Entries in Tooth Decay (2)


Preschool Mouths: Dental Disaster Zones

iStockphoto/Thinkstock(NEW YORK) -- Preschoolers across the country are increasingly getting fillings and extractions for extensive dental decay, sometimes requiring surgery and general anesthesia in an operating room, pediatric dentists report.

The trend, seen in families both rich and poor, points to neglect driven by several factors. Despite decades of emphasis on eliminating tooth decay with fluoride toothpastes and frequent brushing, many parents aren’t getting the message that dental care begins when a child’s first tooth comes in, and that a child should be brushing with fluoride by age 2.

Parents of all income levels indulge young children in too many sugary snacks and sippy cups filled with sugar-laden fruit juices, dentists say. Too often, they put toddlers to bed with a bottle of juice or milk. Saliva levels go down overnight, making the mouth even more acidic and allowing sugars in the drinks to eat into tooth enamel for hours at a time.

As a result, dentists are fighting more aggressively to counter the resulting decay, often treating cavities in baby teeth before the bad bacteria can spread elsewhere in the body or harm the adult teeth forming below them in the jaw.

“The myth has been for years, these are just baby teeth, they’re just going to fall out anyway,” said Dr. Amr Moursi, chairman of pediatric dentistry at NYU’s College of Dentistry. Moursi said the need for dental operating rooms at NYU exceeds the supply, forcing dentists to compete with cardiac surgeons and neurosurgeons for operating room time, and forcing patients to wait three to six months to have their dental surgeries scheduled. In addition, he said, it’s hard to find pediatric dentists with operating room privileges, which further squeezes the ability to treat children in need.

“There’s not enough operating rooms in the country equipped to do dental work,” he said.

Severe neglect of a child’s oral health most often occurs among poor families “trying to make ends meet, pay the rent; it’s not a high priority,” Moursi said. However, dentists also are seeing a troublesome trend of lax parenting among more well-off mothers and fathers who don’t enforce brushing-after-meals rules.

As parenting styles have shifted, there has been evidence of changes that “sometimes include a de-emphasis on oral health or anything that the child doesn’t necessarily want, whether that’s bath time, or practicing the piano, or eating their vegetables,” Moursi said. “That’s when we have the conversation: You’re the parent and it’s in their best interest. We give them some techniques to make it easier.”

Just Tuesday morning, Dr. Jonathan D. Shenkin, a pediatric dentist in Augusta, Maine, found six small cavities between the teeth of a 4-year-old girl during her first-ever appointment with a dentist. The child should have been seen by her first birthday. The girl’s mother was at a loss to account for all the decay in her daughter’s mouth, telling Shenkin that she thought she had her children doing everything right: “We don’t drink soda. They brush their teeth twice a day.”

But when he asked if the family uses fluoride toothpaste, she responded that they had just started to use it.

“Brushing with fluoride toothpaste is the most important thing you can do,” he said. Next, parents must pay attention to what their children eat and drink. Numerous well-intentioned parents tell him they only give their children “all natural” products, thinking those somehow are better for their dental health. However, many fruit juices contain just as much sugar as sodas, he said.

Although dentists prefer to spend their time on prevention, a parent’s decision to wait until a child is in pre-school before making a dental appointment is too late to prevent tooth decay that already may have begun, Shenkin said. “The kids coming into our offices at this age already have it at this point. There’s no way to turn back.”

“The goal should always be to treat in the office if possible,” Shenkin said. “The last resort should be going into the operating room under general anesthesia.”

By and large, the children going to the operating room tend to be lower-income children, he said. “When we talk about tooth decay, 80 percent of the disease is in 20 percent of the population…usually the lowest income population. The need for anesthesia disproportionately affects the Medicaid population.”

Although there aren’t good statistics establishing the extent of preschoolers requiring extensive dental work, Moursi said he’s seen a dramatic rise in the number of children with “really severe decay” warranting operating room treatment.

During an interview, he said he’d just received a phone call from an NYU pediatric dental resident who had examined a 4-year-old with several cavities, including one that had caused major facial swelling. “The infection had gone through the tooth, down into the surrounding bone of the jaw and spread up into the face under the eye,” Moursi said.

The child was going to be treated with powerful antibiotics, but might still require a trip to the operating room to extract the tooth, he said. In rare cases, such dental infections can spread to the brain, or into the heart and lungs, he said.

“When you have a 6-month wait to get into the O.R. and they’re all 3-year-olds, we know we have a problem,” Moursi said.

Copyright 2012 ABC News Radio


When Dentists Drill Too Much

Comstock/Thinkstock(NEW YORK) -- By the time a dentist finds a cavity, that tooth has been through several stages of a chronic infectious disease called dental caries, where acids dissolve tooth enamel, letting bacteria inside. Unchecked, the tooth can die.

