how dental caries has changed – and why it is still an ... · dental caries or cavities. as we...

How Dental Caries Has Changed Why It Is Still an EpidemicSpeaker: The information provided in this presentation is for educational and

informational purposes only. It is not a substitute for

professional medical and/or

condition. Always seek the advice

qualified health care professional for any questions you may have regarding

a medical or dental condition.

Scott: Hello, everyone! Welcome back to the Functional Oral H

Scott Saunders of Healthy with Dr. V. Kim Kutschcarries which is the technical term for cavitidental care today. Dr. Kuts

a private practice in AlbanyUniversity of Oregonpatents in dentistry. H

speaker, past President of the Academy of Laser Dentistry and World Congress of Minimally Invasive Dentistrypublications and has served on the Board of Directors for the WInstitute and for the

contributed chapterscan see why I kind of Functional Oral Health Summitshocking details about what is going on with

despite all of the advances in technology are still such a worldwide public health problem and maybe shed some light on where we can go and whfix this problem moving forward

Kim: Thanks a lot, Scott. It's

tellingone my favorite topics with you today

Scott: Yes and that topic arePowerPoint slide here todaytechnology that we have to

about dental carries Kim: Yes. You know, Scott, I think dental caries historically as a disease has been

mankind probably from the beginning

my career I've never seen

How Dental Caries Has Changed Why It Is Still an Epidemic Speaker: V. Kim Kutsch, DMD

The information provided in this presentation is for educational and

informational purposes only. It is not a substitute for – nor does it provide

professional medical and/or dental advice to diagnosis or treatment any

condition. Always seek the advice of your physician, dentist or other


a medical or dental condition.

! Welcome back to the Functional Oral Health Summit

Healthy Mouth Media.Today, it is my privilege to be talking with Dr. V. Kim Kutsch of Albany, Oregon. Dr. Kutsch is an expert in dental

which is the technical term for cavities, which are such a problem in . Dr. Kutsch is the CEO of Dental Alliance Holding

n Albany, Oregon. He completed his DMD degree at the f Oregon, School Of Dentistry and he's an inventor holding nume

patents in dentistry. He's a product consultant,internationally recognized

speaker, past President of the Academy of Laser Dentistry and World Congress nvasive Dentistry. He has authored over 90 peer-reviewed

publications and has served on the Board of Directors for the Worfor the American Academy of Cosmetic Dentistry. He ha

contributed chapters to several textbooks and his CV goes about 24 pagescan see why I kind of got to cut this short, and he is here with us today on the Functional Oral Health Summit. He's going to be giving us some fascinating shocking details about what is going on with dental caries and why cavities

the advances in technology are still such a worldwide public health problem and maybe shed some light on where we can go and whfix this problem moving forward.Welcome Kim!

. It's great to be here. I look forward to talking about my favorite topics with you today.

are dental caries or cavities. As we can see on your first PowerPoint slide here today, this is still a real problem despite alltechnology that we have to combat cavities. Why is there such concern

ries or tooth decay? Can you please walk us through that

You know, Scott, I think dental caries historically as a disease has been mankind probably from the beginning. But today, we're seeing in levels that in

never seen. The World Health Organization tracks 290 diseases

How Dental Caries Has Changed – and

The information provided in this presentation is for educational and

nor does it provide -

advice to diagnosis or treatment any

of your physician, dentist or other


ealth Summit. I'm Dr.

y privilege to be talking an expert in dental

which are such a problem in oldings. He operates

e completed his DMD degree at the holding numerous

recognized

speaker, past President of the Academy of Laser Dentistry and World Congress reviewed orld Clinical Laser

. He has

goes about 24 pages. You and he is here with us today on the

ing us some fascinating and and why cavities,

the advances in technology are still such a worldwide public health problem and maybe shed some light on where we can go and what we can do to

ard to talking about

see on your first a real problem despite allof the

h concern today

an you please walk us through that?

You know, Scott, I think dental caries historically as a disease has been with in levels that in

ization tracks 290 diseases

©2017 Healthy Mouth Media for the Functional Oral Health Summit

worldwide and dental caries or the disease that causes cavities is number one in every country in the world, and virtually, every age demographic in every

country in the world.

So this disease today is just ubiquitous. I mean everybody has deals with it. Everybody is confronted with it. So the challenge we've got, I mean it's the

number one disease in the world. Untreated decay in children, in primary teeth, is the number 10 disease in the world. So we're dealing with a disease that is really I think a function of our lifestyle, of modern man and all the things that we've done and developed in dentistry to treat tooth decay have worked

periodically from time to time. Now, I think we're facing a battle where the bacteria-- our lifestyle has changed dramatically in the last 30 years. We've added a lot of different things to our diet. Our diets changed, particularly here in

the US. So we're battling dental caries in just huge proportions. There may be some disparity in the distribution of tooth decay within our population, but certainly, we have high levels of population. Dental decay rate in

children is going up. It's been going up for last 16 years. I think we had a generation. I'm part of the baby boom generation,and my children were raised in the era of fluoride and there was a generation where fluoride was really

effective. So most of my children have never had any tooth decay, but now we're seeing their children, the next generation, are starting to experience tooth decay like we had previous to that.So it's something that I think we'd like to think that tooth decay is out of control but in reality, we're still dealing with the

disease. It's like I've never seen actually in my career. Scott: Wow! Is it fair to classify dental caries as an epidemic?

Kim: I think it's very fair to classify it as an epidemic. Thereare probably people that want to argue with that,but when you look at the decay rates that we have globally, this is certainly something that is in epidemic proportions.

Scott: Yes. I guess these findings shouldn't shock us given some of the factors that

we're dealing with, and the landmark reviewed by Kassebaum in 2015. A 2015 issue of the Journal of Dental Research, one of the highest dental journals

published and these numbers are shocking and frightening yet to me. I ran into this article doing some other research back in 2016 and it just amazed me. Are these numbers reflective of what you see in your practice?

Kim: Yes and I think every other dentist practicing in the US as well. I'm busier than

I've ever been in my career and interestingly enough, I mean you and I are from the same generation.When I was in dental school in the 1970s, they literally told

me that by the time I got to this point in my career, there willreally be very little need for dentistry because fluoride would have solved the problem of tooth decay. I think there was this huge anticipation in the profession of fluoride alone was going to be an answer.

