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?
We know counseling patients can be challenging. Today we offer a few reasons why it can be so hard, and a few strategies that work to help patients really make change.
One of the greatest forces working against us (and our patients) is called proactive interference. Old habits are a significant force keeping us from forming new habits. In essence you don’t just have to learn something new, you have to also unlearn old habits.
Proper tooth brushing is a seemingly simple motor activity that can promote oral health. Applying health theories, such as the Information-Motivation-Behavioral Skills (IMB) model, Motivational Interviewing (MI) and Integrated Health Coaching (IHC), may help optimize tooth brushing technique in those with suboptimal skills. Some motor activities, including tooth brushing, may over time become rote and unconscious actions, such that an existing habit can inhibit new learning, i.e., exert proactive interference on learning the new skill. Proactive interference may impede the acquisition of new tooth brushing skills; thus, in this report, we: (1) Review how the habit of tooth brushing is formed; (2) Postulate how proactive interference could impede the establishment of proper tooth brushing retraining; (3) Discuss the merits of this hypothesis; and (4) Provide guidance for future work in this topic within the context of an approach to behavior change that integrates IMB, MI and IHC methodology.
“Some motor activities, including tooth brushing, may over time become rote and unconscious actions, such that an existing habit can inhibit new learning, i.e., exert proactive interference on learning the new skill. Proactive interference may impede the acquisition of new tooth brushing skills.”(Thavarajah R, Kumar M, Mohandoss AA, Vernon LT. Drilling Deeper into tooth brushing skills: Is proactive interference an under-recognized factor in oral hygiene behavior change? Curr Oral Health Rep. 2015 Sep;2(3):123-128)
One consistent message we convey to all doctors is that changing someone’s behavior surrounding sugar consumption is harder than changing their behaviors surrounding alcohol. This is a significant challenge. If alcohol treatment requires a 12 step program, changing sugar habits may be a 13-14 step process. We mention this to hammer home just how difficult behavior change around diet can be.
The Cochrane Oral Health Group Trials Register CENTRAL, Medline, Embase, PsycINFO, CINAHL, Web of Science conference proceedings (IADR and ORCA), reference lists and Dissertations Abstracts were searched.
Randomised controlled trials assessing the effectiveness of 1:1 dietary interventions in a dental care setting were included. This could be brief advice, skills training, self help materials, counselling or lifestyle strategies delivered by any member of the dental team.
DATA EXTRACTION AND SYNTHESIS:
Two reviewers independently screened and abstracted data with disagreements resolved by discussion and a third review author. The Cochrane risk of bias assessment tool was used.
Five studies were included; two were at high risk of bias, three were at unclear risk of bias. Two were multi-intervention studies where the dietary intervention was one component of a wider programme of prevention, but where data on dietary behaviour change were reported. One of the single intervention studies concerned caries prevention. The others concerned general health outcomes. No studies were aimed at preventing tooth erosion. Four out of five studies found a significant change in dietary behaviour in at least one of the primary outcomes.
“There is some evidence that one-to-one dietary interventions in the dental setting can change behavior, although the evidence is greater for interventions aiming to change fruit/vegetable and alcohol consumption than for those aiming to change dietary sugar consumption.”(Evans D. Some evidence that one-to-one dietary interventions in the dental setting can change behaviour. Evid Based Dent. 2012 Jun;13(2):42. Sys Rev. 5 trials.)
Ask open ended questions
So what do we do? One of the greatest strategies I have learned to implement is asking open ended questions. These are questions that cannot be answered ‘yes’ or ‘no’.
Instead of asking: Do you floss? How many times per day?
What would you like to focus on?
How has this affected your life?
One of the best non-judgmental statements is:
Tell me more about…
Telling (selling) vs. Asking
Another trap we fall in is telling patients what they need instead of asking what they want.
Are we telling them what they “should” do?
Or are we asking them what they want?
Are we selling or are they purchasing?
These are just a few of the strategies I find helpful in counseling my patients. What strategies do you find helpful?
Wellness Coaching helps the patient understand why they have a problem and empowers them to do something about it.
Wellness Coaching helps the patient develop their own answers.
The Baraka Institute and Feroshia Knight
This myth came from a plastic surgeon who determined that it took patients about 21 days to get used to their rhinoplasty. It has nothing to do with real behavior change.
“There’s no shortage of apps out there designed to help you form a habit, and many of those are built on the assumption that all you need is 21 days. This number comes from a widely popular 1960 book called Psycho-Cybernetics by Maxwell Maltz, a plastic surgeon who noticed his patients seemed to take about 21 days to get used to their new faces.”(SIGNE DEAN. Here’s how long it takes to break a habit, according to science: You’re gonna need more than will power. Science Alert 24 SEP 2015)
New habits take 66-254 days
“In conclusion, repeating a behavior in response to a cue appeared to be enough for many people to develop automaticity for that behavior. Although consistency in repetition is required, the degree of consistency is not yet known. There was variation both in the maximum automaticity reached and the time taken to plateau.”(Lally p, Van Jaarsveld CM, Potts HWW, Wardle J. How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology Eur. J. Soc. Psychol. 40, 998–1009 (2010))
Patients change at their pace. We need to know how to help them change. It also takes daily reinforcement.
