Caries the ten biggest myths about the hole in the tooth

Everything has been said about caries, you think now. One Google search and you know all about this plague. And yet almost everyone gets tooth decay in their lifetime. A vaccination against it does not exist so far. My name is Dr. Volker Storcks, I have been a dentist for more than 20 years and I would like to share with you a few more aspects on the subject that really matter from my point of view.

Myth no. 1: Enamel soft from birth

If you eat too much sweets, you will get caries, you say rightly. And yet there are people who eat a very sweet diet and get little or no tooth decay. How can it be? Apparently there are even more factors that influence the development of caries. For example, I have observed that these people often brush their teeth relatively well, but they are not even aware of it. From a scientific point of view, there are no soft teeth, the enamel is always equally hard, in each of us. So you can forget this excuse. At this point I refer only briefly to a major exception, which is increasing sharply among children: "chalk teeth" resp. Molar incisor hypomineralization, as the experts say. This disease is actually congenital and in various forms causes unripe enamel on the first permanent incisor (the 1s) and the first permanent molar (the 6s). To this day, it is still unclear how this comes about and is associated with a great deal of suffering among those affected.

Back to caries: This is always caused by acids, which produce bacteria that stick to our teeth as a coating. When these bacteria get sugar as food, they produce a lot of acid, which really dissolves the calcium out of the teeth. So this means that if you remove the bacterial plaque thoroughly every day, no acid can be produced, even if you eat sweets!

Very few people are able to remove all the plaque from their teeth every day, not even dentists are able to do this. Nevertheless you will not get caries. So there must be more parameters, such as e.B. the saliva. If you produce a lot of saliva, the acids of the bacteria are buffered and the plaque is better washed away when you eat. Some medications now cause decreased saliva flow, such as antidepressants. These patients have an increased risk of getting cavities.

Another important aspect is, of course, diet. This should be tooth-friendly, which means: as few low-molecular carbohydrates as possible, i.e. sugar. Plenty of vegetables and fruit, cereal products, staple foods such as potatoes, rice, bread. As few industrially "refined" products as possible, these usually contain a lot of sugar. Bananas and other fruits are of course cariogenic, but they are much healthier than foods made from industrial sugar, because they contain proteins, fats, trace elements, salts (minerals), fiber and many vitamins in addition to carbohydrates.

Myth no. 2: Dental floss protects against caries in the interdental space


Dental floss: Non Plus Ultra?
Image by Mudassar Iqbal on Pixabay

For a long time I myself believed that daily flossing protects against tooth decay. There are waxed, unwaxed, soaked with fluoride and other chemicals. Thus, flossing has been recommended by dentists for many years. Today we know from many scientific studies: flossing has hardly any measurable effect. The European Federation of Periodontology sees it the same way and says:

"However, there is no evidence to recommend the use of dental floss for cleaning the interdental spaces in the patients with periodontitis. Interdental space brushes are the most effective method and the means of choice in places that allow atraumatic application."

The more important aspect is proven to be the twice daily cleaning of the teeth with a fluoride toothpaste together with a tooth-healthy diet.

But this does not mean that you should not use dental floss. Coarse food debris can be removed very well with it and those who additionally care for their dentures with dental floss should continue to do so. It can do no harm. The best tool for removing plaque from the interdental spaces is a brush, the interdental brush.
The interdental spaces of young people in particular are often so small that they cannot be reached with a brush, so you can confidently continue to use dental floss. We usually recommend the interdental brush to fight gingivitis and periodontitis. Of course, the interdental brush also removes the plaque bacteria that cause tooth decay.

Myth no. 3: The electric toothbrush is basically better

There are now several types of electric toothbrushes

1. rotating-oscillating (z.B. Oral b Plak Control)

2. sonic (z.B. Philips sonicare)

One swears by the type, the other swears by the type. Science says that both types work, but the rotary-oscillating technique is still considered the gold standard.

Electric toothbrush Manual toothbrush

Electric toothbrush vs. Manual toothbrush: what performs better?
Image by andreas160578 on Pixabay

In a scientific comparison between manual and electric toothbrushes, the electric one actually performs better. So the myth is true!

However, many people get along so well with the manual toothbrush and also show in prophylaxis that they can remove a lot of plaque with it. For them, the change is usually not worth it. In addition, the electric toothbrushes are considerably more expensive than manual toothbrushes and are ecologically inferior.

However, especially for people with little manual dexterity, people with disabilities, elderly people with limited mobility, the electric toothbrush is a real boon that can help prevent tooth decay. As part of your prophylaxis at the dentist’s office, you can work with the prophylaxis specialist to determine which brush is best for you. Try it out!