Here I find myself 38 years later, I see more tooth decay today. I'm busier in my practice today than I've ever been in a point in time where I really figured like

we'd be winding down and have conquered this disease. The reverse is true. It's still the number one disease in the world and seems to be growing, rather than improving.So it's a challenge for all of us in the profession and for patients trying to get an understanding of what's causing that disease and how to best treat it.


Scott: Most of your time is spent restoring decayed teeth in your practice?

Kim: I think if you look statistically for every dentist, it's a number one thing that we

do in our day. We treat gum disease and the bite. We treat, restoring and replacing teeth that are missing. I'd say probably, when I first startedpractice,

the average person that was over the age of 65, many of them had no teeth. They had lost their teeth due to gum disease. So that was the primary cause of tooth loss in an adult 40 years ago.

Today, I don't think that's the case anymore. We've made so many improvements in being able to treat gum disease and manage it effectively enough for people to be able to maintain their teeth. What I see now in my

practice is that most people, adults lose their teeth from dental caries or tooth decay rather than from gum disease. So we end up spending the majority of our time either working on teeth that have previously been restored and the restorations have now worn out or failed, we have new decay around those

restorations, or it's just we have a new decay on teeth.

So it's become a real challenge, and I'd say I spend a greater part of my day

dealing with treating the rummages and the end results of this disease. We try and focus a lot during my daywith each patient individually trying to identify what's causing the disease for them and coaching them on how they can make corrections in their life, so they could become decay free and maybe decay free

for rest of their life. Scott: That would be a wonderful goal to realize, wouldn't it?

Kim: Yes. Scott: I'd like to drill into some of the causative factors for dental caries because you

do detail that as the multifactorial diseasethat it is. But before we move into that, any thoughts on why this−for lack of a better term−reversal of fortune? You mentioned your own children who grew up with fluoride from various sources and the consciousness was the fluoride was going to fix everything and

here we arefour decades later,we see that everything is not fixed. Now, caries is more of a problem than it's ever been. What factors contributed to that?

Kim: You know, Scott? That's a $64 million question. I think there are several things going on. If you look at us historically as humans over the last couple thousand years,our lifestyle has changed dramatically. Our diets changed dramatically like 2000 years ago. We went through daily and seasonal episodes of fasting. We

didn't have the access 24/7 to all the fruits andvegetables and all the food that we have available today. So certainly, our diet has changed dramatically. The bacteria that we have in our mouth and in our bodies-- I mean we're literally bacterial planets. I've heard data that as many as 90 percent of the cells in a

human body are actually bacteria cells. They help us digest our food and protect us. They're our first line of defense,and we're now beginning to learn that these bacteria actually communicate with our host cells as well. So our bodies are

talking to our bacteria. Over the last 200 years, and let's really say the last 30, 35, 40 years, American diet has changed dramatically. We’ve addedhigh fructose corn syrup in so much of our food supply and we're consuming so much sugar today.


So on one hand, we've got the same bacteria but now we're creating a totally

different environment for them because of our diet. Then we introduced fluoride into our water supply, in toothpaste and we as dentistshave gotfluoride treatments in the office. We give our patientsdifferent levels and types of fluoride to take home and use.Fluoride worked really well for a span of about a

generation, let's say.Today now, we're using higher and higher levels of fluoride, particularly on small children. Childrenat the age of fivethat we term as "severe early childhood caries," these are children that have three or more cavities before the age of three. We're treating them four times a year now in ouroffice

withfluoride varnish, which is the highest level of concentration of fluoride that we've ever used, and yet the decayseems to continue on. So it's either a function of the bacteria or learning to adapt and maybe behavein the presence

of fluoride or a function of the fluoride worked well until our diet has changed so much that it just can't account anymore from the amount of sugar and things that we see in our diet or the frequency that we eat.

I think there's a combination of things there that are going on.That's really, as we drill down into what's causing the disease for each patient, we look at those common risk factors. At the end of the day, Philip Marsh's work from Leeds

University in the UK back in the 1980s actually discovered that it wasn't the sugar availability that was causing cavities per se, but rather that the pH changes. So as soon as we consume literally anything in the mouth, the pH of our mouth drops. We start to lose some of the mineral out of our teeth when

that happens, but it's trapped in the biofilm on the surface of our teeth and then a function of the body to be healthy,our saliva has an elevated pH (it's alkaline) and it's already beginning to protect our teeth as soon as we start to eat. So over a period of 15 to 30 minutes after you've eaten something, all of the tooth

mineral that you lost is trapped right there and erase the pH from your saliva. Some of the bacteria actually, not biofilm, their role is to raise the pH as well to maintain health and that mineral goes right back into the tooth.

So you have that dynamic going on and as long as that's in balance, you're not going to get tooth decay. But I really look at this disease now-- Traditionally, the way I was trained was a pathogen causes disease. Two bacteria, specifically

mutans streptococci and lactobacillus cause disease. What we understand now is that this is really a function of pH in the mouth and those prolonged periods of low pHend up with mineral that you lose out of your teeth. Eventually, a hole

develops and then bacteria are able to invade the tooth and then that whole process of tooth decay gets started. Interestingly enough, as we're getting better and better at being able to identify the bacteria in the body and particularly in the mouth, 40 percent of the people that have a lot of tooth decay

in the United State have zero mutans streptococci in their mouths. So we're just trying look at this. This is not a pathogen-driven disease anymore. It's really a behavioral disease of the bacteria based on the environment,but it really comes down to pH at the end of the day.

Scott: I would speculate how that pH envisioned through all these other factors on the

slide. I love the slide, by the way. Talking about saliva, diet, bacteria, genetics

and probably the Uber factor as you point out (pH) and all of this, I'm gathering depends on what would be termed homeostasis or a good balance in the biofilm that you're seeing in the mouth and because of the contributions of each one of these factors, it seems that that's getting further and further out of balance and


the whole oral microbiome (which we'll get into a little bit later in the talk in a little bit greater depth) is becoming more and more out of balance. Some of our

audience members may have heard the term dysbiosis, which could be applied to a microbiome or a society of bacteria,in whatever system of the body it resides, that is out of balance or in disarray and that contributes, I'm sure, to the horrific numbers that we're seeing in terms of tooth decay.

