Chapter 2 A shining tooth

[The life term of baby teeth.]

Mothers have a strong desire of “not wanting my child to suffer dental problems”, hence they are eager for medical checkups. A tooth begins to grow from around six months after the child is born. Around 20 baby teeth grow and develop by the time the child reaches three years of age. Although there is individual differences in the time it takes for a tooth to grow, except in the case of diseases like ectodermal dysplasia where the person will never develop hair or teeth, there is no need for concern.

As is widely reported in many books on child care, at infancy after the child eats baby food or drinks milk the mother needs to wipe the child's gums with a soft cloth. I think that it is enough to do this to the point where the mother feels that enough has been done to clean the gums without using force. If the child develops several teeth, a babies toothbrush will be given to the mother and she will be instructed how to carry out toothbrushing as part of play time with her child.

“What should we do to prevent cavities in children's baby teeth?” is a frequently asked question. Although the parent and child brushing their teeth together, the use of a fluride application, and prevention filling are all effective ways of limiting problems, the important factors are upbringing and lifestyle education. Since natural protection is inadequate at this stage a cavity easily forms and the advancement of the cavity is also extremely quick. The pH level of the mouth 30 minutes after eating is fearfully low. The belief that soon after eating it is necessary to brush is very true, especially for baby teeth that are at high risk of damage.

Everyone knows about the benefits of brushing within three minutes after eating but in reality do people do this? How about reducing the number of times we eat? If people set a firm schedule for eating meals at regular times, the number of times for snacking should be reduced. Even if the person snacks the time “allowed” for snacking is limited. I don't believe that it is necessary to avoid sweet foods completely. Don't you think that the habit of eating foods of natural fiber, such as cucumbers, apples and takuan ( pickled radish) as a snack or at the end of a meal, and performing natural cleaning with them is a good policy? At any rate having a low pH level in the mouth should be avoided.

It is thought that children's training by their parents is an effective means of preventing cavities in their child’s baby teeth as well as in the child's permanent teeth. Special attention is required if in the child, by three years of age a cavity is found. Do you ever consider putting juice into a nursing bottle or giving your child a pet bottle, and allowing your child to drink from it endlessly?

Looking at results from annual school medical checkups,Ｉthink the rate of generation of cavities is decreasing every year. This result is thanks to the eager work of mothers to produce a healthy condition in their child’s mouth. If throughout life this eagerness is continued troubles will not occur.

[Infancy]

In a quick developing child a 6 year olds molar may develop or the front teeth may be replaced by the permanent teeth before the child enters elementary school. It is generally common for 20 baby teeth to have developed by this stage of the child's life. Although recently cavity cases have decreased, this is the situation where many cavities may be found.

The way of thinking that because the tooth will fall out to be replaced by a permanent tooth anyway it is alright, if the baby tooth comes out before it's time, is dangerous. It is dangerous because of the important duty called the space reservation by baby teeth for a new permanent tooth. If a tooth is lost before it's time, there is a tendency for back teeth to push together towards the front. The loss of the space is a fatal problem in Japanese people with the size of the jaw and the number of teeth imbalanced plus a strange alignment of the teeth.

The alignment of permanent teeth is greatly connected with the generation of a cavity or gingivitis, and also influences the care and medical treatment of the teeth. Therefore not only the care taken at home but in cooperation with the dentist it is important to consider the teeth's positioning. If at the time of the child's teeth changing from baby to permanent the parent is concerned about the alignment of the teeth there is nothing that can be done at this time to correct any problems. Realignment treatment can start to take place when the child is around 10 years of age.

If the patient discovers that a cavity has “recently” developed and rushes in for treatment at this stage it is already too late. In my clinic a periodical treatment of scaling is sometimes begun in patients not yet 2 years old. While it is tartar it is not the same as adult tartar as adult tartar tends to be stuck more firmly to the teeth. It is more a like light plaque which has adhered to the tooth’s surface. One way of limiting potential problems and the need for the child to experience cleaning treatment is for the child to have regular applications of fluoride applied to their teeth. In so doing while there is not complete insurance that problems will not develop the potential risk is greatly decreased.

According to the latest research, in the time before a cavity generates, it appears that re-calcification is expectable on the enamel surface. In order to make re-calcification more efficient a product called RECALDENT (supplied in the form of chewing gum), a fluoride application, which promotes keeping the dental surface as clean as possible and promotes re-calcification exists.

