Dental Caries Case Study Answers
Dental Caries
1.1 – Describe a problem biologists are trying to solve
Dental caries (tooth decay) is the destruction of the outer surface of a tooth. Decay results from the action of numerous bacteria, including Streptococcus mutans, which inhabit plaque, formed by colonies of bacteria. The plaque sticks to tooth enamel and metabolizes carbohydrates from food to produce lactic acid. The lactic acid, if left in contact with the teeth for a sustained period of time, causes the demineralization of the teeth. Over time, the reduction of the mineral content in the teeth may lead to the formation of a cavity.
Tooth decay is one of the most widespread health problems in the UK. It is estimated that 31% of adults in the UK have tooth decay. Tooth …show more content…
decay is also a problem for children. It is thought around 31% of children starting school and around a third of children aged 12 have visible tooth decay [1]
The diagram above shows the three different types of cavities:
Pit and fissure– these usually occur on the chewing surfaces of the molars and pre-molars
Smooth surface – these usually occur on the smooth side of the teeth in the side of your mouth
Root – these usually occur in the root at the front of your teeth. This is most common in older people because as you age, gums recede, making the roots more susceptible to decay
Tooth decay is treated in one of three ways dependant upon its severity:
Fillings - a dental restorative material used to restore the function, integrity and morphology of missing tooth structure. [3]
Root canal treatment – treatment for the pulp of a tooth that results in the elimination of infection and protection of the decontaminated tooth from future microbial invasion. [4]
Extraction - The removal of the decayed tooth is performed if the tooth is too far destroyed from the decay process to effectively restore the tooth [21].
Dental caries are an expensive and time-consuming problem with “Americans making 5000 million visits to the dentist each year and in 2012 an estimated $108 billion spent on dental services in the United States”[5] making it important for biologists to develop a better understanding into what can be done to prevent the disease, or in the onset of the disease, what can be done to minimize its impact or where possible, to reverse its actions.
1.2 - Method One - Water fluoridation
Water fluoridation is the controlled addition of fluoride to water supplies in order to reduce tooth decay. It has been described as “one of the ten greatest public health achievements of the 20th century”[6]. Fluoride reduces the incidence of dental caries and slows the progressions of existing lesions by working in two ways:
Remineralization – Plaque acids work to remove minerals from teeth, weakening them and sometimes leading to cavities. Fluoride helps reverse the demineralization process by bringing minerals to the outer tooth surface.
Strengthening – Fluoride can be absorbed into the enamel layer of the tooth; increasing both it’s strength and increasing its resistance to further acid attacks.[7]
In order to determine the effectiveness of water fluoridation as a means to reduce the prevalence of dental caries, a number of studies have been undertaken. The Centre for Reviews and Dissemination at the University of York undertook a systematic review that looked at 26 previously conducted studies and tried to identify a trend in their results. They came to the conclusion:
Water fluoridation reduces the number of decayed, miss and filled teeth in children ages 5 to 15 by, on average 2.25 teeth per child. This works out as an overall reduction in tooth decay of approximately 40% in fluoridated areas.
Water fluoridation increases the percentage of people totally free from tooth decay by, on average 14.6% [8]
The reduction in the prevalence of dental caries, in the US, has the potential to reduce the spending on dental services from $108billion annually to $92billion. This potential saving in spending could be used in other ways which would benefit the economy such as increased spending on education or the improvement of the infrastructure which has the potential to increase the performance of the US economy, which is relatively simple if they problem of tooth decay is solved.
“Extensive studies over the past 50 years have established that individuals whose drinking water is fluoridated show a reduction in dental caries.”[9]
This was written in a report by the American Department of Health and Human Services reviewing the benefits and risks of fluoridation of public water sources. With 196million US residents receiving artificially or naturally fluoridated water at the optimum concentration for oral health, this equates to 64% of the US population. [10] With massive controversy surrounding the addition of fluoride to water supplies, the US government has to monitor the effectiveness of fluoridation and to monitor, if any, its adverse effects. Their review was a thorough, well researched one carried out by a research team that is part of the American Department of Health and Human Services.
A study was undertaken by the Irish Department of Health in order to determine the true costs and benefits if they were to fluoridate public water sources for the population of nearly five million. They compared the average DMFT (number of decayed, missing or filled teeth) in 1963 and 1984 when in the latter year, in the Republic of Ireland; the test group had received artificially fluoridated water.
These results show that over time, dental health seems to have improved. However, in Northern Ireland where the children were not exposed to artificially fluoridated water, the average decrease in decayed, missing or filled teeth across the three age groups was at 18.2%. You can compare this to the results from the Republic of Ireland where naturally fluoridated water is present and average DMFT is lower than that of Northern Ireland in the same year and when water sources were fully fluoridated, the average decrease in decayed, missing or filled teeth across the three age groups is 53.1%. The artificial fluoridation of water dramatically reduces the prevalence of tooth decay and reduces the need to treat patients for the disease.
1.2. - Vaccination against dental caries
A caries vaccine is a method in which to improve immunity against dental caries. Streptococcus mutans is a bacterium found in the oral cavity that aids the development of tooth decay. It is a bacterium that metabolizes sucrose from food to lactic acid, which breaks down the surface enamel of the teeth. There are two methods in which immunization can be made:
1.2.1. - The introduction of antibodies
The introduction of a synthetically produced plantibody - an antibody produced by genetically modified crops – in this case produced by genetically modified tobacco plants, CaroRx™, produced by a firm called Planet Biotechnology Inc. is one way in which to inhibit the ability of S. mutans to adhere to tooth surfaces.
