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Year : 2017  |  Volume : 8  |  Issue : 3  |  Page : 116-120

Sialochemical profile in depressive individuals: A cross-sectional ex vivo study

Department of Oral Pathology & Microbiology, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth University, Puducherry, India

Date of Web Publication18-Sep-2017

Correspondence Address:
G Umamaheswari
Department of Oral Pathology & Microbiology, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth University, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_17_17

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Introduction: Depression is a mental disorder that is pervasive and affects people all around the world. In India, about one in five people is affected by depressive disorders. An autonomic nervous system affected by depressive disorder can affect the salivary composition since salivary secretion is controlled by the sympathetic and parasympathetic innervations. Alteration in the salivary composition can affect oral health and makes them vulnerable to oral infection. Aim: The aim is to study the sialochemical alteration in depressive individuals. Materials and Methods: A total of 100 patients were divided into two groups: Group I (normal individuals) and Group II (patients with depressive disorder). Depression level was assessed with Hospital Anxiety and Depression Scale. Whole unstimulated saliva was collected and subjected to sialochemical analysis (sodium, potassium, chloride, total protein, urea, salivary amylase, calcium, and pH). Result and Conclusion: The parameters were statistically analyzed using parametric ttest and showing statistically significant raised levels in salivary amylase, total protein, sodium, chloride, and calcium, and there was no statistical difference in salivary pH, urea, and potassium levels.

Keywords: Autonomic nervous system, depression, depressive disorder, neurophysiology, norepinephrine, sialochemistry

How to cite this article:
Umamaheswari G, Vezhavendhan N, Sivaramakrishnan M, Suganya R, Devy A S, Vidyalakshmi S. Sialochemical profile in depressive individuals: A cross-sectional ex vivo study. SRM J Res Dent Sci 2017;8:116-20

How to cite this URL:
Umamaheswari G, Vezhavendhan N, Sivaramakrishnan M, Suganya R, Devy A S, Vidyalakshmi S. Sialochemical profile in depressive individuals: A cross-sectional ex vivo study. SRM J Res Dent Sci [serial online] 2017 [cited 2022 Dec 6];8:116-20. Available from:

  Introduction Top

Depression is a common affective disorder, affects >350 million people all around the world,[1] and it could be second most common disease in the world by the year 2020.[2] In India, about one in five people are affected by depressive disorders.[3]

Depression in the early stages induces various adaptational physiologic responses. Chronic depression leads to hyperactivity of hypothalamus–pituitary–adrenal axis as well as sympathetic-adrenal-medullary system and makes them more vulnerable to various diseases such as hypertension, diabetes, cardiovascular diseases, and salivary gland dysfunction.[4],[5] Salivary gland function is controlled by both sympathetic and parasympathetic innervations, and in depression, both sympathetic and parasympathetic system get affected which leads to altered salivary function,[5],[6] and this could reflect in altered salivary composition also.[7]

Salivary gland dysfunction could be an altered salivary composition or secretion that may cause transient inconvenience to severe impairments of oral health such as mucositis, burning sensation, altered taste sensation, dental caries, periodontal diseases and oral candidiasis.[8],[9]

Sialochemistry is an emerging diagnostic tool that can provide qualitative information on certain important parameters of saliva which are used for the diagnosis and research purpose.[10] Various studies analyzed sialochemical alteration in depressed patient under antidepressant therapy,[11],[12],[13],[14] but sialochemical profile in depressive individuals who are not under medication assessed widely. Hence, the present study was carried out to analyze the sialochemical alteration in depressive individuals who are not under medication as compared to healthy controls.

  Materials and Methods Top

This cross-sectional ex vivo study was conducted in the department of psychiatry over a period of 6 months between January to June 2016. This study proposal was approved by the Institutional Review Board and Institutional Ethical Committee.

Patient selection

A total of 100 patients between the age range of 18–50 years were included in the study based on conventional sampling. Suspected depressive patients were thoroughly examined by the clinical psychiatrist. Based on the depression and anxiety assessment using Hospital Anxiety and Depression Scale (HADS)[15] and clinical history, patients were diagnosed as depressive and nondepressive individuals. Patients who were scored a depression value using HADS were ≤8 and value >8 were taken as control and depressive patients, respectively. Patients with systemic disorders such as diabetes mellitus, hypertension, and autoimmune disorders or under any other medication that alters salivary secretion and radio/chemotherapy in the head and neck region in the past 6 months were excluded from the study based on clinical and laboratory investigations.

