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Salivary Secretion in Health and Disease

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Salivary Secretion in Health and Disease Accepted: 1 June 2018 DOI: 10.1111/joor.12664 REVIEW ARTICLE Salivary secretion in health and disease A. M. L. Pedersen1 | C. E. Sørensen2 | G. B. Proctor3 | G. H. Carpenter3 | J. Ekström4 1Oral Medicine, Oral Pathology & Clinical Oral Physiology, University of Copenhagen, Summary Copenhagen, Denmark Saliva is a complex fluid produced by 3 pairs of major salivary glands and by hundreds 2 Oral Biochemistry, Cariology & of minor salivary glands. It comprises a large variety of constituents and physico- Endodontics, Department of Odontology, Faculty of Health and Medical chemical properties, which are important for the maintenance of oral health. Saliva Sciences, University of Copenhagen, not only protects the teeth and the oropharyngeal mucosa, it also facilitates articula- Copenhagen, Denmark tion of speech, and is imperative for mastication and swallowing. Furthermore, saliva 3Mucosal & Salivary Biology Division, King’s College London Dental Institute, London, UK plays an important role in maintaining a balanced microbiota. Thus, the multiple func- 4Department of Pharmacology, Institute tions provided by saliva are essential for proper protection and functioning of the of Neuroscience and Physiology, The Sahlgrenska Academy at University of body as a whole and for the general health. A large number of diseases and medica- Gothenburg, Gothenburg, Sweden tions can affect salivary secretion through different mechanisms, leading to salivary Correspondence gland dysfunction and associated oral problems, including xerostomia, dental caries A. M. L. Pedersen, Oral Medicine and Oral and fungal infections. The first part of this review article provides an updated insight Pathology, Department of Odontology, Faculty of Health and Medical Sciences, into our understanding of salivary gland structure, the neural regulation of salivary University of Copenhagen, Copenhagen N, gland secretion, the mechanisms underlying the formation of saliva, the various func- Denmark. Email: [email protected] tions of saliva and factors that influence salivary secretion under normal physiologi- cal conditions. The second part focuses on how various diseases and medical treatment including commonly prescribed medications and cancer therapies can af- fect salivary gland structure and function. We also provide a brief insight into how to diagnose salivary gland dysfunction. KEYWORDS autonomic nervous system, saliva, salivary dysfunction, salivary glands, xerostomia 1 | INTRODUCTION functions, which are linked to its fluid characteristics and to spe- cific components. Saliva protects the teeth and oropharyngeal The saliva present in the oral cavity constantly covering the teeth mucosa, it facilitates articulation of speech, it is imperative for and oral mucosa is termed whole or mixed saliva. It is a complex mastication and swallowing, it exerts digestive actions, and plays mixture of fluids secreted by 3 pairs of major salivary glands, the an important role in maintaining a balanced microbiota.10,13,14,20-32 parotid, submandibular and sublingual glands, and by numerous Several diseases, medical conditions and medications can affect minor salivary glands, but it also contains various amounts of gin- salivary gland function leading to a sensation of dry mouth (xe- gival crevicular fluid, microorganisms, desquamated epithelial cells rostomia), usually caused by reduced salivary flow and altered and food debris.1 Salivary glands are mostly regulated by neural salivary composition.33-37 Salivary hypofunction increases the reflexes as part of the autonomic nervous system, but are also risk of oral disease (dental caries, dental erosion and fungal in- under the influence of various centres in the brain and gastroin- fections) but may also lead to changes in dietary intake resulting testinal hormones as well.1-15 Salivary output differs with regard in malnutrition and/or weight loss as well as impaired quality of to volume and composition depending on differential activation of life.1,10,14,28-34,38,39 This review article focuses on the salivary glands by different types of stimuli.7,10,12-14,16-19 Saliva has multiple gland structure, the neural mechanisms of salivary secretion, the 730 | © 2018 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/joor J Oral Rehabil. 