Your Teeth for a Lifetime
The goal of our office is to have you keep your teeth for a lifetime, and with as little intervention on our part as is possible. We will do what we have to, in order to keep you in excellent dental health, but you can certainly minimize our responsibilities by understanding and following our recommendations on the following pages. This is your “Dental Prevention 101”.
These notes are distilled and amalgamated from 2 newsletters that we sent out in 2012 and 2014.
Why do we lose teeth? The two major causes of tooth loss are dental decay and periodontal disease (gum disease).
The following notes discuss the causes of decay and periodontal disease and what you can do at home to prevent them.
Summary: Plaque is the very soft, white film that builds up on your teeth. It is a biofilm: an organized layer of bacteria. Plaque causes dental decay and contributes heavily to periodontal disease. If you remove the film of plaque from your teeth by brushing and flossing, you will have almost no problems with decay and generally very few with gum (periodontal) disease.
1: Tooth Decay: why we get tooth decay and what to do about it.
Why do teeth decay?
Summary: Bacteria form plaque: once the plaque is thick enough (after 48 hours) some of the bacteria convert sugars and starches into acid, which dissolves your tooth, creating decay or a cavity.
Decay is primarily caused by bacteria called Streptococcus mutans (S. mutans) and their ability to ferment simple carbohydrates (sugars and starches) to form lactic acid. Almost all of us have these bacteria in our mouth, but some varieties produce more acid than others. Your teeth are made up of a calcium compound called calcium hydroxyapatite and it dissolves when contacted by the lactic acid. You may remember high school chemistry when the teacher dropped a strong acid onto a piece of limestone and it bubbled up, slowly dissolving. The same thing happens in your mouth, but very slowly. The dissolved area on your tooth is what we refer to as a cavity or decay (or in dentist talk: dental caries).
S. mutans is part of a bacterial colony or bio-film called plaque. Most of us are familiar with plaque. It’s the soft white stuff that builds up on your teeth when you go camping for a few days and forget your toothbrush. By about the third day your teeth feel like they have a fuzzy film on them (referred to as “sweaters on your teeth” when talking to kids).
Oxygen inhibits S. mutans’ ability to ferment carbohydrates, but oxygen is blocked once the plaque gets thick enough (after about 48 hours). After this starches and sugars pulled into the plaque and are fermented to form lactic acid (along with carbon dioxide and water) and the tooth begins to dissolve: a cavity is formed.
How can I prevent decay?
There are a number of approaches.
- The most important is to remove plaque. Oxygen inhibits the fermentation process. A thick layer of plaque blocks oxygen. So if there is thick plaque, there is too little oxygen and decay results. Remove the plaque and there is no decay. Plaque is very soft. Remember that camping trip: you got rid of that “fuzzy” feeling just by wiping your teeth with Kleenex, so with a brush and floss plaque doesn’t stand a chance. It takes plaque about 2 days to rebuild after it is removed, so if you brush and floss your teeth thoroughly once a day, almost all decay will be stopped. Interestingly, as a young guy I was very prone to decay. Also I had never heard of dental floss. In the fall of 1971 I started dental school and was introduced to floss for the first time. I began using it every day and have had zero new cavities since 1971. This works!
- Diet: What you eat: Plaque converts sugars and starches into acid, so when you eat sugars and starches (candy, fruit, bread etc.) you are feeding your plaque. After you “feed” your plaque by eating sweets or starches acid production continues for about 20 minutes. So if you have nooks and crannies in your teeth where your brushing and flossing haven’t removed all of the plaque, acid will be produced for 20 minutes after ingestion of carbohydrates. If you have a glass of orange juice and drink it all at once, you get acid production for twenty minutes. If you sip at it all afternoon long, then you will have a much longer span where acid is produced. Similarly, slowly consuming a package of Lifesavers will cause a much longer period of acid production than wolfing down a chocolate bar.
- Fluoride: Fluoride protects your teeth by making them more resistant to the acids formed by plaque. Fluoride ions react with calcium hydroxyapatite to replace the calcium and form fluorohydoxyapatite, a compound that is very acid resistant. This is the basis for fluoridated toothpaste, fluoride treatments for children and for fluoridation of water. With time, teeth absorb fluoride from various sources and become more resistant to decay. We are generally most prone to decay just after our teeth erupt and for another decade until they take in enough fluoride to toughen them up.
Tell me more about sugars and starches.
Refined sugars and starches (the white stuff) are particularly potent in terms of decay. Studies using tiny electrodes to measure acid production in teeth report that there is little difference in the effect of sugars and starches. Eating sweetened and unsweetened cereals result in the same levels of acid production.