Our attitude affects the outcome
Front line providers of care are frequently lacking in knowledge on and sensitivity to social and structural determinants of underprivileged patients’ health. Developing and evaluating approaches to raising health professional awareness and capacity to respond to social determinants is a crucial step in addressing this issue. McGill University, in partnership with Université de Montréal, Québec dental regulatory authorities, and the Québec anti-poverty coalition, co-developed a continuing education (CE) intervention that aims to transfer knowledge and improve the practices of oral health professionals with people living on welfare. Through the use of original educational tools integrating patient narratives and a short film, the onsite course aims to elicit affective learning and critical reflection on practices, as well as provide staff coaching.
A qualitative case study was conducted, in Montreal Canada, among members of a dental team who participated in this innovative CE course over a period of four months. Data collection consisted in a series of semi-structured individual interviews conducted with 15 members of the dental team throughout the training, digitally recorded group discussions linked to the CE activities, clinic administrative documents and researcher-trainer field notes and journal. In line with adult transformative learning theory, interpretive analysis aimed to reveal learning processes, perceived outcomes and collective perspectives that constrain individual and organizational change.
The findings presented in this article consist in four interactive themes, reflective of clinic culture and context, that act as barriers to humanizing patient care: 1) belief in the “ineluctable” commoditization of dentistry; 2) “equal treatment”, a belief constraining concern for equity and the recognition of discriminatory practices; 3) a predominantly biomedical orientation to care; and 4) stereotypical categorization of publically insured patients into “deserving” vs. “non-deserving” poor. We discuss implications for oral health policy, orientations for dental education, as well as the role dental regulatory authorities should play in addressing discrimination and prejudice.
Humanizing care and developing oral health practitioners’ capacity to respond to social determinants of health, are challenged by significant ideological roadblocks. These require multi-level and multi-sectorial action if gains in social equity in oral health are to be made.(Lévesque MC, Levine A, Bedos C. Ideological roadblocks to humanizing dentistry, an evaluative case study of a continuing education course on social determinants of health. Int J Equity Health. 2015 Apr 30;14:41).
We must be non-judgmental
“Briefly, this health coaching approach is based on an interactive assessment (both physical and psychological), a non-judgmental exploration of patients’ knowledge, attitudes, and beliefs, a mapping of patient behaviors that may contribute to disease progression, gauging patient motivation, and tailoring health communication to encourage health-promoting behavior change.”(Vernon LT, Howard AR. Advancing Health Promotion in Dentistry: Articulating an Integrative Approach to Coaching Oral Health Behavior Change in the Dental Setting. Curr Oral Health Rep. 2015 Sep;2(3):111-122.)
There is a lot of shame, guilt and emotional baggage associated with dental caries. We must tell them that we believe in them and they are capable of making the change. They need the positive reinforcement in order to be successful. Next time we will look at some strategies I have learned to help patients change.
How about you? Do you implement wellness coaching strategies with your patients?
Saliva is nature’s most effective protective strategy for your mouth. Resting saliva has a pH of about 6.75 and stimulated saliva has a pH of 8.0. When we begin to look at things that threaten this protection there are several that come to mind.
1. Medication Induced Xerostomia
70% of Americans take at least one medication daily, across all age demographics. Unfortunately I can’t take my patients off of their medications. So my job is to help them understand how it relates to their caries risk. I also let them know how much more susceptible they are when eating and drinking. I encourage them to keep their mouth moist and stay hydrated.
Adolescents with psychiatric conditions may be at risk for xerostomia. In this preliminary study, we estimated xerostomia prevalence in adolescents ages 9 to 17 years from an inpatient psychiatric clinic (N = 25) and examined whether: (1) gender and age were associated with xerostomia and (2) xerostomia was associated with self-reported cavities.
We used a modified 11-item Xerostomia Index to identify xerostomia (no/yes) and asked if adolescents ever had or currently have cavities (no/yes).
The mean age was 14 years (SD = 2.3) and 72% were male. Sixty percent reported xerostomia (SD = 50). There were no significant associations between xerostomia and gender (p = 0.99) or age (p = 0.66), or between xerostomia and past (p = 0.26) or current cavities (p = 0.11). Larger proportions of adolescents with xerostomia reported previous and current cavities.
“Sixty percent of adolescents from an inpatient psychiatric clinic reported having xerostomia, which may lead to increased caries risk over time. Additional research should examine the prevalence and consequences of xerostomia in high-risk adolescents.”(Kaur M, Himadi E, Chi DL. Prevalence of xerostomia in an adolescent inpatient psychiatric clinic: A preliminary study. Spec Care Dentist. 2015 Dec 21. doi: 10.1111/scd.12154. [Epub ahead of print])
2. Sjogren’s Syndrome
The photo is of a patient who was averaging 2 new caries a year, yet had impeccable home care. Her issue was she had virtually no saliva.
As North Americans live longer, have more chronic conditions and take more medications, adverse oral events are likely to increase and aggravate the symptoms of Sjögren syndrome (SS).
A total of 151 adults who self-reported having SS and who had a mean (standard deviation [SD]) age of 65.8 (11.5) years completed a survey that included questions about basic demographic information, current medical conditions, medications used (prescription and over the counter [OTC]) and the use of oral products to manage SS symptoms. Owing to the self-reporting process in our survey, the term “SS” in our study population represented a mixture of people with SS and people with dry mouth symptoms.
