ORAL HEALTH DIALOGUE

1/2015

2 Editorial 3 Sugar – curing the addiction 6 A new pathway to caries prevention?10 Relieve the suffering of your patients12 What dentine sensitivity sufferers expect from their dentist14 A growing threat to quality of life

2 | ORAL HEALTH DIALOGUE | 1/2015 | 3Sugar – curing the addictionEditorial

cheap and readily available and easy to add to all kinds of foods and drinks. They appear in foods we consume throughout the day – from breakfast foods to complete ready meals. We can, if we choose; rely entirely on manufactured food in-stead of cooking anything from scratch. At www.grub4life.com we see how dietary habits are formed most acutely in young children. Lifelong taste preferences are shaped by children’s early experience of food. Regular consumption of sug-ary drinks and snacks early in life instills the same dietary habits for life. We’d be horrified if we were promoting cigarette smoking to our youngest chil-dren, yet we seem oblivious to the constant bom-bardment of obesogenic and cariogenic sugar filled foods we expose them to.

What is the role of sugar in oral health?Svante Twetman: Caries is a biofilm-mediated dis-ease and sugar plays an important role in its etiology. The oral biofilm (dental plaque) is an aggregate of dif-ferent bacteria colonizing the oral cavity in a complex ecosystem. As long as the biofilm is stable and di-verse, it contributes to the maintenance of oral health. Sugar, and especially sucrose, acts like a ‘starter’ in a car for a series of unwanted events that destabilize the biofilm and reduces its diversity. Frequent intakes of sugar boost the microbial metabolism resulting in an increased acid production in the biofilm. These ex-tended low-pH conditions will favor acid-tolerant bac-terial strains that will grow instead of less tolerant bacteria. With the beneficial and harmless bacteria outcompeted, the sugar-stressed biofilm is associat-ed with a rapid mineral loss from the dental hard tis-sues and eventually cavity formation. Sugar-exposure enhances also the production of an extracellular ma-trix within the biofilm which shields the bacteria from outside influences and makes it ‘sticky’ and hard to remove. However, the comforting thing is that the sugar-induced ecological shift in the biofilm can be reversed by an improved diet with less frequent in-takes of sugar-containing foodstuff. A stressed bio-film can regain its balance and stability only a few weeks after a diet change.

The other main challenge to the teeth, erosion, is a chemical process due to exposure of intrinsic or ex-trinsic acids (from diet). Thus, this is a life-style process independent of biofilms and bacterial metabolism.

Interview with: Prof. Svante Tewtmann and Nigel Denby

QUESTIONS

What and how much Europeans eat has changed dramatically in the last century. What are the factors for increased sugar intake? Nigel Denby, Nutritionist: The European diet has changed beyond recognition in the last century. We are now able to eat whatever we want when-ever we want it. Seasonal and regional food is a thing of the past, we eat strawberries at Christmas and can farm Scottish salmon in all four corners of the world. In many respects this is a good thing and has improved the variety of foods in our diets enormously. However, as fresh food had become abundant, there’s also been a shift towards man-ufactured convenient and ready prepared food. This has increased our intake of nutritional nasties like salt, fat and above all sugar. We’re often una-ware of what’s in these foods, and as a result we’ve lost control over what we eat. Manufactured food and drinks are full of ingredients which taste great but do us harm when consumed in excess – this is especially true of sugar.

Manufactured food and drinks are full of ingredients which taste great but do

us harm when consumed in excess – this is especially true of sugar.

It’s no accident that the increase in obesity, diabe-tes cancers and dental caries has followed the explosion of manufactured food. In short the Eu-ropean diet makes it very easy to be over fed but under nourished. Our diets have become more calorie dense and less nutrient dense.

Living standards in Europe changed significantly over the last 50 years and the price for food went down at the same time. How does this impact dietary habits? ND: It may not always seem like it but food is cheaper now than ever. Europeans on the lowest incomes no longer need to go hungry. Sadly the ingredients which make food cheap to manufac-ture do us most harm. Salt, fat and sugar are all

Sugar – curing the addictionEditorial

Welcome to our readers!

Keeping up with the pace of change in oral health technologies is a challenge for all busy professionals, so this second edition of the newly launched Oral Health Dialogue (the first of two in 2015) aims to simplify life by focusing on three key aspects – tooth decay and dentine hypersensitivity and periodontitis.

Caries is still the world’s most prevalent disease, affecting 80% of the world’s popu- lation – despite being preventable with proper oral hygiene and the appropriate toothpaste, thanks in no small part to fluoride. This second edition reflects some of the latest innovations in the progress being made towards eradica-ting cavities.

Read about the new opportunities for caries prevention made possible by modifying the dental biofilm. We are also taking a hard look at sugar from the perspectives of a dentist and a nutritionist. Sugar is much in the spotlight for its impact on obesity, diabetes and caries, but what can dental professionals do to help patients consume less of this addictive sweetness?

Our decision to tackle dentine hypersensi- tivity alongside caries may come as more of a surprise, until we reflect on the significant

suffering that it causes some patients. The impact of this pain is brought vividly to life in this issue by Prof. Dr. Hans-Günter Schaller in his account of living with the condition. Research indicates that only a small proportion of people suffering from sensitive teeth seek treatment and according to a Danish survey, only 23% of dentists ask their patients whether they suffer from hypersensitivity as part of a regular check-up. Yet, for some patients, the degree of discomfort can cause them to avoid basic oral health care routines. The impact on dental caries is very clear – hence our decision to handle the two interrelated subjects in the same issue.

Finally, we take an overview of the impact of periodontitis on the oral health of elderly people with the new chairman of Europerio 2015 Francis Hughes.

Good reading and please give us feedback on this magazine by contacting eugenio_garcia@colpal.com

Effie MataliotakiHead of European External Affairs and CommunicationsColgate-Palmolive

It has been labeled ‘the legal heroin’ by some experts fighting the rise in obesity, but sugar carries many more hidden dangers to health as nutritionist Nigel Denby and caries expert Prof. Svante Twetman tell OHD.

