Dietary Chemicals vs. Dental Caries - ACS Publications

10

Application of Chemical Agents for the Control of Dental Caries

Downloaded by UNIV OF LIVERPOOL on December 19, 2016 | http://pubs.acs.org Publication Date: June 1, 1970 | doi: 10.1021/ba-1970-0094.ch010

ROBERT C. C A L D W E L L School of Dentistry, University of California, Los Angeles, Calif. 90024 JOE P. T H O M A S School of Dentistry, University of Alabama, Birmingham, Ala. 35233

Vehicles for caries-preventive agents include dentrifices, mouthwashes, chewing gum, drinking water, cereals, flour, milk, table salt, tablets, and concentrated solutions which are applied by dentists. Many chemicals reduce dental caries in experimental animals. Those which have been subjected to clinical trials on humans include NaF, SnF , Na PO F, and other fluorides; CaHPO , anionic detergents, antibiotics, chlorophyll, urea, and vitamins. As a group, the fluorides have been most effective, and no single procedure has yet been as effective at the public health level as water fluoridation. However, several new approaches have promise. For example, topical application of acidulated sodium or stannous fluoride solutions once a year has resulted in a substantial reduction in caries, and fluoride mouthwashes prevent caries more effectively than dentifrices. 2

2

3

4

Many

approaches have been developed to reduce dental caries by chemical means; however, even the most effective procedures cannot yet be expected to eradicate the disease. A complete program of dental caries prevention includes dietary management, good oral hygiene, patient education and motivation, and early treatment of initial carious lesions, as well as the utilization of the various chemical agents. The use of a therapeutic agent is, in some instances, part of the oral hygiene technique, while in other cases it may be in the form of a dietary supplement. Very large caries reductions are possible in individuals who receive complete preventive care, but the 55-65% reduction resulting 161 Harris; Dietary Chemicals vs. Dental Caries Advances in Chemistry; American Chemical Society: Washington, DC, 1970.

162

DIETARY

from water

fluoridation

remains

C H E M I C A L S

VS.

D E N T A L

t h e best p r o t e c t i o n a v a i l a b l e

CARIES

at t h e

p u b l i c h e a l t h l e v e l at this t i m e . T h e most effective r e g i m e f o r t h e c h e m i c a l p r e v e n t i o n of d e n t a l caries p r o b a b l y consists of a c o m b i n a t i o n of p r o c e d u r e s , i n c l u d i n g w a t e r fluoridation

or some other means of fluoride i n g e s t i o n d u r i n g c h i l d h o o d ,

p e r i o d i c a p p l i c a t i o n o f a caries-preventive

agent i n a r e l a t i v e l y h i g h

c o n c e n t r a t i o n t o the t o o t h e n a m e l surface, a n d r e g u l a r a p p l i c a t i o n o f a less c o n c e n t r a t e d booster p r e p a r a t i o n of t h e caries-preventive agent. T h e Downloaded by UNIV OF LIVERPOOL on December 19, 2016 | http://pubs.acs.org Publication Date: June 1, 1970 | doi: 10.1021/ba-1970-0094.ch010

t i m e i n t e r v a l r e c o m m e n d e d f o r t h e a p p l i c a t i o n o f t h e c o n c e n t r a t e d agent varies s o m e w h a t d e p e n d i n g o n t h e agent b e i n g discussed, w h i l e t h e less concentrated

booster agent is f o r m o r e f r e q u e n t use to m a i n t a i n the

c h e m i c a l at o r i n t h e e n a m e l surface b e t w e e n c o n c e n t r a t e d

applications.

C a r i e s - p r e v e n t i v e c h e m i c a l agents c a n b e i n c o r p o r a t e d i n t o a v a r i e t y of vehicles w h i c h c a n b e d i v i d e d into f o u r m a i n categories. ( 1 ) A g e n t s a p p l i e d b y t h e d e n t a l t e a m : T h e s e i n c l u d e concentrated solutions o f v a r i o u s fluorides f o r t o p i c a l a p p l i c a t i o n , p r o p h y l a x i s pastes c o n t a i n i n g fluoride, v a r i o u s fluoride gels, a n d agents a p p l i e d to i n h i b i t the g r o w t h o f d e n t a l b a c t e r i a l p l a q u e . ( 2 ) T h e r a p e u t i c agents p r e s c r i b e d f o r p e r s o n a l a p p l i c a t i o n : T h e s e i n c l u d e fluoride tablets, lozenges, d r o p s , m o u t h w a s h e s , p r o p h y l a x i s pastes. ( 3 ) P u b l i c h e a l t h measures: T h e s e i n c l u d e w a t e r fluoridation, large scale s u p e r v i s e d s e l f - a p p l i c a t i o n of fluoride-containing agents, a n d t h e use o f m i l k , t a b l e salt, b r e a d , breakfast cereals, a n d flour as vehicles f o r fluoride or other caries-preventive agents s u c h as c e r t a i n phosphates. (4) Over-the-counter preparations: mouthwashes, a n d chewing g u m .

These

include

dentifrices,

Agents Applied by Dental Team T h e c u r r e n t status o f t o p i c a l

fluoride

solutions has b e e n r e v i e w e d

b y H o r o w i t z a n d H e i f e t z ( 4 5 ) . I n g e n e r a l , there appears to b e m e r i t i n the use o f t o p i c a l solutions a n d p r o p h y l a x i s pastes c o n t a i n i n g

fluoride

f o r t h e r e d u c t i o n of d e n t a l caries; h o w e v e r , i n spite o f 25 years of c l i n i c a l investigations i n t o v a r i o u s solutions a n d t e c h n i q u e s , n o c l e a r l y s u p e r i o r s o l u t i o n o r t e c h n i q u e to date has b e e n i d e n t i f i e d . C l i n i c a l testing m e t h ods t o d a y are r e l a t i v e l y u n r e f i n e d w h e n c o m p a r e d w i t h methods a v a i l a b l e i n the p h y s i c a l sciences. T r e a t m e n t effects, therefore, c a n b e o n l y estim a t e d grossly. D e P a o l a has a p p r o p r i a t e l y c o m m e n t e d that i n d e p e n d e n t tests of t h e same or s i m i l a r agents " f r e q u e n t l y s h o w m a r k e d differences i n t h e percentages of r e d u c t i o n i n d e n t a l caries; therefore, w e s h o u l d n o t take p e r c e n t a g e r e d u c t i o n figures too l i t e r a l l y , a n d r e d u c t i o n s f r o m one s t u d y to another s h o u l d b e c o m p a r e d w i t h c a u t i o n "

(16).

T h e w e l l - k n o w n m e t h o d of t o p i c a l a p p l i c a t i o n o f s o d i u m

fluoride

to t h e e n a m e l surface d e s c r i b e d first b y B i b b y (7) has b e e n w i d e l y u s e d .

Harris; Dietary Chemicals vs. Dental Caries Advances in Chemistry; American Chemical Society: Washington, DC, 1970.

10.

C A L D W E L L

Application

A N D T H O M A S

of Chemical Agents

163

T h e p r o c e d u r e w a s d e v e l o p e d b y K n u t s o n a n d c o w o r k e r s ( 3 0 , 3 1 , 54, 56-59),

w h o u s e d a 2 % s o d i u m fluoride s o l u t i o n w h i c h w a s a l l o w e d to

d r y o n t h e teeth f o r 3 to 5 m i n u t e s . T h e 2 % s o d i u m fluoride is a p p l i e d at 4 w e e k l y intervals w i t h a p r o p h y l a x i s b e i n g d o n e at the first a p p o i n t m e n t o n l y . T h i s series o f a p p l i c a t i o n s is r e p e a t e d at age 3, 7, 11, a n d 13.

T h e s e investigators r e p o r t e d r e d u c t i o n s i n d e n t a l caries ( D F T ) o f

39.7, 41.4, a n d 3 6 . 7 % after 1, 2, a n d 3 years, r e s p e c t i v e l y .

T h e majority

of studies u s i n g this t e c h n i q u e h a v e s h o w n d e n t a l caries i n c i d e n c e to b e


r e d u c e d 30 to 4 0 % i n the p e r m a n e n t teeth o f c h i l d r e n r e s i d i n g i n a n area w i t h

fluoride-deficient

water.

T h e major d i s a d v a n t a g e o f this thor-

o u g h l y s t u d i e d t e c h n i q u e has been the necessity of f o u r p a t i e n t visits over a short p e r i o d o f t i m e . W i t h the a d v e n t of stannous

fluoride,

m a n y dentists s w i t c h e d to t h e

t e c h n i q u e o f M u h l e r ( 7 8 ) . T h e r e c o m m e n d e d p r o c e d u r e i n v o l v e s thoro u g h i n i t i a l p r o p h y l a x i s a n d i n t e r p r o x i m a l flossing a n d the a p p l i c a t i o n o f a fresh 8 % s o l u t i o n o f stannous

fluoride,

k e e p i n g t h e teeth m o i s t w i t h

the s o l u t i o n f o r 4 m i n u t e s . T h i s t e c h n i q u e has the a d v a n t a g e of i n v o l v i n g a s i n g l e v i s i t f o r the i n i t i a l treatment. months

to a year,

of t h e patient.

