2008;139;35S-40S J Am Dent Assoc

Mahvash Navazesh and Satish K.S. Kumar

opportunities
Measuring salivary flow: Challenges and
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Background. Saliva is being studied extensively
and is being used for risk assessment, diagnosis and
monitoring high-risk behavior and disease progres-
sion. A variety of medical conditions and medications
are associated with salivary gland hypofunction. The
major disadvantage in the use of saliva for health-related purposes is the
lack of standardization in saliva collection methods.
Methods. The authors provide a brief overview of different methods of
saliva collection and the advantages and disadvantages associated with
each method, as well as of how to assess the salivary flow rate.
Results. The authors present the complete set up and step-by-step
guidelines for the collection of unstimulated and stimulated whole
saliva.
Conclusions. The life expectancy of people will continue to increase
with advances in medicine and therapeutic modalities, and the preva-
lence of salivary gland hypofunction in the elderly population will
increase owing to their longevity. The assessment of salivary gland hypo-
function will need to be incorporated into everyday clinical practice.
Clinical Implications. The saliva collection methods outlined in
this article can be used by dentists to assess patients at risk of devel-
oping diseases and by scientists for scholarly activities.
Key Words. Saliva; saliva collection; salivary flow rate; salivary
glands; salivary gland hypofunction; xerostomia.
JADA 2008;139(5 suppl):35S-40S.
P
romoting health by pre-
venting disease is a goal of
health care providers, and
risk assessment and dis-
ease prevention are
common themes in the surgeon gen-
erals report on oral health in
America.
1
Clinicians commonly use
health questionnaires and clinical
evaluations to identify patients at
risk of developing diseases. Hemato-
logic, serologic and imaging diag-
nostic modalities are used to assess
these patients further. In recent
years, saliva-based diagnostic tests
have been increasing in popularity
because of their noninvasive
nature.
2,3
Technologies are available that
use saliva to diagnose, follow and
assess the risk and severity of dis-
eases, high-risk behaviors or both.
Salivary biomarkers have been used
to assess the risk of developing oral,
ovarian and breast cancers; HIV
infection; Sjgren syndrome; and
dental caries and periodontal dis-
eases, as well as to detect exposure
to alcohol and illegal drugs. Nico-
tine and cotinine levels also can be
measured in saliva and be used by
the life insurance industry to verify
the smoking status of applicants.
Hormone levels detected in saliva
AB STRACT
A
R
T
I CL
E
4
Dr. Navazesh is a professor and the chair, Division of Diagnostic Sciences, University of Southern Cali-
fornia School of Dentistry, 925 W. 34th St., DEN 4320, Los Angeles, Calif. 90089-0641. Address
reprint requests to Dr. Navazesh.
Dr. Kumar is an assistant professor of clinical dentistry, Division of Diagnostic Sciences, University of
Southern California School of Dentistry, Los Angeles.
J
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Measuring salivary flow

Challenges and opportunities
Mahvash Navazesh, DMD; Satish K.S. Kumar, MDSc
JADA, Vol. 139 http://jada.ada.org May 2008 35S
Copyright 2008 American Dental Association. All rights reserved.

