SALIVA AND ITS PROSTHODONTIC IMPLICATIONS

INTRODUCTION
The secretions of the major and minor salivary glands,
together with gingival crevicular fluid constitute oral fluid which
provides chemical milieu of the teeth and oral soft tissue.
The environment of the oral cavity is to a large degree
created and regulated by saliva. The fact that the teeth are in
constant contact with and bathed by the saliva would suggest that
this environmental agent could profoundly influence the state of
oral health of a person. Saliva has manifold functions in protecting
the integrity of the oral mucosa. Most often, the dentist is called
upon to treat patients in whom he finds out a few of the symptoms
and clinical signs of abnormal salivary secretions and function.
Hence the knowledge of salivary glands, secretion and function is
important in diagnosis, treatment planning, treatment and in
predicting the prognosis.
1
Sources of saliva
Saliva is a comple miture of fluids with contributions from
the major salivary glands !parotid, submandibular and sublingual",
the minor # accessory glands and the crevicular fluid. $dditionally
it contains a high population of bacteria normally resident in the
mouth, des%uamated epithelial cells and transient residues of food
or drink following their ingestion. &hen referring to the fluid
normally present in the mouth the term whole saliva is commonly
used, as distinct from 'direct saliva( which is that flowing from
individual glands.
Formation of saliva
Saliva is formed in two stages) a primary secretion occurs in
the acini, then modified as it passes through the ducts. The primary
secretion is formed actively by the movement of sodium and
chloride ions into the lumen, creating an osmotic gradient which
leads to the passive movement of water. *ther acinar components
are added here before the fluid enters the ducts, where sodium ions
+
are actively reabsorbed !chloride ions follow passively to maintain
electrical e%uilibrium" and potassium and bicarbonate ions
secreted.
The macromolecular components !amylase mucous
glycoproteins etc." are formed in the usual way in the acinar cell
endoplasmic reticulum, processed into secretory vesicles in the
golgi apparatus and are eported from the cell by eocytosis.
Sinal trans!uction
&hen the nerve to the salivary gland is stimulated, the
transduction of this signal to increase the formation of saliva is
first brought about by the release of a neurotransmitter substance.
These include noradrenaline and acetyl holine, substance , and
vasointestinal polypeptide !parasymphathetics". &hen the
neurotransmitter arises at a secretory cell membrane it binds to and
activates a receptor !which may be stimulatory or inhibitory" on the
eternal surface of the membrane. This activates an intermediate
%uanine nucleotide-dependent membrane protein known as '.(
/
protein which in turn activates a regulatory en0yme on the inner
cytoplasmic surface of the cell. The regulator en0yme may be a
phospholipase 1 or adenyl cyclase. ,hospholipase 1 is activated on
binding of acetyl choline at mucoarinic receptors and it controls the
intracellular pathway leading to the secretion of water and
electrolytes. $drenyl cyclase is activated when noradrenaline binds
to -adrenergic acinar receptors. $ctivation leads to ceocylosis of
secretory proteins.
Control of Salivation
The salivary glands are unusual among the glands of the
digestive tract in being under purely nervous control. Hormonal
influences can alter the composition of saliva, but are not
responsible for its secretion.
The nerve supply to the major glands is derived from both
sympathetic and parasympathetic branches of the autonomous
nervous system. The sympathetic supply is trophic, the stimulation
of which leads to the release of secretory proteins such as amylase
2
and vasoconstrictor. The parasympathetic nerves are secretomotor
and vasodilator. The nerves innervate the acinar cells, the direct
cells, blood vessels and myoepithelial cells.
Restin flo"
3nder resting conditions, without the eogenous stimulation
associated with feeding, there is slow flow of saliva which keeps
the mouth moist and lubricates the mucous membranes. This
unstimulated flow, which is present, the majority of the time, is
very important for the health and well being of the oral cavity. The
unstimulated flow is influenced by)
a) Circadian variation:
3nstimulated flow peaks at approimately 4pm in most
individuals with a minimum flow during the night. This variation is
independent of eating and sleeping behaviour.
b) Light and arousal:
5f one is blind folded, or in an unlit room, the unstimulated
flow rate falls. This is probably associated with the effect of usual
4
input in maintaining a state of arousal. Saliva flow in much reduced
during sleep.
c) Dehydration:
$ loss of 67 body water results in a cessation of saliva flow.
The resultant drying of the oral cavity is a feature of thirst,
although thirst and water intake are under hypothalamic control and
not dependent upon oral dryness.
d) Exercise and stress:
$ dry mouth is a feature of the 'fright and flight( response.
