Content Dam Diq Online Articles 2017 08 Goldilocks Diqthumb

The Goldilocks principle: Finding a caries treatment that fits right

Aug. 22, 2017
We need to change the way we think about caries treatment, according to Patti DiGangi, RDH, BS. In this article, she makes a case for measuring pH and assessing risk, then identifies a remineralizing product that allows for teeth to be treated and cleaned in a single step.
"THIS PORRIDGE IS TOO HOT," Goldilocks exclaimed.
So she tasted the porridge from the second bowl.
"This porridge is too cold."
So she tasted the last bowl of porridge.
"Ahh, this porridge is just right!" she said happily.
And she ate it all up.

The Goldilocks principle is well known to most of us. It’s about finding the right fit, whether it be for our food, shoes, clothes, work, or oral health. This month MI Paste One from GC America was launched for patient use at home. This paste will be a good fit for many patients by allowing them to treat and clean in a single step.

Caries: A pH-mediated infection

To better understand the opportunity MI Paste One provides, we need to consider our traditional disease-based thinking. We have been using the terms "caries" and "cavity" interchangeably. This is no longer accurate. Current cariology theory has moved from a thinking of caries as a hole to be fixed to thinking of it as a risk that can be eliminated, reduced, and managed.

In other words, caries is an infection, and a cavity is the outcome. Repairing the cavity with a restoration does not eliminate the infection or risk for infection.

What’s more, caries is a pH-mediated infection, not caused by sugar. (1) It’s time to shift dentistry’s focus from finding the results of the infection (i.e., a cavity) to treating the infection. Watching and waiting make no sense.

Many of us were taught the specific plaque hypothesis. Although there are many species in the oral flora, the theory stated that only a few specific species caused damage. (2) That theory has been replaced with the ecological plaque hypothesis. Rather than asserting that specific species cause damage, this theory says the biofilm shifts from being balanced and supporting health to having an acidic pH that allows certain species to thrive. (1)

We all learned the pH scale goes from 1 to 14, with a pH of 1 being the most acidic with a pH of 7 being neutral. Studies have shown acidic pH levels are associated with a greater risk of serious health conditions, including type 2 diabetes, heart disease, and obesity. (3–5) At a pH of 5.5, the teeth begin to demineralize, putting them at risk for caries infection.

Demin-remin cycles

Enamel and dentin go through unlimited cycles of oral demineralization and remineralization. Under normal physiological conditions, salivary pH ranges from 6.2 to 7.6 and is supersaturated with calcium and phosphate ions. When the pH falls to 4.5–5.5, a shift occurs, and the saturation point of the minerals changes.

The lower the pH, the higher the concentrations of calcium and phosphate required to reach saturation with respect to hydroxyapatite. (6) This is called the critical pH. (6) The critical pH is around 5.5 for hydroxyapatite and around 4.5 for fluorapatite. (6) Demineralization occurs below the critical pH, while remineralization occurs above the critical pH. (6) This cycle is dependent on enamel solubility and ion gradients, and it varies with individual patients. (6)

Measuring pH

Neither dental professionals nor patients can magically know their pH without testing. The diagnosis of active phases and patients at risk for active disease is challenging for clinicians. There are compelling reasons to use saliva as a diagnostic fluid. It’s easy to access, inexpensive, noninvasive, and easy-to-use.

I love GC Tri Plaque ID Gel (GC America).It is a chairside diagnostic assessment and motivation test that helps dental professionals and patients easily visualize what is happening in their mouths. Disclosing is not anything new, but this gel is unique because it identifies new (red-pink), mature (dark blue–purple), and acid-producing biofilms (light blue).

When you and the patient see light blue, you know the biofilm has a pH of less than 4.5. This raises many questions, such as, “Should you scale and polish?” Raising the pH is critical before scaling and polishing. This is a necessary break from tradition. Knowing the pH gives us compelling reasons to change.

Another in-office product is Saliva-Check Buffer (GC America). This saliva risk assessment examination tool identifies, measures, and assesses the patient’s saliva condition. It helps determine the risk of active caries infections. It tests for hydration, salivary consistency, resting saliva pH, stimulated saliva flow, stimulated saliva pH and saliva buffering capacity. It is ideal for use during routine oral examinations for both the clinician and patient. It provides tangible reasons for change.

We know many things affect pH. After you demonstrate pH to the patient at the office, we want to continue the person’s awareness. Almost all of our patient have smartphones. Developed by A.T. Still University Dental School in Mesa, Arizona, pH2OH is a free mobile app that works with both iOS and Android and requires no login.

All that is needed are testing supplies created by GC America that can be purchased through Henry Schein. Your office can order this very inexpensive test for your patients. To begin using the app, the patient clicks on My pH2OH. Then, the patient simply expectorates on the pH paper and uses the smartphone camera to take a photo of the paper and determine the pH value. This value can be saved, graphed, and compared.

Product evolution: A treatment that fits right

Knowing the pH has provided compelling, tangible reasons to do something. Should it be the traditional brush, floss, rinse lecture? How well does that work?