Kim: When you look at all of the risk factors, each of these are part of that equation

for that balance or health, like you say,"the homeostasis" and keeping that biofilm functioning in a normal and healthy manner. If we were to eat like three

meals a day, we know that the pH is going to drop as soon as you eat. Within 30 minutes in a healthy mouth that has adequate saliva, the pH returns to normal and then your mouth is in balance or at rest for a period of hours before you eat

again. If you did that like three times a day and you weren't consuming high levels of sugar, you had an effective healthy diet and plenty of saliva, your risk for tooth decay is certainly diminished because of that. The factors that you see listed on the slide-- and I like this slide too. I have to written a number of papers

on dental carries and the usual suspect.

One of the challenges that we've had as we tried to create a new model for

diagnosis and treatment of this disease, we tried to create a risk assessment base model. We made it really complicated to start with. So we made it really difficult for dental practitioners to incorporate that into their practice. If you start looking at all of the risk factors and different protective factors, it gets pretty

overwhelming and confusing and the same for patients as well. So one of the things that I tried to do in the last 10 years or so is trying to simplify it so that in our practice, it is something that we can just talk about on a daily basis for the patients and something that our patients are going to understand.

So what I really began to identify in my own experience with my patients is dental caries really presents itself with three primary patterns of disease, and

then combinations of those. This data that you see is based on risk assessment forms that my patients have self-reported their risk factors on a form. These risk factors were validated by John Featherstone at UCSF in huge clinical trial of over 12,000 patients. So we know the kind of things that help drive this disease. This

data is my own personal data, and I have my patient self report these risk factors. There are a couple of reasons for that, but I want to hear from them. I want them to tell me what's wrong with them rather than me trying to convince

them that there's something wrong with them that I see, when they don't feel like they're having any symptoms.

The number one risk factor that we see, based on a report by my own patients,

is 63 percent of my patients self-report that they feellike sometime during the day or night, they have a dry mouth. Saliva is the primary protective factor, if you think about itbeing alkaline. That's nature's way of protecting our teeth, and so you start to take away some of that saliva−we'll talk about the reasons why

we lose saliva−and suddenly that's a huge issue for us.

The second is diet and that typically presents itself as either my patients are

consuming too much sugar or they're consuming it too frequently. So when we talked about having maybe three meals a day and having a period of restso your teeth could recover-- If you continue to snack all day long, youcontinue to just drop the pH and lose mineral out of the tooth. So that becomes more of a


problem. You're better off if you're going to have a 20 oz Mountain Dew. You're better off to gulpthe thing down one time, rather than sip it for six hours.

So the answer there is whatever you're drinking during the day, unless it's water, gulp, don't sip. Either they're consuming way too much sugar to begin with and I think that's almost an American phenomenaor they're eating too

frequently. When it comes to bacteria, we really look at overall bacterial load and then the behavior of the bacteria. Is the biofilm in their mouth highly active likeis it producing a lot of acid? If you create an environment from our diet and lack of saliva, those bacteria that prefer to live in an acidic environment actually

predominate in that biofilm, and then we get into that dysbiosis that you talked about.

The wild card right at the moment is genetics. When I was in school and I first graduated, I would hear patients come in and tell, "Oh, it's not my fault Dr. Kutsch. My previousdentist told me I have soft teeth." I think we'd all have that inside voice going "Yes, right. You have soft teeth." We really blamed the patient

for not taking care of their teeth, not brushing or flossing, not eating right.It's all theirfault.What we know now based on a lot of researches coming out just in the last seven years, genetics plays a major role in dental caries and much more so

than I think that we previously appreciated and from a variety of diverse factors that appear to be related to your susceptibility to tooth decay.

Well, I'm not going to go back and tell somebody they have soft teeth. I think

that certainly, the reality for us today is that genetics does play a role. That's not something that we can measure outright just yet. I think in 10,15, 20years, we may be doing a genetic scan on a patient to see if they have certain genes that we know increase their risks for tooth decay. But at the end of the day,

when you take all of these risk factors, it still comes down to pH. This is a disease that's really a dysbiosis of the biofilm in the mouth that has prolonged periods of acidic conditions that causes mineral loss from the teeth.

Scott: Yes. That is the big enchilada. Why don't we move to your next slide? Kim: Yes. So one of the things I try to do is break it into things like I tell dentists. Just

think about saliva, diet and bacteria. When I see a patient that has decay, it's just a mantra−saliva, diet and bacteria. I just go through those three risk factors for that patient and ask them questions about. Typically, with saliva if we start

there, the main reason that patients don't have enough saliva is medication-induced. Again, when I started practicing, there weren't that many patients that run medications and there were fewer medications that were routinely prescribed. Today,the PDR must weigh 30 lbs. It's hard to keep up with all the

medications that are being introduced and that patients are taking and how they affect it. But the number one issue with all prescription medications, the number one side effect is dry mouth. That's the most frequent.

This data comes from the Mayo Clinic survey in 2013. Seventy percent of Americans take at least one prescription medication perday and that is across all age demographics. So 7 out of 10 patients that walk into my office are taking at

least one prescription medication, which we know the number one side effect from is going to be to create a loss of saliva or dry mouth; Fifty percentof Americans take two or more and 20 percent take five or more medications. As we continue to create new drugs and treat the health issues that we have, one


of the side effects and I think it's contributed a lot to the decay rate that we see today is the medications that we're taking.

I would tell you too, Scott, the thing that concerns me the most. I wasn't really aware of how serious this was until recently, but looking at the data, this comes from 2013 as well. If we look at adolescents in our country, so children from 0 to

age17,we have 15 million children in the United States taking psychotropic drugs on a daily basis, either for depression, anxiety or ADHD. I just read a report yesterday on the anxiety level in our youth,because of social media and how many of them are seeking counseling. It's hardnot being teenager and then

being a teenager in the age of social media, but I was shocked at how many of these kids are taking prescription medications for this and the psychotropic drugs really create a serious issue when it comes to dry mouth.

The second thing for children is the number one disease obviously is tooth decay or dental caries. Number two is asthma. So you start giving a childantihistamines to treat the asthma. Antihistamines dry everything in the

body including the mouth. So our children today are struggling with a dry mouth and so to have children that don't have enough saliva, that's really a more recent phenomenon for us. But I think that's contributed a lot to the level of

tooth decay that we see.

