‘NO RM AL’ FUNCTION DEFINED J O N A T H A N A . S H IP , D .M .D ., P H IL IP C. FOX, D .D .S., B R U C E J. B A U M , D .M .D ., P H .D
aliv a is im p o r ta n t fo r th e p re s e rv a tio n a n d m a in te n a n c e of o ral h e a lth .1,2W ith o u t a d e q u a te sa liv a ry g la n d fu n c tio n , a n in d iv id u a l m a y e x p e rie n c e se v e re im p a irm e n t o f o ra l h e a lth . F o r ex am p le, n e w o r r e c u r r e n t d e n ta l caries, m u c o u s m e m b ra n e a lte ra tio n s, d iffic u ltie s in sp e e c h a n d d e g lu titio n , a n d m ic ro b ial in fe c tio n s m ay d ev e lo p w ith o u t a d e q u a te q u a n titie s o f saliva. S aliv a ry g la n d d y sfu n c tio n m ay b e ca u se d b y m a n y fa c to rs.3-4 N u m e ro u s p r e s c rip tio n a n d n o n p re s c rip tio n m e d ic a tio n s a re a s so c ia te d w ith d im in is h e d sa liv a ry p ro d u c tio n . T h e m a jo r th e ra p ie s fo r m a lig n a n c ie s, ra d ia tio n a n d c h e m o th e ra p y , c a n r e s u lt in te m p o ra ry o r p e r m a n e n t d a m a g e to th e sa liv a ry g la n d s. S aliv ary d y sfu n c tio n m ay also a c c o m p a n y m a n y sy ste m ic d ise ase s, th e b e s t s tu d ie d a n d m o st f re q u e n t e x a m p le b e in g S jo g re n ’s s y n d ro m e . T h e d ia g n o sis of sa liv a ry g lan d d y sfu n c tio n re q u ir e s a c o m p re h e n siv e d e n ta l/m e d ic a l e v a lu a tio n , in c lu d in g th e a s s e s s m e n t of sa liv a ry fluid o u tp u t. C u rre n tly , h o w ev e r, it is u n c le a r h o w m u c h sa liv a is re q u ire d to m a in ta in n o rm a l o ral fu n c tio n or, in fact, w h a t c o n s titu te s n o rm a l sa liv a ry g la n d fu n c tio n . A n u n d e r s ta n d in g of th e m in im a l sa liv a ry g la n d p e rfo rm a n c e n e c e s s a ry to s u p p o r t n o rm a l o ral fu n c tio n is n e e d e d to e v a lu a te p a tie n ts w ith d y sfu n c tio n o f th e sa liv a ry g lan d s. N u m e ro u s s tu d ie s w ith a
ABSTRACT
Saliva is important for the preservation and main tenance o f oral health. It is unclear, however, how much saliva is required to maintain normal oral function. M^jor salivary gland flow rates, objective measurements o f oral health, and subjective complaints o f oral problems were assessed in differentaged, healthy persons. Results suggest that the comparison o f nuyor salivary gland flow rates of an individual with population standards to identify patients susceptible to the effects o f salivary dysfunction is unreliable. Changes in salivary function over time are a more mean ingful gauge o f the impact of saliva on oral health. The clinician should monitor salivary production to identify patients with declin ing salivary gland output. v a rie ty o f p a tie n t/s u b je c t p o p u la tio n s h a v e m e a s u re d sa liv a ry o u tp u t. M any in v e stig a to rs h a v e a tte m p te d to e s ta b lish n o rm a l ra n g e s o r “c u t
