How Does Diet Influence Caries Risk: Part 1

written by CariFree


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).


sugar2Amount not frequency


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.


Category: Education

What About Behavioral Strategies?

written by CariFree

Tooth care concept on a blackboard Hand drawm brush apple and happy tooth

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.

One suggestion

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!

Category: Education

Should I Recommend Probiotics?

written by CariFree


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!


Bifidobacterium animalis probiotic2

“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.



Category: Education

Silver Diamine Fluoride: An Important Tool

written by CariFree

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).

I use the product Advantage Arrest and follow Steve Duffin’s technique:

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.

silver-pic-1 siver-pic-2









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.)

hole1 hole2


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!

Category: Education

What about Nano HA?

written by CariFree


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.


How about you-Do you use Nano HA strategies? Why or why not?

Category: Education

The Prescriptive Phase: pH as Therapeutic Strategy

written by CariFree

Why is pH important?

We know that long periods of low pH select for acid producing bacteria. Thus, the makeup of the biofilm can shift as a result of the pH of the oral cavity. Additionally, ‘good’ bacteria, if given the right environment (low pH) start behaving like ‘bad’ acid producing bacteria. pH is important because not only does low pH select for acid producing bacteria, it can transform good bacteria to bad bacteria. On the other hand, elevating the pH has shown to de-selct for the acid producers in favor of the ‘good’ bacteria in the biofilm.

We know that the critical pH of enamel is 5.5, which is true in the larger sense, however, you need to know how much saliva and calcium and phosphate and nano particles of nano hydroxyapetite and fluorapetite they have in their saliva, or the more mineral they have in the saliva, the lower the critical pH becomes. On the other end of the spectrum, having less saliva and less mineral created an environment where the critical pH for the enamel may be higher.


“Thus the critical pH is not a constant, because the levels of calcium and phosphate in plaque fluid vary among individuals. The more calcium and phosphate that are present in a solution, the lower the critical pH.” (Dawes C. What is the critical pH and why does a tooth dissolve in acid? JCDA December 2003. 69(11):722-24)

It is important to use products to elevate the pH, in order to try and mimic saliva and select for healthy bacteria.

“Therefore, the suppression of sugar catabolism and acid production by the use of metabolic inhibitors in oral care products, the consumption of nonfermentable sweeteners in snacks, the stimulation of saliva flow, and/or other strategies that maintain supragingival plaque at a pH around neutrality will assist in the maintenance of microbial homeostasis in plaque.” (Marsh PD. Dental plaque as a biofilm: the significance of pH in health and caries. Compend Contin Educ Dent March 2009; 30(2):76-90)


The image below shows the black spots are acid producing bacteria. The difference between the top panel and the bottom panel, is they controlled for pH. The bottom panel shows the bacteria in an elevated pH environment periodically over a period of days–ridding some of the acid producing bacteria.

“In silico modelling studies have been performed which support the concept that either reducing the frequency of acid challenge and/or the terminal pH, or by merely slowing bacterial growth, results in maintaining a community of beneficial bacteria under conditions that might otherwise lead to disease (control without killing).” (Marsh PD, Head DA, Devine DA. Ecological Approaches to Oral Biofilms: Control without Killing. Caries Res. 2015;49 Suppl 1:46-54)




pH Buffering

“No current oral products can easily change or modify xerostomia as a caries risk. However, there are some products available that contain calcium, phosphate, and pH buffering ingredients that may play a role in the reduction of caries risk.” (Chapman RJ, Roberts DR, Kugel G. Caries and Periodontal Risk Assessment and Management)

We also know that within the biofilm there is a gradient and clustering of bacteria. This shows that the way the bacteria grow are not random. There are certain bacteria always found together.

“We demonstrated that some bacterial species implicated in caries progression show selective clustering with respect to pH gradient, providing a basis for specific therapeutic strategies.” (Kianoush N, Adler CJ, Nguyen KA, Browne GV, et al. Bacterial profile of dentine caries and the impact of pH on bacterial population diversity. PLoS One. 2014 Mar 27;9(3):e92940)


pH is, therefore an important therapeutic strategy for the management of the biofilm.

