Testing, testing……one, two, three!

Anne N. Guignon,RDH, MPH, CSP

anne@anneguignon.com 832-971-4540 Copyright 2020

This course is supported by an educational grant from

We are grateful for their generous support and interest in

professional continuing education programs.

Providing the virtual platform support for this series

The Problem=saliva-decay-erosion

rates and risk factors

© 2020

‣ 28% - age 20-34

‣ 26% - age 35-59

‣ 22% - age 50-64

28% men, 23% women

‣ 18% - age 65+

20% men, 16% women

Adults - untreated decay

nidcr.nih.gov/DataSta7s7cs/FindDataByTopic/DentalCaries/DentalCariesAdults20to64.htm

nidcr.nih.gov/DataSta7s7cs/FindDataByTopic/DentalCaries/DentalCariesSeniors65older.htm © 2020

‣ 28% age 2-5

‣ 50% by age 11

‣ 68% at age 19

Children and adolescents

hJp://www.cdc.gov/OralHealth/publica7ons/factsheets/dental_caries.htm © 2020

Predisposing risk factors

! medium/high levels of cariogenic microbes

! heavy / visible plaque accumula7ons

! snacking - 3+ 7mes / day Caries risk assessment appropriate for the age 1 visit. J Calif Dent Assoc. 2007 Caries risk assessment in prac7ce from age 6 through adult. J Calif Dent Assoc. 2007 Bacteria of dental caries on primary and permanent teeth in children and young adults. Aas JA, et al.J clin Microbiol. 2008 Apr;46(4):1407-17. profiles of root caries in elderly pa7ents. Preza D, et al. J Clin Microbiol. 2008 Jun;46(6):2015-21. Researchers: S. Mutans bacteria not the problem. Harrison L. drbicuspic.com Accessed 9/1/09

© 2020

! increased acidogenic microbes

! aciduric microbes thrive

! decreased buffering capacity

! s7cky plaque biofilm

Insufficient saliva

Saliva and the Control of Its Secre7on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos7c Imaging, Springer-Verlag Berlin Heidelberg 2012 Graham I, Mount WH. (2005). Preserva7on and restora7on of tooth structure. 2nd Edi7on. Queensland, Australia: Knowledge Books and Soiware.

© 2020

© 2018

! dehydra7on

! cancer therapy

! coughing / COPD

! cogni7ve impairment

! radia7on treatment

! chronic renal failure

! autoimmune disorders

! ea7ng disorders

! HIV - hepa77s C

! disrup7ve breathing

! dry climates / AC / heat

! OSA - CPAP therapy

! salivary gland pathology

! hormone imbalances

! laxa7ve/diure7c abuse

! medica7ons - over 700

! sodium intake

! nursing / pregnancy

Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. © 2020

Who has the highest risk?

© 2020

The new canaries in

the coal mine

© 2020

Headaches, exhaustion, anxiety The physical and emotional challenges of returning to work during the pandemic | DentistryIQ.html

Guignon AN. Headaches, exhaus7on, and anxiety: The physical and emo7onal challenges of returning to work during the pandemic. Den7stry IQ. June 11, 2020 © 2020© 2020

Guignon AN. Are you more than just thirsty? The dangerous impact of dehydra7on. Den7stry IQ. July 24, 2020

Asking the right questions

© 2020

‣ feel dry when ea7ng?

‣ sip liquids to swallow dry food?

‣ amount of saliva seem reduced?

Dry mouth (Xerostomia): Diagnosis, Causes, Complica7ons and Treatment. Dental Professional Version. Delta Dental. 2011© 2020

‣ dry during

the day7me

Dry mouth (Xerostomia): Diagnosis, Causes, Complica7ons and Treatment. Dental Professional Version. Delta Dental. 2011© 2020

‣ night 7me

‣ wake up dry ‣ tongue burn?

‣ difficulty swallowing?

Dry mouth (Xerostomia): Diagnosis, Causes, Complica7ons and Treatment. Dental Professional Version. Delta Dental. 2011

‣ problems tas7ng?

‣ sensi7ve to acidic, salty or spicy foods?

© 2020

‣dry eyes

‣eyes feel sandy

Dry mouth (Xerostomia): Diagnosis, Causes, Complica7ons and Treatment. Dental Professional Version. Delta Dental. 2011

‣recurring decay problems

‣chew gum/candy for relief

© 2020

Microbial strategies

© 2020

Ecological plaque hypothesis - caries

Marsh PD. Dental plaque as a biofilm and a microbial community - implica7ons for health and disease. BMC Oral Health 2006, 6(Suppl 1):S14. © 2020

Ecological plaque hypothesis - caries

Marsh PD. Dental plaque as a biofilm and a microbial community - implica7ons for health and disease. BMC Oral Health 2006, 6(Suppl 1):S14. McLean JS. Advancements toward a systems level understanding of the human oral microbiome. Fron7ers in Cellular and Infec7on Microbiology. 2014;4:98.

