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.
As a dentist, it’s not unusual to find me browsing the dental aisle from time to time. I like to see what’s new. What I find particularly interesting, though, is watching people as they make their product choices.
My impression is that one area which seems to attract the most indecision relates to the subject of which toothbrush to buy. With manual toothbrushes people ponder over whether to get a soft bristle, a medium hardness, or an outright hard bristle. Then, the question becomes should it be angled or straight?
In my office, people also frequently ask: “How often should I replace my toothbrush?” (As often as once every other month. Don’t let it go beyond three months on average, however. Also, replace your brushes after being sick. The bristles retain germs.)
Then there is the question: is an electric toothbrush really better than a manual? If so, what kind of electric brush? Sonic, rotary, or oscillating?
It can get pretty confusing. So let me sum it up for you.
While I’m not sure every dentist will agree with me (only “three out of four” of us agree on anything anyway) 🙂 here is my opinion:
If you’re buying a manual brush, get a soft bristle. If you are deciding between a manual and electric – go for the electric. In my experience battery-powered brushes are fine, but rechargeable brushes are more convenient and eliminate the cost of frequent battery changes. Rotation-oscillation is usually preferred, but I have seen excellent results with the sonics as well.
Soft bristles are kinder to the gums, and since you should be paying attention to your gum-line when you brush, this is important. When I was in dental school I recall a lecture explaining that soft bristles were also “end-rounded,” which means that if you looked at the tips of the bristles under magnification, their ends are, well, rounded. This is in contrast to bristles that are cut off at sharp angles on the harder brushes. I guess the manufacturers figure if you’re going to buy the harder bristle, “What the heck. There is no point to rounding off these babies, let’s keep ’em really rough.” The trouble is this can be abrasive to your gums.
As for the electric brush, I think a consensus exists that — per time spent brushing — more plaque is removed. So this is worth the extra investment. If finances are tight, I believe that you still can achieve excellent results with a manual brush – if you use it correctly. This means brushing in the correct directions, with the right motions and with the appropriate amount of force. Have your dentist or hygienist demonstrate the recommended technique to you. Also, if you have all of your teeth, you should spend at least two minutes brushing them. In my observation, the trouble is that most people simply don’t brush long enough. So time your brushing. One study showed most people think they are brushing much longer than they actually are. Since human nature seems to be inclined to “rush the brush,” this is where electric brushes have an advantage over the manual variety. Many of the electrics have built-in timers. You can still cheat, but at least you will know you are doing it.
Here is an interesting exchange I had with a patient not too long ago. I’m getting ready to start a cleaning after completing my examination. His gums are red (he has gingivitis), there is plaque visible, and I just know those gums will bleed when I start to clean them. I’d like to help him get this under control, but I suspect he doesn’t floss, so I ask “Do you floss?”
His answer: “Whenever I need to.”
I’m thinking: “That would be, like, EVERY DAY.” But instead I ask: “How often is that?”
He replies: “Whenever food becomes noticeably stuck between my teeth.”
I’m actually detecting just a little annoyance now, and then he says: “Yeah, every dentist I have ever been to mentions the flossing thing.”
Well, I suppose I could talk about his favorite color, or maybe something equally inane, like the weather — but somehow the ‘flossing thing’ seemed appropriate. And then it occurred to me, maybe that IS “flossing” for this guy. And how many others, I wondered?
Therefore, in my quest to help rid the world of gingivitis and periodontal disease, (which just may be the shared goal of “every other dentist” who has recommended flossing) I’d like to clarify a few points about what it is and what it isn’t. While floss is unquestionably effective at removing food particles from between your teeth, just picking out the occasional chunk of steak from between your teeth doesn’t classify as “flossing.”
Flossing involves taking a piece of floss – say, about eighteen inches or so – grasping it between your thumb and index finger (just a few inches apart), then holding it in a “C” shape against the side of your tooth. Pre-threaded flossers are just fine in my opinion. Use whatever you are most comfortable with and whatever will get you to floss regularly. Rub the floss up and down the sides of every tooth. You actually want to slide the floss under the gum line. This cleans out areas your toothbrush cannot effectively reach.
Imagine not cleaning some parts of your teeth – ever. Or maybe, you just clean some teeth and not others. Do you think the unclean teeth might become more subject to tooth decay? If you answered “Yes!” then you would be right. This is exactly what occurs when you don’t floss. The parts of the teeth that are in contact with each other never get brushed. It’s not physically possible. So, a sizeable portion of all the fillings I end up having to place for patients are between the teeth. This is so easily helped . . . floss!
If you are just beginning to floss, you can expect your gums to bleed. Don’t let this ‘freak you out.’ A number of patients have said to me over the years “I tried flossing but it made my gums bleed, so I quit.” No. Bacteria, gingivitis, and nutritional deficiencies made your gums bleed. Flossing will help. You just need to stick with it until you notice less and less bleeding.
It is important to have your teeth and gums examined regularly. While gingivitis and periodontal disease are bad enough, there are a few even more serious conditions that could contribute to bleeding gums.