Of course, the tooth in the state that is widely recognized as having a cavity is accompanied by problems that may only be noticed by a dentist (these are also cavities) needs to be medically treated at once. The treatment of baby teeth and permanent teeth is not the same. The reason being that even though the baby teeth will eventually be replaced by the permanent tooth if it is not treated the premature loss of the tooth will have a negative effect on the permanent teeth. Moreover, the medical treatment plan changes with the position of the successive permanent tooth, direction and the age of the patient.

For a small cavity the treatment is not really affected by the age of the patient. However the treatment of a large cavity is directly related to the age of the patient. For example, in the case of an adult, it may be necessary for the nerve to be removed in the treatment process. In the case of a child with a sever cavity in a baby tooth the removal of the nerve will have a negative effect on the permanent tooth to develop. Therefore the nerve is left and instead diamine silver fluoride is packed into the cavity space. Although the result of such treatment is that the cavity will discolor to a deep-black, advancement of the cavity is stopped. If this treatment method is used on an adult's permanent tooth the aesthetic nature of a person's teeth is not being considered. This treatment process can be considered for problems in baby teeth simply because they will eventually be replaced by a permanent tooth.

Fig.3 Patient E 5 years 7 months old Female This is a baby teeth sequence just before the permanent teeth come through. An important reason for having baby teeth is for space reservation for the permanent teeth.

For molars, while for a permanent molar the cavity is shaved off and the crown made to fit exactly from a cast of the tooth. However the cavity in a baby molar is treated much more simply by fitting a crown to the shaved tooth without making a cast. Although the medical treatment will not last a long time, as the tooth will be replaced by the permanent tooth, it can be considered a worthwhile medical treatment because the space for the permanent tooth has been secured which will allow a beautiful permanent tooth to grow.

Nerve medical treatment is difficult for a permanent tooth but it is even more difficult for a baby tooth. The treatment for a baby tooth is more specialized. There are times when the removal of the nerve is the same as for the treatment of a permanent tooth. However there are also times when partial removal of the nerve is undertaken. As for baby teeth, as the permanent tooth grows underneath, the root of the baby tooth decreases. If the nerve of the baby tooth is removed then pus will form on the root (apical lesion). The pus will cause the patient to feel pain. While removing the baby tooth will result in the pain disappearing, if the permanent tooth is not yet at the stage where it naturally will soon appear then the baby tooth must remain so that the space is kept for the future permanent tooth. In this case the pain is stopped by making an incision in the gum to release the pus. There is a high chance that the pus will later redevelop and the process will need to be repeated but in order to provide space for the future permanent tooth the baby tooth must remain at this stage.

Anyway, I think that it is important to care for the tooth so that it is not necessary to carry out such medical treatment.

[Childhood]

Like baby teeth, since a newly developed permanent tooth has inadequate calcification the advancement of a cavity is extremely fast. In newly developed permanent teeth at this time there are many examples of in only a few months cavities generating down to the pulp chamber, therefore early treatment is needed. To make early detection and cavity treatment control possible I think that it is worth having medical checkups for every vacation period- spring, summer and winter. By going in for a checkup and having scaling and cleaning performed, at the same time any smaller, finer cavities can be discovered and treated hence helping to promote re-calcification.

[Orthodontics]

A child’s alignment of teeth is a big worry for parents. The bad alignment of baby teeth has the hope of being corrected when they are replaced by permanent teeth. However, if bad alignment develops in permanent front teeth it is a big concern.Ideally, there should be no cavities in the baby teeth, if the growth of the jaw is favorable, the permanent tooth will grow from right under the baby tooth, the root of the baby tooth will shrink and the permanent tooth will push the baby tooth out naturally. Just before the baby tooth falls out if the child bites may feel some pain. In the past sometimes thread was tied around the tooth and then it was pulled out forcefully, however it seems that recently the patient is anesthetized and the tooth extracted in the dentist's chair.

If a cavity develops in a baby tooth or there is a lesion on the root of the tooth, the direction in which the permanent tooth grows will change and even though the baby tooth has not fallen out the permanent tooth may grow. In such a case the root of the baby tooth will not be absorbed normally and therefore the baby tooth will remain forever if left. If the baby tooth is left too long the alignment of the teeth will be influenced. Therefore the baby tooth should be extracted as early as possible. The permanent tooth from which the natural direction of growth had shifted will return to a normal position even if it left as it is, therefore concern is unnecessary.