“CaroRx™ binds specifically to Streptococcus mutans, the bacteria that cause tooth decay, and prevents the bacteria from adhering to teeth. CaroRx™ is intended for regular topical preventative administration by both dental hygienists and patients following a thorough cleaning and intervention for any existing decay.”[12]
The results of the graph above show that 120 days after the application of the plantibody “CaroRx™” the presence of S. mutans in the plaque is less than 1% of the original count whereas after the application of the saline solution and the unrelated antibody, the levels of S. mutans in the plaque were returning towards their original level. This suggests that plantibody is effective in reducing the metabolizing capabilities of the of the bacteria S. mutans thus reducing the amount of lactic acid present in the mouth so also reducing its capability to break down surface enamel, thus reducing the prevalence of dental cavities.
1.2.2. Replacement Therapy
This technique would involve the introduction of an alternative, genetically modified bacterium into the oral cavity that itself would produce a lantibiotic – a class of peptide antibiotics that contain the characteristic polycyclic thioether amino acids lathinonine or metyllanthionine as well as the unsaturated amino acids dehydroalanine and 2-aminoisobutyric acid [14] - to destroy S. mutans whilst the new bacterium would also, unlike S. mutans would not metabolize carbohydrates to form lactic acid thus reducing the prevalence of dental caries.
One firm developing this technique of tooth decay prevention is Oragenics Inc. – a biopharmaceutical company whose main focus are oral health products, they were founded by Dr Jeffrey D Hillman – a Harvard graduate who went on to become a professor at Harvard Dental institute. His firm is strives to develop advancements in dental technology that he was discovered during his career.
“SMaRT Replacement Therapy is designed to be applied topically to the teeth by a dentist, pediatrician or primary care physician during a routine office visit. A suspension of the SMaRT strain is administered using a cotton-tipped swab during a single five-minute, pain-free treatment. Following treatment, the SMaRT strain should displace the native, decay-causing S. mutans strains over a six to twelve month period and permanently occupy the niche on the tooth surfaces normally occupied by native S. mutans.”[15]
The genetically engineered strain of S. mutans has been tested extensively in laboratory rats and its success has been shown, as it does not create lactic acid under any conditions, reduces the prevalence of dental caries and displayed no adverse side effects. During Phase I clinical trials, no adverse effects were seen and SMaRT was effective in the aggressive displacement of the native, decay-causing S. mutans.
2.1 - Ethical, Social and Economic Issues
2.1.1 - Ethical issues associated with water fluoridation
The artificial addition of fluoride to water may be deemed unethical because people should have the right to decide whether or not their water is fluoridated and this would not be the case if water were to be introduced.
Fluoridation can also be
“Under Article 35 of the European Charter of Fundamental Rights, the right to health care includes the right to refuse health care, for whatever reason. It establishes the individual’s right to receive particular drugs or treatments – or to prevent them from having such treatment against their wishes”
Fluoridation may be deemed to have infringed this fundamental right. If the government were to implement the delivery of fluoridating water in those areas of the country whereby levels are not water supplies are not naturally fluoridated, not all those within that area would have been able to make the decision as to whether or not their water supplies contained fluoroscilates. One of the ethical frameworks is determining between right and duties. Although health professionals have to duty to reduce the incidence of dental caries, people may argue they do not have the right to mass medicate. Water fluoridation therefore is deemed by many to be a case of mass medication has massive ethical implications for all
involved.
If water is artificially fluoridated, not only is it possible that not all those in the area receiving it will have consented to it, but also that the companies that supply the water will have no way to control the exact amount of fluoride that people consume, but also if any of those receiving fluoridated water were to have adverse effects to its consumption, there were would be no way in which its supply could be stopped.
“I am appalled at the prospect of using water as a vehicle for drugs. Fluoride is a corrosive poison that will produce serious effects on a long-range basis. Any attempt to use water this way is deplorable”
- Dr Charles Gordon Heyd, Past President of the American Medical Association.
2.1.2 - Economic problems associated with caries vaccinations
The recent advancements in the world of caries vaccinations imposes both social and economic problems for the future. The development of a one-time treatment to treat dental caries would surely decrease the need for people to visit the dentist, except in extraordinary cases such as tooth loss or a need for restoration due to trauma to the mouth, if their protection against dental caries would be life-long. This may mean that many of the 20,000 practicing dentists in the UK may well be out of work. With the average dentist salary being at £63,920 [16] a loss of two-thirds of the employment in the dental market could lead to a total loss of the output of the UK economy by around £8.5million. The loss of output would translate into either slower economic growth or possibly, if the economy were behaving poorly before the introduction of caries vaccinations, recession.
Another economic problem involved with caries vaccinations is the massive costs involved with developing the drugs, not taking into account the cost of its distribution, reaching somewhere on average between $4billion and $11billion [17] Although tooth decay affects the majority of the developed world and is affecting more and more of the developing world, there are much more pressing diseases out there that the money spent on developing the vaccination could be spent on. For example, cancer accounted for 7.8million deaths – around 13% of all deaths – in 2008 and has a projected rise to 13.1million deaths in 2030. [18] If the capital spent on developing caries vaccination were spent on the treatment of cancers, people would feel as if that were a much better way in which for the money to be spent as it may save lives whilst caries vaccination would reduce the prevalence of dental caries but would not in fact save lives.
