Dental cavities Symptoms, Diagnosis and Causes

A brown spot which is dull in appearance is probably a sign of active caries. In addition to the four main requirements for caries formation, reduced saliva is also associated with increased caries rate since the buffering capability of saliva is not present to counterbalance the acidic environment created by certain foods. As a result, medical conditions that reduce the amount of saliva produced by salivary glands, particularly the parotid gland, are likely to cause widespread tooth decay. Some examples include Sjögren's syndrome, diabetes mellitus, diabetes insipidus, and sarcoidosis. Medications, such as antihistamines and antidespressants, can also impair salivary flow. Moreover, 63% of the most commonly prescribed medications in the United States list dry mouth as a known side effect. Radiation therapy to the head and neck may also damage the cells in salivary glands, increasing the likelihood for caries formation.

The use of tobacco may also increase the risk for caries formation. Smokeless tobacco frequently contains high sugar content in some brands, possibly increasing the susceptibility to caries. Tobacco use is a significant risk factor for periodontal disease, which can allow the gingiva to recede. As the gingiva loses attachment to the teeth, the root surface becomes more visible in the mouth. If this occurs, root caries is a concern since the cementum covering the roots of teeth is more easily demineralized by acids in comparison to enamel. Currently, there is not enough evidence to support a causal relationship between smoking and coronal caries, but there is suggestive evidence of a causal relationship between smoking and root-surface caries.

As the enamel and dentin are destroyed further, the cavitation becomes more noticeable. The affected areas of the tooth change color and become soft to the touch. Once the decay passes through enamel, the dentinal tubules, which have passages to the nerve of the tooth, become exposed and cause the tooth to hurt. The pain can be worsened by heat, cold, or sweet foods and drinks. Dental caries can also cause bad breath and foul tastes. In highly progressed cases, infection can spread from the tooth to the surrounding soft tissues which may become life-threatening, as in the case with Ludwig's angina. Primary diagnosis involves inspection of all visible tooth surfaces using a good light source, dental mirror and explorer. Dental radiographs, produced when X-rays are passed through the jaw and picked up on film or digital sensor, may show dental caries before it is otherwise visible, particularly in the case of caries on interproximal (between the teeth) surfaces. Large dental caries are often apparent to the naked eye, but smaller lesions can be difficult to identify. Unextensive dental caries was formerly found by searching for soft areas of tooth structure with a dental explorer. Visual and tactile inspection along with radiographs are still employed frequently among dentists, particularly for pit and fissure caries.

Some dental researchers have cautioned against the use of dental explorers to find caries. In cases where a small area of tooth has begun demineralizing but has not yet cavitated, the pressure from the dental explorer could cause a cavitation. Since the carious process is reversible before a cavitation is present, it may be possible to arrest the caries with fluoride to remineralize the tooth surface. When a cavitation is present, a restoration will be needed to replace the lost tooth structure. A common technique used for the diagnosis of early (uncavitated) caries is the use of air blown across the suspect surface, which removes moisture, changing the optical properties of the unmineralized enamel. This produces a white 'halo' effect detectable to the naked eye. Fiberoptic transillumination, lasers and disclosing dyes have been recommended for use as an adjunct when diagnosing smaller carious lesions in pits and fissures of teeth. here are four main criteria required for caries formation: a tooth surface (enamel or dentin); cariogenic (or potentially caries-causing) bacteria; fermentable carbohydrates (such as sucrose); and time. The caries process does not have an inevitable outcome, and different individuals will be susceptible to different degrees depending on the shape of their teeth, oral hygiene habits, and the buffering capacity of their saliva.

Dental caries can occur on any surface of a tooth that is exposed to the oral cavity, but not the structures which are retained within the bone. Having "soft teeth" is usually not the cause of caries, despite commonly held belief to the contrary. There are certain diseases and disorders, however, that affect teeth that can leave an individual at a greater risk for caries. Amelogenesis imperfecta, which occurs between 1 in 718 and 1 in 14,000 individuals, is a disease in which the enamel does not form fully or in insufficient amounts and can fall off a tooth. Dentinogenesis imperfecta is a similar disease. In both cases, teeth may be left more vulnerable to decay because the enamel is not as able to protect the tooth as it would in health.

