How to Prevent Tooth Decay Re-Visited

In a previous article I wrote on ideas for preventing tooth decay. I would like to re-visit this topic because despite the fact that we have the means available to completely prevent this disease it is still very rampant in our society. Take a look at this well-written article on WEBMD:

http://www.webmd.com/oral-health/guide/tooth-decay-prevention

I liked this article and thought it was a good practical summary of prevention ideas similar to my article on prevention. However, cavity prevention cannot be achieved simply by reading a list of instructions in every case. There is a reason why less educated and people with lower socioecconomic status have a much higher rate of tooth decay: more than likely they were never taught the habbits that lead to oral health and they probably don't understand how this disease process works. I would like to expound on this article and the one I wrote previously. Tooth decay is a multifactorial disease meaning there are a lot of causes. However, Understanding a few basic ideas of how tooth decay works can help you change your daily habits and prevent new cavities from forming.

We were taught in dental school that 3 conditions must exist for a cavity to form:
#1 an agent: bacteria
#2 a succeptible host: you
#3 an environment that supports the agent or reduces hosts defenses.

#1 Tooth decay is the result of a bacterial infection. Your mouth is chuck-full (yes this is a very scientific term) of bacteria! The specific types of bacteria that cause cavities like Streptococcus Mutans are passed from mother to child. Cavity causing bacteria eat and digest sugar and other easly broken down carbohydrates then they produce acid. This acid is what starts to brake down your tooth structure forming a cavity. The bacteria cannot be eliminated completely with our current treatments. Even after rinsing with Listerine (which does kill them) they will re-bound, antibiotics would have a similar effect except with more negative side effects.

#2 Tooth decay is the result of a succeptible host: you! These bacteria need a hard surface to attach to: your teeth! Newborn babies that do not have teeth yet have very low numbers of these cavity causing germs. As soon as infants get some teeth especially molars with grooves in them the levels of cavity causing bacteria go up exponentially. Part of your succeptibility to decay may be genetic. Some people may have natural cavity protection in the form of good anti-cavity saliva and less succeptible tooth anatomy. However there are aspects of you that you can change. "Soft teeth" is usually not the reason for your decay. There are very rare disorders where the dentin or enamel on your teeth does not form properly thus this person would truely have soft teeth.

#3 Cavities are the result of an environment conducive to the growth of specific bacteria. If I were a cavity causing bacteria I would love the following environment: a dry mouth and plenty of carbohydrates frequently placed in the mouth of my host throughout the day and especially right before bed. The frequency of carbohydrate or sugar consumption throughout the day is a risk factor for tooth decay.

We learned about something in dental school called the Stephen's curve which describes the pH or acidity of your mouth immediately after eating a sugary or carbohydrate rich food. In some people who have poor quality or low quantity of saliva it takes a long time (more than 30 minutes) for the acid to be neutralized or brought above the critical pH of 5.5 (the critical pH is the acidity level at which your enamel begins to dissolve or de-mineralize). If this type of person is snacking on crackers, sipping soda, eating bread, or cookies 5-6 times throughout the day then there teeth may be in an acidic environment all day long. People with very dry mouths may have an oral environment which is constantly below the critical pH of 5.5. However in someone with normal salivary function the acid is neutralized within 20 minutes but even in this case the person could spend a significant portion of the day with their teeth being dissolved!

Now a few things you can do about it: You can't completely eliminate the bacteria or change your genetics but you can drastically change the environment that the bacteria live in.

#1: Chew a piece of sugar free gum or suck on a sugar free mint after meals and snacks. The main goal here is saliva stimulation immediately following a meal... Why? Because saliva in most cases is very effective at neutralizing the acid produced by the bacteria and washing away excess bacteria and food debris. Unfortunately a great deal of our modern medicines have the side effect of inhibiting the production of saliva causing dry mouth. This is why people can go their whole life without having much decay then all of the sudden when they start taking medicines which cause dry mouth (Xerostomia) they get a lot of cavities. If you have a dry mouth then you need to see your dentist and ask him or her about how to prevent decay with aggressive high strength fluoride therapy and saliva substitutes.

For everyone with normal saliva flow the sooner you can stimulate saliva following a meal, snack or drink of soda the faster you will reduce the acid levels in your mouth to normal and thus prevent decay. So chew some xylitol sweetened gum! If you don't have any gum then buy some, if you can't buy some then get a drink of water after a snack or meal.

#2 Don't rinse with anything including water for at least 30 minutes after you brush your teeth (with ADA approved fluoride toothpaste). Fluoride has the opposite affect from sugar on your teeth, it re-mineralizes rather than dissolves the tooth structure. The problem with fluoride is that it has poor substantivity meaning it does not stick to your teeth very well. After brushing your teeth you should spit the remaining paste out THEN DO NOT RINSE WITH WATER! If you rinse after brushing you are washing away most of the protective fluoride. Fluoride needs contact time with your teeth and in your saliva to help repair the damage done by the acid producing bacteria. It is especially important if you have a high risk for cavities to expose your teeth to fluoride right before bed as the fluoride can remain in your mouth uninterrupted for 7-8 hours. If you don't brush and floss your teeth before you go to bed then you are letting the bacteria dissolve your teeth for 7-8 hours!