I actually could go on for quite a while about the many benefits to your overall health that flossing brings, but I’ll spare you for now. Or shall we just talk about the weather?
In almost any field there are basics, the fundamental facts or principles from which other truths can be derived.
Without an understanding of these basics we lack the building blocks for greater knowledge or competence. For example, before we can write we learn our ABCs. Geometry first requires an understanding of arithmetic, and so on.
Lacking these basics, we can become lost in a sea of information, lacking the correct drops of water that hold the answers to our questions or allow us to be effective.
Know the basics of automotive care and you are likely to have a car that runs well and needs few repairs. Understand the basics of grammar and you can communicate.
What, then, are the basics of dental care?
While there are several key concepts which I cover in some of my earlier articles, there is one often overlooked principle I want to briefly cover herein.
Let’s first assume you are already in good dental health or, perhaps you weren’t, but now you got things under control. You are starting off with a “clean slate.” So, what do you do now?
The simple answer is taking a look at what got you there.
You spent months and maybe hundreds, even thousands, of dollars to handle dental problems that may not even have been causing you pain. Things feel good and you have gotten the clean bill of dental health from your doctor. What now? Continue to do what fixed the problem.
Did you start brushing after meals? Good. Continue.
Did you change your diet to reduce refined carbohydrates? Good. Continue.
Do you floss every day? Good. Continue.
Do you come back for your regular visits? No?! Why not?
If that was a successful part of the formula, don’t make the mistake I see so many people commit. There is probably many a dentist who will vouch for the fact that patients come in to them and say: “Yeah, I had a bunch of dental work done somewhere about fifteen years ago and it is starting to come apart.” When asked about the time of their last dental visit: “Oh, it was around then. Since my teeth were fine, it didn’t see the point of going in for a dental visit.”
Didn’t see – that’s a key point. There are many conditions that the patient neither sees nor feels. More importantly, dental health has a direct relationship to overall health. So the fact that one doesn’t feel gum disease, bone loss, dental cavities or oral cancer – especially in the early stages is a poor excuse not to see your dentist. Regular checkups are fundamental to defending yourself against serious problems. Caught early, your treatment can be approached conservatively, saving you time in the dental chair, the potential discomfort of extensive work and, of course, money.
Why is it that patients who visit the dentist regularly seem to need less dental work? I’d like to think it also has to do with their increased care and effort – but that effort includes keeping up with regular visits. These checkups can prevent small problems from turning into big ones and help to keep your existing work in good shape. Don’t be a penny wise and a pound foolish. See your dentist at least twice a year.
Consider this article a public service announcement. I really dislike seeing patients lose teeth that could have been saved.
My philosophy is simple: if a patient has a dental problem, I address it—but just as importantly, I give them the tools and knowledge to prevent future issues. Ideally, most visits after that are just for routine maintenance.
Unfortunately, I often meet new patients with teeth so badly decayed there’s little chance of saving them. Just as frequently, I see people who finally schedule a checkup—often after years away from dental care—shocked to learn they have cavities. Many assume they lost a filling, when in fact, a chunk of enamel has broken off.
So why the surprise? Most people believe cavities are supposed to hurt.
Sometimes they do. But in the early stages, they’re usually painless.
By the time a tooth actually hurts, the cavity has likely reached a serious stage. Often, I’m deciding whether to attempt a root canal—or whether extraction is the only option. A basic understanding of dental anatomy helps explain why.
Scroll down to the illustration below.
The outer layer of your tooth—enamel—is the hardest substance in your body. It’s made to last a lifetime and helps you chew your food efficiently.
But here’s the key: it doesn’t have nerves. Enamel is more than 95% mineral. The rest is water and organic material. Because it lacks nerves, it doesn’t feel anything. That’s useful—you wouldn’t want pain every time you bit into food. But it also means decay can silently destroy it without causing any warning signs.
Even when decay reaches the underlying layer—dentin—you may still feel nothing. Only when it approaches the soft center—the pulp, where nerves and blood vessels live—do you usually feel pain. By then, the damage is often extensive.
To make matters worse, decay doesn’t spread in a straight line. Take a look at the black triangles in the diagram. A cavity often starts at a small point on the outside and fans out wide inside the enamel. The tooth might look intact—until the undermined enamel collapses due to internal damage.
Cavities also tend to form between teeth—places you can’t see. Even I need x-rays to catch them in those areas.
So what does all this mean? Cavities don’t always show up with pain. Dentists rely on visual checks, dental probes, x-rays, and sometimes laser detection to find them. Even then, spotting decay under old fillings can be tricky.
Don’t wait for pain to tell you something’s wrong. If it hurts, the problem is already advanced—and the treatment will likely be more complex, more costly, and less predictable.
If someone you care about hasn’t seen a dentist in a while, ask them to read this article. You might help them avoid discomfort, costly procedures, and even tooth loss.
And for those thinking, “If it gets bad, I’ll just pull it,”—well, sometimes that’s necessary. But that’s a conversation for another day.
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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