CHAPTER 5

Remineralization: Reversing Cavities

Many medical facts are not facts in any sense of the
word, they have simply been made up. And that, ladies
and gentlemen, is a fact.

—Dr. Malcolm Kendrick, Doctoring Data

How do we determine mouth health? We cannot be satisfied with great-looking teeth or believe that the number of fillings we have are an indicator, because these are not true measurements of mouth health. We cannot even celebrate comments by our dentist, because even this can be misplaced confidence. How does your dentist judge mouth health without using some sort of quantifying and health-measuring tool? As you learned in the preface, a group of doctors, dentists, and other health professionals had their own oral health tested at the 2015 Oral Systemic Health Challenge, and the results showed problematic levels of gum-disease bacteria, plaque in their arteries, and even systemic chronic inflammatory markers in their blood. These are dentists and hygienists who relied on meticulous brushing, flossing, and regular dental cleanings to maintain their mouths. They thought that their mouths were healthy, which indicates how impossible it is to determine oral health, or know if harmful pathogens are multiplying in your gums, or know if plaque is building in your carotid arteries. We need a better way to measure invisible mouth health, so we can know if our mouth is healthy or not. Without some clarity, we can imagine that we have a healthy mouth, but if we look through the wrong lens, we may be ignoring problems that are dangerous if left unchecked. We need to know if we are in a situation where small changes and a different approach could help us enjoy a lifetime of less dental treatment and possibly improved general health.

Dental offices normally follow a standard protocol that has been accepted for about four decades, and the routine kicks into gear as soon as you walk through the office door. First, you have a dental cleaning, and then one of the staff will gather data about your teeth and gums by probing with a metal spike to measure pockets in your gums or sticky spots on teeth. X-rays are usually taken, and a camera may magnify your mouth to illustrate cracks in surfaces or other problems so that your dentist can use this information to draw a conclusion about the treatment he or she will recommend for you.

REACTIVE VERSUS PREVENTIVE CARE

Traditional dentistry is based on a find-and-fill approach, and it represents reactive dental care. The dentist is looking for damage that can be fixed. You as a patient are rarely involved in this evaluation, and the problem is that there is a high probability that many of these traditional measurements can be false positives or ignore impending problems that at this stage could be reversed easily with effective home care. A preventive approach would be a dental evaluation that anticipates your future problems and alerts you to them before you need treatment. This type of care would offer advice about how to make changes for an outcome that would help you avoid treatments now, but it would also potentially offer even greater benefits in later life, when repairs of old fillings often become complex and expensive.

Ideally, patients must be involved in preventive care as they need to understand why they have dental problems and how they can improve their mouth health. Only motivated patients can be enrolled in such a program and make the changes that will reverse their problems. On the other hand, few patients really understand how precious mouth health is and how it connects with overall bodily health. A conversation about the impact of periodontal pathogens on your risk for stroke, for example, could be far more motivating than the silly and inaccurate joke that you should “floss the teeth you want to keep.”

The problem is that most insurance systems do not pay for in-depth oral-systemic education at this time. Even the so-called preventive measures that are currently endorsed by the ADA are in fact types of treatment, such as the application of fluoride, sealants, or regular cleanings. We can argue that these things can be helpful for some patients, but none of them address the underlying imbalance in the mouth’s ecology, which is the reason for most dental damage. When patients work to improve their mouth health, they will need some kind of reevaluation of their progress, but in most offices, there is no way to monitor if teeth are getting stronger. Most dentists know that oral health affects bodily health, yet there is little financial incentive to promote this fact. Very few dentists are trained to take the salivary tests that show levels of periodontal pathogens—the carotid intima-media thickness scans that show plaque deposits in the carotid arteries—or take A1c or C-reactive protein blood tests to show signs of inflammation in your blood that can alert you to an increased risk for stroke, cardiovascular disease, and other health- and even life-threatening conditions.

SALIVA—OUR NATURAL ALLY

The biggest misconception, in my opinion, is that food causes teeth to decay. If food is the core problem and cavities happened when food becomes lodged in teeth, it would be simple to advise everyone to brush and floss, and this meticulous care would indeed keep everyone’s teeth healthy. Certainly there’s an element of truth in this food idea, but mouth problems are more complex and must be looked at from a different perspective. Although our dietary selection contributes to mouth health, it is not the actual pieces of food, but rather food particles dissolved in saliva that flow around our mouth that affect our mouth ecology in a positive or negative way.

This means that rather than food being the enemy, it is liquids and liquid products from food dissolution that influence mouth health, from sugars dissolved in saliva to the acidity of sugarless drinks and sometimes even plain water. Everything we introduce into our mouth can directly affect mouth health in either a positive or negative way. Sugars and carbohydrates create sugary liquids that feed the kind of plaque bacteria that produce acids. Aggressive anaerobic plaque bacteria, which are specifically found in highly infected plaque, can even ferment dairy products and produce very strong acids that easily initiate cavities and trigger a destructive chain of gum problems. Proteins and fats are generally pH neutral, and some may help with mineralization of teeth and promote healthy biofilm.

When you see the various ways that foods have the potential to create dental problems, you understand why trying to limit sweets or control decay though diet alone is an impossible task. If you want to control cavities, it is far easier to embrace your mouth’s best ally, which is natural saliva at a nonacidic pH of around 7.4, which is normally found alongside healthy oral biofilm, especially when your diet is low in sugar and carbohydrates and high in mineral-rich, plant-based foods. Check your eating patterns to control acidity, and allocate adequate time each day for your saliva to directly contact your teeth and gums so it can transfer minerals into enamel, where they will build tooth strength and repair any acidic damage.

