Dental Articles
Finding Cavities
While all dentists still use mirrors and explorers (that sharp thing we poke around with), finding dental caries or cavities has greatly changed in the past few years. Technology has given the dental community a few more tools in our arsenal against dental decay.
The other surface of a tooth is the hard, whitish portion called enamel. It is made up of thousands of tiny rods that are glued together by a matrix. These enamel rods are very strong and pretty impervious to most things. When you introduce sugars into the oral environment, however, an interesting thing occurs. The sugars feed bacteria that may be clinging to the hard enamel surfaces, and as these bacteria feed, they produce an acidic byproduct that eats away at the enamel, usually following the path and direction of the rods, and softens it. The softened areas then attract more bacteria to them as they now have irregular surfaces instead of being smooth. More bacteria yields more acid and more tooth destruction. Finally the bacteria make their way beyond the enamel layer and into the dentin of the tooth.
Dentin, unlike enamel, is living tissue. It is soft and yellow in color and you can see it in areas where the enamel is thin, usually at the base of your teeth. Once the cavity gets to the dentin area, it can spread rapidly, both in width and depth. So, while you may only have a pinhole break in the enamel layer, the softer dentin may have a large cavity easily spreading within it. When a cavity spreads past the dentin layer and into the pulp is when the real problems begin.
The pulp within the pulp chamber contains nerve tissue, blood vessels and various connective tissues. The nerve is what causes tooth pain that we all want to avoid. Once the cavity reaches the nerve and the blood vessels, the tissue may become infected and cause an abscessed tooth. All of this can occur from a simple cavity that has been ignored or undiagnosed.
Avoiding this cascade of events is relatively simple. Cavities are found and treated when they are small. The name of the game is staying away from the nerve or pulp. This is easily accomplished with the proper diagnostic tools. Let’s first talk about the usual way to find a cavity.
With a mirror and sharp explorer, a dentist probes your teeth and looks for soft spots in the enamel. If the explorer sinks into what should be hard enamel, we know that a cavity is present. On the X-rays, which should have been taken, we can see if the cavity extends to areas between the teeth and sometimes we can see the approximate depth of the cavity. I said sometimes because very often a dentist only knows the true extent of the problem when he or she is actually cleaning the carious material out of the tooth.
The story only begins with the X-rays and explorer. Research has shown that almost 35% of all cavities are missed with conventional methods. That’s a third of all cavities that are left to enlarge and expand beneath the enamel layer, destroying healthy tooth structure and encroaching upon the tooth’s nerve. Wow!
To remedy this, dentists who are on the cutting edge of technology use several devices to aid in accurate caries detection. In my office, we use the Diagnodent laser diagnostic device. The Diagnodent shines a laser light into the cracks, pits, and fissures of a tooth, and measures the amount of light absorption. The laser light will bounce back on healthy hard structure but will be absorbed by soft areas. The Diagnodent emits a sound that increases in volume with the increase in cavity depth. It also gives a numeric read out that allows the practitioner to quantify the result. Normally, a dentist will choose a threshold number at which he will begin filling cavities. Research has shown evidence of caries as low as a reading of 12, but most clinicians do not add fillings until a larger number is seen. In otherwise cavity –free patients, we use a higher number as a threshold, around 30. For patients who have had a large number of previous cavities, and we know from experience how things will progress, a lower threshold may be followed. As we explained before, soft areas are normally cavities which should be filled to stop their advance. In a few instances, soft enamel is due to a lack of proper mineralization of the enamel as it developed. These areas of hypocalcification may not be filled, as no cavity may be present. Your clinician will decide.
Along the same lines as the Diagnodent is an LED devices called the Midwest Caries I.D. I have not used this device, bbut it claims to detect caries by the deflection and diffraction of the light. Lastly, the Spectra unit takes a picture of a tooth and shows a visual representation with the depth of caries being color coded on a monitor that both doctor and patient can see. While I have not personally used the Spectra either, as it is a recent introduction to the dental scene, I do like the fact that it will show exactly where the cavity is, and the patient can see the image. I will be looking at possibly incorporating this device into my practice along with my Diagnodent units.
While discussing the visualization of cavities, I should mention that a good set of magnification loupes/glasses helps a dentist see many things that he would have missed. In dental school, we young bucks made fun of the old guys who needed magnifiers. Well, after wearing magnification loupes up to 5x over the last twenty years, I can say that those old guys we made fun of were just smarter than us youngsters were. A good set of magnifiers is invaluable in not only finding cavities but restoring them as well. I wouldn’t practice without them.
Floss, it may save your life!
What do diabetes, coronary artery disease, cerebral vascular disease or stroke, pancreatic cancer, and, in women, premature birth and low birth weight babies all have in common? All of these diseases have been directly linked to periodontal disease. Medical and dental researchers have been finding remarkable links between oral and systemic diseases. Rheumatoid arthritis and Alzheimer’s are also being looked at closely.
While your parents knew it as “pyorrhea” or getting “long in the tooth,” today’s health professionals refer to diseases of the jaw bone and surrounding structures of the gum tissue as Periodontal Disease. A Chronic, inflammatory disease that slowly invades the gum tissues makes periodontal disease often go unnoticed by many patients. This slow invasiveness or incipient characteristic of the disease causes destruction of the oral tissues such as the bone supporting the teeth. Once the bone is gone, it will not regenerate, and tooth loss may follow. More importantly, researchers are finding that periodontal disease also causes systemic inflammation and produces bacterial plaque that enters the circulatory system. This bacterial plaque can clog arteries as well as any other type of arterial plaque.
