DT News - UK - Caries prevention is not just more fluoride

Prof. David Manton, Australia

Wed. 30 August 2017

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A behaviourally driven bacterial disease, dental caries is one of the most prevalent primarily preventable conditions in the world. Even in developed countries with water fluoridation and ready access to fluoridated toothpaste, a large proportion of children still have experience of advanced dental caries. In the past 50 years, the prevention of dental caries has focused mainly on the delivery of fluoride, whether it be via reticulated water, toothpaste or professionally delivered products, such as varnishes and gels.

A sound knowledge of the causative factors of dental caries, however, is important in the process of developing a holistic preventative programme for the individual. Demineralisation occurs when the fluid at the surface of the tooth becomes undersaturated with respect to tooth mineral. This is normally due to a decrease in pH below the often-stated critical pH of around 5.6. The critical pH is not a constant, but relates to the amount of calcium and phosphate present, as well as the pH. The microbiome of the dental biofilm develops after birth, and is influenced significantly by the ingestion of fermentable carbohydrates, especially sucrose and fructose. The production of organic acids from the metabolism of sugars decreases the pH in the biofilm, creating an amphibiotic change to an aciduric and acidogenic microbiota, also known as Marsh’s ecological shift. Dietary change to infrequent ingestion of sugary foods and drinks therefore is the first step in prevention of dental caries.

In addition to dietary control, fluoride is still considered the gold standard for caries prevention. However, the action of fluoride, especially for remineralisation, is limited by the concentration of bioavailable calcium and phosphate in the local environment (biofilm fluid). Remineralisation is only possible in the presence of bioavailable calcium and phosphate, with the intrinsic source being saliva, a limited resource. Recently, several products containing calcium and phosphate have been developed and are available commercially.

While a number of claims of efficacy have been made, the evidence for many is still limited. For example, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) is a milk-derived product that utilises a peptide to stabilise calcium and phosphate in a bioavailable state—reacting to acidity and saturation with respect to tooth mineral. Incorporation of CPP-ACP into products such as a topical crème can provide high concentrations of calcium and phosphate ions that can diffuse into demineralised tooth structure down a concentration gradient. This remineralisation is enhanced by the presence of fluoride ions.

The inhibition of demineralisation and subsequent remineralisation of early carious lesions (white spot lesions) is sometimes considered unlikely owing to an inability of the patient to reduce risk factors, such as a sugary diet, poor oral hygiene habits, including interdental cleaning, as well as poor salivary flow and possibly developmental defects of enamel. In these instances, the use of sealing or infiltrating agents, such as fissure sealants or resin infiltrate, can be effective, although remineralisation of the treated area may not be possible afterwards. These products either seal the surface of the lesion or infiltrate the porosity of the lesion to decrease the loss of mineral from the tooth, and can prevent the lesion progressing to cavitation.

The prevention of dental caries is far more than just fluoride. A sound knowledge of the caries process assists the clinician in formulating an individualised preventative programme for patients.

This afternoon, Prof. Manton is presenting a paper titled “The prevention of dental caries—It is a lot more than fluoride” as part of this year’s World Dental Congress programme in Madrid.

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