It requires r e a p p l i c a t i o n i n 6

d e p e n d i n g o n the i n d i v i d u a l

caries

susceptibility

H o r o w i t z a n d H e i f e t z ( 4 5 ) s u m m a r i z e d the extensive

c l i n i c a l investigations

o f stannous

fluoride

solutions

his associates, w h o h a v e r e p o r t e d a range r e d u c t i o n i n D M F surfaces

o f benefit

by Muhler and of 47 to 7 8 %

i n c h i l d r e n . T h i s range of benefit is also

assessed b y Stookey ( 5 1 ) at f r o m 40 to 6 0 % , w h i c h is i n excess of t h e range o f benefit r e p o r t e d f o r the 2 % N a F t e c h n i q u e . A f e w studies h a v e s h o w n negative results w i t h stannous vantages

fluoride

(47, 104, 113),

and disad-

of taste, g i n g i v a l b l a n c h i n g , i n s t a b i l i t y of aqueous

solutions,

a n d unesthetic p i g m e n t a t i o n s h a v e b e e n p o i n t e d o u t ( 5 1 ) . A c i d u l a t e d p h o s p h a t e fluoride has b e e n r e v i e w e d b y D e P a o l a

(16).

T h i s r e l a t i v e l y n e w agent consists of a s o l u t i o n of s o d i u m fluoride a d justed to p H 3 b y t h e a d d i t i o n o f 0.1 M p h o s p h o r i c a c i d . T h e s o l u t i o n contains 1.23% s o d i u m fluoride a n d , i n i n i t i a l c l i n i c a l studies, seemed to surpass agents a l r e a d y i n use (11, 81, 112).

T a b l e I i n c l u d e s representa-

t i v e d a t a s h o w i n g that at the e n d of a t w o - y e a r s t u d y a r e d u c t i o n i n d e n t a l caries ( D M F S ) of 7 0 % (112) B r u d e v o l d , i n a n i n v e s t i g a t i o n (113)

resulted. W e l l o c k , M a i t l a n d , a n d

i n w h i c h h a l f the m o u t h w a s treated

w i t h 2 % N a F a n d half w i t h acidulated phosphate

fluoride

( A P F ) , re-

p o r t e d 5 0 % f e w e r n e w carious lesions o n t h e A P F side o f the m o u t h . T h i s t e c h n i q u e w a s also m o r e successful w i t h subjects w h o m a i n t a i n e d g o o d o r a l h y g i e n e . T h e a d d i t i o n o f a c i d to stannous fluoride w a s s t u d i e d b y M u h l e r , Stookey, a n d B i x l e r (86)

w i t h g o o d results r e p o r t e d . T a b l e I

shows that M e r c e r a n d M u h l e r (74)

a n d Scola a n d O s t r u m (97) reduced

the 4 - m i n u t e stannous

fluoride

treatment

to 15 o r 30 seconds w i t h n o


164

DIETARY

C H E M I C A L S

Table I. Age Group, Years

Principal Investigator

VS.

Recent

Solution

D E N T A L

CARIES

Developments

Used

Acid Phosphate8-11 1 . 2 3 % N a F i n 0.1 M p h o s p h o r i c a c i d 4-10 2 % N a F i n 0.15 M p h o s p h o r i c a c i d Grade School 1 0 % N a H P 0 plus 8 % S n F

W e l l o c k (112) P a m e i j e r (87) M u h l e r (86)

2

4

2


15-30-Sec. M e r c e r (74)

5-12

8 % S n F (4 m i n . ) 1 0 % S n F (30 sec.) S n F p r o p h y paste, t o p i c a l & d e n t i f r i c e : 4 m i n . topical 15 sec. t o p i c a l 8 % S n F 4 m i n . topical 1 0 % S n F 30 sec. t o p i c a l 2

2

S c o l a (97)

17-24

H o r o w i t z (46)

2

7-9

2

2

a p p a r e n t loss o f effectiveness. H o w e v e r , i n a n e v a l u a t i o n of a 30-second a p p l i c a t i o n o f a stannous

fluoride

solution, H o r o w i t z a n d Heifetz

h a d d i s a p p o i n t i n g results w i t h this r a p i d t e c h n i q u e .

(46)

A v e r i l l et al. (2) i n

a 2-year s t u d y o f t h e effects o f three t o p i c a l fluorides ( 2 % aqueous s o d i u m fluoride,

4%

stannous

fluoride,

a n d 2% A P F ) a p p l i e d t w i c e a n n u a l l y i n

c h i l d r e n l i v i n g i n a n o n f l u o r i d a t e d c o m m u n i t y f a i l e d to s h o w c o n c l u s i v e s u p e r i o r i t y o f a n y o n e o f these agents. Caries-reducing

c h e m i c a l agents h a v e b e e n a d d e d to p r o p h y l a x i s

pastes. T h e a d d i t i o n o f stannous fluoride a n d A P F to p r o p h y l a x i s pastes has b e e n s t u d i e d c l i n i c a l l y . A caries r e d u c t i o n of 3 4 % ( D M F S ) w i t h a stannous

fluoride

p r o p h y l a x i s paste w a s r e p o r t e d b y B i x l e r a n d M u h l e r

( 9 ) , w h i l e G i s h a n d M u h l e r (34)

have obtained about a 4 0 % reduction

( D M F S ) w i t h t h e same paste. I n this s t u d y , t h e c o m b i n e d use o f stannous fluoride paste a n d t o p i c a l stannous fluoride w a s m o r e effective t h a n paste alone.

S c o l a a n d O s t r u m ( 9 7 ) r e p o r t e d a caries r e d u c t i o n of 1 2 %

after t h e use o f a stannous fluoride p r o p h y l a x i s paste, w h i c h is p r o b a b l y n o t a significant r e d u c t i o n ; h o w e v e r , t h e paste s e e m e d to e n h a n c e the effect of a t o p i c a l s o l u t i o n a n d a stannous H o r o w i t z a n d L u c y e (48)

fluoride

dentifrice.

i n a 2-year s t u d y o f c h i l d r e n r e c e i v i n g

a n n u a l p r o p h y l a x i s w i t h the stannous

fluoride-lava

p u m i c e paste o b s e r v e d

n o p r o t e c t i o n against caries i n c i d e n c e as c o m p a r e d to controls. a n d others ( 8 9 ) s t u d i e d a n a c i d u l a t e d

fluoride-lava

Peterson

pumice prophylaxis

paste a p p l i e d a n n u a l l y i n c h i l d r e n i n c o m m u n i t i e s w i t h

fluoridated

and

others w i t h n o n f l u o r i d a t e d w a t e r s u p p l i e s , a n d r e p o r t e d m i n i m a l r e d u c t i o n i n d e n t a l caries increments. H o r o w i t z (42-44) and solution.

s t u d i e d t h e c a r i e s - r e d u c i n g effect of a n A P F g e l

A f t e r 3 years, those r e c e i v i n g a n n u a l a p p l i c a t i o n o f t h e


10.

C A L D W E L L

Application

A N D T H O M A S

of Chemical

165

Agents

in Topical Fluoride Therapy Frequency of A pplication

No. in Exptl. Group

Length of Study, Years

1 per y e a r 4 X i n 2 weeks 1 application

115 77 100

2 15 m o . 9 mo.

Caries Reduction (DMFS)

Fluoride 70 50° 75


Application 2 per y e a r 2 per y e a r 1 1 1 1 1

per per per per

year year year year

135 132

2 2

56 59

200 194 420 421

1 1 3 3

45 54 21 3.8

Compared to effect of 2% N a F .

A P F solution experienced a 24%

r e d u c t i o n i n d e n t a l caries

(DMFS)

w h i l e those r e c e i v i n g s e m i a n n u a l a p p l i c a t i o n of the A P F s o l u t i o n h a d a 4 1 % r e d u c t i o n i n caries i n c i d e n c e . T h e A P F g e l was a p p l i e d i n a w a x tray a n d p r o d u c e d a 2 4 %

r e d u c t i o n as c o m p a r e d w i t h the controls.

graham and W i l l i a m s (52)

In-

e v a l u a t e d an A P F g e l a n d s o l u t i o n . A f t e r 2

years, those treated w i t h the g e l d e m o n s t r a t e d a 4 1 % effect as c o m p a r e d w i t h controls.

B e n e f i c i a l results f r o m treatment w i t h the A P F s o l u t i o n

were minimal.

B r y a n a n d W i l l i a m s (12)

reported a 28%

d e n t a l caries

r e d u c t i o n after 1 y e a r u s i n g a n A P F g e l i n a f o a m r u b b e r t r a y i n one a p p l i c a t i o n . O n e r e p o r t s h o w e d n o effect as c o m p a r e d w i t h controls of 1 a p p l i c a t i o n of A P F g e l (102).

Cons, Janerich, and Senning (15), i n a

3-year s t u d y to evaluate the c a r i e s - p r e v e n t i v e effect of f o u r t o p i c a l

flu-

o r i d e p r o c e d u r e s as c o m p a r e d w i t h controls, f o u n d that, statistically, the g r o u p treated w i t h A P F g e l e x p e r i e n c e d s i g n i f i c a n t l y f e w e r n e w carious teeth t h a n the c o n t r o l g r o u p b u t the a c t u a l difference was s m a l l . agents s t u d i e d w e r e s o d i u m fluoride, 2 % ; fluoride

s o l u t i o n , 1.23%

stannous

fluoride,

The

8%;

at p H 3; a n d an A P F fluoride g e l , also

at p H 3. T h e treatments w e r e g i v e n a n n u a l l y . T h e difference

APF 1.23%

between

the other treatments a n d the controls was not statistically significant.