This is probably not a direct action of the sympathetic supply to the
gland, but the rather is due to inhibitory influences on the salivary
nuclei arising from the hypothalamus.
PS#CHIC FLO$
$ mouth watering sensation is a universal eperience on the
anticipation or sight of food, especially if temptingly presented
when hungry. However, although the sensation is of a sudden flow
of saliva into the mouth, it has not proved possible to demonstrate a
8
large increase in flow rate in man arising from such 'psychic(
stimuli.
Uncon!itional refle%es
The most important stimuli to salivation are those associated
with feeding9 masticatory movement and especially taste.
Mastication
This is a refle response wherein receptors in the muscles of
mastication, temporomandibular joint, periodontal ligament and
mucosa detect the presence of a bolus and its mastication and
stimulate the salivary nuclei to increase the parasympathetic
secretomotor discharge.
&ustator' stimuli
Sour stimuli are more effective, followed by sweet, salt and
bitter. Most foods also elicit olfactory stimuli and a refle response
to smell can be demonstrated.
:
Ot(er stimuli
a" There appears to be connections between
the salivary nuclei and the vomiting center in the medulla,
since copious refle salivation as well as nausea fre%uently
occur just before vomiting, perhaps as an attempt to dilute or
neutrali0ed the irritant which is giving rise to nausea.
b" Hypersalivation !ptyalism" is also
described in pregnancy, but the physiologic basis is unclear9
perhaps it stems from morning sickness or oesophageal
irritation following refle of gastric contents due to raised
abdominal pressure in late pregnancy.
c" ;cess salivation may be seen associated
with motor disturbances of orofacial musculature.
P('sioloic factors t(at effect salivation
1" $greeable taste stimuli result in profuse salivation whereas
distasteful stimuli can result in temporary cessation of
salivation.
6
+" $ smooth object inserted into the mouth will result in an
increase in salivation whereas a rough object will inhibit
salivation !the polished surfaces of a denture should be
smooth".
/" <ehydration = Saliva decreases.
2" $s one ages, the saliva becomes ropy in consistency.
4" ;motions and other psychic effects eite the autonomic
nervous system and in turn the function of body organs are
altered.
Pat(oloic con!itions t(at !ecrease salivation)
1" Senile atrophy of the salivary glands.
+" 5rradiation therapy for head and neck tumors.
/" <iseases of the brain sten that directly depress salivary
nuclei and block salivation.
2" Some types of encephalitis including poliomyelitis.
4" <iabetes mellitus and # or insipidus.
>
8" <iarrhea caused by bacteria # food.
:" ;levated temperature from acute infectious diseases.
Pat(oloic con!itions t(at increase salivation)
1. <igestive tract irritants.
+. ,ainful afflictions of the oral cavity.
These may be from)
a. ?itamin deficiency.
b. Trauma from surgery.
c. 5ll fitting denture.
d. 5nade%uate interocclusal distance when
dentures are made.
Com*osition of saliva)
Saliva is made up of approimately >>7 of water. The
concentrations of dissolved solids !organic and inorganic" are
characteri0ed by wide variation.
1@
Protein
1omprise approimately +@@mg#1@@ml. 5t includes en0ymes,
immunoglobulins, other antibacterial factors, mucous glycoproteins
!mucins", traces of albumin and certain polypeptides and
oligopeptides.
+am'lase
5t is present in parotid saliva in concentrations of 8@-
1+@mg#1@@ml and in submandibular at approimately by
+4mg#1@@ml.
The en0yme hydrolyses the 1)2 glycosidic bond between
glucose units in the polysaccharide chain of starch, hydrolysis takes
place anywhere along the chain and thus the end products of
amylase digestion are mainly maltose together with
oligosaccharides and some free glucose.
11
Immunolo,ulins
Secretory 5g$ is the predominant immunoglobulin at
approimately +@mg#1@@ml with 5g. !1.4mg#1@@ml" and 5gM
!@.+mg#1@@ml".
Anti,acterial *roteins
Ayso0yme is an antibacterial en0yme which attacks
components of the cell wall of certain bacteria leading to lysis.
Aactoferrin is an iron binding protein which removes free
iron from saliva depleting the supply of iron needed for bacterial
growth.
Sialoperoidase oidi0es salivary thiocyanate to
hypothiocyanate, a potent antibacterial substance, using hydrogen
peroide produced by oral bacteria as an oidant.