The next major risk factor is diet, like we talked about before. I think the biggest challenge that I see here is just in how much sugar we consume in America. The

average American eats almost 23 teaspoons of sugar per day. One of the things I like to do whenever I'm speaking to dental audiences or even working with my patients−I already encouraged everybody to go do this−go to your kitchen, get out a Ziploc baggie and your measuring spoon. Measure out 23 teaspoons of

sugar and see what that looks like because nobody would sit down and eat 23 teaspoons of sugar, but when you realize that is what's in our food supply and the average American, that's what we consume and most of that are hidden

sugars. So many of those are in sugars and sweetened beverage. I thinkthat’s one of the major challenges that we have in the US and certainly, that's starting to happen globally as well is that amount of sugar, fluoride can't

compensate for. Then you look at high fructose corn syrup, which we introduced into our diet in the United States basically in 1981. American's are number one in the world of high fructose corn syrup at 51 lbs/person/year on average.

Interestingly, Mexico is like number two at like 32 lbs per year. So we're off the chart literally in the amount of high fructose corn syrup that we consume. Again, most of that is in the form of being added to processed foods that we're consuming.

The dietary issue today has changed a lot. Certainly, if you look at all of our health issues in terms of obesity, heart disease and diabetes and how much those have changed in the last 30 years, a lot of that goes back to a change in

some of our behaviors and diets as well.So diet is a serious issue for a lot of people. Just being able to identify what particularly about your diet may be contributing to your tooth decay, I had a patient referred to me by another

dentist out of town, and this was an adult.He'd been decay free pretty much his entire adult life. He started running marathons and suddenly, he was developing five cavities per year on average.They couldn't identify what was causing it.


So I said I need to talk to him. He was eating some of these energy drinks, but particularly there is this paste that they (runners) buy for carbohydrate load.

Well, he was consuming thislike all day long−five packages of this stuff every day. Basically, it was sugarpaste. It was like frosting. People just aren't aware of what it is they're consuming or how that might affect their decay rate.

So it might just be for many patients, just one thing that they're doing wrong that's tipped the balance off the scale as causing their tooth decay. Just being able to identify what that is, rather than just grill and fill, correcting the source of the problem then we can help patients get back to their health.

Scott: So what you're describing, Kim sounds like a true functional medicine approach

to oral health and getting it into the route or the cause, the etiology if you will,

of dental caries. From what you're saying, it sounds like you're putting that into practice and actually trying to get to the root of what is causing decay in specific patients in your practice. Now, can we talk about getting to the root cause of what's causing dental caries in your patients? You said awhile back that you

were doing specific testing or asking focused questions of your patients, as to what they're doing with their diet and with other lifestyle variables. You talked about the one person who had a very good record and very few cavities, became

a marathon runner and then all of sudden, he started getting five new cavities per year and it turned out that he was using this marathoner's paste (carbohydrate loading) and keeping this paste in his mouth to ostensibly keep his energy level up while he was running marathons. It came to light that this

was very likely what was causing his negative turnaround and starting to develop cavities again.

What I like to tell my viewers and my audience members with the books that I'm

writing, blog posts and whatnot is that you should forever be reading ingredient list, which I think people in the US are gradually getting a hang of doing that. But looking at ingredient and this particular person probably would have found

some ingredients in his marathon energy paste or whatever name it went by that enhanced the stickiness of the biofilm in his mouth and probably a very high sugar or even high fructose corn syrup content tipping the microbiome into dysbiosis at a very low pH,very acidic environment. That is one success story

where you have managed to get to the root of what is causing tooth decay. You talked about implementing a program in your practice where if you see

someone with the decay problem, you try to ascertain what is causing it and this is very aproposbecause we're talking about functional medicine/functional oral health. Functional medicine, of course being focused on identifying and fixing or modifying the root causes of disease rather than just treating symptoms, which

unfortunately is probably 80 to 90 percent of what medicine and dentistry do today.Can you talk a little bit more about getting to the root cause of tooth decay with patients in your practice?

Kim: Yes. So this philosophy of care wasI thinkgrounded by Dr. John Featherstone and Doug Young, probably 16 to 17years ago. I got involved at that point in time because just looking for answers to my patients and continuing the IDK, I came

to a realization that what I was trained to do restoratively in dental school, if it worked it would work, and patients would start gettingcavities. Unfortunately, it didn't work. All I was really doing was just treating those symptoms. So I really started looking for answers on how do we help this patient. I want to cure their


disease. I want to treat the disease, not the symptoms.

So I got involved with this movement and the acronym we used is CAMBRA, which is Caries Management by Risk Assessment. We started with this risk assessment base model trying to identify what's causing this disease. So we do that with a risk assessment form.Those have taken a lot of different formats

through the years and there are several of those that are available to practitioners. Certainly, important for everyone to understand, the risk assessment form is really, of those risk factors that we talked about, primarily saliva, diet, bacteria and genetic, trying to identify for that individual patient

what it is in their life that's causing their disease. If I can identify that and get that part then at least they have the information they need to be able to do something about that and make that change in their life so that they can

become healthy.

If you look at it really, it is functional medicine in terms of trying to get to the root cause and make those changes. If you don't have that answer, then you

don't really have a diagnosis and all you're doing is just treating symptoms. You'll be treating symptoms with this disease. I tell patients, you'll be drilling and filling until you run out of teeth or die. So it's really functional. We can

figure out what exactly it is causing their problem. Then I can help coach the patient on what kind of changes that they could make and other patients that had the same experience did to become successful in their own lives. I guess it's an opportunity, at least to focus on treating the disease.

Scott: Just to back up for a minute, these risk assessment forms, that's how you came

up with the numbers in one of the previous slides here−the usual suspect slide?

Kim: Yes. Correct. Scott: Okay. So we've got diet. We've gotthis huge sugar and high fructose corn syrup

consumption here in the US. Then we move to bacteria and that would be your next slide. That also amazed me, that there are over 54 bacteria now identified as potential cariogens or cavity-causing bacteria. Appropriately enough, the most recent one, propionibacterium acidifaciens. Acidifaciens, for those of you

who are Latin scholars, literally translates into acid making. So it's sad and funny at the same time. Ironic, I guess, is the word I'm looking for.