The production of saliva is a complicated process, and alterations in your general health, nutrition, and hydration will affect its quality and pH. Stress, inactivity, pregnancy, depression, hormones, and medications can create acidic saliva that may be too thin or thick to support mouth health. Poor-quality saliva will have a direct impact on teeth and on the mouth’s ecology, weakening teeth and allowing your gums to deteriorate. Saliva flows from three glands on each side of the face, one located in the cheek and two under the lower jawbone.

In addition to liquid from these glands, a component called crevicular fluid oozes from around teeth, and there is also input from smaller glands in the mouth, producing a total of about a liter of saliva daily. Saliva is mostly water, but a vital 1 percent is composed of proteins and electrolytes. Healthy saliva aids in digestion, lubricates the mouth, and provides the matrix for healthy biofilm, which can prevent food from sticking between and around teeth. Saliva moistens the mouth to make talking, swallowing, and eating more comfortable, and it helps wash away food particles. If saliva is sufficiently alkaline, it can neutralize acids that could otherwise cause tooth damage, as it is a solution supersaturated with calcium and phosphate ions, the two most important minerals for building and repairing teeth. It’s important to know that our saliva has not yet been outperformed by any of the expensive new and heavily marketed mineralizing rinses and pastes. Use your own healthy saliva as an ideal ally for improving your oral health, and work to support its flow and mineral content, and give it adequate time to interact with your teeth and gums to keep them healthy.

The flow rate of saliva varies from hour to hour and from person to person, and its mineral and protein content is influenced by stress, hormonal balance, blood flow, diet, posture, and digestive health. In a healthy mouth, saliva is stimulated as we look at food, a reaction generated by our nervous system. Studies on saliva by J. Ekstrom et al. looked at how the elements in this secretion, especially the enzymes, become modified to fit specific and changing digestive needs as we view and think about the food we are going to eat. As we chew, muscles around our mouth squeeze saliva from the parotid glands that are located in each of our cheeks, and they activate the submandibular and sublingual glands, which are underneath our lower jaw and tongue.

Someone with copious amounts of mineral-rich, protein-rich, and alkaline saliva may manage to achieve oral health with apparent ease. On the other hand, anyone with poor saliva flow or who has acidic saliva will need to be especially careful about their choice of toothpaste, their frequency of eating, and their selection of foods and drinks. Problems begin when teeth do not have sufficient contact with saliva. This can occur if you have frequent snacking or sipping habits or wear braces or a night guard that may prop open your mouth and allow it to become dry. Similar problems occur if your teeth naturally protrude outside the cover of your lips, or if you have lips that do not close over your teeth. This anatomy puts your teeth outside the area of salivary flow, and so they easily become dry, demineralized, and prone to cavities. Your skeletal structure is of course hereditary, and if your entire family has this kind of lip structure, called incomplete lip closure, the resultant dental problems may appear to be genetic. The genetic component that influences your anatomy may increase your risk for decay, but when you understand the real problem is about teeth interacting with saliva, this risk is not insurmountable.

There are various ways to encourage saliva to flow and make teeth healthier. Adopt routines that give teeth time to be in contact with saliva, and if you have protruding teeth or know your teeth become dry, ensure you lick them and work saliva over them as often as possible. Xylitol is probably your best ally if you have acidic or poor-quality saliva or a dry mouth. Eating a pure xylitol mint or piece of gum will stimulate a flow of saliva into your mouth, and this saliva is usually at a perfect pH for mouth health. Good nutrition helps mineralize saliva, but even then, saliva pH is not always under your control. Saliva flow increases at mealtimes and slows when you sleep. Early afternoon is a peak flow time, and the dark hours of night are when teeth are most at risk. This is why it is important to ensure your teeth are adequately protected before you go to sleep at night, and no sugary food particles are left to dissolve during the night, a time when we have sluggish saliva and our teeth are at greater risk.

DEMINERALIZATION AND REMINERALIZATION

Dentists call the process of losing and gaining minerals in tooth enamel demineralization and remineralization, respectively. Calcium and phosphates mineralize tooth enamel, and both these minerals occur abundantly in saliva. A healthy mouth is protected by a thin biofilm on every surface, including the gums and teeth. The biofilm on teeth attracts vital minerals to leave saliva and land on the tooth’s outside enamel.

From here, the minerals diffuse deeper into the tooth and move toward any area of shortage to repair and rebuild enamel that has been weakened by previous acidic attacks. The replacement of minerals into deficient areas should occur as soon as possible after acidic attacks to minimize damage and ensure total, immediate repair. When saliva is alkaline, it’s rich in calcium and phosphates, which support this natural process of mineralization, keeping teeth strong and densely mineralized. Rebuilding enamel is a natural process, but it can only occur under the correct conditions when teeth are covered by healthy biofilm and they are given adequate interaction time with mineral-rich saliva.

After an extended period of mineral loss, your saliva may not be able to repair this damage, which will leave the tooth weaker and demineralized. Acidic saliva will not have enough minerals for repair, and if you have acidic saliva, it is especially important to minimize loss of minerals and use strategies to strengthen your teeth. Acid attacks occur everytime we sip acidic drinks like coffee, smoothies, or wine. If we sip at five- or ten-minute intervals, substantial demineralization can occur, because there is inadequate time for any repair between the acidic attacks. The secret for protecting teeth from excessive demineralization is to control snacking and sipping, especially in the afternoon hours when saliva is most healing, and use food pairing to minimize demineralization when you choose to sip or nibble. Pure xylitol gum or mints can also help us limit demineralization damage when they are used at the end of every meal, snack, or drink.The flow of alkaline saliva stimulated by eating xylitol will help wash away acids and provide minerals to help heal demineralized enamel.

