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Can you name the most common disease in the world today? It isnt cancer, heart disease or influenza. Throughout every continent, across every demographic and age bracket, the most prevalent disease is tooth decay. While its not generally life-threatening, tooth decay can lead to lost time on the job or at school, impose a financial burden on families and significantly affect a persons quality of life.
The traditional (and still effective) model for treating cavities is simply to drill and fillthat is, to remove the decayed area of the tooth and replace the lost structure with a filling. But over the past few decades, a growing body of research has given us a new understanding of the true nature of the tooth decay process and opened up new avenues for the management of this disease.
At one time or another, almost everyone has heard how tooth decay gets started: Sugars in the diet feed harmful bacteria in the mouth; those bacteria release acids, which cause tiny pits to form in the surfaces of teeth; the pits in turn shelter more bacteria and in a short time a cavity (a small hole in the enamel) develops, requiring treatment. Reducing the number of bacteria by brushing and flossing regularly is one way to fight tooth decay. Another way is limiting or eliminating excess sugar in the diet.
Yet despite good efforts, many people have recurrent problems with decay. In fact, two people could have a similar diet and oral hygiene routinebut one routinely develops cavities while the other never does. We might think the cavity-prone individual just has bad luck (or bad habits). However, research points to several factors that can drastically increase your risk of getting cavitiesas well as the steps we can take to manage that risk.
The first risk factor is salivaor more precisely, the lack of it. Normally, the salivary glands release about two liters of saliva into the mouth every day. This helps maintain a neutral acid-base balance, which corresponds to a pH of 7 (the exact middle of the pH scale; the strongest acids are pH 1, while the strongest bases are pH 14). Saliva is natures way of protecting the teethand that protection is needed because the process of digestion begins in the mouth. Whenever you eat, tiny particles of food are broken down on the surfaces of teeth and small amounts of acid are released. The chemical substances in saliva keep the pH of the mouth from tilting too much toward the acidic, which can break down tooth enamel.
But many people dont produce enough salivaa condition called xerostomia or dry mouth. In some people, increasing age slows saliva production. Others experience dry mouth as a result of taking certain medications. According to the Mayo Clinic, some 70% of all Americans (including both adults and children) take at least one prescription drug daily; about half take two or more. Dry mouth is a common side effect of many medications. Regardless of the cause, the lack of sufficient saliva can have serious consequences for the teeth. Enamel, the tooths outer coating, is the hardest substance in the body. But when teeth are subjected to a pH of 5.5 (moderately acidic), the enamel starts to dissolve, seriously weakening the tooths structure.
Diet is the second major risk factor for tooth decay. Americans consume on average around 23 teaspoons of sugar every day, and some 51 pounds of high-fructose corn syrup every year. Sweetened beverages make a major contribution to excess sugars in the diet of adults and children, and are helping to drive an epidemic of obesity. Whether consumed in food or drink, sugar is metabolized (processed) by oral bacteria, some of which release acids as an end product. Those acids are the direct cause of cavities.
But the effect of diet comes not just from what you eat; when you eat also makes a big difference. As you eat or drink, the pH in your mouth drops (becomes more acidic). But in about 30 minutes, thanks to the action of saliva and helpful bacteria, the mouth returns to a neutral state. If you eat too frequently, howevergrazing throughout the day and constantly sipping sugary drinksthe normal process of recovery to a normal pH doesnt have enough time to occur.
The surfaces in your mouth are coated with a thin film of proteins, fluids, biochemical substances and microorganisms called a biofilm. This environment hosts both beneficial and harmful bacteria, which exist in a dynamic balance. The makeup of an individuals biofilm plays a major role in susceptibility to tooth decay. In a healthy mouth, excess acids are neutralized and harmful bacteria are kept in check by helpful ones. But when the biofilm is continually pushed toward an acidic state, problems can start. The helpful bacteria (which we formerly considered good bugs) must adapt to the changed environment or die; their metabolism shifts, becoming more like the acid-loving bacteria (bad bugs)much to the detriment of your teeth.