Kim: Yes. Interestingly,we started−when I was trained−looking at two primary pathogens in. That's a disease model that is so antiquated that we really need to let go of it and yet, so many in the profession are still hanging on to that old disease model when we know that 40 percent of people with this disease don't

even have mutans streptococci in their mouth at all. The challenge isn't just anymore looking at-- We've spent the last 20 years trying to identify the pathogen and then maybe create a vaccine or maybe we're able get rid of this one particular bad player out of the biofilm. This isn't a disease that's going to

work that way because it's really about the behavior of the biofilm. It's really about the dysbiosis and that biofilm becoming acidic. If you still got all of the supporting factors, maybe the diet, lack of saliva or whateverthat arestill

creating or favoring acid loving bacteria,you cantake one player out and it's going to be replaced by another acid-loving bacteria.

So the real question that we're looking at today is not which particular bacteria


there but what is really the output of the biofilm itself. We want to look at the metabolic behavior of the output of the biofilm. Those bacteria share genes

easily and between each other, and so we're really looking at which genes are present. That's probably more appropriate than actually which specific bacteria but at the end of the day, we really need to know like what's happening with the biofilmand how's it behaving.

One of the things that I worked on to develop actually was looking at ATP (adenosine triphosphate) levels on the teeth and correlating that to the bacterial load−how much total bacteria that the patient has on their teeth. So if you have

too much bacteria present,that's going to create an issue, in terms of increasing your risk for tooth decay or if you've got a highly acid activebiofilmthat's going to dramatically increase your risk for tooth decay as well.

So one of the things I use in my practice too is a quick screening. It's a 15-second tier side swab test, and I look for ATP levels. It just gets me a baseline and an opportunity to try and figure out, are we making progress in the therapy

like where they're at? Or maybe, is bacteria a problem for this patient at all? Like if theycome in and have clean teeth, they don't have a lot of plaque buildup on their teeth (it's not visible) and I can measure the ATP and its low. I know

that we're not dealing with a bacterial issue for this patient then I can focus on is it a dietary issue or is it a saliva issue.Of course, if we can't find anything else, we're going to suspect that they maybe having agenetic component involved.

The bacteria certainly play a major role and it's good for us to know what the overall bacteria level is. In terms of trying to identify it, like I say there's been over 54 species identified, in the last two years, three different Candida albicans and Candida dubliniensis species have been identified so that we know that

Candida is highly acid-producing and acid loving as well. So of course those aremicrobes that we all have is part of the oral microbiome too. So Candida has been added to this list. So that list continues to grow, in terms of which

bacteriaare potentially bad players.Another shocking thing is that many of the bacteria that we thought were commensal or healthy bacteria actually after 30 minutes, if exposed in an acid environment, they switch a number of different genes and then they start producing acid. They use the same adaptive

mechanisms and they look just like the acid loving bacteria as well. So they kind of join the party. It's really more a function of what the biofilm is doing rather than who's present.

Scott: So if I understand you correctly, these bacteria are pretty smart and they adapt

to their environment, communicate with one another and with the human cells. Is that correct?

Kim: Yes, that's correct, Scott. I think the bacteria are a lot more intelligent if you

would.They'rea lot smarter than we've given them credit for. They survived probably for billions of years here. They may be the last menstanding.We tend

to think of them as single cell organisms that really are not intelligent, but when you look at their behaviors and adaptability, it's an amazing part of life. They play a role in this and I think that we can never forget that we have bacteria on

our teeth. We actually need bacteria on our teeth. They're primary defense mechanism for our teeth as well,and help us digest our food. So we need them there. We just need to make sure that we're creating an environment for them so they can behave correctly or in a healthy manner so that we can stay healthy


as well.

Scott: So there actually is such a thing as a healthy oral biofilm. In an ideal situation, it doesn't really matter if you have a certain amount of plaque on your teeth if it happens to be a homeostatic mix of more good guys than bad guys, for lack of a better term.

Kim: Yes, Scott. I think that's a fair statement. Certainly, if you have a healthy biofilm

on your teeth that reduces your risk for getting cavities, and biofilms are very stable. In fact, they're very hard to drive and change. Once you get a healthy

stable biofilm in your mouth, that really favors health for you. But again, it's those changes that we make either by taking a new prescription medication or maybe a change in our diet or we've taken up marathon running. There's

something that we've done that we've altered the environment and that's going to create a change in both the makeup and the output of the biofilm on our teeth. Bacteria, not bad if there is a healthy biofilmand it's very diverse but it's really what allows us to have teeth.

Scott: Yes, they're definitely part of the ecosystem in the mouth. Unfortunately, the

flipside of that is once the biofilm deteriorates and you have more bad players

than good players−we see this with caries and also working the periodontal side−you're looking at increasing pocket depths,red complex bacteria, P. gingivalis and its nasty cohorts. Once a biofilm like that, which is in the other direction, a bad direction, gets established, that is unfortunately pretty stable

too and hard to correct. Would that be a fair statement? Kim: Yes, that's a really fair statement, Scott. So once you have a bad biofilm in the

mouth, particularly in dealing with dental carries, once you have an acid loving

biofilm, that's pretty difficult to correct as well.One of the challenges we've got there is trying to create and drive the pH. We've spent way too much time on oh, we're going to give them some more fluoride, we're going to teach them how

to brush and floss better, but what we really need to do is spend time with the patients figuring out what's causing those low pH episodes in their mouth and helping them figure out how to correct that, so we can drive that pH back up. Actually, I was instrumental in helping develop the first product line for oral

health care products that's actually focused on pH. So they're all alkaline like your saliva that help reverse that situation and try and raise the pH backup, and discourage those bad players, trying to help weed them out of the biofilm and

help correct the behavior of the commensal bacteria, the good healthy bacteria that we got there, and get them behaving correctly again in a healthy manner, so that you've got a healthy balance going on in the mouth.

Scott: Our audience members can find out more about those products on your website, I'm guessing.

Kim: Yes, the company name is www.carifree.com.So they can go and there is a lot of

information. All of the things that we're discussing, they can find there as well, a lot of scientific studies,research data, educational materials for patients and dentists, as well for the profession. So there's a lot of information on that

website. Scott: Good.


