Bacterial Activity in Active Carious Lesion vs Sound Surfaces

written by CariFree

bacteria decay

When we take a look at the way a patient’s biofilm impacts their caries risk, we are learning more and more every day. We know that patients with either too much plaque or an overly-active biofilm are at higher risk, but what do we know about individual species of bacteria and how they play a role?

In this study, they looked at the inside of active caries lesions and then on sound surfaces. They found that the most bacterial activity (growth, population numbers present) inside the lesion was lactobacilli. On the sound surfaces where there was no carious lesions, the highest activity was Fusobacteria. Identifying the different bacteria on healthy surfaces vs. diseased surfaces can further our understanding of how this disease functions.



“Caries-associated bacteria showed the highest relative activity in caries lesions, Lactobacilli, lower activities on sound surfaces, whereas asaccharolytic Fusobacteria were most active on sound surfaces and less active in caries lesions. Thus, the present study suggests different activity patterns for biofilms from CF and CA individuals.”



Dental caries is a multifactorial disease with many associated microbial taxa, but only a few are notably contributing to acidogenicity. The ribosome number and the corresponding 16S ribosomal RNA (rRNA) concentration are considered a molecular indicator for general metabolic activity of bacteria, as they are elevated with increased anabolic and catabolic activities. We hypothesize that the activity of aciduric/acidogenic bacterial taxa, reflected by a rise in ribosomal counts, could resolve differences between plaque biofilm from sound surfaces and caries lesions. The included subjects were allocated to two groups: caries-free (CF) or caries-active (CA). CF subjects presented one donor site, namely one sound surface (CFS, n = 10), whereas CA subjects presented two donor sites: a cavitated lesion with an ICDAS score of 5-6 (CAC, n = 13), and a sound reference surface (CAS, n = 13). Four aciduric/acidogenic bacterial taxa (Streptococcus mutans, lactobacilli, Bifidobacterium dentium, and Scardovia wiggsiae) and one asaccharolytic taxon (fusobacteria) as a contrast were selected. 16S rRNA and 16S rRNA genes were quantified by quantitative PCR. Based on these parameters, bacterial and ribosomal counts, as well as relative activities were calculated as the quotient of relative ribosomal abundance and relative genome abundance. Caries-associated bacteria showed the highest relative activity in caries lesions (e.g. lactobacilli CAC: 177.5 ± 46.0%) and lower activities on sound surfaces (e.g. lactobacilli CAS: 96.3 ± 31.5%), whereas asaccharolytic fusobacteria were most active on sound surfaces and less active in caries lesions (CFS: 275.7 ± 171.1%; CAS: 205.8 ± 114.3%; CAC: 51.1 ± 19.0%). Thus, the present study suggests different activity patterns for biofilms from CF and CA individuals. (Henne K, Gunesch AP, Walther C, Meyer-Lueckel H, Conrads G, et al. Analysis of Bacterial Activity in Sound and Cariogenic Biofilm: A Pilot in vivo Study. Caries Res. 2016;50(5):480-488).


Category: Education

Sugar Consumption Recommendations Based on Low-Quality Evidence?

written by CariFree

This study we found interesting. It determined the recommendations given to the public from governmental agencies and various medical communities on sugar intake did not meet the criteria for trustworthy recommendations and are based on low-quality evidence.  Now, that does not mean that recommending limiting sugar intake is wrong, simply that the recommendations being provided are based on low-quality evidence. This information can  help us better understand our own recommendations to patients as well as help us educate those who take the standard recommendation and absolute truth.



Guidelines on dietary sugar do not meet criteria for trustworthy recommendations and are based on low-quality evidence. Public health officials (when promulgating these recommendations) and their public audience (when considering dietary behavior) should be aware of these limitations.



The relationship between sugar and health is affected by energy balance, macronutrient substitutions, and diet and lifestyle patterns. Several authoritative organizations have issued public health guidelines addressing dietary sugars.


To systematically review guidelines on sugar intake and assess consistency of recommendations, methodological quality of guidelines, and the quality of evidence supporting each recommendation.

Data Sources:

MEDLINE, EMBASE, and Web of Science (1995 to September 2016); guideline registries; and gray literature (bibliographies, Google, and experts).

