For most of my career, I’ve watched dentistry become increasingly comfortable discussing the connection between periodontal disease and systemic health. Today, the relationship between inflammation, cardiovascular disease, diabetes, and oral health is woven into everyday clinical conversation. It’s no longer controversial, it’s part of the profession’s collective understanding.
Yet another disease process affects nearly every dental practice every day and somehow remains largely confined to discussions about restorations, fluoride, oral hygiene, and insurance codes: dental caries.
Michael Ventriello.
That disconnect struck me while preparing for this conversation with Dr. Brian Novy. We routinely describe caries as the world’s most prevalent chronic disease, yet we seldom ask whether it might also tell us something about the patient’s overall biology.
Could recurrent decay be more than a localized dental problem? Could it be an early indicator of systemic imbalance? And if so, are we still approaching it with a 20th century mindset while the science quietly moves in another direction?
Dr. Novy has spent much of his career challenging accepted thinking in cariology. As president of the National CAMBRA Coalition and one of dentistry’s leading advocates for minimally invasive care, he has never been particularly interested in protecting conventional wisdom. He is far more interested in asking whether conventional wisdom still deserves protection.
Our discussion quickly became too expansive for a single Dental Duets column. Rather than condense it, we’ve divided it into two conversations.
In this first installment, we explore why dentistry may need to rethink the biology of dental caries itself, from dysbiosis and saliva to disease management and the rapidly evolving understanding of the oral microbiome. In Part 2, we’ll examine what those ideas could ultimately mean for medical collaboration, prevention, innovation, and the future of dental education.
Whether you agree with every conclusion Novy reaches is almost beside the point. I believe the questions themselves deserve our attention.
Michael Ventriello: We’ve spent decades talking about periodontal disease and systemic health as though they’re inseparable. Yet the conversation almost never extends to dental caries. Are we overlooking something important?
Novy: I believe we are. Periodontal disease has received enormous attention because it’s a recognized specialty, and researchers have done an outstanding job identifying many of the organisms involved. But when you examine the broader medical literature, Viridans streptococci -- organisms traditionally associated with dental caries -- appear repeatedly.
The larger issue is that we’ve become comfortable placing bacteria into neat categories like “periodontal” and “cariogenic.” Nature doesn’t organize biology that way. These are oral microorganisms living within the same ecosystem, influencing the same host. The distinctions we’ve created are useful academically, but they can also limit how we think about disease.
That may be one reason the conversation around caries has remained narrower than it should.
Has dentistry become so procedure-oriented that we’ve started treating caries primarily as something to restore rather than something to manage?
Dr. Brian Novy.
I think that’s exactly what happened. Historically, medicine recognized the relationship between diet and oral disease very early. Somewhere along the way, however, dentistry shifted its attention from prevention to procedures.
The economic reality didn’t help. Procedures generate revenue. Prevention is often viewed as something that reduces treatment opportunities. Too often the question becomes, "How does a dentist make money with healthy patients?"
That’s an unfortunate way to think about healthcare, but it’s influenced our profession for decades.
Many clinicians still describe tooth decay largely as a hygiene issue. Others see it as evidence of broader biologic dysfunction involving saliva, diet, medications, and the microbiome. Which view do you subscribe to?
Without question, the second view. One of my concerns is that many dental students still graduate believing caries is essentially Streptococcus mutans eating sugar while fluoride attempts to interrupt the process.
I don’t fault the students. Dental schools are primarily training surgeons, and that’s an important responsibility. But I believe we’ve emphasized dental materials science far more than biological science.
Understanding disease biology has to become just as important as understanding how to prepare and restore a tooth.
The more we talked, the more the discussion drifted from teeth and toward physiology, dry mouth, diabetes, polypharmacy, sleep disorders, and endocrine function. None of those subjects typically appear in conversations about “cavities.” Perhaps they should.
When does caries stop being a dental problem and become a medical one?
I would argue it’s a medical issue from the very beginning. I subscribe to a systemic theory of dental caries. Carbohydrates still fuel the disease, but that’s only part of the story. Sucrose influences the biochemistry of the hypothalamus, which affects the endocrine communication between the brain, the salivary glands, and the odontoblasts.
When that system becomes disrupted, susceptibility to caries changes. The biology is much more sophisticated -- and much more modifiable -- than simply saying bacteria consume sugar. That’s why I believe cariology deserves a broader medical perspective.
If that’s true, the logical implication is that intervention should begin long before a dentist reaches for a handpiece. Can clinicians realistically detect and reverse cariogenic activity before drilling becomes necessary?
Absolutely, but only if we first understand why the microbiome became dysbiotic. Is the patient’s saliva modifiable? If not, how do we reset the microbial community so it becomes symbiotic again rather than destructive?
People often joke that everything begins with a caries risk assessment because it’s become such a familiar phrase. But it really does. Once you understand saliva quality, microbial ecology, and patient behavior, you can develop a therapeutic strategy that patients are actually willing to follow.
Only after disease is under control do I feel comfortable investing in more expensive definitive restorations. Until then, I’ll often stabilize teeth with glass ionomer. Many of those restorations perform remarkably well for years because the underlying disease process has finally been addressed.
Final thoughts
For decades, dentistry has described plaque as biofilm. Novy believes that description itself may eventually prove incomplete. That observation sets the stage for one of the most thought-provoking sections of our conversation, which will be continued in Part 2 of this Dental Duets conversation with Dr. Brian Novy.
Michael Ventriello is widely regarded as the "Dental Product Launch Expert" and is the owner and founder of Ventriello Communications and the co-founder and chief communications officer of the Personify Group. Ventriello is an award-winning copywriter, a former journalist, broadcaster, and frequently published author and dental industry pundit. Connect with him on LinkedIn.
Dr. Brian Novy is a nationally recognized expert in cariology, preventive dentistry, and evidence-based oral healthcare. He serves as president of the National CAMBRA Coalition and holds faculty appointments at the Harvard School of Dental Medicine and other leading institutions. Novy has served on the ADA Council on Scientific Affairs and as a consumer representative to the U.S. Food and Drug Administration's Dental Products Panel. Novy is also the cariology and preventive dentistry adviser for Personify Group.
The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.