Sample collection and processing

Unstimulated whole salivary samples were collected between 8 a.m. and 12 p.m. (to avoid circadian variations), based on spitting method illustrated by Navazesh.[16] The individuals were asked to refrain from eating, drinking (except water), toothbrushing, practice physical exercises, or be under great physical stress for at least 1 h before sample collection. The patients were instructed to wash their mouths thoroughly with deionized water and allowed to sit in a relaxed position for 5 min and allow saliva to accumulate in the mouth and then to expectorate into a sterile plastic container once every 60 s over a period of 5 min. Collected sample was then transported to the biochemistry laboratory. Salivary samples were centrifuged at 3200 rpm for 10 min, and supernatant fluid was collected and subjected to sialochemical analysis (α-amylase, total protein, urea, calcium, sodium, phosphate, chloride, salivary pH, etc.). Salivary sodium, potassium, and chloride levels were estimated by ion-selective electrode method, EasyLyte analyzer (Medica). Spectrophotometric analysis of salivary α-amylase, total protein, urea, and calcium was done by the International Federation of Clinical Chemistry approved method, using a Hitachi 902 autoanalyzer.

Statistical analysis

Mean and standard deviation were used for describing the data. Parametric t-test was used to compare the salivary parameters between the groups.

  Results Top

The following observations were made on statistical analysis [Table 1].
Table 1: Comparison of statistical values among group I and group II

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Estimation of salivary pH

[Table 1] reveals no statistically significant differences in the unstimulated salivary pH levels (P = 0.257) in between Group I (6.4 ± 0.3) and Group II (6.5 ± 0.43).

Estimation of electrolytes (sodium, potassium, and chloride)

[Table 1] shows statistically significant differences in the unstimulated salivary sodium levels (P = 0.028) in between Group I (11.15 ± 5.23) and Group II (13.6 ± 5.75).

[Table 1] shows no statistically significant differences in the unstimulated salivary potassium levels (P = 0.38) between Group I (24.37 ± 5.34) and Group II (25.4 ± 6.3).

[Table 1] reveals statistically significant differences in the unstimulated salivary chloride levels (P = 0.016) between Group I (20.31 ± 5.58) and Group II (24.1 ± 9.39).

Estimation of total protein and α-amylase

[Table 1] reveals statistically significant differences in the unstimulated salivary total protein levels (P = 0.0001) between Group I (0.25 ± 0.12) and Group II (0.542 ± 0.338).

[Table 1] reveals statistically significant differences in the unstimulated salivary amylase levels (P = 0.001) between Group I (38.55 ± 23.55) and Group II (67.29 ± 55.03).

Estimation of urea

[Table 1] reveals no statistically significant differences in the unstimulated salivary urea levels (P = 0.613) between Group I (26.7 ± 9.5) and Group II (28 ± 13.9).

Estimation of calcium

[Table 1] reveals statistically significant differences in the unstimulated salivary calcium levels (P = 0.046) between Group I (5.32 ± 1.88) and Group II (6.12 ± 2.10).

  Discussion Top

“Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration.”[1] It affects >350 million people all around the world. By the year 2020, major depression might be projected as the second-leading cause of disability worldwide alongside the ischemic heart disease.[2]

Sialochemistry is a useful means of chronologically monitoring quantitative changes of chemicals that are present in saliva. It is based on presumed relationship with intraglandular transport processes such as sodium, potassium, and chloride and intracellular synthesis such as protein, α-amylase, and diffusion of plasma constituents such as urea.[17]

Salivary glands are innervated by both sympathetic and parasympathetic branches of autonomic nervous system (ANS). The sympathetic transmitter – norepinephrine activates both α- and β-adrenergic receptors, whereas the parasympathetic transmitters activate cholinergic receptors. Protein secretion is mediated by α-adrenergic receptor. Stimulation of β-adrenergic and cholinergic receptors carries low level of protein secretion but mainly involved in water and electrolyte secretion.[18] Depression/stress triggers the ANS, resulting in norepinephrine release. This evokes the protein secretion and in particular amylase secretion from the salivary gland acinar cells.[19]

The present study analyzed the salivary total protein and salivary α-amylase level in depressive individuals (Group II) and found a statistically significant increase in total protein (P = 0.0001) and salivary α-amylase (P = 0.001) concentration when compared with the nondepressive individuals (Group I). The result of the raised salivary amylase in depression is consistent with findings of Booij et al.[20] and Jung et al.[21] Vineetha et al. revealed that increase in salivary alpha-amylase level during psychosocial stress might be explained by physiological response to stress.[5]

