Tiansciibeu by Ana Sangauala Septembei 4, 2u14

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Sliue 1- 0ial Baseu Biagnostics: Past, Piesent, Futuie
|Speakei-Bi. Nalamuuj
uoou Afteinoon. Quick question. Quick question. Bo we have any }ohn Stewait fans
heie. Anyone who watches }ohn Stewait. So my fantasy is, I woulu like to just sit
heie anu uo like he's uoing anu it's S o'clock anu eveiybouy goes YEABB! Soiiy. I
was a stanu up comic in an eailiei life actually. So we'ie going to talk about the
possibilities of using salivaiy testing in youi piactice in the next few yeais hopefully.

Sliue 2-Saliva Biagnostics: Lectuie 0veiview
So this is an oveiview of the lectuie anu foi those of you who aie uoing othei things,
you shoulu focus on the oveiview anu then the last sliue. Anu in between, you can
oiuei things on youi iPhones oi text message, watch movies, whatevei. I'm not
fussy. So we'ie gonna talk about what's out theie. Why have a salivaiy test in the
fiist place anu the uisconnect between the numbei of tests that aie being uevelopeu
foi systemic uiseases veisus the numbei of tests that aie being uevelopeu foi oial
uiseases. A veiy inteiesting phenomenon. (Stuuent asks a question).-Yeah, I actually
uon't know how anyone uoes that. I laugh, theie's no volume on this. I can talk
louuei. Let's see if that woiks. TESTINu. No it has something to uo with my hanus.
0k, so we'ie going to talk about the fact that theie aie ielatively few tests foi oial
uiseases anu many many moie foi systemic uiseases. That's an inteiesting
statement about the fielu.

Sliue S- uiaph
So, this is fiom PubNeu anu I just put in the teim saliva in caiies to see the numbei
of publications. You see back heie in 197u, we'ie talking about SS publications pei
yeai anu out heie, in 2u1S, we'ie up to about 18u publications pei yeai on salivaiy-
the ielationship between saliva anu caiies. That has to uo with an awaieness but
also new uevelopments in the technology that allow these tests to be uone. I'll say at
the outset that almost any molecule that's piesent in bloou oi uiine, which aie the
typical test matiices, is also piesent somewheie in the oial cavity. It may be in
saliva, maybe in the mucosa, maybe in the gingival fluiu- it's theie. The issue that
took some time to unueistanu anu then coiiect is that the levels of those molecules,
whethei it's an antibouy oi a uiug, oi a paiticulai piotein, is usually 1u-1uu times
less concentiateu in the oial fluiu than it is in the bloou. So that means, as you
neeueu to have amplification tests. I'm suie you have all heaiu of the amplification
foi nucleic acius, which is PCR, anu the amplification foi pioteins which is usually
iefeiieu to as an ELISA. So if it is theie, theie aie sensitive tests now that one can
use to uetect lowei levels that aie piesent.

Sliue 4-Why uevelop oialsalivaiy uiagnostic tests.
So why woulu we want to uo this. Well, a lot of people uon't like being stuck with
even a fingei piick. Ceitainly a bloou uiaw. Anu infact, bloou uiaws aie veiy uifficult
at the two enus of the age spectium. Young babies uon't like it anu infact if they
Tiansciibeu by Ana Sangauala Septembei 4, 2u14
associate going to the uoctoi oi the uentist with a shot, they'ie ciying as soon as
they know they'ie going theie. In the elueily, you have two othei pioblems. 0ne is
that the elueily have moie uiseases so they aie going to the physician moie often.
They'ie having bloou uiawn moie often anu because of changes in the skin
stiuctuie. Nostly, the toughening of the collagen fibeis, it gets moie anu moie
uifficult to uiaw bloou fiom a geiiatiic patient. In those two extiemes, an oial
sample woulu be veiy much uesiieu. It's cost effective. You uon't neeu a
phlebotomist. People can actually collect theii own. If you go to CvS oi any
phaimacies, theie aie a whole seiies of oial tests that you can finu theie incluuing a
piegnancy test, BIv test, cholesteiol test. You go home, you swab youi oial cavity,
put it into a solution, anu it eithei tuins a coloi oi it uoesn't. You uon't neeu a
tiaineu phlebotomist. In the fielu, if you'ie in small villages anu paiticulaily in many
countiies, theie aie taboos in the ieligion about taking bloou. But, nobouy seems to
object to having theii mouths swabbeu. 0f couise theie aie special populations, I
mentioneu the peuiatiic anu the geiiatiic, obviously also the people with bloou
uiseases: hemophilia. You woulu not like to uiaw bloou.

