Tooth Remineralization Protocol

Every dentist/hygienist has had a patient that you know had braces not by how straight their teeth are, but by those little white, chalky demineralized spots on their teeth.  I often wondered, why didn't the orthodontist do something about that in the first place?  Then I look at the patient's plaque control without braces, and realize the ball is in my court now!  That is why I have tried to implement a tooth remineralization protocol. Dr. Ellie Phillips is the daughter of one of my patients, and she wrote a book called Kiss You Dentist Goodbye.  I read her book about a year ago, and it really inspired me to look deeper into remineralization of teeth.  She gave some excellent points, and some not so good points, but all in all it is a very good read.  She visited my office not too long ago when she was in town to see her mother.  At the end of her book she spelled out a patient care plan that included rinsing with a fluoride mouthwash BEFORE you brush.  She felt that acids throughout the day had weakened the outer tooth structure enough for the toothbrush to remove the outer surface when brushing.  She also felt that using a fluoride containing mouthwash before brushing would sufficiently harden this weakened enamel enough to help prevent it from damage.  I am personally not aware of how many seconds it would take to have a fluoride mouthwash harden a days worth of acid erosion on the outside of your teeth, but if you think about it, it makes sense to at least try and harden it before brushing your teeth.  One of the points I did not like in her book was her view on flossing. In the book, I felt it came off like she didn't promote flossing at all, but after talking with her I understood it was more that she didn't want to discourage non-flossers from following her plan.  Flossing is good if you do it correctly, and do not damage your gingiva (gums).  Unfortunately, and I had to agree with her, most patients do not floss correctly in the first place.  They just pop the floss through the contacts as fast as possible. They do not push the floss against one tooth and then pull it against the other to cut the accumulated plaque. Just pop, pop, pop, and your done! Next Dr. Ellie instructs to brush your teeth thoroughly. She promotes her own website's toothbrush, but as long as the bristles are soft, and the toothbrush head is not too large to reach all the surfaces of the teeth, then I don't think it really matters which brand you use.  The toothpaste she wants you to use is the simplest formula possible with fluoride, like original Crest. After brushing she wants you to use TWO different mouthwashes.  The first post-brushing mouthwash is the antiseptic Listerine.  The second is a sodium fluoride mouthwash ACT. One kills germs but is acidic (melts your teeth), and the other strengthens your teeth. I have to admit, I'm not really crazy about this process.  Many points are good and should be followed, but others, not so much.  I actually like the part about a pre-rinse with fluoride mouthwash.  I do want my patient to floss even though most do not do it correctly.  If they get used to flossing, who is to say that with a little training from one of our office's excellent hygienists, they would not do it better?  There are many advanced toothpastes on the market today that contain more than just fluoride that can be used for remineralization.  The one I recommend and have been using myself is Sultan's Topex Renew toothpaste.  It has a new formula containing NovaMin that has proven to remineralize tooth structure very well. Listerine?  No way!  I don't care if it received the ADA seal of Approval, I don't like it. Kills bacteria by the million, it does, but that is not important if you brush and floss. Beside, doing so will kill off your normal good bacteria and leave room for the bad guys to grow.  There is nothing wrong with ACT mouthwash. All of these "Oral Hygiene Plans" made me want to come up with my own protocol:

Cape Dental Care Remineralization Protocol:

  • Brush your teeth in the morning with Smart Mouth® fluoride toothpaste and rinse with Smart Mouth® mouth wash (for 12 hours of fresh breath).
  • Eat a xylitol mint or chewing gum after each meal or shack (at least 5 exposures per day)
  • Before going to bed:
  • Take any prescription medications you normally take before bedtime with water
  • Scrape your tongue with a tongue scraper if you have one.
  • Rinse with PerioMed fluoride mouthwash (Rx strength from your dental office)
  • Floss.  Use a proxibrush and floss threaders if you have been instructed to so by your hygienist/doctor
  • Brush with a soft toothbrush using Sultan's Topex Renew toothpaste (Rx strength from your dental office)
  • Chew a xylitol mint or sprinkle some xylitol into your mouth
  • Use a pea sized amount of MI Paste on your finger and then wipe it onto your tongue.  Use your tongue to spread the paste over all your teeth
  • Go to bed!
What do you think?  I think that covers just about every base.  Not everyone needs to follow this protocol, but if your dentist told you you have demineralization on your teeth then follow this and be rewarded with stronger teeth!

References:

