Demin/Remin in Preventive Dentistry: Demineralization By Foods, Acids, And Bacteria, And How To Counter Using Remineralization

By Robert L. Karlinsey

Despite significant progress in the management of oral health, tooth decay remains stubbornly widespread and resilient. Complicating this further, there remain gaps in clinical use and knowledge involving fluoride and remineralization therapies. To help address these problems, Demin/Remin in Preventive Dentistry&nbsp

• Language: English
• Publisher: RLK Ventures, LLC
• Release date: Aug 14, 2018
• ISBN: 9780999559918

Robert L. Karlinsey

A Principal Investigator whose research has been supported by a variety of funding mechanisms, including multiple awards from the National Institutes of Health, Dr. Robert L. Karlinsey holds a BS in Physics and PhD in Chemical Physics. Inspired by his own tooth decay, he created patented tooth-strengthening technologies found in several 3M Oral Care dental products. By infusing historical successes (and failures) with today's prevention-focused innovations, his knowledge of and research in preventive dentistry forms a compelling, enlightened perspective beneficial to clinicians, researchers, and laypeople alike.

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Recommendations by Professionals

"Dr. Karlinsey is an Oral Health Care Ninja Warrior. His passion for the topic is manifest in this amplified work on how foods, drinks, and toothpaste impact the teeth. Demin/Remin in Preventive Dentistry is a comprehensive resource that provides a mouthful of great information. This is a must-read for any Oral Health Care Professional and those focused on oral health and overall wellness."

—Rich Christiansen, National Bestselling Author (Wall Street Journal, USA Today), Prolific Entrepreneur, and Philanthropist, Utah, USA

"Demin/Remin in Preventive Dentistry is well-thought-out, has good flow, is full of scientific research spanning more than 100 years, and can certainly expand on a clinician’s knowledge of demineralization and remineralization. I loved the historical tidbits (especially the early 20th century advertisements for toothpaste). This is a fine work, and I’m impressed with the depth of knowledge Dr. Karlinsey provides, not to mention his motivation to become engaged in preventive dentistry."

—Dr. Dylan Yung, Aevitas Dentistry,

Auckland, New Zealand

"Dr. Karlinsey has an amazing talent of explaining a sometimes confusing or misunderstood topic in an easy-to-understand way. As a practicing dentist for 15+ years, I have seen first-hand a lot of dental demineralization and disease in a real-world clinical setting. Demin/Remin in Preventive Dentistry provides some real world applications and up-to-date solutions, and encouraged me to circle back and revisit my understanding of demin/remin processes in order to better combat these ongoing struggles."

—Dr. Chris Hardin, Hardin Cosmetic & Family Dentistry,

Indiana, USA

"As our overall health begins in the oral cavity, this is an excellent book on demineralization, including the effects of various foods and drinks on the dentition. Demin/Remin in Preventive Dentistry should not only be required reading for health care providers, especially dentists, hygienists and pediatricians, but should also be a part of education in all dental and hygiene schools!"

—Dr. Greg Hardin, Hardin Cosmetic & Family Dentistry,

Indiana, USA

"Demin/Remin in Preventive Dentistry has the potential to augment the standard of education in dental schools. Additionally, I believe it can change a dental patient’s life and is a great contribution to preventive dentistry!"

—Dr. Makoto Asaizumi, Asaizumi Orthodontic Practice,

Mobara, Japan

"Based on my clinical perspective, I refer to the mouth as a dynamic chemical laboratory consisting of minerals, compounds, acids, buffers, etc. Furthermore, dental decay results from an imbalance of demineralization/remineralization processes. In order to tip the scale to a caries-free state, a clinician needs to assess not only the oral environment but also the functioning of the body as a whole. The factors that influence the oral environment need to be understood, and in Demin/Remin in Preventive Dentistry, Dr. Karlinsey has explained all these aspects so beautifully with references and cross-references. He has systematically detailed the dental caries process, remineralization approaches, and so much more; in doing so, it is now well-understood that there is more to dental caries than what we previously knew, and there is more to prevention than just brush, use fluoride, and do not eat sugars. Demin/Remin in Preventive Dentistry is a marvelous book, is much needed by dental clinicians, and could become the bible of preventive dentistry!!"

