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A Close Look At Cavities

Posted Aug 24 2008 1:49pm
DAVID FOLK THOMAS: Welcome to our webcast. I'm David Folk Thomas. Now even the bravest among us grow fearful when the dentist says, "Cavity" as in "You have a cavity." Right away we think of needles, drills and, of course, maybe a little bit or a lot of pain. But there are ways to prevent cavities from forming. For those of you who are unlucky enough to have gotten an occasional cavity, there are a number of treatment options.

Here to shed some light on the prevention and treatment of cavities are two experts. To my left is Dr. Graziano Giglio. He's the Associate Clinical Professor at the Advanced Education Program in Prosthodontics at New York University. And Graz, as I will be calling him, is also in private practice in New York specializing in aesthetics and implants.

Next to Dr. Giglio is Dr. Paul Kamen. He is the Associate Professor of Clinical Dentistry at Columbia University School of Dental and Oral Surgery. Paul is also in private practice in Manhattan. He specializes in periodontics and implants. Gentlemen, thank you for joining me on the webcast.

Paul, let me start with you. How do cavities form? What are cavities?

PAUL KAMEN, DDS: Cavities are actually a demineralization of the tooth surface. They're caused by plaque, the bacteria of the plaque, which if you eat sweet foods the bacteria create acids. The acids actually leach out the enamel of the tooth structure and begin to invade the tooth causing destruction of some of the softer parts of the tooth and eventually decay of the tooth.

DAVID FOLK THOMAS: Graz, where do most cavities form?

GRAZIANO GIGLIO, DDS: Most of them form inside pits and fissures on top of teeth. The nooks and crannies of the tooth. There are other types of cavities that occur between teeth. We can prevent those by flossing. The contact point between one tooth and the other.

DAVID FOLK THOMAS: So it's like partially in one and partially in another.

GRAZIANO GIGLIO, DDS: It actually is caused by getting a piece of food stuck there and the food is there for a long period of time. Plaque accumulates around it. The bacteria make acid which then demineralizes -- most likely -- both teeth. So you're not just getting one. When a dentist tells you get a cavity between the teeth, it's not usually on one tooth. It's on the adjacent tooth also which is awful.

DAVID FOLK THOMAS: Paul, very briefly because we're going to be assuming the worst that people already have a cavity out there. Very briefly on prevention. How can you prevent cavities? What's the best way to do that?

PAUL KAMEN, DDS: The best way of preventing cavities are the old fashioned words to brush and floss every day.

DAVID FOLK THOMAS: Once a day? Twice a day?

PAUL KAMEN, DDS: You should brush twice a day. Most people flossing once a day is adequate. Although if you feel that you're getting food stuck between your teeth, especially people who have lots of fillings or whose teeth are very, very close together, they tend to have that feeling that something is stuck in-between. It certainly doesn't hurt to floss more and get that food out between each meal.

DAVID FOLK THOMAS: Sometimes I've heard brush after every meal. Is that overdoing it?

GRAZIANO GIGLIO, DDS: You need to brush at least twice a day. What I tell most of my patients, if you get a chance after lunch, is to have a toothbrush around and brush. Not only just to remove the food and the bacteria, but also to coat the teeth with some fluoride which also prevents cavities. It now coats the tooth and protects it and also remineralizes the area.

Say you have a small cavity and you happen to put a lot of fluoride in that area. It remineralizes part of the tooth surface so the cavity doesn't get any larger.

DAVID FOLK THOMAS: What are sealants? I've heard about that. How does that relate to cavities?

PAUL KAMEN, DDS: Before I answer that, I'd kind of like to jump in -- sort of finish up a thought about the last issue -- about how many times to brush.

I certainly agree with what Graz said to brush after meals. Absolutely correct. The only thing that I would add is I like to see patients spend at least one time during the day brushing in a very concerted way. Brushing really properly, really taking the time to get into those gum crevices. Get to the back teeth, get to the inside surfaces of the teeth, and then of course, to floss.

DAVID FOLK THOMAS: How long should that all take?

PAUL KAMEN, DDS: That should take about seven minutes if you do all of that correctly. That's why I don't expect any of my patients to brush seven minutes three or four times a day. But I'd be happy if they'd spend one time a day doing that and then at least one other time, if not a few more times, doing it a little more haphazardly.

DAVID FOLK THOMAS: Okay, now let's get to sealants now. What's that about?

PAUL KAMEN, DDS: Sealants are a kind of polymeric resin that dentists use to cover the pits and fissures that Graz talked about earlier. Those are those little squiggly things on the biting surfaces of your teeth that you look into a mirror. Microscopically they're kind of like the Grand Canyon for bacteria. But they're very, very hard to get to. The bristle of a toothbrush could not fit into one of those little microscopic fissures. Dentists place these sealants over them to prevent the bacteria, prevent the plaque from settling into those fissures.

