Global oral health inequalities: the view from a research funder.

Despite impressive worldwide improvements in oral health, inequalities in oral health status among and within countries remain a daunting public health challenge. Oral health inequalities arise from a complex web of health determinants, including social, behavioral, economic, genetic, environmental, and health system factors. Eliminating these inequalities cannot be accomplished in isolation of oral health from overall health, or without recognizing that oral health is influenced at multiple individual, family, community, and health systems levels. For several reasons, this is an opportune time for global efforts targeted at reducing oral health inequalities. Global health is increasingly viewed not just as a humanitarian obligation, but also as a vehicle for health diplomacy and part of the broader mission to reduce poverty, build stronger economies, and strengthen global security. Despite the global economic recession, there are trends that portend well for support of global health efforts: increased globalization of research and development, growing investment from private philanthropy, an absolute growth of spending in research and innovation, and an enhanced interest in global health among young people. More systematic and far-reaching efforts will be required to address oral health inequalities through the engagement of oral health funders and sponsors of research, with partners from multiple public and private sectors. The oral health community must be "at the table" with other health disciplines and create opportunities for eliminating inequalities through collaborations that can harness both the intellectual and financial resources of multiple sectors and institutions.

Artificial salivas: present and future.

Modern technology has allowed us to understand better the functions of saliva and now provides a rationale for developing: (1) diagnostic reagents for monitoring oral and systemic health status and (2) replacement therapies for individuals with salivary dysfunctions. Several areas of dental research are directed at augmenting or enhancing both the quality and quantity of saliva for individuals with dry mouth. An "intrinsic" approach is being explored which utilizes medications such as pilocarpine and bromhexine to stimulate the salivary glands to produce more saliva. An "extrinsic" approach proposes to use topically applied artificial saliva. Studies in our laboratory have been directed toward developing artificial salivas which incorporate many of the protective features of "native" saliva. An ideal artificial saliva should be "long-lasting", provide lubrication, inhibit colonization of microflora responsible for dental caries and gingivitis, and coat the oral soft tissues for protection against environmental insult and desiccation. Studies are currently under way to determine the structural requirements of salivary molecules responsible for these protective functions. Composite salivary molecules consisting of multiple biologically active or "functional domains" could then be designed and synthesized based upon primary sequence and conformational analyses, computer-assisted structural predictions, and in vitro testing. These supersalivary substances could then be used as saliva substitutes for targeting to selected oral surfaces to promote mineralization, hydration, and/or regulate microbial-mediated disease.

Characterization of low-molecular-weight peptides in human parotid saliva.

The low-molecular-weight components of human saliva remain poorly characterized. Therefore, low-molecular-weight peptides (Mr < 3000) have been purified from human parotid saliva and characterized with respect to their amino acid sequence. From the sequences obtained, it is likely that these peptides are derived from proteolysis of the hydroxyapatite-interactive human salivary proteins, histatins, proline-rich proteins, and statherins. Since human parotid saliva is an amicrobial fluid, much of the low-molecular-weight peptide fraction of this secretion appears to be derived from the proteolytic processing of the larger proteins. Because of their small size, these peptides are likely to be in exchange with dental plaque fluid and may therefore help modulate events such as demineralization/remineralization, microbial attachment, and dental plaque metabolism at the tooth-saliva interface.

Juvenile periodontitis as a model for neutrophil function: reduced binding of the complement chemotactic fragment, C5a.

The binding of the chemotactic complement fragment, C5a, to peripheral blood neutrophils of Localized Juvenile Periodontitis (LJP) patients and normal controls was quantitated using iodinated human C5a and a rapid centrifugation assay. There was a significant reduction in the number of binding sites per cell on neutrophils from the patient group, whereas the binding affinity remained the same as control values.

Neuraminidase activity: a biochemical marker to distinguish Streptococcus mitis from Streptococcus sanguis.

Selected reference and freshly isolated strains of Streptococcus mitis (mitior) and Streptococcus sanguis were assayed for cell-associated neuraminidase activity by their ability to hydrolyze [3H-] sialyllactitol. A cell-associated neuraminidase was detected with S. mitis and S. sanguis serotype II (reclassified as S. mitis) but not with S. sanguis serotypes I and III. Neuraminidase activity of S. mitis correlated with this organism's inability to hydrolyze arginine, aesculin, and few, if any, sugars. The findings indicate that the presence of cell-associated neuraminidase activity is useful for the taxonomic classification of S. mitis.

Lipid composition of submandibular saliva from normal and cystic fibrosis individuals.

The submandibular saliva of patients with cystic fibrosis was found to contain about 66% more lipids/100 ml of saliva than that of normal individuals and exhibited elevated levels of neutral lipids, phospholipids, and glycolipids. No significant differences were noted in the proportions of individual neutral lipid and phospholipid components present in both types of samples. The glycolipids of normal saliva consisted entirely of glyceroglucolipids, whereas those of cystic fibrosis saliva, in addition to glyceroglucolipids, also contained small amounts of glycosphingolipids. These quantitative and qualitative differences may affect the physicochemical properties of the secretion.

Association of free arginine and lysine concentrations in human parotid saliva with caries experience.