Demineralization occurs every time our mouth is acidic. The minerals in teeth dissolve into the acid, and the longer our mouth is acidic, the more damage occurs. When minerals have dissolved, a fragile skeleton of enamel remains, like a honeycomb without the honey. In this situation, any pressure or stress on the tooth can cause the enamel shell to break, forming a hole, or cavity. Despite the huge amount of fear, myth, and insecurity in many people’s minds about cavities, there is only one way for a cavity to form: Acids in the mouth (from various sources, including acidic saliva, acidic drinks and foods or acids produced by harmful mouth bacteria) dissolve the minerals from a tooth’s surface and reduce its strength until a point is reached where some everyday stress overwhelms the weak enamel, and it breaks.

Weak or soft teeth lack minerals, and this is either a problem with inadequate mineral transfer into the tooth or excess transfer of minerals out of the tooth. We should always address both issues, correcting any mineral-deposit problem while working to prevent mineral withdrawals as much as possible. When minerals accumulate in the surface layers of teeth, the enamel becomes brighter, stronger, and smoother. Imagine teeth as a bank account: If your teeth have too few minerals, it is like a bank with too little money. If your bank account is devoid of money, you will need to take out less and put in more, right? If teeth are deficient in minerals, you must protect them from mineral loss and create a healthy mouth environment that encourages minerals to deposit into them as frequently as possible.

CAVITIES

You cannot win any game unless you have a clear understanding of the rules and the game’s goals. If your goal is to avoid cavities, you need to know the exact definition of a cavity, precisely how and why cavities form, and exactly what you can do to effectively stop or avoid them. A lack of knowledge, inaccurate perspective, or ineffective training will mean you never reach your goal, no matter how much effort you put to the task.

A cavity is simply a hole in a tooth, and as mentioned, it occurs only after the tooth’s outer shell has been dissolved by acids, which opens up microscopic passages. If your mouth is infected with cavity bacteria, they will use this demineralized passage to penetrate inside the tooth. Corrosive acids are produced by aggressive plaque bacteria, and these are the acids most often responsible for breaching a tooth’s surface. Obviously, the stronger your enamel, the better it will resist acid attacks. This is why effective cavity control should always include strategies to strengthen tooth enamel. When harmful microbes burrow inside enamel, they create additional acids that cause deeper demineralization, and this allows them to penetrate further inside the tooth.These bacteria will survive and thrive if they continue to derive energy from their usual food source—sugars from the foods you eat that are dissolved in mouth liquids.

Saliva flows all around teeth like an ocean washing over a coral reef. When harmful bacteria get inside a tooth, they continue to have direct contact with saliva, as mouth liquids are able to travel along the demineralized access passages, opened up as the cavity-forming bacteria gained entry to the tooth. These channels function like a straw and allow these bacteria to feed happily on sugars from any foods or drinks you consume.

The soft mix of cavity-forming bacteria and damaged tooth debris creates a discolored defect known as dental caries, or tooth decay, which may look like an inert clay-type substance, but it is alive with bacteria. Dental caries is one of the most prevalent childhood conditions, and repairing teeth damaged by caries is the reason so many children have treatments in dental offices and often require sedation or even a general anesthetic in a hospital setting to fix the damage this disease can cause. As the bacteria continue to multiply, this area of dental caries expands under the tooth’s surface, weakening the tooth structure until the enamel covering the area finally collapses. This moment is the time when dental caries usually becomes clinically visible as a hole, noticeable in the tooth’s surface and full of brownish decay.

Dental caries is a slowly progressing bacterial infection and a cavity is the eventual defect that is created by this disease. Caries does not happen by chance, is never at a random location on a tooth, and cannot be caused by foods alone, since even sugary foods require processing by cavity-producing bacteria. When cavity-forming bacteria are present in plaque or in a cavity, they will also be floating in saliva, traveling all over the mouth, being transported everywhere saliva goes, and landing on other vulnerable teeth, where the bacteria will launch a similar attack and possibly form similar cavities.

Teeth have different shapes, and some of these shapes make them more vulnerable to the attacks of cavity-forming bacteria. This is why dentists understand the sequence in which teeth are usually damaged. For example, the grooves of molar teeth are more vulnerable than the thick, smooth enamel of a canine or front tooth, and the smooth sides of teeth are more resistant than their biting surface. Because the grooves of molar teeth are generally the most vulnerable locations for decay, seeing healthy grooves is usually an excellent indicator that the rest of the mouth will be healthy, too. There are exceptions, especially for dry front teeth or when people have habits like sucking candies or acidic fruit, which can demineralize teeth in odd areas that are not normally at risk.

One of the most misunderstood messages about teeth involves why cavities form. Patients somehow think that filling this hole or cavity will stop tooth decay, and they do not understand that the same bacteria will continue to damage other teeth, no matter how many have been filled. Conversely, if the disease is controlled with an effective strategy, the actual filling of the cavity becomes less important. We can think of this in the same way as we would view extinguishing a fire, and we all know this is far more important and urgent than fixing the damage it has caused. In a healthy mouth, fillings are only necessary for the structural repair of a defect that is unable to naturally repair and rebuild itself. A filling is not, as many think, a way to stop the mouth’s infection, and fillings do nothing to change the imbalance in the mouth’s ecology—which is the real, underlying problem.

Something else you should know: Fluoride cannot change or improve the bacterial ecology in your mouth or remove cavity-forming bacteria. Fluoride’s only power is that correct use of certain fluoride products can strengthen teeth to resist acidic attack, and it can also help speed the rate of remineralization to help repair any weak or damaged teeth. Complete reversal of a cavity will occur only if the “cavity infection” can be eliminated, which is why fluoride products are unable to reverse or heal cavities when they are used alone. This is vital knowledge as it explains why fluoride is only useful in a limited way and as part of a more complete strategy.

Reversing Cavities

The reason that I wrote my first book, Kiss Your Dentist Goodbye, was because I noticed few people in the United States knew that cavities could naturally heal and repair themselves. I wanted to explain how the process of acidic demineralization creates cavities and how reversal is easily possible under correct mouth conditions. Many people in Europe, Australia, New Zealand, Asia, and Japan have known about tooth remineralization for decades.