Myth no. 4: The bristles must be hard!

…because only what is hard makes properly clean! Scrubbing for all it’s worth. In most cases, the gum and the neck of the tooth are swept away at the same time. Goodbye! As always in life, the golden mean is probably the right way to go: it should not be too hard and not too soft, the decisive factor is that you do not use too much force with the manual toothbrush, the bristles are rounded and the bristle field is not huge. Try to perform circular or shaking movements with little pressure, whereby the gums and the tooth should be equally touched by the bristles. With this technique, the bristles also reach the entrances to the interdental space. A clear sign of too much brushing pressure is when the bristle field of your toothbrush looks like an old scrubbing brush after just a few days. In a good prophylaxis session, you learn how to use your toothbrush optimally.

Wooden toothbrushes

Wooden toothbrushes – sustainable but ..
Image by Monfocus on Pixabay

for hygienic reasons you should use nylon bristles and not wooden toothbrushes with natural bristles.

Myth no. 5: It must be a brand toothpaste!

Aronal in the morning, Elmex in the evening, that’s what the advertising has told us – and not infrequently the dentists as well.

Toothbrush Toothpaste

Expensive cleans well. But is it really so?
Image by Daniel Albany on Pixabay

Comparatively expensive toothpastes are certainly good, but not better than many cheap toothpastes. Toothpastes are also advertised as being specifically against periodontitis – forget it, they don’t exist.

You can get a good toothpaste with the same effect for less than 1 Euro: All toothpastes use cleaning agents, binders, foaming substances, preservatives, humectants, flavors, possibly also fluoride. antibacterial substances, dyes and last but not least: fluoride! Fluoride is the most important ingredient from the dental point of view.

We know from numerous scientific studies conducted over decades that fluoride as a salt in toothpaste always acts only locally on the tooth surface and hardens the top layer of tooth enamel, making it more resistant to the acid attack of caries bacteria. Areas with high fluoride concentrations in drinking water had much lower rates of tooth decay in the general population. At the same time, the fluoride in drinking water also acts only while it is in the oral cavity and rinses the tooth, not from the inside. In contrast, all other substances, such as any herbal additives or antibacterial substances, are meaningless. What’s more, these additives are subject to fads and are often criticized after a few years, such as zinc additives or triclosan, and then taken off the market again.

The recommended concentration of fluoride is regularly checked and adjusted if necessary. There are different fluoride recommendations for children, adolescents and adults, and toothpastes differ accordingly.

Thus, fluoride acts on tooth enamel only through external application. Thus, from a dental point of view, fluoride tablets for children have been passe since 2004. Fluoride was also thought to make tooth enamel hard from the inside during enamel formation. Unfortunately this does not happen. Rather, it is because of tablet fluoridation that we "owe" tooth enamel fluorosis: This refers to white, yellow to brownish spots on the teeth, which are not desirable. Local application of toothpaste does not cause enamel fluorosis.

In areas where the drinking water has a high fluoride concentration, there are still fluoroses.

Myth no. 6: Toxic fluorine!

Salt in the hand

Does fluoride harm teeth?
Image by LoggaWiggler on Pixabay

You will find heaps of "fluoride critics" on the Internet. Some people claim that fluorine is highly toxic. This is true – fluorine as a molecule is highly toxic, but it is not present as such in toothpaste, but always as a charged particle, as a salt. In the form of fluoride, most often it is sodium or amine fluoride.

No one would think of demonizing table salt, for example, just because it contains chlorine. The "chlorine" in table salt is not present as a free molecule but as chloride particles and has nothing in common with the effect of the dangerous chlorine gas.

You would have to eat a whole tube of toothpaste to get symptoms of disease. However, many dentists are critical of the fact that some children’s toothpaste is sweet and tastes like strawberries. We don’t think we need to give children the incentive to eat the toothpaste.

Drinking water fluoridation for caries control is forbidden in our country, but in many countries it is still common practice. Fluoride is present in many foods. In our country, fluoride is supplied mainly by fluoridated table salt, which you usually buy in supermarkets. 1 mg of fluoride (one thousandth of a gram) as a total intake per adult per day is the recommended dose. This should not be exceeded in the sum of toothpaste, table salt, tap water and food.

So it is your responsibility whether you trust in the effect of fluoride: We dentists recommend cooking with fluoridated table salt.

