Fight Back! Proactively Addressing the Caries Process

[DrAnil]

Fight Back! Proactively Addressing the Caries Process

 

THE CARIES PROCESS: A BRIEF OVERVIEW

There is a call to action for the profession of dental hygiene to employ the same standards in caries assessment, prevention, and subsequent management as we have in our treatment of periodontal disease. With the vast array of new and innovative products designed to assist both chairside and self-care protocols, we may emerge confident in having a strong impact on preventive intervention. The understanding of the mechanism of both the disease and its prevention is critical in counterbalancing the effects of today’s modern lifestyle. The need to intervene in the earliest stages of caries development cannot be overstated.
Dental caries is ranked as the most prevalent global disease even though we have witnessed a significant reduction during the past several decades. It is defined as a “dynamic disease process” which is caused by acids from bacterial metabolism diffusing into enamel and dentin creating dissolution of the tooth matrix.¹ The disease itself is an infectious, communicable disease that, if left untreated, can lead to pain, infection, tooth loss, and cellulitis of significant proportion. The psychological trauma associated with emergency-based care, although not measurable, can be debilitating. The process of dental caries is now well understood and is not the enigma it once was. However, there has been debate about whether early caries turns into eventual cavitation, and whether the different types of caries are both comparable and predictive.² The predominant bacteria implicated in the process is Streptococcus mutans, which is a gram-positive facultatively anerobic bacterium and an early colonizer in plaque biofilm. The microbe was initially isolated by J. Clarke in 1924. In addition to describing S mutans, he introduced the concept of microbial succession with different bacteria being dominant at different stages of the caries process.³ The clinical significance of this finding becomes essential in the development of a rational approach to risk assessment and the introduction of mechanisms of intervention.
Assessment, education, treatment, and prevention are all key components of addressing this disease successfully. One of the most critical factors is the recognition of the caries process being cyclic in nature and transitioning from demineralization to remineralization. This provides the dental hygienist with many opportunities to intervene in this dynamic process. Remineralization may be introduced with calcium and phosphate ions in conjunction with minimal amounts of fluoride facilitating a natural reparative process designed to rebuild stronger and less soluble structure than the original mineral.
The secondary challenge arises with the confrontation of making an evidence-based decision regarding product selection and treatment interventions both chairside as well as self-care recommendations. Fluoride selection falls into this category, given the immense and vast array of product availability. The ADA Council on Scientific Affairs has assisted our profession greatly by evaluating the collective body of scientific evidence as it pertains to the efficacy of professionally applied topical fluoride for caries prevention.⁴The recommendations were published as a guide, rather than a requirement or regulatory statement, to assist the dental professional in the selection of an effective product. MedLine and the Cochrane Database of Systematic Reviews were both consulted for clinical studies and systematic reviews of professionally applied topical fluoride including gels, foams, and varnishes. The evidence was further graded and classified according to the strength of the recommendations as well as the highest category of evidence. There was clear, strong evidence to support the recommendation of fluoride varnish for prevention of caries in children and adolescents.⁵ New innovations in fluoride varnish have prompted a shift, with one of the most compelling rationales being the prolonged contact time that fluoride varnish provides.

Figure 1. 3M ESPE Preventive Measures Oral Health Risk Assessment and Management.	Figure 2. 3M ESPE Caries Risk Assessment Form.

The primary benefits of topical fluoride include inhibition of demineralization, enhancement of remineralization, and inhibition of bacterial enzymes. Low but slightly elevated levels of fluoride in saliva and plaque help prevent and reverse caries by inhibiting demineralization and enhancing remineralization.⁶ Remineralization may be further enhanced by providing calcium and phosphate in conjunction with minimal amounts of fluoride. This is due to the fact that fluoride acts as a catalyst and influences reaction rates with dissolution and transformation of various calcium phosphate mineral phases within tooth structure and reacts within the plaque adjacent to tooth surfaces.⁷ Continuous low levels of a slow release extended contact fluoride varnish containing both calcium and phosphate in a resin-modified glass ionomer applied to site-specific areas of demineralization provide further protection against demineralization and acid erosion.
Complimentary remineralization strategies may be employed in daily self-care regimens that are simple to incorporate into oral health practices. When the bacterial challenge is high and/or pH is lowered, there is a volatile oral environment that emerges. The added consideration of inadequate salivary flow to provide a buffering capacity further tips the scale towards demineralization. The remineralization process can be successfully integrated through the selection of remineralization toothpastes. Calcium and phosphate technologies such as the casein protein (CPP-ACP) as well as bioactive glasses containing NovaMin have been more recently developed to improve upon the earlier calcium phosphate products.
Recaldent (CPP-ACP) results in localization of CPP-ACP at the tooth surface by binding to dental plaque biofilm both in the microorganisms and in the extracellular matrix. Higher concentration fluoride toothpastes in combination with both calcium and phosphate have also been developed, producing favorable results when the dose response relationship was observed clinically.^8,9NovaMin is a sodium calcium phosphosilicate glass that releases calcium and phosphate ions in an aqueous environment such as saliva. Sodium ions are the driving mechanism that exchange with hydrogen cations allowing both calcium and phosphate ions to be released. The result is a rapid and continuous release and deposition of a natural crystalline hydroxyl-carbonate apatite layer that is chemically and structurally the same as tooth mineral.^10,11 
Nature also provides a “secret weapon” to fight back effectively against the caries process, and that product is xylitol. Xylitol is a 5 carbon sugar alcohol or polyol that cannot be metabolized by S mutans resulting in starvation or inability to assist in the demineralization or dissolution of tooth structure. The American Academy of Pediatric Dentistry has recognized the benefits of caries strategies implementing xylitol. Their recommendations were based on the overwhelming clinical data which underlines the caries reduction effects of xylitol. Their goal was to “assist oral healthcare professionals make informed decisions about the use of xylitol-based products in caries prevention.”¹² Studies suggest xylitol intake that consistently produces positive results ranged from 4 to 10 g per day divided into 3 to 7 consumption periods.^13-16