The

t e c h n i q u e f o r a p p l y i n g c h e m i c a l b y the use of a n a p p l i c a t o r tray or m o u t h p i e c e w h i c h h o l d s the active agent against the e n a m e l surface w a s reported by H o r i i and Keyes Stralfors ( 9 9 )

(41).

has d e s c r i b e d a " d i s i n f e c t a n t c a p s p l i n t " c o n t a i n i n g

a t h i n l a y e r of a fine-grained p o w d e r e d d i s i n f e c t a n t s u c h as C h l o r a m i n e - T . T h e s p l i n t c o n t a i n i n g the d i s i n f e c t a n t is w o r n o v e r the teeth for 5 m i n utes, a n d Stralfors r e p o r t e d a n a l m o s t 1 0 0 %

decrease i n the n u m b e r of


166

DIETARY

C H E M I C A L S

VS.

D E N T A L

CARIES

s u r v i v i n g b a c t e r i a . A f t e r a b o u t 6 h o u r s t h e b a c t e r i a l count rises, a n d b y 12 hours has almost r e a c h e d t h e o r i g i n a l l e v e l . Therapeutic

Agents Prescribed for Personal

Application

I n areas w h e r e t h e w a t e r is deficient i n fluoride s u p p l e m e n t s , v a r i o u s o t h e r f o r m s o f fluoride h a v e b e e n p r e s c r i b e d f o r systemic use. A b r i e f d i s c u s s i o n o f c e r t a i n aspects of systemic

fluoride

therapy follows. F o r


m o r e extensive i n f o r m a t i o n , t h e r e v i e w o f B i r c h ( 8 ) is r e c o m m e n d e d . T a b l e t s u s u a l l y c o n t a i n 2.21 m g o f s o d i u m fluoride ( 1 m g F " ) , w h i c h is e q u i v a l e n t t o t h e average a m o u n t o f fluoride i n g e s t e d d a i l y f r o m w a t e r w h i c h contains 1 p p m fluoride. A p a r t f r o m A r n o l d , M c C l u r e , a n d W h i t e s s t u d y ( I ) i n w h i c h t h e b e n e f i c i a l effect o f fluoride tablets w a s e q u a t e d w i t h that o f

fluoridated

w a t e r , most studies i n d i c a t e fluoride tablets t o

b e n o m o r e t h a n h a l f as effective i n r e d u c i n g d e n t a l caries as

fluoridated

w a t e r . B i r c h states i n h i s r e v i e w that t h e r e d u c t i o n i n d e n t a l caries i n c i d e n c e i n e i g h t studies r a n g e d f r o m 12 to 8 7 % b u t that t h e use o f fluo r i d e i n tablets to r e d u c e caries i n c i d e n c e r e m a i n s to b e p r o v e d f a c t u a l l y i n l o n g - t e r m c l i n i c a l i n v e s t i g a t i o n . T h e use of fluoride i n tablets appears to h a v e great p o t e n t i a l b u t requires f u r t h e r s t u d y . M u l t i p l e v i t a m i n - f l u o r i d e tablets h a v e b e e n p r e s c r i b e d b y p h y s i c i a n s a n d dentists. H e n n o n , Stookey, a n d M u h l e r ( 3 9 ) i n 1967 r e p o r t e d o n a n i n v e s t i g a t i o n o f t h e effect o f the d a i l y use o f fluoride v i t a m i n s b y infants a n d b y c h i l d r e n u p to 5 years of age. A f t e r 48 m o n t h s , a r e d u c t i o n i n t h e p r e v a l e n c e of carious lesions o f 6 8 % ( d e f surfaces) i n p r i m a r y a n d 4 6 % (DMF

s u r f a c e s ) i n p e r m a n e n t teeth h a d r e s u l t e d .

Doherty (17) re-

v i e w e d t h e use o f d i e t a r y fluorides a n d does n o t encourage t h e use o f v i t a m i n - f l u o r i d e s because o f the n e e d to adjust t h e dose w i t h v a r y i n g w a t e r fluoride content a n d t h e n e e d f o r f u r t h e r s t u d y o n t h e effect o n p e r m a n e n t teeth.

A l s o , t h e C o m m i t t e e o n N u t r i t i o n of t h e A m e r i c a n

A c a d e m y ot P e d i a t r i c s questions the r o u t i n e a d m i n i s t r a t i o n o f v i t a m i n supplements. F l u o r i d e passes t h r o u g h the p l a c e n t a a n d is d e p o s i t e d i n t h e bones a n d teeth o f t h e d e v e l o p i n g c h i l d . T h e r e seems to b e a r e g u l a t o r y m e c h a n i s m i n v o l v e d w h i c h l i m i t s t h e a m o u n t c f fluoride t r a n s f e r r e d

because

e v e n i n areas o f e n d e m i c fluorosis one does n o t see m o t t l i n g o f p r i m a r y teeth. T h e effect o f p r e n a t a l exposure to fluoridation has b e e n r e v i e w e d b y H o r o w i t z a n d H e i f e t z ( 4 7 ) , w h o r e p o r t e d n o m e a n i n g f u l benefits to b e d e r i v e d f r o m d i e t a r y s u p p l e m e n t s of fluoride to p r e g n a n t w o m e n . T h e F o o d a n d D r u g A d m i n i s t r a t i o n i n its "Statements interpretation, oral prenatal drugs containing (29), fluoride

of g e n e r a l p o l i c y o r

fluorides

for human use"

banned marketing b y manufacturers of dietary supplements of offered to g r a v i d w o m e n f o r " p r e n a t a l d e c a y p r e v e n t i o n . "


10.

C A L D W E L L

Application

A N D T H O M A S

of Chemical

167

Agents

V a r i o u s U . S . p h a r m a c e u t i c a l c o m p a n i e s a p p a r e n t l y d o n o t adhere to the dosage s c h e d u l e r e c o m m e n d e d b y the A m e r i c a n C o u n c i l o n D e n t a l Therapeutics.

T h e dosages suggested o n the labels o f different m a n u -

facturers o f fluoride tablets a n d d r o p s v a r y , as d o t h e instructions as to w h e n o r w h e n n o t to use systemic fluoride t h e r a p y .

It is n o t s u r p r i s i n g

that there s h o u l d b e some c o n f u s i o n a b o u t fluoride p r e s c r i p t i o n s because there are o v e r 4 0 different k i n d s o f fluoride tablets, lozenges, o r d r o p s on the U . S . market.


F l u o r i d e m o u t h w a s h e s w i l l b e d i s c u s s e d a l o n g w i t h other m o u t h washes i n t h e section o n over-the-counter p r e p a r a t i o n s . Public Health Measures It has b e e n e s t a b l i s h e d b e y o n d a n y reasonable fluoridation

d o u b t that

is a h i g h l y d e s i r a b l e a n d effective p u b l i c h e a l t h

water

measure.

I n this c o u n t r y , t h e state legislature o f C o n n e c t i c u t l e d t h e w a y i n m a k i n g fluoridation

a v a i l a b l e o n a state-wide basis, a n d n o w M i n n e s o t a , I l l i n o i s ,

Delaware, M i c h i g a n , South Dakota, a n d O h i o require

fluoridation

of

p u b l i c w a t e r s u p p l i e s . S e v e r a l other states are c o n s i d e r i n g s i m i l a r legislation. I n Ireland,

fluoridation

has b e e n a p p r o v e d f o r the entire c o u n t r y .

H o p e f u l l y , these actions f o r e t e l l a n a t i o n a l

fluoridation

a c t f o r the U n i t e d

States. K n u t s o n ( 5 5 ) e s t i m a t e d that 7 0 % o f the U . S . p o p u l a t i o n n o w has access to w a t e r

fluoridation.

I n areas w h e r e the w a t e r does n o t

c o n t a i n e n o u g h fluoride, a n u m b e r o f other m e t h o d s h a v e b e e n e m p l o y e d to m a k e fluoride a v a i l a b l e o n a p u b l i c h e a l t h l e v e l . Supervised Self- Application

of Fluoride

Agents

T h e i d e a o f large n u m b e r s o f c h i l d r e n i n s c h o o l a p p l y i n g fluoride to t h e i r o w n teeth a p p a r e n t l y o r i g i n a t e d i n S w e d e n . B e r g g r e n a n d W e l a n d e r (5)

evaluated a 1 %

solution of sodium

fluoride

w h i c h 568 c h i l d r e n

b r u s h e d o n t h e i r teeth n i n e times over a 2-year p e r i o d , a c h i e v i n g a 2 5 3 0 % r e d u c t i o n i n caries o n the u p p e r teeth. I n the past f e w years, several other studies h a v e b e e n p u b l i s h e d i n w h i c h a v a r i e t y o f solutions h a v e been used (Table I I ) .

