeth and periodointium, provide insight of?
the importance of oral health to the patient
What is Saliva?
- 99.5% water
- tooths 1st defense against cariogenic pathogens!
- A symbiotic ecology
- protein-rich secretions of salivary glands are
- -antibacterial enzymes
- -inorganic elements
- -high # of bacteria
What are the functions of Saliva
- -lubrication-moistening of food for swallowing
- -antibacterial, antifungal, and antiviral
- -Mucosal integrety
- -Lavage, clensing
- -Buffering Capacity
- resists acidic pH which casue caries,
- Food-Related functions
- -Preparation for digestion
- -Digestion (initiation of digestion from the following enzymes.
- -pancrease secretes amylase (break down starches), and ribonuclease and lipase help too
- -a defense mechanisism, and it solubalizes materials so we can taste it.
- -lubrication for water and mucins aids in speech
- maintain pH of upper GI
- Maintian health of oral mucosa
- Keeps microflora balance which helps prevent oportunistic infections
- Cleans mouth and clears esophagus.
Source of Saliva
and which of the glands are serous?
- Major salivary glands
- -polly ductal and empty secretions through a main duct into the mouth
- -Parotid gland
- minor salivary glands (clover shaped
- - mono ductal and empty secretions directly into mouth)
Secretory Contributors to whole saliva
- Von Ebner's glands
- -in moats surrounding the circumvallate and fliate papilla in posterior 1/3 of tongue, anterior to termial sulcus
Unstimulated Whole Saliva
- resting saliva
- -produced while sleeping, reading, bathing etc.
- -protects the dentition and supporting structures.
- -unstimulated saliva is what is most suseptible to disease.
Stimulated Whole Saliva
process of stiumlated salive involves numerous and comples neuroogical pathways and one of them is gustatory.
Stimulated vs Unstimulated whole saliva produced ?
unstimulated saliva produces about 1/3 the amount of stimulated saliva
when looking to see if a patient has swolen glands what are you looking for?
What instrument is used to collect whole saliva?
What are the normal flow ranges for stimulated and unstimulated? in a 5 min collection
- you are looking for symmetry. if non then probably swolen.
- Sialometer is instrument used and collection period is for 5 min.
- Stimulated flow rates
- Parotid-->unstimulated-->.3 - .5 ml/min
- Submandibular and sublingual-->untimulated-->.5 - .7 ml/min
- Parotid-->stimulated-->.5 - 3.0 ml/min
- Submandibular and sbulingual-->unstimulated-->.5 - 2.0 ml/min
What are the normal Salavary flow Rates
saliva per day? what are the contributions fromt he Parotid, submandibular and sblingual when unstimulated? and Stimulated
- .5 L per day
- Unstimulated--> Parotid-25%, submadibular-60%, sublingual-7-8%
- Stimulated-->parotid-as much as 50%
if one has low flow rates unstimulated they could chew gum to have increase in saliva so that they will have flow since it's stimulated.
Saliva characheristics in Lupus Erthematosus and Sjogrens syndrom saliva
- Lupus (autoimmune disease)-thick saliva consistency
- Sjogrens-frothy lots of bubbles
How do flow rates differ from person to person and between stimulated and unstimulated?
- lots of variation from person to person!
- and flow rate is much greater in stimulated vs unstimulated. Also the flow rate varies amoug different types of stimulation.
how does flow differ with time in relation to electrolytes?
flow rate and electrolyte output decrease overtime b/c glands get tired.
What is Gingival Cervicular Fluid
- also called GCF
- -Serum exudade that is NOT glandular secretion
- -Contributes to Whole saliva!
What is the Tooth Pellicle?
- biological consequece of the oral ecology.
- -Salivary and GCF glycoproteins bind to oral mucosa and dentition (this is what makes it up)
- -Will bind to oral prostheses
- -bind via electrostatic and van der Waals forces.
- Radiation of the head and neck inhibits this from forming b/c salivary glands are affected.
What is the relationship between the tooth pellicle and Bacteria?
- bacteria colonize on the tooth pellicle (and do so rapidly)
- types that colonize are
- -Gram + facultatve- Stretococcus, Actinomyces, and Lactobacillus (these guys are 1st to colonize)
- -Bind via adhesins and fibriae
When does tooth pellicle maturation occur? and why is formation of the tooth pellicle an oral biological necessity?
