A twenty-year-old man goes to the dentist for the first time in a few years. He is thin, and well groomed. He has a friendly manner and a wide, toothy smile. Large black spots of decay punctuate all of his front teeth. Perhaps he wishes to impress a new girl friend, or to be more successful at the store where he works. He informs the young dentist that he intends to do whatever it will take to regain his old, attractive smile.
Of course, the dentist knows all of the techniques and has all of the latest equipment to turn back the clock on this young man’s mouth, but first, he will need more information. The patient and the dentist must understand how these teeth got this way. Otherwise, anything that the dentist does to repair or replace the teeth is likely to fail in a short time.
Three factors work together to cause tooth decay. Decay causing bacteria build up on teeth in plaque. Brush and floss well, use antimicrobial mouth rinses such as Peridex and Listerine, and there is not enough bacteria to cause decay.
Bacteria can not cause decay without sugar. Bacteria ingest sugar and produce acid. The acid weakens the tooth surface allowing the bacteria to enter deeper into the tooth. Stay away from sweet and sticky foods to rob bacteria of the nutrition necessary to multiply and cause decay.
Finally, some people are more likely to get tooth decay than others; dentists refer to this factor as host resistance. For example, disease and medications may cause the mouth to be dry. Saliva washes away decay causing bacteria. Additionally, calcium in saliva hardens teeth in the face of the acid attack of bacteria. Another host factor is the shape of teeth. Back teeth with deep pits and fissures are much more likely to decay than smoother teeth. Acid from a variety of sources weakens enamel which lowers resistance to decay. Fluoride in water, toothpaste and mouth rinses hardens enamel increasing host resistance. Dentists can improve host resistance by applying sealants to teeth with deep pits and fissures to exclude bacteria.
There is a triple balance of the presence of bacteria, sugar and host resistance. Our twenty year old threw this balance off. The dentist must figure out which of the three factors is out of line and help the patient set his balance right. This happens when the dentist asks the patient questions and listens to his answers. Hopefully, the patient will cooperate by being open and sharing his full story with the dentist.
A common cause of tooth decay is the buildup of bacteria. Perhaps the patient does not care for his own teeth by brushing and flossing. It is relatively easy for the dentist to figure this out. Patients like this have a heavy coat of bacteria or plaque and calculus or tartar. This patient may be relatively easy to work with. The dentist will have to help the patient understand the importance of the daily ritual of brushing and flossing two or three times a day. Of course, this is important for all patients, but improving home care can be curative for many patients.
Saliva is important for host resistance. Saliva helps to wash away food and bacteria, calcium in saliva hardens teeth (dentists call this remineralization) when acid from food, drink and bacteria softens the outer layer of the tooth. Chemicals in saliva kill or incapacitate some bacteria, aid digestion, and lubricate food on the way to the stomach.
Xerostomia is the medical name for dry mouth. Many diseases, medical conditions, and over 400 medications cause the mouth to dry. The cause may be as simple as mouth breathing. It is the dentist’s responsibility to diagnose and treat xerostomia enlisting the aid of the patient’s physician when necessary. Treatment usually includes drinking more water, sucking on sugar free hard candies, mouth rinses, fluoride applications, and sometimes, medication.
Gastro-Esophageal Reflux Disease or GERD is a common cause of extensive tooth decay. Acidic stomach contents back up the esophagus (the tube that connects the throat to the stomach) into the mouth. Causes include diet, medical conditions ranging from pregnancy to diabetes, and changes in the connection between the stomach and the esophagus. The strong acid weakens teeth causing erosion and tilting the balance of oral health heavily towards causing decay. Patients may not realize that they have GERD. Dentists may recognize the pattern of erosion and decay, and instruct their patient to speak with their physician about diagnosis and treatment.
Diet is a very common cause of tooth decay. Sticky candy is an obvious cause of tooth decay. Candy causing tooth decay is a common thread in children’s books and cartoons. Less well known is that dried fruit, including raisins, dates, and apricots, are just as sticky sweet and decay causing. Chips and bread have small amounts of sugar, but are almost completely formed of starches. Saliva contains a chemical that breaks down starches into sugars. That is why it is very important to brush and floss before sleeping.
Soda is especially bad for teeth. Soft drinks such as Coca Cola and Pepsi have a very large concentration of sugar. Energy drinks may have even more sugar. Interestingly, it is not only the sugar that causes damage to teeth. Carbonated beverages are very acidic. The carbon dioxide that bubbles out of the drink is completely safe, but the carbon dioxide that remains dissolved in the drink becomes carbonic acid. It is the carbonic acid that gives soda a tart taste and leaves teeth feeling a little rough.
When a healthy person drinks a single soda, the carbonic acid removes a little calcium from all of the exposed tooth surfaces. Over time, calcium in saliva remineralizes the teeth. However, sip soda water or soft drinks all day every day, and the teeth never have an opportunity to repair. People who drink a couple of cans of soda every day will have new tooth decay at every dental examination and will lose crowns and fillings for the same reason. One more note about carbonated beverages, the acid and gas increase the frequency of GERD.
Recreational drug abuse can affect well being and health in many ways. Methamphetamine is the drug of choice of many young people who appreciate the rush of excitement they feel when they take it. “Meth” has side effects that seriously damage oral health. Meth is a medication that causes xerostomia. As stated previously, dry mouth is a cause of tooth decay. Many people with xerostomia – especially young people – add to the problem by quenching that thirst with soft drinks.
How does all of this information apply to our young patient? The friendly young man has the thin, gaunt appearance of a Methamphetamine abuser. The pattern of decay is common to abusers of that medication. When asked, he denies the use of any recreational drugs, however he admits to drinking several cans of a popular energy drink daily. While this may be a half truth, it is a good start.
Information on Methamphetamine abuse and prevention, including photos of teeth damaged by methamphetamine abuse, is available on the web site of the METH Awareness and Prevention Project of South Dakota, http://www.mappsd.org.