2019 Dry As a Bone

Life is a breeze…….. Complicated, real life situations Spotlight on Sjogren’s syndrome - except when you’re dry as a bone primary

‣ dry mouth ‣ 2012 – nearly 6 years

‣ dry eyes ‣ 2016 – down to 3

Saliva and tears Demographics Ocular symptoms ‣90% female ‣ abraded cornea ‣age 40 approx - menopause ‣ inﬂamed lacrimal glands ‣ infec@ons ‣10% male – 10% ‣ body destroys glands ‣ discomfort ‣under and undiagnosed ‣ lack of ﬂow ‣children – not common ‣ blurry vision ‣ poor quality ‣enlarged paro@d gland ‣ stuck eye lids © 2019 © 2019 © 2019

Improving the patient’s outcome Impact Te st i n g o ral p H

IndividualIndividual ! Best ! clinical ! external ! expertise evidence ‣ quality of life EBMEBM$ ‣ ﬁnancial emo@onal Patient values! ‣ & expectations ‣ 5+ heath care providers

‣ 70 year old female ‣ severe polypharmacy-induced Who has the xerostomia ‣ high caries risk highest risk? ‣ every 3 months - something new ‣ extremely sensi@ve @ssues ‣ has had severe mucosi@s to everything I have recommended for use in her custom ﬂ trays

Multiple terms - quality of life Hyposalivation Xerostomia

‣ subjec@ve term ‣ dry mouth / syndrome ‣ clinical diagnosis ‣ perceived lack of moisture ‣ hypo-saliva@on ‣ decreased salivary ﬂow ‣ changes in composi@on ‣ xerostomia ‣ insuﬃcient in saliva

Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide Wiley, Blackwell. May 2010. © 2019 . Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2019 Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. Villa, A., Connell, C., Aba@, S. (2014). Diagnosis and management of xerostomia and hyposaliva@on. Therapeutics and Clinical Risk Management, 45. © 2019 Prevalence Insufﬁcient ﬂow Visual observations

‣ 30% popula@on ! subtle changes ‣ red, glossy, parched

‣ more women ! 50% decrease - no@ceable ‣ pebbled tongue

‣ 10% early 30s ! pH decreases ‣ cracking in commisures ‣ chapped lips ‣ over age 50 ! increased demineraliza@on ‣ thick, foamy, ropy saliva Takahashi N, Nyvad B.Caries ecology revisited: Microbial dynamics and the caries process. Caries Res. 2008;42(6):409-18. Thomson WM, Lawrence HP, Broadbent JM, Poulton R. The impact of xerostomia on oral-health-related quality of life among younger adults. Health Qual Life Outcomes. 2006 Nov 8;4:86. Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 Anil S, Vellappally S, Hashem M, Preethanath RS, Pa@l S, Samaranayake LP. Xerostomia in geriatric pa@ents: a burgeoning global concern. J Inves@g Clin Dent. 2014 Sep 1. © 2019 Graham I, Mount WH. (2005). Preserva@on and restora@on of tooth structure. 2nd Edi@on. Queensland, Australia: Knowledge Books and Sooware. © 2019 Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. © 2019

Clinical complaints Additional complaints

‣ sore mucosa ‣ feel dry when ea@ng? ‣ burning sensa@on ‣ sip liquids to swallow dry ‣ s@ckiness ‣ diﬃculty talking ‣ problems chewing food? ‣ halitosis ‣ taste altera@ons ‣ diﬃculty swallowing ‣ amount of saliva seem metallic taste reduced? ‣ ‣ dry/sore throat ‣ den@nal hypersensi@vity Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide Wiley, Blackwell. May 2010. Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010. . © 2019 © 2019 Dry mouth (Xerostomia): Diagnosis, Causes, Complica@ons and Treatment. Dental Professional Version. Delta Dental. 2011 © 2019 Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45.

problems tas@ng? ‣ night @me ‣ dry during ‣ tongue burn? ‣ ‣dry eyes ‣recurring decay problems wake up dry the day@me ‣ sensi@ve to acidic, salty ‣ ‣ diﬃculty swallowing? eyes feel sandy chew gum/candy for relief or spicy foods? ‣ ‣

Dry mouth (Xerostomia): Diagnosis, Causes, Complica@ons and Treatment. Dental Professional Version. Delta Dental. 2011 Dry mouth (Xerostomia): Diagnosis, Causes, Complica@ons and Treatment. Dental Professional Version. Delta Dental. 2011 © 2019 © 2019 Dry mouth (Xerostomia): Diagnosis, Causes, Complica@ons and Treatment. Dental Professional Version. Delta Dental. 2011 © 2019 Saliva - The magic ﬂuid Digestion

‣ chewing ‣ bolus ‣ swallowing ‣ enzymes Saliva functions ‣ taste

Protection Protection Additional functions ‣ dilu@on ‣ buﬀering-neutralizes ‣ lubrica@on ‣ remineraliza@on ‣ cleansing ‣ an@-microbial ‣ speech ‣ kissing ‣ increase pH ‣ healing ‣ nutri@on ‣ licking ‣ social interac@on ‣ excre@on de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composi@on and func@ons: A comprehensive review. J Contemp Dent Pract 2008 March; (9)3:072-080. de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composi@on and func@ons: A comprehensive review. J Contemp Dent Pract 2008 March; (9)3:072-080. Hara AT, Zero DT. The caries environment: saliva, pellicle, diet, and hard @ssue ultrastructure. Dent Clin North Am. 2010 Jul;54(3):455-67. Hara AT, Zero DT. The caries environment: saliva, pellicle, diet, and hard @ssue ultrastructure. Dent Clin North Am. 2010 Jul;54(3):455-67. Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2019 Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2019 © 2019 astoundingminds.blogspot.com/2012/04/boiling-point-of-human-saliva.html

Sources The kiss 90% - whole saliva ‣paro@d - 30% ‣ longest - 58 hours, 35 minutes and 58 sec ‣sub-mandibular- 60% ‣ lowers cor@sol levels ‣sub-lingual - 5% ‣ heart beats faster ‣10% - minor glands - 5% ‣ more oxygen reaches your brain Saliva - found throughout the mouth