Study Selection:

Guidelines addressing sugar intake that reported their methods of development and were published in English between 1995 and 2016.

Data Extraction:

Three reviewers independently assessed guideline quality using the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II), instrument. To assess evidence quality, articles supporting recommendations were independently reviewed and their quality was determined by using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methods.

Data Synthesis:

The search identified 9 guidelines that offered 12 recommendations. Each of the reviewed guidelines indicated a suggested decrease in the consumption of foods containing nonintrinsic sugars. The guidelines scored poorly on AGREE II criteria, specifically in rigor of development, applicability, and editorial independence. Seven recommendations provided nonquantitative guidance; 5 recommended less than 25% to less than 5% of total calories from nonintrinsic sugars. The recommendations were based on various health concerns, including nutrient displacement, dental caries, and weight gain. Quality of evidence supporting recommendations was low to very low.


The authors conducted the study independent of the funding source, which is primarily supported by the food and agriculture industry.


Guidelines on dietary sugar do not meet criteria for trustworthy recommendations and are based on low-quality evidence. Public health officials (when promulgating these recommendations) and their public audience (when considering dietary behavior) should be aware of these limitations.

Primary Funding Source:

Technical Committee on Dietary Carbohydrates of the North American branch of the International Life Sciences Institute. (PROSPERO: CRD42015029182)

(Erickson J, Sadeghirad B, Lytvyn L, Slavin J, Johnston BC. The Scientific Basis of Guideline Recommendations on Sugar Intake: A Systematic Review. Ann Intern Med. 2016 Dec 20. 1995-2016 9 Guidelines, 12 recommendations)


What are your thoughts on this study?

Category: Education

Does Breast Feeding Increase Dental Caries Risk in Children?

written by CariFree


Have you ever been asked if breastfeeding increases a child’s risk of decay? This study (of 63 papers) points out that up to 12 months breastfeeding does not contribute to decay risk, but might actually offer some protection for the child. It makes sense that nature would not set the child up for decay, but would in fact help in preventing disease. However, beyond 12 months, children did have an increased risk. There is no hard evidence that it is the breast milk or if other things are contributing like cariogenic foods, extended bottle feedings, and the researchers caution about jumping to the conclusion that breast feeding beyond 12 months alone causes an increase in decay risk.


“Breastfeeding up to 12 months of age is not associated with an increased risk of dental caries and in fact may offer some protection compared with formula. However, children breastfed beyond 12 months, a time during which all deciduous teeth erupt, had an increased risk of dental caries.” (Richards D. Breastfeeding up to 12 months of age not associated with increased risk of caries. Evid Based Dent. 2016 Sep;17(3):75-76. Sys Rev, 63 papers)



Two reviewers independently selected studies for inclusion Data extraction and synthesis Study quality was assessed independently by two researchers using the Newcastle Ottawa Scale (NOS). Key data items, exposure and outcome definitions and effect estimates (odds ratios (OR), relative risks, prevalence ratios) with 95% Confidence Interval (95%CI) were abstracted where available for inclusion in a meta-analysis. The aim was to assess breastfeeding in two specific time windows; up to 12 months of age and beyond 12 months of age. Results: Sixty-three papers were included. These consisted of 14 cohort studies of which six were nested within RCTs of breastfeeding promotion interventions, three case-control studies and 46 cross-sectional studies. The studies were predominantly conducted in high and middle income countries with only eight studies from low income countries. Forty-six studies were not included in the meta-analysis because of methodological differences in the measures of exposure and outcomes, or reporting of correlational analyses only.Meta-analysis of one prospective cohort and four cross-sectional studies reported odds ratios for the association between children who were exposed to more versus less breastfeeding up to 12 months OR= 0.50; (95%CI; 0.25-0.99, I2 86.8%).In the two studies which compared ever breastfeeding in the first 12 months with never breastfeeding, both showed a marked protective effect of breastfeeding on dental caries compared with other feeding. Whereas the three studies which compared a longer duration of breastfeeding in the first 12 months to a comparison group which included children who had had some exposure to breastfeeding did not (34,52,59). A meta-analysis of this three study subgroup found OR= 0.92; (95%CI; 0.69-1.23, I2 0%)Meta-analysis of two cohort studies, one case-control study and four cross-sectional studies reported odds ratios for the association between more or less breastfeeding after the age of 12 months and dental caries.Comparison groups for these studies included both those who had never been breastfed and those who had been breastfed for shorter durations. The pooled estimate was OR= 1.99; (95% CI: 1.35-2.95, I2 69.3%).Meta-analysis of one cohort, one case-control and three cross-sectional studies reported odds ratios for the association between more versus less nocturnal breastfeeding and the risk of dental caries amongst the subgroup of children breastfed longer than 12 months. OR= 7.14; (95%CI; 3.14-16.23, I2 77.1%). Conclusions Breastfeeding up to 12 months of age is not associated with an increased risk of dental caries and in fact may offer some protection compared with formula. However, children breastfed beyond 12 months, a time during which all deciduous teeth erupt, had an increased risk of dental caries. This may be due to other factors which are linked with prolonged breastfeeding including nocturnal feeding during sleep, cariogenic foods/drinks in the diet or inadequate oral hygiene practices. Further research with careful control of pertinent confounding factors is needed to elucidate this issue and better inform infant feeding guidelines.