—Dr. Rajeev Thaper, Thaper Dental Clinic,

Rajasthan, India

"Demin/Remin in Preventive Dentistry brings to light the wide variety of acid types that patients encounter daily that lead to demineralization, while putting emphasis on food and beverage items we may not necessarily expect. Dr. Karlinsey explains the processes behind demineralization, as well as efforts we, as clinicians, can take to provide better quality dental health not only through education but also in-office fluoride formats to promote remineralization."

—Vanna Murphy, Registered Dental Hygienist,

North Carolina, USA

"Demin/Remin in Preventive Dentistry is well-written and very informative. In particular, the dynamics of dental caries and the role of saliva are beautifully explained."

—Dr. Meenu Bhola, Professor and Head of the Dept. of Pediatric Dentistry at the Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India

Copyrighted Material

Demin/Remin in Preventive Dentistry

Copyright © 2018 by Robert L. Karlinsey. All Rights Reserved.

This is a nonfiction book. Names have not been changed, and the research and experiences discussed by the author have not been fabricated. The advice and strategies discussed herein may not be suitable for every situation. The author and publisher used best efforts to ensure accurate information in this book, and the author or publisher disclaim any liability to any party for any loss, damage, or disruption caused by errors or omissions that may result from negligence, accidence, or any other cause.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means—electronic, mechanical, photocopying, recording or otherwise—without prior written permission from the publisher, except for the inclusion of brief quotations in a review.

Published by RLK Ventures, LLC

7750 Centerstone Drive, Indianapolis, Indiana 46259

Library of Congress Control Number: 2018905810

ISBN:

Print: 978-0-9995599-0-1

E-book: 978-0-9995599-1-8

Printed in the United States of America

I dedicate this book to Tami and Teegan, two very special, loving, and supportive people in my life.

Table of Contents

Table of Figures

List of Tables & Short Captions

Foreword

Chapter 1 Tooth Decay is Still Problematic

Chapter 2 Key Components in the Mouth: Teeth, Bacteria and Bacterial Acids, and Saliva

Chapter 3 Ultrastructural Characteristics of Healthy (Sound) enamel

Chapter 4 Demineralization of Enamel Structure

Chapter 5 On the Nature of Demineralizing Acids

Chapter 6 Acids and pH: Demineralization Risks of Foods, Drinks, and Other Comestibles

Chapter 7 A Glimpse into the Past: Pre-Fluoride Preventives

Chapter 8 Fluoride: Thwarting Demineralization and Accelerating Remineralization

Chapter 9 Remineralization

Chapter 10 Put it to Practice

Bibliography

Index

Acknowledgments

About the Author

Table of Figures

Chapter 1

Figure 1.1: Mean caries prevalence in children and adults (1999–2004).

Figure 1.2: Mean DMFT in children and adults (1999–2004).

Chapter 2

Figure 2.1: 19th century sketches of maxillary and mandibular tooth structure.

Figure 2.2: 19th century front-view sketch of idyllic tooth alignment.

Figure 2.3: Nonspecific ecologies existing in supragingival plaque.

Figure 2.4: Dynamic equilibrium and the acidic/alkaline balance.

Figure 2.5: Microbial metabolism of saccharides.

Figure 2.6: Microbial metabolism of proteins.

Figure 2.7: Common acids produced by microbial metabolism of saccharides and proteins.

Figure 2.8: Acids naturally produced in resting plaque.

Figure 2.9: Acetic acid content produced by chewing sucrose-sweetened gum up to 45 minutes.

Figure 2.10: Lactic acid content produced by chewing sucrose-sweetened gum up to 45 minutes.

Figure 2.11: Plaque pH in participants without access to saliva.

Figure 2.12: Plaque pH in participants with free access to saliva.

Figure 2.13: Plaque pH produced by chewing sucrose-sweetened gum up to 45 minutes.

Figure 2.14: Volume of saliva produced after aerobic and anaerobic exercise.

Figure 2.15: Salivary lactate content produced after aerobic and anaerobic exercise.

Figure 2.16: Salivary protein content produced after aerobic and anaerobic exercise.

Chapter 3

Figure 3.1: SEM of sound enamel surface.

Figure 3.2: SEM of sound enamel cross-section.

Chapter 4

Figure 4.1: Images of molars with different levels of decay.

Figure 4.2: Clinical images of mandibular molar with caries experience.

Figure 4.3: Clinical image of mandibular anteriors manifesting white-spot lesions.

Figure 4.4: Images of a cross-sectioned carious molar.

Figure 4.5: SEM of enamel white-spot lesion surface.

