Transcribed by Erica ManionSeptember 19th, 2014

Diagnosis and Treatment of Oral Diseases-- Lectures #35 and 36 Histopathology of the Dental Tissues as Relates to Caries I and II, Review Session by Dr. Wolff

Note: The audio and the slides on the podcast do not match up, so I did the best I could to put things in the right place. Sorry if there is any confusion!

[1] [Title Slide: Strategies, Questions, and Answers][Dr. Wolff] So the time is 1:03. Ok. So we are going to speak about different strategies and I have to pick up on fluoride, which I left behind. Many of you are going to go out and practice in non-fluoridated communities. And the strategies for fluoride management of patients becomes extremely different there. So we have pediatricians out in Suffolk county that recommend fluoride and if the mother says no, thats the end. They dont talk about it, they dont explain it, they dont talk, discuss the whole routine. Yet Suffolk county, Long Island has no fluoride. Has no public fluoridated water, I should say. There is available fluoride in other mechanisms. So how can we deliver fluoride to an infant? How do you get them a fluoride dose? Thats the, when does the central incisor start to develop? Whats that? The enamel on the central incisor! Dont tempt me to get Dr. Bucklan in here! It is starting anywhere from in utero to within a few months of birth, the incisal edges of the incisors start to form. So thats one of the first teeth that are forming, the permanent ones that Im talking about. If we fail to get fluoride into that enamel we lose some of the anti-caries benefit of developing a true fluoroapatite crystal in the tooth structure. So at birth forward, it becomes important to have strategies that introduce fluoride to the child in a non-fluoridated community. Where do we put this fluoride? Whats that? Well tell me about milk in fluoride. Thats the set up of the discussion. Yes, somebody said it here. Problem is the calcium binds the free and available fluoride. So we need to find a method of either putting the drops into the childs mouth, or into a water bottle that they should be using. So if the mother is breast-feeding, you have to figure out how to get it there and it is important to have this discussion. Physicians dont have the same fire in the belly, Ill call it, to see to it that the patient is receiving fluoride treatment, and thats a real problem because it starts the children off on the wrong foot right off the bat. So even breast-fed children should be getting fluoride. And we look at about a quarter mg of fluoride on children pretty much from infancy until 3 years of age. The recommendations have changed recently. Until 6 it is about le-mm, eh then it jumps up to a half mg, and after age 6 it goes up to a mg per day of fluoride. But you cant give a child, so you give a child a vitamin, and most children are receiving trivisol or trivifluor, which is a liquid vitamin that can be dripped directly into their mouth or placed into water. Should not be placed into milk was the moral of the story I was heading towards. And it is very tough to get it into breast-milk by the way. Well, directly delivered into breast-milk. It is difficult to deliver into any milk no matter what. So the fluoride story becomes important in that moment. What do we use so when a child, uh, anybody take polyvifluor when they were growing up? All of you grew up in fluoridated communities? These little vitamins come in a color and see this is a big discussion out in a place like Suffolk county where some of you may practice. 40% of America is not covered with fluoridated water so you better know these strategies unless you know for sure that you are going back to some place with fluoride. Polyvifluor comes in different doses, it is generally when a child can chew the vitamin you allow them to start taking the vitamin, comes in different comes in quarter mg, half mg, and mg doses. We ask them to take 1 vitamin per day. My daughters only liked the purple vitamins. well not my daughters. My older daughter, my younger daughter just didnt like any vitamins. but the older daughter only liked the purple ones. She used to throw the other ones outside in front of the house. So I tried just getting purple. And when we found them when we were gardening, there was only one child in the house. Polyvifluor is sitting outside, right by the very front where she used to stand waiting for the bus, and there were all these different color vitamins. And you come in with a handful of vitamins from the garden, and you go what is this? She says I dont know. She really did. And we discovered that she only liked the purple ones, she really loved eating those. You cant get them by flavor. So the reason why I tell you the moral of the story is even when we administer fluoride to children in something as concentrated as a vitamin, you cant count on the fact that they are getting it unless you supervise them. Which raises the question about this whole toothpaste thing and tooth brushing. Unless you are supervising the tooth brushing very carefully everybody go log on and go get your lecture.

Ill give you the special password for the lecture later on if you didnt get a chance to download it. It is available for the next 6 minutes. Um, whats that? I gave you the lecture just now, but it is only up for the next 6 minutes. [Student: what about the people who dont have a computer?][Dr. Wolff] It tells me that you werent here last week and you havent listened to the iPod yet! You didnt have to confess publically, but it was ok! Theyll be a magic password given out. Now there was a magic password given out in the podcast, and a number of students who are maybe here, maybe not, have asked me for the lecture by emailing me the password xylitol. Those who actually attended the class understand that the podcast had a slightly different password to it. So, we can be so sneaky, its so much fun. I enjoy it. Ill give each of you the password to email me at the end of the lecture with the microphone off and Ill be happy to forward you a copy of everything that I just gave everyone to download.

Compliance with tooth brushing is horrendous. And its one of the biggest issues associated with delivery of toothpaste to children. We know that the toothpaste works. It works highly successfully and when a child comes into your office with a mouthful of decay, the one thing that we know at that moment is that theyre not brushing with fluoride toothpaste and keeping the toothpaste on their teeth. Because its really hard to keep clean teeth and get high levels of caries at the same moment. Doable, but much harder than normal. Fluoride supplementation. In office, weve already said that the most common fluoride turns out today to be the fluoride varnish, not one of the fluoride rinses.