off” v a lu e s to d is tin g u is h n o rm a l fro m a b n o rm a l sa liv a ry fu n ctio n . F o r e x a m p le , S re e b n y an d V ald in i6 h a v e su g g e ste d 0.1 m illilite r /m in u te as a lo w e r lim it of n o rm a l u n s tim u la te d w h o le saliv a o u tp u t b a s e d o n th e ir p o p u la tio n s tu d ie s a n d th o s e of o th e rs .6'8 T h e se d a ta , h o w ev er, a re d e riv e d fro m h e te ro g e n e o u s p o p u la tio n s, a n d in c lu d e in d iv id u a ls b e in g tr e a te d fo r sy stem ic d ise ase s. M oreover, sin c e c o n s id e ra b le v a ria tio n e x ists in th e n o rm a l ra n g e o f sa liv a ry flow ra te s, it a p p e a rs d ifficu lt, a p rio ri, to se t s ta n d a r d s fo r w h a t c o n s titu te s an ab n o rm a lly low flow ra te .9 U sin g a sin g le v a lu e fo r d e fin in g a b n o rm a l fu n c tio n m a y allo w p a tie n ts w ith sa liv a ry d y s fu n c tio n to r e m a in u n d ia g n o se d a n d u n tre a te d . We, a n d o th e r in v e stig a to rs, h av e r e p o r te d d a ta fo r in d iv id u a l sa liv a ry g la n d s e c re tio n s am o n g h e a lth y s u b je c ts .1016T o o u r k n o w led g e, h o w ev e r, th e re h av e b e e n n o p re v io u s a tte m p ts to re la te in d iv id u a l sa liv a ry g la n d flow r a te s w ith in fo rm a tio n re le v a n t to th e fu n c tio n o f saliv a a n d th e o ra l h e a lth s ta tu s o f a n in d iv id u al. A cco rd in g ly , w e m e a s u re d m a jo r sa liv a ry g la n d fu n c tio n a n d o ra l s ta tu s in a g ro u p o f h e a lth y in d iv id u a ls to d e te r m in e if th e r e is a d isc re te r a n g e of saliv a p ro d u c tio n n e c e s s a ry to s u p p o r t n o rm a l o ra l fu n c tio n . M A T E R IA L S A N D M ETHODS
In d iv id u a ls e v a lu a te d in th is s tu d y
JADA, Vol. 122, March 1991
63
F IG U R E 1
0.488 0.472
0 .8
0 .6
0.4
0.106 0.097
0 .2
0.076 0.059
i
0 .0 UNSTIMULATED
STIMULATED
P A R O T ID
UNSTIMULATED
STIMULATED
S U B M A N D IB U L A R
Major salivary gland flow rates in healthy individuals. Open bars are males (n=50) and hatched bars are females (n=52). Results are mean values ± s.d. Actual mean values are shown above each bar.
in c lu d e d 102 p e r s o n s (5 0 m a les a n d 52 fe m a le s ) b e tw e e n th e ages o f 20 a n d 90. S u b jec ts w ere v o lu n te e r p a r tic ip a n ts in n o rm a tiv e ag in g p ro g ra m s c o n d u c te d by th e N a tio n a l In s titu te o n Aging. All su b je c ts w e re h e a lth y w h ite s, of m id d le so c io e c o n o m ic class, a n d a t th e tim e o f th e s tu d y w e re n e ith e r ta k in g a n y m e d ic a tio n s fo r th e tr e a tm e n t o f sy ste m ic d ise a se n o r b e in g tr e a te d fo r m e d ic a l
p ro b lem s. All p a rtic ip a n ts u n d e r w e n t a n id e n tic a l s ta n d a rd iz e d clin ic al e x a m in a tio n a n d in te r v ie w 16d e s ig n e d to ev a lu a te sig n s a n d sy m p to m s su g g e stiv e of sa liv a ry g la n d d y sfu n c tio n a n d x e ro sto m ia . All su b je cts w e re se en b y o n e e x a m in e r (J.A .S.). All su b je c ts r e fra in e d fro m ea tin g , d rin k in g a n d o ral h y g ie n e fo r a m in im u m of 90 m in u te s b e fo re s a liv a ry c o lle c tio n a n d w e re
s e e n b e tw e e n 8:30 a.m . a n d 11 a.m . U n s tim u la te d a n d s tim u la te d p a r o tid saliv as w e re c o llec te d fro m a sin g le p a ro tid g la n d as d e s c rib e d p re v io u sly .1011 F o r a n y su b je ct d isp la y in g n o u n s tim u la te d p a r o tid sa liv a p ro d u c tio n a fte r five m in u te s , a r e te s t w as p e rfo rm e d . O nly a f te r tw o n e g a tiv e u n s tim u la te d te sts, p lu s p o sitiv e ev id en c e o f a s tim u la te d se c re tio n , w as a su b je c t c o n s id e re d to h