Figure 3. Post-treatment oral hygiene instruction.	Figure 4. Philips Sonicare FlexCare+ with UV Sanitizer.
Figure 5. Pretreatment demineralization on tooth No. 7.	Figure 6. Two weeks post-treatment VANISH XT (3M ESPE) on tooth No. 7.

CARIES RISK ASSESSMENT
Our standards for the practice of dental hygiene include risk assessment in order to facilitate patient-centered comprehensive care. Caries risk assessment and caries management by risk assessment exemplify a rapidly changing facet of the dental hygiene process.^17,18 The dental hygienist plays an integral role in risk assessment determining not only the development and implementation of preventive interventions but also the evaluation of successful treatment outcomes. Risk assessment is not intended to replace clinical judgment regarding individual patient circumstances but rather to aid in applying a comprehensive approach identifying treatment options to achieve and maintain oral health.
Today’s youth is bombarded with nutritional choices that serve to compromise the oral environment. Soft drinks with low pH and corresponding high sucrose levels as well as the advent of energy drinks provide an ideal environment for demineralization. Demineralization happens in an oral environment that falls below a pH of 5.5. The average soft drink or energy drink has a pH of 2.5 to 3.
There are a number of caries risk indicators as well as protective factors that need to be weighed in order to develop an effective individualized treatment plan (Figure 1). It becomes imperative that daily biofilm management incorporating effective plaque removal and remineralization strategies coupled with education all serve to provide optimal oral health.
The following case report has encompassed risk assessment as part of the assessment phase of the dental hygiene process of care. The product recommendations both for chairside as well as self-care selections are by no means a comprehensive listing of all available therapies. They have been selected to illustrate a patient specific treatment plan.

CASE REPORT
The patient was a 16-year-old female with a noncontributory medical history.
She had a history of routine preventive care and active orthodontic treatment for 3 years (debonded in 2007). Plaque had been noted on several appointments around orthodontic brackets while in active treatment, and she was prescribed home fluoride rinses in past which she was unable to tolerate. Several areas of interproximal incipient caries were noted in 2010; however oral hygiene status had been noted as improving over the last 6 to 12 months. Her care had also included radiographs taken every 6 to 12 months to assess incipient lesions, and in-office fluoride rinse was provided to her at 6 month intervals.

Oral Hygiene Status
Light plaque was visible along gingival margin in posterior areas; both lingual and buccal. Posterior interproximal bleeding on probing was localized to Nos. 2, 3, 14, 15, 18, and 31; all periodontal probing were depths < 3 mm.

Risk Assessment
High risk factors

• Caries restored in the past 3 years
• Frequent (> 3x/daily) between meal snacks of sugars/cooked starch
• Fixed orthodontic retainers on upper/lower arch.

Moderate risk factors

• Deep pits and fissures
• Interproximal enamel lesions/radiolucencies
• Other white spot lesions or occlusal discoloration.

Protective factors

• Lives/attends school in fluoridated community
• Uses over-the-counter fluoride dentifrice daily
• Salivary flow visually adequate (Figure 2).

Clinical Assessment Summary

• Permanent dentition; Nos. 1, 16, 17, and 32 unerupted
• Occlusal restorations present on teeth Nos. 2, 15, 18, and 31
• Pit and fissure sealants on Nos. 3, 14, 19 and 30
• Fixed lingual orthodontic retainers from teeth Nos. 7 to 10 and 22 to 27
• Demineralization noted on 6 mesiolabial, 7 labial and mesiolabial, 8 distolabial and mesiolabial, 9 distolabial, 22 labial, 23 mesiolabial, 24 distolabial and mesiolabial, 25 mesiolabial and distolabial, 26 mesiolabial, 29 buccal, 30 buccal
• Incipient lesions were noted clinically as well as supported by radiographic evidence on 7 mesial, 8 mesial and distal, 9 mesial and distal, 23 mesial, 24 mesial and distal, 25 mesial.

Patient Participation and Comments

• Infrequent flossing
• Difficulty tolerating fluoride rinses both chairside and with self-care
• Brushing twice a day and immediately following ingestion of any soft drinks with a manual toothbrush.

