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Fighting Cavities

Here’s what we know about teeth, according to the hundreds of years of research in conventional dentistry.  Most of this information comes directly from the American Dental Association (ADA), a not-for-profit dental association. The ADA is considered the leading source of oral health related information for dentists and their patients. If you’re super dorky, like me, here’s the link for the ADA’s Center for Evidence-Based Dentistry. tooth medical anatomy

  1. There are four tissues that make up a tooth.  Enamel, dentin, and cementum are the hard tissues of a tooth.  The pulp is the soft tissue in the center.
  2. Enamel forms the outer surface of the crown of the tooth. It’s the hardest tissue in the body. Enamel allows the tooth to able to withstand a great amount of stress, seeing as your teeth are your chompy-chompers!  Once enamel is completely formed, it can’t grow more or repair itself, but it does have the ability to remineralize.  This means that areas experiencing early demineralization (loss of minerals) are able to regain minerals and stop the caries (cavity) process. I have difficultly understanding why that’s not considered an ability to repair…
  3. Dentin makes up the main portion of the tooth; it’s softer than enamel but harder than bone.  Dentin is permeated with microscopic canals (dentinal tubules).  These tubules contain fibers that transmit pain stimuli and nutrition throughout the tissues. Dentin does have the ability for further growth.
  4. Cementum is the tissue that covers the root of the tooth in a very thin layer.  It is not as hard as enamel or dentin, but it is harder than bone.  It contains fibers that help stabilize the tooth within the bone.
  5. The pulp is located in the center of the tooth, and is surrounded by dentin.  The pulp is made up of blood vessels, connective tissue, nerve tissue, and cells that are able to produce dentin. The pulp nourishes the tooth and produces and repairs dentin.  If the pulp tissues dies, then a root canal procedure is recommended to save the tooth.

Here’s what else we know about teeth:

  1. Approximately 96% of tooth enamel is composed of minerals. These minerals will become soluble when exposed to acidic environments. All acidity weakens teeth, but the amount of time that acids are in contact with teeth that determines the amount of damage. If mineral breakdown is greater than build up from sources such as saliva, cavities can result. Remineralization can also occur if the acid is neutralized by saliva. Rinsing with water can help.
  2. At 77°F, the pH of pure water is very close to 7, and is considered neutral.
  3. Enamel begins to demineralize at a pH of 5.5. When the pH at the surface of the tooth drops below 5.5, demineralization proceeds faster than remineralization.
  4. Dental caries (caries is Latin for “rottenness”), is also known as tooth decay or cavities. Cavities are considered a breakdown of teeth due to the activities of bacteria, most notably Streptococcus mutans. (Of interest: Many studies show that chewing xylitol gum may reduce salivary S. mutans levels.) Before the cavity forms in the dentin, the process is reversible, but after it spreads to the dentin, it is not.
  5. In the presence of sugar and other carbohydrates, bacteria in the mouth produce acids that can demineralize enamel, dentin, and cementum.The bacteria break down the hard tissues of the teeth by making acid from food debris or sugar on the tooth surface. The more frequently teeth are exposed to this environment the more likely dental caries are to occur.
  6. Bacteria collect around the teeth and gums in a sticky, creamy-colored deposit called plaque, which acts as a biofilm (a thin, slimy film of bacteria that adheres to a surface).
  7. Some sites collect plaque more commonly than others, like in the pits and fissures of the surface of the molars and cervical margins of the teeth.
  8. The primary focus of brushing and flossing is to remove and prevent the formation of plaque.
  9. As the amount of bacterial plaque increases, the tooth is more vulnerable to dental caries when carbohydrates in the food are left on teeth after every meal or snack.
  10. A toothbrush can be used to remove plaque on accessible surfaces, but not between teeth or inside pits and fissures on chewing surfaces. When used correctly, dental floss removes plaque from areas that could otherwise develop caries.
  11. There are certain things that can increase your risk for dental caries, such as tooth location and surface. Caries are most commonly found on incisors, canines, premolars, and fissure sites in molars.

Other things that increase your risk of caries include: vector illustration of diagram for anatomy of human mouth

  • Foods that cling to the teeth, such as candy or chocolate.
  • Frequent snacking and sipping on sugary drinks.
  • Bedtime infant feeding.
  • Inadequate brushing of teeth.
  • Dry mouth.
  • Heartburn.

Here’s what we know about taking care of your teeth and preventing cavities:

  1. Regular professional cleaning of the teeth – 2 prophylactic cleanings are recommended per year. (This can be problematic for many, for multiple reasons outlined in my previous post.)
  2. Brush your teeth at least two times per day (make sure one of these times is before you go to bed).
  3. Floss between the teeth at least once a day; more so if you have a problematic tooth that catches food. Toothpicks can be helpful for getting food out of hard to reach areas.
  4. Do not brush immediately after meals, especially those that are high in acid. Instead of brushing, consider rinsing your mouth with plain water.
  5. Chewy and sticky foods (such as dried fruit or candy) tend to adhere to teeth longer, so they are best eaten as part of a meal. For children, the American Dental Association recommends limiting the frequency of consumption of drinks with sugar, and not giving baby bottles to infants during sleep.
  6. The ADA recommends brushing twice a day with a fluoride toothpaste.

