Why is pH important?
We know that long periods of low pH select for acid producing bacteria. Thus, the makeup of the biofilm can shift as a result of the pH of the oral cavity. Additionally, ‘good’ bacteria, if given the right environment (low pH) start behaving like ‘bad’ acid producing bacteria. pH is important because not only does low pH select for acid producing bacteria, it can transform good bacteria to bad bacteria. On the other hand, elevating the pH has shown to de-selct for the acid producers in favor of the ‘good’ bacteria in the biofilm.
We know that the critical pH of enamel is 5.5, which is true in the larger sense, however, you need to know how much saliva and calcium and phosphate and nano particles of nano hydroxyapetite and fluorapetite they have in their saliva, or the more mineral they have in the saliva, the lower the critical pH becomes. On the other end of the spectrum, having less saliva and less mineral created an environment where the critical pH for the enamel may be higher.
“Thus the critical pH is not a constant, because the levels of calcium and phosphate in plaque fluid vary among individuals. The more calcium and phosphate that are present in a solution, the lower the critical pH.” (Dawes C. What is the critical pH and why does a tooth dissolve in acid? JCDA December 2003. 69(11):722-24)
It is important to use products to elevate the pH, in order to try and mimic saliva and select for healthy bacteria.
“Therefore, the suppression of sugar catabolism and acid production by the use of metabolic inhibitors in oral care products, the consumption of nonfermentable sweeteners in snacks, the stimulation of saliva flow, and/or other strategies that maintain supragingival plaque at a pH around neutrality will assist in the maintenance of microbial homeostasis in plaque.” (Marsh PD. Dental plaque as a biofilm: the significance of pH in health and caries. Compend Contin Educ Dent March 2009; 30(2):76-90)
The image below shows the black spots are acid producing bacteria. The difference between the top panel and the bottom panel, is they controlled for pH. The bottom panel shows the bacteria in an elevated pH environment periodically over a period of days–ridding some of the acid producing bacteria.
“In silico modelling studies have been performed which support the concept that either reducing the frequency of acid challenge and/or the terminal pH, or by merely slowing bacterial growth, results in maintaining a community of beneficial bacteria under conditions that might otherwise lead to disease (control without killing).” (Marsh PD, Head DA, Devine DA. Ecological Approaches to Oral Biofilms: Control without Killing. Caries Res. 2015;49 Suppl 1:46-54)
“No current oral products can easily change or modify xerostomia as a caries risk. However, there are some products available that contain calcium, phosphate, and pH buffering ingredients that may play a role in the reduction of caries risk.” (Chapman RJ, Roberts DR, Kugel G. Caries and Periodontal Risk Assessment and Management)
We also know that within the biofilm there is a gradient and clustering of bacteria. This shows that the way the bacteria grow are not random. There are certain bacteria always found together.
“We demonstrated that some bacterial species implicated in caries progression show selective clustering with respect to pH gradient, providing a basis for specific therapeutic strategies.” (Kianoush N, Adler CJ, Nguyen KA, Browne GV, et al. Bacterial profile of dentine caries and the impact of pH on bacterial population diversity. PLoS One. 2014 Mar 27;9(3):e92940)
pH is, therefore an important therapeutic strategy for the management of the biofilm.
When looking at both the pH and the demineralizing effect of certain products on patients with dry mouth, researchers found the CTx2 Spray had the highest pH and the same demineralization effect of tap water 0.0%.
“The average pH values are as follows: Oasis, 6.3, Bioténe Moisturizing Mouth Spray, 6.1, CTx2 Spray, 9.1, Mouth Kote, 3.0, Thayer’s, 6.3, Bioténe Oral Balance, 6.6, Rain, 7.1, tap water 6.99, and citric acid 1.33. The results (% of tooth structure lost) of the gravimetric analysis were as follows: Mouth Kote, 9.6%, Bioténe Moisturizing Mouth Spray, 4.6%, Oasis, 3.2%, Thayer’s, 2.0%, Bioténe Oral Balance, 0.0%, Rain, 0.0%, CTx2 Spray, 0.0%, tap water 0.0%, and citric acid 18.8%. There was a significant negative correlation between the pH values and the erosive potential.” (Delgado AJ, Olafsson VG, Donovan T. pH and Erosive Potential of Commonly Used Oral Moisturizers. J Prosthodont. 2015 Jul 27. doi: )
What are your thoughts? Do you use elevated pH products in your practice? Do you have questions for Dr. Kutsch about his pH elevating protocol? Let us know in the comments below.
