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Utilidad de la saliva = como=20 fluido diagn=F3stico

Dres. MEDINA, = Myriam L., MERINO=20 Luis A., GORODNER Jorge O.
Instituto de Medicina Regional = -=20 Universidad Nacional del Nordeste - Resistencia - Chaco -=20 Argentina.

RESUMEN
La saliva = constituye=20 una muestra biol=F3gica de f=E1cil obtenci=F3n, de bajo = costo, indolora y=20 sin el uso de t=E9cnicas invasivas, cuya composici=F3n puede = reflejar,=20 en gran medida, ciertos acontecimientos patol=F3gicos de = manifestaci=F3n=20 sist=E9mica.
En el presente trabajo se pretende realizar = una=20 revisi=F3n de las diferentes posibilidades diagn=F3sticas = que ofrece la=20 saliva en el estudio de diversas patolog=EDas infecciosas, = hormonales,=20 inmunol=F3gicas, t=F3xicas y metab=F3licas.
En base a la = informaci=F3n=20 recogida se puede afirmar que la saliva representa un medio=20 diagn=F3stico de creciente utilidad.=20

Palabras claves: = saliva,=20 hormonas, t=F3xicos, microbiolog=EDa, estado = inmunitario.

INTRODUCCI=D3N
En los = =FAltimos veinte=20 a=F1os se ha demostrado c=F3mo la saliva ha tomado un papel = relevante en=20 la investigaci=F3n. Actualmente, gracias a nuevas t=E9cnicas = microanal=EDticas, es posible utilizar la saliva no s=F3lo = como un=20 auxiliar de diagn=F3stico cl=EDnico, sino tambi=E9n en el = monitoreo de=20 drogas y f=E1rmacos, contaminantes ambientales, = etc=E9tera.=20 21,1,38,43

Reconociendo la importancia de la = misma=20 como un fluido para el diagn=F3stico, la Academia de = Ciencias de Nueva=20 York, el Instituto Nacional de Investigaci=F3n Dental de los = Estados=20 Unidos de Am=E9rica, los numerosos grupos de investigaci=F3n = sobre=20 saliva en el mundo y la industria privada de pa=EDses = desarrollados=20 han apoyado y recomiendan maximizar el potencial de este = fluido para=20 su uso en investigaci=F3n, a fin de extender la = investigaci=F3n en=20 saliva de manera prioritaria para facilitar el diagn=F3stico = y=20 monitorear el estado de salud general y bucodental de la=20 poblaci=F3n. 17, 34,35.

No = obstante, hay=20 que considerar que las variaciones en el flujo y la = composici=F3n de=20 la saliva total se han estudiado por muchos a=F1os, en un = intento de=20 auxiliar en el diagn=F3stico de enfermedades sist=E9micas y = de gl=E1ndulas=20 salivales. 6,8,11

Se ha = comprobado la=20 existencia de factores que influyen en las variaciones del = mismo=20 como ser las caracter=EDsticas individuales de cada sujeto: = el sexo,=20 la edad, la nutrici=F3n, los h=E1bitos o los factores = gen=E9ticos; todos=20 ellos podr=EDan jugar un papel importante, reduciendo la = velocidad de=20 secreci=F3n de la saliva estimulada sin afectar a la no=20 estimulada.20,25,39

Tambi=E9n = se determin=F3=20 que ciertas modificaciones en el flujo salival de la = poblaci=F3n=20 estudiada se deb=EDan a factores socioecon=F3micos, = situaci=F3n geogr=E1fica=20 y racial, as=ED como a otro tipo de factores no controlables = como los=20 emocionales y psicol=F3gicos (estr=E9s por ex=E1menes = acad=E9micos, manejo=20 de pacientes en la cl=EDnica, etc.).5

Hasta=20 hoy en d=EDa, cuando nuevas t=E9cnicas microanal=EDticas = cuantitativas y=20 cualitativas se han vuelto disponibles, se ha incrementado = la=20 informaci=F3n que sugiere que los estudios del flujo y de la = composici=F3n salival ser=E1n de gran utilidad no s=F3lo en = el diagn=F3stico=20 de enfermedades de las gl=E1ndulas salivales, sino tambi=E9n = como=20 auxiliares de diagn=F3stico y pron=F3stico, para el mejor = entendimiento=20 de otras enfermedades sist=E9micas y su tratamiento.=20 27,37,40

Resulta necesario a trav=E9s de la = presente=20 revisi=F3n poner en conocimiento del lector las variadas = utilidades de=20 este marcador biol=F3gico.

