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Who can forget January 1^st, 2021 when the entire world exclaimed in one unified voice, “Hallelujah!  2020 is over!”  OK, maybe not, but most of us were thinking it.  Agreeably 2020 was pretty awful, with the COVID pandemic, social unrest, and economic worries making all the headlines.  And while it’s good to have 2020 in the rear-view mirror, I have some bad news for you: 2021 wasn’t much better and 2022 isn’t exactly off to a great start.

Recently I wrote an article about bruxism, or clenching and grinding, and how to manage it, from home care techniques to professionally-made custom appliances.  I wrote that article because of the increase in bruxism we’re seeing as a profession due to stress.  Worn teeth, broken teeth, and noises in the jaw joint are some of the signs and symptoms, but unfortunately these are the end effects.  Damage such as this only appears after the bruxism has been going on for a while, and the damage can be expensive to treat and often irreversible.

Fortunately, there are some early signs that can be surprisingly reliable.  Just like any early warning sign, they need to be taken in context and are not a guarantee of an underlying dysfunction, nor is their absence a guarantee of health.  Here are some simple things you can do right now to see if you might be having an issue.

Any Scouts out there?

 With either hand, hold your pinkie down with your thumb and keep the other three fingers lined up against each other (this is the ‘scout sign’ that scout leaders display to get the troop to quiet down, which never works so is followed with a shout of “QUIET!”).  Now, with your fingers aligned vertically, open as wide as you can and try to fit your fingers between your front teeth.  This technique is a rule of thumb for how wide the jaw should be able to open.  Any tension in the joint or muscles will lead to restricted opening and not allow enough room for all three fingers.

This maneuver assumes no prior jaw injury or issues that limit jaw movement.  Keep in mind, you should never get to the point of eliciting pain or risking further jaw injury when performing this test.  Every jaw movement, whether a measurement test, stretching exercise, or regular function, should remain within the envelope of comfort.

Stick your tongue out

Standing in front of a mirror, stick your tongue out and look at the sides.  If you see indentations that run from the back, around the tip, and over to the other side, you are seeing a common sign of bruxism.  Clenching and grinding often involves thrusting of the tongue forcefully into the teeth.  This thrusting will lead to indentations, called scalloping, that will persist for hours, even days.

Any extra jawbone?

While you’re in front of the mirror, pull your cheeks out and look at the sides of your upper teeth and the gum tissue above.  The teeth and gums should form a relatively straight line all the way up; repeat this observation for the lower jaw.  However for some people the bone will display a bulged-out appearance.

The bone in your system is not static.  Your body will build bone where it is needed, and take it away where it is not.  Clenching and grinding creates extra forces on the teeth, which is transferred to the surrounding bone, and the body responds by strengthening the bone to compensate.  This extra bony growth in the jaw is called an exostosis and is a fairly common, benign condition.  Many people will have these bony growths for no discernible reason, so the important factor here is if the growths are new or getting bigger.

Any of the findings listed here warrant a discussion with your dentist.  Growths of any kind in your mouth should be professionally evaluated, and while they are often benign, only your dentist can rule out a more serious condition.

When is your next cleaning appointment?

 Think about your upcoming cleaning appointment.  (Assuming you have one scheduled.  If you don’t, you know what to do.  Yes, now.)  Think about staying open so the hygienist can get things sparkly and fresh again.  How do you feel right now?  Is your jaw already starting to ache?  Are you thinking of excuses for rescheduling?  If your jaw gets sore from being open for a routine cleaning, there is a significant likelihood that clenching or grinding is the culprit.

Believe it or not, many people actually enjoy going to the dentist for a cleaning.  If dental visits often lead to jaw soreness, request a ‘mouth prop’ next time you’re in.  This simple device keeps your jaw open, allowing you to relax and take the pressure off the muscles and joint.

In my experience, about half of people who clench and grind their teeth are aware of it.  I tell my patients that simply recognizing it is 50% of the battle.  Just like any health condition, early diagnosis and treatment are critical to a successful outcome.  Most people are rightly concerned about the damaging effects of tooth decay, but through clenching and grinding, we can actually cause just as much damage to our dentition as the bacteria in our mouth.

– Dr. McGann

In poll after poll, health insurance is one of the prominent issues on the minds of Americans today.  “How do I get it, how much does it cost, what does it cover, and who do I have to see” are the common questions people have.  While politicians struggle to come up with something that makes everybody happy (when has that ever happened?), almost lost in the shuffle is the sub-category of dental insurance.

Created in the 1950’s in Washington as a way to boost the dental business in the Seattle area, the first dental plan was offered to a local union as part of their larger benefit package.  The benefit proved popular and soon expanded across the region, eventually becoming the Delta Dental we know today.  Dental coverage soon assumed its regular role among the other employee offerings, with health insurance taking center stage, and dental and vision as more of an “Oh yeah, that too.”

In very simplified terms, medical insurance kicks in after you pay your initial healthcare costs up to a set amount (your yearly deductible), while dental insurance pays expenses right away up to a limit (your yearly benefit), then you’re responsible for everything after that.  Financially speaking, medical insurance therefore works best for those who are ‘high users,’ while dental insurance works best for those who are not.  Given this limitation, how can you make sure your dental coverage is working for you?  Here are a couple suggestions:

1. Use it or lose it.

The standard yearly benefit I see is $1,000.  This will typically cover your preventive work with some left over to go towards a couple fillings or a crown.  Don’t need any fillings or crowns?  You and I are happy about that, but your insurance carrier is absolutely thrilled.  Why?  They just collected a year’s worth of premiums without paying out much in return.

What if you have one older filling or crown that should be replaced?  Your insurance will still kick in whether you do it now or later, so there’s really no difference from a benefits standpoint.  The risk comes if you put it off too long; what may be just a new filling or crown now could become a bigger, and more expensive, project down the road.

What if you have multiple fillings or crowns that are breaking down and in need of replacement?  This is where most people go wrong.  In a perfect world, one crown/filling would fail per year, making things regular and predictable, and enabling you to maximize your insurance benefit.  Unfortunately, dental problems aren’t regular and predictable, which makes them random and not held to any logical pattern.  This is known as the law of randomness*, and it governs events such as coin flips, lottery drawings, and celebrity relationships.

Your insurance company knows this, and is in fact banking on it.  Literally.  By delaying multiple projects you are increasing the chances of groupings, or multiple issues occurring in any one year.  Don’t relinquish control of your oral health status to luck.

2. Or don’t use it at all.

If you get dental insurance through your employer, chances are they are paying a portion of the premium.  A disturbing trend I’ve seen lately is employers going with cheaper plans as part of a cost cutting measure.  Since so much of the benefits focus is on health coverage, changes to dental coverage often go overlooked.

