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Caries Prevention Essay

Prevention of Dental Caries-Measures beyond Fluoride

Ravi Agarwal*, Chanchal Singh, Ramakrishna Yeluri and Kalpna Chaudhry

Department of Pedodontics, K D Dental College and Hospital, Mathura, India

*Corresponding Author:
Ravi Agarwal
Department of Pedodontics and Preventive Dentistry
K D Dental College and Hospital
Mathura-281001, Uttar Pradesh, India
Tel: +918755525993
Fax: 0565-2530764
E-mail:[email protected]

Received Date: January 28, 2014; Accepted Date: February 25, 2014; Published Date: March 03, 2014

Citation: Agarwal R, Singh C, Yeluri R, Chaudhry K (2014) Prevention of Dental Caries-Measures beyond Fluoride. J Oral Hyg Health 2:122. doi: 10.4172/2332-0702.1000122

Copyright: © 2014 Agarwal R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Dental caries is one of the most common infectious microbial diseases. It is rightly said that prevention is better than cure. Various steps in prevention of dental caries have been taken, fluoride being the most common among them. Various non- fluoride agents are also present which helps in prevention of dental caries. Various agents like, arginine, plant extracts, sucrose free polyol gums, probiotics, novamin, Dentrifrices, antimicrobials, CPP- ACP etc are commonly used in prevention of dental caries. This paper reviews about these non-fluoride agents in the prevention of dental caries.


Dental caries; Non fluoride agents; Prevention


Dental caries is one of the most common preventable childhood disease; people are susceptible to this ailment throughout the lifetime [1]. Data from the National Health and Nutrition Examination Survey (NHANES) conducted between 1999 and 2004 revealed that 28 percent of children ranging from 2 to 5 years of age had one or more primary tooth affected by dental caries and 51 percent of children had one or more primary tooth affected by age 6 to 11. In the permanent dentition, 10 percent of children aged 6 to 8 had dental caries and 51 percent of children were affected by age 12 to 15 [2]. The preventive care providers have the intention for prevention beyond the scope of providing hygiene therapy and oral hygiene instructions. Dental decay is mainly due to demineralization which is caused by acids produced by bacteria, particularly mutans Streptococci and possibly lactobacilli that ferment dietary carbohydrates. This occurs within a bacteria-laden gelatinous material called dental plaque that adheres to tooth surfaces and becomes colonized by bacteria. Thus, caries results from the interplay of three main factors over time: dietary carbohydrates, cariogenic bacteria within dental plaque, and susceptible hard tooth surfaces [3]. The use of fluoridated toothpastes [4], other topically applied fluorides [5], fluoridated municipal water [6] and pit and fissure sealants [7,8] along with dietary improvement remain mainstays of caries management. These modalities, which are based on high quality evidence, are the first choice for prevention and control of dental caries. Fluoride’s anti-caries efficacy is well-proven and may arise from multiple modes of action, i.e., inhibition of tooth demineralization, promotion of incipient lesion remineralization, and perhaps, antibacterial effects on cariogenic bacteria [9]. Clinical evidence would suggest that increasing the concentration of fluoride above the conventional level of 1000 or 1500 ppm in dentifrices will give an increased benefit although there would appear to be something of a law of diminishing returns [10]. Although fluoride is highly effective on smooth-surface caries, its effect would seem to be more limited on pit and fissure caries, and these lesions tend to dominate the caries experience of developed countries currently enjoying the benefits of fluoride. Apart from fluoride, dental health education programme, diet counselling, oral hygiene measures like dentifrices, different brushing technique are also used in prevention of dental caries. Various anti plaque agents, and other agents like enzymes have been effectively used as prevention of dental caries. From the 1930‘s when the researches came to know the anti-caries effect of the fluoride, many gargantuan water fluoridation program have been implicated, but these programs has shown to be successful only in attaining a 50% caries reduction but none of them was able to contain the caries process [11]. Since 1970‘s researches started to search for non-fluoride agents for the prevention of dental caries [12]. Non-fluoride agents may serve as adjunctive therapeutics for preventing, arresting or even reversing dental caries. The objective of this paper is to present a complete review of recent advances of various non-fluoridated caries preventing agents.

Recent Advances in Caries Prevention


Arginine, a common amino acid found in saliva is broken down by oral plaque bacteria to acid neutralizing alkali. The production of acid by dental plaque is the direct cause of dental caries; it is noteworthy that increases in the proportions of aciduric organisms appear to occur at the expense of species that are less aciduric and generally associated with dental health; including Streptococcus sanguinis and Streptococcus gordonii [13-15]. Some of the less aciduric organisms associated with dental health derive protection from plaque acidification by hydrolysing urea or arginine to ammonia, either by expressing a urease enzyme or by the arginine deiminase system (ADS), respectively. Production of ammonia by oral bacteria can positively influence the balance between remineralization and demineralization of the tooth and may help to prevent the emergence of a cariogenic microflora [16-18]. Therefore, the capacity of oral biofilms to generate alkali appears to be a major caries-inhibiting factor [19]. Urea and arginine can be rapidly metabolized by oral bacteria to elicit a rise in environmental pH. A strong correlation between elevated levels of free arginine in saliva and caries resistance has also been revealed [20]. In addition, dental plaque of caries-resistant individuals has been shown to have higher pH values compared to the plaque of caries-susceptible individuals, and in part the increased pH has been correlated with elevated ammonia levels [21-33].