Kim: Yes. The genetics is like the real wildcard. There've been a couple of very specific patterns of tooth decay that we've connected to a couple of different

genes, but this fieldis, I would say, exploding over the last seven years. The thing we have to appreciate is our computer power has increased. It's given us the ability to look at several million gene sites on a thousand patients and run a sample on it. It's through a computer program like that, and do a genome-wide

association study in a matter of a few hours. It's something that usually takes months.We have the ability now to do just in a matter of hours. So it's given us the ability to really study genetics and specific genes as they appear to relate to tooth decay. I think you're going to see a lot more in the next 10 years

developed there. As we begin to hone in on a few major genes, we may develop some tier side test for those so, that we can test people to see whether or not that's a part of their equation or not as well.

Scott: Yes, that would definitely be helpful because we do have some of that on the

periodontal side. We can test for some pathogens and in fact, quantify the pathogen load. The word seems to be spreading rather slowly as I see it but if

we were to come up with something, it would probably be a more complicated test or an array of test to just focus in on the specific microbiome in a specific patient's mouth and maybe, the next step would be to tailor a specific therapy or

at least a specific diet modification plan. But then,we're into the whole subject of compliance. The patient obviously has to want to modify what he or she has to modify and that's a whole different subject.

Kim: Yes, that's always a challenge. Certainly, whatever we're going to do for a patient, whether it's a medication that they're taking that is causing the dry mouth, and I can't take them off of that medication, but what I do need to do is try and create a balance on their scales. I may need to add some more

protective mechanisms for them to outweigh the challenge that they've got from that medication. So the patient really has to participate and want to help solve that problem, but so many times our profession, we just haven't even gotten to

the point where we would identify that was an issue in the first place. I have so many patientswho come in to see me that have had a lifetime of tooth decay and I asked them, you know what's causing your cavitiesand they have no idea. So we sit down and try and go through that and then coach them. As we go

through coaching with the patient, it's like you can lead a horse to the water but you can't make them drink; but you can feed them salty peanuts.

Scott: Okay. Kim: So that's one of those things we say in coaching is that I can keep giving them

the information and show them what the benefits are, but I have to tell you

nobody wants to have cavities. When they identify, most patients in my own experience really do participate in our very compliant. This is a disease that comes with a lot of emotional baggage. It's embarrassing, expensive and a challenge on so many levels. Given the opportunity to correct it, patients are

really, really compliant. That has been my experience. Scott: That is great to hear and it sounds like a practice model that could really catch

on. If you could be the one to keep beating the drum and keep publicizing it, that would certainlybe the continuation of your life's work. How long have you been doing this program in your practice?


Kim: I've been at itfor 17 years, Scott. It seems amazing to me that it's been thatlong.Yes, so it's been awhile. The good thing about that is I've developed a

lot of experience at it, and so I have a lot to share with our colleagues on how to-- If there was a mistake on how to do this, I probably could write a book on that because I probably made every mistake you can think of. What's important to notice is not necessarily just what to do but what not to do as well. I really

think that we made a mistake early on at making this whole process way too complicated, and being able to simplify it makes it easier to implement for hygienist to help and understand, my entire dental team to be a part of it and patients to understand. They pick it upquite rapidly.

Scott: That's excellent. That's very heartening to hear you say that.So thank you, Kim,

for that and for your work over the past 17 years doing these patient risk

assessments and making the tremendous effort to get to the root cause of what is causing dental decay in the individual patient and for the success that you've had. We'll continue to look forward to more and more of the dental literature being focused on these genetic studies, picking out what maybe additions to

those 34 separate genes already identified as being carries associated, and that's just in the past five years. So we'll look forward to more research on that from you and your fellow researchers being published. That should be a pretty

exciting frontier, and I would think that we're going to see some game-changing results probably in the next few years.

So moving to your next slide which is fluoride, now fluoride is a controversial

topic. We've touched on it a little bit here and interestingly, in terms of how fluoride has been very effective at preventing/stopping tooth decay,but then there has been an after fluoride period where despite fluoride administration, we've seen caries epidemic go through the roof despite that. So getting into the

history and the mechanics of the various administration forms of fluoride is maybe what we should talk about next. Your next slide talks about Grand Rapids, Michigan which you characterized as fluoride ground zero?

Kim: Yes. So that was the first public water system that was fluoridated. That was

back in 1945. So a lot of the fluoride studies were done on-- Certainly, we start with animal studies, then we went to enlisted men. This was during World War

II. Then the next cohort studies, we used dental students to be part of those studies. Fluoride has played a really important role. If you look at the CDC statistics even today estimate that fluoride in our drinking water reduces our

decay rate in the United States by about 27 percent per year. So it still plays a role and an important tool for us to have in the profession to utilize as well. The challenge with fluoride is we put it in the drinking water and then Crest introduced stannous fluoride in the first toothpaste I think in 1951. So it's been

in our toothpaste,mouth rinses and all of that. Certainly, it's been examined in the last four to five years. The question has been raised in our research circles, in the advent of a fluoride world, is fluoride in the drinking water still relevant? Is it making a difference?

So there'vebeen a number of studies looking at just with the amount of fluoride that people have available to them in every other source, is it still important to

have it in the drinking water? Most of the studies were done prior to 1975, so we really don't maybe have an exact answer on that. It appears to still play a pretty important role in reducing decay in children. We know that fluoride doesn't kill these bacteria. It doesn't cure cavities. What it does is it makes the enamel


more acid resistant, and so that makes the enamel stronger in the face of those dysbiotic acidic episodes on the biofilm in the teeth. So it actually makes the

enamel stronger, and it may reduce a little of the output from a few of the bacteria as well−not eliminate but maybe reduce that. So we know that it plays a role in the enamel itself and the biofilm.

Today, it seems to be a challenge, and it could be a function of our diet, it's just overwhelming whatever fluoride benefit is capable of providing for us. Another challenge we've got, we actually reduced the amount of fluoride two years ago in the United States. It used to be a 1ppm and now it's 0.75 ppm in the drinking

water,because it seemed to be enough fluoride available in every other source that we could safely reduce that. One of the risks with fluoride is that it causes spotting or modeling on the teeth. So the CDC recommended that we reduce. So

wereduced the fluoride in our drinking water. Of course, I live in Oregon and Oregon isa very progressive state. A number of our communities here voted to take fluoride out of the water and that's happened in Canada,I know in Calgary, and in a number of different areas.