[2] [Fluoride Supplementation]We talked last time briefly about it. The tray material, the gels, they were well researched, they were the things that first brought us fluoride treatments in office and showed that it was effective. Research studies looking at the fluoride in the prophy paste, you scrape off enough fluoride with the paste and put on back the same fluoride again. It ends up as a net zero. you arent fluoridating the tooth by using a fluoride containing prophy paste. So thats not an effective way.Using the trays can be effective. Theres no evidence that 1 minute gels actually work. But the fluoride varnish, I did yesterday. I saw five children, I did fluoride varnish on all of them at the end of my operative procedures because that is caries management. High risk patient, Im already doing an operative procedure on the child, they should be getting fluoride varnish frequently, so I fluoride varnish them. Each time I time how long it took, I finished the complete thing of fluoride varnish on them in the chair in less than a minute. That was the best 15 dollars I ever earned. Ill do 15 dollars a minute all day long if you want. I would only probably do 2 or 300 minutes a day of that. Do the math on that. Its actually simple to do and we know, highly effective.Take home, take home applied fluoride. so we use a number of different fluoride techniques for take home, and we need to talk about the science about it. Whats the most common prescription fluoride that we use? Its a toothpaste, it happens to be in the Colgate brand, it is called Prevident. There are two types, Prevident plus and Prevident. Prevident is purely a sodium fluoride, 5000ppm paste. The instructions for this paste are to brush with it. Expectorate off the excess but dont rinse. This can be used in the high caries risk once a day, in the very high caries risk, twice a day. Now if you want to substitute for the toothpaste that they normally brush with, then you prescribe the Prevident 5000 plus. The plus in the Prevident, equals, they put abrasives in it to make it a toothpaste. Now whats important for our commentary, you need to remember that tooth brushing alone, theres been no evidence that tooth brushing reduces tooth decay. In real studies where they gave children in deprived areas, many years ago now, tooth brushes, they went in there and they looked to see whether or not there had been a reduction in tooth decay and there was none. You need to add the fluoridated toothpaste to reduce the decay. And it is the number of times that they brush with the fluoride toothpaste that turns out to be most important. So telling them to brush twice a day, once with paste and once without, doesnt increase the caries preventive regimen. So its not just keeping the teeth clean, its keeping the teeth clean and getting fluoride on the surface.

So the swishes as it turns out were the most popular. Theres another Phos-flur, another Colgate product. They were the leaders in this, I tell the class again, I am a paid consultant on toothpaste design with Colgate. All the facts Im giving you still remain to be the facts. Theres nothing there.

There are generics available on all of it. A sodium fluoride, the first one on the market was the Phos-flur. It is a swish and spit product, it should not be swished and drank. The size bottles are generally designed so that the whole bottle provides less than a toxic dose should a child drink it. That being said, you must be very careful about these concentrated fluorides, where it is the 5000ppm. It only comes in a small tube, because of the fear of a child, an infant particularly eating the whole tube of toothpaste. You have to worry about the fluoride being toxic, it is a neurotoxin. What was the antidote for it, I gave it to you? Milk is the very quick antidote, and call poison control.

Stannous fluoride is a tin containing fluoride. Actually has been demonstrated because of the tin to have some effect when irrigated in periodontal disease. The tin binds an enzyme that is active in the sulcus and reduces the activity of some of the bacteria in the sulcus. And stannous fluoride, so it has an antimicrobial effect. Stannous fluoride rinses have been shown to have an anti-caries effect, theyve had a great anti-caries effect. The big difficulty with them is that the material doesnt have a long shelf life once it has been mixed. So it takes it cant sit on the shelf, its not easy to ship, there are a lot of difficulties with it. The acidulated sodium fluoride, oh Im sorry, acidulated sodium fluoride is what we were talking about. Tell me, anyone have a problem with an acidulated product? Like an acidulated fluoride. Can you think of any application that this might be damaging to somebody? What is the reason we put acid in the fluoride? Most fluorides come in an acidulated variety, why? Somebody, do we have a chemist in the house? Nobody was a chemistry major? Ok, then were going to make you all remember freshman chemistry. Im going to point to one of you randomly. Yes its the one thats wearing her infection control coat in my lecture hall. You are it! Why would I add acid to a fluoride varnish or to a fluoride paste? Whats that? It dissolves what? And? How do you bond? How do you bond something to a tooth, step number one? Wait a minute, did you just say acid etch, and Im telling you we put acid in the fluoride? Shake your head yes, there you go. So we are dissolving the outer surface layer of tooth structure, putting a high fluoride content in there, and if we can neutralize that acid, what occurs? Infection control coat! Youre still on! AND, its still on! Whats the answer if I neutralize, what happens if we put fluoride, dissolve the top surface of the tooth, we make an acid solution, what happens if the saliva gets on top of it? How does it precipitate? The answer is yes, it precipitates, on the surface of the tooth, why does it precipitate? Whats that? It is neutralizing what? No, it is not neutralizing the sodium fluoride, you were close, somebody is muttering it over here, but I want somebody else to mutter it out loud back there. What is getting neutralized? The acid, thank you. So an acid solution has the capacity to hold more calcium, phosphates, and fluoride in it. When we neutralize that environment using saliva, the solution can no longer hold the dissolved calciums and phosphates in it, and the fluoride in this case, and it precipitates back on the tooth surface. So you see, better uptake of fluoride at the surface of the tooth as a result of the acid, then neutral fluorides. Why might I not want to use an acid fluoride? Whats that? It is not the enamel surface that Im worried about because that is remineralizing. Its not the dentin surface because thats remineralizing. Its not the root surface, that will remineralize if you neutralize the acid. There is, what materials do you put inside the patients mouth? You put composite resins in there, which are damaged by prolonged acid exposure, and you place porcelains in there, which are damaged by prolonged acid exposure. So using an acid fluoride for a prolonged period of time on a patient that has porcelain laminates for instance, will etch the porcelain laminate and make it stain. Ah ha! As a matter of fact, one of the methods that was used to prepare the surface to put acid on the surface of a porcelain to try and re-bond it was actually to take the office-applied acid fluorides, leave it on there for five minutes, it dissolves the surface, makes it rough, and away you go. So you shouldnt be using acid fluorides on restorative dentistry.

