Is saliva collected passively without forceful coughing sensitive to detect SARS-CoV-2 in ambulatory cases? A systematic review.

OBJECTIVE: This systematic review was conducted to assess the sensitivity rate of SARS-CoV-2 detection in the saliva of ambulatory asymptomatic and mildly symptomatic patients, with saliva being collected passively without any forceful coughing. STUDY DESIGN: A literature search was performed from January 2020 to July 2021. Prospective studies excluding letters to editors were included in our review only if saliva and nasopharyngeal samples were collected simultaneously and sensitivity was reported using reverse transcription polymerase chain reaction (RT-PCR) in asymptomatic or mildly symptomatic ambulatory cases. RESULTS: A total of 436 studies were assessed; 10 (4 cohorts and 6 cross-sectional) studies met our inclusion criteria. The sensitivity rate of saliva to detect SARS-CoV-2 varied from 85.7% to 98.6% in all except for 3 studies. Lower sensitivity levels were attributed to low viral load (51.9% and 63.8%) or lack of supervision while collecting saliva (66.7%). CONCLUSIONS: Passively collected saliva in the absence of coughing has a high sensitivity rate to detect SARS-CoV-2 in asymptomatic and mildly symptomatic patients compared with nasopharyngeal swabs. Limitations of previous studies, such as lack of attention to the method of saliva collection, stages, and severity of the disease at the time of sample collection, can be researched in future investigations.

Clinical practice guidelines for oral management of Sjögren disease: Dental caries prevention.

BACKGROUND: Salivary dysfunction in Sjögren disease can lead to serious and costly oral health complications. Clinical practice guidelines for caries prevention in Sjögren disease were developed to improve quality and consistency of care. METHODS: A national panel of experts devised clinical questions in a Population, Intervention, Comparison, Outcomes format and included use of fluoride, salivary stimulants, antimicrobial agents, and nonfluoride remineralizing agents. The panel conducted a systematic search of the literature according to pre-established parameters. At least 2 members extracted the data, and the panel rated the strength of the recommendations by using a variation of grading of recommendations, assessment, development, and evaluation. After a Delphi consensus panel was conducted, the experts finalized the recommendations, with a minimum of 75% agreement required. RESULTS: Final recommendations for patients with Sjögren disease with dry mouth were as follows: topical fluoride should be used in all patients (strong); although no study results link improved salivary flow to caries prevention, the oral health community generally accepts that increasing saliva may contribute to decreased caries incidence, so increasing saliva through gustatory, masticatory, or pharmaceutical stimulation may be considered (weak); chlorhexidine administered as varnish, gel, or rinse may be considered (weak); and nonfluoride remineralizing agents may be considered as an adjunct therapy (moderate). CONCLUSIONS AND PRACTICAL IMPLICATIONS: The incidence of caries in patients with Sjögren disease can be reduced with the use of topical fluoride and other preventive strategies.

Triple jump examination evaluation of faculty examiners by dental student examinees.

The triple jump examination (TJE) is an oral examination that poses challenges for objective assessment. Student satisfaction levels with faculty assessment can provide information on quality of teaching and students' perceptions of the learning environment. The purpose of this study was to determine scale and interrater reliability of an instrument used by approximately 576 first-year dental students at one U.S. dental school for assessment of their faculty evaluators following midterm and final TJEs over a three-year period. One hundred and one faculty members served as administrators of the TJE with a range of one to 187 times (mean=44.10, median=29, mode=11). The grand mean for six items on a six-point Likert scale was 5.39 with a pooled standard deviation of 1.01. Results indicate positive agreement toward performance of examiners with strong interrater reliability (Average Measures ICC=0.936, Single Measures ICC=0.708) (F5,23475 = 51.564, p<0.001) and consistency across all items (Cronbach's α=0.936). The a priori assumption that students would rate faculty higher as they gained experience over time was rejected (r=0.018, p=0.429). Indications are that faculty members, who are relatively inexperienced with TJE examining, can perform acceptable assessment from the students' perspective. Overall, these students expressed a high level of satisfaction with TJE faculty performance.

The rationale for and implementation of learner-centered education: experiences at the Ostrow School of Dentistry of the University of Southern California.

This report describes the design, implementation, and function of integrated, learner-centered education at the Ostrow School of Dentistry of the University of Southern California. The 190 required courses of the previous curriculum have been condensed to forty-four courses. Four courses, presented for each of eleven trimesters of the four-year D.D.S. program, are entitled Human Structure, Human Function, Human Behavior, and Human Clinical Dentistry. An integrated biomedical sciences curriculum is supported by small-group, facilitator-based, problem-based learning (PBL) and an electronic PBL case library. Modules, rotations, and preclinical and clinical sessions make up remaining instructional units of the curriculum. Selected assessment outcomes measuring student knowledge, behavior, and skill development are discussed. As an external measure, first-attempt pass rates on the National Board Dental Examination (NBDE) Part I show a range of 87-96 percent over a ten-year period (for Classes 2005-14). First-attempt pass rates on the NBDE Part II for Classes 2005-12 ranged from 74 percent to 93 percent. Perceived barriers and opportunities for better performance on the NBDE Part II are addressed. Additionally, an exit survey, administered over the past four years, indicates a high level of student satisfaction with "depth and breadth" of their education (82-93 percent) and that graduates feel well prepared to enter the practice of dentistry (94-97 percent).

