Caries

The most common infectious disease which

affects humanity, and other dental problems
such as gingivitis, begin with dental plaque

Now you can identify

cariogenic plaque with
a new 5 minute test

Dental caries is caused by a number of interrelated

factors including bacterial ecology, frequency of
fermentable carbohydrate intake, unhealthy saliva
and retained acid producing plaque.

Good plaque / bad plaque

Dental plaque is a biofilm on the tooth surface comprising bacteria, extracellular
matrix and pellicle. The microstructure of the biofilm has a network of fluid channels
to regulate the levels of waste products and nutrients. In the natural state (good plaque)
the thickness is reduced by regular oral hygiene. Although it grows continuously, it
does not mature into a biofilm dominated by bacteria whose waste products from
fermentation (such as acids) can damage the teeth and initiate the caries process.
When left undisturbed and provided with fermentable sugars, plaque grows into a thick
impermeable biofilm, containing acidogenic and aciduric bacteria. This bad plaque can
demineralize hard tissue such as enamel, dentine or cementum. It is the change in key
environmental factors that causes a shift from good plaque to bad plaque.

Reduction of carbohydrate intake

Frequent intake of fermentable sugars is the environmental factor that upsets the
ecological balance in the biofilm. Sucrose has been identified as the main culprit
because it facilitates the production of the extracellular matrix and increases the
stickiness of plaque. However, all monosaccharides and disaccharides are easily
fermented and should be regarded as risky in susceptible patients, such as those
with reduced salivary defences. Consumption of sugars should be restricted to the
three main meals to reduce the risk of caries.

Getting saliva into balance

Saliva and the pellicle layer formed is the first line of defence against caries, erosion and
attrition of hard tissue.
Saliva has a buffering effect and contains the ions required for remineralization of hard
tissue, and also has antibacterial, antiviral and antifungal properties. It is very important
for the clearance of food and micro-organisms from the oral cavity. To maintain good
oral health, it is essential to have sufficient good quality, well balanced saliva.

Proper brushing and flossing

Mechanical debridement by brushing and interdental cleaning can keep the biofilm thin.
However normal brushing does not remove pellicle and bacteria will start recolonizing a
cleaned tooth surface immediately.
Regular tooth brushing and interdental cleaning assist in maintaining good oral health,
enabling the natural protective elements in saliva to diffuse through the pellicle onto the
tooth surface.

Introducing Plaque - Check +pH

A simple patient motivation test to identify whether
plaque is cariogenic or non cariogenic, combined with
a visual picture of plaque accumulation sites at the
highest risk of developing future lesions.

Check Saliva First!

Saliva Check BUFFER provides valuable information about the salivary environment.

PURPOSE

AND ALSO

To gain initial information on the

salivary environment for patients
presenting with:

To check the oral environment before

undertaking complex dental work
such as:

dental erosion
tooth wear
cervical dentinal hypersensitivity
dry mouth
high coronal caries rate
root surface caries

restorative dentistry
crown and bridge work
tooth whitening
orthodontics

WHEN?
As part of the comprehensive assessment for new patients entering your practice.
The Saliva Check Buffer Test should be repeated 2 weeks after giving lifestyle
advice to monitor compliance (e.g. hydration). Then it should be undertaken at the
6 or 12 month recall examinations.

Why you should start using the plaque test.

This test shows whether plaque is cariogenic or non cariogenic.
There is a causal association between the production of strong acids from plaque, in
response to sucrose, and caries activity. Micro-organisms designated as capable of acid
production at low pH conditions are significantly increased in plaque from patients with
high caries risk.
This test can be useful for all patients, regardless of age.

WHO TO TEST?
For all new patients as a baseline
for those needing restorative care
For patients suspected of having
a high caries risk due to dry mouth
or other factors
For patients undergoing orthodontic
treatment
For patients requiring complex
or extended dental treatments

PURPOSE
To demonstrate plaque acid
production to a patient as part
of their education about caries
To assess the effect of dietary
changes (reduced acidic drinks)
on plaque pathogenicity

HOW OFTEN SHOULD

PATIENTS BE CHECKED?
Initially the test should be repeated after 1 or 2 weeks to see the impact of dietary
changes
The test should be repeated at least every 2-3 months in orthodontic patients with
visible plaque to encourage increased oral hygiene compliance because of the risk
of decalcification
This test shows whether plaque is cariogenic or non cariogenic.

