Tooth decay is amongst the most common diseases to affect the human race.
Statistics show that 35% of the global population, that is some 2.4 billion people, have untreated decay in their permanent teeth.
The World Health Organisation ranks tooth decay and oral diseases as the 4th most expensive health conditions to treat.
Scary figures these are, particularly considering the fact that you are not born with decay. You do not inherit it and rarely are you more susceptible to it.
Tooth decay is an entirely preventable condition.
This article is a guide to tooth decay, the causes, the treatments and preventative steps you can take to protect and maintain your teeth, but those of your family too.
If you want short to the point facts then here they are:
- Tooth decay is a diet and lifestyle related disease that is completely preventable.
- Decay is where the enamel surface of the tooth is dissolved by acids, produced by bacteria in the mouth.
- The bacteria are fed by sugars we consume as part of our diet.
- Saliva helps protect the teeth and can repair decay in the early stages.
- Decay often shows no initial signs. It develops often as white or dark spots on your tooth, and eventually into a cavity that extends to the inner tooth structure. Sensitivity and pain usually occurs at this point — pain from a cavity is more severe than early tooth decay pain.
- Decay can be treated by dentists via a number of means, most commonly a filling.
- Regular dental visits can detect decay before fillings are required.
- You can prevent tooth decay by eating a healthy diet (avoiding sugars), drinking plenty of tap water instead of sugary drinks, brushing your teeth twice a day using a fluoride toothpaste, and flossing.
We urge you to read on, to better understand the subject of tooth decay, the causes and what you can do to prevent it.
What is tooth decay?
Tooth decay is where naturally produced acids soften and essentially eat away at the hard outer layer of your teeth.
Also known as dental caries, tooth decay can, if left untreated, lead to holes, also known as cavities, in the enamel that makes up the outer surface of the tooth.
Tooth decay is the breakdown of tooth surfaces due to high levels of bacteria. The bacteria can build up due to diet (sugary and fizzy foods), lack of oral hygiene over a period of time on the tooth surface.
Dr Chhaya Chauhan – In-house dentist – GDC Number: 83940
Over 600 types of bacteria naturally exist within the mouth. This bacteria collects together to form a sticky substance called plaque.
Plaque is natural, it forms in everyone’s mouths within hours of tooth brushing.
Food and drink we consume contain sugars, which the bacteria feed on and produce potentially damaging acid.
This production of acid occurs virtually every time we eat or drink. The more times we eat or drink foods that contain sugars, the more times our enamel is exposed to acid.
To limit the damage, this acid needs to be removed. Our saliva will naturally do some of this for us, but the existence of plaque is the primary reason why we brush and floss our teeth.
If the teeth are not cleaned properly, or at all, the plaque remains in place. The more plaque, the more acid is produced and the bigger the threat.
Whilst the body has a natural ability to fight it off, there comes a point, where it can no longer fight it and the consequence is the decay to the tooth surface.
What is a tooth cavity?
A cavity is another name for a hole, a hole that exists in the surface of the tooth.
Enamel is the hardest substance in the human body and forms the outer layer of the tooth.
Once decay has reached such a point that there is a hole in the tooth, the inner softer layers of the teeth are now susceptible to decay.
The difference with the dentin and pulp that sit inside the teeth, is that they have no mechanism to fight back and resist the decay.
Decay to the tooth is not always obvious or painful. However, when the cavity exists, the decay dissolves the dentin and hits the nerve filled pulp section of the tooth. This is when sensitivity and pain begins.
Sugars, acid attacks and saliva
Not all the food we eat can be broken down by the bacteria into acids.
Foods are broken down into 3 groups, protein, fat and carbohydrates.
Protein and fat rich foods are not really a problem linked directly to decay.
However, carbohydrate based foods contain natural sugars and starches as well as artificial sugars that are a threat to tooth health. These are the food types that bacteria thrive off.
Feeding off these carbohydrates (sweet and savoury), within a matter of minutes the bacteria (notably streptococcus mutans) turns the sugars into potentially damaging acid.
The acid is actually a waste product of the bacteria and is relatively weak, but this begins what is often known as an ‘acid attack’.
The attack is at its worst for about 20 minutes, but can last for up to about 2 hours after eating.
It is now that the saliva in the mouth does what it is designed to do.