How much better would it be to use proactive prevention and rebalance an infected mouth ecosystem and establish a protective biofilm before damage occurs? I see dentistry’s current reactive approach as similar to playing a whack-a-mole game. This game is one where kids make a frantic attempt to stop little moles from popping out of holes in a table; as one is whacked, another pops up. Filling cavities without concern for the underlying whole-mouth bacterial infection paints a similar picture, whereas a proactive approach would be to remove the moles from this game (i.e., bacteria) and end the “fun” of whacking at them every time they reemerge.

Remineralization is the rebuilding of teeth, and it is a natural process that occurs constantly in a healthy mouth as saliva contacts tooth enamel. This process is slow, but it provides the ongoing repair that helps ensure our teeth remain strong. Tooth rebuilding and breakdown is like the constant breakdown and repair of bones in our body. This ongoing rebuilding ensures that our bones and teeth are restored with new, fresh minerals, allowing them to remain strong and healthy. The good news is that remineralization can be accelerated by a tiny amount of sodium fluoride applied topically to the tooth surface, and this is why I often recommend using a well-formulated sodium fluoride toothpaste or mouth rinse.

Remineralization is the body’s way of repairing a damaged tooth, and it is impossible to say at what point the damage becomes too severe for natural repair, especially when correct sodium fluoride products are paired with xylitol, since they work synergistically. Many times, I have helped patients return their teeth to total health, but success is easier to predict if we begin remineralization before the tooth’s enamel skeleton has been physically broken. Most small cavities take at least a year to form, and the reversal and repair can happen in a fraction of this time—often in less than three months. In 2008, a group of Australian researchers looked at how easily small cavities can be reversed, and they concluded it may not be ethical for dentists to fill early cavities, because doing so ignores their potential to remineralize. The most important fact is that remineralization will only occur when saliva has the time to interact with teeth and when the biofilm of the mouth is healthy.

Sometimes dentists express concern about trying to reverse a cavity, because they worry about cavity-forming bacteria being too deep inside a tooth. This may have been their teaching in dental school, and without a comprehensive strategy to deal with the cavity infection, I would agree. The caveat is that reversing deep decay requires three methods be used in synergy to address various parts of the cavity problem equation:

 

1.Change and improve the bacterial ecology in the mouth with frequent use of at least 3–10 grams of xylitol daily.

2.Use my Complete Mouth Care System, which we will explore in chapter 9, to address the dental caries infection inside a tooth without damaging good bacteria or the proteins of healthy biofilm.

3.Use my diet and lifestyle suggestions to improve saliva health and give your teeth time to interact directly with saliva for a few hours every afternoon.

When these strategies are followed, they can be so successful that even caries deep in dentin will reverse. Always remember, the fight is between you and living bacteria inside the carious lesion lodged inside your tooth. These bacteria sit at the end of a straw-like tube, surviving because they continue to derive nutrients taken from your mouth, especially any sugars dissolved in mouth liquids. The more often you feed these aggressive anaerobic bacteria with sugars, milk products, or acids, the more destructive they will be. Many people are amazed to think that their own diet is literally feeding the cavity bacteria and keeping them alive in their little cave under the tooth’s surface, every time they eat or drink supportive products. On the other hand, frequent exposure to xylitol will have the opposite effect and can help limit the propagation of these cavity-forming bacteria. This is why frequent exposure to small amounts of xylitol is so beneficial. There isn’t a wound anywhere in the body that can heal until the infection has been stopped. The same principle applies to teeth. The carious area cannot begin to heal and remineralize completely until all these cavity-forming bacteria are controlled.

Cavity bacteria thrive in the acidic conditions that are generated by acidic drinks, juices, lemonades, sodas, fresh fruits, dehydrated fruits, crackers, cookies, sweet treats of all kinds, ice creams, breads, and carbohydrates in every form, as carbohydrates break down to form sugar. This list also includes foods that are organic, gluten-free, or certified healthy. The more frequently we snack, eat, or drink, the quicker cavity bacteria grow, and the more aggressive they become. To eat for a healthy mouth:

Consider increasing time between meals and snacks.

Consume sugary or acidic foods and drinks at mealtimes, incorporating them in the meal, and end with 100 percent xylitol to protect teeth.

End meals or snack between meals with a protein or tooth-safe food (e.g., cheese, chicken strips, turkey, sausage, unsweetened plain kefir or yogurt, celery, avocado, salad lettuce, salty nuts) or xylitol mints or gum.

Try not to sip constantly, even water (which dilutes saliva). Give you teeth uninterrupted time to interact with saliva, especially after lunch, when your saliva is healthiest.

Alkaline foods help negate acidity and the damage caused by acidic conditions that occur at the end of almost every meal. Tooth-safe foods are the best snacks between meals, as they do not promote cavities. Making smart food choices will make a big difference in mouth health, especially for children or adults trying to develop and establish a new mouth ecology and end any ongoing problems of cavities or gum disease.

WHITENING TEETH

Teeth that are fully mineralized will be strong, resist damage, and reflect light from their hard, diamond-like surfaces to appear shiny and bright. Healthy enamel will be hard enough to resist staining. Strong enamel that is covered by healthy biofilm will not stain or soak up colors from liquids, like tea or wine. They will be unable to penetrate the tooth surface and stain the tooth. Acid-damaged or artificially whitened teeth are often very porous, and far more likely to stain. Weak enamel is less mineralized, which makes it appear to have a chalky, dull whiteness. This whiteness is not a good sign, and the coloration occurs when light is not reflected normally from the tooth’s surface. Although soft enamel may begin by looking white, it will gradually darken and become more yellow. Weak teeth are more likely to break, chip, and crumble. Staining from tea or other drinks only happens if tannins or colored ingredients are able to soak into the porous structure of weak enamel. This is why teeth that have been artificially whitened are at greater risk for staining, and patients are usually told to avoid colored drinks for hours or days after the treatment. Hard, fully mineralized teeth are not at risk for staining.