[3] [Home Supplementation]We deliver home items in gels, rinses, toothpastes, and tray delivery. Tray delivery had the highest effectiveness but the least compliance. It looked just like a bleaching tray, you fill the bleaching tray with a fluoride, you give it to the patient. Either a sodium fluoride varnish, a neutral sodium fluoride or an acid sodium fluoride. You give it to them, they put in the tray,

A couple of drops in the tray, they wear it for five minutes, take the trays out, spit it out, it was the most effective technique, but compliance was the worse. Toothpaste turned out to be reasonable. Rinses and gels so the over the counter rinse is almost as effective in clinical trials as using a high concentration fluoride toothpaste. So a patient comes in to you and says Dr. Wolff, I dont have a lot of money, I cant afford to get a prescription of fluoride gel, can I use one of the mouthwashes that has fluoride in it? The answer is yeah, Im pretty happy with that. Because the prevented increment of decay, youre looking at a 2,3,4,5% difference between the two products, so it makes a real difference there.

You had a question? [student: How do you tell a patient which has the acid fluoride?] So we prescribe typically acidulated fluoride. [flips to previous slide] So when you do Prevident 5000, thats an acid fluoride. Ok it is a sodium fluoride thats acidulated. Its this one down bottom. So theres actually a number of products, the one thats on the top of my head, I hate the brand name, its a 5000ppm sodium fluoride called Neutricare. Its from Oral-B, its a neutral sodium fluoride. The problem is you dont get quite as much anti-caries increment but you get no damage to teeth. So I actually have both products in the office depending on what Im working on with patients. We dont see as much damage to composites with acid exposure as we do to porcelains. So I still use the more aggressive acid sodium fluoride with composites, but when patients have lots of porcelain restorations, we only use neutral. [Student: So regular fluoridated toothpaste - ] No, regular fluoridated toothpaste is relatively neutral. Ok. Now some of the whitening toothpastes, in order to maintain the whitening product, they acidulate it, and that is some of the negatives about whitening toothpastes. Not the whitening toothpastes that are coming out of Colgate and Crest, any of the Glaxo and Sensodyne. None of those are acidulated. pHs drop as low as 6.4, 6.5, as high as 7.5. So they stay in a pretty neutral band. Nobody gets anywhere near the critical pH. But when you look at some of the we just looked at some toothpastes, OTC toothpastes for whitening, and some of them actually, the non big boys, non ADA approved, theyre pretty acid, and thats because they are trying to keep the carbamide [?] peroxide active, and in order to do that they have to acidulate it. Theyre pretty unsafe to use, you get a lot of tooth destruction when you brush with those.

[4] [Home Supplementation]So should I use an over the counter 900ppm or a gel, you know that works, the one that we give. Caries reduction with non-fluoridated water when using home supplementation can get you very close to, this is stuff primarily from RIPA, was the 29-51%. There have been lots of studies reporting high caries rates several of the studies reported high reduction in caries rates when using placebo toothpastes. And that is one of the reasons why you see a 51% reduction. If I use a non fluoridated toothpaste versus a fluoride gel or a fluoride rinse, I see a greater preventive increment. Those studies are no longer ethical to run. I ran the first caries trial on that pro-argine material in 2000, 1999-2000 in Venezuela. The children received a non-fluoridated toothpaste and the pro-argine technology as the two cells in the study, a double blind controlled study. The problem with the study today, you would not be allowed to do that. Because even though the standard of care in Caracas was not fluoridated toothpaste, the children didnt have toothbrushes and toothpaste. As a matter of fact, some of the parents were taking their toothpaste away and selling them. The standard of care in the United States where we come from is fluoridated toothpaste. I would no longer be allowed to run that study in that format. The ethics of that changed over the last several decades.

[5] [Fluoride Supplementation]Fluoride toothpaste over the counter. There are all sorts of different products available. You need to recognize this. These toothpastes, reduction and decay seems fairly aggressive. We had 1500ppm toothpastes. What we actually have is 1500ppm that actually have to have at least 900ppm active is what is targeted in the toothpaste. Active and available. So it is very hard, the toothpaste language uses total fluoride and available fluoride as the two terms. The key is the available fluoride has to be somewhere around 900ppm. So our big number doesnt mean as much as it should. In Europe they have adult toothpastes that are 1500 to 2000ppm, in the United States we cap out at 1500ppm, and that toothpaste only has a 900ppm available fluoride.

