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A large proportion of people in the countries where sucrose became widely available developed rapidly-advancing dental caries which began in the tooth enamel. For reasons that we now understand well, these individuals experienced pain, severe localized infection within relatively dense bone and then systemic illness. Suddenly, a disease which could be extremely painful and even deadly became common in children and young adults.
When the epidemic began no-one understood its cause. All that people could do at the time was treat its consequences. Treatment was by surgery, usually by extracting the tooth, and was very difficult for the surgeon (and very painful for the patient). Surgeons were not particularly admired at the time, because their work was crude, painful and often failed. A new type of surgeon, the dental surgeon, was needed. The dental profession began as a group of people who were also not very admired, but were very much needed.
How the disease has been treated in the past
It is useful to consider caries treatment in three historical phases.
When the enamel caries epidemic began, the disease was thought to be gangrene of the teeth. Gangrene is death of part of the body. If left untreated, a gangrenous area increases in size until the afflicted individual became ill and died. Caries was treated as gangrene of other parts of the body was treated at that time, by surgical removal. Extraction was the equivalent of amputation for gangrenous limbs. The surgical specialty of dentistry developed because of the high demand for caries treatment by extraction. Extraction is physically difficult in young people with good periodontal health. However it was effective in eliminating the disease from an individual when all of the teeth had gone.
When debridement by extraction was the principal method of treatment diagnosis was simple. It was appropriate to respond to patients' symptoms of discomfort or pain and to make the diagnosis of disease at that stage. 'Maintaining the vital force' through good nutrition and good general health was the only preventive strategy available. There is no evidence that this approach was effective.
An alternative method of surgical removal, and a simpler one than extraction, was local debridement by cleaning out the decayed area. Many dentists advocated using a small file to abrade away approximal areas of teeth, including the area of the early lesion, to treat the disease. After the file was used the area was left open to saliva. This had some advantages because it was a simple treatment and the decay was slow to recur. But it also had the disadvantages that food tended to lodge between the teeth and the teeth tended to move over time.
Local removal and then filling the resultant cavity was also attempted. The decay was removed with hand scrapers ('excavators) or rotating burs. The early filings sealed badly and tended to fail within months, or a few years at most, because of continuing decay. Despite its low success rate, some dentists used fillings because they were less difficult and, in a time when there was no local anesthesia, less traumatic for the patient.
Early fillings were metal - lead, tin or gold. Each of these metals could be pressed or hammered into the cavity. Pure gold was the most difficult of these metals to handle, but tended to last longer if it was very carefully placed and thoroughly condensed. Small bundles of very thin sheets of pure gold, called gold foil, were added one-by-one with tiny instruments and welded together using small hammers, called mallets. A mixture of silver and mercury, called dental amalgam, was also used to fill cavities. The mixture is initially soft, so it can be packed into the cavity with only moderate pressure, and because of chemical reactions between the silver and mercury new compounds are formed and it becomes hard.
The concept that caries was gangrene continued well into the 20th Century, and many patterns of care which flow from that concept continue up to the present time.
The fastidious and systematic refinement of cavity design and filling technologies in the early 1900's, mainly through the work of dentists in North America, changed the nature of caries treatment. Through this work the outcome of the restorative approach was improved until by mid-century it became preferable to extraction. Carefully-placed restorations (which by mid-century included fillings, onlays and crowns) tended to leak less. It became commonplace for restorations to last several years before they failed through continuing decay.
Complete removal of carious enamel and dentin was thought to be an essential part of successful filling design. Restorative materials did not adhere to teeth. In order for them to stay in place decayed areas had to be modified in shape, with hand or rotary cutting instruments, to make retentive cavity forms. Cavity shapes were also modified to increase the strength of the tooth and restoration. Minimal sizes of cavities were also mandated, so that the junction between the filling and tooth was on areas of the tooth where caries did not usually begin, in the hope that this would result in restorations which would last longer before recurrent decay occurred. This was called 'extension for prevention'. The act of making a restoration therefore usually involved the removal of substantial amount of tooth structure, often several times more than was actually decayed.
Preparing large cavities in hard tooth structure with hand cutting instruments (chisels, hatchets and hoes) was very slow and difficult, but it became easier as rotary cutting instruments (rotary burs) were developed and refined. By the 1970's high-speed, air turbine-driven rotary cutting instruments became widely available. It became relatively easy to prepare large cavities using tungsten carbide burs and industrial diamond-impregnated rotary instruments.
