Hygiene Tribune Middle East & Africa No. 6, 2023

Hygiene Tribune Middle East & Africa No. 6, 2023

Researchers develop special toothpaste for peanut allergy treatment / Could your patients’ enamel wear end up aging them? Make them look older?

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www.dental-tribune.me

Vol. 13, No. 6

Researchers develop special toothpaste for
peanut allergy treatment
By Iveta Ramonaite, Dental
Tribune International
Oral immunotherapy for peanut allergy entails giving people
small amounts of peanuts over
time to desensitise them to the legume, thus ensuring a milder reaction to peanuts in the future. Now,
researchers have developed a special toothpaste that can eﬀectively
deliver allergenic proteins to immunologically active areas of the
oral cavity. The new approach offers a safe and convenient alternative to allergy immunotherapy for
individuals with food allergies.

Peanut allergy is one of the
most common food allergies in the
world and is especially common in
children. It leads to emergency department admissions and even
fatal allergic reactions, and the
prevalence of peanut allergy is increasing. Its management mostly
involves avoiding the allergen altogether and following an emergency action plan in the event of
accidental exposure to peanuts resulting in an adverse reaction.
Although certain food allergies, such as allergies to eggs or
milk, improve over time, peanut allergy is diﬃcult to outgrow and is
often lifelong. However, thanks to

Researchers have recently developed a toothpaste that may lower the risk of allergic reactions in adults with peanut allergy.
(Image: Freepik)

peanut oral immunotherapy, it is
possible to build a tolerance to
peanuts in children.
Seeking to improve the lives of
people with peanut allergy, researchers have developed a novel
desensitisation method that does
not require patients to actually ingest peanuts. “Oral mucosal immunotherapy (OMIT) uses a specially formulated toothpaste to deliver allergenic peanut proteins to
areas of the oral cavity,” Dr William
E. Berger, who led the research and
is a board-certiﬁed paediatric allergist at Children’s Hospital of Orange County in the US, said in a
press release. “OMIT as a delivery
mechanism for peanut protein has

great potential for food allergy desensitisation. Due to its targeted
delivery and simple administration, it supports the goal of improved adherence,” he added.
The study enrolled 32 adults
with peanut allergies aged between 18 and 55, who received either an increasing dose of peanut
toothpaste or a placebo. The participants were then observed over
48 weeks.
“We noted that 100% of those
being treated with the toothpaste
consistently
tolerated
the
pre-speciﬁed protocol highest
dose,” Dr Berger stated. “No moderate nor severe systemic reactions occurred in active partici-

pants. Non-systemic adverse reactions were mostly local (oral itching), mild and transient. There was
97% adherence to treatment with
no dropouts due to study medication.”
The researchers now plan to
carry out additional long-term
studies to further evaluate the use
of the toothpaste therapy to provide long-term protection against
accidental ingestion of peanuts.
“OMIT appears to be a safe
and convenient option for adults
with food allergies. The results
support continued development
of this toothpaste in the paediatric
population,” Dr Berger concluded.

