Prevora Blog

A family dentist recently asked if caries originates when the mother cross-infects her young infant with Streptococci mutans, would adults cross infect others who had been treated with Prevora, and thereby negate the prevention of this treatment? Here is what the studies indicate:

1. Two studies have shown that cross-infection can occur after the early childhood. A Finnish study found that 2 of 4 married couples shared the same sero- and ribotypes of S. mutans.[1] A Dutch study found that 2 out of 12 families (father, mother, child over 5 years of age) harbored strains of mutans streptococci with a similar profile.[2]

2. On the other hand, two Swedish reports show that cross-infection between adults is difficult. On study found that none of the individuals in 13 pairs of couples had identical genotypes of mutans streptococci.[3] A similar study found that few spouses amongst a group of 25 Swedish pairs and 11 Chinese pairs acquired mutans streptococci from each other over a period of 2 to 5 years.[4]

3. The literature does show that the composition of dental plaques over several years remain remarkably stable despite the fact that new species are continually being introduced into the oral cavity and indigenous microbes are repeatedly being removed by oral hygiene procedures.[5] This stability is attributed to the characteristics of the biofilm, a complex web of many different microorganisms which serves to prolong vitality and mortality. It has been shown that the biofilm on the tooth surface re-emerges rapidly after brushing and flossing; this is partly due to the difficulty of cleaning the tooth surface – even after careful oral hygiene technique, there are still approximately 10⁶ bacteria per mm² adhering to the enamel.[6] At the root surface, the residual biofilm after cleaning is also substantial; for example, a professional debridement of the root surface can remove about 99% of viable bacteria, but about 10⁵ cfu remain the tubules, surface indentations or adjacent soft tissue. Recolonization of the root surface then occurs and viable counts can reach pre-treatment values within 3 to 7 days.[7]

So what does this evidence mean for Prevora and the opportunity for re-infection within a couple or a family after treatment? It would appear that while cross-infection is possible, it is unlikely between adults. Cross-infection may happen, moreover, immediately following a dental cleaning, not just Prevora. Without Prevora, the patient’s risks are clearly heightened for (more) root caries. Withholding Prevora treatment because of some unlikely event of cross-infection, seems to raise the risks un-necessarily. Perhaps another strategy could be considered: have both spouses treated.

Ross Perry

Hello Everyone,

I would like to take this opportunity to introduce a new co-author who will be starting to write posts for this blog. The new author is Todd, one of my fellow Professional Education Advisors with the Partners in Prevention. Todd represents the offices within the Partners in Prevention who are located in Central Toronto and the Northern part of the GTA.

Going forward both Todd and myself will be writing posts in order to give you the readers, a different point of view on the topics and to provide you with a perspective of how the material affects the offices in the different geographical regions.

I know that I am looking forward to Todd’s posts and I would like to take this time to thank him in advance for his contributions.

Until the next time,

Tyler

Hello everyone,

Recently the Partners in Prevention held its first guest speaker event which featured Dr Sally Mauriello an associate professor and coordinator of the Dental Hygiene Program at the School of Dentistry at the University of North Carolina. Dr Mauriello is one the lead researchers of the link between root caries and systemic health. She presented the finding of her research during presentations to the upper year hygiene classes at both George Brown College and the Canadian Academy of Dental Hygiene, as well as a contingent of the Partners in Prevention in Oakville. All three of these presentations were very well received by the audience and elicited many insightful questions and discussion.

Dr Mauriello’s findings have been summarized in three abstracts that have published over the past ten years a brief summary of these finding is below.

• In 1996, Mauriello reported that older adults with ≥ 2 new root caries lesions were four times more likely to die during the 3 to 5 year follow period, than those with fewer than 2 root lesions.[1] A subsequent study in 1999 by the Mauriello research team extended and confirmed these findings.[2]
• A 2006, Mauriello reported that amongst Americans aged 52-74 the incidence of heart attack over a 6 year period was 4.7% amongst the root caries group versus 2.4% for those without root decay.[3] In a regression analysis, root caries was significantly associated with a heart attack in this population, adjusting for periodontal pocketing, race, age, sex and the usual risk factors such as smoking, income, diabetes, hypertension and LDL

In her recent visit to Toronto, Dr. Mauriello provided some unpublished data from the Atherosclerosis Risk in the Community Study (ARIC), a large prospective study of risk factors for cardiovascular disease funded by the National Institutes of Health in the late 1980s and 1990s. ARIC tracked over 15,000 middle-aged Americans for cardiovascular disease over 10 years. Scientific articles from ARIC are still being published but the root caries connection has yet to be described. Dr. Mauriello reported that in ARIC, root caries out-weighed cholesterol as a risk factor for heart disease.