This is the 2nd post in a series of three. See How to Avoid a Root Canal and Fighting Cavities for the other two articles.

 

 

 


How to Avoid a Root Canal

I recently had a root canal and though it wasn’t painful, the experience absolutely sucked. I left the endodontist’s office two and a half hours later, $1300 less in my savings, feeling pretty dang defeated. After all was said and done, my debit card swiped by an ill-tempered front desk person,  I sat in my 90 degree car and took a fit (cried). This was the 6th dental appointment that I’d had in 2 months for the same problematic tooth.  Three nights previous to the root canal I dreamed that my teeth were falling out, one at a time. They looked like giant pieces of white coral. I’m used to experiencing dreams as tightly bundled metaphors; this was uncomfortably literal.

WHAT is going on with my teeth? 

I asked my dentist and my endodontist this exact question.

“I’m so anal about my teeth!” I reported. “I brush and floss twice a day, sometimes three.  Aside from a single cup of coffee in the morning, I drink water throughout the day. So why this dying tooth? Why the increase in cavities? Do you think that it could be related to changes in my diet?”

Though I asked these questions separately of my dentist and my endodontist, they had the same reaction: a shrug followed by silence. Though I might be wrong, I understood this body language to mean: Don’t know, don’t care, probably not. The only feedback I’d received from my dentist up to that point was that he attributed the problem to the location of the tooth and a history of grinding. But when I asked about the other two cavities that had been discovered, and wondered aloud why suddenly there was such an influx of problems in my pie hole, and mentioned again my regimented (read:anal) care of my teeth, and asked one more time about the potential role of nutrition since that was the only thing that had really changed for me, he shrugged again.

He didn’t even bother to answer why he didn’t think nutrition could play a role.

SAVE THE MOUTH OF THE WORLD, LAUREN!
The 1-2-3 punch: Policy, nutrition, proper care.

I couldn’t help but be momentarily overcome by self-doubt. Perhaps I’m so grossly uninformed about dental health that I am coming off as a giant idiot? Maybe questions are annoying? Maybe I’m annoying for asking questions? (I answered my own questions quickly: No. No. No.)

I was told by my dentist that a root canal was the only option left, so I set up an appointment with the endodontist that he recommended. For whatever reason, extracting the tooth wasn’t mentioned. Three weeks later, I went in for the procedure. The first step was an x-ray of my tooth so the endodontist could examine the root. As soon as the image popped up on the screen, the assistant asked a question.

“Why are we giving her a root canal? Her tooth looks perfectly healthy.”

The endodontist cleared her throat and answered, irked, “I’m the doctor; you’re the assistant.” She then turned to me, rolled her eyes, and said “You’re getting a root canal because all the other signs point to a root canal.”

This exchange, as you can imagine, instilled a surge of confidence.

Ohhhhh, crap!” I thought, and though my anxiety swelled and threatened to invade my body with a sickening heat, I stopped it in its tracks. I wasn’t the expert. Neither was the assistant. The endodontist had spent many years of her life studying how to care for teeth. Root canals are her thing! my rational brain exclaimed.

So, I opened my mouth, a meek pup, and 150 minutes later  I was released to the wild. The endodontist and her assistant talked about many things while the insides of my tooth were filled with Gutta-percha – basically, the assistant asked decent questions and the doctor scolded her for being silly. Not my cup of tea, and 150 minutes of this was a bit much, but c’est la vie. Honestly, I just wanted to be able to chew food on the left side of my mouth again.

Before leaving the office, I asked my endodontist for her opinion about my tooth. I explained to her about my diligent care of my teeth, and told her that my dentist said that maybe the damage was due to the location of the tooth. I asked if she thought that diet could be a possible factor.

She shrugged and said nothing.

Then she turned around and went into another room, where she immediately started bickering with her dental assistant.

As soon as I was in my car, I began to cry out of pure frustration. $1300 was a big chunk of change for dental work, especially in addition to the $150 I’d spent first trying to fill it like a regular old cavity. And the whole damn experience would have been 70 percent less frustrating if those on the receiving end of my cheddah’ could have taken the time to talk to me. Taken a single minute to answer a single question.

Anyway, back to the pitiful sobbing. Two boogery minutes later, my inner warrior-pirate lifted my chin and said, Get it together, Lauren. Go home. Do some research. SAVE THE MOUTH OF THE WORLD, LAUREN!!!!

Cue Chariots of Fire theme song.

Once I got home, I sipped at a tall glass of water with my fat-lipped, half-numbed face and for the next 3 hours (which turned into the next month), I researched the subject of all-things-teeth.

