Scope of Saliva as an innovative diagnostic tool for oral

and systemic diseases – A Review

Authors:
1. Dr. VaishaliVasant Koranne
Assistant Professor, Department of Oral Medicine and Radiology,Bharati Vidyapeeth(
Deemed to be University), Dental College and Hospital – Pune.
2. Dr. Samir Achyut Joshi.
Associate Professor, Department of Oral and Maxillofacial Surgery,Bharati Vidyapeeth
(Deemed to be University), Dental College and Hospital – Pune.
3. Dr. Darshan R.Prasad Hiremutt
Associate Professor, Department of Oral Medicine and Radiology, Bharati Vidyapeeth
(Deemed to be University), Dental College and Hospital – Pune.
4. Dr. Swapna Patankar
Assistant Professor, Department of Oral Pathology,Bharati Vidyapeeth( Deemed to be
University), Dental College and Hospital – Pune.
5. Dr. Hamaza Salema
PG Student , Department of Oral and Maxillofacial Surgery ,Bharati Vidyapeeth ( Deemed to
be University), Dental College and Hospital – Pune.
6. Dr. Jay Patel
PG Student , Department of Oral and Maxillofacial Surgery ,Bharati Vidyapeeth ( Deemed to
be University), Dental College and Hospital – Pune.

Corresponding contributor:
Dr. Darshan R.Prasad Hiremutt
Associate Professor, Department of Oral Medicine and Radiology, Bharati Vidyapeeth( Deemed to be
University), Dental College and Hospital – Pune.
Email id:
[email protected]
Phone no.:9970292248

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Abstract -
Early detection of disease is an important factor for reducing its severity and preventing its
complications. Also it is helpful in to increasing success rate of therapy. All over world Saliva
has been studied widely as a potential diagnostic tool over the last decade due to its ease and
non-invasive accessibility along with its many biomarkers, such as genetic material and
proteins. This review will guide dentist on recent advances in salivary biomarkers to diagnose
autoimmune diseases Sjogren's syndrome and cystic fibrosis, cardiovascular diseases, HIV,
oral cancer, caries and periodontal diseases. In future due to its accuracy, efficacy, ease of use
and cost effectiveness saliva will be considered as a diagnostic innovative tool useful to dentist.
Keywords: Saliva, Diagnostics, Diseases

INTRODUCTION –

In humans saliva is a mouth fluid which have many functions and involved in oral health and
homeostasis. Saliva helps bolus formation by moistening food, protects the oral mucosa against
mechanical damage and plays an important role in preliminary digestion of food through the
presence of α-amylase and other enzymes. It also helps in taste perception
Generally laboratory diagnostic procedures involve the analyses of cellular and chemical
constituents of blood. However saliva have advantages when used for diagnosis of any disease.
Collection of saliva is non invasive and cost effective method. Collection of saliva is easy
method for children. Also for screening of large populations analysis of saliva is cost-effective
method .Normal daily salivary flow range from 0.5 to 1.5L with average volume of 1ml at any
given time. Saliva can be considered as gland-specific saliva and whole saliva. However, whole
saliva is most frequently studied when salivary analysis is used for the evaluation of systemic
disorders. Whole saliva is a mixture of the secretions of the major and minor salivary glands,
mucosal transudations, gingival crevicular fluid, serum and blood derivatives from oral
wounds, desquamated epithelial cells, expectorated bronchial and nasal secretions, bacteria and
bacterial products, viruses and fungi,other cellular components and food debris. It is a complex
fluid containing an entire library of hormones, proteins, enzymes, antibodies, antimicrobial
constituents, and cytokine1. The mechanism of entry of these constituents from the blood into
the saliva is by transcellular, passive intracellular diffusion and active transport, or paracellular
routes by extracellular ultrafiltration within the salivary glands or through the gingival
crevice.2,3 Saliva has been studied widely as a potential diagnostic tool over the last decade.4
Autoimmune Disorders –
Sjogren's syndrome -Sjogren's syndrome (SS) is a chronic autoimmune disease
characterized by salivary and lacrimal dysfunction, multiple organ abnormalities and
serological changes.5 Salivary secretions from these patients shows elevated levels of
antibodies and cytokines such as IgA, IgG, prostaglandin-E2, and interleukin-6. This is
accompanied by a reduction in oral phosphate levels and xerostomia due to reduced salivary
flow which can lead to infections, progressive caries, dysphagia and oral pain.6 Current tests
for SS include sialometry or salivary flow rate determination, salivary scintigraphy,
sialography, serological tests or minor salivary gland biopsies. However these tests are
invasive, expensive or in many cases non-conclusive.5,6 Salivary proteomics represent a
valuable aid for diagnosis of SS. It is based on the detection of several biomarkers that are
simultaneously influenced by the disease. Recently,

