Delivery Challenges for Fluoride, Chlorhexidine and Xylitol

The progression or reversal of dental caries is determined by the balance between pathological and protective factors. It is well established that a) fluoride inhibits demineralization and enhances remineralization, b) chlorhexidine reduces the cariogenic bacterial challenge, and c) xylitol is non-cariogenic and has antibacterial properties. The challenge that we face is how best to deliver these anti-caries entities at true therapeutic levels, over time, to favorably tip the caries balance. High caries risk people, including children with Early Childhood Caries (ECC), are a special challenge, since high cariogenic bacterial activity can override fluoride therapy. Current fluoride and chlorhexidine varnishes deliver all their activity within about 24 hours. Early studies with experimental slow release fluoride devices retained elevated levels of fluoride for months in a therapeutic range but have not been pursued. Preventive dentistry has largely ignored the benefits of reducing the bacterial challenge, partially due to primitive and inadequate delivery systems. For example, Chlorhexidine applied as a rinse partially reduces some bacteria but not others that are hiding within the biofilm. Better antibacterials and better delivery systems are needed. Xylitol delivered by gum or lozenge appears to be effective clinically in reducing cariogenic bacteria and caries levels, but novel systems that deliver therapeutic amounts when needed would be a major advance, especially for young children. Reducing the cariogenic bacterial challenge and enhancing the effect of fluoride by the use of new sustained-delivery systems would have a major effect on dealing with caries as a disease

Iron Behaving Badly: Inappropriate Iron Chelation as a Major Contributor to the Aetiology of Vascular and Other Progressive Inflammatory and Degenerative Diseases

The production of peroxide and superoxide is an inevitable consequence of aerobic metabolism, and while these particular "reactive oxygen species" (ROSs) can exhibit a number of biological effects, they are not of themselves excessively reactive and thus they are not especially damaging at physiological concentrations. However, their reactions with poorly liganded iron species can lead to the catalytic production of the very reactive and dangerous hydroxyl radical, which is exceptionally damaging, and a major cause of chronic inflammation. We review the considerable and wide-ranging evidence for the involvement of this combination of (su)peroxide and poorly liganded iron in a large number of physiological and indeed pathological processes and inflammatory disorders, especially those involving the progressive degradation of cellular and organismal performance. These diseases share a great many similarities and thus might be considered to have a common cause (i.e. iron-catalysed free radical and especially hydroxyl radical generation). The studies reviewed include those focused on a series of cardiovascular, metabolic and neurological diseases, where iron can be found at the sites of plaques and lesions, as well as studies showing the significance of iron to aging and longevity. The effective chelation of iron by natural or synthetic ligands is thus of major physiological (and potentially therapeutic) importance. As systems properties, we need to recognise that physiological observables have multiple molecular causes, and studying them in isolation leads to inconsistent patterns of apparent causality when it is the simultaneous combination of multiple factors that is responsible. This explains, for instance, the decidedly mixed effects of antioxidants that have been observed, etc...Comment: 159 pages, including 9 Figs and 2184 reference

Schematic diagram of the "Caries Balance" (adapted from Featherstone, 2003)2

<p><b>Copyright information:</b></p><p>Taken from "Delivery Challenges for Fluoride, Chlorhexidine and Xylitol"</p><p>BMC Oral Health 2006;6(Suppl 1):S8-S8.</p><p>Published online 15 Jun 2006</p><p>PMCID:PMC2147587.</p><p></p

Long‐Term Adoption of Caries Management by Risk Assessment Among Dental Students in a University Clinic