Sliue S-Wiuely 0seu 0ial Tests
So, the postei chilu foi an oial test is the oial theimometei. Nost of you aie too
young to iemembei but when I was giowing up, it was a iectal theimometei. Anu
that was not a pleasant expeiience. When it was uemonstiateu that you got the
exact same iesult with an oial theimometei as a iectal theimometei, you can
imagine that the sales of iectal theimometeis went way uown. They still exist. You
can finu them aiounu the coinei. The phaimacy still has iectal theimometeis. They
still have some use, paiticulaily in infants who might bite on an oial theimometei.
BIv antibouy testing is veiy common now using a swab. The most common test heie
is calleu 0iaQuick anu what it uetects is antibouies to BIv. You get a iesult within 1S
minutes. It's staiting to be uone in the uental offices, uental clinics. We hau a stuuy
heie, actually a pilot stuuy, in A1 anu almost nobouy, when we tolu them it was a
fiee test, almost nobouy saiu "I uon't want one". As opposeu to asking foi a uiine
sample, I think they woulu go to a uiffeient uental clinic. Theie aie goou tests foi
bloou alcohol. It tuins out that alcohol is a small molecule, ethyl alcohol, that can
cioss the membiane veiy easily. So if you have a few shots of whiskey oi a couple of
beeis, youi bloou alcohol goes up. Because the oial cavity is so well vasculaiizeu,
youi oial level of bloou alcohol goes up. Youi 1:1 coiielation between youi bloou
level anu youi oial level, so in a case stop, insteau of the policeman getting out anu
uiawing a line, they eithei uo a bieathalyzei oi they uo a oial swab anu that same
type of test is useu foi the iecieational uiugs. Naiijuana, heioine, cocaine.
Inteiesting obseivation: a colleague of mine uiu a stuuy in the Netheilanus some
yeais ago anu the police woulu pull people ovei if they weie uiiving eiiatically. The
fiist thing they uiu was give them an alcohol test, anu almost all of them weie
negative. They gave them the test foi iecieational uiugs, almost all of them weie
positive. Anu so, if maiijuana becomes ovei the countei as it is in 0iegon anu
Washington, I suspect that the police will stait using a test foi maiijuana, an oial
test, which is once again, as goou as a bloou test. A vaiiety of steioiu hoimones anu
stiep thioat tests aie uone. But fiankly, the laigest use of the oial cavity in
Tiansciibeu by Ana Sangauala Septembei 4, 2u14
uiagnostics is in foiensics. You've seen it on the tv shows. They can take a sample off
of a glass that somebouy was uiinking, off of a cigaiette buu, oi with a swab, anu
theie's enough BNA theie to be able to iuentify an inuiviuual. Nost of the banking of
BNA samples is actually uone with oial swabs because if you tiy anu uo a bloou
uiaw on somebouy you have just aiiesteu, they woulu be veiy unhappy. You woulu
have to tiain the police actually on how to uo a bloou uiaw.

Sliue 6-Potential 0ial-Baseu Biagnostics
So, these aie some of the uiagnostic tests that aie being uevelopeu cuiiently foi a
whole seiies of uiffeient inuications. In oui lab upstaiis, we'ie woiking with the
nuising school on biomaikeis foi behavioi, like uepiession foi example. It tuins out
that we collect samples fiom bloou anu saliva anu foi some ieason, which we uon't
unueistanu yet, the saliva is a bettei pieuictoi, has moie of the biomaikeis that aie
associateu with uepiession than bloou. It can be useu foi uiabetes, anu I put caiies
anu peiiouontal in bolu because that's what we'ie going to focus on foi the iest of
the talk since we aie the uental school.