S o d i u m fluoride also has b e e n u s e d as a 0 . 5 %

s o l u t i o n o r as 1.23% s o d i u m fluoride i n 0.1 M p h o s p h o r i c a c i d . I n the case of t h e w e a k e r s o l u t i o n , u s e d five times a year, there w a s a 2 9 % r e d u c t i o n i n caries ( D M F T ) ( 6 ) . T h e a c i d u l a t e d 1.23% s o d i u m fluoride u s e d five times a year r e s u l t e d i n a 1 5 % caries r e d u c t i o n ( D M F S ) ( 1 3 ) . G o a z et al

(37)

fluoridated phate.

o b s e r v e d a n a d d i t i o n a l 4 2 % caries r e d u c t i o n i n a c i t y w i t h water b y daily brushing w i t h 6 %

A f t e r 21 m o n t h s , G o a z et al

sodium monofluorophos-

( 3 6 ) , u s i n g a caries i n d e x n o t i n

c o m m o n use a n d h a v i n g a n u m b e r o f reversals i n diagnosis, r e p o r t e d a


168

DIETARY

Table II. Age Group, Years

Principal Investigator Berggren

(5)

Rosenkranz


Goaz

8-15 (94)

(37)

Berggren

6-14 (6)

10

Hunstadbraten B u l l e n (13)

50%

12-14

(50)

7-14 6-8

C H E M I C A L S

stannous

5 X 1st y r . , 4 X 2nd y r . 6/year

Zirconium-citratefluoride ( 0 . 4 2 % N a F ) 6% Sodium monofluorophosphate 0.5% N a F

1/day Unsupervised 5/year 2/year 5/year 2/year 5/year 2/year 4/year 4-5/year

Z i r c o n i u m fluoride (0.11% F~) F e r r i c fluoride (0.36% F - ) 1% N a F 1.23% N a F i n 0.1 M phosphoric acid

A large-scale p r o g r a m a m o n g the m i l i w h i c h consisted of s u p e r v i s e d tooth

b r u s h i n g b y the patient w i t h a n 8 % stannous a p p l i c a t i o n of 1 0 %

Frequency of Application

Used

1% N a F

r e d u c t i o n i n rate of d e c a y .

CARIES

Caries Reduction with Fluoride

Solution

tary was r e p o r t e d b y K y e s ( 6 2 ) ,

D E N T A L

VS.

fluoride

fluoride-lava

p u m i c e paste,

s o l u t i o n f o r 15 seconds or m o r e ,

a n d the use of a stannous fluoride d e n t i f r i c e . S c o l a (96)

reported a 5 0 %

r e d u c t i o n i n i n c r e m e n t of d e n t a l caries as c o m p a r e d to controls i n this m i l i t a r y p r o g r a m after 1 year. O t h e r studies have b e e n r e p o r t e d r e g a r d i n g the use of s e l f - a d m i n i s t e r e d stannous p h y l a c t i c paste (73, 76, 81).

fluoride-zirconium

It was estimated

(92)

silicate p r o -

that i n 1969

over

1,500,000 a p p l i c a t i o n s b y this m e t h o d w o u l d b e o c c u r r i n g . L a n g et (64)

al.

r e p o r t e d results of f o u r a p p l i c a t i o n s at 6 - m o n t h intervals of a 9 %

stannous

fluoride-zirconium

tained 9 %

m o n o s o d i u m d i h y d r o g e n phosphate.

silicate p r o p h y l a x i s paste w h i c h also c o n A reduction i n dental

caries i n c r e m e n t ( D M F S ) of about 4 0 % was n o t e d . T h e c h i l d r e n s t u d i e d resided in a

fluoridated

c o m m u n i t y . T h e a d d i t i o n of a stannous

fluoride

d e n t i f r i c e r e s u l t e d i n n o significant f u r t h e r decrease i n caries increments. E n g l a n d e r a n d others ( 2 4 ) , u s i n g a custom-fitted u p p e r a n d l o w e r m o u t h p i e c e , s t u d i e d r e p e a t e d a p p l i c a t i o n of a c i d u l a t e d a n d n e u t r a l w a t e r s o l u b l e s o d i u m fluoride gels f o r 21 months. O n e g r o u p a p p l i e d a n a c i d u lated phosphate sodium

fluoride

gel 6 minutes each school day for 2

a c a d e m i c years a n d the s e c o n d g r o u p f o l l o w e d the same p r o c e d u r e w i t h the n e u t r a l s o d i u m fluoride g e l . A t h i r d g r o u p s e r v e d as c o n t r o l . A f t e r 21 m o n t h s , o u t s t a n d i n g results of 75 a n d 8 0 %

r e d u c t i o n i n d e n t a l caries

i n c r e m e n t ( D M F surfaces) o c c u r r e d w i t h the t w o groups as c o m p a r e d


10.

C A L D W E L L

A N D T H O M A S

Application

of Chemical

169

Agents

Solutions Brushed on the Teeth No. in Exptl. Group


568

2

25-30

84

1

34

96 Downloaded by UNIV OF LIVERPOOL on December 19, 2016 | http://pubs.acs.org Publication Date: June 1, 1970 | doi: 10.1021/ba-1970-0094.ch010

Per Cent Caries Reduction (DMFS)

14 m o .

177 174 176 162 167 170 800 235

2 2 2 2 2 2 2 2

42 29° 17* 17* 0° 33* 8* 15

Comments M o r e effective o n u p p e r t e e t h t h a n o n lower D r i n k i n g water fluoridated (1 p p m ) f o r 10 y r

"Significant reduction"

° D M F T values. w i t h controls (23).

R e c e n t l y , the authors r e p o r t e d that 23 m o n t h s after

the treatments h a d b e e n d i s c o n t i n u e d , the c h i l d r e n a v a i l a b l e f o r reexa m i n a t i o n s t i l l r e t a i n e d the a d v a n t a g e of 55 a n d 6 3 %

fewer new D M F

surfaces t h a n the c o n t r o l c h i l d r e n . I n the s t u d y , the h i g h e r p e r c e n t a g e effect was o b t a i n e d w i t h the a c i d u l a t e d fluoride gel. M u h l e r et al.

(82)

r e p o r t e d o n the c l i n i c a l e v a l u a t i o n of p a t i e n t - a d m i n i s t e r e d stannous o r i d e z i r c o n i u m silicate p r o p h y l a c t i c paste i n c h i l d r e n i n the Islands.

flu-

Virgin

A f t e r one year, c h i l d r e n u s i n g the treatment paste c o n t a i n i n g

9 % stannous fluoride o b t a i n e d a r e d u c t i o n i n n e w D M F surfaces of 6 4 % as c o m p a r e d w i t h c h i l d r e n a p p l y i n g a p r o p h y l a x i s paste c o n t a i n i n g n o fluoride. Fluoridation

of the Diet

U n t i l a l l the w a t e r s u p p l i e s w h i c h c a n b e i n this c o u n t r y h a v e b e e n s u p p l e m e n t e d w i t h

fluoridated

fluoride,

economically

fluoridation

d i e t w i l l b e of s e c o n d a r y i m p o r t a n c e to most p u b l i c h e a l t h g r o u p s . ever, e v e n w h e n a l l of the a v a i l a b l e w a t e r s u p p l i e s h a v e b e e n

of the How-

fluoridated,

a v e r y large n u m b e r of citizens i n r u r a l areas a n d i n s m a l l t o w n s s t i l l w i l l not h a v e the benefits of fluoride unless some m e t h o d other t h a n w a t e r fluoridation

is d e v i s e d . A c c o r d i n g l y , some of the studies w h i c h h a v e b e e n

c o n d u c t e d i n E u r o p e a d d i n g fluoride to the d a i l y d i e t of c h i l d r e n are of c o n s i d e r a b l e

importance.

Table

salt has b e e n

fluoridated

in


some

170

DIETARY

Table III. Age Group, Years



Muhler Muhler Muhler Muhler Jordan

(84) (85) (83) (79) (53)

5-15 5-15 17-36 6-15 8-11

M u h l e r (80) Peffley (88)

6-18 10-19 9-16 17-24 6-18 6-17

H i l l (40) K y e s (63) M u h l e r (75,77) B i x l e r (9)

C H E M I C A L S

G i s h (54) G i s h (35) T o r e l l (105) H e l d (38) T h o m a s (103) H o r o w i t z (49)

D E N T A L


Number in Exptl. Group

1.5 1.5 1 1 2 4

214 219 131 257 190 104 189 156 189 180 165 219 230 461 408 206 207 169 66

2 3

158 288

1 1 2 1 2 2 10 m o . 2 2 3 1

7-16 6-10

parts o f S w i t z e r l a n d , r e s u l t i n g i n a r e d u c t i o n i n d e n t a l caries. c u s s i n g these Swiss fluoride

findings,

CARIES

Reduction in Dental Caries

6-7 12 6-14 6-14 10 13-17

Z a c h e r l (1/4)

VS.

I n dis-

E r i c s s o n ( 2 5 ) p o i n t e d o u t that too l i t t l e

was a d d e d to the salt a n d that a s u b s t a n t i a l effect o n t h e i n c i -

dence o f d e n t a l caries is possible w i t h the correct f o r m u l a t i o n . I t is gene r a l l y c o n s i d e r e d that t h e d i s t r i b u t i o n p r o b l e m i n t h e U . S . w o u l d b e too great to m a k e

fluoridated

table salt a p r a c t i c a l d e n t a l p u b l i c h e a l t h

measure. F l u o r i d a t i o n o f m i l k is a l o g i c a l i d e a because t h e d i s t r i b u t i o n o f s c h o o l m i l k is a l r e a d y i n effect i n m a n y areas.