Diagnosis in Phase 2
In phase 1 patients' symptoms had been central to diagnosis. Perhaps unfortunately the main symptom of caries, pulpal pain, develops relatively late, when substantial amounts of tooth structure
have been lost. Waiting for pain to develop was not a good strategy if fillings were to be used as the method of treatment. The most successful way to manage caries using filling technologies involved finding the decay early, whether it was new caries (primary caries, on previously unrestored tooth surfaces) or recurrent caries (adjacent to existing restorations).
Detection became essentially the same as diagnosis. Diagnostic technologies were developed which aided early detection, namely:
Prevention in phase 2
In the 1950s the concept that caries was caused by acids produced by bacterial action on residual food on and around the teeth became widely accepted. Brushing teeth after meals to remove residual food was widely advocated as a preventive strategy but had little effect on caries rates. Advising patients to change their food choices and to eat less often was a rational approach, but few individuals took that advice.
In the 1970s the concept that caries was caused by dental plaque became widely accepted. Patients were advised to brush and floss teeth to remove plaque. The epidemiological discovery that fluoride in the diet and then the experimental demonstration topical application of fluoride both decreased caries experience led to the dietary fluoride supplements in children, water fluoridation and the use of topical fluorides in dentifrices, rinses and gels. The combination of fastidious plaque removal and fluoride use was shown to be effective in reducing caries in individuals and in whole populations.
The development of polymeric materials which bonded to enamel brought with it the ability to seal fissures. Fissures are areas of high likelihood for caries initiation in individuals who have the disease. Sealed fissures have a greatly reduced incidence of caries initiation. During this phase, when all individuals were considered to be at risk for caries, placement of fissure sealants in all children and young adults was an appropriate preventive strategy.
Standard of care in Phase 2
By mid-century the principal method of treatment of caries had become the restoration. Extraction was reserved for the extensively restored tooth which could no longer retain a restoration or which had fractured, or for patients who could not afford restorative treatment. The accepted standard of care for patients who could afford repeated restoration was to be examined frequently (usually at 6-monthly intervals) using the best aids to detection available. The repeated cycles of tooth restoration resulted in larger and larger restorations. Ideally, this continued until the patient died of old age. Improvements in restorative materials, particularly those which adhere to teeth and therefore tend not to leak(e.g. composite resin in some applications, and glass ionomer cement) and those which release fluoride (e.g. glass ionomer cement) increased the longevity of restorations. Unfortunately, however, extensively restored teeth sometimes fracture and must be extracted. Fixed bridges, removable dentures and implant-supported replacements could be offered to assist patients who had lost teeth because of this style of care. Because virtually the entire population of the industrialized societies with had caries (except those who had no teeth), it was appropriate to apply these preventive technologies to everyone with teeth. 'Prevention' was essentially the same for everyone. 'Cure' was not a concept that was used in dentistry relative to caries in this phase, because the only cure for caries was to extract all of the teeth.
Phase 3 - the present
Our Present Understanding of the Disease
Throughout the late 20th Century an increasingly detailed concept of the nature of caries developed, because of scientific research. There is now very strong evidence that the disease is not gangrene. There are therefore strong grounds to change the ways that the disease is treated.
A large body of data show that caries is the progressive loss of tooth mineral, followed by bacterial invasion into the demineralized tooth. It is a relatively complex disease. The nature of caries can be described in terms of five interrelated factors. In addition to helping explain the nature of the disease, each factors gives guidance to how to prevent it and to how it can be cured.
Factor 1. Caries is a bacterial disease
There is abundant evidence that the initiation of caries requires a relatively high proportion of mutans streptococci within dental plaque. These bacteria adhere well to the tooth surface, produce higher amounts of acid from sugars than other bacterial types, can survive better than other bacteria in an acid environment, and produce extracellular polysaccharides from sucrose. When the proportion of s. mutans in plaque is high (in the range 2-10%) a patient is at high risk for caries. When the proportion is low (less than 0.1%) the patient is at low risk. Infection with s mutans usually happens early in childhood by transmission from the mouths of parents or playmates. Because they are more acid tolerant than other bacteria, acid condition within plaque favor the survival and reproduction of mutans streptococci. Two other types of bacteria are also associated with the progression of caries through dentin. These are several species of lactobacillus, and actinomyces viscosus. These bacteria are also highly acidogenic and survive well in acid conditions.