av e an u n s tim u la te d flow ra te of zero. S u b m a n d ib u la r saliv a w as c o lle c te d fro m th e o rifice of W h a rto n ’s d u ct, as p rev io u sly d e s c rib e d .4 S aliv ary flow w as s tim u la te d b y sw ab b in g 2 p e rc e n t c itric a c id o n th e d o rso -late ra l s u rfa c e s o f th e to n g u e a t 30-seco n d in te rv a ls .12 A fter c o llec tio n , th e v o lu m e s o f all sa liv a s w e re d e te rm in e d g ra v im e tric a lly , a s su m in g a sp e cific g ra v ity o f 1.0. S u b m a n d ib u la r saliva, as d efin e d in th is p a p e r, re p r e s e n ts a c o m b in e d s u b m a n d ib u la r/ su b lin g u a l se c re tio n d u e to th e f re q u e n t c o m m o n e x it o f th e g la n d d u c ts .17 All p a r tic ip a n ts w e re g iv en a su b je ctiv e x e ro sto m ia q u e s tio n n a ire .16T h e re sp o n se s to fo u r sp e cific q u e s tio n s th a t c o rre la te w ell w ith objectiv e
HIGHEST AND LOWEST 10TH PERCENTILES FOR SALIVARY FLOW RATES S E C R E T IO N C O L L E C T E D 1 LO W 1 O TH %
H IG H 1 0 T H %
MALES (N— 50)
LO W 10 T H %
H IG H 1 Q TH %
FEMALES (N=52)
Parotid U n s tim u la te d S tim u la te d
0.000 0.201
0.160 0.866
0.000 0.180
0.156 0.838
0.020 0.133
0.223 0.644
0.025 0.107
0.216 0.716
Submandibular U n s tim u la te d S tim u la te d
1Flow rates are expressed as mL saliva/m in • gland and re p re sen t the value a t the indicated percentile level. For exam ple, m ales w ith stim ulated parotid saliva in th e low est 10th p ercentile had flow rates at or beloW 0.201 m L /m in • gland, and those in the highest 10th percentile had flow rates a t or above 0.866 m L/m in. gland.
64
JADA, Vol. 122, March 1991
S h ip a n d W olff,20 a c c o rd in g to NIDR c rite r ia .18 T h e o ra l m u c o s a w a s a sse ss e d w ith a m o d ifie d m u c o s a l ra tin g scale.21 N o rm al m u c o sa o r m ild c h a n g e s (d ry , p a le o r g lo ssy m u c o sa a n d a lte ra tio n s in m u c o sal to p o g ra p h y ) w e re r a te d zero , a n d m o d e ra te o r se v e re c h a n g e s (e ry th e m ic o r le u k o p la k ic lesio n s, u lc e ra tio n s, e ro s io n s ) w e re ra te d o n e .22 S aliv a ry flow r a te s w e re in itia lly e x a m in e d fo r ag e a n d se x effec ts b y o n e-w ay A n o v a p ro c e d u re s (flow b y ag e g ro u p —ag es 20 to 39, 40 to 59 a n d 60 to 9 0 12; flow b y sex). E a c h of th e fo u r flow ra te s w as th e n d iv id e d in to p e rc e n tile s . We h y p o th e s iz e d th a t if a n y d iffe re n c e s w e re to e x ist in a su b je c t’s o ral h e a lth o r su b je ctiv e p e rc e p tio n o f sa liv a ry fu n c tio n it w as lik ely to b e g r e a te s t b e tw e e n p e rs o n s in th e lo w e s t a n d h ig h e s t te n th p e r c e n tile flow r a te g ro u p s. F lo w r a te s in th e lo w e s t te n th p e rc e n tile w e re c o n s id e re d in d ic a tiv e of low p e rfo rm a n c e in a
FIG U R E 2
1 .4 0 1 .3 0
1 .2 0 1 .1 0 1 .0 0 0 .9 0 0 .8 0 0 .7 0 0 .6 0 0 .5 0 0 .4 0 0 .3 0
0 .2 0 0 .1 0 0 .0 0
♦ - rf»
Ü Ü Ü U N S T IM P A R O TID
ST IM PAR O TID
U N S T IM SUBM AND
STI IVI SUBM AND
The distribution of salivary flow rates in 50 healthy males. Salivary flow rates are expressed as mL/min • gland. Solid lines represent average values and dashed lines represent values at the highest and lowest 10th percentiles, for each of the four salivary flow rates.