The pH scale is a unit of measure used to determine how acid or alkaline a substance or environment is. pH7 is considered neutral, neither acidic or alkaline.
Saliva is neutral and the body aims to keep the mouth this way to protect the mouth and teeth within.
During these ‘acid attacks’, the pH level in the mouth changes and at a microscopic level the acid is dissolving the enamel on the outer surface of the tooth. This process is called demineralisation.
The saliva works to neutralise this attack by being secreted from the glands around the mouth.
Working to bring the pH level back to a neutral 7, it is as this point a period of healing can essentially begin.
The tooth surface then goes through what is known as remineralisation. Although the tooth surface cannot fully heal itself like other cells in the human body it can essentially reverse the decay from the majority of acid attacks.
Mayo Clinic describe best what actually happens.
“Saliva supplies high levels of calcium and phosphate particles (ions) that enhance protection of the tooth’s enamel surface. The calcium and phosphate ions act to slow loss of tooth enamel (demineralization) and promote rebuilding of tooth enamel (remineralization). Saliva protects your mouth by washing away food and the sticky film of acid-producing plaque that can cling to teeth. Saliva also neutralizes damaging acids and limits bacterial growth that can dissolve tooth enamel”
Now, if everyone ate 3 meals a day and never snacked in between, decay would not be such an issue. This is because the teeth would have more time to heal in comparison to the length of time they are attached.
However, with each snack comes the potential of another acid attack and an increase in potential dental decay.
Many foods contain sugars, fruit included. However, it is the refined sugars that are added in the production process of the foods we like to snack on that are worst. Used to flavour or preserve food, they are ‘hidden’ in things like jars of tomato based sauces. Many of us do not know they exist or are present at the levels they are.
The act of eating and chewing will, to a point, naturally dislodge and clean the surfaces of the teeth, but what adds to the issue of decay, is that plaque and the bacteria that creates the acid tends to stick in areas where it can not easily be dislodged. Along the gumline, between the teeth, and around the edges of dental restorations such as fillings, crowns and dentures.
Another popular place is in what is known as fissures, this is the depression between the cusps on the biting surfaces of the teeth. You can feel or notice them on the top of your back molar teeth. A natural crevice, it is a great place for the bacteria to reside.
Toothbrushing and flossing is what allows us to dislodge and remove a large amount of this plaque.
The National Institute of Dental and Craniofacial Research sums up what goes on in the mouth as a tug of war. A battle between the saliva in the mouth and the fluoride of toothpaste to protect the teeth against the plaque and sugars that exist.
Whilst decay causing bacteria and acid attacks will happen daily, cutting out entirely the sugars bacteria feed on is very difficult.
The body is designed to and can resist a certain number or attacks. But it is the repeated attacks that come as a result of frequent snacking on sugar rich foods that accelerate and encourage the decay.
What causes tooth decay?
Tooth decay is caused by acids that attack the tooth surface and dissolves the hard enamel outer layer of the tooth.
But, the root cause is the sugars within our diet that feed the naturally occurring bacteria, allowing it to produce the acids.
The most common tooth decay causes include:
- Consuming food with high levels of sugar (natural and added)
- Drinking sugar rich drinks such as fizzy drinks
- Eating high amounts of citrus fruits
- Snacking between meals (sweet and savoury carbohydrates)
- Not brushing and flossing regularly or correctly
- Failing to get regular dental checkups
- Not cleaning teeth adequately whilst wearing braces
Decay is something that anyone with natural teeth is susceptible to, but the speed at which the decay develops is linked to how often we consume foods that contain sugars and how we go about maintaining our oral health.
The key takeaway here is that with a few simple adjustments, the causes of decay can be controlled. More information on how, is provided later in this article.
Signs of tooth decay
What is the most common sign of tooth decay?
The most common sign is usually pain and sensitivity or even a broken tooth.
Dr Chhaya Chauhan – In-house dentist – GDC Number: 83940
In the early stages, decay begins at a microscopic level. This makes it difficult for you or I to even know whether we have any decay at all.
Dentists are trained to look for this and will spot signs that you and I would likely miss. Therefore regular dental checkups allow you to be alerted to potential decay before it becomes a big issue.
Whilst in the later stages there are more noticeable symptoms, plaque buildup is initially something to look out for.
