Many people (including yours truly) who are at least old enough to have college-age children are walking around with “medals of valor” in their mouths, reflective of a dental age gone by. These “medals” or actually “metals” that I playfully refer to are of course silver-mercury amalgam fillings.
Silver-mercury amalgam was the mainstay of restorative dentistry for generations long before the advent of dental bonding and protective occlusal sealants. Amalgam fillings predate water fluoridation, which began in earnest in the 1950’s (and no, fluoridation was not some Communist plot to poison Americans as some had theorized!).
In those days, was not uncommon for a child to come from the dentist’s office with the news of five or six cavities, each of which would subsequently be treated and restored with silver-mercury amalgam. While I don’t mean this in a pejorative way, “drill-and-fill” was a common moniker for that process of treating cavities. Quite a few of us baby boomers are walking around with veritable mouthfuls of silver-mercury amalgam fillings.
But times have changed. Thanks to preventive dentistry, healthier diets, and the aforementioned fluoride and sealants, numerous teenagers and young adults have never had a single cavity! But there have been recent reports, such as the one cited in this New York Times article, A Closer Look at Teeth May Mean More Fillings, that heretofore pristine mouths are being diagnosed and treated for a condition (I use the term loosely) called “microcavities”. “Microcavities” are not a new phenomenon. In fact, they are essentially a very early stage of the tooth decay process that may or may not develop into a full-blown cavity. Today’s “microcavities” are what dentists have for decades referred to as incipient caries, or to put it more simply, “surface cavities”.
What Causes Cavities Anyway?
A cavity begins with a bacteria-induced acid attack of the enamel surface of a tooth (enamel is the hardest substance in the body). If this acid attack persists, pitting and softening of the tooth structure occurs and renders it susceptible to breakdown. Thus a cavity is born. But incipient caries affect only the enamel of the tooth. They are superficial and do not penetrate beyond the outer half of the tooth’s protective enamel. Incipient caries can be treated with fluoride to re-mineralize the tooth structure and reverse the destruction, thus eliminating the need for a filling.
As mentioned before, not all incipient caries will progress to true cavities. Good clinical judgment is required to make the right decision. “To treat or not to treat, that is the question! Sometimes watchful waiting (along with dietary counseling and fluoride application) is the most prudent course of action. New technologies can help with monitoring and aid in treatment decisions and one such development is Diagnodent, a diagnostic laser that can measure the relative depth and progression of a cavity.
Unfortunately, many of the so-called “microcavities” are being rushed into treatment with fillings. What’s important is this: once a filling is placed into a tooth, the greater the likelihood that the filling will need to be replaced someday.
So, remember, all cavities are not the same. If you are diagnosed with an uncharacteristically large number of cavities, ask questions! While it is not uncommon to see your kids go off to college with perfect teeth and come back with their first cavities (blame it on increased sugar and junk food intake accompanied by a slackening in oral home care) I fear that the “discovery” of “microcavities” has led to over-treatment of what is often a reversible condition.
Michael Sinkin practices cosmetic, implant, and restorative dentistry in New York City. He is known for the wonderful care he provides to his patients, and for his wicked sense of humor! To contact Dr. Sinkin, link here.
Diane Brandon says
My day ghter just came back fromthe dentist and was told she had 10 incipient cavities between her teeth wih a costof 300 a tooth. She is devastated as her teeth have been n pristine conditionand this dentist found no othe dcay. Should she seek a second ooinion?
Michael Sinkin says
By definition, incipient cavities are shallow in nature and confined to the enamel. If your daughter was my patient I would compare what is currently visible on the recent x-rays to her past x-rays and evaluate the progression – if any. In this case, a second opinion is certainly appropriate.
Don’t fret just yet!
Wishing you and yours good health,
Jamie Hansen says
Dear Dr Sinkin,
Thank you for your extremely informative posts, they are very helpful.
If it’s not too much trouble, I’d like to get your opinion on what to do about large molar fillings that my new dentist has suggested I should ‘re-do’ soon. This seems to be due to my bruxism wearing down the surface of the teeth, although I’m worried about having more work done on teeth with already large restorations, since I read that this could further weaken the teeth. How do you normally proceed in such cases? Is it better to prevent issues from happening, or safer to leave the tooth/filling as it is until something happens?
I’m also concerned about the idea of having crowns placed if/when I re-do these molars. So far, I had to have a molar crown removed due to an infection below the gum, and another molar crown fell out… am I doomed to continue having bad luck with crowns because of my bruxing habit? I wear a mouthguard at night and have managed to control daytime bruxing.
Any advice would be greatly appreciated. I’ve gotten to the point where I’m quite depressed and anxious, too afraid to eat most things in case they are too hard or get stuck between my teeth, which isn’t a great situation. Thank you!