[6] [Fluoride]Fluoride in our food varies greatly. This is the study I referred to before. Teas have tremendous fluoride content. In natural tea, theres fluoride in lots of teas. When you start looking at the bottled teas that have been concentrated to give you intense flavor, they have very high concentrations of fluoride, as high as 3ppm.

[7] [Fluoride Dentrifice Formulation]The world of dentrifices. You will see everybody advertising a different fluoride. I dont have the tetra up there either. These fluoride agents are highly aggressive and honestly, the companies cant get any brand distinction in the fluoride. There is very little difference between one fluoride concentration or one fluoride content no I shouldnt say concentration, one fluoride content and the other. We know there is a linear relationship to tooth decay reduction as we increase the fluoride content, the free, available fluoride.

Abrasive systems is where they are making their real big difference. They use multiple abrasive systems. All American Dental Association tested and approved toothpastes must have an abrasivity that will not damage teeth. So I dont recommend we use the ADA approval system for anything, except for toothpaste in the respect that it protects the patient. It is a very quick way to know that it is not an abrasive toothpaste. If theyre not carrying an ADA seal on it, you better worry that the size of the particle or the nature of the particle that is used in there for scrubbing is too high. Now in addition to all of this stuff inside the toothpaste that effects cleaning and whitening, they also put a whole load of soaps and other items in here. Japan doesnt like foaming toothpaste. They now do by the way, but when they had initially introduced American toothpaste into Japan in the 1960s, it fell on its face. They equated it to being rabid, like a dog having rabies. Bad marketing routine, so you have to be sensitive to cultural differences.

The SLS, the sodium lauryl sulfate, that turns out to be a fairly controversial additive to toothpastes. The SLS is a soap, how do you tell when your teeth are clean? You run your tongue over the outside of your tooth and it feels smooth. Do you know how toothpaste manufacturers get that to take place? They put soaps in the toothpaste and they put waxes in the toothpaste in an effort to give you that feeling after you brush of mmm, thats nice and clean. Now it does happen to be that abrasives help clean, but even if you left some toothpaste in your mouth and you went over the surface, its going to feel smooth and glossy and clean is what they want you to say. The mints, the flavors, are all placed for cleaning. I have to put the shout out that flavorings can be very annoying to patients with dry mouth. You need to play with different flavorings and intensity of flavorings. Flavorings make a difference to children. They like sweet flavorings, they like different flavorings than adult. Wintergreen is not a childs tooth[paste] if you looked at the literature on marketing of toothpaste, this stuff is wild. I mean, they give flavor after flavor, they increase the intensity, they do all sorts of things to manage it. Adults dont want bad breath, kids dont know what bad breath is. So an adult, giving you a toothpaste, anybody remember the slogan thats used on Altoids? Curiously strong. What was the old advertisement campaign on Listerine? They used to show somebody swishing the stuff in their mouth and going: I know you can make it. You have to swish for two minutes. They had a vile taste to it and they wanted that medicine taste because everyone knows medicine makes things better. And they had that medicinal taste to it. You put it in there and swish it around, and do its thing, and they used to make fun of it. It was actually something that they poked fun at. So you need to be conscious of flavorings. Dont hesitate to find flavorings. I use childrens toothpaste frequently with my dry mouth patients, to get them, particularly with my cancer patients and my Sjogrens patients, they have a more pleasant flavor and they avoid the mint. Mint causes that real odd flavor. Lets spend some more time on this.

[8] [Antimicrobial Approaches to Caries Management]Anybody see the latest stuff on the micropellets? So one of the big things that is taking place is the microplastics have been made. These nanoplastics. They were originally put in face creams to help scrub the face a little bit and clean it off. Also gives this smooth feeling to your face. The big problem with it is after you wash it off your face, it went down the sewer, the sewage treatment plants had all these little pellets floating at the top of it. They had no way, because they were nano in size, to filter them out. They actually went into the waste stream and into the oceans and theyve actually demonstrated large areas of the ocean that have piles of these nanopellets in them. Then somebody discovered, and this isnt a hit at P&G by the way, at Proctor, they were in some of the Crest toothpastes. So somebody ratted out Crest toothpaste and said theyve got these mircoparticles in here, look at the blue particles stuck in the gums! Nobody has ever found any disease associated with it, they are nano in size, theres no tissue reaction, and as much as Id like to make the other company look bad, the truth is it wasnt harming anybody. In the last two days in the news, I was asked to do an interview on ABC that I declined. I saw it yesterday on NBC. Its real popular, its a hot topic right now, your family will be asking you about it when you come home on the weekends, breaks, holidays, things like that.

Antimicrobial approaches to caries, and I forgot to put the important slides! We ran one of the seminal studies here at NYU on a new product called a stamp. And I have all the slides for it and I meant to throw them in here, but I didnt put them in. It would be absolutely wonderful, you know, you can tell yourself to take care of something and unless you do it in that moment you just, or its just me that forgets things. Young brains, they forget nothing, theyre traps, they hold it all! .. yeah right. It would be wonderful, so three main spheres. We were talking about fluoride, that effects the tooth primarily. Maybe a little bit on the microbial. We talked about microbes and food, weve talked a little bit about how to manage this from a foods perspective. And we are talking about how to modify saliva and what to do with it. That makes for one person who gets caries and another person who doesnt get caries, um It would be nice to take a microbe, um, an anti-microbe, and wipe out the specific bacteria that causes tooth decay. Right now, there are no anti-microbial products that target only Strep mutans, lactobacillus. Except an experimental product called a stamp. We just ran the study. Kenny, stamp? Specifically Targeted Anti Microbial Peptide, there it is, its back. They are called stamps, they target very specifically Strep mutans. The goal of this product was to swish it around your mouth. It serves as a pheromone that is attracted to the Strep mutans, it blows up the cell wall, and the Strep mutans die, 80 90% of them with each swish. Over the course of 2-3 weeks of using the product you would sown your Strep mutans rate and reduce your decay. Turned out we were able to show that it decreased the Strep mutans but it didnt have any lasting effect. Its been reformulated now in a gel that can be put in a tray, you wear the tray and do this over a week. Its a future product, but that is not whats on the market today. So what do we have on the market today for it, we have all sorts of additives.