NUEVAS = PERSPECTIVAS EN=20 EL AN=C1LISIS DE LA SALIVA - UTILIDADES
La saliva como muestra = para la=20 detecci=F3n de consumo de drogas en los controles = preventivos de=20 tr=E1fico
Entre las razones que justifican su empleo = tenemos la=20 posibilidad de detectar en controles preventivos de = tr=E1fico a=20 conductores que han consumido cualquier tipo de droga, = utilizando=20 muestras alternativas, como la mencionada 26.=20 Puesto que es sabido que durante estos procedimientos es = preciso=20 contar con t=E9cnicas anal=EDticas especiales que no = requieran un=20 instrumental complejo y que se puedan efectuar "in situ", es = decir,=20 en el mismo lugar donde se realiza el control preventivo. = Por eso se=20 ha dirigido la atenci=F3n hacia muestras que tambi=E9n sean = admitidas=20 por la norma vigente. Desafortunadamente, a=FAn no se = dispone de=20 suficientes m=E9todos comerciales para el uso de este fluido = y su=20 manejo requiere complejos ajustes de los reactivos = convencionales.=20 Esto dificulta su empleo generalizado.

Como = inconvenientes=20 por parte de la misma, tenemos: la escasa informaci=F3n de = que se=20 dispone acerca de la posibilidad de detectar diferentes = sustancias=20 en relaci=F3n con el tiempo teniendo en cuenta su = metabolismo y los=20 m=E9todos anal=EDticos actuales; el hecho que no se puedan = utilizar tal=20 cual las mismas t=E9cnicas anal=EDticas que se usan para las = muestras de=20 orina; la ausencia de suficiente informaci=F3n anal=EDtica = con la que se=20 puede hacer comparaciones; la existencia de dos tipos = diferentes de=20 saliva (la procedente de par=F3tida, serosa y la saliva = mixta, serosa=20 y mucosa), en las cuales los t=F3xicos exhiben diferencias = cin=E9ticas;=20 y la recogida de la saliva en los controles preventivos de = tr=E1ficos.=20 Adem=E1s, las concentraciones en saliva son menores que las = alcanzadas=20 en orina, y en algunos casos tambi=E9n m=E1s bajas que las=20 correspondientes en plasma; y finalmente, el riesgo de = secuestro de=20 la droga en la cavidad bucal. 28=20

Hallazgos salivales en = pacientes=20 con cirrosis hep=E1tica
Otros estudios = llevados a cabo=20 permitieron determinar alteraciones salivales en pacientes = con=20 cirrosis hep=E1tica; la ingesti=F3n cr=F3nica de alcohol = origina cambios=20 en la par=F3tida que motivan alteraciones en la secreci=F3n = salival, as=ED=20 como en su composici=F3n. Sin embargo no se pudo explicar = porque las=20 gl=E1ndulas salivales par=F3tidas produjeron mayor cantidad = de flujo=20 salival en pacientes con cirrosis hep=E1tica tras los = est=EDmulos.4

La saliva como una v=EDa de excreci=F3n de=20 t=F3xicos
Por su parte la saliva, al igual que = otros=20 fluidos corporales, constituye una v=EDa de excreci=F3n de = t=F3xicos. En=20 la saliva se pueden excretar compuestos liposolubles no = disociados=20 que se vuelven a deglutir y empieza de nuevo el ciclo de = absorci=F3n,=20 distribuci=F3n, metabolismo y excreci=F3n. Por medio de los = estudios=20 realizados en este fluido se pudo constatar la situaci=F3n = real de las=20 amalgamas, a trav=E9s de la concentraci=F3n exacta del metal = en dicho=20 medio. 29

Se han llevado a cabo = numerosos=20 estudios tendientes a medir la concentraci=F3n de mercurio = en saliva,=20 heces, plasma, eritrocitos y orina luego de remover las = amalgamas=20 dentales de manera de determinar la toxicidad de la misma = para todo=20 el sistema.10 Los resultados hallados = han puesto=20 en alerta a los investigadores en toxicolog=EDa por lo que = en la=20 mayor=EDa de los pa=EDses escandinavos ya se realiza de = rutina la=20 remoci=F3n de las piezas tratadas con amalgamas o el = reemplazo de la=20 obturaci=F3n por otra m=E1s inocua. 49 =

Adicionalmente se ha empleado a la saliva para la = detecci=F3n=20 de numerosos contaminantes ambientales en el cuerpo, ya que = existe=20 una asociaci=F3n entre los niveles de toxicidad que se = presentan en el=20 plasma y los que se manifiestan en la saliva, considerando = que la=20 misma constituye un ultrafiltrado de plasma.52=20 De esta manera y teniendo en cuenta la simplicidad de la = recolecci=F3n=20 y el menor riesgo de contaminaci=F3n durante los = procedimientos, se ha=20 utilizado a la saliva como indicador biol=F3gico de = exposici=F3n=20 ocupacional de numerosos metales entre ellos cadmio.53 Asimismo, siendo la contaminaci=F3n con = metales=20 pesados un problema de Salud P=FAblica a escala mundial, se = ha=20 empleado a la sialoqu=EDmica en la cuantificaci=F3n de una = diversidad de=20 metales pesados como por ejemplo plomo, cadmio y cromo, = empleando=20 para tales muestras la t=E9cnica de espectrofotometr=EDa de = absorci=F3n=20 at=F3mica con horno de grafito.24

