Tooth decay can be rampant in youngsters. That is why so many of us have mouths full of dental fillings and crowns. Decay generally subsides in adults until age 50, when it can become rampant again, even in a previously decay-free mouth. We all know that children love candy, soft drinks and other refined sugars, but why is it that older adults can suddenly have ten cavities or more? The reasons for high decay rates in seniors will be explained in a bit. Let me first share a couple of anecdotes to illustrate how dental tragedies can occur.

The first experience is that of the wife of a prominent physician from Newport Beach, California. A weekend toothache required the services of a young, “on-call” dentist. A cursory examination was shocking. This very attractive 37 year-old woman had ALL twenty-eight of her teeth capped just two years earlier, and she presented with cavities around almost every one of the caps. Not only did she need a root canal, but all the caps required replacement! How awful it must have been for her to hear this bad news! You might imagine how ill she felt upon hearing the diagnosis. With today’s knowledge of dental disease we could have prevented her painful and expensive disaster.

The second experience is about the athletic wife of a regional hospital administrator. She had three crowns placed, but did not return for a dental visit for several years. When she did return, there was decay around two of the crowns and five additional teeth had severe enough decay to require crowns. Had she read and heeded the advice of this article she would have prevented her disaster as well.

Most dentists observe the third situation every week. Older patients present with root decay, usually hidden between their teeth, but sometimes right up front where you can see it in their smiles. Most of these patients have had regular dental care from an excellent dentist whom they loved. Frequently the treating dentist was a great friend or even a relative of the patient. Most of these patients share that they inherited bad teeth and they seem to feel predestined to endless cycles of crowns, root canals, extractions, and bridgework. Sure enough, if only the obvious problem is repaired, this cycle may continue until teeth break off and more bridgework is required. With today’s dentistry you can stop this downward spiral.

Each of the patients discussed had a habit that contributed to their dental disease. Although habits are hard to break, dentists can now prescribe preferred alternatives that are less destructive. Appropriate dental materials will reduce the potential for disaster and supportive prevention treatments can provide the defenses your teeth need. This is preservation dentistry.

Many of you may relate to one of the above patients. You may know someone whose story is very similar. The secrets to avoiding these situations require an understanding of how these dental disasters occurred and knowledge of what you can expect your dentist to recommend as preventive and corrective treatment.

How Dental Decay Can Result in a Disaster in Your Mouth

Teeth on mature adults are extremely susceptible to decay if any of these conditions exist:

1. Receding gums and bone loss that exposes root surfaces
2. Sugar habits, such as sweetened drinks (including coffee, tea, soft drinks, etc.), sucking on hard candies or mints (Jolly Ranchers, TicTacs, Altoids, lemon drops, Tums, Rolaids, etc.), use of soft candies (gumdrops, chews), regular drinking of fermentable alcohol (most hard liquor)
3. Reduction in salivation may be caused by: prescription drugs (especially high blood pressure drugs, diuretics and antidepressants), over-the-counter medications and herbal remedies, radiation therapy, and post-menopausal hormonal fluctuations.
4. Poor oral care. This is especially a problem for patients who lose manual dexterity and patients with particular ailments such as arthritis, Parkinson’s disease, poor eyesight and Alzheimer’s disease.
5. Poorly restored teeth and spaces between teeth that serve as food impaction areas.

Let’s look at each of these contributing factors. As we do, you will learn how you can avoid or remedy each situation.

How Receding Gums Contribute to Tooth Decay

The enamel on the outside of the crown portion of your teeth is extremely hard. Because enamel can take up additional fluoride over your lifetime, it becomes harder and less susceptible to decay as we get older. Exposure to strong acid solutions (created from sugar and dental plaque) can soften the enamel to start a cavity. Receding gums encourage root decay because the recession can leave large areas of root accessible to plaque food entrapment. Root surfaces are much softer and rougher than enamel, so plaque sticks easily and decay can start wherever plaque accumulates.

Root surfaces can be hardened with strong topical fluoride. In fact, studies show that even surfaces that have started to soften (beginning of the decay process) can be hardened (remineralized). Because the roots were not exposed to fluoride for all those years that enamel was getting harder, the roots are easily attacked and decay can proceed very rapidly into the nerve of the tooth. In fact, teeth with root decay often decay all the way across the tooth, breaking off at or above the gumline, resulting in a difficult restorative situation at best and extraction at worst.

