Human plaque pH responses to meals and the effects of chewing gum

Fluoride exchange by glass-ionomer dental cements and its clinical effects: a review

The topic of fluoride release and uptake by glass-ionomer (glass polyalkenoate) dental cements is reviewed. The study was based on a literature search carried out using PubMed. The main key words used were glass-ionomer and fluoride, and further refinements were made by adding the keywords anti-microbial, anti-caries and remineralization. Papers were selected from the initial search, which concentrated on fundamental aspects of fluoride release, including kinetics and the influence of the cement composition, and resulting clinical performance against caries. Other relevant papers were cited where they added useful and relevant data. From these published papers, it was possible to explain the detailed mechanism of fluoride release by glass-ionomer cements and also its uptake. Fluoride release has been shown to be a two-step process. In neutral solutions, the steps can be divided into early wash-out and long-term diffusion. In acid conditions, the early wash-out remains, though with greater amounts of fluoride released, and the long-term release becomes one of slow dissolution. The effect of fluoride on the viability of oral micro-organisms has been described, and glass-ionomers have been shown to release sufficient fluoride to reduce the size and viability of adjacent populations of oral bacteria. The effect of low levels of fluoride on the remineralization of tooth tissue has been considered. Levels needed to increase remineralization are much lower than those needed to adversely affect oral bacteria, from which we conclude that glass-ionomers release sufficient fluoride to promote remineralization. Despite this, there remains uncertainty about their overall contribution to sound oral health, given the widespread use of other sources of fluoride, such as toothpastes.

Fluoride resistance in Streptococcus mutans: a mini review

For decades, fluoride has been used extensively as an anti-caries agent. It not only protects dental hard tissue, but also inhibits bacterial growth and metabolism. The antimicrobial action of fluoride is shown in three main aspects: the acidogenicity, acidurance, and adherence to the tooth surface. To counteract the toxic effect of fluoride, oral bacteria are able to develop resistance to fluoride through either phenotypic adaptation or genotypic changes. Strains that acquire fluoride resistance through the latter route show stable resistance and can usually resist much higher fluoride levels than the corresponding wild-type strain. This review summarizes the characteristics of fluoride-resistant strains and explores the mechanisms of fluoride resistance, in particular the recent discovery of the fluoride exporters. Since the fluoride resistance of the cariogenic bacterium Streptococcus mutans has been studied most extensively, this review mainly discusses the findings related to this species.

RNases J1 and J2 are critical pleiotropic regulators in Streptococcus mutans

In recent years, it has become increasingly evident that post-transcriptional control mechanisms are the principal source of gene regulation for a large number of prokaryotic genetic pathways, particularly those involved in virulence and environmental adaptation. Post-transcriptional regulation is largely governed by RNA stability, which itself is determined by target accessibility to RNase degradation. In most Firmicutes species, mRNA stability is strongly impacted by the activity of two recently discovered RNases referred to as RNase J1 and RNase J2. Little is known about RNase J1 function in bacteria and even less is known about RNase J2. In the current study, we mutated both RNase J orthologues in Streptococcus mutans to determine their functional roles in the cell. Single and double RNase J mutants were viable, but grew very slowly on agar plates. All of the mutants shared substantial defects in growth, morphology, acid tolerance, natural competence and biofilm formation. However, most of these defects were more severe in the RNase J2 mutant. Phenotypic suppression results also implicate a role for RNase J2 as a regulator of RNase J1 function. Unlike Bacillus subtilis, RNase J2 is a major pleiotropic regulator in S. mutans, which indicates some fundamental differences from B. subtilis in global gene regulation. Key conserved residues among the RNase J2 orthologues of lactic acid bacteria may hint at a greater role for RNase J2 in these species.

Acid tolerance mechanisms utilized by Streptococcus mutans

Since its discovery in 1924 by J Clarke, Streptococcus mutans has been the focus of rigorous research efforts due to its involvement in caries initiation and progression. Its ability to ferment a range of dietary carbohydrates can rapidly drop the external environmental pH, thereby making dental plaque inhabitable to many competing species and can ultimately lead to tooth decay. Acid production by this oral pathogen would prove suicidal if not for its remarkable ability to withstand the acid onslaught by utilizing a wide variety of highly evolved acid-tolerance mechanisms. The elucidation of these mechanisms will be discussed, serving as the focus of this review.

Characterization of mleR, a positive regulator of malolactic fermentation and part of the acid tolerance response in Streptococcus mutans

Background

One of the key virulence determinants of Streptococcus mutans, the primary etiological agent of human dental caries, is its strong acid tolerance. The acid tolerance response (ATR) of S. mutans comprises several mechanisms that are induced at low pH and allow the cells to quickly adapt to a lethal pH environment. Malolactic fermentation (MLF) converts L-malate to L-lactate and carbon dioxide and furthermore regenerates ATP, which is used to translocate protons across the membrane. Thus, MLF may contribute to the aciduricity of S. mutans but has not been associated with the ATR so far.

Results

Here we show that the malolactic fermentation (mle) genes are under the control of acid inducible promoters which are induced within the first 30 minutes upon acid shock in the absence of malate. Thus, MLF is part of the early acid tolerance response of S. mutans. However, acidic conditions, the presence of the regulator MleR and L-malate were required to achieve maximal expression of all genes, including mleR itself. Deletion of mleR resulted in a decreased capacity to carry out MLF and impaired survival at lethal pH in the presence of L-malate. Gel retardation assays indicated the presence of multiple binding sites for MleR. Differences in the retardation patterns occurred in the presence of L-malate, thus demonstrating its role as co-inducer for transcriptional regulation.

Conclusion

This study shows that the MLF gene cluster is part of the early acid tolerance response in S. mutans and is induced by both low pH and L-malate.