F l u o r i d e is c o m p a t i b l e

w i t h m i l k a n d i n t h e s t u d y b y Rossoff et al. (95) fluoride

in Louisiana, 1 m g

i o n as s o d i u m fluoride w a s a d d e d b y 6 - 1 0 year o l d c h i l d r e n to

the h a l f p i n t o f m i l k c o n s u m e d d a i l y . A f t e r 3Vi years, i t a p p e a r e d that caries w a s r e d u c e d b y 7 0 % i n n e w l y e r u p t e d p e r m a n e n t teeth as c o m p a r e d w i t h teeth o f controls. T h i s i n v e s t i g a t i o n a n d others r e v i e w e d b y B i r c h (8)

p o i n t o u t the n e e d f o r f u r t h e r s t u d y o f the effectiveness

of

d i e t a r y s u p p l e m e n t w i t h fluoride i n m i l k . T h e a d d i t i o n o f caries-preventive c h e m i c a l s to flour u s e d f o r b r e a d or b a k e d goods has b e e n t h e subject of studies i n several countries. F l o u r u s e d f o r b r e a d b a k i n g is often e n r i c h e d b y C a H P 0

4

or C a C 0

3

to p r o v i d e


10.

C A L D W E L L

Application

A N D T H O M A S

of Chemical

Agents

171

with Stannous Fluoride Dentrifices


Per Cent Caries Reduction (DMFS) 1 yr.

2 yr.

49 36 41 23 34

34

23 57 14 1 19 1° 40 39 34 7 35 a

8 yr.

21 12 25

-

Comments

S u p e r v i s e d b r u s h i n g once d a i l y Supervised brushing 3 X daily

15 14 19 42 39

22 -

a

Plus S n F Plus S n F 10 a n d 18 10 a n d 18 Plus S n F 0.91 p p m 2

2

2

21° Significant reduction a

p r o p h y l a x i s paste paste a n d t o p i c a l m o n t h results m o n t h results paste a n d t o p i c a l fluoride i n w a t e r

Supervised brushing 2 X daily w i t h N a F - S n F dentifrice Supervised brushing 3 X daily B r u s h i n g at home a n d school 2

17 10

30(DFS) 12

21

° Calculated from authors data. 1

a dietary calcium. With the comprehensive evidence available for a caries-protective effect of various phosphates in experimental animals, Stralfors (100) incorporated 2% C a H P 0 • 2HoO into soft bread, hard bread, wheat flour used for cooking, and sugar in a 2-year study of 2102 children, half of whom ate the phosphate-enriched bread and half of whom ate the bread without phosphate. Although caries was inhibited by 50% in the experimental group the first year and 40% the second year, evaluation was difficult since the dicalcium phosphate used contained 250 ppm fluoride the first year and only 25 ppm fluoride the second year. This made separation of the phosphate effect impossible. Since Averill and Bibby (3) and Ship and Mickelsen (98) failed to find a significant caries reduction with 2% dicalcium phosphate incorporated into bread, pastries, desserts, or sugar, it seems that this approach to caries prevention requires further study. The use of phosphates as a diet supplement to effect dental caries activity has been reviewed by Gilmore (33). The addition of fluoride to bread has been proposed from time to time. Ericsson (25) has reviewed the feasibility of this procedure and points out that in Holland there is less variation in bread consumption 4


172

DIETARY

C H E M I C A L S

VS.

D E N T A L

CARIES

t h a n i n w a t e r c o n s u m p t i o n . L i k e w i s e , E g e ( 2 0 ) has s h o w n that i n D e n m a r k the c o n s u m p t i o n o f cereals varies less t h a n d r i n k i n g w a t e r . fore, i n these t w o countries at least, the

fluoridation

There-

o f cereals seems

feasible. Over-the-counter

Preparations

D e s p i t e a l l o f the scientific a n d a d v e r t i s i n g f u r o r , n o n e o f t h e d e n t i -


frices a v a i l a b l e at t h e present t i m e is l i k e l y to r e d u c e d e n t a l caries i n c h i l d r e n u n d e r c o n d i t i o n s o f h o m e use b y m o r e t h a n 2 5 - 3 0 % . w o u l d b e e x p e c t e d i f adults u s e d these p r o d u c t s . ( 1 0 9 ) , W a l l a c e (110), a n d H i l l (40)

M a n d e l a n d C a g a n (68),

Less

Volker and Caldwell Bartelstone et al.

(4),

h a v e r e v i e w e d the e a r l y investigations o f dentifrices c o n -

t a i n i n g t h e r a p e u t i c agents f o r d e n t a l caries r e d u c t i o n . F o r t h e p u r p o s e of this p a p e r , stannous

fluoride

dentifrices w i l l b e r e v i e w e d a n d some

r e c e n t d e v e l o p m e n t s w i t h other agents w i l l b e discussed. T a b l e I I I c o n tains t h e p e r t i n e n t d a t a . T h e U n i v e r s i t y o f I n d i a n a S c h o o l o f D e n t i s t r y a n d the I n d i a n a D e p a r t m e n t o f P u b l i c H e a l t h h a v e b e e n r e s p o n s i b l e f o r the m a j o r i t y of reports d e a l i n g w i t h stannous fluoride dentifrices. U s u a l l y t h e i r results h a v e b e e n f a v o r a b l e , a l t h o u g h t w o reports are d i f f i c u l t to evaluate.

B i x l e r a n d M u h l e r ( 9 ) f o u n d n o d e n t i f r i c e effect after use o f

a stannous

fluoride

p r o p h y paste b u t they o b s e r v e d a 4 0 %

effect f o l l o w i n g stannous

fluoride

t o p i c a l . T h i s contrasts w i t h G i s h a n d M u h l e r ' s (34) no d e n t i f r i c e effect w i t h stannous fluoride

topical.

dentifrice

p r o p h y paste a n d stannous fluoride

finding

fluoride

of little o r

p r o p h y paste a n d stannous

A p a r t f r o m f a v o r a b l e results f r o m t h e m a n y

Indiana

studies, J o r d a n a n d Peterson ( 5 3 ) , H i l l ( 4 0 ) , K y e s , O v e r t o n , a n d M c K e a n (63) h a v e h a d n e g a t i v e results i n studies o f u n s u p e r v i s e d b r u s h i n g , w h i l e T o r e l l a n d E r i c s s o n ( 1 0 5 ) h a v e o b t a i n e d about a 2 5 % r e d u c t i o n , Z a c h e r l a n d M c P h a i l (114)

a 4 2 % r e d u c t i o n , a n d T h o m a s a n d J a m i s o n (103)

a

3 0 % r e d u c t i o n w h e n t h e teeth w e r e b r u s h e d three times d a i l y . H e l d a n d S p i r g i (38)

i n a study of a N a F - S n F

2

d e n t i f r i c e also h a v e o b s e r v e d a

significant r e d u c t i o n i n caries. A n i n t e r e s t i n g series o f papers o n fluoride d e n t i f r i c e trials a p p e a r e d i n t h e British

Dental Journal

v o l v i n g stannous

fluoride

(10).

F i v e studies w e r e d e s c r i b e d , a l l i n -

dentifrices.

abrasive w a s i n s o l u b l e m e t a p h o s p h a t e .

I n some

studies, t h e d e n t i f r i c e

I n one o f t h e studies, a s o d i u m

m o n o f l u o r o p h o s p h a t e w a s also e v a l u a t e d .

T h e s e w e l l p l a n n e d a n d exe-

c u t e d studies w e r e c a r r i e d o u t u n d e r rigorous c o n d i t i o n s i n v o l v i n g use of t h e d o u b l e b l i n d t e c h n i q u e w i t h a d e q u a t e s a m p l e sizes f o l l o w e d l o n g e n o u g h to demonstrate r e a l differences b e t w e e n g r o u p s .

S o m e general

conclusions c a m e o u t o f t h e five studies. F i r s t , a p p a r e n t l y t h e e a r l y p r o b lem

of i n c o m p a t i b i l i t y b e t w e e n the abrasive i n the d e n t i f r i c e a n d t h e


10.

C A L D W E L L

Table IV.


Type of Active Ingredient

Application

A N D T H O M A S

of Chemical

173

Agents

Therapeutic Dentrifices for Dental Caries

Mechanism of Action

Chemical Agents Used

General Conclusions about Effectiveness

Detergent

Antienzyme

Urea

Buffering, Dibasic ammonium protein phosphate denaturation Urea

Ineffective i n the low concentrations used

Antibiotic

Antibacterial

Penicillin Tyrothrycin

D o u b t f u l if s u i t a b l e for general use

Fluoride

Antienzyme, decreased enamel dissolution, increased remineralization

A m i n e fluoride S o d i u m fluoride Sodium monofluorophosphate S t a n n o u s fluoride

L i m i t e d effect

Surfacecoating agent

Reduced adhesion of food a n d bacteria to enamel

Tetradecylamine

Ineffective

S o d i u m dehydroacetate L i m i t e d effect S o d i u m l a u r o y l sarcosinate possible; v a r i able results

fluoride

has b e e n

fluorides

are n o w a v a i l a b l e . S e c o n d , i n a l l five studies, stannous

l a r g e l y o v e r c o m e , a n d stable

dentifrices c a u s e d s t a i n i n g of the teeth.

products w i t h

active fluoride

I n one report, the increase i n

s t a i n i n g was d e s c r i b e d as a t r e m e n d o u s increase i n b r o w n stain. u n d e s i r a b l e effect of stannous

fluoride

This

d e n t i f r i c e s indicates that n o n - t i n -

c o n t a i n i n g dentifrices seem to h o l d m o r e p r o m i s e for f u t u r e s t u d y a n d use.