A similar outcome occurs comparing candy to apples – they both have fermentable sugars and produce similar levels of acid.
Our recommendations to prevent decay:
1: Brush and floss thoroughly at least once a day. Removing all the plaque from your teeth on a daily basis is enough to stop the decay process. Brushing cleans the outside of your teeth and flossing cleans between them. As we like to say: “You don’t have to floss all of your teeth, just the ones that you want to keep”.
2: Don’t consume sugar on a continual basis: sugar in coffee, juices, chewing gum or candies allow slow release of sugar and prolonged acid production. Fruit contains sugar as well: both fresh and dried: if you snack on fruit (fresh or dried) all day long, you are feeding any plaque that is on your teeth all day long.
3: Use fluoridated toothpaste, and if you are particularly prone to decay ask us about supplemental fluoride treatments or a home fluoride programme.
4: Have your teeth examined regularly. A small cavity is easily treated. With time it becomes a large cavity: treatment is more complicated. After that the decay enters into the tooth’s pulp (nerve) and this becomes infected: much more complicated yet. Catch cavities and have them treated when they are small – it’s so much easier.
Scores of academic careers are based on researching tooth decay. This is a very abbreviated version of all of that research. We hope that it helps clarify your understanding of decay and its prevention.
What is toothbrush abrasion?
If you brush too hard, with too stiff a brush, with too much toothpaste, you can literally wear your teeth away. This is toothbrush abrasion.
Toothbrush abrasion refers to grooves worn into teeth, generally by the gum line. It is self-inflicted damage brought about by a combination of the abrasives in toothpaste and overly enthusiastic brushing (scrubbing). These can be shallow, or in some cases quite deep – halfway through the tooth into the nerve. Generally growing sensitivity brings the situation to our attention earlier than that.
Toothpaste contains abrasives designed to remove (scrape) stain from your teeth. Lots of toothpaste along with too much elbow grease can result in tooth structure, along with the stain, being scraped off your teeth. Once the grooves get deep enough, we fill them in. If we notice this starting we advise you about the cause and steps to prevent things from getting worse.
Avoiding toothbrush abrasion is fairly simple. Brush your teeth thoroughly, not aggressively – note: no vigorous/violent back and forth scrubbing. An electric toothbrush generally won’t lead to abrasion, but neither will a properly used traditional toothbrush. Use a soft brush. We generally recommend toothpaste once a day (to remove stain) and thereafter brush with water and then use mouthwash for that nice minty taste. If in doubt, ask us. We are happy to discuss all of this for as long as needed.
Food Catching Between Teeth (Food Impaction)
If teeth aren’t in firm contact with their neighbours then food can get jammed between them when chewing. This “impacted” food feeds the bacteria that cause decay all day long. Very serious decay can result in short order (months rather than years).
Food impaction can result if a filling or tooth fractures opening a space between teeth. Also, occasionally teeth drift apart and food gets jammed in.
The Summary: If you have a place where food is always getting caught, tell us sooner rather than later: small problems are much easier to fix than large ones.
2: Periodontal disease:
Why should you care?
Periodontal disease, or gum disease is an active, on going infection in your mouth. Not only does periodontal disease lead to the loss of more teeth than decay, it also has profound effects on the rest of your body. According to numerous health studies, people with periodontal disease are almost twice as likely to have coronary heart disease (also called heart disease). There is also evidence that periodontal disease can exacerbate an existing diabetic situation and is associated with negative effects for pregnant women and their pregnancy.
Researchers believe that inflammation and inflammatory products caused by periodontal disease may be responsible for these effects outside of your mouth.
What is periodontal disease?
Periodontal disease is a disease of the tissues (gingiva (gums), bone etc.) that support your teeth. It is a combination of infection and inflammation of these tissues. Bacteria are the usual causative organisms. The bacteria are found in plaque (the soft white “fuzzy” stuff that builds up on your teeth a day or two after brushing) as well as in calculus (tartar) the hard deposits that build up on your teeth.
Early signs of periodontal disease are red and bleeding gums. As the disease progresses the bone that supports the teeth becomes involved. Bone doesn’t like infection and inflammation and so it shrinks back down the root. With time, in a severe case, all the bone supporting a tooth will disappear; the tooth will loosen and then fall out. This often happens with no pain at all.