However, you can now also get fluoride-free toothpastes from various suppliers (ex. Weleda). If you eat little sweet and brush your teeth perfectly (you can do that without toothpaste), you can succeed in staying caries-free. But it is more likely that you will not get rid of the plaque completely, and you will still eat sweets and get cavities as a result. You have to take responsibility for your child: In my 20 years as a dentist, I have seen many parents who, against my advice, gave their children only fluoride-free toothpastes and had to answer for many holes in their children’s bites along the way. Yet they meant it so well. I am curious about the children’s question later to their parents as to why they did not give them the protective toothpaste. For these parents, the additional question is: Which repair material do I choose?? Gold, ceramic, plastic, amalgam or cement? The best material is still your own tooth. Not to mention the biological effects, because no repair material can be called healthy. It is always a more or less poor substitute. And these repair materials offer again a large attack surface for critics of each coleur and worried parents.

Now there are new toothpastes (Biorepair, Karex) that promise miracles. Toothpastes that contain artificial enamel and claim to have a biomimetic effect: By this, the manufacturer means that the "artificial enamel" contained in the pasta, with its hydroxyapatite crystals, reseals existing holes in the tooth enamel.

These toothpastes do not contain fluoride, because it would deactivate the active ingredient.

What effect these micro-particles have on the organism is still completely unclear. In addition, these new toothpastes are very expensive and the manufacturer recommends that you also consume the corresponding tooth milk with the same ingredient! Just to call this product "milk" I find reprehensible. Milk is generally a drinkable food and not meant for rinsing. I remember a patient whom I have been taking care of for 20 years: he never had caries. During the last visit and the inspection of his teeth with my fivefold magnifying glasses I became suspicious – I saw signs of demineralization in the form of incipient caries between his teeth. I asked him if he was suddenly very sweet, only drank cola, or he was taking medication or had somehow restructured his life? He denied all that. He only said that he has been using this new fluoride-free biomimetic toothpaste for about two years. I fell out of all clouds. This is not a scientific work but for me a case report, a single case study resulting from an observation.

In fact, we do not have data about this. However, I felt confirmed that stopping the fluoride toothpaste must have encouraged the development of the cavities here. The incipient caries areas, which were already radiologically visible, were treated with a sealing agent (Icon). Since then, the patient has been using fluoridated toothpaste again and the caries progression has stopped.

So brushing your teeth with fluoridated toothpaste is the tribute to our modern society: we all eat way too sweet and want to live to be older than 80 with our own teeth. Stone Age people did not have fluoridated toothpaste, but did not eat as sweet and did not grow as old. But even otzi was diagnosed with tooth decay and must have suffered from toothache as well. I can only recommend that you trust the scientifically backed recommendations of the professional societies.

Myth no. 7: "The hole was suddenly there!"

Secret Surprised

Image by Robin Higgins on Pixabay

With this statement, patients come to our practice every day. Most of the time they notice the cavity because food debris now gets stuck between the teeth and gingivitis forms. Here, the caries has slowly formed under the enamel surface, through a small puncture canal below the point of contact with the neighboring tooth. At some point, the crown of the tooth was undermined to the point that the enamel above it has collapsed. Only now does the person notice something, but the disaster started much earlier. Caries is always a dynamic process, the hole develops over months to years. As long as the "lesion is not cavitated", we dentists say, we can bring the whole thing to a stop. But what does that mean exactly? This means that as long as there is an enamel structure, even if weakened by mineral deprivation, this structure can be replenished by minerals from saliva and toothpaste. The surface must still be visibly intact, albeit interspersed with microporosities. If this incipient caries is detected at an early stage, which is possible by X-rays (bite wing radiographs), by high magnification magnifying glasses, by using cold light or special light (laser fluorescence technology KaVo Diagnodent), the progression of caries can be stopped. We say the caries is arrested and watch to see if progression occurs. This is what we call caries monitoring.

In order to be absolutely sure that the porous tooth tissue does not collapse after all, since approx. ten years, a method developed in Kiel and Berlin to stabilize this fragile structure: With the Icon method, a liquid resin is brought into this structure. The affected enamel absorbs this resin (the icon infiltrant) like a sponge, which is then cured under blue light. Unfortunately, this method is not covered by public health insurance and costs about € 150.00 per tooth.

In the past, the dentist used to poke around in the tooth enamel with his probe to detect caries. This procedure is frowned upon today. Because poking with the probe breaks up initial (incipient) caries and thus creates a cavity (hole) that requires treatment.