The mean (SD) number of daily medications recorded as prescription, OTC and oral care products were 4.9 (3.5), 4.5 (2.8) and 4.6 (1.4), respectively. Participants with four or more comorbid medical conditions (n = 74; 49.0 percent) had significant differences (P < .05) in oral symptoms compared with those who had fewer than four (n = 75; 49.7 percent). Participants who were taking fewer than four prescription and OTC medications daily (n = 61; 40.4 percent) has significant differences (P < .05) in voice hoarseness compared with those taking four or more prescription and OTC medications daily (n = 54; 35.8 percent).
The survey results indicated that medication use and comorbid medical conditions demonstrated significant differences and may have had a substantial impact on the oral symptoms in adults who self-reported having SS.
Given the prevalence of SS, obtaining an accurate and complete medical and pharmacological history has implications for dental practitioners because medication use and comorbid medical conditions have a significant impact on oral symptoms in patients with SS.(Donaldson M, Epstein J, Villines D. Managing the care of patients with Sjögren syndrome and dry mouth: Comorbidities, medication use and dental care considerations. J Am Dent Assoc. 2014 Dec;145(12):1240-7. 151 Ad, >4 Rx)
The authors used a large community sample of methamphetamine (MA) users to verify the patterns and severity of dental disease and establish a hierarchy of caries susceptibility by tooth type and tooth surface.
Using a stratified sampling approach, 571 MA users received comprehensive oral examinations and psychosocial assessments. Three calibrated dentists characterized dental and periodontal disease by using National Health and Nutrition Examination Survey protocols. The authors also collected data on substance use history and other attributes linked to dental disease.
On all dental outcome measures, MA users evidenced high dental and periodontal disease, with older (≥ 30 years) and moderate or heavy MA users disproportionately affected. Women had higher rates of tooth loss and caries, as well as a greater prevalence of anterior caries. Current cigarette smokers were more likely to manifest 5 or more anterior surfaces with untreated caries and 3 or more teeth with root caries. Nearly 3% were edentulous, and a significant percentage (40%) indicated embarrassment with their dental appearance.
MA users have high rates of dental and periodontal disease and manifest a dose-response relationship, with greater levels of MA use associated with higher rates of dental disease. Women and current cigarette smokers are affected disproportionately. The intraoral patterns and hierarchy of caries susceptibility in MA users are distinctive.
The prevalence and patterns of dental and periodontal disease could be used to alert dentists to possible covert MA use and to plan treatment. Concerns about dental appearance have potential as triggers for behavioral interventions. (Shetty V, Harrell L, Murphy DA, Vitero S, Gutierrez A, Belin TR, Dye BA, Spolsky VW. Dental disease patterns in methamphetamine users: Findings in a large urban sample.J Am Dent Assoc. 2015 Dec;146(12):875-85.)
Special needs individuals truly have special needs when it comes to dental caries. Under the direction of Drs. Steve Perlman and Allen Wong, CariFree has donated materials to begin studying these individuals and their caries needs at Special Olympics events. We are gaining the best ever data on this under served and often neglected and forgotten population.
“The subjects in this study had a high prevalence of dental caries and need for restorative care. They would benefit from parental education on diet modification, improvement of oral hygiene practices and regular dental visits.”(Oredugba FA, Akindayomi Y. Oral health status and treatment needs of children and young adults attending a day centre for individuals with special health care needs. BMC Oral Health October 2008. 22(8):30.)
How do we help patients modify their behaviors when it comes to dry mouth? What do you suggest?
Of course sugar consumption plays a large role in our patients caries risk. However even practicing 30+ years, I am still surprised to find new places sugar is showing up in my patients’ diets.
Over the years people have begun to understand the link between sugary soda and poor oral and systemic health. Many, in an effort to make healthier choices have migrated from soda to sports drinks, thinking they are doing themselves a favor. However, drinking sports drinks or supplements like GU are doing themselves a disservice.
For optimal athletic performance, an athlete requires good oral health to reduce the risk of oral pain, inflammation, and infection and thereby minimize the use of analgesics and antimicrobial agents. Increased intake, frequency, and dental contact time of carbohydrate-rich foods, sports nutrition products, and acidic carbohydrate-containing sports and energy drinks may contribute to risks of dental erosion, caries, and inflammatory periodontal conditions in the athlete, especially when he or she also exhibits dehydration and poor oral hygiene habits. Examining the athlete before he or she begins participating in a sport allows the dental care provider to determine the patient’s existing oral health, hygiene, and susceptibility to risk factors for erosion, caries, and inflammatory periodontal disease. This oral profile, in conjunction with the individual athlete’s dietary needs, can be used to establish a treatment and preventive program, including oral health education. Good oral hygiene practices and application of topical fluoride, especially via fluoridated toothpastes and topical fluoride varnishes, must be available to the athlete. Rinsing with water or a neutral beverage after exposure to carbohydrates or acidic sports nutrition products may reduce carbohydrate contact time and bring oral pH levels back to neutral more quickly, reducing the risk of caries and erosion. Finally, the dentist should encourage the athlete to consult with an experienced sports dietitian to ensure that principles of sports nutrition are being appropriately applied for the type, frequency, and duration of exercise in consideration of the individual’s oral health needs.(Broad EM, Rye LA. Do current sports nutrition guidelines conflict with good oral health? Gen Dent. 2015 Nov-ec;63(6):18-23)
“Rinsing with water or a neutral beverage after exposure to carbohydrates or acidic sports nutrition products may reduce carbohydrate contact time and bring oral pH levels back to neutral more quickly, reducing the risk of caries.”