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can be used to determine the presence of physio-
logical changes (for example, pregnancy) and
emotional disorders (for example, depression).
2,3
Quantitative and qualitative salivary changes
associated with local or systemic disorders are not
always easily captured or appreciated by clini-
cians and scientists owing to the lack of standard-
ization in saliva collection methods.
4
Different
sources (mixed versus individual glands) and
methods (unstimulated versus stimulated) of col-
lection significantly affect the desired qualitative
or quantitative changes being evaluated. In this
article, we focus on
methods of saliva collec-
tion and the opportunities
and challenges associated
with each method.
THE SALIVARY
GLANDS
The three major salivary
glands (parotid, sub-
mandibular and sublin-
gual) contribute to 90 per-
cent of the mixed fluid in
the mouth that is known
as whole saliva; minor
salivary glands that are
scattered throughout the
mouth contribute to the
remaining 10 percent of
the mixed fluid. Food
debris, microorganisms
and gingival crevicular
fluid are other compo-
nents of whole saliva.
Saliva is composed of
approximately 99 percent
water and 1 percent pro-
teins and salts. The
normal daily production of
saliva is between 0.5 and
1.5 liters. The subman-
dibular glands are the
major contributors to
resting (unstimulated)
saliva, and the parotid
glands are the major con-
tributors to stimulated
saliva. The contribution of
sublingual glands to un-
stimulated and stimulated
whole saliva is low.
5,6
Although the minor salivary glands are not
major contributors to the whole-saliva volume,
they play a significant role in the lubrication and
protection of the oral mucosa because of their
mucous secretions. Parotid gland secretion is
purely serous, and submandibular and sublingual
gland secretions are mixed (mucous and serous).
The primary saliva, formed by the acinar cells,
36S JADA, Vol. 139 http://jada.ada.org May 2008
BOX
University of Southern California School of Dentistry
guidelines for saliva collection.*
A. COLLECTION OF UNSTIMULATED WHOLE SALIVA
The patient is advised to refrain from intake of any food or beverage (water
exempted) one hour before the test session. Smoking, chewing gum and intake of
coffee also are prohibited during this hour. The subject is advised to rinse his or her
mouth several times with deionized (distilled) water and then to relax for five min-
utes. The patient is then told the following: I will first obtain measures of saliva
flow while you are at rest. This means that before and during the collection you
should make every effort to minimize movement, particularly movements of your
mouth. To begin a collection trial, I will ask you to swallow to void the mouth of
saliva. Then you should lean your head forward over the test tube and funnel
(demonstrate). Keep your mouth slightly open and allow saliva to drain into the
tube. Keep your eyes open. At the end of the collection period, I will ask you to col-
lect any remaining saliva in your mouth and spit it into the test tube. This move-
ment should be done very quickly and should be done in the same manner from trial
to trial. This is very important. Do you understand the procedures?
When you start a trial, tell the subject:
1. Swallow to begin a trial (begin timing).
2. Make as little movement as possible. Do not swallow, and keep your eyes open
during collection periods.
3. At the conclusion of the trial, collect the remaining saliva and spit it out.
For each subject, collect saliva for one minute of practice trial and discard it. A
plastic or paper cup may be used for this trial. The actual trial should last for five
minutes, and the sample should be saved for further analysis if indicated.
B. COLLECTION OF STIMULATED WHOLE SALIVAGUM
1. Instruct the subject to sit motionless.
2. Instruct the subject to lean the head forward over the funnel.
3. Instruct the subject to swallow to void the mouth of saliva (starting time).
4. Instruct the subject to chew the inert gum base according to the pace of the
metronome (approximately 70 strokes per minute).
5. Every one minute, ask subject to spit saliva into the tube without swallowing. Tell
subject, Spit out, keep chewing (after first minute), Spit out, keep chewing (after
second minute), etc. Discard the first two-minute collection. A plastic or paper cup
may be used for this collection. Proceed with another three-minute collection. Save
this sample for further analysis if indicated.
6. Ask the patient to spit everything (that is, both saliva and gum base) into the
tube.
7. Remove the gum base from the funnel before weighing the tube and funnel with
saliva.
8. If the patient is too dry (that is, has dry mouth), it is possible to add the weight of
the gum base to the preweight measure with the gum base in the funnel of the test
tube of saliva.
C. COLLECTION OF STIMULATED WHOLE SALIVACANDY
Repeat steps one through eight as in B. Substitute chewing gum base with sucking
on sugar-free, lemon-flavored candy.
Remember, unstimulated whole saliva collection always should precede stimulated
whole saliva collection.
* Adapted with permission of Mahvash Navazesh, DMD.
ABBREVIATION KEY. SWS-Candy: Stimulated whole
salivacandy. SWS-Gum: Stimulated whole saliva
gum. UWS: Unstimulated whole saliva.
Copyright 2008 American Dental Association. All rights reserved.

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JADA, Vol. 139 http://jada.ada.org May 2008 37S
Figure 2. Three tubes with measurements, funnels, inert gum base
and sugar-free candy used for the collection of unstimulated and
stimulated whole saliva.
Name of Patient: Date:
UWS
SWS-Gum
SWS-Candy
* Salivary gland hypofunction is considered as whole unstimulated saliva < 0.1 g/minute (that is,
mL/minute), whole chewing stimulated saliva
<
0.7 g/minute or both.
Collection Period
(Minutes)
5 1
2
3
5
5
Saliva Tube No. Postweight
(Grams)
Preweight
(Grams)
Flow
Rate/Minute
Salivary Flow Rate* = postweight measure preweight measure = g/minute
Collection period
Figure 1. University of Southern California School of Dentistry Salivary Flow Rate Measurement Sheet. UWS: Unstimulated whole saliva.
SWS-Gum: Stimulated whole salivagum. SWS-Candy: Stimulated whole salivacandy. mL: Milliliters. Adapted with permission of Mahvash
Navazesh, DMD.
patients response to a health questionnaire and
the outcome of clinical evaluation as the basis for
identification and assessment of dry mouth. For
example, yes responses to the following four
questions have been significantly associated with
salivary gland hypofunction:
dDoes the amount of saliva in your mouth seem
too little?
dDoes your mouth feel dry when eating a meal?
dDo you have difficulty swallowing any food?
dDo you sip liquids to aid in swallowing dry
food?
12
Some clinicians and scientists use a visual analog
has an ionic composition similar to that of plasma.
It is modified by the ductal cells to a hypotonic
solution by reabsorption of sodium and chloride
without water.
Saliva secretion can be enhanced by a variety of
stimulants. The salivary flow depends on the
nature of the stimulus and its duration and inten-
sity. Strong acidic stimulus, high-frequency
chewing and high bite force result in increased
saliva output. Parasympathetic stimulation
results in increased watery (less viscous) saliva,
whereas sympathetic stimulation results in
mucoid (more viscous) saliva secretions.
7
SALIVARY GLAND HYPOFUNCTION
AND XEROSTOMIA
Lack of salivary flow affects a persons quality of
life by causing difficulties in speaking, eating,
swallowing and tasting.
8
Xerostomiathe subjec-
tive feeling or complaint of dryness in the
mouthcan be caused by several medications
without actual reduction in salivary flow. The
major cause of xerostomia, however, is objectively
assessed salivary gland hypofunction,
9-11
which
could be attributed to several systemic diseases
such as Sjgren syndrome, rheumatoid arthritis
and systemic lupus erythematosus.
8
Salivary flow
rate measurement becomes essential in diag-
nosing salivary gland hypofunction as the cause
of xerostomia.
5
Accurate measurement of salivary
flow rate also is essential for various other clini-
cal and research purposes.
ASSESSMENT OF SALIVARY FLOW RATES
Salivary flow rates are assessed differently for
different purposes. Clinicians commonly use a
Copyright 2008 American Dental Association. All rights reserved.