&l'co*roteins)
The major groups of glycoproteins consist of two classes of
mucous glycoproteins !M.
1
and M.
+
" found in submandibular and
1+
sublingual saliva and a group of proline rich glycoproteins found in
parotid saliva.
Ot(er *ol'sacc(ari!es
Siatherin is a small phosphoprotein !1+@@@ daltons" relatively
rich in tyrosine and proline which has the property of inhibiting
hydroy apatite crystal growth. 5t also prevents the precipitation of
calcium phosphates from supersaturated solutions and may be
important as an inhibitor of calculus formation both in glands and
on the teeth.
Sialin a tetrapeptide can be utili0ed by several bacteria
leading to formation of alkaline end products which are believed to
help regulate pH of pla%ue.
Ot(er oranic com*oun!s)
Bree amino acids with concentration below @.1#1@@ml.
3rea is present in levels of about 1+-+@mg#1@@ml. 5t is
hydrolysed by many bacteria with the release of ammonia leading
to rise in pH.
1/
.lucose concentration is about @.4-1mg#1@@ml but may be
raised in diabetics.
Inoranic constituents)
1" Sodium !@-6@mg#1@@ml".
+" ,otassium !8@-1@@mg#1@@ml".
/" 1alcium !+-11mg#1@@ml".
2" ,hosphorous !8-:1mg #1@@ml".
4" 1hloride !4@-1@@mg#1@@ml".
8" Thiocyanate.
:" Bluoride !@.@1-@.@2mg#1@@ml".
6" Cicarbonate !@-2@mg#1@@ml".
Factors influencin t(e com*osition of saliva
1) Flow rate:
$s the flow rate increases, the concentrations of proteins,
sodium, chloride and bicarbonate rise, while the levels of
12
phosphate and magnesium fall. This is true for direct saliva as
well as whole saliva.
2) Differential gland contributions
5n unstimulated whole saliva, the parotid glands contribute
only about 1@7 of the fluid volume, whereas on stimulated
saliva they become predominant. Thus the composition of the
mied fluid approaches that of parotid saliva at high flow rates.
$s the calcium concentration in parotid saliva is lower than that
in submandibular saliva, stimulated whole saliva secretion,
despite the fact that the levels may rise in both direct salivas as
their flow rate increases.
3) Circadian rhyth:
Dhythmic variations in the concentrations of many salivary
constituents are seen. ;ample) The levels of calcium and
phosphorous ions are low in mornings.
14
!) Duration of stiulus:
$s a constant rate of flow, the composition may vary with the
duration of stimulation.
") #ature of stiulus:
5f the flow rate is held constant the secretions elicited with
sour, salt, sweet or bitter stimuli are similar in electrolyte
composition. However, salt stimulates a higher protein content.
Sugar stimuli give rise to a high amylase content. Eone of these
are biologically significant.
$) Diet:
Aong term changes in diet do not appear to have a dramatic
effect on salivary composition. 1hanges in plasma phosphate
and urea concentrations induced by dietary alterations may be
reflected in the saliva.
Pro*erties an! Function of Saliva
1) Digestion:
18
Salivary amylase initiates the digestion of starch but is
inactivated in the stomach because of low pH and proteolytic
acid.
However, considerable breakdown of starch can occur prior
to inactivation of salivary amylase and especially after a heavy
meal this may account for a significant fraction of starch
digestion.
2) Lubrication:
The lubrication of hard and soft oral surfaces is very
important for speech, mastication and swallowing and for
general oral health and comfort. Saliva provides a tissue coating
film which is responsible for lubrication and bolus formation, a
property which is due to water and mucous glycoproteins it
contains.
3) Dilution and clearance:
$nother effect of water content of saliva is the dilution of
substances introduced into the mouth, and their subse%uent
1:
removal by swallowing or spitting. Bood solids are first
dissolved !whereby they can be tasted" and diluted as the saliva
flows into the mouth. $fter swallowing the bulk of food or
drink, the food residues are cleared slowly by the continuing
flow of unstimulated saliva. 5f the substance is noious or
distasteful, cleansing may be achieved by spitting.
Neutrali-ation an! ,ufferin)
Saliva is alkaline and is an effective buffer system. These
properties protect the oral tissues against acids from food or from
pla%ue. The principle constituent responsible for these properties
!especially in stimulated saliva" is bicarbonate. The salivary
neutrali0ation and buffering effect can markedly reduce the
cariogenic potential of foods. ,hosphate and proteins also provide
small amount of buffering effect.