Figure 4.6: Reflected light images of sound and enamel white-spot lesion cross-sections.

Figure 4.7: SEMs of sound and enamel white-spot lesion cross-sections.

Figure 4.8: Cross-sectional microhardness and X-ray patterns of sound and enamel white-spot lesions.

Figure 4.9: SAXS and WAXD of sound and enamel white-spot lesion cross-sections.

Figure 4.10: SEM of eroded enamel surface.

Figure 4.11: SEMs of sound and eroded enamel surfaces.

Figure 4.12: 3-D demineralized dentin section imaged with submicron X-ray tomography.

Figure 4.13: 3-D demineralized dentin cross-section imaged with submicron X-ray tomography.

Figure 4.14: Cross-sectional HAP concentration for sound and eroded tubular and intertubular dentin.

Chapter 5

Figure 5.1: Equilibrium dissociation constants for several inorganic and organic acids.

Figure 5.2: Effect of calcium chloride on organic acid solutions.

Figure 5.3: Stability constants of acid anion-Ca²+ complexes.

Figure 5.4: Experimental diffusion coefficients in water.

Figure 5.5: Experimental diffusion coefficients and approximate hydrated radii.

Figure 5.6: Plaque acid content before and after exposure to sugar.

Chapter 6

Figure 6.1: pH of maxillary premolar plaque after consumption of foodstuffs.

Figure 6.2: Lactic acid content of maxillary premolar plaque after consumption of foodstuffs.

Figure 6.3: Minimum pH of interproximal molar/prostheses plaque from caries experience participants.

Figure 6.4: Minimum pH of approximal molar plaque from low caries experience participants.

Figure 6.5: Microbial populations recovered from fissure surfaces with specific food supplementation.

Figure 6.6: Microbial populations recovered from smooth surfaces with specific food supplementation.

Figure 6.7: pH values of some common foods determined by FDA.

Figure 6.8: Small acid content of 15 common edible Mediterranean plant species.

Figure 6.9: Small acid content of 14 common vegetables.

Figure 6.10: Small acid content of some other common vegetables.

Figure 6.11: Small acid and sugar content of five common fruits.

Figure 6.12: Small acid content of various citrus fruits.

Figure 6.13: Small acid and sugar content of various berry fruits.

Figure 6.14: pH of various berry fruits.

Figure 6.15: Small acid content of some other common fruits.

Figure 6.16: pH of various carbonated sodas.

Figure 6.17: Small acids present in various Coca-Cola® brand carbonated sodas.

Figure 6.18: Small acids present in various PepsiCo® brand carbonated sodas.

Figure 6.19: Small acids present in various Dr Pepper Snapple Group® brand carbonated sodas.

Figure 6.20: pH of various noncarbonated waters.

Figure 6.21: pH of various flavored waters.

Figure 6.22: pH of various sparkling waters.

Figure 6.23: Small acid content of various bottled waters.

Figure 6.24: pH of various juices.

Figure 6.25: pH of various juice drinks.

Figure 6.26: pH of various sports drinks.

Figure 6.27: Small acid content of various sports drinks.

Figure 6.28: pH of some alcoholic beverages and vinegar.

Figure 6.29: Small acid content of red and white wines sourced from Spain.

Figure 6.30: Small acid and sugar contents of some Austrian red wines.

Figure 6.31: Small acid content of two regional Spanish red wines.

Figure 6.32: Small acid content of four regional Italian lager beers.

Figure 6.33: pH of liquid eggs and several nonplant milks.

Figure 6.34: pH of several plant-based milks.

Figure 6.35: pH of several protein milks.

Figure 6.36: pH of several specialty drinks.

Figure 6.37: pH of several dairy and nondairy creamers.

Figure 6.38: pH of several brewed coffees.

Figure 6.39: pH of several ready-to-serve coffees available in the US.

Figure 6.40: Small organic acid content of 20 arabica or robusta coffees.

Figure 6.41: pH of several ready-to-serve teas.

Figure 6.42: pH of several brewed white, green, black, oolong, fruit, and herbal teas.

Figure 6.43: Small organic acid content of several tea infusions.

Figure 6.44: Fluoride content of several black tea infusions.

Figure 6.45: Fluoride content of several green tea infusions.

Figure 6.46: Fluoride content of several nonblack and nongreen tea infusions.

Figure 6.47: Fluoride content of ready-to-serve teas.

Figure 6.48: pH of various candy items.

