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Reduce Tooth Decay Effectively By This Cavity Prevention Approach

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A scientifically based approach that includes a tooth-decay risk assessment, aggressive preventive measures, and conservative restorations can dramatically reduce decay in community dental practices, according to a study by researchers at UC San Francisco.

The findings, which support earlier research demonstrating positive results of the assessment and treatment method in a university setting, have the potential to transform dental care for high-risk patients at a lower cost to both patients and dental clinics and practices. Results appear online Jan. 22, 2018, in Advances in Dental Research.

“We put the 2012 UCSF clinical study into the real world and showed it works,” said lead author Peter Rechmann, DMD, Ph.D., professor of preventive and restorative dental sciences in the UCSF School of Dentistry.

“The patients at high caries risk who used prescription products went down significantly over time in their risk level. Those in the control group also reduced their risk to a lesser degree, simply by using over-the-counter products that also protect teeth and affect the bacteria.”

Treating Tooth Decay at Its Earliest Stages

Dental caries (tooth decay) is caused by bacteria on the tooth surface feeding on carbohydrates, then making acids as waste. These acids destroy the protective tooth enamel and the dentin layer beneath it. If not halted or reversed, this leads to a cavity.

Caries Management By Risk Assessment (CAMBRA®) is an evidence-based approach to preventing or treating dental caries at its earliest stages. It was launched in 2003 through the UCSF School of Dentistry by the paper’s senior author, John Featherstone, Ph.D., MSc, former dean of the school and distinguished professor of preventive and restorative dental sciences.

A dentist who uses CAMBRA obtains the patient’s dental and medical history and conducts a clinical exam to assess caries early enough to reverse or halt progression and to determine caries risk factors. These factors include, among other things, acid-producing bacteria, frequent eating and drinking of fermentable carbohydrates (“snacking”), and abnormally low saliva flow and function.

From this assessment, the dentist utilizes behavioral approaches and chemical treatments to optimize protective factors. The treatment plan typically incorporates remineralization through the use of fluoride and/or antibacterial therapies such as chlorhexidine and xylitol, minimally invasive restorative procedures to conserve tooth structure, and regular patient follow-up.

The authors published their initial validation of CAMBRA for ages 6 through adult in 2006, followed by several additional years of data published in 2011, 2012, 2015 and 2016. Since then, more than half of the U.S. schools and colleges of dentistry have adopted CAMBRA in one form or another as part of their standard curriculum. The authors said now that this has been shown to be effective in a non-academic clinical setting, there also is potential for insurance companies to reimburse CAMBRA and other preventive therapies for adults, thereby lowering patient costs while increasing profits for dental practices.

Treatment Effective Even Without Prescription Products

In the Advances in Dental Research study, Rechmann and his colleagues recruited 20 dentists – 17 in private practice, three in community clinics – to participate in a two-year CAMBRA trial of 460 patients ages 12-65 years old, with 239 in a CAMBRA group and 221 in a control group.

In the CAMBRA group, high-risk patients received prescription fluoride toothpaste, chlorhexidine antibacterial rinse, xylitol mints and fluoride varnish. The control group received regular fluoride toothpaste, an assumed inactive mouth rinse, sorbitol candies and a non-fluoride varnish.

Follow-up visits occurred at six, 12, 18 and 24 months, in which new caries lesions or changes in caries risk level were recorded. Overall, the researchers found that a significantly greater percentage of high-risk participants were classified at lower risk after receiving CAMBRA preventive therapies. Dental decay was low in both groups.

Among 242 patients (137 intervention, 105 control) initially identified as high risk for caries, only a quarter of the patients remained at high risk in the CAMBRA group at 24 months, while just over half (54 percent) of the control group did. Of the 192 low-risk participants (93 intervention, 99 control), most participants remained low risk, indicating that the assessment correctly identifies who is at risk for caries.

The researchers said the risk reduction among the control group may have been caused by the fluoride toothpaste enhancing tooth repair, as well as the mouth rinse enhancing saliva flow and having bactericidal effects. While not as significant as the CAMBRA group in this study, the risk level of these patients dropped more dramatically over time than for those in the 2012 UCSF CAMBRA study.

