Caries Beware the Wykked Worme!

Caries

Beware the wykked worme! If you lived during the Middle Ages and were unfortunate enough to experience the agony of an aching tooth, it was thought that a little worm was the cause. There were no dental restorations, so the only cure was an extraction. The practice of dentistry was primitive and the village dentist was also the barber. There were no anesthetics and no specialized instruments. The tooth was yanked with a pair of pincers, "after which there was no hope of repairing the loss with a brand-new set of dentures" (Legge, 1950, p. 50).

We now know, of course, that there are no "wykked worms," but acid-producing bacteria that thrive in the mouth. Without good daily oral hygiene, the bacteria feed on the sugars left in the mouth from foods. They begin to eat away at tooth enamel, eventually causing decay or what patients commonly refer to as "a cavity." Dental disease, including caries, can "impair quality of life and have a negative impact on self-esteem, eating ability and health, causing pain, anxiety and impaired social functioning (Moynihan, 2005, p. 654). J

Just as there are no "wykked worms," there are no reasons modern patients have to suffer. Tooth decay does not have to mean an individual has to lose the tooth. Restorative procedures can repair a diseased tooth so that it looks and functions like a healthy tooth. It is good for patients' overall dental health if they can keep their own teeth and certainly good for self-esteem if they can display an attractive smile. Dental hygienists play an important role in educating patients about the causes of dental caries. They can provide information to patients about healthy nutrition choices that can help prevent caries.

Sugary foods, particularly sticky ones that leave residue adhering to the teeth, have long been associated with dental caries. Arola, Bonet et al. (2009) noted "it is generally agreed that fermentable carbohydrates are required for causation of dental caries" (p. 57). Moynihan (2005) explored the role of diet and nutrition in oral diseases, including caries, and also found evidence of sugar as a cause of oral mucosal diseases, erosion, and even periodontal disease (p. 694). Sugar and fermentable carbohydrates are hydrolyzed by salivary amylase (Bell, 2011), providing excellent growing conditions for the bacteria that attack enamel and cause caries.

Unfortunately, human beings are programmed to enjoy a sweet taste. Anderson, Curzon, van Loveren, Tatsi and Duggai (2009) point out that, thousands of years before processed sugar, humans sweetened their food with honey. They reviewed the literature about peoples from Stone Age, Antiquity, the Middle Ages and early modern times and found there was evidence that people ate large amounts of honey and, in fact, "intakes at various historical times may well have rivaled current consumption of refined sugar" (p. 41). Mennella (2010) studied taste preferences of children and found they naturally prefer sweet things. As a developmental psychobiologist, Mennella was particularly interested in the "rewarding and good feeling" (p. 387) children associated with eating sugary foods.

As humans, we have a predisposition towards sugary foods and evidence shows that we are indulging our collective "sweet tooth" more than ever. The average American consumes an average of twenty-two teaspoons of sugar per day; teenagers eat an average of thirty-four teaspoons (Associated Press, 2009). Rachel K. Johnson, a professor of nutrition at the University of Vermont, notes that soft drinks are a huge problem, especially with the teenage population, and that sugars are also found in foods Americans perceive as healthier options: fruit-flavored yogurt, which has about six teaspoons of added sugar; chocolate milk, with about four teaspoons; and a cup of frosted, whole grain cereal, with about three teaspoons of added sugar (Associated Press, 2009).

Johnson did not even discuss the increased risk for dental caries when she discussed Americans' over-consumption of sugar. Many health professionals, including Johnson, cite sugar's role in the nation's obesity epidemic and the correlation between obesity and heart disease, diabetes and other serious health problems. There is no evidence anywhere that tells us sugar is good for us, whether one is considering dental health or overall physical health. All the evidence points to the fact that we should be reducing sugar consumption, yet Americans are consuming more of it than ever. We are programmed biologically to enjoy a sweet taste and we are literally feeding that basic preference. People know it is not good for them, yet they find sugar difficult to resist.

It is not the role of the dental hygienist to prevent people from eating sugary foods -- even if that were possible. What we can do, as dental health professionals, is educate patients about the role of sugar in oral health and perhaps guide patients towards better choices. We can also provide dental care and teach patients how to care for their teeth themselves in between visits to the dental office to minimize, as much as possible, the damage that sugars cause. Anderson, Curzon et al.(2009) point out that caries occur in patients of all ages, although they found that the type of caries varies in different populations. Children, they found, generally have coronal caries only, while adults tend to have both coronal and root caries. They also found most carious lesions in adults are "recurrent caries, requiring replacement restorations" (p. 43).

Anderson, Curzon et al. (2009) found that it is the frequency of sugar consumption, rather than quantity, that is the real culprit. In their review of the literature, they found no reliable relationship between quantity of sugar consumed and dental caries. A significant relationship was found, however, between the frequency of use and dental caries (p. 51) it makes sense that duration would have a greater negative impact than quantity, at least with respect to caries. Overall calorie intake from sugar is obviously much higher in a large slice of cake than in a package of hard candies such as Lifesavers, yet the Lifesavers can actually pose a greater risk to dental health. One consumes cake and the contact between sugar and tooth is eventually dissipated by saliva and any beverage consumed with the cake. A roll of Lifesavers, however, can last for hours. When a person consumes one ten calorie candy after another, she is continually bathing her teeth in sugary liquid. Hard candies have a very long-lasting effect on the teeth; chewy candies are likewise bad for the teeth, as they bathe the teeth in sugar liquid as they are chewed. Tiny pieces of candy can stick to the teeth. A person may feel that a small roll of candy is a better choice to satisfy a craving for sweets than cake, cookies or ice cream, but that is not the case when it comes to caries prevention. This is just one aspect of preventative care in which dental hygienists can provide instruction to patients to help them make better, more informed choices.

Anderson, Curzon et al. (2009) also noted that baked goods, and not necessarily sweet-tasting ones, can contribute to increased incidence of caries. Refined sugar became widely available in the nineteenth century at the same time as mass production of refined white flour. "Pastry and baked goods, such as biscuits [became] widely available or made at home" (p. 51). The researchers reported on findings that "prevalence [of caries] in the U.S.A. was related more significantly to the use of baked goods and not to sugar per se" (p. 51). This is more information that hygienists can share with their patients as part of overall education about diet and its relationship to oral health.