Are Your Teeth Safe? Infographic

written by Carifree


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!



Category: Education

Patient Success Story: Lauren W.

written by Carifree

Check out this encouraging message we received on Facebook from CariFree patient Lauren.


11141232_10206147671950495_7043672094220994733_o“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!”


Lauren W


The Prescriptive Phase: 3 Reparative Strategies for Dental Caries

written by Carifree


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!

Category: Education

Dr. Kutsch’s Simple Caries Risk Diagnostic Guidelines

written by Carifree


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

Category: Education

5 Proven Benefits of CAMBRA

written by Carifree


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!



Category: Education

Epilepsy Medication and Dental Caries Risk

written by Carifree
Sick Child Taking Medicine Or Cod Liver OilA recent study finds children who suffer from Epilepsy and take liquid oral medication long-term are at higher risk for dental caries.  Using a Caries Risk Assessment form that asks the question about medication use and ‘other health issues’ could help identify these children and allow an opportunity to provide protective intervention and or offer parents suggestions on how to neutralize the mouth after taking medication each day. Chronic health issues like asthma and diabetes tend to be on our radar as practitioners, but being aware of other medical issues and their implications on oral health are imperative to our diagnosis and treatment of patients.


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.

Goyal A1, Bhadravathi MC2, Kumar A3, Narang R1, Gupta A4, Singh H5.



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.


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.

Category: Education

Mark your calendar August 23 – You won’t want to miss this!

written by Carifree


We will be having part 2 of the webinar series with Dr. V. Kim Kutsch entitled: Dental Caries, a Disease of Choice? On August 23. If you have not had a chance to hear part 1 you can do so here.


Here is a snippet of information from the first webinar regarding the role genetics play in dental caries.

The NIH Consensus Development Program released a statement in 2001 and listed six major clinical caries research directions. One of these directions was the need for genetic studies to identify genes and genetic markers of diagnostic, prognostic and therapeutic value. This last decade has seen a steep increase in studies investigating the presence of genetic factors influencing individual susceptibility to caries. This review revisits recent caries human genetic studies and provides a perspective for future studies in order to fulfil their promise of revolutionizing our understanding of and the standard of care for the most prevalent bacteria-mediated non-contagious disease in the world. © 2014 S. Karger AG, Basel.

There is such a broad array of genetics that play a role in dental caries. Our capacity to study them has increased significantly over the past 10 years.

Current Dental Caries Genes

>Enamel Formation Genes: 7  (AMELX, ENAM)

>Immune Response Genes: 7 (BDEF1, CD14)

>Saliva Genes: 2 (AQP5, PRH1)

>Other Genes: 11 (TAS2R38, MMP13)

>34 Total at present

What we now know is that genetics loads the gun and the environment pulls the trigger so to speak.








As practitioners, we cannot change the genetic makeup of our patients, but we can help them understand their risk and make changes to their environment to help mitigate damage.

Interestingly, a study done on young adults; 77 caries active, 77 caries free looked at environmental and genetic factors. They found that:

“Based on stepwise multiple linear regression analyses, dental plaque amount, lactobacilli count, age, and saliva buffer capacity, as well as DEFB1, TAS2R38, and CA6 (Carbonic anhydrase) gene polymorphism, explained a total of 87.8% of the variations in DMFT scores.

What this tells us is these 7 factors explained almost 88% of what was going on in these patients. We need to be aware of the patterns that we can identify and alter.

To register for the live webinar with Dr. Kutsch and learn more about the advances in research SIGN UP HERE TODAY.

You won’t want to miss it!

Category: Education

To Floss or Not to Floss: That is the question!

written by Carifree

By: Dr. V. Kim Kutsch, DMD

11098 Comic

Dental floss made from silk thread first became a commercial product in 1882, and has probably been a controversial topic since that first introduction. The dental profession routinely recommends patients floss daily and dental hygienists daily instruct patients on flossing technique as a standard of care. Despite the profession’s continued efforts, self-care with dental floss has a very low adoption rate. The news media widely reported the results of a recent Associated Press examination of scientific evidence from a Freedom of Information Act request with the Human Health and Services. Upon receiving a letter from HHS acknowledging that this topic has not really been studied, the AP then examined 25 studies and found little or no scientific evidence to support flossing. So why floss?