Discussion
Upon completion of risk assessment, the patient was placed in a high-risk category due to having caries restored in the past 3 years. There was also a number of moderate risk factors noted that would automatically place the patient in a high-risk category. The patient stated that she would consume soft drinks during the day and immediately following consumption would brush her teeth. The patient was provided with additional oral hygiene education informing her of the effects of acid erosion and the need to wait a minimum of 30 to 60 minutes before brushing her teeth19 (Figure 3) (Read and Watch video 1).
A power toothbrush was also recommended to meet the specific needs of the patient. One of the main reasons for the suggestion of a power toothbrush is supported by the numerous studies suggesting that a power toothbrush has been found to remove significantly more plaque than a manual toothbrush when used for one minute of brushing. The Philips Sonicare FlexCare+ with UV sanitizer was recommended for a number of reasons for this particular patient. The Philips Sonicare FlexCare+ has an integrated UV sanitizer that effectively kills up to 99% of selected microorganisms on selected toothbrush heads including S mutans, the predominant microorganism associated with the caries process.20 The patient reported infrequent and intermittent flossing. Through the patented technology of dynamic fluid force, Sonicare FlexCare+ has been studied resulting in conclusive evidence that it is able to remove interproximal biofilm beyond the reach of the bristles at a distance of 2 to 4 mm.²1 This will aid in delivering the remineralization toothpaste into a number of noted demineralized areas and interproximal incipient lesions (Figure 4).
The patient was placed on a 3-month interval with a recommended application of fluoride varnish (Figures 5 and 6) (Read and Watch video 2). Extended contact fluoride varnish was placed in site-specific noted areas of demineralization (Read and Watch video 3). In the interim, a remineralization toothpaste was recommended to be used twice daily containing calcium and phosphate as well as a therapeutic regiment of xylitol chewing gum taken after each meal and snack. A radiographic prescription was provided to assess radiolucent areas at regular intervals until the caries risk category had been diminished. Further salivary assessment and bacterial culture testing has also been recommended as well as subsequent caries evaluation using caries detection devices.

CONCLUSION
The preceding case report follows the assessment, dental hygiene diagnosis, and resulting implementation of a patient specific treatment plan. Evaluative outcomes will be measured, reassessed, and revised related to progress toward minimizing caries risk. There exists a powerful opportunity to support minimally invasive dentistry by embracing caries management by risk assessment. It’s time to fight back!

        

[drmithila]

The majority of the Germans only change their toothbrush every five to six months—not often enough to prevent unpleasant side-effects. According to a new study, using a toothbrush for a period of six months may lead to gingivitis, which in turn increases the risk of other diseases.
For the study, researchers from the University of Göttingen divided participants into two test groups. Over a period of six months, the members of one group cleaned their teeth with one toothbrush, while the participants in the other group were given a new one every four weeks.

After six months, the scientists found an increase in gingival inflammation in the group that had not changed toothbrushes. The participants in the other group showed a better overall state of oral hygiene at any time in the test phase than at the beginning of the study, particularly concerning plaque.

“The results of the study are of significant relevance to oral health in Germany,” said Dr Dirk Ziebholz, research associate at the Department of Preventive Dentistry, Periodontology and Cariology at the University of Göttingen and leader of the study. “Gingivitis can lead to other problems such as periodontitis."

According to the GfK Group, a German market research company, Germans bought an average of 2.5 toothbrushes each in 2010. However, the recommended amount is four. Families in particular tend to change their toothbrushes only rarely (2.3 toothbrushes per year). With 4.5 toothbrushes, single professionals change their toothbrush even more frequently than every three months.

Most Germans change their toothbrush when the bristles are worn-out (70 per cent) or when they are concerned that their toothbrush may no longer be hygienic (66 per cent), according to GfK.

The study was conducted in collaboration with Dr. Best, a brand of GlaxoSmithKline.

 

        

[Drsumitra]

 At bedtime, remove partial or full dentures from the mouth. Brush teeth thoroughly with soft toothbrush and regular toothpaste. Floss teeth by sliding the floss up and down each side of each tooth. Note: It is very important to remove all food and plaque from between teeth before using fluoride. Food and plaque can prevent the fluoride from reaching the surface of the tooth.
Place a thin ribbon of the fluoride gel into each upper and lower fluoride tray so that each tooth space has some fluoride. Either 0.4% stannous fluoride (Gel Kam) or 1.1% sodium fluoride (Prevident) may be used. The fluoride can be spread into a thin film that coats the inside of the trays, by using a cotton-tipped applicator, finger or toothbrush.
Seat the trays on the upper and lower teeth and let them remain in place for 5 minutes. Only a small amount of fluoride should come out of the base of the trays when they are placed, otherwise, there may be too much fluoride in the trays.
After 5 minutes, remove the trays and thoroughly expectorate (spit out) the residual fluoride. Very Important – do not rinse mouth, drink or eat for at least 30 minutes after fluoride use.
For head and neck radiation patients, begin using fluoride in the custom trays no longer than one week after radiotherapy is completed. Repeat daily for the rest of your life!! Remember that tooth decay can occur in a matter of weeks if the fluoride is not used properly.
Care for Fluoride Carriers (Trays)
Rinse and dry the trays thoroughly after each use. Clean them by brushing them with a toothbrush and toothpaste.
Occasionally, the trays can be disinfected in a solution of sodium hypochlorite (Clorox) and water. Use one tablespoon of Clorox in about one-half cup of water. Soak them for about 15 minutes.
If the trays become covered with hard water deposits, soak them in white vinegar overnight and brush them the next morning.
Do not boil the trays or leave them in a hot car as they may warp or melt.

