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What is the composition of saliva?
- 99% water
- 1% solids (electrolytes & proteins)
- VARIABLE (with flow rate)
What is normal daily production of saliva?
- 0.5-1.0 L
- 90% produced by parotid, submandibular and submental
What are the 3 major salivary glands?
(largest to smallest) parotid, submandibular, sublingual
What type of saliva does the parotid produce?
Serous: thin, watery, amylase-rich
What type of saliva does the submandibular gland produce?
- mixed mucous & serous
- serous: thin, watery, amylase-rich
- mucous: viscous, slimy, mucin-rich
What type of saliva does sublingual gland produce?
mucous: viscous, slimy, mucin-rich
Where are the minor salivary glands located?
- oral mucosa (labial, buccal, palatine, lingual)
- 10% saliva production
- Large fraction of salivary protein: oral tissue lubrication
What is salivary protein function of minor salivary glands?
oral tissue lubrication
Describe the functions of saliva.
- Teeth: lubrication, remineralization, clearance, inhibit demineralization
- Microbes: antifungal, antibacterial, antiviral
- food: taste, bolus, digestion
What are the roles of mucins?
- inhibits demineralization
- anti viral
- lubrication and visoelasticity
What are the unconditioned salivary relexes?
- masticatory-salivary reflex (chewing)
- gustatory-salivary reflex (taste)
How does the masticatory-salivary reflex work?
- chewing activates mechanoreceptors in the PDL
- could be a problem in denture wearing pts (must be stimulated by different mechanism)
What is the mechanism of the gustatory-salivary reflex?
taste activated chemoreceptors in the taste buds within the lingual papillae
What are the conditioned reflexes for salivary secretion?
- impulses from higher brain centers to salivary nuclei (non-mechanical, non-physical)
- power of suggestion (think about favorite food)
What are some conditioned relfex factors that may inhibit salivary flow?
- mental depression
- stress (anxiety, yet stress can increase flow (will to fight))
What are the effects of stress on salivary flow?
- increased flow (will to fight)
- decreased flow (anxiety)
What components increase as salivary rate increases?
Na, Cl, HCO3, Ca, pH, ionic strength (submandibular/submental)
What components decrease as salivary rate increases?
Inorganic Phosphate, Mg, K (parotid)
Explain the features of dynamic saliva composition.
- Final composition of saliva depends on flow rate
- In stimulated saliva: increased bicarbonate, buffering and pH (more alkaline)
What is salivary clearance?
- diluctiona dn elimination of substances from the oral cavity (ex fermentable carbohydrates)
- sucrose intake->salivary gland stimulation (taste & chewing)-> swallowing-> [Sucrose] in saliva decreases to zero
How does decreased flow affect clearance?
increases acid exposure time
How does plaque affect salivary clearance?
- [Sucrose] in plaque rises rapidly with sugar intake and remains high despite [Sucrose] saliva decreasing
- sugar is available for plaque bacteria long after [sugar] in saliva falls below the taste threshold.
What is xerostomia?
SUBJECTIVE feeling of oral dryness affecting swallowing, speech & QOL
What is hyposalivation?
- abnormally low salivary flow rates OBJECTIVELY measured by saliva producton
- Unstimulated: <=0.1mL per minute
- Stimulated: <-0.5-0.7 mL/min
What is low saliva flow rates?
- Unstimulated: 0.1-0.25 mL/min
- Stimulated: 0.7-1.0 mL min
What is normal salivary flow rates?
- Unstimulated: > 0.25 mL/min
- Stimulated: > 1.0 mL/min
What are the causes of salivary gland hypofunction?
- Medications: antidepressants, antianxiety, antihistamines, antihypertensives (diuretics)
- >3 different drugs taken daily (polypharmacy) CAMBRA risk facor
- Systemic disease: autoimmune, hormonal, infectious, neurological
- autoimmune: sjogrens, rheumatoid arthritis, SLE (systemic lupus erythematosus
- Hormonal: diabetes mellitus (labile)
- infectious: HIV, HEP-C
- neurological: depression, cerebral palsy (open, dry mouth)
- cancer treatment: (should prescribe fluoride trays & frequent recall) radiation tx to H&N, chemotherapy
What is polypharmacy?