By now, most oral health professionals have heard of Recaldent (CPP-ACP). The mechanism of action works this way: fluoride ions promote the formation of fluorapatite in the presence of calcium and phosphate ions, yet fluoride ions can only promote remineralization of enamel with fluorapatite if enough salivary calcium and phosphate ions are available when the fluoride is applied. This means the topical application of fluoride ions is the limiting factor for net enamel remineralization to occur. (7,8)

Casein phosphopeptide (CPP) is an amorphous calcium phosphate (ACP) carrier localizing the highly soluble calcium phosphate at the tooth surface. This localization maintains a high concentration of calcium and phosphate ions in the subsurface enamel and surrounding biofilm, thereby facilitating remineralization.CPP-ACP, coupled with fluoride, has been shown to increase fluoride’s uptake into subsurface enamel and increase subsurface enamel remineralizationdue to the bioavailable ions. (7,8)

Introducing MI Paste One

For more than a decade, GC America has manufactured minimal intervention products containing Recaldent (CPP-ACP) technology:

  • MI Paste with Recaldent (CPP-ACP) bioavailable calcium and phosphate (2003)
  • MI Paste Plus with Recaldent (CPP-ACP) bioavailable calcium and phosphate enhanced with a patented form of 900 ppm fluoride (2005)
  • MI Varnish with Recaldent (CPP-ACP) helps drive beneficial ions into the tooth, enhances enamel acid resistance, and boosts the salivary fluoride level (2012)

The newest product isMI Paste One, which has the same clinical benefit of MI Paste Plus without the need for a separate step. MI Paste One has all the features enabled by Recaldent (CPP-ACP), plus those of a toothpaste:

  • Remineralizes with calcium, phosphate, and fluoride
  • Binds to the tooth surfaces to localize bioavailable minerals
  • Occludes the dentinal tubules with CPP-ACP
  • Contains 1,100 ppm sodium fluoride
  • Contains 5% potassium nitrate

In addition to 10% Recaldent (CPP-ACP), MI Paste One also contains sodium fluoride and 5% potassium nitrate. For maximum benefit (just like regular toothpastes), it is recommended not to rinse immediately after brushing with MI Paste One. (9) MI Paste One is free of sodium lauryl sulfate (SLS) and contains a milder surfactant instead. The mild foaming helps to reduce the discomfort after no-rinse brushing. It is designed to be effective at cleaning yet gentle to teeth. MI Paste One has a relative dentin abrasivity (RDA) value of 64.

"This product takes too much time," Goldilocks exclaimed.
So she tried the second product.
"This product doesn’t clean very well."
So she tried the last product, MI Paste One.
"Ahh, this product is just right—treatment and cleaning in a single step."
And she used it twice a day as instructed.

Editor's note: This article first appeared in Pearls for Your Practice: The Product Navigator.Click here to subscribe. Click here to submit a products article for consideration.


1. Hurlbutt M, Novy B, Young D. Dental caries: A pH-mediated disease. CDHA J. 2010;25(1):9-15. Accessed July 20, 2017.

2. Rosier BT, De Jager M, Zaura E, Krom BP. Historical and contemporary hypotheses on the development of oral diseases: are we there yet? Front Cell Infect Microbiol. 2014;4:92. Accessed July 20, 2017.

3. Javaid MA, Ahmed AS, Durand R, Tran SD. Saliva as a diagnostic tool for oral and systemic diseases. J Oral Biol Craniofac Res. 2016;6(1):66-75. Accessed July 22, 2017

4. Rosengard H, Elston D. Oral manifestations of systemic diseases. Medscape website. Published July 27, 2016. Accessed July 22, 2017.

5. Nagelberg R. The tidal wave of saliva research. Dental Economics website. Published March 30, 2016. Accessed July 22, 2017.

6. Dawes C. What is the critical pH and why does a tooth dissolve in acid? J Can Dent Assoc 2003; 69(11):722–4. Available at: Accessed 7/22/17

7. Kaira DD, Kalra RD, Kini PC, Allama Prabhy CR. Nonfluoride remineralization: An evidence-based review of contemporary technologies. J Dent Alli Sci. 2014;2:24-33.;year=2014;volume=3;issue=1;spage=24;epage=33;aulast=Kalra. Accessed July 22, 2017.

8. Moezizadeh M, Moayedi S. Anticariogenic effect of amorphous calcium phosphate stabilized by casein phosphopeptide: A review article. J Biol Sci. 2009;4(1):132-136. Accessed July 22, 2017.

9. Pitts N, Duckworth RM, Marsh P, Mutti B, Parnell C, Zero D. Post-brushing rinsing for the control of dental caries: Exploration of the available evidence to establish what advice we should give our patients. Br Dent J. 2012;212(7):315-320. doi: 10.1038/sj.bdj.2012.260. Accessed July 25, 2017.

Patti DiGangi, RDH, BS, is an international speaker and author helping dental professionals to embrace the opportunities and understand the metrics that accurate insurance coding provides. This increases practice profitability while improving the oral-systemic health of the patients we serve. Patti holds publishing and speaking licenses with the American Dental Association (ADA) for Current Dental Terminologyand SNODENT diagnostic coding. She is an ADA Evidence-Based Champion and a member of the National Speaker’s Association. She is the author of the DentalCodeology series of bite-sized books to help dental professionals prepare for the transition toward oral medicine efficiently and profitably. Patti can be reached at [email protected].
For the most current dental product articles, click here.
For the most current dental headlines, click here.