WHY?
Dental caries problems begin with cariogenic bacteria, reduced salivary defences
and acid producing dental plaque.
Plan for your dental practice to become a sanctuary of preventive care and
aesthetic excellence by preventing problems whenever possible and ensuring that
any aesthetic work undertaken is in an oral environment of healthy saliva, minimal
levels of bacteria and plaque with a low disease causing potential.

In less than 5 minutes...

You can visually demonstrate areas of retained plaque

Newly formed plaque stains red

Unremoved food and mature plaque stains blue

In less than 5 minutes...

Dr Hien Ngo

You can begin to change your patients attitude from

complacency to concern

Both newly formed (red) and old (blue) plaque

In less than 5 minutes...

Dr Hien Ngo

You can work together to prepare a new prevention plan, and

advise which products will assist your patient to change the
current situation

Acid producing plaque

When the rate of acid production is high

Preventive strategies which limit fermentation of dental plaque may include:
Twice daily tooth brushing and flossing, to reduce the thickness of the dental
plaque biofilm.
Dietary restriction of sucrose, other fermentable simple sugars and starches
between meals.
Dietary replacement of sucrose by alternative sweeteners.
Dietary restriction of highly acidic foods and drinks.
Regular use of sorbitol, xylitol or a CPP-ACP chewing gum, such as
Recaldent gum.
Use of milk based foods, such as cheese, as snacks.
At home, a regular topical application of GC Tooth Mousse that contains
CPP-ACP
Use of high fluoride toothpastes or gels (not applicable for young children)
Regular use of sodium bicarbonate containing products, such as some toothpastes
and mouth rinses.

In less than 5 minutes...

You can take full control and assist the patient to take charge
of compliance issues to change the current situation

How to use Plaque - Check +pH

Samples of plaque should be removed from an obvious site on one side of the mouth
such as the cervical surface of maxillary incisor teeth, mandibular canines, premolars
and interproximal sites. Once harvested, each sample should be exposed to an in vitro
sucrose challenge (Solution A).
Whilst the plaque is fermenting, apply the new easy to clean disclosing gel with a
microbrush to the same sites but on the opposite side of the mouth (Tube C). Instruct
the patient to rinse.
Newly formed plaque will stain red, mature plaque and any remaining food debris will
stain blue. These are easily identified and shown to the patient.
Whilst applying disclosing gel, any rapid production of organic acids on the harvested
plaque sample (by fermentation) will mean a drop in pH, causing the plaque to change
colour.
If the fermenting plaque sample is not affected by the sucrose solution it will have a
green colour. However as the pH drops towards a more acid environment, the plaque
sample will change to yellow or even red. A red colour within 5 minutes indicates pH 5.5
or less. A red or orange pH will indicate preventive action is recommended.
In order to motivate the patient and provide confidence that acidic plaque is still
reversible, a special neutralizing solution has been provided to demonstrate that with
regular oral care it is possible to change the oral environment to a healthy pH around
7.2 (Solution B).
This test assesses total acid production and is not only restricted to lactate acid, but is
responsive to the protective buffering effects of weak organic acids.

pH 7.0

pH 6.5
pH 6.0
pH 5.5

WHICH SITES TO CHECK WITH THIS NEW TEST?

Those sites most at risk for development of dental caries. The cariogenicity of plaque is
location dependent, because of site specific effects of saliva. It is generally more fermentative
in regions which lack access to the protective effects of saliva such as:
cervical surfaces of maxillary incisor teeth
buccal surfaces of mandibular canines and premolars
interproximal sites
Plaque samples can also be taken from sites with white spot lesions. Plaque collected
from sites of active caries will show a greater pH fall after a sucrose challenge than
plaque from sites without active caries.
Ageing of dental plaque (particularly if undisturbed for 24-48 hours) gives a greater level
of acid production than immature plaque. Therefore sites with mature plaque should be
selected for the Plaque-Check test. Confirmation of the location of mature plaque can be
gained by using the plaque disclosing gel.
The plaque pH will reduce to its lowest
point within 5 minutes. Accordingly, this
is the appropriate time to read the test
result. However if plaque is highly
acidic a low pH colour (red) will
often be visible within one minute.