Many dental offices are now offering in-house discount plans for patients with poor or no dental insurance.  The plans usually take the form of a flat yearly amount to cover preventive care and a percentage discount on dental work.  While there will be variations from office to office, I have noticed that these in-house plans are sometimes better than the dental insurance offered by employers.  There are four parties affected by a dental insurance plan: you, your employer, the insurance provider, and your dentist.  The employer and the insurance provider do the negotiating, and you and your dentist have to live with the results.  Just because your employer offers it, don’t assume it’s the best option.

With the new year underway, it’s a great time to take a look at your dental coverage and see what makes sense.  Talk to your dentist and review what work he/she is recommending and how urgent it is.  Taking care of your dental work in a planned and orderly fashion puts you in control; waiting until something breaks puts your teeth in control.  And in my experience, teeth just seem to have a knack for knowing when you’re on vacation.

Dr. McGann

* I’m not sure this is actually a law but it should be.

Most dentists have a license with the DEA to prescribe medications related to the work they do.  The most commonly-prescribed drugs are antibiotics, but next on the list are medications to control pain, or analgesics.  Included in the list of analgesics are the common over-the-counter types such as ibuprofen (Advil) or acetaminophen (Tylenol), but sometimes these are mixed with an opioid such as hydrocodone or oxycodone to give them a little extra ‘kick’.

Any medication will have its primary, or ‘desired’, effect, but they all have secondary, or ‘side’, effects as well.  Often these side effects are minor and manageable, but the side-effect profile of opioids is different.  While helpful in controlling pain, opioids are also known for creating a euphoric feeling in the user.  While at first blush this might not seem all that bad, the euphoric effect can become addictive, and as time goes on, more and harder drugs are required to achieve it, often causing the sufferer to do anything to get it.

So if opioids are such a problem, why are we still prescribing them?  The simple answer is, for severe pain, we just don’t have anything better.  All prescribers are trained in the dangers and judicious use of opioids, but often they’re given out routinely, even when not warranted, and in excessive quantities.  In fact, numerous studies have shown that the best medication for mild to moderate pain is ibuprofen.  Yep, regular old Advil.  Opioids can help with an extra boost for severe pain, but in the vast majority of situations, Advil (or Motrin or one of the generics) is all you need.

No doubt you’ve heard about the ‘opioid crisis’ that is ravaging parts of America.  With all the other illegal drug choices out there, you may wonder why someone’s pain medication is suddenly such a problem.  Hard drugs can be expensive, hard to come by, and have a dangerous reputation, but oxycodone might be sitting right in the home medicine cabinet.  And after all, it’s just pain medication, right?

Opioids are derived from the resin of the opium poppy; in other words, they’re all chemically-modified versions of heroin.  Those facing addictions tend to move up the ladder of whatever they’re abusing: alcoholics move from beer to liquor, gamblers move from casinos to online, and opioid abusers move from Vicodin or Percocet to morphine, fentanyl, and heroin.

And when it comes to ranking dangerous drugs, heroin is king.  It has the highest addiction potential and causes more health damage than anything else out there.  Health effects include nausea, cognitive impairment, constipation, respiratory depression, coma, and brain damage.

You may be wondering “This sounds like a medical problem, why is a dentist telling me this?”  It turns out that dentists are responsible for roughly 12% of all opioid prescriptions in the US, and dentists (and oral surgeons) are the top prescriber of opioids for patients under age 19, often related to wisdom tooth extractions.  Therefore the DEA and other governmental bodies are appealing to all healthcare providers to be much more selective in their prescribing habits.

In the future, expect your providers to ask more questions and prescribe opioid pain medications in smaller quantities.  In situations where one might expect to get a prescription for Vicodin or Percocet, your provider may just recommend an over-the-counter product.  Finally, if you have any unused pain medication sitting around in your house, take it to the nearest sheriff’s office for disposal.  For more information, in Washington County visit www.co.washington.mn.us/meds.

For some, an experience with opioids can become the ultimate toxic relationship.  They start out as a friend by providing pain relief, then comes the addiction, and eventually they can ruin one’s life, or even end it.  While opioids can be helpful, they are definitely not your friend.  Just like the axiom pertaining to fire, they make a good servant but a terrible master.

Dr. McGann

1.  We’re looking at more than just your teeth.

A significant portion of our dental school education is spent on head/neck anatomy and pathology (diseases).  Each time you come to see us we’re looking for anything out of the ordinary in our field of view, which includes all of the tissues in and around the mouth.  Some of the more common conditions we see are cold sores and canker sores, but over the years I’ve found cancer, such as squamous cell carcinoma in the mouth and basal cell carcinoma on the face, thyroid disorders, and non-dental infections.  On X-rays we can identify cysts and other abnormal growths in the jaw, and I will occasionally see plaques forming in the carotid artery in the neck.  By seeing your dentist twice a year, these medical conditions can be discovered early and referred for treatment in a timely fashion, greatly increasing the chances of a successful resolution.

2.  Yes, even we get cavities.

Contrary to popular opinion, we weren’t born with a mirror and a drill in our hands.  Some of us didn’t even know we wanted to be a dentist until well into adulthood.  That left all of our formative years to collect fillings and crowns that we still carry with us today.  Eventually those fillings and crowns will need to be repaired or replaced, sometimes starting with the formation of a cavity around them.

As of this writing the World Cup Soccer tournament is wrapping up, and for the sake of a timely analogy, fighting the bacteria in your mouth is a lot like a game of soccer.  You can play an entire game of good defense and not give up a goal, then have just one lapse and the opponent scores on you.  Bacteria in your mouth can sit there for years, even decades, just waiting for that opportunity to score.  Often that opportunity comes in the form of an old filling or crown breaking down, which is all the bacteria needs to start a cavity.  Oh, that reminds me: soccer players should wear mouthguards.

3.  We really do want you to have a healthy mouth.

The patients who regularly need new crowns or fillings can certainly keep our chairs full, but what gives us the most satisfaction is bringing someone to a state of health and helping them stay there.  There will never be a shortage of cavities, chipped teeth, and toothaches to keep us busy, so we’re not really worried about running out of things to do.  Helping someone achieve a healthy, pain-free mouth and the confidence to smile again is the best part of what we do.  Talk to your dentist about what you’d like to achieve and he/she should be excited to help you get there.  Remember: we’re on the same team.

Nearly all of us have had a door at home that just doesn’t want to stay shut.  You close it, and it pops right back open, almost as if it’s mocking you (maybe the faint “creak” in the hinge is laughter).  Anyhow, we usually ignore it until it becomes annoying enough that we decide to investigate.  The problem is that the door latch (the springy metal cylinder that sticks out of the door) doesn’t engage in the catch (the hole in the door frame).  Either due to faulty installation, humidity, or old age, the door latch is usually below the catch when the door is closed.