- maturation occurs when coaggregation occurs among bacterial species that DO NOT initially colonize the tooth and gingival surfaces.
- It is importatn biologically b/c it PREVENTS desiccation(extreme dryness) of the oral mucosa
Describe how we benefit from Oral Flora...
- -make it hard for other microoganisms to colonze
- -contribute to nutrition by making vitamins
- -contribute to immunity by inducing low levels of circulating and secratory antibodies (can come in contact with pathogens)
- -produce inhibitory substances to nonindigenous species vai microbial antagonism
- -they produce fatty acids, peroxides, and bacteriocins(toxins that inhibit growth of other bacteria).
Minor Gland locations are?
- Labial, Lingual, Palatal, Buccal, Glossopalatine, and retromolar surfaces just below and within the mucous membranes.
- -in short duct systems
- Von Ebners- at base of circumvallate papilla.
GCF? what does it stand for and where is it?
- Gingival cervicular fluid
- -found in gingival pocket btwn tooth and free gingiva
- -NON EXOCRINE secreation.
What is in saliva?
- 99.5% water
- inorganic electrolytes- 13 electrolytes and minerals
- enzymes- 7 small organic molecules
- proteins- 40 essential
- 10^8 - 10^9 bacteria/ ml of saliva!
- -exfoliated mucosal cells
- -cellular debris
- -food debris
- -bacterial products
- -viral particulates
What factors Affecting composition of Saliva?
- Circadian Rhythm
- Circannual Rhythm
- type of stimulation
- Systemic disease
Major Salivary components are?
- Proline-Rich Proteins
- Carbonic Anhydrases
- Mucin 2 (MG2)
- Mucin 1 (MG1)
Salivary Proteins do what?
- Control Ca2 and PO4 (very importatn it enamle reimineralization)
- Regulate pH
Salivary mucins do what?
provide attachment for pathogens
Secretory IgA's do what?
Prevent bacterial adherence to soft tissues.
How does enamel Mineralization/demineralization occur?
At low pH you have demineralization by leaching calcium from teeth
at high pH you have remineralization of teeth and this is due to the buffering capacity of saliva. and saliva also provides calcium and phosphates as ions.
Meth Syndrome does what?
- causes destruction of tooth enamle and underlysin softer core of teeth.
- once enamle has been breached decay occurs rapidly.
- -excessive mountain dew usage can do the same thing!
What are the Digestive enzymes in the oral cavity and what do they do?
- Amylases-breaks down complex carbs
- -one of the 1st steps in digestive process
- -when attached to tooth surface
- -promotes adherence of bacteria
- -digest's starch to maltose and makes ACID
Statherin is what and does what?
- stabilizez inorganic ions
- allows for supersaturation
Mucin is what and does what?
protein that causes bacteria to aggregate
Lysozyme is what and does what?
- antibacterial protein
- -is depressed by Fe and Cu (copper)
Lactoferrin is what and does what?
- protein that combines with Fe and Cu to
- -protect lysozyme
- -deprive bactera of Fe and Cu
Saivary peroxidase is what and does what?
- protein reacts with salivary thicyante with peroxide is around
- -forms hypothiocyanite
- -this inhibits bacteral glucose metaboisim (stops bacteria form making energy)
Lactoperoxidase is what and does what?
protein that adsorbs to hydroxyapatite and alters primary bacterial attachment
Histatins is what and does what?
protein that are antimicrobial wound closers
Cystatins is what and does what?
proteins that affect mineral balance of the tooth.
Mucins, describe there weight, where they are made, and what they do.
- -high molecular weight glycoproteins with > 40% carbohydrates
- two types in oral cavity MG1, and MG2
- -produced only in mandibular/sublingual glands
- -protein core is <15% of its weight and is about 1000kDa
- -a single peptide chain (150 kDa)
- Mucins maintain mucosal integrity and aggregate bacteria so they get cleared from the mouth!
What causes saliva to have a buffering capacity?
- Bicarbonate-stabalizes the pH and resist's fluctuation -the measurement of the bicarbonate concentration is the buffering capacity and indicates how well saliva can moderate plaque pH changes
- - High buffering capacity rsists changes in pH and keeps mouth stable
Normal pH ranges of saliva in resting and stimulated flow.
