Using pH testing for caries management

When we treat our patients, we should include an assessment of their conditions. This is not only while they’re in our chair, but also their daily habits that may lead to the conditions we see. As students, we learn about the many factors that contribute to caries risk, however, we’re considered successful clinicians when we put it all together. Implementation of saliva testing and caries risk assessment tools provide support for dental hygienists to make customized home care recommendations for our patients. 

Why pH is important

Why is pH relevant to the oral condition and caries management? We know that every time we eat or drink, the pH in our mouth changes. This may lead to an acidic environment in the oral cavity. With this change in pH and the presence of caries-causing bacteria, mouths are susceptible to decay. “The pH scale measures a substance's acidity or alkalinity. The scale ranges from 0 to 14, with 7 representing neutrality. The lower end of the scale is acidic, and the higher end of the scale is alkaline.”¹ 

Do you know the pH of your oral cavity? What about your patients’? “Saliva has a normal pH range of 6.2 to 7.6 with 6.7 being the average pH.”² How can we test the pH of saliva? There are many resources and tools to guide us while educating our patients to implement caries prevention practices.  

Saliva testing

We know that much of caries management is about habits, and we can complete a more accurate assessment of our patients’ oral environment through chairside and at-home saliva testing. Frequent snacking and consumption of sugary beverages increases a patient’s risk for dental caries. We know there are ways to more safely consume these items to help combat the risks, but do we share this information with every patient? 

In-office saliva testing is a conversations starter about pH. There are a few ways to think about this. You’re able to provide a baseline pH level in a controlled environment and use the results as an educational tool. One easy-to-use test kit is the Saliva-Check BufferR by GC America. It’s used in schools and practices to educate students and patients on saliva pH factors. It includes tests for resting saliva, visual inspection of hydration, saliva consistency, and pH measurement.³ “Resting pH of mouth does not fall below 6.3. In the oral cavity, the pH is maintained near neutrality (6.7–7.3) by saliva.”² The stimulated saliva is tested through saliva quantity and buffering capacity. All instructions, test strips, and charts are provided. 

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The OralRisk Caries test by OralDNA tests for “three types of harmful bacteria known to cause cavities: Streptococcus mutans, Streptococcus sobrinus and Lactobacillus casei.”⁴ This test is completed via an oral rinse procedure and sent to OralDNA for a report. You and your patients can interpret the level of caries-causing bacteria and devise an appropriate plan for management.  

Home testing has become more popular through the years. As people take a more active role in testing for things such as food sensitivities and fertility, the concept of testing at home is accepted. If an in-office protocol and in-depth testing do not seem feasible, consider purchasing pH strips. Using these tests chairside can also start a conversation about oral pH, and for patients with increased risk, at-home monitoring and data collection may be a good fit. 

An excellent source of information is the podcast “Tipisode” by A Tale of Two Hygienists. Spring Hatfield, RDH, discusses her experience implementing saliva testing chairside and the conversations she’s had with her patients. She shares that though she has worked in many offices, she had not seen the practice of pH testing widely implemented. ⁵ We should be asking, why not? 

Caries management

We know that by educating our patients we can equip them with the prevention tools. A long-standing practice is caries risk assessment (CRA) and caries management by risk assessment (CAMBRA). Though we’ve refined this process in the past 20 years, it’s considered by many to be the standard of care to assess patient risk and educate accordingly. Published in the Journal of Dental Hygiene, a study by Urban and Rowe concluded, “CAMBRA protocol has not been widely implemented in private practice, although the current data do not indicate insurmountable barriers.”⁶ There are a variety of quality resources and studies available at our fingertips if we only take time to implement them into our clinics.  

In an April 2021 article, Featherstone et al. compare four of the most internationally recognized caries risk assessment tools—Cariogram, CAMBRA, American Dental Association, and American Academy of Pediatric Dentistry CRAs. If you want to take a deep dive into finding the best assessment for you, read their article.⁷ Gathering a baseline knowledge of the patient condition can aid in the development of a customized, comprehensive, caries risk and management protocol.  

In addition to assessing your patients’ current oral conditions, items you may discuss as it relates to caries risk management include: 

• Use of fluoride products and other caries preventive agents.
• Diet and consumption of sugary beverages and food.
• History of dental disease and stability of a dental home.
• Systemic health connections such as chemo/radiation treatment, medication use, eating disorders, alcohol, and/or drug use. 

The ADA has resources⁸ available to guide you in the efficient formation and implementation of a protocol in your practice. Some resources include how to implement⁹ a protocol, as well as forms for patients 0-6 years of age¹⁰ and over the age of 6.¹¹ 

A quick self-audit: maybe you already implement these items, but if not, consider implementing a formal caries risk assessment and management program in your practice. Also, consider the ways you and your patients work as a team to improve their oral health. We have the tools, and together with our patients, we can build a plan for health and success!

References 

1. Do you know your saliva pH? Here's why it's important. Colgate. Accessed February 6, 2022. https://www.colgate.com/en-us/oral-health/threats-to-dental-health/do-you-know-your-saliva-ph-heres-why-its-important
2. Baliga S, Muglikar S, Kale R. Salivary pH: A diagnostic biomarker. J Indian Soc Periodontol. 2013;17(4):461-465. doi:10.4103/0972-124X.118317
3. GC America. Saliva-check buffer–test for saliva quality, pH and buffering capacity instructions for use. GC America. Accessed February 6, 2022. https://www.gcamerica.com/products/preventive/Saliva_Check_BUFFER/ 
4. Oral DNA Labs. Oral Risk Caries. 2021. Accessed February 6, 2022. https://oraldna.com/test/ocaries/
5. Hatfield S. A Tale of Two Hygienists podcast. Tipisode: Are you testing your patients’ pH? February 4, 2022. https://www.ataleoftwohygienists.com/listen/tipisode-are-you-testing-your-patients-ph/
6. Urban RA, Rowe DJ. Knowledge, attitudes, and practices of dental hygienists regarding caries management by risk assessment. ADHA J Dent Hygiene. 2015;89(1):55-62. https://jdh.adha.org/content/89/1/55.short
7. Featherstone JD, Crystal YO, Alston P, et al. A comparison of four caries risk assessment methods. Frontiers in Oral Health. 2021;2. doi:10.3389/froh.2021.656558 
8. Caries risk assessment and management. American Dental Association. June 9, 2021. Accessed February 6, 2022. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/caries-risk-assessment-and-management 
9. ADA Caries Risk Assessment Form Completion Instructions. ADA. Accessed February 6, 2022. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/public-programs/give-kids-a-smile/gkas_caries_risk_assessment_forms.pdf
10. Caries Risk Assessment Form age 0-6. ADA. 2011. Accessed February 6, 2022. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/oral-health-topics/topics_caries_under6.pdf 
11. ADA.org: Caries risk assessment >6. Caries Risk Assessment Form (Age >6). 2011. Accessed February 6, 2022. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/oral-health-topics/topic_caries_over6.pdf