In a previous blog we discussed the first prescriptive phase of caries management: Repair- Discussing remineralization, prevention and restoration and then we took on the first therapeutic strategy: Sodium Hypochlorite. Today we are going to begin the discussion of another therapeutic strategy Dr. Kutsch employs with his patients: Xylitol.
- pH strategies
There are strong feelings both for and against the use of this 5 carbon sugar alcohol. There are a lot of studies out there on Xylitol. In Dr. Kutsch’s opinion, the best approach is to couple Xylitol and fluoride. The conclusion of the study is that Xylitol and fluoride have synergistic effects, Xylitol potentiates even trace amounts of fluoride. A good strategy to combine them.
“This study indicates that fluoride and xylitol together have synergistic inhibitory effects on the acid production of Mutans streptococci and suggests that xylitol has the potential to enhance inhibitory effects of low concentrations of fluoride.”
Maehara H, Iwami Y, Mayanagi H, Takahashi N. Synergistic inhibition by combination of fluoride and xylitol on glycolysis by mutans streptococci and its biochemical mechanism. Caries Research November December 2005. 39(6):521-528
We all remember this study: Bader JD, Vollmer WM, Shugars DA, et al. Results from the Xylitol for Adult Caries Trial (X-ACT). J Am Dent Assoc. 2013 Jan;144(1):21-30. 691 Ad, 33 mo.
Where 5 xylitol mints were given to a group of high caries risk patients, and the results were nil.
“Daily use of Xylitol lozenges did not result in a statistically or clinically significant reduction in 33-month caries increment among adults at an elevated risk of developing caries.”
HOWEVER, when looking back at the results, they found that for patients with root surface caries, the results were quite profound:
“Participants in the xylitol arm developed 40% fewer root caries lesions (0.23 D2FS/year) than those in the placebo arm. Among these caries-active adults, xylitol appears to have a caries-preventive effect on root surfaces.”
Ritter AV, Bader JD, Leo MC, Preisser JS, Shugars DA, Vollmer WM, Amaechi BT, Holland JC. Tooth-surface-specific Effects of Xylitol: Randomized Trial Results. J Dent Res. 2013 Jun;92(6):512-7. 620/21-80/12/24/33MO
The lesson here, as practitioners we need to target our therapy recommendations to our patient’s needs.
For more on Dr. Kutsch’s take on Xylitol listen to: Sugar and Xylitol, What you Need to Know
What do you think? How has Xylitol played a role in your therapeutic strategy?
This video by the National Institute of Health offers a brief video going over several caries risk factors for infants. While comprehensive, is there anything you would add to the video? There was no mention, for example, of vertical transmission. What do you think of the video? Would your patients watch it? Why or why not? What would you change or add (if anything) to make it more relevant to your patients?
In a previous blog we discussed the first prescriptive phase of caries management: Repair. Discussing remineralization, prevention and restoration. Today we are going to begin the discussion of therapeutic strategies Dr. Kutsch employs with his patients. His list includes:
- pH strategies
Today we will begin with Antimicrobials.
Antimicrobial Strategy- Sodium Hypochlorite
When discussing antimicrobial agents, Dr. Kutsch prefers sodium hypochlorite.
4 Key points about Sodium Hypochlorite
1. It is broad spectrum
Sodium Hypochlorite is safe, effective and has a broad spectrum of activity. It has been recommended for periodontal disease by Jorgensen Slots for years, and Dr. Kutsch has been using it for dental caries management for over a decade.
“0.1- 0.5% sodium hypochlorite for patient self care. These antiseptics have significantly broader spectra of antimicrobial action, are less likely to induce development of resistant bacteria and adverse host reactions, and are considerably less expensive than commercially available antibiotics in controlled release devises.”
Jorgensen MG, Aalam A, Slots J. Periodontal antimicrobials—finding the right solutions. Int Dent J February 2005. 55(1):3-12
In addition, a 3 year clinical trial in Queensland, Australia where two high-risk groups of school children were treated. One group treated with a placebo fluoride rinse and the other with the CariFree Treatment Rinse. The results?
2. Reduced caries index
“The placebo fluoride rinse reduced the mean caries index by 29%, and the Carifree Treatment Rinse reduced the caries index by 73% over a 3-year period. There was no additional benefit after 2 years of use.”
Hallett KB, O’Rourke PK. Oral biofilm activity, culture testing and caries experience in school 3-year double-blind randomized clinical trial. Queensland, Australia 2007-2010
Also, while this study was done looking at perio patients, the decrease in dental plaque cannot be overlooked.