When looking at both the pH and the demineralizing effect of certain products on patients with dry mouth, researchers found the CTx2 Spray had the highest pH and the same demineralization effect of tap water 0.0%.

“The average pH values are as follows: Oasis, 6.3, Bioténe Moisturizing Mouth Spray, 6.1, CTx2 Spray, 9.1, Mouth Kote, 3.0, Thayer’s, 6.3, Bioténe Oral Balance, 6.6, Rain, 7.1, tap water 6.99, and citric acid 1.33. The results (% of tooth structure lost) of the gravimetric analysis were as follows: Mouth Kote, 9.6%, Bioténe Moisturizing Mouth Spray, 4.6%, Oasis, 3.2%, Thayer’s, 2.0%, Bioténe Oral Balance, 0.0%, Rain, 0.0%, CTx2 Spray, 0.0%, tap water 0.0%, and citric acid 18.8%. There was a significant negative correlation between the pH values and the erosive potential.” (Delgado AJ, Olafsson VG, Donovan T. pH and Erosive Potential of Commonly Used Oral Moisturizers. J Prosthodont. 2015 Jul 27. doi: )


What are your thoughts? Do you use elevated pH products in your practice? Do you have questions for Dr. Kutsch about his pH elevating protocol? Let us know in the comments below.

Category: Education

The Prescriptive Phase: Xylitol as a Therapeutic Strategy

written by CariFree


In a previous blog we discussed the first prescriptive phase of caries management: Repair- Discussing remineralization, prevention and restoration and then we took on the first therapeutic strategy: Sodium Hypochlorite. Today we are going to begin the discussion of another therapeutic strategy Dr. Kutsch employs with his patients: Xylitol.

Therapeutic Strategies

  • Antimicrobial
  • Xylitol
  • pH strategies
  • Fluoride
  • Nano-HA

There are strong feelings both for and against the use of this 5 carbon sugar alcohol. There are a lot of studies out there on Xylitol. In Dr. Kutsch’s opinion, the best approach is to couple Xylitol and fluoride. The conclusion of the study is that Xylitol and fluoride have synergistic effects, Xylitol potentiates even trace amounts of fluoride. A good strategy to combine them.


“This study indicates that fluoride and xylitol together have synergistic inhibitory effects on the acid production of Mutans streptococci and suggests that xylitol has the potential to enhance inhibitory effects of low concentrations of fluoride.”

Maehara H, Iwami Y, Mayanagi H, Takahashi N. Synergistic inhibition by combination of fluoride and xylitol on glycolysis by mutans streptococci and its biochemical mechanism. Caries Research November December 2005. 39(6):521-528


We all remember this study: Bader JD, Vollmer WM, Shugars DA, et al. Results from the Xylitol for Adult Caries Trial (X-ACT). J Am Dent Assoc. 2013 Jan;144(1):21-30. 691 Ad, 33 mo.

Where 5 xylitol mints were given to a group of high caries risk patients, and the results were nil.

“Daily use of Xylitol lozenges did not result in a statistically or clinically significant reduction in 33-month caries increment among adults at an elevated risk of developing caries.”


HOWEVER, when looking back at the results, they found that for patients with root surface caries, the results were quite profound:


“Participants in the xylitol arm developed 40% fewer root caries lesions (0.23 D2FS/year) than those in the placebo arm. Among these caries-active adults, xylitol appears to have a caries-preventive effect on root surfaces.”

Ritter AV, Bader JD, Leo MC, Preisser JS, Shugars DA, Vollmer WM, Amaechi BT, Holland JC. Tooth-surface-specific Effects of Xylitol: Randomized Trial Results. J Dent Res. 2013 Jun;92(6):512-7. 620/21-80/12/24/33MO

The lesson here, as practitioners we need to target our therapy recommendations to our patient’s needs.


For more on Dr. Kutsch’s take on Xylitol listen to: Sugar and Xylitol, What you Need to Know


What do you think? How has Xylitol played a role in your therapeutic strategy?