© 2018 © 2018 © 2018 www.lifedaily.com/12-most-surprising-facts-about-kissing/ Accessed 10/1/15. production, composition, flow Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 Healthy saliva - composition Secretions Salivary protein serous and mucous functions also contains ! proteins ! antibacterial ! tissue coating ! enzymes ! paro@d - serous and enzymes ! antifungal ! wound healing mucins ! ! submandibular - 90% serous, 10% mucous ! remineralization 99% water ! antiviral ! buffering compounds ! digestion ! sublingual and minor - 80% daily mucous ! buffering

Types of flow Mucins - wetness and comfort Proline-rich proteins proteins with carbohydrate chains and arginine !spontaneous minor salivary glands - mucins ! lubricates !s@mulated ! controls viscosity / elas@city ! PRPs - 70% of all salivary proteins paro/d - serous ! affects s@ckiness ! forma@on / func@on acquired pellicle !uns@mulated (res@ng) ! saliva contact with oral cavity ! arginine - ammonia produc@on sublingual and minor - serous and mucous ! buffering compounds Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. © 2019 Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2019 © 2019

Healthy - daily ﬂow rate Flow rate - visual inspection Testing ﬂow rate / per min

0.5 to 1.5 liters ‣ retract lower lip ‣ chew wax - 5 min

‣ spit in cup ‣ res@ng - 0.25 to 0.4 /min ‣ dry with gauze

• normal - 1 to 3ml ‣ 1 min - drops on mucosa ‣ s@mulated - 1 - 3 ml / min • low - 0.7 to 1 ml ‣ sufficient flow - pooling in floor of mouth ‣ establish a baseline! • very low - < 0.7 ml Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2019 © 2019 Saliva and the Control of Its Secre@on. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnos@c Imaging, Springer-Verlag Berlin Heidelberg 2012 © 2019 Stimulated saliva Stimulated saliva Saliva – Fast facts……. ‣ quality improves - proteins

80 - 90% daily salivary produc@on ‣ increased bicarbonate peak flow - late aGernoon " an@cipatory tongue/lip movements ‣ neutralizes acids ! " chewing ! during sleep - near zero flow ‣ bicarbonate reserves are limited " taste ! acid substances salivary flow rates " smell ‣ proteins - secondary path - neutralizaCon

García-Godoy F, Hicks MJ. Maintaining the integrity of the enamel surface: the role of dental bioﬁlm, saliva and preven@ve agents in enamel demineraliza@on and remineraliza@on. ! paro@d gland – 50% of s@mulated saliva J Am Dent Assoc. 2008 May;139 Suppl:25S-34S. de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva Composi@on de Almeida PDV, Grégio AMT, Machado MÂN, de Lima AAS, Azevedo LR. Saliva composi@on and func@ons: A comprehensive review. de Almeida PDV, Grégio AMT, et al. Saliva Composi@on And Func@ons: A Comprehensive Review. J Contemp Dent Pract 2008 March; (9)3:072-080. And Func@ons: A Comprehensive Review. J Contemp Dent Pract 2008 March; (9)3:072-080. © 2019 © 2019 J Contemp Dent Pract 2008 March; (9)3:072-080. © 2019

Salivary pH - When do impact on tooth structure Critical pH teeth melt???

! cri@cal pH – is a dynamic number ! root structure - pH 6.7 ! dependent - salivary calcium and phosphorus ! enamel - between pH 5 and 5.5 ! average res@ng salivary pH 6.4 – 7. ! ﬂuorapatite - pH 4.5 Mount GJ and Hume WJ. Preserva@on and restora@on of tooth structure. Knowledge books and sooware. 2nd Edi@on. 2005

Dawes C. What is the cri@cal pH and why does tooth dissolve in acid? J Can Dent Assoc 2003; 69(11):722–4 Mount GJ and Hume WJ. Preserva@on and restora@on of tooth structure. Knowledge books and sooware. 2nd Edi@on. 2005 Stookey GK. The eﬀect of saliva on dental caries. JADA 2008 May; 139;11S-17S. Stookey GK. The eﬀect of saliva on dental caries. JADA 2008 May; 139;11S-17S.

© 2018 Lussi A1, Schlueter N, et al. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45 Suppl 1:2-12. Lussi A1, Schlueter N, et al. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45 Suppl 1:2-12. © 2019 © 2019 Hoppenbrouwers PM, Driessens FC, Borggreven JM. The mineral solubility of human tooth roots. Arch Oral Biol. 1987;32:319–322.

Healthy salivary pH Quality of life Tasting

‣ res@ng - pH 6.8 - 7.2 ‣ favors homeostasis ‣ supports remineraliza@on ‣ suppresses pathogens

Sreebny LM, Vissink A. Dry mouth, The malevolent symptom: A clinical guide. Wiley, Blackwell. May 2010.

Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2019 Neuroscience made understandable Alexander van Aken Brighton and Sussex Medical School - 2014 © 2019 © 2019 Tasting fo o d Tongue papillae Taste buds

‣ saliva ini@ates taste ‣ poor taste - anorexia sensi@ve to - sweet, biNer, salt, or sour ‣ 1 - 200 tastebuds per papillae ‣ ‣ adequate nutri@on ‣ taste pores house taste cells ‣ taste buds - taste pores ‣ supports muscle mass ‣ chemicals in solu@on - s@mulate receptor cells ‣ 50-150 taste receptor cells per taste bud ‣ immune system Nordén J, Grönberg AM, et al. Nutri@on impact symptoms and body composi@on in pa@ents with COPD. Eur J Clin Nutr. 2015 Feb;69(2):256-61. Ekstrom J, Khosravani N, et al. Saliva and its control of secre@ons. Dysphagia,Medical Radiology. Diagnos@c Imaging. Ed. Ekberg O. Springer-Verlag Berlin Heidelberg 2012. http://www.cbsnews.com/news/worlds-ﬁrst-images-of-taste-buds-in-action/ © 2019 http://www.cbsnews.com/news/worlds-ﬁrst-images-of-taste-buds-in-action/ © 2019 © 2019