- Resting pH >6.8,
- stimulated flow rate >.7mL/min, pH >7, buffering capacity >10
- in Unhealthy saliva
- resting pH < 6.8
- stimulated flow rate <.7 mL/min, pH <7, buffering capacity <10
What occurs in a basic environment?
- -precipitation of ions and calcification of plaque
- -mouth with high amt's of calculus have high salivary pH
- -patients with renal failure develope more calculus due to high content of urea in saliva.
What is Amylase?
- Digestive enzyme in saliva
- - initiates process of digestion of carbohydrates (rice, wheat, corn, potatoes, beans, nuts, etc.)
- -opperates at a optimum pH of 6.7-7.0.
- -and alpha amylase
- -breaks down large, insoluble starches(amylodextrin erythrodextrin, achrodextrin)d into solubles ones ultimately makes maltose
What types of bonds does Amylase hydrolyze?
- -alpa 1-4 bonds of starches such as amylose and amylopectin
- -Major end product is maltose (20% glucose)
What is the Role of Lipase in salive and where does it come from?
- secreated as salavary lipase
- -initiate fat digestion
- -has large role in fat digestion in newborns b/c pancreatic lipases still need to develope. (and milk has lot of fat)
- -prtective function
- -prevents bacterial build up on teeth
- -washes away adhered food particles.
- Secreted by Von Ebner's gland
- -makes tongue involved in first phase of fat digesiton
- -hydrolyzes medium to long chain triglycerides
- -importatn in digestion of milk fat in new-borns
- -highly hydrophobic and ready enters fat globules (not characteristic of other mamalian lipases)
what is Statherin and what does it do? where does it come from?
- a proline rich protein (PRP)
- -calcium binding protein
- -stabalizes inorganic ions
- -allows for super saturation
- -comes from parotid and submandibuar saliva
- -entire molecule inhibits inhibits primary precipitation
- -Amino-terminal hexapeptide inhibits 2ndary precip. (crystal growth)
- - promotes adhesions of actinomyces viscosus, and streptococcus gordonii to tooth surfaces.
- - responsible for unique ability to stabilize calcium and phosphate, this protein inhibits the precipitation from saliva to dental enamel
- ENTIRELY SEROUS
- -main secratory duct (stensons duct) empties to oral cavity
- -stensons duct is located opposite the 2nd molar
- -larges salavary gland
- -inverted pyramid
- -6cm long, 3-4 cm wide, 15-30 g
- -anterior and inferior to ext. acoustic meatus (ear hole)
- -inferior to zygomatic arch (cheek bones)
- -posterior to ramus of mandible and masseter muscle
- -lateral to styloid process
Parotid blood supply
- Arterial supply
- -external carotid
- -posterior auricular
- -superficial temporal
- -transverse facial
- -retromandibular vein
- lymphatic vessels drain into deep parotid nodes
- -embedded deep within gland and to superfical and deep cervical nodes
Salavary Gland Anatomy
- Acinius-has aciner cells (single grape)
- Myoepithelial cells-constrict intercalated duct and squirt (propells) saliva into striated duct
- Acinar epithelium secretes PROTEINS and ISOTONIC filtrate
- When it's at the duct cells it's a Hypotonic solution
SubMandibular Gland is what type of gland? and what are some characteristics
- -MIXED salivary gland
- -predominately serous
- -intralobular ducts are same type as parotid
- -larger number of ducts, and longer than parotid glands
- -mucous alveoli
- -usually capped with serous demilunes(a cap in the shape of a half moon and they secrete the enzyme lysozyme which degrade bacteria)
SubMandibular Gland Anatomy
- -roughly egg-shaped 4-5cm long, 7-19g
- -in submandibular fossa on medial surface of the body of the mandible below mylohyoid line.
- -bed or recess also includes mylohyoid, hypoglossus muscles medially and superiorly.
Submandibular gland blood supply
- -tributary to the submental
Lymphatics of Submandibular
lymphatic drainage to nearby submandibular nodes
Sublingual Gland is what type of gland?
