Aims and objectives
Te aim of this article is to explore the multifactorial aspects of caries and to consider the challenge in a holistic manner, in an efort to help improve the situation for susceptible patients. On completing this CPD session, the reader will:
• Understand why caries is considered a multifactorial disease
• Understand the dynamic caries process
• Understand the potential role of genetics
• Understand current recommendations for plaque control
• Understand who in the population may be most susceptible to dental caries.
This article explores the multi-factorial aspects of caries and considers the challenge in a holistic manner, in an effort to help improve the situation for susceptible patients. Earlier this year, Pitts and colleagues (2017) published a primer on dental caries.
Beginning with the premise that dental caries, ‘[…] is a biofilm-mediated, sugar-driven, multifactorial, dynamic disease that results in the phasic demineralization and remineralization of dental hard tissues’, the aim of the primer was to provide a ‘global overview’ of the disease.
1. Pitts and colleagues (2017) continued to write that caries results from, ‘[…] interactions between the tooth structure, the microbial biofilm formed on the tooth sur¬face and sugars, as well as salivary and genetic influences. The dynamic caries process consists of rapidly alternating periods of tooth demineralization and remineralization, which, if net demineralization occurs over sufficient time, results in the initiation of specific caries lesions at certain anatomical predilection sites on the teeth. In line with this, Keyes Concept indicates that susceptible tooth enamel, plaque biofilm and sugar metabolism, in combination, lead to acid production, which contributes to the development of dental caries.
2. In the 50 yearsplus since the Concept was created, it has been developed to include elements such attitudes to oral hygiene, income and education level as having a role to play in caries prevalence.In addition, the idea of genetics influencing dental caries is currently a growing field of study.
3. Reporting back from the joint European Federation of Periodontology/ European Organisation for Caries Research workshop, Chapple and colleagues (2017) indicated that there is some evidence to suggest that genetic risk factors may influence the development of caries\
4. For example, they discussed the possibility that genetics may affect food choices; current evidence suggests that, among the genes that have been found to have the most significant impact on caries susceptibility, are those involved in dietary preferences.4 Specifically, as summarised by Gati and Vieira (2011), individuals with genetically low taste sensitivity to 6-n-propylthiouracil experienced a lower caries risk than those with high tasting sensitivity.
5.Such genetic predisposition, however, need not affect the advice dental healthcare professionals (DHCPs) provide to their patients, given that, as yet, the jury is out in terms of the applicability of genetic findings in everyday dental practice, although it does offer promise for the future.
Currently, given that standard of living has a role to play in caries prevalence, patients may benefit from being educated about the importance of reducing plaque bacteria in the mouth by making tooth-friendly food and drink choices.2,4 The Oral Health Foundation offers patients simple guidance on why sugary or acidic foods are potentially damaging to their teeth, as well as listing appropriate alternatives, such as cheese, raw vegetables, nuts and breadsticks because they are alkaline.
6. It is also important to communicate to patients that the timing of consuming sugary foods or drinks is key to maintaining oral health – namely, to be eaten or drunk at mealtimes to reduce the incidence of demineralisation throughout the day.
7. Also worthy of note is that van Loveren and colleagues (2012) provided a list of foods, food constituents and plant extracts that possess natural anti-caries properties, including:
• Edible fungi
• Roasted coffee
• A variety of fruits and vegetables, including apples and raisins
• Wine and grapes
8. The group also considered the effect of artificial sweeteners (sugar alcohols) on the teeth, noting that ‘[…] it is widely believed that xylitol is superior to the other sugar alcohols for potential caries control […]’. Generally, sugar alcohols have been found to have a low or non-cariogenic effect, 2 which may serve to offer patients an appropriate alternative to traditionally sugar-laden foods and drinks.
THE FLUORIDE FACTOR
In 2004, ten Cate wrote: ‘The cariespreventive effects of fluoride are beyond any reasonable doubt! Inclusion of fluoride use in caries prevention protocols has resulted in significant reduction in caries prevalence in the majority of the population.
7. Public Health England’s guidance on ‘Delivering better oral health: an evidencebased toolkit for prevention’ also extols the virtues of fluoride application: ‘High quality evidence of the caries-preventive effectiveness of fluoride varnish in both permanent and primary dentitions is available and has been updated recently. A number of systematic reviews conclude that applications two or more times a year produce a mean reduction in caries increment of 37% in the primary dentition and 43% in the permanent. The evidence supports the view that varnish application can also arrest existing lesions on the smooth surfaces of primary teeth and roots of permanent teeth.
8.Pitts and colleagues (2017) also explored the efficacy of fluoride in terms of remineralisation and its potential to prevent further caries damage. They reported that topical application of silver diamide fluoride is typically both costeffective and efficacious in the elderly suffering from root caries lesions, as well as to stop the progression of early childhood caries (ECC).
