The mouth is an ecosystem. A microscopic living, breathing, eating and digesting system that has co-evolved with us since pre-historic times. Just like a coral reef, it exists at the space between two worlds…the hard and the soft tissues on which it sits, is like the bottom of the sea; and the free flowing saliva, is like the ocean.
Emerging science calls this oral ecosystem, ‘the biofilm’, and it acts as an intelligent semi-permeable membrane. Foundational research in this field is being done by P.D. Marsh of the Leeds Dental Institute in the U.K., David Relman out at Stanford University in Palo Alto, and at the Center for Biofilm Engineering at the University of Montana/Bozeman campus.
The biofilm absorbs nutrients and excretes its waste into the saliva.
The Biofilm also exchanges with the structures on which it sits. But these exchanges are dependent on the condition of this ecosystem. It can be a storehouse of the minerals and ions that keep enamel hard and the pH neutral. Or, if the organisms in the biofilm demand free calcium or phosphate, they may create a deficit of these minerals and ions with the result being a low pH and demineralization.
The concept of the biofilm serving as a storehouse or being in deficit goes far beyond commonly known minerals and ions. Less well known is the balance of molecular and ionic oxygen. Molecular oxygen supports aerobic bugs and keeps anerobic bugs from overgrowing. Ionic oxygen is a free radical that can damage epithelial cell membranes. Bacteria in an unbalanced biofilm secrete radical oxygen in order to poke holes in cell membranes and get the cytoplasm to leak out—to them, it’s just like candy! When it happens, we see gingivitis.
The biofilm is made up of water, salivary proteins, crevicular fluid, immune complexes, minerals, and vast numbers of microorganisms—these are mostly bacteria and, in a balanced biofilm most of these are aerobic. For aerobes to stay healthy the biofilm needs to be structured so that molecular oxygen, “O-2” can permeate it.
In addition to exchanging with the saliva above and the tissues below, the biofilm protects the hard tissues from drying out and it aids in keeping the lining of the mouth well lubricated. Think of salivary muco-proteins as oil in a machine; think of the bacteria as really tiny ball bearings—reducing friction as a bolus of food happens by.
The bacteria that make up the biofilm differ from the free floating organisms in saliva as they exhibit complex architectural structures.
The bacteria of the biofilm form clusters that include mixed species. These co-operate with each other and have several kinds of intelligence: They can sense the number of their own species as well as the number of other species through a process called ‘quorum sensing’, and by doing so they can adjust their own biochemical processes in order to fit better into the collective. Second, they form relatively stable structures to assure adequate nutrient collection, waste removal and collective survival. Third, the organisms can modulate their positioning within the biofilm so that a challenge or a threat from, say, a topically applied antibiotic, will be met with a layer of organisms most able to prevent penetration…It is like a garden or a meadow, with many species living in harmony, but it is also like a bee-hive with a well formed structure and agreed upon job descriptions.
Every living thing that possesses a mouth possesses a unique oral biofilm. The community of organisms in the mouth of a human or dog or cat are all different from the organisms alive within the mouths of sharks or frogs or giraffes, or komodo dragons—like this youngster.
Each of these ecosystems has co-evolved with its host, and by the laws of evolution, these bugs confer a survival advantage. Otherwise, if, they resulted in early disease or death, the bugs would have less chance to survive and propagate.
Take Mr. Komodo here. He lives on a few islands in Indonesia, and he’s handsome, but he is not a good long distance runner. So he catches his prey by administering a quick bite, and then he waits around, sometimes for a few days for the pathogenic bacteria which inhabit his biofilm, but don’t affect him, to cause sepsis and death in his prey.
In November, 2005, National Geographic reported that if you totaled up all of the bacterial DNA in all of the biofilms in and on a person, you’d find ten times as much bacterial DNA as there is human DNA.
It is as if we are living to be a good substrate for all of these bugs! It means that it goes against the laws of nature to try to eliminate a naturally occurring, beneficial, symbiotic community of organisms from the oral cavity—an environment that has not been found to be germ free in any species on the planet—in a misguided attempt to control disease.