Plant extracts

There is a global need for alternative prevention and treatment options and products for oral diseases that are safe, effective and economical. One such strategy would be to verify the enormous use of medicinal plants. A number of phytochemicals, including antibacterial agents have been derived from edible plants and demonstrate antibacterial properties against Streptococcus mutans.

Neem, Azadirachta indica: Wolinsky et al. [24] investigated the inhibitory effects of acqueous extracts from Neem upon bacterial aggregation, growth and adhesion to hydroxyapatite and production of insoluble glucan, which may effect in vitro plaque formation.

Tulsi, Ocimum sanctum: Tulsi, Ocimum sanctum is a plant of Indian origin and a time tested premier medicinal herb. The extract of tulsi is used to treat a variety of illnesses that include diabetes mellitus, arthritis, bronchitis and skin diseases. The antimicrobial property of tulsi has been tested against a variety of microorganisms like Staphylococus aureus, Klebsiella, candida albicans, E. coli and proteus sp. The antimicrobial activity of tulsi is attributed to its constituents namely ursolic acid and carvacrol. Agarwal et al. [25] in their study demonstrated an antimicrobial potential of tulsi extract at various concentrations and achieved maximum antimicrobial potential at 4% concentration level.

Prunus mume:Prunus mume is a common fruit in Asia, which has been used in traditional Chinese medicine. It is considered to be the potential candidate for developing an oral antimicrobial agent to control or prevent dental diseases associated with oral pathogenic bacteria like Streptococcus mutans, S. sobrinus, S. mitis, S. Sanguinis, Lactobacillus acidophilus, P. gingivalis, Aggregatibacter actinomycetem comitans [26].

Green and black tea (Camellia sinensi): Various component in green and black tea (leaves of Camellia sinensis, [Theaceae]) notably simple catechins, have anticariogenic activity. These include: a direct bactericidal effect against S mutans and S sobrinus; prevention of bacterial adherence to teeth; inhibition of glucosyl transferase, thus limiting the biosynthesis of sticky glucan; inhibition of human and bacterial amylases. Ferrazzano et al. [27] concluded that the anticariogenic effect against alfa hemolytic streptococci by polyphenols from cocoa, coffee and tea suggest further possible application of these beverages in the prevention and pathogenesis of dental caries.

Hop plant (Humulus lupulus): Tagashira et al. [28] reported the inhibition of S. Mutants and other oral streptococci, by the antimicrobially active ingredients of hop plant. They found that all tested hop constitutes inhibited the streptococci with minimum inhibitory concentration at pH 7.5 ranged from 2 to 50 μg/ml. Antimicrobial acticity of hop constituents was greater than other plant products such as thymol, nerol, cinnamon oil, oil of clove, menthol and eucalyptol.

Oleic acid, Linoleic acid, epicatechin polymer (Cacao bean husk): These shows antimicrobial activity against planktonic cells of mutans Streptococci. It has an inhibitory effect on water-insoluble substances, polymer glucan synthesis, adherence, acid production by mutans streptococci. It also helps in reduction in plaque accumulation and caries development in rats infected with S. mutans or S. sobrinus [29,30].

Proanthocyanidins, phenolic acids, flavonols (Cranberry): These shows antimicrobial activity against biofilm cells of mutans streptococci. It causes disruption of acidogenic/aciduric properties of planktonic and biofilm cells of S. mutans. It has inhibitory effects on Gtf activity and adherence by mutans Streptococci and causes reduction of formation of S. mutans biofilms and EPS content. Reduction in caries development in rats infected with S. mutans is also seen [31-33].

Apigenin and tt Farnesol: Apigenin and tt Farnesol are two naturally occurring agents that affect the development of cariogenic biofilms. Apigenin inhibits the activity of glucosyltransferases in solution and on the surface of saliva-coated hydroxyapatite beads and it was devoid of antibacterial activity. tt-Farnesol showed modest antibacterial activity against biofilms and its effects on glucosyltransferases were minimal [34]. It also enhances the cariostatic effectiveness of fluoride. The combination of these novel agents with fluoride may represent a potentially useful and an alternative approach to the current chemotherapeutic strategies to prevent this ubiquitous disease by reducing the expression of virulence of S. mutans without necessarily suppressing the resident oral flora [35].

Meswak chewing sticks (Twigs of Salvadora persica): These sticks embedded in agar or suspended above the agar plate had strong antibacterial effects against all tested bacteria. The antibacterial effect of suspended meswak sticks suggested the presence of volatile active antibacterial compound [36-39].

Propolis: Propolis is a natural beehive product, and cacao bean husk extracts have also shown significant antibacterial activity against S. mutans and/or S. sobrinus in vitro [29,38,39] Propolis extract when used as a mouthwash exhibits an in vivo antimicrobial activity against S. mutans and might be used as an alternative measure to prevent dental caries [40]. Topical applications of chemically characterized Propolis extracts have also been shown to be highly effective in reducing the incidence and severity of smooth surface and sulcal caries in rats [39,41]. However, the cariostatic effects of propolis are highly variable depending on its chemical composition and geographical origin. There are many other reports in the literature concerning the antimicrobial activities that various plant extracts may have against cariogenic bacteria, although the majority of these studies provide limited or incomplete information due to the lack of chemical characterization of the extracts. However, there are a few exceptions. For example, Li et al. [42] have identified gallotannins from Melaphis chinensis and triterpenes (ceanothic acid and ceanothetric acid) from Ceanothus americanus as antimicrobial agents that harbor activity against mutans streptococci. Furthermore, a chemically characterized extract of Galla chinensis (containing gallic acid and methyl gallate) has been demonstrated to impede the growth of S. mutans and other caries- related organisms, including Lactobacillus rhamnosus and Actinomyces naeslundii, within biofilms [43]. Recently, established that naturally occurring phenolic compounds generally display antibacterial activity by disrupting the membrane lipid-protein interface as nonionic surface-active agents [44]. Ramakrishna et al. [38] studied various natural alternatives derived from plants and plant products and concluded that it can serve as a prevention and treatment option against cariogenic bacteria.