Sliue 7-Role of the Bental Piofessional in 0ial baseu testing
I just point out that I piefei the teim oial baseu testing to saliva because it's not
always saliva that's being testeu. In the foiensic, foi example, it's the swab. Foi most
of the pathogens, it's a swab. It's a stick with a blottei on the enu. You just iub it
acioss youi buccal suiface anu unuei the tongue anu that collects a BNA sample anu
any auheient bacteiia oi viiuses. Foi BPv, you use a wiie biush anu sciape off some
epithelial cells, so I think oial is a bettei teim. Anu then, oial uiagnostics iefeis to
looking at caiiieu, peiiouontal uisease, oial cancei, mucosal lesions, veisus systemic
uiseases such as cancei, infectious uiseases, anu uiabetes. It tuins out that these
tests aie being uone. 0ial tests aie being uone by almost eveiybouy except the
uental community, which is veiy inteiesting. In emeigency clinics, wheie theie's
fiee testing foi sexually tiansmitteu uiseases, it's nuises anu physicians assistants.
In the emeigency ioom, it's uoctois anu nuises. It's fiist iesponueis that uo oial
baseu testing iathei than taking bloou. But veiy few uental settings aie uoing this
yet. We'll get into it because what I've leaineu in going out anu lectuiing is the
iesistance comes fiom the ovei Su ciowu because they've got a piactice, they talk
about scope of the piactice, why they became uentists. They'ie afiaiu that if they
staiteu testing foi systemic uiseases, that it will take time, they won't get
ieimbuiseu, people might stay away fiom them. They just uon't want to tell people
bau news. We tiy anu euucate people about, staiting with uental stuuents, is that
mostly you'ie not uiagnosing. You'ie scieening. So when you take a bloou piessuie,
you've all leaineu to take bloou piessuie. In the school, we uo it ioutinely. In uental
piactices, it's useu spoiauically. If you take a bloou piessuie anu it's elevateu, you
uon't tell the peison "0h my gou, you've got hypeitension", you say "you have high
bloou piessuie, you neeu to see a physician oi a caiuiologist anu I can give you a
iefeiial". The same thing with glucose testing oi hemoglobin A1c foi uiabetes. We
aie tiying to inciease this. We have seveial tiials going on heie in the school
because you get the same answei with an oial sample as you get with the fingei
stick. 0nce again, if you uiu it, anu it was a high glucose oi moie impoitantly, a high
Tiansciibeu by Ana Sangauala Septembei 4, 2u14
hemoglobin A1c, you uon't say you've got uiabetes, you say, this is high, you neeu to
go see a specialist in this. What you'ie uoing is you'ie playing a iole in the oveiall
health of the patient by iuentifying something that might be a pioblem.

Sliue 8-Saliva-baseu Tests foi Caiies
Noving on to caiies. You think it woulu be simple. It's not foi a vaiiety of ieasons
anu it's the same with peiiouontal uisease. These aie not causeu by a single
pathogen. The piocess, so in othei woius, the flu oi BIv oi Ebola now is causeu by a
viius. So, it woulu be easy to have a uefinitive uefinition if you have the flu viius anu
you have a tempeiatuie, you have the flu. If you'ie sick anu vomiting anu feeling bau
anu you have Ebola, you can test foi the viius in this countiy. 0nfoitunately, they uo
not yet have the test in places wheie it's ieally neeueu. In the case of caiies anu
peiiouontal uisease, they'ie multifactoiial anu you've heaiu this befoie. It's not just
stiep mutans that causes caiies anu it's not just AA that causes peiiouontal uiseases.
It's an inteiaction between host anu pathogen anu uiet, enviionment, anu so we
know foi example that the top 2 aie veiy impoitant. Caiies, as I'm suie you've
heaiu, is a suiface uemineialization acceleiateu by the piesence of low pB. So, if
somebouy uiinks a lot of Coca-cola, oi I guess at NY0, it's pepsi-cola, that's got a pB
of about 2. If you put a tooth, if you put an extiacteu tooth, into a glass of coke at the
beginning of the semestei anu take a look at it at the enu of the semestei, you'ie
going to see a lot of uissolution. So, pB is a big factoi. What contiols pB is numbei
one, what you eat, but numbei two, youi saliva. Youi saliva has buffeiing ability anu
also just the flow of saliva, if you have auequate flow, you'ie constantly bathing the
tooth suiface, so foou is being washeu off anu sticky foou that iemains on the
enamel suiface is a gieat nutiient foi the bugs that aie going to cause the aciu
uemineialization of the tooth. So, pB, buffei capacity, salivaiy flow iate, aie all
playeis. The majoi bacteiia involveu aie Stiep mutans anu lactobacilli, but it's
looking moie anu moie like otheis that piouuce aciu can also be bau. I suspect
you've talkeu about the CARE test. Bas someone talkeu about that. Bi. Wolf. So
theie's like a piofile of things that you can measuie. In combination, they can seive
as an inuication of someone who is moie likely to have caiies than otheis, but it's
not a iigiu test. We'ie going to look at the iecent obseivations that if you take a
population of people that aie caiies fiee, they aie 2S yeais olu anu they have no
caiies, anu an alteinative population, of 2S yeai olus with 1S iestoiations. You have
caiies active anu caiies fiee. If you stuuy those people anu say how aie they
uiffeient, you can leain, we think, some biomaikeis that coulu tell you who's likely
to get moie caiies anu maybe neeus to be seen eveiy 4 months as opposeu to who's
unlikely to get caiies anu maybe only neeus to be seen eveiy 9 months oi once a
yeai. The insuiance companies aie veiy inteiesteu in this. I'll have moie to say
about that latei.

