For years I have been treating children with cavities. I have no idea how many thousands of fillings, crowns, and extractions I have performed, but it is a staggering amount. I have given advice to all of my patients as to why their children have cavities. I talk to them about sugar, carbohydrates, the frequency of eating, brushing teeth, flossing, etc. After fourteen years of giving everyone the same advice, and hearing the same answers I decided it was time for a change.
There are three things needed for decay to occur. You need a tooth, bacteria, and a food source for the bacteria. When these three come into contact, you can make a cavity. I consistently hear the story of “bad teeth” in the family; a generational story of parents/grandparents/fathers/mothers having cavities no matter how much they brush, and dentures or crowns at an early age. I have decided it’s time to find out what is going on. No more generalized advice on what the problem might be, no more telling the parents to brush and floss and watch the carbohydrate intake. I feel as though we are supposed to be a preventative profession, yet all the decisions made are reactive and not proactive.
The first hurdle we need to cross is how do we find out what is going on.
If we look at the triad that makes tooth decay, the first component is teeth. It is easy to know if you have teeth; that just requires a look. The idea of “bad enamel” or “bad teeth” is not so easy to identify. There are times when you can look at a tooth and determine if there indeed was an issue with enamel formation, but it is fairly uncommon, and the presentation is easy to see.
The second component is bacteria present in the mouth.
That is a more difficult issue to assess. In medicine, blood samples, swabs, etc. are taken and cultured to determine what type of “bug” is responsible. Taking biological samples is something we shy away from in dentistry. We know the two main types of bacteria responsible for decay, so that does simplify the problem. Now we just need to know how high the levels are. In our office, we will now be taking samples of plaque in children’s mouth to culture and determine if they do indeed have a high bacterial count. The samples will let us know if we need to incorporate anti-bacterial regimens into our preventive plan.
The third component is the carbohydrate source for the bacteria.
We have focused so much on sugar intake over the years that we’ve neglected the other culprits. The thing we need to look at is the total carbohydrate frequency in our diets. Sugar is a carbohydrate in itself, but there are other carbohydrates we pass over, such as starches and grains. There are very few things that we consume today that do not contain carbohydrates. When we put food in our mouth, the bacteria convert these carbohydrates into fuel for themselves, with a byproduct of acid dumped onto the teeth. The body has a wonderful defense mechanism in place called saliva. When the acid shows up, the saliva works to neutralize the acid, and even repair the tooth. Unfortunately, this takes time. When eating, the pH drops for about 20 minutes, and then the saliva can effectively neutralize the acid and start the repair process on the teeth. The issue comes when there is constant eating, grazing, and frequent snacking, and the saliva cannot bring the pH level up to where the repair process can occur. Over time, the acid eats through the enamel, and a cavity develops. Once the “cavity” has moved through the enamel and spread in the dentin, I have to mechanically remove it. Unfortunately, this is something that not everybody knows or cares about. To combat this, I will be having the parents log for one week what food is eaten and what time it is eaten so we can take a look and see if the issue is linked to carbohydrates. Along with the nutrition logs, we will be following the American Academy of Pediatrics, and American Academy of Pediatric Dentistry recommendations to track the BMI on our patients. Alone, BMI does not determine well whether one is overweight or not. What the BMI does allow us to do is track over time if we are moving to an unhealthy body composition. With the nutrition information and BMI, we can discuss whether a referral to a pediatrician or nutritionist is in the best interest of the child.
Now, what do we do with this information?
By determining bacterial count, and carbohydrate source we can tailor a preventive plan for each individual. It can range from simple diet counseling to multiple in-office visits throughout the year. We have a range of products from fluoride, to anti-bacterial rinses, varnishes, and Calcium/Phosphate gels, the list goes on, at our disposal to help stop the cavities before we reach the point of a filling/crown/extraction.
Historically, we have diagnosed decay with examinations utilizing mirror/explorer and radiographs. However, with these conventional techniques, sometimes by the time we were able to detect a problem, it was too late. The question then arises, how do we find the decay before it’s too late. With the Canary system, we can scan teeth and analyze the crystalline structure. We’ll then score the tooth on a scale of 1-100, with one being perfect and 100 being a giant cavity. The score will tell us if there are issues long before x-rays and even mirror/explorer exam. Using the number value, we can start preventive regimens and scan to track and see if they are working. If the number continues to go up, then we are heading to a cavity. If the number goes down or stays the same, the decay is not progressing. We will also be able to move to a more visual exam. The explorer has been an invaluable tool for years, but research is now showing that it can transfer bacteria from one tooth to another, and if used improperly, actually cause damage in the pits and fissures of the teeth. Being able to rely on the scan, and visual examination will only help keep the teeth healthy.
All treatment we render is on a risk assessment.
Those who are in high-risk categories for decay will need more interventions, versus those who are in low-risk categories. There are many variables in assessing risk, but one that stands out most is the decay history of the primary caregiver. When the primary caregiver has a significant history of decay, generally they will have a high bacterial count. Bacteria in a child’s mouth can come from a few places, but primarily it is contact with the primary caregiver that has the most impact. Kissing, cleaning off a pacifier with their mouth, sharing spoons, the list goes on. All of these activities are transferring bacteria to the child’s mouth. By working with local pediatricians and dentists, we are hoping to get the word out to start combating the bacterial levels in the primary caregiver before the baby is born. By working in this way, we can help prevent high bacterial counts, and keep the risk of decay low.
Now the hope is that with all the information, interventions and treatments we can stop decay before it begins.
Dr. Boyd Simkins, DDS
Lee JY, Bouwens TJ, Savage MF, Vann WF. Examining the cost-effectiveness of early dental visits. Pediatr Dent 2006;28(2):102-105, discussion 192-8
Douglass AB, Douglass JM, Krol DM. Educating pediatricians and family physicians in children’s oral health. Academic Pediatr 2009;9(6):452-6
Loesche WJ. Role of Streptococcus Mutans in human dental decay. Microbiol Rev 1986;50(4):353-80
Douglass JM. Response to Tinanoff and Palmer: Dietary determinants of dental caries and dietary recommendations for preschool children. J Public Health Dent 2000;60(3):207-9
Kranz S, Smiciklas-Wright H, Francis LA. Diet quality, added sugar, and dietary fiber intake in American preschoolers. Pediatr Dent 2006;28(2)164-71
Reisine S, Douglass JM. Psychosocial and behavioral issues in Early Childhood Caries. Comm Dent Oral Epidem 1998;26(suppl 1):32-44
Tinanoff NT, Kanellis MJ, Vargas CM. Current understanding of the epidemiology mechanism, and prevention of dental caries in preschool children. Pediatr Dent 2002;24(6):543-51
Erickson PR, Mazhari E. Investigation of the role of human breast milk in caries development. Pediatr Dent 1999;21(2):86-90
Tinanoff NT, Palmer C. Dietary determinants of dental caries in preschool children and dietary recommendations for preschool children. J Pub Health Dent 2000;60(3):197-206
American Academy of Pediatrics Committee on Nutrition. Policy statement: The use and misuse of fruit juices in pediatrics. Pediatrics 2001;107(5):1210-3, Reaffirmed October, 2006