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ORAL
HEALTH
DIALOGUE
1/2015
Editorial
3 Sugar – curing the addiction
6 A new pathway to caries prevention?
10 Relieve the suffering of your patients
12 What dentine sensitivity sufferers
expect from their dentist
14 A growing threat to quality of life
2
Editorial
Sugar – curing the addiction
It has been labeled ‘the legal heroin’ by some experts fighting the rise in obesity, but sugar
carries many more hidden dangers to health as nutritionist Nigel Denby and caries expert
Prof. Svante Twetman tell OHD.
Interview with: Prof. Svante Tewtmann and Nigel Denby
QUESTIONS
Effie Mataliotaki
Head of European
External Affairs
and Communications
Colgate-Palmolive
Welcome to our readers!
Keeping up with the pace of change in oral
health technologies is a challenge for all busy
professionals, so this second edition of the
newly launched Oral Health Dialogue (the first
of two in 2015) aims to simplify life by focusing
on three key aspects – tooth decay and dentine
hypersensitivity and periodontitis.
Caries is still the world’s most prevalent
disease, affecting 80% of the world’s population – despite being preventable with proper
oral hygiene and the appropriate toothpaste,
thanks in no small part to fluoride. This second
edition reflects some of the latest innovations
in the progress being made towards eradicating cavities.
Read about the new opportunities for caries
prevention made possible by modifying the
dental biofilm. We are also taking a hard look
at sugar from the perspectives of a dentist and
a nutritionist. Sugar is much in the spotlight
for its impact on obesity, diabetes and caries,
but what can dental professionals do to help
patients consume less of this addictive
sweetness?
Our decision to tackle dentine hypersensitivity alongside caries may come as more of
a surprise, until we reflect on the significant
2 | Editorial
suffering that it causes some patients. The
impact of this pain is brought vividly to life in
this issue by Prof. Dr. Hans-Günter Schaller
in his account of living with the condition.
Research indicates that only a small proportion
of people suffering from sensitive teeth seek
treatment and according to a Danish survey,
only 23% of dentists ask their patients whether
they suffer from hypersensitivity as part of
a regular check-up. Yet, for some patients, the
degree of discomfort can cause them to avoid
basic oral health care routines. The impact on
dental caries is very clear – hence our decision
to handle the two interrelated subjects in the
same issue.
Finally, we take an overview of the impact of
periodontitis on the oral health of elderly
people with the new chairman of Europerio
2015 Francis Hughes.
Good reading and please give us feedback
on this magazine by contacting
[email protected]
Effie Mataliotaki
Head of European External Affairs
and Communications
Colgate-Palmolive
ORAL HEALTH DIALOGUE | 1/2015
What and how much Europeans eat has
changed dramatically in the last century. What
are the factors for increased sugar intake?
Nigel Denby, Nutritionist: The European diet has
changed beyond recognition in the last century.
We are now able to eat whatever we want whenever we want it. Seasonal and regional food is a
thing of the past, we eat strawberries at Christmas
and can farm Scottish salmon in all four corners of
the world. In many respects this is a good thing
and has improved the variety of foods in our diets
enormously. However, as fresh food had become
abundant, there’s also been a shift towards manufactured convenient and ready prepared food.
This has increased our intake of nutritional nasties
like salt, fat and above all sugar. We’re often unaware of what’s in these foods, and as a result
we’ve lost control over what we eat. Manufactured
food and drinks are full of ingredients which taste
great but do us harm when consumed in excess –
this is especially true of sugar.
M
anufactured food and drinks are full of
ingredients which taste great but do
us harm when consumed in excess – this is
especially true of sugar.
It’s no accident that the increase in obesity, diabetes cancers and dental caries has followed the
explosion of manufactured food. In short the European diet makes it very easy to be over fed but
under nourished. Our diets have become more
calorie dense and less nutrient dense.
Living standards in Europe changed
significantly over the last 50 years and the
price for food went down at the same time.
How does this impact dietary habits?
ND: It may not always seem like it but food is
cheaper now than ever. Europeans on the lowest
incomes no longer need to go hungry. Sadly the
ingredients which make food cheap to manufacture do us most harm. Salt, fat and sugar are all
cheap and readily available and easy to add to all
kinds of foods and drinks. They appear in foods
we consume throughout the day – from breakfast
foods to complete ready meals. We can, if we
choose; rely entirely on manufactured food instead of cooking anything from scratch. At www.
grub4life.com we see how dietary habits are
formed most acutely in young children. Lifelong
taste preferences are shaped by children’s early
experience of food. Regular consumption of sugary drinks and snacks early in life instills the same
dietary habits for life. We’d be horrified if we were
promoting cigarette smoking to our youngest children, yet we seem oblivious to the constant bombardment of obesogenic and cariogenic sugar
filled foods we expose them to.
What is the role of sugar in oral health?
Svante Twetman: Caries is a biofilm-mediated disease and sugar plays an important role in its etiology.
The oral biofilm (dental plaque) is an aggregate of different bacteria colonizing the oral cavity in a complex
ecosystem. As long as the biofilm is stable and diverse, it contributes to the maintenance of oral health.
Sugar, and especially sucrose, acts like a ‘starter’ in a
car for a series of unwanted events that destabilize the
biofilm and reduces its diversity. Frequent intakes of
sugar boost the microbial metabolism resulting in an
increased acid production in the biofilm. These extended low-pH conditions will favor acid-tolerant bacterial strains that will grow instead of less tolerant
bacteria. With the beneficial and harmless bacteria
outcompeted, the sugar-stressed biofilm is associated with a rapid mineral loss from the dental hard tissues and eventually cavity formation. Sugar-exposure
enhances also the production of an extracellular matrix within the biofilm which shields the bacteria from
outside influences and makes it ‘sticky’ and hard to
remove. However, the comforting thing is that the
sugar-induced ecological shift in the biofilm can be
reversed by an improved diet with less frequent intakes of sugar-containing foodstuff. A stressed biofilm can regain its balance and stability only a few
weeks after a diet change.
