Tuesday, 26 July 2011

Dental Caries

Published in Panorama

Preventing Dental Caries

Dental caries, though largely preventable, is one of the most common chronic conditions faced by most people at one time or another during their life time. While it can affect people of any age, it is more common among children and young adults. It is especially very common in children between the ages of five to seventeen years and is believed to be five times more common than asthma in this age group. Once, established the problem can only loom larger unless treated appropriately and on time, says Dr.Mehdi Abbas, Dental Surgeon, Zulekha Hospital, Dubai.

Dental caries is a destructive disease of the teeth which is usually caused by accumulation of food particles, especially carbohydrate-rich foods like sweets, getting wedged between teeth and in the grooves of the oral cavity. Dr.Abbas explains, “Caries are formed by action of bacteria which are naturally present in the mouth. The bacteria adhere to the sides of the tooth and then begin a process of demineralization which progressively breaks down the tooth and causes decay. The type of carbohydrate and when they are eaten, are more important in caries formation than the quantity of these eaten. Sticky foods are more harmful than non-sticky foods because they remain on the surface of the teeth and make it easy for bacteria present in the mouth, to feed on it and convert it to acid. The acid then mixes with the remnants of food, bacteria and saliva to form plaque, a sticky substance which adheres to the teeth. Dental caries or decay occur when the acids in plaque dissolve the enamel surface of the tooth and create cavities in the tooth. Cavities are usually painless until they grow very large inside the internal structures of the tooth which include the dentin and the pulp at the core, where it can cause death of the nerve and blood vessels in the tooth, resulting in tooth abscess. Left untreated, this can lead to total damage of the internal structures of the tooth, resulting in its eventual loss.”

People who take snacks regularly are more at risk of caries because fresh acid is formed after each meal and the teeth are thus exposed to acid for a longer time. Similarly, those eating carbohydrate-rich foods, sweets, colas and carbonated drinks are at greater risk of developing caries, explains Dr.Abbas.

Having said that, even infants can develop dental caries due to what is called as the “nursing bottle syndrome”, reveals Dr.Abbas. “Caries may typically happen with bottle-fed babies who sleep with the bottle in their mouth. As the baby sleeps while sucking from the bottle, there’s a pooling of milk, usually on one side of the mouth. This is very conducive for bacteria to start acting on the milk and setting the process of caries in motion. This is the reason why we advice mothers not to leave babies with sucking bottles, unattended and also to have their head elevated while feeding, to facilitate swallowing of the milk so that it does not pool in the mouth.”

Elaborating on the carious process Dr.Abbas explains, “Teeth are made of three layers: enamel, dentine and the pulp. Caries move from the enamel, the outermost layer of the teeth, in an “inverted cone” pattern, to the dentine and then to the pulp which is the innermost layer consisting of nerve fibres and blood vessels. Very often, the earliest signs of caries appear as a white chalky area on the enamel, a sign not easily visible to the person having it; only a trained eye can see it. This small white spot is the initial or incipient caries, the first signs of demineralization occurring. At this stage, it is not yet a cavity and the tooth surface is still hard. “Decay” does not set in at this stage and with appropriate measures the caries process can be halted and even reversed. However, at this stage since there is no manifestation of the condition, neither pain nor any other sign, people do not seek assistance at the dentists. Left untreated, this chalky patch, softens and the enamel is destroyed. Unless a dentist cleans and fills the resulting cavity that forms where enamel is destroyed, the damage will spread to the underlying dentin. The tooth becomes very sensitive.”

Caries do not manifest any symptoms initially. Since a large number of people have caries without any symptoms at all, they do not seek medical attention until it has advanced significantly and presents with symptoms of pain. As the caries progresses to the dentine, the person affected may experience toothache after hot, cold or sweet foods or drinks. It is unfortunate, rues Dr.Abbas, “especially here in the UAE, even when the caries progresses to this stage and the dentine is affected, people do not bother to come to a dentist. They deal with the pain by self medicating with analgesics, antibiotics and painkillers. Even at this stage, should they seek help, their tooth can be saved by making a filling.”

“However, once it reaches the pulp, symptoms manifest are pronounced with severe pain, sensitivity in the region and sleeplessness from the pain. The pulpitis or inflammation of the pulp is of two types: reversible and irreversible. The reversible pulpitis can be treated by direct or indirect pulp capping. This involves providing a cover with calcium hydroxide which promotes the formation of dentine along with the living tissue of the pulp. In the case of irreversible pulpitis, the pulp is necrosed and it forms pus and starts becoming infected. At this stage we definitely need to do root canal treatment to save the tooth. However, if even at this stage, no dental attention is sought, the infection begins to move around the tooth’s root which is embedded into the bone. Once it reaches there, it forms an abscess which is excruciatingly painful and tooth extraction may be the only solution.”

Adding a further word of caution Dr.Abbas explains, “Sometimes, once the pulp is necrosed, the pain disappears and the tooth just stays there and starts getting eroded, fractured because it is dead already. But the underlying tissues usually get affected. So it is always better for patients to seek help as soon as they spot even a small cavity in the tooth when they are brushing. This would save time, money and pain for the patients.”

Dental caries are best dealt with in children from about two to twelve years when the permanent teeth have all erupted. In the sense, it is best for children to have their first dental check up even before they turn two years, before any extensive cavities are established! If not treated in the initial stages, caries progress towards the pulp and will then require extensive treatment to save the tooth.

The aim of dental check ups in children, is the prevention of caries, emphasizes Dr.Abbas. “Caries actually start with pits and fissures where food particles get stuck. The best way to take care of caries in young children is to do pit and fissure sealing. We fill the grooves so that it is smooth and does not allow food to get wedged there. This would also allow the children to brush their teeth properly with fluoride containing paste which would penetrate into the tooth, resulting in the tooth structure to be caries-resistant.”

Treatment for dental caries involves filling the affected tooth, explains Dr.Abbas. The decayed material is removed and replaced with an inert restorative material, which is either amalgam or composite. Crowns made of gold or porcelain are used if the decay is extensive, as a protective layer over the rest of the tooth. Where the pulpitis is irreversible, root canal treatment is the normal treatment modality.

Dental Caries may be prevented by taking appropriate measures, says Dr.Abbas. These include:
Brushing teeth twice a day after eating, especially after taking sugary, sticky food.

Use fluoride toothpaste and mouthwash.

Use of mouthwash reduces the virulent microorganisms.

Brush teeth using medium or soft bristle brush.

Clean the gingival or gum portion of the teeth regularly.

Use dental floss at least once a day, to clean areas between the teeth.

Do not use vigorous brushing or brush excessively (more than twice a day) since this can cause erosion of the enamel.

Brush the teeth using the motion of 8 – that is, brush in an 8-formation.

Brushing hard will not remove stains occasioned by smoking or tobacco chewing. In these instances, the teeth need to have “scaling” done on them.

Avoid snacking in between meals.

Remove plaque at regular intervals.

Have a balanced diet and avoiding too much of carbohydrate rich foods.


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