What do you say to mothers when they ask about breast feeding and decay risk?

Category: Education

Low BMI and Dental Caries Risk

written by CariFree


There have been a number of studies conducted over the past 10 years looking at the correlation between Dental Caries risk and high BMI. These studies (basically) conclude that high BMI correlates to higher Caries Risk; in general children with high BMI consume more carbohydrate and sugar than their normal BMI counterparts. What is interesting about this study out of India is children that are underweight also have a higher incidence of dental caries.



Body mass index (BMI) is an index that measures height for weight, which is commonly used to categorize underweight, overweight, and obese individuals. Deviation from normal weight results from an imbalance between caloric consumption and energy expenditure. Childhood obesity and childhood dental caries are coincidental in many populations, probably due to common confounding risk factors, such as intake frequency, cariogenic diet, and poor oral hygiene. So the aim of the present study was to assess the BMI status and to corelate between dental caries and BMI among the Anganwadi children of Belgaum city, Karnataka, India.


Four hundred and thirty three children from 20 Anganwadi’s belonging to the age group of 2 to 6 years of both sexes were measured for BMI and dental caries status. The caries index was measured as the number of decayed (d) and filled (f) teeth (t) (dft). The BMI in units of kg/m2 was determined and children were categorized according to age-and gender-specific criteria as underweight (<5th percentile), normal (5th-85th percentile), at risk for overweight (85th- 95th percentile), and overweight (>95th percentile). The data were subjected to statistical analysis using Student’s t-test, analysis of variance (ANOVA), and Karl Pearson’s correlation coefficient test with the help of Statistical Package for the Social Sciences (SPSS) version 18.0.


The proportion of subjects in Centre for Disease Control (CDC) weight categories was: 5% underweight, 79% normal, 9% under the risk for overweight, and 6% overweight.


A significant association was found between children with normal BMI and those who were underweight, overweight, and under the risk for overweight. Children with overweight/obese or underweight/malnourished children had higher decayed and filled surfaces compared to children with normal weight.


Nutritional status has a profound effect on dental caries. Both underweight/malnutrition and overweight/ obesity have significant adverse implications for health. Childhood obesity and childhood dental caries are coincidental in many populations. (Aluckal E, Anzil K, Baby M, George EK, Lakshmanan S, et al. Association between Body Mass Index and Dental Caries among Anganwadi Children of Belgaum City, India. J Contemp Dent Pract. 2016 Oct 1;17(10):844-848. India 433 2-6 yro).
Category: Education

The Social Side of Dental Caries Prevention

written by CariFree

Children Kids Diversity Friendship Happiness Cheerful Concept

Recent research coming from Boston University suggests our traditional one-on-one behavioral interventions with patients may not be the best for long-term preventive behaviors. In fact, researcher Brenda Heaton, an assistant professor of health policy and health services research at Boston University’s Henry M. Goldman School of Dental Medicine offers information that may change the way information is dispersed throughout communities in order to have larger, long-term effect.