The other main challenge to the teeth, erosion, is
a chemical process due to exposure of intrinsic or extrinsic acids (from diet). Thus, this is a life-style process
independent of biofilms and bacterial metabolism.
Sugar – curing the addiction | 3
Nigel Denby
Registered dietician,
author and
broadcaster
Hidden sugar in foodstuff (eg fizzy drinks in
particular) seems to be an issue of growing
importance. How can consumers be more
aware of what they eat in terms of reducing
sugar intake?
ND: Sugar appears in many guises. Bread, cereals,
savoury sauces and many low fat products can all
have sugar added to them. These foods don’t
taste especially sweet so it’s only by reading labels
that you’d know the sugar was there. It’s easy to
consume far more sugar than you realize unless
you’re a savvy label scanner. Check labels on
foods you buy regularly – look to see how much of
the carbohydrate value on the label comes from
sugar, 15g or more per 100g is a lot!
You need to be equally vigilant about the sugar you consume from drinks. A lot of us don’t consider the nutritional value of drinks, we focus on
food. Some fizzy drinks contain as much a seven
teaspoons of sugar in one 330ml can. Fruit drinks
are a problem too, as any dental professional
knows free sugar combined with acid is the perfect recipe for tooth decay.
ST: The hidden sugar is of course a problem
and the average person is probably unaware of
the fact that the sugar intake per capita exceeds
40 kg/year in most westernized countries. Sugar
counselling must however be a joint responsibility among all health professionals according to
the ‘common risk factor approach’. An increased
awareness and sugar discipline may not affect
only the oral health but also overweight, diabetes
and the entire metabolic syndrome. Recent systematic reviews have displayed insufficient quality
of evidence for various technologies for dietary
interventions and I am afraid that these conclu-
4 | Sugar – curing the addiction
sions have been misinterpreted by many dental
professionals to do nothing. In fact, the individual
one-to-one dietary intervention in the dental setting can change behavior and we cannot simply
afford to miss this opportunity to improve oral
and general health. The dental recall-system with
scheduled and regular follow-ups is also unique
for monitoring changes over time and for re-evaluation of disease activity. In this context, screening of general medical conditions is already an
integrated part of the dental check-ups in several
public and private clinics in Scandinavia today.
The WHO released a report with impressive facts on sugars. How do you see the
importance of this WHO statement?
ND: Reports are all very good, they can underpin
knowledge and public health messages, but in my
experience they rarely promote a great deal of action. It’s no secret that too much sugar is bad. We’ve
seen the effect of excess sugar in the diets of Americans, we are now seeing it in Europeans. As the fast
food giants and food manufacturing brands move
in we are even beginning to see the same disease
and poor health trends replicated in developing
countries. In my view, instead of more reports what
we need is research into developing less harmful
food ingredients and also effective interventions to
motivate people to change what they eat.
ST: The systematic review behind the WHO
report by Moynihan and Kelly (2014) is comprehensive and well-executed, establishing a clear
association between caries and a sugar content
exceeding 10% of the total energy intake. One
should however keep in mind that the report is
based on a number of ‘old’ studies conducted before the widespread use of fluoride toothpaste. It is
also limited to the amount of sugar while for caries
development, sugar frequency is more important
as stated above. For example, Arola et al (2009)
found a positive relationship between sugar frequency and caries in 19 out of 31 papers compared
with only 6 papers on sugar quantity and caries.
The authors did also point out the fact that the relationship between sugar and caries has weakened
in recent years along with the widespread use of
fluorides. Nevertheless, the WHO-report will act as
an important reminder on the impact of diet on oral
diseases and hopefully bring more focus on how
to deliver the healthy-eating message to patients.
It is almost a paradox that the ‘infamous’ Vipeholm
study that provided the first prospective proofs on
ORAL HEALTH DIALOGUE | 1/2015
sugar and caries development is nowadays almost
more used in the medical ethics curriculum than
in cariology.
Conventional fluoride toothpastes might
not be able to protect teeth from cavities
anymore. Do you consider there to be
a need for a new technology to fight that
issue?
ND: Any development which helps to protect teeth
from cavities gets my backing. Of course, as a dietitian I want people to change and improve their diets, but I know wide scale change take time. While
we wait for change to take affect we can be thankful
that tooth brushing is established in most people’s
daily routine. So, if new; advanced toothpastes can
help while we reduce our sugar intake they’d be a
valuable part of the tool kit of solutions we need.
ST: I do not agree with the first part of the
question. New and improved technologies will
hopefully always appear but the sad fact is that
we are under-utilizing what we already know with
strong evidence. Around 25% of the population
does not use fluoride toothpaste on a daily basis and this figure is unfortunately higher among
disadvantaged groups. Even worse, only 10%
of patients use fluoride toothpaste in an optimal
way (2 times per day for 2 minutes, at least 1
cm toothpaste, minimum of water rinsing afterwards) according to a questionnaire among patients of all ages (Jensen et al, 2012). The main
problem seems to be that the fluoride message
is overlooked by dental health professionals as
they take for granted that their patients already
know (Jensen et al, 2014). More time is spent on
mechanical cleaning than on fluoride action and
there is obvious room for improvement. Consequently, we cannot rely only on improved toothpaste technologies because they do not work if
not used properly.
Svante Twetman
Professor of
Cariology at the
Faculty of Health
and Medical
Sciences, University
of Copenhagen
crackers and cheese or hummus and raw vegetables. Check labels on the manufactured foods you
buy regularly – look to see how much of the carbohydrate value on the label comes from sugar,
15g or more per 100g is a lot!