The laryngeal and esophageal manifestations of Sjögren’s syndrome

Laryngopharyngeal reflux (LPR) is the syndrome caused by the backflow of gastric contents into the upper aerodigestive tract. Acid and pepsin in the pharynx, larynx, oral cavity, and trachea have been associated with dysphonia, chronic cough, reactive airway disease, middle ear effusion, throat pain, excessive throat mucus, postnasal drip, dental caries, and laryngeal cancer. The symptoms of LPR frequently occur in the absence of heartburn and esophagitis, and, thus, the diagnosis may be elusive. Individuals with Sjögren's syndrome are predisposed to reflux, and a high index of suspicion for LPR must be maintained in all individuals with the disease. This manuscript describes the laryngeal, pharyngeal, and esophageal manifestations of reflux in patients with Sjögren's syndrome and reviews state-of-the-art diagnostic and treatment strategies.

Effect of sodium nitrite and ascorbic acid on the growth and acid production of Streptococcus mutans

Nitrite at acid pH has been shown to be antibacterial particularly against the highly cariogenic species Streptococcus mutans. Nitrite might yield nitrosamines in vivo but ascorbic acid (vitamin C) could counteract these potential ill effects. The aim of this study is to determine whether ascorbic acid would interfere with the ability of sodium nitrite to suppress growth and acid production of S. mutans, NCTC 10449(T) and NCTC 10832. Strains were grown in Fastidious Anaerobe Broth before exposure to 200 mM nitrite in the presence of various concentrations of ascorbic acid (0.0, 5.7, 11.4, 17.0, 22.7, 28.4, 56.8, 85.2 mM). End pH was measured after 24 h exposure and cultures were serially diluted for viable counts. Statistical significance of differences in end pH values, each from 10 experiments, was determined using the Mann-Whitney U-Test. At all concentrations of ascorbic acid plus 200 mM nitrite plus S. mutans the pH was higher than with controls lacking ascorbic acid and/or nitrite (p>/=0.001). S. mutans was viable (between 4.5 x 10 (8) and 7.9 x 10 (9) cfuml (-1)) after growth in the presence of ascorbic acid at all concentrations without nitrite, whereas it was not detected when 200 mM nitrite was also present.

CONCLUSIONS

ascorbic acid does not prevent the action of nitrite against S. mutans. Therefore ascorbic acid could be used in conjunction with nitrite to help counteract potential ill effects for humans.

Effects of gum chewing on pharyngeal and esophageal pH

We investigated the effects of gum chewing on pharyngeal and esophageal pH levels in patients with laryngopharyngeal reflux (LPR) who were undergoing reflux testing. Forty consecutive, unselected, adult patients who were undergoing ambulatory double-probe (simultaneous pharyngeal and esophageal) pH monitoring for diagnosis of LPR were asked to chew 2 sticks of gum 4 times during their pH studies. Twenty subjects chewed regular sugarless gum, and 20 subjects chewed a sugarless gum containing bicarbonate. The subjects recorded the beginning and end of each gum-chewing period. The mean pH values for the gum-chewing intervals and for comparable pre-gum-chewing intervals were analyzed statistically for both the pharyngeal and esophageal probe data. The regular gum group and the bicarbonate gum group were analyzed separately. In addition, the gum-chewing pH data were compared to controls, ie, normal postcibal buffering effects. The data show that gum chewing consistently increases esophageal and pharyngeal pH, and that bicarbonate gum causes greater increases than regular gum. For patients with LPR, gum chewing appears to be a useful adjunctive antireflux therapy.

Dental complications of head and neck radiotherapy: Part 2

Radiotherapy for head and neck tumours is a viable treatment modality. However, a wide range of potentially debilitating dental complications may accompany the treatment. In Part 2 of this article, prevention and management strategies available to the dental practitioner to stave off the dental side effects of radiotherapy are explored and particular attention is given to the management of xerostomia and radiation caries.

Characterization of the sat operon in Streptococcus mutans: evidence for a role of Ffh in acid tolerance

An essential protein translocation pathway in Escherichia coli and Bacillus subtilis involves the signal recognition particle (SRP), of which the 54-kDa homolog (Ffh) is an essential component. In a previous study, we found that a transposon insertion in the ylxM-ffh intergenic region of the designated secretion and acid tolerance (sat) operon of Streptococcus mutans resulted in an acid-sensitive phenotype. In the present study, we further characterized this genomic region in S. mutans after construction of bona fide sat operon mutants and confirmed the role of the SRP pathway in acid resistance. Northern blot and primer extension analyses identified an acid-inducible promoter upstream of ylxM that was responsible for upregulating the coordinate expression of all five genes of the sat operon when cells were grown at acid pH. Two constitutive promoters, one immediately upstream of satD and one just 3' to the acid-inducible promoter, were also identified. Except for Ffh, the functions of the sat operon gene products are unknown. SatC, SatD, and SatE have no homology to proteins with known functions, although YlxM may function as a transcriptional regulator linked to genes encoding SRP pathway proteins. Nonpolar mutations created in each of the five genes of the sat locus resulted in viable mutants. Most striking, however, was the finding that a mutation in ffh did not result in loss of cell viability, as is the case in all other microbial species in which this pathway has been described. This mutant also lacked immunologically detectable Ffh and was severely affected in resistance to acid. Complementation of the mutation resulted in restoration of acid tolerance and reappearance of cytoplasmic Ffh. These data provide evidence that the SRP pathway plays an important role in acid tolerance in S. mutans.

Influence of starvation and biofilm formation on acid resistance of Streptococcus mutans

The aim of this study was to investigate acid resistance induced by starvation or biofilm formation in Streptococcus mutans ATCC 25175. The artificial biofilms were made on cover glasses, starved for 24 h and immersed in 0.1 M lactate buffer at pH 3.8 for 10 min. The biofilms were also exposed to 5% sucrose solution for 20 min to simulate acid shock produced by sucrose metabolism. Confocal laser scanning microscopy with fluorescein isothiocyanate staining measured the resultant minimum pH in biofilms. Live and dead organisms in biofilms were differentiated by confocal laser scanning microscopy with proidium iodide and SYTO9 staining. The same processes were used to treat planktonic organisms. The results showed that starved biofilms or planktonic cells showed significantly more viable bacteria after acid shock induced either by lactic acid or during sucrose consumption than non-starved biofilms or planktonic cells. In addition, biofilms showed greater resistance to acid shock induced by lactic acid than planktonic cells, whereas similar results were obtained where sucrose was used as a carbon source to reduce pH in biofilms and planktonic cells. Thus, it is suggested that starvation protects both biofilm and planktonic S. mutans from acid shock induced either by lactic acid or during sucrose consumption, while biofilm formation seemed to protect bacteria only from acid shock induced by pH 3.8 lactate buffer but not the acid shock of a slightly higher pH produced during sucrose consumption.

