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CARIES PREVENTION
JOHN D.B. FEATHERSTONE
J Am Dent Assoc 2000;131;887-899
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ARTICLE 1
C O V E R S T O R Y
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A B S T R A C T
The reasons for the reduc- plaque are acidogenic—that is, Any fermentable carbohy-
tions in caries prevalence dur- they produce acids when they drate (such as glucose, sucrose,
ing the last 20 years are diffi- metabolize fermentable carbo- fructose or cooked starch) can
cult to pinpoint. Strong evi- hydrates.12,14,15 These acids can be metabolized by the acido-
dence exists, however, that the dissolve the calcium phosphate genic bacteria and create the
near universal use of fluoride- mineral of the tooth enamel or aforementioned organic acids as
containing products such as dentin in a process known as byproducts.22 The acids diffuse
dentifrice, mouthrinses and top- demineralization.16-18 If this through the plaque and into the
ical gels applied in the dental process is not halted or re- porous subsurface enamel (or
office have been major contribu- versed via remineralization— dentin, if exposed), dissociating
tors.7,8 Earlier caries reductions the redeposition of mineral via to produce hydrogen ions as
of 40 to 70 percent (before the saliva—it eventually becomes a they travel.17,23 The hydrogen
1970s) had resulted from the frank cavity. ions readily dissolve the miner-
fluoridation of public water sup- Dental caries of the enamel al, freeing calcium and phos-
plies in many communities.9-12 typically is first observed clini- phate into solution, which can
Dental caries in adults also cally as a so-called “white-spot diffuse out of the tooth. Most
in a recent review article.1 showed the posteruptive (topi- um and phosphate, which are
Pathological and protec- cal) effects of fluoride in the derived primarily from saliva
tive factors in the caries bal- drinking water. Other studies and plaque fluid.
ance. Caries progression, as have illustrated the weak pre- Pathological factors. Patho-
opposed to reversal, consists of eruptive effects of fluoride. For logical factors obviously include
a delicate balance between the example, in two groups of cariogenic bacteria and the fre-
aforementioned factors—name- Okinawa nursing students aged quency of ingestion of ferment-
ly, a bacterially generated acid 18 to 22 years, there was no dif- able carbohydrates that sustain
challenge and a combination of ference in caries status between these bacteria. The importance
demineralization inhibition and those who had received fluori- of mutans streptococci (which
reversal by remineralization.1,42 dated water only until about 5 includes S. mutans and S.
The balance between pathologi- to 8 years of age (and none sobrinus) in the development of
cal factors (such as bacteria and thereafter) and those who had dental caries has been reviewed
carbohydrates) and protective never received fluoridated extensively.12,14,15,49,50 Numerous
factors (such as saliva, calcium, drinking water.44 cross-sectional studies in
phosphate and fluoride) is a The cariostatic effects of fluo- humans have shown that great-
TABLE
antibacterial therapy—such as one-to-one direct correlation tors are in balance, caries does
treatment with chlorhexidine between levels of these bacteria not progress. If they are out of
gluconate rinse—as a caries- and caries progression.24,49 balance, caries either progresses
preventive measure. Although However, it now is well-estab- or reverses.
