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Mineral Rites by Deborah Levin-Goldstein

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The Real Access to Care
by Deborah Levin-Goldstein

Dental caries continues to be a major public health problem despite the increased availability of commercial preventive products—including powered toothbrushes and flossers—and an improved understanding of the caries disease process. As a result, the dental hygienist and the dentist are the solution to individualized, comprehensive caries management.

Oral bacteria, known as plaque or biofilm, constantly forms on the teeth. Eating or drinking foods containing sugars causes the bacteria in biofilm to produce acids that attack tooth structures. The stickiness of the plaque and biofilm keeps these acids in contact with the tooth and, over time, the enamel can break down, forming a cavity. This is the process of demineralization, during which calcium and phosphate are removed from the enamel.

Saliva and fluoride aid in the re-establishment of calcium and phosphate back into the enamel, which is known as remineralization. Acid challenges abound in the oral cavity throughout the day as the equilibrium between demineralization and remineralization continually shifts.

Keeping the balance
The caries imbalance model (Fig.?1) was created to represent the multifactorial nature of dental caries disease and to emphasize the balance between pathological and protective factors in the caries process.

Oral health is sustained when there’s a balance between protective and pathological factors. Tooth enamel rods/prisms are composed of hydroxyapatite crystals calcified to 96 percent. Although highly inorganic, enamel is still vulnerable to demineralization. Its main biological defense is saliva, which has buffering ability and contains components of calcium and phosphate. Salivary phosphoproteins help stabilize calcium and phosphate ions to ensure they remain bioavailable and can diffuse into mineral-deficient enamel lesions, mainly on the surface layer.

Without calcium and phosphate in saliva, fluoride cannot repair tooth structure. If fluoride is present in the biofilm when bacteria produce acids, it will penetrate along with the acids at the tooth’s subsurface, adsorb to the hydroxyapatite crystal surface and protect the crystals from dissolution.

Remineralization occurs only when there are sufficient calcium and phosphate ions from saliva, along with fluoride, to enter the demineralized enamel and form a new layer of fluorapatite. These remineralized crystals are less acid-soluble than the original ones.

The Real Access to Care Fig. 1: J.B. Featherstone, S. Domejean, L. Jenson, M. Wolff, and D. Young, “Caries Risk Assessment in Practice for Age 6 Through Adult,” CDA Journal 35, No. 10 (October 2007).

Assessing caries risk
Placing a restoration does very little to manage the caries disease process. A shift away from the “drill and fill” mentality occurred in 2007, when the California Dental Association Foundation, in partnership with the University of California at San Francisco School of Dentistry, published evidence in the Journal of the California Dental Association that caries could be prevented and contained through risk assessment following the medical model.

Caries management by risk assessment (CAMBRA) is a method of assessing caries risk. The questionnaire enables the clinician to make dental treatment and restorative recommendations based on a patient’s caries risk. CAMBRA forms for ages 0–6 and ages 6 and older are available to dental professionals from the American Dental Association, the California Dental Association, Phillips Sonicare and CariFree.

By using the CAMBRA approach to assess caries risk, dental professionals can perform tests for oral bacteria levels, take radiographs, and examine disease indicators and risk factors. This includes current decay condition and bacterial challenges, dietary habits, prescription medications, saliva flow, systemic medical conditions and oral hygiene habits. Then hygienists or dentists can make recommendations based on those risk factors.

Patients at high risk of caries require dental intervention, including dietary counseling, more frequent radiographs, fluoride varnish applications, prescription fluoride gels or rinses, antimicrobial rinses, prescription or over-the-counter (OTC) salivary stimulants, and use of prescription or OTC remineralizing agents. These patients may need existing tooth decay restored and protected with sealants, and also may need to postpone elective cosmetic dental procedures or orthodontics until their risk levels can be decreased. Recurrent decay can cause expensive dental work to fail. A remineralizing product used twice a day may be suggested for these individuals.

Patients at moderate risk should receive a recommendation to use a prescription or OTC fluoride mouth rinse and a remineralizing agent once a day, as they have or had a risk factor that can move them to high risk at any time, such as previous decay or localized recession.

Patients at low risk may receive recommendations for home-care preventive products, such as toothpaste with fluoride, to keep risk levels low. They will be better candidates for fewer radiographs and elective cosmetic procedures. These patients do not need to use a remineralizing product.

Patients who will most benefit from remineralizing products include:

  • Adults and children with a high caries risk (visible carious lesions).
  • Those with tooth sensitivity.
  • Patients undergoing orthodontic treatment.
  • Those with sensitivity before or after bleaching or whitening.
  • Patients suffering from xerostomia or salivary dysfunction.
  • Those with exposed root surfaces or erosion.
  • Oncology patients.
  • Those suffering from gastric reflux.
By using the CAMBRA approach to assess caries risk, dental professionals can perform tests for oral bacteria levels, take radiographs, and examine disease indicators and risk factors.

Products with a punch
Remineralizing products in the form of gels or creams have been created to replace calcium and phosphate loss from enamel for use in both children and adults.

These products include varying amounts of fluoride and may or may not require a prescription by a dentist. They may be applied with a toothbrush, a finger or a custom tray. Their ability to remain active in the mouth for extended periods of time differs and they are safe for daily multiple applications.