Saturation)
Saliva is supersaturated with respect to tooth material. This is
responsible for the growth of hydroyapatite crystals during the
16
reminerali0ation phase of carious process. Salivary calcium and
phosphate are source of minerals for calculus formation.
Anti,acterial .ffects
%unoglobulins
Salivary antibodies are mainly of 5g$ class whose principle
action is to aggregate specific bacteria and prevent their adhesion
to oral hard and soft tissues. Cactericidal lysis due to complement
activation may occur in gingival crevice as a result of the effects of
5g. in crevicular fluid which may also opsonise bacteria to assist
phagocytosis by ,MEAS.
&acterial co'etition:
Cecause of large number of bacteria in saliva, competition
for source nutrients is free and pathogens fastidious may thus be
unable to survive.
Pellicle an! *la/ue formation
,ellicle formation is a physico-chemical process involving
selective se%uential adsorption of salivary glycoproteins to the
1>
tooth surface. ,ellicle protects teeth against both chemical and
mechanical insult. 5n addition it acts as a substrate for coloni0ation
by bacteria.
,la%ue formation involves incorporation of salivary proteins
but their characteri0ation is difficult because they are etensively
degraded in pla%ue.
PROSTHODONTIC IMPLICATIONS
The functions of saliva in edentulous subjects are)
1" Saliva removes debris and damaging factors by transportation
to oropharyn. 1oats the soft tissues with film @.1mm thick
!therefore to maimi0e physical retentive factors, any space
between complete dentures and supporting tissues should not
eceed this value". The rate of debris clearance depends on
velocity of movement of film !@.6-6.@mm#minute, depending
on salivary flow rate and environmental muscle activity.
5rritants within oral cavity !e.g. new dentures" simulate
secretion.
+@
+" $ntimicrobial action most effective against non-commensal
organisms. 5t is thus a determinant of the bacterial
composition of denture pla%ue which itself may be associated
with denture related stomatitis.
/" Hydrophilic components lubricate, moisten and protect
moving tissues in contact aided by pellicle formation.
;specially important for denture wearers. Secretions of minor
salivary glands are critical, senile dentures open onto all
mucosal surfaces !ecept anterior region of hard palate".
Saliva plays an important role as a physical agent in the
retention of complete dentures.
The physical factors consists of )
a" $dhesion.
b" 1ohesion.
c" Surface tension.
d" 1apillary attraction.
e" $tmospheric pressure.
+1
a" (dhesion: 5t is the physical molecular attraction of
unlike surfaces in close contact.
5t acts when saliva wets and sticks to the basal surfaces of
dentures and at the same time to the mucous membrane of the
basal seat.
;ffectiveness of adhesion depends upon close adaptation of
denture base to the supporting tissues and fluidity of saliva.
b" Cohesion: 5t is the molecular attraction between two
similar surfaces in close contact.
5t occurs in the layer of saliva between the denture base and
mucosa.
c) %nterfacial surface tension:
5t is the resistance to separation possessed by the film of
li%uid between two well adapted surfaces.
5t is found in the thin film of saliva between the denture base
and the mucosa of basal seat.
++
d) Ca'illary attraction:
5t is the force that causes the surface of li%uid to become
elevated or depressed when it is in contact with a solid.
&hen the adaptation of denture base to mucosa on which its
rests is sufficiently close, the space filled with a thin film of
saliva acts like a capillary tube and helps retain the denture.
Saliva as a physiological factor of retention affects the
effectiveness of physical forces.
The higher the viscosity occurring to the mucoid content, the
lower the flow and greater is the fiation. Hence the mucos saliva
provides better cohesion that serous saliva.
Distri,ution of saliva
Saliva may be distributed in one of the three ways)
1" Saliva film covers all surface of the denture and the oral
mucous membrane. &ith this distribution of saliva there is no
meniscus and no contribution to retention by surface tension.
+/
+" The saliva film covers the oral mucous membrane but is
incomplete over the polished surface of the denture. This
distribution of saliva produces a meniscus and hence there is a
retentive force due to surface tension.
/" Saliva beneath the tissue basal surface of denture only. &ith
this distribution of saliva, there is meniscus and a considerable
retentive force due to surface tension.
,ractical applications of knowledge of salivary glands and
saliva in complete denture prosthodontics)
1" ;cessive salivation particularly by maillary and sublingual
glands presents a problem in impression making.
&hen this problem eists, atropin sulfate can be administered
orally prior to impression making.