ST: On the protective side, the most important
thing is to make sure that elevated fluoride levels
are available in the oral biofilm over the 24-hour
period to be able to influence the balance between
de- and remineralization and there is a palette of
commercial self-care products to achieve this. On
the diet side, it is crucial to reduce the frequency
of sucrose intake. One easy way is to skip sugar
in coffee and select natural, less stressful sugars
rather than refined and processed products. However, most of us have a sweet preference and sugars can never be totally avoided. A good way to
minimize the stress is always to drink water after
sugar exposure and/or stimulate saliva clearance
via a sugar-free chewing gum.
References
1. Arola L, Bonet ML, Delzenne N, Duggal MS, Gómez-Candela C, Huyghebaert A, Laville M, Lingström P,
What would you recommend to patients on
how they can protect their teeth better from
nutritional point of view?
ND: From a nutritional point of view, I’d recommend that people try to avoid sugary drinks and
drink more water. I’d encourage them to a cut
down on manufactured foods by inspiring people
to cook more from scratch. Start with one extra
home cooked family meal a week. Enjoy regular
snacks but stick to foods with less or no added
sugar like unsalted nuts, fresh fruit, plain popcorn,
Livingstone B, Palou A, Picó C, Sanders T, Schaafsma G, van Baak M, van Loveren C, van Schothorst
EM. Summary and general conclusions/outcomes on the role and fate of sugars in human nutrition and
health. Obes Rev 2009; 10 Suppl 1: 55–58.
2. Jensen O, Gabre P, Sköld UM, Birkhed D. Is the use of fluoride toothpaste optimal? Knowledge, attitudes
and behaviour concerning fluoride toothpaste and toothbrushing in different age groups in Sweden.
Community Dent Oral Epidemiol 2012; 40: 175 – 84.
3. Jensen O, Gabre P, Sköld UM, Birkhed D, Povlsen L. ‘I take for granted that patients know’ – oral health
professionals’ strategies, considerations and methods when teaching patients how to use fluoride
toothpaste. Int J Dent Hyg 2014; 12: 81– 8.
4. Moynihan PJ, Kelly SA. Effect on caries of restricting sugars intake: systematic review to inform WHO
guidelines. J Dent Res 2014;93:8-18.
Sugar – curing the addiction | 5
Influencing biofilm metabolism
A new pathway to caries prevention?
Prof. Dr. Elmar Hellwig
The microbial biofilm usually guarantees
a healthy oral cavity. But when the frequent
consumption of low molecular weight
carbohydrates causes repeated falls in the
pH of the biofilm, an acidogenic and
aciduric microflora develops, leading to
demineralisation of enamel and dentine.
Caries is the result of the metabolic activity
of a cariogenic microbial biofilm.
Recent systematic reviews have shown that the
regular use of toothpastes, varnishes, gels, and
mouth rinses containing fluoride clearly reduce
the development of caries. In Germany, caries
prevalence declined considerably in recent years,
particularly in adolescents. However, large numbers of initial caries lesions still occur. And the
prophylactic effects of fluoride are reduced in patients with high caries activity. Caries prevention
with fluoride products aims primarily to influence
the demineralisation and remineralisation processes on tooth surfaces. However, fluorides
hardly affect the caries-inducing biofilm covering
these surfaces. That’s why ways of achieving better caries prevention have been sought for quite
some time. With this aim in mind, calcium-containing compounds such as amorphous calcium
phosphate/casein phosphopeptide (ACP-CPP)
have been developed for additional remineralisation. Data on the clinical efficacy of these products
are, however, contradictory. In 2011, the American
Dental Association’s Center for Evidence-Based
Dentistry declared there was no confirmed evidence that such products actually contribute to
caries prevention. In addition, their main mechanism of action is once again the remineralisation of
previously demineralised tooth enamel. As far as
possible, new methods of caries prophylaxis
should also prevent the development of initial caries lesions. In this respect, it can also be said that
clinical studies have not yet provided any evidence
that fluoride-free toothpastes containing other ingredients, such as nano-hydroxyapatite, protect
effectively against caries.
As a result, research has increasingly focussed on the importance of the cariogenic microbial biofilm. At first glance, effective antimicrobial mouth rinses might offer good possibilities for
caries prevention. However, cariogenic bacteria
in biofilms live in a sort of community, on which
antimicrobial substances have very little effect.
6 | A new pathway to caries prevention?
Bacteria in biofilms can successfully protect themselves against these agents, so that very much
higher concentrations than are usually found in
mouth rinses would be required to achieve effective caries prevention.
C
ariogenic bacteria in biofilms live
in a sort of community, on which
antimicrobial substances have very little
effect.
Mechanical oral hygiene alone, without the use of
fluoride toothpaste, is also insufficient for effective
prophylaxis. After the teeth have been cleaned,
biofilm that contains acidophilic and aciduric organisms often remains on tooth surfaces in many
areas. Some micro-organisms, which are found in
the ‘normal’ microflora and correlate with a healthy
situation in the mouth, are able to metabolise molecules from the food and saliva into ammonia
(NH 3). In this way, they hold the biofilm in equilibrium and help to suppress the development of a
cariogenic microflora. There even seems to be an
inverse correlation between the presence of these
alkali-producing micro-organisms and the prevalence of caries. Factors including lactic acid production from low molecular weight carbohydrates
and NH 3 production from proteins, peptides and
other molecules therefore determine the pH in biofilms on the tooth surface. In turn, the pH determines bacterial growth and hence the composition of the bacterial population. Conversely, the
buffering capacity of the biofilm also affects this
parameter.