- >3 different drugs taken daily
- CAMBRA high risk factor
What are the signs of salivary deficiency
- difficulty eating or swallowing
- tongue sticking to palate (may affect speech)
- mouth/cheeks sticking to teeth
- burning sensation of mucosa and tongue
- changes in taste
- inadequate denture retention (especially maxillary)
- increased rate of decay
- soft tissure trauma
What is saliva check?
- objective measure of quality and quantity of saliva (pH and buffering capacity)
- production, consistency, resting and stimulated pH and flow, buffering capacity
- useful for planning, risk assessment, montitoring
- not for in vivo diagnostic use
- stimulation via paraffin wax chewing
What does ivoclar (CRT buffer) test?
buffering capacity only
What are the treatments of xerostomia?
- from Ram "mgt of xerostomia and salivary gland hypofunction" 2011:
- increased water intake (spray bottles)
- change meds
- saliva substituetes (biotene and oral balance)
- lubricating gel intraorally (KY jelly, GC dry mouth gel)
- Vaseline on lips
- toothpastes without additives (Biotene), some additives cause irritation
- xylitol gums, mints, candies
- DO NOT USE lemon & glycerine swabs (turns to alcohol)
- DO NOT USE alcohol contatining mouthwashes
What are contraindicated for treated xerostomia?
- additives in toothpaste
- lemon & glycerine swas/toothettes (turns to alcohol)
- alcohol containing mouthwashes
Why is perinatal oral health important?
- pregnant women have high risk for erosion and perio disease
- untreated maternal decay increases risk in child
- untreated infections can complicate pregnancy (esp w diabetes)
What is ECC?
- any tooth decay including extrations and fillings in primary dentition
- most prevalant chronic childhood disease
- 5x more prevalant than asthma
- 7x more than hay fever
What is severe ECC?
- distictive decay pattern beginnning in upper primary teeth (DEFG and laterally spreading as they erupt)
- ethnicity risk factors
Who are children with disabilities and special needs and what are their risk factors for ECC?
- has difficulty accessiong dental care because of complicated medical, physical, social or psychological situations.
- sweetened medications
- reduced salivary flow
- restricted diets
- difficulties brushing
- many competing health problems and needs
What are the risk factors for ECC?
- lower socio-economic status
- certain ethnic/cultural groups
- disabilities and special needs (medication, OHI)
What is the status of ECC in California?
- children fall well below nation in oral health
- about 1/3 preschoolers and 70% of children K-3 have experienced tooth decay
What are some avg cost figures to treat ECC?
- 12-15K if hospitalized
What is the decay recurrance rate of treated children?
- 40-50% have new decay within 4-12 months
- must treat infection reasons (CAMBRA)
- general anesthesia full mouth rehab come back within 2 years with new or worse caries.
What are the effects of ECC?
- pain, infection, self-esteem
- some may not realize pain/emotional problems arise from caries
- pain->missed school days, impaired concentration, school readiness, sleep and overall health and well being
- infection->failure to thrive and delayed growth patterns
- self-esteem->steel crowns/unattractive smiles
Why are primary teeth important?
- eating and nutrition
- holding space
- proper speech development
What are the pathological and protective factors of increasing caries risk (featherstone's model)?
- reduced salivary funciton
- bacteria: S mutans Lactobacilli
- Diet: frequent carbs
- salivary flow & components
- proteins, antibacterial
- Fluoride, Ca, PO4
- Dietary components: protective
Discuss the tranmissibility of ECC.