A s o d i u m m o n o f l u o r o p h o s p h a t e d e n t i f r i c e was s l i g h t l y , a l t h o u g h

not s i g n i f i c a n t l y , m o r e effective t h a n stannous fluoride d e n t i f r i c e a n d d i d not stain the teeth.

In a previous study b y F i n n and Jamison (27)

in

the U . S . , i t w a s s h o w n that m o n o f l u o r o p h o s p h a t e was m o r e effective t h a n a stannous fluoride d e n t i f r i c e . A t h i r d finding i n the B r i t i s h studies was that girls benefitted m o r e f r o m the use of the t h e r a p e u t i c d e n t i f r i c e s t h a n b o y s , p r o b a b l y because of t h e i r better o r a l h y g i e n e habits.

It is some-

w h a t d i s a p p o i n t i n g to observe that l i t t l e i m p r o v e m e n t i n o r a l h y g i e n e h a d r e s u l t e d at the e n d of a 3-year p r o g r a m of o r a l h y g i e n e i n s t r u c t i o n a n d r e g u l a r t o o t h b r u s h i n g . T h e r e d u c t i o n i n caries r e p o r t e d r a n g e d f r o m n o r e d u c t i o n i n caries to 3 6 %

r e d u c t i o n i n p r o x i m a l caries of posterior


174

D I E T A R Y

C H E M I C A L S

Table V .


Solution

W e i s z (111)

5-6 8-9

0.25% 0.25%

T o r e l l (106)

8-9

0.2% N a F 0.2% K F

L u n d s t a m (67)

7-15

0.2%

10

T o r e l l (105) M c C o r m i c k (72)

t o o t h surfaces.

CARIES

Reduction in Dental Caries

Age Group j Years


D E N T A L

VS.

Used

NaF NaF

NaF

0.05% N a F 0.2% N a F C a , P 0 , F " (3 p p m ) F ~ (3 p p m ) F ~ (40 p p m )

6-8

4

W h e n t h e D M F S i n d e x w a s u s e d , t h e r e d u c t i o n i n caries

w a s m a r g i n a l . O n l y b y m a k i n g s p e c i a l c o m p u t a t i o n s o n teeth w h i c h h a d e r u p t e d d u r i n g t h e s t u d y c o u l d t h e observers detect a n y s u b s t a n t i a l effect of t h e fluoride d e n t i f r i c e . T h e s e B r i t i s h studies t e n d t o c o n f i r m t h e o p i n i o n c o n c e r n i n g stannous

fluoride

effect i n r e d u c i n g d e n t a l caries.

d e n t i f r i c e s that t h e y h a v e a m a r g i n a l D u c k w o r t h (19)

reviewed

fluoride

d e n t i f r i c e s , i n p a r t i c u l a r trials i n the U n i t e d K i n g d o m , a n d c o n c l u d e d that dentifrices c o n t a i n i n g stannous fluoride h a d a s m a l l b u t u s e f u l role i n t h e p r e v e n t i o n o f d e n t a l caries i n teen-age s c h o o l c h i l d r e n . T h e greater benefits

s h o w n b y girls d e m o n s t r a t e d

that p r e v e n t i o n d e p e n d s u p o n

conscientious use. T a b l e I V s u m m a r i z e s i n a v e r y g e n e r a l w a y t h e c u r r e n t status o f t h e v a r i o u s dentifrices w h i c h h a v e b e e n f o r m u l a t e d to p r e v e n t d e n t a l caries. T h e most effective dentifrices c o n t a i n

fluoride

i n some f o r m , b u t e v e n

these h a v e a l i m i t e d a b i l i t y to p r o t e c t against d e n t a l caries. S o m e studies h a v e b e e n d e s i g n e d to p r o v i d e a m o r e stable d e n t i f r i c e f o r m u l a t i o n b y u s i n g either n o n - c a l c i u m - c o n t a i n i n g abrasives o r other t h a n stannous

fluoride.

M a n l y (69)

fluorides

a n d E r i c s s o n (24) h a v e d r a w n

a t t e n t i o n t o t h e p r o b l e m of t i n a n d fluoride r e a c t i n g w i t h t h e a b r a s i v e , w h i c h , as m e n t i o n e d earlier, w a s a p r o b l e m w i t h e a r l i e r stannous dentifrices.

fluoride

Dentifrices c a n vary w i d e l y i n the compatibility of the i n -

gredients, m a k i n g i t d i f f i c u l t to c o m p a r e the effectiveness

o f different

d e n t i f r i c e s o r e v e n t h e same d e n t i f r i c e f r o m t i m e to t i m e w h e n s l i g h t modifications i n the f o r m u l a have been made. A n a m i n e fluoride d e n t i f r i c e has b e e n d e v e l o p e d i n S w i t z e r l a n d

(71),

the r a t i o n a l e f o r t h e a m i n e fluoride b e i n g that i t has a n t i e n z y m e a c t i o n a n d is r e t a i n e d better o n t h e e n a m e l surface t h a n other fluorides. M a r -


10.

C A L D W E L L

A N D T H O M A S

Application

of Chemical Agents

175

with Fluoride Mouthwashes


No. in Exptl. Group 21 11

10 4

912 520

1 1

1 / t w o weeks

2400

1/day 1 / t w o weeks

160 172

1/day 1/day 1/day


90 90 90

S i g n i f i c a n t decrease i n a n t e r i o r p r o x i m a l caries

9 mo.

36

2 2

49 21 45* 0 23*

30 m o . 30 m o . 30 m o .

° Reduction calculated for mesial surfaces of 6-year molar. No effect on occlusal surfaces. thaler (70)

r e p o r t e d caries i n h i b i t i o n after 7 years of u n s u p e r v i s e d use

of a n a m i n e d e n t i f r i c e .

T h e d e n t i f r i c e c o n t a i n i n g the a m i n e

fluorides

i n h i b i t e d n e w carious lesions b y 3 2 % b a s e d o n n e w D F surfaces. p r o m i s i n g results w e r e o b t a i n e d b y L u d w i g (66)

Less

w i t h a tetradecylamine

d e n t i f r i c e . T h e i d e a of r e d u c i n g f o o d a n d b a c t e r i a l p l a q u e r e t e n t i o n o n the t o o t h surface is l o g i c a l , b u t so f a r n o effective m e t h o d has b e e n d e v i s e d f o r a c h i e v i n g this w i t h a d e n t i f r i c e . It is a m u s i n g to n o t i c e i n H e l d a n d S p i r g i s (38)

a r t i c l e that the n a m e

of one of the dentifrices tested w a s D r a b — a n a m e h a r d l y l i k e l y to excite the U . S . a d v e r t i s i n g c o m m u n i t y . M o u t h w a s h e s h a v e b e e n p o p u l a r f o r centuries because of t h e i r ref r e s h i n g p r o p e r t i e s a n d a b i l i t y to mask m o u t h o d o r . H o w e v e r , n o t u n t i l r e c e n t l y h a v e t r u l y t h e r a p e u t i c m o u t h w a s h e s b e e n f o r m u l a t e d to p r e v e n t d e n t a l caries.

F o r several years, W e i s z (111)

has c l a i m e d that c h i l d r e n

i n his p r a c t i c e h a v e v e r y h i g h resistance to caries w h e n a n 0 . 2 5 %

NaF

m o u t h w a s h is u s e d t w i c e d a i l y . T a b l e V s u m m a r i z e s some of the a v a i l a b l e studies o n fluoride m o u t h w a s h e s . It c a n b e seen f r o m T a b l e V that fluoride

m o u t h w a s h e s offer definite possibilities f o r c o n t r o l l i n g d e n t a l

caries. It is n o t k n o w n w h e t h e r or not these benefits w o u l d b e a d d i t i o n a l to other m e t h o d s of caries c o n t r o l s u c h as t o p i c a l

fluoride

or

fluoride

pastes a p p l i e d b y the dentist, b u t it is q u i t e possible that m o u t h w a s h e s w i l l p r o v e to b e m o r e effective t h a n dentifrices i n r e d u c i n g d e n t a l caries. T h e s i m p l e fact is that n o i n c o m p a t i b l e or i n a c t i v a t i n g agents s u c h as a n a b r a s i v e or b i n d e r n e e d b e i n c l u d e d i n a m o u t h w a s h . A n a p p r a i s a l of T a b l e V indicates that t w o factors i n f l u e n c e the results, the f r e q u e n c y of


176

DIETARY

m o u t h w a s h i n g a n d the s t r e n g t h of the

C H E M I C A L S

fluoride

VS.

D E N T A L

CARIES

solution. A l t h o u g h an

e d i t o r i a l c o m m e n t w h i c h a c c o m p a n i e d one of W e i s z ' s papers (111) gested that a n 0.25%

use, as a p r a c t i c a l matter, n o p r o b l e m s seem to h a v e b e e n b y W e i s z o r other investigators.

encountered

C e r t a i n l y , the d a i l y use of 0.05%

as s t u d i e d b y T o r e l l a n d E r i c s s o n (105)

NaF

is v e r y safe.