ARGININE AFFECTS BIOFILM
ECOLOGY
In the 1970s, attempts were made to influence the
biofilm with substances acting as buffers to control the pH during cariogenic attacks. These substances had to be metabolised by specific micro-organisms in order to obtain certain end
products such as ammonia. It was shown that the
production of alkaline metabolites in the oral biofilm played an important part in caries prevention
as they buffered the acids in plaque, resulting in a
less cariogenic oral flora. These results gave rise
to a new strategy for promoting oral health. Studies by Kleinberg et al identified arginine as one of
ORAL HEALTH DIALOGUE | 1/2015
these substances. Arginine is present in saliva in
the free state (7–15 μmol/l ), and is also bound to
salivary proteins and peptides. It is metabolised by
the arginine deiminase (AD) system of certain micro-organisms to produce ornithine, ammonia
and CO 2. These bacteria include Streptococcus
gordonii, Streptococcus parasanguinis and Streptococcus mitis. Certain lactobacilli, actinomycetes and spirochaetes have also been identified as
arginolytic. A study in 2013 showed that the arginine deiminase activity in the biofilm on caries-free
tooth surfaces was higher than that in biofilms
from carious enamel or dentine. Improved availability of arginine increases the activity of the enzyme in the saliva and in the biofilm. Clinical studies have shown that individuals without caries
have higher ammonia concentrations and higher
pH values, significantly higher free arginine levels
in the saliva and greater arginine deiminase activity in both plaque and saliva. The bacterial production of alkaline substances correlates very closely
with a low level of caries. Laboratory tests have
demonstrated that
• a cariogenic biofilm can metabolise
arginine to NH 3
• the corresponding metabolic pathways
can be identified
• the pH of the biofilm rises with repeated
administration of arginine and thus counteracts
a fall in pH during a carious attack
• micro-organisms that produce basic
metabolites increase with time when arginine
is given regularly.
T
he use of fluoridated arginine toothpaste
causes a shift in the bacterial population
of the plaque, towards the composition
found in the biofilm of caries-free individuals.
Overall, it can be concluded from the available in
vitro studies that the anticariogenic effects of a
toothpaste containing arginine can be attributed
primarily to its properties of stimulating the arginine deiminase system and making the substrate
for ammonia production available to the plaque
bacteria. Salivary components are also metabolised in this way and contribute to the greater production of alkaline substances in the plaque. The
use of fluoridated arginine toothpaste also causes
a shift in the bacterial population of the plaque,
towards the composition found in the biofilm of
caries-free individuals. This apparently results in
Prof. Dr. Elmar Hellwig
Medical Director Department
of Operative Dentistry and
Periodontology University
of Freiburg, Germany
an ecologically healthy oral milieu in which it is
difficult for the acid-tolerating pathogens associated with caries to establish themselves.
COMBINED EFFECTIVENESS OF
ARGININE/CALCIUM/FLUORIDE
These findings then led to the in situ investigation
of arginine-containing dental care products with
respect to their caries-inhibiting effects. The results were resoundingly positive. For example,
one study tested toothpaste with 1.5% arginine,
calcium carbonate, and 1450 ppm fluoride ions (F-)
as sodium monofluorophosphate (NaMFP). Another toothpaste contained 1.5% arginine, dicalcium phosphate and 1450 ppm F- in the form of
NaMFP. A fluoridated toothpaste (NaMFP: 1450
ppm F-) with a dicalcium phosphate base acted as
the positive control, while the negative control
contained NaMFP (250 ppm) also with a dicalcium
phosphate base. Twenty-nine subjects participated in the study and each of them was fitted with
two enamel specimens held on the lower jaw by
an intraoral device. The enamel specimens were
subsequently demineralised by immersing them in
acetic acid for 48 hours. The cross-over study required the subjects to clean the enamel specimens twice a day, using the relevant toothpaste for
one minute and then rinsing with tap water for 10
seconds. After two weeks, the enamel specimens
were removed from the mouth and evaluated with
microradiography (a special X-ray procedure to
determine the mineral content). Toothpastes
A new pathway to caries prevention? | 7
The Sugar Acid Neutralizer technology contains 1,5%
arginine, which is:
•a naturally occurring amino acid
•an essential building block for proteins
•naturally found in dairy products, beef, pork, poultry,
sea food, soy beans, granola, etc.
•a natural part of human saliva
•playing an important role in cell division, the healing of
wounds, immune function and the release of hormones
•Used today in a variety of dietary supplements
TM
8 | A new pathway to caries prevention?
ORAL HEALTH DIALOGUE | 1/2015
efficacy of this toothpaste has also been tested in
studies with standard clinical diagnostic investigations of caries.
A large-scale study enrolled 6000 subjects
aged between six and 12 years, each with at
least four erupted permanent molars and at last
one erupted central incisor. The study was a double blind randomised trial in parallel design, with
2000 subjects allocated to each group. Both test
groups had moderate caries activity. Subjects
were instructed to clean their teeth twice a day
with the toothpaste provided. A 1.5% arginine
and 1450 ppm F- (NaMFP) toothpaste was produced with a calcium carbonate base. A second test toothpaste had the same arginine and
fluoride content but a dicalcium phosphate base.
The control product was a toothpaste containing sodium fluoride (1450 ppm). The study lasted
two years and at the end showed that the test
toothpaste offered significantly better protection
against caries than the standard sodium fluoride
toothpaste. No difference was found between the
two arginine test toothpastes (figure 1). The tooth-
paste with arginine, fluoride and dicalcium phosphate also gave better results than the toothpaste with fluoride alone with respect to arresting
(re-hardening) caries-induced demineralisation
on the root surfaces.
SUMMARY
The topical application of fluoridated products is still
the keystone of caries prevention. Nevertheless,
modification of the cariogenic biofilm has opened
possible new ways of caries prevention in the future.