This link between root caries and overall health is still being investigated and is not completely understood at this point. However there is beginning to be more and more evidence of this link in the published literature. One of the most interesting articles has come from a Japanese research group which detected significant quantities of Streptococcus mutans in surgically removed heart valves and atheromatous plaque of patients with cardiovascular problems (Chart 1). This may indicate a pronounced or prolonged Bacteremia effect from recurrent root caries. The results of this study indicate that S. mutans is a possible causative agent of cardiovascular disease[4].

Chart 1

Source: Nakano K. et al, 2006. Detection of Cariogenic Streptococcus mutans in Extirpated Heart Valve and Atheromatous Plaque Specimens. J Clin Micro, 44: 3313 – 3317.

You can read more about both Dr Mauriello and the Japanese studies by following the links to the articles below.

Dr Sally Mauriello’s Research

Detection of Cariogenic Streptococcus mutans in Extirpated Heart Valve and Atheromatous Plaque Specimens

I hope that this post has given you a little more insight into the relationship between root caries and overall health and that it makes you look forward to the next Partners in Prevention guest lecture event.

Until the next time, take care
Tyler

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1 Mauriello S et al. 1996. Risk modeling for root caries and mortality in older adults. IADR Abstract 896.
2 Mauriello S et al. 1999. Root caries incidence as a risk predictor for mortality. IADR Abstract 3582.
3 Mauriello S et al. 2006. Root caries prevalence and incident myocardial infarction. IADR Abstract 1471.
4 Nakano K. et al, 2006. Detection of Cariogenic Streptococcus mutans in Extirpated Heart Valve and Atheromatous Plaque Specimens. J Clin Micro, 44: 3313 – 3317

Hello everyone,

Please see below for the press release that began circulating yesterday that is talking about some of the market research that was conducted by CHX Technologies in collaboration with Ipsos-Reid. I think that you will find the content very informative.

Take care,
Tyler

For immediate release: October 20, 2008 Toronto

Boomers & Seniors Are Looking for More Preventive Dental Care

Dental care is a major component of the Canadian healthcare system. It accounts for 7% of total spending,rivals the nation’s budget for heart disease and cancer, and becomes vital to overall health as Canadians grow older. It is increasingly clear, for example, that healthy gums and teeth are linked to a healthy heart. Dental benefits, moreover, are the second most expensive benefit cost for Canadian employers and are thereby important to the competitiveness of the Canadian economy.

As people age, their preferences for health care services and a healthy lifestyle change. The Boomers, for example, take multivitamins like no other age group, clog the local gym at mid-morning and regularly visit the Internet for health care information. Boomers are the new healthcare consumers who ask for second opinions and are more demanding of healthcare providers.

In this context, it is important to know what Boomers and Seniors want from their dental services – a topic for which there is little or no information. To find out, CHX Technologies, a dental pharmaceutical company, commissioned Ipsos-Reid, the leading Canadian market research firm, to conduct a national survey of Canadians aged 40+ about their preferences for dental services. The results are insightful and instructive not only to Canadian dental offices, but also to the overall Canadian healthcare debate.

The survey found the following:

— 41% of Canadians aged 40+ have had a filling or a crown put in over the past year.

— The most common method for which Canadians over the age of 40 pay for their dental services is out of pocket, with 37% reporting this is how they usually pay. This number increases to six in ten (59%) among those 70+.

— Over the past two years, one quarter (24%) of Canadians aged 40+ have spent more then $400 out of their own pocket on dental services.

— If they had to purchase a dental plan for their family, 75% said that it was important that this plan include filling for cavities, while 74% stated that it was important that this plan included prevention of gum disease. Other important factors include oral cancer diagnosis (66%), a new preventative program for tooth decay (63%), crowns (53%), dental implants (40%), and cosmetic services such as whitening (25%)

— Half (50%) said that they would follow their dentists recommendations for purchasing a new preventive coating to reduce their chances of further decay at the gum line. One in five (21%) would pay for this new preventive coating regardless of whether insurance would cover it or not..

— Six in ten (59%) Canadians aged 40+ expressed interest in Partners in Prevention, a growing network of Canadian dental offices which provide prevention services to people over 40. Four in ten said they would want their dentist to join Partners in Prevention or would ask their dentist if they were going to become a Partner in Prevention. Two in ten (18%) said they would either visit a Partner in Prevention or select a Partner in Prevention as their new dentist.