this has been proposed for lished that high levels of Antibacterial therapy for
many years58-60 and used in sev- mutans streptococci, high levels caries control. Currently, the
eral European countries, an of lactobacilli or both constitute most successful antibacterial
antibacterial approach almost a “high bacterial challenge.”24 therapy against cariogenic bac-
never is used in the United This bacterial challenge can be teria is treatment by chlorhexi-
States for the prevention of the balanced by the protective fac- dine gluconate rinse or gel.47,61
progression of dental caries. tors described earlier, which Chlorhexidine is available by
One of the difficulties in per- include salivary components— prescription in the United
suading clinicians to use the especially calcium, phosphate States. Studies have shown that
antibacterial approach is that and fluoride—and the amount a daily dose of chlorhexidine
there have not been rapid and of saliva present.42 rinse for two weeks can
accurate methods of determin- Figure 5 illustrates the bal- markedly reduce the cariogenic
ing the levels of cariogenic bac- ance between pathological fac- bacteria in the mouth and that,
teria in the mouth. Further- tors (including cariogenic bacte- as a result, recolonization takes
more, although numerous ria, reduced salivary function place in three to six months
studies have indicated that and frequency of use of fer- rather than immediately.58 In
mutans streptococci and lacto- mentable carbohydrates) and patients with high levels of bac-
bacilli definitely are risk factors protective factors. If these teria, therefore, chlorhexidine
for dental caries, there is no pathological and protective fac- treatments at three-month
intervals are indicated. probes will be available com- assess the level of risk of
The problem faced by clini- mercially in the near future, caries progression in individ-
cians is how to determine, in a and that clinicians will be able ual patients. Studies still are
timely fashion, whether the to use them chairside and under way, and there is no
bacterial challenge is high, obtain results within a few definitive formula yet avail-
medium or low. For many minutes. This will enable clini- able. The status of risk assess-
years, commercial “dip slides” cians to determine the quanti- ment was summarized, how-
have been available in Europe, tative levels of bacteria in a ever, by the authors of a spe-
and they recently became patient’s mouth while he or cial supplement to The
available in the United she is in the operatory and to Journal of the American
States.58 A saliva sample is factor these numbers into an Dental Association in 1995;
taken from the patient and overall risk assessment of this publication can be used as
incubated on the dip slide; two caries for that patient. It is a guide until more definitive
days later, a result is provided envisaged that computer pro- information is available.64
of the levels of S. mutans and grams will be available that Figure 5 represents a basis for
lactobacilli bacteria in the will include the assay num- determining caries risk with
ultrasonography are likely to laser for use on teeth. This was mineralization-remineraliza-
become available for use by cli- the first approval for laser use tion model in the laboratory by
nicians in the near future.68 It on dental hard tissues. This up to 85 percent. They have
will be possible to detect approval by the FDA was for demonstrated that carbonate is
lesions in the occlusal surface this particular laser to be used lost from the CAP mineral of
and to determine whether they for the removal of dental caries the tooth during specific laser
have progressed into the dentin and the cutting of sound tissue irradiation, making the miner-
and, if so, how far. This is not before the placement of restora- al highly resistant to dissolu-
possible with current radio- tions. This event has ushered tion by acid. Although they
graphic technology. in a new era for lasers in den- have demonstrated in the labo-
Once new methods are intro- tistry. Since then, other lasers ratory, using pH cycling mod-
duced for the early detection of have been approved for the els, that as little as 20 pulses of
caries, they can be used in two same purpose, and additional 100 microseconds each can pro-
opposing fashions. Clinicians hard-tissue uses are likely to duce a preventive effect similar
with traditional training are be approved in the future, to daily use of fluoride denti-
likely to use these methods to including the use of lasers for frice, these promising and
placed. The cavity walls will be health of their patients. ■ 15. Loesche WJ, Hockett RN, Syed SA. The
predominant cultivable flora of tooth surface
highly resistant to acid attack plaque removed from institutionalized sub-
Dr. Featherstone is a professor and the
and therefore resistant to sec- chair, Department of Preventive and
jects. Arch Oral Biol 1972;17(9):1311-25.
16. Featherstone JD. An updated under-
ondary caries. Providing bacter- Restorative Dental Sciences and Department standing of the mechanism of dental decay
of Dental Public Health and Hygiene,
ial intervention via chlorhexi- University of California, San Francisco, 707
and its prevention. Nutr Q 1990;14:5-11.
17. Featherstone JD, Rodgers BE. Effect of
dine rinse was also part of the Parnassus Ave., Box 0758, San Francisco, acetic, lactic and other organic acids on the
Calif. 94143, e-mail “jdbf@itsa.ucsf.edu”.
treatment in the same patient, Address reprint requests to Dr.
formation of artificial carious lesions. Caries
Res 1981;15(5):377-85.
future caries would be unlikely. Featherstone. 18. Featherstone JD, Mellberg JR. Relative
rates of progress of artificial carious lesions
SUMMARY AND The author sincerely acknowledges contri- in bovine, ovine and human enamel. Caries
CONCLUSIONS butions from numerous colleagues over many Res 1981;15(1):109-14.
years to much of the work reviewed here. 19. Silverstone LM. Structure of carious
enamel, including the early lesion. Oral Sci
The mechanism of dental caries 1. Featherstone JD. Prevention and rever- Rev 1973;3:100-60.
is well-established to the point sal of dental caries: role of low level fluoride. 20. ten Cate JM, Duijsters PP. Influence of
Community Dent Oral Epidemiol 1999; fluoride in solution on tooth demineralization.
where new approaches are 27(1):31-40. II. Microradiographic data. Caries Res 1983;
being made for caries preven- 2. Kaste LM, Selwitz RH, Oldakowski RJ, 17(6):513-9.