Before I share what I found, here’s a bit of history. At age 36, I’ve had a total of 4 cavities (not counting the recent proliferation of problems with ma’ pearls). Since I’ve lived in various places, I’ve seen a handful of dentists and my experiences have been mostly consistent. Any time I’ve had to have a cavity filled, I’ve started the appointment with a request for information: What can I do – other than brush and floss –  to keep my teeth healthy? With the exception of a recent Facebook exchange with a friend who’s a dentist, I’ve received little to no feedback or instruction. For instance, I did not know that you probably shouldn’t brush right after eating, especially if you’ve just eaten or sipped something acidic.

Historically, after a dental procedure, my tongue darting across some newly polished teeth or poking at a newly filled tooth, I’ve been reminded (as my debit card is being swiped) that dental insurance is inadequate. More than once, the priced-out sheet of what the dentist did that day and how much won’t be covered has made me cringe. Then my brain starts churning out concerns: What about people without insurance? What about the single moms, the students, the elderly, the working class, the kids, the poor? If regular cleanings are one of the most proactive things you can do to protect your teeth (get rid of that plaque!), and if any work done on your teeth quickly consumes your coverage, and if many people don’t even have the millimeter of padding that dental insurance affords, and if paying out-of-pocket is too expensive for many, and if the majority of dentists don’t accept Medicaid, then…well, we have an obvious problem.

“Lauren, that’s why the poor are associated with bad teeth,” my sister calmly explained. “And that’s why they show up to the ER with an abscessed tooth and leave with a prescription pain killer.” Dental medicine and healthcare - dentist examining little child boy patient open mouth showing caries teeth decay

Which is how an article titled “How to Avoid a Root Canal” turned into this post. (Yes, I do have practical suggestions in regards to dental care in the next posts; see here and here.)

But many people, and not just the poor, are unable to get the basic treatment they need. About 130 million Americans lack dental coverage, and the rest aren’t off the hook. Dental insurance rarely covers the full cost of treatment: In 2011, $39.2 billion—46 percent—of the $85.2 billion spent on dental care came directly out of patients’ pockets. Dentistry is expensive enough that many people postpone procedures they urgently need—even though an abscessed tooth is excruciatingly painful and potentially deadly if infection spreads to the bloodstream. Disrupting Dentistry, by June Thomas

According to The United States Department of Labor Occupation Employment Statistics, the annual mean wage of the general dentist is $166,810. Dental school is expensive (in 2013, dental school graduates had an average of $215,000 in educational debt), and most new dentists feel they have to embrace the for-profit model to pay back these loans. Because of this, many dentists end up serving a very specific population. As for dental “insurance?” Here’s some food for thought: In 1972, Delta Dental offered a maximum yearly benefit of $1,000, which bought a decent amount of dental care. Today, the average cap on dental plans is … $1,000. In over 40 years, the benefit has not gone up.

So, what exactly is going on here? Below is another except from a great article I came across in my maniacal consumption of all things dentistry. I’d highly recommend reading it if you’re interested in the complexity of the problem, including the problem that the dentists themselves have to face. One of the solutions suggested to confront the issue of accessibility is (somewhat) similar to…the community acupuncture model. Go figure!

When you hear how rare it is for private practice dentists to take on Medicaid patients, it’s easy to conclude that they’re selfish snobs prioritizing profit over the needs of poor kids. But it’s not that simple. There’s no question that Medicaid pays less than market rates, and as small-business owners, dentists can’t ignore financial considerations. Anyone with a limited number of billable hours each week would be sensible to fill them with the best-paying clients.

Dentists also have other reasons to be selective about the patients they serve. For people in good oral health, dentistry is an aesthetic pursuit. These people’s twice-yearly appointments typically consist of a cleaning by the hygienist and a thumbs-up from the dentist. Some dentists may prefer these quick and easy cleanings, with occasional elective procedures such as whitenings, over the complicated business of managing serious tooth decay and gum disease, which are more common among poor patients who may have missed out on good care as children. A dentist’s office has a lot in common with a fancy department store: The more expensive the clothes, the fancier the changing room, the more solicitous the saleswoman. Similarly, the higher a dentist’s fees, the more exclusive the waiting room. That’s why those dentists who do treat Medicaid patients often set aside a day just for them—it’s better for business to keep the two groups separate. –Disrupting Dentistry, by June Thomas

Before we move into the next blog post where I share my ideas on how we may practice preventative dental health through diet and other little tricks of the trade, below are a couple of resources, for those of you who might have found yourself stuck between a rock and a bad tooth. We have a serious dental crisis in Maine. Read about it here and here.

And please understand that my personal experiences around getting my tooth fixed are not representative of all visits to the dentist. When I started sharing my stories of dental woes, many, many people were happy to share the names of the dentists that they loved.

Though my tooth isn’t giving me acute pain any more, it’s still not resolved. I still can’t chew on that side of my mouth, and to complete the fix, it needs a crown – another $1300 out of pocket. It’s recommended that you get the tooth crowned ASAP in order to prevent complications, but many people have to wait for their insurance to ‘refill’ to complete the fix. Many never get it done because they simply can’t afford it.

This is the first of 3 blog posts on this subject. See Fighting Cavities and Your Teeth and Your Diet: What’s the Deal for the following posts on this subject.