3. Marked decrease in dental plaque levels
“A twice-weekly oral rinse with 0.25% sodium hypochlorite produced marked decreases in dental plaque level and bleeding on probing and may constitute a promising new approach to the management of periodontal disease. Long-term controlled studies on the effectiveness of sodium hypochlorite oral rinse are needed and encouraged.”
Galván M, Gonzalez S, Cohen CL, Alonaizan FA, Chen CT, Rich SK, Slots J. Periodontal effects of 0.25% sodium hypochlorite twice-weekly oral rinse. A pilot study. J Periodontal Res. 2013 Dec 14. 30PDD, 15/15,0,2wk, 3 mos, Subgingirrig
4. Dissolves biofilm
“Overall, 2.5% NaOCl dissolved and killed bacteria significantly more efficiently when used against polymicrobial mature biofilm on human dentine. Cetrimide improved the antimicrobial activity of chlorhexidine and alexidine.”
Ruiz-Linares M, Aguado-Pérez B, Baca P, Arias-Moliz MT, Ferrer-Luque CM. Efficacy of antimicrobial solutions against polymicrobial root canal biofilm. Int Endod J. 2015 Dec 13. doi: 10.1111/iej.12598
We have been using sodium hypocholorite during root canals for nearly 100 years. One of the greatest challenges to treating dental caries is penetrating the biofilm. To Dr. Kutsch, Sodium Hypochlorite is the best option to date.
What are your thoughts? What is your go-to antimicrobial and why? Share in the comments below.
We had a wonderful submission from Bright Side Dental, sharing a simple-to-read infographic about food and oral health. We wanted to share their message to patients with you today for inspiration and sharing!
Most people would probably agree that proper dental care is an important aspect of your overall health, unfortunately not everyone takes the necessary preventive measures by visiting their dentist at least twice a year for a check up. Dental offices can of course assist you with any dental troubles that you may run into, but you’ll be much better off if you can prevent those troubles from occurring in the first place. If you live near Indianapolis, Austin, or anywhere in Southeastern Michigan you are never far from a Bright Side Dental dentist office that will be happy to have you in for a regular check up.
Aside from your regular dental check up there are also things you can do on your own to decrease the risk of cavities and discolored teeth. Knowing how certain foods and drinks affect your teeth is one way to stay on top of your own dental health. It’s not likely that you’ll be able to keep track of every single last thing that you eat, inevitably some of what you eat (even healthy things) will naturally wear down your teeth in small ways. Fortunately Bright Side Dental made this infographic which will give you a quick overview of the types of food that can do the most harm to your beloved teeth. If you use this as a handy guide you will have a general idea of what to avoid, or at least what to cut down on. Being well-informed is the first step to protecting the long term health of your teeth.
Do you have anything like this you share with your patients? We would love to see it and share here on the blog!
Check out this encouraging message we received on Facebook from CariFree patient Lauren.
“Hi guys! So if you ever need a spokeswoman or a real story of success from CariFree, I am your poster child. It started in November with a failed crown (came out by the post) and somehow spiraled down a path of $9000 (not including what insurance covered) worth of fillings, root canals, crowns, root canal re-treatments, caries galore, three extractions (my back last ones, thankfully), and it just didn’t stop. I felt like my dental team and I (my general, my emergency, my endodontist, my oral, etc.) would never get ahead of this. I literally went to the dentist several times a week with pop-up problems. There were a few days when I saw TWO dentists (once even three) in the same day because of huge problems that popped up.
Today, I went for my four month check up and for the first time since I was in high school (almost 20 years ago), I was caries-free! My hygienist couldn’t believe that I didn’t bleed and had no sensitivity (cleanings are usually more painful for me than dental problems). I am so, so grateful that my general dentist (who was replaced with my emergency dentist because his hours were more conducive and he always had a moment for me to walk in and get treated) gave me the CariFree kit as a Christmas gift. We were all so frustrated.
There were many things that contributed, I used to eat a pineapple a day (cut back a bit to one cup), and I ate every hour (serious snacker here- I have been trying to gain weight and constant snacking was my only line of gain since I used to eat only fruit and veggies- I’ve added to that and cut back on the snacking a bit). You guys have been amazing through it all. Your customer service has always been so kind and they answer all of my questions.