In short your teeth are constantly in a flux of either being re-mineralized or de-mineralized. Tooth decay depends on how well you keep your teeth in the re-mineralized category. Your job is to stop the teeth from dissolving by stimulating saliva with a sugar free gum or sugar free candy and help the teeth re-mineralize or solidify by allowing your fluoride toothpaste to sit on your teeth uninterrupted for as long as possible.

Or if you want it in even simpler terms... For cavities: Fluoride & Saliva GOOD, frequent sugar exposure without anything to neutralize the acid BAD!

I'm glad I don't have to go to school tomorrow it's getting late!

Here are some other suggestions for preventing cavities:

7 Ways to Prevent Cavities
http://dentistry.about.com/od/dentalhealth/tp/preventing_cavities.htm

How to prevent cavities and gum disease while saving yourself a bundle of money when you go to the dentist

Several years ago as a college student I ended up needing a root canal and crown on one of my teeth which ended up costing me a little over $1,500 even with a student discount. If I had known better how to prevent cavities I may have been able to avoid that cost, especially at a time when I had such a tight budget. Also, if I had been going to the dentist more regularly I maybe could have gotten away with just a filling rather than a root canal which would have saved me around $1,250.

Cavities are caused by 1) an infection by acid producing bacteria such as streptococcus mutans. 2) carbohydrate or sugary food for the bacteria. 3) a bacteria friendly environment: your teeth. While part of your susceptibility to decay is genetic, most tooth decay is preventable! Many dentists say the same thing: “Brush twice per day and floss daily to prevent tooth decay” which is essential for optimal oral health but there is more that can be done!

If you want to prevent tooth decay or periodontal disease here are a few suggestions:

1. Brush at least twice daily after meals. I brush after breakfast and after dinner. Use ADA approved fluoridated toothpaste, such as Colgate Total which has Fluoride and Triclosan to decrease tooth decay and gum disease. Studies have shown that toothpaste with Triclosan provides some protection against gum disease. Gum disease includes gingivitis and periodontitis which is a major cause of tooth loss. People who smoke or have diabetes are at a higher risk of developing gum disease. If you have excellent oral hygiene habits and go to the dentist regularly then you may not need to use toothpaste with triclosan. However if you are at a higher risk of developing gum disease, Colgate Total with triclosan may be a good choice of toothpaste to use. I would avoid triclosan for pregnant or nursing women and just be extra diligent with tooth brushing and flossing during that time to prevent pregnancy associated gingivitis. Don’t forget to brush your tongue! After brushing do not rinse, eat, or drink for 30 minutes to let the fluoride remineralize your teeth. Brush the right way.
2. Floss every day after dinner or before bed; make sure you floss the right way.
   
3. Chew Xylitol sweetened gum immediately after eating snacks and after lunch if you cannot brush. Try to use 100% Xylitol sweetened gum which includes: Spry, Xlear, Epic, Zapp, Xylichew and others which are available for sale at the dental school, health food stores, and online. If you cannot readily find 100% Xylitol gum then use gum which has Xylitol as the first ingredient—a good example is Icebreakers gum. Some gum recently became ADA approved which does not contain Xylitol. This is because sugar free gum helps just because it stimulates saliva production. Xylitol gum goes beyond just saliva production to actually inhibit cavity causing bacteria. Xylitol gum is also good for people who are on medications which decrease saliva flow. Do not chew Xylitol gum if you have TMJ pain or if your chewing muscles and joints are sore or stiff. The only side affect of Xylitol is that it has a laxative affect if you consume too much of it but the amounts you would consume chewing a few pieces of gum per day should not cause a problem. Malitol and Sorbitol have the same affect just don't consume any of these sugar substitutes if you have diarrhea. Here is a paper I wrote my first year of dental school on Xylitol.
4. Buy a new toothbrush regularly this includes the brush head to electric brushes (replace every 2-3 months or more). Use a soft bristled toothbrush and don’t push too hard when brushing to avoid damaging your teeth and gums. It is more important how long you brush for and the technique you use rather than how hard you push. Brush for a full two minutes each time being sure to brush at or near the gum line on all sides of your teeth front and back.
5. Use a good electric toothbrush research has shown that an oscillating rotating toothbrush is more effective at reducing gingivitis than a traditional manual toothbrush long term. This may be because you are more likely to brush for a longer period of time with an electric toothbrush than with a manual brush; maybe because you will not get as tired, and some electric toothbrushes even have a timer on them.
6. Rinse with Listerine every other day if you have gum disease the equate brand is also ADA approved and is essentially the same thing. Listerine is also is an alternative to using toothpaste with Triclosan to prevent gingivitis. However each of these has their side effects. Listerine can dry out your mouth if used too much and Triclosan, while yet un-proven, may produce stronger bacteria that have become resistant to Triclosan after years of use. However, Listerine and Triclosan are the most effective (over the counter) chemical means we have available of reducing the bacteria in your mouth that cause gum disease. When using Listerine, follow the directions and rinse for 1 minute. Listerine is the most effective over-the-counter mouthwash at decreasing the amount of bacteria in your mouth which cause cavities and periodontal disease. Do not use Listerine if you have a history of alcoholism—using too much Listerine can also dry out your mouth if used excessively. If you have a problem with dry mouth or alcoholism then use Crest Pro-Health mouth rinse. Recently there have been complaints of the blue Crest Pro-Health rinse staining teeth. You can purchase the clear version to avoid this problem.
   