Chewing gum--facts and fiction: a review of gum-chewing and oral health

The world market for chewing gum is estimated to be 560,000 tons per year, representing approximately US $5 billion. Some 374 billion pieces of chewing gum are sold worldwide every year, representing 187 billion hours of gum-chewing if each piece of gum is chewed for 30 minutes. Chewing gum can thus be expected to have an influence on oral health. The labeling of sugar-substituted chewing gum as "safe for teeth" or "tooth-friendly" has been proven beneficial to the informed consumer. Such claims are allowed for products having been shown in vivo not to depress plaque pH below 5.7, neither during nor for 30 minutes after the consumption. However, various chewing gum manufacturers have recently begun to make distinct health promotion claims, suggesting, e.g., reparative action or substitution for mechanical hygiene. The aim of this critical review--covering the effects of the physical properties of chewing gum and those of different ingredients both of conventional and of functional chewing gum--is to provide a set of guidelines for the interpretation of such claims and to assist oral health care professionals in counseling patients.

Composition of plaque and saliva following use of an alpha-tricalcium-phosphate-containing chewing gum and a subsequent sucrose challenge

Previous studies demonstrated that the chewing of a 2.5% (mass fraction) alpha-tricalcium-phosphate-fortified (alpha-TCP) experimental chewing gum released sufficient calcium and phosphate to eliminate any fall in the tooth mineral saturation of plaque fluid after a sucrose rinse (Vogel et al., 1998). In contrast, the chewing of a conventional sugar-free gum did not eliminate this decrease in saturation. The purpose of this study was to examine if the release of ions from plaque calcium-phosphate pools induced by this gum could provide protection during subsequent exposure to cariogenic conditions. Fourteen subjects accumulated plaque for 48 hrs, fasted overnight, chewed a control or experimental gum for 15 min, and subsequently rinsed 1 min with a mass fraction 10% sucrose solution. Before gum chewing, and at 7 min and 15 min afterward, whole plaque, plaque fluid, and salivary samples were obtained and analyzed by micro-analytical techniques. Additional samples were collected and analyzed at 25 min (7 min after the sucrose rinse). Although the results confirmed the deposition of large amounts of calcium and phosphates in plaque seen in the previous study, only a small increase was seen in plaque-fluid-free calcium and phosphate before sucrose administration. This suggests that few of the mineral ions were mobilized under non-cariogenic conditions. However, 7 min after the sucrose rinsing, an increase in these concentrations was seen which, based on hydroxyapatite ion activity product calculations, indicated a decrease in the driving force for demineralization compared with that seen with the control gum. These results suggest that the chewing of the experimental gum deposits a labile mineral reservoir in plaque that can resist a subsequent cariogenic challenge.

In situ de- and remineralisation of enamel in response to sucrose chewing gum with fluoride or non-fluoride dentifrices

OBJECTIVES

Enhancement of the remineralisation of artificial enamel lesions has been observed in an intraoral model whether subjects chewed gum sweetened with a non-cariogenic sweetener such as sorbitol [1-3] or sucrose [4] after meals or snacks, and with use of a conventional (1500 ppm F) fluoride dentifrice. Since most of the clinical surveys which have shown the potential cariogenicity of sucrose chewing gum [5] were conducted before use of fluoridated dentifrices became widespread, the effect of fluoride dentifrice on de- and remineralisation of artificial lesions in enamel in response to chewing sucrose-sweetened gum has been examined with the aim of attempting to resolve this apparent discrepancy.

METHODS

Subjects wore an intraoral device bearing an enamel lesion and chewed one piece of sucrose gum for 20 min after each of three meals and two snacks daily for two 3-week periods, during which they used a dentifrice containing either 0 or 1500 ppm F in a double-blind, cross-over design. Measurement of the mineral content of the lesions was determined by microradiography or polarised light microscopy.

RESULTS

It was found that remineralisation tended to occur with 1500 ppm F dentifrice, but demineralisation with non-F dentifrice; the difference in enamel mineral content between the two periods was significant (P < 0.05).

CONCLUSIONS

The results indicate that the potential cariogenicity of sucrose-containing chewing gum may indeed be negated by the use of a conventional fluoride dentifrice.

The effect of chewing sugar-free gum after meals on clinical caries incidence

To determine the effect of chewing sugar-free gum on caries incidence, the authors conducted a randomized clinical study. A total of 1,402 children in Puerto Rico, in grades 5 through 7 at baseline, completed the study. They were randomized by classroom into a control group or chewing gum group; those in the gum group were instructed to chew sugar-free gum for 20 minutes after each of three meals a day. Clinical and radiographic evaluations were performed at baseline and after two and three years. The results show that all subjects and high-risk subjects, respectively, in the gum group developed 7.9 percent and 11.0 percent fewer decayed, missing or filled surfaces than subjects in the control group. Based on these findings, the authors concluded that chewing sorbitol-based sugar-free gum after eating significantly reduces the incidence of dental caries.