2.2 – Benefits and Risks
2.2.1 – Benefits and Risks to humans of water fluoridation
Water fluoridation has many benefits to humans. There is a reduction in the number of sick days taken from work or school due to dental disorders or visits to the dentist [19]. Also, there is a noticeable decrease in the number of decayed, missing of filled teeth in both adults and children, children experience less toothache and have less dental abscesses, the costs to NHS for treating avoidable diseases such as toothache would have fallen and it is cost effective in terms of treatment versus fluoridation with:
“The annual cost to fluoridate a community averages $.51 per person per year, depending on community size, labor costs, and type of chemicals and equipment used. (Garcia, 1989)[20]. This figure amounts to less than the cost of one filling.” [19]
As well as the obvious benefits, there are also some risks that come along with dental fluoridation. At the recommended levels of fluoride consumption, the only adverse effect would be mild dental fluorosis - a change in the appearance of the tooth’s enamel –, which is completely cosmetic and does not affect the development of teeth nor their ability to carry out their proper function. However, as exact levels of fluoride consumption cannot be measured, as people may consume fluoride from other sources such as toothpaste, milk and in some countries table salt. Excessive consumption of fluoride may lead to more serious effects such as skeletal fluorosis – a debilitating bone disease. This has the ability to massively hamper a person’s quality of life. This poses a massive problem to the population because one person’s susceptibility to the disease may vary greatly to another’s. This means that if the “safe” level of fluoride in water were to be reduced, although it may not cause skeletal fluorosis in some, it may cause skeletal fluorosis in others, perhaps lowering their quality of life or even their life expectancy.
2.2.2 – Benefits and risks of caries vaccinations
One obvious benefit of the two methods of caries vaccinations is the potential for a life-long protection from tooth decay and therefore avoiding the debilitating pain and the inconvenience it may cause. However there is a risk, in the case of replacement therapy, of the native strain of S. mutans becoming resistant to the lantibiotic produced by the genetically modified bacterium. This that the S. mutans would still be able to colonize the oral cavity and continue to metabolize carbohydrates to form lactic acid which would cause the breakdown of the tooth enamel. Another risk associated with caries vaccinations is that the long-term side effects are unknown, and without long, thorough, investigation, there may be harmful side effects for the humans that are treated with the vaccinations.
2.3 – Alternative solutions to solve dental caries
Tooth decay is donned a completely preventable diseases in the sense that maintaining good oral hygiene can limit if not halt its progression. Good oral hygiene can be maintained by:
Brushing with fluoride toothpaste: this involves the topical application of fluoride. Fluoride reverses the demineralization caused by lactic acid. Also, brushing also removes the bacteria that metabolize carbohydrates to form lactic acid. Fluoride can be absorbed into the enamel layer of the tooth, increasing its strength and thus improving its resistance to further acid attacks.
Flossing: flossing removes the remnants of food from between the teeth so if there are no carbohydrates left in the mouth, the S mutans will have nothing to metabolize so tooth decay will not occur.
Dental sealants: as decay is most common to occur on the molars, where food can become trapped between the grooves, soon after molars have erupted, dental sealants are an option to avoid the onset of caries on the chewing surface of teeth. Sealants are lightly coloured plastic coatings. Unlike fillings and root canal treatment, sealants are a preventative measure in order to avoid tooth decay. Their application does not involve invasive treatment so does not weaken the tooth structure. They can last for up to ten years
Antibacterial mouthwashes: regardless of the oral hygiene of some people, they are a high caries risk due to having a dry mouth or producing very little saliva. The regular use of an antibacterial mouthwash take the place of saliva as it destroys the caries causing bacterium, therefore lowering the risk of tooth decay.
All of these methods avoid the social and economic problems involved with water fluoridation, as dental fluorosis is less likely to occur as the levels of fluoride intake can be monitored and “mass medication” will not have occurred as those who use the fluoride toothpaste will have made an informed decision as to the benefits and risks of it use and those opposed to it will merely choose not to use it.