Chinese licorice root: A new cavity fighting herbal lollipop that contains a special herbal formula extracted from the Chinese licorice root can help to immobilize major organisms responsible for tooth decay. These orange flavoured herbal lollipops was discovered by microbiologist at the UCLA school of dentistry should be consumed twice a day- one in the morning after breakfast and another after professional teeth cleaning between two and four times a year.

Xylitol: A sweet alternative discovered in 1891 by German chemist Emil Fischer. Dental benefits of xylitol were first recognized in Finland in 1970 using animal models. The first chewing gum developed with the aim of reducing caries and improving oral health was released in Finland in 1975 and in United States shortly after. Xylitol is not fermented by cariogenic plaque bacteria and thus does not lower the pH of the plaque. It reduces the accumulation of plaque on the surface of the tooth. It accumulates intracellular in MS and inhibits the bacterial growth. Xylitol reduces MS by altering their metabolic pathways. It has long been known to have antibacterial properties, in particular to depress the proportion of Streptococcus mutans in plaque [45,46], and also to reduce its acidogenicity [47]. In addition, xylitol has been suggested to have an ability to inhibit enamel dissolution in vitro [48]. In clinical studies, xylitol chewing gums have, in general, been reported to inhibit the development of caries [49]. In children reporting caries experience, consumption of xylitol containing lozenges or hard candy reduces incidence of coronal caries [50-52]. For children below age two, in addition to the study that evaluated xylitol tablets, the xylitolcontaining syrup among children in the Marshall Islands and reported a statistically significant difference in favor of xylitol syrup [53]. There is insufficient evidence that xylitol syrup prevents caries in children under 2 years of age. There is insufficient evidence regarding xylitol dentrifrice as it contains other ingredients which might inhibit the production of dental caries [54,55].

Probiotics and replacement therapy: Probiotics are defined as live micro-organisms, principally bacteria, that are safe for human consumption and when ingested in sufficient quantities, have beneficial effect on human health, beyond basic nutrition [56]. First probiotic species to be introduced in research was Lactobacillus acidophilus by Hull et al. in 1984; followed by Bifidobacterium bifidum by Caglar et al. [57]. Probiotic have shown to influence immune system through several molecular mechanisms: In oral cavity, probiotics can create a biofilm, acting as a protective lining for oral tissues against oral diseases. Such a biofilm keeps bacterial pathogens off oral tissues by filling a space pathogens would invade in the absence of the biofilm; and competing with cariogenic bacteria and periodontal pathogens growth. The administration of probiotic lactobacilli (LGG) in milk to kindergarden children in Helsinki, Finland resulted in reduction of initial caries development. Comelli et al. [58] studied 23 dairy bacterial strains for the prevention of dental caries and reported that only two strains namely Streptococcus thermophilus and Lactcoccus lactis were able to adhere to saliva-coated hydroxyapatite and were further successfully incorporated into a biofilm similar to the dental plaque. Recently it was shown that probiotic cheese reduced the prevelance of oral candida [59]. Cheese might be the ideal vehicle for administering probiotics to humans. Cheese enhances remineralization and prevents demineralization of enamel. Yogurt products containing L. reuteri showed a significant growth inhibitory effect against S. mutans, while yoghurts with lactobaccilli other than L. reuteri did not show such inhibition. Residence time of probiotics in oral cavity after treatment withdrawal was studied by Çaglar et al. [60]. A reduced S. mutans level was shown after a two-week use of a L. reuteri-enriched yogurt; effects were observed during use and for a few days after discontinuation. A loss of L. reuteri colonization was observed by Wolf et al. [61] two months after having discontinued probiotic use. Sucking a medical device containing the probiotic lozenge with L. reuteri once daily for 10 days reduced the levels of salivary mutans [62]. However it is unlikely that a permanent colonization occurs. Therefore, regular consumption of probiotic products is needed to maintain the preventive and therapeutic levels.

In addition to probiotics, another measure that competitively reduces the pathogen composition in the oral flora has emerged with the advances in gene engineering and DNA recombination technology. This method is the so-called replacement therapy. Replacement therapy involves the use of a harmless effector strain that is permanently colonized in the host’s microflora. This effector strain is designed to prevent the colonization or outgrowth of a particular pathogen. To prevent an infection using replacement therapy (recently referred to as probiotic therapy), a natural or genetically modified effector strain is used to intentionally colonize the sites in susceptible host tissues that are normally colonized by a pathogen. If the effector strain is better adapted than the pathogen, colonization or outgrowth of the pathogen will be prevented by blocking the attachment sites, by competing for essential nutrients, or via other mechanisms. As long as the effector strain persists as a resident of the indigenous flora, the host is protected potentially for an unlimited period of time. S. mutans strain BCS3-L1 is a genetically modified effector strain designed for use in replacement therapy to prevent dental caries. To be an effective effector strain, BCS3 L1 must satisfy four prerequisites: It must have a significantly reduced pathogenic potential to promote caries. It must persistently colonize the S. mutans sites, thereby preventing colonization by diseasecausing strains whenever the host comes into contact with them. It must aggressively displace indigenous strains of S. mutans and allow previously infected subjects to be treated with replacement therapy. It must be safe and not make the host susceptible to other disease conditions. From a standpoint of replacement therapy for caries prevention, implantation of an effector strain would best be achieved in children immediately after tooth eruption and before the acquisition of a caries-inducing strain. A final aspect of replacement therapy safety is the requirement for controlled spread of the effector strain within the population. Mutacin 1140 up-production clearly provides a selective advantage to BCS3-L1 colonization. However, the minimum infectious dose has not been determined for this strain or any S. mutans strain in humans.