The oral biofilm exists on a spectrum. It begins with the acquired pellicle and within minutes, in healthy circumstances, it is colonized and organized by aerobic bacteria.
If the early colonizers form without ecological stress then they form a low film thickness, helpful, friendly, odorless biofilm that controls the pH and mineral balance for the hard tissues and keeps chemical and physical insults from reaching the soft tissues. This layer is odorless, and teeth coated with this biofilm feel smooth and slick to the tongue. This is a Balanced Biofilm, because there is a symbiosis between the bugs and us—it’s a win-win situation.
But if the biofilm becomes unbalanced—it often starts with lots of carbohydrates—we get an unbalanced --‘win’ for the bugs, but ‘lose’ for us.
The early colonizers get matted down and convert from aerobes to facultative anaerobes. These form the ‘soil’ in which true anerobes take root. The opportunistic bugs pile up and destroy the architecture of the basal layer. The molecular oxygen tension within this high film thickness biofilm approaches zero, and an entirely different metabolism begins.
Now we have low pH gradients propagating through the basal layer and a reciprocal mineral transport up through the basal layer and into the crown layer...We have the production of bacterial toxins in quantities sufficient to create stress in the cell membranes that border the biofilm. This is called ‘oxidative stress’ and is due to the oxidation or ‘rusting’ of the cell membranes that occurs as a result of the ionic oxygen present in the bacterial toxins. As cell membranes lose their ability to control outflow and inflow, their own nutrients leak out, feeding the biofilm, and a process of cellular inflammation and destruction follows.
The common approach to oral biofilm management is to strip it down to the pellicle with detergents alone or in combination with antimicrobial agents to slow or prevent recolonization. But this approach ignores three laws of nature:
First, Darwin’s Theory of Natural Selection guarantees that the long term use of agents designed to suppress the growth of certain organisms will result in abundant growth of strains that are virulent enough to resist these agents. The result of this is that if a patient has been managing his or her oral cavity with an agent meant to work in this way over a prolonged period of time, then sooner or later…but it is inevitable… a resistant ecosystem will establish itself that will be much harder to eliminate.
Second is the law that: “Nature abhors a vacuum.” What this means is that, if the conditions exist for the survival and propagation of life, even an ecosystem stripped bare, will not remain bare for long. This is a picture of the crater rim around Mt. St. Helen’s less than one year after its devastating eruption in 1980. This is ‘fire-weed,’ an ‘early colonizer,’ which began to grow abundantly almost as soon as the ashes were cool. The implications in the mouth are that, even if an approach designed to ‘kill 100% of the germs’ was successful, the oral ecosystem would not stay germ free for any length of time.
The third law is that ecosystems are stable but subject to becoming unbalanced. Recent science has shown that the oral ecosystem is a marvel of complexity, stability, and balance. But if it is disturbed beyond its homeostatic limit, it will degenerate into an irritating, smelly, pathogenic mass. But if we assist this ecosystem to stay in balance, or assist it in righting itself if it has become unbalanced, we can use the benefits of this biofilm to help support and maintain our hard and soft oral tissues.
If we strip the oral ecosystem bare, the re-establishment of a symbiotic biofilm is not guaranteed. Its the same in any ecosystem stripped bare. If a farmer ploughs a meadow down to the dirt, the first new growth will likely be weeds. This is a picture of ‘goosefoot,’ a common weed found in recently dug up soil.
A common occurrence in people who use detergent based oral hygiene products alone or in concert with antimicrobial ingredients is that the biofilm does re-grow but becomes unbalanced at a much faster rate than would a biofilm that has been allowed to mature without these biologic stressors. Because of this, plaque forms more rapidly, requiring more frequent brushing, simply to keep the teeth feeling, “squeaky clean.” Also, too frequent tooth brushing is a risk factor for root surface hypersensitivity, particularly if the toothpaste contains high concentrations of silica, which is a mineral that is harder than enamel and can erode it.