        

[drmithila]

Researchers from India have successfully tested a method that could help dentists to identify children who are at risk of developing Early Childhood Caries, the highly virulent form of tooth decay. In clinical tests conducted on pre-schoolers from Mangalore in southern India, they reported a link between the children’s bitter taste perception of a drug used in the treatment of autoimmune disease and their oral health status.
Oral bacteria attack children early
According to the researchers, who recently published their results in the Indian Journal of Human Genetics, children who reacted to 6-n-propylthiouracil (PROP) also showed a greater dislike of sweet foods and fewer signs of tooth decay compared with those who could not taste the compound. They also had fewer dental problems than those who did not react to it, the researchers said.

They concluded that taste perception could be used as a future diagnostic tool to identify children at risk of developing dental caries at an early age. “Tasters or sweet dislikers might avoid sweet food because their oral sensations are too intense, thus making tasters less prone to decay,” they stated in the paper.

Besides testing the perception of taste through questionnaires, the researchers observed the facial expressions of the children tested when exposed to the drug.

PROP, which is used in the treatment of Graves’ disease, among other thyroid diseases, is perceived as bitter tasting by the majority of people. However, studies have suggested that one out of three is insensitive to the compound. The ability to taste the drug is controlled by a specific gene that functions as a taste receptor.

First approved in the late 1940s, PROP is currently classified as a Pregnancy Category D drug by the US FDA and, therefore, its use is limited. Reported side-effects include increased risk of agranulocytosis and liver damage, including complete renal failure.

According to figures from Yale University, five to ten children die every year from taking PROP

 

        

[drmithila]

 Seaweed bacterial enzymes could manage to thwart tooth decay.

Scientists at New Castle University in the United Kingdom have isolated an enzyme from the marine bacterium bacillus licheniformis. It has been determined that this seaweed cuts through plaque and cleans the hard-to-reach dental areas.

This bacterial enzyme is generally used to clean the hulls of ships. This information, however, may provide an alternative method for teeth scaling that removes plaque and tartar buildup in the area between the teeth and gumline. Regular brushing can’t always account for this.

While conducting this study, researchers learned that the biofilm created by the bacteria for the adhesion makes it immune to basic oral health treatment. But when the bacterium exits the bacterial colony, it gives off an enzyme that breaks down the external DNA and biofilm. There could soon be various dental products with this enzyme, including toothpaste, mouthwash, and other products.

More research is necessary on this seaweed enzyme. But if it truly does destroy the plaque that contains bacteria, it will soon become widely used.

        

[drmithila]

SMaRT Replacement Therapy™ is designed to be a painless, one-time, five-minute topical treatment applied to the teeth that has the potential to offer lifelong protection against tooth decay caused by S. mutans, the principal cause of this disease. We have extensively and successfully tested the SMaRT strain for safety and efficacy in laboratory and animal models, and we are in the process of commencing a second Phase 1 clinical trial with an attenuated version of our SMaRT Replacement Therapy.

Market Opportunity

Dental diseases are the most prevalent chronic infectious diseases in the world, affecting up to 90% of schoolchildren and the vast majority of adults. Annual expenditures on the treatment of dental caries in the U.S. are estimated to be $40 billion a year according to the Dental, Oral and Craniofacial Data Resource Center. Tooth decay is characterized by the demineralization of enamel and dentin, eventually resulting in the destruction of the teeth. Dietary sugar is often misperceived as the cause of tooth decay; however, the immediate cause of tooth decay is lactic acid produced by microorganisms that metabolize sugar on the surface of the teeth. Studies suggest that of the approximately 700 oral microorganisms, S. mutans , a bacterium found in virtually all humans, is the principal causative agent in the development of tooth decay. Residing within dental plaque on the surface of teeth, S. mutans derives energy from carbohydrate metabolism as it converts dietary sugar to lactic acid which, in turn, promotes demineralization in enamel and dentin, eventually resulting in a cavity. The rate at which mineral is lost depends on several factors, most importantly the frequency and amount of sugar that is consumed.

Fluoride is used to reduce the effect of lactic acid-based demineralization of enamel and dentin. Despite the widespread use of fluoride in public water systems, toothpastes, dental treatments and sealants, and antiseptic mouth rinses, over 50% of 5-to-9-year-olds and almost 80% of 17-year-olds in the United States have at least one cavity or filling, according to the U.S. Surgeon General. In addition to non-compliance with the behavioral guidelines of the American Dental Association such as routine brushing and flossing, there are several factors that are likely to increase the incidence and frequency of tooth decay, including increasing consumption of both dietary sugar and bottled water. Bottled water generally does not contain fluoride, and thus does not impart any of the protective effects of fluoridated water from public systems. In 2008, U.S. consumers drank more bottled water than any other alcoholic or non-alcoholic beverage, with the exception of carbonated soft drinks, according to the Beverage Marketing Corporation.

 

 replacement therapy technology is based on the creation of a genetically altered strain of S. mutans, called SMaRT, which does not produce lactic acid. Our SMaRT strain is engineered to have a selective colonization advantage over native S. mutans strains in that SMaRT produces minute amounts of a lantibiotic that kills off the native strains but leaves the SMaRT strain unharmed. Thus SMaRT Replacement Therapy can permanently replace native lactic acid-producing strains of S. mutans in the oral cavity, thereby potentially providing lifelong protection against the primary cause of tooth decay. The SMaRT strain has been extensively and successfully tested for safety and efficacy in laboratory and animal models.