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HYGIENE TRIBUNE

Hygiene Tribune Middle East & Africa Edition | 06/2023

Could your patients’ enamel wear end up
aging them? Make them look older?
By HALEON
Nobody wants to look old before their time, yet when it comes
to the signs of ageing, we worry
about most, teeth are often lower
on the list. Twice as many people
fear their skin becoming wrinkly or
losing elasticity versus those concerned about tooth wear.1 The
numbers reﬂect our behaviors; we
routinely take steps to protect our
skin from sun damage but fewer
actively look to prevent enamel
wear. It’s surprising. Because although there’s no causal link between age and tooth wear, the
most visible symptoms of wear –
surface changes (smoothing),
translucency, yellowing, loss of
structural features (such as rounding) – can create the appearance of
aging, making us look or feel older
than we actually are.
But it’s not just about aesthetics. Tooth wear can negatively impact self-esteem, body image, and
quality of life. 2,3,4,5 It can also lead
to dentin hypersensitivity6 and, in
extreme cases, complete loss of
the crown7. Progression isn’t inevitable – but steps can be taken to
help prevent it.
Dental healthcare professionals (DHCPs) can help patients prevent erosive tooth wear (ETW);
they’re the only people who can
spot the early signs. When patients
are alerted to the problem, they
can be motivated to act.
Management hinges on athome behaviors: diet, lifestyle, and
oral hygiene. However, prevention
begins in clinical practice, with
DHCPs routinely checking for
symptoms and tailoring advice.
In a world where appearance
matters more than ever,8,9 DHCPs
can help patients avoid the ramiﬁcations of ETW. If they protect their
enamel like they protect their skin,
the risk of tooth wear can be reduced.
What is ETW?
ETW is the cumulative loss of
mineralized tooth substance with
dental erosion being the primary
cause.10 The term recognizes that
although severe tooth wear rarely
occurs without erosion, erosion almost always has a partner in crime.
“ETW is erosion combined with
other forms of physical wear such
as abrasion and attrition,” says Professor David Bartlett, Head of the
Centre for Oral, Clinical & Translational Science and Prosthodontics,
King’s College London. “The term is
an acknowledgment that with ETW,
in most instances, you have a combined eﬀect: chemical loss (erosion), and mechanical loss (wear).”
Scientists believe frequent acid
exposure on to enamel overwhelms
protection from the pellicle (the
protective ﬁlm over enamel that

60. The growth of aesthetic dentistry24 suggests people are open
to invasive procedures to achieve
the perfect smile. However, young
adults shouldn’t have to wait until
restorative treatment is the only
option. They’re a willing audience
for tooth wear prevention.

(Image: Freepik)

comes from saliva) and saliva, leaving teeth vulnerable11. “The enamel,
we believe, demineralizes: the
outer surface of it, and some inner
surface, lose the ions into the saliva,” says Prof. Barlett. “If you help
stop that process, then that mineral
bit can re-calcify, reharden. If the
acid eﬀects on enamel are not repaired by saliva or toothpaste the
surface remains porous and weak.
If a mechanical process such as
abrasion or attrition acts on that
surface it can be worn away. And
once that surface is lost, it is lost
forever.”
Tooth wear is sometimes described as erosion, but erosion is
just the opening act. Dr Jon Creeth,
Principal Medical Aﬀairs Scientist,
GSK Consumer Healthcare, explains:
“Dietary acids soften enamel
and can lead to erosion, but that
really only sets teeth up for being
vulnerable to wear through surface-to-surface contact.”12,13 When
enamel is over-exposed to dietary
acids, even toothbrushing can
damage it.12,13 Jon explains that in
addition to avoiding toothbrushing
directly after consuming acidic
food or drink, a toothpaste with a
mild abrasive can help minimize
the risk14,15.
Prevalence & Awareness
Prevalence
The global prevalence of erosive tooth wear (ETW) ranges between 20-45%,16,17 with 2-10% of
adults and children showing severe
signs of wear that might need
treatment.16,18 Prevalence and severity are reported to increase with
age,17,19,20 with the cumulative effects of dietary acids, chewing, and

bruxism invariably leading to wear.
The risk of severe wear increases
from 3% at 20 years old to 17% at
70. 21
However, there are signs that
tooth wear is becoming more common in younger people. In a European study, 29% of young adults
had distinct ETW, 22 and severe wear
is increasing in adolescents too.19,20
The trends are largely attributed to
modern diets and lifestyles. The
consumption of acidic soft drinks23
and fruit has skyrocketed, while the
pursuit of the ‘perfect smile’ – a
Gen-Z priority24 – can lead to excessive or more vigorous brushing
known to increase the risk of
enamel wear.12,13
Ester Hoekstra, a teaching and
practicing dental hygienist in Germany, says the eﬀects are showing
up in the waiting room.
“I can remember that erosion
patients were rare. Nowadays I see
multiple patients a week with early
signs of erosion. You see [it] with
children, but also in teenagers, and
yes with 20-30 years old. You see a
lot more erosion… They have more
erosion from dietary acids.” And for
late-stage erosion, “most of the
time, these patients who have sensitive teeth, they develop anxiety
because it hurts all the time.”
However, Prof. Nicola West,
Professor of Periodontology and
Head of the Clinical Trials Unit at
the School of Oral and Dental Sciences, University of Bristol, UK, reports that as expectations of a
pleasing dentition grow, attitudes
to tooth wear are crystallizing
among young adults - the majority
think it’s unacceptable to have noticeable wear under the age of 30,
many believe it’s only palatable at