Fluoride has become a fairly controversial topic with patients. In my practice, I probably have a significant percentage of people who refuse to have any fluoride

at all: won't use any fluoride toothpaste and no to any fluoride treatments.That makes it a challenge for me, particularly if they've got a lot of tooth decay because fluoride's in almost all of our products. So I have a few things available for them. That becomes a challenge.Then I think the other challenge we've got

too is even though you put in the drinking water, Americans consume I don't know how many billions of gallons of bottled water every year. It's like people typically don't drink tap water anymore to begin with.So we have fluoride in the tap water but if nobody's drinking it, there's not really going to be a huge benefit

from that. Fluoride is not in all of the bottled waters that we see. The other challenge with the bottled waters, most of those are made by the soda

company manufacturers and most of them take the chlorine and all of those chemicals out of the water. They use pure spring water and the way that they're able to keep it shelf stable without having growing in it is they acidifyit. So about half of the bottled waters on the market have a pH of 4.0, which is an acidic

level that is not healthy for the bacteria in the biofilm or your teeth. That's becomes a challenge for us, as well.

For us, it's a hot topic. I don't see it becoming any less controversial in the next few years. I think it's still relevant. I think it plays a role in helping us reduce overall decay rate but certainly, it's not the end all and be all because we're using higher and higher levels of fluoride and yet we're seeing decaycontinue to

grow, particularly in our young children. That's the biggest concern to me. Scott: Can you speak a little bit to probably more and more literature in the last few

years being published on the potential systemic effects of fluoride?

Kim: Yes, that's another interesting point, Scott. When I was in school, we believed

that the fluoride was most important to be taken systemically, like the biggest

benefit came from systemic fluoride. So people that were on well water, we gave them fluoride tablets to take for their children. We thought it was really important while the teeth were developing that the fluoride was incorporated into the enamel while the enamel is developing.


Our more current researches is real clear, the real benefit from fluoride is all topical. It all comes from the water and the fluoride rinsing over your teeth.

That's where the benefit occurs, not after you swallow it. So then the question becomes, what effect does fluoride have in the rest of the body? It appears to be fairly safe.It also gets incorporated into bone, but not levels that appear to be harmful. So otherwise, from most of the studies that I've seen, Scott, the levels

of fluoride that certainly we have in our drinking water appear to be safe, in terms of systemic effects to the rest of the body. I would tell you there may be things going on there that we don't know yet.

Scott: Yes, that's certainly possible. All right, do we want to move to your simplified diagram on the next slide?

Kim: Yes. This really for me I think hit home. In about 2007, a group of us published in the California Dental Association Journal. We published all of our knowledge up to that point in time on CAMBRA−carries management. Personally, I was so proud of all the articles and they were all about children and tooth decay,

adults,management, risk factors, protective factors and a position paper.We really spent a lot of time and effort in putting that together, and I was really part of that.

The challenge that I felt was so here we've got this functional medicine model that's working, and I was working in my practice, it's helping people, this is something that patients want, and it's not being adopted. Itwas a glacial. Let's

say that it was beingadopted at a glacial rate right.So that was my frustration. One day, I happened to open up one of the journals. Inside we had this whole chart. I looked at it and it was so complicated that I thought I've been so involved in this that it made sense to me. I looked at it and for the first time I

realized, this is our mistake. This is the problem right here. This is so complicated that if I weren't familiar with this topic and I had to start with these two pages foldout chart,and thisis my map of how to do this, I'll just close it up

and forget about it because it was way too complicated.

So if we want this to be adopted by the profession, it has to be functional in terms of their daily practice and needs to become just part of their lexicon. It

needs to be part of your daily conversation that you have with patients and to go through a large, long list of risk factors and protective factors and get into all of these different things in detail, that's probably not going to happen.The other

challenge in my own practice was my hygienist. We would have the hygienist fill out the risk assessment form with the patient in an interview style.The problem with that is hygienistsare already overwhelmed. We expect them to do about 30 things in a 60-minute appointment and there's no room to add anything else to

that.

So it wasn't being done and is not being done for that reason.Two things changed for me at that point in time. Number one was I tried to simplify it. So I

went to the usual suspects. What do I usually see? Well, it's either saliva, diet or bacteria. I can remember those three things and those are easy to talk about with patients. Then I simplified the risk assessment form just getting down to

the very basics on those three risk factors and a couple of questions for each of those. I have the patients answer those and self-identify. A couple of things happen there. It took that whole process out of the hygiene operatory, because there wasn't room for it to begin with in terms of the time.


The second thing that I didn't anticipate thatwas the most remarkable was that in the patient's mind, they were reporting to us that they identified that they had

this problem. Rather than me going in and wanting to talk to them about their diet and say oh, I see on the form that we asked you this and you said you consumed that and we're going to talk about your diet−and maybe they didn't want to− now, it's like they've identified that "Oh, you know what? I have a dry

mouth and now I'm kind of expecting you to address that."They come in, rather than me talking about something they don't want to hear about, it's really a function of they've told me that they themselves identified a problem and now, they're expecting me to figure out how we're going to address that. It was a

change in the psychology for the patient's mind to understand that,"You know you're in control of your health. I'm your health professional. I'm on your team.I'm your eyes and ears and your resource. I'm here to help you identify

this and help you be healthy."

So itchanged that whole relationship in my practice in a really dramatic way. I didn't anticipate that. So now it's like patients expect to talk about that. In my

practice, they expect that they're going to see that risk assessment form once a year and have it updated. They spontaneously bring things up and ask questions. "Is this a problem? Do you think that's causing problems for me?"

So it truly changed how my practice behaves. I've got to tell you, it's wonderful. It's the most fulfilling thing I've been in my 38 years of practice because I feel like now I'm really, actually helping people, rather than just drilling and filling

their teeth. So it's been wonderful. But it takes simplifying it so that it fits into a daily practice and then it just becomes part of your conversation. Thisbecomes part of your norm. This is how we do it and patients really appreciate that. I tell you, if you can get somebody healthy and I can get them decay-free for the first

time in their life, have them understand that they know what causes that disease, and they're able to successfully stay healthy, that's a life-changing experience. So it's been wonderful.

Scott: Yes. That makes a tremendous impact at the level of the individual patient. I'm

guessing that it's been a game changer as well with the parents in your practice of children who are also patients in your practice. The typical question is,"My

child has a lot of cavities. What's causing them? What are our options?" or you could probably use the same model or a similar model.