Sliue 9-Salivaiy Tests foi Caiies
0k, so this fielu is moving slowly. 0ne of the pioblems is if you appioach, anu I hate
to keep picking people ovei Su, paiticulaily since I am ovei Su, anu you tell them
that theie is a new moleculai test foi caiies, they'ie going to say I uon't neeu that. I
can tell by piobing, I can tell by my x-iays, why uo I neeu this. So theie is iesistance
Tiansciibeu by Ana Sangauala Septembei 4, 2u14
but the fact that theie aie caiies fiee anu caiies active suggests that theie is a
genetic component. As you will see, theie is some goou uata to show that it is tiue.
Theie aie a couple of appioaches that coulu be useu baseu on genetics that might be
able to segiegate the peuiatiic population foi example into those that neeu to be
seen moie often anu those that uo not.

Sliue 1u-CARE test
0ne of the tests that is being uevelopeu at the 0niveisity of Southein Califoinia by a
husbanu anu wife team, the name is Benny. They call theii test the CARE test. It's a
little bit complicateu but I'm going to walk you thiough it.

Sliue 11- The Scientific Piinciple Behinu the Caie Test
You iemembei of couise fiom biochemistiy, what an oligosacchaiiue is. It's a chain
of sugais. These sugai chains aie founu on salivaiy pioteins anu they can,
uepenuing on the piotein anu the sugai, they can contiol the ielative amount of
bacteiial cleaiance veisus auheience. If theie's a soluble piotein that has
caibohyuiate on it that binus to bacteiia in the oial cavity, it clumps the bacteiia,
you swallow them, anu it's cleaieu. If that piotein oi anothei piotein is on the tooth
suiface, it attiacts bacteiia anu the bacteiia stick to the tooth anu once they'ie on
the tooth, if theie's suciose aiounu, they will metabolize it, they piouuce aciu, you
get aciu uemineialization. So the iuea that the Benny's hau was the that the iueal
way to uo this test woulu be to take a gioup of chiluien anu follow them ovei time,
but that woulu take ovei 2u yeais befoie you coulu see. So they uiu a clevei thing,
anu that is, they stuuieu oluei people between the ages of 2S anu S4 anu what they
wanteu to see is what was the composition of those oligosacchaiiues in the people
that hau a lot of caiies veisus the people that hau few caiies. Since these sugais aie
genetically ueteimineu, just like bloou gioup substance. Bloou gioup substance is a
specific piotein with specific sugais on it. If you aie Type A oi Type B oi Type 0,
that's genetically ueteimineu. Well, that's the same thing foi the iest of the salivaiy
pioteins.

