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Introduction
Introduction
As a COHA, it will be important for you to understand dental caries and the impact this disease has on the community. Recognized as a national public health issue, dental caries is the most common chronic disease affecting people of all age groups[1] . It is also a slowly progressive chronic disease affecting people throughout life[2].
Although dental caries rates have largely decreased among Americans over the past four decades, disparities remain in some population groups. Mexican American and Black or African American adults were more likely than white adults to have untreated caries[2]. For example, between 2013-2014 the majority of Mexican American children (72%) between ages 6 to 9 years experienced dental caries compared to 42% of white children[2].
In this module, we will describe caries concerning:
Pathology (how cavities develop)
Epidemiology (which and to what degree different communities are affected)
Clinical interventions (how caries are prevented or treated once they occur)
Health care systems that address the prevention and treatment of caries
Basic Understanding
Basic Understanding
Definition
Definition
Dental caries, commonly referred to as cavities, are occurrences where tooth decay is present. This is problematic because it leaves the inner structures of the tooth vulnerable to harmful pathogens. If left untreated, dental caries can lead to worse oral health outcomes and ultimately, a much more serious and expensive issue to fix.
Let's suggest the photo above is from an adult. Can you propose a reason why dental caries are present? Think of a few reasons that cause dental caries to develop on the labial/facial surface of a tooth.
Pathophysiology
Pathophysiology
Anatomy
Anatomy
Understanding the anatomy of the mouth will be beneficial in your journey as a COHA and as a clinician. The Gingiva section is worth particular attention where more serious oral health conditions may arise like gingivitis and periodontitis, especially if complicated with diabetes.
The stages of caries development. The cariogenic activity starts to wear away the enamel layer, then onto the dentin layer, followed by invasion into the pulp chamber, and lastly, onto soft tissue and the bone supporting the tooth. [image source]
Causes
Causes
What exactly causes dental caries? Looking deeper into the physiological causes, we take a look at the bacteria known as Streptococcus mutans (S. mutans). When S. mutans are allowed to reproduce, they clump and form a thin, clear layer known as dental biofilm. If further clumping occurs, they can form more complex structures like dental plaque. S. mutans are largely regarded as the main cause of dental caries due to their metabolizing sugars from food particles into harmful acids. These acids then weaken the outer enamel layer which causes the removal of mineral materials of the tooth. Eventually, this causes the tooth to form a cavity. Over time, this acidic destruction progresses to the middle layer of the tooth known as dentin. If this progresses even further, the inner portion of the tooth will become infected and the overall health of the tooth will drastically decline.
Questions to consider
How might salivary flow play a role in caries development?
Discussion Prompt
Discussion Prompt
What factors can affect salivary flow? Discuss your findings as if you were explaining to a client like Maria in the case study below.
Write out your response in Classroom.
Epidemiology in Hispanic communities
Epidemiology in Hispanic communities
The Impact of Culture and Diet
The Impact of Culture and Diet
We all know that one’s culture can influence their diet and food choices and how these choices might be harmful in developing chronic diseases like dental caries. However, culture is not the only aspect to consider. One’s social and personal environments can influence these choices too. Socioeconomic factors can adversely affect mental and physical health. For example, lack of income or education, low-paying jobs, limited social support, inadequate access to nutrition, limited transportation, and lack of available health service may impede the ability of a person to seek the care they need[8]. In fact, there are many other factors beyond culture, social or personal environments that affect one’s health and what one might choose to eat. Taken all together, we can consider these factors as determinants of health and we use this idea to understand how eating behavior might be influenced.
An Ecological Model Identifying Factors Influencing Eating Behaviors[3]
There are many determinants that are out of one’s realm of control. Mobley, C. et al. suggest that “a spectrum of dynamic, synergistic conditions in the global environment including political and industrial systems and policies interact with regional and community programs and cultures to create environments that determine availability and access to food choices”[3]. In this regard, we consider common cariogenic foods that are common across various diets and how they may be influenced by one’s social and individual environments.
Diet can play a role in the development of caries, sugar being especially noteworthy. Common sources of sugar are present within, but not limited to honey, syrups, fruit juices, and fruit juice concentrates. In many beverages, sweeteners are added and labeled as sucrose, glucose, fructose, lactose, maltose which in turn increase the number of free sugars present in the drink.
