Claimed effects, outcome variables and methods of measurement for health claims on foods proposed under Regulation (EC) 1924/2006 in the area of oral health

Some of the requests of authorization to apply health claims in the context of oral health have received a negative scientific opinion from the European Food Safety Authority (EFSA). The main reasons refer to the design of human intervention studies, including the inappropriate choice of outcome variables (OVs) and of their methods of measurement (MMs). The present manuscript reports the results of an investigation aimed at collecting, collating and critically analysing the information in relation to claimed effects, OVs and MMs, in the area of oral health and compliant with Regulation (EC) 1924/2006.  Claimed effects, OVs and the related MMs were collected from EFSA guidance documents and from the scientific opinions on the substantiation of health claims under Articles 13.5 and 14. The collection, collation and critical analysis of the relevant scientific literature consisted in a definition of the keywords, PubMed search strategies and in the creation of databases of references.  The critical analysis of the OVs and their MMs was performed on the basis of the literature review and was aimed at defining the appropriateness of OVs and MMs in the context each specific claimed effect.  The information provided in this document could serve to EFSA for the development of further guidance on the scientific requirements for health claims related to oral health, as well as to the stakeholders for the identification of existing and design of novel randomized controlled trials aimed at substantiating such health claims.

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title: Oral Microbiome Metabolism
abstract: Recent advances in molecular biology have facilitated analyses of the oral microbiome (“Who are they?”); however, its functions (e.g., metabolic activities) are poorly understood (“What are they doing?”). This review aims to summarize our current understanding of the metabolism of the oral microbiome. Saccharolytic bacteria—including Streptococcus, Actinomyces, and Lactobacillus species—degrade carbohydrates into organic acids via the Embden-Meyerhof-Parnas pathway and several of its branch pathways, resulting in dental caries, while alkalization and acid neutralization via the arginine deiminase system, urease, and so on, counteract acidification. Proteolytic/amino acid–degrading bacteria, including Prevotella and Porphyromonas species, break down proteins and peptides into amino acids and degrade them further via specific pathways to produce short-chain fatty acids, ammonia, sulfur compounds, and indole/skatole, which act as virulent and modifying factors in periodontitis and oral malodor. Furthermore, it is suggested that ethanol-derived acetaldehyde can cause oral cancer, while nitrate-derived nitrite can aid caries prevention and systemic health. Microbial metabolic activity is influenced by the oral environment; however, it can also modify the oral environment, enhance the pathogenicity of bacteria, and induce microbial selection to create more pathogenic microbiome. Taking a metabolomic approach to analyzing the oral microbiome is crucial to improving our understanding of the functions of the oral microbiome.

title: Surface analysis of dentinal caries in primary teeth using a pH-imaging microscope.
abstract: The aim of this in vitro study was to evaluate the pH value of intact and carious dentin in primary teeth using a pH-imaging microscope (SCHEM-100, HORIBA Ltd., Kyoto, Japan). Bucco-lingual cut sections of extracted human primary teeth, which had either mild or severe dentinal caries lesions, were placed on the pH-imaging sensor of the microscope. The pH values were compared statistically by Levene's test for equality of variances and Tukey HSD multiple comparison test (p < 0.05). For both mild and severe lesions in primary dentin, the lowest pH values in the carious lesions were lower than those of intact dentin (6.6, range 6.3-6.9). There were statistical differences between the lowest pH value within the mild lesions (6.2, range 5.8-6.4) and that of the severe lesions (6.0, range 5.9-6.2) (p < 0.05). It was concluded that SCHEM-100 was able to distinguish the pH-value distribution of intact and carious dentin in primary teeth.

title: Biological factors in dental caries: role of saliva and dental plaque in the dynamic process of demineralization and remineralization (part 1).
abstract: Dental caries is a complex disease process that afflicts a large proportion of the world's population, regardless of gender, age and ethnicity, although it does tend to affect more indivduals with a low socioeconomic status to a greater extent. The process of dental caries is dependent upon biological factors that are present within the saliva and dental plaque. There are many different agents within saliva and plaque that serve to protect the tooth surface against caries development. Salivary flow rate, buffering capacity, antimicrobial activity, microorganism aggregation and clearance from the oral cavity, immune surveillance, and calcium phosphate binding proteins all interact to inhibit or reverse demineralization of exposed tooth surfaces. Cariogenic bacteria levels within the saliva and plaque determine whether caries will occur or not, and the concentration in saliva and plaque are intimately related to the type of carbohydrate ingestion and the frequency of ingestion, as well as the oral hygiene practiced by the individual.

title: Dietary Carbohydrates and Dental-Systemic Diseases
abstract: Two contradictory hypotheses on the role of dietary carbohydrates in health and disease shape how dental-systemic associations are regarded. On one side, Cleave and Yudkin postulated that excessive dietary fermentable carbohydrate intake led—in the absence of dental interventions such as fluorides—first to dental diseases and then to systemic diseases. Under this hypothesis, dental and systemic diseases shared—as a common cause—a diet of excess fermentable carbohydrates. Dental diseases were regarded as an alarm bell for future systemic diseases, and restricting carbohydrate intake prevented both dental and systemic diseases. On the opposite side, Keys postulated the lipid hypothesis: that excessive dietary lipid intake caused systemic diseases. Keys advocated a diet high in fermentable carbohydrate for the benefit of general health, and dental diseases became regarded as local dietary side effects. Because general health takes precedence over dental health when it comes to dietary recommendations, dental diseases became viewed as local infections; interventions such as fluorides, sealants, oral hygiene, antimicrobials, and dental fillings became synonymous with maintaining dental health, and carbohydrates were no longer considered as a common cause for dental-systemic diseases. These opposing dietary hypotheses have increasingly been put to the test in clinical trials. The emerging trial results favor Cleave-Yudkin’s hypothesis and may affect preventive approaches for dental and systemic diseases.

title: Diet and Dental Caries
abstract: The importance of sugars as a cause of caries is underemphasized and not prominent in preventive strategies. This is despite overwhelming evidence of its unique role in causing a worldwide caries epidemic. Why this neglect? One reason is that researchers mistakenly consider caries to be a multifactorial disease; they also concentrate mainly on mitigating factors, particularly fluoride. However, this is to misunderstand that the only cause of caries is dietary sugars. These provide a substrate for cariogenic oral bacteria to flourish and to generate enamel-demineralizing acids. Modifying factors such as fluoride and dental hygiene would not be needed if we tackled the single cause—sugars. In this article, we demonstrate the sensitivity of cariogenesis to even very low sugars intakes. Quantitative analyses show a log-linear dose-response relationship between the sucrose or its monosaccharide intakes and the progressive lifelong development of caries. This results in a substantial dental health burden throughout life. Processed starches have cariogenic potential when accompanying sucrose, but human studies do not provide unequivocal data of their cariogenicity. The long-standing failure to identify the need for drastic national reductions in sugars intakes reflects scientific confusion partly induced by pressure from major industrial sugar interests.

title: The third Italian National Food Consumption Survey, INRAN-SCAI 2005-06--part 1: nutrient intakes in Italy.
abstract: Italian National Food Consumption Survey, INRAN-SCAI 2005-06, is the third national food consumption survey performed in Italy. This study describes energy and nutrient intakes in Italy.



A national cross-sectional food consumption survey was conducted using consecutive 3-day food records between October 2005 and December 2006. A sample of 3323 males and females aged 0.1-97.7 years living in private households was investigated. Individual food records were converted into energy and nutrient intakes with the use of recently updated national food composition databases. For each subject, intakes of energy and of 27 nutrients were calculated, including six minerals (i.e., iron, calcium, phosphorus, magnesium, potassium and zinc) and 10 vitamins (i.e., thiamine, riboflavin, vitamin C, vitamin B₆, retinol, β-carotene, vitamin A as retinol equivalents (REs), vitamin E, vitamin D and vitamin B₁₂. On average, 36% of calories appeared to derive from fat (11% from saturated fatty acids) and 45% from available carbohydrates (15% from soluble carbohydrates).



The results of the INRAN-SCAI 2005-06 survey in terms of nutrient intakes provide an important piece of information for nutrition surveillance of the population and may also be used to identify priorities for further research.

title: Nutrition, dental caries and periodontal disease: a narrative review
abstract: To provide a narrative review of the role of macro- and micronutrients in relation to dental caries, gingival bleeding and destructive periodontal disease.



This review is based on systematic reviews (when available) and comparative human studies.



Dental caries cannot develop without the presence of dietary fermentable carbohydrates, in particular sugar. The susceptibility to develop caries in the presence of carbohydrates may be influenced by genetics and micronutrients such as vitamin D. Gingival bleeding and destructive periodontal disease are sensitive markers to both abnormalities in macronutrient content (excessive carbohydrates or poly-unsaturated fat intake, deficient protein intake) and micronutrient intake (e.g. vitamin C and B12).



Dental caries and periodontal diseases are a sensitive alarm bell for an unhealthy diet, which predicts the future onset of the diseases of civilizations.

title: An oral health optimized diet can reduce gingival and periodontal inflammation in humans - a randomized controlled pilot study
abstract: BackgroundThe aim of this pilot study was to investigate the effects of four weeks of an oral health optimized diet on periodontal clinical parameters in a randomized controlled trial.MethodsThe experimental group (n = 10) had to change to a diet low in carbohydrates, rich in Omega-3 fatty acids, and rich in vitamins C and D, antioxidants and fiber for four weeks. Participants of the control group (n = 5) did not change their dietary behavior. Plaque index, gingival bleeding, probing depths, and bleeding upon probing were assessed by a dentist with a pressure-sensitive periodontal probe. Measurements were performed after one and two weeks without a dietary change (baseline), followed by a two week transitional period, and finally performed weekly for four weeks.ResultsDespite constant plaque values in both groups, all inflammatory parameters decreased in the experimental group to approximately half that of the baseline values (GI: 1.10 ± 0.51 to 0.54 ± 0.30;  mm2 to 284 mm2). This reduction was significantly different compared to that of the control group. diet low in carbohydrates, rich in Omega-3 fatty acids, rich in vitamins C and D, and rich in fibers can significantly reduce gingival and periodontal inflammation.

title: Dietary ratio of n-6 to n-3 polyunsaturated fatty acids and periodontal disease in community-based older Japanese: a 3-year follow-up study.
abstract: The longitudinal relationship between dietary n-6 to n-3 PUFAs ratio and periodontal disease in 235 Japanese subjects for whom data were available for the years 2003-2006 was investigated. PUFAs intake was assessed at baseline with a brief-type self-administered diet history questionnaire. Full-mouth periodontal status, measured as the clinical attachment level (CAL), was recorded at baseline and once a year for 3 years. The number of teeth with a change in the loss of CAL ≥3 mm at any site over a year was calculated as 'periodontal disease events'. Poisson regression analysis was conducted, with dietary n-6 to n-3 PUFAs ratio as the main predictor, to estimate its influence on periodontal disease events. A high dietary n-6 to n-3 PUFAs ratio was significantly associated with greater number of periodontal disease events. The findings suggest the dietary n-6 to n-3 PUFAs ratio is associated with periodontal disease among older Japanese.

title: Low serum level of 1,25(OH)2 D is associated with chronic periodontitis.
abstract: Vitamin D has been studied primarily for its involvement in calcium and phosphate absorption and bone metabolism. The active form of vitamin D-1,25(OH)2 D-has also been investigated for its immune modulatory properties. We explored associations between serum levels of 25(OH)D and 1,25(OH)2 D and periodontal health.



This case-control study included 55 subjects with chronic periodontitis (cases) and 30 periodontally healthy subjects (controls). Their serum levels of 25(OH)D, 1,25(OH)2 D, ultrasensitive C-reactive protein and high-density lipoprotein cholesterol were determined. Associations between vitamin D and periodontal health status were studied using logistic regression analysis.