The theory behind flossing is that tooth brushing does not reach into the interproximal region between teeth and daily flossing to disrupt the biofilm will improve the outcomes in dental caries and periodontal disease. While the theory is logical and intuitive, flossing is a difficult habit to establish, is technique sensitive and depends completely on patient adherence for any outcome. Unfortunately, the AP report was mostly right. There is little scientific evidence to support daily flossing providing any benefit.1,2 A search of Pubmed provides studies that demonstrate flossing adds little to no additional benefit to tooth brushing. One report did demonstrate a significant improvement with interdental brushing compared with flossing.3  A recent study even demonstrated improved outcomes in four patients with refractory periodontal disease when they stopped flossing.4 The evidence indicates one cannot simply brush and floss dental diseases away. So, should we all stop flossing? What is the risk versus the benefit?


Dental caries and periodontal disease are both multifactorial biofilm based diseases. They are frustrating diseases for both patients and the dental professionals treating them. Since the biofilm is one of the risk factors in both diseases, it still makes sense to disrupt that biofilm on a daily basis. While most studies demonstrate little to no evidence, there are a few that do.5 One study clearly demonstrated improved outcomes with dental caries bacteria6, while another study utilized daily professional flossing on students.7



Recognizing that the topic needs better scientific investigation, lack of evidence at this point should not be interpreted as lack of outcome. I will still floss and I will recommend it for my patients, but only as a part of my complete approach of risk assessment based care. I will still focus on helping patients understand the causes of their diseases, and helping them establish targeted therapies to reduce their risks.



  1. Berchier CE, Slot DE, Haps S, Van der Weijden GA. The efficacy of dental floss in addition to a toothbrush on plaque and parameters of gingival inflammation: a systematic review. Int J dent Hyg Nov 2008. 6(4):265-79.
  2. Dorri M, Dunne SM, Walsh T, Schwendicke F. Micro-invasive interventions for managing proximal dental decay in primary and permanent teeth. Cochrane Database Syst Rev 2015 Nov. 5(11).
  3. Salzer S, Slot DE, Van der Weijden FA, Dorfer CE. Efficacy of inter-dental mechanical plaque control in managing gingivitis—a meta-review. J Clin Periodontol April 2015. 42 Suppl 16:S92-105.
  4. Wilder RS, Bray KS. Improving periodontal outcomes: merging clinical and behavioral science. Periodontol 2000 June 2016. 71(1):65-81.
  5. Chapple IL, Van der Weijden F, Doerfer C, et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol April 2015. 42 Suppl 16:S71-6.
  6. Corby PM, Biesbrock A, Bartizek A, et al. Treatment outcomes of dental flossing in twins: molecular analysis of interproximal microflora. J Periodontol. August 2008. 79(8):1426-33.
  7. Hujoel PP, Cunha-Cruz J, Banting DW, Loesche WJ. Dental flossing and interproximal caries: a systematic review. JDR April 2006. 85(4):298-305.
Category: Education,Opinion

New York Times Report on Silver Diamine Fluoride

written by Carifree



The New York Times ran a story on July 11 titled: A Cavity-Fighting Liquid Lets Kids Avoid Dentists’ Drills

With the increasing national attention, and the fact that in Oregon, Medicaid patients are being reimbursed for SDF treatment,  we wanted to make sure our readers were up to date on Dr. Kutsch’s thoughts posted in December. Have you noticed an increase of public awareness of Silver Diamine Fluoride by your patients? Have you been using it? Let us know in the comments below.


By V. Kim Kutsch, DMD, originally published December 22, 2015.


Silver Diamine Fluoride was market cleared by the FDA earlier this year as a “Cavity Varnish” for the treatment of hypersensitivity only in adults over the age of 21.  But the use of the silver ion as an anti-cavity agent dates back to GV Black.1 He described the use of a silver nitrate solution painted onto lesions to arrest the process. I have personal experience with using silver nitrate in a technique modified by Dr. Steve Duffin. He immediately covered the lesion with fluoride varnish following the silver nitrate solution.2 I have used this technique for years with excellent outcomes. There is a drawback however, the silver ion turns the yellow to dark brown dentin lesion to black. It arrests the process, but turns the lesions black. So while effective, a technique that may not work for every patient. The good news, is that it does not stain sound enamel.