Novamin: Novamin falls into a newer category of bioactive glass-ceramic material that has been available since the 1960’s as materials to help in bone repair. The active ingredient is a calcium sodium phosphosilicate that reacts when exposed to aqueous media, thus providing calcium and phosphate ions to the applied surface. Examples of Novamin powered technology include Oravive, a product from Natural Health Organics, which is a non-fluoridated, and non-prescription dentifrice containing 5% Novamin. Bioactive glasses have been tested under different clinical situations, such as having an antibacterial effect [63]. Novamin-containing dentifrice is statistically more effective than a placebo dentifrice [64]. One of these studies was done by and compared a dentifrice containing 5% Novamin and Fluoride (MFP) to a commercially available dentifrice in remineralization of subsurface carious lesions in human tooth enamel. It used confocal laser scanning microscopy (CLSM), which is able to distinguish between sound enamel and demineralized enamel using a fluorescent dye [65].

Dentifrices: Tooth-pastes are the valuable adjuncts to oral hygiene as they make brushing more pleasant and more effective. Many attempts have been made at various times to add-therapeutical agents with the object of interfering with oral flora, limiting plaque formation and making teeth more resistant to caries.

Chlorophyll: Chlorophyll was one of the earliest agents added to the paste and is still present in some tooth-pastes. Although in vitro tests showed that chlorophyll- containing tooth pastes limits bacterial growth, but clinical trials have not shown any anti- caries effects [12,66].

Ammoniated tooth-paste: This usually contains urea, and developed in an attempt to control the acid production in plaque. A numbers of clinical trials were carried out, but all gave very little positive or inconclusive results. Ammoniated pastes have been superseded by more effective agents, Anti-biotic toothpastes containing penicillin, triclosan or topical anti-biotic such as tyrothricin have also been tried. It was based on the assumption that if acidogenic bacteria are destroyed, caries will be controlled.

Anti-enzyme paste: These toothpastes were introduced on the basis that they interfere with enzyme systems of the bacteria and thus with their growth and function. Still their effectiveness has not been evaluated by clinical trials [12,66]. Various other dentrifices containing herbal products like neem, tulsi, clove oil, propolis are available which show beneficiary effect in preventing dental caries.

Antimicrobials: Typically antimicrobial agents target both supragingival plaque, and more importantly sub-gingival plaque buildup. Clinical decisions to deliver antimicrobial agents exist in a balance between delivering relevant and clinically measurable amounts, but at the same time not disrupting the natural ecology of the mouth which provides protection from opportunistic pathogens and the overgrowth of exogenous microbes.

Chlorhexidine: Currently mouthrinses that contain 0.12% chlorhexidine are marketed within the United States. Chlorhexidine is a broad spectrum antibiotic that kills Gram-positive and Gram-negative bacteria as well as yeasts at high concentrations. At lethal concentrations chlorhexidine causes irreparable damage to the cell membrane of target microbes, and at sub-lethal concentrations chlorhexidine can interfere with the sugar transport and acid production of the cariogenic streptococci strains, providing a bacteriostatic effect. Chlorhexidine is typically utilized because of its great retention within the plaque coated enamel surface, and studies report that 30% of the delivered chlorhexidine is retained in the mouth after use [67,68]. The efficacy of the chemical has come under scrutiny as some clinical trials have failed to produce significant level of caries reduction, and side effects such as staining and an altered taste sensation have been reported [69].

Triclosan is used to increase the ability of mouthwashes to bind to the oral mucosa, and thus be available for long period of time. Jenkins et al. compared the magnitude and duration of salivary bacterial count reduction produced by a single rinse of 0.2% triclosan, 1% sodium lauryl sulfate and 0.2% chlorhexidine mouthwashes. They found considerable reduction in bacterial count which remained significant for three hours with triclosan and for 7 hours with sodium lauryl sulfate and chlorhexidine [70]. The use of 0.3% triclosan mouth rinse showed significant reduction in salivary Streptococcus mutans count [71].

Essential oils: Essential oils have also been extensively studied for antimicrobial activity against caries-related bacteria. Essential oils derived from plants are typically a complex mixture of approximately 20-60 compounds that are in solution at various concentrations. Overall, the main chemical group is primarily composed of terpenoids, followed by aromatic and aliphatic constituents [72]. Thymol and eugenol inhibit the growth of a wide range of oral microorganisms including mutans streptococci [36,37].

Trace elements: Different trace elements has been investigated were zinc, tin, aluminium, copper, iron, strontium, barium, manganese and molybdenum, gold, lead etc. Aluminum, copper, and iron have the most commonly used as cariostatic agent, although each would probably have organo-leptic problems if used in oral care products as simple salts. Moreover, the toxicity of many metals like aluminum, copper, barium molybdenum, would restrict the concentration at which they could be safely used [66,73].

