Name of journal: World Journal of Stomatology esps manuscript no: 15716 Columns: review salivary gland disorders: a comprehensive review

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Metastatic malignant salivary gland neoplasms: Studies suggests that polymorphous low grade adenocarcinoma, adenoid cystic carcinoma and muco epidermoid carcinoma of the salivary glands[66] are found to have increased metastatic potential. Adenoid cystic carcinoma[67] has been found to metastasize to lungs, bones, skeletal muscles and skin.

Advances in radiotherapy for head and neck cancer sparing the salivary glands

Intensity modulated radiotherapy (IMRT) for head and neck cancer has partial parotid sparing effect which reduces the intensity of post radiotherapy xerostomia[65].

Exposure of salivary glands to Ionizing radiation cause damage to the secretory apparatus of the glands causing xerostomia which could be avoided by the use of any one of the presently available[66] techniques: (1) Shielding of one or more salivary glands form radiation - During radiotherapy for the tumors of parotid gland and areas outside the oral cavity, radio protecting shield can be used to protect the major salivary glands. Shielding may not be feasible in radiotherapy for midline lesions, cancer of oropharynx and larynx due to the position of the cancer and the alignment of the radiotherapy port. Use of conformational dose delivery techniques - The 3 dimensional imaging techniques like CT scans provide for accurate and precise delivery of radiation to the affected tissues with no or minimal damage to the surrounding normal structures. These radiotherapy techniques helps in minimizing the radiation induced xerostomia; (2) Stimulation of acinar cells prior to Radiotherapy - Administration of salivary stimulants like Pilocarpine before each radiotherapy session is found to reduce the complication of diminished salivary flow. However in radiation dose above 50 Gy this beneficial effect is reduced; (3) Use of salivary sparing agents during radiotherapy - Use of agents like Amifostine and heat shock proteins during radiotherapy for head and neck cancer helps in protecting the salivary glands against radiation induced damage; (4) Transplantation of the salivary gland away from the radiation filed - A few studies have reported the beneficial effects of transplanting the major salivary gland away from the radiation filed with maintenance of the ductal connection; and (5) Advanced methods like gene therapy for repairing the damaged acinar cells, injecting the stored pre radiotherapy salivary cells after the completion of radiotherapy, inducing the hematopoietic stem cells to differentiate into salivary acinar cells and thereby replacing the damaged cells and fabricate artificial salivary tissues from donor tissues and introducing them in place of damaged glands using tissue engineering techniques help in restoring the functions of salivary glands and reduce the complications of reduced salivary flow[67-74].
Emerging salivary diagnostics: Molecular and protein markers of oral diseases

In the oral cavity the presence of multifarious microbial flora exhibits more than many hundreds of microbial species which have been identified so far. Advance microbial research has thrown open to much more new insights and saliva has become the major source to a library of information, and the biomarkers represent the disease and health status of the oral cavity[68-71].

Saliva is a fluid that can be easily collected and contains locally and systemically derived markers of oral disease[67]. The term “salivaomics” was coined in 2008 to reflect the rapid development of knowledge about the various “omics” constituents of saliva. Salivaomics includes five diagnostic alphabets proteins, mRNAs, miRNAs, metabolic compounds, and microbes offers substantial advantages because disease states may be accompanied by detectable changes in one, but not all, dimensions[68]. Human salivary proteome analysis is important for understanding oral health and disease pathogenesis.

Metabolomics is the global assessment and validation of endogenous small-molecule metabolites within a biologic system that has gained increasing popularity and significance in life sciences[69]. Analysis of these key metabolites in body fluids has become an important role to monitor the state of biological organisms and is a widely used diagnostic tool for disease. Metabolomics provides potential advantages that classical diagnostic approaches do not, based on the discovery of clinically relevant biomarkers that are affected by the disease[70-79].

Increase in the incidence of oral cancer has prompted research in salivary biomarkers for oral cancer. More than 100 different salivary biomarkers for oral cancer have been identified. A review on salivary biomarkers for oral cancer categorized this vast variety of salivary biomarkers under different groups which include: (1) Non-organic compound biomarkers, e.g., sodium, calcium, magnesium; (2) Peptide or protein biomarkers, e.g., P53 autoantibody, alpha amylase etc.; (3) DNA, RNA and microRNA biomarkers, e.g., P53 gene codon 63, IL 8, miR-125a etc.; (4) Metabolomic biomarkers, e.g., Valine, lactic acid etc.; and (5) Miscellaneous biomarkers, e.g., Telomerase activity[80-95].

Salivary biomarkers are also used for assessment of caries risk. DNA based methods like DNA hybridization, mono clonal antibody (MAb) technique, 16S rRNA/ rDNA, gene cloning and genomic sequencing or T-RFLP methods of analysis help in identification and cariogenic microbial taxonomy using saliva without the need for culture methods[62,72,76,79].