Effie MataliotakiHead of European External Affairs and CommunicationsColgate-Palmolive

4 | ORAL HEALTH DIALOGUE | 1/2015 | 5Sugar – curing the addictionSugar – curing the addiction

sions have been misinterpreted by many dental professionals to do nothing. In fact, the individual one-to-one dietary intervention in the dental set-ting can change behavior and we cannot simply afford to miss this opportunity to improve oral and general health. The dental recall-system with scheduled and regular follow-ups is also unique for monitoring changes over time and for re-eval-uation of disease activity. In this context, screen-ing of general medical conditions is already an integrated part of the dental check-ups in several public and private clinics in Scandinavia today.

The WHO released a report with impres- sive facts on sugars. How do you see the importance of this WHO statement? ND: Reports are all very good, they can underpin knowledge and public health messages, but in my experience they rarely promote a great deal of ac-tion. It’s no secret that too much sugar is bad. We’ve seen the effect of excess sugar in the diets of Amer-icans, we are now seeing it in Europeans. As the fast food giants and food manufacturing brands move in we are even beginning to see the same disease and poor health trends replicated in developing countries. In my view, instead of more reports what we need is research into developing less harmful food ingredients and also effective interventions to motivate people to change what they eat.

ST: The systematic review behind the WHO report by Moynihan and Kelly (2014) is compre-hensive and well-executed, establishing a clear association between caries and a sugar content exceeding 10% of the total energy intake. One should however keep in mind that the report is based on a number of ‘old’ studies conducted be-fore the widespread use of fluoride toothpaste. It is also limited to the amount of sugar while for caries development, sugar frequency is more important as stated above. For example, Arola et al (2009) found a positive relationship between sugar fre-quency and caries in 19 out of 31 papers compared with only 6 papers on sugar quantity and caries. The authors did also point out the fact that the rela-tionship between sugar and caries has weakened in recent years along with the widespread use of fluorides. Nevertheless, the WHO-report will act as an important reminder on the impact of diet on oral diseases and hopefully bring more focus on how to deliver the healthy-eating message to patients. It is almost a paradox that the ‘infamous’ Vipeholm study that provided the first prospective proofs on

Hidden sugar in foodstuff (eg fizzy drinks in particular) seems to be an issue of growing importance. How can consumers be more aware of what they eat in terms of reducing sugar intake? ND: Sugar appears in many guises. Bread, cereals, savoury sauces and many low fat products can all have sugar added to them. These foods don’t taste especially sweet so it’s only by reading labels that you’d know the sugar was there. It’s easy to consume far more sugar than you realize unless you’re a savvy label scanner. Check labels on foods you buy regularly – look to see how much of the carbohydrate value on the label comes from sugar, 15g or more per 100g is a lot!

You need to be equally vigilant about the sug-ar you consume from drinks. A lot of us don’t con-sider the nutritional value of drinks, we focus on food. Some fizzy drinks contain as much a seven teaspoons of sugar in one 330ml can. Fruit drinks are a problem too, as any dental professional knows free sugar combined with acid is the per-fect recipe for tooth decay.

ST: The hidden sugar is of course a problem and the average person is probably unaware of the fact that the sugar intake per capita exceeds 40 kg/year in most westernized countries. Sugar counselling must however be a joint responsibil-ity among all health professionals according to the ‘common risk factor approach’. An increased awareness and sugar discipline may not affect only the oral health but also overweight, diabetes and the entire metabolic syndrome. Recent sys-tematic reviews have displayed insufficient quality of evidence for various technologies for dietary interventions and I am afraid that these conclu-

sugar and caries development is nowadays almost more used in the medical ethics curriculum than in cariology.

Conventional fluoride toothpastes might not be able to protect teeth from cavities any-more. Do you consider there to be a need for a new technology to fight that issue? ND: Any development which helps to protect teeth from cavities gets my backing. Of course, as a die-titian I want people to change and improve their di-ets, but I know wide scale change take time. While we wait for change to take affect we can be thankful that tooth brushing is established in most people’s daily routine. So, if new; advanced toothpastes can help while we reduce our sugar intake they’d be a valuable part of the tool kit of solutions we need.

ST: I do not agree with the first part of the question. New and improved technologies will hopefully always appear but the sad fact is that we are under-utilizing what we already know with strong evidence. Around 25% of the population does not use fluoride toothpaste on a daily ba-sis and this figure is unfortunately higher among disadvantaged groups. Even worse, only 10% of patients use fluoride toothpaste in an optimal way (2 times per day for 2 minutes, at least 1 cm toothpaste, minimum of water rinsing after-wards) according to a questionnaire among pa-tients of all ages (Jensen et al, 2012). The main problem seems to be that the fluoride message is overlooked by dental health professionals as they take for granted that their patients already know (Jensen et al, 2014). More time is spent on mechanical cleaning than on fluoride action and there is obvious room for improvement. Conse-quently, we cannot rely only on improved tooth-paste technologies because they do not work if not used properly.

What would you recommend to patients on how they can protect their teeth better from nutritional point of view? ND: From a nutritional point of view, I’d recommend that people try to avoid sugary drinks and drink more water. I’d encourage them to a cut down on manufactured foods by inspiring people to cook more from scratch. Start with one extra home cooked family meal a week. Enjoy regular snacks but stick to foods with less or no added sugar like unsalted nuts, fresh fruit, plain popcorn, crackers and cheese or hummus and raw vegetables.