CPP-ACP: Recent developments in the area of remineralization include casein phosphopeptide-amorphous calcium phosphate (CPPACP) Dairy products such as milk, milk concentrates and cheese are recognized as non-cariogenic or cariostatic in several laboratory studies due to the presence of milk phosphoprotein, casein [74]. The casein phosphopeptides (CPP) are derived from casein by tryptic digestion. In 1987, Reynolds found that CPPs were incorporated into the intra-oral appliance plaque and were associated with a substantial increase in the plaque’s content of calcium and phosphate [75]. All CPPs contain the sequence motif -Pse-Pse-Pse-Glu-Glu-, where Pse is a phosphoseryl residue. Through these multiple phosphoseryl residues, CPPs have a marked ability to stabilize calcium phosphate ions in solution and to form an amorphous calcium phosphate (ACP) complex, referred to as CPP-ACP [74,76]. The milk protein, CPP, stabilizes high concentrations of calcium phosphate ions in ACP solutions. The CPP-ACP is taken up by dental biofilms and localizes to the enamel surface as nanoparticles. Calcium, phosphate and fluoride from CPP-ACP, which are released during Acidogenic challenge, help to maintain the supersaturated state of these ions in the biofilm and so promote remineralization over demineralization [77]. Several randomized clinical trials (RCT) have shown that CPP-ACP added to sugar-free chewing gums, [78] tooth paste [79] or dental cream [80,81] increased enamel subsurface remineralization. These RCT results suggested both a short-term remineralization effect of CPP-ACP and a caries-preventing effect for long-term clinical CPP-ACP use [82]. A recent study has demonstrated that CPP could be detected on the tooth surface 3hours after chewing sugar free gum containing CPP ACP. Recaldent is an active ingredient derived from caesin, part of protein found in cow’s milk. It works safely; strengthen teeth by delivering calcium and phosphate in a unique soluble form to remineralize enamel. Recaldent will not affect people with lactose intolerance. The acid resistance of enamel lesions remineralization in situ by a sugar free chewing gum containing CPP ACP is similar to gum not containing CPP ACP [83]. Cai et al. [84] demonstrated the effect of CPP ACP incorporated into a sugar free lozenges on enamel remineralization in a human in situ model.


We have a variety of new agents which can be used to prevent dental caries but application of these agents in clinical trials is still limited in the developing countries. Moreover dental caries is a multifactorial and all non-fluoride measures should be evaluated properly in human trials so that they can be introduced at the community level for the prevention of dental caries.


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Keywords: dentist, orthodontics, decay, cavity, caries, bacteria, sugar, acid, diet, fluoride, gingivitis, grinding, whitening


Jordana Huber's article for Canwest News Service quoted Dr. Ian McConnache, past president of the Ontario Dental Association: "Decay in children is the most widespread chronic disease of childhood, much higher than the No. 2 which is asthma. Decay rates in kids are rising again where they have been falling for decades." She writes that Dr. Peter Cooney, Health Canada's Chief Dental Officer, said that a growing rate of tooth decay has occurred in children around the world. (1) David Satcher, the former Surgeon General in the U.S. described the problem of dental disease among children as a silent epidemic which needs immediate care and long-term solutions to provide good oral health care for children. (8)

I've been blessed with better than average teeth, but I remember one summer when I was fifteen and I got a toothache at the beginning of a long weekend. I lived in a small town, far from our dentist who would have been off at his cottage for the weekend anyway, and so I had to put up with the pain of the cavity until Monday when my mom could take me to the dentist. I got a degree of relief from some applied medication that our druggist suggested, but by the end of the three days it seemed that all of my upper and lower teeth on the left side of my mouth must be infected; even my sinuses ached; I was miserable. I can sympathize with anyone who has a painful cavity. Smiles are very important in communication. There's a song that goes,"You can smile, when you can't say a word, you can smile; you can smile anytime anywhere." When I read the statements about the increase in dental carries among children, I thought about my own pain and the importance of good teeth in a winning smile, it seemed to me that the public needs to become more aware and more active in addressing this problem. This paper will focus on the problem of tooth decay among children, but I want to mention that there are other dental problems including gingivitis, broken teeth, poor alignment, bruxism (teeth grinding or clenching), discoloration and thumb-sucking which affect the health and well-being of our children.

The Canadian Situation Regarding Tooth Decay in Children

Canadian national tooth decay rates have not been accessed since 1972, however Statistic Canada is currently assessing this issue as part of the Canadian Health Measures Survey. This survey will identify the scope of the problem. In the article previously mentioned, McConnache said that there have been sporadic studies across Canada which show access to good care is low among families of low income, First Nations and new immigrants. He cites a Toronto survey among five-year-olds attending public schools, which found that the prevalence of tooth decay has risen from 9.8 percent in 1999-2000 to 11.6 percent in 2005-2006. The percentage of five-year-olds with two or more untreated decayed teeth increased from 9.9 percent to 14.6 percent during this period. He noted that there was an increase in the number of children requiring general anesthetic or hospitalization due to serious infections. McConnache believes that poor dietary practice is the main reason for the increase. The governments of Quebec, Newfoundland and Labrador provide regular dental coverage for children, but most other provinces in Canada provide services based on the financial needs of the family and are usually supplied only in dire circumstances. The Ontario government recently announced that the dental care program for low income families would be expanded to include children up to the age of 18. Included in the proposal is money for funding prevention and education. In North Carolina, U.S.A. nurses in the dentists' offices provide fluoride to the children and educate the parents about dental health during the children's visits to the dentist. Both McConnachie and Cooney point to the North Carolina program as a good example for Canada to follow. (1)

A new system called the Canary System was approved by Health Canada on May 6, 2011. Without x-rays the system can identify cavities between the teeth, cavities as small as 50 microns and as deep as 5 millimeters below the surface. Dr. Stephen Abrams, DDS, President and Founder of Quantum Dental Technology, says that the Canary System uses a low-powered laser-based device that employs heat and light to directly examine the tooth structure. (7)

The North Carolina Dental and Orthodontic Services

The Medicaid program in the U.S. is jointly provided by the federal and state governments to families with low incomes and resources who meet certain criteria. It is administrated separately by each state and enrolled children are entitled to comprehensive preventive and restorative dental services. (This is not to be confused with Medicare, which is a social insurance program funded entirely by the federal government that focuses on the older population and people with certain disabilities.) Even so many children do not get the dental care they need.

