The American Dental Association has come up with a way for you to measure your risk for tooth decay. It’s a questionnaire called Caries Risk Assessment or CRA, for short. (Caries is the medical term for tooth decay.) You can access CRA on my professional website at smilefitness.info/additional-resources under Health and Wellness Issues.
Once you’ve completed the CRA survey, I encourage you to gain even more insight into your personal risk for decay by answering the twelve questions to follow. For various reasons, some people are more prone to tooth decay than others, and it’s best to know if you’re one of them.
If you’re not, great. If you are, there are simple, painless, inexpensive things you can do to reduce the risk and prevent trouble. Each question is followed by an explanation and solutions you can apply if your answer is yes.
1. Is there plaque build up on your teeth?
The answer to this one is automatically yes because everyone has plaque! Plaque is a sticky film of good and bad bacteria, invisible but active, that coats the teeth and can start the process of decay if conditions are right for it. Earlier, I mentioned my friend and colleague Dr. Kim Kutsch in connection with his war on tooth decay. Kim and I believe prevention starts with being aware of plaque and getting rid of it before it does damage.
I caught up with Kim recently so we could compare notes on this subject.
Mary Sue Stonisch: In my practice, I refuse to fill holes in teeth without explaining to patients the options they have for reducing or eliminating decay. Dr. John Derango, whom I think you’ve met, Kim, compares such counseling with teaching folks how to remove nails from a driveway to reduce risk of a flat tire, meaning decay.
Kim Kutsch: I like John’s comparison. Good information is the key to prevention. My goal is to reduce my patients’ susceptibility to dental caries. Go ahead—put me out of business! I’d love it. We’ve both said this, Mary Sue: Often, the best dentistry is no dentistry. So my message to your readers would be, let’s aim for that target by reducing the need for dental intervention.
Mary Sue: Kim, I’d say plaque is the first thing we look at in assessing risk of decay, wouldn’t you?
Kim: Absolutely. We all have a small layer of it on our teeth. If the bacteria in the plaque are the wrong kind, your mouth becomes acidic—because that’s the environment these bugs thrive in—and they proceed to eat away at the enamel and cause cavities. Good bacteria, the kind that produce a favorable pH, don’t have a chance against the bad guys.
Mary Sue: So we can test the plaque.
Kim: Right. We do that with a pH test strip or, even better, a meter called a CariScreen® (carifree.com), which, in one minute, can tell us the amount of bad bacterial activity in plaque.
Mary Sue: This gives us a way to monitor whether a patient’s oral environment is improving over time.
Kim: You got it.
Mary Sue: Are the bad germs wearing black hats?
Kim: Kind of! Bad bacteria use 100 percent more energy than good ones. The CariScreen measures the biological activity level in plaque, and that lets us know what’s in your mouth and what it’s doing there.
Mary Sue: It works. I use it, and it’s a great diagnostic tool. In my book, I’m
advising my readers to ask their dentists if a CariScreen test of their plaque would be a good place to start in assessing their oral health.
Kim: Let’s say you find a highly acidic environment, Mary Sue. What do you tell your patients?
Mary Sue: We start with a prescription mouthwash that neutralizes the acid and establishes a much healthier oral environment. But that’s just the beginning. Patients must do their part, which can mean better, more frequent flossing, brushing, and rinsing and using a prescription-strength fluoride toothpaste. And it can certainly mean a change of diet. Sugar has to go, for sure. I also recheck with the CariScreen meter periodically to confirm that the changes my patients are making in their home care are working.
Kim: The only thing I might add, and I’m sure you’d agree, is the frequent use of an oral irrigator, known to a lot of people as a Waterpik®. That’s a specific brand of irrigator, and I’m not endorsing any brand. They’re all good if you use them after meals, when possible, to remove the tiniest food particles that can get lodged between the teeth. You don’t see or feel the process, but that food ferments in your mouth, producing bacteria that waste no time getting to work on tooth enamel.
Mary Sue: When my patients use an irrigator, they’re often surprised at how much food rinses out into the sink. That alone motivates them to use it again because they get the connection between left-behind food and not only decay but bad breath.
Kim: Right, and that proverbial piece of spinach stuck in your teeth for everyone to see.
Mary Sue: Now that’s motivating! Kim, thanks for your time today. I wanted my readers to get the skinny from a guy who’s on the front lines in the battle against decay.
Kim: It’s total war, Mary Sue, and for the well-being of our patients, we’ve got to win.
One important takeaway from my conversation with Dr. Kim Kutsch is that we dentists can’t do it alone. Our patients have to take tooth decay seriously. I know some think of it as a kid’s problem that somehow doesn’t have much to do with adults. Wrong! Don’t wait for the pain of a cavity to find that out. By then, damage has been done. End of lecture!
