New Horizons in Dental Care

Tooth Decay - A New Approach For Your Dental Health

    In this article, tooth decay will be explained.  New information will be presented that points out that tooth decay is a disease process whose progress can be arrested and even reversed.  A new approach referred to as CAMBRA (Caries Management by Risk Assessment) will be outlined where each patient receives a risk assessment and thereafter is treated accordingly to eliminate tooth decay and prevent its future re-occurrence.

   Dental caries is the process of tooth decay and the most prevalent chronic childhood disease.  Caries affects young and elderly people in disproportionate numbers.  Since its occurrence is so common and usually non-life threatening, it has not received the attention of other chronic illnesses.  However, the death of a 12 year old boy in Maryland last year from an abscessed tooth has begun to increase public awareness of the problem.  While the prevalence of dental caries has diminished in this country in the past 50 years, it never the less continues to be a major health issue.  In a national survey conducted from 1988 to 1994, fifty percent of 5 to 8 year old children were found to have dental caries (tooth decay) in their baby teeth.  The data also indicated that approximately 25% of children and adolescents in the 5 to 17 year old range had 80% of the caries in permanent teeth.  Therefore, as you can see, tooth decay is still very prevalent, and a small percentage of the population manifests the most dental cavities.

   Let's talk on a more personal level about tooth decay, ask a few questions and strive to answer the questions as the mechanism of tooth decay is explained.  So you brush and floss regularly and still get diagnosed with cavities at almost every dental check-up?  Do you know someone who takes very little care of their teeth and never gets a cavity?  If you never get a cavity, will you always be this fortunate or if you always get tooth decay will you continue on this path and eventually loose your teeth?  Now let us look at the science of tooth decay to shed some light on these questions.

   For over a hundred years dental caries in its simplest assessment is a bacterial infection in the mouth.  However, it was not until recent history that research has identified the specific causative bacteria.  Although over 700 bacterial species have been identified in the mouth only 2 species are mainly responsible for tooth decay.  Dental research has also shown that these organisms are transmissible by kissing, sharing utensils, etc.  Horizontal transmission is considered to take place from sibling to sibling, spouse to spouse, etc.  Babies are not born with the harmful bacteria and usually acquire the bacteria from their mother (if she is infected with the bacteria) by 2 years old which is called vertical transmission.  Studies have shown that salivary exchange is the mechanism by which transmission occurs.  Research also has shown that without the harmful bacteria a child will not get a cavity.

   Once these causative bacteria become established in the mouth, they will produce glucans, levans (both gooey polymers) and acid when exposed to sugar (the more sugar the more they thrive).  The polymers allow the bacteria to attach to the surface of the teeth and the acid seeps into the tooth structure and causes a loss of structural minerals (demineralization) from inside the tooth.  Tooth decay therefore starts on the inside of a tooth.  If the acid stays on the tooth long enough and sufficient structural minerals are lost, then the outer tooth enamel will collapse and tooth decay (a cavity) is created.  However, given the proper environment, the demineralized subsurface areas can be remineralized (repaired) and a cavity will never develop.  Also, another drawback of the high acid production is that it causes the good bacteria to die off and the bad bacteria to flourish.

   Tooth decay is a multifactorial process.  Research has shown that 3 risk factors definitely cause tooth decay:  bad bacteria, poor eating habits (lots of sugar) and xerostomia (dry mouth).  Research has also identified protective factors and they include:  saliva, sealants, antimicrobial agents (e.g. chlorhexidine, herbal lollipop, iodine and xylitol), fluoride and a good diet (low in sugar).

   Dr. Featherstone, from the University of California, uses a teeter-totter to illustrate the dynamic back and forth battle going on in the mouth between the good and the bad.  The struggle is ongoing every minute of the day as changes occur in the pathological and protective factors. When the pathologic factors and protective factors are in balance, then you will not get cavities.  Since the risk factors change, they must be monitored over time.  For example, someone who is in balance and starts taking medication that causes dry mouth will become out of balance and will start developing numerous cavities.   

   The traditional treatment for tooth decay has been to "drill and fill".  Research has shown that placing a filling does little or nothing to eliminate the infectious bacteria and other risk factors in the mouth which cause the cavity.  The modern approach or medical model concentrates on reducing the pathologic factors and increasing the protective factors.  The most important component of the new model is the elimination of the infectious component of tooth decay i.e. kill the bacteria that causes the cavity.

   Only persons infected with the harmful bacteria need to be treated.  Therefore in our office we have implemented CAMBRA - caries management by risk assessment.  Each patient is evaluated for pathologic and protective factors and categorized as low, medium, high or very high risk.  Once categorized then the patient is treated accordingly to obtain a "caries balance" by reducing pathologic factors, increasing protective factors, and most importantly by eliminating the "bad bacteria" in the mouth.

   Now back to the questions previously posed.  If you are meticulous about brushing and flossing your teeth and still wind up with cavities, that means that you are infected with the bad bacteria and may or may not have other pathologic factors.  To prevent further cavities, the bad bacteria must be eliminated and other pathologic factors addressed.  On the other hand, if a person's oral hygiene is poor but never gets cavities then that individual does not have the bad bacteria that cause tooth decay and may have other protective factors.  However, the mouth is a dynamic system capable of slow or abrupt changes.  Remember the teeter totter and the concept that any changes in the protective or pathologic factors can result in a different outcome on your next dental check up.

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