I n c o m p a r i n g v a r i o u s p r o c e d u r e s , T o r e l l a n d E r i c s s o n (105) a d a i l y m o u t h w a s h of 0.05%

found

N a F was m o r e effective t h a n a 2 %

m o u t h w a s h u s e d once e v e r y 2 weeks. Downloaded by UNIV OF LIVERPOOL on December 19, 2016 | http://pubs.acs.org Publication Date: June 1, 1970 | doi: 10.1021/ba-1970-0094.ch010

sug-

N a F m o u t h w a s h is too c o n c e n t r a t e d f o r safe h o m e

NaF

L i k e w i s e , the m o u t h w a s h w a s

m o r e effective t h a n the s t a n d a r d techniques f o r t o p i c a l 2 % N a F or 1 0 % S n F , o r dentifrices c o n t a i n i n g stannous 2

fluoride,

p h o s p h a t e . F j a e s t a d - S e g e r a n d others (28) w i t h 0.2%

or s o d i u m m o n o f l u o r o -

r e p o r t e d that a w e e k l y rinse

n e u t r a l s o d i u m fluoride or a n i r o n

fluoride

solution showed

a significant caries r e d u c t i o n i n c h i l d r e n . T o r e l l a n d S i b e r t (106) m o n t h l y s u p e r v i s e d r i n s i n g of a 0 . 2 %

studied

s o d i u m fluoride s o l u t i o n a m o n g

s c h o o l c h i l d r e n . A s i n the case of the other S w e d i s h s t u d y ( 2 8 ) ,

the

effect was expressed as percentage of c h i l d r e n r e c e i v i n g n e w restorations after one year. U s i n g this less precise assessment, 13 to 2 7 % f e w e r c h i l d r e n r e c e i v e d care after one year. S w e r d l o f f a n d S h a n n o n (101), i n g the f e a s i b i l i t y of the use of a stannous 0.4%

fluoride

study-

mouthwash daily

i n a s c h o o l p r e v e n t i v e d e n t i s t r y p r o g r a m , w e r e a b l e to r e p o r t a

30.5%

r e d u c t i o n i n n e w carious surfaces after o n l y 5 m o n t h s . T h i s t i m e p e r i o d a n d the s m a l l n u m b e r of subjects s t u d i e d m a d e the results not significant other t h a n to l e n d s u p p o r t to the other studies q u o t e d . A n e w d e v e l o p m e n t is the use of a ' r e m i n e r a l i z i n g " m o u t h w a s h . T h e rationale f o r this m o u t h w a s h is b a s e d o n the e v i d e n c e of K o u l o u r i d e s , C u e t o , a n d P i g m a n (60)

a n d K o u l o u r i d e s a n d R e e d (63)

that softened

e n a m e l c a n b e r e h a r d e n e d b y solutions of c a l c i u m a n d p h o s p h o r u s a n d that the process is accelerated b y s m a l l amounts of fluoride. M c C o r m i c k a n d K o u l o u r i d e s (72)

r e p o r t e d that the r e m i n e r a l i z i n g m o u t h w a s h is

c a p a b l e of r e d u c i n g caries o n the m e s i a l surface of the first m o l a r b y 4 5 % . T h e use of c h e w i n g g u m as a v e h i c l e for caries-preventive c o m p o u n d s predates several of the other methods d e s c r i b e d i n this p a p e r .

A good

r e v i e w of the subject has b e e n p u b l i s h e d b y R i c h a r d s o n a n d C a s t a l d i (93).

T a b l e V I s u m m a r i z e s the effect of c h e w i n g g u m o n d e n t a l caries.

T h e first fact w h i c h s h o u l d b e m e n t i o n e d is that i n n o p u b l i s h e d s t u d y h a v e g u m chewers h a d m o r e caries t h a n n o n c h e w e r s . A c t u a l l y , as s h o w n b y D r e i z e n a n d Spies ( 1 8 ) , V o l k e r ( 1 0 8 ) , a n d T o t o , R a p p , a n d O ' M a l l e y ( 1 0 7 ) , o r d i n a r y c h e w i n g g u m seems n e i t h e r to cause n o r p r e v e n t d e n t a l caries. P r o m i s i n g results b y i n c o r p o r a t i n g v i t a m i n K , F u r a d o x y l ( a n i t r o f u r a n ) , or c h l o r o p h y l l i n g u m h a v e b e e n r e p o r t e d b u t none of these has b e e n f o l l o w e d u p . I n a c o u n t r y s u c h as the U . S . A . , w h e r e c h e w i n g g u m is w i d e l y u s e d , this a p p r o a c h has u n t a p p e d p o t e n t i a l .

It has b e e n re-


10.

CALDWELL AND THOMAS Table VI.

Effect of Chewing Gum on Dental Caries

Principal Type of Investigator Gum Additive Burrill (14) Dreizen (18) Gerke (32)


L i n d (65)

177

Application of Chemical Agents

Synthetic vit. Κ Furadoxyl Chlorophyll

Number in Exptl Type of Group Subjects 55 30 102 229

Burrill (14)

Potassium fluoride None

Volker (108) Dreizen (18) Toto (107)

None None None

50 25 275

45

Dental students Age 6-38 Adults (bakers) Age 11 Dental students Age 18-32 Age 8-35 Primary school

Duration of Study

Caries Reduction

18 mo.

60-90%

12 mo. 12 mo. 12 mo.

80% 20% (approx.) None

18 mo.

13-80%

18 mo. 12 mo. 12 mo.

None None None

ported that fluoride or dicalcium phosphate can be released from a gum while chewing (21, 90, 91). In a clinical study of phosphate-containing chewing gum (27), F i n n and Jamison demonstrated reduction of caries incidence in children after a 2-year period of 39.7 to 52.9% considering proximal surfaces of teeth only. Literature Cited (1) Arnold, F. Α., McClure, F . J., White, C. L., Dental Progr. 1960, 1, 8. (2) Averill, H . M . , Averill, J. E., Ritz, A. G., Little, M . F., Am. J. Public Health 1967, 57, 1627. (3) Averill, Η. M . , Bibby, B. G., J. Dental Res. 1964, 43, 1150. (4) Bartelstone, H . J., Mandel, I. D., Chilton, N. W., Ν. Y. Dental J. 1962, 28, 147. (5) Berggren, H . , Welander, E., Acta Odontol. Scand. 1960, 18, 209. (6) Ibid., 1964, 22, 401. (7) Bibby, B. G., Tufts Dental Outlook 1942, 15, 4. (8) Birch, R. C., J. Public Health Dentistry 1969, 29, 170. (9) Bixler, D., Muhler, J. C., J. Am. Dental Assoc. 1964, 68, 792. (10) Brit. Dental J. 1967, 123 (1). (11) Brudevold, F., Gron, P., Spinelli, M . , Trantz, O., Arch. Oral Biol. 1963, 8, 167. (12) Bryan, E . T., Williams, J. E . , J. Public Health Dentistry 1968, 28, 182. (13) Bullen, D . C. T., McCombie, F., Hole, L. S., J. Can. Dental Assoc. 1966, 32, 89. (14) Burrill, D . Y., Calandra, J. C., Tilden, Ε. B., Fosdick, L . S., J. Dental Res. 1945, 24, 273. (15) Cons, N . C., Janerich, D . T., Senning, R. S., J. Am. Dental Assoc. 1970, 80, 777. (16) De Paola, P. F., J. Am. Coll. Dentists 1968, 35, 22. (17) Doherty, J. M . , Wis. Med. J. 1968, 67, 599. (18) Dreizen, S., Spies, T. D., J. Am. Dental Assoc. 1951, 43, 147. (19) Duckworth, R., Brit. Dental J. 1968, 124, 505.