[10] [Toothpaste]This is one that is Colgate, its getting a lot of hit right now. Triclosan is one of these items people are concerned about cancer with. It comes back to the same thing as the cyclomates and the others. Large amounts of triclosan put us at very significant risk for developing other disease. But thats not what you see in toothpaste. The estimate is youd have to eat 600 tubes of toothpaste a day to get to the doses they were feeding the rabbits. Not very realistic. That being said, triclosan is one of these antimicrobials. It has been shown to be highly highly effective at preventing or reducing gingivitis. But you have to be careful as I describe that. So we look at gingivitis using the Loe Silness index. Its a bleeding index. We look at the gingiva, we see zero if it has no redness, its nice and pink. 1 if it is red, or red at the margins. 2 if it bleeds on probing, and 3 essentially if it just bleeds on contact. So patients who participated in these studies had to have measurements higher than 1, or 1.5 on average. So patients were given the toothpaste, they brushed with it, and we found a .4 or .5 Loe Silness index reduction in gingivitis, which allows them to make a claim of being anti-gingivitis. But has a patient ever been cured by brushing with the toothpaste? Actually its brushing. If you got in there and really did the cleaning, did everything effectively, you can get the cure, but the vast majority of people will never not get gingivitis because they switched from using Crest regular to the Colgate with triclosan.

[11] [Colgate Total]And thats this total, anti-gingivitis, anti-plaque, anti-bad breath.

[12] [Toothpaste: Triclosan]Unsupervised use of a dentrifice containing copolymers significantly improved the removal of supragingival plaque and gingival health when compared with a fluoride dentrifice alone. There was no evidence, Im sorry, I didnt reformat that slide. There was no evidence that it had an anti-caries effect.

[13] [Toothpaste-stannous fluoride/sodium hexametaphosphate]Stannous fluoride. Back to that stannous. The stannous fluoride is effective at preventing decay, stannous does have an effect on the bacterial. But it does not have any greater effect on preventing tooth decay than putting in any other 1500ppm fluoride. It strengthens the enamel, the stannous has the ability but it hasnt been shown.

[14] [Crest Pro Health]Crest uses a number of oh, I dont know why sodium hexametaphosphate is the antimicrobial in the Crest Pro Health, its been demonstrated once again to reduce gingivitis. Its never been demonstrated to have any effect on caries rates.

[15] [Clinical Efficacy of Dentrifices]Lets go to our, this was Stookeys study on it. The anti-microbial approach of preventing caries came to a real head when we had available in the United States, it came out of Sweden initially, chlorhexidine.

[16] [Antimicrobial Approaches of Caries Prevention]The chlorhexidine that we have on the market today is a 0.1% solution? Yeah, Im pretty sure it is a 0.1% solution of chlorhexidine that you are supposed to swish with it. It is called Peridex, theres been a number of different items on the market. But does a general kill of anything really make sense? First the question is can we kill everything with one antibiotic or one anything? And the answer is, not particularly well. I mean, we have to irradiate people to sterilize things, to eliminate them. These antimicrobials seem like a great idea, but the problem is, less doesnt mean you are not going to get caries. Elimination of the acidogen would mean you are not going to get caries. Just removing the bulk, if you keep feeding it, isnt going to do it.

[17] [Antimicrobials]So study after study failed to prove that the antimicrobial would actually have a longevity effect in preventing tooth decay until a very recent study that was published by a good friend, John Featherstone. Where he demonstrated a decrease in Strep mutans as a result of it, but he never demonstrated a decrease in tooth decay rate. And thats, thats a problem in the study. So the fact that you decrease the Strep mutans, less, doesnt mean that you reduce the decay.

[18] [Chemotherapeutic Strategies to Control Biofilms Based]There are lots of other agents that have been effective, or put in things to go ahead and reduce tooth decay.

