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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. Colgate is proud to be platinum sponsor of the EuroPerio 8 EURO PERIO 8 June 3-6, 2015, London UK Chaired by: Francis Hughes, Chairman of the EuroPerio8 Organising Committee The EuroPerio Congress has established itself as the world’s leading conference in periodontology and implant dentistry, and has become the essential triennial fixture on the meetings calendar. KEEP UP with the major issues, new trends and techniques in Periodontology, Implant Dentistry and Dental Hygiene www.efp.org/europerio8/ 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