The new dentures may feel like foreign bodies and stimulate
the flow of saliva.
The patient should be assured that the feeling and flow of
saliva will decrease gradually.
+2
+" ;cessive secretions of mucous from the palatal glands may
distort the impression material in the posterior two thirds of
the palate. To counteract this problem.
a" The palate may be massaged to encourage the glands
to empty.
b" The mouth may be irrigated with an astringent
mouthwash just prior to inserting impression material.
c" The palate may be wiped with gauge.
Bailure to counteract the thick and ropy saliva because
of heavy secretions of mucous from palatal glands under
maillary denture will result in)
i. <islodgement of the denture.
ii. ,resence of voids in the impression surface
while the impression material sets.
iii. Borms a factor in causing the patient to gag
while impressions are made and after
placement of new dentures.
+4
5deally there should be a moderate flow of serous type saliva
which seems to be the situation most fre%uently found.
/" &hen it is determined that saliva is a problem, the cause
should be investigated. 5f necessary, therapy should be
instituted to correct the problem.
2" &hen the cause is undetermined or there is no favourable
response to therapy, the problem should be discussed with
the patient prior to treatment so that by patients
understanding, patients cooperation is assured.
4" $ lack of saliva, erostomia, presents some serious
problems)
a" The possibility of reduced retention increases.
b" $bsence of saliva often causes cheeks and lips to stick
the denture base in uncomfortable manner.
,etroleum jelly applied over the surface can alleviate
this problem.
+8
c" 5ntolerance to denture wear. 5t may be necessary to
limit denture use to short periods.
d" ,roblems in mastication, swallowing, speaking etc.
this predisposes to nutritional deficiency.
The diet should be restricted to nutritious moist foods that
are soft or li%uid.
True erostomia occurs with a resting flow rate of @.1ml#min.
or less.
Causes)
- Aack of or diseases of salivary glands !e.g. ectodermal
dysplasia, Sjogren(s syndrome".
- 5rradiation of head and neck.
- Medication is a potent cause of erostomia in the
elderly.
Common !ru t'*es *ro!ucin %erostomia)
1" $nti arrhythmics.
+" $nticonvulsants.
+:
/" $ntidepressants.
2" $ntihistamines.
4" $ntinauseants.
8" $ntineoplastics.
:" $ntiparkisonian drugs.
6" $ntipsychotics.
>" $ntispasmodics.
1@" $tropines.
11" <iuretics.
1+" Hypotensive agents.
1/" Minor tran%uili0ers.
12" Muscle relaants.
14" Earcotics.
18" Sympathomimeteics.
$pproimately one third of the adult population has
symptoms suggestive of dry mouth. 5t is important to appreciate
that the complain is a normal conse%uence of aging.
0.ROSTOMIA
Salivary flow less than @.+ml#minute.
<ue to emotional reaction.
+6
Clockage of duct by calculus.
$cute and chronic infection of
salivary glands.
$dministration of drugs.
Salivary gland aplasia.
,ostoperative radiation damage
because of obliteration of major and minor salivary glands.
This is due to failure to ade%uately shield the salivary glands
which results in rapid atrophy and functional incapacity.
?itamin $ deficiency = $ deficiency
of vitamin $ affects speciali0ed epithelium throughout the
body, including the epithelium of salivary glands.
5t is also reported in patients with
riboflavin and nicotinic acid deficiencies.
Sjogrens syndrome !primary" = one
of the characteristic features of this disease !also called sicca
+>
syndrome" is erostomia which occurs because of destruction
and atrophy of the acinar tissue of the salivary glands.
,ernicious anemia.
Aoss of fluid from the body through
haemorrhage, ecessive sweating, diarrhoea or vomiting.
,olyurea accompanying diabetes
mellitus and diabetes insipidus.
*rganic lesions of nervous system
which interfere with normal secretory nerve stimulation.
CLINICAL F.ATUR.S
Severe alterations in the mucous
membranes and the patient may have etreme discomfort.
The mucosa will appear dry and atrophic, sometimes
inflamed or more often pale and translucent.
The tongue may manifest the
deficiency by atrophy of the papillary inflammation,
/@
fissuring and cracking and in severe cases by areas of
denudation.
Soreness, hardening and pain of the
mucous membrane and tongue are common symptoms.
,atients complain of difficulty in
swallowing and talking, and also altered taste.
5t will also predispose to
opportunistic oral infections, particularly candidasis and
leads to an increase in periodontal disease and caries.