Plaque is another name for a thick layer of biofilm on your teeth. Brushing and flossing can remove itbut when it is allowed to build up and harden, it is called dental calculus or tartar. Unlike plaque, tartar cant be removed by brushing or flossing, and its an ideal home for the bacteria that cause oral health problems. Scientists used to think that just two kinds of bacteria, Streptococcus mutans and some Lactobacillus species, were responsible for tooth decay. But with improved methods of genetic identification, we now know that about 40% of adults and children in the US with serious tooth decay dont even have Streptococcus mutans in their mouths. This finding changed our understanding of the tooth decay process: Instead of a disease caused by particular bad bacteria, we now think of it as a disease of the biofilm driven by a prevalence of acid (low pH).
The final major risk factor for decay is genetics. There are some 40 to 50 genes that play a role in your risk for developing cavities. Some affect anatomy or physiology: how your teeth are formed or how much saliva you produce. Others may have a behavioral impact: for example, whether or not you have a craving for sugara sweet tooth. While the overall influence of genetic factors on cavities is thought to be about 9%, for some it may have a big effect. Genetic variation can explain why individuals with the same diet, environment and oral hygiene habits have a very different outcome with respect to cavities.
When your dentist discovers a cavity, the standard solution is to remove the decay using a dental drill and replace the lost tooth structure with a filling material. This is an effective treatment, but it doesnt change the reason why the cavity developedand it doesnt keep you from getting more. Thats where an evaluation of your particular risk for developing cavities (also called dental caries) can help. It could be that youre taking a medication that inhibits saliva production; maybe your biofilm is being pushed out of balance; perhaps your diet is a contributing factor. Caries risk assessment is aimed at pinpointing an individuals specific risk factors.
Once, caries risk assessment (if done at all) was mainly handled by dental staff. Today, its easier and more productive for people to begin by filling out a short form, answering questions like: What medications do you take? Do you often snack between meals? Do you notice plaque on your teeth between brushings? The answers not only help pinpoint issues that may make you more susceptible to cavities, they can also provide a great starting point for discussion with your dentist about your overall oral health. Your dental professionals can also perform testing on your mouth chemistry and even do an assessment of your biofilm, which can give specific information about your risks.
Does the system really work? Years of research, including a recent large study in the San Francisco Bay Area, demonstrate that it does. In fact, caries risk assessment is now the standard of practice taught in every accredited dental school in the United States. And while it isnt yet a routine part of all dental checkups, the practice is becoming more and more widespread.
Once you know the risk factors, can you do anything about them? Generally, the answer is yes. One positive step is to use a fluoride toothpaste and/or mouth rinse with a higher (more basic) pH. This can help maintain healthier (less acidic) conditions in your mouth and promote a healthier oral environment.
Fluoride itself is highly beneficial to your teeth: It is readily incorporated into your tooth structure, and it actually reduces the process of demineralization (erosion of tooth enamel) caused by acids. When used as directed, fluoride toothpastes and mouth rinses are safe and proven ways to reduce the incidence of cavitiesas are the small amounts of fluoride added to some municipal water systems. Xylitol is another ingredient of toothpastes and rinses that can help fight cavities. It is thought to interfere with the metabolism of acid-loving bacteria, and studies show some evidence of its therapeutic benefits.
Changing your diet can also be a big help. Reducing excess sugar and limiting your consumption of food and drinks (not including water) to around mealtimes is a good way to help keep your biofilm in a healthy state. If a caries risk assessment points to other issuesdry mouth from medications, for examplemaking positive changes in the way you eat can be even more important.
Despite our growing knowledge about it, tooth decay is likely to remain a common disease in the near future. However, we have seen that its quite possible for an individual to reduce the risk of decay, and even become cavity-free. With a better understanding of how the oral biofilm mediates the diseaseand how it is driven by acidic pH levelswe can assess each persons risk for tooth decay and tailor a plan to counter it. As more people understand the benefits of caries risk assessment, we have reason to hope it will become a more routine part of dental care.