A proper fix would require time and tools, so the interim “solution” is just to yank up on the door and voila!  The latch goes into the catch and the door stays closed!  This workaround does the trick well enough, but the door and the hinges suffer the consequences.  Each time the door is closed in this manner the bottom hinge gets pulled out, the top hinge gets pushed in, and the door rubs on the frame.  Do this enough times and things start to loosen up, wear down, and eventually fall apart.

Enter the analogy: Your jaw works the same way in that the jaw joints function as hinges, the jaw bone represents the door, and the teeth represent the latch/catch system.  When everything functions properly together, we say they are in ‘harmony.’  How do things get out of harmony?  The problem almost always starts with the teeth.

The best way to simplify any complex problem is to remove, or neutralize, one of the factors.  While I don’t advocate extracting teeth to solve jaw problems, luckily I already have a number of patients without teeth (lucky for me, maybe not them).  And over the years I have found that, by and large, people without teeth do not have TMJ problems. 

The hallmark treatment for TMJ problems is a rigid plastic device that fits over the teeth (top or bottom) called a nightguard.  While nightguards do a good job of managing the symptoms, if you remove the appliance, the symptoms eventually come back.  So maybe we should stop viewing nightguard appliances as solutions and more so as diagnostic tools and adjunct therapies.

Just like our door analogy where the hinges can loosen and the frame can wear down, the jaw/joint system can suffer damage from repeated trauma.  In the early stages this is just inflammation or other reversible changes, and nightguards can be helpful in restoring the joint to a state of health, a condition which is necessary before any definitive treatment can begin.  If the trauma continues, permanent damage can occur and treatment can be more complicated.

If you suffer from TMJ problems, remember that effective treatments are available and you can get relief.  It is important to seek help right away, before the symptoms become intolerable.  A good option for immediate relief is a boil-and-bite product available at the drug store.  Avoid chewy foods and gum.  The natural rest position for your jaw is where your teeth are slightly apart and your tongue is on the roof of the mouth.  Practice this.  A lot.  Throw in some active jaw stretching (don’t use your hand to pull or push the jaw) and apply a warm, moist towel when you can.

Schedule an appointment with your dentist for an evaluation and make sure you understand the treatment plan.  Treatment will likely involve an appliance of some kind to get the symptoms under control and reduce inflammation.  If there is permanent damage, treatment can still be effective but it may take longer and involve more modalities.

Remember that the jaw/joint/teeth system is fundamentally a mechanical system, and any treatment plan that ignores the mechanics is missing the forest for the trees.  Your treatment plan should include a thorough evaluation of your teeth and bite; only then can the primary cause of most TMJ problems be identified and remedied.

Dr. McGann

Headahces.  Jaw pain.  Aching teeth.  Stiff neck.  Popping and clicking noises.  Migranes.  Anybody who suffers from jaw joint (TMJ) issues has had one or more of these symptoms.  They can be aggravating, progressive, destructive, and sometimes even debilitating.  My patients will ask, “It’s just one small joint, why does it cause so much trouble?”  The answers they get, from various providers they’ve seen, can often be confusing, complicated, and conflicting.  So let’s take a look at this mysterious joint and see if we can shed some light on why it causes so many problems for so many people.

The joint itself is pretty simple; the top of the mandible (lower jaw) forms a “head” and fits into a socket in the base of the skull, about 1cm in front of the ear.  Between the head of the mandible and the socket is a cartilage disk that provides cushion and friction-free movement.  Muscles attach to the mandible to move it in different directions (this is how we talk and chew), but muscles and ligaments also attach to the cartilage disk to try to keep it in the right position (like a “hat” sitting on the “head”) as the mandible moves around.  When the head of the mandible is fully seated in the socket and the cartilage disk is properly between them, the TMJ is in its “happy place.”

Seems pretty simple, so how do things go wrong?  It turns out the TMJ is rather unique in three key respects, and it is these unique attributes that can lead to trouble.  First, the TMJ isn’t one joint, it’s actually two joints (the left and the right) operating on one bone.  Since the skull and mandible are rigid, anything that happens in one joint directly affects the other.  In an ideal situation, the two joints work in coordination to perform the jaw’s various functions, but the rigid connection between the two can often result in excessive and unnatural forces on one side or the other.  For example, if you were to bite into something chewy on your right side, you might think this would put pressure on the right TMJ.  In reality, the biting force is actually borne on the teeth on the right side, and it’s the left TMJ that has to shift out of its “happy place” while bearing the biting force.

The second difference is that the jaw joint actually performs two different movements.  When you open slightly, the head of the mandible simply rotates in the socket.  When you open fully, like when yawning, the head of the mandible actually slides down and forward; in other words, out of its happy place.  This movement itself isn’t problematic, but this position is inherently unstable, and if a strong biting force is applied, the disk can get pulled out of position causing discomfort and damage.

Lastly, the mandible is the only bone that locks into a very specific position, i.e. when the teeth come together.  Ideally, the teeth will fit together perfectly when the two TMJs are in their happy place.  The problem is this is seldom the case.  Teeth move and shift, sometimes intentionally with braces, sometimes all by themselves.  The teeth themselves can change, such as when fillings or crowns are done, but sometimes just with wear or breakage.  When changes like these occur the jaw then has to shift to get the teeth to come together comfortably, and the joints are then locked into an unnatural position.

I refer to this last issue as a bite discrepancy.  And while all three items can certainly contribute to TMJ problems, a bite discrepancy is usually the one that starts the dominoes falling.

Dr. McGann

Part 2 will cover why this is and what to do about it.

Ah, sugar.  What a wonderful, simple little substance that makes our world so much sweeter.  It adds flavor and energy to our food; yeast turns it into fuel for our cars and alcohol for our drinks; bees seek it out and pollinate our plants in the process; it’s plentiful, cheap and ubiquitous.  Some say oil powers the modern world, but I claim sugar is king.

Just about everything alive produces, uses, or consumes sugar, from the largest animals to the smallest microbes.  Sugar is the fuel that bacteria use to produce acid, the source of tooth decay.  The world has known about sugar’s effect on teeth for decades, but it wasn’t until a new process for the cheap and efficient production of high-fructose corn syrup in 1957 that the damaging effects of sweeteners moved from the mouth to the whole body.  High-fructose corn syrup was rapidly introduced to processed foods and beverages throughout the 70’s and 80’s and Americans couldn’t get enough.  (For the purposes of this article, sugar refers to refined sugar, high-fructose corn syrup, and other natural sweeteners)

Statistics from 2016 say we consumed 120 million tons of sugar worldwide, or roughly 40 pounds per person.  That’s around 1/3 to 1/5 of average body weight.  In sugar.  That rate is growing, too, at 1.6% per year, which is higher than the world population growth rate of 1.1%.  When sweetened foods and beverages first came on the scene it was thought the worst effects sugar caused were cavities and hyperactivity.  Easy solution: just brush your teeth and exercise regularly and no harm done!  Keep that sugar coming!  All was well and good until people started to take notice of some troubling health trends.