fin d in g s of sa liv a ry h y p o fu n c tio n w e re e v a lu a te d : D oes y o u r m o u th feel d ry w h e n e a tin g a m e a l (d ry e a t); Do y ou sip liq u id s to aid in sw allo w in g d ry foo d s (sip ); D oes th e a m o u n t o f sa liv a in y o u r m o u th se e m to b e to o little , to o m u c h , o r y ou d o n ’t n o tic e it (a m sa l); Do y ou h a v e d ifficu lties sw allo w in g a n y foods (d ifsw al). If a n in d iv id u a l re s p o n d e d “to o m u c h sa liv a ” or “d o n ’t n o tic e i t ” to th e q u e s tio n “a m sa l,” th e n a n e g a tiv e re sp o n se w as c re d ite d . T h e to ta l n u m b e r o f te e th (e x c lu d in g th ird m o la rs), DM FT score, n u m b e r o f te e th w ith c o ro n a l a n d ce rv ica l c a rie s, a n d n u m b e r o f te e th w ith c o ro n a l a n d cerv ical re s to r a tio n s w e re re c o rd e d fo r e a c h p a rtic ip a n t, a c c o rd in g to c r ite r ia e s ta b lis h e d b y th e N atio n al I n s titu te o f D en ta l R e s e a rc h ’s N a tio n a l S u rv e y of O ral H e a lth o f U.S. A d u lts.18 T h e m e sio b u c cal, m id b u c ca l, d isto b u c c a l, m e sio lin g u a l, m id lin g u a l a n d d isto lin g u a l su rfa c e s o f th e six te e th p ro p o se d
b y R a m fjo rd 19w e re e x a m in e d for p e rio d o n ta l p a r a m e te r s (p laq u e , ging iv al b le ed in g , ca lc u lu s, re c e ssio n , p o c k e tin g a n d a tta c h m e n t loss) as d e s c rib e d in
FIG U R E
o
z
-
0 .7 0
a < > j
aliv a is im p o r ta n t fo r th e p re s e rv a tio n a n d m a in te n a n c e of o ral h e a lth .1,2W ith o u t a d e q u a te sa liv a ry g la n d fu n c tio n , a n in d iv id u a l m a y e x p e rie n c e se v e re im p a irm e n t o f o ra l h e a lth . F o r ex am p le, n e w o r r e c u r r e n t d e n ta l caries, m u c o u s m e m b ra n e a lte ra tio n s, d iffic u ltie s in sp e e c h a n d d e g lu titio n , a n d m ic ro b ial in fe c tio n s m ay d ev e lo p w ith o u t a d e q u a te q u a n titie s o f saliva. S aliv a ry g la n d d y sfu n c tio n m ay b e ca u se d b y m a n y fa c to rs.3-4 N u m e ro u s p r e s c rip tio n a n d n o n p re s c rip tio n m e d ic a tio n s a re a s so c ia te d w ith d im in is h e d sa liv a ry p ro d u c tio n . T h e m a jo r th e ra p ie s fo r m a lig n a n c ie s, ra d ia tio n a n d c h e m o th e ra p y , c a n r e s u lt in te m p o ra ry o r p e r m a n e n t d a m a g e to th e sa liv a ry g la n d s. S aliv ary d y sfu n c tio n m ay also a c c o m p a n y m a n y sy ste m ic d ise ase s, th e b e s t s tu d ie d a n d m o st f re q u e n t e x a m p le b e in g S jo g re n ’s s y n d ro m e . T h e d ia g n o sis of sa liv a ry g lan d d y sfu n c tio n re q u ir e s a c o m p re h e n siv e d e n ta l/m e d ic a l e v a lu a tio n , in c lu d in g th e a s s e s s m e n t of sa liv a ry fluid o u tp u t. C u rre n tly , h o w ev e r, it is u n c le a r h o w m u c h sa liv a is re q u ire d to m a in ta in n o rm a l o ral fu n c tio n or, in fact, w h a t c o n s titu te s n o rm a l sa liv a ry g la n d fu n c tio n . A n u n d e r s ta n d in g of th e m in im a l sa liv a ry g la n d p e rfo rm a n c e n e c e s s a ry to s u p p o r t n o rm a l o ral fu n c tio n is n e e d e d to e v a lu a te p a tie n ts w ith d y sfu n c tio n o f th e sa liv a ry g lan d s. N u m e ro u s s tu d ie s w ith a