The theoretical possibility of influencing the biofilm
by alkalescent molecules such as arginine, first
postulated by Kleinberg at the end of the 1970s,
has been realised in products for clinical use that
have been successfully put to the test. In addition,
the calcium components in these products offer an
opportunity of increasing the quantity of free calcium ions for remineralisation processes after a carious attack on the tooth surface.
Lesion volume over time
Increase in DMFT
Negative control
Control product (with NaF)
Arginine/NaMFP
35
30
est toothpaste
T
with arginine, NaMFP and
dicalcium phosphate
0,7
0,6
25
0,5
20
0,4
15
0,3
est toothpaste with arginine,
T
NaMFP and calcium
carbonate
Positive control with NaF
10
5
0
0,2
0,1
0,0
baseline
3 months
6 months
Figure 1: Volume of initial caries lesions at the start, after three months, and at the end of a
clinical study using different toothpaste formulations
Increase DMFT 1
THE SUGAR ACID
NEUTRALIZERTM
TECHNOLOGY
the secondary molars, there was once again a
highly significant difference in favour of the group
using the arginine toothpaste.
Further development resulted in a toothpaste
that contained 1.5% arginine, 1450 ppm fluoride
(sodium monofluorophosphate) and a calcium
component. Several studies were carried out with
this toothpaste, including one which compared it
with a sodium monofluorophosphate paste (1450
ppm F-) and one containing no fluoride at all. The
study was carried out in five schools in Chengdu,
China, and included 446 children aged between
10 and 12 years, each of whom had at least one
incipient caries lesion on the buccal surface of
one of the six front teeth (incisors and canines)
of the upper jaw. Using a special procedure (quantitative light-induced fluorescence, QLF), the authors investigated whether the size of the initial
caries lesions had altered after six months on the
corresponding treatment. It was a double-blind
randomised controlled trial with three parallel
treatment arms. All subjects had to clean their
teeth with the corresponding toothpaste twice a
day at home. On schooldays, they also brushed for
two minutes under supervision in the afternoons.
The fluoride toothpaste with arginine reduced
the average size of the lesions by 50% or more
in 45% of the subjects. Only 23% of the subjects
using the pure fluoride toothpaste achieved similar results, while only 13% of those in the negative
control group showed corresponding changes in
the lesions. The authors concluded that the use of
toothpaste containing both fluoride and arginine
was more effective in preventing caries than the
application of fluoride alone. A second study, with
an almost identical study design, compared the
above-mentioned arginine toothpaste (containing
1450 ppm fluoride as sodium monofluorophosphate and a calcium carbonate base) with a toothpaste containing 1450 ppm fluoride as sodium fluoride. Once again, the negative control contained
no fluoride. After six months, the lesion volume in
the group using the arginine/fluoride toothpaste
was reduced by 51%. The corresponding figure
was 34% for the fluoride-only toothpaste and
13% for the negative control (figure 2). This study
demonstrated that the arginine-containing toothpaste was also more effective than a toothpaste
with ionically bound fluoride. A third study with a
similar design, carried out in children in Thailand,
also found the arginine/fluoride toothpaste to be
superior to toothpaste with fluoride alone. The
Lesion volume (mm 2 %)
containing arginine showed significantly better
remineralisation than the other toothpastes. In the
negative control group (250 ppm fluoride as NaMFP, no arginine), there was even demineralisation
of the enamel samples.
Clinical studies were then carried out on the
efficacy of arginine-containing toothpastes, as
only the clinical use of a product can provide real
evidence that it is an effective caries prophylactic. In particular, of course, it is important to test
whether a substance reduces caries to a greater
extent than the fluoride gold standard.
Clinical studies have primarily focussed on
toothpastes containing arginine and various calcium compounds. A study published by Acevedo
et al in 2005 tested a fluoride-free arginine bicarbonate/calcium carbonate toothpaste in 11- to
12-year-old schoolchildren for a period of two
years: 304 children used the toothpaste designated CaviStat, while 297 children acted as controls
by using a toothpaste containing 1100 ppm fluoride. The researchers came to the conclusion that
the arginine-containing toothpaste was clinically
and statistically more effective than the fluoride
toothpaste in preventing both the development
and progression of caries. After two years, however, the overall DMFS no longer showed a significant difference between the two groups. That
said, considering the DMFS of the premolars and
1 year
2 year
Figure 2: Increase in DMFT after one and two years using
different toothpastes
A new pathway to caries prevention? | 9
Relieve the suffering
of your patients
It would be natural to assume that a dental pain
affecting up to 74% of the population and troublesome enough to have an impact on eating habits
and even make people avoid the dentist, would be
well understood and managed – but dentine hypersensitivity is still often ignored and under treated in general practice.
Dentine hypersensitivity (DH) is relatively easily
defined, but much less easy to manage. According to the Canadian Advisory Board on Dentine
Hypersensitive, 2003, it is sharp pain arising from
exposed dentine in response to stimuli – typically
heat, cold air, touch or acidity in food – and which
cannot be ascribed to any other dental defect or
disease. Pain however is subjective, which makes
it difficult for both patients and dental professionals to quantify and treat.
M
any patients accept that pain is part of
a dental visit and do not even consider
that anything might be done to prevent it.
According to research, only a small proportion of
people suffering from sensitive teeth seek treatment for it, even though Norwegian figures suggest one in four suffer from it at least once a week.
Many patients accept that pain is part of a dental
visit and do not even consider that anything might
be done to prevent it. While many dentists fail to
10 | Relieve the suffering of your patients
take DH seriously – according to a Danish survey,
only 23% actually ask their patients routinely
about whether they suffer from it, as part of a
check up.
