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Destruction of a tooth by cervical decay from dental caries
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, also known colloquially as '''tooth decay''', is a disease of the teeth resulting in damage to
Tooth structure. The cavities formed because of dental caries are called '''''dental cavities'''.
Dental caries is one of the most common disorders affecting humans
[http://www.wrongdiagnosis.com/lists/prevonly.htm . It usually occurs in children and young adults, but can affect any person. It is the most significant cause of tooth loss in younger people.
The mouth contains a wide variety of bacteria, but only a few specific species of bacteria cause dental caries: ''
Streptococcus Mutans '' and ''
Lactobacilli ''. These bacteria convert foods—especially
Sugar and
Starch —into acids such as
Lactic Acid created through
Fermentation processes. These acids seep into the tooth and can wear away tooth structure. If conditions in the mouth are favorable, ''S. mutans'' and ''Lactobacilli'' will continue to thrive and continue to secrete these acids. Bacteria, acid, food debris and saliva combine in the mouth to form a sticky substance called
Plaque that adheres to the teeth.
It is most prominent on the grooved chewing surfaces of
Molar s, just above the
Gum line on all teeth, and at the margins of
Fillings . Plaque that is not removed from the teeth may mineralize into
Calculus (formerly known as tartar). Plaque and calculus irritate the gums, resulting in
Gingivitis .
Periodontitis occurs when there is loss of gingival attachment.
The acids secreted by ''S. mutans'' and ''Lactobacilli'' in the plaque dissolve the enamel surface of the tooth. As the bacteria become more prolific, the bacteria will follow the advancing front of acid damage and infect the dentin within the tooth. Left untreated, carious lesions will increase in severity from small discolored stains to actual holes in the tooth (cavities). Cavities are usually painless until they grow very large inside the internal structures of the tooth (the
Dentin and the pulp at the core) and can kill the nerve and disrupt the blood vessels in the tooth. If left untreated, complications may occur such as acute irreversible pulpitis (infection of the pulp) or acute apical pulpitis (abcesses within the mandible.)
Plaque and bacteria begin to accumulate within 20 minutes after eating, the time when most bacterial activity occurs. If plaque and bacteria are left on the teeth, cavities can develop, and untreated tooth decay can result in death of the internal structures of the tooth and ultimately the loss of the tooth.
Dietary sugars and starches (
Carbohydrates ) increase the risk of tooth decay. The type of carbohydrate and the timing and frequency of ingestion are more important than the amount. Sticky foods are more harmful than nonsticky foods because they remain on the surface of the teeth. Frequent snacking increases the time that acids are in contact with the surface of the tooth.
- Toothache (technically called ''odontalgia'' or ''odontalgy'')-- particularly after sweet or hot or cold foods or drinks (sensitivity)
- visible pits or holes (cavities) in the teeth
- Halitosis (bad breath)
The earliest sign of a carious lesion is the appearance of a chalky white spot on the surface of the tooth (aka white spot lesion), indicating an area of demineralization caused by acid. As the lesion continues to demineralize, it begins to turn brown. If the lesion's progress continues unchecked, the demineralization can turn into a gross cavitation (a 'cavity'). Brown spot lesions that look shiny indicate that the demineralization process has stopped; this is now just a stain. Brown spot lesions that look dull indicate that active caries are present.
Most dental caries are discovered in the early stages during routine checkups. The surface of the tooth may be soft when probed with a sharp instrument, such as a
Dental Explorer . Pain may not be present until the advanced stages of tooth decay, when the bacterial infection reaches the deeper layers of the tooth and begins to involve the nerve fibers at or near the pulp. Dental radiographs, produced when X-rays are shot through the jaw and picked up on film, may show some cavities before they are visible to the eye.
An image showing various stages of dental caries is shown
here .
Carious lesions may form on different surfaces on a tooth. caries are on the chewing surface, '''facial''' caries are on the surface of the tooth opposite the tongue, and '''lingual''' caries are on the surface facing the tongue. '''Interproximal''' cavities occur in between two adjacent teeth. Facial caries can be further subdivided by nomenclature: facial surfaces of posterior teeth are termed '''buccal''' while those of anterior teeth are termed '''labial'''.
Cavities that occur on the root usually occur when gross decay on the facial or lingual surfaces extends apically (towards the root, or the ) past the '''CEJ''' (cementoenamel junction) or when the root surfaces have been exposed due to gingival recession. Because the cementum enveloping the root surface is not nearly as durable as the enamel encasing the crown, root caries tends to progress much more aggressively than decay on other surfaces.