Remembering that the acid that decays the tooth is produced by plaque, large plaque buildup will be one of the early indicators to potential decay.
If you run your tongue across your teeth and they feel a bit fury, this is a sign of plaque.
Run your fingernail across the teeth and you may feel a sticky substance, that you might actually pull off the teeth, that is plaque too.
It is really only when the decay begins to get more severe do the signs become more noticeable.
Common tooth decay symptoms include:
- Small white, yellow, brown or even orange spots on the teeth
- Bad breath
- A bad taste in the mouth
- Sensitivity to food and drink, be that hot or cold
- Pain and discomfort when eating
- Visible holes or pits in your teeth
Of these symptoms, it is typically the toothache, sensitivity and pain that are the biggest indicators of dental decay.
Whilst the cause might not always be decay, it is the most common reason.
The tooth enamel has no nerves within it and therefore under normal circumstances teeth do not feel pain.
However, if the decay has caused a tooth cavity, the internal structure of the tooth is now exposed.
The dentin and pulp inside the tooth are not normally exposed to air, food and drink. More delicate, the nerves inside the teeth relay the contact as pain and sensitivity to the brain.
As you can now feel such pain it is a much bigger indicator that the decay has made its way through the outer tooth surface.
The larger the cavity, the more of the internal tooth structure is exposed.
Should you find or experience any of these symptoms, you should get them checked out by a dentist to have the problem confirmed and begin taking steps to correct the issue.
When to see a dentist
Ideally you should have regular dental checkups with your dentist, every 6-12 months.
As you may not be aware of your teeth decaying, having a professional give your teeth a once over can be very important in spotting and dealing with any signs of decay early, before restorative approaches need to be taken.
Just because you feel no pain, does not mean everything in your mouth is all fine.
Should you get to the stage of experiencing pain, and have any of the symptoms listed in the section above, you should arrange to see a dentist as soon as possible as even if the pain stops the decay is too advanced to reverse itself.
If you do not have a dentist already, use the NHS find a dentist tool, available here, to help find a practice local to you.
I think I have tooth decay. When should I see a dentist?
You should see your dentist asap. Tooth decay can be vert damaging for the tooth so it is important to have get it sorted asap.
Dr Chhaya Chauhan – In-house dentist – GDC Number: 83940
How to prevent tooth decay?
The key messages to preventing decay involve reducing sugar, improving cleaning, and the use of fluoride on your teeth. Dentists will tailor the advice they give you, but it is based on the “Delivering Better Oral Health” toolkit available here.
The best way to prevent dental decay is to have a good oral hygiene routine as well as controlling what you eat and drink and how often.
- Brushing your teeth twice a day for 2 minutes.
- Use a fluoride containing toothpaste.
- Spit, don’t rinse after brushing.
- Use a fluoride containing mouthwash at a different time of day to brushing.
- Cleaning between your teeth, e.g. flossing once a day.
- Limiting or reducing the sugar rich food or drinks you consume to meal times only.
- Limiting the number of acid attacks you expose the teeth to 3-4 times per day
A change in your diet (food and drink) is the most effective modification to reduce the likelihood of dental decay.
Even with proper brushing routines, if your diet consists of snacks between the 3 regular meals (Breakfast, Lunch and Dinner) decay can still take place.
As you have learned, it is the acid attacks and the frequency at which they occur that can be a big influence on the decay of the teeth.
A change in diet does not mean that you have to stop eating or drinking sugary food entirely, but being sensible about how much and when you consume them is most important.
Did you know that the World Health Organisation recommends that adults consume roughly 7 cubes of sugar a day, yet:
- A can of energy drink contains on average 13 cubes of sugar (based on a 500ml can)
- A can of cola contains on average 9 cubes of sugar (based on a 330ml can)
- A juice drink with added sugar contains on average 5 cubes of sugar (based on 200ml juice drink pouch) (Facts taken from Public Health England)
With such alarming statistics in mind, here are 2 lists, 1 of good and another of bad foods for your teeth.
- Unflavoured crisps
- Unsweetened yoghurt
- Low-fat cheese
- Raw fibrous vegetables such as carrots and celery
- Non-citrus fruit, such as apples, pears and peaches
- Sweet and chocolate bars
- Fizzy drinks
- Pure citrus fruit juices
- Tea and coffee with sugar
When you are hungry or peckish and looking to snack on something, here are a number of questions you could ask yourself.