ABSTRACT
Saliva is important for the preservation and main tenance o f oral health. It is unclear, however, how much saliva is required to maintain normal oral function. M^jor salivary gland flow rates, objective measurements o f oral health, and subjective complaints o f oral problems were assessed in differentaged, healthy persons. Results suggest that the comparison o f nuyor salivary gland flow rates of an individual with population standards to identify patients susceptible to the effects o f salivary dysfunction is unreliable. Changes in salivary function over time are a more mean ingful gauge o f the impact of saliva on oral health. The clinician should monitor salivary production to identify patients with declin ing salivary gland output. v a rie ty o f p a tie n t/s u b je c t p o p u la tio n s h a v e m e a s u re d sa liv a ry o u tp u t. M any in v e stig a to rs h a v e a tte m p te d to e s ta b lish n o rm a l ra n g e s o r “c u t
off” v a lu e s to d is tin g u is h n o rm a l fro m a b n o rm a l sa liv a ry fu n ctio n . F o r e x a m p le , S re e b n y an d V ald in i6 h a v e su g g e ste d 0.1 m illilite r /m in u te as a lo w e r lim it of n o rm a l u n s tim u la te d w h o le saliv a o u tp u t b a s e d o n th e ir p o p u la tio n s tu d ie s a n d th o s e of o th e rs .6'8 T h e se d a ta , h o w ev er, a re d e riv e d fro m h e te ro g e n e o u s p o p u la tio n s, a n d in c lu d e in d iv id u a ls b e in g tr e a te d fo r sy stem ic d ise ase s. M oreover, sin c e c o n s id e ra b le v a ria tio n e x ists in th e n o rm a l ra n g e o f sa liv a ry flow ra te s, it a p p e a rs d ifficu lt, a p rio ri, to se t s ta n d a r d s fo r w h a t c o n s titu te s an ab n o rm a lly low flow ra te .9 U sin g a sin g le v a lu e fo r d e fin in g a b n o rm a l fu n c tio n m a y allo w p a tie n ts w ith sa liv a ry d y s fu n c tio n to r e m a in u n d ia g n o se d a n d u n tre a te d . We, a n d o th e r in v e stig a to rs, h av e r e p o r te d d a ta fo r in d iv id u a l sa liv a ry g la n d s e c re tio n s am o n g h e a lth y s u b je c ts .1016T o o u r k n o w led g e, h o w ev e r, th e re h av e b e e n n o p re v io u s a tte m p ts to re la te in d iv id u a l sa liv a ry g la n d flow r a te s w ith in fo rm a tio n re le v a n t to th e fu n c tio n o f saliv a a n d th e o ra l h e a lth s ta tu s o f a n in d iv id u al. A cco rd in g ly , w e m e a s u re d m a jo r sa liv a ry g la n d fu n c tio n a n d o ra l s ta tu s in a g ro u p o f h e a lth y in d iv id u a ls to d e te r m in e if th e r e is a d isc re te r a n g e of saliv a p ro d u c tio n n e c e s s a ry to s u p p o r t n o rm a l o ra l fu n c tio n . M A T E R IA L S A N D M ETHODS
In d iv id u a ls e v a lu a te d in th is s tu d y
JADA, Vol. 122, March 1991
63
F IG U R E 1
0.488 0.472
0 .8
0 .6
0.4
0.106 0.097
0 .2
0.076 0.059
i
0 .0 UNSTIMULATED
STIMULATED
P A R O T ID
UNSTIMULATED
STIMULATED
S U B M A N D IB U L A R
Major salivary gland flow rates in healthy individuals. Open bars are males (n=50) and hatched bars are females (n=52). Results are mean values ± s.d. Actual mean values are shown above each bar.
