Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Biofilm (König 1987) 1 st Phase: immediately to approximately 4 hours Formation of aquired pellicle from salivary glycoproteins and maturation. Early colonisation from initial bacteria mainly Streptococcus strains. 2 nd Phase: 4 to 48 hours Colonisation of predilection sites, i.e. fissures, iatrogenic retention factors (restorations/overhangs/ortho brackets) and white spots. 3 rd Phase: 3 to 7 days Aerobic bacterial metabolic products compromise the hard dental tissues; anaerobic bacterial metabolic products compromise the soft tissues. 4 th Phase: 7 to 14 days Mature plaque biofilm is established that consists of sessile bacteria firmly attached to the hard dental tissues and planktonic (floating) bacteria.
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Early Colonizers Late Colonizers Fl- Biofilm The Formation of Biofilm Quorum sensing Salivary Pellicle Fl- resistance Enamel Surface Statherin -amylase Proline-rich protein Salivary agglutinin Sialylated mucins Strep. oralis Strep. sanguis Strep. mitis Strep. gordonii A.oris A.naeslundii A.israelii C.achracea C.gingivalis C.sputigena AA T.forsythia PG T.denticola
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Sugar-Free Gum Saliva flow rates under stimulation Saliva flow (ml in 20 min) Un-stimulated saliva Stimulated saliva after chewing paraffin Stimulated saliva after chewing sugar- free gum (Edgar 1993) - Chewing gum increases the saliva flow rate up to 10 times. - “Empty” chewing, without flavor additive (e.g., paraffin), only stimulates up to 5 times. - Chewing sugar-free gum with flavor additive improves flushing and accelerates the removal of soluble compounds. Salivary Flow Rate
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Sugar-Free Gum Polyol-sweetened gum stimulates the production of saliva by two mechanisms: - Gustatory stimulation (taste buds) - Masticatory action (periodontal mechanoreceptors) (Dawes and Macpherson. 1992) Salivary Flow Rate
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Sugar-Free Gum - Salivary stimulation lasts more than 2 hours with SF gum. - Flavour and chewing increase salivary flow. (Dawes, C., et al. Arch Oral Biol 2004, 49, 665-669.) Salivary Flow Rate Unstimulated flow rates of less than 0.1 mL/minute are considered evidence of hypo-salivation
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Sugar-Free Gum Salivary Flow Rate and Xerostomia* -Chewing sorbitol gum increased saliva flow rates and neutralized plaque pH drop from sucrose in subjects with xerostomia. 1,2 - 69% of cancer patients with xerostomia preferred chewing gum to artificial saliva 3 ; 60% of hemodialysis patients preferred gum to saliva substitutes. 4 - Gum chewing (12 months, 2x/day) increased stimulated saliva flow rates in 111 frail older people. 5 -A 6 month study in 186 older (community-dwelling) adults showed significant improvements in plaque and gingival indices, but not saliva flow 6 ; self-perceived oral health status improved significantly in the gum group. 1.Markovic N; Abelson DC; Mandel ID (1988): Gerodont. 7: 71-75 2.Abelson DC, Barton J, Mandel ID (1990): J Clin Dent 2: 3-5 3.Davies AN (2000): Palliat Med 14: 197-203 4.Bots CP, Brand HS, et al (2005): Palliat Med 19: 202-207 5.Simons D, Brailsford SR, Kidd EAM, Beighton D (2002): J Am Geriatr Soc 50: 1348-1354 6.Al-Haboubi M, Zoitopoulos L, Beighton D, Gallagher JE (2012): Community Dent Oral Epidemiol 40: 415-424 Sugar-free gum may have benefits in older and medically-compromised patients * Module Two
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Sugar-Free Gum Oral Clearance 15 10 5 0 0 0.20.40.60.81.0 Unstimulated Flow Rate UNSTFR(ml/min) Halftime(min) Saliva and Oral Health, Edgar M. Dawes C., O’Mullane, D. Eds. 4 th Ed, 2012 - Relies on swallowing and flow rate. - Higher salivary flow rate = increased clearance. - Unstimulated flow rate < 0.2ml/min = prolonged clearance. - Prolonged clearance = greater risk of caries. - Greater risk of acid erosion. Effect of changes in the UNSTFR on the clearance halftime of sucrose
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Sugar-Free Gum Buffering Capacity Saliva stimulation and buffering of acids by chewing gum pH value 10% sugar solution Chewing gum with sugar substitute Time in minutes (Stoesser 1996) -Buffer capacity is the ability to neutralise acids (buffering). -The pH value is raised due to the increased concentration of bicarbonate in stimulated saliva. (Bicarbonate increases from 5.47 unstimulated to 16.03mmol/L in stimulated saliva). -Increased flow rate exposes hard tissues to low pH for a shorter period. ( Flow rate increases from 0.32 ml/min unstimulated to 2.08ml/min in stimulated saliva). Fast flowing saliva neutralises plaque (pH value increases).