North Carolina has been part of the Give Kids A Smile! program since 2003. February is set aside as National Children's Dental Health Month to provide oral health education to all children regardless of their economic situations. The first Friday in February is devoted to providing education and preventative and restorative care to low-income children who have not had access to care. One out of every five North Carolina children enters kindergarten with untreated dental disease. In 2010, from a population of 2.2 million children (age 0-17), 915,041 were eligible for Medicaid (the joint Federal and State program paying the costs of dental care for low income families) yet only 38% were actually enrolled. An additional 165,835 children were in need of dental care. The reason why so few children utilize the right to comprehensive preventive and restorative dental services is due in large measure to the lack of dental providers who will work under Medicaid. In some areas, less than half of all active dentists participate in Medicaid. Reasons given for lack of participation are low reimbursement rates and the complexity of the forms and administrative requirements. The Give Kids a Smile program functioning in several states is an effort to remedy this problem. With the leadership of the North Carolina Dental Society and thousands of volunteers, North Carolina children have been provided with dental treatment, and prevention and/or educational programs. "During February 2010, more than 1,660 dental professionals and volunteers provided 1.7 million dollars in oral health care to 15,544 children." Providers must meet the requirements and qualifications of Medicaid. (8)

The Cause and Treatment of Dental Cavities

The outer layers of teeth are comprised of several hard layers that protect the inner nerves and blood vessels. The outer layer, the enamel, is not living, but is composed of calcium salts (calcium hydroxyapatite). There are millions of aerobic Streptococci bacteria and anerobic Fusiforms, Vibrious and Spirochaetes bacteria living in our mouths. The bacteria survive by metabolizing sugars and in so doing convert those sugars to acid which dissolves the hydroxyapatite component of the enamel. The bacteria live in the deposit of plaque comprised of food debris, mucin and dead cells adhering to the teeth. The holes formed from the decay of the enamel are called cavities or dental caries. These cavities first appear as white spots on a tooth near the gum line. Active cavities usually look golden-brown in colour. Many factors affect the activities of these bacteria: diet and nutrition, oral hygiene, preventive measures such as fluoridation, the child's genetic susceptibility, saliva flow and its acidity (pH), and lifestyle. (5) (2)

When a cavity forms the dentist must clean away the decayed residue and fill the opening. Dentists have been using amalgam, a pasty alloy of metals including mercury, silver, copper, tin and some other metals to fill teeth for over 150 years. Gold, silver and other alloys may also be used. Another option is a composite filling, a mixture of glass or quartz in a resin medium. Iconomers, transparent materials made of glass power and acrylic acids are currently in use. (9)


This is an infection of the gums and supporting tissues of the teeth, caused by the bacteria: Fusiforms, Vibrious or Spirochaetes. These bacteria live without air in mature, long- standing plaque in the mouth. Over time the plaque hardens to tartar. The bacteria form toxins and enzymes that inflame the gums and cause them to become red and tender and to bleed. This chronic disease affects about 40% of the world's population including children. There is often an onset associated with hormone changes at puberty, and the condition may reoccur from time to time depending on the health of the teeth. The use of certain medications is associated with gingivitis. Prevention involves superior oral hygiene. Treatment involves good hygiene, periodic scaling and polishing by a dental hygienist or dentist, and often an antibacterial mouth wash is recommended. (2)

Caregiver Actions that Introduce Harmful Bacteria

Parents and caregivers who put the baby's spoon or chop stick in their mouths and then into the baby's mouth risk spreading harmful bacteria from their mouths to the baby's. Dirty teething rings may also carry bacteria. Caregivers should have a supply of clean teething rings on hand for the baby to chew on when one is dropped. (5)

What Parents Can Do to Help Prevent Dental Caries

It is the kind of sugar and the length of time the sugar remains in the mouth to be acted on by the bacteria that is crucial, said Dr. Ferne Kraghund, Assistant Professor in the Faculty of Dentistry at Dalhousie University, Halifax, Nova Scotia on a CBC radio program. (Follow reference (1) and listen to her speak.) She explained that when one partakes of sugar we should not rush to brush our teeth immediately, but wait for the bicarbonate in saliva to neutralize the acid formed by the bacterial metabolism of the sugar, otherwise the acid will be swallowed and can upset the stomach. We should limit the frequency of sugar intake. (10)

Articles in the on-line journal "Pediatric Dental Health," Dr. Daniel Ravel, Editor, and from the U.S. Surgeon General's Report identifies important factors parents should know. The natural sugar in fruit and milk does not significantly affect bacterial activity, however, fruit juice is primarily water and sugar and should be taken only with meals. It has little food value and is not a substitute for fruit, which has more nutrients and fibre. 1) A child should be put to bed with only a bottle of water, not fruit juice or formula or milk because of the prolonged length of exposure to the sugar they contain. Toddlers should not be given sippy cups for the same reason, nor should they be given juice as a reward, and older children should not be given juice repeatedly though out the day. 2) Babies should have their gums and first teeth wiped with clean gauze. Forming good oral health habits increases the likelihood of good teeth. Children should be introduced to a tooth brush soon after the age of one, using only a baby tooth cleaner. By the age of three a child can be introduced to a pea-sized drop of toothpaste. Parents should introduce the habit of brushing and flossing after meals and after taking oral medications. Nearly 100% of children's medications contain sucrose (sugar). 3) Children should have their first dental visit within six months of the eruption of their first tooth and should continue to have regular checkups. 4) Parents should provide healthy, balanced meals and avoid fizzy drinks including diet drinks, table sugar, food with sugar added (many processed foods and ready-made meals contain sugar), sweets, carbohydrate-rich pastries, chocolate snacks.