1. IN VITRO EVALUATION OF CASEIN PASTE CYTOTOXICITY – MI PASTE. SK. Bussadori, FERNANDES KPS, GUEDES CC, MARTINS MD, SANTOS EM 2. Casein Phosphopeptide-Amorphous Calcium Phosphate Paste: Root Surface Caries Formation. J. HICKS, Baylor College of Medicine, Houston, TX, USA, and C. FLAITZ, University of Texas - Houston / Health Science Ctr, USA 3. The Effects of Casein-Phosphopeptide-Amorphous-Calcium-Phosphate Paste on Plaque Calcium and Phosphate. C. AMORNPIPITHKUL, S. SANGUANSIN, and P. LEELATAWEEWUD, Mahidol University, Bangkok, Thailand 4. Dentine Bonding Following Casein Phosphopeptide Amorphous Calcium Phosphate Paste ApplicationO. ADEBAYO, M. BURROW, and M. TYAS, University of Melbourne, Melbourne VIC, Australia 5. Amorphous Calcium Phosphate-Casein Phosphopeptide Paste: Effect on Enamel Caries FormationJ. HICKS, Baylor College of Medicine, Houston, TX, USA, and C. FLAITZ, University of Texas Dental Branch - Houston, USA 6.  CPP-ACP Paste and ACP-Fluoride Varnish: In Vitro Root Caries. F. GARCIA-GODOY, C.E. GARCIA-GODOY, C.M. FLAITZ, and J. HICKS, Nova Southeastern University, Fort Lauderdale, FL, University of Texas - Houston/Health Science Center, Houston, TX, Baylor College of Medicine, Houston, TX 7. Effect of Argon Laser and Remineralizing Paste on Root Caries. G. WESTERMAN, Creighton University Medical Center School of Dentistry, Omaha, NE, C. FLAITZ, University of Texas Houston/Health Science Center, Houston, TX, G. POWELL, University of Utah, Salt Lake City, UT, and J. HICKS, Baylor College of Medicine, Houston, TX 8. Effect of CPP-ACP Paste and Fluoride Gel on Eroded Enamel. U. KALLAYATHI, M. PANICH, and S. POOLTHONG, Chulalongkorn University, Bangkok, Thailand 9. SEM evaluation of casein phosphopeptide-amorphous calcium phosphate-treated and conditioned enamel. O. ADEBAYO, M. BURROW, and M. TYAS, University of Melbourne, Melbourne VIC, Australia 10. Resin Bonding to Dentine After Casein Phosphopeptide-Amorphous Calcium Phosphate TreatmentsV. SATTABANASUK, M. BURROW, Y. SHIMADA, and J. TAGAMI, Srinakarinwirot University, Bangkok, Thailand, University of Melbourne, Melbourne VIC, Australia, Tokyo Medical & Dental University, Tokyo, Japan 11. Argon Laser and Remineralizing Paste Effect on Root Surface Caries. G. WESTERMAN, Creighton University Medical Center School of Dentistry, Omaha, NE, USA, J. HICKS, Baylor College of Medicine, Houston, TX, USA, C. FLAITZ, University of Texas Houston / Health Science Ctr, USA, and G. POWELL, University of Utah, Salt Lake City, USA 12. Remineralization Potential of Casein Phosphopeptide-Amorphous Calcium Phosphate---- Confocal Microscopy Study E.C. KAO1, S. HODNETT2, P. NGAN1, C. MARTIN1, and E. GUNEL3, 1West Virginia University School of Dentistry, Morgantown, WV, 2private practice, Morgantown, WV, 3West Virginia University, Morgantown, WV 13. CPP-ACP Paste with Fluoride: In Vitro Root Surface Caries Formation C.P. TRAJTENBERG, University of Texas - Houston/Health Science Center, USA, C. FLAITZ, University of Texas Houston / Health Science Ctr, USA, and J. HICKS, Baylor College of Medicine, Houston, TX, USA 14. Remineralization of Eroded Teeth Using CPP-ACP Paste A. HUANG, and D. TANTBIROJN, University of Minnesota, Minneapolis, USA 15. Artificial Caries Inhibited with MI Paste and Two Restorative Materials S. WRIGHT, J.O. BURGESS, L.C. RAMP, and P. BECK, UAB School of Dentistry, Birmingham, AL, USA 16. Effect of CPP-ACP Paste on Demineralization of Bovine Tooth T. TAKAMIZAWA1, K. YAMAGUCHI1, M. MIYAZAKI1, K. HINOURA2, and B.K. MOORE3, 1Nihon University, Tokyo, Japan, 2Hinoura Dental Clinic, Tokyo, Japan, 3University of Indiana - Indianapolis, USA 17. COMPARISON OF TOOTH MOUSSE (MI PASTE) WITH CLINPRO IN SITU E. REYNOLDS, F. CAI, P. SHEN, G. WALKER, Y. YUAN, N. COCHRANE, D. MANTON, and C. REYNOLDS, Oral Health CRC, Melbourne Dental School, University of Melbourne, Melbourne, Australia 18. Remineralization of Artificial Caries by CPP-ACP Paste U. THEERAPIBOON, R. PUANAIYAKA, and C. MANEENUT, Chulalongkorn University, Bangkok, Thailand 19. Incorporation of Casein Phosphopeptide-Amorphous Calcium Phosphate into a Temporary Cement R. WONG1, J. PALAMARA2, and P.R. WILSON2, 1Cooperative Research Centre for Oral Health, University of Melbourne, Melbourne, Australia, 2University of Melbourne, Australia 20. CALCIUM-CONTAINING REMINERALIZING GEL AND PASTE EFFECTS ON ROOT CARIES J. HICKS, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, and C. FLAITZ, Department of Diagnostic Sciences, University of Texas at Houston, Houston, TX 21. Preventing Acid Induced Enamel Demineralization Using CPP-ACP Containing Paste Y. SAKAGUCHI, S. KATO, T. SATO, S. KARIYA, and L. CHEN, GC corpolation, Tokyo, Japan 22. Enamel Hardening Properties of Two Dental Pastes V.J. SETIEN, M. KOIKE, P. RAGHUNATH, and K. AJLOUNI, Baylor College of Dentistry, Dallas, TX 23. In-vitro Remineralization Effect of Calcium-Containing Pastes in Enamel Lesions T. SMITH, M. FONTANA, and C. GONZALEZ-CABEZAS, Indiana University School of Dentistry, Indianapolis, IN 24. INSTANT/LASTING DENTIN HYPERSENSITIVITY REDUCTION EFFICACY OF TWO PROFESSIONALLY-APPLIED DESENSITIZING PASTES Y. LI1, S. LEE1, E. DELGADO2, Y.P. ZHANG2, W. DE VIZIO2, and L.R. MATEO3, 1Loma Linda University School of Dentistry, CA, USA, Loma Linda, CA, 2Colgate Palmolive Technology Center, Piscataway, NJ, 3LRM Statistical Consulting, Hoboken, NJ 25. Calcium-Containing Remineralizing Gel and Paste Effects on Root Caries J. HICKS, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, and C. 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