© 2020

Survival strategies

‣ mature biofilm - 24 hours

‣ mechanical disrup7on - rapid recovery

‣ 2-4 days - fully mature

‣ high biocide resistance

‣ shedding planktonic bacteria Phillips PL, WolcoJ RD, Fletcher j, Schul GS. Biofilms made easy. May 2010. Vol 1. Issue 3. woundsinterna7onal.com

© 2020

Oral microfloraHow fast does it grow?

‣ 1 mg plaque = 100,000,000 microbes

‣ en7re mouth = 20,000,000,000 microbes - at any given 7me

‣ 1 liter saliva swallowed daily - 100 billion microbes

‣ oral bacteria - double every 4.8 hours!

Loesche, WJ. Dental caries: a treatable infec7on. Springfield, IL: Charles C. Thomas; 1982. p. 558 © 2020

Predisposing risk factors

! new research – caries biofilm more complex

! bacteria on different surfaces

! mutans streptococci dominate fissures

Bacteria of dental caries on primary and permanent teeth in children and young adults. Aas JA, et al.J clin Microbiol. 2008 Apr;46(4):1407-17. Bacterial profiles of root caries in elderly pa7ents. Preza D, et al. J Clin Microbiol. 2008 Jun;46(6):2015-21. S. Mutans bacteria not the problem. Harrison L. drbicuspic.com Accessed 9/1/09

© 2020

New news about caries biofilmStrep mutans not the only organism -

Different microbes colonize

! white spots

! den7n lesions

! root caries

! primary and secondary den77on

! specific tooth surfaces

Asa JA, Griffen AL, et al. Bacteria of dental caries in primary and permanent teeth in children and young adults. J of Clin Microbiol. April 2008. 46(4):1407-17.

Preza D, Olden I, et al. Microarray analysis of the microflora of root caries in elderly. Eur J Clin Infec iDs. May 2009. 28(5).

Cavalcan7 YW, Bertolini MM, et al. A three-species biofilm model for the evalua7on of enamel and den7n demineraliza7on. Biofouling. 2014;30(5)579-88.

Costalonga M, Herzberg MC. The oral microbiome and the immunobiology of periodontal disease and caries. Immunology le+ers. 2014;162(2 0 0):22-38© 2020

Ecological plaque hypothesis

! health = homeostasis

! disease sites species differ from health

! caries - shii - acidogenic / aciduric

! imbalance in resident microflora Marsh PD. Dental plaque as a biofilm and a microbial community - implica7ons for health and disease. BMC Oral Health 2006, 6(Suppl 1):S14. Asa JA, Griffen AL, et al. Bacteria of dental caries in primary and permanent teeth in children and young adults. J of Clin Microbiol. April 2008. 46(4):1407-17.

© 2020

! increase mutans streptococci (gateway)

! den7n lesions = lactobacillus + proteoly7c microbes

! sustained low pH - select for Ms and Lb

Marsh PD. Dental plaque as a biofilm and a microbial community - implica7ons for health and disease. BMC Oral Health 2006, 6(Suppl 1):S14. Asa JA, Griffen AL, et al. Bacteria of dental caries in primary and permanent teeth in children and young adults. J of Clin Microbiol. April 2008. 46(4):1407-17.

Ecological plaque hypothesis

© 2020

More news - caries biofilm

! S. mutans - early colonizer

! 30% rampant caries - not posi7ve

Takahashi N, Nevada B. Caries ecology revisited: Microbial dynamics and the caries process. Caries Res. 2008;42(6):409-18. Xiao J, Grier A, Faustoferri RC, et al. Associa7on between Oral Candida and Bacteriome in Children with Severe ECC. J Dent Res. 2018 Dec;97(13):1468-1476.

© 2020

! children with ECC

high levels of S. mutans and C. albicans

‣ low income children - 2 X decay

‣ 4 X more common than asthma (42% versus 9.5%)

‣ 52,000,000 lost school hours/year - dental disease

hJp://www.cdc.gov/OralHealth/publica7ons/factsheets/dental_caries.htm © 2020

Microbial adaptation

Takahashi N, Nevada B. Caries ecology revisited: Microbial dynamics and the caries process. Caries Res. 2008;42(6):409-18. FalseJa ML, Klein MI, Symbio7c rela7onship between Streptococcus mutans and Candida albicans synergizes virulence of plaque biofilms in vivo. Infect Immun. 2014 May;82(5):1968-81.