Otros=20 estudios llevados acabo permitieron asimismo el empleo de = este=20 fluido biol=F3gico en la determinaci=F3n de ars=E9nico por = medio de la=20 t=E9cnica de espectrofotometr=EDa de absorci=F3n = at=F3mica.2,14 Muchos investigadores se han preocupado = en=20 estudiar respecto de cuales ser=EDan los procedimientos = m=E1s=20 conveniente para valorar los distintos tipos de compuestos = de los=20 diferentes materiales biol=F3gicos contaminados con = ars=E9nico.=20

Sus experiencias le han permitido concluir que lo = m=E1s=20 conveniente ser=EDa aplicando el m=E9todo de = Espectrometr=EDa de Absorci=F3n=20 At=F3mica Electrot=E9rmica (ET-AAS). La importancia de este = hallazgo=20 radica en que debido a que la toxicidad del compuesto est=E1 = sumamente=20 relacionada a la forma qu=EDmica en que se encuentra el = mismo, la=20 determinaci=F3n total de =E9ste podr=EDa no ser suficiente = para establecer=20 el grado de intoxicaci=F3n, de ah=ED la utilidad de los = procedimientos=20 de extracci=F3n selectiva para el fraccionamiento y = evaluaci=F3n de cada=20 tipo de compuestos con posterior valoraci=F3n en su caso = mediante=20 ET-AAS.

Por otro parte, los esfuerzos en materia de=20 determinaci=F3n de la toxicidad de estos compuestos se = debieron a la=20 necesidad de controlar el grado de exposici=F3n de los = trabajadores en=20 su ambiente laboral al ars=E9nico inorg=E1nico. Tambi=E9n se = han analizado=20 y comparado los procedimientos como la absorci=F3n at=F3mica = de llama y=20 el procedimiento de generaci=F3n de arsina, concluyendo que = la primera=20 no se adapta a concentraciones de ars=E9nico inferiores a 10 = microgramos/ml. Mientras que la segunda permite revelar = hasta 20=20 nanogramos de ars=E9nico, lo que equivale a un l=EDmite de = 0,001=20 microgramos/ml para una muestra de 20 microlitros. Este=20 procedimiento permite obtener muy buena = sensibilidad.

Estudios hormonales = en=20 saliva
Hace m=E1s de = cuarenta a=F1os=20 fue demostrado que la saliva contiene hormonas. Los estudios = han=20 permitido en varias ocasiones establecer que el nivel de una = hormona=20 en saliva se correlaciona con el nivel libre de esa hormona = en la=20 sangre. Las hormonas esteroides en saliva son = excepcionalmente=20 estables y pueden ser medidas exactamente. Esta estabilidad, = combinada con la naturaleza no invasora de la colecci=F3n, = permite=20 emplearla como un m=E9todo =FAtil, exacto y confiable. = Tambi=E9n, se=20 emplea esta t=E9cnica para detectar un posible parto = prematuro,=20 incluso semanas antes de que este ocurra, de manera de = detectar=20 aquello que esta ocasionando el problema e intentar=20 solucionarlo.48

Mientras que = para muchas=20 hormonas como por ejemplo el cortisol, el estr=F3geno, la=20 progesterona, la testosterona, la androstenediona se ha = encontrado=20 una buena correlaci=F3n entre los niveles sangre/saliva, ha = resultado=20 de poco valor para otros como por ejemplo: cortisona,=20 dehidroepiandrosterona, sulfato del dehidroepiandrosterona, = tiroxina=20 y hormonas pituitarias. Para otras, la relaci=F3n de = saliva/plasma no=20 se entiende todav=EDa suficientemente por lo que a=FAn no se = puede=20 determinar su validez. En muchos estudios realizados se = midieron=20 mediante radioinmunoan=E1lisis las concentraciones del = estradiol y de=20 la progesterona en saliva y estos resultados permitieron = determinar=20 que la concentraci=F3n de las hormonas mencionadas en saliva = puede ser=20 usado como un indicador importante de la fecundidad. =

La = determinaci=F3n=20 de las concentraciones salivales de la progesterona se ha = utilizado=20 extensamente puesto que permite diariamente, proporcionar un = medio=20 valioso de determinaci=F3n de la funci=F3n ov=E1rica de = manera de=20 recopilar datos durante el ciclo y el embarazo = temprano.48 Adem=E1s, para ver si la saliva = constituye un=20 substituto v=E1lido del plasma en el an=E1lisis de la = progesterona=20 durante el embarazo se llevaron a cabo diversos estudios,=20 encontr=E1ndose correlaciones altamente significativas entre = la=20 progesterona total y libre en plasma y la progesterona = salival. En=20 base a estos estudios se concluy=F3 que la progesterona = salival es=20 evidentemente una alternativa muy buena respecto del plasma = como=20 muestra de uso frecuente durante el embarazo.