The aim of this study was to evaluate the long-term adoption of a risk-based caries management program at a university dental clinic. The authors extracted data from electronic records of adult non-edentulous patients who underwent a comprehensive oral evaluation in the university predoctoral clinic from July 2007 through June 2014 (N=21,984). Consistency with caries management guidelines was measured as the percentage of patients with caries risk designation (low, moderate, high, or extreme) and the percentage of patients provided non-operative anti-caries agents within each designated caries risk category. Additionally, patient and provider characteristics associated with risk assessment completion and with provision of anti-caries therapy were identified. Results showed that the percentage of patients with documented caries risk grew steadily from 62.3% in 2007-08 to 92.8% in 2013-14. Overall, receipt of non-operative anti-caries agents increased with rising caries risk, from low (6.9%), moderate (14.1%), high (36.4%), to extreme (51.4%), but percentages were stable over the study period. Younger patients were more likely to have a completed risk assessment, and among high- and extreme-risk patients, delivery of anti-caries therapy was more common among patients who were younger, identified as Asian or Caucasian, received public dental benefits, or were seen by a student in the four-year DDS program or in the final year of training. These results demonstrate that extensive compliance in documenting caries risk was achieved within a decade of implementing risk-based clinical guidelines at this dental school clinic. Caries risk was the most strongly associated of several factors related to delivery of non-operative therapy. The eventual success of this program suggests that, in dental education, transition to a risk-based, prevention-focused curriculum may require a long-term commitment

Baseline caries risk assessment as a predictor of caries incidence

UnlabelledFew studies have evaluated clinical outcomes following caries risk assessment in large datasets that reflect risk assessments performed during routine practice.ObjectivesFrom clinical records, compare 18-month caries incidence according to baseline caries risk designation.MethodsFor this retrospective cohort study, data were collected from electronic records of non-edentulous adult patients who completed an oral examination and caries risk assessment (CRA) at a university instructional clinic from 2007 to 2012 (N=18,004 baseline patients). The primary outcome was the number of new decayed/restored teeth from the initial CRA to the ensuing oral examination, through June 30, 2013 (N=4468 patients with follow-up). We obtained doubly-robust estimates for 18-month caries increment by baseline CRA category (low, moderate, high, extreme), adjusted for patient characteristics (age, sex, payer type, race/ethnicity, number of teeth), provider type, and calendar year.ResultsAdjusted mean decayed, restored tooth (DFT) increment from baseline to follow-up was greater with each rising category of baseline caries risk, from low (0.94), moderate (1.26), high (1.79), to extreme (3.26). The percentage of patients with any newly affected teeth (DFT increment&gt;0) was similar among low-risk and moderate-risk patients (cumulative incidence ratio, RR: 1.01; 95% confidence interval, CI: 0.83, 1.23), but was increased relative to low-risk patients among high-risk (RR: 1.28; 95% CI: 1.10, 1.52), and extreme-risk patients (RR: 1.52; 95% CI: 1.23, 1.87).ConclusionsThese results lend evidence that baseline caries risk predicts future caries in this setting, supporting the use of caries risk assessment to identify candidate patients for more intensive preventive therapy.Clinical significanceIdentification of patients at greater risk for future caries helps clinicians to plan appropriate personalized care. In this study, a multifactorial approach to caries risk assessment effectively stratified patients into groups of higher or lower caries propensity. Dentists can apply risk assessment in practice antecedent to patient-tailored caries management

Pediatric Caries Risk Assessment as a Predictor of Caries Outcomes.

PurposeTo determine cumulative dental treatment experience in a retrospective clinical cohort, according to baseline caries risk assessment (CRA) information.MethodsEvaluated were electronic records from a university pediatric dental clinic (2009 to 2014) of new, six- to 72- month-old patients who were not treated under sedation or general anesthesia (N equals 750). The mean number of teeth restored or extracted (two-year total and omitting the first 190 days post-baseline to discount initial treatment needs) was compared by baseline CRA category and CRA items (caries risk indicators, protective items, and clinical disease indicators).ResultsThe CRA category was associated with mean treated teeth over two years (low equals 0.53, moderate equals 1.02, high/extreme equals 4.47) and post 190 days (low equals 0.51, moderate equals 0.89, high/extreme equals 2.11). Any treatment probability was greatest for high/extreme-risk children but not statistically significantly different between low- and moderate-risk. Age-standardized means were greater for all individual baseline clinical indicators and most risk indicators, but lower for most protective items (not statistically significantly for all items). Clinical indicators were the strongest outcome correlates.ConclusionsIn this population, baseline risk information was associated with clinical outcomes. CRA can help identify patients needing more intensive caries prevention