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Caries Plaque pH Manning RH, Edgar WM (1993) Brit Dent J 174: 241-4 Plaque pH Time (min) Factors affecting plaque acids - Fermentable carbohydrates. - Oral bacteria produce: - Extracellular polysaccharides in the presence of excess sucrose. - Glucans increase plaque adhesion and thickness. - Fructans produce acid metabolites. - Intracellular polysaccharide stores provide ongoing acid production in resting plaque. Saliva stimulation from chewing gum helps to neutralise plaque acids
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Caries Demineralisation- Remineralisation - Demineralisation shifts to remineralisation by the use of fluoridation and saliva activation. Saliva provides the medium for remineralisation. - Supersaturation of saliva with ionic Ca and Pi, can effectively help remineralise incipient caries lesions. - Enhancing remineralization resulting in enamel with a higher Fl content and lower acid solubility. - Fluoride inhibits demineralisation by penetrating and coating enamel crystals to prevent dissolution.
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk THE CARIES BALANCE PATHOLOGiCAL FACTORS - Acid producing bacteria - Frequent eating/drinking of fermentable carbohydrates - Subnormal saliva flow and function PROTECTIVE FACTORS - Saliva flow and components- - Fluoride-remineralisation with calcium and phosphate - Antibacterials: chlorhexidine, xylitol CARIESNO CARIES Caries Redrawn from Featherstone BMC Oral Health 2006 6(Suppl 1):S8
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Caries Reduction Studies Clinical Caries Studies - Three year study in children with high caries prevalence showed caries-protective benefit of sugar-free gum (Beiswanger et al. 1998) Three year study, Puerto Rico N = 1402 subjects, age 8-13 Chewed gum 3 x/day for 20 min after meals 7.9% fewer DMFS in all subjects and 11.0 fewer in high-caries subjects. - Another two year study confirmed caries-protective benefit in lower-caries prevalence population (Szöke et al, 2001) Two year study, Hungary n = 547 subjects, age 8-13 Chewed gum 3 x/day for 20 min after meals or no gum Results show 38.7% reduction in DMFS increment after 2 years INCREMENTAL DMFS Chewing SF gum reduces caries in prospective 2-3 year clinical trials.
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Caries Reduction Studies StudyIntervention (n/N)Control (n/N) Reduction of Caries Incidence (%) Möller 1973 Sorbitol gum 3x/day after meals. 161/313No gum. 152/313 10% Glass 1983 Sorbitol gum 2x/day. 269/540No gum. 271/540 2% Kandelman 1990 15% Xylitol gum 90/274No gum. 97/274 61% Kandelman 199065% Xylitol gum 87/274 No gum. 97/274 66% Mäkinen 1995a Sorbitol gum pellets 2x1.3g, 5x/day 129/1135 No gum. 121/1135 17% Mäkinen 1995a 3:2 xylitol/sorbitol pellets, 5x/day 120/1135No gum. 121/1135 44% Mäkinen 1996 Sorbitol stick, 1, 5x/day. 63/471 No gum. 86/471 28% Beiswanger 1998 Sorbitol gum, 3x/day after meals. High risk subjects, intention to treat, 607/1256 No gum. 649/1256 12% Szöke 2001 Sorbitol stick, 3x/day after meals. Including white spots, 269/547 No gum. 278/547 33% Peng 2004 Sorbitol/xylitol/carbamide gum, 4x/day. 363/733 No gum. 370/733 42% Machiulskiene 2001 Sorbitol gum, 5x/day after meals. 68/432 No gum. 80/320 25% Tabulated Summary of Data from Pertinent Human Intervention Studies
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Caries Reduction Studies Caries Reduction and Gum - Conclusions -Multiple studies support the anti-caries benefits of sugar-free gum chewed after eating. -The majority showed reductions in the range 20-60%. -Systematic reviews have also supported this position. (eg Mickenautsch et al, 2007; Deshpande and Jadad, 2008) - Studies have been reviewed by expert panels resulting in supporting reviews and statements from regulatory and authoritative bodies (FDA, FDI, ADA, EFSA, etc).