Heaton specializes in social epidemiology with a focus on oral health. In 2008, she, along with other members of BU’s Center for Research to Evaluate & Eliminate Dental Disparities, began a new line of research, focused on understanding oral health and disease among residents in Boston public housing. The majority of the work to date has focused on whether or not “motivational interviewing” can influence how women care for their children’s diet and oral health—specifically, the impact on kids with dental caries (also known as tooth decay). There is mounting evidence that one-on-one behavioral interventions, like motivational interviewing, may change short-term behavior, but the effects don’t last long. “We started to get a sense that there may be more influences that we need to acknowledge beyond just the individual,” says Heaton. She found that social networks—not Facebook and Twitter, but networks of friends, family, and acquaintances—may play an overlooked role in oral health care.


Since 2008, her team has interviewed close to 200 women living in Boston public housing and identified nearly 1,000 individuals who were influential. Heaton is using those network maps to find similarities about how information flows through these communities.

The ultimate goal, she says, is to use the map to introduce health information and resources into a community in ways that change long-term behaviors.

“You can’t design those interventions until you actually have a really strong grasp of the network structure,” says Heaton. For instance, if you want to make an impact, should you look for community members with the most personal connections or for people with large influence but fewer personal ties? Should you take advantage of existing connections or seed new ones?

The power of this approach is that it focuses on prevention rather than cures, says Heaton. It might take a village, but tooth decay “is an entirely preventable health outcome.”


To read the full article go here


What do you think? Is social mapping a positive move for oral health practitioners who want to prevent tooth decay?


Category: Education

What is that black stain?

written by CariFree

Picture1Actinomyces/Black Stain

Have you ever had a young patient come to your office with strange black staining? Something we see from time to time are children who present with superficial black stains on the teeth. Parents will always ask what causes it, and usually we discuss things like water and vitamins, but often we throw our hands in the air because the answer seemed elusive. Well, this recent study might shed some light on what is going on:



Assess prevalence, familial predisposition and susceptibility to caries of Black Stains (BS). Evaluate the microbiological composition of BS, saliva and subgingival plaque.


Sixty nine subjects with BS (test group) and 120 subjects without BS (control group) were analysed for oral status. For each BS-patient, a BS-deposit, 1 ml of saliva and subgingival plaque were collected and microbiologically analysed. Five deciduous teeth with BS were observed under SEM.


This study showed a BS prevalence similar to that of the Mediterranean area and a familiality. The microbiological origin of BS was confirmed by SEM and culture method and the BS flora differ from that of supragingival plaque.


Predominance in BS and saliva of Actinomycetes and the low salivary prevalence of S. mutans and L. acidophilus may be related with low caries incidence in BS patients. The high presence of Actinomyces spp can be a causative factor for BS.

(Tripodi D, Martinelli D, Pasini M, Giuca MR, D’Ercole S. Black Stains: a microbiological analysis and a view on familiarity and susceptibility to tooth decay of patients in childhood. Eur J Paediatr Dent. 2016 Dec;17(4):261-266. 69+BS, 120 –BS, 5 Decid teeth.)

So what can we tell our patients when they are concerned about their children? Patients with black stains typically have low caries incidence and high presence of the bacteria Actinomyctes causing the black coloration. It turns out the black stain is a bacterial origin issue, and seems to not be anything serious.


What about you? Have you seen patients with black stain? If so, what did you tell them?

Category: Education

Science Update Series: Saliva, Dental Caries and Periodontal Disease

written by CariFree

pattern recognitionIt was an interesting year in Dental Caries research. For this update series we started with about 100 articles, and pared it down to 50 that we believe broaden our knowledge and will help us better diagnose and treat our patients. Over the next several weeks we will walk through the research, feel free to ask questions or provide your experience in the comments section.


The series will be organized by unpacking what we refer to as the “Usual Suspects” or patterns we have identified as being the common reasons patients suffer from dental caries. Our ability to recognize and identify these patterns allow us to focus our diagnosis and treatment of the disease. The first we will tackle is saliva flow. Low saliva flow is the number one self-reported risk factor in our data base of nearly 13,000 patients. 63% of these patients self-report dry mouth or low saliva. When beginning the conversation with patients, starting with saliva is smart.