2018;45:730–746. PEDERSEN ET AL. | 731 Acinus Intercalated duct Striated duct Excretory duct Oral cavity Myoepithelial cells Surrounding blood vessels/capillary network FIGURE 1 Secretory end piece (acinus) terminating into a duct system. An acinus consists of either serous or mucous acinar cells or mucous cells capped with a serous demilune. The intercalated duct, consisting of a monolayered cuboidal epithelium, leads into the striated duct, which consists of a monolayered columnar epithelium with several folds of the plasma membrane basally, and mitochondria between the folds. The final segment of the duct system is the excretory duct (multilayered columnar epithelium), which leads the final saliva into the main excretory duct into the oral cavity. Acini and intercalated ducts are surrounded by myoepithelial cells process of saliva formation, functions of saliva and the factors that Myoepithelial cells are contractile cells with a stellate shape that influence salivary secretion and composition under normal phys- surround the acini and intercalated ducts variably in the different iological and pathophysiological conditions. The latter includes glands. They are located between the basal lamina and the cytoplas- various diseases, medical conditions, commonly prescribed med- mic membrane of acinar or ductal cells (Figure 1). The myoepithelial ications and cancer therapy. The search for biomedical literature cells are controlled by the autonomic nervous system and upon con- on normal salivary gland structure and function and dysfunction traction they are believed to assist the flow of saliva by compressing (years 1954 to 2017) was conducted in PubMed, Embase and Web the acini and the ducts and also to provide structural resilience to of Science databases. Articles from the primary, secondary and the parenchyma during secretion.41 Although they are contractile tertiary literature were selected for inclusion on the basis of their there is no evidence to suggest they force saliva out of acini by in- significance and relevance to the clinician. creasing intra- acinar pressure and indeed their presence is not re- quired for secretion to occur. The connective tissue capsule that surrounds the major salivary 2 | SALIVARY GLAND STRUCTURE glands forms septa, which divide the gland into lobes and lobules. These septa contain large blood vessels, nerves and ducts, whereas Salivary glands are categorised into the 3 pairs of major glands, in- the acini, intercalated and striated ducts, small blood vessels and cluding the parotid, submandibular and sublingual glands and about nerves are located within the lobules. In the minor salivary glands, 600 to 1000 minor salivary glands particularly located in the labial, the connective tissue merges imperceptibly with the surrounding buccal, palatal, lingual and retromolar regions of the oral mucosa.40 connective tissue.41 The parenchyma has a rich supply of blood The salivary glands consist of parenchymal and stromal components. vessels, which form a capillary plexus, particularly adjacent to the The parenchyma is composed of secretory end pieces (acini), which ducts. Sympathetic stimulation makes the blood vessels constrict, make a primary fluid/saliva, connected to a system of ducts (inter- whereas parasympathetic stimulation lead to vasodilation and in- calated, striated and excretory) which modify the saliva (Figure 1). creased blood flow to the salivary glands.42 Virtually all protein in Each acinus consists of either serous or mucous cells, or mucous cells “pure glandular saliva” is derived from the salivary glandular cells and capped by serous demilunes (only found in the submandibular gland), not the blood stream. Most of the about 2.500 different proteins arranged about a central lumen. The salivary glands are classified his- in whole/mixed saliva probably originate from exfoliating epithelial tologically according to their structural composition and their secre- cells and oral microorganisms, and only one- tenth is thought to be tions1,5,6,9,10,12-14,22-28 (Table 1). The length and the diameter of the of gland origin.26 duct system vary depending on the gland type. The major salivary The final saliva that enters the oral cavity is composed of more glands have long, branched ducts, the parotid and submandibular than 99% water and less than 1% solids, including proteins and salts. glands contain all ductal segments (intercalated, striated and excre- The normal daily production of saliva is approximately 0.6 L.37,43 The tory), whereas the sublingual and minor glands lack striated ducts.40 major salivary glands produce about 90% of the fluid secretion and 732 | PEDERSEN ET AL. TABLE 1 Salivary gland structural features, parasympathetic innervation and contribution to whole saliva volume under unstimulated (in the absence of exogenous stimuli) and under chewing- stimulated conditions1,10,12-14,40 Contribution (%) to Parasympathetic Ducts to the oral Acinar cell type Secretory product whole saliva volume nerve supply cavity Major salivary glands Parotid glands Serous Watery, amylase- rich Resting: 25% Glossopharyngeal Stensen’s duct Stimulated: 50% nerve Submandibular glands Mixed, mainly Viscous, mucin- rich Resting: 60% Facial nerve Wharton’s duct serous Stimulated:
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