in c lu d e d 102 p e r s o n s (5 0 m a les a n d 52 fe m a le s ) b e tw e e n th e ages o f 20 a n d 90. S u b jec ts w ere v o lu n te e r p a r tic ip a n ts in n o rm a tiv e ag in g p ro g ra m s c o n d u c te d by th e N a tio n a l In s titu te o n Aging. All su b je c ts w e re h e a lth y w h ite s, of m id d le so c io e c o n o m ic class, a n d a t th e tim e o f th e s tu d y w e re n e ith e r ta k in g a n y m e d ic a tio n s fo r th e tr e a tm e n t o f sy ste m ic d ise a se n o r b e in g tr e a te d fo r m e d ic a l
p ro b lem s. All p a rtic ip a n ts u n d e r w e n t a n id e n tic a l s ta n d a rd iz e d clin ic al e x a m in a tio n a n d in te r v ie w 16d e s ig n e d to ev a lu a te sig n s a n d sy m p to m s su g g e stiv e of sa liv a ry g la n d d y sfu n c tio n a n d x e ro sto m ia . All su b je cts w e re se en b y o n e e x a m in e r (J.A .S.). All su b je c ts r e fra in e d fro m ea tin g , d rin k in g a n d o ral h y g ie n e fo r a m in im u m of 90 m in u te s b e fo re s a liv a ry c o lle c tio n a n d w e re
s e e n b e tw e e n 8:30 a.m . a n d 11 a.m . U n s tim u la te d a n d s tim u la te d p a r o tid saliv as w e re c o llec te d fro m a sin g le p a ro tid g la n d as d e s c rib e d p re v io u sly .1011 F o r a n y su b je ct d isp la y in g n o u n s tim u la te d p a r o tid sa liv a p ro d u c tio n a fte r five m in u te s , a r e te s t w as p e rfo rm e d . O nly a f te r tw o n e g a tiv e u n s tim u la te d te sts, p lu s p o sitiv e ev id en c e o f a s tim u la te d se c re tio n , w as a su b je c t c o n s id e re d to h av e an u n s tim u la te d flow ra te of zero. S u b m a n d ib u la r saliv a w as c o lle c te d fro m th e o rifice of W h a rto n ’s d u ct, as p rev io u sly d e s c rib e d .4 S aliv ary flow w as s tim u la te d b y sw ab b in g 2 p e rc e n t c itric a c id o n th e d o rso -late ra l s u rfa c e s o f th e to n g u e a t 30-seco n d in te rv a ls .12 A fter c o llec tio n , th e v o lu m e s o f all sa liv a s w e re d e te rm in e d g ra v im e tric a lly , a s su m in g a sp e cific g ra v ity o f 1.0. S u b m a n d ib u la r saliva, as d efin e d in th is p a p e r, re p r e s e n ts a c o m b in e d s u b m a n d ib u la r/ su b lin g u a l se c re tio n d u e to th e f re q u e n t c o m m o n e x it o f th e g la n d d u c ts .17 All p a r tic ip a n ts w e re g iv en a su b je ctiv e x e ro sto m ia q u e s tio n n a ire .16T h e re sp o n se s to fo u r sp e cific q u e s tio n s th a t c o rre la te w ell w ith objectiv e
HIGHEST AND LOWEST 10TH PERCENTILES FOR SALIVARY FLOW RATES S E C R E T IO N C O L L E C T E D 1 LO W 1 O TH %
H IG H 1 0 T H %
MALES (N— 50)
LO W 10 T H %
H IG H 1 Q TH %
FEMALES (N=52)
Parotid U n s tim u la te d S tim u la te d
0.000 0.201
0.160 0.866
0.000 0.180
0.156 0.838
0.020 0.133
0.223 0.644
0.025 0.107
0.216 0.716
Submandibular U n s tim u la te d S tim u la te d
1Flow rates are expressed as mL saliva/m in • gland and re p re sen t the value a t the indicated percentile level. For exam ple, m ales w ith stim ulated parotid saliva in th e low est 10th p ercentile had flow rates at or beloW 0.201 m L /m in • gland, and those in the highest 10th percentile had flow rates a t or above 0.866 m L/m in. gland.