Taste disturbances Compromises Compromises

‣ ageusia - complete lack of taste ‣ food s@cks to teeth ‣ hypogeusia - decrease taste sensi@vity ‣ sip on sweet drinks ‣ raw food - hard to chew ‣ dysgeusia - metallic/foul/rancid/salty ‣ increase s@cky, processed foods ‣ require no chewing / prepara@on ‣ phantoguesia - phantom taste ‣ high carb nutri@onal supplements

‣ cacogeusia - revol@ng taste Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). http://www.webmd.com/oral-health/tc/taste-changes-topic-overview © 2019 © 2019 Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2019

Compromises

Liquid intake ‣ high ﬂuid intake challenges ‣ ooen sweet ‣ dilutes exis@ng saliva ‣ frequent bathroom breaks ‣ disturbed sleep

Medical and

© 2018 Ekstrom J, Khosravani N, et al. Saliva and its control of secre@ons. Dysphagia,Medical Radiology. Diagnos@c Imaging. Ed. Ekberg O. Springer-Verlag Berlin Heidelberg 2012. © 2019 © 2019 environmental conditions

Medical Medical Medical conditions conditions conditions

‣ diabetes ‣ endocrine disorders ‣ Sjögren syndrome - primary ‣ HIV / AIDS ‣ hepa@@s C ‣ Parkinson’s disease ‣ Hashimoto’s disease - thyroid ‣ ea@ng disorders ‣ Alzheimers ‣ pregnancy - nursing ‣ rheumatoid arthri@s ‣ laxa@ve abuse ‣ gene@c disorders ‣ secondary SS - other autoimmune disorders ‣ chronic fa@gue syndrome

Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2019 Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2019 Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2019

Medical conditions - Pathology and sequela Treatments complication ‣ intes@nal failure ‣ hemodialysis ‣ salivary gland disfunc@on ‣ COPD ‣ radia@on treatment ‣ removal salivary glands ‣ anxiety ‣ hormone imbalance ‣ end of life / terminal illness depression ‣ ‣ menopause ‣ cancer therapy ‣ liver transplant

‣ HBP ‣ nausea ‣ anxiety ‣ seasonal allergies ‣ depression ‣ facial anatomy pain ‣ sleep apnea ‣ ‣ dust / wind ‣ appe@te control ‣ fever ‣ diarrhea ‣ mouth breathing ‣ nasal conges@on ‣ seasonal allergies ‣ vomi@ng ‣ blood loss ‣ asthma ‣ coughing

Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2019 ‣ excessive swea@ng ‣ burns © 2019 Guignon AN, Novy B. Dry mouth syndrome and the role of arginine-based technologies. Dent Today. 2015;34(10). © 2019

Oral appliances Lifestyle ‣ dentures / par@al dentures ‣ bite guards ‣ orthodon@c aligners ‣ sports mouth guards ‣ whitening trays

Lifestyle Lifestyle Climate

‣ stress ‣ air condi@oning ‣ smoking / vaping anxiety/fear ‣ ‣ central heat ‣ recrea@onal drugs ‣ caﬀeine ‣ desert climates ‣ C-Pap machine ‣ alcohol ‣ cold temperatures ‣ prolonged speaking / singing ‣ heavy exercise ‣ airplanes / hotel rooms

2013 data 26.1% 26.8% 19.4% 18.3% 12.1% 9.6%

© 2018 hNp://www.cdc.gov/tobacco/data_sta@s@cs/fact_sheets/adult_data/cig_smoking/index.htm Accessed 7/7/2012 © 2018 cdc.gov/VitalSigns/AdultSmoking/index.html#StateInfo - Behavioral Risk Factor Surveillance System, 2010 Accessed 7/25/15 © 2019 hNp://www.cdc.gov/tobacco/data_sta@s@cs/fact_sheets/fast_facts/index.htm/24/15 Accessed 7/24/15

Lifestyle - diet Understand sodium intake levels 94% from food!

Who has the highest risk? ‣ high sodium intake ‣ processed foods

Gateway - the rest of the body Erosion ‣ oral disease is complex ‣ changing hormone levels ‣ medica@ons causing dry mouth • progressive loss of hard @ssue ‣ gene@cs • chemical loss - not bacterial ‣ immune system • most important factor - hypersensi@vity ‣ lifestyle / environmental factors How does erosion happen? • erosive lesions – generally sensi@vity Bamise CT, Olusile AO, Oginni AO. An analysis of the e@ological and predisposing factors related to den@n hypersensi@vity. J Contemp Dent Pract. 2008 July; (9)5:052-059.

‣ natural aging process Gandara BK and Trulove EL. Diagnosis and management of dental erosion. J Cont Dent Prac. 1999;1(1):1-17

Erosion - a multifactorial condition Erosion - surface softening Erosion vs. caries • citric acid pH 2.3 • 6 X 5 min/day • 10 days • surface-sooening lesion • stored in salt solu@on • non-bacterial - extrinsic and intrinsic acids • complicated by aNri@on and abrasion • remineraliza@on diﬃcult • prevalence - increases with age Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45. © 2019 Ren, YF. Dental erosion: E@ology, diagnosis and preven@on. Acad of Dent Thera Stoma. April 2011. © 2019 Lussi A1, Schlueter N, et al. Dental erosion--an overview with emphasis on chemical and histopathological aspects. Caries Res. 2011;45 Suppl 1:2-12. © 2019

Sensitivity and Dentinal Stimulus fungal infections hypersensitivity

• common • thermal s@mulus (cold) 75%

• transient pain • tac@le s@mulus 25%

• short, sharp sensa@ons • osmo@c s@mulus (sweet) 16% • • exogenous s@muli air blast ?%

© 2019 © 2019 © 2019 Cummins D. Den@n hypersensi@vity: from diagnosis to a breakthrough therapy for everyday sensi@vity relief. J Clin Dent. 2009;20(1):1-9. Splieth CH, Tachou A. Epidemiology of den@n hypersensi@vity.. Clin Oral Inves@g. 2013 Mar;17 Suppl 1:S3-8.