If you have a balanced oral biofilm in your mouth and you brush your teeth with a non-detergent, non-antimicrobial toothpaste before you go to bed, your teeth ought to feel as squeaky clean when you wake up in the morning as they did after you brushed. But if you use a conventional product, your teeth will feel coated in the morning, even if you didn’t get up in the middle of the night for milk and cookies.
But if we partner with the ecosystem— supporting native species that grow well together, nourishing the soil to serve as a strong foundation for organic growth, and steering clear of harsh chemicals that can stress or unbalance the ecosystem, then we, as physicians of the mouth…as ‘oral ecologists’…can work with the forces of nature in the same way as the organic gardener did who created this beautiful garden.
Our goal becomes driving the ecosystem to its low film thickness, odorless, protective, slick and slippery state, by supporting the organisms and biochemistry that favors that niche. This has the effect of making it tough for the high film thickness ecosystem to maintain itself, not because we kill it off with detergents, antimicrobials or alcohols, but because it has different biochemical needs and we exploit that difference. We do this in the same way an organic gardener tends his or her garden, only our plants and flowers are really, really tiny and we can do it pretty quick, because the speed of biological maturation and biochemical turnover is orders of magnitude faster on the micro-biology level. How do we do it?
We feed the biofilm a vitamin and mineral rich diet that fortifies it against degenerative change. The specific type of each ingredient and the specific ratios of each ingredient, along with how we keep the formula stable is all proprietary information. I developed the earliest version of this formula in a back room of my dental practice. After thirteen years, three patents, and the help of a product development chemist brought in the convert my formula into a commercializable product, we now have Revitin Oral Therapy for sale. The active portion of the formula is called NuPath Bioactives, and we plan other products with NuPath inside.
The benefits to managing the oral biofilm in an ecological way are tremendous. Teeth stay smooth and slick; if you brush at night before bedtime, they still feel squeaky clean in the morning. Any meal with refined carbohydrates will result in a change in the biofilm where it becomes thick and cheesy—what we call ‘plaque,’ but when the biofilm is healthy, it resists this degradation and less plaque builds up.
Gum tissues stop bleeding and acute inflammation disappears, usually in a week. This holds true even for problem patients, for instance, in poorly controlled diabetics, where their capillary walls are friable and their crevicular fluid can run a bit sweet. We have seen patients who, despite regular periodontal maintenance visits for over a decade, finally are able to brush their teeth without seeing bleeding—and this is after a week of using Revitin. Also, if they run out and switch to a conventional toothpaste, the bleeding resumes. You will be amazed to see just how very quickly a biofilm can be made healthy and how very quickly this translates into firm, toned gum tissue.
Without question, our most dramatic testimonials have come from cancer patients who are undergoing chemotherapy and suffer from chemotherapy associated mucositis. For years we manufactured only very small test batches and had no product for sale, let alone to give away to patients. But someone undergoing chemo would somehow get a sample and then the letters or e-mails would start, “Please, can I have some more of this product. It is the only thing that helps my mouth feel better.”
Hard tissue mineralization is an easy thing. The low film thickness, healthy biofilm is naturally very slightly alkaline and has a high concentration of calcium, phosphate, and other minerals helpful for the maintenance of strong, hard enamel and dentin. Our trace minerals aid in keeping the mineral content of the biofilm high and balanced so that this ecosystem will not be pulling minerals out of the teeth.
Our first clinical was a pilot coupled with a meta-analysis of other studies that involved other oral hygiene products that looked at similar metrics. Anita Daniels, the former Editor-in-Chief of the Journal of Practical Hygiene, performed the pilot, and Steven Jefferies of Temple University performed the meta-analysis. For purposes of disclosure, neither of these individuals had any financial interest in CS Bioscience.