3.1 – Bibliography
1. NHS Choices – Tooth Decay http://www.nhs.uk/conditions/Dental-decay/Pages/Introduction.aspx Last updated 07/06/12
Accessed 6/11/12
2. Mayo Foundation for Medical Education and Research – Cavities and Tooth decay http://www.mayoclinic.com/health/medical/IM00619 Last updated 28/04/11
Accessed 6/11/12
3. Wikipedia – Dental Fillings http://en.wikipedia.org/wiki/dental_fillings Last updated 19/09/12
Accessed 6/1/12
4. Wikipedia – Endodontic Therapy http://en.wikipedia.org/wiki/Endodontic_therapy Last updated 17/11/12
Accessed 6/11/12
5. Centre for Disease Control and Prevention: Oral Health – Preventing Cavities, Gum Disease, Tooth Loss And Oral Cancers, Page 2 http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2011/Oral-Health-AAG-PDF-508.pdf Published 29/7/11
6. Centre for Disease Control and Prevention: Ten Great Public Health Achievements in the 20th century http://www.cdc.gov/about/history/tengpha.htm Last updated 29/7/09
Accessed 6/11/12
7. Aquafresh – Teeth Brushing http://www.aquafresh.com/Teeth_Brushing_Fluoride.aspx Accessed 6/11/12
8. British Fluoridation Society – One in a Million: the facts about water fluoridation, Page 6 http://www.bfsweb.org/onemillion/onemillion2012.html Published 06/2004
9. Department For Health And Human Services – Review of Fluoride: Benefits and Risks http://www.health.gov/environment/ReviewofFluoride/default.htm Published 02/1991
10. British Fluoridation Society – One in a Million: the facts about water fluoridation, Page 8 http://www.bfsweb.org/onemillion/onemillion2012.html Published 06/2004
11. Irish Department of Health – Forum on fluoridation
Chapter 2, Page 48
Published 03/2003
Accessed 7/11/12
12. Planet Biotechnology Inc. – Products http://www.planetbiotechnology.com/products.html Accessed 7/11/12
13. Planet Biotechnology Inc. http://www.planetbiotechnology.com/images/plaque.gif Accessed 7/11/12
14. Wikipedia – Lantibiotics http://www.wikipedia.org/wiki/Lantibiotics Last updated 14/7/12
Accessed 9/12/12
15. Oragenics - SMaRT Replacement Therapy™ http://www.oragenics.com/cavity-prevention Last updated 01/2011
Accessed 9/12/12
16. MySalary – Dentist http://www.mysalary.co.uk/average-salary/Dentist_839 Last updated 01/12
Accessed 9/12/12
17. Forbes: The Truly Staggering Cost Of Inventing New Drugs by Matthew Herper http://www.forbes.com/sites/matthewherper/2012/02/10/the-truly-staggering-cost-of-inventing-new-drugs/ Published 7/10/12
Accessed 9/12/12
18. World Health Organisation: Cancer http://www.who.int/mediacentre/factsheets/fs297/en/ Last reviewed 01/2013
Accessed 07/01/13
19. California Department of Public Health: Fluoride and Its Cost Effectiveness http://www.cdph.ca.gov/programs/Pages/FluorideandCost-Effectiveness.aspx Last reviewed 29/5/2008
Accessed 29/1/13
20. Garcia, A.I. 1989. Caries incidence and costs of preventive programs. J. Public Health Dent. 49 (Special Iss): 259-71.
21. Wikipedia – Dental caries http://en.wikipedia.org/wiki/Dental_caries Last updated 14/3/13
Accessed 18/3/13
22. Cosmetic Dentistry Guide – Crowns http://www.cosmeticdentistryguide.co.uk/crowns.html Accessed 18/3/13
23. Truman BI, Gooch BF, Sulemana I, et al., and the Task Force on Community Preventive Services. Reviews of evidence on interventions to reduce dental caries, oral and pharyngeal cancers, and sports-related craniofacial injury. American Journal of Preventive Medicine 2002;23(1S): 1–84.
3.2 – Evaluation of References
Wikipedia – Dental caries http://en.wikipedia.org/wiki/Dental_caries Wikipedia is a free encyclopedia whose pages are both written and edited by those who use it. Their content is not peer reviewed therefore making its information less valid. A frequent contributor to the dental caries page is registered as “Jmh649” who is James Hielman, a practicing doctor, clinical assistant professor at the University of Saskatchewan and clinical instructor at the University of British Columbia. He updates the page regularly with 10 updates in January and February of this year. Although, the contributor has a medical background, the extent of his knowledge into dental caries may be limited so the validity of his contributions is less so than if the contributor was a practicing dentist. As well as this, in original creator of this page was the user “Davodd”. Upon reading his user page, I can find out that that the author is David Speakman, A professional journalist and law school graduate. This undermines the validity of the article as having specialized in law; he would have little insight into dental caries, meaning the accuracy of the information he supplied likely to be poor. The information I extracted from this page was that tooth removal is necessary when decay means that the tooth cannot be restored. However, this is not always the case as recent advancements in dental technology mean that root canal treatment can be carried out, removed all the decayed section of the tooth and removing the bacteria that caused this decay, filling it and then placing a crown over the damaged tooth. One option for a crown would be a porcelain crown, which can be both aesthetically pleasing and a barrier to stop bacteria from damaging the tooth again. They can last up to 15 years dependent upon how well the patient takes care of their teeth22.
Garcia, A.I. 1989. Caries incidence and costs of preventive programs
This article was written in the Journal of Public Health Dentistry in the December issue of 1989 whilst the author, Dr Isabel Garcia, had been completing her Masters degree in dental public health at the University of Michigan, after having completed a doctorate in dental surgery at the Medical College of Virginia. She is now Director of the National Institute of Dental and Craniofacial Research. The Journal of Public Health Dentistry is a publication for the discussion and debate of international public health issues. Before publishing, the articles are reviewed by the author’s peers. The review by a group of highly educated individuals who all would have a degree in dental public health vastly increases the validity of the information contributed in the article. Dr Garcia has also publishing many other articles, all of which have been peer reviewed, thus increasing both the reliability of the article I have made reference to in this issue report. Although Dr Garcia is extremely qualified now, when she had written the report, it would seem as though she were relatively inexperienced however, I am fully confident that if the research in her report had been inaccurate, they would not have allowed for its publication so the data I have taken this report can be deemed to be reliable. The information I extracted from her report was that “the annual cost to fluoridate a community averages $.51 per person per year, depending on community size, labor costs, and type of chemicals and equipment used”. In order to check validity, I cross-checked this with other sources which suggested that fluoridation may cost as little as $.40 for large communities but up to $2.70 for small communities.23
1.1 – Describe a problem biologists are trying to solve
Dental caries (tooth decay) is the destruction of the outer surface of a tooth. Decay results from the action of numerous bacteria, including Streptococcus mutans, which inhabit plaque, formed by colonies of bacteria. The plaque sticks to tooth enamel and metabolizes carbohydrates from food to produce lactic acid. The lactic acid, if left in contact with the teeth for a sustained period of time, causes the demineralization of the teeth. Over time, the reduction of the mineral content in the teeth may lead to the formation of a cavity.
