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Home , Tooth decay

Decay Is the Most Prevalent

CAPT Christine Heng, DDS, MPH, USPHS

Unmet dental needs and untreated dental decay represent a significant disease burden for children and adults.

here are 2 leading types of has been a shift in the peak preva- dental : tooth decay lence of untreated tooth decay from Take-Home Messages (dental caries or cavities) and children to adults, possibly attribut- Dental caries continue to exert a heavy gum disease (periodontal dis- able to socioecologic factors.3,5 The burden on some individuals and the T health care system. ease). Tooth decay is by far the more prevalence of untreated decay in • Tooth decay disproportionately affects prevalent of the 2, causing a greater, children and adolescents was about some communities needless loss in the quality of life. 15%. However, the prevalence of • It is caused by the transmissible untreated decay among adults aged S mutans PREVALENCE OF TOOTH DECAY 20 to 64 years was higher: 27% of • Decay normally starts at the occlusal Dental caries is a major public health the adults had decayed teeth that surfaces or proximal contacts of teeth problem. Even though in the past were left untreated.3,4 • , , and sealants help 50 years there has been a signifi- The rates of untreated decay protect teeth from decay cant decline in dental caries, it is the among these adults were higher most common ailment in the U.S., among Hispanics (36%) and non- and large segments of the popula- Hispanic blacks (42%) than among by childbirth or low dietary intake tion experience various barriers to non-Hispanic whites (22%) and non- of .7,8 Tooth decay typically care. Among children and adoles- Hispanic Asians (17%).3,4 Despite the starts on the chewing surfaces or cents, dental caries is 4 to 5 times decline in dental caries, disparities proximal contacts of teeth. more common than .1,2 Data persist among different racial, ethnic, S mutans is introduced into the from the National Health and Nu- educational, and income groups; it mouth principally from another per- trition Examination Survey, 2011- remains a modern curse for large seg- son. The bacteria colonize the mouth 2012, show that among children ments of the population. and with the formation of plaques, aged 2 to 8 years, 37% had dental adhere to the teeth. Plaque is the soft, caries in their primary teeth. Among Basics of Tooth Decay sticky film formed on teeth from food adolescents aged 12 to 19 years, the Tooth decay is caused by Streptococ- degradation. The is condu- prevalence of dental caries in the per- cus mutans (S mutans) bacterial in- cive to bacterial proliferation and manent teeth was 58%. About 90% fection. The cariogenic bacteria are teeming with bacteria. of adults aged ≥ 20 years had dental transmissible from mother or care- The S mutans bacteria break down caries.3,4 giver to children.6 After tooth erup- and produce lactic , tion, the mouth is quickly colonized which cause tooth decay—a pro- Unmet Dental Needs by S mutans. Even though the bacte- cess of demineralization, or loss of The real disease burden of dental car- ria are ubiquitous, the disease bur- calcium phosphate, from the tooth ies is the amount of unmet needs or den is more concentrated in some structure.2,9 As a result, the tooth untreated decay. In recent years, there populations. “softens” and eventually collapses on What makes some people more itself, forming a cavity. Tooth decay CAPT Heng is a dentist at the Federal Correctional susceptible to tooth decay? Contrary most commonly occurs at the oc- Institution in Danbury, Connecticut. to popular belief, it is not caused clusal (chewing) surfaces and the