ST: On the protective side, the most important thing is to make sure that elevated fluoride levels are available in the oral biofilm over the 24-hour period to be able to influence the balance between de- and remineralization and there is a palette of commer-cial self-care products to achieve this. On the diet side, it is crucial to reduce the frequency of sucrose intake. One easy way is to skip sugar in coffee and select natural, less stressful sugars rather than re-fined and processed products. However, most of us have a sweet preference and sugars can never be totally avoided. A good way to minimize the stress is always to drink water after sugar exposure and/or stimulate saliva clearance via a sugar-free chewing gum.

References

1. Arola L, Bonet ML, Delzenne N, Duggal MS, Gómez-Candela C, Huyghebaert A, Laville M, Lingström P,

Livingstone B, Palou A, Picó C, Sanders T, Schaafsma G, van Baak M, van Loveren C, van Schothorst

EM. Summary and general conclusions/outcomes on the role and fate of sugars in human nutrition and

health. Obes Rev 2009; 10 Suppl 1: 55–58.

2. Jensen O, Gabre P, Sköld UM, Birkhed D. Is the use of fluoride toothpaste optimal? Knowledge, attitudes

and behaviour concerning fluoride toothpaste and toothbrushing in different age groups in Sweden.

Community Dent Oral Epidemiol 2012; 40: 175 – 84.

3. Jensen O, Gabre P, Sköld UM, Birkhed D, Povlsen L. ‘I take for granted that patients know’ – oral health

professionals’ strategies, considerations and methods when teaching patients how to use fluoride

toothpaste. Int J Dent Hyg 2014; 12: 81– 8.

4. Moynihan PJ, Kelly SA. Effect on caries of restricting sugars intake: systematic review to inform WHO

guidelines. J Dent Res 2014;93:8-18.

Nigel Denby Registered dietician, author and broadcaster

Svante TwetmanProfessor of Cariology at the Faculty of Health and Medical Sciences, University of Copenhagen

6 | ORAL HEALTH DIALOGUE | 1/2015 | 7A new pathway to caries prevention?

Prof. Dr. Elmar Hellwig Medical Director Department of Operative Dentistry and Periodontology University of Freiburg, Germany

an ecologically healthy oral milieu in which it is difficult for the acid-tolerating pathogens associat-ed with caries to establish themselves.

COMBINED EFFECTIVENESS OF ARGININE/CALCIUM/FLUORIDE

These findings then led to the in situ investigation of arginine-containing dental care products with respect to their caries-inhibiting effects. The re-sults were resoundingly positive. For example, one study tested toothpaste with 1.5% arginine, calcium carbonate, and 1450 ppm fluoride ions (F-) as sodium monofluorophosphate (NaMFP). An-other toothpaste contained 1.5% arginine, dicalci-um phosphate and 1450 ppm F- in the form of NaMFP. A fluoridated toothpaste (NaMFP: 1450 ppm F-) with a dicalcium phosphate base acted as the positive control, while the negative control contained NaMFP (250 ppm) also with a dicalcium phosphate base. Twenty-nine subjects participat-ed in the study and each of them was fitted with two enamel specimens held on the lower jaw by an intraoral device. The enamel specimens were subsequently demineralised by immersing them in acetic acid for 48 hours. The cross-over study re-quired the subjects to clean the enamel speci-mens twice a day, using the relevant toothpaste for one minute and then rinsing with tap water for 10 seconds. After two weeks, the enamel specimens were removed from the mouth and evaluated with microradiography (a special X-ray procedure to determine the mineral content). Toothpastes

these substances. Arginine is present in saliva in the free state (7–15 μmol/l ), and is also bound to salivary proteins and peptides. It is metabolised by the arginine deiminase (AD) system of certain mi-cro-organisms to produce ornithine, ammonia and CO2. These bacteria include Streptococcus gordonii, Streptococcus parasanguinis and Strep-tococcus mitis. Certain lactobacilli, actinomycet-es and spirochaetes have also been identified as arginolytic. A study in 2013 showed that the argi-nine deiminase activity in the biofilm on caries-free tooth surfaces was higher than that in biofilms from carious enamel or dentine. Improved availa-bility of arginine increases the activity of the en-zyme in the saliva and in the biofilm. Clinical stud-ies have shown that individuals without caries have higher ammonia concentrations and higher pH values, significantly higher free arginine levels in the saliva and greater arginine deiminase activ-ity in both plaque and saliva. The bacterial produc-tion of alkaline substances correlates very closely with a low level of caries. Laboratory tests have demonstrated that • a cariogenic biofilm can metabolise

arginine to NH3

• the corresponding metabolic pathways can be identified

• the pH of the biofilm rises with repeated administration of arginine and thus counteracts a fall in pH during a carious attack

• micro-organisms that produce basic metabolites increase with time when arginine is given regularly.

The use of fluoridated arginine toothpaste causes a shift in the bacterial population

of the plaque, towards the composition found in the biofilm of caries-free individuals.

Overall, it can be concluded from the available in vitro studies that the anticariogenic effects of a toothpaste containing arginine can be attributed primarily to its properties of stimulating the argi-nine deiminase system and making the substrate for ammonia production available to the plaque bacteria. Salivary components are also metabo-lised in this way and contribute to the greater pro-duction of alkaline substances in the plaque. The use of fluoridated arginine toothpaste also causes a shift in the bacterial population of the plaque, towards the composition found in the biofilm of caries-free individuals. This apparently results in

A new pathway to caries prevention?

Influencing biofilm metabolism

A new pathway to caries prevention?

Prof. Dr. Elmar Hellwig

The microbial biofilm usually guarantees a healthy oral cavity. But when the frequent consumption of low molecular weight carbohydrates causes repeated falls in the pH of the biofilm, an acidogenic and aciduric microflora develops, leading to demineralisation of enamel and dentine. Caries is the result of the metabolic activity of a cariogenic microbial biofilm.