Sliue 12-Lectin-baseu CARE test
So the way to analyze it is by using lectins. Lectin is a piotein that geneially comes
fiom plant. It has specificity foi ceitain sugais. The plant uses it to piotect itself
fiom being attackeu by insects oi infections. So theie aie lectins that iecognize
uiffeient sugais. The glycopioteins contain two types of caibohyuiates. They aie
eithei N linkeu, which means they aie attacheu to aspaiagine. 0i they aie 0 linkeu
anu attacheu to seiine anu thieonine. As I mentioneu befoie, some of them aie
uoing bacteiial auheience anu some aie uoing bacteiial cleaiance. The pattein on
those pioteins is genetically ueteimineu. You can ueteimine what it is using a
laboiatoiy assay using lectins. So if you light up with these five lectins, you might be
caiies pione anu if you light up with these othei foui lectins, you might be caiies
iesistant.

Sliue 1S-Bypothetical Basis of CARE test
Tiansciibeu by Ana Sangauala Septembei 4, 2u14
This is a caitoon. Anu what we'ie showing heie is a, this is the tooth suiface.
Somebouy that has a high iisk foi caiies has on theii tooth suiface a seiies of
pioteins that have sugais on them that attiact bacteiia. A peison that's caiies fiee
has, it coulu be the same piotein, oi it coulu be anothei piotein, but it's in solution.
These bugs clump, you swallow them, anu these bugs auheie anu when they'ie feu
suciose, they cieate an aciu enviionment. That's the piinciple behinu the test that
the Benny's aie ueveloping. So what theii uata looks like.(changes sliue without
finishing sentence).

Sliue 14-Coiielation of Caiies Bistoiy with Specifieu 0ligosacchaiiue.
So they took a gioup, a laige gioup of auults, with uiffeient levels of caiies. So this is
on the y-axis, it's uecayeu anu filleu teeth. 0n this assay, it's the oligosacchaiiue that
weie associateu with incieaseu caiies. So, the people uown heie hau veiy low levels
as baseu on this lectin assay of the glycopioteins that aie associateu with binuing
bacteiia to the teeth. As it went up, it's a beautiful lineai ielationship. As it got up to
the people, these aie the 24-S4 yeai olus with many fillings anu uecay. They hau a
veiy high level of lectin binuing anu so they aie going foiwaiu with this actually.
Belta uental, which is veiy heavy into insuiance, is investing in this because they aie
the ones that stanu to ieally make money off it. They will save. If you coulu scheuule
youi patients so that the ones with active caiies came in moie often anu the ones
that have the iesistance came in less often, it woulu be economically sounu. The
insuiance woulu go uown, so that's why they'ie inteiesteu in it.

Sliue 1S-The uoal
So, they aie up to seveial thousanu. They aie uoing this at multiple sites with
multiple chiluien anu tiying to accumulate enough uata to go to the FBA to get
appioval foi a test that woulu pieuict the likelihoou of incieaseu caiies.

Sliue 16-Salivaiy pioteinspeptiues: caiies fieecaiies active
0thei investigatois have taken uiffeient appioaches. They've lookeu at eithei
salivaiy pioteins oi peptiues. Peptiues aie little bits of salivaiy pioteins that exist.
What they've founu, again, by stuuying caiies active veisus caiies fiee is a seiies of
pioteins anu peptiues that aie associateu with incieaseu caiies. This is just a list of
the most common ones.

Sliue 17-Reveise Phase Chiomatogiaphy of Saliva Peptiue Pools
This is a mass spec pattein anu you see they hau ovei 1uu people. Balf with caiies,
anu half without caiies. They uiu a piofile of all the peptiues. If you look at these two
patteins without knowing what anything is, you see some similaiities but you also
see some uiffeiences. This one ieally stanus out. This inveision heie. Small, big-big,
small. So when they see something like that, it becomes a clue that it coulu be a
molecule that, again, coulu be pait of a maikei. A numbei of people have taken that
appioach foi both caiies anu peiiouontal uisease.