Chapter 7

Figure 7.1: Early 20th century advertisements for Listerine antiseptics.

Figure 7.2: Late 19th century advertisements for Sozodont liquid dentifrice.

Figure 7.3: Late 19th century advertisement for Dr. Lyon’s tooth powder.

Figure 7.4: Late 19th century advertisement for Doctor Sheffield’s tube dentifrice.

Figure 7.5: Late 19th century advertisements for Lloyd toothache drops.

Figure 7.6: Late 19th century advertisement for G. F. Boehringer & Soehne manufacturing chemists.

Figure 7.7: Early 20th century advertisement for Colgate ribbon dental cream.

Figure 7.8: Early 20th century advertisement for Pebeco toothpaste.

Figure 7.9: Early 20th century advertisement for Pepsodent dentifrice.

Figure 7.10: Mid-20th century advertisement for Ipana dentifrice.

Figure 7.11: Mid-20th century advertisement for GLEEM dentifrice.

Figure 7.12: Mid-20th century advertisement for Listerine dentifrice.

Figure 7.13: Mid-20th century advertisement for Colgate dentifrice.

Figure 7.14: Mid-20th century advertisement for PEB-AMMO dentifrice.

Figure 7.15: Mid-20th century advertisement for Chlorodent dentifrice.

Figure 7.16: Mid-20th century advertisement for Colgate dentifrice.

Figure 7.17: Mid-20th century advertisement for Amm-i-dent dentifrice.

Chapter 8

Figure 8.1: Types of mineral generally formed from topical fluoridated systems.

Figure 8.2: Estimated caries reduction relative to topical fluoride format.

Figure 8.3: WAXD, SAXS, and SEM of white-spot enamel lesions with Clinpro™ dentifrices.

Figure 8.4: Effect of fluoride in the oral environment.

Chapter 9

Figure 9.1: Schematic of the symmetry sites of the β-TCP unit cell.

Figure 9.2: Late 19th century advertisement for S. S. White anti-hypersensitivity paste.

Figure 9.3: Mineral distribution for pastes based on labeled Ca, PO4, and F.

Figure 9.4: Distribution of fluoride species for pastes based on labeled Ca, PO4, and F.

Figure 9.5: Distribution of phosphate species for pastes based on labeled Ca, PO4, and F.

Figure 9.6: Distribution of calcium species for pastes based on labeled Ca, PO4, and F.

Figure 9.7: Mineral distribution for pastes based on measured Ca, PO4, and F.

Figure 9.8: Distribution of fluoride species for pastes based on measured Ca, PO4, and F.

Figure 9.9: Distribution of phosphate species for pastes based on measured Ca, PO4, and F.

Figure 9.10: Distribution of calcium species for pastes based on measured Ca, PO4, and F.

Figure 9.11: Mineral distribution for varnishes based on Ca, PO4, and F released at neutral pH.

Figure 9.12: Distribution of fluoride species for varnishes based on measured Ca, PO4, and F.

Figure 9.13: Distribution of phosphate species for varnishes based on measured Ca, PO4, and F.

Figure 9.14: Distribution of calcium species for varnishes based on measured Ca, PO4, and F.

Figure 9.15: Mineral distribution for varnishes based on Ca, PO4, and F released at acidic pH.

List of Tables & Short Captions

Chapter 5

Table 5.1: Equilibrium reactions and pKa values for acids listed in Figure 5.1.

Chapter 9

Table 9.1: Some possible calcium compounds produced from saliva and/or dental treatments.

Foreword

DESPITE SIGNIFICANT PROGRESS in the management of oral health, tooth decay remains stubbornly widespread and resilient; in fact, tooth decay is the single most preventable disease affecting children. Complicating this further, there remain gaps in clinical use and knowledge involving fluoride and remineralization therapies. While there are plenty of books, reports, and research papers that highlight this ongoing problem, this book is not meant to highlight the fact there is a problem. The problem is well-known and typical solutions involve abstaining from sugar, encouraging more responsible manufacturing of foods, and shifting third-party reimbursement systems (e.g., incentivizing) away from restoration and toward minimal intervention. While efforts to attain a critical mass of each of these stakeholders remains challenging, tooth decay continues to present worldwide problems. Therefore, in a bid to stimulate better oral health today, new approaches and perspectives are in demand now.