Dear Doctor, I recently had my wisdom teeth removed. Everything seemed to be going fine until I woke up in severe pain a few days later. The oral surgeon treated me for dry socket and the pain went away. Can you tell me more about this condition?
Dear Jake, Dry socket, or alveolar osteitis, is a complication that occasionally develops after oral surgery. Although it is not dangerous, dry socket can be very painful, as you have experienced. This condition can occur when a blood clot doesnt form properly, breaks down or is dislodged from the socket where a tooth was removed. After tooth extraction, a blood clot forms in the empty socket as part of the normal healing process. The clot serves as a barrier to protect the bone underneath from air, food and fluids as it heals. But in the absence of a protective clot, the bone and nerves can be exposed, causing the moderate to severe pain associated with dry socket.
With dry socket, pain will usually develop on the third or fourth day after a tooth is extracted and will typically lessen after 1 to 3 days. Dry socket is uncommon after a routine extraction, occurring only about 2% of the time, and it rarely happens in upper teeth. In fact, almost all dry sockets develop after lower molars are removed. According to some research reports, 1 in 5 people (20%) experience dry socket after the removal of impacted lower third molars (wisdom teeth) or other lower molars.
The term dry socket describes the appearance of the painful tooth socket. When you look at an affected socket, it appears to be empty, with a blood clot partially or completely missing and some exposed bony surfaces which are very sensitive. Dry socket is characterized by dull, aching, throbbing pain that may radiate to the ear. The area of the socket often has a bad odor, and frequently there is a foul taste in the mouth. Dry socket is not usually associated with infection, so it is not typically accompanied by fever, swelling or redness.
People over age 25, smokers and women who take oral contraceptives are more likely than others to get dry socket. Engaging in activities that put pressure on the extraction site too soon after surgerysuch as vigorous chewing or tooth brushingcan also contribute to dislodging or breaking down the protective blood clot. In addition, when the extraction procedure is complicated and there is more than usual trauma to the area, dry socket is more likely to occur.
Its important to keep the mouth clean after an extraction procedure, but ask your dentist whether you should brush your teeth on the first day. You may be advised to simply rinse your mouth. If you brush, do so very gently. Chew very carefully as well, and stick to soft foods at the beginning. Avoid rinsing the mouth too aggressively, drinking through a straw, consuming hot liquids and smoking. For smokers who find it extremely difficult to stay away from cigarettes, a nicotine patch should be used instead for a few days.
Oral surgeons help reduce the risk of dry socket by taking steps to avoid bacterial contamination and minimizing trauma to the area during the extraction. Using an antimicrobial mouth rinse before or after surgery and flushing the area with saline solution after the procedure can reduce the incidence of dry socket. Suturing the extraction area has also been shown to substantially decrease the chance of dry socket. Well-controlled studies indicate that these measures can reduce the incidence of dry socket after impacted lower wisdom tooth surgery by 50% or more.
The risk of dry socket is present until the empty tooth socket is well on its way toward healing, which takes 7 to 10 days in most cases. Dry socket is no longer a risk once the extraction site has healed.
If you develop dry socket after oral surgery, take heart: Profound relief from pain often comes within 5 minutes of beginning treatment at the dentists office, and the pain should continue to subside over the following days. To treat this condition, your dentist may irrigate the socket and/or apply a medicated dressing that should be changed every other day for 3 to 6 days. Once the pain decreases significantly, the dressing should not be replaced because it will actually prolong the wound healing process.
Oral antibiotics are generally not used to treat dry socket, but nonsteroidal anti-inflammatory pain relievers such as ibuprofen (Motrin or Advil, for example) may be prescribed for a few days if necessary.
Keep in mind that the goal of any treatment for dry socket is to relieve pain, but treating the condition does not speed up healing. If a person receives no treatment for a dry socket, the only negative effect will be continued pain. Even though dry socket does not cause any long-term damage, its certainly uncomfortable. Therefore, its wise for anyone who thinks they may have dry socket to call their dentist as soon as possible.
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