Triple jump examinations for dental student assessment.

The triple jump examination (TJE) attempts to assess a higher level of learning with demand for analysis, critical thinking, and resolution of problems presented by written scenarios based on patient care situations. The purpose of this study was to examine the internal consistency, scale reliability, and interrater reliability of the TJE used at the Ostrow School of Dentistry, University of Southern California. On the sample of 2,227 examinations administered by seventy-seven raters across a three-year time period, the Cronbach's coefficient alpha for internal consistency of the overall TJE was found to be good (a=0.869). The internal consistency of the three subscales was found to be acceptable (a=0.731), good (a=0.820), and good (a=0.820). Average and single measures intraclass correlation coefficients (ICC) for scale reliability were significant at p<0.001, indicating strong interrater reliability. There were no statistically significant differences (p≤0.05) in the mean scores assigned on the TJE between rater groups defined by rater experience level with the TJE. A very high level of agreement among rater pairs was also observed. Across the entire three-year study period, with over 19,152 ratings, the seventy-seven raters were in general agreement 99.5 percent of the time and in exact agreement 77.2 percent of the time.

Salivary gland and associated complications in head and neck cancer therapy.

Xerostomia and salivary gland hypofunction are two of the most common and significant complications of head and neck cancer therapy in the head and neck region. This article will provide a brief overview of salivary gland hypofunction and associated complications in head and neck cancer therapy, mainly in radiation therapy. The discussion will include quality of life issues as well as current advances in cancer therapy to reduce xerostomia and salivary gland hypofunction.

Management of xerostomia and salivary gland hypofunction.

Xerostomia and salivary gland hypofunction are conditions that have been associated with increased prevalence of caries, periodontitis, and candidiasis. Oral health care providers must be aware of the etiologies and clinical manifestations of salivary gland hypofunction in order to identify patients with this condition and to prevent its potential complications. The various modalities available to manage this condition range from frequent sips of water to the intake of systemic medications like pilocarpine or cevimeline.

Systemic and mucosal differences in HIV burden, immune, and therapeutic responses.

BACKGROUND: Mucosal tissues represent major targets for HIV transmission but differ in susceptibility and reservoir function by unknown mechanisms. METHODS: In a cross-sectional study, HIV RNA and infectious virus were compared between oral and genital compartments and blood in HIV-infected women, in association with clinical parameters, copathogens, and putative innate and adaptive HIV inhibitors. RESULTS: HIV RNA was detectable in 24.5% of women from all 3 compartments, whereas 45% had RNA in only 1 or 2 sites. By comparison, infectious HIV, present in blood of the majority, was rare in mucosal sites. Innate mediators, secretory leukocyte protease inhibitor and thrombospondin, were highest in mucosae. Highly active antiretroviral therapy was associated with an 80% decreased probability of shedding. Multivariate logistic regression models revealed that mucosal HIV RNA was associated with higher plasma RNA, infectious virus, and total mucosal IgA, but not IgG. There was a 37-fold increased probability of detecting RNA in both genital and oral specimens (P = 0.008; P = 0.02, respectively) among women in highest versus lowest IgA tertiles. CONCLUSIONS: Mucosal sites exhibit distinct characteristics of infectious HIV, viral shedding, and responses to therapy, dependent upon both systemic and local factors. Of the putative innate and adaptive mucosal defense factors examined, only IgA was associated with HIV RNA shedding. However, rather than being protective, there was a striking increase in probability of detectable HIV RNA shedding in women with highest total IgA.

Xerostomia: prevalence, diagnosis, and management.

This article summarizes the common causes, clinical presentation, and complications of xerostomia and salivary gland hypofunction in the geriatric population and discusses the various management options.

Measuring salivary flow: challenges and opportunities.

BACKGROUND: Saliva is being studied extensively and is being used for risk assessment, diagnosis and monitoring high-risk behavior and disease progression. 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 prevalence 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 developing diseases and by scientists for scholarly activities.

The proteomes of human parotid and submandibular/sublingual gland salivas collected as the ductal secretions.