When you sip wine, tea, or coffee over many hours, the initial damage is the loss of minerals as the acidic drink demineralizes teeth and opens up pores in the enamel surface. This allows the staining to occur, when tannins or colors from the beverage are able to soak into the porous enamel and leave stains on your teeth. The most important protection against this kind of staining is to strengthen your teeth to their maximum state of mineralization. Strong teeth resist staining. Another helpful suggestion is to drink any dark or acidic drinks as part of a meal and end the meal with xylitol.

No matter our intentions, sometimes we may end up sipping acidic drinks, maybe at parties or social events. In these situations, try to interrupt the sips of acidity by nibbling something that is alkaline or tooth-friendly. This is a trick that can also be used for toddlers who have a habit of sipping juices. Between sips, nibble foods that are salty or acid-neutral, like nuts, cheese, cucumber, celery, or some pure xylitol mints or gum.

The more whitening you do, the more likely your teeth will be porous, damaged, and prone to staining. This is because whitening treatments strip teeth of the waxy biofilm protection that normally defends healthy enamel from staining, and the chemicals in most tooth-whitening products also alter the protein structure inside teeth, leaving them less able to resist damage from cavity bacteria. The abrasives and corrosives in whitening pastes and whitening strips etch and scratch teeth to make them appear whiter, but this is a superficial illusion achieved in the same way acids and sandpaper can etch or whiten glass.

Whitening with peroxide occurs as a hydroxyl free radical is released to bleach the deeper layers of teeth, and this can alter the tooth’s internal protein structure. Whitening may cause sensitivity to your teeth and damage your gums—damage that may last a few weeks or possibly for the rest of your life. Some people have whitened their teeth and so damaged their gums that it opened up a space that was previously filled by gum tissue, but now this area appears as an empty, black triangle between teeth. Peroxide has also been shown to cause the release of mercury from silver amalgam fillings, which would raise your risk of toxicity from any silver fillings in your teeth (mercury toxicity is believed to cause damage to our body and brain). Recent research corroborates the warnings that have been given in scientific literature for years, even before whitening products emerged into the marketplace in the 1980s. Studies show that bleaching upsets a tooth’s live internal tissues in the pulp area and can cause inflammation and damage to these cells in the center of the tooth. In most cases, the damage from bleaching is not apparent immediately, and it may be years before tooth death, enamel weakness, dentin permeability, or changes in the pulp cells are noticed, which can make it difficult for us to link this damage with the whitening and bleaching procedures. Bleaching and the use of peroxide may also roughen tooth surfaces, strip away healthy biofilm protection (leaving the mouth more prone to ulcers), and allow foods to stick to tooth surfaces and lodge between teeth.

Tooth whitening makes no sense to me when I consider it from a health perspective, yet it is a booming business even among avid health seekers, and sales of whitening products in stores and dental offices doubled between 2000 and 2006. There were many studies that have questioned the safety of bleaching, but in recent years, these have become difficult to access. One review by Professor Alberto Consolaro was published in 2013 in the Dental Press Journal of Orthodontics, giving clear warnings about the use of peroxide. Even so, most dentists and doctors debate the quality of these studies, and many completely ignore the warnings. The cost of a one-time whitening treatment may be $300 or less, and sometimes this can be offered as a free service. The problem is that a free treatment may cause gum and enamel damage that can create substantial expense in the future, maybe many years ahead. Repeat bleaching is often done annually, and the potential damage that whitening could cause to fillings, enamel, and gums may require dental work of various kinds, including veneers and crowns, cosmetic gum grafting and surgeries, treatment for sensitivity and soft enamel, and even root canals or implants that need special maintenance and bite guards. All this damage could add up over the next few decades, creating the need for treatments and repairs that could potentially total over $50,000 in expenses. Remember, this damage may have been initiated by a free whitening treatment. In chapter 9, I will share a safe and natural way to improve your enamel strength with a program that is designed to guard your mouth health and provide healthy teeth that are naturally whiter, shinier, and brighter.

WEAK ENAMEL

Weakened enamel is not able to adequately protect the vulnerable live tissues of the dentin and pulp inside a tooth. If you have damaged or softened enamel, you will usually notice that your teeth feel sensitive to hot or cold temperatures, and this progressively worsens if your teeth continue to be harmed. Eventually, the demineralization damage will become irreversible and potentially result in the death of the tooth. When a tooth has died, the dead part will need to be cleaned and the space blocked with a root filling. Finally, after a root has been filled, the tooth will need some kind of protective covering to prevent the tooth from splitting or absorbing mouth liquids into its core. Most often this means making a gold or porcelain crown. Weak enamel was the cause of this drastic and expensive scenario, yet strengthening enamel is relatively easy and should be something you do daily to prevent these problems.

Under high-power magnification, the design of natural enamel that creates the crown covering of a tooth is seen as an awesome construction. The structure resembles intersecting cathedral arches, radiating in every direction. Small rod-shaped prisms build this arch structure, and the rods are arranged in a pattern that gives healthy enamel incredible resistance to biting forces. The enamel covering a pristine tooth protects the underlying tooth during biting and chewing to resist damage and not harm the opposing teeth. The rod prisms radiate like sunrays or porcupine spines at right angles to the tooth’s surface. These rods are longest where enamel is thickest, at the pointy cusps that dig into food as we bite.