A statistically significant association was found between serum 1,25(OH)2 D level and periodontal health status; in that subjects with a low 1,25(OH)2 D were more likely to belong to the periodontitis group (OR = 0.97, 95% CI = 0.95-1.00). There was practically no association between 25(OH)D level and periodontal health status.



In this case-control study low serum 1,25(OH)2 D level appeared to be associated with periodontitis, which was in line with the previously reported associations between serum 1,25(OH)2 D levels and other inflammatory diseases. Whether this association is causal in nature, remains to be confirmed in future studies.

title: Functional foods and their expanding applications in the improvement of human health.
abstract: Gabriella Gazzani is a Professor in the Department of Drug Sciences at the University of Pavia. Her research focused on two lines: (1) study of biological properties (Maillard’s reaction products mutagenicity, antioxidant and antiradical properties, antibacterial and anti-adhesive activity against plaque bacteria) of components either naturally present or induced following thermal treatments in foods; (2) development of analytical chromatographic and spectrometric methods useful in the isolation and characterization of food bioactive compounds.

title: Evaluation of Plant and Fungal Extracts for Their Potential Antigingivitis and Anticaries Activity
abstract: The link between diet and health has lead to the promotion of functional foods which can enhance health. In this study, the oral health benefits of a number of food homogenates and high molecular mass and low molecular mass fractions were investigated. A comprehensive range of assays were performed to assess the action of these foods on the development of gingivitis and caries using bacterial species associated with these diseases. Both antigingivitis and anticaries effects were investigated by assays examining the prevention of biofilm formation and coaggregation, disruption of preexisting biofilms, and the foods' antibacterial effects. Assays investigating interactions with gingival epithelial cells and cytokine production were carried out to assess the foods' anti- gingivitis properties. Anti-caries properties such as interactions with hydroxyapatite, disruption of signal transduction, and the inhibition of acid production were investigated. The mushroom and chicory homogenates and low molecular mass fractions show promise as anti-caries and anti-gingivitis agents, and further testing and clinical trials will need to be performed to evaluate their true effectiveness in humans.

title: Probiotics for managing caries and periodontitis: Systematic review and meta-analysis.
abstract: Probiotics might be beneficial to prevent or treat caries, gingivitis or periodontitis. We aimed to appraise trials assessing probiotics for managing caries and periodontal disease.



We included randomized controlled trials comparing the efficacy of probiotics versus (placebo) control with regards to Streptococcus mutans [SM], lactobacilli [LB], periodontal pathogens numbers, gingivitis, oral hygiene, caries incidence/experience increment, or periodontitis. Meta-analysis and trial-sequential-analysis were performed.



Three electronic databases (Medline, Embase, Central) were screened.



50 studies (3247 participants) were included. Studies were mainly performed in children and used lactobacilli (45); bifidobacteria (12) or other genus (3). Probiotics significantly increased the chance of reducing SM (OR: 2.20, 95% CI: 1.23/3.92) or LB (OR: 2.84; 1.34/6.03)<10(4)CFU/ml. Such reduction was confirmed for SM counts (standardized mean differences: -1.18, 95% CI: -1.64/-0.72), but not LB (SMD: 0.33; 0.15/0.52). For periodontal pathogens, no significant difference was found. Probiotics significantly reduced bleeding-on-probing (SMD: -1.15; -1.68/-0.62) and gingival index (SMD: -0.86; -1.52/-0.20), but not plaque index (SMD: -0.34; -0.89/0.21). Caries incidence was not significantly reduced (OR: 0.60; 0.35/1.04), neither was caries experience (SMD: -0.26; -0.55/0.03) or CAL (SMD: -0.46; -0.84/0.08). In contrast, probing-pocket depths (SMD: -0.86; -1.55/-0.17) were significantly reduced. Data was quantitatively insufficient for conclusive findings, and risk of bias was high.



Current evidence is insufficient for recommending probiotics for managing dental caries, but supportive towards managing gingivitis or periodontitis. Future studies should only record bacterial numbers alongside accepted disease markers or indicators.



Probiotic therapy could be used for managing periodontal diseases. For caries, further studies should ascertain both efficacy and safety.

title: Prevention and control of dental caries and periodontal diseases at individual and population level: consensus report of group 3 of joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases
abstract: The non-communicable diseases dental caries and periodontal diseases pose an enormous burden on mankind. The dental biofilm is a major biological determinant common to the development of both diseases, and they share common risk factors and social determinants, important for their prevention and control. The remit of this working group was to review the current state of knowledge on epidemiology, socio-behavioural aspects as well as plaque control with regard to dental caries and periodontal diseases.



Discussions were informed by three systematic reviews on (i) the global burden of dental caries and periodontitis; (ii) socio-behavioural aspects in the prevention and control of dental caries and periodontal diseases at an individual and population level; and (iii) mechanical and chemical plaque control in the simultaneous management of gingivitis and dental caries. This consensus report is based on the outcomes of these systematic reviews and on expert opinion of the participants.



Key findings included the following: (i) prevalence and experience of dental caries has decreased in many regions in all age groups over the last three decades; however, not all societal groups have benefitted equally from this decline; (ii) although some studies have indicated a possible decline in periodontitis prevalence, there is insufficient evidence to conclude that prevalence has changed over recent decades; (iii) because of global population growth and increased tooth retention, the number of people affected by dental caries and periodontitis has grown substantially, increasing the total burden of these diseases globally (by 37% for untreated caries and by 67% for severe periodontitis) as estimated between 1990 and 2013, with high global economic impact; (iv) there is robust evidence for an association of low socio-economic status with a higher risk of having dental caries/caries experience and also with higher prevalence of periodontitis; (v) the most important behavioural factor, affecting both dental caries and periodontal diseases, is routinely performed oral hygiene with fluoride; (vi) population-based interventions address behavioural factors to control dental caries and periodontitis through legislation (antismoking, reduced sugar content in foods and drinks), restrictions (taxes on sugar and tobacco) guidelines and campaigns; however, their efficacy remains to be evaluated; (vii) psychological approaches aimed at changing behaviour may improve the effectiveness of oral health education; (viii) different preventive strategies have proven to be effective during the course of life; (ix) management of both dental caries and gingivitis relies heavily on efficient self-performed oral hygiene, that is toothbrushing with a fluoride-containing toothpaste and interdental cleaning; (x) professional tooth cleaning, oral hygiene instruction and motivation, dietary advice and fluoride application are effective in managing dental caries and gingivitis.



The prevention and control of dental caries and periodontal diseases and the prevention of ultimate tooth loss is a lifelong commitment employing population- and individual-based interventions.

title: Scientific Opinion on the substantiation of a health claim related to “toothkind” drinks and reduction of tooth demineralisation pursuant to Article 13(5) of Regulation (EC) No 1924/2006
abstract: Following an application from GlaxoSmithKline, submitted pursuant to Article 13(5) of Regulation (EC) No 1924/2006 via the Competent Authority of the United Kingdom, the Panel on Dietetic Products, Nutrition and Allergies was asked to deliver an opinion on the scientific substantiation of a health claim based on newly developed scientific evidence and including a request for the protection of proprietary data related to “toothkind” drinks and reduction of tooth demineralisation. The food constituent, “toothkind” juice drinks, which is the subject of the health claim, is sufficiently characterised. The Panel considers that reduction of tooth demineralisation is a beneficial physiological effect. The applicant identified 25 human intervention trials and 10 in vitro studies as being pertinent to the health claim. In weighing the evidence for reduced potential of “toothkind” juice drinks for demineralisation of dental enamel by reducing plaque pH, the Panel considers that “toothkind” juice drinks reduced tooth demineralisation when compared to sugar solution (10 g/100 ml) at an exposure frequency of seven times daily. No evidence has been presented for an effect at lower exposure frequencies. In weighing the evidence for reduced erosive potential, the Panel considers that “toothkind” juice drinks reduced tooth demineralisation when compared to typical conventional juice drinks at an exposure frequency of four times daily. No evidence has been presented for an effect at lower exposure frequencies. The Panel concludes that a cause and effect relationship has been established between the consumption of “toothkind” juice drinks and reduction of tooth demineralisation when compared to typical conventional juice drinks at an exposure frequency of four times daily and when compared to typical sugar-containing acidic non-alcoholic beverages at an exposure frequency of seven times daily.

title: Scientific opinion on the substantiation of a health claim related to "non fermentable" carbohydrates and maintenance of tooth mineralisation by decreasing tooth demineralisation pursuant to Article 13(5) of Regulation (EC) No 1924/2006.
abstract: Following an application from Roquette Freres, submitted for authorisation of a health claim pursuant to Article 13(5) of Regulation (EC) No 1924/2006 via the Competent Authority of France, the EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA) was asked to deliver an opinion on the scientific substantiation of a health claim related to Nutriose® which should replace “fermentable carbohydrates” in foods or beverages in order to obtain the claimed effect, i.e. maintenance of tooth mineralisation by reducing tooth demineralisation. From the information provided, the Panel noted that the main characteristic of carbohydrates which is relevant to the claimed effect is the rate and amount of acid production resulting from their fermentation by saccharolytic bacteria in the oral cavity. This Opinion applies to “non-fermentable” carbohydrates, which should replace “fermentable” carbohydrates in foods or beverages in order to obtain the claimed effect. The Panel considers that maintaining tooth mineralisation by reducing tooth demineralisation resulting from acid production in plaque caused by the fermentation of carbohydrates is a beneficial physiological effect. The Panel concludes that a cause and effect relationship has been established between the consumption of foods/beverages containing “fermentable” carbohydrates at an exposure frequency of four or more times daily and an increased tooth demineralisation, and that the consumption of foods/beverages containing “non-fermentable” carbohydrates instead of “fermentable” carbohydrates may maintain tooth mineralisation by decreasing tooth demineralisation. In order to bear the claim, “fermentable” carbohydrates should be replaced in foods or beverages by “non-fermentable” carbohydrates, so that consumption of such foods or beverages does not lower plaque pH below 5.7 during and up to 30 minutes after consumption, and does not lead to dental erosion.

title: Scientific Opinion on the substantiation of a health claim related to sugar free chewing gum and neutralisation of plaque acids which reduces the risk of dental caries pursuant to Article 14 of Regulation (EC) No 1924/2006
abstract: Following an application from Wrigley GmbH submitted pursuant to Article 14 of Regulation (EC) No 1924/2006 via the Competent Authority of United Kingdom, the Panel on Dietetic Products, Nutrition and Allergies was asked to deliver an opinion on the scientific substantiation of a health claim related to sugar-free chewing gum and neutralisation of plaque acids which reduces the risk of dental caries. Sugar-free chewing gum is sufficiently characterised. The Panel considers that plaque acid neutralisation might be a beneficial physiological effect in the context of reducing the risk of caries. The applicant identified a total of 47 publications as being pertinent to the health claim. In weighing the evidence, the Panel took into account that many human studies of sugar-free chewing gum consumption were consistent in showing neutralisation of plaque acid, that almost all clinical trials on sugar-free chewing gum consumption showed a reduction in caries incidence, and that there was strong evidence supporting the biological plausibility for the effect. The Panel concludes that a cause and effect relationship has been established between the consumption of sugar-free chewing gum and plaque acid neutralisation and a reduction in incidence of caries. Plaque acid production may contribute to increased risk of caries. In order to obtain the claimed effect, 2–3 g of sugar-free chewing gum should be chewed for 20 minutes at least three times per day after meals. This quantity and pattern of use of chewing gum can easily be included within a balanced diet.

