Editing Tooth decay (section)

==Prevention==
[[File:Toothbrush 20050716 004.jpg|right|thumb|alt=Head of a toothbrush|[[Toothbrush]]es are commonly used to clean teeth.]]

===Oral hygiene===
The primary approach to dental hygiene care consists of tooth-brushing and [[dental floss|flossing]]. The purpose of [[oral hygiene]] is to remove and prevent the formation of [[dental plaque|plaque]] or dental biofilm,<ref>[http://www.dentistry.leeds.ac.uk/OROFACE/PAGES/micro/micro2.html Introduction to Dental Plaque] {{webarchive|url=https://web.archive.org/web/20060623041937/http://www.dentistry.leeds.ac.uk/OROFACE/PAGES/micro/micro2.html |date=2006-06-23 }}. Hosted on the [[Leeds Dental Institute]] Website. Page accessed August 14, 2006.</ref> although studies have shown this effect on caries is limited.<ref>{{Cite journal|last1=Hujoel|first1=Philippe Pierre|last2=Hujoel|first2=Margaux Louise A.|last3=Kotsakis|first3=Georgios A.|year=2018|title=Personal oral hygiene and dental caries: A systematic review of randomised controlled trials|journal=Gerodontology|language=en|volume=35|issue=4|pages=282–289|doi=10.1111/ger.12331|pmid=29766564|s2cid=21697327|issn=1741-2358|doi-access=free}}</ref> While there is no evidence that flossing prevents tooth decay,<ref>{{Cite journal|last1=Sambunjak|first1=Dario|last2=Nickerson|first2=Jason W|last3=Poklepovic|first3=Tina|last4=Johnson|first4=Trevor M|last5=Imai|first5=Pauline|last6=Tugwell|first6=Peter|last7=Worthington|first7=Helen V|date=2011-12-07|title=Flossing for the management of periodontal diseases and dental caries in adults|journal=Cochrane Database of Systematic Reviews|issue=12|pages=CD008829|doi=10.1002/14651858.cd008829.pub2|pmid=22161438|s2cid=70702223 |issn=1465-1858}}</ref> the practice is still generally recommended.<ref name="Oli2017">{{cite journal|last1=de Oliveira|first1=KMH|last2=Nemezio|first2=MA|last3=Romualdo|first3=PC|last4=da Silva|first4=RAB|last5=de Paula E Silva|first5=FWG|last6=Küchler|first6=EC|title=Dental Flossing and Proximal Caries in the Primary Dentition: A Systematic Review|journal=Oral Health & Preventive Dentistry|year=2017|volume=15|issue=5|pages=427–434|doi=10.3290/j.ohpd.a38780|pmid=28785751}}</ref>

A toothbrush can be used to remove plaque on accessible surfaces, but not between teeth or inside pits and fissures on chewing surfaces. When used correctly, dental floss removes plaque from areas that could otherwise develop proximal caries but only if the depth of [[Gingival sulcus|sulcus]] has not been compromised. Additional aids include [[interdental brush]]es, [[water pick]]s, and [[mouthwash]]es. The use of rotational electric toothbrushes might reduce the risk of plaque and gingivitis, though it is unclear whether they are of clinical importance.<ref>{{Cite journal|doi=10.1002/14651858.cd004971.pub2|pmid=21154357|title=Different powered toothbrushes for plaque control and gingival health|journal=Cochrane Database of Systematic Reviews|issue=12|pages=CD004971|year=2010|last1=Deacon|first1=Scott A.|last2=Glenny|first2=Anne-Marie|last3=Deery|first3=Chris|last4=Robinson|first4=Peter G.|last5=Heanue|first5=Mike|last6=Walmsley|first6=A Damien|last7=Shaw|first7=William C.|volume=2020|pmc=8406707}}</ref>