A child in the early years of elementary school is too young to have the bad alignment of their teeth corrected. In order to fix the alignment of the teeth because the patient's cooperation is required, children of an age that can understand the meaning of reform, namely high school students, are treated. However it is safer to consult with an orthodontist even when the child is in elementary school since there are times when it is advantageous to treat earlier.

I think that orthodontic treatment is often avoided because the period of orthodontic treatment is usually long and expensive. However, since a consultation costs around 3000 yen I think that yearly consultations should be taken. Consequently parents ask when their child should start having orthodontic consultations. I think that any consultations during this stage of the child's life are worth it. Although diagnostic consultation expense changes from hospital to hospital it is usually in the range of between 50000 to 100000 yen. Once diagnosis has been reached the orthodontic treatment required, the method of treatment, how long the process is expected to take and the expense are discussed with the family.

[Adolescence]

The term used to describe children in their junior high school and high school years is adolescence. I think that a great portion of Japanese people head towards trouble with the condition of their teeth from this time.
“Although I say let's visit the dentist my child does not listen to what I say.”
“Because my child does not say they have pain we do not visit the dentist.”
Even though there are reasons not to go if this mentality continues the custom of regular checkups will begin to disappear.

In the case of a new car owner, with the new car it is not fatal and is even natural to cut corners a little with the care. However, considering the long life of teeth we need to treat the teeth more carefully. After seeking treatment for a problem the patient may feel that they are immune to future problems until they feel pain. However in not visiting the dentist again until this point a lot of damage surely will have developed.

Part of the problem getting the adolescent child to visit the dentist may be due to the fact the usually the child visits with their mother, something the child regards as “uncool”. Nevertheless, there is sufficient effect by just continuing to have a medical checkup every spring, summer and winter vacation like when the child was in elementary school.

Moreover, since dental tartar begins to develop upon the bottom of the gum and can start to cause gingivitis from the moment dental eruption has finished, periodical scaling is indispensable. Although it is not exactly the same for everyone and is effected by the condition of health, from the age of 18 years in some patients we can see a lot of subgingival calculus attached to the bottom of the gum.

Fig 4. Patient S 22 years old woman I think that such beautifully aligned teeth without cavities or a trace of medical treatment are like a kind of work of art built by the parents and child.

We can never know whether in the future the last stage of gingivitis will develop at the age of about 30 or if things will be fine until about 70 years. However as the final stage is certain to occur we must take great care in preventing it. An adolescent child's intention and sense of values begin to develop at this time. However since their experience is still insufficient they cannot necessarily make the right judgment. I have a feeling that they are not of the age which can judge dental medical treatment and the importance of dental care.

If this time period can be overcome safely, the patient will at the end of adolescence gain from having beautiful teeth without cavities or fillings.(Fig 4.) In order not to repeat the same problems their parents faced, even if the adolescent child is forcibly taken to the dentist, because it is not of their own will, quite possibly they will not learn and understand about the necessity and importance of dental care.

[Wisdom teeth]

I will explain a little about wisdom teeth here. From a scientific point of view the jawbone will develop and in the past it was believed that wisdom teeth had enough space to grow. Over generations the jaw has degenerated and become smaller. The space in which wisdom teeth once had space to grow has been lost. Also since the wisdom teeth themselves have degenerated, wisdom teeth sometimes do not develop at all. Moreover there are also cases where because there is no place for the wisdom teeth to grow the teeth they remain buried into the bone.

It is easy for wisdom teeth to be targets of cavities for a couple of reasons. One being that the position of the wisdom teeth at the back of the mouth makes them difficult to reach for cleaning and the other is that they lack adequate calcification. Therefore cavities in wisdom teeth will advance easily. If an ache is felt and a cavity or other an abnormality is found I recommend you pull the tooth out promptly. If the wisdom teeth are left much longer it will not only affect the important molar teeth, but will have an influence on the alignment of the teeth. Except for about 10% of cases you should extract wisdom teeth a little early. In Japan there is a slogan that says “Wisdom teeth should be removed early while remain teeth should never be removed.”