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powered toothbrushes have been
used to stimulate salivary flow.
15
UNSTIMULATED AND
STIMULATED WHOLE SALIVA
COLLECTION
Several methods for collecting saliva
have been reported and tested for
validity and reproducibility.
13,16
In this article, we
provide in detail the guidelines for collecting
unstimulated and stimulated whole saliva (Box,
page 36S) and measuring salivary flow rate
(Figure 1) as followed at the University of
Southern California School of Dentistry
(Figures 2-5).
COLLECTION OF SALIVA FROM INDIVIDUAL
GLANDS
Saliva collection from individual glands should
not be contaminated with food debris and micro-
organisms, so it is prudent to acquire saliva from
scale, an ordinal scale based on rank-ordered cat-
egories (for example, I have no/slight/severe/
annoying feeling of dry mouth) or both to assess
salivary gland function.
Objective measurements of qualitative or
quantitative changes in saliva are best captured
by collecting saliva from individual glands or
from all that contribute to whole saliva.
13
Com-
monly used stimulants include gum base,
paraffin wax, rubber bands and citric acid. Secre-
tagogues such as pilocarpine and cevimeline
hydrochloride
14
and mechanical stimuli such as a
transcutaneous electrical nerve stimulator and
38S JADA, Vol. 139 http://jada.ada.org May 2008

4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Unstimulated StimulatedGum StimulatedCandy
COLLECTION METHOD
F
L
O
W

R
A
T
E

(
g
/
M
I
N
U
T
E
)
Patient 1
Patient 2
Patient 3
Patient 4
Figure 5. Changes in salivary flow rates obtained by using three methods in four
patients. The healthy patients (1 and 3) have increased salivary output in response to stim-
ulation compared with that of the subjects with salivary dysfunction (2 and 4). g: Grams.
Figure 4. Comparison of amount of saliva col-
lected (from left to right): unstimulated whole
saliva, gum-stimulated (masticatory) whole saliva
(note the heavy sediment of salivary contami-
nants such as food debris, microorganisms and
gingival crevicular fluid) and candy-stimulated
(gustatory and masticatory) whole saliva.
Figure 3. To collect unstimulated whole saliva, the patient drools passively into the
collection tube for five minutes.
Copyright 2008 American Dental Association. All rights reserved.

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individual major glands. The techniques, how-
ever, are tedious and require custom-made collec-
tion devices.
17
Parotid gland. The parotid gland secretion is
voided in the oral cavity via the Stensen duct at
the vicinity of the parotid papilla opposite the
maxillary second molar. A modified Lashley cup
or Carlson-Crittenden collector often is used for
collecting saliva from the parotid glands
(Figure 6).
Submandibular and sublingual glands.
The submandibular and sublingual gland secre-
tions are voided in the oral cavity via the
Wharton duct, which opens into the floor of the
mouth. Many custom-made collectors such as the
Wolff collector are used (Figure 7).
17,18
Minor salivary glands. Minor salivary gland
secretions do not have much clinical application,
owing to the labor-intensive nature of collecting
them. Specific methods are used to measure
minor salivary gland secretions.
19
CONCLUSION
With advances in medicine and therapeutic
modalities, human life expectancy is increasing
steadily. One can expect an increase in salivary
gland hypofunction, along with other more preva-
Figure 6. A modified Carlson-Crittenden device
for collecting parotid gland saliva.
Figure 7. A custom-made Wolff saliva collector for submandibular and sublingual
gland saliva collection.
lent medical conditions, in the elderly population.
In this article, we presented saliva collection
methods that can be used by dentists in their
practices to assess patients at risk and by scien-
tists for scholarly activities.
Disclosure. Drs. Navazesh and Kumar did not report any
disclosures.
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