"The researches of the late Professor W.D.Miller, published about 1880, finally gave to the world the true explanation of the process of tooth decay."
"Briefly stated, Miller, as the result of a long and exhaustive experimental study of the subject, found that the destruction of the hard structures of the tooth by dental caries was accomplished by the agency of a certain class of microorganisms which had the characteristic function of fermenting certain of the sugars and converting these sugars into lactic acid, which acid in its turn attacked the solid tooth structure wherever it came into contact with it, dissolving out its mineral matter which caused the structure to disintegrate, forming a cavity which gradually enlarged until it eventually included the entire crown; indeed, if unchecked, the whole tooth may in this manner become disintegrated and lost."
--Edward Cameron Kirk, DDS, UPenn Dean from 1895-1917, writing (with rather less periods than we would use today) in Alfred Fones' remarkable text Mouth Hygiene. This is my original 1916 edition.
Dr. Kirk goes on to say,
"Dental caries is a characteristic disease with a well-marked and definite group of symptoms and within certain limits it has a known causation, which is the localized destruction of the hard tissues of the tooth by the solvent action of lactic acid generated at the point of decay by the agency of bacteria acting upon carbohydrate foodstuff."
And so. Although Dr. Kirk and others had a little further to go in terms of understanding the dynamics of the frequency of refined sugars consumption, we had the answer to the total prevention of dental caries ***138*** years ago, with Dr. Miller's astonishing insightful research.
Why did, and does, caries remain such a widespread public health problem?
For one, the sugar lobby in the U.S. is extraordinarily powerful. Labeling foods and drinks for their cariogenicity potential will likely NEVER happen in the U.S. Which is a shame, because it really needn't decrease sales of high cariogenic foodstuffs. I positively love chocolate, more than I can put into words. I only eat it around meals, though, and usually only once a day. I dig raisins, sugary little beasties that stick in tooth grooves for hours, on cereal in the morning. But that's the only time I eat them, and I brush afterwards. Frequency matters with sugars, even natural ones. We can still safely enjoy cariogenic foods and drinks--just not via grazing.
The other reason that dental caries is still so widespread is that the industrialists who run things discovered long ago that foods high in sugar, fat and salt sell very well in the U.S. Across our nation, healthy foods are expensive and unhealthy foods are cheap--as well as designed to be maximally addictive via the enticements (powerful ones, that speak directly to our species' lean evolutionary past) of sugar, fat and salt. This makes me angry. You can't tell me that it costs more to ship a head of lettuce from California to Philadelphia than it does to make a pack of Twinkies, with all the processing and ink and packaging that a pack of Twinkies entails. And yet routinely, the vegetables cost more than the high-carb snack foods.
Most maddening of all, though, is the inherent and rather unfair paradox that has been built into our foods, beverages and oral health care patterns in recent decades.
What I have noticed--and perhaps you have too--is that well-educated patients with a sound economic life often have few caries. (Most of the new patients we see between ages 21-40 have good educations, great jobs and no caries. Minimal existing restorations as well.) In contrast, less educated patients with less economic means, in my experience and perhaps in yours, tend to have more caries. Industrialists are more than happy to market and sell unhealthy foods to the most susceptible segments of our society. Hence the inherent unfairness--
Today, those who can least afford to treat dental caries generally have the most dental caries.
This is a markedly different situation than the one that existed from at least the 1920s to the 1980s, in which captains of industry, wealthy businesspeople and Hollywood celebrities often had mutilated dentitions. Nowadays, I doubt there's even one CEO of a Fortune 500 company who has posterior bite collapse due to the effects of severe dental caries. Or from periodontal disease, for that matter.
In my view, this epidemiological challenge--not the latest, greatest, costly means of restoring multiple implants, nor the finer nuances of "digital workflow"-- is the key challenge in American dentistry today.
And so a pair of vital questions arise.
How do we practice prevention in the face of what the industrialists of the food and beverage businesses are doing?
And how do we reach those many potential patients, those often at-risk patients who believe--mistakenly--that they cannot afford us, and therefore do not seek care?