!“good” bacteria mutate / adapt

!become acid producers to survive-pathobionts

!adapt in 30 minutes to survive low pH

© 2020

Gateway - the rest of the body

‣ oral disease is complex

‣ changing hormone levels

‣ medica7ons causing dry mouth

‣ gene7cs

‣ immune system

‣ lifestyle / environmental factors

‣ natural aging process© 2019

Getting preliminary dataSaliva testing viscosity

and flow rates

© 2020

Healthy - daily flow rate

0.5 to 1.5 liters

‣ res7ng - 0.25 to 0.4 ml /min

‣ s7mulated - 1 - 3 ml / min

‣ establish a baseline!

Saliva and the Control of Its Secre7on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos7c Imaging, Springer-Verlag Berlin Heidelberg 2012© 20120

Flow rate -visual inspection

‣ retract lower lip ‣ dry with gauze

Saliva and the Control of Its Secre7on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos7c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2020

‣ 1 min - drops on mucosa

‣ sufficient flow ‣ pooling in floor of mouth

Testing flow rate / per min ‣ chew wax - 5 min

‣ spit in cup

• normal - 1 to 3ml

• low - 0.7 to 1 ml

• very low - < 0.7 Saliva and the Control of Its Secre7on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos7c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2020

Testing….. salivary pH and

buffering© 2020

Salivary pH - impact on tooth structure

© 2020

When do teeth melt???

! root structure - pH 6.7! enamel - between pH 5 and 5.5! fluorapatite - pH 4.5

Mount GJ and Hume WJ. Preserva7on and restora7on of tooth structure. Knowledge books and soiware. 2nd Edi7on. 2005

Stookey GK. The effect of saliva on dental caries. JADA 2008 May; 139;11S-17S.

Lussi A1, Schlueter N, et al. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45 Suppl 1:2-12. Hoppenbrouwers PM, Driessens FC, Borggreven JM. The mineral solubility of human tooth roots. Arch Oral Biol. 1987;32:319–322. © 2020

Critical pH

! cri7cal pH – is a dynamic number

! dependent - salivary calcium and phosphorus

! average res7ng salivary pH 6.4 – 7.

Mount GJ and Hume WJ. Preserva7on and restora7on of tooth structure. Knowledge books and soiware. 2nd Edi7on. 2005

Dawes C. What is the cri7cal pH and why does tooth dissolve in acid? J Can Dent Assoc 2003; 69(11):722–4

Stookey GK. The effect of saliva on dental caries. JADA 2008 May; 139;11S-17S.

Lussi A1, Schlueter N, et al. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45 Suppl 1:2-12. © 2020

Healthy salivary pH

‣ res7ng - pH 6.8 - 7.2

‣ favors homeostasis

‣ supports remineraliza7on

‣ suppresses pathogens

Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010.

Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2020

Salivary pH

© 2020

‣Baseline data

‣ Snapshot in 7me

‣ Data can change

‣ Monitor for trends

PH2OH App

© 2020

hJp://ph2oh.com/

first thing in the morning later in the day

pH and buffering

© 2020

© 2020

Flow rate / pH ‣ res7ng ‣ s7mulated volume

Viscosity

Buffering capacity

Data collection kit

© 2020

BokaFlo Test

‣ Simple ‣Results in 60 seconds ‣ FDA registered

Measure resting saliva

© 2020

Multiple points SillHa Test

Buffering capacity Microbial load pH

Ammonia

Bleeding Leukocytes Protein

© 2020

cle

anlin

ess

00

0

0 0

100

0

Ave.:53

Ave.:43

Ave.:49

Ave.:22

Ave.:36

Ave.:43

Ave.:37

Acidity

100

100

100

100

100

0

100

The result is based on color tone of reagent pads after application of saliva (not the actual No. of bacteria or the conc.).

Average from past studies

Test result

Protein

Ammonia

Leukocyte Blood

Buffer capacity

Cariogenic bacteria

23℃2019/11/11

Brian B. NovyAlliance Dental Center

The findings above reflect the physiology of your mouth based on saliva and bacteria. These results help us develop a highlypersonalized plan to prevent cavities, gingivitis, and gum disease. Our goal is to ensure your optimal oral health for years to come.

Your saliva contains an average ammonia content. You may want to try and increase this level by increasing the amount of protein in your diet.

Your saliva doesn't contain high levels of protein, which could indicate your diet may contain too many carbohydrates.

You have a slightly elevated level of white blood cells in your saliva probably due to gingivitis or other sores in your mouth.

There are elevated levels of blood in your saliva. This can be caused by aggressive brushing, gingivitis, gum disease, or other sores in your mouth.

Date 2019/12/24

Your mouth appears to have elevated levels of the bacteria that cause cavities. We will provide you with some strategies to decrease this level.

Congratulations! Your saliva contains all the chemistry necessary to help your teeth and gums stay healthy.

Congratulations! Your salivary pH is considered "very good." While this can help prevent cavities, you may notice more tartar forming on your teeth.