To contribute to the fight against tooth decay, Demin/Remin in Preventive Dentistry explores demineralization and remineralization processes by synthesizing a variety of data and research to produce a fresh perspective from one who has devoted significant effort to improving remineralization therapies in preventive dentistry. Supporting prevention, stimulating thought, and inspiring change are the major goals of this book, since the decay statistics demand the need for improved oral health strategies. After all, as my good friend and colleague, Dr. Rajeev Thaper, has said to me you have to have passion for preventive dentistry to make things work. Well, I’m following Dr. Thaper’s advice and the result is this book.

In addition to sharing my perspectives, I’m literally revealing a part of myself to you. I admit it: I have a history of dental decay, ever since I was a young boy. I’ve had so many cavities that I had been predisposed to thinking that cavities were a part of growing up; strangely, my brother didn’t get cavities and I always found this confusing as we ate nearly the same foods and he didn’t appear to take better care of his teeth than I did (in fact, it might have been worse!). But many years later and after completing my graduate studies in chemistry and physics, I learned I was harboring a cracked molar, and that it would need to be crowned. Indeed, this proved to be a ‘crowning’ moment, and I promptly shifted my research focus to dental research and prevention, with the hope I could somehow contribute to improving topical dental products and help others reduce the risk of aggressive intervention. And, through the course of my research, I developed innovative forms of calcium phosphate for enhanced remineralization benefits, and these are presently found in several topical 3M Oral Care products, such as Clinpro™ 5000 and Clinpro™ Tooth Crème.

Therefore, a primary motivation for writing this book is to share my in-depth knowledge and understanding of preventive dentistry, which includes highlighting the benefits of remineralization as part of a minimally invasive dentistry approach. Still, this is not a compilation of my own research as this would be a much shorter read! Rather, I utilized research from around the world and used my best efforts to avoid hashing over timeworn concepts that can be found elsewhere. In doing so, this book provides fundamental, fascinating, and instructive information, underscoring several aspects not addressed in other dentistry books.

For purposes of scope and perspective, each chapter in this book contains rich information dedicated to several key aspects alluded to above. For more in-depth information the reader is respectfully pointed to the relevant references (and the references within those references), especially since there exists a number of very well-researched and well-documented efforts by scientists and agencies worldwide. Many of the references in the bibliography are ‘open access’ and hyperlinks are provided in such instances.

Here is a brief overview of the book chapters:

Chapter 1 acknowledges and reminds us that tooth decay remains problematic. Just about everyone can relate to the effects of dental decay, which can ultimately lead to the sequela of invasive procedures commonly used to stabilize the condition. Some statistics are shared that underlines this ongoing problem of dental decay that affects either you or someone you know, including perhaps your family, friends, clients, or patients.

Chapter 2 introduces some of the key players in the mouth starting with basic information about the teeth. A more detailed look at the oral flora and the associated acids is then presented, with an emphasis on the mixed ecology of microbes. The value of saliva, which is the most critical part of remineralization, is reviewed.

Chapter 3 reviews micro- and ultrastructural characteristics of sound enamel in order to gain insight into how acids may lead to enamel demineralization. In doing so, crystallite size and morphology is discussed, as is the nature of the water and protein content residing in enamel. Additionally, the existence of microscopic voids is presented.

Chapter 4 explores the structural characteristics of the hard and soft components of the tooth when demineralized by acids. In addition to some clinical observations, simulated caries and erosive lesions are considered, along with demineralization of dentin. Perspectives on microscopic-level demineralization mechanisms are also presented.

Chapter 5 probes why and how some acids are more damaging to the teeth than others based on a variety of characteristics including acid strength, diffusion and size of undissociated and dissociated acids, and stability with calcium complexes. The purpose of this important chapter is to establish the chemical basis for the acid-susceptibility of tooth structure. The information presented here helps establish a foundation for the discussion on the nature of acids found in foods as well as those produced by microbes. A novel perspective of acetic acid is shared, and the chapter closes with a point-by-point generalized perspective of dental demineralization by acids.