Tooth decay is one of the most widespread health problems in the UK. It is estimated that 31% of adults in the UK have tooth decay. Tooth …show more content…
decay is also a problem for children. It is thought around 31% of children starting school and around a third of children aged 12 have visible tooth decay [1]
The diagram above shows the three different types of cavities:
Pit and fissure– these usually occur on the chewing surfaces of the molars and pre-molars
Smooth surface – these usually occur on the smooth side of the teeth in the side of your mouth
Root – these usually occur in the root at the front of your teeth. This is most common in older people because as you age, gums recede, making the roots more susceptible to decay
Tooth decay is treated in one of three ways dependant upon its severity:
Fillings - a dental restorative material used to restore the function, integrity and morphology of missing tooth structure. [3]
Root canal treatment – treatment for the pulp of a tooth that results in the elimination of infection and protection of the decontaminated tooth from future microbial invasion. [4]
Extraction - The removal of the decayed tooth is performed if the tooth is too far destroyed from the decay process to effectively restore the tooth [21].
Dental caries are an expensive and time-consuming problem with “Americans making 5000 million visits to the dentist each year and in 2012 an estimated $108 billion spent on dental services in the United States”[5] making it important for biologists to develop a better understanding into what can be done to prevent the disease, or in the onset of the disease, what can be done to minimize its impact or where possible, to reverse its actions.
1.2 - Method One - Water fluoridation
Water fluoridation is the controlled addition of fluoride to water supplies in order to reduce tooth decay. It has been described as “one of the ten greatest public health achievements of the 20th century”[6]. Fluoride reduces the incidence of dental caries and slows the progressions of existing lesions by working in two ways:
Remineralization – Plaque acids work to remove minerals from teeth, weakening them and sometimes leading to cavities. Fluoride helps reverse the demineralization process by bringing minerals to the outer tooth surface.
Strengthening – Fluoride can be absorbed into the enamel layer of the tooth; increasing both it’s strength and increasing its resistance to further acid attacks.[7]
In order to determine the effectiveness of water fluoridation as a means to reduce the prevalence of dental caries, a number of studies have been undertaken. The Centre for Reviews and Dissemination at the University of York undertook a systematic review that looked at 26 previously conducted studies and tried to identify a trend in their results. They came to the conclusion:
Water fluoridation reduces the number of decayed, miss and filled teeth in children ages 5 to 15 by, on average 2.25 teeth per child. This works out as an overall reduction in tooth decay of approximately 40% in fluoridated areas.
Water fluoridation increases the percentage of people totally free from tooth decay by, on average 14.6% [8]
The reduction in the prevalence of dental caries, in the US, has the potential to reduce the spending on dental services from $108billion annually to $92billion. This potential saving in spending could be used in other ways which would benefit the economy such as increased spending on education or the improvement of the infrastructure which has the potential to increase the performance of the US economy, which is relatively simple if they problem of tooth decay is solved.
“Extensive studies over the past 50 years have established that individuals whose drinking water is fluoridated show a reduction in dental caries.”[9]
This was written in a report by the American Department of Health and Human Services reviewing the benefits and risks of fluoridation of public water sources. With 196million US residents receiving artificially or naturally fluoridated water at the optimum concentration for oral health, this equates to 64% of the US population. [10] With massive controversy surrounding the addition of fluoride to water supplies, the US government has to monitor the effectiveness of fluoridation and to monitor, if any, its adverse effects. Their review was a thorough, well researched one carried out by a research team that is part of the American Department of Health and Human Services.
A study was undertaken by the Irish Department of Health in order to determine the true costs and benefits if they were to fluoridate public water sources for the population of nearly five million. They compared the average DMFT (number of decayed, missing or filled teeth) in 1963 and 1984 when in the latter year, in the Republic of Ireland; the test group had received artificially fluoridated water.
These results show that over time, dental health seems to have improved. However, in Northern Ireland where the children were not exposed to artificially fluoridated water, the average decrease in decayed, missing or filled teeth across the three age groups was at 18.2%. You can compare this to the results from the Republic of Ireland where naturally fluoridated water is present and average DMFT is lower than that of Northern Ireland in the same year and when water sources were fully fluoridated, the average decrease in decayed, missing or filled teeth across the three age groups is 53.1%. The artificial fluoridation of water dramatically reduces the prevalence of tooth decay and reduces the need to treat patients for the disease.
1.2. - Vaccination against dental caries
A caries vaccine is a method in which to improve immunity against dental caries. Streptococcus mutans is a bacterium found in the oral cavity that aids the development of tooth decay. It is a bacterium that metabolizes sucrose from food to lactic acid, which breaks down the surface enamel of the teeth. There are two methods in which immunization can be made:
1.2.1. - The introduction of antibodies
The introduction of a synthetically produced plantibody - an antibody produced by genetically modified crops – in this case produced by genetically modified tobacco plants, CaroRx™, produced by a firm called Planet Biotechnology Inc. is one way in which to inhibit the ability of S. mutans to adhere to tooth surfaces.