In 1960, before the sugar craze got started, the type II diabetes rate in the U.S. was less than 1% of the population.  Today it’s 9.3% and growing.  In 1975 the obesity rate was around 12%, over the next twenty years it shot up to 25%, today it’s over 35%.  Is sugar the culprit?  The science is starting to say yes, at least in part.  Sugar = calories, and that’s pretty much it.  There is no nutritional value.  Calories = energy.  Back in the good old days when we were chasing animals around for dinner, or animals were chasing us around for dinner, energy equaled survival.  Your body therefore placed a premium on energy, and stored it any chance it got in the form of fat.  Today we are dealing with two harsh realities: we really don’t need sugar anymore, but we still want it; and our body doesn’t have an “off” switch for energy storage.  As long as the calories keep coming in we will keep storing the extra energy in the form of fat, until it kills us.  Literally.

“So, too much sugar causes weight gain?  I already knew that!”  Here’s where the new science comes in.  It turns out sugar has other, more subtle effects, even in people considered “normal-weight.”  Too much sugar can cause fat to accumulate in the liver and other organs, not just the belly, which can affect their function.  Sugar has also been linked to higher levels of cholesterol and heart disease, cancer, insulin resistance, cardiovascular disease and liver disease.  Newer studies suggest an effect on decreased immune function, accelerated aging, and cognition in children.  Oh yeah, and tooth decay.  Let’s not forget that.

So what’s a society to do?  The two main avenues are educate and legislate.  Education is the first and best option, but it takes a lot of time and money and participation is still voluntary.  Just look at the anti-smoking campaign; it’s made progress, but not nearly as fast as we’d hoped given all the time, effort and money put into it.  Nevertheless, education efforts regarding sugar consumption have already begun, focused on two key areas: The health dangers discussed above, and the ubiquitous nature of sugar in our everyday foods.

The two most common forms of sugar are the common granulated, refined variety, and the aforementioned high-fructose corn syrup.  What would you think if you saw “malted barley extract” on a label?  Sounds like it might even be something healthy, right?  Sorry, it’s just sugar in disguise by calling it something that sounds better, kind of like “pre-owned’ is the new term for used, “right-sizing” means layoffs, and an “opportunity to participate in the system” is paying taxes.  Almost makes you excited to pay taxes, right?  OK maybe not.

Other names for sugar on food labels include anything ending in –ose, cane juice, dextrin, caramel, diatase or diatastic malt, fruit juice concentrate, turbinado, ethyl maltol, honey, and anything containing syrup.  Sugar is present in high quantities in our granola/energy/snack bars, yogurt, ketchup and barbecue sauce, crackers, cereal, spaghetti sauce, salad dressing, bread, and packaged foods that advertise low fat content.  They have to make it taste good somehow, usually with sugar and sodium.

Just like the anti-smoking efforts started off with education and followed up with legislation in the form of taxation and banning smoking in restaurants, bars, and other public places, some municipalities have taken the next big step in the battle against sugar.  In 2015 the city of Berkeley, CA added a one-cent-per-ounce tax on sugary beverages, the first in the nation.  The rationale behind such a tax is two-fold: to improve the health of the community and to raise revenues.  The revenues come in immediately; any evidence on improvement in community health will have to wait.    It wasn’t without controversy, and was vigorously opposed by the beverage industry, but was perhaps viewed as an aberration in an otherwise liberal-leaning jurisdiction.  However other cities soon followed, many much larger, with similar measures recently approved in San Francisco, Philadelphia, Oakland, Denver and Seattle.

Once these cities started seeing the revenue benefits from the tax, larger localities became interested.  Cook county, IL, which includes Chicago and has a population of 5.2 million, recently passed its own soda tax, the first county in the nation.  Not to be outdone, the state of Massachusetts is considering a soda tax which could add as much as 2 cents per ounce.   As more and more governments see shrinking revenues and budget shortfalls, soda taxes start to look very appealing.

But is it the right thing to do?  Statistics show that the majority of sweetened beverage consumers are lower income, making a soda tax primarily regressive, something politicians are typically loathe to support.  Also, the question must be asked if the government should be in the business of trying to influence citizen behavior.  While these are important topics to consider, the reality is the government is already doing both in the form of tobacco taxes.

While not very controversial, and typically the go-to sin tax when governments need more money, ever-increasing tobacco taxes have indeed contributed to the steady decline in smoking rates in the U.S.  The next obvious question, and truly the foundational question of this debate, is whether sugar consumption rises to the level of tobacco use.  A decade ago this question would have seemed ludicrous; today it seems, well, still pretty ludicrous.  Surely no rational person would equate giving your kids a cookie with giving them a cigarette, right?  Or is sugar consumption the new social sin?

Experts at the World Health Organization (WHO) and the American Heart Association (AHA) are making the claim that “sugar is the new tobacco,” in the sense that Big Sugar is having its Big Tobacco moment.  So, no, a cookie is not as bad as a cigarette (they actually used to make candy cigarettes for kids, how could they have possibly thought that was a good idea?)  Nevertheless, the sugar industry has been put on notice.  The WHO and AHA support taxes on sweetened beverages, and their recommendations carry a lot of weight in public policy decisions.

Tobacco taxes made it through despite heavy opposition from the wealthy tobacco industry, in part because most of the population doesn’t smoke.  There just wasn’t that much uproar from the voters.  Soda taxes don’t have that luxury, which means politicians will often be hesitant to even discuss them.  Both sides have deep pockets and heavy hitters to bring to bear, notably Michael Bloomberg (a billionaire) on one side and Big Soda (a multi-billion-dollar industry) on the other.

So while the billionaires spend their millions it’s ultimately up to us (the thousandaires?) to decide.  And it’s a tough decision.  I think most people would tend to agree that those who make unhealthy nutritional choices should be the ones contributing more to our healthcare system.  The catch is that we will be allowing the government more taxes on us and more influence on our behavior, something I think most people would tend to oppose.

The soda tax measures that have passed in Seattle, Philadelphia, and Cook County are serving as a sort of “testing ground” on whether such taxes can be successful.  Governments across the country, from large to small, are assuredly watching very closely.  Chances are you don’t live in an area with a soda tax, but if they can survive the legal and political challenges in those areas then a soda tax may soon be coming to a city, county or state near you.