title: Scientific Opinion on the substantiation of a health claim related to calcium-containing fruit juices and the reduction of tooth demineralisation pursuant to Article 14 of Regulation (EC) No 1924/2006
abstract: Following an application from FrieslandCampina submitted pursuant to Article 14 of Regulation (EC) No 1924/2006 via the Competent Authority of The Netherlands, the Panel on Dietetic Products, Nutrition and Allergies was asked to deliver an opinion on the scientific substantiation of a health claim related to acidic calcium-containing fruit juices and the reduction of tooth demineralisation. The scope of the application was proposed to fall under a health claim referring to reduction of disease risk. The Panel considers that the food, acidic calcium-containing fruit juices and comparative products, conventional fruit juices (not containing added calcium), are sufficiently characterised. The Panel considers that reducing tooth demineralisation resulting from erosive potential of a food is a beneficial physiological effect, provided that it is not accompanied by tooth demineralisation resulting from acid production in plaque through the fermentation of carbohydrates. A total of 37 pertinent studies were identified by the applicant, including observational studies, reviews, intervention studies on the erosive potential of fruit juices and other acidic drinks with and without added calcium in situ, in vitro studies on the erosive potential of acidic drinks with and without added calcium, and an animal study on the effect of calcium added to acidic drinks on dental erosion. The Panel notes that the potential of fruit juices with and without added calcium for demineralisation of dental enamel by acid production in plaque as a result of sugar fermentation was not assessed in any study. The Panel considers that the potential of fruit juices with and without added calcium for demineralisation of dental enamel, including the possible effects of both acids and sugars, has not been assessed appropriately. The Panel concludes that a cause and effect relationship has not been established between the consumption of acidic calcium-containing fruit juices in replacement of fruit juice without added calcium and the reduction of tooth demineralisation.

title: Claimed effects, outcome variables and methods of measurement for health claims proposed under European Community Regulation 1924/2006 in the framework of protection against oxidative damage and cardiovascular health.
abstract: The high number of negative opinions from the European Food Safety Authority (EFSA) to the requests for authorization of health claims is largely due to the design of human intervention studies, including the inappropriate choice of outcome variables (OVs) and of their methods of measurement (MMs). The present manuscript reports the results of an investigation aimed to collect, collate and critically analyse the information in relation to claimed effects, OVs and MMs, in the context of protection against oxidative damage and cardiovascular health compliant with Regulation 1924/2006.



Claimed effects, OVs and the related MMs were collected from EFSA Guidance documents and applications for authorization of health claims under Articles 13.5 and 14. The OVs and their MMs were evaluated only if the claimed effect was sufficiently defined and was considered beneficial by EFSA. The collection, collation and critical analysis of the relevant scientific literature consisted in the definition of the keywords, the PubMed search strategies and the creation of databases of references. The critical analysis of the OVs and their MMs was performed on the basis of the literature review and was aimed at defining the appropriateness of OVs and MMs in the context of the specific claimed effects.



The information provided in this document could serve to EFSA for the development of further guidance on the scientific requirements for health claims, as well as to the stakeholders for the proper design of human intervention studies aimed to substantiate such health claims.

title: Claimed effects, outcome variables and methods of measurement for health claims on foods proposed under European Community Regulation 1924/2006 in the area of appetite ratings and weight management
abstract: All the requests for authorisation to bear health claims under Articles 13(5) and 14 in the context of appetite ratings and weight management have received a negative opinion by the European Food Safety Authority (EFSA), mainly because of the insufficient substantiation of the claimed effects (CEs). This manuscript results from an investigation aimed to collect, collate and critically analyse the information related to outcome variables (OVs) and methods of measurement (MMs) in the context of appetite ratings and weight management compliant with Regulation 1924/2006. Based on the literature review, the appropriateness of OVs and MMs was evaluated for specific CEs. This work might help EFSA in the development of updated guidance addressed to stakeholders interested in bearing health claims in the area of weight management. Moreover, it could drive the applicants during the design of randomised controlled trials aimed to substantiate such claims.

title: PERIODONTAL DISEASE IN PREGNANCY. I. PREVALENCE AND SEVERITY.
abstract: (1963). Periodontal Disease in Pregnancy I. Prevalence and Severity.  21, No. 6, pp. 533-551.

title: Effect of initial periodontal therapy on gingival crevicular fluid cytokine profile in subjects with chronic periodontitis
abstract: Cytokines are thought to play an important role in the pathogenesis of periodontal disease. Because periodontal disease is known for its inhomogeneous distribution within the dentition, it is unclear to what extent the detection of various cytokines at different sites correlates with presence of disease. We evaluated whether levels of 12 cytokines in gingival crevicular fluid (GCF) discriminated periodontally diseased sites from healthy ones, or periodontally diseased persons from healthy ones, and assessed the impact of nonsurgical periodontal therapy on these readings. This study included 20 periodontally healthy persons (H) and 24 patients with chronic periodontitis (P). In every participant, we measured the plaque index, gingival index, probing pocket depth (PD), bleeding on probing, and recession at six sites of every tooth. GCF was collected with Durapore® filter strips from two healthy sites (PD<4 mm; HH) in group H, and from two periodontally diseased sites (PD≥5 mm; PP) and two periodontally healthy sites (PD≤3 mm; PH) in group P. The periodontally diseased participants underwent comprehensive nonsurgical periodontal therapy including deep scaling and root planing under local anesthesia. In these participants, GCF samples were again collected at the same sites 1 and 3 months after therapy. Twelve cytokines (il‐1β, il‐1ra, il‐6, il‐8, il‐17, b‐fgf, g‐csf, gm‐csf, ifn‐γ, mip‐1β, vegf, and ) were assessed using the Bio‐Plex suspension array system. Mean plaque index, gingival index, bleeding on probing, PD, and recession were significantly different between groups H and P. Differences between PP and PH sites were not significant for any of the cytokines. Il‐1ra, il‐6, il‐17, b‐fgf, gm‐csf, mip‐1β, and tnf‐α differed significantly between HH sites and both PH and PP sites, whereas il‐8 was significantly higher only at PP sites. Periodontal treatment increased gm‐csf and decreased il‐1ra levels in PP sites. Il‐1ra, il‐6, il‐8, il‐17, b‐fgf, gm‐csf, mip‐1β, and tnf‐α identified patients with chronic periodontitis, rather than diseased sites, suggesting a generalized inflammatory state that is not limited to clinically diseased sites only.

title: Results of limited initial periodontal therapy in smokers and non-smokers.
abstract: Eighty-seven adult patients (54 non-smokers and 33 smokers) with moderate to advanced periodontitis were treated with 1-hour full-mouth subgingival scaling and root planing, with no maintenance recalls, during this 9-month study. Clinical parameters assessed at target sites included probing depth, clinical attachment level, bleeding on probing, gingival index, and plaque index. Data were collected at baseline, and 3, 6, and 9 months. Baseline probing depth for non-smokers was 5.46 +/- .46 mm and for smokers 5.70 +/- 0.66 mm. Data analysis (t test) revealed that both non-smokers and smokers had a statistically significant decrease (P < 0.05) in probing depth at 3 months which was maintained throughout the study. At 9 months non-smokers maintained a mean decrease in probing depth of 0.60 mm and smokers a mean decrease of 0.65 mm. Both smokers and non-smokers displayed a significant gain (P < 0.05) in clinical attachment level after initial therapy when compared to baseline readings. At 9 months the mean gain in clinical attachment level for non-smokers was 0.47 mm and 0.59 mm for smokers. Plaque index scores remained consistent for smokers and non-smokers for the duration of the study. The gingival index at baseline was significantly (P < 0.05) lower in smokers (1.32 +/- 0.45) than non-smokers (1.45 +/- 0.40). By 9 months only the gingival index of non-smokers decreased significantly compared to baseline (1.26 +/- 0.37). Bleeding on probing was a prerequisite for target sites at baseline. At 9 months both smokers (0.67 +/- 0.39) and non-smokers (0.78 +/- 0.30) had a significant decrease in bleeding on probing compared to baseline. At 9 months there were no significant differences between smokers and non-smokers comparing probing depth, clinical attachment level, plaque index, bleeding on probing, and gingival index. The data have shown that smokers and non-smokers responded similarly after 9 months to the limited amount of initial therapy provided.

title: Effect of initial periodontal therapy on oral health-related quality of life in patients with periodontitis in Japan.
abstract: It is becoming increasingly important for periodontists and dental hygienists to take a biopsychosocial approach to care when considering periodontal interventions. However, information on how patients perceive periodontitis and its treatment is limited. The purpose of the present study is to gain insight into the patient perception of oral health and the impact that periodontitis and treatment have on self-assessed quality of life (QoL).



This was a prospective, two-center, clinical study in Japan. Patients with periodontitis were assessed for their perceptions of oral health by using an instrument for oral health-related QoL (OHRQL) before and after initial periodontal therapy.



A total of 58 patients (mean age: 53.6 years; 23 male and 35 female) participated in the study and completed initial periodontal therapy. At baseline, 97% of the patients perceived that their oral health status impacted on their QoL in one or more ways. Pain, eating and chewing, and psychologic function were identified as compromised OHRQL domains. More than one-half of the patients rated their overall oral health as poor. Initial periodontal therapy, consisting mainly of oral hygiene instructions and scaling and root planing, significantly improved OHRQL scores (P = 0.0027). The effect size was calculated to be 0.51, indicating a moderate improvement. Compared with baseline, a significantly higher proportion of patients reported rarely or never having a problem regarding OHRQL domains such as pain (P = 0.0049) and eating and chewing (P = 0.0145) after treatment. No significant difference in the OHRQL improvement was found with respect to disease severity.



Periodontitis negatively affected QoL in this population of Japanese patients with periodontitis. Conventional non-surgical periodontal therapy has a potential to ameliorate patient perceptions of oral health.

title: Gingivitis as a risk factor in periodontal disease
abstract: '...development of periodontitis only occurs in areas of long-standing gingivitis'.

title: Dental plaque biofilm in oral health and disease.
abstract: Dental plaque is an archetypical biofilm composed of a complex microbial community. It is the aetiological agent for major dental diseases such as dental caries and periodontal disease. The clinical picture of these dental diseases is a net result of the cross-talk between the pathogenic dental plaque biofilm and the host tissue response. In the healthy state, both plaque biofilm and adjacent tissues maintain a delicate balance, establishing a harmonious relationship between the two. However, changes occur during the disease process that transform this 'healthy' dental plaque into a 'pathogenic' biofilm. Recent advances in molecular microbiology have improved the understanding of dental plaque biofilm and produced numerous clinical benefits. Therefore, it is imperative that clinicians keep abreast with these new developments in the field of dentistry. Better understanding of the molecular mechanisms behind dental diseases will facilitate the development of novel therapeutic strategies to establish a 'healthy dental plaque biofilm' by modulating both host and microbial factors. In this review, the present authors aim to summarise the current knowledge on dental plaque as a microbial biofilm and its properties in oral health and disease.

title: Dental plaque biofilms: communities, conflict and control.
abstract: From the very beginning of the discipline of microbiology, the dogma has been to isolate bacteria in pure culture in order to be able to define their individual properties. This process also involved the use of conventional broth (planktonic) culture to prepare biomass and to determine the phenotype of particular species. This approach provided a sound foundation for contemporary investigations of classical infectious diseases. Recently, however, there has been a renaissance in our understanding of microbial behaviour in natural habitats, and a recognition that chronic diseases can have a complex aetiology. It is now accepted that, in nature, bacteria exist for the most part attached to a surface as a biofilm, often as a member of a polymicrobial community (or consortium) of interacting species. If biofilms were merely planktonic-like cells that had adhered to a surface and the properties of a multi-species microbial community were just the sum of the constituent populations, then the scientific and clinical imperative for their study would be low. However, application of novel imaging (confocal or epifluorescence microscopy, fluorescence in situ hybridization, live ⁄ dead stains, etc.) and molecular techniques (16S rRNA gene amplification and sequence comparison, proteomics, transcriptomics, reporter gene technology, etc.) has radically altered our understanding of the biology of multi-species biofilms (Table 1), and key developments that are pertinent to the control of dental plaque are highlighted in this review. Another major shift in our understanding of microbial behaviour has come from our increased knowledge of microbial ecology (3), and recognition of the intimate relationship between the resident human microflora and the host. Changes in the host environment have a direct impact on gene expression, and thereby influence the metabolic activity, competitiveness and composition of the microflora, while the action of resident microorganisms can have consequences for the host. An appreciation of this dynamic relationship is critical to fully understand the relationship between the oral microflora and the host in health or disease.