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk - Exogenous dietary acids occur at much lower pH values in comparison to plaque acids. - Saliva stimulation from chewing gum: - Increases the rate of mouth clearance from acidic food or drink 1. - Stimulates saliva production 2. - Increases levels of bicarbonate and calcium ions in saliva 3. - A ids in more rapid remineralisation of the enamel surface following an acid challenge 4. *Initial study suggests salivary stimulation may help 5. *Direct clinical evidence pending Erosion Remineralisation Sugar free gum may help prevent erosion and erosive tooth wear* 1.Trlolo P et al:J Dent Res 1990:69(1Suppl);136 2.Dawes C et al:Arch Oral Biol 2004;49(8):665-669. 3.Dawes C et al: Arch Oral Biol. 1995;40:699-705. 4.Wefel JS et al:J Dent Res 1989;68(1supp):214. 5. Rios D et al: Caries Res 2006;40:218-23.
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Diet -Acids : Food, drinks and frequency. -Sugars: Added, hidden and frequency. -Timing: Avoid before bed time - reduced salivary flow. Oral Hygiene -Tooth brushing technique, bristle type. -Toothpaste abrasives. -Bacterial acids, plaque scores, demineralisation. Fluoride Exposure -Frequency -Age appropriate fluoridation Saliva -Quality: serous, mucoid, frothy. -Quantity: adequate and reaches all areas of the mouth. -Buffering capacity. Clinical Assessment Examination
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Clinical Assessment Risk Assessment Tools Caries
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Basic Erosive Wear Examination 0 No surface loss 1 Initial loss of enamel surface texture 2* Distinct defect, hard tissue loss less than 50%of the surface area 3* Hard tissue loss more than 50% of the surface area *Dentine is often involved BEWE: a new scoring system for scientific and clinical needs. Clin Oral Investig. 2008 March; 12(Suppl 1): 65–68. BEWE Index Clinical Assessment Risk Assessment Tools
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Chairside Testing 1. Measuring the saliva flow rate (ml/min) Saliva categories Saliva flow rates (ml/min) Normal flow rate 1 - 3 Reduced saliva flow rate 0.5 - 0.8 Mouth dryness (xerostomia) <0.5 2. Consistency Visual inspection Categories Characteristics Strongly increased viscosity Sticky frothy saliva Increased viscosity Frothy bubbly saliva Normal viscosity Watery clear saliva 3. Measuring the buffer capacity The change in color on the test strip is compared with the sample card and this indicates the buffer capacity: Saliva Low Medium High
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk - Chew SFG for 20mins after sugar or acid challenge. - Encourage regular saliva stimulation in between meals. -Chew sugar free gum, to increase the saliva flow rate. - Dental care on the go: chewing sugar free gum can: - Provide mouth clearance - Help prevent plaque accumulation. - Increase saliva buffering capacity. - Decrease plaque pH. - Decrease caries and erosive potential. Recommendations Sugar Free Gum
Saliva and Oral Health www.wrigleyoralhealthcare.co.uk Conclusions Saliva is the most important part of the body’s own protective systems for maintaining oral health. Reduced saliva quantity and quality increase the risk of caries, erosion, xerostomia and interfere with the ecological balance in the mouth. Informing the patient and activating the saliva’s protective function for the mouth and teeth is the basis of a modern, prevention- oriented treatment strategy. It has been scientifically proven: saliva stimulation by chewing sugar free gum helps to increase the saliva flow-rate up to tenfold, which can reduce the risk of caries by up to 40%.
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