Secondly, a diet rich in acidic foods and drinks can cause tooth enamel to wear away causing teeth to become sensitive[4]. Here are some acidic foods and drinks to be aware of:
Citrus fruits — lemons, limes, grapefruits, tangerines, and oranges
Apples, grapes, peaches, pomegranates, blueberries, pineapples
Fruit juices and sodas (both regular and diet)
Tomatoes and tomato juice
Jams and jellies
Vinegar
Sauerkraut
Discussion Prompt
Discussion Prompt
Can you think of cariogenic foods that might be common within the Latinx community? How often might such foods be consumed as a regular part of their diet? What is your personal experience? Submit pictures to share with your classmates.
Write out your response in Classroom.
Caries Statistics in Hispanic Communities
Caries Statistics in Hispanic Communities
Case Study
Case Study
Maria Diaz, a Hispanic, 32-year-old woman (she, her, hers) with complaints of fatigue and nausea. She started her problems started 3 weeks ago and had to miss some days of work as a domestic worker cleaning houses. She was reluctant to seek professional help due to missing work but has decided to get checked out as her symptoms seem to be getting worse. Upon talking and getting more information with Maria, you have noted:
No recorded history of chronic illnesses and no current medications prescribed
Familial history of diabetes from mother and father
No medical or dental care for 4 years
Drinks a beverage (sometimes juice, sometimes soda) while at work as a thirst quencher
Under stress due to financial concerns
Blood Pressure: 150/95, Heart Rate 80
You notice her gums appear to be inflamed, she says they have been bleeding easily in the past few months. She also has a small cavity.
Discussion Question
Discussion Question
How might you raise urgency and awareness for Maria’s oral health condition, despite her chief complaints being nausea and fatigue? Please include sources along with citations in your response.
Write out your response in Classroom.
How To Prevent Disease
How To Prevent Disease
Personal Hygiene Maintenance
Personal Hygiene Maintenance
Controlling and preventing dental caries can be thought of as reducing the number of bacteria through plaque and biofilm removal. Brushing your teeth twice a day and flossing at least once can disrupt biofilm production and adhesion on tooth surfaces. For professional cleaning, a dental hygienist or dental professional can remove the stubborn plaque, known as tartar or calculus using special metal or water pressured tools. In such cases, it is often recommended to receive professional dental cleaning 1-2 times a year.
Fluoride Use
Fluoride Use
Additionally, we can consider improving resistance to demineralization by strengthening teeth with fluoride use. Common sources of Fluoride can come from:
Dental Toothpaste
Fluoride Wash
Fluoride Varnish administered by a dental professional
Community Fluoridated Water Supply in tap water
Note: Approximately 75% of King County’s population is on fluoridated water systems.[5]
Advocacy Resources
How To Treat Disease
How To Treat Disease
Treating dental caries varies depending on the severity of the condition. However, most case scenarios for dental cavities are treated in the following way:
Oral Exam Appointment
Oral Exam Appointment
The patient has been referred to a dental provider or schedules an appointment themselves at a dental office.
Health history is taken and chief complaints (if any) are voiced
Dental professional asks for relevant health information to obtain a holistic view of the patient to be treated.
Radiographs (x-rays)
Radiographs of the patient's teeth are taken to obtain a three-dimensional view of the mouth used to identify problems like cavities, tooth decay, and impacted teeth.
Inspection by Dentist
The dentist inspects the patient's mouth using the dental lamp and dental tools to verify anything that may be found on x-rays. Tooth sensitivity may be tested at this point using cold air.
Dental Probing/Charting
This is the point where the dentist calls out a bunch of numbers to their assistant like “1-1-1” or “2-3-2”, etc. Here, the dentist is using their dental probing tool to gauge the health of the gingiva by measuring pocket depth in millimeters around every tooth.
- Numbers 1-3 indicate healthy gum level readings, a "4" suggests to watch carefully but is not a major concern, and 5 or above would often call for deep cleaning or a “Scale and Root-Planning” (SRP) appointment with the dental hygienist to allow for the gums to repair itself.
Forming a Treatment plan (regular checkups, fluoride application)
At the end of the oral examination, the dentist discusses with the patient the type of work that needs to be done to restore the patient’s oral health. If any cavities are found, they will need to schedule another appointment specifically for dental restoration.