However, oral hygiene is effective at preventing gum disease (gingivitis / periodontal disease). Food is forced inside pits and fissures under chewing pressure, leading to carbohydrate-fuelled acid demineralisation where the brush, fluoride toothpaste, and saliva have no access to remove trapped food, neutralise acid, or remineralise tooth enamel. (Occlusal caries accounts for between 80 and 90% of caries in children (Weintraub, 2001).) Unlike brushing, fluoride leads to proven reduction in caries incidence by approximately 25%; higher concentrations of fluoride (>1,000 ppm) in toothpaste also helps prevents tooth decay, with the effect increasing with concentration up to a plateau.<ref>{{Cite journal|last1=Walsh|first1=Tanya|last2=Worthington|first2=Helen V.|last3=Glenny|first3=Anne-Marie|last4=Marinho|first4=Valeria Cc|last5=Jeroncic|first5=Ana|date=4 March 2019|title=Fluoride toothpastes of different concentrations for preventing dental caries|journal=The Cochrane Database of Systematic Reviews|volume=3|issue=3 |pages=CD007868|doi=10.1002/14651858.CD007868.pub3|issn=1469-493X|pmc=6398117|pmid=30829399}}</ref> A randomized clinical trial demonstrated that toothpastes that contain [[arginine]] have greater protection against tooth cavitation than the regular fluoride toothpastes containing 1450 ppm alone.<ref>{{Cite journal|last1=Kraivaphan|first1=Petcharat|last2=Amornchat|first2=Cholticha|last3=Triratana|first3=T|last4=Mateo|first4=L.R.|last5=Ellwood|first5=R|last6=Cummins|first6=Diane|last7=Devizio|first7=William|last8=Zhang|first8=Y-P|date=2013-08-28|title=Two-Year Caries Clinical Study of the Efficacy of Novel Dentifrices Containing 1.5% Arginine, an Insoluble Calcium Compound and 1,450 ppm Fluoride|url=https://www.researchgate.net/publication/256289867|journal=Caries Research|volume=47|issue=6|pages=582–590|doi=10.1159/000353183|pmid=23988908|s2cid=17683424|doi-access=free|access-date=2018-05-26|archive-date=2020-05-10|archive-url=https://web.archive.org/web/20200510055506/https://www.researchgate.net/publication/256289867_Two-Year_Caries_Clinical_Study_of_the_Efficacy_of_Novel_Dentifrices_Containing_15_Arginine_an_Insoluble_Calcium_Compound_and_1450_ppm_Fluoride|url-status=live}}</ref> A Cochrane review has confirmed that the use of fluoride gels, normally applied by a dental professional from once to several times a year, assists in the prevention of tooth decay in children and adolescents, reiterating the importance of fluoride as the principal means of caries prevention.<ref>{{Cite journal|last1=Marinho|first1=Valeria C. C.|last2=Worthington|first2=Helen V.|last3=Walsh|first3=Tanya|last4=Chong|first4=Lee Yee|date=2015-06-15|title=Fluoride gels for preventing dental caries in children and adolescents|journal=Cochrane Database of Systematic Reviews|volume=2021|issue=6|pages=CD002280|doi=10.1002/14651858.CD002280.pub2|issn=1469-493X|pmid=26075879|pmc=7138249}}</ref> Another review concluded that the supervised regular use of a fluoride mouthwash greatly reduced the onset of decay in the permanent teeth of children.<ref>{{Cite journal|last1=Marinho|first1=Valeria C. C.|last2=Chong|first2=Lee Yee|last3=Worthington|first3=Helen V.|last4=Walsh|first4=Tanya|date=2016-07-29|title=Fluoride mouthrinses for preventing dental caries in children and adolescents|journal=Cochrane Database of Systematic Reviews|volume=7|issue=2|pages=CD002284|doi=10.1002/14651858.CD002284.pub2|issn=1469-493X|pmid=27472005|pmc=6457869}}</ref>

Professional hygiene care consists of regular dental examinations and professional prophylaxis (cleaning). Sometimes, complete plaque removal is difficult, and a dentist or [[dental hygienist]] may be needed. Along with oral hygiene, radiographs may be taken at dental visits to detect possible dental caries development in high-risk areas of the mouth (e.g. "[[bitewing]]" X-rays which visualize the crowns of the back teeth).