I am so grateful to the products (I’m no longer allowed to chew gum so this time, they sent me a spray to try- so far I’m loving it). If there is anything I can do to help with your research (surveys, mouth swabs, whatever you need), please let me know. You have no idea how much you guys mean to me and how you have saved me! Thank you! Thank you! Thank you!”
Last week we introduced Dr. Kutch’s simple caries risk diagnosis guidelines. Today we look at how he approaches the prescriptive phase, and we break down the first strategy: reparative.
The 3 Prescriptive phases include:
- Reparative (remineralization, restoration)
- Therapeutic (antimicrobial therapy, metabolic strategies and pH strategies)
- Behavioral (homecare, diet, medications, special needs)
Today we will focus on 3 reparative strategies
1. Remineralization (Fluoride)
“Fluoride varnish seems to be an effective treatment for the reversal of incipient carious lesions in primary and permanent dentition; however, further clinical trials concerning efficacy of topical fluorides for treating those lesions are still required, mainly regarding the fluoride gel.” (Lenzi TL, Montagner AF, Soares FZ, de Oliveira Rocha R. Are topical fluorides effective for treating incipient carious lesions?: A systematic review and meta-analysis. J Am Dent Assoc. 2016 Feb;147(2):84-91. Sys Rev, 754>21>5>3)
2. Prevention (Sealants)
“Pupils with 4 FS showed the lowest number of teeth with caries. Children with an early application of FS had a lower D-component than children with a later or missing application. Pupils with less than 4 FS had a higher risk of developing caries in their permanent dentition compared to peers with 4 FS (OR 4.36).” (Heinemann F, Ifland S, Heinrich-Weltzien R, Schüler IM. [Influence of Fissure Sealants on Dental Health of Elementary School Children in Weimar – A Longitudinal Observational Study under Real-life Conditions]. Gesundheitswesen. 2015 Dec 2. [Epub ahead of print][Article in German]505 7-10yr/o, 5yr
Conclusion: FS is an effective caries preventive measure under real-life conditions. Early application and sealing of all 4 molars can optimize the prevention of caries in the permanent dentition.
3. Restoration (Drill and Fill)
According to a survey of nearly 17,000 dentists showed wide diversity in when lesions were restored and when the doctor would wait and attempt remineralization strategies.
Investigators use questionnaire surveys to evaluate treatment philosophies in dental practices. The aim of this study was to evaluate the management strategies California dentists use for approximal and occlusal caries lesions.
In May 2013, the authors e-mailed a questionnaire that addressed approximal and occlusal caries lesion management (detection and restorative threshold, preferred preparation type, and restorative materials) to 16,960 dentists in California. The authors performed a χ2 statistical analysis to investigate the relationship between management strategies and respondent demographic characteristics.
The authors received responses from 1,922 (11.3%) dentists; 42.6% of the respondents would restore approximal lesions at the dentinoenamel junction, and 33.4% would wait until the lesion reached the outer one-third of dentin. The preferred preparation type was the traditional Class II preparation. Dentists who graduated more recently (20 years or less) were more likely to delay approximal restorations (P < .0001); 49.9% of the more recent graduates would wait to restore an occlusal lesion until the outer one-third of dentin was involved, and 42.6% would restore a lesion confined to enamel.
There is wide variety among California dentists regarding their restorative treatment decisions, with most dentists restoring a tooth earlier than the literature would advise. More recent dental graduates were more likely to place their restorative threshold at deeper lesions for approximal caries lesions.
Clinical evidence shows that noncavitated caries lesions can be remineralized; therefore, early restorative treatment may no longer be necessary or appropriate. Noninvasive and minimally invasive measures should be taken into consideration. (Rechmann P, Doméjean S, Rechmann BM, Kinsel R, Featherstone JD. Approximal and occlusal caries lesions: Restorative treatment decisions by California dentists. J Am Dent Assoc. 2016 Feb 9. pii: S0002-8177(15)01037-5. doi: 10.1016/j.adaj.2015.10.006. [Epub ahead of print)
Next week we will tackle therapeutic strategies which includes antimicrobial therapy, metabolic strategies and pH strategies.
What do you think of these restorative strategies? Share your thoughts in the comments below!
When it comes to Caries Risk Assessment, many doctors complain of the complexity. While the disease is complex, after years and years of work, Dr. Kutsch has developed super-simple diagnostic guidelines:
LOW CARIES RISK CDT D0601 (Only green answers)
No Risk Factors / Healthy
MODERATE CARIES RISK CDT D0602 (At least 1 yellow answer)
+ Risk Factors
HIGH CARIES RISK CDT D0603 (At least 1 red answer)
+ Disease Indicators
Let’s look at a real example of diagnosing a patient.