Enamel gets progressively thinner on the sides of a tooth, thinning toward the gumline, and it eventually disappears at the junction where the tooth root is covered in cement. As enamel thins, the rodshaped prisms become shorter, more fragile, and more easily dislodged. Mouth acidity can weaken short rod prisms and loosen them. Damaged enamel crystals may split away from the tooth surface in flakes, leaving a void on the side of the tooth close to the root, at the gumline. When enamel crystals flake at the same time from multiple teeth, a sensitive channel can develop at the gumline. Mouth acidity attacks everywhere, but its damage is first seen on the most fragile crystals, the shortest ones. When these crystals break away, usually simultaneously, a groove will form, and sometimes patients can be blamed for aggressive toothbrushing or tooth grinding.

The underlying problems, however, are loss of the protective biofilm and mouth acidity. I always work with clients to try and determine the reason for these problems and figure out what may have damaged their mouth’s ecology and caused acidic damage, so we can ensure their teeth are protected in the future. Sometimes this damage was from acidic saliva that was a consequence of stress, pregnancy, or hormonal imbalance. A dry mouth can make acidic damage worse, and brushing acid-softened teeth after meals or after drinking something acidic like wine can also create serious problems. Whatever the cause, it’s important to control acidic damage, and xylitol can be a helpful tool. My Complete Mouth Care System will also help remineralize and hydrate enamel to prevent tooth crystals from flaking away at the sides of your teeth. This protection will help minimize your risk of acidic damage, so we can enjoy wine without dental problems!

When enamel is healthy, it functions as a perfectly engineered helmet that can absorb the strong pressing forces that occur as we bite, chew, or clench our teeth.The average biting force is 160–265 pounds, and a healthy tooth can safely transmit these forces and dissipate them through its structure, so there is no damage to the internal parts of the tooth, the surrounding gum, or the underlying jawbone. When a pristine tooth structure has been cut with a dental drill, even for a tiny filling, this natural mechanism for dissipating forces is compromised, and the tooth will never again function in the natural way. The forces will now be transmitted through the filling until they hit the base of the filling, where they will shoot sideways across the tooth. These unnatural forces often cause microscopic cracks in the enamel at the sides of the tooth and at the widest part, the place where teeth touch adjacent ones, which is an area known as the contact point. Cracks in enamel allow mouth liquids and bacteria to enter into the teeth and potentially start cavities at these contact points, tucked between teeth, in places called the interproximal areas. Decay at the contact point between two teeth is called interproximal caries.

If harmful bacteria live in your mouth, cracks will always be a danger, since they offer a preformed entrance for cavity bacteria to enter and damage your teeth. This is why cavities can easily occur in teeth that have preexisting fillings, which may have caused stress cracks. Because biting forces are transmitted through all molar teeth with every bite, these cracks can often damage many teeth at the same time.This is why it is not unusual for someone to discover twelve or fifteen interproximal carious lesions simultaneously, especially during their teen or young adult years.

Teeth with interproximal caries usually have a history of being cut during sealant preparations or a filling a few years before, something that may have seemed insignificant at the time. The news of fifteen fillings can be shocking, and it should jolt you into action, especially if you understand what this means for the future of your teeth. These lesions are usually quite reversible if you take rapid action, and certainly this would be my recommendation. You must be motivated and do everything possible to balance acidity in your mouth and develop a healthy ecosystem.

It is also important to realize that, from now on, biting forces will always be a danger, since a molar tooth that has been cut will never again have the strength of a pristine, uncut tooth. There is no way to remove this risk, so enamel cracks will always be a concern if you have had sealants or fillings in molar teeth. You cannot change the biomechanics of teeth, but you can reverse an early cavity and restore a tooth to its original pristine form and strength. Remember, this is why it is worth reversing a cavity and avoiding even a small filling. Your teeth are like beautiful diamonds, far too valuable to be drilled and filled if treatment can be avoided. Anyone with fillings should be aware of their risk for cracks and embrace the fact that my system of care will help remineralize cracks every day.

WHITE SPOTS

As discussed, plaque is a thickened layer of oral biofilm that is infected by harmful, acid-producing, cavity-forming bacteria. These bacteria expand the biofilm and thicken it so that sometimes it can form a mass thick enough to be seen and scraped off your teeth. As the harmful bacteria layer on each other, the ones pushed to the inside, close to the tooth, may begin to run out of oxygen. This environment causes them to adapt to these low-oxygen conditions, and as they become anaerobic, they become more aggressive. Anaerobic plaque produces strong acids that harm your teeth and toxins or poisons that cause gum damage and inflammation.

Three weeks of damage by the acids produced by these anaerobic plaque bacteria can pull sufficient minerals from a tooth’s surface to create a weakened patch that is visible as a dull and chalky white area in the enamel. These damaged sections are known as white spots, and they are not only whiter in color but also weak. The acids damage the enamel, and when it no longer reflects light from its surface in the normal way, this creates the illusion of the enamel being a whiter color.

Fighting Plaque

Xylitol is a superb tool to control damaging plaque bacteria as it makes them less sticky and more easily washed away by good mouth rinsing. Aguirre-Zero et al. have also shown xylitol as particularly useful in helping to neutralize the mouth’s acidity in studies published in the 1990s in various journals, including Caries Research. A review by J. M. Tanzer in the International Dental Journal concludes that xylitol can control the development of thick, infected plaque. As mentioned, xylitol also works in harmony with dilute sodium fluoride to help remineralize tooth enamel more quickly and completely. My Complete Mouth Care System teams with xylitol to effectively heal white-spot damage within a week or two and returns the tooth to its normal strength naturally.

White spots tell us that the tooth’s enamel is weak, and the next stage of weakness is that the tooth crumbles, fractures, or becomes a cavity. Often, brown speckles will be visible in the white patches, and this is an indication of the imminent failure in the tooth’s structure. White spots are completely reversible, but success depends on remineralizing and repairing them as early as possible. A dental cleaning can shine over a white-spot area, but it will not replace minerals, control the infection, or reverse the damage. Some dentists will etch the area and fill all the porosities with a smear of plastic. This is a quick fix, but in most cases, the repair will soon stain, and subsequent repairs will become larger and more invasive as the years unfold. Once plastic has been put onto or into a tooth, the enamel can no longer repair itself naturally.