What do we know about Sugar Sweetened Beverages?
What about 100% fruit juice?
This study that hit the NY Times and stated that 100% fruit juice would NOT contribute to dental caries. However, in the study it was a 4-6 oz can. it was consumed one time with a meal. People took the idea and ran with it. We need to be very careful about our recommendations with regard to juice. The below image shows how much juice was consumed in the study.
The results of several studies conducted in the United States show no association between intake of 100 percent fruit juice and early childhood caries (ECC). The authors examined this association according to poverty and race/ethnicity among U.S. preschool children.
The authors analyzed data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) for 2,290 children aged 2 through 5 years. They used logistic models for caries (yes or no) to assess the association between caries and intake of 100 percent fruit juice, defined as consumption (yes or no), ounces (categories) consumed in the previous 24 hours or usual intake (by means of a statistical method from the National Cancer Institute).
The association between caries and consumption of 100 percent fruit juice (yes or no) was not statistically significant in an unadjusted logistic model (odds ratio [OR], 0.76; 95 percent confidence interval [CI], 0.57-1.01), and it remained nonsignificant after covariate adjustment (OR, 0.89; 95 percent CI, 0.63-1.24). Similarly, models in which we evaluated categorical consumption of 100 percent juice (that is, 0 oz; > 0 and ≤ 6 oz; and > 6 oz), unadjusted and adjusted by covariates, did not indicate an association with ECC.
Our study findings are consistent with those of other studies that show consumption of 100 percent fruit juice is not associated with ECC.
Dental practitioners should educate their patients and communities about the low risk of developing caries associated with consumption of 100 percent fruit juice. Limiting consumption of 100 percent fruit juice to 4 to 6 oz per day among children 1 through 5 years of age should be taught as part of general health education.
“Dental practitioners should educate their patients and communities about the low risk of developing caries associated with consumption of 100% of 100% fruit juice to 4 to 6 oz. per dayfruit juice. Limiting consumption among children 1 through 5 years of age should be taught as part of general health education.”(Vargas CM, Dye BA, Kolasny CR, Buckman DW, McNeel TS, et al. Early childhood caries and intake of 100 percent fruit juice: Data from NHANES, 1999-2004. J Am Dent Assoc. 2014 Dec;145(12):1254-61. 2,290 2-5 yo) SSB/Medications
Another important area to consider is sugary medication.
AIM:An investigation was conducted in a population of pediatric patients with a high risk of caries in order to assess the association between caries history (CH) and the number of early carious lesions (ECLs) and the frequency and timing of cariogenic food and beverage intake, sugar-containing medication, the frequency and efficacy of tooth brushing, and the use of topical fluorides.
MATERIALS AND METHODS:
Study design: descriptive study. One hundred children aged 6-15 years with≥ ECL of a permanent tooth and not enrolled in any dental health educational or preventive programme were selected. For diagnosis it was used an explorer according to the ICDAS II criteria. The participants completed a closed-list questionnaire on the frequency and timing of cariogenic food intake.
There was a nonsignificant tendency to present more ECLs and a greater CH among patients who consumed cariogenic foods and beverages. A significant relationship (p<0.05) was observed between cariogenic beverages and the number of ECL or CH. Using the number of ECLs as dependent variable, regular fluoridated rinses (p=0.003), frequent sugar-containing medication (p=0.007), and cariogenic beverage consumption (p=0.024) were identified as explanatory parameters in the linear regression model.
The Student t-test was used to compare ECL and CH with dietetic factors, fluoridated rinses, sugar- containing medicines, and the frequency and efficacy of tooth brushing. Linear regression analysis correlated the number of ECLs to the mentioned explanatory variables.
The frequent consumption of sugary beverages and medications, and failure to regularly use fluoridated rinses, were positively correlated to an increased number of ECLs in patients with a high prevalence of caries.
“The frequent consumption of sugary beverages and medications, and failure to regularly use fluoridated rinses, were positively correlated to an increased number of early caries lesions (ECL)s in patients with a high prevalence of caries.”(Llena C, Leyda A, Forner L, Garcet S. Association between the number of early carious lesions and diet in children with a high prevalence of caries. Eur J Paediatric Dent. 2015 Mar;16(1):7-12. 100 6-15 yo)
In my experience, both amount and frequency of sugar consumption contribute to dental caries–not one or the other. We as practitioners need to be vigilant in our risk assessment to determine if there are sugary substances being consumed that may be putting our patients at risk.
How about you? How do you determine how often and how much sugar your patients are consuming? What do you tell them to do if it is in excess?
When discussing how diet influences dental caries risk, the number one dietary concern that comes to mind is sugar. What does the research say about the challenges we are up against when counseling patients about decreasing their sugar intake? Well, according to this study, the neurobiological response to sweet reward is more robust than that of cocaine.