Dentinal Structural differences between Hidden hypersensitivity sensitive and non-sensitive dentin* hypersensitivity

two condi2ons are necessary

• exposed den/n via loss of enamel or periodontal @ssues Non-sensi@ve Sensitive No of open tubules x 8 x Diameter of tubules 0.43 0.83 • open den/n tubules - patent to the pulp – loss of smear layer Fluid Flow (Poisseuille’s law) y 16 y

Bamise CT, Olusile AO, Oginni AO. An Analysis of the E@ological and Predisposing Factors *Absi et al, J Clin Periodont 1987; pictures from hNp://www.thejcdp.com, Sept 2006 Related to Den@n Hypersensi@vity. J Contemp Dent Pract 2008 July; (9)5:052-059.

Rule out other conditions Redheads Candidiasis ‣ occlusal trauma

‣ cracked tooth syndrome ‣ high anxiety • tongue ‣ fear of pain ‣ caries – new and recurrent • commisures ‣ avoid dental care ‣ pulpal pathology • buccal mucosa ‣ more sensi@ve to cold

‣ gingival sensitivity ‣ subcutaneous lidocaine signiﬁcantly less eﬀec@ve • palate

‣ layered sensitivities Binkley CJ et al. Gene@c varia@ons associated with red hair color and fear of dental pain, anxiety regarding dental care and avoidance of dental care. J Am Dent Assoc. 2009 Jul;140(7):896-905. Jenkinson HF and Douglas LJ. Interac@ons between Candida species and bacteria in mixed infec@ons. www.ncbi.nlm.nih.gov/bookshelf/ © 2019 Liem EB, Joiner TV, Tsueda K, Sessler DI. Increased sensi@vity to thermal pain and reduced subcutaneous lidocaine eﬃcacy in redheads. Anesthesiology. 2005 Mar;102(3):509-14. © 2019 br.fcgi?book=pmd&part=A2773#A Accessed 7/25/2009 © 2019

Conversation starters! Conversation starters! oral health to general health

★ get the facts Solutions ★ coaching not scolding ★ health beneﬁts

J Am Dent Assoc. 2008 May;139 Suppl:25S-34S. García-Godoy F1, Hicks MJ. ★ develop posi@ve energy ★ save money, @me, comfort

★ create a legi@mate spin ★ oﬀer alterna@ves

© 2019 iom.edu/Reports/2012/Accelera@ng-Progress-in-Obesity-Preven@on/Report-Brief.aspx May 12, 2012 © 2019 iom.edu/Reports/2012/Accelera@ng-Progress-in-Obesity-Preven@on/Report-Brief.aspx May 12, 2012 © 2019

Solutions

! s@mulate saliva ! raise pH

J Am Dent Assoc. 2008 May;139 Suppl:25S-34S. García-Godoy F1, Hicks MJ. J Am Dent Assoc. 2008 May;139 Suppl:25S-34S. García-Godoy F1, Hicks MJ. ! balance components ! limit fermentable CHO intake Improving saliva and ! non-fermentable sweeteners ! an@-adhesion - xylitol ! metabolic inhibitors - fluoride ! arginine products Marsh PD. Dental plaque as a biofilm and a microbial community - implica@ons for health and disease. BMC Oral Health 2006, 6(Suppl 1):S14. neutralizing acids Marsh PD. Dental plaque as a biofilm and a microbial community - implica@ons for health and disease. BMC Oral Health 2006, 6(Suppl 1):S14. García-Godoy F, Hicks MJ. Maintaining the integrity of the enamel surface: the role of dental biofilm, saliva and preven@ve agents in enamel and remineraliza@on. J Am Dent Assoc. 2008.© 2019 © 2019 © 2019 García-Godoy F, Hicks MJ. Maintaining the integrity of the enamel surface: the role of dental biofilm, saliva and preven@ve agents in enamel and remineraliza@on. J Am Dent Assoc. 2008. The magic of xylitol Xylitol products Using xylitol

! interferes with Strep Mutans metabolism ! disrupts biofilm integrity ! one of first three ingredients ! promotes neutral pH ! gum/candy - four @mes a day for 3-5 minutes ! s@mulates salivary flow ! 4 - 10 grams per day Can be fatal to dogs and ferrets ! tooth paste, wipes, pacifier, mouth rinse, spray, gel Avoid fructose for up to one hour a>er use ! excessive use – laxa@ve effect

Policy on the use of xylitol in caries preven@on. American Academy of Pediatric Den@stry - Oral health policies – Adopted 2006. Policy on the use of xylitol in caries preven@on. American Academy of Pediatric Den@stry - Oral health policies – Adopted 2006.

Ribelles Llop M, Guinot Jimeno F, et al. Effects of xylitol chewing gum on salivary flow rate, pH, buffering capacity and presence of Streptococcus mutans in saliva. Eur J Paediatr Dent. 2010 Mar;11(1):9-14. J Am Dent Assoc. 2006 Feb;137(2):190-6. Eur J Paediatr Dent. 2010 Mar;11(1):9-14. Effects of xylitol chewing gum on salivary flow rate, pH, buffering capacity and presence of Streptococcus mutans in saliva. The use of sorbitol- and xylitol-sweetened chewing gum in caries control. © 2019 Ribelles Llop M1, Guinot Jimeno F, Mayné Acién R, Bellet Dalmau LJ. Burt BA. © 2019 García-Godoy F, Hicks MJ. Maintaining the integrity of the enamel surface: the role of dental biofilm, saliva and preven@ve agents in enamel demineraliza@on and remineraliza@on. Burt BA. The use of sorbitol- and xylitol-sweetened chewing gum in caries control. J Am Dent Assoc. 2006 Feb;137(2):190-6. J Am Dent Assoc. 2008 May;139 Suppl:25S-34S. © 2019

Washington New! state Hydris Dry Mouth System Lozenges - pH 2.43! xylitol innovations! soothing locks in moisture ★ slow release low impact ﬂavor

★ adhesive back 2016 Washington State Encore Entrepreneurs - SBA ‣ super saturated 44% xylitol ★ stick and stay ‣ muco-adhesive complex ‣ contains spilanthes plant-based ingredients ‣ pH 7 ‣ natural plant extract coconut oil ★ US birch xylitol increases salivary flow rate ‣ more viscous ‣ sodium fluoride ★ 18 flavors ‣ 2 oz boNle ‣ hydrates the mouth Cleared by the FDA as a Medical Device: no alcohol To relieve the symptoms of dry mouth ★ © 2019 © 2019 © 2019 one tin = 1 week Phytochemistry, Pharmacology and Toxicology of Spilanthes acmella: A Review. Pharmacol Sci. 2013;2013:423750.

