“Doc, I think I have a cavity. Every time I drink some soda, my tooth hurts.”
Experience tells me it’s certainly possible, so I’ll naturally take a look – but quite often, I already know that what is causing the discomfort is an entirely different issue. Patients are often surprised when I explain that while I understand this area hurts, it’s not a cavity.
Hot, cold, air, or sweets – the triggers can be different for different people – but the effect is the same: dental pain. For some, it can be mild or tingly. For still others, it can be excruciating and intense. And yet, this can occur without decay.
So what’s going on? Often, it has to do with changes to the tooth enamel. This protective outer layer of your tooth is both the hardest substance in your body and it acts as an insulator to the inner and more sensitive dentin layer, as well as the pulp. Hard as it is, enamel is still subject to changes that can have consequences for your comfort and tooth function.
So what causes enamel to become damaged or thinned?
In a word – life. But here are a few practices or habits that tend to accelerate changes:
— Dietary factors such as acidic drinks (sodas, fruit juices, wine) and foods — Teeth clenching and grinding — Dehydration of teeth caused by a dry mouth condition (medications or insufficient water intake) — Digestive problems such as acid reflux — Damaging habits (using your teeth in ways you shouldn’t, such as opening things with them) — Improper brushing (overly aggressive or excessively abrasive)
The result of thinned enamel – also referred to as enamel erosion – is sensitivity. Gum recession can also produce a similar result because this exposes the root surface, which is not covered by enamel. Nevertheless, the result is comparable. The teeth hurt.
Yet another popular activity – tooth whitening – can lead to sensitivity due to the cleansing activity of peroxides that are used to remove stain and debris within and between the complexes of enamel rods (the basic unit of tooth enamel). It also removes something called smear plugs (debris in the dentin tubules), and this increases the conductivity of fluid that exists in the tooth’s inner layer, the dentin. When the fluid backs up – once again, you experience pain.
In many cases, desensitizing toothpastes can help. The active ingredient is typically potassium nitrate. It usually takes several weeks of continued use to experience relief. If this does not resolve your symptoms, your dentist may be able to administer a desensitizer that provides instant relief. Any persistent pain should be evaluated by a dental professional in order to prevent more serious and expensive problems.
Recently, I saw four new patients in my dental office during a given week. All four of those patients scheduled their visits because they perceived pieces of their tooth chipping away. In three out of four of those cases, the offending tooth was so badly decayed that the tooth couldn’t be saved. Yet only one of those patients came in with any discomfort.
The common thread in each of these cases is that the patient waited until the tooth was actually breaking apart to seek dental care. All too often, the trigger that brings people to the dentist is pain. Yet here, we had at least three cases where pain was not a factor and yet the tooth was decaying.
How is this possible?
A little understanding of dental anatomy helps here. The outer layer of teeth, the enamel, is the hardest substance in your body. Because its composition is predominantly mineral, it is possible to have decay throughout that layer without experiencing any sensation. In fact, it is even possible for your dentist to drill that part of the tooth (in most cases) without pain. The next layer under your enamel is called dentin. Decay can travel into the dentin – where it usually spreads more quickly, because it is not as hard – and a person still may not experience pain.
By the time a tooth that is decayed hurts, the decay has generally travelled so far that it nears the innermost layer – the pulp. The pulp contains nerves and blood vessels – so, naturally, pain becomes a factor. If a patient is lucky enough to have enough tooth structure remaining, chances are that the tooth will need a root canal if it is to be saved. Otherwise, extraction is the usual alternative.
One lost tooth can lead, in turn, to still other dental problems. Most notably these include shifting teeth, TMJ problems, periodontal problems, cosmetic difficulties or simply difficulty chewing. It may even lead to the loss of more teeth – not to mention the fact that tooth replacement options can become rather expensive.
Hopefully, just understanding that a lack of pain does not equate to a lack of problems will prompt some readers that haven’t seen a dentist in a long time to do so. Sometimes people fear learning that they have cavities that need to be treated, and so they put off the examination. Consider, however, that it is better to learn you have five teeth that need fillings, than to learn you have several that have to be extracted.