Adding to the body of evidence on the use of fluoride, in 2010, Albertsson and colleagues reported that: ‘Caries prevalence has declined during the last decades not least by increased customary tooth cleaning with fluoridated toothpaste.
9.Public Health England’s toolkit offers key recommendations for caries prevention in adults, including:
• Brushing at least twice daily with fluoridated toothpaste
• Brushing last thing at night and on at least one other occasion
• Using fluoridated toothpaste with at least 1,350ppm fluoride
• Spitting out after brushing and not rinsing, to maintain fluoride concentration
• The frequency and amount of sugary food and drinks should be reduced.
10. Added to this, in 2015, Chapple and colleagues published the consensus views of Working Group 2 of the 11th European Workshop in Periodontology, reporting:
•‘There is a universal recommendation to brush twice daily for at least 2 minutes with a fluoridated dentifrice. For periodontitis patients, 2 minutes is likely to be insufficient.’
• ‘Daily interdental cleaning is strongly recommended to reduce plaque and gingival inflammation.
• ‘In patients with gingivitis, the adjunctive use of chemical agents for plaque control offers advantages.
11. They also concluded that, ‘[…] where improvements in plaque control are required, adjunctive use of antiplaque chemical agents may be considered.
12. In addition, Public Health England’s toolkit suggests that, in some patients, the use of a mouthrinse may offer caries support. For example, those who have obvious current active caries, dry mouth, special needs or other predisposing factors might find the use a fluoride mouth rinse daily (0.05% NaF-) at a different time to brushing beneficial.
PREVALENCE AND SUSCEPTIBILITY
Results from the most recent Adult Dental Health Survey (2009) indicated that nearly onethird of adults in England, Northern Ireland and Wales had obvious tooth decay in either the crowns or roots of their teeth, while 66% had visible plaque.11 This was the case even though 75% of dentate adults reported that they brushed their teeth at least twice a day.
13. It has also been demonstrated that some people are more susceptible to dental caries than others; for instance, developmental defects such as enamel hypoplasia, ‘[…] may lead to increased acid solubility and loss of surface structure, which creates sites of plaque stagnation and increases the risk of caries in primary teeth.
14. In addition, ‘Caries susceptibility can also be affected by the proximity of teeth to salivary gland orifices, and salivary film thickness and velocity at specific tooth sites. Dental appliances (such as orthodontic appliances and dentures) and faulty restorations can also increase caries susceptibility at specific tooth sites by creating areas of stagnation, encouraging biofilm formation.
15. Others who may be more susceptible to caries than the average person include immunocompromised patients, those with cognitive disabilities, or genetic disorders such as cleft lip palate, as well as anyone suffering from salivary dysfunction or diabetes, whilst regular intake of any medications causing xerostomia may also have an effect.
16.For all patients, according to Pitts and colleagues (2017), it is imperative that, ‘Dentists and other dental professionals […] stage the caries progress, assess risk factors (on the dental, medical, biological, behavioural and social level), develop compre¬hensive management plans to prevent new caries based on risk status of patients, control initial lesions, restore cavitated lesions, rehabilitate the dentition and develop a follow up plan.
17. This article is equivalent to one hour of verifiable CPD. To provide feedback on this article, please contact firstname.lastname@example.org
1. Pitts NB et al. Dental caries. Nature Reviews Disease Primers 2017; 3(17030): 1-16
2. van Loveren C et al. Functional foods/ingredients and dental caries, European Journal of Nutrition 2012; 51 (supplement 2): S15-S25
3. Weyant RJ. The ‘new’ genetics and its impact on oral care delivery. Current Oral Health Reports 2016; 3(3): 140-146
4. Chapple ILC et al. Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: consensus report of group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol 2017; 44 (Suppl. 18): S39-S51
5. Gati D, Vieira AR. Elderly at greater risk for root caries: a look at the multifactorial risks with emphasis on genetics susceptibility. International Journal of Dentistry 2011; Article ID 647168
6. https://www.dentalhealth.org/tell-me-about/topic/caring-for-teeth/diet. Accessed 9 October 2017
7. ten Cate JM. Fluorides in caries prevention and control: empiricism or science. Caries Research 2004; 38: 254-257
8. Delivering better oral health: an evidence-based toolkit for prevention. Public Health England, 3rd edition 2014. Revised 2017
9. Albertsson KW et al. Effects of mouthrinses containing essential oils and alcohol-free chlorhexidine on human plaque acidogenicity. Clin Oral Invest 2010; 14: 107-112
10. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 2015; 42 (Suppl. 16): S71-S76
11. Adult Dental Health Survey 2009. The Health and Social Care Information Centre 2011