How important of a factor is Periodontal Disease in systemic problems? Let’s take a quick look at Diabetes. There is an increase in diabetes of near epidemic proportions with over four time as many cases of diabetes being reported since 1980. Add to this the fact that one third of all diabetes cases remain undiagnosed in America, and you can see a vast problem arising. With 60% of Americans seeking regular dental care, dentists have a good chance of possibly diagnosing diabetes in the dental office via screenings of periodontal patients. In fact, if a person is finding it difficult to stabilize their diabetes, they may have periodontal disease as a contributing factor to the lack of control. Physicians, who are bombarded with new findings of medical research on a daily basis, may not be aware of this link and should take note of this. Diabetic patients who have difficulty in maintaining proper blood sugar levels should bring this up to both their physician and dental professionals.
Periodontal, or Gum Disease, is prevalent in today’s society with some studies showing that over 80% of the adult population is afflicted to some degree beginning with gingivitis. Many people do not even know that they have the problem, or how to detect it. If you have red, swollen gums, accumulations of plaque or hard tartar on your teeth, bleeding gums when flossing or freely bleeding gums, root surfaces being exposed (your teeth look longer), or chronic bad breath, you probably have Periodontal Disease.
The bacteria involved in the etiology of periodontal disease increases the body’s resistance to insulin. This in turn makes it difficult for the body to control blood sugars and high blood sugars have a significant negative impact on the body’s white blood cells’ ability to fight infection. Periodontal Disease also increases the release of the enzyme collagenase which has a detrimental effect on heart muscle and soft tissue.
Examination by your dentist should include a visual examination, a full set of approximately eighteen dental X-rays to check your jaw bone level, and a six point probing of the space between your tooth and gum called the “periodontal pocket.” If you have never had a six point probing of every tooth in your mouth, you need to do two things. First, ask your dentist or dental hygienist to do this exam, which, in my office is done at every adult’s initial examination and then, at least, annually. Secondly, if you have never had this exam, ask your dentist why you have not had it! It is that important. If your dentist has ignored your periodontal health, you may wish to consider being evaluated by a Periodontist (a specialist that treats gum diseases) or find one of the many dentists, such as myself, who are involved in diligently diagnosing, treating, and monitoring periodontal diseases.
Sadly, some new patients that come to my office claim that they have had “cleanings” every six months for years, but they have already lost half of their supporting bone. They have had periodontal disease slowly advancing without their knowledge. Not only have they had their periodontal disease undiagnosed and mismanaged, but they may have already had years of damage caused by the accumulation of the aforementioned plaque and systemic inflammation that could affect their systemic health.
Treating periodontal diseases involves more than just a dental “cleaning.” There are specific protocols for the treatment of the various levels of disease that necessitates multiple visits. Usually, the plaque and hard attached tartar needs to be removed leaving the periodontal pockets and tooth surfaces spotlessly clean. Then, you may be prescribed medicated mouth rinses, antibiotic fibers placed in your periodontal pockets, or even laser therapy to get rid of necrotic tissues and leave as near sterile of a pocket and surface that you can have. We have found that laser bacterial reduction (LBR) has a great effect on our patient’s periodontal health. In order for periodontal disease to be controlled, a person must maintain active participation in their treatment by brushing, flossing, and using other prescribed methods of home care specifically designed to meet their own needs. Often, to prevent the ability of the bacteria that cause the disease from recolonizing, a periodontal maintenance cleaning is needed at three month intervals. It takes a lifelong commitment to good oral health, as periodontal disease can be controlled but never totally cured. That is, you will always have the disease lying in wait to come back if you ignore your care.
New advances in periodontal screening include salivary testing. Samples of a person’s saliva are sent to a lab and the offending bacteria are identified. The dentist can then target the causative organism specifically. A second test after the treatment has been completed can then be done to quantify the results. If the bacterial population has been lowered to acceptable levels, treatment success will be greater.
Of course, the best way to take care of periodontal disease is to never have it take hold in the first place. Brush, floss, use non-alcohol based mouthwashes and see your dentist and hygienist regularly or have your dentist refer you to a Periodontist if they do not screen for or treat periodontal disease themselves.
Heart disease, stroke, diabetes…there is more reason than ever to receive proper dental care. Brush, floss, and see your dentist—it could make your life a whole lot healthier.
Dr. Alan R. De Angelo, DDS is a general esthetic/cosmetic dentist located at 14232 S. Bell Rd. in Homer Glen, IL. As a member of the editorial advisory board of Aesthetic Dentistry magazine, he has been active in the education of his peers in topics such as cosmetic, esthetic and restorative dentistry, ethics, and practice management. He was awarded the title of one of America’s Top Dentists by the Consumer’s Research Council of America in 2008 and 2009. Please mail any questions that you would like to see in a future article along with your name, address, and phone number, in case we need to clarify your question, to the above address. To make an appointment, please call (708) 301-3111. Visit us at www.drdeangelodds.com