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A 41-year-old homeless man presents to a clinic on “skid row” with a toothache (Figure 45-1). He has a history of alcoholism and smoking. Many of his teeth are loose and a number of his teeth have fallen out in the past year. He acknowledges that he does not floss or brush his teeth regularly. He has been sober for 60 days now and wants help to get his teeth fixed. He states that no one will hire him with his teeth as they are. He also has pain in a molar and wants something for the pain until he can see a dentist. On oral examination, you see missing teeth, generalized plaque, and teeth with multiple brown caries.

Figure 45-1

Severe caries in a homeless man. (Courtesy of Richard P. Usatine, MD.)

Dental caries is a multifactorial disease that is primarily caused by an interaction between bacteria and fermentable carbohydrates producing acid that has potential to demineralize the tooth surface over time. Host factors, such as the plaque (biofilm) adherence, quality and quantity of saliva, immune system response, use of fluoride, and a diet that is caries-promoting, play a role in the formation of incipient demineralized lesions that progress to dental caries. Caries risk is impacted by factors that may be behavioral, biologic, environmental, lifestyle-related, and physical. Age, diabetes, ethnic origin, gingival recession, smoking, and socioeconomic status are frequently associated with high caries prevalence.1

Dental decay, dental cavities, cavitated lesions.

  • Many adults (e.g., 31% of those 20 to 34 years of age, 27% of those 35 to 49 years of age, 24% of those 50 to 64 years of age, and 20% of those 65 years of age and older) have untreated dental caries (Figure 45-1).2
  • Black and Hispanic adults, younger adults, and those with lower incomes and less education have more untreated decay.3
  • Many older adults suffer from root caries (decay on the roots of their teeth) (Figure 45-2). The percentage of adults with root caries increased with age: 8% of adults 20 to 39 years of age had root decay, compared with 11% of adults 40 to 59 years of age, and 13% of adults 60 years of age and older. The prevalence is greater for black non-Hispanics (20%) and adults below 100% poverty level (19%).4
  • More than twice as many current smokers (19%) as nonsmokers (7%) had root caries.4

Figure 45-2

Root caries in a woman with a history of substance abuse. She has lost all of her upper teeth and is beginning to lose her lower teeth. Note the exposed and darkened roots. (Courtesy of Richard P. Usatine, MD.)

  • Dental caries result from the activity of dental bacterial plaque, ...

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