Recent systematic reviews have shown that the regular use of toothpastes, varnishes, gels, and mouth rinses containing fluoride clearly reduce the development of caries. In Germany, caries prevalence declined considerably in recent years, particularly in adolescents. However, large num-bers of initial caries lesions still occur. And the prophylactic effects of fluoride are reduced in pa-tients with high caries activity. Caries prevention with fluoride products aims primarily to influence the demineralisation and remineralisation pro-cesses on tooth surfaces. However, fluorides hardly affect the caries-inducing biofilm covering these surfaces. That’s why ways of achieving bet-ter caries prevention have been sought for quite some time. With this aim in mind, calcium-contain-ing compounds such as amorphous calcium phosphate/casein phosphopeptide (ACP-CPP) have been developed for additional remineralisa-tion. Data on the clinical efficacy of these products are, however, contradictory. In 2011, the American Dental Association’s Center for Evidence-Based Dentistry declared there was no confirmed evi-dence that such products actually contribute to caries prevention. In addition, their main mecha-nism of action is once again the remineralisation of previously demineralised tooth enamel. As far as possible, new methods of caries prophylaxis should also prevent the development of initial ca- ries lesions. In this respect, it can also be said that clinical studies have not yet provided any evidence that fluoride-free toothpastes containing other in-gredients, such as nano-hydroxyapatite, protect effectively against caries.

As a result, research has increasingly fo-cussed on the importance of the cariogenic mi-crobial biofilm. At first glance, effective antimicro-bial mouth rinses might offer good possibilities for caries prevention. However, cariogenic bacteria in biofilms live in a sort of community, on which antimicrobial substances have very little effect.

Bacteria in biofilms can successfully protect them-selves against these agents, so that very much higher concentrations than are usually found in mouth rinses would be required to achieve effec-tive caries prevention.

Cariogenic bacteria in biofilms live in a sort of community, on which

antimicrobial substances have very little effect.

Mechanical oral hygiene alone, without the use of fluoride toothpaste, is also insufficient for effective prophylaxis. After the teeth have been cleaned, biofilm that contains acidophilic and aciduric or-ganisms often remains on tooth surfaces in many areas. Some micro-organisms, which are found in the ‘normal’ microflora and correlate with a healthy situation in the mouth, are able to metabolise mol-ecules from the food and saliva into ammonia (NH3). In this way, they hold the biofilm in equilibri-um and help to suppress the development of a cariogenic microflora. There even seems to be an inverse correlation between the presence of these alkali-producing micro-organisms and the preva-lence of caries. Factors including lactic acid pro-duction from low molecular weight carbohydrates and NH3 production from proteins, peptides and other molecules therefore determine the pH in bi-ofilms on the tooth surface. In turn, the pH deter-mines bacterial growth and hence the composi-tion of the bacterial population. Conversely, the buffering capacity of the biofilm also affects this parameter.

ARGININE AFFECTS BIOFILM ECOLOGY

In the 1970s, attempts were made to influence the biofilm with substances acting as buffers to con-trol the pH during cariogenic attacks. These sub-stances had to be metabolised by specific mi-cro-organisms in order to obtain certain end products such as ammonia. It was shown that the production of alkaline metabolites in the oral bio-film played an important part in caries prevention as they buffered the acids in plaque, resulting in a less cariogenic oral flora. These results gave rise to a new strategy for promoting oral health. Stu- dies by Kleinberg et al identified arginine as one of

8 | ORAL HEALTH DIALOGUE | 1/2015 | 9A new pathway to caries prevention?A new pathway to caries prevention?

THE SUGAR ACID

NEUTRALIZERTM

TECHNOLOGY

The Sugar Acid NeutralizerTM technology contains 1,5% arginine, which is:• a naturally occurring amino acid• an essential building block for proteins• naturally found in dairy products, beef, pork, poultry,

sea food, soy beans, granola, etc.• a natural part of human saliva• playing an important role in cell division, the healing of

wounds, immune function and the release of hormones• Used today in a variety of dietary supplements

containing arginine showed significantly better remineralisation than the other toothpastes. In the negative control group (250 ppm fluoride as NaM-FP, no arginine), there was even demineralisation of the enamel samples.

Clinical studies were then carried out on the efficacy of arginine-containing toothpastes, as only the clinical use of a product can provide real evidence that it is an effective caries prophylac-tic. In particular, of course, it is important to test whether a substance reduces caries to a greater extent than the fluoride gold standard.

Clinical studies have primarily focussed on toothpastes containing arginine and various cal-cium compounds. A study published by Acevedo et al in 2005 tested a fluoride-free arginine bicar-bonate/calcium carbonate toothpaste in 11- to 12-year-old schoolchildren for a period of two years: 304 children used the toothpaste designat-ed CaviStat, while 297 children acted as controls by using a toothpaste containing 1100 ppm fluo-ride. The researchers came to the conclusion that the arginine-containing toothpaste was clinically and statistically more effective than the fluoride toothpaste in preventing both the development and progression of caries. After two years, how-ever, the overall DMFS no longer showed a sig-nificant difference between the two groups. That said, considering the DMFS of the premolars and

the secondary molars, there was once again a highly significant difference in favour of the group using the arginine toothpaste.

Further development resulted in a toothpaste that contained 1.5% arginine, 1450 ppm fluoride (sodium monofluorophosphate) and a calcium component. Several studies were carried out with this toothpaste, including one which compared it with a sodium monofluorophosphate paste (1450 ppm F-) and one containing no fluoride at all. The study was carried out in five schools in Chengdu, China, and included 446 children aged between 10 and 12 years, each of whom had at least one incipient caries lesion on the buccal surface of one of the six front teeth (incisors and canines) of the upper jaw. Using a special procedure (quan-titative light-induced fluorescence, QLF), the au-thors investigated whether the size of the initial caries lesions had altered after six months on the corresponding treatment. It was a double-blind randomised controlled trial with three parallel treatment arms. All subjects had to clean their teeth with the corresponding toothpaste twice a day at home. On schooldays, they also brushed for two minutes under supervision in the afternoons.