Alternative methods of oral hygiene also exist around the world, such as the use of [[teeth cleaning twig]]s such as [[miswak]]s in some Middle Eastern and African cultures. There is some limited evidence demonstrating the efficacy of these alternative methods of oral hygiene.<ref>{{cite journal |vauthors=al-Khateeb TL, O'Mullane DM, Whelton H, Sulaiman MI | year = 2003 | title = Periodontal treatment needs among Saudi Arabian adults and their relationship to the use of the Miswak | journal = Community Dental Health| volume = 8 | issue = 4 | pages = 323–328 | pmid = 1790476 | issn = 0265-539X }}</ref>

===Dietary modification===
[[File:Cavity numbers increase exponentially with sugar consumption.jpg|thumb|left|Annual caries incidence increases exponentially with annual per capita sugar consumption. Data based on 10,553 Japanese children whose individual lower first molar teeth were monitored yearly from the age of 6 to 11 years of age. Caries plotted on a [[Semi-log plot|logarithmic scale]], so line is straight.]]

People who eat more [[free sugar]]s get more cavities, with cavities increasing exponentially with increasing sugar intake. Populations with less sugar intake have fewer cavities. In one population, in Nigeria, where sugar consumption was about 2g/day, only two percent of the population, of any age, had had a cavity.<ref>{{cite journal |last1=Sheiham |first1=A |last2=James |first2=WP |title=A new understanding of the relationship between sugars, dental caries and fluoride use: implications for limits on sugars consumption. |journal=Public Health Nutrition|date=October 2014 |volume=17 |issue=10 |pages=2176–84 |doi=10.1017/S136898001400113X |pmid=24892213|pmc=10282617 |doi-access=free }}</ref>

Chewy and sticky foods (such as candy, cookies, potato chips, and crackers) tend to adhere to teeth longer. However, dried fruits such as raisins and fresh fruit such as apples and bananas disappear from the mouth quickly, and do not appear to be a risk factor. Consumers are not good at guessing which foods stick around in the mouth.<ref>{{Cite journal|last1=Kashket|first1=S.|last2=Van Houte|first2=J.|last3=Lopez|first3=L. R.|last4=Stocks|first4=S.|date=1991-10-01|title=Lack of correlation between food retention on the human dentition and consumer perception of food stickiness|journal=Journal of Dental Research|volume=70|issue=10|pages=1314–1319|issn=0022-0345|pmid=1939824|doi=10.1177/00220345910700100101|s2cid=24467161}}</ref>

For children, the [[American Dental Association]] and the European Academy of Paediatric Dentistry recommend limiting the frequency of consumption of drinks with sugar, and not giving baby bottles to infants during sleep (see earlier discussion).<ref>{{cite web |url=https://www.eapd.eu/index.php/post/nutrition-and-tooth-decay-in-infancy |title=Nutrition and tooth decay in infancy |website=European Academy of Paediatric Dentistry |publisher=Kyriaki Tsinidou |access-date=2019-04-06 |archive-date=2019-04-06 |archive-url=https://web.archive.org/web/20190406141205/https://www.eapd.eu/index.php/post/nutrition-and-tooth-decay-in-infancy |url-status=dead }}</ref><ref>[http://www.ada.org/public/topics/decay_childhood_faq.asp Oral Health Topics: Baby Bottle Tooth Decay] {{webarchive|url=https://web.archive.org/web/20060813180046/http://www.ada.org/public/topics/decay_childhood_faq.asp |date=2006-08-13 }}, hosted on the American Dental Association website. Page accessed August 14, 2006.</ref> Parents are also recommended to avoid sharing utensils and cups with their infants to prevent transferring bacteria from the parent's mouth.<ref>[http://www.aapd.org/media/Policies_Guidelines/G_InfantOralHealthCare.pdf Guideline on Infant Oral Health Care] {{webarchive|url=https://web.archive.org/web/20061206020725/http://www.aapd.org/media/Policies_Guidelines/G_InfantOralHealthCare.pdf |date=2006-12-06 }}, hosted on the [http://www.aapd.org American Academy of Pediatric Dentistry] {{webarchive|url=https://web.archive.org/web/20070112073325/http://www.aapd.org/ |date=2007-01-12 }} website. Page accessed January 13, 2007.</ref>