“At the neurobiological level, the neural substrates of sugar and sweet reward appear to be more robust than those of cocaine (i.e., more resistant to functional failures), possibly reflecting past selective evolutionary pressures for seeking and taking foods high in sugar and calories.”(Ahmed SH, Guillem K, Vandaele Y. Sugar addiction: pushing the drug-sugar analogy to the limit. Curr Opin Clin Nutr Metab Care. 2013 Jul;16(4):434-9.)
We know sugar is a significant contributor to dental caries, but what is more detrimental to patients? Frequency of intake or the amount of sugar consumed?
What about frequency?
Food is necessary for the proper growth and development of children. The excessive intake of low-molecular carbohydrates constitutes a serious health issue, which has an unfavourable impact on the dental health status. The aim of this study was to assess the food habits in healthy children aged 6-12 years and the effect on their oral risk profile. The study included 100 children. The assessment of their nutrition was done with the help of a seven-day reproduction of the food intake and a survey used to determine their underlying food habits and preferences. The results revealed unbalanced nutrition of the children and increased intake of simple sugar, which will increase the risk of development of dental caries. The observed high levels of DMFT (number of decayed, missing and filled teeth) in 54% of the children is a logical result of the frequent intake of sugary foods and beverages for a long period of time, as this will increase the acid production by microorganisms in dental plaque, which is one of the leading etiologic factors for the development of caries. It is necessary for dentists to administer control over the carbohydrate intake and the food habits of children, as well as to encourage non-cariogenic diet in order to keep their good oral health.
“The results revealed unbalanced nutrition of the children and increased intake of simple sugar, which will increase the risk of development of dental caries. The observed high levels of DMFT (number of decayed, missing and filled teeth) in 54% of the children is a logical result of the frequent intake of sugary foods and beverages for a long period of time.”(Doichinova L, Bakardjiev P, Peneva M. Assessment of food habits in children aged 6-12 years and the risk of caries. Biotechnol Biotechnol Equip. 2015 Jan 2;29(1):200-204.100 6-12yr Diet 7 day/DMFT).
Dental caries is considered a diet-mediated disease, as sugars are essential in the caries process. However, some gaps in knowledge about the sugars-caries relationship still need addressing. This longitudinal study aimed to explore 1) the shape of the dose-response association between sugars intake and caries in adults, 2) the relative contribution of frequency and amount of sugars intake to caries levels, and 3) whether the association between sugars intake and caries varies by exposure to fluoride toothpaste. We used data from 1,702 dentate adults who participated in at least 2 of 3 surveys in Finland (Health 2000, 2004/05 Follow-up Study of Adults’ Oral Health, and Health 2011). Frequency and amount of sugars intake were measured with a validated food frequency questionnaire. The DMFT index was the repeated outcome measure. Data were analyzed with fractional polynomials and linear mixed effects models. None of the 43 fractional polynomials tested provided a better fit to the data than the simpler linear model. In a mutually adjusted linear mixed effects model, the amount of, but not the frequency of, sugars intake was significantly associated with DMFT throughout the follow-up period. Furthermore, the longitudinal association between amount of sugars intake and DMFT was weaker in adults who used fluoride toothpaste daily than in those using it less often than daily. The findings of this longitudinal study among Finnish adults suggest a linear dose-response relationship between sugars and caries, with amount of intake being more important than frequency of ingestion. Also, daily use of fluoride toothpaste reduced but did not eliminate the association between amount of sugars intake and dental caries.
“The findings of this longitudinal study among Finnish adults suggest a linear dose-response relationship between sugars and caries, with amount of intake being more important than frequency of ingestion. Also, daily use of fluoride toothpaste reduced but did not eliminate the association between amount of sugars intake and dental caries.”(Bernabé E, Vehkalahti MM, Sheiham A, Lundqvist A, Suominen AL.The Shape of the Dose-Response Relationship between Sugars and Caries in Adults. J Dent Res. 2015)
Next week we will continue the conversation about diet and dental caries.
What about you? Do you think the amount or the frequency of sugar intake contributes more to disease? Let us know in the comments below.
We have covered our therapeutic strategies, so now we wanted to move into the behavioral strategies.
There are two types of behaviors, modifiable (home care and diet) and non-modifiable (medication use and special needs).
One of the greatest behaviors we encourage in our patients is of course tooth brushing, but what does the research actually say?
Does tooth brushing prevent decay?
While it seems to be intuitive and logical, we don’t have a ton of science to support it reducing the caries rate. However, this study looked at children who were taught to brush their teeth in nursery school and then followed them over 12 years.
Nursery Tooth Brushing
We aimed to assess the association between the roll-out of the national nursery tooth brushing program and a reduction in dental decay in five-year-old children in a Scotland-wide population study. The intervention was supervised tooth brushing in nurseries and distribution of fluoride toothpaste and toothbrushes for home use, measured as the percentage of nurseries participating in each health service administrative board area. The endpoint was mean d(3)mft in 99,071 five-year-old children, covering 7% to 25% of the relevant population (in various years), who participated in multiple cross-sectional dental epidemiology surveys in 1987 to 2009. The slope of the uptake in tooth brushing was correlated with the slope in the reduction of d(3)mft. The mean d(3)mft in Years -2 to 0 (relative to that in start-up Year 0) was 3.06, reducing to 2.07 in Years 10 to 12 (difference = -0.99; 95% CI -1.08, -0.90; p < 0.001). The uptake of tooth brushing correlated with the decline in d(3)mft (correlation = -0.64; -0.86, -0.16; p = 0.011). The result improved when one outlying Health Board was excluded (correlation = -0.90; -0.97, -0.70; p < 0.0001). An improvement in the dental health of five-year-olds was detected and is associated with the uptake of nursery tooth brushing.