PCR based identification techniques allow for accurate measurement of cariogenic microbiota. Salivary diagnostics suggests a new diagnostic tool for the detection and quantification of oral pathogens directly from its liquid state without the need for isolation of bacterial cells. In children low salivary levels of alpha defensins HNP1-3 may represent biological factor that contributes to caries susceptibility while salivary IgA antiboby responses to streptococci mutants can be observed in early childhood[72].

Salivary epithelial cells are found to secrete proteins into blood stream which has led to research on the duacrine function of salivary glands. This function of salivary epithelial cells is being researched as a potential target site for in situ gene transfer producing proteins for treating several systemic disorders[73,81].

Saliva, the fluid bathing the oral cavity, is one of the important secretions in the human body. One of the main functions of saliva is digestion of complex carbohydrates and lipids. Technological advancements in the field of diagnostics have opened new avenues to understand the other important and far reaching functions of saliva. The constituents of saliva, also known as biomarkers, act as an index for underlying systemic disease ranging from infections to malignancies.

Salivary glands are surrounded by a rich network of vasculature allowing the biomarker constituents of blood to enter salivary acinus and finally into the salivary secretions. Biomarker is defined as an objectively measured and evaluated indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to therapeutic intervention.

Biomarkers can be in the form of proteins, carbohydrates, lipids or microorganisms. Change in the constitution of these biological molecules may reflect the status of underlying disease processes and can aid in diagnosis, management, evaluating the prognosis and monitoring the outcome of the condition[74]. Biomarkers in saliva have the potential to be used for screening purposes in epidemiological studies.

Matias I, Gatta-Cherifi B, in their study were able to quantify endocannabinoids in human saliva as potential and useful biomarker of obesity[75,96]. Two major forms of Ghrelin (GAH) a recently identified peptide hormone in saliva shows their decrease levels in salivary samples in obese type 2 diabetic patients.

The levels of mRNAs regulating the metabolism of endocannabinoids, N-acylethanolamines and of cannabinoid type 1 [CB (1)] receptor, were assessed in human salivary glands. The study helps in further understanding of the physiopathological mechanisms leading to type 2 diabetes and obesity.

There are numerous investigative tools to identify and quantify the type and load of microbes in the oral cavity. Most of these tools are based on microbial culture methods for identifying disease specific pathogens. Biomolecular microarray based diagnostics (quantitative 16S rRNA gene sequencing, terminal restriction fragment length polymorphism analysis etc.) are advancements over the conventional culture methods. These methods, when combined with microbial culture techniques, help in enhancing the chances of accurate identification of pathogens[76]. Salivary fluid can also be used for detection of systemic infections. Saliva based enzyme - linked immunosorbent assay (ELISA) has shown promising results in detection of HIV pathogens with 99.3% sensitivity and 99.8% specificity. However positive test results are to be confirmed with western blot analysis. Other systemic infections which can be detected by salivary analysis include hepatitis A, B, C infections, malaria, Ebola, Dengue, CMV, EBV[76,92,93,97] and human herpes virus (HHV) infections. These infections are identified by assessing the viral load, viral antibodies and viral antigens in saliva. These diagnostic parameters are found to correlate well with their corresponding levels in serum. Leptin, is a cytokine identified in human saliva play a protective role in bacterial P. gingivalis infection[9,98] induced inflammatory responses. Another salivary component Ghrelin is found to have a countering effect on P. gingivalis induced impairment of mucin synthesis which plays a role in periodontal infections[61].

Molecular analysis of saliva employing next generation sequencing (NGS) and human microbe identification micro array (HOMIM) techniques have enabled the clinician to identify and characterize a large number of oral microbiota in diseases including Crohn’s disease, pancreatic cancer, oral cancer and obesity. In children suffering from Crohn’s disease, there is an overall decrease in diversity of oral microorganisms as compared to healthy children. Studies employing the advance microarray techniques report suggests overall significant reduction in Neisseria elongate and Streptococcus mitis species count in the saliva of patients with pancreatic cancer as compared to normal subjects[61,74].
Future research direction: Advances in the management of salivary gland tumours studies stress the need towards molecular targeted therapy of the unusual subpopulation of tumorigenic cancer cells which could arrest the recurrence and metastasis of the tumor. In this direction the cancer stem cell research needs to be further explored in the salivary gland tumors[77,99,100].