Sounds like a pretty basic question for a dentist, doesn’t it? In fact, I’m not really asked that question often because “everybody knows” you should brush your teeth twice a day. But should you really?
After all, you can pick up almost any tube of toothpaste and it says right there” brush twice daily, or as directed by your dentist”.
Some time ago, I started asking patients how often they brushed their teeth when they came in for their periodic cleanings. The most common answer – by far – is “twice a day.” My next question is usually, “Yes, but when during the day do you brush?” As you read this, many of you who do brush twice daily are thinking “when I get up and again before I go to bed.”
If you have experienced dental cavities, that could be part of the problem.
When I mention this to patients I usually get this sort of silent stare. It’s kind of a cross between, “well that makes no sense at all” or, “then I might as well just give up.”
Let me explain.
It starts with an understanding of what causes dental cavities. There are a few basic elements. The most obvious is that you need to have a tooth. Additionally, you need cavity-causing bacteria. Then you also need a fermentable carbohydrate. This is an important point. Carbohydrates include sugars and starches, but the process of fermentation creates acids. Once the acids form, there is another element that comes into play: time.
If we break these factors down further, it is useful to look at what we can control in the cavity-causing process. For the sake of argument, let’s assume we are starting out with a full set of teeth, so that’s not entirely in our control. Next, there is the factor of cavity-causing bacteria. We all have both good and bad bacteria in our mouths. While I could get into a discussion of promoting the good and suppressing the bad, this is also not always easily controlled.
The next two factors, however, we have a great deal of control over.
We can control what we eat. Recognition of which foods are acid forming is also useful. But I’m a realist and understand that sometimes we are just going to eat (or drink) those things anyway.
And this is where the time factor comes in.
A little analogy may be helpful here. What would you do if you spilled a strong acid on your bare skin? Chances are you would run right over to the nearest sink and try to wash it off. But what if you had a leather jacket on and didn’t notice right away? First of all, you would end up with a hole in your jacket, but eventually – with time – it would reach your skin and start to hurt.
It’s much the same with teeth. Your enamel is a protective layer that doesn’t have any feeling because it is mostly mineral and doesn’t contain any nerves. But given enough time, the acid – even a weak one – breaks through and gets to the underlying softer and more sensitive areas. So, don’t give it time.
Change your brushing habits and do so after every meal. About a half hour after eating is ideal. If you absolutely can’t brush on occasion, chewing a sugarless gum (preferably containing xylitol) can help.
What most people do, though, is wake up and brush. Then they have breakfast and don’t brush. The acids that are formed following the meal slowly dissolve our tooth enamel. Roughly when the acids wear off, they have another meal or a snack and freshen up the acid. Few people brush after lunch, so it’s a few more hours of wearing the enamel away. Just when that acid wears off people freshen it up again with dinner. They don’t always brush after dinner either, so the acid now has even more time to work. Finally, they brush before going to bed. This cycle can, and typically does, go on for days, weeks, months and years. Given enough time, the cavity becomes large enough to require a filling.
So, if you only eat two meals a day, brushing twice a day is probably fine. But if you eat three times a day, how often should you brush? You get the idea.
The really odd thing is that I can go over this with someone thinking they get it. A couple of years later, I’ll ask: “How often do you brush your teeth?” Believe it or not, the answer is often the same as when I asked the first time. Hopefully, however, you will get it. Remember also that you can’t ignore flossing and expect to escape cavities, even if you do brush after every meal. The area between your teeth can’t be reached by the toothbrush bristles. About a third of all cavities filled by dentists occur in this location.
Nevertheless, if you follow the advice above I think you will find yourself encountering far less tooth decay over the years. Hoping it works for you as well as it has for me.
Dr. Richard Walicki is a dentist practicing general and cosmetic dentistry. While we hope you find the information contained herein interesting and useful, this blog is for informational purposes and is not intended to diagnose any oral disease. Dental conditions should be evaluated by your dental health professional or a qualified specialist.
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