The Adult Dental Health Survey 2009 indicated that 31 per cent of adults in England, Northern Ireland and Wales had obvious tooth decay in either the crowns or roots of their teeth, and 66 per cent had visible plaque; and this despite the fact that three out of four dentate adults were brushing their teeth at least twice a day.
Caries susceptibility
How is it then, that if 75 per cent of adults are brushing their teeth at least twice-daily, caries is still a problem?
The Adult Dental Health Survey provides one avenue of enquiry, in that: “There are social variations in dental decay with adults from routine and manual occupation households being more likely to have decay than those from managerial and professional occupational households (37 per cent compared with 26 per cent).” According to Selwitz et al (2007), all of the following contribute to a higher risk of caries: “…high numbers of cariogenic bacteria, inadequate salivary flow, insufficient fluoride exposure, poor oral hygiene, inappropriate methods of feeding infants, and poverty.”
Albertsson et al (2010) reported that: “Caries prevalence has declined during the last decades not at least by increased customary tooth cleaning with fluoridated toothpaste.” It is also recognised, however, that the effectiveness of a patient’s mechanical cleaning technique is important if fluoridated toothpaste is to achieve its greatest value in preventing caries. “In several individuals, the level of oral hygiene is still insufficient at many sites in order to provide a good plaque control consistent with oral health.”
It has also been explained that the susceptibility of teeth to dental caries varies “…according to composition, morphology, location and position…”, as each factor will affect the level of plaque retention.
Caries and its causes
As illustrated in Keyes Concept, susceptible tooth enamel, plaque biofilm and sugar metabolism leading to acid production all contribute to the development of dental caries.
Van Loveren et al (2012) reported that, “…the presence of acidogenic species [is required] for caries to develop. Caries will not develop in the absence of bacteria.” These acidogenic bacteria then need something to feed on, for example fermentable carbohydrates and sugars such as monosaccharides and disaccharides.
When fermentable carbohydrates and sugars come into contact with acidogenic bacteria, the pH in the oral cavity falls below the critical level, resulting in demineralisation. In addition: “Caries lesions develop where oral biofilms are allowed to mature and remain on teeth for long periods.”
The biological antidote, remineralisation, occurs repeatedly in most people, “…especially when the biofilm pH is restored by saliva, which acts as a buffer. The remineralised areas have a higher concentration of fluoride and less microporous enamel structure than the original tooth structure because of the acquisition of calcium and phosphates from saliva.”
It is the demineralisation and remineralistion balance that determines whether dental caries “… progresses, stops, or reverses…”
Patient lifestyle
Selwitz et al (2007) state: “…people are susceptible to the disease [dental caries] throughout their lifetime. It is the primary cause of oral pain and tooth loss. It can be arrested and potentially reversed in its early stages, but is often not self-limiting and without proper care, caries can progress until the tooth is destroyed.”
In the years since Keyes designed his caries model, it has been expanded to take into consideration modifying elements such as the significance of time in caries development, as well as lifestyle, for instance attitudes to oral hygiene, income and education level.
Since one’s way of life plays such a significant role in caries prevalence, patients may well benefit from being educated about the importance of reducing plaque and bacteria in the mouth by making tooth-friendly food and drink choices (resulting in fewer acid attacks), chewing sugar-free gum, eating a piece of cheese after a meal, and so on.
In addition, van Loveren et al (2012) have provided a list of nondairy foods, food constituents and plant extracts that possess natural anti-caries properties, such as:
- Tea
- Cranberries
- Cocoa
- Edible fungi
- Roasted coffee
- A variety of fruits and vegetables
- Wine and grapes
The researchers also looked at studies that concluded that sugar alcohols (artificial sweeteners) are “… (extremely) low or non-cariogenic.” Of particular note, they found that: “In all these experiments, xylitol stands out. With rare exceptions, xylitol is not fermented by oral microorganisms.”
Further, they note, “…it is widely believed that xylitol is superior to the other sugar alcohols for potential caries control…”.
Oral hygiene
Selwitz et al (2007) consider: “The approach to primary prevention should be based on common risk factors. Secondary prevention and treatment should focus on management of the caries process over time for individual patients, with a minimally invasive, tissue-preserving approach.”
ten Cate (2009) has written that: “By far, the most effective and widely used methods for caries prevention are fluoride-based.” However, he continues: “Studies have shown that while fluoride usage may counteract tooth destruction caused by sugar consumption, there is a limit to this repair potential.”
One year later, Albertsson et al (2010) reported that: “Dental plaque forms naturally on the teeth. In the absence of adequate oral hygiene, it can accumulate beyond levels that are compatible with dental caries, which may then develop at susceptible sites.” He continued: “During the last years, there has been a re-emerged interest in the use of mouth rinses for chemical plaque control as [an] adjunct to daily mechanical plaque control.” Indeed, mouthwashes offer the benefit of making contact with areas that are difficult to reach, helping patients to improve their home oral care.
Taking all of this on board, a new mouthwash, Listerine Advanced Defence Cavity Guard, delivers a multifactorial approach to caries prevention, integrating highly efficient fluoride delivery, plaque reduction and reduced acid production in residual plaque.
Offering efficient fluoride delivery to protect and strengthen tooth enamel against caries, it has been proven to provide nearly double the fluoride protection against dental caries versus fluoride paste (p<0.001)>in vitro. Alcohol-free, containing xylitol and mild in taste, Advanced Defence Cavity Guard helps patients work in partnership with their dental team, to protect against caries between appointments when used in conjunction with mechanical cleaning.
A lifetime burden
Selwitz et al wrote (2007): “This disease [caries] and its sequelae can cause significant pain and are expensive to treat. The burden of dental caries lasts a lifetime because once the tooth structure is destroyed it will usually need restoration and additional maintenance throughout life.”
They continue, “…a major challenge for the clinician is to detect lesions at an early stage, before surgical intervention is needed.”
With the arrival of new multifactorial products dental professionals can look forward to delivering advanced at-home treatment outcomes for their patients.
References available on request.