Kim: Absolutely, the same model. You know when I was in dental school, the most important thing was to sit down with the probe, a pick and a mirror and figure out how many cavities a patient had and where they were, right. Now, instead of asking how many cavities you have, I want to know why you have cavities. The

why is much more important than the how many. When it comes to children, those risk factors are pretty much the same, although there are some additional risk factors that we know of. Particularly, it appears to be that the mom or the primary caregiver plays the most important role in establishing the oral biofilm in

that child's mouth. So whether that's mom or grandmother or whoever the primary caregiver is, they transfer bacteria.

We're humans. We share spoons, drinks and cups.I watch my own daughter and daughter-in-laws, they'll pick up the binky, lick it off and stick it back in the child's mouth.That's how we behave as humans. So we know that the mother plays a really important role in the child's risk for tooth decay. Again, then you


just come down to saliva, diet and bacteria and you're dealing with those same risk factors.

One identified, particularly for those kids,if they're under the age of three, it's really difficult to do any restorative work on a child with that age. Some people are better at it than others. Usually, if you have a child that has a really high

decay rate like that, they get sent to the operating room and they go through sedation dentistry with a pediatric dentist. Those members are a profession I really respect and admire. It's a tremendous challenge that they have, but on the flipside of that, the outcome there, the average child that goes to the OR to

have a full mouth of restorative dentistry done is back in the OR on an average of about 20 months to have it done again. I have to tell you, it was a burden on our healthcare system. That episode averages around $12,000 in terms of cost,

and then you've also got morbidity and mortality with sedation, right. I have young parents that come into my practice and what's the best treatment? Certainly, one of the things that's newly developed that we were allowed to use

silver diamine fluoride now, which is the silver ion along with the fluoride arrest those little cavities. It turns them black but having an arrested cavity that's not getting bigger or worse (it's not progressing at all) and having a little black spot

on the tooth versus going to an operating room, spending a lot of money and running the risk with the medications in terms of sedation. It certainly gives us another option for care for patients. So once we go through that, again the standard risk assessment with the parents,I have an option that-- All you do is

paint that on the teeth and most two-year-olds would let you do that if you're nice to them, right?If you approach a two-year old correctly, behaviorally, they'll let you paint some stuff on their teeth.

This happened within my own family. I have one grandson who was like five years old and there may be a genetic component there but it appeared to be mostly dietary−an issue for him. He ended up with 10 cavities. Behaviorally, he

wasn't going to allow somebody to use needles and drills on him, so he was looking at going to the OR and it was literally going to cost my son and daughter-in-law $12,000 with a specialist and to have that done.Then they didn't have dental insurance.So that's a huge financial burden for them as well.

I talked to them about well, let me treat his teeth with this silver diamine fluoride and we arrested nine of those 10 lesions. They've been arrested now for

about a year-and-a-half. I've got the other one I need to retreat. But of course now, he's developing to the point where he's allowing me to do this periodically. We're developing a relationship, aprofessional relationship, where I think that I'll be able to restore his teeth without any sedation and stuff as time moves

forward. There are a lot of different options available to people today. Silver diamine fluoride, certainly added one more tool in our tool bag that gives us an

opportunity for maybe those young children to avoid going to the OR, having all that dentistry done. Again, the same thing though,you can take him there and you can do that restorative work, but if we haven't identified what's happening

in their life that caused that decay in the first place, they're just going to be going back again and again. It's a huge risk for the child. It's a burden for the parents.It's a financial burden for the parents and on our healthcare system as well. That's something we can avoid just by identifying what's causing the


disease.

Scott: That's quite a success story with your grandson and the intervention with those silver diamine fluoride.I'm seeing little snippets about that published in certain publications. I think there was a piece in Dr. Bicuspid,a couple of years ago, talked about the benefits of that. So just kind of nipping something in the bud

and eliminating a lot of risk factors and certainly a lot of expense. I wouldn't even guess as far as how much of that $12,000 ticketwould be covered by medical insurance. I don't know how much of that would reside at the state level or the regulatory medical insurance. Certainly, dental insurance isn't going to

put too big a dent in that. Kim: Right. So that gives us one more option to--The more options that we can have

for care for patient, certainly the better we all are. But at the end of the day here, this disease is all about the pH and the dysbiosis of biofilm. Our job really as dental care professionals, the best thing that we can do, the best option and the best care that we can provide for patient is to be able to help them identify

specifically what's causing their disease and being able to help them identify and understand that. Maybe, we can offer suggestions or coach and help them correct those things so that they can be healthy.That's our goal.

Scott: A very worthwhile one. Fascinating and positive note to end on, we've been

talking with Dr. Kim Kutsch who is a general dentist in Albany, Oregon. He is an expert on dental caries which is cavities, dental decay. He has been doing cause-

focused research with risk assessments for his patients in his own practice for the past seven years and trying to get into a real functional medicine approach to what causes dental decay. He's having some fascinating success with it but we hope will spread to other practices and other states.

As I said, his private practice is in Albany, Oregon. He is also the CEO of Dental Alliance Holdings.He holds a DMD degree from the University of Oregon, School

of Dentistry. In addition, he is an inventor with numerous patents that he holds indentistry, product consultant, internationally-recognized speaker, past President of the World Congress of Minimally Invasive Dentistry, as well as the Academy of Laser Dentistry. He has served on the Board of Directors for the

World Clinical Laser Institute and the American Academy of Cosmetic Dentistry. As an author, he has published over 90 peer-reviewed articles and abstracts on minimally invasive dentistry, carries risk assessment, digital radiography and

other technologies in both dental and medical journals, and contributed chapters to several textbooks. Once again, I feel myself segwaying into that 24-page CV. I'm just going to stop right there on the positive note. Dr. Kim Kutsch, thank you so much for being with us here on the Functional Oral Health Summit. It's been

a tremendously enlightening bit of information and a pleasure speaking with you today. Thank you so much.

Kim: Hey, thank you Scott. Thanks for inviting me. I got to tell you it's an exciting

time in dentistry and how we can help patients with this disease. Scott: Great. Thank you for your work in that regard and we look forward to seeing

more good stuff coming from you and your colleagues. Kim: You bet.


Scott: Thank you.

how dental caries has changed – and why it is still an ... · dental caries or cavities. as we...

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