- Additionally, the dentist may create a referral for various dental specialties, i.e. orthodontics, endodontist, periodontics, oral and maxillofacial, etc.
Discussion Prompt
Discussion Prompt
You know someone who is anxious about their dental visit and is considering not showing up for their follow-up dental procedures. What can you suggest to help ease them to get the care they need?
Write out your response in Classroom.
Blood pressure is taken
Blood pressure needs to be taken before administering anesthesia. Cancellation is recommended if uncontrolled blood pressure is greater than 180/110 mmHg for urgent oral health care and greater than 160/100 mmHg for elective oral health care[6]. So, it is very important that dental patients have their blood pressure under control before having dental work done.
Medical management of caries
In cases where access to care is limited or for patients when a general anesthetic is not considered safe, Silver Diamine Fluoride (SDF) can be applied to stop cariogenic activity at the tooth[7].
No tooth structure is removed if SDF is the means for treatment. Instead, SDF works by remineralizing tooth structure while putting a stop to the cariogenic activity.
Example of signed consent forms in various languages to inform patients about SDF developed by Jeremy Horst D.D.S, Ph.D
Anesthesia
Topical anesthesia is placed on the gums using a cotton tip applicator near the site of injection for patient comfortability and desensitization of the local anesthesia injection.
Local anesthesia is injected into the nerve tissue using a dental syringe to numb the specific area of the oral cavity.
Restoration
Removal of tooth decay in cavities
The dentist uses a high-speed bur (drill) to remove any decay present around the tooth cavity.
The tooth is prepared for dental restoration
The dentist uses the high-speed bur to further minimally remove tooth structure for better adherence to dental restoration material.
The tooth is then etched and bonded using primer and a bonding agent
Tooth structure is restored using tooth-colored composite resin material and shaped using various shaping tools.
After shaping to a natural tooth structure, a direct curing light is applied to harden the composite resin.
Checking bite and adjustments
The dentist checks the patient’s bite by having the patient bite down on articulating tape. Along with patient feedback about their bite comfortability, this process reveals whether fine-tuned adjustments are needed using a slow-speed bur.
Follow-up appointments according to the treatment plan
Not all cavities identified from the Oral exam may not be addressed in a single appointment. Follow-up appointments might still be needed to complete the treatment plan.
How To Access Care
How To Access Care
In Progress
References
References
Oral Conditions - Healthy People 2030 | health.gov. (n.d.). Healthy People 2030. Retrieved February 27, 2022, from https://health.gov/healthypeople/objectives-and-data/browse-objectives/oral-conditions
Burt, B. A., & Eklund, S. A. (2020). Dentistry, Dental Practice, and the Community (7th ed.) [E-book]. Saunders.
Mobley, C., Marshall, T. A., Milgrom, P., & Coldwell, S. E. (2009). The contribution of dietary factors to dental caries and disparities in caries. Academic pediatrics, 9(6), 410–414. https://doi.org/10.1016/j.acap.2009.09.008
Acidic foods and how they affect your teeth. Colgate®. (n.d.). Retrieved February 14, 2022, from https://www.colgate.com/en-us/oral-health/nutrition-and-oral-health/acidic-fruits-and-teeth-effects
Oral Health Promotion: Fluoride and Sealants. Oral health promotion: Fluoride and sealants - King County. (n.d.). Retrieved February 14, 2022, from https://kingcounty.gov/depts/health/locations/dental/oral-health-program/promotion.aspx
Yarows, S. A., Vornovitsky, O., Eber, R. M., Bisognano, J. D., & Basile, J. (2020). Canceling dental procedures due to elevated blood pressure: Is it appropriate?. The Journal of the American Dental Association, 151(4), 239-244.
Silver Diamine Fluoride. (2021, July 19). American Dental Association. Retrieved February 27, 2022, from https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/silver-diamine-fluoride
Sabato, E., Owens, J., Mauro, A. M., Findley, P., Lamba, S., & Fenesy, K. (2018). Integrating Social Determinants of Health into Dental Curricula: An Interprofessional Approach. Journal of Dental Education, 82(3), 237–245. https://doi.org/10.21815/JDE.018.022
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