Will that eventually happen?  Soda taxes have some momentum, and there will surely be some defeats as well as successes for both sides along the way.  As more and more information comes out about the damaging effects of sugar on our overall health we may very well see a shift in public attitude.  So is sugar truly the new tobacco?  The world always needs a villain; a shadowy, wealthy enterprise pretending to be our friend but secretly enriching itself at our expense.  That villain used to be tobacco, but tobacco’s time in the spotlight is waning.  I think the public will need a new villain soon, and Big Sugar is the leading candidate.

Dr. McGann

A study was conducted recently where participants were asked a series of questions of varying difficulty, from easy (i.e. What is the capital of Minnesota) to difficult (i.e. What is the airspeed velocity of an unladen swallow).  Then they were asked to gauge the confidence in their answers, from ‘100% confident’ to ‘total guess.’  Of the answers they rated as 100% confident, they were still wrong 15% of the time.  While confidence is a good thing, overconfidence, or denying the possibility of error, is not.  We’re all human, we’re going to be wrong from time to time whether we want to admit it or not.

This example seems particularly applicable to the great amalgam debate.  On one side you have the medical research community that expresses confidence in their conclusions but is always open to more information, and on the other side you have the ‘amalgam haters’ that exude overconfidence and refuse to entertain any contrary opinions.  In my experience, alarmists, conspiracy theorists and doomsayers only see things in black and white, while realists see the world in shades of gray.  In other words, those who only deal in absolutes tend to rely on hype and fear to propagate their views.

The amalgam debate has mostly focused on its potential health effects.  For most people, in most situations, the evidence is pretty clear that amalgam fillings are not going to cause any health problems.  But health concerns are only part of the picture when it comes to the use of amalgam.  Another prevalent concern is environmental.  In 2009 Sweden banned amalgam altogether, along with other mercury-containing products, in a sweeping move to eliminate potential leaks into their ecosystem.  Will other countries follow?  Only time will tell, but the general trend is already moving in that direction, particularly in the rest of the EU.

Another concern is the long-term effectiveness of its use as a filling material.  The mouth is a rather hostile environment; constantly alternating between hot and cold, acidic and basic.  Restorations need to be done, and often eventually redone.  The battle for oral health is never won, only ongoing.

When an amalgam filling is placed there is a microscopic gap between the filling and the tooth.  Over the next month that gap is filled with “corrosion products” from the filing itself, much like rust forming on iron.  This gap is then sealed and for the next few years the amalgam is fine.  The problem is this corrosion process doesn’t stop, and that’s why your amalgam fillings, which started out shiny and smooth, are now black and pitted.  As time goes on new openings will develop which allow fluid (saliva) to invade.  This can eventually lead to stains, cracks in the enamel, and then decay.  At this point the filling has effectively failed and is actually doing more harm than good.

Thankfully technology has come to the rescue.  Newer bonded materials not only look better but last longer and contain no hazardous ingredients.  So why haven’t they supplanted amalgam entirely?  Simply: cost.  Amalgam is cheap, newer materials are more expensive.  While you want what’s best for your mouth, your insurance carrier usually wants what’s best for the bottom line.  Like it or not, in our current healthcare system, insurance companies are still driving the bus.

There are many factors in the great amalgam debate, and while advocates on both sides continue with their philosophical arguments, ultimately the driving force behind amalgam’s survival or demise may very well be money.  Perhaps we’d be overconfident to think otherwise.

Perhaps no other material in the healthcare industry is as controversial as dental amalgam.  Despite being used around the world for decades as the workhorse of dental restorative materials, it has been plagued with controversy from the beginning and accused of causing everything from sensitive teeth to insanity.  Still it has managed to survive, and to this day remains the most commonly-used dental filling material – by far.  Let’s take a look at what makes amalgam use so controversial, and how it has managed to remain so popular despite more advanced, and arguably better, materials being available.

The main ingredient in dental amalgam is mercury, representing about 50% of the makeup, with the rest being silver, tin, copper, and other trace metals.  Mercury, in its pure form, is extremely toxic and can cause damage to the brain, kidneys, lungs, and other systems.  Mercury in fillings is combined with other materials, or amalgamated, and thus not in its pure form.  So the big question is: how much pure mercury from amalgam fillings gets released into the body?

When an amalgam filling is placed, the material is mixed and adapted to the prepared tooth and allowed to set up.  During setting, the mercury bonds with the other ingredients and hardens, producing a durable, final restoration that “traps” the mercury and prevents its release into the body.  If the filling remains completely undisturbed then that would be the end of it, but it turns out that chewing causes a small amount of mercury to be released in the form of “mercury vapor.”

The World Health Organization (WHO) established the maximum amount of mercury the body can tolerate at 300-500 micrograms per day (a microgram, µg, is a millionth of a gram) and still have no ill effects.    As for the amount of mercury vapor released during chewing, the average person, with around five amalgam fillings, receives about 2 µg per meal.  Assuming three meals per day, that comes to about 6 µg, still well short of the WHO limits.

The experts therefore conclude, while admitting some mercury is released via chewing, that amalgam fillings are a safe and acceptable restorative material.  To bolster their claim, they cite numerous studies that have failed to show a link between amalgam fillings and various diseases.  Detractors contend that mercury is accumulative and no amount is safe to ingest.  They also cite their own anecdotal reports of people who have had their amalgam fillings removed and subsequently recovered from these afore-mentioned various diseases.

So who’s right?  Unfortunately, we will never know with 100% certainty.  Medical research doesn’t work that way; there are no absolutes.  And perhaps that’s the rationale behind some recent changes in the dental community’s attitude on amalgam, basically saying “We’re confident it’s safe, but why take any unnecessary chances?”  Recently, the FDA altered its position on amalgam by effectively saying that pregnant women and children under age 6 should consider other options.  While this might seem like a relatively innocuous statement, it actually represents a tectonic shift in the establishment’s position on amalgam.  For the first time they are saying that certain higher-risk individuals may be adversely affected by amalgam placement, or at the very least, they just can’t be sure.

For the rest of the post, check out Part 2 here.

Wow, now that’s quite a headline.  Am I really trying to tell you that your teeth can bring you the best that life has to offer and also the worst?  Yes, I am.  Why?  Because I see examples of this on a regular basis in my profession.  Your teeth are amazing little creations, something I’m sure only a dentist can truly appreciate.  But considering what they can do for us and do to us, sometimes others can appreciate this as well.

First, a caveat: the terms “best” and “worst” are highly subjective, especially when you’re experiencing one or the other.  I think the best way to illustrate these extremes is to tell a story of a patient I saw about seven years ago at an event in Minneapolis called the Project Homeless Connect.