Los = niveles de=20 estradiol en saliva se pueden utilizar para determinar la = din=E1mica=20 folicular. Adem=E1s los an=E1lisis del estr=F3geno se = utilizan=20 extensamente para determinar bienestar fetal, aunque el = valor=20 cl=EDnico de tales an=E1lisis todav=EDa se est=E1 = discutiendo.3=20 La posibilidad de colecciones diarias de la muestra y = sus=20 resultados est=E1n animando a llevarse a cabo, puesto que el = muestreo=20 diario de la sangre demanda demasiado tiempo y poco tolerado = por los=20 pacientes. Esto a conducido a estudiar la utilidad cl=EDnica = del=20 muestreo salival para otros esteroides, ya que la saliva es = un=20 material biol=F3gico f=E1cilmente accesible, comparado con = orina de 24=20 horas y sangre. Por su parte, la concentraci=F3n salival del = estriol=20 parece aumentar de conformidad perfecta con su = concentraci=F3n en el=20 suero durante el curso de la gestaci=F3n. Si el estriol en = saliva=20 tambi=E9n refleja valores bajos del suero y una funci=F3n = deteriorada de=20 la unidad feto-placentaria, los an=E1lisis de la saliva = pueden=20 aplicarse como procedimiento de investigaci=F3n en embarazos = de riesgo=20 elevado. Adem=E1s, la muestra contiene la hormona = biol=F3gicamente=20 activa.

Aunque los an=E1lisis de la saliva para = varias=20 hormonas esteroides est=E1n disponibles y son utilizados = extensamente,=20 los an=E1lisis para el estradiol salival no est=E1n a=FAn = acabados, sobre=20 todo debido a limitaciones metodol=F3gicas. El an=E1lisis de = esta=20 hormona puede ser particularmente provechoso puesto que = permite=20 investigar la funci=F3n ov=E1rica, adem=E1s permite su = estudio en las=20 varias etapas del ciclo reproductivo de la mujer.

Los = resultados sugieren que la determinaci=F3n de la = testosterona salival=20 representa un m=E9todo de confianza para detectar cambios en = la=20 concentraci=F3n de la hormona biol=F3gico activa disponible = en la=20 circulaci=F3n. Debido a la buena correlaci=F3n existente, se = demostr=F3=20 que los niveles salivales de testosterona pueden ser usado = como un=20 =EDndice de la testosterona libre hallada en el suero.48

La concentraci=F3n salival del = cortisol es un=20 indicador excelente de la concentraci=F3n libre del mismo en = el plasma=20 y ofrece un acercamiento pr=E1ctico para determinar la = funci=F3n=20 pituitario-suprarrenal.16 Para = verificar la=20 utilidad cl=EDnica de la saliva en la determinaci=F3n de la = funci=F3n=20 adrenocortical, se midieron los niveles del cortisol de la = saliva=20 por medio de radioinmunoan=E1lisis, concluy=E9ndose que la = medida del=20 mismo en la saliva se puede utilizar suficientemente para = supervisar=20 sus concentraciones libres desatadas en suero.

Los = an=E1lisis=20 para el cortisol salival, por lo tanto, proporcionan la = informaci=F3n=20 que es tanto cl=EDnicamente =FAtil como la de las = determinaciones en=20 plasma, siendo en algunos casos de mayor significaci=F3n = diagn=F3stica=20 que concentraciones totales en plasma. Esto puede facilitar=20 grandemente el estudio longitudinal de la actividad del eje=20 hipotal=E1mico-pituitario-suprarrenal en pacientes con = des=F3rdenes=20 psiqui=E1tricos e investigar de manera simple y confiable el = S=EDndrome=20 de Cushing, especialmente en ni=F1os.Adem=E1s, las medidas = salivales de=20 la mencionada hormona pueden simplificar la evaluaci=F3n del = hipercortisolismo intermitente sospechado, y pueden = facilitar la=20 investigaci=F3n de las poblaciones con riesgo elevado = (pacientes con=20 diabetes mellitus).

Tambi=E9n se ha empleado a la = saliva como=20 m=E9todo para determinar la presencia de factores de = crecimiento y su=20 posible relaci=F3n con las observaciones cl=EDnicas. Por su = parte, este=20 estudio sugiri=F3 que la saliva humana puede ser un = indicador=20 espec=EDfico de maduraci=F3n para evaluar cl=EDnicamente a = pacientes=20 tratados durante o per=EDodo prepuberal y puberal.48

La saliva en el = diagn=F3stico=20 de Esclerosis M=FAltiple
En el caso de la = Esclerosis=20 M=FAltiple se emplea a la saliva junto con otros = par=E1metros biol=F3gicos=20 LCR, suero, l=E1grimas (test de los cinco humores) para = establecer un=20 diagn=F3stico m=E1s certero y precoz de la misma as=ED como = tambi=E9n=20 monitorear su actividad biol=F3gica. Cabe aclarar que este = m=E9todo est=E1=20 siendo empleando en los brotes iniciales de la mencionada=20 enfermedad. 7,44