64
JADA, Vol. 122, March 1991
S h ip a n d W olff,20 a c c o rd in g to NIDR c rite r ia .18 T h e o ra l m u c o s a w a s a sse ss e d w ith a m o d ifie d m u c o s a l ra tin g scale.21 N o rm al m u c o sa o r m ild c h a n g e s (d ry , p a le o r g lo ssy m u c o sa a n d a lte ra tio n s in m u c o sal to p o g ra p h y ) w e re r a te d zero , a n d m o d e ra te o r se v e re c h a n g e s (e ry th e m ic o r le u k o p la k ic lesio n s, u lc e ra tio n s, e ro s io n s ) w e re ra te d o n e .22 S aliv a ry flow r a te s w e re in itia lly e x a m in e d fo r ag e a n d se x effec ts b y o n e-w ay A n o v a p ro c e d u re s (flow b y ag e g ro u p —ag es 20 to 39, 40 to 59 a n d 60 to 9 0 12; flow b y sex). E a c h of th e fo u r flow ra te s w as th e n d iv id e d in to p e rc e n tile s . We h y p o th e s iz e d th a t if a n y d iffe re n c e s w e re to e x ist in a su b je c t’s o ral h e a lth o r su b je ctiv e p e rc e p tio n o f sa liv a ry fu n c tio n it w as lik ely to b e g r e a te s t b e tw e e n p e rs o n s in th e lo w e s t a n d h ig h e s t te n th p e r c e n tile flow r a te g ro u p s. F lo w r a te s in th e lo w e s t te n th p e rc e n tile w e re c o n s id e re d in d ic a tiv e of low p e rfo rm a n c e in a
FIG U R E 2
1 .4 0 1 .3 0
1 .2 0 1 .1 0 1 .0 0 0 .9 0 0 .8 0 0 .7 0 0 .6 0 0 .5 0 0 .4 0 0 .3 0
0 .2 0 0 .1 0 0 .0 0
♦ - rf»
Ü Ü Ü U N S T IM P A R O TID
ST IM PAR O TID
U N S T IM SUBM AND
STI IVI SUBM AND
The distribution of salivary flow rates in 50 healthy males. Salivary flow rates are expressed as mL/min • gland. Solid lines represent average values and dashed lines represent values at the highest and lowest 10th percentiles, for each of the four salivary flow rates.
fin d in g s of sa liv a ry h y p o fu n c tio n w e re e v a lu a te d : D oes y o u r m o u th feel d ry w h e n e a tin g a m e a l (d ry e a t); Do y ou sip liq u id s to aid in sw allo w in g d ry foo d s (sip ); D oes th e a m o u n t o f sa liv a in y o u r m o u th se e m to b e to o little , to o m u c h , o r y ou d o n ’t n o tic e it (a m sa l); Do y ou h a v e d ifficu lties sw allo w in g a n y foods (d ifsw al). If a n in d iv id u a l re s p o n d e d “to o m u c h sa liv a ” or “d o n ’t n o tic e i t ” to th e q u e s tio n “a m sa l,” th e n a n e g a tiv e re sp o n se w as c re d ite d . T h e to ta l n u m b e r o f te e th (e x c lu d in g th ird m o la rs), DM FT score, n u m b e r o f te e th w ith c o ro n a l a n d ce rv ica l c a rie s, a n d n u m b e r o f te e th w ith c o ro n a l a n d cerv ical re s to r a tio n s w e re re c o rd e d fo r e a c h p a rtic ip a n t, a c c o rd in g to c r ite r ia e s ta b lis h e d b y th e N atio n al I n s titu te o f D en ta l R e s e a rc h ’s N a tio n a l S u rv e y of O ral H e a lth o f U.S. A d u lts.18 T h e m e sio b u c cal, m id b u c ca l, d isto b u c c a l, m e sio lin g u a l, m id lin g u a l a n d d isto lin g u a l su rfa c e s o f th e six te e th p ro p o se d
b y R a m fjo rd 19w e re e x a m in e d for p e rio d o n ta l p a r a m e te r s (p laq u e , ging iv al b le ed in g , ca lc u lu s, re c e ssio n , p o c k e tin g a n d a tta c h m e n t loss) as d e s c rib e d in
FIG U R E
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z
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0 .7 0
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