I like to participate in volunteer events when I can, providing free dental care to those who can’t otherwise afford it.  We do what we can given the limits of our facilities, but mostly we’re dealing with pain and infection control.  With my surgical background I was placed on extraction detail.  My third patient of the day was Julia (not her real name).  Julia was 19 years old and she said she wanted all of her teeth out because she was in constant pain.  I was skeptical at first, usually dental pain comes from one source even though it might hurt all over.  We took some X-rays and I did an exam.

It turns out Julia had been on methamphetamine for the last nine months and had developed a condition called “meth mouth.”  She was finally drug-free by the time I saw her, but the damage had been done.   Meth causes dry mouth and paranoia; the dry mouth leads to heavy sugary soda consumption and the paranoia leads to teeth grinding.  In a very short time a person’s oral health can go from excellent to hopeless.  In Julia’s case I ended up extracting her remaining 31 teeth.

At this point in her life Julia had experienced the worst that her teeth could offer: constant pain, poor speaking ability, embarrassment for the horrible appearance, and shame for the lifelong reminder of the poor decisions she made.  At least she had taken the first steps to recovery, and the organizers of the event were going to make her a set of dentures.  The dentures will help restore her appearance and allow her to chew, but they are far from a perfect solution.  With no teeth she will continue to lose bone from her jaws, which will require new dentures as time goes on, with each set fitting more poorly than the last.

When it comes to chewing, tasting, and the overall eating experience, dentures perform about 25% as well as natural teeth, which is why I describe them as “a good option when there are no other options.”  The ability to chew, taste, and enjoy food is one of the most basic pleasures we enjoy.  People will go to great lengths and spend small fortunes to seek out the best restaurants, or to find the best ingredients and recipes for cooking at home, all for the pleasure of that perfect dining experience.  The most important meetings in our life are often centered around food.  The ability to properly chew, taste, and experience a great meal is one of the best things that life has to offer.

The last I heard Julia was a candidate for dental implants through a campaign called Donated Dental Services of Minnesota.  Implants will perform far better than dentures; they will allow her to chew more effectively, help preserve the bone in her jaws, and may last a lifetime with proper care.  I describe implants as the closest thing we have to natural teeth.

For Julia at least there’s hope, she may yet have the opportunity to restore what she’s lost.  Unfortunately I lost contact with her a while back so I may never know.  From the old saying “the best things in life are free,” it seems clear that the worst things in life can be extremely costly.

Dr. McGann

We all know why the dentist wants us to brush and floss regularly, but someday soon our family physician may be recommending this too, albeit for a different reason.  Recent studies are starting to build a link between your oral health and other conditions in the body, such as heart disease.

Physicians have long been concerned about bacteria in the mouth traveling to the heart or artificial joints and causing infections.  Anyone who has ever been told to take an antibiotic before dental treatment is aware of this.  Also, periodontal (gum) disease in pregnant women has been strongly linked to premature birth and low birth weight babies.

But can an unhealthy mouth be connected to other conditions such as heart disease, diabetes and stroke?  As of right now the research isn’t conclusive, but enough evidence exists to warrant further study and look for a definitive link.

And what might that link be?  Quite simply, inflammation.  Inflammation is divided into two types: acute and chronic.  Acute inflammation is the initial redness and swelling when you injure yourself, like when your shin hits the coffee table or you catch a cold.  If all goes well with the healing process, the body repairs itself or removes the invader, the inflammation goes down, and everything returns to normal.  Chronic inflammation is when the body tries to repair itself but can’t, either because it is overwhelmed or is somehow compromised, like if you kept kicking the coffee table every day, or your immune system can’t fight off the cold due to poor health.

In an effort to win the battle, the immune system gets cranked up and several new proteins are activated.  Some of the more common ones you may have heard of are interleukin 1 and C-reactive protein.  Now if these proteins simply stayed where they’re supposed to stay and did what they’re supposed to do, everything would be OK.  The problem is that they travel throughout the body and cause effects in other places, and it’s usually destructive.  Given enough time, their destructive effects can increase the risk of type-2 diabetes, heart disease, cancer, Alzheimer’s disease, rheumatoid arthritis, and other serious conditions.

So what does this have to do with your mouth?  If you’ve ever had bleeding after brushing or flossing, that is acute inflammation.  It probably won’t lead to any serious disease, but it is the first step in a more sinister process.  If your dentist has ever said you need a special cleaning because of deep pockets in the gums or signs of bone loss, that is chronic inflammation.

Heart disease is the number one cause of death in the US.  If something as simple as good oral care can help with prevention, I can’t think of a simpler, more cost-effective way to “defang” this killer.  Come to think of it, I’m willing to bet your family physician brushes and flosses every day and sees the dentist every six months.  Any takers?

Dr. McGann

About a year ago I began my Botox education, taking multiple classes over dozens of hours learning how and where to treat patients for wrinkles on the face.  However, when I first heard about Botox I was as alarmed as I’m sure most of you were: “You’re injecting what into your face?”  Still, the trend persisted, even grew, and as more research has come out as of late, the trend has absolutely exploded.

Let’s start with taking a look at what exactly Botox is.  Botox is the brand name for a type of botulinum toxin, the same kind that causes botulism, and is produced by a certain type of bacteria.  “Toxin” is a collective term for any substance produced by an organism that can cause harm in another organism.  “Venom” is an injected toxin (snakes, spiders, scorpions) while a biological “poison” is generally produced by plants and microorganisms (poison ivy, anthrax, botulism).  These substances are generally used for defense or to subdue prey.

Taking a tip from the Swiss-German physician Paracelsus, considered the father of toxicology, who said “Everything is a poison, there is poison in everything.  Only the dose makes a thing not a poison,” maybe these harmful substances can actually be helpful, if used in much lower doses.  And that turns out to be the case.  ACE inhibitors, useful in treating high blood pressure, were created after studying the venom of the Brazilian pit viper.  Exenatide, a diabetes drug that lowers blood sugar and increases the body’s production of insulin, is a synthetic version of a component in the saliva of Gila monsters.  And perhaps the best-known example, the discovery in 1928 of mold spores creating a toxin that killed bacteria, and the subsequent development of Penicillin.  Just like fire, they can be very helpful in small doses but dangerous when not controlled.  As the saying goes, fire makes a good servant but a terrible master.

Upon further consideration, perhaps a better definition of a toxin is something that alters normal physiologic function.  This removes the “good” or “bad” appellation and frees us up to consider these substances for medicinal use.  To alter an old cliché, perhaps “The devil is in the dose.”  Properly screening patients, careful monitoring of the administration, and used in measured doses, we can hope to harness the benefits of these substances while avoiding the harms.