The Ipsos-Reid survey of 1,048 Canadians aged 40 and over was conducted on-line over 7 days in mid July, 2008. An unweighted probability sample of this size, with a 100% response rate, would have an estimated margin of error of +/- 3.1 percentage points, 19 times out of 20, of what the results would have been had the entire adult population aged 40+ in Canada been polled.

For more information on this survey visit www.partnersinprevention.ca or www.Ipsos-Reid.ca, or contact

Ross Perry	Sean Simpson
CHX Technologies	Ipsos-Reid
rossperry@chxtechnologies.com	Sean.Simpson@Ipsos.com

I was recently in a dental clinic and one of the hygienists asked me: What is this “Partners in Prevention” thing that I keep hearing about?

I explained to her that Partners in Prevention is a growing network of dental professionals throughout Canada who are trained to provide more preventive services to older adult dental patients. I talked to her about how the program is a unique education, training and promotion program designed to expand those dental services most preferred by Boomer Plus patients (those age 40+).

This network responds to the most significant opportunity now in dental care — more prevention to an aging community.  The hygienist I was speaking to agreed that older patients tend to “disappear” from the normal recall pattern in her office — seniors just don’t visit the office as much as younger patients do. And with more and more seniors, her hygiene team was beginning to wonder about its bookings.

I asked this hygienist if she and her hygiene team had ever asked these older patients what they preferred in their dental care? She said, rather embarrassed, that she had never thought of doing so. I said that our company had asked many older Canadians this fundamental question in several surveys and found that overwhelmingly, these older patients wanted more prevention, far more than other dental services such as cosmetics, implants, crowns, etc.

So, with the aging of her patients, this hygienist understood the importance of shifting her efforts to new preventive services such as Prevora, the antibacterial tooth coating which is the only approved preventive treatment for root caries.

This conversation with the hygienist explains the rationale to Partners in Prevention. It is a network  of dental offices shifting their services to more preventive care, as this is what their aging community best responds to.

Our company’s ongoing market research has indicated that 8 out of 10 of older patients want to pursue preventive strategies and almost all of them are willing to pay for this, regardless of insurance. In a recent survey conducted by Ipsos – Reid, it was demonstrated that 2 out of 10 patients would look for a dental office that is a Partner in Prevention and 4 out of 10 will ask you about it and expect your clinic to be a part of this growing network.

What is the cost of joining the Partners in Prevention network?  There is no charge for the following services but every Partner is committed to recommending prevention of root caries with Prevora, when it is appropriate. And given that Prevora is the only proven and approved preventive treatment for this most common disease in aging Canada, that commitment only makes sense.

The Partners in Prevention program means you will be raising the profile of your clinic in your community. You will be improving the level of care you provide to your patients while developing a more efficient and productive hygiene department, gaining the required continuous education credits and at the same time increasing the value of your practice.. There are a wide range of services within the Partners in Prevention program that are offered at no charge to a partner practice some of which are listed below.

Partners in Prevention consists of education programs that include:
● Semi-annual Educational Seminar Series
● Guest Lecture Series
● Lunch and Learn Sessions
● Training Sessions
● Hygienist education courses

As well there are education resources consisting of:

A Partners in Prevention Monthly Newsletter, a Partners in Prevention website, a Prevention of root caries video and a Prevora video, Patient brochures, Prevora poster and a Prevora blog.

Along with this there will be extensive training on identifying the patients at risk, counseling patients on appropriate preventive therapy and the application of Prevora – the only approved treatment for the prevention of root caries.

Once your clinic is on board with the Partners in Prevention program it will be included in:

• On-page advertising in your local newspaper media
• Inserts listing the Partner in Prevention clinics in your local newspaper media

At the end of my chat with this hygientist, it was clear to her that becoming a Partner in Prevention was a way to set a new standard of care for their older patients. A standard of care that they want and are willing to pay for.

I hope that this helps out with your understanding of what the Partners in Prevention is all about and if you would like more information see the website www.partnersinprevention.ca 

Take care,
Tyler

Hi everybody,

Recently we received a question from a patient through the Prevora website asking about what steps they can take in order to comply with the treatment protocol of Prevora. Below is their question and the response that they received.

Question: How do I care for my teeth throughout this process? Are there foods or liquids I should avoid? What about smoking, kissing or coffee?