The most profound example of this that I have seen was a 22 year-old woman who came to see me. She had never seen a dentist, her teeth appeared outwardly perfect and she had no pain. The night before one of her front teeth fell out and when she arrived in our office she had it in her hand. She wanted to know what could be done. We took x-rays and found that there was essentially no bone around any of her teeth. We discussed the situation and subsequently she had all of her teeth removed and had complete upper and lower dentures made. This was an extreme case, but telling.
Could this happen to anyone?
Periodontal disease is a very complex interplay between the causative organisms (bacteria) and the host’s body. Some people’s immune systems make them very susceptible to periodontal disease (see above) and some are very resistant (“Uncle Harry never saw a dentist, never brushed and he died at 94 with all his teeth still there. So why do I need to brush mine?”). Most of us are somewhere in the middle: if we look after our teeth they will be there for our lifetime. And if we don’t, they won’t.
How can I keep my teeth, gums and bone healthy? I would in fact like them around for my old age.
There are two parts to this: plaque and calculus. They both are loaded with bacteria and both have to be removed. Once the bacteria are gone the disease process will stop and the further destruction of gums and bone will cease.
Plaque: You are in charge of this: Brushing and flossing: Plaque is an organized layer of bacteria known as a biofilm. It’s the soft white stuff that you remove with your toothbrush and floss. Plaque is very soft. When younger I occasionally ended up on a canoe trip without a brush (young/dumb) and by day 3 my teeth had developed a fuzzy film that I could wipe away with a piece of Kleenex. So: Plaque builds up over time and it is very easily removed: A brush will clean along the gumline on the outside and inside of your teeth. Floss cleans between your teeth. Ask us if you aren’t clear on how this should be done most effectively. We also have small brushes for cleaning between teeth when flossing isn’t working for you. Again, ask us if you would like our help. Plaque rebuilds after 48 hours, so remove it once a day, thoroughly, and all will be well in the plaque department.
An interesting note: 1 cubic millimetre of plaque (a large grain of sand) contains approximately 10 billion (10,000,000,000) bacteria. This is a lot of bacteria. Do you really want them on your teeth? Do those close to you want that on your teeth?
Calculus: We (the dental team) are in charge of this: Calculus is calcified plaque. Calcium phosphate salts from your saliva precipitate onto the plaque on your teeth forming mineral deposits. This hard, porous layer is loaded with almost as many bacteria as plaque. It cannot be removed by brushing and flossing and has to be removed by scraping it off with dental scalers. This is what hygienists work diligently, carefully and with focus to remove from your teeth.
What if I am diagnosed with periodontal disease? What can be done?
Mild disease: bleeding gums with no bone loss: We talk to you about removing the bacteria (plaque: your job: brushing and flossing)(and calculus: our job: a hygienist cleans your teeth). In almost all cases this will be sufficient: the bleeding will usually be fully resolved in 3 or 4 days after all plaque and calculus are removed. Our bodies really like to heal. Thereafter keep brushing, flossing to remove plaque; and seeing a hygienist on a regular basis to keep your teeth free from calculus (every 3 – 12 months depending on how quickly calculus rebuilds).
Moderate disease: bleeding gums and minor bone loss: Generally the protocol above is sufficient. Your body likes to heal. The bone may regenerate, but often won’t. However as long as more bone doesn’t disappear, you will have teeth for a lifetime.
More severe disease: bleeding gums, and more significant bone loss: One measure of the destruction from the disease that has occurred is to measure the pockets: the distance between the top of the gum and that to which a probe can be gently inserted below the gums before it encounters resistance. With healthy teeth this measure is generally 1 – 3 mm. Once pocket depths go far below this depth some bone is likely to be disappearing. At 5 – 6 mm the bone is about half gone and at around 10mm the bone loss will extend to the bottom of the root and tooth loss is imminent. Somewhere around 4 – 5 mm of pocketing we begin to think seriously about referring our patient to a periodontist.
A periodontist is a dentist specializing in the treatment of disorders of the gums. Periodontists make it their life’s work to understand the mechanisms of periodontal disease. In addition to the thorough removal of plaque and calculus from all the root surfaces, this can involve understanding the patient’s immune system, patient compliance and other factors. An understanding of genetic predispositions is playing a vastly increased role in our understanding and treatment of the periodontal disease process.
The most important thing that you can do is to remove plaque from your teeth thoroughly every 24 hours. When there is no plaque, there is far less calculus, far less infection and far less for us, as a dental profession, to do for you.
Our Overall Summary:
Remove all the plaque from your teeth every 24 hours. After this your life (dentally) will be much simpler than if you don’t.
And: if you have any questions about any of this: please do ask!
Your Team at Lakeside Dental: Dr. Bergen, Edith and Jennifer