In most people, disorders or diseases affecting teeth are not the primary cause of dental caries. Ninety-six percent of tooth enamel is composed of minerals. These minerals, especially hydroxyapatite, will become soluble when exposed to acidic environments. Enamel begins to demineralize at a pH of 5.5. Dentin and cementum are more susceptible to caries than enamel because they have lower mineral content. Thus, when root surfaces of teeth are exposed from gingival recession or periodontal disease, caries can develop more readily. Even in a healthy oral environment, the tooth is susceptible to dental caries.

The anatomy of teeth may affect the likelihood of caries formation. In cases where the deep grooves of teeth are more numerous and exaggerated, pit and fissure caries are more likely to develop. Also, caries are more likely to develop when food is trapped between teeth.  The mouth contains a wide variety of bacteria, but only a few specific species of bacteria are believed to cause dental caries: Streptococcus mutans and Lactobacilli among them. Particularly for root caries, the most closely associated bacteria frequently identified are Lactobacillus acidophilus, Actinomyces viscosus, Nocardia spp., and Streptococcus mutans. Bacteria collect around the teeth and gums in a sticky, creamy-coloured mass called plaque. Some sites collect plaque more commonly than others. The grooves on the biting surfaces of molar and premolar teeth provide microscopic retention, as does the point of contact between teeth. Plaque may also collect along the gingiva. In addition, the edges of fillings or crowns can provide protection for bacteria, as can intraoral appliances such as orthodontic braces or removable partial dentures. Bacteria in a person's mouth converts sugars (most commonly sucrose - or common sugar, glucose and fructose) into acids such as lactic acid through fermentation processes. If left in contact with the tooth, these acids cause demineralization, which is the dissolution of its mineral content. The process is dynamic, however, as remineralization can also occur if the acid is neutralized and suitable minerals are available in the mouth from saliva but also from preventative aids such as fluoride toothpaste, dental varnish or mouthwash. Caries may be arrested at this stage. If sufficient acid is produced over a period of time to the favor of demineralization, caries will progress and may then result in so much mineral content being lost that the soft organic material left behind will disintegrate, forming a cavity or hole. The frequency of which teeth are exposed to cariogenic (acidic) environments affects the likelihood of caries development. After meals or snacks containing sugars, the bacteria in the mouth metabolize them resulting in acids as by-products which decreases pH. As time progresses, the pH returns to normal due to the buffering capacity of saliva and the dissolved mineral content from tooth surfaces. During every exposure to the acidic environment, portions of the inorganic mineral content at the surface of teeth dissolves and can remain dissolved for 2 hours. Since teeth are vulnerable during these periods of acidic environments, the development of dental caries relies greatly on the frequency of these occurrences. For example, when sugars are eaten continuously throughout the day, the tooth is more vulnerable to caries for a longer period of time, and caries are more likely to develop than if teeth are exposed less frequently to these environments and proper oral hygiene is maintained. This is because the pH never returns to normal levels, thus the tooth surfaces cannot remineralize, or regain lost mineral content.

The carious process can begin within days of a tooth erupting into the mouth if the diet is sufficiently rich in suitable carbohydrates, but may begin at any other time thereafter. The speed of the process is dependent on the interplay of the various factors described above but is believed to be slower since the introduction of fluoride. Compared to coronal smooth surface caries, proximal caries progress quicker and take an average of 4 years to pass through enamel in permanent teeth. Because the cementum enveloping the root surface is not nearly as durable as the enamel encasing the crown, root caries tends to progress much more rapidly than decay on other surfaces. The progression and loss of mineralization on the root surface is 2.5 times faster than caries in enamel. In very severe cases where oral hygiene is very poor and where the diet is very rich in fermentable carbohydrates, caries may cause cavitation within months of tooth eruption. This can occur, for example, when children continuously drink sugary drinks from baby bottles. On the other hand, it may take years before the process results in a cavity being formed, if at all.