Because dentists see so much of this gumline decay, it is surprising that topical fluoride solutions aren’t dispensed more often for adult patients. Most dentists just do not have the time to educate patients to the value of fluoride on exposed roots. Many dentists are not comfortable dispensing medications from their offices. Yet, such solutions are necessary to control root decay.

PRO-TIPs for those prone to tooth decay You can prevent root decay with the help of your dentist and dental hygienist. First, adults with exposed root surfaces should use concentrated fluoride toothpaste (available by prescription). Second, these patients, who also have a history of root decay, should use a fluoride rinse or gel once or twice a day. Your dental office should dispense or prescribe the proper solutions for you. You may be instructed to use a rinse or apply a gel with a brush in a plastic tray at bedtime. Of course, fluoride works best on clean tooth surfaces, so regular cleanings and good home care are critical. For $20 to $50 a year spent on fluoride solutions many patients can maintain healthy teeth in their later years, saving thousands of dollars a year in dental costs.

Controlling Your Sugar Habit

Controlling sugar habits does not mean discontinuing all intake of sugar. It does mean reducing prolonged exposure to sugar on a daily basis. You can have relatively little sugar in your diet, and still end up with rampant decay if you are consuming small amounts of sugar all day long. Typical examples of this are the desk worker who sips sweetened coffee throughout the day, or the chronic gastritis sufferer who munches Rolaids every hour or so.

It is the number of minutes that you are exposed to sugar that is important, not the amount of sugar consumption. A bowl of ice cream eaten in a few minutes is much less damaging than the constant exposure from a hard candy that is sucked on for half an hour.

The bacterial plaque that sticks to root surfaces uses sugar as its food. The sugar is converted to an acid that eats away at the tooth surface. You can interrupt the action of the plaque by starving the little critters that you can’t see. They would like to eat all day long. Take away their food and you will reduce your decay rate tremendously! Many people do not realize that decay is a bacterial disease. If we can snuff out the bad guys, we can eliminate the disease.

The most difficult part of reducing sugar’s contribution to root decay is identifying the sugar that is consumed. Patients with rampant decay usually have a good idea as to the habit(s) that are contributing to the decay. At least half the time, these patients are unable or unwilling to put a finger on the habit. In the example of the wife of the hospital administrator, she said she had no idea what could contribute to the decay. In truth, she was embarrassed, but on a subsequent visit admitted that she sucks on candy while watching TV in bed at night. Then, of course, she fell asleep with sugar all over her teeth. There was some pretty aggressive plaque in that mouth!

Many alcohol drinkers are reluctant to reveal their drinking habits. Brandy and exposed roots are a dynamic decay team!

Changing your dietary habits is far beyond the capabilities of this article. If you have an eating disorder, professional counseling may be an effective option. If you can identify a sugar habit, consider the Pro-Tips for Sugarholics.

PRO-TIPs for Sugarholics Replace candy or chewing gum with products containing the artificial sweetener Xylitol. If you can’t replace it, at least follow it with Xylitol gum. Xylitol has been shown to reduce cavities and clean the tooth surfaces. Note, that chewing gum of any kind is not recommended for grinders or patients with temporomandibular joint (TMJ) problems. If your habit has a strong hand-to-mouth element, substitute grapes or carrot pieces for candy. If you must drink alcohol, reduce your consumption time to the half hour before dinner. Always brush, floss and use fluoride after any uncontrolled habit.

The Effect of Reduced Salivation

Saliva helps prevent tooth decay by washing away food matter from your teeth and diluting and neutralizing the concentration of acids in your mouth. Minerals found in your saliva can help remineralize and harden a tooth. Saliva also limits bacterial growth that can dissolve tooth enamel or lead to mouth infections. If you have reduced saliva you are in for trouble and should take early preventive action.

Many people have heard of “radiation caries”, which is rampant decay that can follow radiation treatments to the head and neck. Severe radiation caries can result in a bone infection and that can itself lead to death. It is not the radiation that weakens the tooth surface, but the reduction in salivation, because high radiation inactivates the salivary glands. Chemotherapy and nerve damage can affect salivary flow in a similar manner to radiation.