[[Xylitol]] is a naturally occurring sugar alcohol that is used in different products as an alternative to sucrose (table sugar). As of 2015 the evidence concerning the use of xylitol in [[chewing gum]] was insufficient to determine if it is effective at preventing caries.<ref>{{cite journal|last1=Twetman|first1=S|title=The evidence base for professional and self-care prevention--caries, erosion and sensitivity|journal=BMC Oral Health|year=2015|volume=15|issue=Suppl 1|pages=S4|pmid=26392204|pmc=4580782|doi=10.1186/1472-6831-15-S1-S4|doi-access=free}}</ref><ref>{{cite journal|last1=Twetman|first1=S|last2=Dhar|first2=V|title=Evidence of Effectiveness of Current Therapies to Prevent and Treat Early Childhood Caries|journal=Pediatric Dentistry|year=2015|volume=37|issue=3|pages=246–53|pmid=26063553|url=http://www.ingentaconnect.com/content/aapd/pd/2015/00000037/00000003/art00005|url-status=live|archive-url=https://web.archive.org/web/20170328022551/http://www.ingentaconnect.com/content/aapd/pd/2015/00000037/00000003/art00005|archive-date=2017-03-28}}</ref><ref>{{Cite journal|last=Riley P, Moore D, Ahmed F, Sharif MO, Worthington HV|date=March 2015|title=Xylitol-containing products for preventing dental caries in children and adults|journal=Cochrane Database of Systematic Reviews|volume=2015 |issue=3|pages=CD010743|doi=10.1002/14651858.CD010743.pub2|pmid=25809586|pmc=9345289 }}</ref>

===Other measures===
[[File:FluorideTrays07-05-05.jpg|thumb|alt=Refer to caption|Common dentistry trays used to deliver fluoride]]
[[File:Sodium fluoride tablets.jpg|thumb|Fluoride is sold in tablets for cavity prevention.]]
The use of [[dental sealant]]s is a means of prevention.<ref>{{cite journal |vauthors=Mejare I, Lingstrom P, Petersson LG, Holm AK, Twetman S, Kallestal C, Nordenram G, Lagerlof F, Soder B, Norlund A, Axelsson S, Dahlgren H |year=2003 |title=Caries-preventive effect of fissure sealants: a systematic review |journal=Acta Odontologica Scandinavica|volume=61 |issue=6|pages=321–330 |doi=10.1080/00016350310007581|pmid=14960003 |s2cid=57252105 }}</ref> A sealant is a thin plastic-like coating applied to the chewing surfaces of the molars to prevent food from being trapped inside pits and fissures. This deprives resident plaque bacteria of carbohydrate, preventing the formation of pit and fissure caries. Sealants are usually applied on the teeth of children, as soon as the teeth erupt but adults are receiving them if not previously performed. Sealants can wear out and fail to prevent access of food and plaque bacteria inside pits and fissures and need to be replaced so they must be checked regularly by dental professionals. Dental sealants have been shown to be more effective at preventing occlusal decay when compared to fluoride varnish applications.<ref>{{Cite journal|last1=Ahovuo-Saloranta|first1=Anneli|last2=Forss|first2=Helena|last3=Hiiri|first3=Anne|last4=Nordblad|first4=Anne|last5=Mäkelä|first5=Marjukka|date=2016-01-18|title=Pit and fissure sealants versus fluoride varnishes for preventing dental decay in the permanent teeth of children and adolescents|journal=The Cochrane Database of Systematic Reviews|volume=2016 |issue=1|pages=CD003067|doi=10.1002/14651858.CD003067.pub4|issn=1469-493X|pmid=26780162|pmc=7177291}}</ref>{{Update inline|reason=Updated version https://www.ncbi.nlm.nih.gov/pubmed/33142363|date = January 2021}}