Recently a non-invasive, academic prototype chair side cancer diagnostic kit (GC America Inc.) has been devised by Wong DT for the early detection of cancer[78]. Newer field like Proteomics helps in the analysis of the salivary proteins which is extensively used in identification of a specific protein biomarker in saliva for diseases including AIDS, oral cancer, diabetes, periodontal disease and mammary gland carcinoma. The transudate of oral mucosa contains secretory immunoglobulin IgG, IgM and IgA, which serve as a valuable source for immunodiagnostic-based procedures. Using Point-of-care (POC) salivary diagnostic screening tests kit[78,92] it is possible to detect viruses in viral infectious diseases such as human papillomavirus (HPV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV).

Advanced Molecular Salivary tests for caries susceptibility may further aids in motivation and patient’s education, evidence based dentistry and also in determining effectiveness of anti-caries therapy or caries-control measures including community based services and caries vaccine[72,78]. Further advancements are now being focused at “Omic technologies”, which include genomics, proteomics, transcriptomics, and metabolomics have already set their mark in life science research studies[68,76,78]. These emerging technologies have shown to offer highly sensitive, specific, quick and affordable diagnostic test kits in future. Local drug delivery system is another interesting area with the advent of Nano medicine being used in pharmaceuticals industry and biomedical engineering field have shown promising results in future therapeutics. In cancer therapeutics, Nano particles, such as, semiconductor quantum dots, biodegradable micelles, iron oxide nano crystals[77,80,81,94], are linked with bio targeting ligands, to aim at specific sites in malignant tumors, helpful in cancer therapeutics. Endothelin-1 (ET-1) is one of the probable salivary biomarkers for oral cancer has been reported[81,82,95] for early cancer detection. Dependability of saliva for early diagnosis of dengue disease especially useful in dengue endemic countries is awaited[96]. Salivary ghrelin plays an important protective role in chronic periodontitis and needs further research[86,97-99]. Salivaomics, the future of saliva-based techniques for early diagnosis of dental diseases, is promising. However, further long term studies are needed before these newer methods are adapted to routine clinical practice.
Conclusion: Saliva reflects the physiologic state of the body. Salivary gland diseases may be inflammatory, non-inflammatory, non-neoplastic or neoplastic lesions. Only when a definitive diagnosis is established, treatment depends upon the lesion size, cause, severity, extent and other clinical considerations of the disease. However, a thorough knowledge of the subject including their recent advancements together with a team of associated medical and dental specialists, it is possible to detect the diseases of salivary glands in their early stage and manage them more efficiently. Salivaomics, the future of saliva-based techniques for early diagnosis of dental diseases is promising. Saliva being readily available can be used as a diagnostic tool to help the clinicians for early detection of oral diseases like caries, periodontal disease, oral cancer, salivary gland disorders and non-oral diseases by adapting the advance noninvasive technique and technologies.

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P-Reviewer: Ferri A, Kawamata H, Slomiany BL S-Editor: Ji FF L-Editor: E-Editor:

Table 1 World Health Organization 2005 Classification of salivary gland tumors

I Epithelial tumors

A Benign epithelial tumors

Pleomorphic adenoma


Basal cell adenoma


Canalicular adenoma

Warthins tumors


Papillary cyst adenoma

Mucinous cyst adenoma

Benign sebaceous neoplasm

Sebaceous adenoma

Sebaceous lymphadenoma

Ductal papilloma


Inverted ductal

Sialadenoma papilliferum

B Malignant epithelial tumors

Mucoepidermoid carcinoma

Acinic cell carcinoma

Adenoid cystic carcinoma

Polymorphous low grade adenocarcinoma

Epithelial myoepithelial carcinoma

Clear cell carcinoma

Basal cell adenocarcinoma

Oncocytic carcinoma

Myoepithelial carcinoma

Adenocarcinoma NOS

Carcinoma ex pleomorphic adenoma

Metastatising pleomorphic adenoma


Salivary duct carcinoma

Cyst adenocarcinoma

Low grade cribriform cystadenocarcinoma


Malignant sebaceous tumor

Sebaceous adenocarcinoma

Sebaceous lymphadenocarcinoma

Squamous cell carcinoma.

II Mesenchymal tumors









Malignant fibrous histiocytoma


III Malignant lymphoma

IV Metastatic tumor

Table 2 American College of Rheumatology Classification Criteria for Sjögren’s

Syndrome: Sjogren’s syndrome case definition requires at least 2 out of the following 3

Figure 1 Major Salivary Glands and their related structures.

1 Positive serum anti-SSA and/or anti-SSB or (positive rheumatoid factor and ANA ≥ 1:320)

2 Ocular staining score ≥ 3

3 Presence of focal lymphocytic sialadenitis with focus score ≥ 1 focus/4 mm2 in labial salivary gland biopsies

Figure 2 Mucous secreting cell showing Mucigen vesicle.

Figure 3 Serous secreting cell with secretory granules.

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