178

DIETARY CHEMICALS VS. DENTAL CARIES

(20) Ege, R., Tandlaegebladet 1961, 65, 445. (21) Emslie, R. D., Veall, N . , Duckworth, R., Brit.Dental J. 1961, 110, 121. (22) Englander, H . R., Carlos, J. P., Senning, R. S., et al., J. Am. Dental Assoc. 1969, 78, 783. (23) Englander, H . R., Keyes, P. H . , Gestwicki, M., Schultz, Η. Α.,J.Am. Dental Assoc. 1967, 75, 638. (24) Ericsson, Y., in "Caries Symposium Zurich," H . Muhlemann, Ed., Hans Huber, Berne, 1961. (25) Ericsson, Y., in "Nutrition and Caries Prevention," G. Blix, Ed., Almqvist and Wiksells, Uppsala, 1965. (26) Finn, S. B., Jamison, H . C., J. Dental Assoc. 1967, 74, 987. (27) Finn, S. B., Jamison, H . C., J. Dentistry Children 1963, 30, 17. (28) Fjaestad-Seger, M . , Norstedt-Larsson, K., Torell, P., Sveriges Tandlakarforb Tindn 1961, 53, 169. (29) Food and Drug Administration, Federal Register 1966, Oct. 20. (30) Galagan, D. J., Knutson, J. W., Public Health Rept. 1947, 62, 1477. (31) Ibid., 1948, 63, 1215. (32) Gerke, J., Klimt, W., Zahnnaerztl. Rundschau 1955, 64, 499. (33) Gilmore, N. D., J. Public Health Dentistry 1969, 29, 88. (34) Gish, C. W., Muhler, J. C., J. Am. Dental Assoc. 1965, 70, 914. (35) Gish, C. W., Muhler, J. C., Stookey, G. K., J. Am. Dental Assoc. 1965, 71, 60. (36) Goaz, P. W., McElwaine, L . P., Biswell, Η. Α., et al., J. Dental Res. 1966, 45, 286. (37) Goaz, P. W., McElwaine, L. P., Biswell, Η. Α., White, W . E., J. Dental Res. 1963, 42, 965. (38) Held, A. J., Spirgi, M . , Schweiz. Montsschr. Zahnheilk. 1965, 75, 883. (39) Hennon, D . K., Stookey, G. K., Muhler, J. C., J. Dentistry Children 1967, 34, 439. (40) Hill, T. J., J. Am. Dental Assoc. 1959, 59, 1121. (41) Horii, Α. Α., Keyes, P. H . , J. Dental Res. 1964, 43, 152. (42) Horowitz, H . S., IADR Program and Abstracts of Papers, No. 549, March 1969. (43) Horowitz, H . S., J. Am. Dental Assoc. 1969, 78, 568. (44) Horowitz, H. S., J. Oral Therap. 1968 (Jan.), 4, 286. (45) Horowitz, H . S., Heifetz, S. B.,J.Am. Dental Assoc. 1970, 81, 166. (46) Horowitz, H . S., Heifetz, S. B.,J.Dentistry Children 1969, 36, 355. (47) Horowitz, H. S., Heifetz, S. B., Public Health Rept. 1967, 82, 297. (48) Horowitz, H . S., Lucye, H . S., J. Oral Therap. 1966 (July), 3, 17. (49) Horowitz, H . S., Thompson, M . B., J. Am. Dental Assoc. 1967, 74, 979. (50) Hunsfadbraten, V. K., Dent. Zahnaerztl. Z. 1965, 20, 336. (51) "Improving dental practise through preventive measures," Ch. 5, p. 110, J. L . Bernier and J. C. Muhler, Eds., C. V . Mosby Co., St. Louis, 1966. (52) Ingraham, R. Q., Williams, J. E . , J. Tenn. Dental Assoc. 1970 (Jan.), 50, 5. (53) Jordan, W. Α., Peterson, J. K.,J.Am. Dental Assoc. 1959, 58, 42. (54) Knutson, J. W., J. Am. Dental Assoc. 1948, 36, 37. (55) Ibid., 1970, 80, 765. (56) Knutson, J. W., Armstrong, W. D., Public Health Rept. 1943, 58, 1701. (57) Ibid., 1945, 60, 1085. (58) Ibid., 1946, 61, 1685. (59) Knutson, J. W., Armstrong, W. D., Feldman, F . M., Public Health Rept. 1947, 62, 425. (60) Koulourides, T., Cueto, H . , Pigman, W., Nature 1961, 189, 226. (61) Koulourides, T., Reed, J. L., Arch. Oral Biol. 1964, 9, 585. (62) Kyes, F .M.,J. Oral Therap. 1967, 3, 359.



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Application of Chemical Agents

179

(63) Kyes, F. M., Overton, N . J., McKean, T. W., J. Am. Dental Assoc. 1961, 63, 189. (64) Lang, L . H . , Thomas, H . G., Taylor, J. Α., Rothhaar, R. E., J. Dentistry Children 1970 (May-June), 37, 27. (65) Lind, V., Stelling, E., Nystrom, S., Odontol. Revy 1961, 12, 341. (66) Ludwig, T. G., Ν. Z. Dental J. 1963, 59, 220. (67) Lundstam, R., Sveriges Tandlakarforbund Tidn 1964, 56, 681. (68) Mandel, I. D., Cagan, R. S., J. Oral Therap. 1964, 1, 218. (69) Manly, R. S., in "Caries Symposium Zurich," H. Muhlemann, Ed., Hans Huber, Berne, 1961. (70) Marthaler, T. M . , Brit. Dental J. 1968, 124, 510. (71) Marthaler, T. M . , in "Caries Symposium Zurich," H. Muhlemann, Ed., Hans Huber, Berne, 1961. (72) McCormick, J., Koulourides, T., Intern. Assoc. Dental Res. Abstracts of 43rd General Meeting, 1965, p. 138. (73) Mercer, V. H . , Gish, C. W., J. Indian Dental Assoc. 1968, 47, 432. (74) Mercer, V . H . , Muhler, J. C., J. Oral Therap. 1964, 1, 141. (75) Muhler, J. C., in "Caries Symposium Zurich," H . Muhlemann, Ed., Hans Huber, Berne, 1961. (76) Muhler, J. C., J. Am. College Dentistry 1968, 35, 45. (77) Muhler, J. C., J. Am. Dental Assoc. 1962, 64, 216. (78) Muhler, J. C., J. Dentistry Children 1958, 25, 306. (79) Muhler, J. C., J. Dental Res. 1958, 37, 448. (80) Ibid., 1960, 39, 955. (81) Muhler, J. C., J. Indian Dental Assoc. 1968, 47, 428. (82) Muhler, J. C., Kelly, G. E . , Stookey, G. K., Lindo, F. I., Harris, N. O., J. Am. Dental Assoc. 1970, 81, 142. (83) Muhler, J. C., Radike, A. W., J. Am. Dental Assoc. 1957, 55, 196. (84) Muhler, J. C., Radike, A. W., Nebergall, W . H . , Day, H . G., J. Am. Dental Assoc. 1955, 50, 163. (85) Ibid., 1955, 51, 556. (86) Muhler, J. C., Stookey, G. K., Bixler, D., J. Dentistry Children 1965, 32, 154. (87) Pameijer, J. H . N., Hunt, Ε. E., Jr., Brudevold, F., Arch. Oral Biol. 1963, 8, 183. (88) Peffley, C. E . , Muhler, J. C., J. Dental Res. 1960, 39, 871. (89) Peterson, J. K., Horowitz, H . S., Jordan, W. Α., Pugnier, V., J. Dental Res. 1969, 48, 346. (90) Pickel, F . D., Bilotti, Α., Ala. J. Med. Sci. 1965, 2, 286. (91) Pickel, F. D., Block, Α., Bilotti, A. G., Pigman, W., Ala. J. Med. Sci. 1965, 2, 288. (92) "Progress Report Concerning the Current Status of the Self-Application of the Stannous Fluoride-Zirconium Silicate Preventive Dentistry Paste Program for the Mass Control of Dental Caries," J. Indian Dental Assoc. 1969, 48, 317. (93) Richardson, A . S., Castaldi, C. R., J. Can. Dental Assoc. 1965, 31, 713. (94) Rosenkranz, F., Torell, P., Odontol. Revy 1961, 12, 267. (95) Rusoff, L . L., Konikoff, B. S., Frye, J. B., Johnston, J. E . , Frye, W . W., Am. J. Clin. Nutr. 1962, 11, 94. (96) Scola, F. P., U . S. Naval Submarine Medical Center Memo, Report No. 68-3, 1968. (97) Scola, F. P., Ostrum, C. Α., J. Am. Dental Assoc. 1966, 73, 1306. (98) Ship, I. I., Mickelsen, O., J. Dental Res. 1964, 43, 1144. (99) Stralfors, Α., in "Caries Symposium Zurich," H. Muhlemann, Ed., Hans Huber, Berne, 1961. (100) Stralfors, A. J., J. Dental Res. 1964, 43, 1137.



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(101) Swerdloff, G., Shannon, I. L., U S A F School of Aerospace Medicine Re port—SAM-TR-67-52, 1967. (102) Szwejda, L . F., Tossy, C. V., Below, D . M . , J. Public Health Dentistry 1967, 27, 192. (103) Thomas, A. E . , Jamison, H. C., J. Am. Dental Assoc. 1966, 73, 844. (104) Torell, P., Acta Odontol. Scand. 1965, 23, 287. (105) Torell, P., Ericsson, Y., Acta Odontol. Scand. 1965, 23, 297. (106) Torell, P., Siberg, Α., Odontol. Revy 1962, 13, 62. (107) Toto, P. D., Rapp, G., O'Malley, J., J. Dental Res. 1960, 39, 750. (108) Volker, J. F., J. Am. Dental Assoc. 1948, 36, 23. (109) Volker, J. F., Caldwell, R. C., in "Clinical Pedodontics," S. B. Finn, Ed., 3rd ed., Chap. 27, W . B. Saunders, Philadelphia, 1967. (110) Wallace, D . Α., Dental Progr. 1962, 2, 242. (111) Weisz, W . S., J. Am. Dental Assoc. 1960, 60, 438. (112) Wellock, W . D . , Brudevold, F., Arch. Oral Biol. 1963, 8, 179. (113) Wellock, W. D., Maitland, Α., Brudevold, F., Arch. Oral Biol. 1965, 10, 453. (114) Zacherl, W. Α., McPhail, C. W . B., J. Can. Dental Assoc. 1965, 31, 174. RECEIVED August 15, 1968.


Dietary Chemicals vs. Dental Caries - ACS Publications

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