Large dental cavities are often visually apparent. Smaller cavities may require examination with magnification and visible light,
Dental Explorer , or imaging with dental radiographs. A laser can be used as an adjunct for the diagnosis of smaller cases of caries in the pits and fissures of the teeth.
Destroyed tooth structure does not fully regenerate, although remineralization of very small cavities may occur if dental hygiene is kept at optimal level. However, the progression of dental caries can be stopped by treatment. The goal of treatment is to preserve the tooth and prevent complications.
In filling teeth, the decayed material is removed (by
Drilling ) and/or scraping, and replaced with , made of a restorative material such as
Composite Resin ,
Porcelain , dental
Amalgam or
Gold . Composite resin and porcelain can be made to match the color of a patient's natural teeth, and are thus indicated in aesthetic areas (the front of the mouth). However, composite restorations may be too weak to withstand the cyclic forces that are naturally placed on the occlusal (chewing) surface of posterior teeth. Some dentists therefore consider dental amalgam and gold the only advisable '''intracoronal restoration''' ("filling") for the biting surface of posterior teeth (premolars and molars). Composites also undergo polymerization shrinkage, (that is, they shrink when they polymerize, or harden), and they pull away from the walls and margins of the cavity preparation, leaving an opening for bacteria to enter and cause recurrent decay.
Currently, there are many dissenting opinions on whether amalgam fillings pose a health risk due to the
Mercury contents in amalgams. This is part of the
Dental Amalgam Controversy . Many dentists today use composite instead of amalgam for all fillings, not all are doing so for health reasons only. Many dentists recommend composite fillings for their cosmetic appearance and for the greater preservation of healthy tooth structure, as preparing for a composite filling requires less drilling than an amalgam filling. However, composites may need to be replaced more often than amalgams, and more tooth structure can be lost each time a preparation is made. It is important to note, however, that both materials have advantages and disadvantages, and that dentists must determine which material is appropriate on a case by case basis and obtain
Informed Consent prior to treatment.
are used if decay is extensive enough to preclude an intracoronal restoration (filling). Simply put, if there is not enough tooth structure remaining after the decay is removed, a restorative material cannot be placed ''within'' the remaining tooth structure. The restorative material must be fashioned into a sort of cap that encloses the remaining tooth structure. This "cap," or crown, is fitted over the remainder of the natural crown of the tooth. Crowns are often made of gold, porcelain or porcelain fused to metal (PFM). In certain cases, it may be necessary for root canal therapy to be peformed on a tooth in order to place a crown.
(also called "endodontic therapy") is recommended if the nerve (pulp) in a tooth dies (i.e. pulpal necrosis) and the tooth has a functional role in the dentition. Pulpal necrosis can occur as a result of infection of the pulp with decay-causing bacteria as well as from the unavoidable trauma associated with excavation of caries near the pulp. There are also pathologic processes that occur within the supporting bone that may result in death of the pulp. Traumatic injuries to teeth (such as those that might occur while playing contact sports) are also known causes of pulpal necrosis. During a root canal, the pulp of the tooth, including the nerve and vascular (blood vessel) tissue, is removed along with decayed portions of the tooth. The canals in which the pulpal tissue resided are subsequently instrumented with endodontic files (rasps which clean and shape the canals), and are then filled with a rubber-like material called "gutta percha". The tooth is filled and a crown may be placed over the tooth if needed. Upon completion of a root canal, the tooth is now "non-vital", as it is devoid of any living tissue.
, an
Extraction is performed if the tooth is too far destroyed from the decay process to effectively restore, or if the tooth is considered non-functional (e.g.
Wisdom Teeth frequently, teeth that lack an opposing tooth, or a tooth in a non-useful position) or the patient does not wish to undergo the expense or procedure of restoring the tooth.
Traditionally, a
Dental Drill is used to remove decayed material from a tooth, however, newer painless methods have been developed in recent years. Various surgical lasers such as Erbium:YAG (2940nm) or Erbium,Cr3+:YSGG (2780nm) lasers have been developed for carious tissue removal, amongst other applications. Also air abrasion devices can be used to remove decayed material from a tooth. These devices offer advantages over the mechanical drill but have certain limitations in removing some pre-existing filling materials.
Treatment often preserves the tooth. Early treatment is less painful and less expensive than treatment of extensive decay.
Anesthetic s -- local,
Nitrous Oxide ("laughing gas"), or other prescription medications -- may be required in some cases to relieve pain during or following drilling or other treatment of decayed teeth. For those who fear dental treatment, nitrous oxide anesthesia may be preferred.
Oral Hygiene is the primary prevention against dental caries. This consists of personal care (proper brushing at least twice a day and flossing at least daily) and professional care (regular dental examination and cleaning, every 6 months). Select X-rays may be taken yearly to detect possible cavity development in high risk areas of the mouth.