FLUORIDE

Now seems a good time to discuss the important and confusing subject of fluoride. First, let’s consider that you have just damaged your enamel by drinking something acidic like a soda, a citrus or cranberry juice, or perhaps some apple cider vinegar. If you have alkaline saliva, your tooth enamel will quickly and naturally rebuild itself over the next hour or so. However, if you have acidic saliva, you are not going to be able to naturally reverse this damage, which could lead you to eventually need root canals, crowns, extractions, or implants.

I never recommend drinking fluoridated water, and I believe that fluoride should only be used as a topical application on the outside surface of a tooth. When sodium fluoride is used appropriately, this can speed the repair of demineralized areas and help reverse dental damage. Decades as a clinician has shown me that patients who are unwilling to apply any fluoride to their teeth often endure super soft enamel and dental deterioration, and can end up needing root canals and crowns. I believe that regular use of a little sodium fluoride could prevent this damage, which is why I view the regular use of a little topical sodium fluoride as insurance against future tooth damage. For example, a good paste may help heal and repair interproximal enamel cracks that often occur in the sides of teeth after the enamel is weakened by a filling.

In a perfect world, nothing would damage our teeth, and we would never age or have acidic or dry mouths. Then, it could be argued that fluoride would be unnecessary. In real life, however, many foods, drinks, medications, stress, and hormonal situations—such as occur during pregnancy—are beyond our control and create mouth conditions that put our teeth at risk and in need of extra help. Fluoride will assist the building of minerals into teeth, so they can be strong enough to resist damage, potentially helping us avoid dental repairs or the exposure to filling materials, which could perhaps be considered greater threats to our health.

Sodium Fluoride

Only when your mouth has a balanced ecosystem and healthy saliva will you be able to naturally remineralize damaged teeth. The first step of any mouth rehabilitation should be to limit acidic damage and realize that saliva is our best tool for mouth remineralization. A toothpaste or rinse that contains a tiny amount of sodium fluoride can create an ionic charge on the outside of teeth to help minerals from saliva adhere to the outside surface of your tooth. The use of topical sodium fluoride has been shown to increase the speed of natural remineralization, especially for new adult teeth that erupt in the mouth around five years of age. Used regularly, a little sodium fluoride can strengthen these teeth and prevent demineralization and damage that is caused by acidity. Without fluoride, someone with acidic saliva or a dry mouth will experience minimal or possibly nonexistent remineralization. Regular use of a low-concentration topical fluoride is completely different from using stronger fluorides.

Dilute sodium fluoride has also been shown to work harmoniously with xylitol. If you have cavities, fluoride rinsing twice daily, combined with the use of xylitol after meals and drinks, can dramatically improve your oral health. This approach can help protect adult molars as they erupt in children around five years old, but younger children with no risk for cavities do not need fluoride products. Sodium fluoride is as useful for seniors and adults as it is for school-age children and teens, since teeth are constantly demineralizing and are in need of help to preserve their strength. I cannot repeat too often that I do not endorse drinking fluoride, and this is why children should be supervised when they are using fluoride toothpaste or rinses. I also encourage everyone to spit several times after using any dental products to ensure good clearance from the mouth; do not eat, drink, or wash your mouth for at least an hour, so that your teeth can derive the maximum benefit from fluoride rinsing.

MOUTH ACIDITY

Minerals are lost from teeth whenever they are in contact with acidity, which occurs in everyone’s mouth every day. In a healthy mouth, this damage is almost immediately reversed by the natural process of remineralization. Problems only arise when this process is compromised, or when the amount of mineral loss from acidic damage is too prolonged or too frequent, as this will overwhelm and outpace the natural repair mechanism. Acidity is measured as pH, on a 14-point scale, where the low end indicates extreme acidity (like lemon juice). Mouth health and healthy bacteria flourish at a pH just a little above neutral, from pH 7.0 to pH 7.4. We do not know the point at which a higher pH can be problematic.

Almost everyone’s saliva pH becomes more acidic at night, or when we are tired or unwell. No one has a fixed salivary pH for life, and if today you test and find you have a neutral pH, this is not a guarantee it will remain neutral in the middle of the night or for the rest of your life. When saliva is acidic, it can dip to a level as low as pH 5.0, which usually occurs during the forty weeks of pregnancy, during times of hormonal imbalance, and at times of stress or depression. Mouth pH is affected by what you eat and drink, and most drinks are acidic, like carbonated water, lemonade, or soda, and some have an acidity level as low as pH 2.2, which can be very damaging to teeth, regardless of the sugar content. Acid reflux, acidic foods, some vitamin lozenges and powders, and even a number of popular oral care products are acidic and may cause widespread demineralization problems.

Mouth pH can be tested with special litmus paper or a pH meter dipped into saliva that is collected in a spoon or small dish. Your morning saliva can be used as a baseline reading, but remember, saliva pH fluctuates easily with stress, travel, extra hours of work, or mouth breathing.

An Acidic Dry Mouth

The acidity of saliva is important, but the damage from acidity is made worse when anything reduces saliva flow and causes a drier mouth, including:

Snoring at night, when your saliva may be acidic

Breathing through an open mouth, because your lips do not close because of braces or orthodontic appliances

Allergies, nasal, or sinus problems that may block the nose and cause mouth breathing

Stress or depression that reduces salivary flow

Many medications, including medications for allergies and sinus conditions, stress and depression, and most heart and diuretic medications that have the side effect of causing a dry mouth

Hormonal fluctuations, including pregnancy

Sipping drinks of any kind, including water, dilutes saliva and reduces the percentage of minerals available in saliva to protect and mineralize your teeth. Saliva shows a circadian rhythm, and its composition changes during the day and night. Saliva is usually most mineralizing in the early afternoon, especially after eating a healthy, nutrient-rich lunch. This means that sipping water in the afternoon will disrupt this ideal time for saliva to heal your teeth, something especially important for someone with weak, decayed, or sensitive teeth.