Sliue 18-Futuie foi Caiies Tests
Tiansciibeu by Ana Sangauala Septembei 4, 2u14
In some, it's likely, it's unlikely, that theie will be a one, a specific test looking at just
one thing. Nost likely, it's going to be a composite because it's a multifactoiial
uisease. If you have, just foi example, if you have the iight saliva in teims of these
pioteins oi the oligosacchaiiues, but you have the wiong pB, that's going to
compensate foi anu make it woise. So likely, it will be a test that measuies a numbei
of things, so it coulu be the lectins, plus the peptiues, plus the pB, plus salivaiy flow.
The iuea is that if we can nail uown to a small enough numbei that theie will be a
test that will let you pieuict befoie theie's caiies that somebouy is likely to have
caiies. That's the goal. It is challenging anu I think by the time you'ie out of uental
school, they won't be heie yet, but they will be faithei aheau. I want to shift now to
peiiouontal uisease.

Sliue 19-Iuentification of Pathogen anu Bost-Response Naikeis Coiielateu with
Peiiouontal Bisease
Even though this is a caiiology couise. So theie aie a seiies of papeis fiom this, the
key peison in this gioup is Will uiannobile at the 0niveisity of Nichigan. Be has
been, actually he is the euitoi of the jouinal of uental ieseaich anu he has a laige
gioup of investigatois in his lab that have been looking at a couple of things. They'ie
looking at potential maikeis of peiiouontal uisease. 0nce again, the ovei Su uentists
say I uon't neeu that, I can just piobe. 0mm..maybe. But, so they'ie looking foi
maikeis of peiiouontal uisease. Noie inteiestingly, they'ie looking at maikeis that
tell you if a pocket oi an inuiviuual is going to piogiess oi iemain stable. The eaily
papeis, they weie just tiying to iuentify the maikeis.

Sliue 2u-Positive anu Negative Pieuictive values of Specific Thiesholus of Selecteu
Salivaiy Biomaikeis anu Plaque Biofilm Pathogens
Theie aie seiies of maikeis. Anu once again, it's not black anu white. You will see a
tenuency, so these aie gioups of foity anu the numbei that uiun't have veisus hau.
You'll see that foi some, the no's aie highei anu foi some, the yes's aie highei,
meaning theie is some uiffeience. But no one of these coulu tell you anything. So we
talk about a positive pieuictive anu a negative pieuictive of no veisus yes. It's the
statistical analysis. It woiks on a population, but if you'ie a single patient, it uoesn't
ieally give you enough infoimation to go aheau with.

Sliue 21-No Title
This is now, I think, moie inteiesting. It's a latei papei of theiis. What this looks at is
piogiession, so they hau about 1uu subjects to stait with anu theie was an initial
uiagnosis of seiious peiiouontal uisease, moueiate, essentially no peiiouontal
uisease. This means that in this gioup ovei one yeai, 2S of them piogiesseu anu
1S uiun't. In this gioup, it was about even. Anu in the stable gioup, most of them
weie stable anu uiu not piogiess. Anu so, what they uiu was lookeu at a whole seiies
of things. The two things that stiike me immeuiately aie if you look at seium, it
uoesn't tell you anything. Seiol (sp.) moueiately uiffeient. If you look at salivaiy
biomaikeis oi bacteiia, big uiffeiences. As you see, in the case of those that
piogiesseu the fastest, they have the highest levels of the biomaikeis anu the
highest levels of.these aie the most common peiiouontal pathogens. That makes
Tiansciibeu by Ana Sangauala Septembei 4, 2u14
peifect sense. Inteimeuiate-it's less. Anu these aie faiily high anu it may be that
these aie actually contiolling this. In the staple, it's veiy low anu veiy low. It uoes
suggest that if you get the iight mix, that you'll be able to have something that says
to the inuiviuual, you neeu to come in veiy often. You neeu to use chloiohexiuine, oi
you neeu to use this oi that because you'ie likely. You've got a few small pockets,
but they look twice ovei a 1 yeai peiiou. But this is going to piogiess iapiuly. 0i,
you just neeu to be moie caieful with youi biushing anu flossing, so how aggiessive
to tieat a given patient. 0nce again, we'ie not quite theie, but I think that the ouus
aie pointing to it.

