Salivary Parameters of Buffer Capacity, pH Saliva and pH Plaque

International Journal of Clinical Preventive Dentistry

Volume 9, Number 3, September 2013

Salivary Parameters of Buffer Capacity, pH Saliva and pH Plaque Related to Dental Caries Activity in School Student Risqa Rina Darwita, Peter Andreas Department of Dental Public Health and Preventive Dentistry, Faculty of Dentistry, University of Indonesia, Jakarta, Indonesia

Objective: Dental caries is a major worldwide oral disease problem in children. Although caries are known to be influenced by dietary factors, the disease results from a bacterial infection; thus, caries susceptibility may be affected by environment factors such as saliva. This study aimed to determine a possible correlation between caries prevalence and caries risk markers that important factors for caries development in school children age 7-8 year in 5 areas of DKI Jakarta. Methods: The study was conducted as a cross-sectional study which data were collected from 500 school children in DKI Jakarta age 7-8 years old who were received dental examination including dental caries was used score DMF-S, pH saliva, pH plaque and buffer capacity.The screening starts with simple clinical observations, expanding to a diversified pattern of tests to assess the un-stimulated buffer capacity, pH saliva and pH plaque. Results: The results show that the Mean±SD score DMF-Sof school children was 0.193±0.4015. While Mean±SD buffer capacity of un-stimulated saliva was 4.763±2.1628, the pH un-stimulated saliva 6.830±0.4991, the other result shows that pH plaque was 6.246±0.4094. There was significant correlation (R=0.229, p<0.0001) between score DMF-Sand buffer capacity, pH saliva and pH plaque. Conclusion: The findings suggest that the level of buffer capacity, pH saliva, and pH plaque are the importance of screening for caries risk markers. Keywords: salivary, buffer capacity, pH saliva, dental caries activity, Indonesia


students, i.e., teeth brushing and Fluoride mouth rinsing outside of classes, as well as curative treatment for selected classes (1). However, the last survey conducted in 2000 by the Ministry of Health indicated that the Decay Missing Filling Tooth DMF-T score was still >3, especially in the DKI Jakarta and Central Java provinces (1,2).  The presence of dental caries during primary dentition is a strong predictor for cariogenic breakdown of the permanent dentition. In addition, researchers found that incidence of caries increased slightly with age for both first and second molars during the follow-up period (3-5). Further assessments of oral health, especially concerning the saliva and biofilm conditions, are helpful in the overall management of dental caries. Results will provide a reference for any dental caries treatment manage-

 One of the Community Health Centre programs in Indonesia is the School-Based Oral Health Care Program for 6 to 12 year-old students as a prioritized target group. The program content includes health promotion and dental prevention for all

Corresponding author Risqa Rina Darwita Department of Dental Public Health and Preventive Dentistry, Faculty of Dentistry, University of Indonesia, Jakarta, [13410], Indonesia. Tel: +622194194254, Fax: +622131906289, E-mail: [email protected] Received June, 11, 2013, Revised August, 31, 2013, Accepted September, 6, 2013


International Journal of Clinical Preventive Dentistry

ment in dental practice and for oral health promotion needs (5,6).  Salivary factors related to the development of dental caries are extremely relevant in the disease process. A good way to motivate the school children to be aware of their oral health is through the examination of caries risk assessment from saliva. The salivary tests most often used for clinical purposes are buffering capacity, saliva pH, plaque pH, saliva flow rate, saliva microorganisms, etc (5,7).  The purpose of this study is to determine a possible correlation between caries risk markers and salivary factors relating to caries development in 7- to 8-year-old school children in five districts in DKI Jakarta.

2. Statistical analysis

Material and Methods  The stratified random samplings from all primary schools in DKI Jakarta until five primary schools were selected as a representative sample. The 500 students age 7- to 8-year-old were selected from the selected of 5 primary schools in DKI Jakarta.  Ethical clearance was taken from theinstitutional ethics committee in Faculty of Dentistry University of Indonesia, and informed consent was obtained from the researcher. Permission to conduct the study was obtained from department of health of DKI Jakata and from five of the Head of Primary School.