Category: Education

Video Resource: A Healthy Mouth for Your Baby

written by CariFree

babybigstock-140308241This video by the National Institute of Health offers a brief video going over several caries risk factors for infants. While comprehensive, is there anything you would add to the video? There was no mention, for example, of vertical transmission. What do you think of the video? Would your patients watch it? Why or why not? What would you change or add (if anything) to make it more relevant to your patients?






Category: Miscellaneous

The Prescriptive Phase: Sodium Hypochlorite as a Therapeutic Strategy

written by CariFree

antimicrobialIn a previous blog we discussed the first prescriptive phase of caries management: Repair. Discussing remineralization, prevention and restoration. Today we are going to begin the discussion of therapeutic strategies Dr. Kutsch employs with his patients. His list includes:

Therapeutic Strategies

  • Antimicrobial
  • Xylitol
  • pH strategies
  • Fluoride
  • Nano-HA



Today we will begin with Antimicrobials.


Antimicrobial Strategy- Sodium Hypochlorite

When discussing antimicrobial agents, Dr. Kutsch prefers sodium hypochlorite.

4 Key points about Sodium Hypochlorite




1. It is broad spectrum

Sodium Hypochlorite is safe, effective and has a broad spectrum of activity. It has been recommended for periodontal disease by Jorgensen Slots for years, and Dr. Kutsch has been using it for dental caries management for over a decade.

“0.1- 0.5% sodium hypochlorite for patient self care. These antiseptics have significantly broader spectra of antimicrobial action, are less likely to induce development of resistant bacteria and adverse host reactions, and are considerably less expensive than commercially available antibiotics in controlled release devises.”

Jorgensen MG, Aalam A, Slots J. Periodontal antimicrobials—finding the right solutions. Int Dent J February 2005. 55(1):3-12

In addition, a 3 year clinical trial in Queensland, Australia where two high-risk groups of school children were treated. One group treated with a placebo fluoride rinse and the other with the CariFree Treatment Rinse. The results?


2. Reduced caries index

“The placebo fluoride rinse reduced the mean caries index by 29%, and the Carifree Treatment Rinse reduced the caries index by 73% over a 3-year period. There was no additional benefit after 2 years of use.”

Hallett KB, O’Rourke PK. Oral biofilm activity, culture testing and caries experience in school  3-year double-blind randomized clinical trial. Queensland, Australia 2007-2010

Also, while this study was done looking at perio patients, the decrease in dental plaque cannot be overlooked.


3. Marked decrease in dental plaque levels

“A twice-weekly oral rinse with 0.25% sodium hypochlorite produced marked decreases in dental plaque level and bleeding on probing and may constitute a promising new approach to the management of periodontal disease. Long-term controlled studies on the effectiveness of sodium hypochlorite oral rinse are needed and encouraged.”

Galván M, Gonzalez S, Cohen CL, Alonaizan FA, Chen CT, Rich SK, Slots J. Periodontal effects of 0.25% sodium hypochlorite twice-weekly oral rinse. A pilot study. J Periodontal Res. 2013 Dec 14. 30PDD, 15/15,0,2wk, 3 mos, Subgingirrig


4.   Dissolves biofilm

“Overall, 2.5% NaOCl dissolved and killed bacteria significantly more efficiently when used against polymicrobial mature biofilm on human dentine. Cetrimide improved the antimicrobial activity of chlorhexidine and alexidine.” 

Ruiz-Linares M, Aguado-Pérez B, Baca P, Arias-Moliz MT, Ferrer-Luque CM. Efficacy of antimicrobial solutions against polymicrobial root canal biofilm. Int Endod J. 2015 Dec 13. doi: 10.1111/iej.12598

We have been using sodium hypocholorite during root canals for nearly 100 years. One of the greatest challenges to treating dental caries is penetrating the biofilm. To Dr. Kutsch, Sodium Hypochlorite is the best option to date.


What are your thoughts? What is your go-to antimicrobial and why? Share in the comments below.


Category: Education

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