You asked about care of your teeth while under protection with Prevora. That’s easy:

• Avoid brushing your teeth 24 hours after a Prevora application — let the coating bond to your teeth and do its job
• Avoid flossing for 3 days after a Prevora application ¾ again, in order to not remove the coating from in between your teeth
• Resume brushing your teeth with a new tooth brush to avoid contaminating your mouth the bacteria on your old tooth brush
• Avoid hard foods (a crusty roll, an apple) in the first 4 hours after treatment-you don’t want to remove the coating that was just put on the teeth
• Avoid sugary or acidic drinks (Coke, coffee, lemonade, orange juice) until 4 hours after treatment.

And that’s it. Otherwise, you can follow your regular diet and oral hygiene.

As for Smoking? That’s a risk factor for tooth decay at the gum line which scientists are just beginning to understand. Essentially, smoking shrinks the gums and exposes your tooth’s roots to the bacteria which puts them at risk.

Kissing? Always encouraged, even during Prevora!! But you raise an interesting point. The bacteria that causes tooth decay is communicated from mother to child when the child is very young. This cross-infection is minimal, however, after early childhood this doesn’t take place because our oral ecology becomes too complex later in life, to allow for it. There are no studies that I am aware of, to show that kissing amongst adults or amongst parents and their older children, leads to tooth decay.

As for coffee, as listed above you want to avoid drinking it immediately after your application of Prevora but within a few hours you can have that much needed cup of Joe.

Thanks again for the great questions.
Take care

Tyler

Hello,

As many of you know, Prevora, the antibacterial tooth coating used in Canadian dental offices to prevent root caries, has a very large program of randomized controlled studies and practice management studies underway. One of these studies, the Prevention of Adult Caries Study, has been underway for more than a year and has recently met an important milestone. See below.

Some interesting observations from this study are:

- an excellent safety profile, similar to what we have seen in other studies and in Canadian dental office use

- a ready supply of patients.  The study is enrolling adult patients with advanced stages of this chronic disease, primarily from existing patient caseloads. Seems this disease is as prevalent as many of the epidemiological studies report, and as many of the Prevora users indicate.

I am excited about this growing base of evidence for Prevora, which we will share with our accounts over the coming months.

Thanks for your interest,
Tyler

The Prevention of Adult Caries Study of Prevora Achieves Full Enrolment.

CHX Technologies Inc., a specialty pharmaceutical company developing new preventive products for adult oral diseases, announced today that the Prevention of Adult Caries Study (PACS) of the antibacterial tooth coating called Prevora (100 mg/ml chlorhexidine acetate) has completed enrolment of study participants. Recruitment started in spring 2007, and 983 participants have been randomized in PACS.

PACS is a pivotal Phase III randomized, controlled clinical trial conducted under CHX Technologies’ Investigational New Drug license with the U.S. Food and Drug Administration. The study is expected to be the final study before filing a New Drug Application for Prevora to the FDA and is believed to be the largest study of its kind. PACS’ clinical endpoint is decayed tooth surfaces and the trial’s threshold for efficacy is a 20% reduction of such surfaces in the treated arm of the study versus placebo over one year.

Efficacy results from PACS are expected in the first half of 2010.

PACS has been sponsored largely by the National Institute of Dental and Craniofacial Research, one institute of the National Institutes of Health (NIH). The study is being conducted at four clinical centers. At baseline, the mean age of the study participants was 43, and the mean number of decayed tooth surfaces was 33. Two out of three study participants in PACS visit the dentist at least once a year.

Tooth decay has become a common adult disease as the population ages. The U.S. Center for Disease Control reported last year, for example, that about one third of American seniors under age 74 had tooth decay at the gum line (also called root caries). Root caries is caused by a low-grade asymptomatic bacterial infection. Its emergence in older Americans is largely related to gum recession and the taking of several prescription drugs each day. It is a form of tooth decay which is difficult to treat with conventional restorative procedures and which has been reported to have connections to overall health.

Prevora is a clear and temporary tooth coating applied by the dental professional to the teeth of adult patients in a short, painless appointment. Prevora delivers on a sustained release basis, a common and safe antimicrobial compound, called chlorhexidine, to the bacterial infections on the teeth. This coating has been approved by Health Canada for the reduction of tooth decay at the gum line, and by the Irish Medicines Board for the reduction of tooth decay in adults and adolescents. CHX Technologies has begun marketing Prevora to dentists in several communities in Southern Ontario, and expects to proceed through mutual recognition in late 2008 for broader European approvals in 2009.

Prevora is the first new antibacterial product indicated for the reduction of adult tooth decay available to the dental professional. It is also the first product in CHX Technologies’ development program which is uniquely focused on new proven preventive dental products for the aging population.