Botox is a paralytic; it paralyzes muscles by blocking communication from the nerve ending.  In time, the nerve ending establishes a new connection and regular function returns.  In the case of facial muscles, this usually takes two to six months, with three months being typical.  The facial muscles, or the “muscles of facial expression,” are attached to the skin and allow us to smile, raise our eyebrows, squint, frown, and so on.  It turns out that these movements, done millions of times over the course of our lives, can cause regular creases to form in the skin.  These creases, or wrinkles, or “rhytids” (rye-tids) as they’re called in the medical community, are broken into two categories: dynamic and static.  Dynamic rhytids are present when the muscles contract, and go away when the muscles relax.  If the muscles contract enough times, over many years, these dynamic lines will become present on the skin even when the muscles are at rest, thus creating static rhytids.

As a general rule, Botox is used to treat dynamic lines.  Each treatment lasts around three months, with subsequent treatments lasting longer.  As for the static lines, you have two options.  With Botox relaxing the very muscles causing the lines, as time goes on, and with continued treatment, those static lines will begin to fade as the skin recovers.  However, if you want faster results, that is where dermal fillers comes in.

When you’re young you have a certain amount of fat under the surface of your skin to give the appearance of fullness, acting as a natural “dermal filler” and smoothing out wrinkles.  As you age, the fat in the skin decreases and the wrinkles that were once filled in now become more prominent.  Injectable dermal fillers are used to fill in these areas of static wrinkles to replace the fat that used to do the job.  Again, these usually last about three months and can last longer with continued treatment.

While treating facial wrinkles is probably the best-known use of Botox, it turns out it wasn’t the first, nor is it the only, by a long shot.  Allergan, the maker of Botox, used to make products specifically for the eyes, like contact solution and eyedrops.  In 1988, Allergan acquired the rights to a drug called Oculinum, used to treat people with strabismus, or lazy-eye, and renamed it Botox.  Shortly thereafter, some ophthalmologists began to notice that their patients were experiencing the side-effect of fewer wrinkles around the eyes.  Eventually in 2002 the FDA gave approval for Botox to be marketed for the treatment of facial wrinkles.  Demand soared, and in 2013 sales of Botox topped $2 billion, representing a third of Allergan’s revenue.

Right now Botox is known to help many conditions, and suspected to help in many others.   These include excessive sweating, overactive bladder, migraines, muscle spasm, depression, hair loss, abnormal heartbeat, cold hands, cleft lip scars in babies, acne, and many more.  Some are even calling it the miracle drug of this century.  As more uses continue to be discovered and more people are helped, that may indeed be the case.

Why should you see your dentist for Botox treatment?  Quite simply, we have extensive training in facial anatomy and we’re pretty good at giving injections.  I can’t say you won’t feel a thing, but we can make it as comfortable and quick as possible.  In areas involving the lower two-thirds of the face we can offer to anesthetize (numb) the area first, making the injections essentially painless.  Botox is considered extremely safe and the most common adverse reaction is a drooping eyelid, which usually improves in four to six weeks and is completely gone in three months.

My limits for Botox are based on my training: conditions that involve the muscles of facial expression.  Injection sites for esthetic treatment often overlap with injection sites for TMJ disorders and migraine headaches, and some patients have seen improvement in multiple areas with a single treatment.  Is Botox right for you?  Only a comprehensive evaluation can determine if Botox is likely to give you the results you desire.

Dr. McGann

Perhaps the most popular personal hygiene product in history is toothpaste, or at least some version of it.  Throughout the centuries different substances and combinations have been used, some based on science, some based on personal beliefs, and others based on superstition or just plain quackery.  Modern toothpaste is the result of years of scientific research and measured studies, but is still not without its critics and controversies.  The most common toothpaste brands and formulations all have the same basic types of ingredients, and in this post I attempt to break things down to provide a better analysis of exactly what we’re putting in our mouth every morning and night.

When looking at the ingredient list on a tube of tooth paste you’ll notice one or two active ingredients and a long list of inactive ingredients.  What you won’t see is a nutrition label as is present on all foods.  That’s because the FDA doesn’t consider toothpaste a food, in fact it is in the unusual category of a cosmetic and a drug.  The reason for this is that toothpaste is not meant to be ingested (granted that some will accidentally be swallowed or absorbed through the oral tissues during use).  Fluoride is very helpful in small doses but not so much in large doses, so it is important to emphasize spitting and rinsing afterwards, especially for kids.

The active ingredients are obviously doing the main job of keeping your mouth clean and healthy, but the inactive ingredients are there for a reason too.  It’s kind of like a chocolate chip cookie: the chocolate chips are the main attraction, but the rest of the cookie has its charms.  Anyhow, I’ll also cover the most common inactive ingredients and why they’re in there.

There’s a common misconception about how much toothpaste is really necessary to get the job done.  The advertisers would have you believe you need to squeeze out something that looks like a giant caterpillar.  Here’s the reality: the most you need is a dab no bigger than the size of a pea.  Emphasis on the no bigger than; kids need even less.  I heard a statistic a while ago that 97% of Visine ends up running down the side of your face.  Don’t commit the same crime with your toothpaste; if you see blobs of it in your sink when you’re done brushing, you’re using too much.

I’d like to make an important point at this … uh … point: when it comes to choosing the right toothpaste, you are not alone!  Your dental team is there to help find the best product based on your particular set of needs.  We even have access to products that can’t be purchased over the counter.  Also, if you are having issues such as tooth sensitivity, don’t rely on a toothpaste to mask the symptoms.  If your teeth are sensitive, there’s a reason.  Don’t be the person trying to fix the hole in their tooth with Sensodyne.

A final word before we get started: just about anything that is currently in toothpaste, or ever was in toothpaste, has come under attack from time to time as being useless to harmful to deathly toxic by one group or another (with the possible exception of water, but that’s probably just a matter of time).  I’m not an alarmist, but I will identify any potential controversies as we go through the list and try to provide some perspective.

So without any further ado, I present to you the:

Active Ingredients

Fluorides

I think it’s pretty well known that the main purpose of toothpaste is to give your teeth a good coating of fluoride when you brush.  When it comes to fluoride in toothpaste, the most common form is Sodium Fluoride, or NaF.  It’s effective, cheap, and doesn’t mess with the taste.  Some brands use fluoride in a different form, Stannous Fluoride, or SnF.  Stannous is the chemical name for tin.  Stannous fluoride is actually more effective at delivering the cavity-fighting effects of fluoride to the teeth and it also has been shown to help with sensitivity, but it’s more expensive, can produce mild staining, and can alter the taste.  For people who need a little extra help in keeping cavities in check or sensitivity control, finding a brand with SnF as opposed to NaF may be worth it.  Another less common form of fluoride is Monofluorophosphate, or MFP, and studies show it is equal to NaF in fighting cavities.