The inclusion criteria for the pilot study were individuals who self reported brushing their teeth twice a day, but who still had gums that bled. This individual reported that he used Crest Tartar Control toothpaste twice a day. Although the study did involve an arm where oral hygiene instructions and prophylaxis were given, the first arm involved simply finding study participants who met the inclusion criteria, taking intra-oral photos and some data points, and handing them Revitin Oral Therapy and instructing them to stop using their present brand of toothpaste and to start using Revitin, and to brush with it in the exact same way that they were used to brushing. Their next visit was scheduled four days later for more photos and data points…
After four days with no other intervention, the tissues are already less inflamed, the biofilm is becoming thin and slick instead of thick and sticky. Ms. Daniels comment was, “Following over two decades of experience in periodontics, I am astonished at the improvement in oral health that these patients experienced in just one week. They no longer ‘saw red’ when they rinsed and their mouths were significantly improved.”
Jeffries found numerous studies that looked at reductions in gingival inflammation following the use of various oral hygiene regimens and various oral hygiene products. One study by Oral-B, conducted over a 2 week period—comparing manual brushing with a standard toothbrush; combined with flossing; and using an Oral-B product showed reductions in gingival inflammation in the 10-12% range. One study by Sonicare, conducted over a 4 week period—comparing manual brushing with flossing vs. using the Sonicare showed reductions in gingival inflammation in the 9.5-17% range. One study by Colgate over a 12 week period—comparing their standard paste to Colgate Total showed reductions in gingival inflammation in the 10-22.4% range. Jeffries comparison shows Revitin getting a 25% reduction in 1 week—a superior result to the next best result, Colgate Total, but taking 11 fewer weeks to get there.
Pameijer’s study took the protocol from Daniel’s study and built a more robust frame around it; looking at plaque, bleeding, and gingival indices in individuals with gingival inflammation—comparing Revitin with a control toothpaste over the course of 14 days. Pameijer also had no financial interest in CS Bioscience.
His results gave us greater statistical confidence in our outcomes, with levels of improvements that continued to increase in week #2, from the 25% improvement shown in the Daniels study. Quoting Pameijer, “These results indicate that a biofilm balancing approach to oral health care as taken by the experimental paste appears to more effectively restore oral soft tissue health than traditional detergent based products.”
Here are testimonials from four individuals who each suffered with chemotherapy associated mucositis.
First, from the United Kingdom, came this from Alan: “I am 63 years of age with a serious problem in my mouth and uvula since I was 14. The inner lining of my mouth is very, very sensitive to any form of minor abrasion from hard foods. If my uvula is scraped, it will swell up into a large blister and close off my throat; it is very distressing. The lining of my mouth has always felt thin and fragile. After 6 weeks using Revitin, the mucous membrane in my mouth now feels firmer and stronger, as though it has a protective layer. I feel more confident that it is not about to blister or scratch when eating firmer food. Also, before using Revitin I had bleeding following brushing-this now has stopped. I will continue to use this product because I believe my mouth is healthier because of its use.”
Next, Pamela from New Jersey: “In 1997 I was diagnosed with Non-Hodgkin's lymphoma in my neck. It was treated with chemotherapy and radiation to both sides of my neck. As a result of the radiation treatment, I have permanent damage to my salivary glands. My mouth and throat are very dry. Most toothpastes that are available exacerbate the problem by making my mouth more dry. The more severe issue is that they burn when I use them. Revitin with NuPath Bioactives is a welcome relief in that it soothes my mouth rather than burning and irritating the tissue. It is actually comforting to use.”
Next from Dr Jonathan Ship, now deceased, who was diagnosed with Stage III lung cancer, never having smoked a day in his life. CS Bioscience was working with the Bluestone Center at NYU to have some clinical research done there, and we had some small sample tubes made up for a pilot study. But under the circumstances, we encouraged Jonathan to use the Revitin that we had given to Bluestone. He was put through aggressive chemotherapy, and sent the following message to our company president, “A humble request for more Revitin. It is the only dentifrice I have been able to tolerate throughout my chemo without retching. Revitin should be used for all chemo patients!”