Calcium, as found in food such as milk and green vegetables, is often recommended to protect against dental caries. [[Fluoride]] helps prevent decay of a tooth by binding to the hydroxyapatite crystals in enamel.<ref>[[#Nanci|Nanci]], p. 7</ref> ''Streptococcus mutans'' is the leading cause of tooth decay. Low concentration fluoride ions act as bacteriostatic therapeutic agent and high concentration fluoride ions are bactericidal.<ref>{{cite journal|last1=A|first1=Deepti|last2=Jeevarathan |first2=J|last3=Muthu|first3=MS|last4=Prabhu V|first4=Rathna|last5=Chamundeswari|date=2008-01-01|title=Effect of Fluoride Varnish on Streptococcus mutans Count in Saliva of Caries Free Children Using Dentocult SM Strip Mutans Test: A Randomized Controlled Triple Blind Study|journal=International Journal of Clinical Pediatric Dentistry|volume=1|issue=1|pages=1–9|doi=10.5005/jp-journals-10005-1001|issn=0974-7052|pmc=4086538|pmid=25206081}}</ref> The incorporated fluorine makes enamel more resistant to demineralization and, thus, resistant to decay.<ref>Ross, Michael H., Kaye, Gordon I. and Pawlina, Wojciech (2003). ''Histology: A Text and Atlas''. 4th edition, p. 453. {{ISBN|0-683-30242-6}}.</ref> Fluoride can be found in either topical or systemic form.<ref name="Takahashi-2015">{{Cite journal|doi=10.1002/14651858.cd011850|title=Fluoride supplementation in pregnant women for preventing dental caries in the primary teeth of their children|journal=Cochrane Database of Systematic Reviews|issue=8 |page=CD011850|year=2015|last1=Takahashi|first1=Rena|last2=Ota|first2=Erika|last3=Hoshi|first3=Keika|last4=Naito|first4=Toru|last5=Toyoshima|first5=Yoshihiro|last6=Yuasa|first6=Hidemichi|last7=Mori|first7=Rintaro|editor1-last=Mori|editor1-first=Rintaro|doi-access=free}}</ref> Topical fluoride is more highly recommended than systemic intake to protect the surface of the teeth.<ref>Limited evidence suggests fluoride varnish applied twice yearly is effective for caries prevention in children at {{cite web|url=http://ebd.ada.org/SystematicReviewSummaryPage.aspx?srId=876816cd-5f69-4bd5-b320-3502a1bbd8ea|title=ADA&nbsp;— EBD::Systematic Reviews|archive-url=https://web.archive.org/web/20131203023447/http://ebd.ada.org/SystematicReviewSummaryPage.aspx?srId=876816cd-5f69-4bd5-b320-3502a1bbd8ea|archive-date=2013-12-03|url-status=dead|access-date=2013-07-30}}</ref> Topical fluoride is used in toothpaste, mouthwash and fluoride varnish.<ref name="Takahashi-2015" /> Standard fluoride toothpaste (1,000–1,500 ppm) is more effective than low fluoride toothpaste (< 600ppm) to prevent dental caries.<ref>{{cite journal|last1=Santos|first1=A. P. P.|last2=Oliveira|first2=B. H.|last3=Nadanovsky|first3=P.|date=2013-01-01|title=Effects of low and standard fluoride toothpastes on caries and fluorosis: systematic review and meta-analysis|journal=Caries Research|volume=47|issue=5|pages=382–390|doi=10.1159/000348492|issn=1421-976X|pmid=23572031|s2cid=207625475}}</ref> It is recommended that all adult patients to use fluoridated toothpaste with at least 1350ppm fluoride content, brushing at least 2 times per day and brush right before bed. For children and young adults, use fluoridated toothpaste with 1350ppm to 1500ppm fluoride content, brushing 2 times per day and also brush right before bed. American Dental Association Council suggest that for children <3 years old, caregivers should begin brushing their teeth by using fluoridated toothpaste with an amount no more than a smear. Supervised toothbrushing must also be done to children below 8 years of age to prevent swallowing of toothpaste.<ref>{{Cite journal|date=February 2014|title=Fluoride toothpaste use for young children|journal=The Journal of the American Dental Association|volume=145|issue=2|pages=190–191|doi=10.14219/jada.2013.47|pmid=24487611|issn=0002-8177|author1=American Dental Association Council on Scientific Affairs|doi-access=free}}</ref> After brushing with fluoride toothpaste, rinsing should be avoided and the excess spat out.<ref>{{cite web|url=http://dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_102982.pdf|title=Delivering Better Oral Health: An evidence-based toolkit for prevention, second edition|date=April 2009|publisher=Department of Health / British Association for the Study of Community Dentistry|archive-url=http://webarchive.nationalarchives.gov.uk/20100810041346/http://dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_102982.pdf|archive-date=2010-08-10|url-status=dead}}</ref> Many dental professionals include application of topical fluoride solutions as part of routine visits and recommend the use of xylitol and [[amorphous calcium phosphate]] products. 