1. Clinical examination and saliva analysis  All selected of 500 students received an oral examination using the dental examination standard. The teachers and student were instructed in matters of informe consent and socialized into the activity of research program. Finnaly, the parents of the students completed both informed consent forms and questionaires to assess their own behaviors related to oral health maintanance.  Oral examination of all students age 7-8 year old in the selected of 5 primary school were performed by four dentists, the selected dentist as an examiner of whom had been calibrated to achieve a good level on intra- and inter-examiner reliability, conducted the oral examinations.  The oral examination consisted of obtaining oral health condition, and salivary factors, including to saliva pH, plaque pH, Table 1. Score DMF-S and salivary parameters Salivary parameter and DMF-S Score DMF-S pH saliva pH plaque Buffer capacity

146 Vol. 9, No. 3, September 2013

and the saliva buffer capacity, were analyzed using saliva buffer check and plaque check indicators (from GC Corp). The extent and severity of tooth decay was measured by a universally adopted measurement of the DMF-S index. Damage caused by decay to a tooth is irreversible. The following represent the possible visible states of a decayed tooth: decayed and left untreated (DS), missing (i.e. extracted due to decay) (MS). Or filled (FS). An individual’s total number of teeth affected by tooth decay was sum of DS+MS+FS, known as DMF-S value (8). A measurement salivary parameters including to plaque pH was done using the Plaque-Check kit, the measurement of pH saliva and saliva buffer capacity in unstimulated saliva were done using Saliva-Buffer Check kit (9).

Mean±SD 0.193±0.4015 6.830±0.4991 6.246±0.4094 4.763±2.1628

 The statistical package for socio-science (SPSS) version 12.0 was used for analysis. The Chi-square test was used to compare proportion and one-way analysis of variance method was used to compare means.The Correlation between the salivary factors are plaque pH, saliva pH, buffer saliva and DMF-S were analyzed using Pearson correlation and linear regression analyses.

Results  Table 1 and 2 indicated that score DMF-S have significant correlation with salivary parameters are pH saliva, pH plaque and saliva buffer capacity.  The Figure 1 shows that the higher score of mean DMF-S=0 is found in student age 7 years old (43%) and score DMF-S >3 was not found in student age 7 years old. While score DMF-S of the student age 8 years old in category score 0 is 14%, score DMF-S between 0.1-2.9 is 21%, and score DMF-S >3 is 0.3%. This condition because of the student’s age between 7-8 years old still have few total number of permanent teeth.

Table 2. Correlation between DMF-S and salivary parameters Statistical analyses

Mean DMF-S

Pearson correlation 1.000 DMF-S pH saliva −0.073 pH plaque −0.181 Buffer capacity −0.164 Sig. (1-tailed) DMF-S pH saliva 0.053* pH plaque 0.000*** Buffer capacity 0.000*** N=496, *p<0.1, ***p<0.001.

pH saliva

pH plaque

Buffer capacity




1.000 0.149 0.323 0.053 0.000 0.000

0.149 1.000 0.133 0.000 0.000 0.002

0.323 0.133 1.000 0.000 0.000 0.002 -

Risqa Rina Darwita and Peter Andreas:Salivary Parameters of Buffer Capacity, pH Saliva and pH Plaque Related to Dental Caries Activity

Figure 1. The mean of DMF-S of students age 7-8 years old.

 The Figure 2 shows that there is a significant relation between score DMF-S and Caries Risk Markers, including to pH saliva, pH plaque and buffer capacity (R=0.229, p<0.0001). Whereas the criteria of pH saliva, pH plaque and buffer capacity saliva from normal condition as well as score DMF-S=0, and decreasing the score criteria of pH saliva, pH plaque and buffer capacity saliva from moderate to low condition as well as follows by score DMF-S category moderate (0.1-2.9) and high score DMF-S >3.

Discussion  The results shown in Figure 1 indicate that the highest mean DMF-S score was found in 7-year-old students (43%). This result was indicated by the fact that the total number of erupted permanent teeth in 7-year-old students is lower than those of 8-year-old students and that tooth enamel is an ectodermal structure most susceptible to dental caries (10). Individual susceptibility to dental caries, which varies according to genetic factors and environmental influences, has been linked to salivary pH and bacteria (3-7). If lesions developed they must have progressed, which may explain the number of carious teeth. Genetic susceptibility determines cariogenic potential of enamel at this age. With increasing age other factors may be more significant in causing dental caries. Therefore, the mean score DMF-S=0 of 8-year-old students was lower than that of the 7-year-old students (7).  The relation between saliva pH, plaque pH, buffer capacity, and demineralization has been reported. The production of acids by microorganisms within the dental plaque continues until the carbohydrate substrate is metabolized (11). It is also known that the pH of plaque goes from acidic to normal (or the resting level) within a few minutes and depends on the presence of saliva (12,13). This result primarily is due to the carbonate

Figure 2. The relation between caries risk markers and mean DMF-S of student age 7-8 years old.