However, stopping the decay is much more complicated "than just doing a filling". The dentist is dependent on the patient’s close cooperation in this respect. The patient must make a behavioral change: Brush teeth more frequently and thoroughly, eat and drink less sweet, clean interdental spaces, go for prophylaxis and dental cleaning. Unfortunately, this close cooperation I am describing is very time-consuming and is hardly ever paid for by health insurance companies for adults. In children and adolescents already. This has led to the fact that children in the permanent dentition hardly have any caries, as can be seen from the 5. According to the German Oral Health Study. The adult patient learns how to protect his teeth against caries during individual prophylaxis in the course of professional teeth cleaning. We call this most important part active prophylaxis because you have to take action yourself.

Myth no. 8: Every pregnancy costs a tooth

This is, of course, a lot of nonsense, but some mothers still hold on to it: It’s the child’s fault that the tooth had to come out and not mine. The child has drawn too much calcium from this very tooth. I always ask why the child has chosen this particular tooth?
The fact that a lot of snacking and little brushing may have taken place during pregnancy is not admitted, of course. Maybe it was just a coincidence and the tooth was already damaged before pregnancy?
It is scientifically proven that the baby in the mother’s belly does not draw its calcium for bone formation from the mother’s teeth.
With the general decrease of caries in Germany, we also observe that pregnant women today do not lose more teeth to caries than non-pregnant women!
However, pregnant women are much more susceptible to gingivitis than non-pregnant women. Pregnancy gingivitis" is usually pointed out by the gynecologist, who recommends that pregnant women go to the dentist in time. Good dental care is therefore particularly important during pregnancy.

Myth no. 9: Once the tooth has a crown, it can’t get cavities anymore!

Dentist Comic

Once a crown and done. Can this go well?
Image source: PublicDomainPictures

This view is still widespread and can hardly be dispelled: And I myself still learned from my prosthodontics professor in Kiel in the early 1990s that the crown margin should be below the gum, in the so-called caries-protective zone!

Nowadays this is scientifically no longer tenable, so many patients with crowns weighed themselves in security. Of course, a crowned tooth also gets caries, namely at the edge of the crown. Also underneath the gums. If there is not cleaned and the caries bacteria get sugar. A crown gives the tooth a stable corset, at least it can’t collapse so quickly due to caries, was probably the idea. In some cases crowns were considered to be the better teeth and because the health insurance paid for everything in the past, all teeth were crowned – even those that did not really need it. Even mandibular incisors, which actually never need a crown. Unbelievable from today’s point of view. Today we dentists are trained to save as much tooth substance as possible. "For the sake of appearance," dentists and patients said, teeth used to be ground down even for crowns. Grinding sounds so artistic, but in fact the tooth is massacred in the process. The entire enamel is removed and people were regularly shocked when they saw it. Each tooth is an organ and should not be damaged lightly. Grinding down often leads to the tooth nerve underneath being traumatized and dying under the crown over the years. Teeth still need to be crowned nowadays, but only when a large part of the enamel has been lost is crowning indicated.

In the past, these artificial crowns were often connected to each other – we call them "splinted". Cleaning became even more difficult. Then it was noticed much later, when the tooth underneath had rotted away. If the tooth then hurt, the crown was drilled through and a root canal treatment was done. Then the tooth did not hurt anymore. The gum and the tooth root around it are then usually in a catastrophic condition.

And again and again patients say to me: "Doctor, I’ll save a little now and then we’ll put new crowns on it in two or three years and everything will be fine!" People are not aware that they don’t see "your teeth" in the mirror, but are dazzled by artificial crowns veneered with ceramics. And admittedly: We dentists and dental technicians are getting better at imitating nature.

When this no longer works, we dentists ignite stage 2 of veneering: now it’s time for implants and bridges…and dentures! Why all this is so, I describe in Myth 10, the finale!

Myth no. 10: Every dentist drives a Porsche!


Image from Pexels on Pixabay

These times are long gone. The remuneration for dental services – especially in the private dental sector – has continued to fall in recent years. Dental practices are now modern service centers. Gone are the days of the untouchable white coat who alone determines the treatment. The patient is more and more involved in the therapy and we dentists are paving the way for the population to prevention-oriented dentistry. Almost every dental practice has a prophylaxis department, where dental professionals clean teeth and motivate patients to take even better care of their teeth. This is for the most part not yet a health insurance benefit and the health insurance companies and the legislators are having a hard time with changes, although new preventive concepts have been presented by our Federal Dental Association.

The fact that more is repaired than prevented in Germany is also due to our fee system, which is mainly geared toward invasive therapy. This must change.

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