Xerostom Dry Mouth System Biotene Rinse Rinse or spray ‣ olive oil ‣ chitosan deriva@ves ‣ betaine ‣ arginine ‣ xylitol ‣ betaine - humectant ‣ ﬂuoride ‣ xylitol ‣ calcium ‣ spearmint ﬂavor ‣ potassium

relieves symptoms Up to 200% increase in uns@mulated salivary ﬂow 100% increase - uns@mulated/res@ng saliva 5.39 pH - acidic! 6.61 pH Cleared by the FDA as a Medical Device: ‣ ‣ To relieve the symptoms of dry mouth 23.8% increase - s@mulated saliva MarÅn M, Marín A, et al. Products based on olive oil, betaine, and xylitol in the post-radiotherapy xerostomia Rep Pract Oncol Radiother. 2017 Jan-Feb;22(1):71-76.J Oral Rehabil. 2007 Oct;34(10):724-32. ‣ 6.11 pH

Ship JA, McCutcheon JA, et al. Safety and eﬀec@veness of topical dry mouth products containing olive oil, betaine, and xylitol in reducing xerostomia for polypharmacy-induced dry mouth. J Oral Rehabil. 2007 Oct; 34(10):724-32. Delgado AJ, Olafsson VG, Donovan TE. pH and Erosive Poten@al of Commonly Used Oral Moisturizers. J Prosthodont. 2016 Jan;25(1):39-43. Epstein JB, Villines DC, Singh M, Papas A. Management of dry mouth: assessment of oral symptoms aoer use of a polysaccharide-based oral rinse.Oral Surg Oral Med Oral Pathol Oral Radiol. 2017 Jan;123(1):76-83. Delgado AJ, Olafsson VG. Acidic oral moisturizers with pH below 6.7 may be harmful to teeth depending on formula@on: a short report. Clin Cosmet Inves/g Dent. 2017;9:81–83. Published 2017 Aug 3. doi:10.2147/CCIDE.S140254 © 2019 © 2019 © 2019 Lubricity Moisture Pearls Lipid-based solution

‣ limit water loss pH 4 - 4.5 ‣ moisten OGT technology ‣ lubricate Oxidized Glycerol Triesters (OGT), not Improvements in: found in water-based products, have ‣ not acidic lubricating and moisturizing properties ‣ chewing ‣ tas@ng ‣ 92% improved symtoms ‣ adheres to ‣ forms ‣ Rx spray water, xylitol, hyaluronan, coconut and avocado oil oral mucosa protec@ve ﬁlm lasts up to 4 hours ‣ swallowing sodium benzoate, and vegan / non GMO ‣ speaking ‣ 84% improved quality of life potassium sorbat hygienist developed - USA © 2019 © 2019 © 2019 Mouly, S., Orler, J. B., Tillet., Y., Coudert, A. C., Oberli, F., Preshaw, P., & Bergmann, J. F. (2007). Efficacy of a new oral lubricant solution in the management of psychotropic drug-induced xerostomia. Journal of Clinical Psychopharmacology, 27(5). Mouly, S., Orler, J. B., Tillet., Y., Coudert, A. C., Oberli, F., Preshaw, P., & Bergmann, J. F. (2007). Efficacy of a new oral lubricant solution in the management of psychotropic drug-induced xerostomia. Journal of Clinical Psychopharmacology, 27(5).

#0419 Potential Erosive Assessment of Dry Mouth FAX Prescription To: 866-694-2555

Lozenges and Tablets on Dentin PATIENT INFORMATION Delgado AJ1, Aslam M1, Ribeiro AD1, Olafsson VG2, Pereira PN1 Saliva support Patient Name: SSN (last 4): 1Department of Restorative Dental Sciences, College of Dentistry, University of Florida Date of Birth: Male Female 2Faculty of Odontology, University of Iceland Cell Number: Home Number: Objective Address: To measure the pH values, titratable acidity, and potential erosive effect of commercially available dry mouth lozenges/tablets and their effect on dentin. City, State, Zip: Null Hypothesis Known Allergies: More solutions 1. None of the lozenges, tablets, patches tested would have a pH below that the critical pH of dentin Member ID Number: RX Group Number: 2. None of these samples tested would demonstrate an erosive potential after measured with gravimetric analysis. RX BIN Number: RX PCN: Materials and Methods Lozenges and tablets: Salese™, Oracoat Xylimelts®, Cotton Mouth®, TheraBreath®, DenTek® OraMoist®, SmartMouth, ACT®, CVS Health™ , Rite Aid®, Med Active®, and Hager Pharma