Saliva is a body fluid with important functions in oral and general health. A consortium of three research groups catalogued the proteins in human saliva collected as the ductal secretions: 1166 identifications--914 in parotid and 917 in submandibular/sublingual saliva--were made. The results showed that a high proportion of proteins that are found in plasma and/or tears are also present in saliva along with unique components. The proteins identified are involved in numerous molecular processes ranging from structural functions to enzymatic/catalytic activities. As expected, the majority mapped to the extracellular and secretory compartments. An immunoblot approach was used to validate the presence in saliva of a subset of the proteins identified by mass spectrometric approaches. These experiments focused on novel constituents and proteins for which the peptide evidence was relatively weak. Ultimately, information derived from the work reported here and related published studies can be used to translate blood-based clinical laboratory tests into a format that utilizes saliva. Additionally, a catalogue of the salivary proteome of healthy individuals allows future analyses of salivary samples from individuals with oral and systemic diseases, with the goal of identifying biomarkers with diagnostic and/or prognostic value for these conditions; another possibility is the discovery of therapeutic targets.

A novel caries risk test.

A diagnostic test is particularly beneficial if it reveals the level of susceptibility prior to onset of a disease process. In the case of childhood caries, such a diagnostic test affords the opportunity for preventive measures to be implemented before caries begins. Salivary glycoproteins contain a wealth of individually specific oligosaccharide motifs. Depending on microbial compatibilities and individual genotypes, the glycoproteins that form the pellicle coating of teeth may provide attachment sites that foster colonization leading to cariogenesis. Alternatively, certain oligosaccharides, when present in nonpellicle glycoproteins, can interact with planktonic bacteria and lower their ability to interact with the tooth surface. We have found that in young adults the ratio of the two classes of oligosaccharides present in resting saliva exhibits a strong correlation with caries history (DFT: number of decayed and filled teeth). Oligosaccharide moieties associated with the test are quantitated in dried spots of whole saliva on nitrocellulose using commercially available biotinylated lectins with a variety of reporters. A combination of multiple linear regression and neural net analyses were used to develop the algorithms that describe the relationship between oligosaccharide patterns and DFT. During test development several different groups of adults and children have been studied. The correlation algorithms routinely exceed an R(2) (coefficient of determination) of 0.96. When the test is applied to the saliva of children, it yields a projection of their future caries history. Modifying the test result metric to reflect the groups of teeth with caries in young adults, the test identifies those teeth at risk for future caries in children. This test outcome can then be accompanied with suggested specific preventive measures for each tooth group-based risk level.

Salivary dysfunction associated with systemic diseases: systematic review and clinical management recommendations.

OBJECTIVES: The objective of this study was to identify systemic diseases associated with hyposalivation and xerostomia and develop evidence-based management recommendations for hyposalivation/xerostomia. STUDY DESIGN: Literature searches covered the English language medical literature from 1966 to 2005. An evidence-based review process was applied to management studies published from 2002 to 2005. RESULTS: Several systemic diseases were identified. From studies published 2002 to 2005, 15 were identified as high-quality studies and were used to support management recommendations: pilocarpine and cevimeline are recommended for treating hyposalivation and xerostomia in primary and secondary Sjögren's syndrome (SS). IFN-alpha lozenges may enhance saliva flow in primary SS patients. Anti-TNF-alpha agents, such as infliximab or etanercept, are not recommended to treat hyposalivation in SS. Dehydroepiandrosterone is not recommended to relieve hyposalivation or xerostomia in primary SS. There was not enough evidence to support any recommendations for the use of local stimulants, lubricants, and protectants for hyposalivation/xerostomia. However, professional judgment and patient preferences may support the use of a specific product for an individual patient. CONCLUSIONS: These evidence-based management recommendations should guide the clinician's management decisions for patients with salivary dysfunction related to systemic disease. Future treatment strategies may include new formulations of existing drugs, e.g., local application of pilocarpine. Recent discoveries on gene expression and a better understanding of the etiopathogenesis of SS may open new treatment options in the future.

A novel saliva test for caries risk assessment.

A new saliva test for caries risk assessment introduced in this study integrates a variety of host factors to predict for children, individual risk levels that are tooth-group specific. These various host factors correlate with caries history, DFT (decayed and filled teeth) or DFS (decayed and filled surfaces) in young adults. The test is based on the pattern of genetically determined oligosaccharides present on salivary glycoproteins. The mechanism behind the test is believed to be centered on the specific oligosaccharides that either facilitate bacterial attachment and colonization at the surface of teeth or protect against colonization by promoting agglutination and removal of free bacteria. It is the ratio of the two classes of oligosaccharides that is very strongly correlated with the numerical range of DFS or DFT observed in a young adult population.

Longitudinal evaluation of loss of attachment in HIV-infected women compared to HIV-uninfected women.