Saliva y=20 Osteosporosis
Actualmente se = esta=20 estudiando la posibilidad de estudiar a trav=E9s de la = saliva a=20 pacientes con osteoporosis de manera de "identificar a = personas con=20 riesgo", a fin de comenzar el tratamiento y cambiar los = malos=20 h=E1bitos de vida que dan lugar a la p=E9rdida =F3sea.=20 27

Estudios = microbiol=F3gicos de=20 la saliva
Respecto a los = an=E1lisis=20 microbiol=F3gicos de saliva, los mismos tienen gran utilidad = como=20 medio de diagn=F3stico preventivo para la detecci=F3n precoz = del riesgo=20 de presentar caries. El odont=F3logo dispone desde hace=20 aproximadamente 20 a=F1os de an=E1lisis que le permiten = controlar la=20 presencia de Streptococcus mutans y de Lactobacillus en la = saliva de=20 sus pacientes. 31 Por otra parte, los = altos=20 =EDndices de S. mutans en saliva indican tambi=E9n presencia = masiva de=20 sarro dental. Estudios realizados permitieron demostrar que = los=20 ni=F1os con =EDndices elevados de Streptococos mutans y de = Lactobacillus=20 en la saliva desarrollaron, al cabo de 2 a=F1os, una media = de cuatro=20 superficies afectadas con caries nuevas. Se constat=F3 = adem=E1s, una=20 correlaci=F3n positiva entre los valores de S. mutans en la = saliva y=20 en la placa proximal. La indicaci=F3n de los an=E1lisis de = saliva abarc=F3=20 a los pacientes inicialmente sanos o tratados = adecuadamente.12

El grado de importancia que el = odont=F3logo=20 atribuye a los hallazgos bacteriol=F3gicos salivales se = valora de=20 forma diferente en la bibliograf=EDa. En los pa=EDses = escandinavos y=20 tambi=E9n en Suiza estos an=E1lisis se han consolidado en = los servicios=20 de Salud P=FAblica como exploraciones preventivas para la = detecci=F3n=20 precoz del riesgo individual de presentar caries.18,32,42 = Mediante=20 los an=E1lisis realizados se pretendi=F3 evidenciar c=F3mo = detectar a=20 partir de los resultados de placa dental y de saliva, a los = ni=F1os=20 con riesgo de caries sin que ello constituya un gasto = excesivo de=20 laboratorio. Los hallazgos bacterianos en saliva tuvieron = una=20 sensibilidad superior que la deducci=F3n cl=EDnica y de = hecho,=20 predijeron la enfermedad con un acierto superior en un = 10-20%; estos=20 an=E1lisis de la saliva estar=EDan indicados en este grupo = de ni=F1os de=20 cara a un control preventivo y motivacional.13,36

Es sabido que el Helicobacter = pylori es=20 el agente etiol=F3gico del 90% de las gastritis cr=F3nicas, = 85-90% de=20 las =FAlceras duodenales, 70-75% de las =FAlceras = g=E1stricas, y por estar=20 asociado con la evoluci=F3n de metaplasia a c=E1ncer = g=E1strico, en 1994=20 fue clasificado por la OMS como carcin=F3geno tipo I. A=FAn = no existe=20 consenso sobre la v=EDa m=E1s importante de transmisi=F3n de = la infecci=F3n=20 por H. pylori. Entre las v=EDas propuestas, la de mayor = relevancia es=20 la interpersonal. Esta incluye a la v=EDa oral-oral, en la = cual la=20 cavidad oral juega un papel preponderante como reservorio de = la=20 bacteria (placa dental) y la v=EDa fecal-oral.30 =

Otras rutas=20 de transmisi=F3n propuestas son: alimentaria-oral, = zoon=F3tica,=20 vectorial, ambiental, y la v=EDa iatrog=E9nica. Siendo la = cavidad oral=20 un posible reservorio de H. pylori en el hombre, numerosos = grupos de=20 investigaci=F3n a nivel mundial se han focalizado en la = detecci=F3n de=20 dicha bacteria en la boca. Es as=ED como se ha llevado acabo = diversos=20 m=E9todos de determinaci=F3n de H. pylori uno de ellos es la = determinaci=F3n radiom=E9trica en saliva.45,23 Dicha=20 t=E9cnica resulta r=E1pida, sencilla, econ=F3mica y = pr=E1ctica permitiendo=20 evaluar la colonizaci=F3n oral por H. pylori. Adem=E1s de = controlar la=20 evoluci=F3n de los pacientes luego del tratamiento de = erradicaci=F3n.=20 Por consiguiente, la valoraci=F3n de la actividad ure=E1sica = en saliva a=20 distintos tiempos, puede ser considerada como un buen = marcador de=20 colonizaci=F3n oral por H. pylori, tambi=E9n permite evaluar = si existe=20 una relaci=F3n entre la colonizaci=F3n oral y la infecci=F3n = g=E1strica por=20 H. pylori.

