Why dental care matters

Almost everything that goes wrong with teeth is preventable, and almost all of it is prevented by the same small set of dull habits. That is the whole argument for dental care, and it is worth setting out before the detail, because the detail is more interesting than the conclusion and the conclusion is what matters.

Tooth decay and gum disease are both caused by the bacterial film that forms on teeth within hours of their being cleaned. Both are largely painless until they are advanced. Both are, in their early stages, reversible. By the time either announces itself, the treatment has usually stopped being a conversation about prevention and become a conversation about repair — and repair, unlike enamel, does not last a lifetime. Every filling has a finite life and is eventually replaced by a larger one.

What a tooth is made of

The part that shows is the crown. Below the gum line, anchored into the jaw, is the root, and the junction between the two is the neck of the tooth — the place where several things tend to go wrong, because it is where enamel runs out.

Enamel is the outer layer of the crown, the hardest substance the body makes, and it is translucent rather than white. It contains no living cells and no nerves, which is why early decay in enamel does not hurt, and why enamel does not repair itself in the way a broken bone does — although its mineral surface can be rebuilt to a degree, which is the basis of everything fluoride does.

Dentine lies beneath the enamel and makes up the bulk of the tooth, extending down into the root. It is yellow, and since enamel is translucent, the colour of a tooth is mostly dentine showing through. Dentine is softer than enamel, decays faster once reached, and is sensitive, which is why decay starts to hurt at the point it crosses that boundary.

The pulp sits in a chamber at the centre, and is the living part: connective tissue, blood vessels and nerves. The blood supply feeds the tooth and the nerves report temperature and pain. When decay or a crack reaches the pulp, the result is either severe toothache or, if the pulp dies, an abscess — and the treatment is root canal treatment or extraction.

The root is covered not by enamel but by cementum, a thin mineralised layer over the root's dentine, into which the periodontal ligament is anchored. That ligament is what actually holds a tooth in place, slung in its socket in the jawbone rather than fused to it. The gum, properly the gingiva, seals the join between tooth and bone.

Two consequences of that arrangement explain a great deal. First, the socket and the ligament are living tissue that can be destroyed by inflammation, which is how gum disease loosens and eventually loses teeth that have no decay in them at all. Second, where the gum recedes, root surface is exposed — and root surface has no enamel on it, so it decays faster, stains differently and does not respond to whitening.

Why it matters beyond the teeth

The mouth is not a sealed compartment, and the case for looking after it is not only about keeping teeth.

Diabetes. The relationship with gum disease runs both ways and is the best established of these links. Poorly controlled diabetes makes gum disease more likely and more severe; severe gum disease in turn makes blood glucose harder to control, and treating it produces a modest but real improvement. Anyone with diabetes has a specific reason to take gum health seriously, and anyone with stubborn gum disease has a reason to mention it to their GP.

Heart and circulatory disease. Gum disease is consistently associated with cardiovascular disease. Whether it contributes to it, or whether the two simply share causes such as smoking, is not settled, and honest writing on the subject says so rather than implying that flossing prevents heart attacks.

Pregnancy. Gum disease is associated with preterm birth and low birth weight, though treating it during pregnancy has not been shown to change those outcomes. Separately, gums become more reactive in pregnancy and bleed more easily, which is a reason for more attention rather than less — and NHS dental care is free during pregnancy and for a year after the birth.

Frailty and old age. In frail older people, particularly those in care, bacteria from the mouth being inhaled is a recognised cause of pneumonia, and routine mouth care measurably reduces it. This is one of the most neglected pieces of basic health care there is.

Eating, speaking and appearance. Losing teeth changes what a person can eat, which changes their diet; it alters speech; and it affects how people feel about being looked at and about speaking up. None of that is vanity.

Mouth cancer. Incidence in the UK has been rising. It is frequently first spotted by a dentist, during the soft tissue examination that forms part of a routine check-up — which is the strongest reason to keep going when nothing hurts. Mouth ulcers, patches and sore tongue sets out the signs not to wait on.

The habits, briefly

The whole of prevention, for any age:

• Brush twice a day with fluoride toothpaste, one of them last thing at night, and spit without rinsing.
• Clean between the teeth once a day, with brushes sized by a dentist or hygienist where the spaces allow, and floss where they do not.
• Keep sugar to mealtimes. How often sugar is eaten matters more than how much, because each exposure starts a fresh acid attack.
• Do not smoke, and keep alcohol moderate. Together they are the dominant risk factors for mouth cancer, and tobacco alone is the dominant one for gum disease.
• Go for examinations at whatever interval the dentist advises, and do not wait for one to report a problem.

Cleaning teeth and gums covers the technique, and fluoride and teeth explains why the fluoride instruction is worded as it is.

One thing worth saying plainly

Dental disease in the UK is strongly patterned by income and area, and the pattern tracks access to care, the cost of good food and the availability of an NHS dentist far more closely than it tracks anybody's willingness to brush. Someone who has lost teeth has usually been let down by circumstances rather than by carelessness, and advice that implies otherwise is both unkind and useless.

Bad breath is worth treating the same way. It is common, it usually has a cause that can be found and dealt with — gum disease, a coated tongue, a dry mouth, sometimes something outside the mouth entirely — and it is a reason to see a dentist rather than a thing to be ashamed of. The same goes for being frightened of going: dental anxiety is common, and there is a great deal that can be done about it.

The rest of this section

Prevention, and getting there: cleaning teeth and gums · fluoride and teeth · dental check-ups · dental anxiety

What goes wrong: tooth decay and cavities · gum disease · mouth ulcers, patches and sore tongue

Treatment: fillings, crowns and implants · root canal treatment · wisdom teeth · tooth whitening

Children: teething · dental care for babies

Practicalities: paying for dental care