- Is there a sugar free or reduced sugar option you could chose?
- Do you need the chocolate bar or bag of sweets?
- Could you eat a piece of fruit rather than drink a bottle of juice?
- Do you need to snack between mealtimes?
- Would a piece of sugar-free gum satisfy my craving to eat?
The Oral Health Foundation has shown that chewing sugar free gum for up to 20 minutes after a meal can help the mouth produce more saliva and help cancel out any acids that form.
It is worth noting that water is absolutely fine for the teeth and does not induce acid attacks.
Coffee and tea are not all that bad either, providing they are sugar free (sweetener is a harmless alternative).
Manufacturers of food products can sometimes be a little sneaky and include sugars in more products than we might think. They often label such products as “no added sugar”. These hidden sugars are in more products than you might have imagined.
If you are concerned about decay and the amount of sugar you consume, here are some types of products you might not have expected to contain large amounts of sugar:
- Cooking sauces, particularly those with a tomato base
- Table sauces, including tomato ketchup
- Flavoured crisps
- Fruits canned in syrup
- Some tinned vegetables including baked beans and sweetcorn
- Some breakfast cereals
- Jams, marmalades and chutneys
- Some low fat products, as sugars is used often added to improve their taste.
- Tinned fish and meat in tomato sauce
- Savory crackers and biscuits
- Some processed ready meals
- Energy drinks
Thinking twice about the foods you consume and how often can go a long way to helping prevent or delay decay.
You know that cleaning is important too. It is most important to brush before bedtime, and at least one other time during the day. Brush for two minutes using a fluoride-containing toothpaste. After brushing, spit, don’t rinse out with water, to ensure that the toothpaste is left on the teeth to be able to work. Likewise, do not use mouthwash directly after brushing as this washes off the toothpaste, which actually has more fluoride in it. If you would like to use mouthwash, consider using it at a separate time of day, for example after eating lunch.
As part of this brushing routine, make sure you use a fluoride based toothpaste and replace the brush head on your toothbrush every 3 months. Electric toothbrushes are easier to use than manual toothbrushes and so remove more plaque. Oh and of course regular dental checkups is a must.
Top tip for preventing tooth decay
Tooth decay is caused by too much sugar and not enough good cleaning. My best advice is to keep anything with sugar to mealtimes only and to brush thoroughly, with an electric toothbrush, twice daily.
Dr Gemma Wheeler – In-house dentist – GDC Number: 259369
Is it possible to stop or reverse tooth decay?
Yes, tooth decay can be stopped and ultimately reversed.
However, this does partially depend on the state of decay within your own teeth.
If the decay is bad already, treatments such as a filling may well be needed to restore and protect the tooth or affected teeth. Once treated, further decay can be prevented and stopped.
Where the decay is in its very early stages, treatment might not be required and with the appropriate steps, the decay stopped.
The tooth can to a point, replenish the natural minerals and repair the enamel of the tooth at a microscopic level using minerals available in saliva. A process called ‘remineralisation’ can essentially reverse the effects of early decay.
With any natural teeth there is always a chance of decay. But, with the right approach it can be prevented entirely.
To stop the decay worsening or happening to other teeth, it really relies on changes in diet, with less exposure to sugar, regular brushing, and the use of fluoride.
For those prone to decay or struggling to prevent it, options such as pit and fissure sealants exist.
What is essentially a plastic coating, it is applied to the teeth and fills gaps and crevices within the natural tooth surface, creating a flat and easier surface to clean. Your dentist will usually advise whether this is necessary or appropriate for yourself.
Treatments for tooth decay
Although the most minor stages of decay generally require no treatment, if the decay has advanced to the point you are showing symptoms, then it will likely be necessary for a dental treatment to resolve the issue.
Most common is a filling.
A filling is a form of dental restoration, that uses metals or composite materials to fill restore the shape and function of a tooth damaged by decay.
Quite often the dentist will need to take an x-ray to assess the extent of the decay and the cavity in the tooth. Larger fillings like this will normally require an anesthetic injection to numb the tooth area whilst the dentist removes the decay and restores the tooth surface.
With the most minor of decay and the occurrence of a small cavity, it might well be possible to place a small filling without any numbing agent, because the area to be treated, the enamel, has no nerves in it.