SMaRT Replacement Therapy is designed to be applied topically to the teeth by a dentist, pediatrician or primary care physician during a routine office visit. A suspension of the SMaRT strain is administered using a cotton-tipped swab during a single five-minute, pain-free treatment. Following treatment, the SMaRT strain should displace the native, decay-causing S. mutans strains over a six to twelve month period and permanently occupy the niche on the tooth surfaces normally occupied by native S. mutans.

Tooth decay is a largely preventable disease through implementation of an appropriate oral care hygiene program including brushing, flossing, irrigation, sealants and antiseptic mouth rinses. Nevertheless, tooth decay remains the most common chronic infectious disease in the world, which indicates that the lack of patient compliance with an overall oral care regimen remains a critical issue in tooth decay prevention. We believe that SMaRT Replacement Therapy addresses the issue of patient compliance by requiring only a one-time, five-minute treatment for the potential lifelong prevention of tooth decay.

The SMaRT strain has been extensively and successfully tested in the laboratory as well as in animal models , and has demonstrated the following:

 No lactic acid creation under any cultivation conditions tested;

 Dramatically reduced ability to cause tooth decay;

 Genetic stability as demonstrated in mixed culture and biofilm studies and in rodent model studies;

 Production of a level of MU1140 that is comparable to its wild-type parent strain, which was previously shown to readily and persistently colonize the human oral cavity;

 Aggressive displacement of native, decay-causing strains of S. mutans and preemptive colonization of its niche on the teeth of laboratory rats.

In addition, during preclinical and early-stage clinical testing of our SMaRT Replacement Therapy, we observed the following:

 No adverse side effects in either acute or chronic testing in rodent models;

 Colonization of the treated subjects following a five-minute application of SMaRT Replacement Therapy in our first Phase 1 study using the attenuated strain;

 No adverse side effects during our first Phase 1 study.

 

 

Manufacturing

The manufacturing methods for producing the SMaRT strain of S. mutans are standard Good Manufacturing Practice, or GMP, fermentation techniques. These techniques involve culturing bacteria in large vessels and harvesting them at saturation by centrifugation or filtration. The cells are then freeze dried or suspended in a pharmaceutical medium appropriate for application in the human oral cavity. These manufacturing methods are commonplace and readily available within the pharmaceutical industry. A single dose of our SMaRT Replacement Therapy contains approximately 10 billion S. mutans cells. The SMaRT strain grows readily in a variety of cultivation media and under a variety of common growth conditions including both aerobic and anaerobic incubations. The SMaRT strain can also utilize various carbon and nitrogen sources and is highly acid tolerant. There is no significant limitation to the manufacturing scale of our SMaRT strain other than the size of the containment vessel. For our first Phase 1 clinical trial, we engaged a contract manufacturer to produce an attenuated version our SMaRT strain, using a standard operating procedure provided by us that we believe is readily transferable to outside contract manufacturers with fermentation capabilities

 

        

[Drsumitra]

A double-blind, randomized, cross-over in situ study compared enamel remineralization by chewing sugar-free gum with or without casein phosphopeptide amorphous calcium (CPP-ACP). Remineralization has been shown to be an effective mechanism of preventing the progression of enamel caries. In the study, the enamel lesions were exposed to dietary intake, and some were covered with gauze to promote plaque formation. Participants wore removable palatal appliances containing 3 recessed enamel half-slabs with subsurface lesions covered with gauze and 3 without gauze. Mineral content and plaque composition were analyzed. The study found that for both the gauze-free and -covered lesions, the greatest amount of remineralization was produced by the CPP-ACP sugar-free gum; followed by the gum without CPP-ACP; and then the no-gum control. Recessing the enamel in the appliance allowed plaque accumulation without the need for gauze. There was a trend of less remineralization and greater variation in mineral content for the gauze-covered lesions. The cell numbers of total bacteria and streptococci were slightly higher in the plaque from the gauze-covered enamel for 2 of the 3 treatment legs; however, there was no significant difference in Streptococcus mutans cell numbers. In conclusion, chewing sugar-free gum containing CPP-ACP promoted greater levels of remineralization than a sugar-free gum without CPP-ACP or a no-gum control using an in situ remineralization model including dietary intake irrespective of whether or not gauze was used to promote plaque formation.

 

        

[drmithila]

An indicator to assess caries risk of infants is very important. One conventional risk indicator is the number and/or proportions of Streptococcus mutans, but this method reflects the existing situation and is not suitable for assessing caries risk of infants that have not yet been infected with S mutans. Researchers searched for an indicator for the establishment of S mutans. To evaluate the changes caused by the establishment of S mutans in the microbiota of the infant oral cavity, the authors monitored changes in the oral microbiota of 2 predentate infants over a 3-year period and in a cross-sectional study of 40 nursery school-aged children. Saliva was cultivated on nonselective blood agar, Mitis-Salivarius agar, and Mitis-Salivarius agar supplemented with bacitracin combined with identification of selected isolates. Two longitudinal observations suggested that S mutans establishment would induce a decrease in α-haemolytic bacteria in the microbial population of the oral cavity. This suggestion was compensated with the results of the study, and it was revealed that the establishment of 103 CFU/mL of S mutans in saliva might be predicted by a microbiota comprising less than approximately 55% of α-haemolytic bacteria. The authors conclude that a decrease in the proportion of α-haemolytic bacteria in the saliva of infants is applicable as an indicator to predict the establishment of S mutans and to assess dental caries risk. This information can serve as a background for planning dental care and treatment in the infants before infection with S mutans occurs.

