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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 1  |  Page : 12-15

Salivary changes in medically compromised patients: A clinical and biochemical study


1 Department of Oral Medicine and Radiology, Institute of Dental Education and Advance Studies, Gwalior, Madhya Pradesh, India
2 Department of Oral Medicine and Radiology, Sree Sai Dental College and Research Institute, Srikakulam, Andhra Pradesh, India
3 Department of Oral Medicine and Radiology, Hazaribag College of Dental Sciences, Hazaribag, Jharkhand, India
4 Department of Pedodontics and Preventive Dentistry, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
5 Department of Oral Pathology, Manthena N Raju Dental College and Hospital, Sangareddy, Telangana, India

Date of Submission28-Nov-2014
Date of Acceptance24-Jun-2017
Date of Web Publication04-Aug-2017

Correspondence Address:
Vamsi Pavani Bellana
Department of Oral Medicine and Radiology, Sree Sai Dental College and Research Institute, Srikakulam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_233_14

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   Abstract 

Introduction: Medically compromised patients require special attention when dental procedures are performed on them. These individuals may require modified or slightly altered techniques. Aims and Objectives: The present study was taken up with two main objectives. The first one being examining and recording various oral manifestations in medically compromised patients, and the second objective was to collect samples of saliva from such patients and to analyze and establish any salivary changes in such medically compromised patients. Materials and Methods: A total of 100 patients were selected for the study. These patients were divided into four groups of 25 patients each: diabetes mellitus group, chronic renal failure group, liver cirrhosis group and control group. All the selected patients were subjected to a detailed general and intra oral examinations and the relevant data was recorded on a specially designed proforma; salivary analysis was done to know the flow rate, pH, total salivary proteins, sodium, potassium, and LDH levels. Results: From the findings, it can be inferred that salivary changes namely changes in salivary pH, salivary flow rates, salivary sodium, salivary potassium, salivary total proteins, and salivary lactate dehydrogenase are significant in medically compromised patients namely uncontrolled diabetes mellitus, chronic renal failure, cirrhosis of liver compared to the control group. Conclusion: pH of saliva was elevated in chronic renal failure patients. Salivary flow rates and sodium were decreased in diabetes mellitus, chronic renal failure, and cirrhosis of liver patients. There was a significant elevation of salivary potassium in chronic renal failure patients. LDH elevation was significant in uncontrolled diabetes mellitus.

Keywords: Biochemical analysis, medically compromised patients, salivary changes


How to cite this article:
Tummuru YR, Bellana VP, Koppula SK, Tupalli AR, Erugula SR, Kumar N. Salivary changes in medically compromised patients: A clinical and biochemical study. J Indian Acad Oral Med Radiol 2017;29:12-5

How to cite this URL:
Tummuru YR, Bellana VP, Koppula SK, Tupalli AR, Erugula SR, Kumar N. Salivary changes in medically compromised patients: A clinical and biochemical study. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2017 Oct 22];29:12-5. Available from: http://www.jiaomr.in/text.asp?2017/29/1/12/212085


   Introduction Top


Dental surgeons have a challenging role in diagnosing and treating medically compromised patients as the underlying systemic problem may cause complications during and after the dental procedures.[1] Hence, a thorough examination of the oral cavity and detailed case history is necessary before any dental procedure is undertaken. Many systemic diseases affecting the endocrinal, renal, cardiovascular, respiratory and hemopoitic systems may manifest themselves in the oral cavity to some extent.[2] However, some diseases may not show any manifestations in the oral cavity. Such diseases may pose further complications during dental procedures if not detected in time. As medically compromised conditions may encompass many diseases, it is not practically possible to include all diseases in this project due to limitations. Certain group of patients suffering from some important systemic diseases such as uncontrolled diabetes mellitus, chronic renal failure, and cirrhosis of liver were selected.

Aims and objectives

To undertake thorough clinical examination of oral cavity in medically compromised patients who were diagnosed to have been suffering from such systemic diseases such as diabetes mellitus, chronic renal failure, and cirrhosis of liver.

To undertake salivary analysis of patients suffering from the systemic diseases mentioned above and to compare the results with normal individuals in the control group with specific reference to salivary flow rates, pH, and certain salivary constituents such as sodium, potassium, salivary lactate dehydrogenase (LDH), and salivary total proteins.

To assess the possibility of drawing conclusions from the study whether salivary analysis can be included as one of the investigations that can be advised in diagnosis of any of the above systemic diseases such as diabetes mellitus, chronic renal failure, and cirrhosis of liver.