Michael Sinkin says
Bruxism and clenching can be quite destructive to teeth over time. When teeth already have large fillings, further breakdown is not only common but to be expected. In such situations, a prudent dentist needs to think long-term. How the teeth are aligned, does the patient have other factors contributing to the accelerated wear such as acid reflux, what is the patient’s diet, etc.
Replacing old large fillings just because they are old and large is not reason enough. Are they breaking down or decayed?
If the patient’s teeth are severely worn down, including the front teeth, proper bite relationship and function (proper occlusion) is critical before restoring the teeth. Your experience with crowns is unfortunate. However, if a heavy grinder has poor occlusion, failure can be expected. I suggest a careful evaluation and a thorough treatment plan. Sight unseen, I can’t make a specific recommendation for you, but it’s a good idea to have the big picture in mind.
Best of health,
I have been told for many years that I have this cavity or that micro-cavity and had these imperfections blasted away, mostly with a sand technique, and filled with composite. I am not yet out of my 20s but have had at this point what seems like every single tooth filled, multiple times – including two crowns. It wasn’t until I brought my spouse (who has never had more than 1-2 cavities per year) to this dentist that I realized something was wrong. It appears though that this dentist unfortunately has been overall aggressive, at best, and at worst…. well it’s not a good situation. But my question is this: is it normal to have 4-6 “micro cavities” recommended for filling PER VISIT.
Michael Sinkin says
Perhaps your question: “Is it normal to have…so many cavities with such frequency?” is an expression of doubt as to whether you actually have cavities that need care and if so, why? As to the why, do you have a diet rich in refined carbohydrates, do you have a sweet tooth and frequently consume sweets, how often do you brush your teeth, do you use a fluoridated toothpaste, have you ever been prescribed a fluoride rinse, gel or had an in-office fluoride treatment, how often do you see your dentist, do you swish your mouth with water after consuming sugar, do your brux (grind) your teeth or clench…?
Prevention is the best treatment. Has any strategy been suggested by your dentist to help prevent decay or premature tooth wear?
About whether or not you have “lesions” that need treatment, I cannot comment.
Suffice it to say that something needs modification because the frequency of your dental treatment is beyond what I would expect of a young patient who appears to be conscientious about his dental health.
Thanks for reading!
Andreas Waters says
I recently switched dentists only because their hours were easier for my schedule. I went in for a cleaning and exam, come to find out I have 11 cavities. This is shocking to me. I have no tooth pain. They used a laser and digital imaging. 4 of the cavities are say resin-two surfaces-anterior. The others say composite. Are the 4 cavities surface cavities? And I find this strange because I saw my normal dentist 6 months ago and I was fine.
Michael Sinkin says
Of course there is no way I can determine what just occurred during your recent dental adventure (or misadventure!). Eleven needed restorations is a significant finding and the disparity between the two dentists raises obvious questions. You perhaps should confer with your first dentist for a second opinion. Good luck!
Hi, I have never had a cavity until apparently now and I am 18 years old. I got my braves off about 8 months ago (after having them on for 7 years) and my dentist told me that I didn’t have a cavity or anything but I should get a filling just in case. (Was told that when I was much younger too). I just returned from the orthodontist (4 months after the dentist) and during a check he told me I had a cavity! I’ve taken much better care of my teeth.. I don’t drink sodas and have a fairly healthy, balanced diet. I brush and floss.. Everything. I don’t understand what could have caused a cavity in a matter of months.. My teeth feel fine.
Michael Sinkin says
Don’t grieve the loss of your dental innocence. Having a filling placed will not diminish your overall dental health and taking care of your cavity is a must. You did nothing wrong and in fact, it sounds like you are doing everything right. So allow me to interpret the situation. You did not form a cavity in four months; it’s obviously been developing for a while. Your dentist telling you that you didn’t have a cavity but that he wanted to place a filling “just in case” is curious. Taking the high road and giving him the benefit of the doubt, I suspect that your tooth had some sort of defect in the enamel that he wanted to seal before it became a full blown cavity. Calling such this defect a cavity or an area demineralized tooth structure or even a blemish may be just a matter of semantics. Not addressing the problem at all is far more egregious. Many times, depending upon where a cavity is located, it is possible to monitor with x-ray if the cavity is on the side of the tooth or with a diagnostic laser if it’s on the biting surface. Diagnodent is a diagnostic laser that can gauge how deep a biting surface cavity is and helps in deciding whether it needs to be treated immediately or possibly be remineralized with fluoride treatment. I believe that between what your orthodontist told you and what your dentist tried to tell you, you should make the appointment to treat your “cavity.” From the sounds of it, you are very conscientious with your dental home care. Wearing braces for seven years (which is quite a long time) can put your teeth at greater risk for cavity formation. I salute you for your diligence and have to give credit to both your dentist and orthodontist for keeping you in fine dental form. Take care of your cavity as soon as possible and don’t fret too much (this is not the beginning of the end.) A beautifully placed bonded restoration (filling) will secure your tooth’s health and will be virtually invisible. Keep up the good work.