[19] [Antimicrobial Approach]This was the gold standard, Featherstone is recommending once per day for a week for a month, and then once one week every three months. Theres just no science that says this is the item. As a matter of fact there was an ADA review of anti-caries, non-fluoride anti-caries that I sat on the panel, and they expressly said fluoride varnishes have shown some limited effect on root caries only. Fluoride mouth rinses have had no effect. Did I say fluoride? No, chlorhexidine mouth rinses have had no effect. So concentrated chlorhexidine varnish has had an effect on root caries only. Scratch out that fluoride. Or I could have covered the microphone and told you, and left all those in the background getting the question wrong. This is actually quite controversial when we talk to the anti-caries people because John is a very powerful anti-caries person, and he insists that chlorhexidine should be part of the regimen to prevent tooth decay in the highest risk patients. So in that particular case, and well talk in a few moments, Ill agree that in the very highest risk patients Im fine with them using chlorhexidine. But only in that disaster patient that I cant get under control with everything else. I use different anti-microbial to be effective in them. What is that anti-microbial? Think about it from last week. [Sings Jeopardy theme song] Yes? [Student: Alcohol?] It is an alcohol but its not alcohol. Xylitol. It is an alcohol sugar. And xylitol in high doses, what happens if we take too much xylitol? We get diarrhea. It has to be between 6-10g per day of xylitol, and its been shown to be effective whereas sorbitol and others of the alcohol sugars have not been shown to be effective. I said that wrong. They have not been shown to be they have not been shown to be, its not that they have been shown not to be effective, nobody has shown them to be effective. I have to get that right because Im being recorded. There are some people that actually think that sorbitol, which is much cheaper, will have the same effect. But it doesnt appear that sorbitol does have the same effect. I was just speaking with Dr. Caufield on Monday, and he actually was discussing a recent finding that xylitol even inhibits lactobacillus, which is pretty remarkable if it does that.

[20] [Decayed Surfaces vs. Log MS and Log LB] 45.57, flipped at 46:42 (45 second difference)This is Johns graph. As you get to patients that have high decay you find high lacto and high Strep mutans in both areas. They go up radically in the patients that have the highest risk and we understand that. But he hasnt shown the empiric, that says if we decrease that number, we see a decrease in decay. So it is just empirical, it is weak evidence.

[21] [Mean(SE) logMS]46:26, flipped at 47:08 (42 second difference) And this was his study that he did that.

[22] [Antimicrobial Approaches to Caries Prevention]46:29, flipped at 47:12 (43 second difference) Chlorhexidine does have a negative, you get heavy, heavy stain. You better be ready for it. Give me a scenario where fluoride varnish, even a chlorhexidine varnish, might be a good idea. Anybody attend my elder care lecture last week? A couple of you that were there. What do you think about an 85 year old in a nursing home with early caries, or even with more advanced root caries? Thats the person that you want to get on the chlorhexidine and the fluoride varnish, and try and arrest that caries, stop its path, and let the person expire of natural causes rather than having to do restorations and extractions on them. Add a couple of blood thinners to the picture, severe arthritis, I cant clean my teeth, I cant this, I cant that, thats the case where you want to go there. High risk, theyre getting caries, its on the root, we got problems, thats a chlorhexidine patient. You, you come into my office because you like to eat gummy bears, I dont know if you like to eat gummy bears, Im not picking on you. You have a cavity? No, I dont want to know. Because you like gummy bears, youre not a candidate for chlorhexidine. There are other ways of managing your caries than going at it with the kitchen sink as I like to refer.

[23] [Antimicrobial Approaches to Caries Prevention]47:58, flipped at 48:45 This is the chlorhexidine varnish, its a more aggressive technique. It does work very, very well and very aggressively at reducing the bacterial counts. This is the stuff that the Brazilians have been using to demonstrate reductions in Strep mutans. Once again, they havent gone as far as showing a decrease in decay.

[24] [Mouthwashes]48:18, flipped at 49:04 Anybody know what this is? Whats that the formula to? [Student: Listerine] Listerine! There was a great article in the New York Times, Johnson & Johnson sells Listerine. Theyre changing it because the old idea of it tasting like a medicine wasnt such a big idea. The other thing thats inside here is alcohol, Listerine contains high alcohol. Theres this real question about whats really doing the killing here, its never really been demystified. These are all just odd combinations. Lister had nothing to do with the invention of Listerine. Listerine does anybody know who Lister is? Whats that? Johnny Lister? Whats that? John Lister? What did he do? Whats that? You know, thats so bad when you cant hear from the back of the room. [Student: Listerine?] He DIDNT do Listerine!! And thats the point. So Lister was one of the big anti-microbial people that talked about washing, cleaning, and disinfecting to prevent the spread of disease. The guy who came up with this formula sent it to him, and said what do you think about this, give it a try. He said, oh seems pretty good, and he named it Listerine. It wasnt Lister that named it, it was another marketer that got his approval. So even Listerine is changing the taste of Listerine. Its an interesting product. It is anti-microbial. It was originally sold as an item for killing bad breath. The FDA came to them and said, an interesting question. The logo was, Kills the germs that cause bad breath. Nobody had ever discovered what the germs were. Oops! So Listerine scrambled to go ahead and discover what the germs were that cause bad breath, do all sorts of studies on their mouthwash. And they discovered in the meantime that it reduces gingivitis. Once again, one of those massive studies, I did one of them, that reduced gingivitis from 1.7 to 1.4 on the Loe Silness Index. Never cured a human being of gingivitis and you hear them today tell you Along with proper tooth brushing and seeing your dentist regularly, in a program, this can reduce your gum disease. But everybody knows about plaque and gum disease and gingivitis because of the advertisement of Listerine today. So theyve done some really great stuff with it. Its as much as 30% alcohol, an interesting product.

[26] [Mechanism of Action]51:16, flipped at 52:03 This is CPC as an anti-microbial and as a cleansing item. CPC binds to the surface. This is a Crest item. It is highly effective at reducing microbes. But the real question is, how are we going to go out and treat these areas in a patient.

[27] [Radiograph]51:40 flipped at 52:20 When a patient comes in with this, this is not the person that we start putting on chlorhexidine varnish or a stamp, you know a specifically targeted anti-microbial peptide. We need to come up with something else.