   Materials and Methods Top


A total of 100 patients were selected for the study. These patients were divided into four groups of 25 patients each. The first group of 25 individuals was chosen from the attendants of the patients who were visiting the Dental College and Hospital, and prior determination was done as to whether they were free of the abovementioned systemic diseases. The other three groups of patients consisted of a sample of 25 each diagnosed with diabetes mellitus, chronic renal failure, and cirrhosis of liver, respectively. All the selected patients were subjected to a detailed general and intra oral examinations and the relevant data was recorded on a specially designed proforma; salivary analysis was done to know the flow rate, pH, total salivary proteins, sodium, potassium, and LDH levels.

Method of saliva collection

After the patient was comfortable and relaxed, a paraffin wax was kept in his/her mouth and they were requested to chew on it and spit the saliva outside as it may contain some food debris, which may alter the salivary composition [Figure 1].
Figure 1: Photograph showing armamentarium for clinical method of collecting saliva

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Estimation of flow rate

Patient was again asked to chew on the paraffin wax and spit the saliva into a glass calibrated beaker which was calibrated from 0 to 20 ml for 5 min. Flow rate was calculated by quantity of saliva in ml for 5 min.

Estimation of pH of saliva

The collected saliva was allowed to settle down for 5–10 min. Then, a pH indicator paper strip (2.2–10.2) was dropped into it and observed after 10–15 s. The pH indicator paper strip was then removed and the color of the paper was compared with the standard colors and the corresponding reading was noted. This was determined as the pH of saliva for the particular individual.

Estimation of salivary protein

The most commonly used method of studying salivary protein, employs the Biuret reaction substance which contain two CONH2 groups joined together directly or through a single carbon or nitrogen atom. Those which contain two or more peptide links give a blue or purple colored compound with alkaline copper solution [Figure 2]. This method was used to estimate salivary protein.
Figure 2: Photograph showing materials for protein estimation

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Estimation of sodium and potassium in saliva

For simple and rapid determination of sodium and potassium levels we used emission flame photometry [Figure 3].
Figure 3: Photograph showing flame photometer for sodium and potassium estimation

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Estimation of lactate dehydrogenase

Lactate dehydrogenase is an anaerobic dehydrogenase. The recommended method (optimized at 37°C) of the committee on enzymes of the Scandinavian society for clinical chemistry and chemical physiology in 1974 was used in the study [Figure 4].
Figure 4: Photograph showing auto analyzer for LDH estimation

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   Results Top


In this study, 100 individuals were selected and divided then into four groups of 25 each. Group I was the control group with no underlying systemic disease. Group II was uncontrolled diabetes mellitus group, group III included patients suffering from chronic renal failure, and group IV consisted of patients with liver cirrhosis [Table 1]. In group I, 64% were males and 36% were females. In group II, 32% were males and 68% were females. In group III, 88% were males and 12% were females. In group IV, 84% were males and 16% were females.
Table 1: Salivary parameters of normal controlled individuals and medically compromised patients

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From these findings [Table 2], it can be inferred that salivary changes namely changes in salivary pH, salivary flow rates, salivary sodium, salivary potassium, salivary total proteins, and salivary lactate dehydrogenase are significant in medically compromised patients namely uncontrolled diabetes mellitus, chronic renal failure, cirrhosis of liver compared to the control group.
Table 2: Total significance of salivary changes in medically compromised patients

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   Discussion Top


Medically compromised patients are a special category of patients who need special care because of their underlying systemic conditions, which can cause problems during or after dental treatment. In this study, three categories of medically compromised patients were taken namely patients with uncontrolled diabetes mellitus,[3] chronic renal failure,[4] and cirrhosis of liver.[5] A thorough case history was taken for these patients. For biochemical analysis, large volumes of saliva is required, hence to get large volumes saliva is stimulated by masticatory or gustatory stimuli.[6] Stimulated salivary samples of 5 min was taken from each individual and the determination of flow rate, pH of saliva, total protein estimation, salivary sodium, salivary potassium, and salivary lactate dehydrogenase was done.