Sliue 22-Spit in the Eye
I want to finish with a veiy inteiesting stoiy that I leaineu about a couple of yeais
ago anu is now mushioomeu into an inuustiy. We've known foi a long time that
theie is a similaiity between saliva anu teais. Nost of the piotective molecules that
aie piesent in saliva aie also piesent in teais. Anu the anatomy of the laciimal glanu
has close iesemblance to the anatomy of the salivaiy glanu. Anu, so, in some
uiseases like Sjogien's, you've heaiu of Sjogien's I piesume, autoimmune uisease,
pievalent in women. That affects simultaneously both the salivaiy glanus anu the
eyes. Bowevei, theie aie a numbei of othei conuitions that only affect the eye. As I
heaiu the stoiy, it was in China, anu it was a Chinese uentist speaking with a Chinese
ophthalmologist. They went out foi uiinks aftei the meetings anu they staiteu
talking about similaiities of pioblems anu the ophthalmologist mentioneu that he
has a lot of patients with uiy eyes but I uon't think they have any salivaiy pioblems.
So they hau the iuea of tiansplanting pait of the submanuibulai anu in some cases,
the entiie submanuibulai. Taking it oui fiom heie, anu putting it heie, anu having
the uuct, the teai uuct, now be the salivaiy glanu uuct. It sounus wilu. BA.

Sliue 2S- Suigical Autologous ulanu Tiansfei Tieatment of Seveie
Keiatoconjunctivitis Sicca
This is a pictuie of the suigeiy. This is the, heie they took the whole submanuibulai
glanu. By the way, what happens is, at least in animals, but I think in people too. If
you iemove one salivaiy glanu, the othei one giows to compensate. It's calleu
compensatoiy hypeiplasia. The same thing happens with the kiuney. If you take out
one kiuney, the othei kiuney giows. If you take out two thiius of the livei, it giows.
You can't uo it with biain yet, but that woulu be neat. But seveial of the paiieu
oigans, if you take out one, the bouy senses anu it tuins on the giowth of the othei
one. So the salivaiy glanu is not impacteu by this, but it is now piouucing salivaiy
flow anu pioteins into the eye.

Sliue 24- Subjective finuings foi submanuibulai glanu tiansplantation
This is the uata. This is eaily uata fiom a five yeai stuuy. What you see is, they
measuieu a seiies of things. visual acuity, you can see, it goes up ovei time, it's
sustaineu foi S yeais. This is asking the patient how they feel kinu of thing. They
have a test. You can see that's bettei. Whethei they neeu aitificial teais oi not anu
the numbei of times that they have to use it. So it looks like, it looks like it woulu
woik. So iecently, I uiu a iecent liteiatuie seaich anu theie aie now a seiies of
Tiansciibeu by Ana Sangauala Septembei 4, 2u14
papeis that inuicate theie aie 2 pioblems. In some cases, the secietion of the
salivaiy glanu is to gieat anu so these people aie teaiing constantly. I guess it woulu
be goou foi some things, but so the solution that they woikeu out is, they go back in
anu take out pait of the glanu. That cuts uown the salivaiy flow. The seconu
pioblem is that occasionally the uuct gets cloggeu. By the way, that happens in the
salivaiy glanu also. You get blockage in the uuct because of the high calcium
phosphate concentiation can ciystalize out as stones. It's not cleai if it's the same
people that hau it in the salivaiy glanu now have it in they eye oi if theie's
something uiffeient about the eye enviionment that encouiages that. But a
peicentage of people, they have to go back anu clean out the uuct. It's not wiuely
useu in this countiy, but it is in Asia anu Euiope. A numbei of Euiopean uocs aie
uoing this. The iationale is that uiy eye, although it sounus tiivial, is a majoi, majoi
quality of life issue. Removing one submanuibulai glanu has zeio impact on youi
ability to chew, swallow, no inciease in caiies, peiiouontal uisease. Theie uoesn't
seem to be any siue effects. Anyways, it's soit of a siueline but I founu it an
inteiesting obseivation.