The fluoride toothpaste with arginine reduced the average size of the lesions by 50% or more in 45% of the subjects. Only 23% of the subjects using the pure fluoride toothpaste achieved simi-lar results, while only 13% of those in the negative control group showed corresponding changes in the lesions. The authors concluded that the use of toothpaste containing both fluoride and arginine was more effective in preventing caries than the application of fluoride alone. A second study, with an almost identical study design, compared the above-mentioned arginine toothpaste (containing 1450 ppm fluoride as sodium monofluorophos-phate and a calcium carbonate base) with a tooth-paste containing 1450 ppm fluoride as sodium flu-oride. Once again, the negative control contained no fluoride. After six months, the lesion volume in the group using the arginine/fluoride toothpaste was reduced by 51%. The corresponding figure was 34% for the fluoride-only toothpaste and 13% for the negative control (figure 2). This study demonstrated that the arginine-containing tooth-paste was also more effective than a toothpaste with ionically bound fluoride. A third study with a similar design, carried out in children in Thailand, also found the arginine/fluoride toothpaste to be superior to toothpaste with fluoride alone. The

efficacy of this toothpaste has also been tested in studies with standard clinical diagnostic investi-gations of caries.

A large-scale study enrolled 6000 subjects aged between six and 12 years, each with at least four erupted permanent molars and at last one erupted central incisor. The study was a dou-ble blind randomised trial in parallel design, with 2000 subjects allocated to each group. Both test groups had moderate caries activity. Subjects were instructed to clean their teeth twice a day with the toothpaste provided. A 1.5% arginine and 1450 ppm F- (NaMFP) toothpaste was pro-duced with a calcium carbonate base. A sec-ond test toothpaste had the same arginine and fluoride content but a dicalcium phosphate base. The control product was a toothpaste contain-ing sodium fluoride (1450 ppm). The study lasted two years and at the end showed that the test toothpaste offered significantly better protection against caries than the standard sodium fluoride toothpaste. No difference was found between the two arginine test toothpastes (figure 1). The tooth-

paste with arginine, fluoride and dicalcium phos-phate also gave better results than the tooth-paste with fluoride alone with respect to arresting (re-hardening) caries-induced demineralisation on the root surfaces.

SUMMARY

The topical application of fluoridated products is still the keystone of caries prevention. Nevertheless, modification of the cariogenic biofilm has opened possible new ways of caries prevention in the future. The theoretical possibility of influencing the biofilm by alkalescent molecules such as arginine, first postulated by Kleinberg at the end of the 1970s, has been realised in products for clinical use that have been successfully put to the test. In addition, the calcium components in these products offer an opportunity of increasing the quantity of free calci-um ions for remineralisation processes after a car-ious attack on the tooth surface.

Increase in DMFT

1 year 2 year

0,7

0,6

0,5

0,4

0,3

0,2

0,1

0,0

Figure 2: Increase in DMFT after one and two years using different toothpastes

Test toothpaste

with arginine, NaMFP and

dicalcium phosphate

Test toothpaste with arginine,

NaMFP and calcium

carbonate

Positive control with NaF

35

30

25

20

15

10

5

0

Lesion volume over time

Negative control

Control product (with NaF)

Arginine/NaMFP

Lesi

on

volu

me

(mm

2 %

)

baseline 3 months 6 months

Figure 1: Volume of initial caries lesions at the start, after three months, and at the end of a clinical study using different toothpaste formulations

Incr

ease

DM

FT

1

References

E. Hellwig, Beeinflussung des Biofilm-Metabolismus, zm 104,

Nr. 15 A, 1.8.2014, 1734–1737

10 | ORAL HEALTH DIALOGUE | 1/2015 | 11Relieve the suffering of your patients Relieve the suffering of your patients

It would be natural to assume that a dental pain affecting up to 74% of the population and trouble-some enough to have an impact on eating habits and even make people avoid the dentist, would be well understood and managed – but dentine hy-persensitivity is still often ignored and under treat-ed in general practice.

Dentine hypersensitivity (DH) is relatively easily defined, but much less easy to manage. Accord-ing to the Canadian Advisory Board on Dentine Hypersensitive, 2003, it is sharp pain arising from exposed dentine in response to stimuli – typically heat, cold air, touch or acidity in food – and which cannot be ascribed to any other dental defect or disease. Pain however is subjective, which makes it difficult for both patients and dental profession-als to quantify and treat.

Many patients accept that pain is part of a dental visit and do not even consider

that anything might be done to prevent it.

According to research, only a small proportion of people suffering from sensitive teeth seek treat-ment for it, even though Norwegian figures sug-gest one in four suffer from it at least once a week. Many patients accept that pain is part of a dental visit and do not even consider that anything might be done to prevent it. While many dentists fail to

Relieve the suffering of your patients

take DH seriously – according to a Danish survey, only 23% actually ask their patients routinely about whether they suffer from it, as part of a check up.

The under reporting of DH by clinicians can be explained, in part, by the difficulties of diag-nosing it in the first place. The main symptom is pain (which is difficult to quantify in itself) and the starting point for diagnosis is the elimination of other conditions (such as fractured tooth syn-drome, leaking restorations and caries), so the dental practitioner is presented by something of a challenge, particularly in a busy practice. Estab-lishing a cause with the patient may also not be straightforward, if the emotional effects of pain act as a barrier to communication. Those clini-cians aware of the suffering caused by DH find little research literature to inform their patient management plans.