Microbes…..Do we need to test The players?

© 2020

Mixed biofilm community - proportions

Costalonga M, Herzberg MC. The oral microbiome and the immunobiology of periodontal disease and caries. Immunology le+ers. 2014;162(2 0 0):22-38. =© 2020

‣co-adhesion

‣co-aggrega7on

‣modified:

‣pH

‣nutrient supply ‣salivary factors

‣highly acidic pH

Jenkinson HF and Douglas LJ. Interactions between Candida Species and Bacteria in Mixed Infections. Falsetta ML1, Klein MI, Symbiotic relationship between Streptococcus mutans and Candida albicans synergizes virulence of plaque biofilms in vivo. Infect Immun. 2014 May;82(5):1968-81.

Mixed biofilm community - Candida albicans(opportunis7c fungal pathogen)

© 2020

©2019 OralDNA Labs, A Service of Access Genetics, LLC All Rights Reserved7400 Flying Cloud Drive, Eden Prairie, MN 55344 | Phone: 855-123-1234 | Fax: 952-942-0703 | www.oraldna.com

CLIA#: 24D1033809 CAP#: 7190878

Web enabled system provided by:

Reported: 09/17/2018 15:30Specimen: Oral Rinse(P)Received: 09/16/2018 10:30Accession#: 201809-12635Collected: 09/15/2018Specimen#: 5116160001

OraRisk® CariesFINAL REPORT

Sample, Report Ordering Provider Sample InformationDate Of Birth: 09/20/1980 (38 yrs) Gender: FemalePatient Id: 920-A Patient Location: Test Clinic A

Ronald McGlennen MD7400 Flying Cloud Drive Eden Prairie, MN 55344 855-123-1234

Reason for Testing: Screening/Risk AssessmentPatient History: History of Mouth BreathingDental History: Recent/Current History of Caries

Caries Classification: Class III or ICDAS 3Clinical Findings: Existing Fillings, Enamel Defects Related info: Not Provided

MOLECULAR DETECTION OF S. MUTANS/ S. SOBRINUS/ L. CASEI

Bacteria Test Result

Streptococcus mutans/S. sobrinus Detected

Lactobacillus casei Detected

Bacterial Risk

HIGH RISK

Bacterial Level: 7.9 x 10 (genomes/ml)4

Summary of Results:- Interpretation: S. mutans/S. sobrinus and L. casei have been detected in this sample. The combined amounts of these pathogens indicate a HIGHRISK of the development and progression of dental caries.- Significance: The detection of S. mutans/S. sobrinus DNA indicates presence of these organisms in the oral cavity. This is an indicator of a change inthe oral microbiome, which typically leads to the creation of an acidic environment. The presence of L. casei may indicate further acidic change in thebiofilm and may predict the advancing demineralization of enamel, a hallmark of caries.

Caries Risk Factors:

Bacterial Risk: S. mutans/ S. sobrinus andL. casei in plaque convert dietary sugar intoacid. This acid erodes the hard tissues ofthe teeth (enamel, dentin and cementum).The result of HIGH RISK is based on thequantity of these bacteria present in thesample. Efforts to reduce the level of thesebacteria will lower the risk of future dentalcaries.

Oral Care: Poor oral hygiene and infrequent dental checkups are riskfactors for the build up of plaque on teeth that hold caries-causingbacteria. Tooth brushing with fluoridated toothpaste, along with flossingare a mainstay of good oral health.Patient History: The best predictor of the risk for future dental caries is apast history of cavities. One's personal history is influenced by inheritedgenetic factors, home and work environments and changes in life/healthstatus such as orthodontics, pregnancy and chronic diseases likediabetes.Diet: Caries is caused by the metabolism of sugars into acid. Foods highin sugar should be avoided. This includes soft drinks, candy and othersweets including processed carbohydrates. These foods increase boththe amount of bacteria present and the amount of acid produced.

Treatment Considerations:Follow-up testing for OraRisk Caries of HIGH RISK is recommended every 3 to 6 monthsEfforts to improve oral hygiene are essential for prevention of caries which include frequent tooth brushing with fluoridated toothpaste, flossing toremove food particles and the regular use of a fluoride rinseMaintaining a diet low in sugary foods will reduce the amount of acid-producing bacteria. Additionally, frequently drinking water will cleanse themouth and lower the amount of oral bacteriaRegular professional dental cleaning to remove plaque is essential. In some cases, the use of dental sealants will lessen the risk of plaque formationMaintaining a neutral pH in the mouth with the use of arginine bicarbonate and calcium carbonate may prevent demineralization of enamelOral health supplements such as xylitol gum, prebiotics, probiotics and potentially, antimicrobials, can reduce or eliminate cariogenic bacteriaEarly repair of small cavities is the best approach to preventing more aggressive or severe tooth decay