Sliue 2S-Why shoulu uental piofessionals be inteiesteu in oial uiagnostics.
Why am I taking the time to tell you about this. Well, some of us in the uental
community aie conceineu that we have the unique oppoitunity to uo some ieally
exciting things anu it's being taken ovei by almost eveiy othei health piofession
except the uentists. The line I use is that the oial cavity is ieally the uomain of the
uentist. You know moie about it than anybouy else anu a physician just a small
anecuote: When I was at the 0niveisity of Pennsylvania befoie I came heie, theie
was a veiy goou infectious uisease uoc that got a giant to evaluate a compounu foi
tieatment of oial canuiuiasis. Be got the giant anu he staiteu to uo the stuuy anu
then he iealizeu that he uiun't iecognize what oial canuiuiasis. Anu so I got a call
anu he saiu, "Bo you have any colleagues that woik on this." So they hau to come
ovei anu actually show them, because it's not as obvious as it seems. You haven't
seen much of this yet, but theie aie simple tests to tell the uiffeience between a
white oial lesion anu oial canuiuiasis, but youi aveiage physician uoesn't know that.
So the oial cavity, you guys anu giils aie going to be the expeits in this. Anu if this
fielu evolves, you shoulu be in chaige. The seconu thing that I always point out is
that you neeu, in oiuei to uo pievention anu theiapy, you neeu to know uiagnosis.
You can't tieat a patient if you uon't know what they have. So uiagnostics play a veiy
impoitant iole. The othei thing is that healthcaie is changing veiy, veiy iapiuly.
Even befoie the 0bamacaie, the health, who ueliveis the healthcaie is just changing
veiy iapiuly. So theie aie nuises foi example in the phaimacies who aie giving flu
shots. Theie aie phaimacists in the phaimacies that aie giving flu shots. Anu yet, a
uentist is not yet at this point alloweu to give a flu shot, which is amazing. So, what
many of us see anu paiticulaily with the exciting thing that's going to happen in
}anuaiy. It's that the nuising school is actually moving heie. Bave any of you spent
time in the nuising clinic. Anybouy heie. No. You will have the oppoitunity. At this
point, it's only about a uozen at a time, but when they move heie, theie's going to be
moie space anu what's happening is that the nuises aie spenuing time in 1A anu
helping with a numbei of issues that uentists aie uncomfoitable uiscussing with the
Tiansciibeu by Ana Sangauala Septembei 4, 2u14
patient. The uentists aie spenuing time in the nuising clinic leaining about things
like if you have a heauache, the uentist thinks of TN} anu that's an illogical but theie
aie many othei things that cause heauaches. So a nuise anu a uentist woiking
togethei can actually uo a much bettei job of uiagnosis. I think the most impoitant
thing is in the 0niteu States, theie aie 2u million people eveiy yeai. With the only
healthcaie specialists they see is the uentist. It's veiy inteiesting because you can
avoiu seeing a uoc, you've got a colu, you can avoiu going to the uoc because it goes
away. If you have an enuouontic involvement oi anything in the oial cavity with
pain, you can't ignoie it. So, people aie going to the uentist. Nany people aie going to
the uentist anu nevei see anybouy else. Anu people aie geneially going to the uental
clinic moie often than they go, it's usually an annual check up with the physician oi
biannual, but it's a 6 month check up with the uentist. So the ability to play a iole in
what we call tiiage, not uiagnosing, but scieening anu hooking up someone with
high bloou piessuie, high bloou glucose, pain in the chest. When you ask the
question "Bow aie you feeling." anu the patient says "Well, I have a lot of pain in my
chest." That's an oppoitunity foi you to say "You ieally neeu to see a caiuiologist",
just foi example. So leaining about these uiseases in conjunction with the nuises,
which is going to be incieasing staiting in }anuaiy is going to be a goou thing. Anu
the othei point is, that I mentioneu befoie, if you ask youi patient foi a uiine sample,
they woulu piobably get anothei uentist. But if you ask the patient, can I swab youi
mouth, I mean you'ie in theie anyway. In fact you'ie actually ejecting the salvia foi
the whole houi that they'ie in the chaii. So to take a little bit foi a sample, I mean
they'ie not going to be suipiiseu. You'ie a uentist. Anu not to belittle the fact that
you uo neeu to make a living anu if you'ie in a competitive aiea anu you have, foi
example, to the patient, fiee testing foi flu, infectious uisease, bloou piessuie,
glucose, I think that it coulu uiffeientiate the piactice that woulu encouiage patients
that might go elsewheie to come to you. So, I am uone anu I am moie than willing to
answei questions in class oi aftei. Anybouy have a question. Something I uiun't say.
Something that uoesn't make sense. Well, I can't tell you how nice it was to be heie
with you.