Factor 2. Caries is dependent on dietary sucrose
Dietary sucrose changes both the thickness and the chemical nature of plaque. Mutans streptococci and some other plaque bacteria use the monosaccharide components (glucose and fructose) and the energy of the disaccharide bond of sucrose to assemble extracellular polysaccharides. These increase the thickness of plaque substantially, and also change the chemical nature of its extracellular space from liquid to gel. The gel limits movement of some ions. Thick gel-plaque allows the development of an acid environment against the tooth surface, protected from salivary buffering. Plaque which has not had contact with sucrose is both thinner and better buffered. A diet with a high proportion of sucrose therefore increases caries risk. Thicker plaque occurs in pits and fissures (which is why Site 1 lesions begin there), just beneath the contact area (Site 2) and, in patients with poor oral hygiene, near the gingival margin (Site 3).
Factor 3. Caries is driven by frequency of eating
Each time that plaque bacteria come into contact with food or drink containing simple sugars (monosaccharides such as glucose and fructose, and disaccharides such as sucrose, lactose and maltose) they use them for their metabolic needs, making organic acids as a metabolic by-product. If these acids are not buffered by saliva they dissolve the surface of the apatite crystals of adjacent tooth structure. This is called demineralization. In thick gel-plaque the pH falls within seconds of contact with dietary sugars, and it can stay low for up to 2 hours. When the pH is neutral the same crystals can re-grow, using calcium, phosphate and fluoride from saliva. This is called remineralization. Caries begins and progresses when demineralization outweighs remineralization. Caries therefore depends on the balance between demineralization and remineralization, i.e. on the frequency of eating (and on the microbial composition of the plaque and its chemical nature and thickness, on the local fluoride concentration and on the buffering capacity of saliva). A frequent pattern of eating therefore increases caries risk.
Factor 4. Caries is modified by fluoride
The mineral of enamel, cementum and dentin is a highly-substituted calcium phosphate salt called apatite. The apatite of newly-formed teeth is rich in carbonate, has relatively little fluoride and is relatively soluble. Cycles of partial demineralization and then remineralization in a fluoride-rich environment creates apatite which has less carbonate, more fluoride and is less soluble. Fluoride-rich, low carbonate apatite can be up to ten times less soluble than apatite low in fluoride and high in carbonate. Topical fluoride also inhibits acid production by plaque bacteria. Fluoride in food and drinks, fluoride in dentifrices and oral rinses and gels, and fluoride in filling materials can therefore all reduce the solubility of teeth, helping to reduce caries risk. These effects are very beneficial, but the amounts of fluoride which can be added to the diet or used topically are limited by safety considerations. High levels of dietary fluoride can cause mottling of tooth enamel during tooth formation, while swallowing even higher levels can cause symptoms of poisoning.
Factor 5. Caries is modified by saliva
High flow-rate saliva is a very effective buffer. The balance between demineralization and remineralization can therefore be altered substantially by the rate of salivary flow. Flow is decreased by salivary gland pathology (as occurs in several connective tissue disease and which can follow radiotherapy and cancer chemotherapy), by many mood-altering drugs and some drugs used in other medical treatment, in dehydration and during sleep. Flow increases naturally during vigorous chewing. A maximum salivary flow rate (which can be tested by collecting all saliva which chewing wax or gum) of less than 0.7 mL/min. is associated with high caries risk.
How the disease is treated today
Given this concept of the nature of the disease, the logical and ethical standards of care for both caries diagnosis and caries management (prevention, cure and repair) are now very different than they were during the time when caries was thought to be gangrene.
The present, molecular concept of the nature of caries leads us to very different concepts of management of the disease. This, coupled with the widespread use of fluoride and the development of restorative materials which adhere to tooth structure and which (in some cases) do not leak, has revolutionized the prevention and cure of caries, as well as the repair of carious defects in teeth. The key features of the new care paradigms are summarized below.
Diagnosis - since we understand caries to be a dynamic process which occurs at the molecular level we can diagnose the disease before irreversible loss of tooth structure occurs. It is now reasonable to state, on the basis of diagnosis, that some people do have the disease, while others do not. Detection of lesions at the macroscopic level can no longer be considered to be diagnosis, for two reasons - (1) the disease is present before lesions can be detected macroscopically and (2) large lesions remain after the disease is cured. Determination of risk state is a reasonable diagnostic goal, as is activity state.
Treatment and cure
The goal of treatment is now to change the local biochemistry so that the patient is no longer losing tooth mineral so that the disease is then cured and the patient healed. This is logical, ethical, appropriate and achievable.
Caries can be treated by one or more of the following:
Cure is achieved when diagnostic tests show that the disease is no longer active and the risk is low.