and phosphate pH buffering agents in saliva. Thus, one can think of this process as creating equilibrium of dental plaque: pH of the plaque decreases each time the host ingests a snack or meal that contains fermentable carbohydrates, and afterward pH returns to the resting level of 6.7 to 7.4 because of saliva (7,12).  Table 1 indicated that the correlation and predictors for the final model linear regression between score DMF-S and salivary factor indicators, including to saliva pH, plaque pH, and buffer capacity, was a positive history. This means that those above the salivary factor indicators have significant contribution from the demineralization process to the development of dental caries (R=0.229, p<0.001). As reported by several researchers, the oral cavity is a microbiologists’ delight. It contains a variety of organisms whose proportions can be influenced by dietary and oral hygiene habits (4,14). However, saliva is the main factor because it maintains control over the screening starts. Simple clinical observations, expanding to a diversified pattern of tests to assess the un-stimulated buffer capacity, saliva pH, and plaque pH could enable a design to target high-risk subjects who could be given the most intensive caries preventive measures. The findings in this study support previous research that caries free or mean score DMF-S=0 were significantly higher in the 7-year-old students because total erupted permanent teeth were still lower than the 8-year-old students. In addition, the role of saliva in the neutralization of acids produced within the dental plaque and its involvement in the re-mineralization of demineralized enamel areas is well-documented. However, the effect salivary flow is also known to neutralize the saliva pH, plaque pH, while other factors can influence saliva condition, such as buffer capacity (15,16). Additionally, saliva contains glycoprotein that is known to be antibacterial, such as lysozyme and lacto-peroxidase (17). These compounds act independent of the IJCPD


International Journal of Clinical Preventive Dentistry

host's immune system and are able to destroy invasive bacteria without harming the ecological balance of the oral cavity, since indigenous bacteria have evolved resistance (14,18).

Conclusion  This study clearly illustrates that the three salivary factor parameters contributed to a process of development dental caries. This means that if a child has carious teeth, their salivary pH, plaque pH, and buffer capacity will influence the process of demineralization activity.

Acknowledgment  The authors gratefully acknowledge the support by Universitas Indonesia grant.

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6. Gross EL. Molecular microbiological analysis of dental caries in the primary and permanent dentitions. The Ohio State University 2009;127:AAT 3375849. 7. George KS. The effect of saliva on dental caries. J Am Dent Assoc 2008;139:11S-7S. 8. Kidd EAM. Essentials of dental caries. 3rd ed. New York: Oxford University Press; 2005. 9. Ireland R. Clinical textbook of dental hygiene and therapy. UK: Blackwell Publishing Company; 2006. 10. Thitasomakul S, Thearmontree A, Piwat S, Chankanka O, Pithpornchaiyakul W, Teanpaisan R, Madyusoh S. A longitudinal study of early childhood in 9- to 18-month-old Thai infants. Community Dent Oral Epidemiol 2006;34:429-36. 11. Drobni M, Tong Li, Krüger C, Loimaranta V, Kilian M, et al. Host derived pentapeptide affecting adhesion, proliferation, and local pH in biofilm communities composed of streptoccus and Actinomices species. Inf and Immunity 2006;74:6293-9. 12. Sánchez-Pérez TL, Sáenz-Martínez LP, Gómez-López ME, Pérez-Quiroz J. Enamel resistance to acid dissolution and its correlation with dental caries. Salud Publica Mex 1995;37:224-31. 13. Leme AFP, Koo H, Bellato CM, Bedi G, Cury JA. The role of sucrose in cariogenic dental biofilm formation-new insight. J Dent Res 2006;85:878-87. 14. Levine RS, Stillman-Lowe CR. The scientific basis of oral health education. London: BDJ Books; 2004:23-4. 15. Scheutz F, Matee MI, Poulsen S, Frydenberg M . Caries risk factors in the permanent dentition of Tanzanian children: a cohort study (1997-2003). Community Dent Oral Epidemiol 2007;35: 500-6. 16. Reynolds EC. Calcium phosphate-based remineralization systems: scientific evidence? Australian Dental Journal 2008;53: 268-73. 17. Kivelä J, Parkkila S, Parkkila AK, Rajaniemi H. A low concentration of carbonic anhydrase isoenzyme VI in whole saliva is associated with caries prevalence. Caries Research 1999;33(3): 178-84. 18. Loesche WJ. Role of Streptococcus mutans in human dental decay. Microbiol Rev 1986;50:353-80.


Salivary Parameters of Buffer Capacity, pH Saliva and pH Plaque

International Journal of Clinical Preventive Dentistry Volume 9, Number 3, September 2013 Salivary Parameters of Buffer Capacity, pH Saliva and pH P...

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