Foods that Discourage Dental Disease

Foods that require chewing like raw fruit and vegetables discourage dental disease by stimulating saliva, which dilutes the acid and adds a bicarbonate to counteract the acid. Sugarless gum promotes saliva and helps remove plaque from the tooth surface. The calcium and phosphates in aged cheese promotes salivary flow - which increases food clearance and decreases the acidic environment surrounding the teeth. (6) (5) (2) And now there is an antibacterial candy. A BBC article dated March 14, 2008 describes the work of Dr. Wenyuan Shi, a medical microbiologist at UCLA who has created an anti-germ lollipop. Shi took 2,000 herbs that are available at Chinese medical shops and conducted more than 50,000 experiments looking for a natural enemy of cavity-causing bacteria. He found that licorice root has an anti-bacterial effect. The root must be soacked and the solution left to dry to a powder. This powder can be put into lollipops. Shi proposes that two lollipops a day for ten days, four times a year would offer protection; however he stresses that brushing and flossing are still important for more reasons than cavity fighting. (11)

The Use of Fluoride to Prevent Tooth Decay

Fluorine is essential to life since it is a component of the apatite salts that make up bones and teeth. The fluoride compound of fluorine makes the enamel of teeth resistant to the acid formed as a result of the metabolism of sugars by the bacteria in the mouth. Low levels of fluoride ions in saliva exert a surface veneer effect making the tooth more acid resistant. After the sugar is used up, alkaline ions (namely calcium and phosphate ions) in the saliva act to remineralize the enamel damaged by the acid. Water fluoridation, fluoride toothpaste, mouthwash, gel, varnish and fluoridation of salt and milk are procedures being used throughout the world to give fluoride treatment. The fluoride effects depend on the total fluoride intake from all sources including that naturally occurring in some groundwater, particularly in volcanic and mountainous regions, that acquired from air pollution due to coal dust, insecticides or phosphate fertilizers, from certain tea favoured in China, and in certain foods such as barley, cassava, corn, rice, taro, yams and fish protein concentrate. In infants 80% to 90% of the fluoride is absorbed and the rest is excreted in urine. Adults retain about 60% of the fluoride intake, and it is stored in bone, teeth and other calcium rich areas.

Water fluoridation is believed by many as the most effective means of preventing tooth decay. The Centers of Disease Control and Prevention listed water fluoridation as one of ten great public health achievements of the twentieth century alongside vaccination, family planning, recognition of the dangers of smoking, and other achievements. (1) The practice is sanctioned by other national and international organizations including World Health Organization, the U.S. Surgeon General, the American Public Health Association, the European Academy of Pediatric Dentistry, and the national dental associations of Australia, Canada and the U.S. Water fluoridation is practiced in Hong Kong, Singapore, Ireland, Spain, Australia and Brazil. About 10% of the population of the United Kingdom has fluoride-treated water, about 67% of Americans live in areas with water treatment; half of New Zealand inhabitants have treated water; and in Canada the use of adding fluorine varies according to the wishes of local governments. (13) A friend phoned the Tokyo water department and was told that Kyoto, Japan fluoridated water for a short period but found no significant change in the incidence of cavities and stopped the process. Tokyo does not have fluoridated water.

One of three compounds may be used in the fluoridation treatment: sodium fluoride, fluorosilicic acid or sodium fluorosilicate. Treated water has no change in taste, colour or smell. In parts of Europe fluoride is added to salt or milk.

In 1994 the World Health Organization stated that the amount of fluoride added to water should be between 1.0 mg/L of water and 0.5 mg/L and should vary depending upon the temperature which affects water intake. It is obvious that there is no fixed amount that can be sanctioned for all parts of the world. Fluoridation in the U.S. is estimated to be costing $0.95 per person per year in 2011.

When the total fluoride intake is of acceptable quantity, there are no adverse effects. Harris wrote: "Extensive scientific documentation over the past half-century, including severe comprehensive reviews has established a consistently reaffirmation of the safety and efficacy of community water fluoridation." (3) In some areas where water naturally has a high concentration of fluorine, defluoridation is necessary to bring the level of fluorine in the water down to safe limits. This is accomplished by passing the water through granular beds of activated alumina, bone meal, bone char or tricalcium phosphate; by coagulating the fluorine in the water with alum; or by precipitating it with lime. Household water filters do not remove fluorine from the water. Bottled water may not be fluoridated.

