Five fluoride-free products help maintain healthy saliva and facilitate remineralization
BY Anne Nugent Guignon, RDH, MPH
Many people love to have a sweet treat during the day. Imagine being able to offer a confection that creates and supports a healthy pH on tooth surfaces. Visualize little Regan eating chocolate candy after lunch or before bedtime. What if we were able to give great aunt Martha, who is in the nursing home with diabetes, xerostomia, and dementia, a "candy" in a variety of flavors that would help prevent biofilm buildup, create a neutral pH, and stimulate saliva? What about Mike who drinks soda pop all day long? How about Jennifer whose multiple medications create a mouth drier than a desert? Imagine little Johnny wanting to brush his teeth with chocolate-flavored toothpaste every night? Picture being able to offer an OTC toothpaste that can resolve Cindy's dentinal hypersensitivity without tasting bad. And imagine being able to help each of these patients with products that don't contain fluoride.
Dental practitioners are always eager to find new, novel ways to help patients combat the ravages of tooth erosion and caries. Caries is a pH-mediated bacterial infection of hard tooth surfaces.1 Erosion is defined as a surface-softening lesion resulting from chemical dissolution not involving bacteria.2 Both phenomena result in the loss of valuable tooth structure and have the potential to create pain.3,4
It can be frustrating for clinicians and patients to find ways to either prevent or stop the progress of both caries and erosion. Dental professionals are expected to restore teeth back to full function, provide comfort, and appropriate esthetics.5 Restorative treatment also creates an economic burden for the patient.
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Other articles by Guignon
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For decades, dentistry has relied on fluoride. While fluoride, in many different formats, has helped to both prevent and arrest carious lesions via remineralization, caries continues to be a problem. In addition, increasing numbers of patients are suffering from dentinal hypersensitivity, an often-underreported problem that can create tremendous quality-of-life issues.3,4
Neither caries nor hypersensitivity can develop or progress when the oral cavity is in homeostasis. Healthy saliva has an average resting salivary pH that falls between 6.4 and 7.2. This critical pH range is a dynamic number dependent on the calcium and phosphorus levels in the saliva. Tooth structure is not negatively affected when the oral pH stays in this range; however, as the pH drops, the destructive process begins and the tooth begins to lose valuable calcium and phosphorus molecules on a microscopic level.6,7
Exposed root structure begins to demineralize at pH 6, while the harder enamel surface begins to break down between pH 5 and 5.5. Enamel fortified with fluoride is affected when the pH falls to 4.5 or below. Tooth surfaces exposed over and over, for protracted periods of time, to pH levels in the acidic range are at risk for both caries and hypersensitivity.6,7
Homeostasis is a basic tenet for wellness. The ultimate goal is to achieve and maintain a healthy pH balance in the oral cavity. Caries and demineralization can't occur or progress when the oral pH is maintained in the neutral range of pH 7.6,7 In addition, research has shown that patients with hypersensitivity have eight times more open dentinal tubules that are twice the mean diameter than those who do not have this problem.8
Adding up the risk factors
Myriad factors negatively impact a healthy pH, including acidic foods and beverages, high carbohydrate dietary intake, frequency of dietary intake, composition of the foods and beverages, GERD, and regurgitation. Beverages and foods with a low pH and a high titratable acidity are of particular concern, since the oral pH stays low for a longer period of time. Xerostomia plays a huge role in lowering the oral pH.9 Dry mouth can be a result of medications, salivary gland dysfunctions, tobacco usage, recreational drugs, stress, systemic disease, and mouth breathing. Saliva must also have sufficient buffering capacity to mitigate acid attacks.9,10
Many patients have followed the time-honored litany of "brush, floss, and use a fluoride toothpaste," yet they still suffer from caries and sensitivity. Modern science now offers some unique alternatives that may more appropriately fit into people's busy lifestyles, challenging dietary habits and personal belief systems. In addition, every practice has a certain number of patients who want fluoride-free products or a more "natural" approach to preventing decay or promoting remineralization. For years, there have been few options for patients who do not wish to use products that contain fluoride, leaving both patients and dental professionals frustrated.