Brunelle JA, Winn DM, Brown LJ. Coronal 21. ten Cate JM, Featherstone JD.
tion based on a scientific under- caries in the primary and permanent denti- Mechanistic aspects of the interactions
Amsterdam, Netherlands: Elsevier Science frices. In: Embery G, Rolla R, eds. Clinical Dent Educ 1997;61(11):895-905.
Publishers; 1984:47-51. and biological aspects of dentifrices. Oxford, 61. Lagerlof F, Oliveby A. Clinical implica-
34. Robinson C, Kirkham J, Weatherell JA. England: Oxford University Press; 1992: tions: new strategies for caries treatment. In:
Fluoride in teeth and bone. In: Fejerskov O, 41-50. Stookey GH, Beiswanger B, eds. Indiana
Ekstrand J, Burt BA, eds. Fluoride in den- 48. Arends J, Nelson DG, Dijkman AG, Conference 1996: Early Detection of Dental
tistry. Copenhagen, Denmark: Munksgaard; Jongebloed WL. Effect of various fluorides on Caries. Indianapolis: Indiana University
1996:69-87. enamel structure and chemistry. In: School of Dentistry; 1996.
35. Nelson DG, Featherstone JD, Duncan Guggenheim B, ed. Proceedings of the 62. Cangelosi GA, Iversen JM, Zuo Y,
JF, Cutress TW. Effect of carbonate and fluo- Cariology Today International Congress, Oswald TK, Lamont RJ. Oligonucleotide
ride on the dissolution behaviour of synthetic September 1983, Zurich, Switzerland. Basel, probes for mutans streptococci. Mol Cell
apatites. Caries Res 1983;17(3):200-11. Switzerland: Karger; 1984:245-58. Probes 1994;8(1):73-80.
36. Featherstone JD, Glena R, Shariati M, 49. Krasse B. Biological factors as indica- 63. Shi W, Jewett A, Hume WR. Rapid and
Shields CP. Dependence of in vitro deminer- tors of future caries. Int Dent J 1988;38(4): quantitative detection of Streptococcus
alization of apatite and remineralization of 219-25. mutans with species-specific monoclonal anti-
dental enamel on fluoride concentration. J 50. Ellen RP. Microbiological assays for bodies. Hybridoma 1998;17(4):365-71.
Dent Res 1990;69:620-5. dental caries and periodontal disease suscep- 64. Caries diagnosis and risk assessment: a
37. Featherstone JD, Shields CP, tibility. Oral Sci Rev 1976;(8):3-23. review of preventive strategies and manage-
Khademazad B, Oldershaw MD. Acid reactiv- 51. Alaluusua S, Kleemola-Kujala E, ment. JADA 1995;126(suppl):1-24S.
ity of carbonated apatites with strontium and Nystrom M, Evalahti M, Gronroos L. Caries 65. Ma JK, Hunjan M, Smith R, Lehner T.
fluoride substitutions. J Dent Res 1983; in the primary teeth and salivary Strep- Specificity of monoclonal antibodies in local
62(10):1049-53. tococcus mutans and lactobacillus levels as passive immunization against Streptococcus
38. Fejerskov O, Thylstrup A, Larsen MJ. indicators of caries in permanent teeth. mutans. Clin Exp Immunol 1989;77(3):331-7.
Rational use of fluorides in caries prevention. Pediatr Dent 1987;9(2):126-30. 66. Ma JK, Hikmat BY, Wycott K, et al.
A concept based on possible cariostatic mech- 52. Klock B, Krasse B. Microbial and sali- Characterization of a recombinant plant mon-