“CaroRx™ binds specifically to Streptococcus mutans, the bacteria that cause tooth decay, and prevents the bacteria from adhering to teeth. CaroRx™ is intended for regular topical preventative administration by both dental hygienists and patients following a thorough cleaning and intervention for any existing decay.”[12]
The results of the graph above show that 120 days after the application of the plantibody “CaroRx™” the presence of S. mutans in the plaque is less than 1% of the original count whereas after the application of the saline solution and the unrelated antibody, the levels of S. mutans in the plaque were returning towards their original level. This suggests that plantibody is effective in reducing the metabolizing capabilities of the of the bacteria S. mutans thus reducing the amount of lactic acid present in the mouth so also reducing its capability to break down surface enamel, thus reducing the prevalence of dental cavities.
1.2.2. Replacement Therapy
This technique would involve the introduction of an alternative, genetically modified bacterium into the oral cavity that itself would produce a lantibiotic – a class of peptide antibiotics that contain the characteristic polycyclic thioether amino acids lathinonine or metyllanthionine as well as the unsaturated amino acids dehydroalanine and 2-aminoisobutyric acid [14] - to destroy S. mutans whilst the new bacterium would also, unlike S. mutans would not metabolize carbohydrates to form lactic acid thus reducing the prevalence of dental caries.
One firm developing this technique of tooth decay prevention is Oragenics Inc. – a biopharmaceutical company whose main focus are oral health products, they were founded by Dr Jeffrey D Hillman – a Harvard graduate who went on to become a professor at Harvard Dental institute. His firm is strives to develop advancements in dental technology that he was discovered during his career.
“SMaRT Replacement Therapy is designed to be applied topically to the teeth by a dentist, pediatrician or primary care physician during a routine office visit. A suspension of the SMaRT strain is administered using a cotton-tipped swab during a single five-minute, pain-free treatment. Following treatment, the SMaRT strain should displace the native, decay-causing S. mutans strains over a six to twelve month period and permanently occupy the niche on the tooth surfaces normally occupied by native S. mutans.”[15]
The genetically engineered strain of S. mutans has been tested extensively in laboratory rats and its success has been shown, as it does not create lactic acid under any conditions, reduces the prevalence of dental caries and displayed no adverse side effects. During Phase I clinical trials, no adverse effects were seen and SMaRT was effective in the aggressive displacement of the native, decay-causing S. mutans.
2.1 - Ethical, Social and Economic Issues
2.1.1 - Ethical issues associated with water fluoridation
The artificial addition of fluoride to water may be deemed unethical because people should have the right to decide whether or not their water is fluoridated and this would not be the case if water were to be introduced.
Fluoridation can also be
“Under Article 35 of the European Charter of Fundamental Rights, the right to health care includes the right to refuse health care, for whatever reason. It establishes the individual’s right to receive particular drugs or treatments – or to prevent them from having such treatment against their wishes”
Fluoridation may be deemed to have infringed this fundamental right. If the government were to implement the delivery of fluoridating water in those areas of the country whereby levels are not water supplies are not naturally fluoridated, not all those within that area would have been able to make the decision as to whether or not their water supplies contained fluoroscilates. One of the ethical frameworks is determining between right and duties. Although health professionals have to duty to reduce the incidence of dental caries, people may argue they do not have the right to mass medicate. Water fluoridation therefore is deemed by many to be a case of mass medication has massive ethical implications for all
involved.
If water is artificially fluoridated, not only is it possible that not all those in the area receiving it will have consented to it, but also that the companies that supply the water will have no way to control the exact amount of fluoride that people consume, but also if any of those receiving fluoridated water were to have adverse effects to its consumption, there were would be no way in which its supply could be stopped.
“I am appalled at the prospect of using water as a vehicle for drugs. Fluoride is a corrosive poison that will produce serious effects on a long-range basis. Any attempt to use water this way is deplorable”
- Dr Charles Gordon Heyd, Past President of the American Medical Association.
2.1.2 - Economic problems associated with caries vaccinations
The recent advancements in the world of caries vaccinations imposes both social and economic problems for the future. The development of a one-time treatment to treat dental caries would surely decrease the need for people to visit the dentist, except in extraordinary cases such as tooth loss or a need for restoration due to trauma to the mouth, if their protection against dental caries would be life-long. This may mean that many of the 20,000 practicing dentists in the UK may well be out of work. With the average dentist salary being at £63,920 [16] a loss of two-thirds of the employment in the dental market could lead to a total loss of the output of the UK economy by around £8.5million. The loss of output would translate into either slower economic growth or possibly, if the economy were behaving poorly before the introduction of caries vaccinations, recession.
Another economic problem involved with caries vaccinations is the massive costs involved with developing the drugs, not taking into account the cost of its distribution, reaching somewhere on average between $4billion and $11billion [17] Although tooth decay affects the majority of the developed world and is affecting more and more of the developing world, there are much more pressing diseases out there that the money spent on developing the vaccination could be spent on. For example, cancer accounted for 7.8million deaths – around 13% of all deaths – in 2008 and has a projected rise to 13.1million deaths in 2030. [18] If the capital spent on developing caries vaccination were spent on the treatment of cancers, people would feel as if that were a much better way in which for the money to be spent as it may save lives whilst caries vaccination would reduce the prevalence of dental caries but would not in fact save lives.