Fig.5 Mr T At the time of first medical examination. 15 years old. Male Many deep cavities which are likely to reach a nerve next to the tooth of chief complaint are found.

Fig.6 Mr T 20 years later. 35 years old. About three years after treatment, the patient came for treatment on other worrisome teeth and so pulpectomy was repeated.

Fig 7. Mr S 16 years old Male He has already had one dental nerve removed. Many traces of cavity medical treatment are noticeable as well.

Fig 8. Mr S 20 years later 36 years old After the first medical treatment , as a result of continuing monthly scaling and medical chckups, in the 20 years since the first treatment he has maintained good oral condition without the need of removing any other dental nerves.

[Young adulthood]

About 10 years after the tooth had developed slightly different care to the care that was performed until then should be undertaken.
“As things are at the moment please fix all problem areas.”

This seems like a good attitude, to aim for prompt repairs. However there is a problem with this idea and the problem lies in the phrase “As things are at the moment.” I think that the patient comes to the dentist just because they feel that something is not right.

Sometimes we hear patients comment “ I thought that I could not go to the dentist when there was no noticeable problem” or “Should I go to the dentist only for scaling.” From this conversation I recognize the problem with the insurance institution. In the insurance institutions of Japan for medical checkups where there are no abnormalities insurance can not be used. However please be reassured about the dentistry domain. Even if a patient feels that all is completely normal on a specialist level abnormalities are sure to be found. Abnormalities that more than likely will be found include tartar, gum inflammations, problems with wisdom teeth and early cavities. As a result of the checkup the patient may voice surprise and doubt that “there were indeed so many problems” as found in the checkup. It is telling that the patient’s knowledge of the true condition of their mouth clearly runs short.

Many of the teeth with which the patient notices problems can not but have the nerve removed due to a deep cavity. The beginning of this treatment, called pulpectomy, is something that dentists really want to avoid. The reason for this is that after the treatment the patient is likely to complain of pain and also the fee that the dentist can receive for this treatment is extremely low ( it is about 10% of the fee earned by dentists in other developed countries). Although what is necessary is for the patient to understand the difficulty and imperfection of pulpectomy and to take care to never repeat the same problem. However very often the dentist's explaination is not good enough and also the cost of performing the treatment is low, unfortunately the process is repeated all too often. (Fig. 5-6)

At the time of first medical examination four cavities were discovered and hence their nerves were removed plus all other teeth were treated. This underlines the importance of maintenance and regularly visiting the dentist. After that, the patient appealed against new abnormalities and visited the clinic only every few years. Consequently pulpectomy was repeated each time and 20 years later 11 nerves had been removed. About 20 years after a nerve is removed a small apical lesion will surely appear. Shortly after that the metal crown will need to be removed the root canal treatment will need to be redone. Since the tooth from which the nerve was removed will become weak, the root will fracture and apical lesions are likely to appear one after another, from now on this tooth will definitely have problems.

The case of Mr T is one of someone who is prone to developing cavities. Now I will discuss the case of Mr S, someone who shows resistance to developing cavities and through the comparing the two patients it should be easy to see the differences between these two cases.

Mr S's elder sister was in the situation where she had lost the nerve in 7 teeth by the time she had turned 19 and at the first visit to my clinic 5 more nerves had to be removed. Mr S, three years younger than his sister, had also had 1 nerve removed.

Mr S has already had one dental nerve removed. Many traces of cavity medical treatment are noticeable as well. He had heard from his older sister, who had come in for treatment, about the treatment and his main point of concern was hoping for maintenance. Although cavities were treated at the time of first medical examination and his wisdom teeth were pulled out in subsequent treatment, other than this he hardly needed treatment for 20 years. Furthermore visually ugly pulpectomy, metal crowns, etc. were completely unnecessary and he seemed to enjoy a fortunate life.

Monthly scaling and regular medical checkups have controlled advancement of cavities or gingivitis so efficiently that Mr S's case may be looked at as an example of this method. The bad case of the medical treatment removing the nerve and putting on a metal crown has been reduced and the benefits of this can never be overstated.

[Adulthood]

Fig. 9 Mr I At the time of first medical examination 38 years old Male He complained of a big cavity hence his visit to the dentist. The tooth of chief complaint needed the nerve removed. Teeth which in the past had had the nerve removed were removed and their surrounding healthy teeth used to form a bridge.