Identification of those people most at risk of developing the condition, is the starting point for DH management, as David Gillam and Elena Talioti describe in their overview of the subject. These include over-enthusiastic brushers, peri-odontally-treated patients, bulimics, people with dry mouths, high-acid food/drink consumers, older people with gingival recession and users of snuff or who chew tobacco. Once patients are identified, many treatment

options are possible, employing a wide array of desensitising products in the form of toothpastes, mouth washes, sealants and gels. Desensitising toothpastes have shown the most promise, demonstrating reductions in sensitivity of 30% to 80% when compared with other toothpastes and placebo controls. Clinical studies have document-ed that a dentifrice with 8% arginine, calcium car-bonate and 1450 ppm fluoride is more effective at reducing DH than a pumice-based toothpaste and can deliver immediate improvement in hyper- sensitivity.

Experts are increasingly agreeing that a sin-gle blanket approach to DH treatment can not be taken – it requires individual and multi-facet-ted management. The UK Expert Forum recent-ly-produced guidelines for management of the condition recommending narrowing down treat-ment options according to into which of the fol-lowing three groups individuals fall: • gingival recession due to mechanical trauma• tooth wear lesions• patients being treated for periodontal disease

The essentials for treatment are correct diag-nosis, selection of a suitable desensitising prod-uct and management of patient expectation, as no single treatment is going to work for a patient.

It may be necessary to try a variety of treatment approaches to relieve the client’s pain. Orchard-son and Gillam recommend a stepwise approach, depending on the extent, severity, and underlying cause of DH. Their steps begin with a noninvasive approach, supplemented with preventive meas-ures, and escalated to more invasive treatments if the pain is unresponsive or increasing or if the initial diagnosis may have been incorrect.

Sensitive teeth present a challenge for clients and for the professionals who care for them, but the spur to establishing better prevention and management methods is the degree of suffering experienced by individuals – whatever their walk of life.

Hypersensitivity sufferer Professor Hans-Günter Schaller, Director of Restorative Dentistry Institute at Halle (Saale) University – has given a valuable insight to OHD readers about the impact that the condition has on his life, particularly con-cerning his preparations for receiving dental treat-ment. He is one of many people who look forward to the identification of better and longer-lasting treatments.

References

1. Bekes K, John MT, Schaller H-G, Hirsch C. Oral health-related quality of life in patients seeking care for

dentin hypersensitivity. J Oral Rehabil 2008;36:45–51.

2. Zapera, Survey among dental professionals in Nordic about dentine hypersensitivity, YouGov Zapera 2009

3. David Gillam and Elena Talioti, The management of dentine hypersensitivity, http://www.sciencedirect.

com/science/article/pii/B978012801631200004X

4. Clark GE, Troullos ES. Designing hypersensitivity clinical studies. Dent Clin North Am 1990;34:531–44.

5. Docimo R, Montesani L, Maturo P, Costacurta M, Bartolino M, Zhang YP, DeVizio W, Delgado,

E, Cummins D, Dibart S, Mateo LR: Comparing the efficacy in reducingdentine hypersensitivity of a new

toothpaste containing 8.0% arginine, calcium carbonate, and 1450 ppm fluoride to a benchmark

commercial desensitizing toothpaste containing 2% potassium ion: An eightweek clinical study in Rome,

Italy. J Clin Dent 20: 137–143, 2009.

6. Docimo R, Perugia C, Bartolino M, Maturo P, Montesani L, Zhang YP, DeVizio W, Mateo LR, Dibart S.

Comparative evaluation of the efficacy of three commercially available toothpastes on dentin

hypersensitivity reduction: An eight-week clinical study. J Clin Dent 2011;22 (Spec Iss) : 121–7.

7. Orchardson R, Gillam DG. Managing dentin hypersensitivity.

J Am Dent Assoc 2006;137:990–8.

POWER OF PRO-ARGIN® CONFIR-

MED BY SYSTEMATIC REVIEW

A systematic review has confirmed the effectiveness of new toothpastes containing the Pro-Argin® technology (8% Arginine) in treating dental hypersensitivity (DH).

The meta-analyses by Boxi Yan et al at Sichuan University, Chengdu, China and published in Quintessence International General Dentistry, showed that on the basis of currently available evidence, arginine-containing toothpastes are able to reduce DH. Reviewers however agree that more research is needed to establish exactly how the mechanism works.

Examination of the 18 studies in the review indicates that arginine-containing toothpastes have a superior desensitising effect (and are thus more effective in reducing DH) in compa-rison with placebo toothpastes and potassium salt-containing toothpastes.

Previously published systematic reviews only supported the use of potassium salt-containing toothpastes in reducing DH, whilst laser therapy and toothpastes containing oxalates failed to be associated with this same effect. Arginine-containing toothpastes seem to be an effective option for clinicians to use in the management of DH.

12 | ORAL HEALTH DIALOGUE | 1/2015 | 13What dentine sensitivity sufferers expect from their dentist What dentine sensitivity sufferers expect from their dentist

Professor Hans-Günter Schaller Director of Restorative Dentistry Institute Halle (Saale) University, Germany

Prof. Hans-Günter Schaller

HOW DOES DENTINE HYPERSEN-SITIVITY AFFECT YOUR LIFE ON A DAY-TO-DAY BASIS?

I’ve had several hypersensitive teeth in both my upper and lower jaws for some time now. Despite treatment and the use of dental hygiene products intended to reduce the sensitivity, not to mention the fact that I’m getting older, they now react very painfully to cold foods and cold air. My back teeth are particularly troublesome. The problem is al-most certainly due to inadequacies in my own dental hygiene techniques over the past decades, since my youth. But it hasn’t really affected my routine oral hygiene and I’ve more or less come to terms with my sensitive teeth on a daily basis. Re-peated findings in the literature show that dentine hypersensitivity peaks between the ages of 20 and 40, and slowly diminishes with age due to the physiological defence mechanisms of the pulp-dentine complex. Unfortunately, I am not in a position to confirm these reports, as my own prob-lems are getting steadily worse, with more and more teeth being affected and the pain increasing in intensity every year.

WHAT KIND OF CHANGES HAVE YOU HAD TO MAKE TO YOUR LIFESTYLE IN RESPONSE TO THE DH?