“It was surprising to see the benefits gained by the control group,” Rechmann said.

“More research is needed to see if the products and treatment administered to this group function in the way we speculate, and if so, they might be made easily available to dental patients. Doing so can change the whole picture of caries control.”

Among the study limitations, the researchers noted a high study attrition (65 percent), which partly may have contributed to observed declines in risk level at each subsequent recall visit.

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Regrowing Dental Tissue With Stem Cells From Baby Teeth

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Sometimes kids trip and fall, and their teeth take the hit. Nearly half of children suffer some injury to a tooth during childhood. When that trauma affects an immature permanent tooth, it can hinder blood supply and root development, resulting in what is essentially a “dead” tooth.

Until now, the standard of care has entailed a procedure called apexification that encourages further root development, but it does not replace the lost tissue from the injury and, even in a best-case scenario, causes root development to proceed abnormally.

New results of a clinical trial, jointly led by Songtao Shi of the University of Pennsylvania and Yan Jin, Kun Xuan, and Bei Li of the Fourth Military Medicine University in Xi’an, China, suggest that there is a more promising path for children with these types of injuries: Using stem cells extracted from the patient’s baby teeth. The work was published in the journal Science Translational Medicine.

“This treatment gives patients sensation back in their teeth. If you give them a warm or cold stimulation, they can feel it; they have living teeth again,” says Shi, professor and chair in the Department of Anatomy and Cell Biology in Penn’s School of Dental Medicine.

“So far we have follow-up data for two, two and a half, even three years and have shown it’s a safe and effective therapy.”

Shi has been working for a decade to test the possibilities of dental stem cells after discovering them in his daughter’s baby tooth. He and colleagues have learned more about how these dental stem cells, officially called human deciduous pulp stem cells (hDPSC), work and how they could be safely employed to regrow dental tissue, known as pulp.

The Phase I trial, conducted in China, which has a research track for clinical trials, enrolled 40 children who had each injured one of their permanent incisors and still had baby teeth. Thirty were assigned to hDPSC treatment and 10 to the control treatment, apexification.

Those that received hDPSC treatment had tissue extracted from a healthy baby tooth. The stem cells from this pulp were allowed to reproduce in a laboratory culture, and the resulting cells were implanted into the injured tooth.

Upon follow-up, the researchers found that patients who received hDPSCs had more signs than the control group of healthy root development and thicker dentin, the hard part of a tooth beneath the enamel. Blood flow increased as well.

At the time the patients were initially seen, all had little sensation in the tissue of their injured teeth. A year following the procedure, only those who received hDPSCs had regained some sensation. Examining a variety of immune-system components, the team found no evidence of safety concerns.

As further support of the treatment’s efficacy, the researchers had the opportunity to directly examine the tissue of a treated tooth when the patient reinjured it and had to have it extracted. They found that the implanted stem cells regenerated different components of dental pulp, including the cells that produce dentin, connective tissue, and blood vessels.

“For me the results are very exciting,” Shi says.

“To see something we discovered take a step forward to potentially become a routine therapy in the clinic is gratifying.”

It is, however, just a first step. While using a patient’s own stem cells reduces the chances of immune rejection, it’s not possible in adult patients who have lost all of their baby teeth. Shi and colleagues are beginning to test the use of allogenic stem cells, or cells donated from another person, to regenerate dental tissue in adults. They are also hoping to secure FDA approval to conduct clinical trials using hDPSCs in the United States.

Eventually, they see even broader applications of hDPSCs for treating systemic disease, such as lupus, which Shi has worked on before.

“We’re really eager to see what we can do in the dental field,” Shi says, “and then building on that to open up channels for systemic disease therapy.”

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Antibiotics Destroy ‘Good Bacteria’ And Worsen Oral Infection

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New research shows that the body’s own microbes are effective in maintaining immune cells and killing certain oral infections.

A team of Case Western Reserve University researchers found that antibiotics actually kill the “good” bacteria keeping infection and inflammation at bay.