pH Analysis: Each lozenge or tablet was crushed with a pestle and mortar and 5 grams of the resultant Rinse: 8 - 10 4 - 8 2 - 4 times daily powder was dissolved in 10 ml of distilled water (PH 7.02) The pH of each lozenge solution was assessed Quantity: by using a calibrated pH meter. 300 240 120 Titratable Acidity using pH meter and pH indicator (phenol red): Titratable acidity was measured by Refill: PRN 4 2 adding 0.1 M of NaOH to each homogenous tablet solution until the pH reached 7.0. The amount of base (m/mol) required to reach a neutral pH was recorded and then calculated. If there was a solution that presented a pH value of ≥ 7 this part of the experiment was omitted. PRESCRIBER SIGNATURE: DATE: Gravimetric Analysis: Freshly extracted molars crown/roots were sectioned at the CEJ. The coronal and apical portions of the specimens were sealed with a self-etching dentin bonding agent to avoid influx of the PRESCRIBER INFORMATION 10066 solution into the pulp chamber. The specimens were then dried with air water syringe and weighed on a Name: calibrated analytical balance to obtain a baseline recording. NPI: DEA: The specimens were then submerged in 5 ml of solution containing 2.5 gm of crushed tablets for 24 hours, Address: 48 hours, 96 hours and 1 week with measurements performed at each interval after drying the specimens as previously described. The solutions were renewed at each interval. City, State, Zip: Phone Number: Results Fax Number: In order to verify the data distribution, the Shapiro Wilk test was performed as well as a histogram analysis. All data (pH, TA and dentin loss) presented non-normal distribution and therefore non-parametric test was used (Spearman correlation). Pharmacy Customer Service: 866-694-2553 [REF] FS-4008 v1.2 Product pH mean (SD) TA mean (SD) Product Dentin mean (SD) Hager Pharma (HP) 4.44 (0.11) 0.98 (0.03) Hager Pharma (HP) 0.0066 (.0028)a Smart Mouth (SM) 6.02 (0.26) 0.17 (0.06) Smart Mouth (SM) -.0072 (.003) a ACT 5.72 (0.26) 0.25 (0.03) ACT -.0075 (.004) a a ‣ DenTek (DT) 2.9 (0.22) 8.8 (0.3) DenTek (DT) -.0227 ( .019) super saturated calcium phosphate CVS 5.28 (0.15) 2.17 (0.21) CVS -.0102 (.004) a TheraBreadth (TB) 5.82 (0.47) 0.4 (0.1) TheraBreadth (TB) -.0097 ( .005) a Xylimelts (XM) 8.04 (0.09) - Xylimelts (XM) -.0042 (.006) a Med Active (MA) 3.16 (0.15) 5.35 (0.15) Med Active (MA) -.0109 (.006)a Salese (SL) 8.04 (0.22) - Salese (SL) -.0083 (.007) a ‣ dissolve in water Rite Aid (RA) 5.1 (0.07) 2.03 (0.06) Rite Aid (RA) -.0107 ( .005) a Cotton Mouth (CM) 3.1 (0.07) 2.77 (0.25) Cotton Mouth (CM) -.0306 ( .012)b Table 1: Ph and TA means and standard deviations all samples Table 2: Dentin loss delta means and standard deviations for all samples ‣ electrolyte concentra@on = saliva Initially, statistical analysis was performed to verify the correlation between pH and TA with the dentin loss. Both variables were not correlated with dentin loss (p>0.05, Spearman correlation). In order to verify the difference between the 11 tablets, non-parametric tests were performed. A ‣ Rx product significant difference was observed between the 11 tablets regarding dentin loss (p=0.0002, Kruskal-Wallis). The groups were compared using Mann-Whitney and the statistical analysis Quinn B. Efficacy of a supersaturated calcium phosphate oral rinse for the preven@on and treatment of oral mucosi@s in pa@ents receiving high-dose cancer © 2018 cdn.shopify.com/s/files/1/0035/3832/files/Tayee_et_al-_Ph_values_of_xerostomia_products_2015.pdf?13742613603684799761 therapy: a review of current data. Eur J Cancer Care (Engl). 2013 Sep;22(5):564-79. doi: 10.1111/ecc.12073. Epub 2013 Jun 4. © 2019

What is arginine? Arginine - mode of action

‣ humidiﬁer ‣ salivary ‣ ar@ﬁcial s@mulants saliva ! natural amino acid ! naturally found in saliva

! bipolar molecule - + and - charged groups Urea%!"few"bacteria"" Arginine"!"many"bacteria" ‣ frozen gauze - best ‣ ice chips ‣ moisturizer ! net posi@ve charge "saliva"&"crevicular"fluid" "low"in"saliva/abundant"in"pep:des" "broken"down"by"urea" "ADS"!"3"enzyme"system"" ‣ wet gauze ‣ water spray ‣ lip / mouth "byproduct!ammonia"" "byproduct"!"ammonia"" Panagakis F, Schiff T, Guignon A. Den@n hypersensi@vity: Effec@ve treatment with an in-office desensi@zing paste containing 8% arginine and calcium carbonate. Amer J Dent. 2009. 22:March. "ac:on"produces"ATP © 2019 © 2019 © 2019 Pun@llo K, Nelson JE, Weissman D, et al. Pallia@ve care in the ICU: relief of pain, dyspnea, and thirst—A report from the IPAL-ICU Advisory Board. Intensive care medicine. 2014;40(2):235-248. Burne"RA,"Zeng"L,"Ahn"SJ,"et"al."Progress"Dissec:ng"the"Oral"Microbiome"in"Caries"and"Health."Advances"in"Dental"Research."2012;24(2):77!80." Emerging research - Arginine calcium carbonate Arginine - mode of action Arginine bicarbonate calcium carbonate tooth paste - lower DMFS ! inhibits bacterial adhesion - tooth surfaces ! reduces biofilm thickness