Se resume que mediante esta t=E9cnica se = ha podido=20 correlacionar el estado de contaminaci=F3n de la boca por H. = pylori=20 con el grado de infecci=F3n g=E1strica por dicho agente = pat=F3geno.=20 Permitiendo lograr una mejor evaluaci=F3n de la infecci=F3n. = Por su=20 parte la valoraci=F3n de la actividad de la ureasa en saliva = puede ser=20 considerada como un buen marcador de colonizaci=F3n oral por = H. pylori=20 a trav=E9s de estas observaciones se presume que pueden = resultar de=20 importancia para el =E9xito del tratamiento y erradicaci=F3n = de la=20 infecci=F3n por H. pylori.

Evaluaci=F3n del = estado=20 inmunitario a trav=E9s la saliva
Existen = investigaciones en=20 las cuales se ha podido constatar que los anticuerpos = hallados en=20 saliva de clase IgA e IgG pueden ser utilizados para conocer = la=20 situaci=F3n inmunitaria frente al sarampi=F3n, rub=E9ola y=20 parotiditis.22 El estudio de = anticuerpos=20 salivales es un m=E9todo no invasivo para conocer la = situaci=F3n=20 seroepidemiol=F3gica frente a las patolog=EDas mencionadas = de una=20 poblaci=F3n o con fines diagn=F3sticos. Sin embargo es = recomendable=20 determinar conjuntamente anticuerpos de clase IgG e = IgA.

Utilidades de la = saliva con=20 otros fines diagn=F3sticos
Otra infecci=F3n = que esta=20 tomando gran inter=E9s por parte de los investigadores = durante los=20 =FAltimos a=F1os es la infecci=F3n por VIH. Muchos = investigadores han=20 estudiado y evaluado las pruebas de saliva como alternativa=20 diagn=F3stica encontr=E1ndola tan v=E1lida como los = an=E1lisis de sangre,=20 aunque sus niveles de anticuerpos son m=E1s bajos. Las = pruebas de=20 saliva se han recomendado y se han utilizado sobre = poblaci=F3n en los=20 programas de vigilancia, investigaci=F3n, entre otros. La = prueba ser=EDa=20 especialmente =FAtil para ser tomada en el propio hogar y = luego=20 enviada al laboratorio. En caso de resultar positiva se = aconsejar=EDa=20 la prueba de diagn=F3stico con sangre.47 La=20 detecci=F3n en saliva de anticuerpos para el virus Herpes = simple puede=20 ser utilizada en estudios epidemiol=F3gicos. Investigadores = suizos=20 desarrollaron una prueba ELISA que permite detectar IgG = antiviral en=20 la saliva y la compararon con la prueba ELISA s=E9rica con = el fin de=20 determinar la prevalencia de la infecci=F3n en una = poblaci=F3n=20 pedi=E1trica. Ellos hallaron una sensibilidad de 94,1% y una = especificidad de 95,5%.50,51

Recientemente fue = descripto un=20 m=E9todo para detecci=F3n espec=EDfica de IgA antiameba en = saliva. A=20 trav=E9s del mismo, los autores demuestran que s=F3lo los = portadores de=20 amebas presentan valores de IgA, pero no las personas que no = tienen=20 el par=E1sito en heces. Este estudio tiene un potencial = enorme como=20 herramienta en estudios epidemiol=F3gicos.15=20 Realmente el pensar que una prueba tan sencilla como la=20 determinaci=F3n de IgA espec=EDfica nos puede dar una idea = clara de un=20 contacto reciente con E. histolytica puede ser de enorme = beneficio,=20 ya que se ha comprobado que 45 d=EDas despu=E9s del = tratamiento, los=20 anticuerpos espec=EDficos tipo IgA de pacientes tratados = disminuyen a=20 niveles basales.

Esto demuestra que la presencia de = t=EDtulos=20 de IgA contra ameba sugiere un contacto reciente o una = infecci=F3n que=20 se acaba de resolver. Esto dar=EDa el dato de prevalencia, = dato=20 sumamente importante comparado con el de la serolog=EDa, que = no=20 distingue entre un contacto pasado (aun a=F1os) o reciente. = Dada la=20 facilidad de la obtenci=F3n y manejo de la saliva = (comparando con la=20 de sangre o heces), se prev=E9 que tendr=E1 una enorme = utilidad en=20 pruebas de campo.

Saliva como = t=E9cnica de=20 detecci=F3n precoz de c=E1ncer
El estudio de = fluidos como=20 la saliva o la transpiraci=F3n son la base de las nuevas = t=E9cnicas para=20 detectar en forma temprana diversos tipos de c=E1ncer, = evitando=20 dolorosos e invasivos ex=E1menes. Seg=FAn Cient=EDficos de = la Escuela de=20 Medicina de la Universidad de John Hopkins (EE.UU.), en un = futuro no=20 muy lejano seria posible la detecci=F3n de c=E1ncer en = muestras de=20 saliva, orina o lavado de bronquios reemplazando as=ED a los = complicados procedimientos necesarios en la actualidad para = llevar a=20 cabo el diagn=F3stico33.