Fillings are a straightforward process, completed in the dentists chair and take about 10-15 minutes to complete (for a small one).
Where the decay is severe and infection inside the tooth exists, it might well be necessary to undergo root canal treatment, which is a more complex procedure to save the natural tooth. This removes the infection from the nerve containing part of the tooth (the pulp) and places a filling there to prevent bacteria getting back in later on. A relatively routine treatment, the effects of this are greater and to ensure success and long term reliability, a new, artificial crown may well be required.
Where the diagnosis is too late to save the tooth, extraction is the other option available. Dentists will resort to this as a last choice and will do all they can to save the tooth.
The cost of treating tooth decay
Whilst there are varying degrees of tooth decay and different treatments to prevent further decay, the most common treatment plan is a filling.
If you are an NHS patient, a filling falls under Band 2 of their dental charges, which at the time of writing is £59.10 (England), £45.00 (Wales), from £7.31 (Scotland and Northern Ireland, per tooth).
This charge includes the initial consultation/appointment and the cost of carrying out the filling procedure.
You might be surprised to learn that even root canal treatment, which may be needed for more severe decay, is also covered in this cost in England in Wales, although additional charges apply in Scotland and Northern Ireland .
However, do be aware, root canal treatment, often calls for the fitting of a crown, which falls under the highest price tier, band 3 at £256.50 (England), £195.00 (Wales), and the cost of which varies in Scotland and Northen Ireland.
Many of us desire the filling to be white in colour, to match our teeth, but when getting treatment on the NHS, expect fillings in the rear teeth in particular to be made up of a metal alloy and silver in colour. You cannot get white fillings for these teeth on the NHS.
Where the filling is required on more visible teeth, notably those at the front of the mouth the filling will normally be white in colour under NHS treatment.
Many NHS dental practices, will offer private treatments too.
What this means is, that whilst you are an NHS patient and need a filling, they often present an option to ‘upgrade’ to a white filling. The cost of the filling will be more expensive than the band 2 price, but you have the choice to opt for this.
It is important to remember that you always have a choice. Even if you are an NHS patient, there is nothing stopping you going for private dental treatment. If you are told by your NHS dentist you need a filling, you do not have to have it there and then. You can elect to go elsewhere, providing you are willing to pay for it yourself.
If you get dental treatment privately or are thinking of opting for such, you can expect a filling to cost anywhere from £50-250 subject to the size and material used. There may well be a consultation fee and other costs such as having an x-ray to be added to this price too.
Those requiring root canal treatment to restore a tooth suffering dental decay, may wish to opt for private dental treatment, as quite often there is more choice available to you, particularly when considering the crown that may well be needed to complete the restoration. However, do be aware, the costs get significantly more expensive for such treatment. £1500 is not a ridiculous charge for a single root canal treatment and dental crown.
Tooth decay in children
The state of tooth decay in children’s teeth within the UK makes for pretty sad reading given the access to dental care many have and how knowledgeable we are on the subject of decay.
- 23.3% of 5-year-olds in England had decayed, missing or filled teeth in 2017 (Public Health England)
- Every 10 minutes a child in the UK has a rotten tooth removed. That is around 141 children per day, some just a year old (Public Health England)
- There has been a 24% rise in the number of tooth extractions performed on 0-4 year olds in the last 10 years (Royal College of Surgeons)
Professor Nigel Hunt, Dean of the Faculty of Dental Surgery (FDS) at the Royal College of Surgeons (RCS), has said
“When you see the numbers tallied up like this it becomes abundantly clear that the sweet habits of our children are having a devastating effect on the state of their teeth. That children as young as one or two need to have teeth extracted is shocking. It’s almost certain that the majority of these extractions will be down to tooth decay caused by too much sugar in diets.
Children under 18 get free dental checkups and treatment with the NHS, so there is little excuse as to why more of this decay cannot be picked up and treated sooner.
Just as is the case with adults, the decay in children’s teeth can be prevented in much the same way. Adult teeth start coming through from about 6 years old so it is important to start preventing decay sooner rather than later.