- S mutans, lactobacilli ( about 600 spp of bacteria contribute)
- acidogenic from carbohydrates->demineralization before visible decay
- 40-50 species protect
- horizontal-child to child
- vertical-parent/caregiver to child
- colonization can occur BEFORE eruption
What are white spot lesions?
- 1st visible sign of tooth decay
- decay is reversible (put floridated tootpast on teeth, last to touch teeth before bed)
- Remineralization-> Ca & PO4 from saliva and enhanced by fluoride to become more resistant
- Do BEFORE penetrates dentin otherwise RESTORE (intermediate therapeutic restorations-glass ionomer)
What is the key to preventing ECC?
early intervention w pregnant mothers, young babies
What are the anticaries features of Fluoride?
- inhibit demin
- enhance remin
- inhibit plaque bacteria
What percentage of Californians have Fluoridated drinking water?
- filters can remove impurities but not Fluoride
How should tootpaste be applied to toothbrush?
- across width, not length
- small pea-sized dab used morning and before bed
What kind of fluoride should high risk children below 6 use?
- toothpaste (more for 2-6 that can spit, DO NOT RINSE)
- varnish (3-6 months, professionally applied)
- no mouthrinses, gel or foam (only for good spitters around 7-8 yrs old)
How should fluoride varnish be used?
- 3x in a 2-week period for reminerlaization of white spot lesions
- 3-4x per year for high risk babies and young children
What other technique proves to be successful with preventing caries?
- sealants for occlusal surface
- fluoride for smooth surfaces
What is the brand of children's drink that contains xylitol?
What kind of restrictions on fermentable carbohydrates should be used?
- limit sugary foods, simple carbs
- limit frequency and total amount (also effective against obesity)
How and when should a child be weaned from the breast?
- use cup at 6 months
- weaning at 12-14
- don't put baby to bed w/bottle or cup
What are the (anticipaory guidance) recommendations for ALL children and HIGH RISK?
- ALL: F in H20, F toothpaste (2x day), limit simple CHO
- HIGH RISK: F Varnish, anti-bacterials for mothers & older children, F mouthwash for spit, sealants
How can mothers alter their bacterial flora?
- manage from birth to 2 yrs old
- use anti-bacterials like chlorhexidine and xylitol
- Chlorhexidine gluconate: Rx 10ml daily for 1 week per month for 1 year, (taste, mild staining)
- Xylitol: 5-10g daily, should be 1st listed ingredient, Carefree Koolerz 1.6 g/piece
What are the steps in infant oral health program for babies and young children?
- Supplies: gauze, light, toothbrush, varnish, gloves, optional
- 1. Interview and CAMBRA: F H20, home practices, family history, weaning, diet habits
- 2. Knee to knee position: (with mother and child in lap)
- 3. Toothbrush Prophy: remove plaque, discuss home care, reinforce toothpaste use (small dab)
- assess older children's and caregiver's OH skills
- 4. Oral Assessment: thick plaque, chalky white spots, brown spots or obvious cavities, tooth defects, abscesses
- explain what to look for and how to lift the lip
- 5. Apply F Varnish: wipe & paint each tooth when dried with guaze, egin with lower outsides then insides then upper
- may leave yellowish brown brushable film, should not be brushed for at least a day
- 6. Summarize and Anticipatory Guidance: follow-up, anticipatory guidance and home care based on risk
What are the high risk factors for caries?
- white spot lesions
- carious lesions
- visible plaque
- family history
- impaired saliva composition or flow
- frequent CHO exposure
What are the techniques used for anticipatory guidance?
- small steps: 1-2 key messages
- remain positive
- culturally appropriate
- multiple methods
- use closed and open ended questions
- non-judgemental and friendly
- documentation & referral
What are the factors to change behavior?
triggers over a period of time in combination with individual experience and values necessary to change health behavior
What is intermediate therapeutic restoration?
- minimal cavity prearation
- Fluoride releaseing material (glass ionomer)
- Triage material
When should baby be seen by dentist?
within 6 months of 1st tooth but no later than age 1