For those who are more meticulous about caring for their teeth, it is best to brush not just twice per day but after every act of consuming refined carbohydrate products that stick to the teeth after eating them. For example, if one snacks on oreo cookies or potato chips 5 times per day, one should brush 5 times a day, after every incident of eating these snacks, since they stick to the teeth after eating them. The continued presence of refined simple carbohydrates or sugars stuck to the teeth after eating them gives bacteria a continuous supply of sugar to make acids that break down teeth. Someone who snacks numerous times per day on these substances is likely to continue to get tooth decay in spite of brushing twice per day. If one cannot brush immediately after consuming refined carbohydrates that stick to teeth, one should try to remove as much of them as possible from the teeth using a toothpick, then try to rinse out with water. As a general rule of thumb, do not allow your teeth to have food particles stuck to them at any time.
In addition, those who have the eating disorder bulemia can severely damage their teeth. Bulemics have a habit of making themselves regurgitate the food they have eaten so as to prevent themselves from getting fat. This can cause severe nutritional and acid imbalances in their bodies. But the acidic food that is regurgitated is extremely damaging to teeth. The high acidity of the vomit rapidly dissolves and breaks down teeth. Dentists can know right away if a patient is bulemic because the back of the top front teeth tend to be severely worn away. This symptom is generally unique to bulemia patients. Since bulemia is a psychological disorder, people with bulemia should seek psychological counseling to help cure themselves of the behavior. Only this cure can prevent further breakdown of the teeth. The acidity of regurgitated food is almost at a pH acid level of 1, which is 1,000 times more acidic than lemon juice, and 10,000 times more acidic than the minimum amount of acidity needed to wear away teeth. A dentist can fill and fix teeth damaged by bulemia, but unless the bulemic patient completely stops this behavior, the damage will recur. Bulemia is a psychological disorder related to patients being obsessively negative about the appearance of their bodies. This is called "body dysmorphic disorder." It may be partly caused by a popular culture that constantly shows photos of beautiful, stick-thin women and touts this as an "ideal" body figure.
Chewy, sticky foods (such as dried fruit or candy) are best if eaten as part of a meal rather than as a snack. If possible, brush the teeth or rinse the mouth with water after eating these foods. Minimize snacking, which creates a constant supply of acid in the mouth. Avoid constant sipping of sugary drinks or frequent sucking on candy and mints.
The use of
Dental Sealant s is a good means of cavity prevention. Sealants are thin plastic-like coating applied to the chewing surfaces of the molars. This coating prevents the accumulation of plaque in the deep grooves on these vulnerable surfaces. Sealants are usually applied on the teeth of children, shortly after the molars erupt. Older people may also benefit from the use of tooth sealants.
Fluoride is often recommended to protect against dental caries. It has been demonstrated that people who ingest fluoride in their drinking water or by fluoride supplements have fewer dental caries. Fluoride ingested when the teeth are developing is incorporated into the structure of the enamel and protects it against the action of acids.
Topical fluoride is also recommended to protect the surface of the teeth. This may include a fluoride
Toothpaste or
Mouthwash . Many dentists include application of topical fluoride solutions as part of routine visits.
Chewing gum containing
Xylitol , wood sugar, is widely used to protect teeth in some countries, being especially popular in the
Finnish candy industry. Its effect on reducing plaque is believed to be based on bacteria not being able to utilize it like other sugars.
It has also been found that certain kinds of
Cheese like
Cheddar or milk can help counter tooth decay if eaten soon after having eaten foods potentially harmful for teeth.
Furthermore, recent research shows that low intensity laser radiation of argon-ion lasers may prevent the susceptibility for enamel caries and white spot lesions, as indicated in the publications below.
Lastly, a
Vaccine for dental caries has been researched through previous years, but no effective vaccine has been created yet. Research is currently ongoing.
- Literature in peer-reviewed journals for prevention using argon-ion lasers:
Westerman GH, Hicks MJ, Flaitz CM, Ellis RW, Powell GL: Argon laser irradiation and fluoride treatment effects on caries-like enamel lesion formation in primary teeth: an in vitro study.
Am J Dent. 2004 Aug;17(4):241-4.
Blankenau RJ, Powell G, Ellis RW, Westerman GH: In vivo caries-like lesion prevention with argon laser: pilot study.
J Clin Laser Med Surg. 1999 Dec;17(6):241-3.
Anderson JR, Ellis RW, Blankenau RJ, Beiraghi SM, Westerman GH: Caries resistance in enamel by laser irradiation and topical fluoride treatment.
J Clin Laser Med Surg. 2000 Feb;18(1):33-6.