Five novel, fluoride-free products that are all made in the United States are now available to help maintain healthy saliva and facilitate remineralization. Each approach is easy, and these over-the-counter products are readily available in the retail sector or can be dispensed in the professional setting.
Mimic healthy saliva
BasicBites is a chocolate-flavored chew made with arginine bicarbonate and calcium carbonate, two vital ingredients found in healthy saliva. It is formulated to provide multiple strategies for maintaining healthy tooth structure by mimicking how Mother Nature creates healthy saliva.10
Arginine, a common amino acid, supports a long-lasting, neutral pH in the mouth. Certain oral microorganisms, capable of metabolizing arginine, produce alkaline byproducts, resulting in a neutral pH for a protracted period of time. Lab studies on BasicBites demonstrated a neutral pH can last for hours on tooth surfaces even with a glucose challenge. Other studies suggest regular use of an arginine/bicarbonate/calcium carbonate technology can also shift the oral flora in favor of microbes that metabolize arginine.11,12 The bicarbonate portion of the candylike confection neutralizes acid and the calcium bathes the teeth in a mineral vital for remineralization.
The BasicBites AlkaGen chemistry is based on decades of research done at Long Island's Stony Brook University School of Dentistry. It is recommended to chew one individually wrapped bite two times a day to sustain a neutral oral pH. BasicBites chews are sweetened with mannitol, isomalt, and xylitol, contain 20 calories, deliver 20% of the daily calcium RDA, are kosher and gluten free, and are available online.
The magic of xylitol
Over the past decade, xylitol products have gained wide acceptance for a number of oral benefits. While many products now contain xylitol, 100% xylitol products offer more predictable long-range benefits than products that contain only small amounts of this special polyol. Xylitol is a natural product that has many unique properties. It stimulates salivary flow, drives the oral pH up to 7, inhibits the growth of known caries initiator, Streptococcus mutans, disrupts the integrity of biofilm, and sets the stage for remineralization.13,14 It is commonly found in gum, mints, toothpaste, and rinses.
Ice Chips Candy is a 100% xylitol confection, packed in an attractive metal tin that tucks neatly into a purse, pocket, briefcase, or backpack. Along with being a beneficial contributor to oral homeostasis, this fun candy comes in 20 different flavors with special holiday varieties available throughout the year. The creators, Charlotte and Bev, friends for decades, were looking for a safe candy alternative when they concocted this product five years ago. Without realizing it, these "two grannies in a garage" created a great-tasting candy with half the calories of table sugar and a low glycemic index.
To achieve the full therapeutic benefits from xylitol, it is important to have five exposures a day. A tin of Ice Chips contains enough pieces for an entire week's worth of exposures. Ice Chips brand Tooth Powder combines sodium bicarbonate, xylitol, and Himalayan salt with trace amounts of various natural plant extracts and essential oils. The creators of Ice Chips products use xylitol derived from birch trees, not GMO corn-based xylitol. Ice Chips products are manufactured in Yelm, Washington, just south of Tacoma and are available online and in a growing number of retail outlets.
XyliMelts is the brainchild of a Bellevue, Washington, chemist who wanted to find a way to keep this 100% xylitol lozenge in place in the oral cavity. XyliMelts has a unique stick-and-stay delivery system. When the back is moistened, the vegetable adhesive keeps the disc in place in the mouth, a useful benefit for those who want salivary stimulation benefits while sleeping or talking.
The disc adheres to the soft tissue in the mouth, slowly secreting xylitol as it dissolves over time. For maximum benefit, position the disc on the soft tissue above the molars just opposite the parotid gland. Because of diminished salivary flow rates, XyliMelts last longer while sleeping. Keeping the mouth moist for a prolonged period of time helps promote an uninterrupted sleep cycle. XyliMelts dissolve more quickly during waking hours when the salivary flow rate is much higher. XyliMelt discs can be purchased on the Internet as well as pharmacies throughout the country.