For more information contact:

Ross Perry

CHX Technologies Inc.

rossperry@chxtechnologies.com

Over the last couple of weeks during my meetings with our Partners in Prevention clinics there have been some questions around the length of Prevora therapy that seem to be on the minds of a few of the clinics. In order to address these questions I had a Q&A session with Dr John (Jack) Symington and asked him how he would proceed. Dr Symington is Professor Emeritus in Oral Surgery at the University of Toronto.

 

Q: What is the ongoing treatment regimen for Prevora after the patient has received the initial 4 applications in the 2 month span?

 A: The treatment regimen for each patient is going to be slightly different as it will need to address the individual’s specific risk factors. Some patients will be at higher risk of root caries due to the risk factors of gum recession, xerostomia, periodontal disease, poor oral hygiene and lack of manual dexterity. Clinical judgement on the part of the dental professional will need to be used and a more aggressive or passive treatment regimen may be better suited for a particular patient. However with that said there are some guidelines that can be followed.

After four applications of Prevora the chlorhexidine acetate (chx) can remain in the microtubules of the dentin for more than 42-60 days (6-8 weeks) which will help to combat the bacteria within the biofilm on the tooth surface. This is the rationale for the 4 applications within a short time span to maximise the concentration of chx and as a result control re-growth of the bacteria.

Six months after the final initial treatment of Prevora the efficacy starts to diminish due to the decrease in the concentration of chx. It is for this reason that the patient should receive an additional application of Prevora at this time.

At one year (12 months after the initial treatment) the dental professional must use their clinical judgement as to how many treatments the patient will receive at this time (1-4). The determining factor is the number of new caries that the patient has experienced over that 12 month period.

Examples of treatment regimens:

If the patient has no new caries and was previously experiencing 3-4 over the course of 12 months then a single application would be used at the 12 month recall appointment and then observe that patient’s progress over the next 6 months.

If the patient has no new caries at 6 months but then has new root caries at 12 months then it would be prudent to treat with 4 applications and observe again in 6 months.

With Prevora’s 41% reduction rate for root caries the process of minimizing the amount of new caries that develop is something that may have to be observed over the course of a few years. An example would be if a patient exhibits 5 new caries in the year prior to treatment it is possible that this could be reduced to 3 new caries in the first year of the treatment. Then by year 2 of the treatment the number of root caries could be down to 1 or less.

As with any treatment it is important to manage the expectations of the patient and to speak to them about the disease and how this course of action will benefit them and improve their oral health.

I hope that all of you will find this discussion beneficial and if you have any comment please feel free to pass them along

Take care,
Tyler

Hello,

As most of you are aware the International Association for Dental Research (IADR) held their General Session last week here in Toronto at the Metro Toronto Convention Centre. This session included symposia and poster presentations by researchers from around the world.

From the General Session we will be making a couple of blog posts. One will discuss the impact of psychiartric medication on oral health status as presented by Dr Tina Papas of Tufts University. The other will discuss the collaboration between dentistry and medicine when dealing with oral and systemic health, which was presented by Dr Bill Costerton of the University of Southern Calironia.

Also we at CHX Technologies were very happy to host a reception at the University Club on July 2nd in conjuction with the IADR Session, and I would like to take this opportunity to thank all of those people who attended the reception and made it a very enjoyable evenning.

Take care,
Tyler

At the recent International Association of Dental Research (IADR) meeting held in Toronto, Dr. Tina Papas (Tufts University School of Dental Medicine, Boston) presented the results of a nine month study on the changes in oral health status in patients taking psychiatric medications compared to patients who were taking medications known to cause xerostomia (dry mouth). It is well known that many psychiatric drugs such as those used to treat anxiety, depression and those with an effect on the autonomic nervous system all have a xerogenic (drying) effect. Medications that cause dry mouth have been shown to contribute to a higher caries rate.

In her abstract Dr. Papas was able to demonstrate in a population of 653 patients that psychiatric drugs led to a significantly higher increase in periodontal attachment loss and recession and a significantly higher increment of caries than even drugs known to cause xerostomia. This is despite having acceptable oral hygiene habits and receiving regular dental visits.

This reinforces data by Rindal published in 2005 (Community Dentistry and Oral Epidemiology, 33:74-80) demonstrating that for patients taking antidepressants the restoration rate is an amazing 60% higher than for those taking no medication at all.

Clearly, understanding a patient’s medical history and specifically the use of psychiatric drugs could be critical in identifying this risk factor for caries and assist in the development of preventive treatment strategies.

See the link below for the abstract of Dr Papas’ presention

IADR Session 1513 Changes in Oral Health Status in Volunteers on Psychiatric Medications

Take Care,
Tyler