High concentrations of fluorine can cause dental fluorsis, a discoloration of the teeth. Children ages one through eight are susceptible. This is a cosmetic adversity but does not adversely affect the health of the child. Extremely high amounts may cause skeletal fluorosis as had happened in India where there is naturally a high concentration of fluoride. In this condition, the bones thicken and harden impairing joint movement, and making the bones more apt to break. The extremely affected person experiences painful movement and nausea, the stomach lining may rupture and the thyroid gland may secrete uncontrolled amounts of parathyroid hormone, which regulates calcium deposits in bone. (13) (15)

Fluoridation of water has been practiced since 1901, first in research studies. It became the official policy of the U.S. Public Health in 1951 and became widely used without adverse health risks. The use is still contested by many groups based on ethical and political beliefs. Some argue that fluoridation of water is compulsory medication of the population. Others argue that water fluoridation isn't safe because there is no way to monitor the total intake of fluorine an individual is consuming from drinking water and other sources. Another view is that fluoride protection does not come from ingesting fluoride in water but through direct absorption through topical application. Claims that fluoridation causes cancer have been researched by many organizations including the Royal College of Physicians in the U.K, that found "no evidence that fluoride increased the incidence or mortality of cancer in any organ." In 1991 The U.S. Public Health Service establish a subcommittee to study fluorine as related to cancer. "Two annual studies failed to establish an association between fluoridation and cancer." Studies are still ongoing. Large reductions in cavities have convinced most public health professionals that fluoride treatments have benefits. (12) (13) (4) (15) Dr. Darryl Smith, President of the Canadian Dental Association, who endorses fluoridation, told Martin Mittelsteady, a Globe and Mail Reporter, " It's among the greatest public-health measures that has ever been put in place, right up there with vaccination." "Currently about half of the Children of Canada younger than 11 don't have cavities." (14)

Orthodontic Care

About 3,000 American and Canadian teenagers wear braces. There are two types of these appliances: ones that are attached to the teeth and ones that are removable. Their use may be employed for cosmetic reasons or because of difficulty chewing. They are employed to straighten teeth, correct an irregular bite, close a gap, or to bring the teeth and lips into alignment and are involved in cosmetic and implant dentistry after a tooth has been knocked out and replaced. Prolonged thumb sucking or use of a pacifier may cause the upper teeth to protrude and require orthodontic care later. While the brace is in place the child's teeth gradually move and become fixed in sockets. After the brace is removed, a retainer is usually employed to hold the teeth in place for a time. (16)

Bruxism (Teeth Grinding or Clenching)

Bruxism occurs while the child is sleeping and the child is usually not aware of the habit. Causes include teeth out of alignment, a response to pain such as an earache or teething, as a way of alleviating stress and nervous tension, and some hyperactive kids experience teeth grinding. Usually there are no adverse effects, however, some children develop headaches or earaches, and some find that the grinding has worn down the tooth enamel or caused the teeth to chip. In severe cases there are facial pain and/or jaw problems. Children usually outgrow bruxism unless it is caused by stress that is not alleviated. Parents can help the child identify the stress and when possible eliminate it, encourage the child to take a hot bath or shower before getting into bed, listen to soothing music or read a book before lights out. In some cases the dentist may prescribe a night guard, a plastic removable device molded to the child's teeth. It is similar to the mouthpiece worn by football players. (17)

Discoloured Teeth

Teenagers are concerned about stains on their teeth from consuming fruits, tea and coffee. By brushing with baking soda five minutes a day for a week or swishing diluted hydrogen peroxide solution in the mouth two times a day for a week teenagers can whiten their teeth without costly visits to the dentist. (18)


For children and adults good oral health is essential, but today in parts of the world there is an increase in dental caries and other dental diseases among children. Good oral hygiene, brushing and flossing, can enhance the chances of having good teeth. Avoiding refined sugar and sugar-added foods, frothy drinks and fruit juices cuts the risks of having cavities. Fluoride treatment is endorsed by many oral health professionals and international organizations as a means of decreasing the number of cavities among children and adults. To avoid harmful consequences, the total amount of fluoride intake to which a person is exposed must be within acceptable limits. We need to give all children access to good dental education, treatment and restorative care.




(2) Felton, Ann & Alison Chapman (2009). Basic Guide to Oral Health Education and Promotion. Wiley-Blackwell & Sons Ltd, Sussex, U.K.

(3) Harris, Norman O. & Franklin Garcia-Godoy (2004). Primary Preventive Dentistry, 6th Edition. Pearson Education Inc. , Pearson Prentice Hall, New Jersey, U.S.A.

(4) Harris, Norman O, Franklin Garcia-Godoy & Christine Nielsen Nathe (2009). Pearson Education Inc., New Jersey, U.S.A.

(5) "Baby Teeth: The Basics - Pediatric Dental Health." Pediatric Dental Health. December 1, 2002.

(6) "Diet and Tooth Decay in Children." U.S. Surgeon General's Report (2004).


(8) History of Give Kids a Smile

(9) "Various Dental Filling Options" - Associated Contributor network Yahoo!

(10);Past Episode Nov. 6,2010. Fact & Fiction: Candy & Cavities

(11) abc CMA Wenyuan Shi lollipop

(12) "Water fluoridation." Wikipedia.

(13) "Water fluoridation controversy." Wikipedia

(14) Mittelstead, Martin. "Critics raise red flag over fluorine in tap water." Globe and Mail. Toronto. November 23, 2007.

(15) "Flouride Health Effects Database," Review of 2010 Fluoride Scientific Literature.

(16) "Dental Health: Braces and Retainers." Dental Braces: Girls and Boys, Children and Adults/Orthodonics.

(17) "Bruxism (Teeth Grinding or Clenching). " Reviewed by Kenneth H. Hirsch, DDS, November, 2009.

(18) "How to Whiten Teeth Without Paying Big Bucks." Sobel Robins. Yahoo Contributor Network. July 16, 2008.