INTERPRETING RESULTS
Aciduric, acidogenic (fermentative) bacteria include mutans streptococci, certain non mutans
streptococci and lactobacilli.
If the patient does have cariogenic fermenting plaque, the test results will indicate a rapid
reduction in pH with a corresponding colour change. In patients with a low caries risk, there
will be limited fermentation, and the weak organic acids produced will act as buffers and will
limit any pH fall in the plaque (and therefore the extent of the colour change).

Case study
NAME: BILLY
AGE: 10
HISTORY: Eats sugary foods excessively, and consumes at least 6 black cola
drinks per day.

SALIVA TEST RESULT

Hydration level below normal minor salivary flow more than 60 secs
Viscosity - sticky, frothy
Resting pH - 5.2 acidic
Stimulated flow rate 6 ml / 5 min
Buffering - 10 out of 12
These results indicate a lifestyle problem with acidic and sticky saliva.
Stimulated saliva flow and buffering capacity are normal.

PLAQUE-CHECK +pH RESULT

This test shows whether plaque is cariogenic or non cariogenic
Large areas of dark blue plaque
anterior and posterior
Fermenting plaque turned red
after 1 minute, very low pH 5.0
White spots and cavitation
in a number of sites
The results identify areas that are not being cleaned
properly and the plaque is highly cariogenic as
evidenced by a number of white spot and cavitated
lesions.
The use of the neutralizing solution proved
invaluable in providing motivation to
Billy's mum to ensure regular and
proper brushing in future.

TREATMENT PLAN
1. Restoration of cavitated lesions
2. A one week course comprising a daily chlorhexadine rinse (or gel) will help reduce
levels of mutans streptococci, and this in combination with a daily application of GC
Tooth Mousse should help to bring the oral environment into balance
3. Eliminate black cola soft drink and replace with water ensuring adequate hydration.
Oral hygiene instruction, stressing cervical cleaning with a fluoride toothpaste at the
next session and interproximal cleaning with floss.
Re-check saliva viscosity , resting pH and repeat Plaque-Check +pH tests in 2-3 weeks

RECALL VISIT AND RESULTS

SALIVA TEST RESULT
Hydration level normal - minor salivary flow 45 secs
Viscosity - bubbly, frothy
Resting pH - 6.4
The saliva viscosity and resting pH had improved, but there was still some additional
work to be done before it could be considered normal.

PLAQUE-CHECK +pH RESULT

A big improvement had occurred but still some areas of dark
blue plaque were present in the anterior and posterior regions
This means more effort is needed on systematic brushing and flossing in these areas.
Plaque turned red after 5 minutes, low pH 5.5
This indicates that the sites sampled have a thick cariogenic plaque that is still
producing large amounts of acid in response to a sugar challenge. This also means
continued episodes of enamel demineralization could lead to visible white spots and
possible cavitation if uncorrected.
Some improvement in areas of existing white spots
It was obvious that Billy and his mother worked hard at improving his oral hygiene.
The Tooth Mousse application frequency has been increased to twice daily. Depending
on his progress, the dietary changes and oral hygiene will be assessed once again after
a further 3 months. Monitoring of the progress of the white spot lesions should show
obvious signs of arrest and reversal.

Case study
NAME: CAROLE
AGE: 23
HISTORY: Left home at 19 for university after a year travelling in
Europe. Had a complete change in lifestyle with many late nights,
too much smoking and drinking, and no dental care.
She is now in a serious relationship and wants to get her mouth back
into shape.