Deshpande et al. in their study reviewed that the salivary proteins can be considered as “double-edged sword” since it has both protective and detrimental roles. The function may depend on the molecule's location or site of action, i. e., antimicrobial and pH-modulating proteins play a protective role whereas agglutinin plays a detrimental role in colonization of microorganisms.[22] Scannapieco et al. showed that raised level of salivary amylase promoted adhesion of oral streptococci and may have a role in dental plaque and caries formation.[23] Few other studies state that salivary total protein concentration is increased in dental caries,[24] gingivitis, and periodontitis.[25]

The parasympathetic stimulation induces binding of acetyl-choline to muscarinic cholinergic receptors and releases Ca 2+ from intracellular stores. The increased Ca 2+ concentration opens Cl channels in the apical cell membrane and K + channel in the basolateral membrane. The apical Cl efflux draws extracellular Na + to the lumen and increases Na + and Cl concentration. The apical Cl channel also transports HCO3 into the lumen. Stimulation of sympathetic β-adrenergic receptor also increases the intracellular concentration of cyclic AMP and stimulates the release of Ca 2+ from intracellular store. The present study shows a significant increase in sodium (P = 0.028), chloride (P = 0.016), and calcium (P = 0.046) levels in depressive individuals when compared to the nondepressive patients.

The important factors affecting the composition of saliva are flow rate, differential gland contribution, circadian rhythm, duration and nature of stimulus, and medication. At high flow rate, salivary HCO3 concentration increases, Na +/H + exchange serves to restore the intracellular pH and positively correlated with salivary flow rate, whereas the concentration of potassium and chloride was negatively correlated. The low flow rate produces significant electrolyte alteration with decreased salivary pH.[26] Morse et al.,[27] Sandin and Chorot,[28] Khalaila et al.,[29] and Cohen and Khalaila [30] reported decreased salivary pH in stressed, anxiety, and depressed patients.[27],[28],[30] The present study did not show any significant change in salivary pH (P = 0.257), and values were within the normal range of 6.7–7.4.[26]

Major ions such as sodium, potassium, chloride, calcium, and bicarbonate are few of the important contributors of the osmolarity of saliva. Calcium and phosphate neutralize acid that would otherwise compromise tooth mineral integrity. It is also proposed that in decreased flow rate, the ductal cells may undergo more reabsorption of Na + and makes the final secretion with less Na + concentration.[26] In depressive individuals, there is diminished membrane transport because of which electrolyte concentration may be increased.[10] Urea is another buffer which is a product of amino acid and protein catabolism. They increase the salivary pH by releasing ammonia and carbon dioxide when hydrolyzes by bacterial urease. Increase in urea decreases the caries incidence, but ammonia is potentially cytotoxic to gingival tissues and initiates periodontal diseases.[31]

The present study revealed that the depressive individuals showed an increase in chloride, sodium, potassium, and urea levels when compared with normal individuals. These increase in electrolyte concentration in depressive individuals might due to diminished membrane transport.[10] Veen et al. found that there was a significant increase in sodium level in manic-depressive or recurrent depressive illness in parotid flow rate.[13] In contrast to this, no specific alteration in electrolyte pattern was reported by Bolwig and Rafaelsen in manic-depressive patients in mixed saliva and also suggested that the mixed saliva would preclude the modest difference among the major and minor salivary glands.[32]

The outcome of the present study revealed that the depressed individuals showed a statistically significant increase in salivary sodium, chloride, total protein, α-amylase, and calcium levels compared with healthy individuals [Chart 1/Table 1]. However, further studies with large sample size and estimation of gland-specific sialochemical analysis have to be initiated to add more information to the existing scientific evidence.

  Conclusion Top

Depressive patients have the risk of developing salivary gland hypofunction, probably to a higher extent, and this could reflect an alteration in the salivary composition. Sialochemical analysis of depressive patient (not under medication) shows a significant alteration in the salivary composition which includes salivary alpha-amylase, total protein, sodium, chloride, and calcium. The patients with altered salivary composition may experience numerous sequelae including xerostomia, taste changes, altered nutrition, oral microbial population shifts, high dental caries risk, and oral mucosal changes. Hence, it is necessary to evaluate the oral health status of depressive individuals by periodic monitoring of sialochemical value and helping them by providing proper prophylactic and interventional therapy to restore oral health status.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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