www.fedprac.com OCTOBER 2016 • FEDERAL PRACTITIONER • 31 Dental Disease

proximal contacts of teeth. paste.8 The most impor- Figure. Tooth Morphology The occlusal aspects of teeth tant time for brushing is have a natural pit-and-fissure before bedtime, because morphology that facilitates less salivation occurs dur- bacterial adherence and coloni- Enamel ing sleep. helps zation. The proximal contacts clear fermented bacterial of teeth also facilitate adher- products, buffers the drop ence of plaque and bacteria. in pH, prevents deminer- A tooth is made up of 3 lay- alization, and enhances ers. The outermost layer of the remineralizaton.10 tooth is the enamel, Fluoride benefits chil- which is the hardest or most dren and adults of all mineralized part of the ages, and comes in the tooth—it is harder than bone. form of fluoridated tap The next layer is the dentin, water, , mouth which has a higher percentage rinse, and professionally of organic material (collagen) applied gel and varnish. and water than the enamel Fluoride occurs naturally has and is softer. In the center in the environment, too. of the tooth is the pulp (con- Its effect is mainly topi- sisting of nerves and blood cal—fluoride gets incor- vessels), which keeps the porated into the tooth as tooth alive and provides sen- , replacing the sation to the tooth. The out- . Fluorapa- ermost layer of the tooth root tite is harder than the hy- is cementum (instead of enamel), tions, which are typically made of droxyapatite; hence, the tooth is followed by dentin, which encases dental , (compos- better able to resist demineraliza- the pulp tissues contained within ite), glass ionomer, porcelain, or tion by bacterial attacks.11 the root canals (Figure). . When the bacteria have in- Professionally applied fluoride is vaded the pulp, a generally recommended for high- Process of will not treat the pain and infec- risk patients, typically patients with At the early stage of tooth decay, tion. Root canal therapy is needed high caries burden, ie, many decayed when the decay is confined to the to remove the infected tissues in teeth. The best predictor of future enamel, the tooth is asymptomatic, the pulp chamber and root canals. caries is the past caries experience. and the damage is reversible. When Further, if the tooth is too com- Sealants are thin, plastic coat- the decay extends into the dentin, promised with extensive destruc- ings that are painted on to tooth restorations are a consideration. The tion from the decay or if there are occlusal surfaces, obliterating the further the decay extends toward the financial or other barriers to root pits and fissures normally found on pulp, the greater the risk of tooth canal therapy, extraction is likely posterior teeth. The smooth seal- sensitivity and pain. Decay naturally the only option. ants effectively inhibit the coloni- progresses faster in the (less miner- zation of S mutans on the occlusal alized) dentin than when the decay KEY TO ORAL HEALTH aspects of teeth.12 Sealants are ap- is still confined to the enamel. If left Personal daily oral hygiene (brush- plied in dental offices (by the den- unchecked, the decay may progress, ing and flossing) helps remove tists or dental hygienists) or in and the bacteria eventually invade plaque from accumulating on tooth school-based programs. ● the pulp. At that point, there is risk surfaces—especially the occlusal of not only pain, but also swelling surfaces and proximal contacts, Author disclosures and tooth loss. which are most prone to decay. The author reports no actual or poten- At the earlier stage of decay, a Brushing teeth is of limited benefit tial conflicts of interest with regard to tooth may be treated with restora- without the use of fluoride tooth- this article.

32 • FEDERAL PRACTITIONER • OCTOBER 2016 www.fedprac.com Dental Disease

Disclaimer The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. REFERENCES 1. U.S. Department of Health and Human Services. Oral health in America: a report of the Surgeon General. http://www.nidcr.nih.gov/DataStatistics /SurgeonGeneral/Report/ExecutiveSummary.htm. Updated March 7, 2014. Accessed August 22, 2016. 2. Centers for Disease Control and Prevention. Hygiene-related diseases. http://www.cdc.gov /healthywater/hygiene/disease/dental_caries.html. Up- dated December 16, 2014. Accessed August 22, 2016. 3. Dye BA, Thornton-Evan G, Xianfen L, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. http://www.cdc.gov/nchs/data/databriefs/db191.pdf. Published March 2015. NCHS Data Brief. Accessed August 22, 2016. 4. Dye BA, Thornton-Evan G, Xianfen L, Iafolla TJ. Dental caries and tooth loss in adults in the United States, 2011-2012. http://www.cdc.gov/nchs/data /databriefs/db197.pdf. NCHS Data Brief. Published May 2015. Accessed August 22, 2016. 5. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global burden of un- treated caries: a systematic review and metare- gression. J Dent Res. 2015;94(5):650-658. 6. Smith RE, Badner VM, Morse DE, Freeman K. Maternal risk indicators for childhood caries in an inner city population. Community Dent Oral Epide- miol. 2002;30(3):176-181. 7. Boggess KA, Urlaub DM, Moos MK, Polinkovsky M, El-Khorazaty J, Lorenz C. Knowledge and beliefs regarding oral health among pregnant women. J Am Dent Assoc. 2011;142(11):1275-1282. 8. Roberts-Thomson KF, Spencer AJ. Public knowledge of the prevention of dental decay and gum diseases. Aust Dent J. 1999;44(4):253-258. 9. Cochrane NJ, Cai F, Hug NL, Burrow MF, Reyn- olds EC. New approaches to enhanced rem- ineralization of . J Dent Res. 2010;89(11):1187-1197. 10. Prabhakar AR, Dodawad R, Os R. Evaluation of flow Rate, pH, buffering capacity, calcium, total protein and total antioxidant levels of saliva in caries free and caries active children—an in vivo study. Int J Clin Pediatr Dent. 2009;2(1):9-12. 11. Hicks J, Garcia-Godoy F, Flaitz C. Biological fac- tors in dental caries: role of remineralization and fluoride in the dynamic process of demineraliza- tion and remuneration (part 3). J Clin Pediatr Dent. 2004;28(3):203-214. 12. Azarpazhooh A, Main PA. Pit and fissure sealants in the prevention of dental caries in children and adolescents: a systematic review. J Can Dent Assoc. 2008;74(2):171-177.