! reduces EPS matrix density ! 6,000 children - low to moderate risk - 6-12 years old ! exogenous source of arginine - toothpaste ! arginine + fluoride - suppresses S. mutans and P. gingivalis ! double blind, randomized - 3 groups - 2 year study ! enhances alkaline pH in saliva and plaque ! suppresses C. albicans growth ! 1,450 ppm Fl paste ! 4 weeks - arginine toothpaste ! facilitates microbial resistance - acidic environment ! 1,450 Fl + 1.5% arginine/calcium carbonate or dicalcium phosphate ! alkali production higher - plaque samples caries active (CA)subjects Fu D, Pei D, Huang C, Liu Y, Du X, Sun H. Effect of desensi@zing paste containing 8% arginine and calcium carbonate on biofilm forma@on of Streptococcus mutans in vitro. J Dent. 2013 Jul;41(7):619-27. Sharma S, Lavender S, Woo J, Guo L, Shi W, Kilpatrick-Liverman L, Gimzewski JK. Nanoscale characteriza@on of effect of L-arginine on Streptococcus mutans biofilm adhesion by atomic force microscopy. ! 16.5% lower DMFS - arginine/calcium/fluoride groups than FL paste alone Microbiology. 2014 Jul;160(Pt 7):1466-73. Zheng X, Cheng X, Wang L, Qiu W, Wang S, Zhou Y, Li M, Li Y, Cheng L, Li J, Zhou X, Xu X. Combinatorial effects of arginine and fluoride on oral bacteria. J Dent Res. 2015 Feb;94(2):344-53. ! CA subjects - shift in bacterial composition - healthier Burne RA, Zeng L, Ahn SJ, Palmer SR, Liu Y, Lefebure T, Stanhope MJ, Nascimento MM. Progress dissec@ng the oral microbiome in caries and health. Adv Dent Res. 2012 Sep;24(2):77-80. Kraivaphan P, Amornchat C,et al. Two-year caries clinical study of the efficacy of novel den@frices containing 1.5% arginine, an insoluble calcium compound and 1,450 ppm fluoride. Caries Res. 2013;47(6) 582-90. Nascimento MM, Browngardt C, et al. The effect of arginine on oral biofilm communi@es. Mol Oral Microbiol. 2014 Feb;29(1):45-54.1. © 2019 © 2019 Koopman JE, Röling WF, Buijs MJ, Sissons CH, ten Cate JM, Keijser BJ, Crielaard W, Zaura E. Stability and resilience of oral microcosms toward acidifica@on and Candida outgrowth by arginine © 2019 Huang X, Schulte RM, Burne RA, Nascimento MM. Characteriza@on of the arginoly@c microflora provides insights into pH homeostasis in human oral biofilms. Caries Res. 2015;49(2):165-76. supplementa@on. Microb Ecol. 2015 Feb;69(2):422-33.

Arginine bicarbonate calcium carbonate - Arginine-based products Remineralization strategies keeping saliva neutral

ACP – Amorphous calcium phosphate Tubule occlusion Tricalcium phosphate action ! releases calcium and phosphorus Stannous ﬂuoride ! toothpaste, gel, rinse ! highly soluble compound - prolonged substan@vity? ! building block of apa@te High ﬂuoride ! varnish, gels

Precipita@ng salts ! calcium phosphate CPP-ACP compounds ! arginine bicarbonate ! contains casein phosphopep@de (Recaldent) ! adheres to soo @ssue, plaque, teeth Restora@ve materials ! adhesives ! silicates ! calcium and phosphate – released during acid challenge ! resins ! hydroxyapa@te ! contraindicated with milk allergy ★ moisture breaks down barrier ★ fluoride, calcium, phosphate - readily available Turssi CP, Maeda FA, et al. Effect of poten@al remineralizing agents on acid sooened enamel. Am J Dent. 2011 Jun;24(3):165-8. Peric TO, Markovic DL, et al. Influence of pastes containing casein phosphopep@de-amorphous calcium phosphate on surface of demineralized enamel. J Appl Biomater Funct Mater. 2014 Mar 30:0. ★ creates fluorapa@te Laser !soolaser © 2019 Cochrane NJ, Cai F, et al. New approaches to enhanced remineraliza@on of tooth enamel J Dent Res. 2010 Nov;89(11):1187-97. © 2019 © 2019 Fluoride platforms Patient-centered choices Varnish recommendations

Benefits ! less @me less pa@ent discomfort Applica@on ! ! pa@ent acceptance ! 2+ @mes a year ! preschool / adolescents / geriatrics Home ! 5,000 PPM fluoride ! 0.21% sodium fluoride ! caries preven@on ! uses TCP chemistry ! high risk popula@ons Professional ! uses TCP chemistry ! Rx ! not an Rx Petersson LG. The role of fluoride in the preven@ve management of den@n hypersensi@vity and root caries. Clin Oral Inves@g. 2013 Mar;17 Suppl 1:S63-71. Murakami C, Bönecker M,et al. Effect of fluoride varnish and gel on dental erosion in primary and permanent teeth. Oral Biol. 2009 Nov;54(11):997-1001. RiNer AV, de L Dias W, Miguez P, Caplan DJ, Swio EJ Jr. cervical den@n hypersensi@vity with fluoride varnish: a randomized clinical study. J Am Dent Assoc. 2006 Jul;137(7). Zero DT, Lussi A. Erosion-chemical and biological factors of importance to the dental prac@@oner. Int Dent J. 2005;55(4 Suppl 1):285-90. ! Amazon or 3M ESPE © 2019 © 2019 Evidence-based Clinical Recommenda@ons: Professionally Applied Topical Fluoride Council on Scien@fic Affairs. American Dental Associa/on May, 2006 © 2019

Patient-centered choices

Stannous Fluoride Zinc Phosphate

! dry teeth / mix product Zn Zn Sn ! paint all suscep@ble surfaces F Zn F ! no wait @me - ea@ng/drinking ! 24 hour uptake @me

! • anti-cavity, anti-gingivitis and anti- applica@on - moist or in plaque sensitivity • natural mineral • stabilizes stannous fluoride ! • bioavailable stannous and fluoride horizontal swipe • optimal fluoride and stannous ions • protective mineral shield ! surface migra@on © 2019 © 2019 © 2019

Increase in surface Theobromine When faced with this……. micro hardness - 7 days

! theobromine - found in cacao (chocolate) plus minerals ! growth of larger hydroxyapa@te crystals (4X larger) ! occlusion - 7 days ! FDA GRAS (generally regarded as safe) status ! does not contain ﬂuoride