Restoration of defects, which was previously thought of as treatment of the disease, is now more reasonably considered to be repair. It will be desirable to stop using the term 'treatment' for such repair, because the standard of care for caries treatment is now behavioral and biochemical, not mechanical. If the disease is cured, restorations should no longer fail because of caries. Limitations on restoration longevity should be related only to failure by wear and fatigue under cyclic load.
Non-specific preventive strategies, such as education about the risks of high eating frequency, use of fluoride in the diet and in dentifrices, education about the benefits of fastidious daily tooth cleaning, are still appropriate. Fissure sealants are now best reserved for patients who are known (through accurate diagnosis) to be at high risk. Sealants need not be used in individuals who are known not to have the disease.
Some predictions on treatment in the near future
It is very likely that we will develop more exact diagnostic tools for risk and activity assessment - bacterial diagnostics, mineral balance monitoring. The availability of these tools will mean that dentists will work to actively diagnose the disease at the molecular level before irreversible damage occurs, then treat the disease if it is present so that it will be cured, again before damage (i.e., 'cavities') occurs.
It is also very likely that we will develop new tools to cure the disease, such as S. mutans adherence inhibiting antibodies, better remineralizing solutions and improved ways of local delivery of fluoride.
Most individual dental insurance plans require you to satisfy waiting periods and deductibles before having major and sometimes even minor restorative work done. Discount dental plans help make maintaining good oral health a lot more affordable. And, with no waiting periods or complicated coverage procedures, dental discount plans are about as simple as you can get.
discount dental plans work? As we become aware about our oral health, there has
been a demand for affordable dental care. Discount dental plans are the newest
option for those without coverage. These dental discount plans are much cheaper
than traditional dental insurance, and also offer almost equal coverage for all
dental work, even cosmetic procedures not covered by standard
What are the ins and outs of discount dental plans? When it comes to dental discount plans, the good news is afford ability, breadth of services, and immediate coverage. The bad news is greater financial risk and responsibility on your part.
Although the monthly cost of most discount dental plans is very low compared to the price of a traditional dental insurance or indemnity insurance policy, there's more allover financial risk with a dental discount plan. No care is totally covered, so an expensive procedure will mean a big out-of-pocket expense, even with the dental plan. And even when undergoing a low-cost service (like cleaning), you'll still be expected to pick up a part of the cost.
However, on the plus side, discount dental plans are effective immediately - so are many procedures you need now will be covered as soon as you buy the dental discount plan. Traditional indemnity and/or insurance dental plans usually impose a waiting period of between 6 and 18 months for any major procedure. The last "pro" is that all good dental discount plans should come with a money-back guarantee.
This type of dental plan pays the dental office (dentist) on a traditional fee-for-service basis. A monthly premium is paid by the client and/or the employer to an insurance company, which then reimburses the dental office (dentist) for the services rendered. An insurance company usually pays between 50% - 80% of the dental office (dentist) fees for a covered procedures; the remaining 20% - 50% is paid by the client.
These plans often have a pre-determined or set deductible amount which varies from plan to plan. Indemnity plans also can limit the amount of services covered within a given year and pay the dentist based on a variety of fee schedules. Some typical features of these plans:
These insurance plans, also known as "capitation plans," operate like their medical HMO cousins. This type of dental plan provides a comprehensive dental care to enrolled patients through designated provider office (dentist). A Dental Health Maintenance Organization (DHMO) is a common example of a capitation plan. The dentist is paid on a per capita (per person) basis rather than for actual treatment provided.
Participating dentists receive a fixes monthly fee based on the number of patients assigned to the office. In addition to premiums, client co-payments may be required for each visit. Some typical features of these plans:
Preferred Provider Organizations
Another true insurance plan, a Preferred provider organizations ( PPO) falls somewhere between an indemnity plan and a dental HMO. This plan allows a particular group of patients to receive dental care from a defined panel of dentists. The participating dentist agrees to charge less than usual fees to this specific patient base, providing savings for the plan purchaser.
If the patient chooses to see a dentist who is not designated as a "preferred provider," that patient may be required to pay a greater share of the fee-for-service. A group of dentists agrees to provide services at a deeply discounted rate, giving you substantial savings — as long as you stay in their network. Unlike the more restrictive DHMO, though, you can go out of network and still receive some benefits. Some typical features of these plans:
This type of dental plan is not insurance. The managing organizations have negotiated with local dental offices to establish a set price for a particular dental procedure and offer deep discounts (some up to 70%) off the regular ADA pricing code.