Acid-regulated proteins induced by Streptococcus mutans and other oral bacteria during acid shock

Our previous research has demonstrated that with the more aciduric oral bacteria, an acid shock to sub-lethal pH values results in the induction of an acid tolerance response that protects the cells at extremely low pH (pH 3.0-4.0) that kills unadapted control cells maintained at pH 7.5 (Oral Microbiol Immunol 1997: 12: 266-273). In this study, we were interested in comparing the protein profiles of acid-shocked and control cells of nine organisms from three acid-ogenic genera that could be categorized as strong, weak and non-acid responders in an attempt to identify proteins that could be classified as acid-regulated proteins and which may be important in the process of survival at very low pH. For this, log-phase cultures were rapidly acidified from pH 7.5 to 5.5 in the presence of [14C]-amino acids for varying periods up to 2 h, the period previously shown to be required for maximum induction of the acid response. The cells were extracted for total protein and subjected to one-dimensional sodium dodecyl sulfate-polyacrylamide chromatography with comparable control and acid-shocked protein profiles compared by scanning and computer analysis. Of particular interest were the proteins in the acid-shocked cells that showed enhanced labeling (i.e., synthesis) over the control cells, since these were considered acid-regulated proteins of importance in pH homeostasis. Streptococcus mutans LT11 generated the most rapid and complex pattern: a total of 36 acid-regulated proteins showing enhanced synthesis, with 25 appearing within the first 30 min of acid shock. The enhanced synthesis was transient with all proteins, with the exception of two with molecular weights of 50/49 and 33/32 kDa. Within the acid-regulated proteins were proteins having molecular weights comparable to the heat shock proteins and the various subunits of the membrane H+/ATPase. By comparison, the strong responder, Lactobacillus casei 151, showed the enhanced formation of only nine proteins within the first 30 min of the acid shock, with a total of 11 acid-regulated proteins formed during the 2-h adaptation period with enhanced synthesis transient for seven of these proteins. Streptococcus salivarius AT2 and Streptococcus gordonii TH12 had the formation of 6 and 8 proteins enhanced, while the weakly responding organisms, Streptococcus sanguis ATCC 10,556 and Streptococcus oralis ATCC 10,557, exhibited 8 and 6 such proteins, respectively. Even non-responding strains unable to survive at very low pH, such as Streptococcus sobrinus CH125/43, Streptococcus mitis ATCC 12,261 and Actinomyces naeslundii 301-13 showed the initial formation of 3-9 acid-regulated proteins, but protein synthesis was not sustained over the entire adaptation period. Clearly, the survival of oral bacteria at very low pH is related, not to the total number of the acid-regulated proteins induced per se but to the formation of key proteins that function to augment normal pH homeostasis.

Composition of plaque and saliva following a sucrose challenge and use of an alpha-tricalcium-phosphate-containing chewing gum

Calcium phosphate concentrations in plaque, plaque fluid, and saliva play an important role in caries prevention. In this study, we used a microanalytical technique to examine the anticaries potential of a 2.5% (mass fraction) alpha-tricalcium-phosphate-fortified experimental gum by measuring the pH, free and total calcium, and total phosphate in plaque fluid, whole plaque, and saliva, and centrifuged saliva from 14 subjects who (1) accumulated plaque for 48 hours, (2) fasted overnight, (3) rinsed for 1 min with sucrose, and (4) chewed a control or experimental gum for 15 min. From these data, the hydroxyapatite (HAp) ion activity products (IAP[HAp]) of saliva and plaque fluid were calculated as a measure of tooth mineral saturation. Results, compared with those of the control gum, show significant increases in pH and in free calcium and phosphate concentrations in plaque fluid and saliva when the experimental gum was chewed following sucrose ingestion. These increases result in a rise in fluid saturation with respect to tooth mineral that, for plaque fluid, nearly cancels the decrease seen with the control gum after the sucrose rinse. This suggests that the experimental gum may be more effective than a conventional gum in ameliorating the cariogenic effects of sucrose. Similar statistically significant increases were also seen in the total calcium content of the plaque fluid, centrifuged saliva, whole saliva, and whole plaque, and in the total phosphate of whole plaque and whole saliva. These results suggest that the deposition of a mineral reservoir in plaque and saliva by the experimental gum may help resist future cariogenic challenges.

Acid tolerance response and survival by oral bacteria

Using 21 species of oral bacteria, representing six acidogenic genera, we undertook to determine whether the pH-limiting exponential growth is related to the ability of the organisms to generate an acid-tolerance response that results in enhanced survival at low pH. The lower pH limit of exponential growth varied by more than two units with that of Neisseria A182 at pH 6.34; growth of Lactobacillus casei RB1014 stopped at pH 3.81, with species of Actinomyces, Enterococcus, Prevotella and Streptococcus falling between these limits. The working hypothesis was that the organisms with the higher pH limits for growth are unable to respond to acidic environments in order to survive, whereas the more aciduric organisms would possess or acquire acid tolerance. Adaptation to acid tolerance was tested by determining whether the prior exposure of exponential-phase cells to a low, sub-lethal pH would trigger the induction of a mechanism that would enhance survival at a pH killing pH 7.5 control cells. The killing pH varied from pH 4.5 for Prevotella intermedia ATCC 25611 to pH 2.3 for the three Lactobacillus casei strains in the study, with the three Streptococcus mutans strains killed at pH 3.0 for 3 h. The adaptation experiments revealed three groups of organisms: non-acid-responders, generally representing strains with the highest terminal pH values; weak acid-responders in the middle of the pH list, generating low numbers of survivors at one or two pH values, and the aciduric, strong responders generating a high number of survivors at pH values in the range 6.0 to 3.5, but not at pH 7.5. Predominant among the latter group were the S. mutans and Lactobacilli casei strains, with the most significant adaptive response exhibited by S. mutans LT11 and S. mutans Ingbritt, involving a process that required protein synthesis. Time course experiments with the latter organisms indicated that 90-120 min was required after exposure to the triggering pH before the acid response was fully functional. These results indicate that the sudden exposure of strains of oral streptococci and lactobacilli, as well as Enterococcus faecalis, to pH values between 6.0 and 3.5 results in the induction of an acid tolerance response that enhances the survival of these strains at or below pH 3.5.

The use of low-tack chewing gum for individuals wearing orthodontic appliances

A clinical study was carried out to determine the acceptability of a sugar-free, low-tack chewing gum by orthodontic patients undergoing fixed appliance treatment. Twenty-five orthodontic and 25 non-orthodontic control subjects were questioned on their preference between regular-tack and low-tack chewing gum. The orthodontic subjects showed a strong preference for the low-tack gum compared with the regular-tack gum. It was concluded that low-tack, sugar-free chewing gum can be used by orthodontic patients to increase saliva flow, with the potential to promote remineralization and help reduce white spot lesion formation related to fixed orthodontic appliances. This gum should also be of value in patients being treated for xerostomia who are wearing a partial denture.