Methodology: Genomic DNA is extracted from the submitted sample and tested for 3 species-specific bacteria [Streptococcus mutans, Steptococcus sobrinus, Lactobacillus casei] known tocause dental caries. The bacteria are assayed by real-time quantitative polymerase chain reaction (qPCR). Bacterial levels are reported in genome copies per mL of sample. Risk ranges werederived from patient testing: Low risk (0 copies/mL); Moderate risk (1x10^1 to 9.99x10^3 copies/mL); High risk (greater than 9.99x10^3 copies/mL). This test was developed, and itsperformance characteristics determined by OralDNA Labs pursuant to CLIA requirements. This test has not been cleared or approved by the U.S. Food and Drug Administration. The FDA hasdetermined that such clearance or approval is not necessary.

Ronald McGlennen MD, FCAP, FACMG, ABMGMedical Director

Page 1 of 1PL-000454-B

OralDNA Labs, A Service of Access Genetics, LLC, 7400 Flying Cloud Drive , Eden Prairie, MN 55344 Phone: 855-672-5362; Fax: 952-767-0446 www.oraldna.com CLIA#: 24D1033809 CAP#: 7190878

Web enabled system provided by:

Collected: 09/16/2015 09:05 Received: 09/18/2015 08:18 Reported: 09/20/2015 09:25Specimen: Oral Rinse

Accession#: 201509-03071Specimen#: 89499693

OraRisk ® CandidaFINAL REPORT

Sample, Report Ordering Provider Sample InformationDate Of Birth: 07/02/1980 (35 yrs) Gender: FemalePatient Id: Patient Location:

Ronald McGlennen MD7400 Flying Cloud Drive Eden Prairie, MN 55344855-672-5362

Reason for Testing: Evaluation of suspicious lesionRelated info: Not ProvidedPatient History: Not Provided

Lesion Size: 1mm x 1mmLesion Color: WhiteLesion Location(s): Buccal Mucosa

MOLECULAR IDENTIFICATION OF CANDIDA SPECIES IN THE OROPHARYNX

Test Results

Candida Species C.albicans

Interpretation:This sample is positive for Candida albicans DNA. This assay cannot rule out infection by Candida dubliniensis. Seecomments.Comments:- Significance: These findings support a diagnosis of oral candidiasis (Oral thrush) caused by C. albicans, the most commonlyimplicated organism in this condition. C. albicans may be present in normal flora. Oral thrush causes creamy white lesions, usually on thetongue or inner cheeks and may spread to the roof of mouth, gums, tonsils, or the back of the throat. Severe symptoms can make eatingpainful and difficult. Left untreated, thrush can spread to the digestive tract and intestines making it difficult to receive adequate nutrition.In immunocompromised individuals, thrush is more likely to spread to the lungs, liver and heart valves. It is not a type of infection that canbe passed on to others.

- Risk: Oral thrush most commonly affects people who wear dentures. People who have difficulties keeping their mouth clean, peoplewith diabetes and those who take steroids are also at a higher risk of developing the condition. Some antibiotics may cause thrush.Certain antibiotics encourage the infection to recur, especially if taken over a long period of time. Very rarely, oral thrush may be one ofthe early signs of HIV.

- Consider: C. albicans accounts for about 50% of oral candidiasis cases, and together, C. albicans, C. tropicalis and C. glabrataaccount for over 80% of cases. Thrush should be treated to keep the infection from spreading. Prescribed antifungal medicines are thestandard treatment for thrush either applied directly to the affected area (topical) or swallowed (oral). Severe infections may require atreatment period longer than 14 days. It is estimated that 1.5-2% of isolates identified as C. albicans are actually C. dubliniensis. C.albicans and C. dubliniensis are closely related Candida species therefore, may respond similarly to first-line treatment.

Methodology: Genomic DNA was extracted and amplified by polymerase chain reaction (PCR) using primers specific for a conserved sequences common to the Candidagenus. Concurrently, analysis of DNA integrity and the presence of inhibitory substances was evaluated by the amplification of the human Apolipoprotein B gene. PCRproducts were subjected to restriction endonuclease digestion and automated electrophoresis fluorescence detection. Digital electropherograms and gel images of datawere generated and the specific Candida species was determined by matching the displayed banding pattern to known Candida species restriction fragment patterns. Theanalytical and performance characteristics of this laboratory-developed test (LDT) were determined by OralDNA Labs, A Service of Access Genetics, LLC pursuant toClinical Laboratory Improvement Amendments (CLIA 88) requirements. It has not been cleared or approved by the U.S. Food and Drug Administration (FDA). The FDA hasdetermined that such clearance or approval is not a requirement prior to use for clinical purposes.References:

Al-Karaawi ZM, Manfredi M, Waugh AC, et al. Molecular characterization of Candida spp. isolated from the oral cavities of patients from diverse clinical settings. OralMicrobiol Immunol 2002;17:44-9.da Silva-Rocha WP, Lemos VL, Svidizisnki TI, Milan EP, Chaves GM. Candida species distribution, genotyping and virulence factors of Candida albicans isolated fromthe oral cavity of kidney transplant recipients of two geographic regions of Brazil. BMC Oral Health 2014;14:20.