This plan has several advantages over traditional dental insurance plans, namely, there are no exclusions for pre-existing conditions. This allows a patient to receive immediate coverage for work without meeting any waiting period requirements.
Direct Reimbursement Plans
A dental care plan now coming into vogue is the direct reimbursement plan. This is a self-funded benefit plan — not insurance — in which an employer pays for dental care with its own funds, rather than paying premiums to an insurance company or third-party administrator.
the patient, pay the full amount directly to the dentist, then get a receipt
detailing services rendered and the cost, which you show to your employer. The
employer reimburses you for part or all of the dental costs, depending on your
Some typical features of a direct reimbursement plan:
What do you look for in choosing a plan?
Does the plan give you the freedom to choose your own dentist or are you restricted to a panel of dentists selected by the insurance company? If you have a family dentist with whom you are satisfied, consider the effects changing dentists will have on the quality or quantity of care you receive. Because regular visits to the dentist reduce the likelihood of developing serious dental disease, it's best to have and maintain an established relationship with a dentist you trust
Who controls treatment decisions--you and your dentist or the dental plan? Many plans require dentists to follow treatment plans that rely on a Least Expensive Alternative Treatment (LEAT) approach. If there are multiple treatment options for a specific condition, the plan will pay for the less expensive treatment option.
If you choose a treatment option that may better suit your individual needs and your long-term oral health, you will be responsible for paying the difference in costs. It's important to know who makes the treatment decisions under your plan. These cost control measures may have an impact on the quality of care you'll receive.
Does the plan cover diagnostic, preventive and emergency services? If so, to what extent? Most dental plans provide coverage for selected diagnostic services, preventive care and emergency treatment that are basic for maintaining good oral health.
But the extent or frequency of the services covered by some plans may be limited. Depending upon your individual oral health needs, you may be required to pay the dentist directly for a portion of this basic care. Find out how much treatment is allowed in any given year without cost to you, and how much you will have to pay for yourself.
What routine corrective treatment is covered by the dental plan? What share of the costs will be yours? While preventive care lessens the risk of serious dental disease, additional treatment may be required to ensure optimal health. A broad range of treatment can be defined as routine. Most plans cover 70 percent to 80 percent of such treatment. Patients are responsible for the remaining costs. Examples of routine care include:
What major dental care is covered by the plan? What percentage of these costs will you be required to pay? Since dental benefits encourage you to get preventive care, which often eliminates the need for major dental work, most plans are not generous when it comes to paying for major dental work, most plans cover less than 50 percent of the cost of major treatment.
Most plans limit the benefits--both in number of procedures and dollar amount--that are covered in a given year. Be aware of these restrictions when choosing your plan and as you and your dentist develop treatment best suited for you. Major dental care includes:
Will the plan allow referrals to specialists? Will my dentist and I be able to choose the specialist? Some plans limit referrals to specialists. Your dentist may be required to refer you to a limited selection of specialists who have contracted with the plan's third party. You also may be required to get permission from the plan administrator before being referred to a specialist. If you choose a plan with these limitations, make sure qualified specialists are available in your area. Look for a plan with a broad selection of different types of specialists.
If you have children, you may prefer a plan that allows a pediatric dentist to be your child's primary care dentist. Since specialized treatment is generally more costly than routine care, some plans discourage the use of specialists. While many general practitioners are qualified to perform some specialized services, complex procedures often require the skills of a dentist with special training. Discuss the options with your dentist before deciding who is best qualified to deliver treatment.
Can you see the dentist when you need to, and schedule appointment times convenient for you? Dentists participating in closed panel or capitation plans may have select hours to see plan patients. They may schedule appointments for these patients on given days, or at specified hours of the day, restricting your access.
Some dentist's fees for seeing you on weekends or during emergencies are high than those the plan allows. You may be required to pay additional costs yourself. If you select these types of plans, have a clear understanding of your dentist's policies as well as the plan's dentist-to-patient ratio. It's the best way to ensure your access to care is not unduly restricted and that you are not surprised by higher fees the plan does not cover.
Insurance companies do their best to ensure that their policyholders understand their plans and benefits, but it is up to an individual to make sure that they are making informed choices. The differences in the various plans you can choose from are:
Understanding these differences will enable you to make an informed decision when selecting a dental plan that is best for you or your family.
The best dental insurance plans are available on a state by state basis such as Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Dist of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming. Find the best dental insurance quotes from some of the finest and solid insurance companies who compare coverages based upon your own personal choices.