The under reporting of DH by clinicians can
be explained, in part, by the difficulties of diagnosing it in the first place. The main symptom is
pain (which is difficult to quantify in itself) and the
starting point for diagnosis is the elimination of
other conditions (such as fractured tooth syndrome, leaking restorations and caries), so the
dental practitioner is presented by something of a
challenge, particularly in a busy practice. Establishing a cause with the patient may also not be
straightforward, if the emotional effects of pain
act as a barrier to communication. Those clinicians aware of the suffering caused by DH find
little research literature to inform their patient
management plans.
Identification of those people most at risk of
developing the condition, is the starting point
for DH management, as David Gillam and Elena
Talioti describe in their overview of the subject.
These include over-enthusiastic brushers, periodontally-treated patients, bulimics, people with
dry mouths, high-acid food/drink consumers,
older people with gingival recession and users of
snuff or who chew tobacco.
Once patients are identified, many treatment
ORAL HEALTH DIALOGUE | 1/2015
options are possible, employing a wide array of
desensitising products in the form of toothpastes,
mouth washes, sealants and gels. Desensitising
toothpastes have shown the most promise,
demonstrating reductions in sensitivity of 30% to
80% when compared with other toothpastes and
placebo controls. Clinical studies have documented that a dentifrice with 8% arginine, calcium carbonate and 1450 ppm fluoride is more effective at
reducing DH than a pumice-based toothpaste and
can deliver immediate improvement in hypersensitivity.
Experts are increasingly agreeing that a single blanket approach to DH treatment can not
be taken – it requires individual and multi-facetted management. The UK Expert Forum recently-produced guidelines for management of the
condition recommending narrowing down treatment options according to into which of the following three groups individuals fall:
• gingival recession due to mechanical trauma
• tooth wear lesions
• patients being treated for periodontal disease
The essentials for treatment are correct diagnosis, selection of a suitable desensitising product and management of patient expectation, as
no single treatment is going to work for a patient.
It may be necessary to try a variety of treatment
approaches to relieve the client’s pain. Orchardson and Gillam recommend a stepwise approach,
depending on the extent, severity, and underlying
cause of DH. Their steps begin with a noninvasive
approach, supplemented with preventive measures, and escalated to more invasive treatments
if the pain is unresponsive or increasing or if the
initial diagnosis may have been incorrect.
Sensitive teeth present a challenge for clients
and for the professionals who care for them, but
the spur to establishing better prevention and
management methods is the degree of suffering
experienced by individuals – whatever their walk
of life.
Hypersensitivity sufferer Professor HansGünter Schaller, Director of Restorative Dentistry
Institute at Halle (Saale) University – has given a
valuable insight to OHD readers about the impact
that the condition has on his life, particularly concerning his preparations for receiving dental treatment. He is one of many people who look forward
to the identification of better and longer-lasting
treatments.
POWER OF PRO-ARGIN® CONFIRMED BY SYSTEMATIC REVIEW
A systematic review has confirmed the effectiveness of new
toothpastes containing the Pro-Argin® technology (8% Arginine)
in treating dental hypersensitivity (DH).
The meta-analyses by Boxi Yan et al at Sichuan University,
Chengdu, China and published in Quintessence International
General Dentistry, showed that on the basis of currently
available evidence, arginine-containing toothpastes are able
to reduce DH. Reviewers however agree that more research
is needed to establish exactly how the mechanism works.
Examination of the 18 studies in the review indicates that
arginine-containing toothpastes have a superior desensitising
effect (and are thus more effective in reducing DH) in comparison with placebo toothpastes and potassium salt-containing
toothpastes.
Previously published systematic reviews only supported the use
of potassium salt-containing toothpastes in reducing DH,
whilst laser therapy and toothpastes containing oxalates failed
to be associated with this same effect. Arginine-containing
toothpastes seem to be an effective option for clinicians to use
in the management of DH.
References
1. Bekes K, John MT, Schaller H-G, Hirsch C. Oral health-related quality of life in patients seeking care for
dentin hypersensitivity. J Oral Rehabil 2008;36:45–51.
2. Zapera, Survey among dental professionals in Nordic about dentine hypersensitivity, YouGov Zapera 2009
3. David Gillam and Elena Talioti, The management of dentine hypersensitivity, http://www.sciencedirect.
com/science/article/pii/B978012801631200004X
4. Clark GE, Troullos ES. Designing hypersensitivity clinical studies. Dent Clin North Am 1990;34:531–44.
5. Docimo R, Montesani L, Maturo P, Costacurta M, Bartolino M, Zhang YP, DeVizio W, Delgado,
E, Cummins D, Dibart S, Mateo LR: Comparing the efficacy in reducingdentine hypersensitivity of a new
toothpaste containing 8.0% arginine, calcium carbonate, and 1450 ppm fluoride to a benchmark
commercial desensitizing toothpaste containing 2% potassium ion: An eightweek clinical study in Rome,
Italy. J Clin Dent 20: 137–143, 2009.
6. Docimo R, Perugia C, Bartolino M, Maturo P, Montesani L, Zhang YP, DeVizio W, Mateo LR, Dibart S.
Comparative evaluation of the efficacy of three commercially available toothpastes on dentin
hypersensitivity reduction: An eight-week clinical study. J Clin Dent 2011;22 (Spec Iss) : 121–7.
7. Orchardson R, Gillam DG. Managing dentin hypersensitivity.
J Am Dent Assoc 2006;137:990–8.
Relieve the suffering of your patients | 11
What dentine sensitivity sufferers
expect from their dentist
Prof. Hans-Günter Schaller
HOW DOES DENTINE HYPERSENSITIVITY AFFECT YOUR LIFE ON A
DAY-TO-DAY BASIS?