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still investigations and more research is required in this field.
Cystic fibrosis (CF) is a genetically transmitted disease of children and young adults. Saliva
of CF patients has increased levels of calcium and phosphate, which may explain higher
incidence of calculus observed in such individuals.8 These patients also have higher salivary
levels of chloride, potassium and sodium ions with a lower salivary volume and pH compared
to healthy individuals.9 In addition, whole saliva samples in younger CF patients have been
found to have higher levels of proteins, antioxidants and uric acid compared to controls.10
Malignancy - The most common form of oral cancer is Oral squamous cell carcinoma
(OSCC).p53 is a tumor suppressor protein which is produced in cells exposed to various types
of DNA-damaging stress. Inactivation of this suppressor through mutation is considered a
frequent occurrence in the development of human cancer. Accumulation of inactive p53 protein
occur, which in turn lead to the production of antibodies directed against this p53 protein. The
p53 antibodies can be detected in the saliva of patients diagnosed with oral squamous cell
carcinoma (OSCC), and can thus help in the early detection and screening of carcinoma .11
Defensins -Elevated levels of salivary defensin-1 were found to be indicative of the presence
of OSCC. A high-positive correlation was observed between salivary defensin-1 levels and
serum levels of SCC-related antigen.12
CA15-3, c-erbB-2 Elevated levels of recognized tumor markers c-erbB-2 (erb) and cancer
antigen 15-3(CA15-3) were found in the saliva of women diagnosed with breast cancer, as
compared with patients with benign lesions and healthy controls. It is useful for the early
screening and detection of breast cancer 13.CA 125 is a tumor marker for cancer. Elevated
salivary levels of CA 125 were detected in patients with untreated breast cancer than healthy
controls and patients who were treated for breast cancer. A positive correlation was found
between salivary and serum levels of CA 125 14.
Dental Caries and Periodontal Diseases– Increased numbers of Streptococcus mutans and
lactobacilli in saliva associated with increased caries prevalence and root caries. Saliva
secretion rate and buffering capacity have proven to be sensitive parameters for caries
prediction.Thereis shift in oral microflora from healthy to more cariogenic. Diagnostic kits for
S. mutans and Lactobacillus counting are easily available in dental practice and can be
conducted as a chairside investigation in dental office. When salivary secretion rate drops
below a certain minimum rate, the amount of dental caries increases. Salivary secretion rate is
easily measured by weighing the saliva volume that is collected by expectoration divided by
the collection time. Low salivary buffering capacity is a risk factor for dental caries and also is
indicative for low saliva secretion. Commercial kits are available for determination of the
salivary buffering capacity.
Periodontal Disease - Another oral disease, for which saliva is used for diagnostics are
evaluated is periodontal disease. Progress from gingivitis to periodontal disease is determined
by genetic susceptibility and the presence of pathogenic bacteria. During active periods of the
disease increased levels of inflammatory markers like interleukins are found in saliva. Recently
it is found that periodontal disease as a risk factor for cardiovascular and cerebrovascular
diseases. Thus it bring new importance to this aspect of salivary analysis 15.

Viral Diseases
HIV Antibody to HIV in whole saliva of infected persons was detected by ELISA and
Western blot assay when correlated with serum antibody levels 16. Salivary IgA levels to HIV
decline as

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infected individuals become symptomatic. It was thus suggested that detection of IgA antibody
to HIV in saliva may, be a prognostic indicator for the progression of HIV infection .
COVID-19 –
Coronavirus disease (COVID-19) is a kind of viral pneumonia with its epicentre in Wuhan,
China. It is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Rapid and accurate detection of Covid-19 is important in controlling the rapid spread within
the community and in hospitals. Nasopharyngeal and oropharyngeal swabs are the suggested
upper respiratory tract specimen types for Covid-19 diagnosis. The collection of these
specimen types requires close contact between healthcare workers and patients, which may
cause a risk of transmission of the virus to the healthcare workers. Also collection of
nasopharyngeal or oropharyngeal specimens causes discomfort and may cause bleeding in
patients.
Saliva can also be used as one of the diagnostic modalities for coronavirus detection, helping
in the rapid testing of individuals at home or at hospital.
Forensic Evidence -
Saliva may be found on victims of many violent crimes. Saliva can recovered from bite marks,
cigarette butts, postage stamps, envelopes etc. Stains of dried saliva are invisible, making its
recognition and collection difficult. However, presence of saliva can be confirmed by amylase
assay. During the biting process, saliva is deposited on the skin or object surface in enough
amount to allow typing of the deoxyribonucleic acid (DNA). Polymerase chain reaction (PCR)
allows replication of thousands of copies of a specific DNA sequence in vitro, enabling the
study of small amounts of DNA.17
Detection of drugs
Saliva has been proposed for the monitoring of systemic levels of drugs.Only the
unbound fraction of the drug in serum is available for diffusion into saliva.This unbound
fraction of a drug is usually pharmacologically active fraction. This may represent an advantage
of drug monitoring in saliva in comparison with drug monitoring in serum, where both bound
and unbound fractions of a drug can be detected.Estimation of salivary carbamazepine levels
is
predictable and convenient method of drug monitoring in epileptic patient, and a positive
correlation (r = 0.659) between salivary and serum carbamazepine levels was observed.18
Many recreational drugs that can be identified in saliva are amphetamines, barbiturates,
benzodiazepines, cocaine,phencyclidine (PCP), and opioids.19
Nicotine saliva can be used to monitor tobacco smoking and exposure to tobacco smoke. The
major nicotine metabolite cotinine was investigated as an indicator of exposure to tobacco
smoking. Cotinine is tobacco-specific and has a relatively long half-life (17hours) compared
with nicotine. Salivary cotinine levels were found to be indicative of active and passive
smoking. Monitoring level of salivary cotinine has proven useful in monitoring compliance
with smoking cessation programs.20
Diabetes – Till now very less research has been done on salivary testing for the diagnosis of
diabetes. Investigators have reported that among a total of 487 analysed proteins in the saliva,
65 had higher levels in type-2 diabetes subjects compared to healthy individuals.21 Salivary
proteomics can be used as an option because it is a less invasive approach for screening.
Conclusion –
Although blood is the gold standard for diagnosis of diseases, saliva can also be used as a
diagnostic tool. Considering its accuracy, efficacy, easy to use, non invasiveness and cost
effectiveness salivary diagnostic tests have demonstrated their applications in dental practice
in future.

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