 

        

[Drsumitra]

Digested coconut oil is able to attack the bacteria that cause tooth decay. It is a natural antibiotic that could be incorporated into commercial dental care products, say scientists presenting their work at the Society for General Microbiology’s Autumn Conference at the University of Warwick.

The team from the Athlone Institute of Technology in Ireland tested the antibacterial action of coconut oil in its natural state and coconut oil that had been treated with enzymes, in a process similar to digestion. The oils were tested against strains of Streptococcus bacteria which are common inhabitants of the mouth. They found that enzyme-modified coconut oil strongly inhibited the growth of most strains of Streptococcus bacteria including Streptococcus mutans — an acid-producing bacterium that is a major cause of tooth decay.
Many previous studies have shown that partially digested foodstuffs are active against micro-organisms. Earlier work on enzyme-modified milk showed that it was able to reduce the binding of S. mutans to tooth enamel, which prompted the group to investigate the effect of other enzyme-modified foods on bacteria.
Further work will examine how coconut oil interacts with Streptococcus bacteria at the molecular level and which other strains of harmful bacteria and yeasts it is active against. Additional testing by the group at the Athlone Institute of Technology found that enzyme-modified coconut oil was also harmful to the yeast Candida albicans that can cause thrush.
The researchers suggest that enzyme-modified coconut oil has potential as a marketable antimicrobial which could be of particular interest to the oral healthcare industry. Dr Damien Brady who is leading the research said, "Dental caries is a commonly overlooked health problem affecting 60-90% of children and the majority of adults in industrialized countries. Incorporating enzyme-modified coconut oil into dental hygiene products would be an attractive alternative to chemical additives, particularly as it works at relatively low concentrations. Also, with increasing antibiotic resistance, it is important that we turn our attention to new ways to combat microbial infection."
The work also contributes to our understanding of antibacterial activity in the human gut. "Our data suggests that products of human digestion show antimicrobial activity. This could have implications for how bacteria colonize the cells lining the digestive tract and for overall gut health," explained Dr Brady. "Our research has shown that digested milk protein not only reduced the adherence of harmful bacteria to human intestinal cells but also prevented some of them from gaining entrance into the cell. We are currently researching coconut oil and other enzyme-modified foodstuffs to identify how they interfere with the way bacteria cause illness and disease," he said.

 

        

[drsushant]

A health committee in the United Kingdom may want to re-explore a recent decision.

The Advertising Standards Authority claimed the McDonald’s drink Fruitizz can be part of the five-a-day portions of fruit and vegetables. The five-a-day portions of fruits and vegetables is a program that encourages healthy and drinking for children.

This ruling comes in spite of the fact that the drink contains six teaspoons of sugar.

The drink comprises fruit juice concentrate, fizzy water, natural flavorings and potassium sorbate.

A serving size of 250 mL has roughly 100 calories and 25 g of sugar. These levels of sugar stem from the amount of fruit juice content. Still, these levels did not nullify its ability to be considered healthy, according to the authority that makes these rulings.

This issue was examined after a British commercial mentioned the drink’s health benefits.

The ruling calls into question the standards used to determine a food or beverage’s health value.

Based on various studies, sugary drinks have been determined to cause tooth decay and erosion. There are also various other problems that can result from sugary drinks.

Still, based on the health standards for the five-a-day guidance in the United Kingdom, this drink manages to meet the requirements.

 

        

[Drsumitra]

There may be a new way to determine the abrasiveness of toothpaste.

A group of researchers from the Fraunhofer Institute for Mechanics of Materials IWM in Halle, Germany recently conducted a study on the subject.

The cleaning particles in toothpaste were examined. These are the particles utilized to mechanically remove dental plaque. If the toothpaste is too abrasive, the tooth enamel can be damaged over time. The damage can be even more pronounced in the dentin.

The abrasive impact of a certain toothpaste on the dentin depends on the hardness level and the quantity and size of the abrasive additives. The abrasiveness was measured on a scale from 30 to 200. The values were assigned after the testers brushed over radioactively marked dentin samples.

The method used in this study differed from the traditional radiotracer system that’s used to determine the abrasiveness of toothpaste.

Human teeth were also part of this study. To achieve the results, toothpaste was diluted with water and saliva to create a solution that corresponded to the mixture of toothpaste and saliva. The friction and wear tests were conducted with a single bristle. An advanced machine was then used to carry out the tests.

The findings from the survey went into intricate details. The results were able to explain the various geometries of toothbrush filaments and how they reacted with toothpaste based on numerous factors.

 

        

[Drsumitra]

The human mouth is a community bustling with microorganisms that live there. Little knowledge exists about what factors control which types that live there and which don’t. In a new study published in Genome Research, investigators have discovered environment has a more controlling stance on determining oral microbiota, an extremely important finding in the field of oral health.