Xylitol fermentation by human dental plaque

The aim of the present study was to examine xylitol metabolism by dental plaque collected immediately after the use of xylitol gum. Plaque was collected from 12 individuals immediately before and after xylitol exposure. The effect on xylitol metabolism by dental plaque of a 3 d discontinuation of the xylitol exposure was also examined. Xylitol metabolism by the plaque suspensions was initiated by adding [14C]xylitol and analyzed by HPLC. The results showed increased xylitol metabolism after 11 wk of chewing xylitol-containing gum. The ability to metabolize xylitol was rapidly reduced after the discontinuation of the xylitol exposure. It is suggested that an induction of enzymes in one or more of the species of plaque bacteria may have caused this effect. Glucose metabolism, which also was studied in the plaque samples, was decreased after xylitol exposure, but increased again 3 d after cessation of the xylitol exposure. It is suggested that the reduced glycolysis was caused by accumulation of intracellular xylitol-5-phosphate in some plaque bacteria during the xylitol exposure.

Gum chewing and jaw muscle fatigue and pains

To study possible associations between gum chewing and fatigue and pains in the jaw muscles, eight healthy adults performed prolonged idling, prolonged unilateral chewing of gum, and brief vigorous clenching of the teeth (MVC). Through surface electromyography (EMG), the authors monitored the cumulative (microV.s) as well as the average rates (microV.s-1) of contractile activities in the right and left masseter muscles. During 10 min of idling there was an absence of muscle fatigue and muscle pains when the EMG rates of the right and left masseter muscles were 2% and 3%, respectively, of those required to elicit isometric muscle pains through MVC. During 10 min of right-sided gum chewing at a rate of 1.2 Hz, the majority of subjects (75%) experienced weak jaw muscle fatigue-not jaw muscle pains-when the EMG rates of the right and left masseter muscles were 38% and 19%, respectively, of those required to elicit isometric pains through MVC. In comparison with 10 min of idling, the weak muscle fatigue of 10 min of unilateral gum chewing appeared when the total contractile activities of the right and left masseter muscles were increased by 1664% and 519%, respectively. It seemed as if prolonged unilateral gum chewing and previous pain-releasing MVC caused some sensitization of muscle nociceptors which, in turn, aggravated subsequent isometric jaw muscle pains elicited through MVC. Even though the right masseter muscle was the most frequent site of clinical fatigue and pains, the authors found no evidence supporting the theoretical foundation of the myofascial pain/dysfunction syndrome.

Role of saliva in caries models

The crucial role played by the actions of saliva in controlling the equilibrium between de- and remineralization in a cariogenic environment is demonstrated by the effects on caries incidence of salivary dysfunction and by the distribution of sites of caries predilection to those were salivary effects are restricted. However, of the several properties of saliva which may confer protective effects, it is not certain which are most important. A distinction can be made between static protective effects, which act continuously, and dynamic effects, which act during the time-course of the Stephan curve. Evidence implicates salivary buffering and sugar clearance as important dynamic effects of saliva to prevent demineralization; of these, the buffering of plaque acids may predominate. Enhanced remineralization of white spot lesions may also be regarded as dynamic protective effects of saliva. Fluoride in saliva (from dentifrices, ingesta, etc.) may promote remineralization and (especially fluoride in plaque) inhibit demineralization. The design of experiments using caries models must take into account the static and dynamic effects of saliva. Some models admit a full expression of these effects, while others may exclude them, restricting the range of investigations possible. The possibility is raised that protective effects of saliva and therapeutic agents may act cooperatively.

Computer modeling of the effects of chewing sugar-free and sucrose-containing gums on the pH changes in dental plaque associated with a cariogenic challenge at different intra-oral sites

Variation in salivary access to different intra-oral sites is an important factor in the site-dependence of dental caries. This study explored, theoretically, how access is modified by chewing sugar-free and sugar-containing gums. A finite difference computer model, described elsewhere, was used. This allowed for diffusion and/or reaction of substrate, acid product, salivary buffers, and fixed-acid groups. Site-dependent saliva/plaque exchange was modeled in terms of a 100-microns-thick salivary film covering the plaque (a) flowing directly from the salivary ducts, (b) flowing from the intra-oral salivary pool, or (c) exchanging with the pool. Computed flow-velocities or rates of exchange were based on previous intra-oral measurements. The model was also tested against an in vitro study conducted by two of the authors. In addition, the three proposed models of saliva/plaque interaction were compared, and the effect of salivary film thickness investigate. Results suggested that: (1) although sugar-free gum chewed during a cariogenic challenge causes a rapid rise in plaque pH, sucrose-containing gums cause the pH, after a temporary rise resulting from increased salivary flow, to stay low for an extended period; (2) the computer model reproduced in vitro tests reasonably well; (3) although the three models of the plaque/saliva interaction start from different assumptions, two lead to closely related predictions; and (4) increasing the assumed salivary film thickness by a large amount (e.g., from 50 to 200 microns) caused no change in modeled Stephan curves, as long as these changes were accompanied by appropriate reductions in film velocity, in accord, theoretically, with the practical clearance data.