Most of the cases I have treated involved young children with SECC, whose parents didn’t want them subjected to sedation or general anesthesia to have restorative dentistry done. They were willing to compromise esthetics in the short term. These patients I then restored as the parents desired after the child was developmentally capable of having dentistry done with local anesthesia, or no anesthesia. Many of the lesions were never restored, but this provided a great service in my opinion. The other patients I have used this technique on were senior citizens in the end stages of life, where neither myself, the patient, or the family members were interested in putting the patient through extensive restorative procedures. It has worked fairly well with that demographic also.


Silver Diamine Fluoride has been used extensively for years in other countries with similar outcomes to silver nitrate. There have been numerous studies published on the topic and I believe it has gained popularity as a necessity with the increasing rates of SECC in the past two decades.3 Silver Diamine Fluoride provided better outcomes than fluoride varnish and GIC.4,5,6 I am now also using Silver Diamine Fluoride for the same types of patients that I have used silver nitrate with in the past. But in my experience contrary to some reports, it too turns the dark dentin lesions black. As long as that outcome is acceptable to the patient/parents/family, it too works very well. There is even evidence that once the silver ion kills a bacterial cell, it continues to kill other bacteria in what is described as a zombie-like state.7 For the right patient, this offers another option to their care.


One final note, these silver ion solutions do stain everything they come in contact with in the operatory, clothing, countertops etc. So just be very careful in handling the solution.



  1. Peng JJ, Botelho MG, Matinlinna JP. Silver compounds used in dentistry for caries management: a review. J Dent. 2012 Jul;40(7):531-41. 1966-2011 Sys Rev.
  2. Duffin S. Back to the future: the medical management of caries introduction. J Calif Dent Assoc. 2012 Nov;40(11):852-8.
  3. Chu CH, Lee AH, Zheng L, Mei ML, Chan GC. Arresting rampant dental caries with silver diamine fluoride in a young teenager suffering from chronic oral graft versus host disease post-bone marrow transplantation: a case report. BMC Res Notes. 2014 Jan 3;7:3.
  4. Chu CH, Lo EC, Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. J Dent Res. 2002 Nov;81(11):767-70.
  5. Rosenblatt A, Stamford TC, Niederman R. Silver diamine fluoride: a caries “silver-fluoride bullet”.J Dent Res. 2009 Feb;88(2):116-25.
  6. Zhi QH, Lo EC, Lin HC. Randomized clinical trial on effectiveness of silver diamine fluoride and glass ionomer in arresting dentine caries in preschool children. J Dent. 2012 Nov;40(11):962-7.
  7. Wakshlak R, Pedahzur R, Avnir D. Antibacterial activity of silver-killed bacteria: the “zombies” effect. Scientific Reports 5, Article number: 9555 doi:10.1038/srep09555.
Category: Education

Research Shows Cavity-Causing Bacteria Transfer from Non-Relative Child to Child

written by Carifree

Babies Plays With Toys

Research taking place at the University of Alabama at Birmingham Department of Biology and School of Dentistry is showing the transmission of S. mutans not only occurs from mother to child, but from child-to-child (non-relatives) as well. Sharing spoons and toys in the daycare center or nursery at church may be the reason “72 percent of children harbored at least one strain of the cavity-causing Streptococcus mutans not found in any cohabiting family members.” Primary researcher Stephanie Momeni stated: “While the data supports that S. mutans is often acquired through mother-to-child interactions, the current study illuminates the importance of child-to-child acquisition of S. mutans strains and the need to consider these routes of transmission in dental caries risk assessments, prevention and treatment strategies.”


Educating parents on the importance of limiting sharing of things like pacifiers, utensils, sippy cups and straws at daycare and home may be beneficial to share based on these findings. Also, asking parents if their children participate in daycare-like settings may be worth considering as it appears to have the potential to be a significant risk factor for dental caries.


What do you think: Is this research evidence enough to consider in your practice?

Category: Cast your vote