title: Advancements toward a systems level understanding of the human oral microbiome
abstract: Oral microbes represent one of the most well studied microbial communities owing to the fact that they are a fundamental part of human development influencing health and disease, an easily accessible human microbiome, a highly structured and remarkably resilient biofilm as well as a model of bacteria-bacteria and bacteria-host interactions. In the last 80 years since oral plaque was first characterized for its functionally stable physiological properties such as the highly repeatable rapid pH decrease upon carbohydrate addition and subsequent recovery phase, the fundamental approaches to study the oral microbiome have cycled back and forth between community level investigations and characterizing individual model isolates. Since that time, many individual species have been well characterized and the development of the early plaque community, which involves many cell–cell binding interactions, has been carefully described. With high throughput sequencing enabling the enormous diversity of the oral cavity to be realized, a number of new challenges to progress were revealed. The large number of uncultivated oral species, the high interpersonal variability of taxonomic carriage and the possibility of multiple pathways to dysbiosis pose as major hurdles to obtain a systems level understanding from the community to the gene level. It is now possible however to start connecting the insights gained from single species with community wide approaches. This review will discuss some of the recent insights into the oral microbiome at a fundamental level, existing knowledge gaps, as well as challenges that have surfaced and the approaches to address them.

title: Antimicrobial photodynamic therapy suppresses dental plaque formation in healthy adults: a randomized controlled clinical trial
abstract: BackgroundOral care is important for oral and systemic health, especially for elderly institutionalized individuals and compromised patients. However, conventional mechanical plaque control is often difficult for these patients because of the pain or the risk of aspiration. Although antimicrobial photodynamic therapy (aPDT), which is considered an alternative or adjunct to mechanical approaches, has potential application as a less stressful method of daily plaque control, no clinical application of this technique has been reported.MethodsWe investigated the inhibitory effect of a combination of toluidine blue O (TBO), and a red light-emitting diode (LED) on dental plaque formation in healthy volunteers. The optimal concentration of TBO was determined in preliminary in vitro experiments to evaluate the bactericidal effect of aPDT on Streptococcus oralis and to clarify its safety in fibroblast cells. To survey the mechanism of TBO-mediated aPDT, the quality and quantity of reactive oxygen species (ROS) generated during aPDT were also examined using electron spin resonance (ESR) spectroscopy. Subsequently, the inhibitory effect of aPDT on dental plaque formation was investigated in eleven subjects as a clinical pilot study. The right or left mandibular premolars were randomly assigned to the treatment (with aPDT) or control (without aPDT) groups. In total, aPDT was applied six times (twice per day) to the teeth in the test group over a period of four days. On the fourth day, the study concluded and the analyses were performed. combination of 500 or 1000 μg/ml TBO and LED irradiation for 20 s significantly decreased the number of colony forming units of Streptococcus oralis. The cytotoxicity of aPDT was comparable to that of standard antiseptics used in the oral cavity. Hydroxyl radicals were detected by ESR analysis, but singlet oxygen was not. A randomized controlled trial demonstrated that aPDT with 1000 μg/ml TBO and red LED irradiation significantly suppressed dental plaque formation without harming teeth or the surrounding tissues.ConclusionsaPDT has the potential to be a promising novel technical modality for dental plaque control.

title: Efficacy of a triclosan formula in controlling early subgingival biofilm formation: a randomized trial.
abstract: The aim of this study was to determine the efficacy of rinses with slurries of a dentifrice containing triclosan (TCS), as compared with rinses with slurries from a control dentifrice, in controlling early subgingival biofilm formation. A double-blind, randomized and cross-over clinical trial was designed, and 26 dental students were included. In the first period, participants were randomized to rinse with a TCS slurry or a control slurry, in a 12 h interval, and to refrain from mechanical cleaning. A Plaque Free Zone Index was assessed at 24 h, 48 h, 72 h and 96 h. After a washout period of 10 days, the second experimental period was conducted, following the same protocol as the first period, except that the slurry groups were switched. Use of the TCS slurry resulted in a significantly higher percentage of plaque-free surfaces, both at 24 h and at 72 h (p < 0.01). In the of 48-72 h interval, the triclosan slurry showed a lower percentage of sites converted to a score of 2 (38.1% for the test versus 40% for the control product, p = 0.015). In conclusion, rinsing with slurries of dentifrice containing TCS retards the down growth of bacterial biofilms from the supra- to the subgingival environment.

title: The plaque control record.
abstract: A N U M B E R OF examination systems have been developed to record the oral hygiene status of an individual. Most systems use either selected teeth or the highest score for a group of teeth within a segment as the basis for their scores. When used for epidemiological studies or for evaluating the results of treatment in a study group these methods yield useful information. A numerical score, however, is of limited value for the clinician treating an individual patient. He is concerned with the locations where plaque accumulates and in the patient's progress in learning how to effectively clean these surfaces.

title: Refinement of the Modified Navy Plaque Index to increase plaque scoring efficiency in gumline and interproximal tooth areas.
abstract: To improve the assessment of plaque present on teeth, a new index, based on the original Modified Navy Plaque Index, has been developed. The primary modifications to the original Modified Navy Plaque Index were: (1) extending areas F (distal) and D (mesial) into the region just below the interproximal contact point, and (2) extending areas C and A so as to increase the gumline (or marginal gingiva) region. The new index assesses the amount of plaque in the tooth area bounded by the tooth contact, the free gingival margin, and mesial or distal line angles. The use of this new index enables the examiner to evaluate and record both the gumline (or marginal areas) and interproximal areas of the tooth, thus giving these an anatomical areas an increased importance. A pilot clinical assessment study was conducted to utilize this new index in evaluating the plaque removal efficacy of five manual toothbrushes. The results from this pilot study indicated that, when the new plaque scoring index was used, significant differences between pre-toothbrushing and post-toothbrushing plaque scores (as well as among toothbrush groups) could be demonstrated. Further, these differences (plaque removal efficacy) were demonstrated on an interproximal (mesial and distal) basis and a gumline (or gingival margin) basis, as well as on a whole mouth basis.

title: Supragingival calculus: formation and control.
abstract: Dental calculus is composed of inorganic components and organic matrix. Brushite, dicalcium phosphate dihydrate, octacalcium phosphate, hydroxyapatite, and whitlockite form the mineral part of dental calculus. Salivary proteins selectively adsorb on the tooth surface to form an acquired pellicle. It is followed by the adherence of various oral micro-organisms. Fimbriae, flagella, and some other surface proteins are essential for microbial adherence. Microbial co-aggregation and co-adhesion enable some micro-organisms, which are incapable of adhering, to adhere to the pellicle-coated tooth surface. Once organisms attach to the tooth surface, new genes could be expressed so that mature dental plaque can form and biofilm bacteria assume increased resistance to antimicrobial agents. Supersaturation of saliva and plaque fluid with respect to calcium phosphates is the driving force for plaque mineralization. Both salivary flow rate and plaque pH appear to influence the saturation degree of calcium phosphates. Acidic phospholipids and specific proteolipids present in cell membranes play a key role in microbial mineralization. The roles of crystal growth inhibitors, promoters, and organic acids in calculus formation are discussed. Application of biofilm culture systems in plaque mineralization is concisely reviewed. Anti-calculus agents used--centering on triclosan plus polyvinyl methyl ether/maleic acid copolymer, pyrophosphate plus polyvinyl methyl ether/maleic acid copolymer, and zinc ion-in commercial dentifrices are also discussed in this paper.

title: Subgingival calculus: where are we now? A comparative review.
abstract: To critically analyse the formation, composition, ethnic variations and pathogenic potential of subgingival calculus in comparison with supragingival calculus.



Using CD-ROM and index medicus, scientific papers relating to subgingival calculus or subgingival and supragingival calculus written in the English language since 1960 were considered, with the emphasis on more recent articles.



Studies were selected for their relevance and contemporary nature re:composition and formation of dental calculus and comparisons of ethnic groups with regard to dental calculus, especially subgingival calculus. Some similar studies were not included.



Abstracts of studies were kept brief unless particularly important to the review. 
Similarities and differences between supragingival and subgingival calculus in composition and formation were shown. Different morphological types of subgingival calculus were demonstrated. There was evidence for an association between calculus formation and ethnicity with regard to supragingival and subgingival calculus, and an association between subgingival calculus composition and ethnicity was indicated.



An association between ethnicity and subgingival calculus formation and composition was found. Further research into the reasons for these ethnic differences in dental calculus and the role of the mineral constituents especially of subgingival calculus would be valuable.

title: Dental calculus: recent insights into occurrence, formation, prevention, removal and oral health effects of supragingival and subgingival deposits.
abstract: Dental calculus, both supra- and subgingival occurs in the majority of adults worldwide. Dental calculus is calcified dental plaque, composed primarily of calcium phosphate mineral salts deposited between and within remnants of formerly viable microorganisms. A viable dental plaque covers mineralized calculus deposits. Levels of calculus and location of formation are population specific and are affected by oral hygiene habits, access to professional care, diet, age, ethnic origin, time since last dental cleaning, systemic disease and the use of prescription medications. In populations that practice regular oral hygiene and with access to regular professional care, supragingival dental calculus formation is restricted to tooth surfaces adjacent to the salivary ducts. Levels of supragingival calculus in these populations is minor and the calculus has little if any impact on oral-health. Subgingival calculus formation in these populations occurs coincident with periodontal disease (although the calculus itself appears to have little impact on attachment loss), the latter being correlated with dental plaque. In populations that do not practice regular hygiene and that do not have access to professional care, supragingival calculus occurs throughout the dentition and the extent of calculus formation can be extreme. In these populations, supragingival calculus is associated with the promotion of gingival recession. Subgingival calculus, in "low hygiene" populations, is extensive and is directly correlated with enhanced periodontal attachment loss. Despite extensive research, a complete understanding of the etiologic significance of subgingival calculus to periodontal disease remains elusive, due to inability to clearly differentiate effects of calculus versus "plaque on calculus". As a result, we are not entirely sure whether subgingival calculus is the cause or result of periodontal inflammation. Research suggests that subgingival calculus, at a minimum, may expand the radius of plaque induced periodontal injury. Removal of subgingival plaque and calculus remains the cornerstone of periodontal therapy. Calculus formation is the result of petrification of dental plaque biofilm, with mineral ions provided by bathing saliva or crevicular fluids. Supragingival calculus formation can be controlled by chemical mineralization inhibitors, applied in toothpastes or mouthrinses. These agents act to delay plaque calcification, keeping deposits in an amorphous non-hardened state to facilitate removal with regular hygiene. Clinical efficacy for these agents is typically assessed as the reduction in tartar area coverage on the teeth between dental cleaning. Research shows that topically applied mineralization inhibitors can also influence adhesion and hardness of calculus deposits on the tooth surface, facilitating removal. Future research in calculus may include the development of improved supragingival tartar control formulations, the development of treatments for the prevention of subgingival calculus formation, the development of improved methods for root detoxification and debridement and the development and application of sensitive diagnostic methods to assess subgingival debridement efficacy.

title: Anticalculus efficacy of a chewing gum with polyphosphates in a twelve-week single-blind trial.
abstract: A twelve-week clinical study was conducted to evaluate the effect of a chewing gum containing pyrophosphate (1%) and tripolyphosphate (1%) on controlling supragingival calculus deposits.