Awareness
Public understanding of ETW is
patchy. Patients rarely detect
changes in tooth shape and structure until they’re severe, 25 but
they’re often only given preventive
advice when they present with hypersensitivity or severe tooth
wear. 26
“I don’t think patients are aware
of erosion,” says Ester. “Most are
surprised when I explain it. They’ll
say: ‘but I’m eating so healthy’ or
‘I didn’t realize cola is acidic’. The
role a dental healthcare professional [DHCP] can play is to educate
the patient, to increase the awareness of erosion.”
Awareness among DHCPs is
also variable, with research indicating some may not have the conﬁdence to diagnose mild tooth
wear. 27,28,29 A 2020 study found
many dentists in the US struggled
to detect ETW until severe. They
were also much less conﬁdent
judging teeth with ETW and less
able to determine if those teeth required management compared to
teeth with decay. 30
ETW is standard training in
dental schools, but, says Ester,
there’s room for improvement. “It
deﬁnitely needs more focus because we see it in a lot of patients….
Some dental healthcare professionals may not know what to look
for.”
Assessment
Early diagnosis of ETW is vital.
Patients often only notice wear
when their teeth look thinner or
more yellow. 31 It’s harder to treat at
this stage. DHCPs are the only ones
who can see the early signs – but
only if they’re actively looking for
them. Unfortunately, dental examinations rarely include routine assessment of ETW.
“We shouldn’t be waiting until
patients have got it so bad that
they’ve got to do something about
it. We should get into the routine of
looking for it, identifying if it's
there, and therefore giving preventive advice as and when it’s
needed,” says Prof. David Bartlett.
“We can’t tell if a person with wear
at 20 will inevitably get worse as
they get older – because we don’t
know, on an individual basis, what
their story is. However, we do know
that if they continue with risk factors it’s likely to get worse”.
“The idea is to check everybody. So we pick up those people
who've got more severe tooth wear

at the earliest stage that we can….
to try and reduce the risk of [it getting so bad]… So, regularly and
routinely look for it. And once
we've found it, to react with prevention.”
According to Prof. Barlett,
there’s currently no data available
to determine a ‘normal’ rate of
wear. The most likely scenario, he
says, is that there are periods when
the rate of wear increases – and
that usually coincides with active
risk factors. When risks are controlled, the rate of wear reduces. 32
A standardized format to record tooth wear as part of routine
dental examinations was devised in
2008. The Basic Erosive Tooth Wear
index (BEWE) helps dentists score
changes to the surface of teeth regardless of etiology, 27 enabling
them to evaluate the severity of
tooth wear systematically. The buccal, occlusal and/or incisal and lingual/palatal surfaces are assessed
in each sextant,33 with dentists
looking for subtle changes in
enamel and scoring each sextant
according to the worst-aﬀected
surface.
BEWE uses a 4-point scale to
assess wear: 0 – no sign of wear;
1 – ﬁrst signs of wear with rounding
of cups and grooves; 2 – distinct
wear <50% of the surface area;
3 – hard tissue loss >50% of the surface area. 33
BEWE was designed to be simple and prevention-focused – to
make it easier for dentists to look
for signs of ETW regularly and routinely. “It’s designed to actually reduce the amount of time and therefore cost to the dentist,” says Prof.
Barlett. “You go methodically, in
each sextant… and you go round in
a routine, so you don't miss anything. You do that for gums, and
we're recommending you do it for
erosive tooth wear at the same
time. And then you record it in the
notes.”
Adoption of the BEWE is growing as policymakers push to make
examining and recording tooth
wear a requirement of clinical practice34. The potential beneﬁts, for
both patient and DHCP, are signiﬁcant. If ETW is not picked up early
through preventive dentistry, it
may have ramiﬁcations further
down the line when patients experience more severe wear and may
question why it wasn’t detected
sooner.
Prevention & solution
Prevention: Risk factors
Prevention of ETW is primarily
about reducing risk factors. Strategies work at every stage of progression; even teeth with severe