Fig. 10 Mr I 20 years later 58 years old The tooth treated 20 years ago has been maintained. Moreover. The area labeled “area of attention” time has passed favorable because during the 20 years treatment was not needed.

In an adult's life it is a time when work and home are busy and often thinking about dental care seems like time wasting. However this is the time when a cavity that was treated in the past can reappear. It is also the time that gingivitis can begin to appear. These are significant reasons for visiting a dentist however I think that there are many people who have prolonged visiting the dentist. Finally when the patient does seek treatment because there are many things which must be treated and since the treatment has become large-scale, expense also increases.

Those who began maintenance early do not need to worry. The person who has monthly scaling performed must already be aware of the mitigation of time and expense. There is also no unpleasant medical treatment but even more importantly I think that young patients are satisfied with the environment in their mouth not changing. It is never to late to stop deterioration. Regular maintenance from now will stop further deterioration.

The tooth treated 20 years ago is also maintained. Moreover, in the case of attention, it has survived well without further treatment in any way.

Mr I. He was 38 years old at the time of first medical examination. Male (Fig. 9-10)
The big cavity was Mr.I's chief complaint. The lower left second molars had such a big cavity that tooth extraction needed to be considered, not to mention removing the dental nerve. Although it was recoverable in the state where root canal therapy was performed, the tooth could barely function and also many other cavities resulted in the removal of nerves. A tooth which in the past had in the past been pulled out and the nerve removed led to the surrounding healthy teeth being used to form a bridge. Futhermore, a tooth which was used as support for the bridge also had a cavity. Mr. I realized that the tooth which had had the nerve removed needed close attention and care. Therefore he continued to monthly maintenance after the medical treatment resulting in no further problems in the following 20 years.

Even now the tooth treated is functioning well. It is the teeth that did not need treating at the time of the first medical examination that we have to watch. Although difficulties were escaped to the age of 38 years, if maintenance was not performed these teeth may have developed large cavities. It can be said that in the adult stage of life it is possible to pass through this time without carrying out any medical treatment and not suffer problems. What if Mr. I's maintenance was begun 20 years earlier from the age of 18 years? Possibly all the teeth were healthy at that time. That being the case the treatment he had at the age of 38 probably would not have been necessary. Possibly all the teeth would have remained healthy to the time that he turned 58 years old. Taking this as a general example regardless of when maintenance is begun it is possible to preserve the condition of the teeth from that time.

[Middle age]

Fig. 11 Ms Y At the time of first medical examination. 54 years old. Woman Although there are 26 residual teeth in total, alveolar bone destruction and a lot of dental calculus on the upper jaw molars are noticeable.

Fig. 12 Ms Y 21 years later. 75 years old. Since the first medical examination things have gone well and the patient has not lost any teeth.

More than half of the patients who visit my clinic for the first time, in the time of life termed middle age, have a hopeless oral condition of the mouth. This is due to past over treatment as well as development of gum disease of the last stage. If treatment is carried out from a viewpoint of trying to maintain the tooth's usage for the whole life of the patient, even if maintenance is begun from middle age, there are likely to be many difficult cases. Even though until this point of life the patient has not had any care taken for their teeth and as a result many teeth have been lost, from this point it is still important to begin dental care to preserve the remaining teeth. If where the tooth has been lost an implant is positioned, it is possible to live life without dentures.

The example of Ms. Y to whom problems were fortunately escaped until the visit to my clinic are noted here. It is the same as the condition as in the case of Mr. I at 58 years old.

Ms. Y At the time of first medical examination. 54 years old. Woman. (Fig. 11-12)
The number of residual teeth, including wisdom teeth, was 28 at the time of first medical examination. A lot of tartar was found on her gum and it was expected that future rapid bone destruction would take place in the alveolar bone in the upper jaw molar region. She was not so eager for maintenance at the beginning and complained about new abnormalities which needed treatment every two or three years. Then she heard that friends around her were needing dentures one after another. This news resulted in seeking maintenance, out of the fear of also developing the need for dentures. Twenty one years since her first medical treatment she has successfully maintained her teeth. I think that she can successfully live her life without the need for dentures.