The oral microbiome starts forming as soon as a person is born. We see a plethora of bacteria brought into our mouth during childhood and as an adult, although little knowledge is known about whether nature (genes), or nurture (environment) has a more powerful influence.

Due to differences in the oral microbiome in health and diseases such as bacteremia and endicarditis, there is a need for a better understanding of the factors that effect oral microbiota communities, in order for more efficient prevention and treatment plans.

During this study, the researchers sequenced the microbial DNA found in saliva samples of a group of twins, and then paired the DNA sequences in a database to see which types of bacteria existed in each individual.

Comparing the salivary microbiomes of identical twins with the same genetic make-up and a common environment, the scientists found that their salivary microbiomes were not notably more similar than those of fraternal twins who only share half the genes. Surprisingly, this finding points to the idea that genetic relatedness is not such an important role.

"We were also intrigued to see that the microbiota of twin pairs becomes less similar once they moved apart from each other," added Simone Stahringer, first author of the study.

It was also seen from samples over time that the salivary microbiome changed the most during adolescence, suggesting behavioral changes or puberty may have a significant influence.

The researchers also uncovered another surprising find, that there is a fundamental community of bacteria that exists in all humans.

Ken Krauter, senior author of the study, explains:

"Though there are definitely differences among different people, there is a relatively high degree of sharing similar microbial species in all human mouths."

The authors believe that this study has provided a framework for future studies of the factors that control oral microbial communities. With this knowledge, people can now better understand how oral hygiene, environmental subjection to substances, methamphetamines, and even food can impact these microbes.

 

        

[Drsumitra]

The Oral Systemic Connection
The premise that oral health may influence systemic health is not new but it has undergone a number of modifications throughout the years. In 400 BC, Hippocrates reported that a patient was cured of arthritis after the extraction of an ill tooth. More recently, the theory that poor dental health can cause several systemic diseases has been called the Theory of Focal Infection. Focal infection can be traced back to the late 19th century when Dr. Willoughby Miller, an oral microbiologist, claimed that cavities played a role in the etiology of gastric problems, lung and brain abscesses, and other medical conditions.

In 1900, Dr. William Hunter, a prominent British physician, drew wide attention to these theories by presenting them in a lecture to the medical students of McGill University in Canada.

Dr. Frank Billings formally introduced the focal infection theory to American physicians. His lectures at Stanford University Medical School were published in 1916 in the book, Focal Infections. Dr. Billings went a step further than Dr. Hunter and promoted tonsillectomies and dental extractions as remedies for focal infections. Even prominent doctors like Dr. Charles Mayo (founder of the prestigious Mayo Clinic) promoted focal infection.

In 1923, Dr. Weston Price, chairman of the Research Section of the ADA, published Dental Infections, Oral and Systemic. Despite Dr. Price himself saying that more research was needed and care should be used in applying focal infection theory, Dental Infections, Oral and Systemic was used as a reference in textbooks and diagnosis guides of the early to mid 1930s.

The focal theory began to lose steam as scientists and physicians began to embrace modern “evidence-based” theories of disease. Perhaps a turning point in the popularity of focal infection was offered in an article published in the Annals of Internal Medicine in 1938. A former proponent of the theory, Dr. Russell Cecil stated that “focal infection is a splendid example of a plausible medical theory which is in danger of being converted by its enthusiastic supporters into the status of an accepted fact.” His study of 200 cases of rheumatoid arthritis documented no curative benefit of tonsillectomies or dental extractions. The final demise of the focal theory can probably be traced to a 1940 paper published in the Journal of the American Medical Association entitled, “Focal Infection and Systemic Disease: A Critical Appraisal,” by Drs. Hobart Reimann and Paul Havens. The authors showed that the theory was completely unproven.

A special 1951 issue of the Journal of the American Dental Association stated: “Many authorities, who formally felt that focal infection was an important etiologic factor in systemic disease, have become skeptical and now recommend less radical procedures in the treatment of such disorder.”

Toward the end of the 20th century, researchers began to view gingivitis and periodontal disease as an infection and chronic inflammatory condition. Like other chronic inflammatory diseases, the results can become widespread. The bacteria and their toxins can enter the bloodstream and reach distant sites, causing havoc and disease in organs throughout the body.

Beginning in the 1980s, a series of journal articles describing the association between periodontal disease and coronary heart disease (CHD), stroke and preterm birth/low-birthweight caught the attention of the medical and dental professions. While in some sense this can be construed as a return to the theory of focal infection, the response from the dental and medical professions has been more conservative. Modern investigative science uses greater sophistication in assaying data. There is a better understanding of the limits of epidemiologic studies in establishing causality and greater appreciation of the etiology of periodontal diseases and associated systemic diseases. In short, we have come to understand that the major killer diseases—cardiovascular disease (CVD) and cancer—have multiple causes and multiple risk factors.

There is no single cause for heart attacks. It is not smoking, not high blood pressure, not obesity, not high cholesterol, not stress, not lack of exercise, not genetics; and no, it is not periodontal disease. Rather it is a combination of these, and other risk factors that add layer upon layer of increased risk of suffering a heart attack. Modern science has come to understand that many chronic diseases such as CVD and cancer are multifactorial in nature, and anything that we can do to eliminate risk factors can go a long way to lengthening our lives.

