Medical management of Caries (decay)

Are you at high risk for caries (decay)? (The disease is called caries, the symptom is decay & cavities).

If you can say “yes” to any of these, you are at risk for decay. The more “yeses”, the higher the risk. You can modify your risk factors! Keep reading to see how you can modify your risk for decay.

1. Do you have dry mouth (or “cotton mouth”)? Dry mouth is extremely common as we get into our upper 50’s and early 60’s. Saliva not only has anti-bacterial enzymes, but also has buffers to buffer acids and, of course, simply the mechanical action of lavage is important.
2. Are you over 60 years old? Our salivary function declines as we get older.
3. Do you have any chronic disease? Over 400 medications can cause dry mouth.
4. Do you have any orthodontia? Lingual bars? It’s hard to clean around braces!!
5. Have you had any new cavities in the last couple of years? That means the bacteria is “active” in your mouth.
6. Has your dentist told you that you have areas under “watch”, or have some “demineralization”? This is a form of very early decay and if caught early enough, can be reversed. Let’s “watch” the area remineralize & harden, NOT DECAY!
7. Do you have any gum recession? Exposed tooth roots are not covered in enamel, they are covered in cementum which is much more vulnerable to decay. Cementum demineralizes at a higher pH ~6, and enamel takes a lower pH ~5.5 to demineralize.
8. Do you have several (6 or more) restorations? Many fillings, restorations, crowns puts you at risk. Each restoration has a tiny micro-margin between the restoration material and your original tooth structure where plaque and bacteria can hide and multiply. They call this secondary or recurrent caries when you get a cavity here.
9. Do you eat a lot of snacks or several small meals a day? Do you eat a lot of carbohydrates or sugars? Every time we eat, especially carbohydrates, we have an “acid attack” on our teeth. Pregnant women can be more vulnerable due to more frequent meals.
10. Little to no fluoride exposure when growing up while teeth were developing? Fluoride can be important anytime, but especially while we are growing and getting our permanent teeth.
11. Do you smoke? Drink alcohol? Use any recreational drugs? All of these can dry the mouth. And a dry mouth is more susceptible.
12. Do you have deep fissures on your molars? Are your teeth crowded? Do you have “food traps”? It is harder to keep crowded teeth clean and deep fissures clean. They become “plaque traps”.
13. Frequent close contact (kissing) with someone with poor oral health or with decay? Caries is a transmissible disease. Yes, you can catch it from someone. We also think of it as a family disease. I don’t treat the individual, I treat the family!
14. Inadequate oral hygiene? Poor plaque control and plaque accumulation can lead to decay.

When patients give me “yeses” to these questions, I have a long conversation with my patients about what this means and how we can TREAT the caries in a “medical management of a chronic disease” protocol. I hate dentists who just “drill & fill & bill” and act as “surgeons” on the teeth without actually medically treating the underlying disease!! And hygienists are taught all this, but the dentists they work for RARELY give them enough time to teach our patient’s this!! (Makes me so MAD!!!)

It is also important to know that caries is a communicable disease. You significant “other” may also be at risk (their risk profile may be different, but you guys are sharing your bacterial flora). If one member of a family has active disease it is better to treat the FAMILY rather than just the one patient with caries. Yep, it is a family disease.

Every time we eat we reduce the pH in our mouth. The pathogenic bacteria in our mouth, well, they eat what we eat. They love carbohydrates of all kinds (not just sugar), and every time they eat, they produce waste product in the form of acid. This reduces the pH in our mouth and (just like ocean acidification reduces shellfish ability to create shells) it attacks our enamel and reduces our enamel and risks decay. If we have normal salivary function our saliva can buffer this acid after about 20-30 minutes, but if our salivary function is compromised, then it may take 40 (or more) minutes before your mouth is in a neutral pH again. If you are eating frequently, your mouth may be in an acid environment all the time!

High Caries Risk Protocols – This is what I recommend to my patients
1. Dental appointments at LEAST every 6 months for clinical exam and fluoride varnish application. Yes, this is the same fluoride treatment kids get. And it works for adults too. Depending on your risk, your provider may have a different recommendation.

2. Bitewing radiographs (x-rays) every 12 months, and either a panograph OR full mouth radiographs every 4-5 years. Bitewings can extend to 18-24 months when no new caries are detected for 3 years (and no periodontal disease exists).
I personally think you shouldn’t go more than 18 months between radiographs for a variety of reasons.

Dental x-rays are extremely low in radiation, but if you are concerned about radiation ask your dentist this: Are the x-rays digital? (digital uses less radiation), Is the collimator SQUARE ? (uses less radiation), is the PID (positional indication device) at least 12 inches long? (Again, you get less radiation when it is a little farther away) and lastly the lead apron should have a thyroid collar to protect your thyroid (a radiation sensitive organ).

Some offices offer salivary flow test, salivary pH test and/or a bacterial culture & count tests. These tests can be helpful in creating a good treatment plan, but you can treat caries without these tests if you’ve recently been diagnosed with caries! Being diagnosed automatically puts you at high risk.

Nutrition: Eat a healthy diet. Make sure you have 6-9 servings of fruit and vegetables & eat good sources of lean protein. Go easy on acidic foods like citrus fruits. They are good for you but they have both sugar AND acid. If you snack, snack on nuts and cheese as these are anti-cariogenic (and high in fat, so don’t go crazy!). There are new guidelines on sugar limitations and there is a pediatric endocrinologist who believes that EVERY sugar-sweetened drink should be cut out of our diets. Not just soda. Fruit juice and anything else we drink that is sweetened – it is not only bad for our blood sugar but it is also bad for our liver and lastly, our teeth. Drink water! The new sugar guideline is that men should have no more than 150 calories (36 grams or 9 teaspoons) of sugar a day. For women it is 100 calories or 24 grams or 6 teaspoons. Yeah, I have trouble keeping to this guideline too.