Although my teeth are very painful at times, I’ve not made any real compromises to my oral hygiene routine or changed my diet. Yes, cold food and drinks hurt a bit, but I can usually still enjoy them. My daily oral hygiene doesn’t present any prob-lems to me. I use lukewarm water, as cold water can be thoroughly unpleasant. It goes without say-ing that I’ve been using special toothpastes for sensitive teeth for many years. All I can say about my diet is that I still drink chilled beverages and eat very cold food without limitation. I can tolerate the resulting symptoms. And although I notice the cold air outside in winter, it doesn’t restrict my lifestyle.

HOW DO YOU FEEL ABOUT SEEING A DENTAL PROFESSIONAL?

Regarding dental prophylaxis and treatment, the biggest problem is my sensitive teeth and that’s usually the main concern at any dental appoint-ment. I can not have a professional scale and polish without it hurting, and I find the procedure very stressful. Likewise, my teeth react very pain-fully to the airflow when suction is applied to the adjacent teeth, the contralateral teeth, and the opposite jaw. You can’t block everything out with a local anaesthetic, otherwise you’d have to anaesthetise all the back teeth in both jaws!

DO YOU INFORM YOUR DENTAL PRACTITIONERS ABOUT YOUR SENSITIVITY ISSUES?

As I experience a great deal of pain from sensitive teeth during prophylactic measures and dental treat-ment, I regularly inform the people involved before they start treatment. Depending on what is planned, I ask for a local anaesthetic. My own dentist, dental hygienist, and dental assistants are aware of my problem and do everything they can to make treat-ment as pleasant and painless as possible.

WHAT DO YOU EXPECT FROM YOUR DENTAL PROFESSIONALS?

I basically expect my dentist and his team to re-member that I have sensitive teeth whenever they are working inside my mouth. They should avoid causing irritation during treatment and use devic-es such as air jets, suction tubes, and probes only as much as they absolutely have to. I can’t tolerate certain treatment without a local anaesthetic, so I also expect the whole team to take this require-ment into consideration. Every time I visit the den-tist, I ask whether there’s any treatment or means of sealing off my sensitive teeth. For many years now, the professional application of an in-house product has been part of every appointment,

either as the main focus of my visit, or carried out at the end of a treatment session. This treatment has usually relieved the symptoms and greatly improved my quality of life. Unfortunately, however, the effects of this treatment don’t last very long and it has to be repeated in yet more appoint-ments, even though I back it up at home with a combination of special products – toothpaste and mouth rinses. I really wish they’d find a lasting solution to the problem through scientific research and the development of new strategies and prod-ucts for the future.

What dentine sensitivity sufferers expect from their dentist

SENSITIVITY IS STILL AN UNRESOLVED ISSUE FOR PATIENTS …

Colgate® Sensitive Pro-Relief™ toothpaste acts in 60 seconds to seal the open tubules and relieve dentine hypersensitivity*

1. Colgate® Dentist survey, UK, 20132. Colgate® Consumer survey, UK, 2013

*When toothpaste is directly applied to each sensitive tooth for 60 seconds

91% considered Colgate® Sensitive Pro-Relief™ toothpaste

to be more effective than sensitivity brands they

have used before

96% of trialists would recommend Colgate®

Sensitive Pro-Relief™ to friends and family

96%

Over 1,000 sensitivity sufferers put Colgate® Sensitive Pro-Relief™ toothpaste to the test by eating ice cream. Then they revealed their thoughts...

Sensitivity is still an unresolved issue for patients…

60SECONDS

91%

There’s an easy solution to address the sensitivity challenge!

report problems of dentine hypersensitivity2

3/5 ADULTS 29% OF ADULTSidentify dentine hypersensitivity

as the biggest cause of pain associated with visiting

their dentist2

Care for your sensitivity patients and recommend Colgate® Sensitive Pro-Relief™ toothpaste

94% of trialists agreed that Colgate® Sensitive Pro-Relief™

worked instantly to provide sensitivity relief

94%

say they see at least one patient a day who experiences dentine

hypersensitivity1

9/10 DENTISTS

1. Colgate Dentist survey, UK, 2013, 2. Colgate Consumer survey, UK, 2013

Find out more and get inspired by interesting facts on the last page of the Oral Health Dialogue.

14 | ORAL HEALTH DIALOGUE | 1/2015 | 15A growing threat to quality of life

EURO PERIO 8

June 3-6, 2015, London UK

Chaired by: Francis Hughes, Chairman of the

EuroPerio8 Organising Committee

The EuroPerio Congress has established itself as the world’s lea-ding conference in periodontology and implant dentistry, and has become the essential triennial fixture on the meetings calendar.

KEEP UP with the major issues, new trends and techniques in Periodontology, Implant Dentistry and Dental Hygienewww.efp.org/europerio8/

Prof. Dr. Francis Hughes Professor of Periodontology/ Honorary Consultant King’s College London, UK

A growing threat to quality of life

Prof. Dr. Francis Hughes

PERIODONTAL PROBLEMS IN THE OLDER PATIENT

The Ageing PopulationIssues concerning an increasingly ageing popula-tion have been widely discussed throughout the media and have enormous implications for Socie-ty. This topic impacts greatly on factors as diverse as increased pressures on Health Services through to pensions and social care issues and there is considerable concern about an ever in-creasing proportion of the population being be-yond retirement age with a consequent reduction in the proportion of the population making up the economically active workforce. Many of these people perhaps do not fit the stereotype of an el-derly person and remain fit, active and are used to having high expectations from (for example) their healthcare services.