[28] [Calcium Products]51:55 52:49 The thing that everybody believes will be the something else turns out to be a calcium-containing product. And well go through three groups of them. ACP was the very first of these products to come out onto the market. It was marketed actually by an NYU dentist. Called Enamelon. It was discovered in the Pathenberger Center, a national research center. Licensed to the American Dental Association, the patent on it, and the question was, did Enamelon actually work at reducing tooth decay, and the initial studies were never done. We showed that it reduced some demineralization, we showed that it reduced tooth sensitivity, but we never went as far as proving that it reduced cavitation, persay on teeth. Before the company went bankrupt, primarily because the president of the company thought he should own a jet, fly around, do things like that. He thought, Im selling toothpaste, I must be a big toothpaste it didnt work out that way. Well go over Denclude, Proclude, thats the product I had something to do with. Well talk about calcium phosphate.

[29] [Therapeutic Interventions]So they come in all sorts of different products. Im sorry about the quality of that slide

[30] [Recaldent]Recaldent is the one we actually use here at school. Recaldent is a fairly specific calcium and phosphate. So the problem, if I put calcium and I put phosphate in the same tube, what do you think we get? It precipitates inside the tube, and when it gets to the outside of the tooth, you get this insoluble brick of calcium and phosphate on the outside of the tooth. It never gets into the tooth. That was the big thing about ACP, the Enamelon. They actually, the initial Enamelon came in two tubes, one with calcium, one with phosphate. It was mixed with your toothbrush on the surface, and now got precipitation. And that was a very tricky routine, that was a real difficulty of the product delivery. They went ahead and came up with Recaldent. It came out of Australia. The people that went ahead and did it, Walsh and Reynolds, were the big inventors. I lecture with them all the time, they are very good friends. They discovered that they can take a milk based protein, it is no longer made from milk so its not a product that you need to be concerned about related to kosher or eating it with meat or anything like that. This casein phosphor-peptide, when mixed with amorphous calcium phosphate, can sit in a tube, stay stable for a long period of time, and in fact, Increase the calcium phosphate content of plaque and allow the plaque to help remineralize the tooth. It has recently been released with a 900ppm fluoride in it, anybody want to take a guess why? Why would 900ppm fluoride be inside this paste? Theyd like to release it as an over the counter toothpaste with a fluoride efficacy. Its being held up in the United States. Other countries are able to market it, not in the United States. So they have this stabilized, slightly alkaline routine. They can place it into gums and in fact youll see it in certain Trident chewing gums. Youll see it in many other products coming out in the near future. What it has been demonstrated, what its actually on market for, is reduction in tooth hypersensitivity. It actually works by precipitating the calcium and phosphate in the tubules and reducing sensitivity.

[31] [Caries Rates]The one study that showed effect of prevention of tooth decay was an incredibly effective study. You chewed this product with Recaldent, you chew this product without the Recaldent, and they showed a decrease in smooth surface decay or a decrease in progression of caries in the aproximal region. That was actually an interesting study. There was one defect in the publication thats actually held it back from being accepted as saying, this was a great product that reduces decay. They only reported surfaces that had early lesions on it. They did not report what happened in the rest of the mouth. Did new decay form? So they were essentially setting it up so that it could stay the same, get better, or get worse, but they werent telling us what was happening everywhere else in the mouth at the same time. As a result of that, this is not considered really great research. And its the only trial that theyve actually run.

[32] [Result of Randomized Controlled Clinical Caries Trial]It was 3x day, 24 weeks.

[33] [MI paste]The product we use in the school, its MI paste. Its about $15 a tube which is not right, is that about right? Yeah, it is not insignificant in cost. We use this in my patients at the practice. I actually manage my patients with caries management fee. It includes 3 times a year sorry, 4 times a year coming in for varnish. Each tube of toothpaste lasts 2 3 months. We supply them with the Recaldent, they come in for the visit and we prophy them twice a year, but we do a fluoride varnish four times a year and dispense the paste to them.

[34] [Pic of teeth]The most effective way to deliver it. When is our circadian rhythm of saliva the lowest? Oh I keep pulling back this stuff from other lectures, so long ago! I havent reviewed it or I wasnt here yet! But Ill study it the night before, its probably not that important, but hes highlighting it here, maybe it is important, I dont know!! When is our circadian rhythm of saliva flow the lowest? At night time. We dont drool all over our pillows. Some of us do drool on our pillows, you dont have to confess. One of the most effective times to saturate the surface with calcium and phosphate would be at night. You make a bleaching tray that covers the teeth, you put a lining of this calcium phosphate inside there, you pop the tray in, you let the patient go to bed with it. And even if they had just eaten beforehand, back to that equation! Remember the fluoride the acid, the fluoride, the calcium, the phosphate? In an acid environment, how can I actually drive remineralization if I wanted to? You have to come up with so much calcium and phosphate in the solution, that it spontaneously starts to precipitate, even in an acid environment. Theres a limit to how much calcium and phosphate an acid solution can hold. Simple, simple, what is that, hendersen hasselbach equation? Some equation from your chemistry days. So it is that balance. If we put the calcium and phosphate out there, we are driving calcium and phosphate into the tooth, whether or not it really wants to. And in fact, its been demonstrated anecdotally to be highly effective, but this is what we use in our cancer patients. So when we are dealing with patients that have had radiation therapy, they sleep with this thing.