An interesting study that came out in December looked at saliva flow and its relationship to dental caries and periodontal disease:



This study examined the relationship between stimulated salivary flow rate and oral health status in an adult population. Multinomial multivariate logistic regression analysis was used to examine the associations of salivary flow rate with dental caries status and periodontal status at the individual level among 2,110 Japanese adults with ≥10 teeth. Then, a spline model was used to examine the nonlinear relationship between salivary flow rate and teeth with dental caries or periodontal disease in multilevel analysis. Odds ratios were calculated for a 1.0-mL/min reduction in salivary flow rate at a point.


After adjusting for confounding variables, participants with a flow rate ≤3.5 mL/min had significantly higher odds ratios for high caries status, and participants with a flow rate ≤1.4 mL/min had a higher odds ratio for broad periodontal disease, than did those with a flow rate >3.5 mL/min. In spline models, the odds ratio for teeth with dental caries or periodontal disease increased with reduced saliva secretion. The present findings suggest that decreased saliva secretion affects both dental caries and general periodontal health status. (Shimazaki Y, Fu B, Yonemoto K, Akifusa S, Shibata Y, et al. Stimulated salivary flow rate and oral health status. J Oral Sci. 2016 Dec 28. 2110 Japan Ad >10 teeth).


So, not only does decreased saliva flow impact risk for dental caries, but also risk for periodontal disease. How does this information impact how you assess your patients?



What do you think? Have you noticed dry mouth as a usual suspect in dental caries and/or perio in your patients?

Category: Education

Don’t Miss Dr. Kutsch’s Science Update TODAY! Free Webinar

written by CariFree


science update

Tonight Dr. Kim Kutsch offers an update on the science of dental caries. Sign up for this free event by clicking the link below.






In other news…


We had an excellent question by a reader on last week’s post Q & A With Dr. Kim Kutsch: Saliva and Brushing


Q: What is the evidence that there is a significant reduction in salivary flow in older adults?

A: Here is one source to consider

PUBMED Format: Abstract

J Am Geriatr Soc. 2015 Oct;63(10):2142-51. doi: 10.1111/jgs.13652. Epub 2015 Oct 12.
Meta-Analysis of Salivary Flow Rates in Young and Older Adults.
Affoo RH1, Foley N2, Garrick R3, Siqueira WL4, Martin RE1,5,6,7.
Author information

To determine whether salivary flow decreases as a function of aging.


Literature review.

Individuals aged 18 and older reported to be free of major systemic disease.

Relevant studies were identified through a literature search of several databases, from their inception to June 2013. Studies were included if saliva had been collected on at least one occasion in subjects aged 18 and older and if the data were presented in a manner that enabled comparisons of younger and older participants. Differences in salivary flow rates between age groups were calculated for each salivary source and condition and reported as standardized mean differences (SMDs), standard errors (SEs) and 95% confidence intervals (CIs). The results were pooled using a random effects model. A separate analysis examining medication use was also conducted.

Forty-seven studies were included. Whole (SMD = 0.551, SE = 0.056, 95% CI = 0.423-0.678, P < .001) and submandibular and sublingual (SMSL) (SMD = 0.582, SE = 0.123, 95% CI = 0.341-0.823, P < .001) salivary flow rates were reduced significantly in older participants and in unstimulated and stimulated conditions. In contrast, parotid and minor gland salivary flow rates were not significantly reduced with increasing age. Additionally, unstimulated and stimulated SMSL, and unstimulated whole salivary flow rates were significantly lower in older adults, regardless of medication usage.

The aging process is associated with reduced salivary flow in a salivary-gland-specific manner; this reduction in salivary flow cannot be explained on the basis of medications. These findings have important clinical implications for maintaining optimal oral health in older adults.


Please join the webinar tonight and get all the latest science on dental caries!

Category: Education

Q&A With Dr. Kim Kutsch: Saliva and Brushing

written by CariFree

The Power Of Good Questions card isolated on white background

Here are some questions posed recently to Dr. Kutsch and his responses:


Q: What is your baseline approach to a saliva compromised patient?

For the patient with reduced salivary flow, which may be a result of age and or medication use, my approach is to make sure they understand the importance of keeping the mouth hydrated and the impact of snacking throughout the day. They need to understand how snacking compromises their saliva flow and pH. I would discuss changing dietary habits to achieve the least amount of negative impact. Also, it would benefit them to replace their saliva with a pH neutral or elevated pH product in order to protect and buffer their pH. I would have them on the CTx4 Gel 5000 for life. Also, after they eat, I tell them to rinse with tap water.