Now back to our questions assessing your risk of decay.
2. Do you have dry mouth? Do you take medications daily?
The two can be related. Some meds can cause dry mouth, which promotes decay. Saliva usually keeps the oral pH at the right level as it flushes and lubricates your mouth. It also assists in digestion, protecting the body from bacterial challenge and—best of all—remineralizing the teeth. That’s right. Saliva helps to
replenish the minerals in your teeth, naturally strengthening them.
When saliva dries up, often at night, the good effects disappear. Bits of food may be left to ferment between the teeth, and tooth surfaces are open to attack by acid-loving bacteria that eat away at enamel.
For a list of medications that can cause dry mouth, please visit our website, smilefitness.info/additional-resources. Page down to Health and Wellness Issues.
There are other causes of dry mouth, too, like stress, poor diet, heredity, and disease. Age can be a culprit because we take more prescription drugs as we get older and also because the saliva-producing mechanism in our mouths slows down. Regardless of cause, dry mouth must be treated to avoid decay.
Show your dentist a list of medications you’re taking and ask if any of them can cause dry mouth. If there’s a match, see your doctor and ask for a substitute medication that won’t give you dry mouth as a side effect.
If there is no good substitute for the problem medication, your dentist can recommend products to raise your oral pH level, increase saliva production, and lubricate your mouth. Not only will your mouth be healthier but it will be feel better, and you will avoid bad breath, which sometimes accompanies dry mouth because of active bacteria.
And here are a few additional steps you can take without a doctor’s prescription to ease dry mouth:
• Use water-based mouthwash and lubricants, not alcohol-based ones.
Alcohol has a drying effect.
• Sip water often.
• Avoid sugary and acidic beverages.
• Use a humidifier at night near your bed.
• Limit caffeine intake.
• Limit between-meal snacks.
• Use sugar-free gum and mints, preferably those with xylitol as a
sweetener. (Xylitol helps keep plaque off the teeth.)
• Use nighttime oral moisture pads like XyliMelts®, placed on the
inside of your cheek. They’re available at drugstores and online.
• Use nighttime fluoride trays custom-made by your dental team.
• Prescription drugs are available that increase saliva production.
They may be in pill form, in a mouth rinse, or in a flavored,
candy-type sucker. Ask your dentist.
Lots of help is available. Your dentist can customize a plan for you.
3. Food and drink: Do you drink beverages other than water between meals more than twice daily? Do you snack between meals?
Frequency of eating and drinking is an important factor in tooth decay. That’s because every time you put something in your mouth, your oral pH level goes down and your mouth gets more acidic.
As that occurs, your system automatically produces more saliva to counteract the acid. This process goes on twenty-four hours a day, protecting your teeth. But the more often you eat and drink, the more you challenge the system and risk pH imbalance. If acid wins, teeth are compromised or destroyed by cavities.
If you’re going to eat or drink between meals, you’re better off doing so as infrequently as possible. Give your saliva a chance to do its work without constant interruption.
And for even more impact on your oral health, deep-six the goodies and switch to more healthful foods. Sweet and sticky are out; fresh and crunchy are in. In addition, ask your dentist to recommend chewing gums and oral sprays that help maintain good pH balance and that taste good, too.
It’s equally important to avoid oral cleansing products that are not right for you. Make good choices! Updated lists of mouthwashes and their pH ratings, can be found at smilefitness.info/additional-resources under Health and Wellness Issues. I recommend to my patients that they use a rinse with a pH of seven or higher.
4. Does food get caught between your teeth (food trap)?
Any food left in the mouth ferments. The sugars in the food, even in nonsweets, create an acid environment conducive to decay. That’s why, for decades,
dentists have asked their patients to floss or rinse after meals. It’s eternally good advice.
But why does food get caught between teeth in the first place? A broken or missing filling might be the answer, and if that’s all it is, the answer is to repair or replace the filling.
More commonly, gum disease is the culprit. We will learn a lot about gum problems in Chapter 3, but to summarize, gum disease can cause bone loss that, in turn, causes teeth to loosen and move, creating gaps in which food gets caught. Gums also recede with age, sometimes leaving open spaces between teeth at the gumline, where food can stick.
A misaligned bite, covered in Chapter 4, can also be the villain. Over time, teeth are pushed out of place by the force of uppers and lowers moving stressfully against one another. The resulting gaps are natural catch-basins for errant food particles.
All these problems can be fixed and should be. Gaps can be closed with bonding, fillings, crowns, and other treatments. Not only will your mouth be healthier but think of the aesthetic benefits! Trapped food breeds bad breath, and it certainly is not attractive visually—yet one more example of cosmetic and health considerations being inseparable.