“The slope of the uptake in toothbrushing was correlated with the slope in the reduction of DMFT. The mean DMFT was 3.06, reducing to 2.07 in Years 10 to 12. The uptake of toothbrushing correlated with the decline in DMFT. An improvement in the dental health of five-year-olds was detected and is associated with the uptake of nursery toothbrushing.”(Macpherson LM, Anopa Y, Conway DI, McMahon AD. National supervised toothbrushing program and dental decay in Scotland. J Dent Res. 2013 Feb;92(2):109-13.99,071/5YR/1987-2009)
Last month, an interesting study highlighted:
Toothbrushing is considered fundamental self-care behavior for maintenance of oral health, and brushing twice a day has become a social norm, but the evidence base for this frequency is weak. This systematic review and meta-analysis aims to assess the effect of toothbrushing frequency on the incidence and increment of carious lesions. Medline, Embase, Cinahl, and Cochrane databases were searched. Screening and quality assessment were performed by 2 independent reviewers. Three different meta-analyses were conducted: 2 based on the caries outcome reported in the studies (incidence and increment) with subgroup analyses of categories of toothbrushing frequency; another included all studies irrespective of the caries outcome reported with the type of dentition as subgroups. Meta-regression was conducted to assess the influence of sample size, follow-up period, diagnosis level for carious lesions, and methodological quality of the articles on the effect estimate. Searches retrieved 5,494 titles: after removing duplicates, 4,305 remained. Of these, 74 were reviewed in full, but only 33 were eligible for inclusion. Self-reported infrequent brushers demonstrated higher incidence (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.34 to 1.69) and increment (standardized mean difference [SMD], 0.28; 95% CI: 0.13 to 0.44) of carious lesions than frequent brushers. The odds of having carious lesions differed little when subgroup analysis was conducted to compare the incidence between ≥2 times/d vs <2 times/d (OR: 1.45; 95% CI: 1.21 to 1.74) and ≥1 time/d vs <1 time/d brushers (OR: 1.56; 95% CI: 1.37 to 1.78). When meta-analysis was conducted with the type of dentition as subgroups, the effect of infrequent brushing on incidence and increment of carious lesions was higher in deciduous (OR: 1.75; 95% CI: 1.49 to 2.06) than permanent dentition (OR: 1.39; 95% CI: 1.29 to 1.49). Findings from meta-regression indicated that none of the included variables influenced the effect estimate.
“Individuals who state that they brush their teeth infrequently are at greater risk for the incidence or increment of new carious lesions than those brushing more frequently. The effect is more pronounced in the deciduous than in the permanent dentition.”(Kumar S, Tadakamadla J, Johnson NW. Effect of tooth brushing frequency on incidence and increment of dental caries: a systematic review and meta analysis. JDR October 2016. 5(11):1230-1236.)
So, there is evidence that tooth brushing does in fact help.
What we need to keep in mind is every time we put something in our mouth, the pH in our mouth changes. The teeth demineralize. The nano particles of Hydroxyapatite and Fluorapatite are trapped int he biofilm and immediately held back to the tooth so that when the pH raises after that episode the minerals are there, readily available to go right back into the tooth. There is a nice sense of equilibrium. If you brush your teeth, right after eating a meal or drinking an acidic beverage, especially with an abrasive toothpaste, you run the risk of increasing the erosion and surface wear of the teeth. I encourage my patients to brush their teeth before they eat. I also suggest they use a gel with nanohydroxapatite.
We do know that it takes a lot of consistent motivation to help build the motivation to brush.
Social factors determine the child’s behavior and motivation is an important task in the teaching-learning process. This longitudinal and cross-sectional study aimed to analyze the effectiveness of a motivational activity program for oral hygiene habits formation after motivation and without constant reinforcement. Materials and Methods: The sample was constituted of 26 children (mean 6 years old) from a Public Kindergarten School in Ponta Grossa, PR, Brazil. Data were collected applying a test-chart, with figures reporting the process of dental health/illness. Some figures were considered positive to dental health (dentist/Cod 1, toothbrush/Cod 3, dentifrice/dental floss/Cod 6, fruits/vegetables/Cod 7 and tooth without caries lesion/Cod 8) and negative on dental health (sweets/Cod 2, bacteria/Cod 4, tooth with caries lesion/Cod 5). The figures presentation occurred in three different stages: First stage – figures were presented to children without previous knowledge; second stage – following the motivational presentation, and third stage – 30 days after the first contact. Results: On the first stage, most children select good for the figures considered harmful to their teeth (Cod 2-88%; Cod 4-77% and Cod 5-65%). On the second stage, there was a lower percentage: 23% (P < 0.0001), 8% (P < 0.0001), and 23% (P = 0.0068) related to the Cod 2, 4, and 5. On the third stage, the results showed again an association with the good choice to these figures considered harmful (Cod 2-85%, Cod 4-65% and Cod 5-54%) similar the results obtained on the first stage. Conclusion: The motivational programs performed without constant reinforcement does not have a positive influence in changing the child’s behavior related to a better dental care.
