John D. Featherstone, Kim Kutsch, DMD
Dental caries is a dysbiotic biofilm disease that is characterized by prolonged periods of low pH in the mouth that results in net mineral loss from the teeth. There are many documented risk factors that play a role in this disease. These risk factors include things such as metabolic behavior of the biofilm, overall bacterial load, consuming too much sugar or eating too frequently, negligent homecare, inadequate saliva function and genetic factors. When creating a strategy plan to treat this disease from a targeted medicine approach, if the patient has a bacterial load issue or metabolic dysfunction of the biofilm is suspected, an antimicrobial regimen should be considered as part of the overall strategy. This will be the case for individuals classified as high or extreme risk for new carious lesions in the near future. The question then becomes what antimicrobial agent to use?
A standard antibacterial agent for dental caries has been chlorhexidine gluconate 0.12% rinse. There is a large body of evidence supporting the use of chlorhexidine as an antiplaque agent. The chlorhexidine molecule attaches to the bacterial cell wall and eventually disrupts it. In the Featherstone treatment model, chlorhexidine is used once a day for one week every month, usually in conjunction with 5000 ppm fluoride toothpaste twice a day every day. Recent studies demonstrated excellent results with this antibacterial treatment regimen. The frequency of use of the chlorhexidine rinse was determined by bacterial testing prior to the conduct of a clinical trial in which chlorhexidine was used for one week a month and alternated with 0.05% sodium fluoride rinse for 3 weeks. In this clinical trial the combined rinse regimen reduced caries incidence by 24% and markedly reduced the cariogenic bacterial load in the mouth.1 In a targeted study with high caries risk patients, monthly behavioral support resulted in a 35% reduction in caries incidence using chlorhexidine rinse and 5000 ppm fluoride toothpaste.2 Potential complications from chlorhexidine rinse include temporary altered taste and potential stains on the teeth.
Another antimicrobial agent with scientific evidence as an antiplaque agent is sodium hypochlorite rinse. Sodium hypochlorite has been used routinely for both disinfection of endodontic canals and treating periodontal disease. Multiple studies confirm that sodium hypochlorite rinse is effective at reducing supra-gingival plaque.3,4 Sodium hypochlorite is a broad spectrum antimicrobial which disrupts the cell wall and also disturbs the biofilm infrastructure.5,6 In the Carifree protocol sodium hypochlorite rinse 0.20% is used daily one time per day. A randomized controlled clinical trial conducted on high caries risk adolescents demonstrated a 73% reduction in caries incidence over a two year period with daily rinsing, although this study remains unpublished at this date. Potential complications from sodium hypochlorite rinse are temporary altered taste and potential stains on the teeth.
When the high caries risk patient has an excessive bacterial load risk factor, targeted strategies should include some form of antimicrobial therapy in conjunction with other prescribed protective factors. In the future antibacterial agents are expected to be more effective and targeted.
Professor John Featherstone is the Dean of the School of Dentistry at the University of California, San Francisco (UCSF) and Professor of Preventive and Restorative Dental Sciences. He holds a Ph.D. in chemistry from the University of Wellington (New Zealand). His research over the past 38 years has covered all aspects of cariology (study of tooth decay) as well as laser effects on dental hard tissues. He has received numerous National and International awards, including the Norton Ross Award for excellence in clinical research from the American Dental Association (2007) and is an Honorary Fellow of the American College of Dentists. He has published over 240 papers and book chapters.
V. Kim Kutsch, DMD, received his undergraduate degree from the Westminster College in Utah and then completed his DMD at the University of Oregon School of Dentistry in 1979. He is an inventor (holding numerous patents in dentistry), product consultant, internationally recognized speaker, past president of the Academy of Laser Dentistry and the World Congress of Minimally Invasive Dentistry. He has also served on the board of directors for the World Clinical Laser Institute and the American Academy of Cosmetic Dentistry. As an author, Dr. Kutsch has published dozens of articles and abstracts on minimally invasive dentistry, caries risk assessment, digital radiography, and other technologies in both dental and medical journals and has also contributed in several textbooks. He acts as a reviewer for several journals including the Journal of the American Dental Association. He serves as CEO of Oral BioTech. As a clinician, he is a graduate and mentor in the prestigious Kois Center and maintains a private practice in Albany, Oregon.
- Featherstone JDB, White JM, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS, Zhan L, Gansky SA. Caries Res 2012;46(2):118-29.
- Chaffee BW, Cheng J, Featherstone JD. Non-operative anti-caries agents and dental caries increment among adults at high caries risk: a retrospective cohort study. BMC Oral Health. 2015 Sep 24;15(1):111. doi: 10.1186/s12903-015-0097-4.
- 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. 2014 Dec;49(6):696-702. doi: 10.1111/jre.12151. Epub 2013 Dec 14.
- Gonzalez S, Cohen CL, Galván M, Alonaizan FA, Rich SK, Slots J. Gingival bleeding on probing: relationship to change in periodontal pocket depth and effect of sodium hypochlorite oral rinse. J Periodontal Res. 2015 Jun;50(3):397-402. doi: 10.1111/jre.12219. Epub 2014 Jul 21.
- Jurczyk K1,2, Nietzsche S3, Ender C3, Sculean A1, Eick S4.In-vitro activity of sodium-hypochlorite gel on bacteria associated with periodontitis. Clin Oral Investig. 2016 Jan 12. [Epub ahead of print]
- Ruiz-Linares M1, Aguado-Pérez B2, Baca P3, Arias-Moliz MT4, Ferrer-Luque CM5. Efficacy of antimicrobial solutions against polymicrobial root canal biofilm. Int Endod J. 2015 Dec 13. doi: 10.1111/iej.12598. [Epub ahead of print]