Learn about the causes, symptoms & treatment options for tooth decay - a common dental problem that can lead to pain, discomfort & tooth loss if left untreated.

Tooth Decay

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

Tooth decay is defined as the gradual breakdown of tooth enamel. 
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The terms tooth decay, cavities, and caries are often used interchangeably. However, these are three different conditions. Tooth decay is characterized by damage to the tooth&rsquo;s enamel while cavities refer to the formation of small holes in the tooth. However, dental caries is a chronic infection resulting from acid-producing bacteria in the mouth, which leads to demineralization of the tooth structure over time.

When tooth decay becomes severe, it can cause toothaches and sensitivity to hot or cold foods1. Dietary sugar intake is considered a major causative factor of tooth decay.

Tooth decay and cavities are the most common health problems around the world. According to available data, approximately 60% of Pakistan&#39;s population suffers from dental caries, and this proportion is similar across all provinces<a href="#accordion">[2]</a>. However, it should be noted that most of the studies included in the meta-analysis were deemed to have a high risk of bias<a href="#accordion">[2]</a>. 
Tooth decay can range in severity from minor enamel wear to painful abscesses in the tooth&#39;s pulp. It often leads to the formation of cavities. 
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There are no specific subtypes of tooth decay. 
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Signs and Symptoms

The signs and symptoms of tooth decay can vary depending on the severity of the decay and its location in the mouth. Early stages of tooth decay typically don&rsquo;t cause any symptoms. As it progresses, it can cause the following signs and symptoms. 
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<ul>
	<li>Toothache Or Sensitivity: A persistent toothache or sensitivity to hot, cold, or sweet foods and drinks can be a sign of tooth decay.</li>
	<li>Visible Holes Or Pits In Teeth (<a href="https://merisehat.pk/disease/cavities">Cavities</a>): Small holes or pits in teeth can indicate the presence of decay.</li>
	<li>Discoloration Or Staining: Discoloration or staining on the surface of a tooth can indicate the beginning stages of decay. White or dark spots may appear on the teeth</li>
	<li>Bad Breath: Tooth decay can cause bad breath that persists even after brushing and using mouthwash.</li>
	<li>Pus Or Discharge: If the tooth decay has progressed to a bacterial infection, there may be pus or discharge around the affected tooth. This is called a dental abscess. It can result in facial swelling, pain, or fever.</li>
	<li>Pain When Biting Or Chewing: Pain when biting down or chewing food can indicate that decay has progressed to a more advanced stage.</li>
	<li>Swelling Or Redness In Gums: Gum tissue can become inflamed and red around the affected tooth due to decay. 
	&nbsp;</li>
</ul>

Causes

Teeth are made up of three layers: enamel, dentin, and pulp. Enamel is the outer, hard layer that protects the tooth, while dentin is the softer layer underneath. Within the center is the pulp which contains blood vessels, nerves, and connective tissue. Tooth decay can cause damage ranging from the wearing of enamel to painful abscesses within the pulp. 
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Tooth decay is primarily caused by the buildup of plaque on teeth, which is a sticky layer of bacteria that forms on teeth. When a person consumes sugary or starchy foods, the bacteria in the plaque produce acids that attack the tooth enamel, leading to erosion over time.

The steps of tooth decay formation are as follows: 
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<h5>Plaque Development</h5>

The formation of dental plaque occurs due to a build-up of sugars and starches that are not removed from teeth through proper cleaning. This results in the formation of a clear, sticky film that coats the teeth i.e. plaque.

Plaque contains acids that can erode the hard, outer enamel of teeth, resulting in the formation of tiny holes or openings. This is the initial stage of cavities, and if left untreated, the bacteria and acid can penetrate deeper into the tooth. 
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<h5>Destruction Continues</h5>

As tooth decay progresses, bacteria and acid continue to move through the tooth, affecting the softer layer of dentin and causing sensitivity. If left untreated, the decay can reach the inner tooth material (pulp) that contains nerves and blood vessels, resulting in pain and discomfort. The nerve may become pressed, leading to further discomfort that can even extend to the surrounding bone. 
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The stages of tooth decay include<a href="#accordion">[4]</a>: 
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<h5>Stage 1: Initial Demineralization</h5>

White spots appear on the teeth. It results from acids produced by plaque bacteria demineralizing and weakening the enamel. This is the earliest stage of tooth decay and is reversible with proper oral hygiene and fluoride treatment. 
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<h5>Stage 2: Enamel Decay</h5>

The white spots on the teeth turn brown. Moreover, the enamel begins to break down and form a cavity. At this stage, there may be some sensitivity or mild pain in the affected tooth. Tooth fillings are required to prevent the cavities from growing larger. 
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<h5>Stage 3: Dentin Decay</h5>

The decay progresses through the enamel and into the dentin layer of the tooth. At this stage, the cavity becomes larger and deeper, and there may be more noticeable pain or sensitivity. 
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<h5>Stage 4: Pulp Damage</h5>

