A reader posed an excellent question to Dr. Kutsch and it is worth repeating and answering here.

Q: Dr. Kenneth Armstrong

Kim I hope you read my comment and hopefully answer some of the points I raise.
Okay, I look at a patient and try to determine the cause of the caries. Is it saliva? Well could be. The patient is on meds that cause xerostomia. What do I do about that? Take him off the meds, not likely, change the medication probably get same result. Saliva substitute, don’t know any good ones. Have him drink water throughout the day. Could try that.
Is it diet? Could modify a constant soda drinker and maybe cut back on the candies. Not sure how effective that would be.
Is it bacteria? Well, yeah, it has to be. You have to have the acid producing bacteria in your mouth to get cavities. What’s the treatment? Homecare, fluoride varnish, Xylitol, brushing twice a day.
Genetics? How do I figure that one out? Check the family? And if it is genetics, what do you do about that anyway. Would you not just recommend a good homecare routine. Would the patient do it? Maybe 20% will. But then people smoke, become obese, don’t exercise. You really have to want to change and that requires some self-discipline.
I am not sure figuring out whether it’s saliva, bacteria, diet or genetics helps you much and if you do figure it out, how that changes your approach to the disease.

A: Dr. V Kim Kutsch

Hi Kenneth: I understand your questions. I’ll do my best to explain. Dental caries is a multifactorial disease. Using a one-size-fits-all approach is not as effective as targeted strategies. Being able to determine the underlying cause and risk factors allows you to target your therapies for a more effective outcome. I have recommendations for each category and will be going through them in my webinar series, but I’ll add them here too.

Consider for a moment a patient that has a fever and an infection with other systemic symptoms. If they were suffering from a bacterial infection, providing them with the appropriate antibiotic would be a good choice. However, giving antibiotics to a person with a viral infection would be a waste of time.

Now carry this thought over to the XACT xylitol clinical trial published in JADA January 2013. They took 691 high caries risk adults and gave them 5 xylitol mints a day for 33 months. There was no difference in the decay rate of the test group and the control group. The conclusion was that xylitol is not effective in controlling dental caries. However, the secondary analysis of the data indicated that the patients in the study who primarily had root surface lesions, often associated with medication induced hypo-salivation, this group demonstrated a 40% decrease in their decay rate from just 5 xylitol mints per day. My point is, is we target our therapies, we’ll be more effective.

The same holds true in my mind for antimicrobial agents. If the patient is high caries risk but has excellent hygiene and low numbers of aciduric bacteria, putting them on antimicrobial therapy is of limited value. CHX or any other rinse won’t make up for 3 big gulps of Mountain Dew being sipped all day long.

I can’t take a person with dry mouth off of their medications, but I can help them understand how the dry mouth is affecting their decay rate and steps they might take to control it. I can’t change their DNA, but if I see a distinct pattern that we know is related to a genetic predisposition, I can again make them aware of their susceptibility and understand how acidic episodes impact their health. My recommendations based on pattern recognition are:

Bacteria: Antimicrobial therapy and/or Behavior change with Oral Hygiene Instruction

Diet: Educate the patient on limiting sweets versus limiting frequency of snacking

Saliva: Importance of staying hydrated and neutralizing their mouth following acidic episodes to support the pH

Genetic: Minimize acid exposure, support wellness

I know this is rather general, but I hope this helps. I’ll be going through this in more detail in the months to come. I appreciate your response and interest.

Kim