Enamel is
the outer or first layer and Dentin, the middle or second layer of any tooth.
If the cavity or decay is restricted to enamel or dentin, a restoration, be it
any, silver, composite, alkasite etc. is good enough to restore it. If the
middle or second layer, dentin is slightly more involved, it is always
preferable to give a liner and/or a base below the restoration. If the decay or
bacteria traverses through to the third layer, the pulp a.k.a. the nerve
tissue, then the tooth might need a root canal therapy. While a tooth’s pulp
tissue does contain nerve fibers, it is also composed of arteries, veins, lymph
vessels and connective tissue. When the pulp seems to have become
infected or inflamed due to a deep cavity, the blood supply to the tooth may be
lost and the tooth pulp may have died in all probability. This can cause pain
and pressure while biting down, chewing, eating or drinking hot or cold foods
and drinks. This stage is the trickiest for any clinician; to decide between
the stages, whether the tooth is actually infected or just inflamed. The
decision at this stage has to be based on experience, clinical judgment and
your own instinct rather than any other clinical finding. This situation often
lands up the clinician in a dilemma of whether to go for Root Canal Treatment
or restore the deep cavity with a proper protection underneath with a good
liner followed by base and then the restoration following a proper sandwich
technique. The unfortunate aspect here is that in the initial stages of tooth
decay, there won’t be any pain. Hence, complacency creeps in and the patient
delays or postpones the visit to the dentist. When an excruciating or sometimes
even more than little pain happens, the patient runs to the dentist and the
radiograph, clinical scenario and the symptoms sometimes make it a Catch 22
situation for the clinician – to go for a Root Canal treatment or to restore it
with the conventional means of a sandwich technique. 



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Enamel being the outer or first layer and Dentin, being the
middle or second layer of any tooth are vital in protection of tooth from any
kind of thermal, chemical and physical insults. The arrest of a tooth by decay
or a cavity at a deep level of the tooth warrants a decision as the symptoms
itself at that stage isn’t alone a guiding force for us; the clinicians.
Whether the decay or bacteria has actually traversed through to the third
layer, the pulp a.k.a. the nerve tissue or not, is the most pertinent question
to answer. In most cases at this stage, the patient might be experiencing
a sensation to cold initially and when he turns up eventually at the clinic, he
might be occasionally getting sensation on taking hot beverages, which
sometimes is an indication of the progression of the decay. In some cases, the
pain in the tooth is on lying down and the patient is having a severe pain
followed by a swelling. Many a patient turns up
at this last stage, to get relief from the pain. At that stage, the patients
are even ready to get the offending tooth removed to get rid of the painful


are caused by tooth decay which is a process that develops slowly but steadily
due to following reasons:

Plaque: Dental plaque is a
clear sticky film causing a coating on the teeth. Plaque formation is due to
carbohydrates primarily which contains sugar and starch and is further
aggravated by not removing the layer from the tooth. When the carbohydrates are
not cleaned off from the teeth, bacteria start colonizing the teeth quickly and
harden with salivary salts leading to a further hard plaque or tartar a.k.a.
the calculus. Tartar makes plaque more difficult to remove and creates an
environment for bacteria to colonize further leading to more plaque formation
from leftover food particles.

Recurrent Plaque attacks: The acids in plaque cause
the demineralization of the tooth’s enamel by causing erosion. This erosion
causes tiny openings or holes in the enamel which is usually the first stage of
a cavity after demineralization. Once the enamel is worn away which is actually
a very long and a tough process and in some stages, taking a time of 3.5 – 4
years on the occlusal surface of the tooth, the bacteria reach the second layer
of the tooth, the dentin. Dentin is much softer than enamel and less resistant
to acid attacks. Dentinal tubules, the micro-openings of the dentin that
directly communicate with the pulp of the tooth causing hyper-sensitivity.

Pathways of Destruction: If the patient is not aware or cautious
at this stage, the bacteria and acid continue to march
through the teeth by moving to the inner most layer a.k.a. the pulp that
contains nerves and blood vessels. The pulp becomes swollen and irritated from
the bacteria, becoming scathed from attack and causing pain. Swelling and discomfort
can even show up on the face of the patient as a result of this sometimes.

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