I’ve had several hypersensitive teeth in both my
upper and lower jaws for some time now. Despite
treatment and the use of dental hygiene products
intended to reduce the sensitivity, not to mention
the fact that I’m getting older, they now react very
painfully to cold foods and cold air. My back teeth
are particularly troublesome. The problem is almost certainly due to inadequacies in my own
dental hygiene techniques over the past decades,
since my youth. But it hasn’t really affected my
routine oral hygiene and I’ve more or less come to
terms with my sensitive teeth on a daily basis. Repeated findings in the literature show that dentine
hypersensitivity peaks between the ages of 20
and 40, and slowly diminishes with age due to the
physiological defence mechanisms of the
pulp-dentine complex. Unfortunately, I am not in a
position to confirm these reports, as my own problems are getting steadily worse, with more and
more teeth being affected and the pain increasing
in intensity every year.
WHAT KIND OF CHANGES HAVE
YOU HAD TO MAKE TO YOUR
LIFESTYLE IN RESPONSE TO
THE DH?
Although my teeth are very painful at times, I’ve not
made any real compromises to my oral hygiene
routine or changed my diet. Yes, cold food and
drinks hurt a bit, but I can usually still enjoy them.
My daily oral hygiene doesn’t present any problems to me. I use lukewarm water, as cold water
can be thoroughly unpleasant. It goes without saying that I’ve been using special toothpastes for
sensitive teeth for many years. All I can say about
my diet is that I still drink chilled beverages and eat
very cold food without limitation. I can tolerate the
resulting symptoms. And although I notice the
cold air outside in winter, it doesn’t restrict my
lifestyle.
12 | What dentine sensitivity sufferers expect from their dentist
HOW DO YOU FEEL
ABOUT SEEING A DENTAL
PROFESSIONAL?
Regarding dental prophylaxis and treatment, the
biggest problem is my sensitive teeth and that’s
usually the main concern at any dental appointment. I can not have a professional scale and
polish without it hurting, and I find the procedure
very stressful. Likewise, my teeth react very painfully to the airflow when suction is applied to the
adjacent teeth, the contralateral teeth, and the
opposite jaw. You can’t block everything out with
a local anaesthetic, otherwise you’d have to
anaesthetise all the back teeth in both jaws!
either as the main focus of my visit, or carried out
at the end of a treatment session. This treatment
has usually relieved the symptoms and greatly
improved my quality of life. Unfortunately, however,
the effects of this treatment don’t last very long
and it has to be repeated in yet more appointments, even though I back it up at home with a
combination of special products – toothpaste and
mouth rinses. I really wish they’d find a lasting
solution to the problem through scientific research
and the development of new strategies and products for the future.
Professor
Hans-Günter Schaller
Director of Restorative
Dentistry Institute Halle
(Saale) University, Germany
DO YOU INFORM YOUR DENTAL
PRACTITIONERS ABOUT YOUR
SENSITIVITY ISSUES?
As I experience a great deal of pain from sensitive
teeth during prophylactic measures and dental treatment, I regularly inform the people involved before
they start treatment. Depending on what is planned,
I ask for a local anaesthetic. My own dentist, dental
hygienist, and dental assistants are aware of my
problem and do everything they can to make treatment as pleasant and painless as possible.
still
an unresolved issue
for patients…
SENSITIVITY Sensitivity
IS STILL is
AN
UNRESOLVED
ISSUE
FOR PATIENTS …
WHAT DO YOU EXPECT FROM
YOUR DENTAL PROFESSIONALS?
I basically expect my dentist and his team to remember that I have sensitive teeth whenever they
are working inside my mouth. They should avoid
causing irritation during treatment and use devices such as air jets, suction tubes, and probes only
as much as they absolutely have to. I can’t tolerate
certain treatment without a local anaesthetic, so I
also expect the whole team to take this requirement into consideration. Every time I visit the dentist, I ask whether there’s any treatment or means
of sealing off my sensitive teeth. For many years
now, the professional application of an in-house
product has been part of every appointment,
ORAL HEALTH DIALOGUE | 1/2015
9/10 DENTISTS
3/5 ADULTS
say they see at least one patient
a day who experiences dentine
hypersensitivity1
report problems of dentine
hypersensitivity2
29% OF ADULTS
identify dentine hypersensitivity
as the biggest cause of pain
associated with visiting
their dentist2
1. Colgate Dentist survey, UK, 2013, 2. Colgate Consumer survey, UK, 2013
There’s an easy solution to address the sensitivity challenge!
Find out more and get inspired by interesting facts on the last page of the Oral Health Dialogue.
60
SECONDS
Colgate® Sensitive Pro-Relief™
toothpaste acts in 60 seconds
What dentine sensitivity sufferers expect from their dentist | 13
to seal the open tubules and
relieve dentine hypersensitivity*
A growing threat to quality of life
Prof. Dr. Francis Hughes
PERIODONTAL PROBLEMS IN
THE OLDER PATIENT
The Ageing Population
Issues concerning an increasingly ageing population have been widely discussed throughout the
media and have enormous implications for Society. This topic impacts greatly on factors as diverse
as increased pressures on Health Services
through to pensions and social care issues and
there is considerable concern about an ever increasing proportion of the population being beyond retirement age with a consequent reduction
in the proportion of the population making up the
economically active workforce. Many of these
people perhaps do not fit the stereotype of an elderly person and remain fit, active and are used to
having high expectations from (for example) their
healthcare services.
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June 3-6, 2015, London UK
Chaired by: Francis Hughes, Chairman of the
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14 | A growing threat to quality of life
Epidemiology of Periodontitis
Periodontal disease may present a particular challenge in the older patient and the dental professional needs to pay increasing attention to the
periodontal health of this fast expanding group.
Epidemiological studies from a number of countries demonstrate the presence of some periodontal disease, at least as gingivitis or mild periodontitis, in up to 50% of adult populations.