De esta manera han dado un = nuevo paso=20 en la lucha contra este mal, intent=E1ndose diagnosticar a = trav=E9s de=20 =E9stos fluidos tumores tan diversos como los de vejiga, = pulmones,=20 cuello y cabeza. Son m=E9todos no invasivos que permiten = hacer un=20 diagn=F3stico de alta certeza. A esta conclusi=F3n llegaron = despu=E9s de=20 encontrar que los tumores de cabeza y cuello, vejiga y = pulm=F3n=20 presentan alteraciones gen=E9ticas espec=EDficas que pueden = ser=20 detectadas en saliva, orina y l=EDquido de bronquios = respectivamente.=20 Dichas alteraciones fueron encontradas en el ADN de las=20 mitocondrias, el cual podr=EDa obtenerse directamente de la = saliva.=20

Tiempo despu=E9s ser=EDa comparada con otras = muestras para=20 determinar la ocurrencia de tales alteraciones gen=E9ticas y = si est=E1n=20 presentes, se podr=EDa intervenir el tumor de manera=20 temprana.

CONCLUSIONES
Por = muchos a=F1os han=20 sido estudiadas las variaciones en el porcentaje de flujo = salival=20 (hiposalivaci=F3n/xerostom=EDa vs = hipersalivaci=F3n/sialorrea) y la=20 composici=F3n y s=EDntesis de prote=EDnas que forman la = saliva total, en=20 un intento por determinar y auxiliar en el diagn=F3stico de=20 alteraciones sist=E9micas y de las gl=E1ndulas = salivales.=20 41,46

La saliva representa un medio de = creciente=20 utilidad para el diagn=F3stico de diferentes enfermedades = sist=E9micas=20 como las que se han descripto, en las cuales se observan=20 alteraciones en la cantidad y composici=F3n de la saliva. No = obstante=20 existen otras entidades como el S=EDndrome de Sj=F6gren = (SS),=20 enfermedades reum=E1ticas, sarcoidiosis, fibrosis = qu=EDsticas,=20 Hipertensi=F3n, Hiperlipemia, Cirrosis alcoh=F3lica, = Malnutrici=F3n,=20 Disfunciones hormonales y Enfermedades neurol=F3gicas, que = pueden ser=20 diagnosticadas por medio de este fluido biol=F3gico. Por lo = tanto, es=20 importante considerar los usos cl=EDnicos de la saliva como = un medio=20 valuable para el diagn=F3stico de enfermedades bucales y=20 sist=E9micas.

Consideramos que la investigaci=F3n = b=E1sica y=20 cl=EDnico-b=E1sica en el =E1rea de la odontolog=EDa debe = extenderse y=20 profundizarse, ya que es fundamental para la aplicaci=F3n y = el estudio=20 de nuevos conocimientos. Los resultados son muy alentadores = para=20 realizar futuros estudios con =E9stas y otro tipo de = entidades=20 patol=F3gicas, tanto bucales como sist=E9micas, con el = prop=F3sito de=20 utilizar la saliva como un auxiliar de diagn=F3stico = cl=EDnico, por lo=20 cual podemos concluir lo siguiente:

=95 Se demostr=F3 = que pueden=20 existir correlaciones entre prote=EDnas-velocidad de flujo y = variables=20 como el peso del sujeto, que podr=EDan ser indicadores de = situaciones=20 cl=EDnicas espec=EDficas.
=95 Existe la necesidad de = extender la=20 investigaci=F3n en inmunosialoqu=EDmica en ni=F1os, adultos = y ancianos,=20 con el prop=F3sito de obtener y comparar los valores = promedio de=20 "normalidad", relacionados con las caracter=EDsticas = fisiol=F3gicas y=20 biol=F3gicas de la poblaci=F3n.
=95 Aplicando estos = datos en=20 situaciones cl=EDnicas, la saliva podr=E1 ser utilizada como = un medio de=20 diagn=F3stico confiable y de bajo costo.

Dres.=20 MEDINA, Myriam L., MERINO Luis A., GORODNER Jorge=20 O.
Instituto de Medicina Regional - Universidad = Nacional del=20 Nordeste.
Av. Las Heras 727 - 3500 Resistencia - Chaco -=20 Argentina.
Tel./Fax: 03722 422793 - E-mail:=20 lmerino@arnet.com.ar

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Nota de = septiembre de=20 2002

