A Broader Look at the Dental Caries Problem

by Anne Nugent Guignon, RDH, MPH

The Internet allows a new and unparalleled level of connectivity, virtually eliminating the isolation clinicians have felt throughout the years. With the click of a mouse or a swipe across a screen, we can connect with our colleagues all over the world, alerting them regarding any dilemma or asking any questions we might have. In turn, they have the opportunity to provide solutions, ideas, and different points of view that make us better clinicians.

An interesting query popped up about a month ago, one that made my brain go into overdrive. A colleague posed a question about recommending a particular therapeutic prescription product that three siblings used at home to help slow down their caries rate. Rather than answer her product-based question, it seemed important to approach the discussion with an eye on why these children were experiencing such a high caries rate.

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These are the key points that she shared with the online group: "I had a family of three kids in my office yesterday, ages 9, 5, and 3. They are all very cavity prone in all primary teeth. We have done sealants on all permanent teeth and are trying to get the parents to do sealants on primary teeth. Insurance does not cover this, so it is out of pocket. They are already doing fluoride treatments at the office and using ACT rinse at home. They have very good oral hygiene and diets. Any other suggestions?"

Since these children are not my patients or responsibility, it was easy to step back and look at the situation from a more global perspective, focusing first on why these children are so caries prone. Here are my thoughts that I shared with the hygienists who participate in this group.

If you don't have those answers up front, how do you know what you are really dealing with? Right now you are aiming the dental shotgun at decay rather than having the target (caries) in the crosshairs of a precision diagnostic rifle, aimed at altering or getting rid of the factors causing the problem. Think homeostasis.

Please don't take offense at my response, but there are many unanswered questions that would allow you to help the children go down a healthier path.

Questions

1. Do each of these children have healthy saliva? In other words, is the salivary pH in a normal pH range, 6.8 to 7.2? Is their buffering capacity sufficient? Do they have adequate salivary flow rates

2. On an individual basis, are their mouths loaded with cariogenic organisms? CariFree has a unique screening device that quantifies the presence of high levels of cariogenic bacteria. The company's website is loaded with valuable information about the complexity of caries and the caries process. Sugar, snacking, and plaque accumulation all play a role, but other factors can ramp up the risk for decay.
   
   
3. What do you really know about their diets? Parents may not have the best handle on dietary intake or may not understand how their kids' diets contribute to the problem. For example, parents or other caregivers may not think that powdered drinks are an issue, but the pH is generally around 2.5 to 3! And the socialization of the nine-year-old can be totally different than his or her siblings, unless the kids are being home schooled, accounting for similar dietary offerings. Are the kids sipping drinks all day long or are they drinking bottled water that is acidic? Most bottled waters are well below a pH of 5. Are the parents giving the kids diet drinks, thinking that no sugar equals no decay? Or are the parents providing "all natural drinks" that contain cane sugar, a fermentable carbohydrate that promotes a caries-level pH? Are the children consuming low pH fruits or fruit juices throughout the day? Think oranges, apple juice, pineapple, or grapefruit. Other culprits can include dried fruits such as raisins or dates -- concentrated sugar bombs.
   

4. Do they have drinks like juice by their bedside? Were they raised with acidic beverages in bottles or sippy cups

5. Just because one does not form heavy biofilm deposits does not mean that a person can't harbor a plethora of caries-causing microorganisms. Everyone's oral cavity is unique, but those that have similar genetic makeup and share similar dietary habits or have the potential for salivary cross-contamination tend to have similar oral flora.
   
   
6. Caries is a pH-mediated disease, meaning the pH has to be low for the tooth to break down, and low pH levels create a favorable environment for the organisms thought responsible for caries. In addition, some organisms can adapt to living in acidic environments within 30 minutes of a dropping pH.
   
   
7. Do these children have some kind of unusual habit that is creating an acidic environment, such as chewable vitamin C, drinking vinegar, eating sour acid candies, drinking water with lemon? Each of these activities or a combination of events can contribute to the problem.
   
   
8. Do these children have GERD? Yes, children can suffer from this condition. If they were adolescents, I would be considering bulimia. Constant purging creates acidic environments and research shows that those with eating disorders tend to have highly acidic diets, along with poor oral hygiene.
   

9. Are they mouth breathers? A dry oral cavity favors acidogenic and aciduric microbes, the organisms responsible for producing copious amounts of acid in the oral cavity. Are they taking medications that cause dry mouth

10. If this family were in my practice, I'd be asking loads of questions about "what are they doing?" Asking the parents to keep a diet diary on each child could provide some really valuable clues, but could be burdensome on an already busy family schedule.

Potential solutions

1. What about recommending xylitol? It comes in myriad forms -- gum, mints, candies, pastes, gels, toothpastes, and oral sprays. All can be obtained OTC by the parents. The responsibility would be on the parents/caregivers. Your practice would not have to spend a penny or be responsible for supplying or carrying a product, only dispensing current information. However, practices throughout the country are supplying needed products to patients, creating modest revenue streams that can be applied back to purchasing supplies for the dental hygiene department.
   
2. What about printing off information from the Internet? Many patients would appreciate a list of xylitol resources and a short explanation about the benefits of xylitol. Interested patients will follow up and choose products that fit with their personal lifestyles.
   
3. While updating health histories is a perfect time to ask questions about diet, eating habits, and GERD. Many patients take acid-reducing OTC medications with abandon, a red flag that GERD is the underlying cause of their distress. The constant acid in the oral cavity as a result of GERD creates an acidic environment that can set the stage for decay.
   
4. Another inexpensive tool is pH paper to demonstrate acidity. You don't need a medical grade pH paper to show patients the relative acidity of beverages. Dip a piece of pH paper into their drink of choice and voila, the paper tells the story. Expound on the science of pH and forget the scolding.

Given today's financial climate, the best tool you may have to offer is your mind and your ability to provide creative answers and ideas that don't impinge on the office budgetary constraints. This kind of strategy may be out of your comfort zone, but you will grow professionally by providing a deeper and wider set of ideas and actions for your patients. RDH

ANNE NUGENT GUIGNON, RDH, MPH, provides popular programs, including topics on biofilms, power driven scaling, ergonomics, hypersensitivity, and remineralization. Recipient of the 2004 Mentor of the Year Award and the 2009 ADHA Irene Newman Award, Anne has practiced clinical dental hygiene in Houston since 1971.