The flow rate and electrolyte composition of whole saliva elicited by the use of sucrose-containing and sugar-free chewing-gums

On two occasions, 12 adults collected unstimulated saliva and then eight samples of saliva over a 20-min period while chewing 3 g of either Wrigley's Spearmint sucrose-containing gum (SCG) or sugar-free gum (SFG) at 70 chews/min. The flow rates peaked initially, then fell with duration of stimulation. With the SFG they were slightly but significantly higher than with the SCG after 4 min of chewing. The sum of the concentrations of cations minus the sum of the concentrations of anions was not significantly different from zero for saliva elicited by the SCG. However, for unstimulated saliva and that elicited by SFG, there was a slight positive anion balance. A second series of saliva collections with SCG and SFG was made by the same 12 participants and these samples were analysed for lactate. For these collections the flow rates with SCG were not significantly less than with the SFG. The lactate concentration in saliva elicited by SCG peaked at 1.82 mmol/l in samples collected over 8-15 min, whereas samples of saliva elicited by SFG had a mean lactate concentration of 0.21 mmol/l. Of the lactate formed during the metabolism of sucrose by the oral bacteria, only 2% or less appeared to be derived from the metabolism of micro-organisms free in saliva, the balance presumably being formed in dental plaque and entering the saliva by diffusion. All saliva samples were supersaturated with respect to hydroxyapatite but stimulated saliva was significantly more supersaturated than unstimulated saliva.(ABSTRACT TRUNCATED AT 250 WORDS)

Chemical generation of nitric oxide in the mouth from the enterosalivary circulation of dietary nitrate

High concentrations of nitrite present in saliva (derived from dietary nitrate) may, upon acidification, generate nitrogen oxides in the stomach in sufficient amounts to provide protection from swallowed pathogens. We now show that, in the rat, reduction of nitrate to nitrite is confined to a specialized area on the posterior surface of the tongue, which is heavily colonized by bacteria, and that nitrate reduction is absent in germ-free rats. We also show that in humans increased salivary nitrite production resulting from nitrate intake enhances oral nitric oxide production. We propose that the salivary generation of nitrite is accomplished by a symbiotic relationship involving nitrate-reducing bacteria on the tongue surface, which is designed to provide host defence against microbial pathogens in the mouth and lower gut. These results provide further evidence for beneficial effects of dietary nitrate.

Effect of xylitol-containing chewing gum on sorbitol metabolism in dental plaque

The aim of the present study was to examine whether a long-term use of chewing gum with xylitol as the only sweetener would affect sorbitol metabolism in dental plaque. Ten test subjects used xylitol-sweetened chewing gum for 12 weeks. Plaque was collected at three occasions; 1) Control plaque; 2) Test plaque I: plaque collected after 12 weeks of chewing xylitol-containing chewing gum; 3) Test plaque II: sucrose-stimulated plaque collected 2 d after Test plaque I was collected. Plaque suspensions were incubated with [14C]sorbitol, and uptake of sorbitol and production of sorbitol metabolites were determined by HPLC. Plaque formation and sorbitol uptake were significantly reduced.

The effect of amoxycillin on salivary nitrite concentrations: an important mechanism of adverse reactions?

Broad spectrum antibiotics are known to predispose towards oral candidiasis and gastroenteritis. Oral nitrite synthesis by commensal bacteria may be important in protecting the mouth and lower intestine from pathogenic organisms, including Candida albicans. The effect of 2 days administration of the broad spectrum antibiotic amoxycillin on salivary nitrite concentration, following a 200 mg potassium nitrate oral load, was studied in 10 healthy volunteers. The Cmax fell by 40% and the AUC was reduced by 1227 microM h (43%, 95% CI 273, 2181, P < 0.006) in the antibiotic treated group when compared with control. These findings suggest that destruction of nitrate reductase containing bacteria in the mouth by antibiotics may explain an increased incidence of infection with Candida and other pathogens.

Does the presence of xylitol in a sorbitol-containing chewing gum affect the adaptation to sorbitol by dental plaque?

It is known that xylitol inhibits sorbitol metabolism in some bacteria in vitro. The effect of xylitol/sorbitol-containing chewing gum on sorbitol adaptation of dental plaque was therefore examined. Ten subjects used this chewing gum for 12 wk, and plaque was collected before (control plaque) and after (test plaque) the exposure to sorbitol/xylitol. The metabolism of sorbitol by the plaque was examined with 14C-labeled sorbitol, and the radioactive metabolites were detected by high-performance liquid chromatography (HPLC). A considerable individual variation in acid formation was found. The mean values of total acids in the test plaque increased, as compared with the control plaque. An adaptation of dental plaque to sorbitol thus occurred in spite of the presence of xylitol in the chewing gum. The concentration of acetic acid predominated over other acids in both the control and test plaques. The proportions of acids expressed in percentage of total acids differed only slightly. Thus, long-term use of xylitol/sorbitol-containing chewing gum did not eliminate the adaptation of dental plaque to sorbitol.

Saliva stimulation and caries prevention

The protective role of saliva is demonstrated by the rampant caries seen in human subjects with marked salivary hypofunction, and in desalivated animals. In normal cases, however, the relationship between saliva flow and coronal or root caries experience is doubtful, and to examine the concept that stimulation of saliva might have protective effects against caries, one must look beyond a simple correlation between caries and flow rate. Protective properties of saliva which increase on stimulation include salivary clearance, buffering power, and degree of saturation with respect to tooth mineral. These benefits are maximized when saliva is stimulated after the consumption of fermentable carbohydrates, by reducing the fall in plaque pH leading to demineralization and by increasing the potential for remineralization. Plaque acid production is neutralized, and experimental lesions in enamel are remineralized, when gum is chewed to stimulate saliva after a carbohydrate intake. The pH-raising effects are more easily explained by the buffering action of the stimulated saliva than by clearance of carbohydrates. The remineralization action depends upon the presence of fluoride. These findings suggest that the protective actions of saliva can be mobilized by appropriate salivary stimulation, and that in addition to established procedures such as tooth cleaning and fluoride regimens, eating patterns which lead to saliva stimulation to increase the potential for saliva protection might be included in recommendations for caries prevention. Confirmation of this concept in clinical tests is required.