Ronald McGlennen MD, FCAP, FACMG,ABMGMedical Director

Page 1 of 11-��������$

© 2020

The Decay Family

Ed Kay

JennaUrsula/SunniShannon ClarkEric

+

Clara Laura Hannah Sara Noah

OSASilent gerdDark circlesSleepySugar intakeMinimal visible biofilmShiny red mucosaMelting teethHBP medsDepression dx

CrowdingModerate biofilmOverweight

Caries - pH 5© 2020

No caries Complex H Hx

Brenna

Hidden risks

© 2020

‣ taking or using? ‣ then… what are you doing? ‣ partner for clues

Health history - Questions

© 2020

! prescrip7on meds

! over-the-counter

Culprits

! home remedies

! supplementsHellwig E, Lussi A. Oral hygiene products, medica7ons and drugs - hidden ae7ological factors for dental erosion. Monogr Oral Sci. 2014;25:155-62.

© 2020

Compromises

‣ sip on sweet drinks

‣ require no chewing / prepara7on

‣ high carb nutri7onal supplementsGuignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10).

Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2020

The why

! combat illness

! provide relief

! support health© 2020

‣ sugary content

‣ pH / 7tratable acidity

‣ chewable tablets

Concerns ! long clearance

! frequency

! night 7me

! packs into occlusal

! s7cky / adherent

‣ slow release

‣ dissolving

‣ contact 7me

Hellwig E, Lussi A. Oral hygiene products, medica7ons and drugs - hidden ae7ological factors for dental erosion. Monogr Oral Sci. 2014;25:155-62. © 2020

Product formulations

© 2020

! effec7ve

! easy to use

! simple dosage ! acceptable taste

! stable over 7me

Douroumis D. Prac7cal approaches of taste masking technologies in oral solid forms. Expert Opin Drug Deliv. 2007 Jul;4(4):417-26. © 2020

‣ gummy chews

‣ par7cle inhalers

‣ swallowed pills

‣ coated discs

‣ slow release lozenges

or hard discs

‣ chewable tablets

Dry products

Fu Y, Yang S, Jeong SH, Kimura S, Park K. Orally fast disintegra7ng tablets: developments, technologies, taste-masking and clinical studies. Crit Rev Ther Drug Carrier Syst. 2004;21(6):433-76. © 2020

! dissolved in water or other

fluids prior to swallowing

‣ powders

‣ effervescent tablets

‣ dispersible tablets

Hybrid preparations

Hellwig E, Lussi A. Oral hygiene products, medica7ons and drugs - hidden ae7ological factors for dental erosion. Monogr Oral Sci. 2014;25:155-62. © 2020

‣ taste

‣ thickener

‣ preserva7ve

‣ an7oxidant

‣ stabilizer

‣ sucrose

‣ glucose

‣ high fructose corn syrup

‣ xylitol

‣ sorbitol

‣mal7tol

‣mannitol

Sweetness

‣ lactose

‣ fructose

Valino7 AC, da Costa LC Jr, Farah A, Pereira de Sousa V, Fonseca-Gonçalves A, Maia LC. Are Pediatric An7bio7c Formula7ons Poten7als Risk Factors for Dental Caries and Dental Erosion? Open Dent J. 2016 Aug 22;10:420-30.

© 2020

Hellwig E, Lussi A. Oral hygiene products, medica7ons and drugs - hidden ae7ological factors for dental erosion. Monogr Oral Sci. 2014;25:155-62.

Bring the subject up

© 2020

Sugars - hidden or in plain sight

! Sucrose - can be 80%

in syrups

Lussi A, Carvalho TS. Analyses of the Erosive Effect of Dietary Substances and Medica7ons on Deciduous Teeth. PLoS One. 2015 Dec 23;10(12):e0143957. © 2020

Sugars - In plain sight?