“The motivational programs performed without constant reinforcement does not have a positive influence in changing the child’s behavior related to a better dental care.”(Teixeira Alves FB, Kuhn E, Bordin D, Kozlowski VA, Raggio DP, et al. Infant motivation in dental health: Attitude without constant reinforcement. J Indian Soc Pedod Prev Dent. 2014 Jul-Sep;32(3)
Next time we will take a look at the ever-challenging diet.
What about you? how to you encourage tooth brushing? What modifiable risk factors do you have the most trouble getting your patients to change? Let us know in the comments below!
There are certain times where probiotics are very effective, primarily with regard to gut and digestive health. However, the story of probiotics and dental caries is a little different. There have been numerous approaches to both the type of probiotics and delivery systems of them to treat dental issues. The challenge is getting the probiotic to become a permanent member of the biofilm, and to this point it has yet to be done. Another challenge is probiotics must be used every single day in order to reap the benefit, if the user stops using it for a day or two, any benefit at all is lost. In dentistry the research has not shown much impact (if any) of probiotics benefit to dental caries.
Here are two recent studies:
Probiotic L. rhamnosus?
“Frequent nutrition supply significantly increased bacterial numbers. (6Xday). Biofilms in dentin cavities compared to smooth enamel harboured significantly more bacteria. Lactobacillus rhamnosus (LGG) induced mineral loss especially in dentin cavities and under highly cariogenic conditions. LGG did not have inhibitory effects on SM, but rather contributed to the caries process in vitro.”(Schwendicke F, Dörfer C, Kneist S, Meyer-Lueckel H, Paris S. Cariogenic effects of probiotic Lactobacillus rhamnosus GG in a dental biofilm model. Caries Res. 2014;48(3):186-92. 240 bovine, 2x,6x, 10 days in vitro).
These probiotics not only didn’t treat the bacteria, they actually joined the party!
“Administration of Bifidobacterium animalis subspecies lactis BB-12 in infancy does not seem to increase or decrease the occurrence of caries by 4 years of age in a low-caries population.”(Taipale T, Pienihäkkinen K, Alanen P, Jokela J, Söderling E. Administration of Bifidobacterium animalis subsp. lactis BB-12 in early childhood: a post-trial effect on caries occurrence at four years of age. Caries Res. 2013;47(5):364-72.1-2mo-2, 4, Xyl,Sorb,Ba)
In this study the probiotic did not join the biofilm and did not have any impact on decreasing the occurrence of dental caries.
Probiotics seem like a good idea, however the research has not proven it to be very effective. I tell practitioners if they want to try it, go ahead, just don’t make it your only strategy.
What about you? Do you use probiotics with patients? Have you had success? Please let us know in the comments below.
We have discussed therapeutic treatment options over the last few weeks, but what about Silver diamine Fluoride? Where does it fit in the picture?
Is Silver Antibacterial?
We know that the Silver ion is a good antimicrobial. It inhibits the bacterial DNA replication process and interferes with cell membranes. It has been shown to be a good anti-caries agent.
The mode of action of Silver compounds on carious tooth tissues is thought to include inhibition of the demineralization process, as well as an anti-bacterial effect by interference of bacterial cell membranes, cytoplasmic enzymes and inhibition of bacterial DNA replication.
However, our understanding is incomplete
“Silver compounds have been shown to be an effective anti-caries agent; however, there is an incomplete understanding of how silver compounds prevent caries. Further research is required to help identify its most efficacious use and limitations.” (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.)
We do know that the Silver does alter bacteria leaving some acting like ‘zombies’ — they continue then to kill other bacterial cells after they are dead.
Here is a study showing success treating a young teen:
“This case report demonstrates success in treating a young teenager with severe rampant dental decay by contemporary caries control and preventive strategy.”(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).
You must be aware that the treatment will turn the decayed areas black. I use the treatment with children to arrest decay, but definitely something to discuss with the parents as it also has a bad taste.
In addition to staining the decay, Silver diamine Fluoride will stain anything it touches, so you must be very careful.
In another study comparing Silver diamine Fluoride to Fluoride varnish they found:
“The respective mean numbers of arrested carious tooth surfaces in the five groups were 2.5, 2.8, 1.5, 1.5, and 1.3 (p < 0.001). Silver diamine Fluoride was found to be effective in arresting dentin caries in primary anterior teeth in pre-school children.”(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. 375 3-5 yr old, 30 mos. SDF, FV, Cont.)
