The Usual Suspects- Saliva

This post is part of a 4-part series from Dr. Kim Kutsch on CAMBRA, risk assessment, and the usual suspects that are causing this disease. If you would also like to watch the video, click here.


Early CAMBRA, seventeen years ago, was a real challenge to implement into dental practice. We’ve been working for sixteen years to make it not complicated, so it can be used in your daily practice. To that end, we’ve identified several patterns of caries disease called the usual suspects that make identifying probable disease causes simpler. These patterns are very distinct and easily recognizable, and they are a great tool to helping your patients since they make CAMBRA more user friendly and clinically adaptable. The very first of these usual suspects is saliva, specifically, the lack of saliva.

On over 12,000 risk assessment forms collecting data, 63% of patients self-reported having dry mouth or taking dry mouth causing medication. When you see someone with a saliva risk-factor, you’ll quickly notice that they really don’t have any saliva or enough saliva. There will not be saliva pooling in the vestibule or bubbling between the teeth. The tissue may also look dry. You may even need to peel the cheek tissue away from the teeth.


Saliva is supersaturated with nanoparticles of hydroxyapatite and fluorapatite. These minerals are how your mouth protects your teeth against caries and erosion. As saliva flow increases, the levels of supersaturation of HA and HF also increase as your body seeks to protect your teeth from damage while eating. Without this action of mineral-rich saliva, your teeth would dissolve from that alone.

As we look at contributors to dry mouth, medication use stands out. There are over 4,000 medications that list hyposalivation or xerostomia as the most common side effect. Typically, a patient who lists a medication on their forms is going to suffer from some degree of medication induced xerostomia (dry mouth) and will be at an increased caries risk because of it.

There are also other conditions that contribute to dry mouth, such as Sjogren’s syndrome. Such a patient may not have a reduced amount of saliva that contribute to caries risk.

Illicit drug use, particularly methamphetamine, contributes to dry mouth. Such patients may not report their drug use. Women and tobacco users are more succpetiple to amphetamine induced dry mouth.


A study of 1,002 children examined salivary flow rate and caries rate. Not surprisingly, it found that children with the highest salivary flow rate had the lowest caries rate and children with the lowest salivary flow rate had the highest caries rate.  Interestingly enough, this same study also found that children who had the highest fiber intake, a marker of a higher quality diet, also had the highest salivary flow rate. Diet quality has an impact on saliva flow.


It’s also important to consider patients with special needs. While they may have an increased amount of salivary flow, it can prove an additional challenge if they have reduced salivary flow that will increase their decay rate.

For patients that have reduced salivary flow, it’s vital to educate them on how this increases their caries risk and counsel lifestyle changes. It’s particularly helpful to advise on palliative and preventive measures. These might include a sugar-free xylitol chewing gum or a pH elevating mouth spray to use during the day. It’s important to keep the mouth moist.


Types of medications that contribute most often to salivary dysfunction are wide ranging, particularly those that act on the nervous system. Over 15 million children in the United States are currently on medications that increase their risk for dry mouth and thus dental caries. It’s an important consideration, particularly since it impacts so many groups of patients.

Dry mouth looks like dry mouth. You may see dry tissue and note a lack of saliva. The patient may report feeling dry mouth or waking in the middle of the night with dry tongue. You may see medications listed on the history form to confirm your suspicions. Dry mouth, because it can lead to caries, is a “usual suspect” you will want to address.

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