Brush your teeth in the morning with good old fashioned baking soda. No, it is not too abrasive, especially if you are brushing gently. I keep a little shot glass of it in my bathroom. Put about a half teaspoon of it in the palm of your hand and dip your toothbrush in it. If you hate the taste, try putting a smear of your regular toothpaste on your brush and then dip into the baking soda – it will make it taste better. Brush 2 minutes. The baking soda has a pH of about 8 (alkaline or “base” if you’ve had any chemistry) and the pathogenic bacteria in your mouth are all acid loving. Over time, this can actually change the flora in your mouth to “healthy bacteria” instead of pathogenic bacteria. You can use this routine forever. Rinse well after brushing, especially if you happen to have high blood pressure (it is sodium, after all). Don’t swallow.

Chlorhexidine gluconate .12% rinse: This is a prescription you should be able to get from your dentist. Really, only one bottle will do it. Use this rinse for one minute daily for one week every month until you are caries free. Use in the morning, after brushing teeth. It alters taste for about 30-45 minutes, so you won’t want to eat or drink after using. You want to use in the morning because it can temporarily stain your teeth -and staining is less if used in the morning. You also don’t want to use too much (no more than one week a month) for two reasons: you want to minimize staining, and because it can cause more calculus buildup (tartar) -so make sure you see your hygienist within 6 months to polish and scale your teeth after using Chlorhexidine rinse for 6 months (but remember, only 1 week out of each month, NOT EVERY DAY ALL MONTH). The idea here is that you would stop using it after 6 months because your bacterial flora should have changed. This is not a treatment you should continue to use forever. For the other three weeks of the month, you can use a fluoride rinse such as ACT.

Xylitol: It comes in many forms, usually gum, mints, candies and sprays. Helps neutralize the acids, messes with the pathogenic bacterial metabolism, reduces plaque and helps prevent bacterial transmission to another person. In other words, it reduces your risk of cavities. Start with a few gum/candies or sprays and slowly work up if you have any GI distress. 6-10 grams total per day of Xylitol, broken up 3 times a day. Best just after meals or snacks. SPRY gum has 1 gram per piece of gum or candy. I like SPRY and EPIC brands because I know they have a therapeutic dose of Xylitol. Other brands may have less. Check the label – if there are OTHER sweeteners then I would be suspect that it only has enough for marketing purposes! You only have to chew 5 minutes to get the full effect. If unable to use gum or candy (choking hazard that they are, esp for the very young or elderly people), SPRY also comes in a spray form called RAIN ~3-4 sprays, 3x a day would put you in the target range of 6-10 grams. I will probably use the xylitol forever. I love how it makes my mouth feel after using for a few weeks. Again, it changes the flora of your mouth.
Xylitol warning – too much too soon can cause gas/laxative effect. Also, it is toxic to dogs, so keep it out of the reach of your furry friends.

Baking soda rinse after any snack or eating any carbohydrate: this is an alternative to the Xylitol above. Use one or the other after any eating/drinking to help bring the low pH in your mouth back up to neutral. About a half a teaspoon of baking soda in an 8 oz glass of warm water. Swish and rinse. You can make some up each morning and use throughout the day. Discard any left over at the end of the day. Do not swallow esp. if you have high blood pressure.

Prescription toothpaste: Your dentist should have already written you a prescription for this and if he or she didn’t, shame on them! 1.1% fluoride. Research has found that the fluoride uptake is better when in the presence of calcium phosphate, so my favorite prescription toothpaste is Clinpro 5000 with TriCalcium Phosphate. Some other anti-caries prescription products have Amorphous Calcium Phosphate or Recaladent (another type of calcium phosphate) which also can enhance fluoride uptake. Talk to your dentist for a prescription. The only warning here is to keep out the reach of small children. If a child were to eat the tube of toothpaste there is enough fluoride to kill them. It is a medication!

Before you brush with the toothpaste: floss (or as I say to my patients: clean interdentally…), use a water pik, and use a tongue scraper, or brush the tongue. THEN, use the toothpaste once a day, in the evening, brush for two minutes (power brushes usually have a timer) and you only need a pea-sized amount. (A tube should last about 6 months.) When you are done brushing: Spit, BUT DO NOT RINSE and do not eat or drink for at least 30 minutes. If you decide NOT to use the oral moisturizer below, then you can use the toothpaste just before bedtime.

If you suffer from dry mouth, especially at night: I recommend Biotene oral moisturizer: Try to brush your teeth 30 minutes before bedtime to give the prescription toothpaste a chance to work. Biotene makes lots of products (toothpaste, rinse, etc.) to combat dry mouth, and you can use them if you wish. My favorite product from their product line is their oral moisturizer. Comes in several forms: spray, lotion, gel. Use right at bedtime to help keep your mouth more moist during the night. Our salivary function decreases dramatically during the night and biotene has special enzymes to replace the salvia that we have lost.

If you consistently wake up with a parched mouth -try to find out what might be causing it: Is it due to a medication? Maybe your doctor can switch you to another medicine. Is it nasal congestion? Maybe a nose strip would help. Is it sleep apnea? Then maybe that should be addressed as there are lots of health consequences from untreated sleep apnea. Older (over 50) over-weight men are at particularly high risk.

If you have very early signs of decay (enamel only) we can actually ARREST and REMINERALIZE the decay with the above medical management of caries protocol without any drilling or filling. Really! We can!!!

Man, I wish I knew this stuff when I was a KID!!!!! If I knew I was going to live this long, I would have taken better care of my teeth!!!

Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!