Microbial ecology of dental plaque and its significance in health and disease

Dental plaque forms naturally on teeth and is of benefit to the host by helping to prevent colonization by exogenous species. The bacterial composition of plaque remains relatively stable despite regular exposure to minor environmental perturbations. This stability (microbial homeostasis) is due in part to a dynamic balance of both synergistic and antagonistic microbial interactions. However, homeostasis can break down, leading to shifts in the balance of the microflora, thereby predisposing sites to disease. For example, the frequent exposure of plaque to low pH leads to inhibition of acid-sensitive species and the selection of organisms with an aciduric physiology, such as mutans streptococci and lactobacilli. Similarly, plaque accumulation around the gingival margin leads to an inflammatory host response and an increased flow of gingival crevicular fluid. The subgingival microflora shifts from being mainly Gram-positive to being comprised of increased levels of obligately anaerobic, asaccharolytic Gram-negative organisms. It is proposed that disease can be prevented or treated not only by targeting the putative pathogens but also by interfering with the processes that drive the breakdown in homeostasis. Thus, the rate of acid production following sugar intake could be reduced by fluoride, alternative sweeteners, and low concentrations of antimicrobial agents, while oxygenating or redox agents could raise the Eh of periodontal pockets and prevent the growth and metabolism of obligately anaerobic species. These views have been incorporated into a modified hypothesis (the "ecological plaque hypothesis") to explain the relationship between the plaque microflora and the host in health and disease, and to identify new strategies for disease prevention.

An in vitro stimulation of the effects of chewing sugar-free and sugar-containing chewing gums on pH changes in dental plaque

The objective of these studies was to simulate the effect of chewing sugar-free and sucrose-containing chewing gums on the return of the pH to neutrality after exposure to sucrose of plaque located on the buccal (BLM) and lingual (LLM) surfaces of the lower molar teeth. In study 1, a 0.5-mm-deep artificial plaque containing Streptococcus oralis cells was exposed to 10% sucrose for one min, and a 0.1-mm-thick film of sucrose-free artificial saliva was then flowed over the plaque surface at the unstimulated salivary film velocities previously found at the BLM and LLM sites. At the time of the pH minimum (pH 4-5), one of three conditions was simulated: (a) a no-gum-chewing control, or chewing for 20 min on either (b) a sugar-free gum or (c) a sucrose-containing gum. The recovery of the plaque pH to resting values was rapid during simulation of chewing a sugar-free gum (SFG), much slower with the no-gum control, and even slower with simulation of chewing a sucrose-containing gum (SCG). The pH recovery was slower with the BLM than the LLM plaque. In study 2, the BLM plaque was exposed to a 2% sucrose solution for 20 min under stimulated salivary conditions, to simulate the consumption of a meal, followed by one of conditions (a), (b), or (c) described above. The pH recovery with simulation of chewing a SCG was faster than with the no-gum control, but much slower than with the SFG simulation.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of chewing-gum stick size and duration of chewing on salivary flow rate and sucrose and bicarbonate concentrations

The objectives were to determine (1) the relations between salivary flow rate and the sample weights of chewing-gum and gum base, (2) whether any reduction in salivary flow rate with duration of chewing is due to a reduction in hardness of gum base with chewing, and (3) the sucrose and bicarbonate concentrations in saliva elicited by different weights of chewing-gum containing sucrose. Ten subjects chewed, for 20 min, samples of 1, 2, 3, 6 and 9 g of gum base and of a sucrose-containing chewing-gum. With each sample, salivary flow rates peaked initially and then fell to a relatively constant value. Flow rates during the periods of 1-2 and 15-20 min were linearly related to the logarithm of sample weight. With the chewing-gum samples, virtually all the sucrose was released into the saliva during the 20 min of chewing, with peak concentrations (201-666 mM) at 1-2 min, and bicarbonate concentrations were higher with the 9-g than the 3-g samples. Six subjects chewed 3 g of gum base and within 45 min the weight of base had increased to 122% of the original, presumably due to the uptake of saliva. The hardness of gum base was determined at 21 and 36 degrees C, 21 and 36 degrees C after it had been chewed, and 21 degrees C after it had been chewed without exposure to saliva, and gave Brinell values of 0.277, 0.038, 0.022, 0.002 and 0.061, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The distribution of saliva and sucrose around the mouth during the use of chewing gum and the implications for the site-specificity of caries and calculus deposition

Over a 20-minute period, subjects expectorated 8 samples of whole saliva (EWS) while chewing gum. Flow rates were calculated, and sucrose was analyzed in these samples as well as in saliva collected on filter paper strips from different tooth surfaces. Salivary film velocity (SFV), based on a 0.1-mm-thick film, was estimated from the clearance half-times of KCl in agarose disks positioned in different regions of the mouth. Salivary flow rate peaked at 5.1 mL/min in the first min but fell to about 1.25 mL/min by the end of the 20 min of gum-chewing. In contrast, flow rate when subjects sucked sour lemon drops averaged about 5.3 mL/min throughout the 20-minute period. The mean salivary sucrose concentration during gum-chewing peaked in the second min at 384 mmol/L (13.1%) but had fallen to 14 mmol/L by the 15-20-minute time interval. The sucrose concentrations on the palatal surfaces of the upper incisors and the facial and lingual surfaces of the lower molars were not significantly different from that in EWS but were much lower on the facial surfaces of the upper incisors and molars, and on the lingual surfaces of the lower incisors. When flow was unstimulated, SFV was 0.8-1.0 mm/min on the facial surfaces of the upper incisors and lower molars but about 5-8 mm/min on the facial surfaces of the upper molars and on the lingual surfaces of the lower incisors and molars.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of chewing gum use on in situ enamel lesion remineralization

Two independent cross-over studies investigated the possibility of enhanced early enamel lesion remineralization with the use of chewing gum. The first study involved a sorbitol-containing chewing gum, and the second, which had an identical protocol, tested a sucrose-containing chewing gum. In each study, 12 volunteers wore in situ appliances on which were mounted enamel sections containing artificial caries lesions. Subjects brushed twice daily for two min with a 1100-ppm-F (NaF) dentifrice (control and test) and in the test phase chewed five sticks of gum per day for 20 min after meals and snacks. Microradiographs of the enamel lesions were made at baseline and at the end of the seven-week experimental period. In the sugar-free gum study, the weighted mean total mineral loss (delta z) difference [(wk7-wk0) x (-1)] was 788 vol.% min. x micron for the gum, corresponding to remineralization of 18.2%, vs. the control value of 526 vol.% min. x micron, 12.1% remineralization (p = 0.07). There were no significant differences for the surface-zone (p = 0.20) and lesion-body (p = 0.28) values. In the sucrose-containing gum study, the delta z difference was 743 vol.% min. x micron for the gum, corresponding to a remineralization of 18.3%, vs. the control value of 438 vol.% min. x micron, 10.8% remineralization (p = 0.08). The surface-zone values were not significantly different (p = 0.55). For the lesion body, however, the sucrose-containing gum value of 6.11 vol.% min. was significantly different (p = 0.01) from that of the control (2.81 vol.% min.).