One-hundred and seventeen subjects enrolled in the study were randomly assigned to either a test gum or no gum group. Each participant received a full oral prophylaxis. Those chewing the test gum agreed to chew four times a day for five minutes each time over twelve weeks. Those assigned to the no gum group agreed not to chew any gum. After twelve weeks, participants were scored for calculus deposits using the modified Volpe-Manhold Calculus Index (VMI), received a second oral prophylaxis and entered the alternate group in this cross-over format. At the end of the twenty-fourth week, all subjects were again scored for calculus deposits and the study was completed. All participants received a supply of a sodium fluoride (0.32%) dentifrice for the study period. Calculus levels were scored by the same examiner for all measurements and recorded on computer. He was blinded to all treatment assignments.



One-hundred and eleven participants completed the study. Six participants left the study but none reported problems linked to the pyrophosphates in the chewing gum. The VMI mean score for the test gum group was 2.55 (+/- 2.50) and the mean score for the no gum group was 4.09 (+/- 3.18). The difference between the mean scores was highly significant with paired sample t-test (p < 0.0001).



The results indicated that a chewing gum containing tripolyphosphate and pyrophosphate reduced calculus formation by 37.6% compared to a no gum treatment.

title: A double blind randomised controlled clinical trial comparing a novel anti-stain and calculus reducing dentifrice with a standard fluoride dentifrice.
abstract: This clinical trial tested the anti-stain efficacy at 3 and 6 months of a novel, sodium polyaspartate-containing, anti-stain dentifrice. In addition, the efficacy of the new dentifrice in controlling gingival inflammation and inhibition of calculus deposition was tested.



Participants were recruited to this double blind randomised control clinical trial, and allocated to either test or control groups. The presence of stain and calculus were entry criteria. Measurements of stain, calculus and gingival inflammation were recorded using the Shaw and Murray Stain score, Volpe-Manhold Calculus score and the Modified Gingival Index respectively. Measurements were made at baseline, prior to the removal of stain and calculus, and after 3 and 6 months. Missing data were imputed by and the outcomes were analysed using univariate analysis.



At three months, toothpaste containing sodium polyaspartate was better (difference of mean 1.13 with SEM 0.57) than control for the control of dental stain (p<0.05). Stain scores also showed a trend in favour of the test product (difference of mean 1.03 with SEM 0.78) at six months (p>0.05). There was no difference between toothpastes with respect to calculus deposition or gingival inflammation.



Toothpaste containing sodium polyaspartate was more effective than a control toothpaste at preventing deposition of dental stain for 3 months after professional tooth cleaning but showed no significant effect at 6 months.



Sodium polyaspartate toothpaste was more effective than a control toothpaste at preventing dental stain formation and maybe helpful in controlling staining between episodes of scaling and polishing.

title: Dental enamel formation and its impact on clinical dentistry.
abstract: The nature of tooth enamel is of inherent interest to dental professionals. The current-day clinical practice of dentistry involves the prevention of enamel demineralization, the promotion of enamel remineralization, the restoration of cavitated enamel where demineralization has become irreversible, the vital bleaching of dental enamel that has become discolored, and the diagnosis and treatment of developmental enamel malformations, which can be caused by environmental or genetic factors. On a daily basis, dental health providers make diagnostic and treatment decisions that are influenced by their understanding of tooth formation. A systemic condition during tooth development, such as high fever, can produce a pattern of enamel defects in the dentition. Knowing the timing of tooth development permits estimates about the timing of the disturbance. The process of enamel maturation continues following tooth eruption, so that erupted teeth can become less susceptible to decay over time. Mutations in the genes encoding enamel proteins lead to amelogenesis imperfecta, a collection of inherited diseases having enamel malformations as the predominant phenotype. Defects in the amelogenin gene cause X-linked amelogenesis imperfecta, and genes encoding other enamel proteins are candidates for autosomal forms. Here we review our current understanding of dental enamel formation, and relate this information to clinical circumstances where this understanding may be particularly relevant.

title: Investigation of erosion and abrasion on enamel and dentine: a model in situ using toothpastes of different abrasivity.
abstract: Studies in vitro suggest that abrasion and erosion may act synergistically to produce wear of enamel and dentine. Methods in situ are recently available to study separately erosion and abrasion of dental tissues. The aim of this study was to combine two in situ protocols to study the interplay between erosion and abrasion of enamel and dentine.



The study was a single-blind, randomised, five-treatment cross-over design involving 15 healthy volunteers. During each 10-day study period, subjects wore from 0900 to 1700 h an upper removable acrylic appliance holding one polished enamel and one polished dentine specimen. The specimen treatment regimens were: 1. Drinking water and brushing with toothpaste A. 2. Drinking water and brushing with toothpaste B. 3. Drinking orange juice. 4. Drinking orange juice and brushing with toothpaste A. 5. Drinking orange juice and brushing with toothpaste B. Drinking and brushing times were around 0900, 1100, 1300 and 1500 h. Drinks were consumed as 250 ml over 10 min and brushing ex vivo for 1 min to each specimen. Measurement of tissue loss was made on days 5 and 10 of each period using a profilometer.



All treatments produced increasing tissue loss over time, which was considerably greater for dentine than enamel. For enamel, the data at days 5 and 10 showed a significant effect for erosion (i.e. orange juice was significantly more erosive than water), but no significant effect for abrasion (i.e. no significant difference between the two toothpaste treatments). The combined orange juice and toothpaste effects were directional for synergy but did not reach significance. For dentine at day 10, many specimens exceeded the 50 microm set limit of the profilometer and only day 5 data were considered. There were significant effects for erosion (orange juice produced significantly more erosion than water) and for abrasion (paste A was significantly more abrasive to dentine than paste B). The synergy effect could not be examined for dentine due to the truncation effect as the set limit of the profilometer was exceeded.



Erosion increases the susceptibility of enamel to toothpaste abrasion. Dentine is considerably more susceptible than enamel to erosion and abrasion alone or combined. Dentine loss appears to correlate with toothpaste abrasivity (RDA value).

title: Gum Containing Calcium Fluoride Reinforces Enamel Subsurface Lesions in situ
abstract: The aim of this study was to assess the effect of chewing gum containing phosphoryl oligosaccharides of calcium (POs-Ca) and a low concentration of fluoride (F) on the hardness of enamel subsurface lesions, utilizing a double-blind, randomized, and controlled in situ model. Fifteen individuals wore removable lingual appliances with 3 bovine-enamel insets containing subsurface demineralized lesions. Three times a day for 14 days, they chewed one of the 3 chewing gums (placebo, POs-Ca, POs-Ca+F). After the treatment period, cross-sectional mineral content, nanoindentation hardness, and fluoride ion mapping by time-of-flight secondary ion mass spectrometry (TOF-SIMS) were evaluated. Although there were no statistical differences in overall mineral content and hardness recovery rates between POs-Ca and POs-Ca+F subsurface lesions (p > 0.05), nanoindentation at 1-μm distance increments from the surface showed statistical differences in hardness recovery rate between POs-Ca and POs-Ca+F in the superficial 20-μm region (p < 0.05). Fluoride mapping revealed distribution of the ion up to 20 μm from the surface in the POs-Ca+F group. Nanoindentation and TOF-SIMS results highlighted the benefits of bioavailability of fluoride ion on reinforcement of the superficial zone of subsurface lesions in situ (NCT01377493).

title: The relationship between enamel softening and erosion caused by soft drinks at a range of temperatures.
abstract: Investigations of the erosive potential of soft drinks are usually performed at room or body temperature, but drinks are more frequently served chilled, with ice, or hot. Since the rate of chemical reactions usually increases with temperature, it is predicted that erosion is more severe at high temperatures and reduced at low temperatures. The aim of this study was to investigate the correlation between enamel softening, enamel erosion, and temperature.



Atomic force microscopy nanoindentation and non-contact optical profilometry were used to assess changes in enamel nanomechanical properties after 5 min and erosive material loss after 30 min exposure to two different non-carbonated soft drinks at 4, 25, 50 and 75 degrees C.



For one drink (Robinson's Original Juice Drink), there was a statistically significant difference between nanomechanical properties and erosion depth at all temperatures, with softening and erosion increasing with temperature. For another drink (Ribena ToothKind Juice Drink), there was a slight softening and virtually no material loss, and temperature had no statistically significant impact on erosion. There was a good linear correlation (R2 = 0.94) between nanomechanical properties and material loss.



The difference between the drinks can be explained by their composition. For the erosive drink, material loss increased, and nanohardness decreased, approximately linearly with temperature. The correlation between softening and erosion demonstrated that nanomechanical properties after very short erosion times can be considered a good predictor of bulk material loss after considerably longer erosion times.

title: Effect of different splint removal techniques on the surface roughness of human enamel: a three-dimensional optical profilometry analysis.
abstract: Because there is no standard protocol for the removal of resin-based materials that retain semi-rigid trauma splints on teeth, iatrogenic enamel damage caused by various splint removal techniques has remained unknown. The purpose of this study was to evaluate the effect of five different resin removal techniques (H6/H7 scaler, ultrafine diamond bur, ultrasonic scaler, 16-blade tungsten carbide bur, and Sof-Lex disks) on the surface roughness of human enamel. Three-dimensional white-light interferometry, a non-contact profilometry technique, was used to obtain qualitative and quantitative measurements of surface roughness both at baseline and after finishing procedures. Statistical analysis using Friedman test and Wilcoxon signed ranks test showed that the roughest enamel surface was obtained after splint removal with the hand scaler (P < 0.05). Overall, the smoothest enamel surface was obtained after removal of resin with Sof-Lex disks and the 16-blade tungsten carbide bur (P < 0.05).

title: Dental caries
abstract: Dental caries, otherwise known as tooth decay, is one of the most prevalent chronic diseases of people worldwide; individuals are susceptible to this disease throughout their lifetime. Dental caries forms through a complex interaction over time between acid-producing bacteria and fermentable carbohydrate, and many host factors including teeth and saliva. The disease develops in both the crowns and roots of teeth, and it can arise in early childhood as an aggressive tooth decay that aff ects the primary teeth of infants and toddlers. Risk for caries includes physical, biological, environmental, behavioural, and lifestyle-related factors such as high numbers of cariogenic bacteria, inadequate salivary fl ow, insuffi cient fl uoride exposure, poor oral hygiene, inappropriate methods of feeding infants, and poverty. The approach to primary prevention should be based on common risk factors. Secondary prevention and treatment should focus on management of the caries process over time for individual patients, with a minimally invasive, tissue-preserving approach.

title: Sex/Gender differences in tooth loss and edentulism: historical perspectives, biological factors, and sociologic reasons.
abstract: This review highlights what is known regarding differences in tooth loss by sex/gender, and describes: gender-related tooth ablation (the deliberate removal of anterior teeth during life) found in skulls from history and prehistory; potential mediators of the relationship between sex/gender and tooth loss; the current epidemiology of gender differences in tooth loss (limited to North America); and risk factors for tooth loss in the general population and in women.

title: A 24-month Clinical Study of the Incidence and Progression of Dental Caries in Relation to Consumption of Chewing Gum Containing Xylitol in School Preventive Programs
abstract: The effect of chewing gum containing xylitol on the incidence and progression of dental caries was tested in a sample of 274 children, aged eight and nine years, of low socio-economic status and high caries rate. They were divided into two experimental groups (15% and 65% xylitol chewing gum distributed three times a day at school) and one control group (without chewing gum). The three groups were exposed to the same basic preventive program. Children who chewed gum had a significantly lower net progression of decay (progressions-reversals) over a 24-month period than did the controls. Results for the two groups chewing gum were similar. Chewing xylitol gum had a beneficial effect on the caries process for all types of tooth surfaces, and especially for bucco-lingual surfaces. The two experimental groups had a DMF(S) increment of 2.24 surfaces, compared with 6.06 surfaces for the control group. For this indicator, there was no difference between the two experimental groups. Results for the plaque index were in agreement with those of the DMF(S) increment and the net progression of decay.

