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Time to stop the toothache - July 2009
Too many of our poorest and youngest children still suffer unnecessarily from toothache. Apart from the distress this causes, treating these children is a major cost to an already over-stretched National Health Service.
The average number of decayed teeth in five year old children has not decreased in the last ten years (1). This is despite the fact that it is clear that tooth decay can be very easily avoided, as shown by the massive fall in decay that followed the introduction of fluoride tooth paste around 1976 (2). And, paradoxically, the decay experience of twelve and fifteen year old children has continued its dramatic improvement throughout this time (1, 2). So, what is going on, and how can the situation be changed without incurring further costs to the NHS?
First it is important to understand what causes tooth decay and how it can be prevented. There are a lot of common misunderstandings about this which hamper effective prevention. Tooth decay is not caused simply by eating too many sweets. Nor is it effectively prevented by avoiding sugar. These out-dated ideas have stood in the way of tackling the problem for too long.
Toothache is a symptom of a pocket of infection affecting the structure of a tooth (3). This infection occurs when the hard mineral surface enamel of the tooth has been weakened by exposure to acid that dissolves it, allowing bacteria to establish a foothold. This acid can be taken into the mouth directly, from foods and drinks such as orange or lemon juice, or it can be produced by the bacteria present on the teeth surfaces acting on any source of sugars. The foods and drinks that provide the nutrients for the acid –producing bacteria to grow on are not merely the obvious sources of the various sugars but also include a wide variety of starchy products. This is because starches are partly broken down to sugars by enzymes present in saliva (4).
If this was the whole picture we would all have lost all our teeth very early in life. If our teeth are constantly under attack, how is it that they survive at all? A lack of understanding of how teeth are protected and repaired by the body’s defence systems has led to the most common misunderstanding of how to prevent tooth decay. This is the mistaken belief that eating less sugar will necessarily reduce the risk of decay. The real key is to do with the action of saliva. It is saliva that reduces the damage done by acids in the first place, by washing them away and neutralising them. Even more importantly, it is saliva that delivers the minerals (calcium and phosphate) to repair the teeth enamel by replacing what the acids have dissolved away (5).
So, in common with all other parts of the body, the teeth are not maintained in a healthy state by the absence of any challenges to their integrity. Instead, a balance is struck between processes that tend to break down their structure and the natural repair mechanisms that return the structure to its healthy state. In the normal course of events, these conflicting activities are not even noticeable. But if the speed of break-down is too great for the repair systems to cope with, then detectable damage results. The secret of healthy teeth is to allow enough time between acid attacks for the saliva to do its repair work. It is therefore much more important to allow a break (for repair) between meals and other eating or drinking occasions than to focus solely on what is eaten or drunk (6).
The sources of sugars used by the tooth surface bacteria to generate acids need not be sugars themselves. Any type of digestible carbohydrate will produce sugars as a result of the action of enzymes present in saliva (4). So, not only will the obvious sugar-containing foods and drinks present a challenge to the teeth, but also any source of starch, such as bread, potatoes, rice or pasta. Since these should form the basis of any healthy diet, it is clear that avoiding all carbohydrates is not a practical approach to preventing tooth decay (7). Indeed, there is very little evidence that manipulating what children eat and drink reduces their risk of tooth decay appreciably (7). Reducing the frequency of eating and drinking would be a more rational approach, but this has not been consciously tested. In fact, there is very little research into the influence of diet on tooth decay nowadays, probably because it is widely seen as of minor importance. A much more effective means of preventing tooth decay is available today, and is widely used – fluoride tooth paste (8).
A variety of different acid-forming bacteria are present in everyone’s mouth most of the time, although some people have far more of them than others (9). Fluoride tooth paste has proved to be an extremely effective means of reducing the effects of these bacteria and probably also reducing their number (10). Children who have used fluoride tooth paste from an early age tend to have less of these bacteria in their mouths and less caries than children who only started brushing later (11).
The reason fluoride tooth paste is so effective is not entirely clear. It probably has three distinct actions (12). One is to strengthen the tooth surface. When mineral is laid down in tooth enamel in the presence of fluoride, some fluoride becomes incorporated into the tooth surface. This enamel is more resistant to being dissolved by acid than enamel without fluoride.
A second action is to reduce the biochemical process in acid-forming bacteria that leads to acids being produced (13). As a result, the amount of acid attacking the teeth surfaces will be less than when no fluoride is present, at least for a while after the fluoride toothpaste has been used. A further result is that these bacteria are disadvantaged when competing with other, harmless bacteria, within the ecology of the mouth. This may explain why children who use fluoride toothpaste from the time that the first teeth erupt (around six months of age) tend to have fewer acid-forming bacteria in their mouths. A number of different types of bacteria compete for places to fix themselves to the newly revealed enamel surfaces in the baby’s mouth. If the available space is occupied by harmless bacteria, the acid-forming ones cannot get such a foothold.