There are medical conditions and medications that can result in reduced saliva and rampant root decay, usually affecting the root surfaces most.

Sjogren’s disease (an autoimmune disease), Alzheimer’s disease, post-menopausal hormonal fluctuations, stroke, anxiety disorders and depression can all reduce salivation.

Smoking or chewing tobacco can reduce saliva production, aggravating dry mouth. Snoring and breathing with your mouth open also can contribute to the problem.

Reduction in salivation may be caused by hundreds of prescription drugs, over-the-counter medications, and herbal remedies. Among the more likely drug types to cause problems are antidepressants, anti-anxiety drugs, antihistamines, high blood pressure medications, anti-diarrheals, muscle relaxants, drugs for urinary incontinence, and Parkinson’s disease medications.

It is baffling that most regions have only one or two dentists who are known to give the special dental care required for radiation therapy patients. This may be due to the fact that most dentists were taught about radiation caries without much regard to its similarity with all the other causes of decay from reduced salivary flow. It is the same disease, just more pronounced and MORE EASILY ANTICIPATED in the radiation patient. All dentists should be treating patients with reduced salivation!

The treatment regimen for radiation patients has changed very little over the last 30 years. This treatment regimen can also be used for other patients with high susceptibility to root decay. (See Practioners’
Guide and Protocol at end of this article).

NO MATTER WHAT THE CAUSE OF REDUCED SALIVATION, IT SHOULD NOT BE IGNORED. YOUR PHYSICIAN MAY BE ABLE TO PRESCRIBE MEDICATIONS TO INCREASE YOUR SALIVARY FLOW AND YOUR DENTIST CAN HELP YOU WITH TREATMENT TO PROTECT YOUR TEETH.

Poor Oral Care

Poor home care is especially a problem for patients who lose manual dexterity from ailments such as arthritis, Parkinson’s disease, stroke, poor eyesight and Alzheimer’s disease.

This is a most difficult problem to treat, because corrective action depends entirely on the patient and any caregivers. The dentist can make recommendations and do some training, but developing good new habits is quite a challenge.

If home care is poor, plaque remains on the teeth even after any brushing attempts. With dietary changes, this plaque becomes active decay-producing gunk. Many seniors with no previous cavities can suddenly have decay along the gumline of many teeth.

If you or a person you care for might be in this situation, please heed the following…

PRO-TIPs for Those with Poor Oral Care 1 . Not all dental offices have hygienists and not all hygienists maintain their enthusiasm for helping patients prone to very poor oral hygiene. This is understandable because many patients, who have been given proper training from hygienists, return no better off on subsequent appointments. This can be really discouraging for the health professional who is motivated by the positive influence of his or her own work. 2. Appeal to the hygienist! Let her know you want help. The hygienist may show you all sorts of devices that can help, including specially designed brushes to reach into the gaps between the teeth, automatic toothbrushes, tongue scrapers (yes, bacteria hide in the tongue) and convenient flossing tools. Ask if the dentist can prescribe a home fluoride solution. 3. Make the commitment to have your teeth cleaned every two or three months. At that time insist on a fluoride treatment in the office. This will help, especially if your teeth have just been cleaned. The money you invest in these extra services will definitely save you in the long run. 4. Use a chlorhexidine mouthwash (available from your dentist or by prescription) for two weeks following each cleaning appointment. Following a cleaning, the bacteria that cause decay are greatly diminished. They are at their weakest, and use of an antibacterial mouthwash will further reduce the “bad guy” germs and help the “good guy” germs take over for the following few months.

Replace Ill-fitting Restorations

Many senior adults report with pride that their fillings and crowns have lasted for years. Unfortunately, just “lasting” is not good enough. Crowns often have large catches and open edges that harbor millions of decay-producing bacteria. Old fillings may have expanded or cracked, leaving hiding places for the bacteria. Gaps between the teeth are very common in seniors and serve as storage locations for plaque and remnants of yesterday’s dinner. Yuck!