title: Effectiveness of Fluoride in Preventing Caries in Adults
abstract: To date, no systematic reviews have found fluoride to be effective in preventing dental caries in adults. The objective of this meta-analysis was to examine the effectiveness of self- and professionally applied fluoride and water fluoridation among adults. We used a random-effects model to estimate the effect size of fluoride (absolute difference in annual caries increment or relative risk ratio) for all adults aged 20+ years and for adults aged 40+ years. Twenty studies were included in the final body of evidence. Among studies published after/during 1980, any fluoride (self- and professionally applied or water fluoridation) annually averted 0.29 (95%CI: 0.16–0.42) carious coronal and 0.22 (95%CI: 0.08–0.37) carious root surfaces. The prevented fraction for water fluoridation was 27% (95%CI: 19%–34%). These findings suggest that fluoride prevents caries among adults of all ages.

title: Xylitol in preventing dental caries: A systematic review and meta-analyses
abstract: Xylitol is a sugar alcohol having the properties that reduce levels of mutans streptococci (MS) in the plaque and saliva. To assess the role of xylitol in preventing dental caries. Systematic review and meta-analysis developed by Cochrane cooperation were adapted. Electronic search was carried out in PubMed through the period up to 2014. Included clinical studies were done on (1) humans (2) participants include both individuals and as pairs (mother-child) (3) participants using orthodontic appliances (4) xylitol dispensed in any form (5) compare the effect of xylitol on dental caries and on other phenotype that determines the preventive effect on dental caries, such as decayed, missing, and filled (DMF/dmf) and salivary or plaque MS level. Twenty articles of the 477 articles initially identified. Among 20 studies indexed, 16 articles were accessed, systematically reviewed, and the meta-analysis was carried out. The evaluation of quality of the studies was done using risk of bias assessment tool. The quality of the studies was high risk and unclear risk for six and five trials. The meta-analysis shows a reduction in DMF/dmf with the standard mean (SM) of −1.09 (95% confidence interval [95% CI], −1.34, −0.83) comparing xylitol to all controls. The effect of DMF/dmf reduction by xylitol to fluoride varnish was with the SM of −1.87 (95% CI, −2.89, −0.84). The subgroup analysis, there was a reduction in MS count with SM of 0.30 (95% CI, 0.05, 0.56) when compared with all other caries preventive strategies; however, it was insignificant. Xylitol was found to be an effective strategy as self-applied caries preventive agent.

title: The impact of polyol-containing chewing gums on dental caries: a systematic review of original randomized controlled trials and observational studies.
abstract: The authors conducted a systematic review of original studies that was designed to assess the impact of polyol-containing chewing gum on dental caries compared with the effect with no chewing gum.



The authors searched MEDLINE, The Cochrane Library and Google Scholar up to May 2008 to identify peer-reviewed articles that compared polyol-containing chewing gum with no chewing gum. The authors extracted study characteristics, data on incremental dental caries and quality by consensus. Data on prevented fraction (PF) were pooled across studies.



The results of 19 articles with data from 14 study populations showed that the use of xylitol, xylitol-sorbitol blend and sorbitol were associated with mean PF (95 percent confidence interval) of 58.66 percent (35.42-81.90), 52.82 percent (39.64-66.00) and 20.01 percent (12.74-27.27), respectively. For the sorbitol-mannitol blend, it was 10.71 percent (-20.50-41.93), which was not statistically significant. Sensitivity analyses confirmed the robustness of the findings.



Although research gaps exist, particularly on optimal dosing and relative polyol efficacy, research evidence supports using polyol-containing chewing gum as part of normal oral hygiene to prevent dental caries.

title: Vitamin D and dental caries in controlled clinical trials: systematic review and meta-analysis.
abstract: Vitamin D has been used to prevent and treat dental caries. The objective of this study was to conduct a systematic review of controlled clinical trials (CCTs) assessing the impact of vitamin D on dental caries prevention. Random-effects and meta-regression models were used to evaluate overall and subgroup-specific relative-rate estimates. Twenty-four CCTs encompassing 2,827 children met the inclusion criteria. Twenty-two of the 24 CCTs predated modern clinical trial design, some of which nonetheless reported characteristics such as pseudo-randomization (n = 2), blinding (n = 4), or use of placebos (n = 8). The relative-rate estimates of the 24 CCTs exhibited significant heterogeneity (P < 0.0001), and there was evidence of significant publication bias (P < 0.001). The pooled relative-rate estimate of supplemental vitamin D was 0.53 (95% CI, 0.43-0.65). No robust differences were identified between the caries-preventive effects of vitamin D(2) , vitamin D(3) , and ultraviolet radiation (Prob > F = 0.22). The analysis of CCT data identified vitamin D as a promising caries-preventive agent, leading to a low-certainty conclusion that vitamin D may reduce the incidence of caries.

title: Visual Inspection for Caries Detection
abstract: We aimed to perform a systematic review including a meta-analysis to evaluate the overall accuracy of visual methods for detecting carious lesions and to identify possible sources of heterogeneity among the studies included. Two reviewers searched PubMed, Embase, Scopus, and other sources through July 2014 to identify published and nonpublished studies in English. Studies of visual inspection were included that 1) assessed accuracy of the method in detecting caries lesions; 2) were performed on occlusal, proximal, or free smooth surfaces in primary or permanent teeth; 3) had a reference standard; and 4) reported sufficient data about sample size and accuracy of methods. The data were used to calculate the pooled sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristics curve. Heterogeneity of the studies was also assessed. A total of 102 manuscripts (from 5,808 articles initially identified) and 1 abstract (from 168) met the inclusion criteria. In general, the analysis demonstrated that the visual method had good accuracy for detecting caries lesions. Although laboratory and clinical studies have presented similar accuracy, clinically obtained specificity was higher. We also observed moderate to high heterogeneity and evidence of publication bias in most papers. Moreover, studies employing widely recognized visual scoring systems presented significantly better accuracy as compared to studies that used their own criteria. In conclusion, visual caries detection method has good overall performance. Furthermore, although the identified studies had high heterogeneity and risk of bias, the use of detailed and validated indices seems to improve the accuracy of the method.

title: Dental plaque as a biofilm: the significance of pH in health and caries.
abstract: Dental plaque is an example of a biofilm; its presence is natural and it supports the host in its defense against invading microbes. In health, the microbial composition of dental plaque is diverse and remains relatively stable over time (microbial homeostasis). The predominant microorganisms prefer host molecules (eg, salivary mucins) and a neutral pH for growth. Under certain circumstances, this microbial homeostasis can break down and diseases such as caries can occur. In dental caries, there is a shift toward increased proportions of acid-producing and acid-tolerating species, such as mutans streptococci and Lactobacilli, although other species with relevant traits can participate in demineralization. Strategies to control caries include effective oral hygiene practices to reduce biofilm development, and adoption of a low-sugar diet to restrict periods of acidic challenge to teeth. These conventional approaches also should be augmented by interference with the factors that enable the cariogenic bacteria to outcompete the organisms associated with health. Evidence suggests that regular conditions of low pH in plaque select for mutans streptococci and Lactobacilli. Therefore, the suppression of sugar catabolism and acid production by the use of metabolic inhibitors in oral care products, the consumption of nonfermentable sweeteners in snacks, the stimulation of saliva flow, and/or other strategies that maintain supragingival plaque at a pH around neutrality will assist in the maintenance of microbial homeostasis in plaque.

title: In vivo dental plaque pH after consumption of dairy products.
abstract: This in vivo study assessed plaque pH in subjects following the consumption of different dairy products. After receiving parental consent to participate, subjects (12-15 years old) were asked to refrain from brushing their teeth for 48 hours prior to the study. At baseline, plaque pH was determined at 4 different sites. Each of the subjects was then assigned randomly to 1 of 4 subgroups and each subgroup was given either cheese, milk, yogurt, or paraffin (control). After baseline, all subjects were allowed to chew and/or swish their respective product for 3 minutes and pH was assessed subsequently at different time intervals. Statistical analysis was performed using unpaired t-test and 1-way ANOVA. The results showed a statistically significant change in mean plaque pH after consuming different dairy products, as the plaque pH after 30 minutes was higher in the cheese group than that of the milk and yogurt groups, both of which showed a pH toward baseline after 30 minutes. These results suggest that cheese has the highest anticariogenic property among the dairy products studied, and that milk and yogurt can be considered as noncariogenic.

title: Effect of Psidium cattleianum leaf extract on enamel demineralisation and dental biofilm composition in situ.
abstract: Previous evaluations of Psidium cattleianum leaf extract were not done in conditions similar to the oral environment. The aim of this study was to evaluate the effect of P. cattleianum leaf extract on enamel demineralisation, extracellular polysaccharide formation, and the microbial composition of dental biofilms formed in situ.



Ten volunteers took part in this crossover study. They wore palatal appliances containing 4 enamel blocks for 14 days. Each volunteer dripped 20% sucrose 8 times per day on the enamel blocks. Twice a day, deionised water (negative control), extract, or a commercial mouthwash (active control) was dripped after sucrose application. On the 12th and 13th days of the experiment, plaque acidogenicity was measured with a microelectrode, and the pH drop was calculated. On the 14th day, biofilms were harvested and total anaerobic microorganisms (TM), total streptococci (TS), mutans streptococci (MS), and extracellular polysaccharides (EPS) were evaluated. Enamel demineralisation was evaluated by the percentage change of surface microhardness (%ΔSMH) and integrated loss of subsurface hardness (ΔKHN). The researcher was blinded to the treatments during data collection.



The extract group showed lower TM, TS, MS, EPS, %ΔSMH, and ΔKHN values than the negative control group. There were no differences between the active and negative control groups regarding MS and EPS levels. There were no differences in pH drop between the extract and active control groups, although they were significantly different from the negative control group. For all other parameters, the extract differed from the active control group.



Psidium cattleianum leaf extract exhibits a potential anticariogenic effect.

title: Developments in dental plaque pH modelling.
abstract: The objectives of this review were to give a comprehensive account of the methods used to determine dental plaque pH over the last 50 years, to review how these methods have been used in dental cariology research and to give an update as to how dental plaque pH studies might be developed in the future.



Published, referred papers and abstracts of conference proceedings in the literature were reviewed.



A comprehensive search of the electronic databases PubMed and Medline, was undertaken. In addition, a hand search of the Index Denticus was done to identify relevant citations before 1966.



Relevant published literature in peer-reviewed publications was reviewed. No additional inclusion criteria were applied.



This comprehensive review gives an account of the background to, history of, relative merits and demerits of, applications of and future of dental plaque pH technologies.

title: Influence of drinking method on tooth-surface pH in relation to dental erosion.
abstract: The aim of this investigation was to study the intraoral pH response on tooth surfaces in relation to dental erosion during and after drinking a sugar-free cola-type soft drink. Six different methods of drinking were tested in a randomized order: holding; short-sipping; long-sipping; gulping; nipping; and sucking. Two methods of pH measurement were used in two series of individuals. In the first series, pH was measured by using the microtouch method in 12 healthy adults at three dental erosion-prone sites: 11 palatally; 11 buccally; and at the mesiobuccal cusp tip of 16. In the second series, pH was measured by using the telemetric method in 6 healthy individuals, producing continuous recordings of pH by means of a glass electrode in a specified approximal area. The two series showed similar results, although the telemetric method generally recorded larger pH falls. Holding the drink in the mouth before swallowing led to the most pronounced pH drop, followed by the long-sipping method. Gulping resulted in only a small decrease of pH. No differences among the three intraoral sites were found when analyzed by using the microtouch method. The conclusion from this study is that the drinking method strongly affects tooth-surface pH and thereby the risk for dental erosion. It therefore seems appropriate to include advice on the method of drinking in dietary counseling related to dental erosion.

title: Effect of plaque accumulation and salivary factors on enamel demineralization and plaque composition in situ.
abstract: This study evaluated the effect of some plaque and salivary factors on caries progression in situ. The salivary secretion rate, buffering capacity and mutans streptococci counts from 13 volunteers were determined. For three distinct periods of time, 4, 7 and 10 days, each of them wore a palatal appliance containing 4 bovine enamel blocks. They used a non-fluoridated dentifrice during the experiment and a 20% sucrose solution was dripped onto the blocks 10 times a day. Mutans streptococci (MS), calcium (Ca), and insoluble polysaccharide (IP) were quantified in the dental plaque formed on the enamel blocks, after each period. Enamel demineralization was assessed by surface microhardness, and the percentage of surface microhardness change (%SMC) in relation to the baseline values was calculated. Enamel demineralization occurred after each period of plaque accumulation (p < 0.05), and the %SMC increased with time (from 13.8 to 48.3%). The concentrations of Ca and IP in plaque were not statistically different among the experimental times, but significant correlations were found between these concentrations and %SMC. Neither the salivary factors assessed initially nor mutans streptococci in plaque presented statistically significant correlations to %SMC. The results suggest that enamel demineralization is time-dependent and is more related to the composition of the biofilm formed than to the salivary factors studied.

title: Evaluation of the pH of a new carbonated soft drink beverage: an in vivo investigation.
abstract: Recently, a modified version of a successful soft drink has been developed that aims to reduce the potential for dental erosion in consumers. The aim of this investigation was to compare the effect of the modified and original formula soft drink on the pH at various tooth surfaces during and after ingestion in subjects without erosion.