We determined the free-amino acid content of stimulated parotid (ductal) saliva from two groups of adult subjects whose caries experiences were markedly different. The levels of free arginine and free lysine in the parotid saliva of caries-free adults were significantly higher than those found in the parotid saliva of individuals with a history of dental decay. There was no correlation, however, between the levels of these amino acids and the DMFS score within the caries-susceptible groups. Microbial catabolism of dibasic amino acids contributes to the neutralization of plaque acids and may partially account for the higher resting plaque pH observed in caries-free subjects. Alternatively, the elevations observed in free levels of arginine and lysine may reflect a systemic alteration in amino acid metabolism which is common to the caries-free group of subjects.

Age-related changes in mucins from human whole saliva.

The predominant mucins in human whole saliva, MG1 and MG2, serve to protect and to lubricate the oral cavity. In this study, both unstimulated and stimulated whole salivas were collected from two groups of subjects: young (18-35 years of age) and aged (65-83 years of age). The subjects were in apparent good health. Saliva samples from each subject were analyzed by SDS-PAGE. The gels were stained with Stains-all, and both MG1 and MG2 were quantitated by video-image densitometry. The protocol gave reproducible values for each mucin. The stimulated and unstimulated salivas from aged subjects showed significant reductions in concentrations of both MG1 and MG2, as quantitated in mucin dye-binding units. Possible associations of these reductions with the aging process are discussed.

The effect of chronic atropine treatment on salivary composition and caries in rats.

Many instances of salivary dysfunction in humans can be traced to the use of medications that have hyposalivary side-effects. In this study, atropine, a cholinergic antagonist, was administered chronically to rats by use of osmotic mini-pumps. Steady-state blood levels, similar to levels obtained in human multiple oral dosing, were thus maintained. Atropine delivered in this manner for 24 days was found to decrease protein concentration of parotid saliva (p less than 0.05) elicited by pilocarpine, and to increase smooth-surface caries scores (p less than 0.05) in rats fed a cariogenic diet. Parotid saliva collected via ductal cannulation from rats subjected to chronic atropine administration (and stimulated to secrete by pilocarpine) exhibited increased levels of two basic proline-rich proteins (Peak A and SP-3), as evaluated by SDS-PAGE, compared with those observed in saliva from controls. Cannulation of sublingual glands in animals receiving high doses of atropine produced no measurable secretion upon pilocarpine stimulation. Carbachol stimulation of dispersed cell aggregates of sublingual glands from sham-operated and high-dose atropine groups indicated that the glands responded similarly once the antagonist was washed from the system, implying that the lack of secretion in vivo was caused by antagonism of the cholinergic receptor by atropine. Our observations suggest that this model system can be exploited for determination of the effects of chronic administration of hyposalivary drugs on salivary composition and caries rates.

The association of basic proline-rich peptides from human parotid gland secretions with caries experience.

To address whether there are associations between the peptide composition of human parotid saliva and dental decay (caries) experience, we have characterized the peptides from parotid ductal saliva collected from nine adults who have remained free from dental caries (mean age = 59.2; Decayed Missing Filled Surfaces index [DMFS] = 0) and nine individuals who have experienced caries (mean age = 51.2; mean DMFS = 38.4). Ethanol-soluble peptides were size-fractionated on columns of Bio-Gel P-2; the salivary peptides derived from caries-susceptible subjects appeared larger than those found in the saliva of caries-free subjects. Peptides were then resolved into 19 species by cation exchange HPLC. Sequence analysis identified 18 peptides that appear to be proteolytic cleavage products of the basic proline-rich proteins IB-4, IB-5, IB-7, IB-8b, and P-B. The peptides that were more abundant in saliva obtained from the caries-free group differed from those isolated from the caries-susceptible group. The median peptide concentration of one possible precursor protein, IB-7, was found to be higher in saliva collected from caries-free individuals than in that from caries-susceptible individuals. Although differences were found in the phenotypes of proline-rich proteins expressed by these groups of caries-free and caries-susceptible subjects, no statistically significant associations were observed among proline-rich phenotypes and the level of any peptide. Collectively, our results indicate that proteolytic processing of parotid salivary proteins differs among individuals who have remained caries-free and those who have experienced dental decay.

Purification of a low-molecular-weight, mucin-type glycoprotein from human submandibular-sublingual saliva.

A low-molecular-weight, monomeric, mucin-type glycoprotein (MG2) has been isolated from human submandibular-sublingual saliva. Initial purification involved sequential gel-filtration on Sephadex G-200 and Sepharose CL-2B, the latter in the presence of 6M urea. Fractions containing MG2 were next separated from contaminating secretory IgA by immunoaffinity chromatography or recycling through Sephadex G-200. Mucin fractions were 14C-labeled by reductive methylation, and then the final purification-step entailed recycling radiolabeled materials through Sephadex G-200. Radiolabeling aided in the assessment of purity, as judged by SDS-PAGE and ion-exchange chromatography. The carbohydrate portion accounted for 69.6% of the recovered weight and was composed of N-acetyl-glucosamine, N-acetylgalactosamine, galactose, fucose, and N-acetylneuraminic acid. Sulfate was also present. The protein comprised 30.4% of the recovered weight with threonine, serine, proline, and glycine accounting for 75.2% of the total amino acids. The oligosaccharides were alkali-labile, indicating an O-glycosyl linkage to the peptide. The mucin was weakly acidic and had an estimated mol. wt. of 200 000-250 000.