The decay reaches the pulp (innermost part) of the tooth. This can cause severe pain, swelling, and infection. As pulp damage progresses, it can lead to pulp death which is also known as pulp necrosis. As the pulp dies, the color of the tooth may change from white to gray to black. People may also report an unpleasant taste in their mouth and the tooth may have a bad smell. A root canal is needed to treat the damaged pulp. 
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<h5>Stage 5: Abscess</h5>

This is the final stage of tooth decay. The infection spreads beyond the tooth and into the surrounding tissues, causing a painful abscess. This results in fever, severe pain that radiates to the jaw, swelling of the gums, face, or jaw, and swollen lymph nodes in the neck. 
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Note: It&#39;s important to catch tooth decay in the early stages to prevent further damage and potential tooth loss. Regular dental checkups and good oral hygiene practices can help detect and prevent tooth decay from progressing. 
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Diagnosis

There are no specific screening tests for tooth decay. However, regular dental checkups can help detect any changes and prevent disease progression.

Diagnosis of tooth decay is done at the dentist&rsquo;s clinic. The dentist will begin by taking a history and then performing a dental examination. They will also probe the area with dental instruments to assess for pain and sensitivity.&nbsp; A dental X-ray may be required to spot any cavities. 
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Treatment

The treatment for tooth decay depends on the severity and extent of the decay. In the early stages, tooth decay can often be treated with simple procedures such as<a href="#accordion">[5][6]</a>:

Fluoride treatments: Fluoride can help to strengthen tooth enamel and reverse the early stages of decay. Dentists can prescribe fluoride in various forms, such as foam, solution, gel, or foam. 
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Fillings: If the decay has progressed to the point where there is a cavity, a filling can be used to restore the tooth.

Crowns: If the decay is more extensive, a crown may be necessary to restore the tooth&#39;s shape, strength, and appearance. A crown is a custom-fitted covering that replaces the tooth&rsquo;s natural crown. The decay and outer portion of the tooth are first removed to place the crown. Crowns may be composed of porcelain, gold, or resin.

Root Canal: If the decay has spread to the pulp of the tooth, a root canal may be necessary to remove the infected tissue and save the tooth. It involves the removal of decayed pulp, cleaning the inside of the tooth and the root, and then filling it with a rubber-like substance and placing a crown or filling on the tooth.

Extraction: In severe cases where the tooth cannot be saved, extraction may be necessary. 
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Note: If you notice any fever, nausea, vomiting, severe pain, swelling, or bleeding after a tooth extraction, contact a healthcare professional immediately. 
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The complications of tooth decay include: 
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<ul>
	<li><a href="https://merisehat.pk/disease/abscessed-tooth">Tooth Abscess</a>: If tooth decay is left untreated, it can lead to a bacterial infection in the tooth, which can cause a painful abscess. Abscesses can lead to sepsis.</li>
	<li>Tooth Loss: Severe decay can weaken the tooth structure, causing the tooth to break or fall out.</li>
	<li>Gum Disease: The bacteria that cause tooth decay can also infect the gums, leading to gum disease.</li>
	<li>Bad Breath: Decay can cause a foul odor in the mouth, leading to bad breath.</li>
	<li>Difficulty Eating And Speaking: Tooth decay can make it difficult to chew food and speak clearly.</li>
	<li>Pain And Discomfort: Tooth decay can cause pain and discomfort in the affected tooth, which can affect daily activities and overall quality of life.</li>
	<li>Cavities: Cavities are holes in the teeth caused by decay. They can cause tooth sensitivity, pain, and difficulty eating. 
	&nbsp;</li>
</ul>

The risk factors of tooth decay include: 
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<ul>
	<li>Poor Oral Hygiene: Not brushing or flossing regularly can lead to the accumulation of plaque and tartar, which can cause decay.</li>
	<li>High Sugar And Carbohydrate Intake: Bacteria in the mouth feed on sugar and produce acid that can erode tooth enamel.</li>
	<li>Dry Mouth: Saliva helps to neutralize acids produced by bacteria and wash away food particles, so a dry mouth can increase the risk of decay.</li>
	<li>Acidic Foods And Drinks: Consuming acidic foods and drinks, such as citrus fruits and soda, can erode tooth enamel.</li>
	<li>Genetics: Some people may have a genetic predisposition to tooth decay.</li>
	<li>Age: As people age, the risk of tooth decay increases due to changes in the mouth and exposure to acids over time.</li>
	<li>Medical Conditions: Certain medical conditions, such as eating disorders and acid reflux disease, can increase the risk of tooth decay.</li>
	<li>Lack Of Fluoride: Fluoride helps to strengthen tooth enamel and protect against decay. A lack of fluoride can increase the risk of tooth decay.</li>
	<li>Receding Gums: Gum recession can expose the root of the tooth, which is more susceptible to decay than the enamel-covered crown. 
	&nbsp;</li>
</ul>