Shallow but persistent tongue ulcers especially along the
posterior ventral surfaces are common in patients with erostomia.
This is because of lack of protective lubrication as well as the
atrophic mucosa.
0.ROSTOMIA PR.DISPOS.S TO)
Curning mouth syndrome !also
called as glossopyrosis, glossodynia or stomatopyrosis".
/1
5t forms an etiological factor for
leukoplakia because of the lack of protective salivary layer.
;tiological factor for oral thrush
which along with chronic local irritants act by alteration of
oral mucous membranes predisposing then to invasion of
microorganisms.
Clinical e%amination)
5n healthy patients saliva pooling in the floor of the mouth is
revealed whereas in erostomia the amount of saliva is reduced but
may also appear frothy. $ useful test is to place a mirror against the
buccal mucosa and this should lift off easily when saliva is present
in normal amounts. <egree of stickiness during this maneuver is a
useful indication of reduced saliva production. ;ach of the major
glands should be palpated and clear saliva seen to be epressed
from each duct orifice.
&hen Sjogren(s syndrome is
suspected a lower lip biopsy specimen should be taken, with
/+
five or si minor salivary lobules harvested from the
submusoa.
$ssessment of antinuclear antibody
should be performed in patients with erostomia, particularly
if Sjogren(s syndrome is suspected.
//
MANA&.M.NT
The treatment will depend upon the
nature of the disease and the cause should be detected and
corrected.
$de%uate amount of saliva in the
mouth is achieved by use of artificial saliva substitutes, such
as saliva orthana, luborant and glandosane.
Ferolube is also a salivary
substitute.
<rug related erostomia can be
minimi0ed by lowering the dosage or changing the
medication in consultation with the patients physician.
Ferostomia associated burning is a
comple management problem since patients with Sjogren(s
syndrome or those who have undergone radiation therapy are
not able to regenerate salivary tissues. Salivary substitutes,
/2
transmucosal electro-stimulation and pilocarpine therapy may
all be of some benefit.
&hen all tests are negative, the
diagnosis is idiopathic erostomia. ,sychosomatic origin
must be considered and discussed with the patient. He or she
must be assured that no organic disease is present.
1hewing sugarless gum and sucking
sugarless candies stimulate flow of residual function.
Bre%uent sips of water and sucking
ice chips diminish the discomfort.
$ggressive use of oral hygiene
measures, fluoride and antibacterial agents are essential to
reduce the associated risks.
PROSTHODONTIC IMPLICATIONS
The mechanical protection of the
denture supporting tissues by the saliva film will be lost
predisposing then to irritation. This dryness of the mucosa
/4
renders it more susceptible to frictional irritation from
denture movement and may interfere with patients ability to
wear the dentures.
$ decrease in salivary flow will
interfere with denture retention since the saliva contributes to
adhesion, cohesion, interfacial surface tension and
capillarity.
<ifficulty in mastication and
deglutition.
The denture use should be limited to
short periods.
Destrict the diet to nutritious moist
food that are soft or li%uid.
.ood denture hygiene should be
encouraged since erostomia predisposes to candidiasis.
R.F.R.NC.S)
/8
1" Clahova Gora et al) ,hysical factors in retention of complete
dentures. H ,rosthet <ent 1>:19 +4) +/@-+/4.
+" Coucher *. 1arl ) Couchers prosthodontic treatment for
edentulous patients, ed. >.
/" ;dgar &.M. ) Saliva ) 5ts secretion, composition and
functions. Critish <ental Hournal $pril 1>>+9 +4) /@4-/1+.
2" B<5 working group 1@, core, saliva ) 5ts role in health and
disease. 5nternational <ental Hournal 1>>+9 2+) +>1-/@2.
4" Heartwell M. 1harles et al ) Syllabus of complete dentures
ed. 2, ,hiladelphia 1>>+, Aea and Bebiger.
8" Aindstrom D.;. et al ) ,hysical = chemical aspects of denture
retention and stability ) $ review of literature. H. ,rosthet
<ent 1>:>9 2+) /:1-/:4.
:" Mardel 5.<. ) The role of saliva in maintaining oral
haemostasis. H$<$ 1>6>9 11>) +>6-/@2.
6" Eiedermeier H.&., &ilhelm et al) Salivary secretion and
denture retention. H ,rosthet <ent 1>>+9 8:) +11-+18.
/:
>" &inkler Sheldon et al) ;ssentials of complete denture
prosthodontics, ed. +, <elhi, 1>>8, $.5.T.C.S.
/6