Toothpaste chemistry that remineralizes
It is a challenge to find toothpaste today that does not contain fluoride, much less one that provides an opportunity for remineralization. Decades ago, scientists discovered theobromine, an ingredient in chocolate, facilitates the deposition of hydroxyapatite crystals on the tooth surface. The crystals occlude dentinal tubules, increasing surface microhardness and reducing tooth hypersensitivity. Research has demonstrated Theodent, a novel toothpaste, achieves this goal.15,16 A recent study demonstrated that twice-daily use of Theodent Classic paste for one week provided nearly complete tubule occlusion in dentin as compared to a readily available over-the-counter fluoride dentifrice that did not occlude open tubules.16
The active ingredient in this unique product is Rennou, a proprietary theobromine/mineral complex that was developed by a group of Tulane University scientists. Theodent Classic is mint-flavored while Theodent for Kids tastes like milk chocolate. Theodent 300 contains a higher concentration of the active ingredients in Rennou and is specifically formulated for treating dentinal hypersensitivity. The ingredients in Theodent products are safe to swallow and fall under the FDA's GRAS classification. All Theodent products can be ordered directly from the company, and most Whole Foods stores carry the Classic and Kids formulas.
What a great time to be in dentistry! Finally we have some good alternatives that will help patients achieve optimal oral health without containing fluoride. The possibilities are endless, and the benefits are limitless. 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.
References
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2. Splieth CH, Tachou A. Epidemiology of dentin hypersensitivity. Clin Oral Investig. Mar. 2013;17(1):S3-S8.
3. Gillam D, Chesters R, et al. Dentine hypersensitivity-guidelines for the management of a common oral health problem. Dent Update. 2013 Sept.;40(7):514-516,518-520, 523-524.
4. Bekes K, Hirsch C. What is known about the influence of dentine hypersensitivity on oral health-related quality of life? Clin Oral Investig. Mar. 2013;17(1):S45-S51.
5. Mount GJ and Hume WJ. Preservation and restoration of tooth structure. Knowledge books and software. 2nd Edition. 2005.
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7. Lussi A, Schlueter N, et al. Dental erosion-an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45(1):2-12.
8. Absi EG, Addy M, Adams D. Dentine hypersensitivity. A study of the patency of dentinal tubules in sensitive and non-sensitive cervical dentine. Clin Periodontol. May 1987;14(5):280-284.
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10. García-Godoy F, Hicks MJ. Maintaining the integrity of the enamel surface: the role of dental biofilm, saliva, and preventive agents in enamel demineralization and remineralization. JADA. May 2008;139 Suppl:25S-34S.
11. Nascimento MM, Browngardt C, et al. The effect of arginine on oral biofilm communities. Mol Oral Microbiol. Feb. 2014;29(1):45-54.
12. Reyes E, Martin J, et al. Caries-free subjects have high levels of urease and arginine deiminase activity. J Appl Oral Sci. Jun. 2014;22(3):235-240.
13. Alamoudi NM, Hanno AG, et al. Impact of maternal xylitol consumption on mutans streptococci, plaque, and caries levels in children. J Clin Pediatr Dent. Winter 2012;37(2):163-166.
14. Milgrom P, Söderling EM, et al. Clinical evidence for polyol efficacy. Adv Dent Res. Sept. 2012;24(2):112-116.
15. Amaechi BT, Porteous N, et al. Remineralization of artificial enamel lesions by theobromine. Caries Res. 2013;47(5):399-405.
16. Amaechi BT, Mathews SM, Mensinkai PK. Effect of theobromine-containing toothpaste on dentin tubule occlusion in situ. Clin Oral Investig. Mar. 27, 2014.