DAVID FOLK THOMAS: Is it permanent then? Or do you put it on children? Or when is the time to use sealants?

GRAZIANO GIGLIO, DDS: Usually when the first molars come in on a child that's six years old. That's teeth that come in behind the primary teeth. That's usually the first sealants that children get. So we place these coatings on teeth and there are different types of resins. I use one which is a filled resin which are a little dense. We coat these teeth and just the whole top surface of the tooth is coated with this. It lasts about 15 years. It's nice. Now you can still get a cavity between the teeth. So this only prevents cavities from food building up inside these crevices for the 15 years or so, but not in-between teeth. You still have to floss.

DAVID FOLK THOMAS: Let me assume now again the worse. I've got a cavity. You out there have a cavity. What are your options?

PAUL KAMEN, DDS: There are many options today. The old standard option was to get an amalgam filling. An amalgam is a compilation of metal -- combining mercury and other metallic elements. We still use those. But today we're using a lot more fillings made out of composites, out of polymerical plastic based materials that look more like teeth and are more cosmetic.

DAVID FOLK THOMAS: So you don't see a mouth full of--

PAUL KAMEN, DDS: You don't see the silver. But there are many options.

GRAZIANO GIGLIO, DDS: What I recommend is and in most instances, if it's a small cavity, a composite is fine. That's the resin that Paul is talking about.

But if it's a larger cavity, I usually recommend in a cosmetic area or in an aesthetic area, I recommend a ceramic filling of some sort. It's an inlay or an onlay. We make a mold of the tooth. Then it goes to the laboratory. The laboratory fabricates a piece, like a jigsaw puzzle that fits right into the tooth of whatever is missing of the cavity.

Another option is gold which most people got before these ceramic fillings which was an option as opposed to the silver. Silver is an inexpensive material. It's not as good as the gold. Gold will last a lot longer.

DAVID FOLK THOMAS: It would seem to me that gold would be -- I want a gold filling, but actually it works better than--

GRAZIANO GIGLIO, DDS: It's the standard. In the back of the mouth all the way on the last teeth in the mouth, I usually use gold whenever a patient allows me to do that because it doesn't show. An upper back tooth doesn't show so I use gold whenever possible.

But most of the patients I would say -- 75% -- get the white ceramic fillings and then 25% allow me to do the gold. Some patients don't mind the gold because they've had it in for so long that every time they get a filling, they just get gold. Some of these gold fillings last 35 years.

DAVID FOLK THOMAS: How much does a gold filling cost? Bring your own gold bar?

GRAZIANO GIGLIO, DDS: A gold filling is more expensive than conventional composite or silver filling. Conventional silver filling may cost $250 whereas the gold may cost $1200, depending on the size of one.

The ceramic filling cost the same as the gold. So the patient says, "Well, if I've got to spend this kind of money, I might as well get the white because it's more cosmetic." But the whites have been around for say ten years and they're predictable. We don't know how much longer they're going to last. The ones that I have that have been ten years are fine. But we don't know if they're going to last 15 or 20 years.

Gold has proven itself. It's been around for a long time. We have track record on that and it works very well. We know that for 35 years you can do a filling on someone and you never have to change it, which is great.

DAVID FOLK THOMAS: You don't want to be stuck up on the subway for your fillings though. We're running out of time. But let me ask Paul about if you have severe cavities that are down near the root canal. What are your options at that point?

PAUL KAMEN, DDS: The root canal is actually a little channel in the tooth. It's actually the nerve that connects the tooth to the bone. The tooth is really a living organism. It's not just a piece of calcium.

If that nerve space is violated by decay or fracture of the tooth, or for any of a variety of reasons, the nerve becomes infected. Root canal treatment involves actually removing that nerve tissue and replacing it with an inert material. That's how we save many, many teeth that otherwise would be condemned.

DAVID FOLK THOMAS: That sounds to me like it can be major work. How long does it take to fix somebody who's got a cavity down by the root canal

GRAZIANO GIGLIO, DDS: First, you have to excavate the cavity. Then you have to go to a root canal specialist who performs the procedure that Paul was talking about where he takes the nerve out, cleans it, disinfects it and then places a rubber material in there. Then you need to go to a restorative dentist or a prosthodontist who can then place a post in the tooth and then a cap or a crown.

You can go from having a small little cavity to a root canal -- it's a big jump now in terms of how much money you spend and the type of work that you need. I would advise patients to get in when you have a cavity. Get in as soon as possible. Take care of it because if it does go into the nerve, then you end up needing root canal. You end up spending somewhere in the range of $3,000 to restore that tooth as opposed to a $250 filling.

DAVID FOLK THOMAS: Great. That's all the time we have. Dr. Giglio, Dr. Kamen, thanks for stopping by. You heard what they said. Start brushing and flossing now because there are great treatments for cavities, but you just don't want to go there if you can avoid it. My name is David Folk Thomas. We'll see you next time.

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