- mixed gland
- -predominately mucos secretion
- -empties in mouth at the side of the frenum of tongue near Wharton's duct
Sublingual gland anatomy
- almond shaped
- -3-4 cm long,2-3 g
- -between genioglossus muscle and body of mandible where it occupies the sublingual fossa of mandible superior to mylohyoid line.
- -main body of gland produces numerous RAVINUS ducts
- -ducts can join together to form the duct of BARTHOLIN
- -which then joins submandibular duct near sublingual papilla.
Sublingual Gland Blood Supply
- -tributaries of vena comitans nervi
- -hypoglossi and facial vein
drain to superior deep cervical nodes
Where are Minor Salivary glands located
- tongue, palate, buccal and labial mucosa
- -produce mucous secretions
- -little buffering capacity
- -Von Ebner's glands on the tongue (on circumvillate papilla of tongue)
- -are serous glands still monoductle and only glad to secrete
- lingual LIPASE (for fat digestion)
What nerve is responsible for sensation in face and mastication (chewing, biting, swallowing)
Trigeminal nerve CN5
Salivary Gland Secretion
- -keeps mucous membranse of mouth moist
- -lubricates food for chewing and swallowing
- -different acinar cells secret different proteins
- -parotid gland secretes serous saliva with amylase
- -sbulingual secrests mainly mucin glycoproteins
Parasympathetic control occurs via?
- Facial nerve VII, innervates sublingual and submandibular glands
- Glossopharyngeal (IX) innervates parotid gland with some fibers from trigeminal nerve.
What does Parasympathetic stimulation o to salivary secretion?
- basal rate-->.5ml/min
- stimulated rate-->5 ml/min
- total volum about 1.5 L/day
- flow is modulated by cholinergic and anti-cholinergic drugs (casue dry mouth)
What does Sympathetic stimulation do to salivary secretion.
- Weaker increase in secretion
- blood flow decreased initially, then increases due to increased metatabolism and release of metabolites.
- stimulates myoepithelial cell contraction
Salivary Gland Secretion
- -secretes ultra filtrate of plasma
- -driven by chloride secretion
- -ductal epithelium Actively absorbs NaCl
- -Excretion of K and HCO3 by ducts
- - is less than the absorption of salt (NaCl)
- -low water permiablity leads to greater salt absorption
- -this is what creates the HYPOTONIC saliva
saliva at low and high flow rates
- low flow rates
- -hypotonic and rich in K
- high flow rates
- -ion comp. is at almost 70% of what plasma has
- -there is reduced time for water reabsorptioin at high flow rates
Cellular ion transport of Acinar cells
- Acinar secretion
- -driven by
- -Na/K pump, Na gradient, and Na/Cl cotransporter
- -Leaky intercellular juncitons allow Na and water to follow
- Cl which makes isotonic secretions
- (Na follows Cl- through tight junctions and water follows salt making it isotonic)
- -K and HCO3- flow with electrochemical gradient
- -the isotonic vonlume flow carries amylase which is
- secreted by acinar cells into ducts
describe fluid transport cascade starting with ACh initiation through the use of Ca, cl, Na, K, and water
- Ach receptor and it starts a cascade of evendts and
- it causes Ca2+ opens pours for Cl- , Na is coming in and K is going out so you have and electrical gradient
- 1st via Na following Cl- through tight junctions and then you have an osmotic gradient (H2O flow) in the
- same direction as the electrical gradient.
- This is b/c water follows the NaCl !
Cellular Ion Transport of Ductal cells
- driven by
- -Na/K pump, Cl- follows electrochemical gradient
- -Ductal cells have Tight cellular junctions which do not
- allow for water to flow through, therefore creating hypotonic solution b/c it has Na and Cl but no water
- - K+ and HCO3- enter the lumen in exchange for Na and Cl
Viscous Saliva happens b/c of?
- head/nasal cold
- chest cold
- cystic fibrosis
- adging -b/c lack of serous secretions due to lack of acinar cells. this will cause less lactoperoxidase and lactoferrin b/c of lack of acinar cells and leads to viscous saliva.
good chart to know slide 65 lec #3
Estrogen receptors and salavary,tear, and mammary glands.
all have estrogen receptors and females are more suceptible to defects in salivary gland function b/c produce more estrogen.
Protein secretion occurs via?
- Passive diffusion of small particles
- Active Transport