2.2 – Benefits and Risks
2.2.1 – Benefits and Risks to humans of water fluoridation
Water fluoridation has many benefits to humans. There is a reduction in the number of sick days taken from work or school due to dental disorders or visits to the dentist [19]. Also, there is a noticeable decrease in the number of decayed, missing of filled teeth in both adults and children, children experience less toothache and have less dental abscesses, the costs to NHS for treating avoidable diseases such as toothache would have fallen and it is cost effective in terms of treatment versus fluoridation with:
“The annual cost to fluoridate a community averages $.51 per person per year, depending on community size, labor costs, and type of chemicals and equipment used. (Garcia, 1989)[20]. This figure amounts to less than the cost of one filling.” [19]
As well as the obvious benefits, there are also some risks that come along with dental fluoridation. At the recommended levels of fluoride consumption, the only adverse effect would be mild dental fluorosis - a change in the appearance of the tooth’s enamel –, which is completely cosmetic and does not affect the development of teeth nor their ability to carry out their proper function. However, as exact levels of fluoride consumption cannot be measured, as people may consume fluoride from other sources such as toothpaste, milk and in some countries table salt. Excessive consumption of fluoride may lead to more serious effects such as skeletal fluorosis – a debilitating bone disease. This has the ability to massively hamper a person’s quality of life. This poses a massive problem to the population because one person’s susceptibility to the disease may vary greatly to another’s. This means that if the “safe” level of fluoride in water were to be reduced, although it may not cause skeletal fluorosis in some, it may cause skeletal fluorosis in others, perhaps lowering their quality of life or even their life expectancy.
2.2.2 – Benefits and risks of caries vaccinations
One obvious benefit of the two methods of caries vaccinations is the potential for a life-long protection from tooth decay and therefore avoiding the debilitating pain and the inconvenience it may cause. However there is a risk, in the case of replacement therapy, of the native strain of S. mutans becoming resistant to the lantibiotic produced by the genetically modified bacterium. This that the S. mutans would still be able to colonize the oral cavity and continue to metabolize carbohydrates to form lactic acid which would cause the breakdown of the tooth enamel. Another risk associated with caries vaccinations is that the long-term side effects are unknown, and without long, thorough, investigation, there may be harmful side effects for the humans that are treated with the vaccinations.
2.3 – Alternative solutions to solve dental caries
Tooth decay is donned a completely preventable diseases in the sense that maintaining good oral hygiene can limit if not halt its progression. Good oral hygiene can be maintained by:
Brushing with fluoride toothpaste: this involves the topical application of fluoride. Fluoride reverses the demineralization caused by lactic acid. Also, brushing also removes the bacteria that metabolize carbohydrates to form lactic acid. Fluoride can be absorbed into the enamel layer of the tooth, increasing its strength and thus improving its resistance to further acid attacks.
Flossing: flossing removes the remnants of food from between the teeth so if there are no carbohydrates left in the mouth, the S mutans will have nothing to metabolize so tooth decay will not occur.
Dental sealants: as decay is most common to occur on the molars, where food can become trapped between the grooves, soon after molars have erupted, dental sealants are an option to avoid the onset of caries on the chewing surface of teeth. Sealants are lightly coloured plastic coatings. Unlike fillings and root canal treatment, sealants are a preventative measure in order to avoid tooth decay. Their application does not involve invasive treatment so does not weaken the tooth structure. They can last for up to ten years
Antibacterial mouthwashes: regardless of the oral hygiene of some people, they are a high caries risk due to having a dry mouth or producing very little saliva. The regular use of an antibacterial mouthwash take the place of saliva as it destroys the caries causing bacterium, therefore lowering the risk of tooth decay.
All of these methods avoid the social and economic problems involved with water fluoridation, as dental fluorosis is less likely to occur as the levels of fluoride intake can be monitored and “mass medication” will not have occurred as those who use the fluoride toothpaste will have made an informed decision as to the benefits and risks of it use and those opposed to it will merely choose not to use it.