▶ Page E4

[3] => DTMEA_No.6. Vol.13_HT.indd

ENJOY

STEAMING
HOT

YOUR DENTIST OR
HYGIENIST HAS RECOMMENDED

WHAT IS SENSITIVITY AND HOW COULD IT BE AFFECTING YOU?
Sensitivity is often described as a short, sharp pain in
the teeth.
Sensitive teeth develop when the inner layer of your teeth
(called dentin) becomes exposed and is no longer protected
by the hard enamel or gums. This means that triggers such
as cold and hot drinks can activate nerves, deep inside the
tooth, causing pain.

HOW CAN I LOOK AFTER MY SENSITIVE TEETH?

Triggers of sensitivity

Cold foods/
drinks

Cold
weather

Hot foods/
drinks

Sweet or sour
Touch (from
foods/drinks your toothbrush)

SENSODYNE Advanced REPAIR & PROTECT DEEP REPAIR

Brush with Sensodyne Advanced Repair & Protect Deep
Repair twice a day, every day, instead of a regular
toothpaste

Clinically proven relief from the pain of sensitivity, and
long-lasting protection so you can enjoy life without the
worry of sensitivity

Maintain good oral hygiene – brush twice a day, every
day

Scientiﬁcally proven to go deep

Avoid brushing aggressively*

Creates a robust reparative layer over and within
exposed dentin for strong repair

Use a soft toothbrush

If your sensitivity pain continues, contact your dentist.

* Ask your dentist or hygienist for advice on the most appropriate brushing technique for you.
PM-BH-SENO-22-00011 prepared on March 221

[4] => DTMEA_No.6. Vol.13_HT.indd

HYGIENE TRIBUNE

Hygiene Tribune Middle East & Africa Edition | 06/2023

◀ Page E2
wear can beneﬁt from changes in
behaviour. 32 However, in young
adults, early intervention is key.
Dental healthcare professionals
can play a crucial role in guiding
them to the right approach.
“The more we educate our patients the better we can help them,”
says Hoekstra. “To educate about
healthy food for body and teeth. To
give tips on how to clean their teeth
at home, to educate about ﬂuoride
and the diﬀerence between toothpaste. As dental hygienists, we
have and take time for that.”
But, says Hoekstra, prevention
is a team sport, and all DHCPs have
a role to play. “It’s important that
they explain what erosion is and
why it’s bad for teeth. We have to
tell patients something! We need
to move to Talking Dentistry.”
Risk factors include acid reﬂux,
bulimia, and excessive oral hygiene. But the most common driver
is dietary acids. Reducing the frequency of acidic foods and drinks,
particularly outside mealtimes, is
key. 32 That’s tough for teenagers –
the core market for a carbonated
soft drinks industry that is growing
considerably. 35 Duration of consumption is a bigger risk than volume; sipping lemonade throughout the day is more damaging than
downing it at mealtime.
Acidic foods are equally challenging. Most patients think fruit is
healthy – which they are - but don’t
recognize that some carry an acidic
risk. Advising patients to have
acidic foods and drinks at mealtimes and ideally to neutralize their
mouths with milk or cheese after
acidic foods is good practice. 31
The best approach is to talk to
patients. Through conversation, it’s
often possible to uncover a dietary
habit – like ‘swishing’ or snacking –
and respond with prevention32.
Asking patients to keep a diary of
what they eat isn’t always eﬀective,
“Automatically, they think about it
and adjust their diet… It’s never an
honest diary,” says Ester. “I prefer to
ask: ‘what did you eat today?’ I can
get more out of it. Once I had a patient, who ate perfectly ﬁne. Drank
1 or 2 glasses of cola every day, but
nothing else was out of the ordinary. After 2 appointments and
treatments, I found out through
chatting with him during the treatment, he was playing with his cola
when he drank it. He was pulling it
between his teeth before swallowing it - swishing. We have to talk to
our patients. That's very important.
That way, we know how they tick
and how we can help them adjust
their behaviour.”
Sustaining behavior change is
diﬃcult; our habits and attitudes
are hardwired. One approach that’s
proven successful with some
DHCPs is to adopt the COM-B
model of behavior change when interacting with patients. The COM-B
model argues that there are three
components to any behavior – Capability, Opportunity, and Motivation – and that positive dialogue
around each of these can help
identify barriers to change and design interventions to help overcome them. 36
One behavior that’s easier to
change is our choice of toothpaste.