Migration of erythrosin-labelled saliva during unilateral chewing in man

The aim was to monitor the distribution of erythrosin-labelled saliva around the mouth during normal, unilateral chewing on gum. Thirty-one subjects chewed chewing-gum containing erythrosin on the preferred side for 5 min. The mouth was examined and the distribution of the dye recorded on standardized charts. The dye was present mainly ipsilateral to the chewing side. Although the dye did cross the mid-line, it was rarely present in the contralateral premolar and molar regions.

The effect of increased mastication by daily gum-chewing on salivary gland output and dental plaque acidogenicity

The effect of increased mastication on plaque metabolism and salivary gland function was determined in 11 human subjects who chewed a sugarless gum for ten minutes of each waking hour for two weeks. Prior to and at the conclusion of the gum-chewing regimen, unstimulated whole saliva and 2% citric-acid-stimulated parotid saliva were collected. Flow rates, pH, and buffer capacity were determined on all saliva samples. In addition, parotid saliva was analyzed for protein concentration and the proteins further studied by SDS-PAGE. The plaque pH response to a 10% sucrose rinse was also measured before and after the regimen. Significant increases were observed in the pH and buffer capacity of unstimulated whole saliva as were similar increases in the flow rate, pH, and buffer capacity of stimulated parotid saliva. Protein concentrations and profiles remained unaffected. In addition, the resting plaque pH and minimum plaque pH reached after a sucrose challenge were both raised significantly, with a significant reduction in the cH area. The results of this study indicate that increased masticatory effort by frequent consumption of sugar-free chewing gum over a prolonged time period resulted in a functional increase in the output of stimulated parotid saliva, as well as in increases in pH and buffer capacity of whole and parotid saliva, which may help to reduce plaque acidogenicity.

The effect of a chewing gum on salivary secretion, oral mucosal friction, and the feeling of dry mouth in xerostomic patients

A new chewing gum (PTC) with the ability to release flavoring substances for a rather long time was tested for its ability to stimulate saliva secretion. The chewing gum is mildly flavored and contains non-cariogenic sweeteners (xylitol and sorbitol). Measurements of saliva secretion rate and oral mucosal sliding friction and subjective evaluations on visual analog scales were made in relation to chewing and compared with those when chewing a commercially available gum (V6). The study was a randomized, crossover comparison with blind evaluation. Both chewing gums stimulated saliva secretion and decreased oral mucosal friction. The PTC gum gave consistently higher mean values of saliva secretion rate and lower oral mucosal friction values than V6. The difference was statistically significant for the saliva secretion rate and most pronounced after 5-10 min of chewing. There was also a statistically significant difference between the subjective evaluations of V6 and PTC with regard to saliva-stimulating ability and taste in favor of the PTC gum.

Effects of salivary bicarbonate content and film velocity on pH changes in an artificial plaque containing Streptococcus oralis, after exposure to sucrose

Chewing-gum stimulation of salivary flow (at the time of the pH minimum following exposure of plaque to carbohydrate) has been shown to cause a rapid increase in plaque pH. The objective of this study was to determine whether the rise in plaque pH is primarily due to the increased buffering capacity of stimulated saliva, or to the fact that an increased flow rate increases the concentration gradient for acid to diffuse from the plaque into the overlying salivary film, which will be moving at a higher velocity. This was investigated with an in vitro technique in which artificial plaque (0.5 or 1.5 mm deep) containing S. oralis cells was exposed to 10% sucrose for one min. The pH values at the proximal and distal undersurfaces of the plaque were then monitored during the passage of a 0.1-mm-thick film of a sucrose-free artificial saliva over the surface, at a range of film velocities (0.8-8 mm/min) that have been estimated to occur in vivo. When a minimum plaque pH had been achieved, the salivary film velocity was either (a) kept the same, with or without 15 mmol/L HCO3 (the concentration measured in chewing-gum-stimulated saliva), (b) increased to 86.2 mm/min, or (c) increased to 86.2 mm/min with 15 mmol/L HCO3 added to the artificial saliva. The findings suggest that after sucrose ingestion, the rapid rise from minimum plaque pH values, which can occur with gum-chewing stimulation of salivary flow, is due to the combined effects of the increase in salivary film velocity, and of a greater availability of bicarbonate.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of chemically modified starches in suspensions and lozenges on pH of human dental plaque

The aim was to evaluate chemically modified starches (CMS) from a cariologic point of view as alternatives to gum arabic in sugar-free lozenges. Two commercial CMS, Purity Gum 40 and Capsul, were selected due to their comparatively low availability to alpha-amylase in vitro. Both gelatinized CMS suspensions and lozenges were tested in vivo by measuring plaque pH. The results showed that suspensions of Purity Gum 40 or Capsul were less available to alpha-amylase in vitro than the soluble starch reference. However, the initial phase of amylolysis was comparatively rapid also with CMS. In spite of the slower rate of hydrolysis, suspensions of the two CMS reduced pH of dental plaque in vivo to the same extent as soluble starch, but somewhat less compared with glucose. Lozenges with Purity Gum 40 also lowered plaque pH, although less than when administered as a precooked suspension. The most prominent pH drop was found with a lozenge containing Purity Gum 40-sucrose-glucose, while tablets with gum arabic-maltitol and pectin-gelatine-Lycasin somewhat increased the pH values. To conclude, it is not recommended to exchange gum arabic for CMS in sugar-free lozenges, since the cariogenic properties of the products are negatively affected.