In the past 2 decades there have been hundreds of studies published in the peer-reviewed medical journals that show periodontal disease is a risk factor for heart attacks. Several thousand more have been published in dental journals. Upon further investigation, it appears clear that brushing your teeth and avoiding periodontal disease really can save your life.

The modern connection between periodontal disease and CVD lies in the chronic, inflammatory nature of gum disease. Periodontal disease, simply put, is a bacterial infection of the gums and structures supporting the teeth. As with most infections throughout the entire body, gum infection leads to inflammation.

 

        

[drmithila]

Written by Sam Halabo, DMD
What causes white spots and why do they form? White spots are signs of demineralization underneath intact enamel. Bacteria produce acids which break down apatite to calcium and phosphate ions.1 When these ions are not replaced in the natural remineralization process, porosities are created within the enamel. This usually results in the underlying porosity becoming fluid-filled, developing the classic whitish discoloration associated with demineralization. This discoloration is the result of the difference in refraction of light through healthy enamel and fluid filled porosity.2 White spots can appear in primary or secondary teeth with differing intensities. Most commonly, white spot lesions are seen after orthodontic bands and brackets are removed. Some of the other causes of white spot lesions include fluorosis, hypocalcification, erosion, hypoplasia, xerostomia, tetracycline staining, and trauma. They can also be the result of arrested incipient decay that stopped progressing and remineralized.

Treatments
In the past, the primary approach to the treatment of white spots is remineralization using pastes, creams, and topical treatments. Some of these include fluoride therapy or some form of calcium phosphate paste. Teeth whitening may also be used as an option to alleviate the appearance of these white lesions but usually requires variable amounts of time. These modalities all have unpredictable degrees of success based upon published literature. Other more invasive approaches to dealing with white spot lesions include microabrasion, composite restorations, and veneers or crowns.

Diagnosis
In order to provide a good treatment plan, a proper diagnosis must be made. We have come to depend on visual examination as a primary diagnostic tool, along with probing of suspected surfaces in order to determine the location of areas of concern. Color, hardness, translucency, and opacity all play a role in diagnosing the presence of lesions.

The best way to do a visual analysis is to dry the teeth and then examine them under good lighting with high magnification. While hypocalcifications are visible wet or dry, incipient caries lesions are often visible only when enamel is dry. (Typically carious lesions are visible when dry but disappear when rewetted.) Also, the surface of an inactive white spot lesion is usually smooth and shiny, while a rough, chalky, and dull lesion can indicate an active caries lesion.
As we continue our search for minimally invasive techniques, a product called Infiltration Concept (ICON) was introduced in the United States in 2009 by DMG America. Designed to arrest the progression of incipient carious lesions, Icon gives us a great solution for treating white spot lesions with a simple technique as well. This is a great treatment for stopping early caries and removing opaque lesions, all without any drilling or need for local anesthesia. There is no shade matching necessary as this material blends with the tooth shade and eliminates the white lesions. This procedure has worked well repeatedly in our office. The procedure is simple and can even be done by auxiliary members (check your state dental practice laws).

This product fills and reinforces the pores of these lesions with a light-cured resin material. A very low-viscosity infiltrating resin (Icon-Infiltrant [DMG America]) is pulled deep into the pores of a lesion by way of capillary action. This resin fills the tooth and replaces the lost structure within the pores. The progression of caries is stopped as no further nutrients are allowed into the pores. Icon accomplishes this without changing the shade of the tooth or altering its shape. This procedure is ideally suited for patients with a history of orthodontic therapy, high acid exposure, and/or poor oral hygiene.

Icon is not indicated for patients with fluorosis, hypocalcification, erosion, tetracycline stain or trauma to the teeth. It is indicated for those lesions, both proximal and smooth surface, that are clearly the result of cariogenic bacteria. Simply put, it is indicated for lesions that are the result of acid demineralization of tooth structure.

        

[Drsumitra]

Operation Smile is celebrating its 30th anniversary with a yearlong series of events in the U.S. and abroad.

To increase awareness about the urgency of the problem cleft lip and cleft palette, Operation Smile is launching a global campaign entitled Change Forever. Operation Smile’s programs are designed to create a permanent global impact and create self-sufficiency in developing countries, according to the organization.

In October and November, more than 350 medical professionals from all over the world are volunteering for a series of anniversary surgical missions in the Philippines, where Operation Smile first started. From November 8-18 and November 22 to December 2, 2012, Operation Smile will provide approximately 16,000 healthcare evaluations and 1,400 life-changing reconstructive surgeries in 24 days through eight surgical sites.

The Change Forever global campaign will also include other events, such as the following:

A large-scale awareness campaign about craniofacial malformations to increase information for families in the U.S. who are affected by orofacial clefts, healthcare providers, and school professionals
An online and social media campaign featuring world-renowned athlete Tony Hawk, which encourages individuals to take a pledge, share their smile, and help create greater awareness of clefting and the impact a smile can make in changing a child’s life
Youth initiatives, including the 22nd annual International Student Leadership Conference in Virginia, where more than 600 students from over 20 countries will develop their philanthropic leadership skills

 

        

[Author]

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