Inac>ve ingredients (assorted fruit)

Adipic acid, corn starch, FD&C blue #1 lake, FD&C red #40 lake,

FD&C yellow #5 (tartrazine) lake, FD&C yellow #6 lake, flavors,

mineral oil, sodium polyphosphate, sucrose, talc

Inac>ve ingredient (peppermint)

corn starch, flavor, mineral oil, sodium polyphosphate,

sucrose, talc

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm © 2020 © 2020

pH, titratable acidity, citric acid

© 2020

Testing pH

Spray

‣ dry paper towel

‣ spray strip

‣ saturate indicator

Liquid

‣ dry glass container

‣ 1/2 tsp product

‣ dip clean strip

© 2020

Chart courtesy of Spear Education © 2020

Titratable acidity

Tenuta LM, Fernández CE, Brandão AC, Cury JA. Titratable acidity of beverages influences salivary pH recovery. Braz Oral Res. 2015;29. pii: S1806-83242015000100234. © 2020

Total acid content of beverages

pH - ini=al acidity

measures hydrogen ion concentra7on

Owens BM, Kitchens M. The Erosive Poten7al of Soi Drinks on Enamel Surface Substrate: An In Vitro Scanning Electron Microscopy Inves7ga7on. J Contemp Dent Pract 2007 November; (8)7:011-020.

TA - =tratable acidity

• total acid molecules / erosive poten7al

• higher TA / longer 7me to neutral

© 2020

What a brew!

carbonated water

high fructose corn syrup

concentrated orange juice and other natural flavors

citric acid

sodium benzoate (preserves freshness)

caffeine (55.2 mg/12 oz)

sodium citrate gum arabic erythorbic acid

(preserves freshness)

calcium disodium EDTA (protects flavor)

brominated vegetable oil yellow 5

© 2020

More news on acidity LOW Carbonated water 5.3 0.1

Lager 4.4 0.5Beer 3.9 0.6

MEDIUM Cola 2.5 0.7Carbonated orange 2.9 2.0

White wine 2.5 2.2HIGH Apple juice 3.3 4.5

Grapefruit juice 3.2 9.3David BartleJ, BDS, PhD – Acids, sensi7vity and teeth: A prac7cal approach to management of erosion and tooth wear. ADA Mee7ng – October 17, 2008 – San Antonio, TX.

pH TA

Rees J, Hughes J, Innes C. An in vitro assessment of the erosive poten7al of some white wines.Eur J Prosthodont Restor Dent. 2002 Mar;10(1):37-42.

Nogueira FN1, Souza DN, Nicolau J. vitro approach to evaluate poten7al harmful effects of beer on teeth.J Dent. 2000 May;28(4):271-6.© 2020

‣ binds (chelates) calcium

‣ accelerates calcium loss

‣ maintains pH below 5.5

West NX, Hughes JA, Addy M. effect of pH on the erosion of den7ne and enamel by dietary acids in vitroJ Oral Rehabil. 2001 Sep;28(9):860-4. © 2020

‣ 97 medicines

‣ 57 pH <5.5

15 sugar free high- strength meds

vs

SF lower-strength meds

‣ lower pH

‣ greater TA

Maguire A, Baqir W, Nunn JH. Are sugars-free medicines more erosive than sugars-containing medicines? An in vitro study of paediatric medicines with prolonged oral clearance used regularly and long-term by children. Int J Paediatr Dent. 2007 Jul;17(4):231-8. © 2020 © 2020

But it’s………..healthy, natural, organic,

homemade, safe, has vitamins, and natural sugar

© 2020

Bottled water!!!pH levels of 5-5.5 are common

Mouth rinses!!!pH levels 3.5 to 5

Pontefract H, Hughes J, et al. The erosive effects of some mouthrinses on enamel. A study in situ. J Clin Periodontol. 2001 Apr;28(4):319-24. Fisher BJ, Spencer A, Haywood V, Konchady G. Relieving Dry Mouth: Varying Levels of pH Found in BoJled Water. Compend Con7n Educ Dent. 2017 Jul;38(7):e17-e20.

© 2020

Testing water pH

© 2020

Tap water - Houston TX Purified water - Kirkland brand

Propel….now vitamin and calcium enhanced

" water

" sucrose syrup

" flavors

" citric acid

" sodium citrate

" potassium citrate

" Splenda (sucrolose)

" acesulfame potassium

" calcium disodium EDTA

" Vitamin B 5 " Vitamin B 6

" Vitamin B 3 " Vitamin B 12

" Vitamin D

One 8 oz contains

• 10 Calories • 35 mg of sodium

• 3 g of carbohydrates

• 2 g of sugarNguyen Ngoc C, Ghuman T, Ahmed SN, Donovan TE. The erosive poten7al of addi7ve ar7ficial flavoring in boJled water. Gen Dent. 2018 Sep-Oct;66(5):46-51. © 2020

Tea - brewed teas

‣ citrus and fruity teas - greatest lesion depths

‣ pH inversely associated with depth

‣ 7tratable acidy posi7vely associated with depth

Hendricks JL, Marshall TA, et al. Erosive poten7als of brewed teas. Am J Dent. 2013 Oct;26(5):278-82. © 2020