These areas should be repaired. Precision-fitting dentistry should replace ill-fitting dentistry as soon as the problem areas are identified. It does not make sense to get a year or two more of life out of an ill-fitting restoration at the expense of the underlying tooth structure. The dentist will present choices for restoring unhealthy teeth that depend on the severity of the problem, the length of service desired, and the patient’s overall health and ability to sit in a dental chair.

A mouth restored to health gives you a great advantage. This is a mouth that can be cleaned and the bacteria that cause decay can be greatly reduced. Floss will not shred, brushes will be more effective, and fluoride and antibacterial solutions can effectively reach the root surface to do their job.

An extra benefit of a healthy mouth is better breath. Why leave it to chance?

PRO-TIPs About Dental Restorations Excellent dentists use follow up x-rays and exams to check the quality of the fit of the restorations they have placed, not just those your previous dentists have placed.

Practitioner’s Guide to Caries Risk Assessment and Treatment Protocol for Adults

*Note to dentists: This table does not use universally accepted risk levels, but levels that will make sense within an individual practice.

 Risk Level: To assess the risk level, determine the correct description for any risk factor, then determine which risk factor f or the patient falls into the highest risk level. Use that risk level to determine the correct protocol for the patient.

* Per evaluation by dentist and dental hygienist

Treatment Protocol

** Dentists may recommend additional preventive treatments N/R = Not required

Drugs That Cause Dry Mouth (partial list; generic names are in parentheses)

ANOREXIANT
Adipex-P,Fastin,Ionamin, Zantryl. Phenteramine, AnorexSR, Adipost, Bontril (PDM.phendirmetrazine), Didrex (benzphetamine, Lonamin, Fastin (phenteramine), Meridia (sibutramine), Tenuate, Tepanil, Ten-Tab (diethylpropion)

ANTIACNE
Accutane (isotretinoin)

ANTIANXIETY
Atarax, Vistaril (hydroxizine),Ativan (lorazepam), Centrax (prazepam), Equanil, Miltown (meprobamate), Librium (chlordiazepoxide), Serax (oxazepam), Sinequan (doxepin), Tranxene (clorazepate), Valium (diazepam), Xanax (alprazolam)

ANTICHOLINERIGIC/ANTISPASMODIC
Anaspaz (hyoscyamine), Bellergal (belladonna alkaloids), Bentyl (dicyclomine), Cantil (mepenzolate), Daricon (oxyphencyclimine), Detrol (tolterodine), Ditropan (oxybutynin), Donnatal, Kinesed (hyoscyamne w/atropine), Phenobarbital (scopolamine), Librax (chlordiazepoxide w/clidinium), Pamine (methscopolamine), Pathilon (tridihexethyl chloride), Pro-Banthine (propantheline), Quarzan (clidinium), Robinul (glycopyrrolate), Transderm-Scop (scopolamine), Urispas (flavoxate)

ANTICONVULSANT
Felbatol (felbamate), Lamictal (lamotrigine), Neurontin (gabapentin), Tegretol (carbamazepine)

ANTIDEPRESSANTS
Anafranil (clomipramine), Asendin (amoxapine), Celexa (citalopram), Desyrel (trazadone), Effexor (venlafaxine), Elavil (amitriptyline), Ludiomil (maprotiline), Luvox (isocarboxazid), Marplan (isocarboxazid), Nardil (phenylzine), Norpramin (desipramine), Parnate (tranylcypromine) Pamelor (nortriptyline), Prozac (fluoxetine), Paxil (paroxetine), Remeron (mirtazapine), Serzone (nefazodone), Sinequan (doxepin), Surmontil (trimipramine), Tofranil (imipramine), Vivactil (protriptyline), Wellbutrin (bupropion), Zoloft (sertraline)

ANTIDIARRHEAL
Imodium AD (loperamide), Lomotil (diphenoxylate w/ atropine)

ANTIEMETICS
Antivert (meclizine), Bucladin (buclizine), Compazine (prochlorperazine), Dramamine (dimenthydrinate), Marezine (cyclizine), Reglan (metocloropramide), Tigan (trimethobenzamide), Torecan (thiethylperazine), Transderm-Scop (scopolamine)