7. Rinse every day with fluoride mouth rinse. ACT brand fluoride mouth rinse, and the Wal-Mart Equate brand fluoride mouth rinses are both ADA approved, over-the-counter fluoride mouth rinses. Rinse for one minute and spit it out without rinsing with water; also do not eat or drink for at least 30 minutes to let the fluoride remineralize your teeth. I recommend you rinse just before going to bed unless you brush your teeth before going to bed. If you brush your teeth following dinnertime then you can wait until bedtime to rinse with ACT. Toothpaste actually has more fluoride in it than the mouth rinse so if you would rather just brush your teeth again you can do that instead just do not rinse your mouth with water after brushing your teeth. Spit out the toothpaste and don’t eat or drink for at least 30 minutes.
8. Avoid drinking large amounts of soda! Fruit juice, sugared coffee, sugary sports drinks, and other sugary or acidic drinks can cause uncontrollable cavities especially in someone who has a dry mouth. If you do drink sugary or acidic beverages, then don’t sip it all day long. Chew Xylitol gum or rinse your mouth with fluoridated water right after a sugary snack or drink. If you drink bottled water, make sure it has fluoride in it or use filtered tap water that still has fluoride in it. Some fruits such as lemons, limes, grapefruits, grapes and others are very acidic and can erode away your teeth just make sure you rinse with water after eating your fruit. Fruit is actually good for preventing oral cancer. Use calcium fortified fruit juices if you drink fruit juice to reduce erosion of your teeth.

9. Eat more fruits and vegetables vegetables do not contain carbohydrates which can be used by cavity causing bacteria in the mouth, and fruits while they do contain some sugar have a fast oral clearance rate due to their stimulation of saliva not to mention they can help prevent cancer, heart disease, and the common fat.
   
10. Eat less sugary foods sugar containing foods have been found to increase cavities especially with people who do not have adequate fluoride exposure. The frequency of using these sugary or carbohydrate rich foods throughout the day is more important thus...
    
11. Snack less frequently
    
12. Don’t Smoke! Smoking is the #1 cause of preventable death in the USA. Smoking increases your risk for lung cancer, oral cancer, emphysema, dry mouth, and periodontal disease which can make you loose all of your teeth.
13. Be aware of Dry mouth. Most medications can cause you to produce less saliva called xerostomia. If you are taking any medications and even some herbal supplements you may have a dryer than normal mouth which drastically increases your chances for developing cavities and other oral problems. This is also why it is so important not to go to bed with a dirty mouth. You do not produce very much saliva at all while you lie down or sleep. I have seen too many cases of patients who have dry mouth combined with consumption of a lot of soda all day long who have cavities on nearly every tooth! If you have dry mouth do not drink soda! Drink water!
14. Ask your dentist about preventative measures… if you have severe tooth decay your dentist can prescribe prescription strength toothpaste, chlorhexidine mouth rinse, do a bacterial test to determine the type and amount of bacteria present and give you specific advice about how to prevent future problems. Sometimes you may have a very small cavity (incipient) that can be reversed with aggressive fluoride treatment. Fluoride varnish or prescription strength fluoride toothpaste along with the suggestions on this blog may help you re-mineralize an incipient cavity without treatment. If you show a little initiative and do your part, your dentist will be more willing to help you win the war on tooth decay rather than just drill, fill, and bill. The responsibility for prevention lies with both the patient and the dentist.
15. Visit your Dentist Regularly I can’t stress this enough! If you want to make your dentist rich then just go once in a while or go all the time but don’t take care of your mouth. Some people don’t go to the dentist because they cannot afford to or they say they want to save money which does not make sense. I have seen time and time again what happens when someone does not go to the dentist on a regular basis. They end up with severe periodontal disease and need their remaining teeth extracted and replaced with a denture because they have not received a professional cleaning in 10-15 years OR they end up with rampant tooth decay which costs a fortune to restore properly with root canals and crowns. If you go to the dentist on a regular basis and take care of your mouth every day you can save yourself a lot of pain and money. You may need some minor preventative procedures, a few small fillings, fluoride varnish, cleanings, etc but it will save you from the really expensive procedures. Also, in most cases, nothing functions or looks better than your own natural teeth!

*These suggestions are intended for people who are adults and teenagers. Ask your dentist about your specific situation and how to prevent tooth decay in infants, toddlers, and young children. I recommend some specific products based on sound research. I am not being paid by any of these companies. For more suggestions go to http://www.adha.org/oralhealth/index.html or http://www.ada.org/public/topics/decay_faq.asp