BACKGROUND: The Women's Interagency HIV Study (WIHS) is the largest, most detailed, controlled longitudinal collection of data to evaluate the influence of human immunodeficiency virus (HIV) disease and its therapies on the periodontium. METHODS: This report evaluates periodontal probing depth (PD), attachment loss (AL), and tooth loss from 584 HIV-seropositive and 151 HIV-seronegative women, recorded at 6-month intervals from 1995 to 2002. Using the random split-mouth method, PD and AL were recorded from four sites per tooth: mesial-buccal, buccal, distal-buccal, and lingual. Influence of viral load, CD4 count, race, smoking, drug use, low income, and level of education were evaluated. RESULTS: At baseline, AL was 1.6 versus 1.1 mm (P = 0.003) and PD was marginally deeper (2.1 versus 2.0 mm; P = 0.02) in HIV-seropositive versus HIV-seronegative women. Adjusted longitudinal analysis showed that HIV infection did not increase the mean PD (rate ratio [RR], 1.00; 95% confidence interval [CI], 0.96 to 1.04), worst PD (RR, 1.03; 95% CI, 0.98 to 1.09), mean AL (RR, 0.97; 95% CI, 0.96 to 1.02), worst AL (RR, 1.01; 95% CI, 0.94 to 1.07), or tooth loss (RR, 1.02; 95% CI, 1.0 to 1.05). CONCLUSIONS: CD4 count and viral load had no consistent effects on PD or AL. Among HIV-infected women, a 10-fold increase in viral load was associated with a marginal increase in tooth loss. The progression of periodontal disease measured by PD and AL did not significantly differ between HIV-infected and HIV-uninfected women. The HIV-seropositive women lost more teeth. Race, smoking, drug use, income, and education level did not influence the results for either group.

Baseline characteristics of participants in the oral health component of the Women's Interagency HIV Study.

OBJECTIVES: This study described baseline sociodemographic and oral health characteristics of a subset of HIV sero-positive and sero-negative women who participated in the oral health component of the Women's Interagency HIV Study (WIHS). METHODS: In 1995-96, 584 HIV sero-positive and 151 sero-negative women from five WIHS core sites were enrolled in the oral study. Data on oral mucosa, salivary glands, dentition and periodontium, along with demographics, socioeconomics, and behavioral characteristics, were used to characterize this population. RESULTS: Mean (SD) age was 37 (8) years for HIV sero-positive and 36 (8) years for sero-negative women; 27% of sero-positive women had CD4 counts < or =200 and 34% had viral loads >50,000 copies/ml. Sero-positive and sero-negative women were similar demographically, as well as on plaque index, gingival bleeding, linear gingival banding, and numbers of DMF teeth and surfaces, but sero-positive women had more abnormal gingival papilla (P = 0.004) and fewer teeth (P = 0.01). Among sero-positive women, those with <200 CD4 counts had more DMF teeth (P = 0.007), and the number of DMF surfaces increased with decreasing CD4 counts (P = 0.04). Sero-positive women who fit the Center for Disease Control (CDC) AIDS criteria were also more likely to have more DMF teeth (P = 0.004), DMF surfaces (P = 0.003), and decayed and/or filled (DF) root surfaces (P = 0.0002) compared to sero-positive women without AIDS. CONCLUSIONS: Dental and periodontal variables showed little difference between HIV sero-positive and sero-negative women. Among sero-positive women, there were significant differences in coronal and root caries by AIDS diagnostic criteria, but no periodontal indicators by either AIDS diagnostic criteria or CD4 status, were observed.

How can oral health care providers determine if patients have dry mouth?

BACKGROUND: Dentists recognize the importance of saliva in maintaining oral health and often are familiar with the clinical effects an insufficient salivary flow can have on oral tissues. A variety of medical conditions and medications can alter salivary secretion and composition. Typically, diagnosis of hyposalivation is made only after damage has occurred to the oral tissues. OVERVIEW: The author describes a series of clinical steps that, if followed properly, may help in the early detection of salivary gland hypofunction and prevention of its severe complications. This four-step approach includes identifying a patient's chief complaint and the symptoms and duration of illness that brought the patient to the dentist, as well as any approaches the patient took to relieve symptoms; obtaining a medical history that includes a review of the body systems; performing a clinical evaluation that notes the patient's overall condition in addition to the health and functioning of the salivary glands and oral soft and hard tissues; and, when needed, conducting further diagnostic evaluations. CONCLUSIONS AND CLINICAL IMPLICATIONS: Oral health care providers will continue to face the challenges of treating new and recurrent carious lesions if the profession's approach to salivary hypofunction remains reactive rather than proactive. The recommendations in this article may enhance clinicians' awareness of the objective methods used to identify patients with salivary gland hypofunction or those at risk of developing it. It is hoped that early identification of asymptomatic patients at risk of developing hyposalivation, as well as symptomatic patients will lower the incidence and prevalence of dental caries and fungal infection in this population and ultimately enhance their quality of life.