5. Do you wear an oral appliance?
Oral appliances (braces, spacers) can harbor bacteria in their plastic or metal crevices. Brush, soak, and scrub your appliance thoroughly to minimize plaque build up, which contributes to tooth decay. When you go for a dental checkup, remember to take the appliance with you so it can be cleaned professionally.
If either you or your child is wearing an appliance, poor hygiene will create a pH imbalance resulting in tooth decay and loss of teeth. It’s a more common
story in orthodontics (dental appliances) than we would like. Your dentist may recommend special toothpastes in an effort to reduce such damage.
6. Do you smoke or chew tobacco?
Tobacco, in any form, dries the mouth and reduces saliva production, contributing to “smoker’s breath.”
7. Do you have acid reflux (GERD)?
GERD stands for gastroesophageal reflux disease, but most people know it simply as acid reflux, which is one of its main symptoms. It occurs when stomach acid backs up into the esophagus. The condition can produce heartburn (chest pain), a sour taste in your mouth, or the taste of food you just ate.
GERD may also be a problem for your teeth. Stomach acid is strong and can bathe your teeth with fluid having a pH of 1.5 to 3.5, either causing or contributing to tooth decay. (Remember—tooth decay starts at an acid level of 5.5. Any number below that is worse.) If you’re uncertain whether you have GERD (or heartburn or acid reflux), an ear-nose-and-throat doctor is best qualified to find out.
Antacids are okay for the occasional episode of heartburn, but you’d be unwise to rely on them for a chronic condition like GERD. GERD is caused by an abnormality in the lower esophagus and can’t be cured with antacids. If in doubt, be sure to see your physician.
8. Are you diabetic?
Diabetics typically snack to control blood sugar—which, as we discussed in Question 3, contributes to a low-pH environment in the mouth. However, snacking is essential for diabetics, so I certainly don’t advise my diabetic patients to
quit. The answer is good oral hygiene, including mouth rinsing after snacks and more frequent visits to the dentist.
Some diabetes drugs can cause dry mouth, which is another decay-inducing factor. If you’re taking meds for diabetes, tell your dentist.
9. Have you ever had radiation of the head and neck?
Radiation of the head or neck for cancer or other kinds of tumors may cause
dry mouth, which contributes to tooth decay. If facing radiation, I recommend seeing your dentist before treatment begins for home-care instructions to protect your teeth. Home fluoride trays for nighttime use can help by providing an added layer of protection while you undergo therapy.
An important note on this subject: If you expect to receive an unusually large amount of head and neck radiation (ask your oncologist), it may be best for your dentist to extract teeth that will be in the path of the radiation. Here’s why: Large doses of radiation can cause a condition in which an area of the jawbone is unable to heal, leaving a constantly open sore and source of infection.
Whether you need extractions depends on your age and overall health, the condition of your teeth, the amount of radiation, and other factors. Your dentist may want to consult with your oncologist or radiologist as part of the decision-making process.
10. Do you use recreational drugs?
Marijuana, heroin, cocaine, meth, ecstasy—they all drastically reduce the flow of saliva, and as we’ve seen, the resulting dry mouth contributes to decay. Compounding the problem for drug users is their strong appetite for high-carb and sugary foods, which feed bacteria and contribute to the formation of plaque.
11. Are you bulimic?
The bulimic process is eat, vomit, repeat. Stomach acids in the vomited food bathe the teeth in high-acid gastric juices that erode tooth enamel. The back side of the upper and lower front teeth are most affected by the loss of enamel. Crowns do not solve the problem. Until vomiting stops, decay will occur around the margins of the crowns, and tooth loss may result. The acidity from bulimia is even more destructive than that of GERD.
12. Do you have an autoimmune disease such as Sjögren’s Syndrome?
Pronounced “show-grins,” this is yet one more cause of dry mouth owing to lack of saliva production. In my practice, this disorder has caused more damage and faster tooth loss than any other that comes to mind. It plagues many older people who are unable to floss and brush as well or as often as they should because of arthritic hands, Alzheimer’s, or other disabling problems.
Moisturizing the mouth by using home-care saliva substitutes is essential for saving the teeth. If you or a loved one receives this diagnosis, don’t put off consulting your dentist.
Three years. No less.
If you’ve answered yes to one or more of our questions, you have an increased risk of tooth decay, possibly severe. Talk with your dentist.
I recommend you stick to the program she gives you until you string together three years—count ’em, three—of cavity-free checkups. Then, and only then, can you move into the enviable category of low risk for dental decay, just as the American Dental Association recommends.
Getting there may take some work, though, especially if your dentist sees white spots on your teeth (a sign that decay has started and possibly stopped) or actual cavities. In that case, he’ll take care of the current damage, investigate causes, and give you a program for preventing more of it.