Thrush: modern prevention without chlorhexidine with polyhexanide

Dental caries is one of the most prevalent diseases in humans. Despite enormous advances in dentistry, 9 out of 10 adults experience dental caries. In preschool children, the incidence reaches 60–80% in many countries—including Greece.

In this article you will see what exactly tooth decay is , why it occurs , who is at increased risk and how modern prevention methods are combined — from fluoride and brushing to the use of antimicrobial solutions with polyhexanide (such as ProntOral® by B|Braun), which target the cause and not just the effect.

1. What is tooth decay

Tooth decay is a multifactorial infectious disease that leads to gradual demineralization and destruction of enamel and dentin. It is not something that “just happens” — it is the result of a specific biochemical cycle.

The quadrilateral of caries

For caries to form, 4 factors are needed simultaneously:

1. Tooth vulnerable
2. Pathogenic bacteria (mainly Streptococcus mutans )
3. Substrate (simple sugars — glucose, sucrose, fructose)
4. Time — repeated episodes of acidification

If you remove any of the 4, caries does not occur. Herein lies the key to prevention.

2. How it is created — biochemical mechanism

1. Streptococcus mutans adheres to the tooth via biofilm (plaque)
2. Produces the enzyme glycosyltransferase that converts sucrose to sticky glucans
3. Metabolizes glucose and produces lactic acid as a byproduct
4. Lactic acid drops the pH on the tooth surface below 5.5
5. At low pH, the hydroxyapatite of the enamel dissolves → demineralization
6. With repeated episodes → visible cavity = tooth decay

“Stephan’s curve”

After each meal/snack containing sugar, the pH on the tooth surface drops from the normal 7 to ~4.5 within minutes, and returns to 7 within 30-60 minutes (if no more sugar is ingested). The more often you eat sweets, the longer your teeth are “at risk”.

3. Risk factors

Dietary

• Frequency of sweet consumption > quantity
• Candies, lollipops , pastilles — prolonged presence of sugar in the mouth
• Sugary drinks — especially between meals
• Acidic drinks (lemon-flavored, sports drinks) — double whammy

Behavioral

• Inadequate brushing
• No flossing
• No dental visits > 1 year
• Bedtime snack without brushing

Normal

• Dry mouth (medications, Sjögren's syndrome, radiotherapy)
• Orthodontics — increase retention areas
• Genetic predisposition in enamel composition
• Post-mortem predispositions in the microbiome

Specific risk groups

• Children (enamel still mature)
• Elderly (root caries from xerostomia)
• Diabetics
• Patients undergoing chemo-/radiotherapy (mucositis + xerostomia)
• Pregnant women (acidic pH from vomiting, hormonal changes)

4. Primary prevention — the foundation

Mechanical cleaning

Item	Frequency	Note
Brushing	2× per day × 2 minutes	Soft brush or electric
Flossing	1× per day	Before evening brushing
Interdental brushes	1× per day	In patients with large interdental spaces
Cleaning tongue scraping	1× daily	With a scraper

Fluoride

• Fluoride toothpaste 1450 ppm (adults) or 1000 ppm (children)
• Rinse with a little water after brushing or not at all (“spit, don't rinse”)
• Professional fluoride application (varnish) 2× annually in high risk

Dietary interventions

• Reduction frequency sugary snacks
• Replacement with xylitol (chewing gum) — has anti-caries effect
• Water between meals instead of juices
• No snacks before bedtime

5. Secondary prevention — antimicrobial approach

In addition to the mechanical approach, in patients at high risk antimicrobial therapy directly targets S. mutans and the biofilm.

Why chlorhexidine is not a long-term solution

Chlorhexidine 0.12-0.2% significantly reduces streptococci, but:

• Not recommended > 14 days (teeth staining)
• Not combined with fluoride toothpaste (neutralization)
• Often causes dysgeusia

Why ProntOral® (polyhexanide) is suitable

The polyhexanide (PHMB) of ProntOral®:

• Acts against S. mutans and other oral streptococci
• Can be used long-term without staining teeth
• Does not interact with fluoride — complements the action of toothpaste
• Alcohol-free — suitable for patients with dry mouth
• Peppermint flavor — maintains compliance

Usage protocol for caries prevention

Patient condition	Dose	Frequency	Duration
Low risk, daily use	10 ml	1× evening	Continuous
High risk	10 ml	2× daily	Continuous
Recent multiple caries	10 ml	2×	3 months, evaluation
Orthodontic patient	10 ml	2×	All duration
Dry mouth	10 ml	2× + hydration	Continuously
Children > 4 years of age at high risk	5 ml	1× evening	Under medical supervision
Pregnant women	10 ml	1×	On medical recommendation

6. Special clinical situations

Children

In children, tooth decay in baby teeth (“baby bottle tooth decay”) is mainly due to frequent exposure to sugary drinks/bottles at night. Prevention:

• No bottles with sugary drinks at night
• Cleaning teeth with gauze/brush from 6 months
• Visit to the dentist from the 1st year
• Fluoride varnish 2×/year
• From 4 years: ProntOral® 5 ml 1× evening in high-risk children

Patients undergoing head and neck radiotherapy

Radiation causes severe dry mouth and radiation caries — an attack on the root of the tooth. Prevention:

• Professional cleaning before radiotherapy
• Fluoride trays daily
• ProntOral® 4× daily throughout treatment

Elderly

Root caries is common due to hypersalivated root canals from gingival recession. We recommend:

• Daily ProntOral® on a sponge/brush
• High-fluoride toothpaste (5000 ppm)
• Visit a dentist 3-4× per year

7. When to visit a dentist

• Systematically: Cleaning 2× per year
• Immediately: If you see dark spots, feel sensitivity to cold/hot, or feel “scratching” with your tongue

8. What does NOT prevent tooth decay

• “Good “heredity” (genetic) — does not eliminate the risk
• Natural fruit juices (often as acidic as soft drinks)
• Honey/brown sugar candies (“natural” — but just as cariogenic)
• Alcohol-only solutions without fluoride/PHMB
• Brushing after an acidic meal (erodes already soft enamel — wait 30 minutes)

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Editor & Editor

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Contact the Traumacare Medical Team

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The entire ProntOral® Cluster

• #00 — ProntOral®: complete user guide
• #01 — Polyhexanide (PHMB) in oral decolonization
• #02 — Pre-surgical MDRO decolonization bundle
• #03 — VAP prevention in the ICU
• #04 — Mucositis in oncology patients
• #05 — ProntOral® in home care
• #06 — ProntOral® vs chlorhexidine
• #07 — From dental prophylaxis to hospital-acquired infection
• #08 — Dental plaque
• #09 — Cervical cancer
• #10 — Gingivitis
• #11 — Periodontitis
• #12 — Oral thrush
• #13 — ProntOral® vs Curasept
• #14 — ProntOral® vs Elgydium & Hexoral