SALIVA TEST RESULT

Hydration low
Viscosity - bubbly, frothy
Resting pH - 6.4 moderately acidic
Flow rate - 5.5 ml / 5 min
Buffering 10 out of 12

PLAQUE-CHECK +pH RESULT

This test shows whether plaque is cariogenic or non cariogenic
Many areas of dark blue
plaque interproximally
Plaque turned red after 2 minutes:
very low pH less than 5.5
White spots on buccal areas
of upper incisors and canines

TREATMENT PLAN
Carole has agreed to commence a quit-smoking program and ensure that water
intake is adequate. Replace soft drinks with water, and keep caffeine intake as low as
possible. The oral hygiene instruction included an illustration of how the buccal white
spot lesions result from the combination of dental plaque in the cervical areas, and
her at-risk lifestyle. She also received instructions in interdental cleaning and was
advised to apply GC Tooth Mousse each evening to reverse the buccal white spot
lesions. Carole should return for a Saliva Buffer test and Plaque-Check+pH test after
2-3 weeks.

3 WEEK RECALL VISIT AND RESULTS

SALIVA TEST RESULT
Hydration normal
Viscosity - watery, clear
Resting pH - 6.8
Flow rate - 6.5 ml / 5 min
Buffering - 10 out of 12

PLAQUE-CHECK +pH RESULT

A few areas stained pink/red
Plaque turned yellow after
5 minutes: moderate pH 6.5
White spots reduced on upper
incisors and canines
Carole was very motivated to improve her oral hygiene
and the results of her efforts were obvious when the
disclosing gel was applied.
Oral hygiene instructions will now be focused on those
regions showing mature (blue) plaque as a priority.
Carole has made substantial lifestyle changes
and this has resulted in better salivary
defences and a less acid producing
dental plaque environment.
She now needs to maintain these
efforts. The results of these tests
will help to motivate her in that
direction.

Case study
NAME: JUSTIN
AGE: 27
HISTORY: Completed a university commerce degree 3 years ago and now
a junior partner in a financial office. Is described by his friends as the
life of the party and can only rarely be found at home from Thursday
evening to Sunday. Chain smokes during the day and is a moderate to
heavy drinker. Has been told on more than one occasion that he has a
halitosis problem. His main concern on this dental visit is to learn why
many of his teeth are so sensitive and feel soft when he brushes.

SALIVA TEST RESULT

Hydration low
Viscosity sticky, stringy
Resting pH 5.6 acidic
Flow rate 3.8 ml / 5 min
Buffering 6 out of 12

TREATMENT PLAN
Justins major dental problem was not dental plaque but rather dental erosion caused
by dehydration from recreational substances consumed in substantial quantities at
weekend parties. Therefore a Plaque-Check +pH test was not warranted at this visit.
However the acidic environment of his saliva will influence the dental plaque ecology
and it can be expected that acid tolerant and acid producing bacteria will thrive under
conditions of low resting salivary pH.
Justin was advised to reduce smoking and to increase hydration by drinking at least 3
litres of water each day for the next week.
He was also encouraged to apply GC Tooth Mousse each morning and evening and to
leave a thin layer of Tooth Mousse on the teeth whilst sleeping. Next visit he will be told
a number of restorations will be necessary once his oral condition has stabilized. He was
asked to return and retest his saliva with the Saliva-Check BUFFER test after 2 weeks.

2 WEEK RECALL VISIT AND RESULTS

SALIVA TEST RESULT
Hydration low
Viscosity sticky, stringy
Resting pH 5.6 acidic
Flow rate 4.0 ml / 5 min
Buffering 6 out of 12
Justin was not happy to hear of changes necessary to
help resolve his problems and, as seen above, was not a
compliant patient. However on learning there was no
improvement in his oral condition plus the fact he
would need extensive restorative work in the
future he saw the wisdom of controlling his
excessive party habits.
He has reluctantly agreed to follow the
initial treatment recommendations
immediately and will return again for
another Saliva BUFFER test in 2 weeks
Chairside tests for saliva and plaque
provide you with knowledge about risk and
information to provide better diagnosis
and, when necessary, enable you to offer
better treatment planning. The results of
the tests can help motivate your patients
into making necessary changes in their
lifestyle to avoid dental caries. Caries risk
assessment is an essential part of patient
management. Before too long it will be
necessary to acknowledge the importance of
checking saliva and plaque before planning
dental treatment procedures.

Important information available

from your GC dental dealer

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GC Asia Dental Pte. Ltd

Changi Logistics Centre
19 Loyang Way #06-27 Singapore 508724
Tel 65 + 65467588 Fax 65 + 65467577
http//www.gcasia.info

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