Dry Mouth and Chemotherapy

We have talked a lot about acidic damage and how remineralization will only occur in an alkaline environment with healthy saliva. This is why I believe it is important to mention my concerns about baking soda (bicarbonate of soda), which of course can make a mouth very alkaline, as it creates a pH of about pH 9.0 when it is in solution. Baking soda is often recommended after chemotherapy and for people with a dry mouth, or who suffer from acidic saliva. The assumption is that baking soda will be helpful because it is alkaline.

Baking soda is a handy cleaning product, because it is not abrasive and is excellent for dissolving grease and removing molds. In the mouth, however, this ability to dissolve fats and grease appears to damage the beneficial proteins that are the foundation of healthy biofilm that covers teeth and stops sensitivity, enamel erosion, and gum recession—particularly for mouths that are acidic or dry. Baking soda appears to strip this protective protein layer away in some mouths, which leaves teeth and gums more vulnerable to mechanical, thermal, and chemical assault.

Baking soda became popular for dental health in the 1920s, when a mixture of baking soda and peroxide was used in a poultice placed on gums and found to stop an invasive and painful gum disease known as acute necrotizing ulcerative gingivitis. This infection was caused by an amoebic gum pathogen that attacked the mouths of soldiers living in the trenches of World War I. The poultice was used to kill these aggressive gum pathogens in the era before antibiotics, and it was found to stop this virtually incurable disease and allow the ulcerated gums to heal. The problem was that patients often experienced severe gum recession following this treatment.

Fifty years later, Dr. Paul Keyes suggested a mixture of baking soda and peroxide as a nonsurgical treatment for periodontal gum disease. Dr. Keyes’s method was successful in stopping the infection, but his work also describes problems from tooth sensitivity and recession following the baking soda treatments. Baking soda may have solved some serious gum problems in the early 1900s, but today it makes sense to use a gentler approach that protects the integrity of the mouth proteins, gum tissues, and healthy biofilm. My Complete Mouth Care System, which we will cover in chapter 9, is recommended for anyone with gum disease, cavities, bad breath, sensitivity, or weak teeth, and I suggest using it as preventative and remedial aid before and after chemotherapy.

Acid-Alkaline Influences

The longer your teeth are bathed in healthy, alkaline saliva, the more minerals they will absorb and the stronger they will become. Conversely, the longer your teeth are in contact with mouth acidity, the more minerals will dissolve from their surface and the weaker they will become. Minerals dissolve from enamel at a speed that increases with the acid’s strength, escalating by a factor of ten for every single-unit pH drop. This is why we must be concerned about lengthy exposure to acids and the strength of these acids, especially liquids with a very low pH like soda, cider vinegar, lemon juice, cranberry juice, citrus juices, whitening products, and even some mouth rinses. These things can drop pH to as low as pH 2.0 or 3.0 in your mouth. Teeth can reclaim minerals after acidic damage if they are able to immediately interact with healthy, undiluted saliva at a pH of around pH 7.4 so that minerals from saliva will enter into the tooth’s surface and replace any missing minerals.

The suggestion to brush your teeth immediately after a meal may sound logical to some people, but not if you understand that your mouth is almost always acidic after a meal. It can take about an hour for this acidity to dissipate. This is why some dentists tell their patients to wait an hour before brushing. If you brush acid-softened enamel, it will easily be abraded or worn. In my opinion, the best solution is to use xylitol at the end of meals, because it stops acidic damage instantly by stimulating a flow of saliva. This means xylitol not only limits acidic damage, but it also creates a flow of saliva to remineralize teeth. If xylitol is not available, an option would be to have a tooth-protective food like whole milk or cheese or to rinse the mouth with water to wash away the acidity. Any problems from acidity after eating will, of course, escalate if you snack or drink many times a day, especially if you have a dry mouth or acidic saliva.

For decades, there have been people who have believed it is important to alkalize the body for improved general health.The belief is that the more acidic your body, the more disease-prone you become. At death, of course, our bodies become acidic and are quickly overtaken by acid-loving bacteria, which decompose our flesh. Louis Pasteur, the recognized father of the germ theory, is said to have somewhat modified this theory while on his deathbed in 1895, saying that the body’s terrain, or landscape, was more important than the bacteria that caused disease. In other words, he recognized that sickness and disease generally occur only when we allow our bodies to become vulnerable to harmful bacteria. We could possibly argue that vulnerability to disease is related to our bodily pH in some way. This is certainly true for the mouth, where a slightly alkaline environment supports a healthy ecosystem that is primed to protect itself and resist cavities, plaque, and gum problems.

Since 2010, there have been great strides in the field of biology, and this has revolutionized our understanding of the diversity of mouth microbes. An improved understanding of the relationship between oral and general health has simultaneously magnified the importance of this knowledge. We now know that the biology of the mouth is far more complex than formerly imagined and that there is great clinical significance to the innumerable microbes that constitute the biofilm on teeth and elsewhere in the mouth. New understanding means we must revisit some traditional dental protocols, especially if we think mouth microorganisms may be pushed into the blood and could potentially cause a transient bacterial event, called a bacteremia. We now know that a bacteremia can play a significant role in the development of atherosclerosis and potentially increase someone’s risk for stroke or coronary heart disease. This new vision helps us develop clearer goals for our mouth health, but it also changes the way we should view older dental ideas and some traditional dental therapies.