A 2009 systematic review showed higher rates of prevention and arrest compared to Fluoride varnish:
“The trials indicated that SDF’s lowest prevented fractions for caries arrest and caries prevention were 96.1% and 70.3%, respectively. In contrast, Fluoride varnish’s highest prevented fractions for caries arrest and caries prevention were 21.3% and 55.7%, respectively.”(Rosenblatt A, Stamford TC, Niederman R. Silver diamine Fluoride: a caries “silver-Fluoride bullet”.J Dent Res. 2009 Feb;88(2):116-25. Sys Rev)
Another study outlining effects after a single application found:
“Only the single application of 38% SDF with or without tannic acid was effective in arresting caries after 6 months, after 1 year, and after 2 years. Arrested Caries Treatment with 38% SDF provides an alternative when restorative treatment for primary teeth is not an option.”(Yee R, Holmgren C, Mulder J, Lama D, Walker D. Efficacy of silver diamine Fluoride for Arresting Caries Treatment. J Dent Res. 2009 Jul;88(7):644-7. 967 Nepalese single appl.)
I use the treatment a lot on seniors or those with Alzheimer’s or dementia, who are looking for a solution that increases their quality of life for an affordable price. I have had great success with this treatment.
Another study we will highlight shows Silver diamine Fluoride in comparison to glass ionimers. It proved to be just as good if not better than glass ionomers.
“The caries arrest rates were 79%, 91% and 82% for SDF, Biannual SDF and GIC, respectively…Annual application of either SDF solution or high Fluoride-releasing glass ionomer can arrest active dentine caries. Increasing the frequency of application to every 6 months can increase the caries arrest rate of SDF application.”(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. 212 3-4 yr old, 24 mos.)
Finally, this study tells us how to use the product:
“Topical application of SDF is a noninvasive procedure that is quick and simple to use. Promising results of laboratory studies and clinical trials have suggested that SDF is more effective than other Fluoride agents to halt the caries process. A review concluded that SDF is a safe, effective, efficient, and equitable caries control agent that has a potentially broad application in dentistry.”(Mei ML, Lo EC, Chu CH. Clinical Use of Silver Diamine Fluoride in Dental Treatment. Compend Contin Educ Dent. 2016 Feb;37(2):93-8.)
I see Silver diamine Fluoride as another tool we can use to help patients get a hold on their decay in order to start the restoration process. I suggest you investigate it and I would recommend all practitioners have the option available in their office.
Have a question about Silver diamine Fluoride? Ask Dr. Kutsch in the comments below!
As we continue the discussion about therapeutic strategies, take a few minutes to go back and review our information on Sodium Hypochlorite, Xylitol and pH. Today we delve into the lesser known strategy of Nano Hydroxyapatite. Nano HA is what is found in the saliva,it is what the body uses to maintain the mineralization of the teeth; and the saliva is supersaturated with Nano HA.
Studies have found that HA nano-particles produced consistent enamel remineralization in 10 minutes, formation of a surface of carbonated HA. The nanocrystals are biomimetic.
“The treatment of demineralized enamel only for ten minutes, by synthetic carbonated HA nanocrystals, induces a consistent enamel remineralization through the formation of a surface carbonate-hydroxyapatite coating. This coating is due to the chemical bond of the synthetic CHA nanocrystals biomimetic for composition, structure, size, and morphology on the surface prismatic hydroxyapatite enamel.” (Roveri N, Battistella E, Bianchi CL, et al. Surface enamel remineralization: biomimetic apatite nanocrystals and fluoride ions different effects. Journal of Nanomaterials 2009, article ID 746383, 9 pages)
“This in-vitro study documented the deposition of nanoparticle hydroxyapatite on demineralized enamel surfaces after treatment with an experimental remineralization gel.” (Kutsch VK, Kois JC, Chaiyabutr Y, Milicich GW. Reconsidering remineralization strategies to include nanoparticle hydroxyapatite. Compendium March 2013. 34(3):170-177)
It has also been documented that Nano HA outperforms fluoride in remineralization on initial enamel lesions.
“In terms of restorative and preventive dentistry, nano-hydroxyapatite has significant remineralizing effects on initial enamel lesions, certainly superior to conventional fluoride, and good results on the sensitivity of the teeth.” (Pepla E, Besharat LK, Palaia G, Tenore G, Migliau G. Nano-hydroxyapatite and its applications in preventive, restorative and regenerative dentistry: a review of literature. Ann Stomatol (Roma). 2014 Nov 20;5(3):108-14. Rev.)
It makes sense because nature uses Nano HA to remineralize the teeth, not fluoride!
In this study Nano HA was equally as effective as fluoride.
“Remineralization therapies led to statistically significant increase of enamel SMH value (P < 0.0001). None of the groups reached their original baseline level of SMH following the remineralization therapy.” (Mielczarek A, Michalik J.The effect of nano-hydroxyapatite toothpaste on enamel surface remineralization. An in vitro study. Am J Dent. 2014 Dec;27(6):287-90. 90 human enam. 3wk pH cycle)
“It was concluded that nano-hydroxyapatite and fluoride had the potential to remineralize initial enamel lesions. CPP – ACP can be used as an effective adjunct to fluoride therapy but cannot be used as an alternative to fluoride.” (Vyavhare S, Sharma DS, Kulkarni VK. Effect of three different pastes on remineralization of initial enamel lesion: an in vitro study. J Clin Pediatr Dent. 2015 Winter;39(2):149-60. SMH, SEM, 3,6,9,12 pH cyc)
At the end of the day it is all about keeping the mouth in balance. If the mouth is not in balance, figure out why. Then you can start to address how the patient can get him or herself back in balance using the therapeutic and restorative strategies discussed over the last few weeks.