Prevention: Solution
Fluoride Toothpaste
Epidemiological studies show
that ﬂuoridation of water and regular use of ﬂuoridated toothpaste
provide added protection from
dental erosion. 37 However, while
the protective beneﬁts of ﬂuoride
are widely understood, its reparative beneﬁts are less well known.
They’re key to halting progression.
Dr. Creeth, explains: “Fluoride goes
into the surface of enamel; it protects it and slows acids from dissolving your teeth. But the way it
does that is by repairing the ﬁrst
stages of acid attack. When the
surface of enamel loses mineral,
ﬂuoride helps put it back. Fluoride
helps the calcium and phosphate in
the saliva go down to the surface
[of the enamel] and repair any
damage. It’s not just about helping
stop things from getting worse – if
you catch wear early enough, it can
help make things better.”38
Longitudinal studies show that
twice-daily brushing with a ﬂuoride
toothpaste results in less tooth
wear than in those who brush less
frequently. 37,39 As such, twice-daily
brushing is gold-standard advice
for tooth wear prevention. However, the formulation of a toothpaste can signiﬁcantly inﬂuence
the delivery of active ﬂuoride into
the enamel. Many ingredients used
in toothpaste can reduce ﬂuoride’s
beneﬁts.
“Lots of abrasives react with
ﬂuoride… detergents that you put
into a toothpaste to make it foam
can interfere with ﬂuoride binding
to enamel,” says Jon. “Polyphosphates – for stain removal – can
also stop the ﬂuoride sticking to
the tooth surface and interfere with
that re-mineralizing process.”
“Pronamel’s optimized technology has been shown to be
highly eﬀective at delivering ﬂuoride to enamel after dietary acid attack,” says Dr Creeth. “It uses a specially chosen detergent to minimize
interference with ﬂuoride binding
to enamel. And a high purity abrasive that doesn’t interfere with ﬂuoride’s beneﬁts – giving patients
high ﬂuoride delivery and good
mineralization to help repair any
early signs of damage.”
Superheroes for smile
The associations between
aging and tooth wear continue to
be explored. Scientiﬁcally, studies
have shown that enamel wear generally increases with age17,19,20 and
can aﬀect anyone – but the evidence-base to date isn’t substantial. Nevertheless, patients’ perceptions matter.
“There isn’t an awful lot of evidence to say as you get older you
inevitably get more tooth wear,”
says Prof. David Bartlett. “But one
of the signs of aging – according to
patients – is that their teeth get
shorter and become yellower and
more translucent. That, in their perception, is understood as aging.
“The weight of clinical evidence
to support age and progression is
insuﬃcient at a clinical level. There
is evidence for a slow and progressive increase and wear over time,
but the main factor in creating a situation where a dentist can recognize wear is the risk factors.”

By routinely assessing tooth
wear and communicating the risk
factors, dental healthcare professionals can play a major part in educating patients and helping them
prevent tooth wear. So patients can
think about caring for their teeth
like they think about caring for their
skin.
It’s the chance to be a superhero for smiles – and help stop patients feeling old before their time.
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Researchers develop special toothpaste for peanut allergy treatment / Could your patients’ enamel wear end up aging them? Make them look older?

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