[Japanese people who are living overseas]

As more and more Japanese people live overseas I think more of them experience concern about receiving dental treatment in the foreign country. Usually the concern stems from the high cost of treatment rather than a technical concern. For Japanese whom have got used to the system of medical treatment in Japan, including dental medical treatment, this can be a type of culture shock.

It seems that many Japanese decide to wait and receive treatment on problem areas when they return to Japan. I think that through this method evil can be avoided. It seems that patients whom continue this method of receiving treatment on return to Japan maintain their teeth better than a Japanese person who lives perminately in Japan but does not get regular treatment. It can be likened to the case of Australians who receive dental checkups once a year.

To continue to treat an area over and over again is not a positive thing. However if a dark patch that turns out to be a cavity is discovered in such an area then it must be treated. It is necessary for the patient to understand that after treatment the tooth will suffer from hypersensitivity and the pain felt in that area is likely to be great hence the tooth will need to have the nerve removed. If the tooth is left untreated then the patient will face such terrible pain that will result in sleepless nights within a few months. Such treatments, in the majority of cases, have positive results, but occasional the end result is that the nerve must be removed.

The patient with a tooth which has had the dental nerve removed and a metal crown has been placed need to be careful. The situation is even more serious if there are many such teeth. Such a patient must surely compare the medical treatment expence of the country in which they are staying with the transportation expenses of returning to Japan. Further concern is due to the fact that the problem may not necessarily be able to be fixed within the period the patient can return to Japan for treatment and there is the possibility of recurrence in the future. Taking certain individual facts into consideration, is it better to follow the advice of the local dentist?

[The crime of school education]

“If you eat sweet food you will get cavities.”
“If your teeth are not brushed every day you will develop cavities and it will become impossible for you to eat delicious things.”

We have been taught and are still being taught such things. Don’t you question such teachings when you look at grandparents who have brushed their teeth every day and now have dentures?

As a child I felt like rebelling against adults who it seemed were able to eat sweets. Still I cut down on sweet things and continued tooth brushing everyday. But when I went to university I was afflicted with cavities.

Believing that something was strange and wrong I continued work as a dentist. The same with the medical treatment method taught to us at university. From the bottom of my heart I feel that the things that we were taught at school are not new developments and are in fact the basis of learning and therefore correct. It took ten years for me to go through medical training at university and realize that there were problems with the things we had been taught. For most dentists they never come to this realization but due to my strong belief this was a very important time.

A greater amount of time is required to change the way you think about matters taught to you in elementary school compared with university. The reason being is that we believe that what we are taught in elementary school are the fundamental basics and are unlikely to be incorrect.

“Things are repairing nicely. Of course I brush my teeth three times a day.”
There are patients who contradict me angrily saying such things.
“Only tooth brushing will only maintain your teeth for at most five years so please receive plaque removal treatment and checkups every month.”
Even though as a dentist I explain the situation the patient can not seen to understand.

“If your teeth are not brushed every day you will develop cavities and it will become impossible for you to eat delicious foods.”
If this statement is reversed it becomes “if your teeth are brushed every day you will be able to eat delicious foods throughout your whole life and will eliminate the need to remove teeth.” As teeth are not able to be maintained throughout life by only tooth brushing this statement is difficult for people to accept even from childhood.

“If you don't go to a dentist every month, have your teeth examined and dirt removed you will lose teeth and it will become impossible for you to eat delicious foods.”
If this message is taught to today's children I am sure the a healthy dental kingdom will be produced in a few decades from now.

[Conclusion]

Overseas when a patient who feels pain in a tooth visits the dentist they will be up for about 200 000 yen in expenses for a tooth extraction. Under the medical insurance system of Japan medical treatment can be undertaken at expense of about 6000 yen. For treatment of the tooth that was painful and hence the problem was discovered too late and emergency extraction is required, the insurance institution of Japan is excellent. However if the emergency extraction treatment is repeated the condition of the mouth is definitely being broken down.

The effect of maintenance may not be recognizable until 10 years after it is begun. However , it would be wise to believe in the results of many foreign countries, and begin maintenance immediately. The effect of maintenance is acquired from the day it is begun.

Although the effect of tooth brushing is not denied, the maintenance which I propose deals with the dirt which remains even after teeth brushing and the newly generated cavity briskly. That is, it only makes dental maintenance an extension of daily brushing. The custom for not suffering troubles with one's teeth should become important especially for one's child or grandchild.