In the present study, the age and sex of the patients were not considered as criteria. However, for group I or normal control patients, the average age was 26.88 years, for group II it was 44.72 years, for group III it was 34.36 years, and for group IV was 34.84 years. Heft et al. in 1995 collected both stimulated and unstimulated parotid saliva from 85 healthy unmedicated individuals between ages of 23–81 years and found there was no significant difference in flow rate related to age with either stimulated and unstimulated secretions.[7]

The results show that there was a significant elevation of salivary pH in patients with chronic renal failure which can be attributed to the increased concentration of urea in the plasma and uremia which increased the pH of blood. Jaffe et al. reported increased calculus index in chronic renal failure patients which is attributed to high salivary pH.[8] In this study, there was reduction of salivary flow rates in all the categories, which was highly significant in liver cirrhosis patients. Govindhan et al. in 1990 reported decreased flow rate in liver cirrhosis patients and other hypoproteinemic states regardless of etiology.[9] The mechanism involved induced xerostomia due to changes in circulation of salivary glands, autonomic dysfunction, dehydration, osmotic diuresis, destruction of acinar parenchyma, or other changes. The salivary protein[10] was significantly lowered in patients with uncontrolled diabetes mellitus and liver cirrhosis. This may have been due to acinic cell damage. Salivary sodium level was decreased in uncontrolled diabetes mellitus, chronic renal failure, and liver cirrhosis patients, and salivary potassium was increased to highly significant levels in patients with chronic renal failure. Salivary LDH was elevated to highly significant levels in diabetes mellitus. Musumeci et al. in 1993 conducted experiments on aspartate (GOT), alanine (GPT), and lactate dehydrogenase (LDH) in saliva samples collected by salivette method from well-controlled insulin dependent and noninsulin dependent diabetic patients. In the IDDM, salivary secretion of LDH was similar to NIDDM, but higher than observed in normal individuals.[11] Thus, it may be reasonable to conclude that at least most of the increased enzymatic activity of GOT, GPT, and LDH found in saliva of diabetics may come from salivary glands.

From the above findings, it can be inferred that the changes in the saliva, namely salivary pH, salivary flow rate, salivary sodium, salivary potassium, salivary total proteins, and salivary lactate dehydrogenase, were significant in the medically compromised patients namely uncontrolled diabetes mellitus, chronic renal failure, and cirrhosis of liver.


   Conclusion Top


From this study the following conclusions can be made

  1. pH of saliva is elevated in chronic renal failure patients
  2. Flow rates are decreased in diabetes mellitus, chronic renal failure, and cirrhosis of liver patients, but more significant in cirrhosis of liver patients
  3. Salivary sodium is lowered in diabetes mellitus, chronic renal failure, and cirrhosis of liver and there is a significant elevation of salivary potassium in chronic renal failure patients
  4. LDH elevation is significant in uncontrolled diabetes mellitus
  5. Salivary analysis can be suggested as one of the investigations in medically compromised patients
  6. There is a necessity of further studies of oral manifestations and salivary changes in other systemic diseases which were not covered in this study to draw more comprehensive and definite conclusions.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Tenovuo J. The biochemistry of nitrates, nitrites, nitrosomines and other potential carcinogens in human saliva. J Oral Pathol 1986;15:303-7.  Back to cited text no. 1
[PUBMED]    
2.
Shafer WG. A Text Book of Oral Pathology. 4th edition. New Delhi: Elsiever publication; 1993. p. 519-23.  Back to cited text no. 2
    
3.
Lynch, Malcom AB, Vernon J. Burket’s Oral Medicine, Diagnosis and Treatment. 8th edition. Philadelphia: Lippincott, 1984. p. 848-9.  Back to cited text no. 3
    
4.
McCormack KR, Mc Dormott RJ. The patient with renal disease: Some implications for dental hygiene practice. Dental Hygiene 1986;60:406-9.  Back to cited text no. 4
    
5.
Scully C, Potts AJ, Hamburger J, Wiesenfeld D, McKee JI, el Kom M. Lichen planus and liver disease: How strong is the association? J Oral Pathol 1985;14:224-6.  Back to cited text no. 5
    
6.
Mandel ID. The diagnostic uses of saliva. J Oral Pathol Med 1990;19:125-9.  Back to cited text no. 6
[PUBMED]    
7.
Heft MW, Baum BJ. Unstimulated and stimulated parotid saliva flow rate in individuals of different ages. J Dent Res 1984;63:1182-5.  Back to cited text no. 7
[PUBMED]    
8.
Jaffe EC, Roberts GJ, Chantler C, Carter JE. Dental findings in chronic renal failure. Br Dent J 1986;60:18-28.  Back to cited text no. 8
    
9.
Govindan M. Salivary secretion in hypoproteinemic states. J Oral Med 1985;40:171-5.  Back to cited text no. 9
    
10.
Sharon A, Ben-Arhey H, Itzhak B, Yoram K, Szargel R, Gutman D. Salivary composition in diabetic patients. J Oral Med 1985;40:23-6.  Back to cited text no. 10
    
11.
Musumeci V, Cheribini P, Zuppi C, Zappacosta B, Ghirlanda G, Di Salvo S. Aminotransferases and lactate dehydrogenase in saliva of diabetic patients. J Oral Pathol Med 1993;22:73–6.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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