And finally this, from Marla in California:
“Dear Revitin™ -
When you are told you have breast cancer there are so many thoughts, fears and questions that begin to take over your life. After meeting with the oncologist and going over what my treatments would be I must say I never realized that the true battle I was about to begin was battling the side effects of chemotherapy and radiation. Though I am grateful for modern medicine, the journey I was about to take was definitely survival of the fittest and I would need all the physical and mental and loving support I could get.
Being in the oral health care industry, I knew the importance of getting in to see my dentist before starting my treatments. The year prior to my diagnosis, I was actively involved with “CAMBRA” (Caries Assessment Management by Risk Association) and understood the challenges that cancer patients face. During my dental exam my dentist explained to me the side effects of chemotherapy as well as the threats they posed. He didn’t have a lot to offer me for dealing with the soon-to-be-experienced side effects except to advise me of the importance of maintaining excellent oral care (ie brushing and flossing and perhaps use fluoride rinses) as I would become a high risk for caries (cavities).
I began the first of eight chemotherapy infusions and, within days, the misery began. The dry mouth, canker sores, bleeding sore gums began to make my already miserable existence even more miserable. To make matters even worse, one of the chemo drugs being used for my treatment, Cytoxin, caused a fungus to grow in my mouth and throat.
A dear friend of mine sent me some Revitin toothpaste that she and her sister used. I began brushing my teeth immediately as well as applying the paste directly to my canker sores and gums. I could not believe how quickly my mouth began to feel better. The canker sores lessened and my gums quit bleeding. The fungus was more manageable. This may not sound like a major thing to you, but believe me alleviating the pain and agony of these conditions was monumental to me. To be able to comfortably chew, drink or talk was a true blessing.
The real testimonial was when I completed my treatments and I returned to my dentist and hygienist for my cleaning and check up. As the hygienist cleaned my teeth and performed the routine perio probing she kept commenting how pleased she was with my gums. When my dentist came in to do the exam and read the x-rays he was amazed to see how healthy my tissues were and I was caries free!
I left his office smiling and once again feeling gratitude in my heart.”
Revitin’s active core, NuPath Complex, has uses in dentistry beyond oral home care. Here is an example that will be of interest to every clinical dentist This is an intra oral photo of an upper molar prepared for a crown, where decay approached the level of the bone, high under the gum line. Here there is more than gingival bleeding, there is connective tissue bleeding—and in order to take an impression for a permanent crown, we might use epinepherine—as long as the patient doesn’t have a heart problem; or we might use an astringent—as long as we don’t rinse the blood clot too strongly, as then it will start the bleeding all over again, or perhaps we ought to just put a temporary crown on this tooth for a week and let the gum tissue heal on its own-- causing the patient to need an additional visit?
This is what we want: a clean dry field, where the gingiva is firm, dry, and a bit puckered. Now we can take an impression that looks….
Like this! This was done by taking the clinical situation in the first picture and syringing Revitin Oral Therapy over the tooth and gum, covering it with a piece of dry gauze just to keep lightly contained, and having the patient bite down. SEVEN MINUTES later, the gauze comes off, the paste is rinsed clean, and the prep is ready for the impression material. Then, we can get a poured model that looks like this…
…all in the same day. CS Bioscience is planning a number of NuPath containing products—one of the first being a therapeutic gel that will make it easy for dentists to deliver this formula onto the teeth and gums. For now, we take the Revitin toothpaste and load it into a syringe with an intra oral tip, but we want it to be easier for dentists to use. The results speak for themselves: by working with the biofilm, an intelligent semi-permeable membrane, we control not only the mineral and ionic oxygen concentrations in the biofilm itself, but because of the exchange between the basal layer of the biofilm and the soft tissue cell membranes on which it sits, we can affect the competence of cell membrane and capillary wall permeability and thus speed the healing process.
Revitin is the beginning of a new way to help improve oral health. By respecting the oral biofilm that has co-evolved with us, supporting it and helping to keep it in balance, we work with nature to speed healing and promote the comfort, function and longevity of all of the tissues of the mouth.
If you would like to order Revitin Oral Therapy, please click HERE.