‣ low pH values - all below 4.03

‣ high 7tratable acidity value

Lunkes, LB and Hashizume, LN. Evalua7on of the pH and 7tratable acidity of teas commercially available in Brazilian market . RGO - Rev Gaúcha Odontol., Porto Alegre, v.62, n.1, p. 59-64, jan./mar., 2014 Hara AT, Zero DT. Analysis of the erosive poten7al of calcium-containing acidic beverages. Eur J Oral Sci. 2008 Feb;116(1):60-5

‣ acidulates added

‣ typically citric acid

© 2020

Kombuchadigestive aid

‣ Kombucha tea

‣ fermented - tea +

sugar + yeast +

bacteria

‣ contains vinegar

‣ pH 2.8 - 3.2

O'Toole S, Mullan F. The role of the diet in tooth wear. Br Dent J. 2018 Mar 9;224(5):379-383. © 2020

‣ apple cider vinegar

‣ 2 tsp twice daily

‣ sweeten with honey

‣ pH 2.8 - 3.0

‣ 24 oz warm water

‣ juice of 1 lemon

‣ pH approx. 2.4

Digestive remedies

O'Toole S, Mullan F. The role of the diet in tooth wear. Br Dent J. 2018 Mar 9;224(5):379-383. © 2020

Marketing! Check the ingredients

© 2020

Marketing! Check the ingredients

© 2020

‣ reduced surface micro hardness

‣ smoothie with yoghurt - no change in surface hardness

‣ recommend - consume during mealBlacker SM, Chadwick RG. An in vitro inves7ga7on of the erosive poten7al of smoothies. Br Dent J. 2013 Feb;214(4):E9. © 2020

Adding calcium to juices

Franklin S, Masih S, Thomas AM. An in-vitro assessment of erosive poten7al of a calcium-for7fied fruit juice. Eur Arch Paediatr Dent. 2014;15(6):407–411. Davis RE, Marshall TA, et al. In vitro protec7on against dental erosion afforded by commercially available, calcium-for7fied 100 percent juices. JAMA. 2007 Dec;138(12):1593-8. Hara AT, Zero DT. Analysis of the erosive poten7al of calcium-containing acidic beverages. Eur J Oral Sci. 2008 Feb;116(1):60-5.

✓ calcium containing beverages

✓ lower enamel demineraliza7on/wear

✓ beverages - calcium supplement

reduces demineraliza7on

© 2020

✓ energy drinks - higher 7ratable acidity (TA)

✓ energy drinks - more significant enamel loss - 2x higher

✓ TA significant predictor of enamel dissolu7on

✓ weight loss greatest = high TA + low pH

Jain P, Hall-May E, Golabek K, Agus7n MZ. A comparison of sports and energy drinks--Physiochemical proper7es and enamel dissolu7on. Gen Dent. 2012 May-Jun;60(3):190-7.

vs

© 2020

Ingredients! active and inactive

Citric acidHigh fructose corn syrup

Sucrose

© 2020

Children’s Sinus Support™ does not

contain any harmful s7mulants found in

many over-the-counter drugs.

This chewable tablet is sweetened only

with xylitol, which is natural, safe and

supports dental health.*

Chewable vitamin C

© 2020 © 2020

Gummies!

© 2020© 2020

© 2020

A recipe for disaster‣ super sized drinks

‣ frequent snacking

‣ sipping, swishing, swilling

‣ holding in the mouth

‣ baby boJles and sippy cups

Consumption…..patterns and habits

Erosion photo - Gandara BK and Trulove EL. Diagnosis and management of dental erosion. J Cont Dent Prac. 1999;1(1):1-17 Ehlen LA1, Marshall TA, et al. Acidic beverages increase the risk of in vitro tooth erosion. Nutr Res. 2008 May;28(5):299-303. Shellis RP1, Finke M, Eisenburger M, Parker DM, Addy M. Rela7onship between enamel erosion and liquid flow rate. Eur J Oral Sci. 2005 Jun;113(3):232-8.

© 2020

The why

! combat illness

! provide relief

! support health© 2020

Using the correct test

© 2020

Ooops…the saliva pH buffering test strips

Ooops…the water kit test strips

Now the results!

© 2020

Finally getting the right test……companion products in the same brand line

Now the results! Different papers

© 2020

Bicarbonate modifies citric acid impact

The Decay Family

Ed

JennaUrsula/SunniShannon ClarkEric

+

Clara Laura Hannah Sara Noah

OSASilent gerdDark circlesSleepySugar intakeMinimal visible biofilmShiny red mucosaMelting teethHBP medsDepression dx

CrowdingModerate biofilmOverweight

Caries - pH 5© 2020

No caries Complex H Hx

Brenna

What would you do?

Announcements- One more CE…..and it’s free….just for you….Coming in December……

© 2020

anne@anneguignon.com

832-971-4540 © 2020