Immunochemical quantitation of alpha-amylase and secretory IgA in parotid saliva from people of various ages.

The alpha-amylase (128 subjects) and secretory IgA (118 subjects) concentration in stimulated parotid saliva of healthy individuals aged 23-84 years, was determined. They were divided into three age groups: I, 23-39; II, 40-59; and III, 60-84 years old. The concentrations (microgram/ml) of alpha-amylase for group I = 803.6; II = 648.0; and III = 652.4; the concentrations for secretory IgA for group I = 96.2; II = 101.8; and III = 97.7. The Kruskal-Wallis test revealed no significant differences between groups for alpha-amylase or secretory IgA.

Characterization of a pentasaccharide in salivary mucin from the stumptail monkey, Macaca arctoides.

Oligosaccharides were prepared by alkaline cleavage and sodium borotritide reduction. Following gel filtration on Sephadex G-25, [3H]-oligosaccharides were further fractionated by anion-exchange and preparative paper chromatography. The principal neutral oligosaccharide contained GalNAcol: GlcNAc: Gal: Fuc (1:1:2:1). Using a combination of exoglycosidase digestion, periodate oxidation and methylation analysis by gas chromatography-mass spectrometry, it structure was determined to be: Gal beta 1 leads to 4 GlcNAc beta 1 leads to 3 (Fuc alpha 1 leads to 2 Gal 1 leads to 6)GalNAcol.

A new assessment in vitro of human salivary lubrication using a compliant substrate.

The lubrication effect of salivary secretions was assessed in terms of separating a rigid object from a compliant substrate. There was little difference among the various secretions of a single donor. The viscosity of salivas increased as a function of time. Neither the friction testing nor viscometry provided an adequate model of the tissue-coating function ascribed to saliva.

The effect of milk and casein proteins on the adherence of Streptococcus mutans to saliva-coated hydroxyapatite.

Experiments sought to determine the nature of the binding of milk proteins to hydroxyapatite (HA) and to saliva-coated hydroxyapatite (sHA), and to determine the effect of milk and casein on the adherence of Streptococcus mutans GS-5 to sHA. The binding of radiolabelled alpha-casein to HA was reduced when incubated simultaneously with parotid saliva, and enhanced in the presence of milk. The binding of beta- and kappa-casein to HA was unaffected by the presence of parotid saliva and enhanced by the presence of milk. The in vitro bacterial adherence of Strep. mutans GS-5 to sHA beads was reduced when beads were coated with milk instead of buffer, or when bacteria were added to sHA in the presence of milk instead of buffer. Casein proteins (alpha, beta, kappa) added to sHA simultaneously with bacteria inhibited the adherence of Strep. mutans GS-5 to sHA. kappa-Casein, when bound to sHA, inhibited streptococcal adherence to sHA; alpha- and beta-casein, when bound to sHA, had no effect on streptococcal adherence. Fractionation of kappa-casein by anion-exchange chromatography revealed the anti-adherence activity of kappa-casein was mediated primarily by a 40,000 mol. wt. glycoprotein-containing fraction. These data show that milk, particularly kappa-casein fractions, can modulate the adherence of Strep. mutans GS-5 to SHA surfaces in vitro.

The effect of chronic propranolol treatment on salivary composition and caries in the rat.

Many drugs are known to affect salivary secretion. The purpose of this study was to explore the chronic effects of a commonly used beta-adrenergic blocker, propranolol. Adult rats were desalivated or treated for 28 days with propranolol HCl (10 or 20 mg/kg, daily) or sterile buffer (sham-operated control) using osmotic pumps for delivery. The parotid and submandibular glands of each rat were cannulated and secretion elicited by pilocarpine (10 mg/kg, intravenous). There were no statistical differences in salivary protein content (Lowry) or output among the groups (ANOVA, p greater than 0.05). Analysis of salivary proteins by SDS-PAGE revealed a constant profile for submandibular secretions, but peak A and SP-3 proline-rich proteins were not detectable in parotid saliva of animals treated with propranolol for the entire experiment. Significantly increased smooth-surface (p = 0.0003) and sulcal (p = 0.0011) caries scores were found within these propranolol groups (ANOVA). The findings provide further evidence that chronic administration of propranolol alters salivary composition by decreasing proline-rich proteins and concurrently enhances susceptibility to caries.

A revolution in biomedical assessment: the development of salivary diagnostics.

Since the early 1900s, saliva has proven to be a noninvasive medium from which to measure a wide range of hormones, pharmaceuticals, and antibodies. It has also proven to be a convenient source of host and microbial DNA. As we enter the era of genomic medicine, increasing use of salivary diagnostics will help catalyze a shift from disease diagnosis to health surveillance. However, with the advances in this technology comes the additional obligation to ensure the privacy and rights of patients.