Whatever the reasons, fluoride toothpaste has succeeded beyond the wildest dreams of its originators. The internationally recognised standard of measurement for comparing different population’s dental health is the average number of decayed, missing or filled permanent (second) teeth among children at an age of twelve. Among twelve year old children’s permanent teeth in the UK the number requiring attention has fallen dramatically since fluoride toothpaste was introduced in around 1976 (14). The average number of teeth effected by decay has fallen in twelve year olds from over four effected teeth prior to 1976 to around one in 2003 (the latest national survey available), resulting in an overall decline in lifetime caries experience of disease of around 75% that has also been seen in many other countries (15).
So why has the average decay experience of 5 year olds not improved similarly? In fact, this statistic conceals very large variations in different parts of the country. The clue lies in the social conditions in which children are being brought up. Decay experience is much worse in under-privileged children, than among those in more affluent, and usually better educated, families (15). This probably reflects a simple failure of health education. Many mothers and carers of very young children do not realise that the use of fluoride toothpaste should start as soon as a baby’s first teeth appear. Too often it is started only after the first visit to the dentist because a child has a tooth ache.
This is why older children have better teeth. Even if the teeth were neglected when the child was very young, by the time the second teeth start to appear, almost every child will know that they should clean their teeth. Of course, whether they will do it regularly is another matter! Indeed, recent survey results show how much further we need to go in persuading children to use fluoride toothpaste optimally by regularly brushing twice a day (16).
The solution is clear, and has been demonstrated by a trial experiment in one of the poorest areas of the country – inner city Leeds (17). If the baby’s mother is simply reminded, when the child is about six months old, that regular cleaning of the baby’s teeth with fluoride tooth paste should start when the first tooth appears, the risk of tooth decay is virtually eliminated. A brief visit by a health professional when the baby reaches six months of age (with follow-up 12 and 24 months later) has been proved to produce most satisfactory results. It is regrettable that this cost-effective intervention has not been adopted more widely by health promotion practitioners, especially in those areas where tooth decay is worst, and the costs to the NHS correspondingly high. This is a campaign that will need to involve a wide range of health professionals and other educators, and not left solely to the dentist, since the key time window (when the baby is around 6 months of age) is one when neither the baby nor the carer may be seen by a dentist.
Of course, straightforward common sense is still valuable when parents decide what their children should eat and drink, and especially how often. Grazing all day is likely to raise the risk of tooth decay, since many snack foods contain either sugars or cooked starches (18). But the evidence is that their teeth will be protected most effectively by regular use of fluoride tooth paste. It is astonishing that surveys still show an appreciable number of children and young people do not practice this simple part of personal hygiene, even among teenagers, who might be expected to care if their mouths were fresh(16)!
References
- http://www.statistics.gov.uk/children/dentalhealth/
- Cottrell RC (2005) Dental Disease in Encyclopedia of Human Nutrition. (eds. Caballero B, Allan L , Prentice A) Elsevier Oxford.
- http://www.nhs.uk/Conditions/Toothache/Pages/Causes.aspx?url=Pages/What-is-it.aspx
- König K.G. (2000) Diet and oral health. International Dental Journal 50: 162–174.
- Sreebny LM (2000) Saliva in health and disease: an appraisal and update. International Dental Journal 50:140-161.
- vanLoveren CM and Duggal M S (2001) The role of diet in caries prevention. International Dental Journal 51: 399-406.
- Kay E J (1998) Caries prevention: based on evidence? Or an act of faith? British Dental Journal 185:432-3.
- Ten Cate JM (2004) Fluorides in caries prevention and control: empiricism or science? Caries Research 38:254-257.
- Beighton D (2005) The complex microflora in high risk individuals and groups and its role in the caries process. Community Dentistry and Oral Epidemiology 33:248-255.
- Hamilton IR (1990) Biochemical effects of fluoride on oral bacteria. Journal of Dental Research 69: 682-683.
- Garcia-Godoy F, Hicks MJ (2008) Maintaining the integrity of the enamel surface. Journal of the American Dental Association 139 (Suppl 2): 25S-34S.
- Featherstone JDB (2007) Prevention and reversal of dental caries: role of low level fluoride. Community Dentistry and Oral Epidemiology 27: 31-40.
- Bradshaw DJ, Marsh PD, Hodgson RJ, Visser JM (2002) Effects of glucose and fluoride on competition and metabolism within in vitro dental bacterial communities and biofilms. Caries Research 36: 81-86.
- Todd JE (1975) Children’s dental health in England and Wales. HMSO London.
- Marthaler TM (2004) Changes in dental caries 1953-2003. Caries Research 38:173-181.
- Walker A, Gregory J, Bradnock G, Nunn J, White D (2000) National Diet and Nutrition Survey: young people 4-18 years. Volume 2 Report of the oral health survey. The Stationary Office, London.
- Kowash MB, Pinfield A, Smith J, Curzon ME (2000) Effectiveness on oral health of a long term health education programme for mothers with young children. British Dental Journal 188:201-205.
- Anderson CA, Curzon MEJ, Van Loveren C, Tatsi C, Duggal MS (2009) Sucrose and dental caries: a review of the evidence. Obesity Reviews 10 (Suppl 1): 41-54.