Fifteen subjects (10 female and 5 male) without dental erosion drank both a modified and an unmodified beverage for over 5 minutes in a randomized order. Oral pH was measured with antimony electrodes positioned on the labial and palatal surfaces of an incisor and premolar and held in place by a close-fitting vacuum-formed appliance. The results were compared (using the Wilcoxon signed rank test, with matched pairs) for the percentage and total time that pH fell below 4, 5, and 5.5.



The percentage and total time that pH fell below 4 was significantly different between the drinks (P <0.02), but the total time that pH fell below 5 and 5.5 was not. The time taken for subjects to return to pre-exposure pH levels in the mouth showed considerable variation between individuals.



The modified-formula drink appeared to have less erosive potential than the original formula when assessed by measuring pH at the tooth surface. Although the erosive potential has been reduced by modifying the soft drink, it has not been eliminated.

title: Meta‐Analysis of Salivary Flow Rates in Young and Older Adults
abstract: To determine whether salivary flow decreases as a function of aging.

title: Health benefits of saliva: a review.
abstract: The aim is to present a review of the literature on human saliva composition, flow rates and some of the health benefits of saliva, with emphasis on studies from our laboratory that have looked at effects of age and age-related diseases on saliva output and composition.



Saliva influences oral health both through its non-specific physico-chemical properties, as well as through more specific effects. The proline-rich proteins, statherin and the histatins are salivary proteins that influence calcium phosphate chemistry, initial plaque formation and candida infection. Increases or decreases in mastication may affect saliva output. Our cross-sectional studies of saliva in a large population-based study cohort (N=1130) indicate that there is an age-related decline in saliva output for unstimulated whole, stimulated parotid, unstimulated submandibular/sublingual and stimulated submandibular/sublingual saliva, as well as some compositional alterations in anti-microbial and other proteins. Some of these alterations also appear to be specific for certain age-related medical conditions, such as diabetes mellitus.



These studies and data presented confirm the importance of saliva in maintaining a healthy oral environment; the practitioner is encouraged to consider saliva output and medical conditions that may compromise it as part of routine dental treatment planning.

title: Review: The physiology of saliva and transfer of drugs into saliva.
abstract: Although saliva or oral fluid "lacks the drama of blood, the sincerity of sweat and the emotional appeal of tears", quoting Mandel in 1990 [I.D. Mandel, The diagnostic uses of saliva,  (1990) 119-125], it is now meeting the demand for inexpensive, non-invasive and easy-to-use diagnostic aids for oral and systemic diseases, drug monitoring and detection of illicit use of drugs of abuse, including alcohol. As the salivary secretion is a reflex response controlled by both parasympathetic and sympathetic secretomotor nerves, it can be influenced by several stimuli. Moreover, patients taking medication which influences either the central nervous system or the peripheral nervous system, or medication which mimic the latter as a side effect, will have an altered salivary composition and salivary volume. Patients suffering from certain systemic diseases may present the same salivary alterations. The circadian rhythm determines both the volume of saliva that will and can be secreted and the salivary electrolyte concentrations. Dietary influences and the patient's age also have an impact on composition and volume of saliva. The latter implies a wide variation in composition both inter- and intra-individually. Sampling must therefore be performed under standardized conditions. The greatest advantage, when compared to blood sample collection, is that saliva is readily accessible and collectible. Consequently, it can be used in clinically difficult situations, such as in children, handicapped and anxious patients, where blood sampling could be a difficult act to perform.

title: The potential benefits of sugar-free chewing gum on the oral health and quality of life of older people living in the community: a randomized controlled trial.
abstract: To determine the effects of prescribing sugar-free chewing gum on the oral health and quality of life of dentate older people living in the community and attending for routine dental care.



A randomized controlled trial was conducted on 186 older people who were not regular chewers of gum, (aged 60 years and over with ≥ 6 teeth) recruited from primary care clinics. Participants were randomly allocated to a gum-chewing group (chewing xylitol-containing gum twice a day for 15 min; n = 95) or a control group (no gum; n = 91). Both groups were examined at baseline and at the end of the study (6 months later). The primary outcome measure for the study was increased in stimulated saliva flow rate. Secondary measures included improvements in Plaque and Gingival Indices, and self-perceived change in oral health.



The retention rate for the study was 78.5% (n = 146 at follow-up); reported compliance with the protocol was 84% (ranged between 12% and 100%). There was no significant change in the saliva flow of the gum-chewing group (1.20-1.17 ml/min), while the control group experienced an increase in flow rate (1.06-1.32 ml/min; P = 0.001). The gum-chewing group, however, demonstrated significant improvement in Plaque and Gingival Index scores over the control group. For the Plaque Index, the mean scores (±SD) were 0.29 (±0.29) and 0.56 (±0.46) for the gum-chewing group and control groups, respectively (P < 0.001), at the second examination, which remained significant after controlling for age and saliva flow rate. For the Gingival Index, the scores were 0.73 (±0.30) and 0.92 (±0.32), respectively (P < 0.001), which persisted after controlling for age. A significantly higher proportion of participants in the gum-chewing group perceived that their oral health had improved during the study period in comparison with the control group (40% cf 21%; P = 0.016).



Prescription of sugar-free chewing gum to dentate older people living in the community and attending routine dental services was not associated with a significant increase in stimulated saliva flow. There were, however, significant improvements in Plaque and Gingival Index scores, and in self-perceived oral health.

title: Xerostomia: evaluation of a symptom with increasing significance.
abstract: Xerostomia is the subjective sensation of oral dryness. Although it is most commonly associated with salivary gland dysfunction, it may also occur with normal gland activity. Xerostomia may be an early symptom of several morbid systemic conditions with important implications for the medical and dental management of patients. Oral dryness also has negative effects on an individual's emotional well-being and quality of life. The complaint of xerostomia necessitates a complete evaluation of a patient's general health, salivary gland function, and oral motor and sensory abilities. The salivary gland assessment includes symptom review, analysis of glandular secretions, scintiscanning, and minor labial gland biopsy. No single component is sufficient to adequately diagnose the presence, extent, or cause of salivary dysfunction. Treatment of a dry mouth, to date, is mainly palliative in nature, with the intent of preserving oral structures and functions. Better therapies are essential in the management of xerostomia, whatever the cause. The importance of xerostomia as a symptom is increasingly recognized in medicine and dentistry. The dentist is commonly the first health professional to hear this complaint and may be critical in directing a full and appropriate evaluation.

title: A Novel System of Human Submandibular/Sublingual Saliva Collection
abstract: The assessment of submandibular/sublingual (sm/sl) saliva is a procedure of increasing significance. However, the collection of these fluids by traditional techniques is difficult and therefore often neglected. To collect sm/sl saliva, we have assembled a novel, universal system consisting of four parts-collecting tubing, a buffering chamber, a storing tube, and a suction device. Submandibular/sublingual saliva samples were collected from ten healthy and ten xerostomic individuals. The system showed intra-examiner reproducibility of 0.92 for healthy and 0.89 for xerostomic subjects, and inter-examiner reproducibility of 0.93 for normal subjects and 0.80 for xerostomic individuals. The flow rates obtained by the present collecting set-up were similar to those measured by all known previous methods that were published during the last 40 years. The system was also efficient, in that more than 90% of the fluid that entered the system was eventually collected in the storing tube for analysis. The system appears to collect relatively pure sm/sl fluids, since contamination of the collected sample by a stimulant solution swabbed repeatedly over the tongue during saliva collection was minimal. The system is reliable, safe, practical, and comfortable for the patient.

title: Update knowledge of dry mouth- A guideline for dentists.
abstract: Dry mouth is usually caused by a reduced salivary flow or by changes in the biochemical composition of saliva.



The aim of this paper is a review of the update literature of dry mouth.



We search in pubmed in the past 10 years using the words «dry mouth», «causes», «symptoms», «treatment» and «dentistry». A large number of papers have been identified. Papers not relevant to the issue were removed reducing the entries to 56 only.



There are no clearly established protocols for the treatment of dry mouth in the literature. Most of identified papers were systematic reviews, non-systematic reviews, and observational studies. The most studied patients were Sjögren's syndrome and the irradiated patients. Treatments are focused on the etiology, prevention, symptomatic, local salivary stimulation and systemic treatments.



It can be concluded that there is no clear evidence for the causes and treatment of dry mouth, therefore the majority of the general dental practitioners refer most of the cases to appropriate specialist. Treatment must be individualized, salivary substitutes and mechanical stimulation techniques can be applied.

title: The role of saliva in oral health: strategies for prevention and management of xerostomia.
abstract: Oral complications are the most frequent and debilitating sequelae of radiation treatment for patients with head and neck cancer. Impaired salivary function and consequent xerostomia can persist for years after radiation treatment, significantly increasing the risk of oral and dental disease and negatively affecting patients' quality of life. Current evidence indicates that many patients undergoing radiation treatment do not receive adequate oral and dental care and follow-up and that patients' compliance with oral care recommendations is frequently poor. Topical lubricants, coating agents,and saliva substitutes or lozenges may provide transient relief from xerostomia. Cholinergic stimulants such as pilocarpine improve salivary flow but have had mixed results in improving patients' assessments of symptoms or other quality-of-life measures. Advances in radiotherapy techniques, such as intensity-modulated radiation therapy, have enabled increased delivery of therapeutic doses of radiation to tumors while limiting exposure to normal tissues, thereby reducing the incidence, duration, and severity of xerostomia in some patients with head and neck cancers. Additionally, radioprotective agents such as amifostine have been shown to reduce radiation-induced toxicity to normal tissues within the radiation field. Studies are ongoing to determine the optimal approaches for these techniques and agents to maximize clinical response while improving the overall quality of life for patients with head and neck cancer.

title: Perception of dry mouth in a sample of community-dwelling older adults in Japan.
abstract: The purpose of this study was to examine the prevalence of perceived dry mouth among a group of independently-living elderly persons in Japan, and to determine its association with general disease, medication, and dental status, as well as its effect on oral function. The study population consisted of participants of the Senior Citizens' College. The subjective sensations of oral dryness on waking and while eating a meal were measured by a questionnaire. The number of usable questionnaires was 1003 or 77.9%. The mean age of the subjects was 66.3 +/- 4.2 years, and 53.0% were male. More than one-third (37.8%) of the subjects reported oral dryness on waking. Only 9.1% of them noticed a subjective feeling of dry mouth during eating. Persons who had at least one of these symptoms made up 41.0%. A multiple stepwise logistic regression analysis indicated the following results: Perception of dry mouth on waking was more frequent among males (p < 0.001), persons who had a low BMI (p < 0.05), and those taking two or more prescribed drugs (p < 0.01). Sensation of dry mouth when eating was more frequent among subjects with a low BMI (p < 0.001) and those who wore a denture in the maxillary arch (p < 0.05). Perception of dry mouth when eating was associated with self-assessed chewing ability (p < 0.01) and dissatisfaction with speaking clearly (p < 0.05), as well as dental status. However, dissatisfaction with tasting a meal had a significant relationship with the reports of mouth dryness on waking (p < 0.01). Our findings suggest that a substantially higher percentage of persons have the perception of dry mouth on waking than when eating, which was associated with medications, being male, and having a low BMI. This perception may influence oral function, especially the reported dissatisfaction with tasting foods.

title: Use of a mucoadhesive disk for relief of dry mouth: a randomized, double-masked, controlled crossover study.
abstract: Dry mouth is a frequent complaint of adults worldwide. In those who experience dry mouth, therapeutic options include the use of salivary substitutes and sialogogues.