Scientists have long known that overuse of antibiotics can do more harm than good. For example, overuse can cause antibiotic resistance. But research into this phenomenon in oral health was uncharted territory.

Pushpa Pandiyan, an assistant professor of biological sciences in the School of Dental Medicine, led a team of researchers to examine “resident” bacteria, their fatty acids and their effect on certain types of white blood cells that combat infections in the mouth.

Specifically, researchers looked at the “short-term maintenance” of Tregs and Th-17 cells in fighting fungal infections, such as Candida, in a laboratory setting.

They found that those natural defenses were very effective in reducing infection and unwanted inflammation — and antibiotics can prevent such natural defenses. Their work was recently published in Frontiers in Microbiology.

“We set out to find out what happens when you don’t have bacteria to fight a fungal infection,” Pandiyan said.

“What we found was that antibiotics can kill short-chain fatty acids produced by body’s own good bacteria.”

“We have good bacteria doing good work every day, why kill them?” Pandiyan added.

“As is the case with many infections, if you leave them alone, they will leave on their own.”

“Of course, antibiotics are still needed for life threatening infections. No question about that. Our bodies have many natural defenses that we shouldn’t meddle with,” she said.

However, needless overuse of antibiotics is not helpful, she said.

“Also, we know there is a definite link between oral health and overall health,” she added.

Pandiyan said the study could have broader implications on protective effects of “resident microbiota” in other types of infections.

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New Findings On Chronic Pain Syndrome In The Mouth

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The picture is becoming clearer regarding the chronic oral pain condition known as Burning Mouth Syndrome, or BMS, which mainly affects women who are middle-aged and older. In a dissertation at Sahlgrenska Academy, additional steps are being taken toward better diagnosis and treatment.

“Our hope is that the new findings will contribute to the development of objective diagnostic criteria and effective individualized treatment both that are currently lacking,” says Shikha Acharya, who has a PhD in oral microbiology and immunology at the Institute of Odontology.

Burning Mouth Syndrome (BMS) is a chronic pain syndrome in the oral cavity that affects approximately 4% of the Swedish population. This chronic condition mainly affects middle-aged and elderly women.

The pain is experienced as burning or stinging. The tongue is most often afflicted, but the palate, lips and gums also may be affected. Other common symptoms include dry mouth and altered taste sensation, such as a bitter or metallic taste in the mouth.

BMS is a challenge for health care providers, particularly in dental care, and a debilitating condition for many of the patients. When they estimate their problem on a visual analogue scale (VAS) where 0 is “not at all difficult” and 100 is “unbearable,” the average response is 66, the dissertation indicates. The findings came from 56 women with BMS.

In her work Shikha Acharya also connected clinical findings and self-reported reported findings from questionnaires from patients with BMS about their symptoms and background (other diseases, use of medications, etc.) along with saliva-related factors. The results have been compared with a gender- and age-matched control group.

It turns out that 45 percent of the BMS patients reported to have altered taste sensations. A total of 73 percent experienced pain that was burning or stinging or a combination of the two, but stinging and numbness also occurred.

In addition to BMS, they have a higher incidence of other types of diseases, use more medications, are more prone to grinding their teeth and report more allergies than the control group. However, more advanced analyses show that BMS was strongly associated to self-reported skin diseases and subjective oral dryness.

The fact that the BMS patients, compared with people in the control group, report that they suffer considerably more from skin diseases and skin problems is a new discovery. Similarly, that the mucin proteins in BMS patients’ saliva are altered and contain lower amounts of carbohydrate structures that affect the oral cavity’s immune system.

Analysis of inflammatory constituents in saliva shows complex relationship between BMS and background inflammation, with some of the BMS patients having higher levels of inflammation than the control group while others had lower.

The dissertation work is part of a larger project aimed at finding a model for BMS that can facilitate diagnosis and treatment in the future. The new pieces of the puzzle are helping to characterize the disease and the persistent mouth pain associated with it.

“It’s important because the afflicted patients often feel that their surroundings and health care professionals doubt their ailment,” says Shikha.

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