<= /TR>

Art=EDculos Publicados=20

		Estudio=20 comparativo del uso de drenaje en la = cirugia de=20 terceros molares = retenidos.
		Una=20 bacteria de la cavidad oral podr=EDa = proteger conta=20 el HIV.
		Incrustaci=F3n=20 de Resina (Cer=F3mero). Fabricaci=F3n en=20 consultorio. Od.=20 ALEJANDRO AMAIZ / Universidad Central de=20 Venezuela.
		Hidroarsenicismo=20 Cr=F3nico Regional End=E9mico (H.A.C.R.E.) = y=20 patolog=EDas gingivoperiodontales en = pobladores del=20 Chaco (Argentina) Medina,=20 Myriam L.; Merino, Luis A.; Miranda, Olga; = Gorodner, Jorge O. Instituto de Medicina = Regional=20 =96 Universidad Nacional del=20 Nordeste
		Actualizaci=F3n=20 en elementos de diagn=F3stico y = clasificaci=F3n de las=20 enfermedades periodontales. Por = el Dr. Carlos Montoya
		Implantes=20 en pacientes anticoagulados. An=E1lisis de = una=20 situaci=F3n cl=EDnica. Por=20 el Dr. Eduardo A. Rey, Sebasti=E1n A. = Puia, Wulfran=20 Castillo.
		=BFEs=20 eficaz un proyecto odontol=F3gico basado = en una=20 filosof=EDa y un m=E9todo pensado en la = salud y no en=20 la enfermedad? Por=20 el Dr. Alejandro Daniel = D=E1vila
		L=E1ser=20 en operatoria dental m=EDnimamente=20 invasiva Por=20 el Dr. Leo Stiberman
		Pr=F3tesis=20 para la tercera edad Por=20 el Profesor Juan C. = Ricci
		Utilidad=20 de la saliva como fluido = diagn=F3stico Por=20 los Dres. Medina, Myriam; Merino Luis y = Gorodner=20 Jorge
		El=20 renacimiento de la Bio=E9tica en el siglo = XXI=20 Por= =20 el Dr. Jos=E9 A. Mainetti. =
		Revisi=F3n=20 de art=EDculos sobre " Odontolog=EDa en = pacientes con=20 s=EDndrome de down " Dr.=20 Jaime Otero M. Dr. Jaime Otero I.=20
		Ergonom=EDa Por=20 Helmut Sch=E4tz
		Estomatolog=EDa:=20 Del reci=E9n nacido hasta los seis meses = de=20 vida Dra.=20 Nydia E. Mart=EDn de = Kramer
		Bio=E9tica=20 en Odontolog=EDa Dra.=20 Patricia Agranatti
		Principios=20 de Bio=E9tica Dra.=20 Ana Falcone, Dra. Laura Galli, Dr. E. A. = Roussos,=20 Dr. Osvaldo Bovoril
		Ronquido=20 y apnea del sue=F1o: Nuevo = tratamiento Dr.=20 Claudio R. Haissiner
		Nuestra=20 AOA Prof.=20 Dr. Eduardo Ceccotti.
		La=20 Academia Nacional de = Odontolog=EDa Dr.=20 Renato Vivone
		Aspectos=20 psico-cl=EDnicos para la atenci=F3n = odontol=F3gica de=20 los pacientes con = discapacidad. Prof.=20 Dr. Clemente Ravaglia
		Usos=20 cl=EDnicos del l=E1ser = arg=F3n. Dr.=20 Jon C. Karna
		Lineamientos=20 actuales para las preparaciones=20 cavitarias. Prof.=20 Dr. Alberto Jos=E9 = Dell'Acqua
		Factores=20 de riesgo para enfermedades g=EDngivo=20 periodontales. Dr.=20 Fernando Sakugawa
		El=20 Odont=F3logo frente al C=E1ncer = Oral. Prof. = Dr. Eduardo Ceccotti.
		Fibroma=20 Amelobl=E1stico. Prof.=20 Dr. Carlos A. Pe=F1a
		Distoclusi=F3n=20 con discrepancia hueso-diente muy=20 marcada Dr.=20 Alberto Baggini.
		Clasificaci=F3n=20 y tratamiento de las=20 Neutroclusiones. Dr.=20 Alberto Baggini.
		Tratamiento=20 de Ortodoncia con Agenesia de = 22. Dr.=20 Alberto Baggini.
		Crecimiento=20 radicular en adulto por tratamiento de = ortodoncia.=20 Dr.=20 Victor A. Sosa=20
		Ortodoncia=20 Actual. Dra.=20 Mar=EDa Esther = Guti=E9rrez
		Artificio=20 Radiogr=E1fico para el estudio del estado=20 Periodontal. Comportamiento Oseo = Perimplantario=20 y otros enfoques = diagn=F3sticos. Prof.=20 Dr. Carlos J. Ausbruch Moreno =
		Prevenci=F3n. Dr.=20 Everestt B. Mancock =
		Uso de=20 Adhesivo Tisular en la Cicatrizaci=F3n=20 Periodontal. Prof. Dr. Hugo = Romanelli,=20 Od. Paulina A. Mosquera
		Enfermedad=20 Periodontal: Diagn=F3stico. Dr.=20 Gary C. Armitage
		Preguntas=20 frecuentes sobre el l=E1ser=20 terap=E9utico.
		Apicectom=EDa=20 con L=E1ser de = Er.YAG. Dr. Marcelo G. Miguez=20
		El=20 L=E1ser de arg=F3n en=20 odontolog=EDa.
		El rol=20 del L=E1ser en la Odontolog=EDa = Moderna. Dr.=20 Leonardo Stiberman =
		La=20 utilizaci=F3n de Internet en el campo=20 profesional. Profesor=20 Dr. Oscar S. Bonal=20 =

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