Chapter 6 takes a close look at the demineralization risks of various foodstuffs and drinks. Besides the many foods that may have the potential to elicit caries-based (i.e., plaque-based) decay, which includes those rich in cereal grains (e.g., wheat, rice, corn), sugar, or other fermentable substrates, there exist others that present erosive risks. Even further, behavior (including purposeful and otherwise) drives much of the resultant damage to tooth structure. The causative factors in these instances include pH and small organic/inorganic acids, and unlike plaque-based decay, do not require the microbial middleman to destroy the dentition. As such, this chapter emphasizes the role of pH and acid in demineralization. Other factors besides pH and acid type certainly contribute to demineralization risk, such as the titratable or neutralizing acidity, degree of saturation, viscosity, surface tension, salivary stimulus, and so on. But irrespective of acid type, a low (i.e., acidic) pH is required to effect dental softening or demineralization (and pertains to both caries and erosive processes), and thus serves as a primary determinant. Secondly, based on the information presented in Chapter 5, the nature of the small organic/inorganic acid also bears on demineralization and varies according to the food or drink. To gain further insight, in this chapter I present an extensive series of figures that highlight the pH and/or small acid composition of many foods (including fruits, vegetables, and plant-derived foods) and beverages (freshly prepared or ready-to-drink). Though much effort has been made to include as many foods and drinks as possible, these lists are not complete due to the myriad foodstuffs available throughout the world, let alone those subjected to analyses and available in the public literature. Importantly, it is my hope that this information can facilitate healthier choices for foods and/or drinks when several options are available, while also bringing awareness to potentially unhealthy behavior. Three helpful options are presented, and 11 strategies are provided at the end of this chapter to help encourage better dietary choices and behavior.

Chapter 7 provides a glimpse into some historical approaches used in preventive dentistry, including antiquated approaches as well as near-modern use of anti-enzyme, ammonia, and chlorophyll ‘actives’ introduced in the 20th century. This treatment is meant to be informative and enjoyable, and helps lay the foundation for why fluoride has been welcomed as a primary agent in the management of tooth decay. This is a must-read chapter.

Chapter 8 is all about fluoride, including its anticaries history, the multipronged mechanistic underpinnings of its anticaries benefits, and features of several popular topical fluoride formats. Discussion is centered on fluoride’s ability to accelerate remineralization and impact microbial activity. The relative antidecay efficacy of various fluoride modalities, including varnishes, gels, toothpastes, and more are covered. To help illustrate remineralization characteristics from different fluoride levels, two dentifrices comprising fluoride and functionalized tricalcium phosphate are compared.

While fluoride accelerates remineralization, calcium and phosphate comprise the basis for mineral formation and is a key function of saliva. Chapter 9 is, therefore, devoted to remineralization. Although saliva is the natural remineralization system, other calcium phosphate systems are also used but work in different ways. But how do remineralization systems work and are all supersaturated systems the same? To help answer these questions, remineralization processes in general are reviewed. Additionally, solubility calculations are performed that estimate fluoride and/or calcium phosphate phases from supersaturated systems, including specific examples using varnish and dentifrice formats comprising different fluoride and calcium phosphate systems.

A discussion on minimal intervention dentistry is presented in Chapter 10 and rounds out this book. This includes commentary and insights regarding the clinician-patient relationship, along with other factors including nutrition and age-related health concerns. The tone of this chapter touts progress, and supports those research activities dedicated to improving oral health for people everywhere around the globe.

The source material for this book is fairly diverse, with more than 900 references called forth (and many more left out for purposes of redundancy) from various fields of study, including medicine, dentistry, chemistry, biology, materials science, food science, along with reports from journalists, nonprofit foundations, and government organizations.

It is my hope that this work inspires students, researchers, or anyone working in the wellness fields who frequently engages with patients. Thus, this is intended for those studying cariology or preventive dentistry, including students in dental or hygiene school; dental hygienists, therapists and assistants; general, pediatric, and specialty dentists (especially orthodontists); dietitians and nutritionists; researchers in the dental and life sciences; pediatricians, physicians, nurses, nurse practitioners, and assistants; those working in private or public dental practices; those working with populations prone to or experiencing significant health-related problems; and, this book is also geared toward those with special interests in the demineralization and remineralization of enamel.

In summary, a motley of historical timelines, food and drink data, past and present research into aspects of demineralization and remineralization, and elements of minimal intervention dentistry, which runs counter to the dreaded ‘drill-and-fill’ prognosis, are presented. Demin/Remin in Preventive Dentistry is not only intended for those with a ‘prevention-first’ mind-set but also for those researchers and clinicians passionate about delivering or improving oral health benefits to those of us (both young and young at heart) most susceptible to tooth decay.

CHAPTER ONE

Tooth Decay is Still Problematic

Some common factors contributing to tooth decay include biological makeup, behavior, environment, and lifestyle.