[35] [Tray]59:41 And its a simple bleaching tray. You put it in, um, they way they talk about it is just rub it on the surface. Leave it on the surface, go to bed. I like the tray

[37] [MI Paste Application]59:54 Around braces where kids are getting demineralization, they can brush it on along the outside.

[38] [Mrs JM Dental Abrasion and Severe Hypersensitivity]And they actually claim that you can get rid of white spots on teeth with this, but Ive never seen that to be effective.

[39] [Amorphous calcium phosphate (ACP)]APC, Enamel Care was the - Enamelon and Enamel Care, Enamel Care is the current company, its the arm and hammer baking soda people. Theyre currently using it, its a sodium fluoride, calcium salts, phosphate. Originally it was separated with a divider, they no longer do [that]. The et al. on this study includes Mark Wolff. Thats what happens when you are a junior scientist. This is just the same slide why did I do that twice? Thats stupid. But Im still the et al. over here, I didnt improve that at all.

[40] [Amorphous calcium phosphate (ACP)]Its the enamel care, is the product that is currently using this.

[41] [Novamin]Novamin is a novel product that came out of a, its a very complex molecule, that came out of the research to regrow bone in shattered femurs. Its a silicate containing - calcium silicate containing product that puts this in high ability. It pre-supposes the presence of highly active phosphate ions in saliva. So without saliva its not nearly as effective. And this is a fairly complicated molecule. It has been demonstrated to precipitate in the tubules. Reduce tooth sensitivity, it too was on the market as an anti-sensitivity.

[42] [Novamin]1:01:37 Novamin was the product at hand. Today, its the Sensodyne Repair and Protect, but not in the United States. They havent been able to release it in the U.S. because of some regulatory issues.

[43] [Novamin]It is in Europe, but its not here. They still release the Repair and Protect, but its just a high concentration fluoride right now.

[44] [What is Novamin?]It is this concentrated molecule. When it hits saliva it breaks down and it starts to form this calcium phosphate. Real promise in here in remineralization. When this product hits the market its one that I will pay attention to. Probably more than the MI paste.

[45] [Hyposalivation]Arginine is the one that Ive been associated with, its now known as the pro-argine technology. Its now available through dentists in the United States. The value of the product is two fold. It contains calcium carbonate, but arginine is sticky so it stays on the tooth. Arginine is a food for base forming bacteria, so it wants to raise the pH. In studies that weve conducted here at the college, weve demonstrated that if you use this toothpaste, every day twice a day for a month, the pH of your plaque will rise from about 6.8 (if youre a caries producer, 6.7, 6.5) to as high as 7.4. It doesnt get much above 7.4 and that is important because if that occurred what would happen? Anybody from that area? Ill take anyone. What happens if I get a really basic pH? Were talking about this acid-base thing. Dissolve if Im acid precipitate if Im base? What did you say? Lots of calculus. It would be very bad if this product made very high pHs in the plaque. You would get calculus formation. But that doesnt seem to occur because it deaminates before it gets to the higher pHs and it no longer serves as food. So Kleinberg was the guy I got my PhD from, Im the et al on Chatterjee, and Im not the et al on Wolff.

[46] [Colgate Sensitive Pro-Relief]Right now it is available in the United States in Sensitive Pro-Relief, available from dentists. In Europe it is available OTC over the counter, in Europe. The problem in the United States with any of these calcium and other products is the FDA doesnt like multiple active products in the item.

[47] [Cavistat Clinical Trial]We demonstrated in this was the Venezuelan trial. In as short as 12 months we saw a reduction of almost a half a surface of caries in patient with or not on the product. So you start to see very quick separation.

[48] [Salivary Stimulation]Stimulation of tooth, so chewing gum has been demonstrated to reduce tooth decay. And how would it do that? Stimulation of saliva. So actually, it was Wrigleys with a sugar-containing chewing gum that demonstrated that chewing gum after eating stimulates saliva right afterward for a longer period of time, the extra saliva is much better than the exposure to the sugar. So I would use the trident line of, you know, I recommend chewing sugarless gum to my patients that chew gum. But the truth? As long as they dont keep popping another piece of sugared gum in their mouth, theyre probably ok even with a sugared gum. You get more effect from the stimulation if you are making saliva. If, on the other hand, you have no saliva in your mouth, chewing gum with sugar would be horrendous. Because you are now putting sugar in there for hours, youve helped make it worse.

[49] [Enamelon]We talked about these, ACP, Enamelon

[50] [Zero 2005 Image]

This is from Dom Zero. It counts on a small acquired pellicle to put the calcium in the surface of it. And That calcium actually does penetrate deeper into the tooth. It happens after multiple acid-base recycling. It doesnt happen at once. Multiple acid-base recycling. And in fact, we demonstrated on in situ, putting enamel chips inside patients mouths, we demonstrated that we were able to both help remineralize and reharden them. The surface of that enamel actually became harder and more resistant to penetration, just by adding the calcium and the arginine.

[51] [TheraMints 100% Xylitol Mints]The curiously strong Altoids, if you buy the sugar free ones, that contain high amounts of xylitol in them, and the xylitol has been shown to interfere with enolase and actually also help to create a hydrofluoric acid inside which kills the bacteria. Lozenges, you have to get up to 6 8.

[54] Antimicrobial ApproachWe talked about Chlorhexidine, I dont know why I duplicated this. Im sorry.

[58] [Introduction]So, Ill take any questions you have during the time, and in case you dont have any questions I would be happy to keep going through some review of how this management works in the maintenance of decay prevention of decay.

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