3.1 – Bibliography
1. NHS Choices – Tooth Decay http://www.nhs.uk/conditions/Dental-decay/Pages/Introduction.aspx Last updated 07/06/12
Accessed 6/11/12
2. Mayo Foundation for Medical Education and Research – Cavities and Tooth decay http://www.mayoclinic.com/health/medical/IM00619 Last updated 28/04/11
Accessed 6/11/12
3. Wikipedia – Dental Fillings http://en.wikipedia.org/wiki/dental_fillings Last updated 19/09/12
Accessed 6/1/12
4. Wikipedia – Endodontic Therapy http://en.wikipedia.org/wiki/Endodontic_therapy Last updated 17/11/12
Accessed 6/11/12
5. Centre for Disease Control and Prevention: Oral Health – Preventing Cavities, Gum Disease, Tooth Loss And Oral Cancers, Page 2 http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2011/Oral-Health-AAG-PDF-508.pdf Published 29/7/11
6. Centre for Disease Control and Prevention: Ten Great Public Health Achievements in the 20th century http://www.cdc.gov/about/history/tengpha.htm Last updated 29/7/09
Accessed 6/11/12
7. Aquafresh – Teeth Brushing http://www.aquafresh.com/Teeth_Brushing_Fluoride.aspx Accessed 6/11/12
8. British Fluoridation Society – One in a Million: the facts about water fluoridation, Page 6 http://www.bfsweb.org/onemillion/onemillion2012.html Published 06/2004
9. Department For Health And Human Services – Review of Fluoride: Benefits and Risks http://www.health.gov/environment/ReviewofFluoride/default.htm Published 02/1991
10. British Fluoridation Society – One in a Million: the facts about water fluoridation, Page 8 http://www.bfsweb.org/onemillion/onemillion2012.html Published 06/2004
11. Irish Department of Health – Forum on fluoridation
Chapter 2, Page 48
Published 03/2003
Accessed 7/11/12
12. Planet Biotechnology Inc. – Products http://www.planetbiotechnology.com/products.html Accessed 7/11/12
13. Planet Biotechnology Inc. http://www.planetbiotechnology.com/images/plaque.gif Accessed 7/11/12
14. Wikipedia – Lantibiotics http://www.wikipedia.org/wiki/Lantibiotics Last updated 14/7/12
Accessed 9/12/12
15. Oragenics - SMaRT Replacement Therapy™ http://www.oragenics.com/cavity-prevention Last updated 01/2011
Accessed 9/12/12
16. MySalary – Dentist http://www.mysalary.co.uk/average-salary/Dentist_839 Last updated 01/12
Accessed 9/12/12
17. Forbes: The Truly Staggering Cost Of Inventing New Drugs by Matthew Herper http://www.forbes.com/sites/matthewherper/2012/02/10/the-truly-staggering-cost-of-inventing-new-drugs/ Published 7/10/12
Accessed 9/12/12
18. World Health Organisation: Cancer http://www.who.int/mediacentre/factsheets/fs297/en/ Last reviewed 01/2013
Accessed 07/01/13
19. California Department of Public Health: Fluoride and Its Cost Effectiveness http://www.cdph.ca.gov/programs/Pages/FluorideandCost-Effectiveness.aspx Last reviewed 29/5/2008
Accessed 29/1/13
20. Garcia, A.I. 1989. Caries incidence and costs of preventive programs. J. Public Health Dent. 49 (Special Iss): 259-71.
21. Wikipedia – Dental caries http://en.wikipedia.org/wiki/Dental_caries Last updated 14/3/13
Accessed 18/3/13
22. Cosmetic Dentistry Guide – Crowns http://www.cosmeticdentistryguide.co.uk/crowns.html Accessed 18/3/13
23. Truman BI, Gooch BF, Sulemana I, et al., and the Task Force on Community Preventive Services. Reviews of evidence on interventions to reduce dental caries, oral and pharyngeal cancers, and sports-related craniofacial injury. American Journal of Preventive Medicine 2002;23(1S): 1–84.
3.2 – Evaluation of References
Wikipedia – Dental caries http://en.wikipedia.org/wiki/Dental_caries Wikipedia is a free encyclopedia whose pages are both written and edited by those who use it. Their content is not peer reviewed therefore making its information less valid. A frequent contributor to the dental caries page is registered as “Jmh649” who is James Hielman, a practicing doctor, clinical assistant professor at the University of Saskatchewan and clinical instructor at the University of British Columbia. He updates the page regularly with 10 updates in January and February of this year. Although, the contributor has a medical background, the extent of his knowledge into dental caries may be limited so the validity of his contributions is less so than if the contributor was a practicing dentist. As well as this, in original creator of this page was the user “Davodd”. Upon reading his user page, I can find out that that the author is David Speakman, A professional journalist and law school graduate. This undermines the validity of the article as having specialized in law; he would have little insight into dental caries, meaning the accuracy of the information he supplied likely to be poor. The information I extracted from this page was that tooth removal is necessary when decay means that the tooth cannot be restored. However, this is not always the case as recent advancements in dental technology mean that root canal treatment can be carried out, removed all the decayed section of the tooth and removing the bacteria that caused this decay, filling it and then placing a crown over the damaged tooth. One option for a crown would be a porcelain crown, which can be both aesthetically pleasing and a barrier to stop bacteria from damaging the tooth again. They can last up to 15 years dependent upon how well the patient takes care of their teeth22.
Garcia, A.I. 1989. Caries incidence and costs of preventive programs
This article was written in the Journal of Public Health Dentistry in the December issue of 1989 whilst the author, Dr Isabel Garcia, had been completing her Masters degree in dental public health at the University of Michigan, after having completed a doctorate in dental surgery at the Medical College of Virginia. She is now Director of the National Institute of Dental and Craniofacial Research. The Journal of Public Health Dentistry is a publication for the discussion and debate of international public health issues. Before publishing, the articles are reviewed by the author’s peers. The review by a group of highly educated individuals who all would have a degree in dental public health vastly increases the validity of the information contributed in the article. Dr Garcia has also publishing many other articles, all of which have been peer reviewed, thus increasing both the reliability of the article I have made reference to in this issue report. Although Dr Garcia is extremely qualified now, when she had written the report, it would seem as though she were relatively inexperienced however, I am fully confident that if the research in her report had been inaccurate, they would not have allowed for its publication so the data I have taken this report can be deemed to be reliable. The information I extracted from her report was that “the annual cost to fluoridate a community averages $.51 per person per year, depending on community size, labor costs, and type of chemicals and equipment used”. In order to check validity, I cross-checked this with other sources which suggested that fluoridation may cost as little as $.40 for large communities but up to $2.70 for small communities.23