Now, for the patient that is completely saliva compromised, like a radiation patient or one that has Sjogren’s syndrome, it is a whole different approach. If their bacteria levels are high, I would put them on an antimicrobial for 3 months-2 years. I may use SDF to arrest any root surface caries while we figure out a treatment plan. I have put many Sjogren’s patients into trays with the CTx4 Gel 5000 to wear during the day or at night. You need to do everything for this patient and know that it is a lifetime treatment as their saliva is forever compromised.


Q: Do you approach a saliva compromised patient differently based on their ‘why’? (i.e Sjogren’s vs. medication or radiation induced xerostomia)

With exception of the radiation patient, the patient who has Sjogren’s or is on many medications I use the approach above. Now, for the radiation patient, short term they lose a lot of saliva, but long term it can go from totally dry to just a hyposalivation situation. You can prescribe Pilocarpine, and it will help with secreting saliva, but it will also produce more tears and sweat. There is a lollipop and sucker version that is an OK short-term solution for some patients.


Q: Are there any benefits of brushing with a toothpaste that do not contain remineralization agents?

A: Yes, even dry brushing is better than not brushing at all. Disrupting the biofilm on the teeth and cleaning it off the teeth everyday is beneficial. Do you get as good a benefit as using a gel with nano-hydroxyapatite or fluoride? Probably not. But, brushing every day will be helpful. The simple answer is: yes. However, in my mind, if you are going to do it anyway, use something alkaline (like saliva or CTx4 Gel 5000 with Nano HA) to reap additional benefits.


Have a question for Dr. Kutsch? Leave it in the comments below and you may be featured on a future blog post!


Category: Education

Finding Balance: Dr. Kutsch’s Caries Protocols for Low, Moderate and High Risk Patients

written by CariFree


My approach to talking to patients about their dental health has changed dramatically over time. I have moved away from telling patients what they ‘have’ to letting them know ‘what I find’. It has made all the difference in the world. Specifically, when discussing caries risk, I have adopted the scripted statements and questions below:

Here are the risk factors that are causing your cavities

Which one do you want to work on first?
What is your plan?
What support would you like from me?

When we talk about these things, we talk about it objectively and without judgement. Remember we can only make one behavioral change at a time. Don’t try and do too much at once. I used to be invested in telling the patient ‘my way'; telling them what to work on first, second etc. Now, I let them choose. They are far more successful that way. Ask them where they want to start.  When it comes to restorations, of course there is a logical order however, when it can be up to the patient, let it be up to them. Let the patient come up with the plan and let YOU know what it is.


What about intervention?

Intervention and treatment needs to target and be specific to the patient’s risk factors. When the patient has decided they are ready to move forward with treatment, let them know the appropriate level of intervention based on your assessment.


Suspects (Risk Factors) Drive the Treatment Strategies

Bacteria: Antimicrobial and/or Behavior

Diet: Limit sweets versus Limit snacking

Saliva: Hydration, Neutralize support the pH

Genetic: Minimize acid exposure, support wellness


Treatment Strategies per risk level

Dr. Kutsch’s Protocol for Low Caries Risk

Caries Risk Assessment with Biometric

Offer 12 month Fluoride Varnish

Offer pH, Xylitol, Nano-HA, Fluoride

Educate about Risk Factors


Dr. Kutsch’s  Protocol for Moderate Caries Risk

Caries Risk Assessment with Biometric

Recommend 6 month Fluoride Varnish

Recommend pH, Xylitol, Nano-HA, Fluoride

Behavioral Coaching targeted to Risk Factors


Dr. Kutsch’s Protocol for High Caries Risk

Caries Risk Assessment with Biometric

3 month Fluoride Varnish (Always)

pH, Xylitol, Nano-HA, Fluoride (Always)

+/- Antimicrobial strategy

+/- Silver Diamine Fluoride

Behavioral Coaching for Risk Factors

At the end of the day it all comes down to balance. A healthy balance in your mouth comes from healthy saliva, healthy diet and healthy home care. Your body cannot be healthy if your mouth is not in balance.


What about you? How do you approach treatment?

Category: Education