The following measures can help prevent tooth decay:

<ul>
	<li>Brush the teeth twice daily using toothpaste containing fluoride.</li>
	<li>Use dental floss or interdental cleaners to clean between teeth every day.</li>
	<li>Rinse daily with a fluoride-containing mouthwash.</li>
	<li>Limit snacks and eat balanced meals.</li>
	<li>Avoid foods like chips and candy that can stay on teeth.</li>
	<li>Speak with the dentist about the use of fluoride supplements.</li>
	<li>Consult the dentist regarding the application of dental sealants on your back teeth (molars) to protect them against decay.</li>
	<li>Drink fluoridated water to prevent tooth decay.</li>
	<li>Visit the dentist regularly for professional cleaning and oral examination. 
	&nbsp;</li>
</ul>

Studies are being conducted on new methods to prevent tooth decay such as chewing gum containing xylitol, fluoride-releasing materials, kinds of toothpaste, and mouth rinses that can reverse early cavities. 
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A recent study compared the effectiveness of probiotic mouthwash and fluoride mouthwash on plaque buildup in children after 7, 14, and 30 days of use. The results showed that probiotic mouthwash was more effective than fluoride mouthwash in reducing plaque accumulation after 14 and 30 days of use, but there was no significant difference after 7 days. Therefore, the study suggests that probiotic mouthwash is an effective and safe alternative to chemical mouthwashes for maintaining oral health<a href="#accordion">[7]</a>. 
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The use of Silver Diamine Fluoride (SDF) is a promising and cost-effective way to prevent tooth decay. However, there is a need to determine how often SDF should be applied to effectively treat cavities in high-risk groups. A recent study aims to compare the effectiveness of applying 38% SDF once a year, twice a year, or four times a year to treat cavities in primary teeth of tribal preschool children aged 2-6 years in India. The trial will enroll 480 children and will be conducted following ethical guidelines. Results will be analyzed at both the tooth- and person-level. The study has been registered with the Clinical Trial Registry of India<a href="#accordion">[8]</a>. 
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Key Points

<ul>
	<li>Tooth decay is a common oral health problem caused by the demineralization of tooth enamel.</li>
	<li>Bacteria in the mouth produce acid that erodes the enamel, leading to the formation of small holes or cavities in the teeth.</li>
	<li>The most common causes of tooth decay are poor oral hygiene, a diet high in sugar and carbohydrates, and inadequate fluoride intake.</li>
	<li>Symptoms of tooth decay can include sensitivity to hot or cold temperatures, pain or discomfort when biting or chewing, and visible pits or holes in the teeth.</li>
	<li>Untreated tooth decay can lead to more severe oral health problems, such as abscesses, gum disease, and tooth loss.</li>
	<li>Preventive measures for tooth decay include regular brushing and flossing, limiting sugary and acidic foods and drinks, and receiving regular dental check-ups and cleanings.</li>
	<li>Fluoride is a mineral that can strengthen tooth enamel and help prevent tooth decay. It can be found in toothpaste, mouthwash, and some community water supplies.</li>
	<li>Dental sealants are a protective coating that can be applied to the chewing surfaces of the back teeth to help prevent tooth decay.</li>
	<li>Treatment options for tooth decay depend on the severity of the condition and can include dental fillings, crowns, root canals, and extractions.</li>
	<li>Children and older adults are at a higher risk of tooth decay, but people of all ages can develop the condition.</li>
	<li>Some factors that can increase the risk of tooth decay include dry mouth, certain medications, and genetic predisposition.</li>
	<li>Good oral hygiene practices and a balanced diet can help reduce the risk of tooth decay and promote overall oral health. 
	&nbsp;</li>
</ul>

[1] Tooth decay: Symptoms, causes, treatment, and prevention. Medical News Today.

[2] Siddiqui AA, Alshammary F, Mulla M, et al. Prevalence of dental caries in Pakistan: A systematic review and meta-analysis. BMC Oral Health. 2021;21(1). doi:10.1186/s12903-021-01802-x

[3] Cavities/Tooth Decay. Mayo Clinic.

[4] Seladi-Schulman J. Tooth decay stages: 5 stages and how to treat each. Healthline.

[5] Tooth decay. MedlinePlus.

[6] NHS choices.

[7] Alhallak E, Kouchaje C, Hasan A, Makieh R. Evaluation of the Effectiveness of Probiotic Mouthwashes in Reducing Dental Plaque in Primary and Permanent Teeth: A Randomized Clinical Trial. Cureus. 2022;14(8):e28125. Published 2022 Aug 18. doi:10.7759/cureus.28125

[8] Janakiram C, Ramanarayanan V, Devan I. Effectiveness of Silver Diammine Fluoride Applications for Dental Caries Cessation in Tribal Preschool Children in India: Study Protocol for a Randomized Controlled Trial. Methods Protoc. 2021;4(2):30. Published 2021 May 11. doi:10.3390/mps4020030

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