Encouragingly, the data also suggest significant
improvements in plaque control and the prevalence of mild disease. However, more severe
chronic periodontitis, which results in progressive
loss of tooth attachment, has not shown a similar
reduction in prevalence. The recent study of global burden of severe periodontal disease ( Kassebaum et al 2014) reports an overall global prevalence of periodontitis of around 14%, and also
suggests that this figure has remained surprisingly constant over recent years. However, most
strikingly this figure rises to over 30% in the over
60s, clearly demonstrating the nature of the challenge facing periodontal professionals.
Persisting high prevalence of severe periodontitis despite improvements seen in levels of
plaque control and prevalence of mild disease
has been similarly reported in a number of other studies from different countries. The reasons
for this are undoubtedly complex but are likely
at least partly to be the result of an increasingly
ageing population who are having fewer teeth extracted. Thus the burden of severe periodontitis,
both in terms of its prevalence and its impact –
resulting in discomfort, poor aesthetics, poor oral
function and reduced quality of life in the over 60s
is very considerable.
with T2DM may not have been diagnosed, so the
dental professional should be alert to the possibility of undiagnosed T2DM in a patient who presents with severe periodontitis or shows exacerbation of periodontal disease, particularly where
the patient has any other T2DM risk factors such
as increased body mass index, family history or
history of hypertension. In these cases the dentist
should consider referral of the patient to their family doctor to investigate this possibility. Furthermore there is some evidence that treatment of
periodontitis may improve glycaemic control in
T2DM patients.
Many medications are also known to have
potential affects on periodontal disease. Most
prominently of these are the Calcium Channel
Blocker family of antihypertensive medications,
particularly amlodipine, nifedipine and felodipine.
These medications are taken by large numbers
of people, and particularly those aged over 60.
For example, in the UK, around 2M people are
prescribed these drugs. Calcium channel blockers can cause gingival overgrowth and can seriously exacerbate periodontitis. In affected cases,
where it is feasible in consultation with a patient’s
physician, changing the medication often results
in rapid improvement in the condition.
Other medical conditions, including many
cancer therapies, may exacerbate or affect periodontal disease and again the dentist needs to be
aware of this and ensure the provision of adequate
periodontal care for these patients.
Finally older patients may have increasing difficulty in maintaining effective oral hygiene procedures, particularly when affected by conditions
such as rheumatoid arthritis.
Periodontitis in the older patient
The clinical presentation of periodontitis in the older patient is not particularly distinct from that affecting other patients, but may be particularly affected by increasingly complex medical histories
of people as they get older. The global epidemic of
type 2 diabetes mellitus (T2DM) has been well
documented and is a major risk factor for periodontitis. The prevalence of T2DM increases dramatically over the age of 60, and although prevalence rates vary regionally, in most populations
may affect well over 10% of this age group. Depending on the level of glycaemic control T2DM
can increase the risk of severe periodontitis by at
least greater than 2 fold. In addition, many people
Periodontal health is part of general health
Periodontal disease is also a possible risk factor
for a number of serious diseases particularly affecting the older patient. It has been found to be
consistently associated with risk of cardiovascular
disease, including heart attack and stroke, with
diabetes, and less clearly with a number of other
conditions such as chronic kidney disease and
rheumatoid arthritis. Although it is difficult to prove
that treating periodontal disease causally affects
the risk of these serious conditions, which mainly
affect older people, it is clear that periodontal
health should be regarded as part of good health
generally.
ORAL HEALTH DIALOGUE | 1/2015
Prof. Dr.
Francis Hughes
Professor of
Periodontology/
Honorary
Consultant
King’s College
London, UK
C
hronic periodontitis is a major and
growing prob­lem in patients over 60. It
has very significant im­pacts on oral function
and quality of life and good periodontal
health should be regarded as a part of good
general health.
Summary
Chronic periodontitis is a major and growing problem in patients over 60. It has very significant impacts on oral function and quality of life and good
periodontal health should be regarded as a part of
good general health. The dental professional
needs to be alert this particular issue and also
needs to be aware of the systemic factors commonly occurring in this population which can impact on periodontal health, liasing when appropriate with the patient’s physician.
IMPRINT
Publisher: Colgate-Palmolive Europe Sàrl
Layout: typo.d AG, Reinach Switzerland
Contact: Colgate-Palmolive Europe Sàrl
Grabetsmattweg, 4106 Therwil
[email protected]
The opinions of the authors do not always have to correspond
to those of the publisher.
Reprinting and publication of extracts if the reference is quoted.
A growing threat to quality of life | 15
Sensitivity is still an unresolved issue for patients…
9/10 DENTISTS
3/5 ADULTS
say they see at least one patient
a day who experiences dentine
hypersensitivity1
report problems of dentine
hypersensitivity2
29% OF ADULTS
identify dentine hypersensitivity
as the biggest cause of pain
associated with visiting
their dentist2
There’s an easy solution to address the sensitivity challenge!
Colgate® Sensitive Pro-Relief™
toothpaste acts in 60 seconds
to seal the open tubules and
relieve dentine hypersensitivity*
60
SECONDS
Over 1,000 sensitivity sufferers put Colgate® Sensitive Pro-Relief™ toothpaste
to the test by eating ice cream. Then they revealed their thoughts...
96%
91%
91% considered Colgate
Sensitive Pro-Relief™ toothpaste
to be more effective than
sensitivity brands they
have used before
®
94%
96% of trialists
would recommend Colgate®
Sensitive Pro-Relief™
to friends and family
94% of trialists agreed that
Colgate® Sensitive Pro-Relief™
worked instantly to
provide sensitivity relief
Care for your sensitivity patients and recommend
Colgate® Sensitive Pro-Relief™ toothpaste
1. Colgate® Dentist survey, UK, 2013
2. Colgate® Consumer survey, UK, 2013
*When toothpaste is directly applied to each sensitive tooth for 60 seconds
16 |
ORAL HEALTH DIALOGUE | 1/2015