[[Silver diammine fluoride]] may work better than fluoride varnish to prevent cavities.<ref>{{cite web|url=http://www.sdcep.org.uk/wp-content/uploads/2013/03/SDCEP_PM_Dental_Caries_Full_Guidance1.pdf|title=Prevention and management of dental caries in children: Dental clinical guidance|date=April 2010|website=sdcep.co.uk|pages=6–7|archive-url=https://web.archive.org/web/20161005142226/http://www.sdcep.org.uk/wp-content/uploads/2013/03/SDCEP_PM_Dental_Caries_Full_Guidance1.pdf|archive-date=5 October 2016|url-status=live|access-date=7 March 2016}}</ref> Systemic fluoride is found as lozenges, tablets, drops and water fluoridation. These are ingested orally to provide fluoride systemically.<ref name="Takahashi-2015" /> 

[[Water fluoridation]] has been shown to be beneficial to prevent tooth decay, especially in low social economical areas, where other forms of fluoride not available. However, a Cochrane systematic review found no evidence to suggest that taking fluoride systemically daily in pregnant women was effective in preventing dental decay in their offspring.<ref name="Takahashi-2015" /> 

While some products containing chlorhexidine have been shown to limit the progression of existing tooth decay; there is currently no evidence suggesting that chlorhexidine gels and varnishes can prevent dental caries or reduce the population of ''Streptococcus mutans'' in the mouth.<ref>{{Cite journal|last1=Walsh|first1=Tanya|last2=Oliveira-Neto|first2=Jeronimo M|last3=Moore|first3=Deborah|date=2015-04-13|title=Chlorhexidine treatment for the prevention of dental caries in children and adolescents|url=https://doi.org/10.1002/14651858.CD008457.pub2|journal=Cochrane Database of Systematic Reviews|volume=2015 |issue=4|pages=CD008457|doi=10.1002/14651858.cd008457.pub2|pmid=25867816|issn=1465-1858|pmc=10726983}}</ref>

An oral health assessment carried out before a child reaches the age of one may help with management of caries. The oral health assessment should include checking the child's history, a clinical examination, checking the risk of caries in the child including the state of their [[Occlusion (dentistry)|occlusion]] and assessing how well equipped the child's parent or carer is to help the child prevent caries.<ref name="sdcep-2010" /> To further increase a child's cooperation in caries management, good communication by the dentist and the rest of the staff of a dental practice should be used. This communication can be improved by calling the child by their name, using eye contact and including them in any conversation about their treatment.<ref name="sdcep-2010">{{cite web|url=http://www.sdcep.org.uk/wp-content/uploads/2013/03/SDCEP_PM_Dental_Caries_Full_Guidance1.pdf|title=Prevention and management of dental caries in children: Dental clinical guidance|date=April 2010|website=sdcep.co.uk|pages=6–7|access-date=7 March 2016|url-status=live|archive-url=https://web.archive.org/web/20161005142226/http://www.sdcep.org.uk/wp-content/uploads/2013/03/SDCEP_PM_Dental_Caries_Full_Guidance1.pdf|archive-date=5 October 2016}}</ref>

[[Caries vaccine|Vaccines]] are also under development.<ref>{{cite journal|last=Russell|first=MW |author2=Childers, NK |author3=Michalek, SM |author4=Smith, DJ |author5=Taubman, MA|title=A Caries Vaccine? The state of the science of immunization against dental caries|journal=Caries Research|date=May–Jun 2004|volume=38 |issue=3|pages=230–5|pmid=15153693|doi=10.1159/000077759|s2cid=5238758 |doi-access=free}}</ref>