A growing threat to quality of life

Epidemiology of PeriodontitisPeriodontal disease may present a particular chal-lenge in the older patient and the dental profes-sional needs to pay increasing attention to the periodontal health of this fast expanding group. Epidemiological studies from a number of coun-tries demonstrate the presence of some perio-dontal disease, at least as gingivitis or mild peri-odontitis, in up to 50% of adult populations. Encouragingly, the data also suggest significant improvements in plaque control and the preva-lence of mild disease. However, more severe chronic periodontitis, which results in progressive loss of tooth attachment, has not shown a similar reduction in prevalence. The recent study of glob-al burden of severe periodontal disease ( Kasse-baum et al 2014) reports an overall global preva-lence of periodontitis of around 14%, and also suggests that this figure has remained surprising-ly constant over recent years. However, most strikingly this figure rises to over 30% in the over 60s, clearly demonstrating the nature of the chal-lenge facing periodontal professionals.

Persisting high prevalence of severe perio-dontitis despite improvements seen in levels of plaque control and prevalence of mild disease has been similarly reported in a number of oth-er studies from different countries. The reasons for this are undoubtedly complex but are likely at least partly to be the result of an increasingly ageing population who are having fewer teeth ex-tracted. Thus the burden of severe periodontitis, both in terms of its prevalence and its impact – resulting in discomfort, poor aesthetics, poor oral function and reduced quality of life in the over 60s is very considerable.

Periodontitis in the older patientThe clinical presentation of periodontitis in the old-er patient is not particularly distinct from that af-fecting other patients, but may be particularly af-fected by increasingly complex medical histories of people as they get older. The global epidemic of type 2 diabetes mellitus (T2DM) has been well documented and is a major risk factor for perio-dontitis. The prevalence of T2DM increases dra-matically over the age of 60, and although preva-lence rates vary regionally, in most populations may affect well over 10% of this age group. De-pending on the level of glycaemic control T2DM can increase the risk of severe periodontitis by at least greater than 2 fold. In addition, many people

with T2DM may not have been diagnosed, so the dental professional should be alert to the possibil-ity of undiagnosed T2DM in a patient who pre-sents with severe periodontitis or shows exacer-bation of periodontal disease, particularly where the patient has any other T2DM risk factors such as increased body mass index, family history or history of hypertension. In these cases the dentist should consider referral of the patient to their fam-ily doctor to investigate this possibility. Further-more there is some evidence that treatment of periodontitis may improve glycaemic control in T2DM patients.

Many medications are also known to have potential affects on periodontal disease. Most prominently of these are the Calcium Channel Blocker family of antihypertensive medications, particularly amlodipine, nifedipine and felodipine. These medications are taken by large numbers of people, and particularly those aged over 60. For example, in the UK, around 2M people are prescribed these drugs. Calcium channel block-ers can cause gingival overgrowth and can seri-ously exacerbate periodontitis. In affected cases, where it is feasible in consultation with a patient’s physician, changing the medication often results in rapid improvement in the condition.

Other medical conditions, including many cancer therapies, may exacerbate or affect perio-dontal disease and again the dentist needs to be aware of this and ensure the provision of adequate periodontal care for these patients.

Finally older patients may have increasing dif-ficulty in maintaining effective oral hygiene proce-dures, particularly when affected by conditions such as rheumatoid arthritis.

Periodontal health is part of general healthPeriodontal disease is also a possible risk factor for a number of serious diseases particularly af-fecting the older patient. It has been found to be consistently associated with risk of cardiovascular disease, including heart attack and stroke, with diabetes, and less clearly with a number of other conditions such as chronic kidney disease and rheumatoid arthritis. Although it is difficult to prove that treating periodontal disease causally affects the risk of these serious conditions, which mainly affect older people, it is clear that periodontal health should be regarded as part of good health generally.

IMPRINT

Publisher: Colgate-Palmolive Europe SàrlLayout: typo.d AG, Reinach SwitzerlandContact: Colgate-Palmolive Europe Sàrl Grabetsmattweg, 4106 Therwil eugenio_garcia@colpal.com

The opinions of the authors do not always have to correspond to those of the publisher.

Reprinting and publication of extracts if the reference is quoted.

Colgate is proud to be platinum

sponsor of the EuroPerio 8

Chronic periodontitis is a major and growing prob lem in patients over 60. It

has very significant im pacts on oral function and quality of life and good periodontal health should be regarded as a part of good general health.

SummaryChronic periodontitis is a major and growing prob-lem in patients over 60. It has very significant im-pacts on oral function and quality of life and good periodontal health should be regarded as a part of good general health. The dental professional needs to be alert this particular issue and also needs to be aware of the systemic factors com-monly occurring in this population which can im-pact on periodontal health, liasing when appropri-ate with the patient’s physician.

16 | ORAL HEALTH DIALOGUE | 1/2015

Colgate® Sensitive Pro-Relief™ toothpaste acts in 60 seconds to seal the open tubules and relieve dentine hypersensitivity*

1. Colgate® Dentist survey, UK, 20132. Colgate® Consumer survey, UK, 2013

*When toothpaste is directly applied to each sensitive tooth for 60 seconds

91% considered Colgate® Sensitive Pro-Relief™ toothpaste

to be more effective than sensitivity brands they

have used before

96% of trialists would recommend Colgate®

Sensitive Pro-Relief™ to friends and family

96%

Over 1,000 sensitivity sufferers put Colgate® Sensitive Pro-Relief™ toothpaste to the test by eating ice cream. Then they revealed their thoughts...

Sensitivity is still an unresolved issue for patients…

60SECONDS

91%

There’s an easy solution to address the sensitivity challenge!

report problems of dentine hypersensitivity2

3/5 ADULTS 29% OF ADULTSidentify dentine hypersensitivity

as the biggest cause of pain associated with visiting

their dentist2

Care for your sensitivity patients and recommend Colgate® Sensitive Pro-Relief™ toothpaste

94% of trialists agreed that Colgate® Sensitive Pro-Relief™

worked instantly to provide sensitivity relief

94%

say they see at least one patient a day who experiences dentine

hypersensitivity1

9/10 DENTISTS