ANTIHISTAMINE
Actifed (triplodine w/ pseudoephedrine), Allegra (fexofenadine), Astelin (azelastine), Atarax, Vistaril, (hydroxizine), Benadryl (diphenhydramine), Chlor-Trimeton, (chlorpheniramine), Claritin (loratiadine), Dimetane (brompheniramine), Hismanal (astemizole), Nolahist (phenindamine), Optimine (azatadine), Periactin (cyproheptadine), Phenergan (promethazine), Polaramine (dexchlorpheniramine), Pyribenzamine [PBZ] (tripelennamine), Tavist (clemastine), Zyrtec (cetrizine)

ANTIHYPERTENSIVE
Accupril (quinapril), Aceon (perindopril), Aldomet (methyldopa), Altace (remipril), Betapace (sotalol), Blocadren (timolol), Capoten (captopril), Cardura (doxazoxin), Cartol (carteolol), Catapres (clonidine), Coreg (carvedilol), Corgard (nadolol), Flomax (tamsulosin), Hylorel (guanadrel), Hytrin (tarazosin), Inversine (mecamylamine), Inderal (propanolol), Kerlone (betaxolol), Leatol (penbutolol), Lopressor (metoprolol), Lotensin (benazepril), Mavik (trandolapril), Minipress (prazosin), Monopril (fosinopril), Norodyne (labetolol), Prinivil, Zestril (lisinopril), Sectral (acebutolol), Tenex (granfacine), Tenormin (atenolol), Univasc (moexipril), Vasotec (enalapril), Visken (pindolol), Wytensin (guanabenz), Zebeta (bisoprolol)

ANTIINFLAMMATORY ANALGESIC
Dolobid (diflunisal),, Feldene (prioxicam), Motrin (ibuprofen), Naprosyn (naproxen)

ANTINAUSEANT
Antivert (meclizine), Dramamine (diphenhydramine)

ANTIPARKINSONIAN
Akineton (biperiden), Artane (trihexyphenidyl), Cogentin (benztropine mesylate), Comtan (entacapone), Eldepryl (selegiline),

Kemadrin (procyclidine), Larodopa (levodopa) Naprosyn (naproxen), Parlodel (bromocriptine), Permax (pergolide), Symmetrel (amantadine), Sineet (carbidopa w/ levadopa), Tasmar (tolcapone)

ANTIPSYCHOTIC
Clozaril (clozapine), Compazine (prochlorperazine), Eskalith (lithium), Haldol (haloperidol), Laxitane (loxapine), Mellaril (thioridazine), Moban (molindone), Navane (thuiothixene Orap), primozide (Permitil), Prolixin (fluphenazine), Serentil (mesoridazine), Stelazine (trifluoperazine), Thorazine (chlorpromazine, Trilifon (perphenazine), Vesprin (triflupromazine), Zyprexa (olanzapine)

BRONCHODILATOR
Alupent (metaproterenol), Atrovent (ipratropium), Combivent (ipratropium/albuterol), Maxair (pirbuterol),

DECONGESTANT
Sudafed (pseudoephedrine)

DIURETIC
Aldactone (spirnolactone), Hydromaox (quinethzone), Bumex (bumetanide), Daranide (dichlorphenamide), Demadex (torsemterene), Diuril (chlorothiazide), Diamox (acetazolamide), Diurese (trichlormethiazide), Diucardin (hydroflumethazide),

Dyazide, Maxzide (iamterene and hydrochlorothiazide), Dyrenium (trimaterene), Edecrin (ethacrynic acid), Enudron (methylclothiazide), Exna (benzthiazide), Glauc Tabs (methazoloamide), HydroDiuril, Esidrix (hydrochlorothizide), Hygroton (chlorthalidone), Lasix (furosemide), Lozol (indapamide), Midamor (amiloride), Naturetin (bendroflumethiazide), Renese (polythiazide), Zaroxolyn (metolazone)

MUSCLE RELAXANT
Flexeril (cyclobenzaprine), Lioresal (baciofen), Norflex, Disipal (orphenadrine)

NARCOTIC ANALGESIC
Demerol (meperidine), MS Contin (morphine)

SEDATIVES
Dalmane (flurazapam), Doral (quazepam), Halcion (triazolam), Restoril (temazepam)

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