THE CHANCES ARE UNFORTUNATELY HIGH that if you were born in the United States and you’re reading this book, you have had at least one decayed, missing, or filled tooth. If so, then your situation is similar to most of the global population—in fact, tooth decay remains the most prevalent disease affecting children [1–3]. Some common factors contributing to tooth decay include biological makeup, behavior, environment, and lifestyle. While lower socioeconomic status increases risk for tooth decay, dental caries still affects those who are educated and/or affluent. In a frustrating twist, however, the disease is manageable and largely preventable but requires a consistent multi-pronged approach involving professional services and recommendations, along with patient education, habits, and compliance. Of course, ignoring the disease or hoping it will go away on its own can be detrimental to overall health and, in extreme albeit rare situations, can even lead to death [3]. While this may seem like a dramatic statement, consider that more than 830,000 emergency room visits in 2009 were caused by preventable dental conditions—and this statistic represents an increase of 16% compared to visits in 2006 [4]!

To set the stage for further discussions on addressing tooth decay, this chapter introduces the motivation for improved preventive approaches by touching on some key statistics relating to tooth decay.

So who is affected from tooth decay and when it does it begin? Personally, my dental history is decorated from relatively benign gingiva-margin measurements to evidence of aggressive intervention marked by fillings and crowns. But this isn’t an adult disease that one naturally matures into; rather, risks begin within the first year of a newborn’s life.

The American Academy of Pediatric Dentistry (AAPD) defines early childhood caries (ECC) as the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of six [5]. Basically, any child with at least one decayed tooth surface meets this criterion. To help thwart the onset of ECC, the AAPD published guidelines with respect to anticipatory guidance and preventive counseling, for infants, children, and adolescents, and recommends establishing a dental home beginning with the first tooth eruption and no later than the first 12 months of the child’s life [5,6]. This call for a dental home is not without merits: in 2008, less than half of US children between the ages of 2 and 17 had ever received advice from a health care provider about the need for timely checkups [7]: and within this age range, children between the ages of 13 and 17 actually received the least advice. This troubling statistic encompasses the teenage demographic who, exploring emerging independence, begin to assume greater stewardship (or lack thereof) in dietary selections and oral hygiene. Separately, the aforementioned statistics consider children having public, private, or no insurance assistance, and reveal that children from families with greater education and/or income were more likely to make a routine visit to the dentist at least once a year; but even with relatively higher socioeconomic standing, only 63% of children from these families saw the dentist at least once a year [7]!

Given the fact that families well above the poverty level strain to achieve consistent routine dental care for their children, one can imagine the statistics that might arise for resource-strapped families. Approximately 37 million children from low-income families in the United States are primarily served by the government-funded Medicaid mechanism for coverage and access to dental care [2]. Though it may seem these children are covered, evidence indicates otherwise: not only are there deficiencies in the number of Medicaid-participating dentists but also the Medicaid coverage failed to support the requisite services established by the AAPD. For instance, among four states (California, Indiana, Louisiana, and Maryland) which represent nearly one-fifth of all Medicaid-enrolled children, 78% (or, about 2.9 million) failed to receive AAPD-recommended services, including biannual oral exams, dental cleanings, and fluoride treatments over a two-year period (2011 and 2012), with more than 25% of the children never having received any dental service during this time [2].

Why is this so? Of course, the answers are many: lack of nearby access to a dentist; poor patient compliance due to myriad reasons; shortage of dental providers due, in part, to ponderous administrative burdens, concerns over low reimbursement rates, or simply misalignment with career aspirations; unethical dental providers with questionable billing practices; or, even the Centers for Medicaid & Medicare Services reluctance to or absence of improving outreach or oversight by, for example, tracking child-specific services on a quarterly basis. Whatever the reason, endemic problems exist, and may contribute—at least in part—to the estimated several million other children living with untreated tooth decay. Hence, it is understandable how deficiencies in such programs can lead to greater oral health problems that, in turn, morph into emergency room visits, the costs of which are estimated to be about 10x that of standard preventive services delivered by a dentist [4].

In 2008 an oral health report was published by the United States Department of Health and Human Services based on data collected from the National Health and Nutrition Examination Surveys [8]. This report provides exceptional detail into prevalence of caries-related tooth decay confronting children and adults at several socioeconomic levels over two separate periods: 1988–1994 and 1999–2004. This included the number of people manifesting some aspect of caries, as well as those experiencing gingival recession or tooth loss. In addition to a most surprising result