Amaechi BT, Porteous N, et al. Remineraliza@on of ar@ficial enamel lesions by theobromine. Caries Res. 2013;47(5):399-405. Amaechi BT, Porteous N, et al. Remineraliza@on of ar@ficial enamel lesions by theobromine. Caries Res. 2013;47(5):399-405. © 2019 © 2019 © 2019 HydrogenHydrogen Peroxide Peroxide concentrations -≤3% ‣ antiseptic ‣ debridement Approved for oral use by FDA ‣ reduces inflammation Effect on biofilm ‣ degrades EPS - slime ‣ breaks down protein chains naturally occurs - breast milk, saliva, liver ‣ ‣ lyses bacterial cell walls ‣ softens hard deposits ‣ no allergic reactions ‣ oxygen - death to anaerobes ‣ no known bacterial resistance © 2019 © 2019 Marshall MV, Cancro LP, Fischman SL. Hydrogen peroxide: a review of its use in dentistry. J Periodontol. 1995 Sep;66(9):786-96. © 2019 Herrero ER, Slomka V, Boon N, et al. Dysbiosis by neutralizing commensal mediated inhibi@on of pathobionts. Scien@fic Reports. 2016;6:38179.

Hydrogen peroxide - comparison Prescription trays 1.7% peroxide gel - S. mutans biofilm

Problem: “Therapeutic delivery of H2O2 to prevent periodontal disease required mechanical access to subgingival pockets.”

‣ trays create hydraulic seal ‣ eliminates dilution Untreated control 5 min contact 1.7% H2O2 10 min contact 1.7% H2O2 Placebo gel - no H2O2 ‣ up to 9mm ‣ S. mutans aerobic - will not die in oxygen Allegheny Singer Study ‣ 3% liquid ‣ 1.7% gel ‣ thick biofilm mass ‣ 10 min therapeutic ‣ pH 3 ‣ pH 5.5 - 5.8 ‣ live/dead dye: intact cell walls - green ‣ 15 min full O2 release degraded, lysed wall - red ‣ rapid spike - bubbling ‣ 15 min active time © 2019 © 2019 © 2019 Dunlap T et al. Subgingival Delivery of Oral Debriding Agents: A Proof of Concept. The Journal of Clinical Den@stry. 2011, Nov;XXII(5):149-158. Dunlap T et al. Subgingival Delivery of Oral Debriding Agents: A Proof of Concept. The Journal of Clinical Den@stry. 2011, Nov;XXII(5):149-158.

Prescription tray therapy

January 2015 July 2016 June 8, 2016 July 7, 2016 tray delivery - 4/2016 ‣ ‣ 3 times a day ‣ 101 bleeding points to 7 only PerioGel ‣ ‣ 15 min per session ‣ 1-2mm probing reduction ‣ twice daily - 15 min ‣ PerioGel only Photos courtesy of Bruce Cochrane, DDS - Fort Dodge IA © 2019 Photos courtesy of Bruce Cochrane, DDS - Fort Dodge IA © 2019 Photos courtesy of Perfect Teeth - Denver, Colorado © 2019 Prescription trays - implant Silver diamine ﬂuoride 38% Silver diamine ﬂuoride 38%

‣ natural an@bacterial ‣ hypersensi@vity relief ‣ carious den@n lesion turns black ‣ no anesthesia

August 2007 May 2009 May 2012 ‣ arrests caries ‣ suppuration - 2yrs after placement ‣ less than $1 / 1-2 teeth ‣ Initial - metronidazole, ozone therapy, mechanical debridement and irrigation - no results ‣ 8ml boNle ‣ Prescription tray - started June 2009 - PerioGel plus doxycycline ‣ 2012 - no suppuration - bone height - two thread gain ‣ anyone who can apply ﬂuoride

© 2019 © 2019 © 2019 Photos courtesy of Greg Sawyer, DDS - Los Gatos, CA RosenblaN A, Stamford TC, Niederman R. Silver diamine fluoride: a caries "silver-fluoride bullet”.J Dent Res. 2009 Feb;88(2):116-25. RosenblaN A, Stamford TC, Niederman R. Silver diamine fluoride: a caries "silver-fluoride bullet”.J Dent Res. 2009 Feb;88(2):116-25.

3 seconds exposure 99.9% removal

“The results were almost impossible for me to believe the first time through,” commented . “One of the difficulties with plaque biofilm is that you really can’t see it, it’s clear. So we didn’t have visual evidence of complete removal. But now with these direct methods, the scanning electron microscopy, you apply the Waterpik to plaque on a surface of a tooth and you look with a scanning scope and it’s gone. It’s simply gone. And that’s unequivocal and unarguable.”

Tongue Getting national press

Slots J, Jorgensen MG. Eﬃcient an@microbial treatment in periodontal maintenance care. JADA, Vol.131, September 2000

Rupesh S, Winnier J, et al. The compara@ve evalua@on of the eﬀects of tongue cleaning on Oral malodor. JADA, Vol.134, February 2003 salivary levels of mutans streptococci in children. Int J Dent Hyg. 2011 Jul 29.

✓ chemical - Fl level, pH, @tratable acidity, calcium & phosphorus

! daily ✓ biological - saliva composi@on, flow, buffering capacity, ! effec@ve ✓ pellicle forma@on and tooth composi@on ! manual behavioral - drinking habits, frequency, dura@on, @ming of exposure ! mechanical ✓

Jain P, Hall-May E, Golabek K, Agus@n MZ. A comparison of sports and energy drinks--Physiochemical proper@es and enamel dissolu@on. Gen Dent. 2012 May-Jun;60(3):190-7. Bordas A, McNab R, et al. Impact of diﬀerent tongue cleaning methods on the bacterial load of the tongue dorsum. Arch Oral Biol. 2008 Apr;53 Suppl 1:S13-8. © 2019 © 2019 © 2019

What do we What is the take What do we home message? owe our patients? owe our patients?

• current, in-depth health hx ‣ dietary intake / paNerns • assess total needs ‣ saliva composi@on / bacterial risk • tell the truth ‣ current scien@ﬁc informa@on ‣ interven@on and remineraliza@on • provide all op@ons ‣ pa@ents must make the ﬁnal choice

‣ every paCent is unique How would you treat your Mom?

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