Currently, five different types are available:

  • Amorphous calcium phosphate (ACP). Found in Enamelon Preventive Treatment Gel by Premier. This OTC product contains 970 parts per million (ppm) stannous fluoride. It eliminates the need for prescription-strength toothpastes and home rinses.
  • Calcium sodium phosphosilicate. Also known as NovaMin. Originally developed for the treatment of dentinal hypersensitivity, products with NovaMin aren’t widely availabile in the United States, but include Nupro Extra Care prophy paste with fluoride and NovaMin. The paste can be applied before or after scaling to decrease sensitivity.
  • Casein phosphopeptide- amorphous calcium phosphate (CPP-ACP), also known as Recaldent. It has a three-hour substantivity. Derived from casein in cow’s milk, CPP-ACP is safe for lactose-intolerant clients, but should not be recommended for clients with milk allergies. It is safe for use in the primary dentition. An example is MI (minimum intervention) Paste with Recaldent by GC America. This is a prescription product that is digestible if swallowed. The company also offers MI Paste Plus with Recaldent with 900 ppm sodium fluoride. It is not recommended for children under the age of 6 and pregnant women, because of its fluoride content.
  • Tricalcium phosphate (TCP). Found in two products by 3M ESPE: Clinpro 5000 1.1% sodium fluoride anticavity toothpaste contains 5,000 ppm sodium fluoride, thus requiring a prescription. It is used in place of regular toothpaste at night. Clinpro Tooth Crème is a dentifrice containing 950 ppm sodium fluoride. No prescription is necessary and it is used once a day in place of a conventional toothpaste. It may be purchased on Amazon.
  • Remin Pro by Voco is a water-based cream that contains nano-hydroxyapatite, an enamel prototype and ingredient unique to this product. It also has the proven cariostatic agent xylitol, which influences remineralization by transporting calcium ions deeper into the carious lesion, as well as 1,450 ppm sodium fluoride. These three ingredients are key factors in the “triple threat” against caries (Fig.?2). Remin Pro adheres to the tooth substance and protects the tooth against demineralization. It fills enamel porosities and seals exposed tubules in dentin, thereby decreasing patient hypersensitivity. Xylitol in Remin Pro stimulates salivation, promoting natural remineralization and neutralizing the acidic environment. The sodium ?uoride strengthens the enamel, making it more resistant to acid attacks.
The Real Access to Care Fig. 2: courtesy of Voco

Remin Pro
Protocol for the use of Remin Pro is to first brush with your regular toothpaste. Then apply a pea-sized amount with a toothbrush, a finger or a custom tray. It is kept in the mouth for three minutes without interruption. Any excess should be expectorated and no cream should be swallowed, due to its fluoride content. Rinsing, eating and drinking should be avoided for 30 minutes after use. It has two-hour substantivity, so multiple applications throughout the day are appropriate.

It is safe for patients with milk allergies, unlike other remineralizing pastes, since it does not contain milk proteins. Remin Pro does not require a prescription and can be obtained only by the patient at a dental office. The dentist purchases the product from either Patterson Dental or Henry Schein Dental and resells it to the patient.

Alternatives
Fluoride varnish products are relatively new to the United States, but have been widely used as dental caries prevention therapies for more than 30 years in Western Europe and Canada. The U.S. Food and Drug Administration has approved them to be used as cavity liners and for the treatment of hypersensitive teeth, but they also can be used off-label as caries prevention agents.

Fluoride varnishes contain 22,600 ppm sodium fluoride and are easily painted onto the teeth as a type of topical fluoride therapy to aid in the remineralization process. In addition to sodium fluoride, some products contain xylitol, such as Profluorid Varnish from Voco and Embrace Varnish 5% sodium fluoride with xylitol, calcium and phosphate. Xylitol cannot be converted into harmful lactic acid by cariogenic bacteria.

Enamel Pro Varnish 5% sodium fluoride contains ACP; Vanish 5% Sodium Fluoride White Varnish has TCP; and MI Paste Varnish contains Recaldent. Dental pros should contact the manufacturers for information about patients with pine-nut allergies.

Conclusion
Assigning risk assessment levels can make a difference in the effective control of dental caries. Dental professionals can significantly contribute to decreasing decay and reversing initial breakdown of tooth structure simply by finding the right product for each patient.

The advantage of these agents is the increased availability of calcium and phosphate to prevent demineralization. Some products simultaneously deliver multiple ingredients, such as fluoride and xylitol, in addition to calcium and phosphate, to restore enamel. Varnish is easy to apply and enhances the remineralization process. It decreases sensitivity as well. Remineralizing products and varnishes provide novel and exciting therapeutic options for dentists and hygienists.


Deborah Levin-Goldstein Deborah Levin-Goldstein is a graduate of the University of Pennsylvania and Columbia University. She has been a dental hygiene educator at Northampton Community College in Bethlehem, Pennsylvania, for 34 years. Levin-Goldstein has presented continuing education courses on a variety of topics to dental and dental hygiene societies, and is a recurring contributor to Dentaltown. She has been published in the Journal of Dental Hygiene and is a contributing author for six chapters in the textbook Head, Neck and Dental Anatomy, 4th Edition.
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