This patient works the night shift and reported drinking a lot of energy drinks, her home care could be better, and she had a high bacterial count.
She has multiple red answers, therefore falls into the extreme risk category (DO603)
Next week we will look at the super-simple therapy recommendations based on the diagnosis.
What do you think? Is this type of CRA realistic to use in your practice? Let us know in the comments below!
View Dr. Kutch’s CRA Form Here: Dr. Kutsch CRA Form Simple
Caries risk assessment has been around for a while. However, new findings of the true benefits continue to surface. Here are 5 ways caries risk assessment is beneficial to the practitioner and the patient.
5 Proven Benefits of CAMBRA
1. Caries Risk Assessment is predictive
We can tell the patient with confidence what will happen in the future. It allows us to then prescribe preventive therapy based on actual knowledge instead of a gut feeling.
Identification of patients at greater risk for future caries helps clinicians to plan appropriate personalized care. In this study, a multifactorial approach to caries risk assessment effectively stratified patients into groups of higher or lower caries propensity. Dentists can apply risk assessment in practice antecedent to patient-tailored caries management. SOURCE
2. There is an outcome
When patients are provided anti-cavity products repeatedly vs. a one-time conversation DMFT is reduced by 1.
Approximately half the patients did not receive any form of non-operative anti-caries agent. Most that received anti-caries agents were given more than one type of product in combination. One-time delivery of anti-caries agents was associated with a similar DFT increment as receiving no such therapy (difference in increment: -0.04; 95% CI: -0.28, 0.21). However, repeated, spaced delivery of anti-caries agents was associated with approximately one decayed or restored tooth prevented over 18 months for every three patients treated (difference in increment: -0.35; 95% CI: -0.65, -0.08). SOURCE
3. It is cost effective
Over a long period of time it is also cost effective. Caries risk assessment saves the system and patient money over time. However, this does not mean the dentists lose money. Instead of spending money on things they don’t want to, patients opt to spend money on elective procedures.
The incremental cost per DMFT avoided at 2 years, 3 years, and lifetime was estimated to be $1287.07, $1148.91, and $1795.06, respectively. SOURCE
4. CAMBRA has long term results
After 4 years, patients that went through a Caries Management System protocol had fewer caries than those who did not.
In practices where adherence to the Caries Management System protocols was maintained during the 4-year post-trial follow-up period, patients continued to benefit from a reduced risk of caries and, therefore, experienced lower needs for restorative treatment. SOURCE
5. The CAMBRA Effect
It was found that there is an improved effect on patient health, even beyond what would be expected based on therapy BECAUSE the patient went through a caries risk assessment process.
These findings suggest a greater intervention effect carried through the combined action on multiple aspects of the caries process rather than through any single factor. In addition, a substantial portion of the total effect of the CAMBRA intervention may have operated through unanticipated or unmeasured pathways not included among the potential mediators studied. SOURCE
If you are interested in learning more about HOW to implement a CAMBRA program in your office we have a team of experts waiting to help. Sign up for a free one-on-one webinar here to get started!
Do you know if you have children with Epilepsy in your practice?
Comparison of Dental Caries Experience in Children Suffering From Epilepsy with and without Administration of Long Term Liquid Oral Medication.
Sucrose is added as sweetening agent in liquid oral medication (LOM) to mask the acrid taste of medicines which may be potentially cariogenic. Many children under long term LOM therapy for treatment of epilepsy may be susceptible to dental caries.
To assess and compare dental caries experience in children under long term liquid oral medication with those not under such medication among 2-12 years old children suffering from epilepsy.
MATERIALS AND METHODS:
A cross-sectional study was undertaken on a total of 84 children aged 2-12 years, who were suffering from epilepsy receiving liquid oral medication for more than 3 months were selected (study group) and for comparison 106 children of similar age group and disease but on other forms of medication were included as control group. Dental caries was assessed using DMFT/DMFS (Decayed, Missing, Fillled Teeth / Surfaces), dmft/dft and dmfs/dfs indices. One-way ANOVA and t-test were used with p-value fixed at 0.05. Univariate logistic regression was applied.
Children on LOM were at increased risk of dental caries than those with other forms of medications (OR: 2.55, 95% CI (2.37-4.15) p=0.000, HS). Caries prevalence was high in the study group (76.1%) when compared to control group (55.6%).
Long term use of liquid medicines containing sucrose is a risk factor for dental caries among children with epilepsy.