Nothing Hurt, and the X-Ray Found Four Cavities

Quick answer: Decay between the teeth cannot be seen by looking, and it does not hurt until it reaches the nerve. Bitewing x-rays are the only way to find it early, which is the entire argument for taking them when nothing appears to be wrong.

The call

"Do I really need x-rays if nothing hurts?"

It is a reasonable question and it deserves better than a shrug. Meir, 33, from Neve Shamir, had not had any taken in about seven years. He brushed twice a day, had no symptoms, and his teeth looked fine — which they did, because the surfaces you can see were healthy.

He agreed to two bitewings, which take about ninety seconds.

What we found

Four lesions, all between the teeth, all invisible on examination.

Two were through the enamel and into dentine — restorable now, and past the point of reversal. Two were confined to enamel, which meant they could potentially be arrested rather than drilled.

Why this decay hides. The contact point between two adjacent teeth is a sheltered area a toothbrush bristle physically cannot enter. Plaque sits there undisturbed. The decay starts on the side wall of the tooth, beneath the contact, and progresses inward through the enamel with no visible change on any surface you can see and no sensitivity, because enamel has no nerve supply.

By the time such a lesion becomes visible as a shadow or a hole, it has usually undermined a large volume of dentine. By the time it hurts, it has reached the pulp — and the conversation has moved from a filling to a root canal.

What a bitewing shows. The x-ray beam passes horizontally through the contact areas, and decay appears as a dark notch in the enamel because demineralised tooth absorbs less radiation. It is a straightforward image to read and it shows what nothing else can.

The radiation question, since he asked it. A pair of bitewings delivers a dose comparable to a small fraction of what everyone receives from natural background radiation in a day or two, and modern digital sensors need considerably less than film did. The interval should be based on risk — someone with active decay needs them more often than someone with none — but "never" is not a defensible interval for an adult with contacts between the teeth.

Seven years is a long gap. Two of his four lesions would have been enamel-only had they been found at four years.

What we did

The two dentine lesions restored with composite, conservatively, accessing through the biting surface and removing only what was decayed.

The two enamel lesions not drilled. Enamel-only decay between teeth can remineralise. We used high-fluoride toothpaste, fluoride varnish, and — the decisive change — interdental cleaning at those specific sites. Drilling a tooth that could have healed is a permanent decision made unnecessarily.

Interdental brushes, sized individually, daily. He had never used anything between his teeth, which is precisely why all four lesions were in that location.

Repeat bitewings at twelve months to see which way the enamel lesions had gone.

The outcome

At twelve months both enamel lesions were unchanged — arrested, not progressing. At two years, still stable, and no new lesions anywhere.

Two fillings he needed, and two he avoided by being told the difference.

What to do if this happens to you

1. Accept x-rays at a sensible interval, even with no symptoms. This decay is invisible otherwise.
2. Ask what the interval should be for your risk, rather than accepting a fixed rule.
3. Clean between your teeth daily. Brushing does not reach the contact areas at all.
4. Ask whether a lesion is in enamel or dentine. Enamel lesions may not need drilling.
5. Do not wait for pain. Pain from decay means it has reached the nerve.
6. Ask to see the x-ray. Interproximal decay is visible to a patient once it is pointed out.

Overdue for x-rays? Ramat Beit Shemesh Urgent Dental Care sets intervals by your actual risk. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh

This is a composite clinical story. It reflects a presentation we see regularly in Beit Shemesh and Ramat Beit Shemesh; the name and details are illustrative and are not those of a real patient.