As a parent or guardian to a child you can help reduces the chances of decay by:
- Making sure a child brushes their teeth twice a day
- Encouraging them to floss and clean interdental spaces once a day
- Use a fluoride toothpaste
- Supervise their brushing until they are about 7 years old
- Have them use an electric toothbrush designed for kids with educational aids to encourage better brushing
- Being aware of and if possible reducing the amount of sugar they consume both in foods and drinks.
- Limit snacking between meals – If they do, encourage raw vegetables and fruit
- Take them for regular dental checkups
To further help parents, Public Health England have setup the Change4Life campaign.
The website https://www.nhs.uk/change4life gives lots of fantastic helpful information to better help guardians of the next generation better understand how to take care of children’s diets and sugar intake.
Where decay is spotted within children’s teeth, the good news is that is can be treated. Ideally it never gets to the stage of needing a filling or extraction.
How a dentist treats a child’s tooth will depend on the age of the child and extent of the decay.
A popular choice is a sealant. Applied to the teeth, this adds an extra level of protection or a barrier if you like. The sealant fills recesses in the tooth surface to give a flatter and more uniform shape to reduce the chances of plaque buildup and decay. These can last several years.
Another option is that of a fluoride varnish. It is applied more regularly (2-4 times per year) and helps give the tooth time to recover and helps resist the acid attacks that the teeth endure. Professional opinion has been mixed by a recent study, led by Cardiff University found that the varnish was just as effective and actually cheaper for the NHS to offer.
Dental decay is a real issue within society today, particularly when you consider the UK and other western cultures are so advanced in the level of knowledge, prevention and treatments available.
Decay needs 4 things to exist:
- Certain types of bacteria
- Carbohydrate based foods
- The production of acids
- Adequate time or frequency
Decay can and will continue to be a threat to anyone with natural teeth.
However, for the vast majority, it is simple diet and lifestyle changes that are necessary to reduce the chances of decay.
You can help prevent tooth decay and keep your teeth healthy by:
- Brushing twice a day with a fluoride toothpaste.
- Cleaning between your teeth daily with floss or an interdental cleaner.
- Eating nutritious and balanced meals and limit snacking.
- Visiting your dentist regularly for professional cleanings and oral examination.
Take note of the preventative steps and you should be able to protect your teeth and that of your family for many years and avoid having to treat what is an entirely preventable condition.
Is tooth decay genetic?
Studies such as those by the University of Pittsburgh have found evidence that genes/DNA can potentially have some influence on the susceptibility and speed of decay within a particular individuals but as yet there is little clinically significant data to suggest this is a big factor with the condition. Diet and teeth brushing remains of uppermost importance in reducing the presence of decay.
Is tooth decay a disease?
Yes, tooth decay is classed as a disease, but is classified as a lifestyle disease because it is for the most part within the control of individuals and would not really exist if the lifestyle was not the way that it is.
Can tooth decay heal?
Yes and no.
Where the human body can repair a large wound to the skin, the body cannot heal a large hole in the enamel of the tooth caused by decay.
At a microscopic level teeth do undergo a remineralisation process that can stop and even reverse early decay, but with repeated attacks on the tooth surface the body is unable to fight and heal the tooth. Read this section of the article on sugar attacks to learn more.
Can tooth decay spread?
Any decay to a tooth can get worse and spread, creating more damage to the that individual tooth if the diet and conditions are right.
The presence of sugars and bacteria in the mouth will mean that all teeth are susceptible and the increased bacteria count can mean that multiple teeth can experience decay at the same time.
The underlying bacteria that causes decay can be spread from one person to another by sharing utensils like knives, forks, spoons and even kissing, but for most adults this risk is low due to the immunity of our body. Children are more at risk
Bacteria requires other conditions for the decay to begin and with regular tooth brushing and oral hygiene and limiting the number of acid attacks reduces the chances of decay.
What does tooth decay smell like?
Left untreated, a decaying tooth will smell rotten and the breath from your mouth will have an unpleasant taste. It is hard to describe the smell but in most healthy mouths there will be no distinguishable smell, other than perhaps a scent left behind by a toothpaste or mouthwash. Those with decay will smell different, quite pungent and unpleasant.
- Levisons Textbook for Dental Nurses
- Oral Health Foundation
- National Institute of Dental and Craniofacial Research
- American Dental Association
- Rethink Sugar
- Mayo Clinic
- Puget Sound Pediatric Dentistry
- Regan Family Dentistry
- Great Ormond Street Hospital