Dentistry today focuses on early intervention to prevent bacterial invasion of the dentin, a layer just inside the enamel, and the vital pulp. Laser scanning, fiber optics and fluorescent technologies have allowed dentists to better visualize weakened, decayed enamel before it becomes visible on an X-ray or to the naked eye. Some dentists say high-tech tools enable them to perform minimally invasive dentistry, which preserves more of the tooth, often by treating "incipient carious lesions," also called microcavities. These abnormalities begin as white spots, which can progress to dark, stained pits and fissures.

Dentistry has evolved from "drill and fill" mechanics to a disease model focused on averting decay, supported by a 2001 National Institutes of Health consensus statement that identified a shift toward improving the diagnosis of early lesions and stopping their progression.

However, this early treatment may -- but need not -- involve the good old dental drill.

Some dentists want to fill all these little pits and flaws, sometimes warning of cavities to come, perhaps leading to a dreaded root canal, or losing the tooth. "Some dentists may honestly believe they're doing a patient a favor by treating early," said Dr. James C. Hamilton, now retired from the University of Michigan dental school. "Some dentists would convince patients caries is like cancer. 'Do you want me to leave a little cancer in your mouth? No.'"

Hamilton led a five-year study that found early treatment of microcavities using an air drill (less painful than a traditional drill) and a composite filling failed to conserve more of the tooth than watchful waiting until caries were diagnosed.

"We found no benefit at any time for early treatment," Hamilton said in an interview Thursday. He worries that expensive equipment pushes some dentists toward more aggressive treatment to get a "return on their investment."

"When you buy this new technology to treat incipient carious lesions, you have increased your overhead. You now have to make this piece of equipment pay for itself," Hamilton said. With the cost of a filling ranging from about $100 to $250, dentists might be "using this to find and treat those lesions when in fact they ought to be just watching them," he said.

Patients may balk at what they perceive as overzealous dentists proposing unnecessary and costly filling of microcavities before they've eaten into the dentin. That's why they should ask for a second opinion as they would for a medical issue, said Dr. Irwin Mindell. His mid-town Manhattan dental practice is very conservative and often proposes "watchful waiting" for microcavities.

"We have a very aggressive recall system. It's not that if you don't do it now, chances are you aren't going to come back to the dentist for another three years and at that time, we have another major problem," Mindell said. "I know I'm going to see the patient six months hence."

Mindell, who has been in practice since the 1950s, said that if damage hasn't reached the dentin, "you don't treat, because it may take years and years and years to become something. A lot of stuff never goes any further." For patients who aren't prone to cavities, removing the compromised enamel could lead to "greater loss of tooth than what the decay process will do."

But there's also a third way, said Dr. Peter Arsenault, a clinical professor at the Tufts University dental school in Boston. "Does treating mean drilling? Not in my eyes. That's what carpenters do," he said.

For the appropriate patient, Arsenault proposes a treatment plan that requires "a lot of dedication and a lot of education." It relies on neutralizing acidity in the mouth with frequent use of pH-boosting sprays and drops; killing mouth bacteria with xylitol--a sugar alcohol derived from birch trees, and using re-mineralizing toothpastes that stabilize and shore up weakened enamel.

Arsenault teaches dental students and dental colleagues the Caries Management by Risk Assessment (CAMBRA) approach, which uses a patient's history of cavities and dental work, oral hygiene habits and consumption of acid-promoting sugary foods, among other factors, to categorize them as low-risk, moderate-risk or high-risk for developing cavities.

"For each level of risk, there's a bit of an art, and a bit of science to it," Arsenault said Thursday. He described a low-risk, highly motivated patient who came to him a year ago with four small spots in her dental enamel and conscientiously adhered to the recommended treatments. When he examined her teeth earlier this week, the spots had shrunk. "She's thrilled I didn't have to drill this tooth," he said.

Arsenault first learned about CAMBRA at an NYU conference four years ago, where he said that at first, "it sounded like hogwash." But he was quickly won over and brought CAMBRA to Tufts. "We're showing with low-risk patients we can slow down, freeze and reverse" the caries process, he said. With extreme-risk patients, they can fill decayed teeth with materials that release fluoride to safeguard the other teeth.

CAMBRA is now being taught at dental schools. Although the American Dental Association supports a risk assessment approach to dentistry, it hasn't yet taken a position on treating microcavities. "Evidence-based things are slow-moving," Arsenault said. "It's a momentum thing. It's on its way. We're getting closer."

Copyright 2011 ABC News Radio

ABC News Radio