The authors compared the efficacy and safety of mucoadhesive disks (OraMoist, Axiomedic, Zurich; distributed by Quantum Health, Eugene, Ore.) applied three times daily with those of placebo mucoadhesive disks in a double-masked, randomized, controlled crossover study. The primary end point of interest was within-participant differences in subjective (visual analog scale) ratings of dry mouth according to the New York University Bluestone Mouthfeel Questionnaire. The secondary end point was within-participant differences in salivary flow rates.



Twenty-seven participants completed the single-site study. The results showed no significant difference between the two types of mucoadhesive disks, both of which were associated with a statistically significant improvement in the subjective experience of moistness across the 60-minute period after application and compared with baseline measures after two weeks of use. Furthermore, both disks were associated with a statistically significant improvement in salivary flow rates across the 60-minute period after application and compared with baseline measures after one and two weeks of use. The disks were well tolerated, and participants did not report any adverse events.



The mucoadhesive disks used in this study were safe and provided symptomatic relief from dry mouth. Practice Implications. Patients with dry mouth may benefit from this novel delivery system.

title: Streptococcus mutans, Caries and Simulation Models
abstract: Dental caries and dental plaque are among the most common diseases worldwide, and are caused by a mixture of microorganisms and food debris. Specific types of acid-producing bacteria, especially Streptococcus mutans, colonize the dental surface and cause damage to the hard tooth structure in the presence of fermentable carbohydrates e.g., sucrose and fructose. This paper reviews the link between S. mutans and caries, as well as different simulation models that are available for studying caries. These models offer a valuable approach to study cariogenicity of different substrates as well as colonization of S. mutans.

title: The virulence of Streptococcus mutans and the ability to form biofilms
abstract: In some diseases, a very important role is played by the ability of bacteria to form multi-dimensional complex structure known as biofilm. The most common disease of the oral cavity, known as dental caries, is a top leader. Streptococcus mutans, one of the many etiological factors of dental caries, is a microorganism which is able to acquire new properties allowing for the expression of pathogenicity determinants determining its virulence in specific environmental conditions. Through the mechanism of adhesion to a solid surface, S. mutans is capable of colonizing the oral cavity and also of forming bacterial biofilm. Additional properties enabling S. mutans to colonize the oral cavity include the ability to survive in an acidic environment and specific interaction with other microorganisms colonizing this ecosystem. This review is an attempt to establish which characteristics associated with biofilm formation—virulence determinants of S. mutans—are responsible for the development of dental caries. In order to extend the knowledge of the nature of Streptococcus infections, an attempt to face the following problems will be made: Biofilm formation as a complex process of protein–bacterium interaction. To what extent do microorganisms of the cariogenic flora exemplified by S. mutans differ in virulence determinants “expression” from microorganisms of physiological flora? How does the environment of the oral cavity and its microorganisms affect the biofilm formation of dominant species? How do selected inhibitors affect the biofilm formation of cariogenic microorganisms?

title: Subgingival biofilm formation.
abstract: The human body contains numerous distinctive ecosystems that provide a unique environment for colonizing microorganisms. The periodontal pocket is one such microniche. This environment is partially sheltered from the physical shear forces in the oral cavity and contains the hard, nonshedding surfaces of the tooth root along with the shedding surfaces of gingival mucosa. The junctional epithelium, which is attached to the tooth root, is poorly differentiated, lacks keratinization and has relatively wide intercellular spaces. Consequently, junctional epithelium is permeable and allows the migration of polymorphonuclear leukocytes into the periodontal pocket. Furthermore, the tissues in the periodontal pocket are bathed in gingival crevicular fluid, a serum exudate with antioxidant properties. The initial bacterial colonizers attach to the available surfaces, as discussed elsewhere in this volume of Periodontology 2000. Later colonizers attach to the antecedent organisms and assemble into polymicrobial communities. The biofilms on the hard surfaces develop into spatially organized structures that can extend several hundred micrometers from the surface. By contrast, the epithelial surfaces, which are continually being sloughed and replenished, tend to be colonized with monolayers of microorganisms. However, several of the more pathogenic species of bacteria are able to invade the gingival cells and tissues where they can remain viable and thus constitute a nidus of infection. 
 
Interspecies adherence interactions help to shape the temporal and spatial development of the complex bacterial consortia in the gingival crevice. Bacteria within these communities encounter high cell densities and, in consequence, community living involves adaptation to higher (and unevenly distributed) levels of metabolic by-products, secondary metabolities and other secreted molecules, and to the sporadic availability of nutrients and oxygen. Bacterial inhabitants of biofilms are known to both collaborate (e.g. through nutritional cross-feeding) and compete (e.g. through production of bacteriocins) as they strive to optimize their adaptation to these environmental constraints. Bacteria can also communicate with one another through a variety of sensing and response systems based on either cell-to-cell contact or detection of soluble mediators. The signaling molecules are processed through transcriptional and post-transcriptional networks and they allow bacterial inhabitants of biofilms to coordinate activities at a group or community level. An understanding of the mechanisms of subgingival biofilm formation and development needs, therefore, to accommodate the multiple interspecies interactions that occur in polymicrobial communities.

title: The efficacy of three formulations of Lippia sidoides Cham. essential oil in the reduction of salivary Streptococcus mutans in children with caries: a randomized, double-blind, controlled study.
abstract: Essential oils of many plants have been previously tested in the treatment of oral diseases and other infections. This study was a randomized, double-blind, in parallel with an active control study, which aimed to evaluate the efficacy of three formulations of the Lippia sidoides Cham. essential oil (LSO) in the reduction of salivary Streptococcus mutans in children with caries. 81 volunteers, aged 6-12 years, both genders, with caries, were recruited to participate in this study, and randomly assigned to either one of five different groups. Each group received topical treatment with either 1.4% LSO toothpaste, 1.4% LSO gel, 0.8% LSO mouthwash, 1% chlorhexidine gel, or 0.12% chlorhexidine mouthwash. A 5-ml volume of each gel was placed inside disposable trays, and applied for 1 min, every 24h, for 5 consecutive days. The mouthwash groups used 5-ml volume of a mouthwash inside disposable syringes. In the toothpaste group, children brushed their teeth for 1 min, once a day for 5 days. Saliva was collected before and after treatment. MS colonies were counted, isolated and confirmed through biochemical tests. Differences in MS levels measured in different days within the same treatment group was only verified with LSO toothpaste, chlorhexidine gel and chlorhexidine mouthwash. Comparison between groups of LSO mouthwash, toothpaste and gel showed that the toothpaste group expressed significantly lower MS levels than the mouthwash and gel groups at day-30. Chlorhexidine significantly reduced MS levels after 5 days of treatment, but these levels returned to baseline in other periods of the study. LSO toothpaste reduced MS levels after 5 days of treatment, and MS levels remained low and did not return to baseline during subsequent analysis. Hence, LSO toothpaste demonstrated the most long-lasting MS reduction in saliva, whereas other LSO formulations did not effectively reduce MS levels in children with dental caries.

title: Reducing dental plaque formation and caries development. A review of current methods and implications for novel pharmaceuticals.
abstract: Dental caries is an oral disease, which has a high worldwide prevalence despite the availability of various prophylactic means, including the daily use of fluoride toothpastes, water fluoridation, dental sealants, oral health educational programs and various antiseptic mouth-rinses. One important reason for this is uncontrolled increase in consumption of foods containing considerable sucrose concentration, especially among children. Sucrose is easily metabolized by oral bacteria (mostly streptococci) to acids and, subsequently, causing tooth decay or dental caries. In the oral ecosystem, streptococci principally reside on tooth surfaces forming biofilm. Important structural and binding materials of biofilm are glucan polymers synthesized by several isoforms of glucosyltransferase enzyme present in certain species of oral bacteria, including mutans group streptococci - Streptococcus mutans and Streptococcus sobrinus, which preferably colonize humans. Thus, there is a constant need to develop the methods and chemotherapeutics for improving oral health care and decreasing teeth decay through the suppression of cariogenic biofilm formation in the oral cavity. The aim of this paper was to review literature related to the pathogenesis of dental caries as well as currently existing and experimental pharmaceutical substances used for prevention of this process.

title: Dental plaque-induced gingival diseases.
abstract: Gingival diseases are a diverse family of complex and distinct pathological entities found within the gingiva that are the result of a variety of etiologies. There are several clinical characteristics common to all gingival diseases and these features include clinical signs of inflammation, signs and symptoms that are confined to the gingiva, reversibility of the disease by removing the etiology, the presence of bacterial laden plaque to initiate and/or exacerbate the severity of the disease and a possible role as a precursor for attachment loss around teeth. Defining and classifying gingival diseases has not been an easy task. The tools and methods to identify gingival diseases have varied depending on the criteria used by epidemiologists, researchers, or the practicing clinician. The classification of gingival disease in this review relied upon experimental and/or epidemiological human studies that accurately and reliably assessed an underlying functional derangement that was localized to the gingiva and was reported in a peer-reviewed journal. The classification of gingival diseases that depends on dental plaque to initiate the disease process(es) has been categorized into two groups. The two categories of plaque-induced gingival diseases are those affected by local factors and those that are affected by local factors and modified by specific systemic factors found in the host. In this review, the clinical characteristics of gingival disease associated with plaque, endogenous hormone fluctuations, drugs, systemic diseases, and malnutrition were investigated.

title: The oral microbiome and the immunobiology of periodontal disease and caries.
abstract: The composition of the oral microbiome differs from one intraoral site to another, reflecting in part the host response and immune capacity at each site. By focusing on two major oral infections, periodontal disease and caries, new principles of disease emerge. Periodontal disease affects the soft tissues and bone that support the teeth. Caries is a unique infection of the dental hard tissues. The initiation of both diseases is marked by an increase in the complexity of the microbiome. In periodontitis, pathobionts and keystone pathogens such as Porphyromonas gingivalis appear in greater proportion than in health. As a keystone pathogen, P. gingivalis impairs host immune responses and appears necessary but not sufficient to cause periodontitis. Historically, dental caries had been causally linked to Streptococcus mutans. Contemporary microbiome studies now indicate that singular pathogens are not obvious in either caries or periodontitis. Both diseases appear to result from a perturbation among relatively minor constituents in local microbial communities resulting in dysbiosis. Emergent consortia of the minor members of the respective microbiomes act synergistically to stress the ability of the host to respond and protect. In periodontal disease, host protection first occurs at the level of innate gingival epithelial immunity. Secretory IgA antibody and other salivary antimicrobial systems also act against periodontopathic and cariogenic consortia. When the gingival immune response is impaired, periodontal tissue pathology results when matrix metalloproteinases are released from neutrophils and T cells mediate alveolar bone loss. In caries, several species are acidogenic and aciduric and appear to work synergistically to promote demineralization of the enamel and dentin. Whereas technically possible, particularly for caries, vaccines are unlikely to be commercialized in the near future because of the low morbidity of caries and periodontitis.