Antibacterial

Some brands include another active ingredient called Triclosan.  Triclosan helps control bleeding gums (gingivitis) by killing the bacteria that causes it.  Although effective in this role, there is some controversy as to its use in toothpaste.  The FDA has banned triclosan for use in hand wash products for two reasons: lack of proven efficacy and potential adverse health effects.  It is still allowed in toothpaste, and it is proven to help control gingivitis, but its effect on the rest your body is disputed.  Bottom line, if you don’t have a major issue with bleeding gums you may not notice any real benefit and it may be smart to stick to products without it.  Often included with triclosan is PVM/MA copolymer which simply helps it work better.

Zinc citrate is included in some brands to help control the bacteria that causes bad breath.  This is the same zinc citrate that is included in multivitamins.  Some brands use it alone or in combination with triclosan.  Studies show it works quite well.

Desensitizers

Just about all brands have a line of “sensitivity” toothpastes, with the most common desensitizer being Potassium Nitrate, or KNO3.  Potassium nitrate is useful ingredient in many products, including fertilizer, gunpowder, rocket propellant, and, of course, toothpaste.  It turns out the potassium part does the real work in reducing sensitivity and the nitrate part is just along for the ride.  That’s why you might see other potassium-containing agents such as potassium chloride (KCl) or potassium citrate used instead.  Science is still trying to figure out exactly how potassium works as a desensitizer and it turns out to be effective for some but not all.  Numerous other compounds are used to control sensitivity, usually in the form of something blocking access to the nerve by “clogging up” microscopic channels in the tooth structure, again with moderate and varied success.  In my experience, sensitivity products do work for most people, the key is to find a product or combination thereof that works the best for you.

Inactive Ingredients

Abrasives

Yes, there are abrasives in toothpaste, and yes, they can constitute up to 50% of the volume.  The abrasives help clean the teeth and allow the fluoride to do its job better, but typically are mild enough not to damage the teeth.  The most common abrasive is hydrated silica (or other silicas), followed by the carbonates – Sodium bicarbonate (NaHCO3 or baking soda), calcium carbonate (CaCO3) and magnesium carbonate (MgCO3), alumina and several phosphate complexes.  I’m not going to go into the specifics of each, but I will make some useful generalizations.

The enamel on your teeth is the hardest substance in the body.  Using the Mohs Scale of hardness (from 1 to 10, where 1 is talc and 10 is diamond), tooth enamel ranks a 5, about the same as glass.  Tooth enamel can generally hold up very well to any of the abrasives listed above during normal brushing.  However, the inner part of your teeth, called dentin, is much softer.  Dentin ranks a 2.5 on the Mohs Scale, and based on how the scale works, it means that dentin is about five and a half times softer than enamel.  If dentin gets exposed anywhere in the mouth it is susceptible to wear.  The most common path of exposure is gum recession; the exposed root surface is unprotected dentin and is very vulnerable to wearing away at an accelerated rate.

If you don’t have any gum recession in your mouth, or any areas where the enamel is worn away, abrasives shouldn’t be a concern for you.  For the rest of us, here’s what to look for.  The mildest abrasive on the list is sodium bicarbonate, or baking soda.  It still cleans your teeth effectively and will go gentle on your precious dentin.  Regular toothpastes without any “enhancements” (whitening, tartar control) will have relatively mild abrasives.  Whitening toothpastes will have medium-to-strong abrasives.  Why?  Basically what whitening toothpastes do is remove surface stains from the teeth, and in doing so, the teeth look whiter and shinier without any actual “whitening” taking place.  I’ll discuss whitening more later.  Toothpastes with the strongest abrasives are typically the tartar control varieties.  Tartar, also known as calculus, is the hard stuff that builds up on your teeth and needs to be removed by your hygienist.  Strong abrasives will help wear it down and limit its buildup, but they will also wear down anything that gets in their path, including exposed dentin.

A final note on abrasives:  One very easy way to limit the amount abrasives getting on your teeth is to use a very small amount of toothpaste.  Remember – pea, not caterpillar.

Surfactants/Detergents

These are ingredients to help the toothpaste “foam up” and spread out evenly over the teeth.  The same ingredients are often found in shampoo and some soaps.  The most common, and the most problematic, is Sodium Lauryl Sulfate, or SLS.  For people who tend to get mouth ulcers (aka canker sores) frequently, SLS may be the culprit.  Most manufacturers offer a line without any SLS for this reason.  Another less-common detergent is Cocamidopropyl Betaine which is derived from coconut oil.  I’ve never heard anybody say it causes mouth sores, probably because nobody knows how to pronounce it.

Humectants

A humectant is a substance that helps preserve moisture.  They are added to keep your toothpaste smooth and creamy (good) instead of dry and crumbly (bad).  Glycerin and sorbitol, both common food additives, are the most used.  Some of the abrasives, such as hydrated silica, also contribute to water retention.

Also often used is propylene glycol, a cousin of ethylene glycol which also known as antifreeze.  Propylene glycol is actually used in a similar fashion to de-ice aircraft wings or as an antifreeze in environmentally-sensitive applications such as boat engines.  Before you get too excited and try to sue Procter & Gamble for poisoning your mouth, you should know that you’ve likely been consuming propylene glycol in other products all your life.  The FDA has labeled it “generally recognized as safe” (GRAS) and it is used as an additive in ice cream and other frozen desserts, and in the pharmaceutical industry in making drugs such as Valium and Ativan and certain formulations of artificial tears.

The only real concern with propylene glycol is that some people develop an allergic reaction to it in the form of inflammation or redness, called a contact dermatitis.

Polyethylene glycol, another non-toxic version of ethylene glycol and often abbreviated as PEG-8 or PEG-12, is sometimes used as well.  PEG is normally used in medicine as a laxative.

Thickeners

Thickeners serve a similar role as humectants in determining the texture and viscosity of your toothpaste.  The most common ones are types of cellulose, which is the basic building block of all plants (think: wood).  Carrageenan (made from edible seaweed), carboxymethyl cellulose (CMC, also known as cellulose gum), and xanthan gum (made from the fermentation of sugars) are the most common.  Xanthan gum therefore may be derived from products to which some people may be allergic, such as corn, soy or wheat.  Other “gum” thickeners include guar gum and locust bean gum.

Sweeteners

Many of the above-mentioned ingredients in toothpaste provide some sweetening ability along with their main roles, such as sorbitol and glycerin.  Saccharin used to be commonly used in food as an artificial sweetener before suffering some bad PR and is now largely replaced by aspartame.  Still, it is considered very safe in small doses and is a common sweetener in toothpaste, especially since it’s not meant to be ingested.  A less common one is Potassium Acesulfame.

By far the best sweetener is Xylitol (pronounced zy-li-tol).  Xylitol is a natural sweetener derived from common plant sources.  Unlike artificial sweeteners, which have no calories, xylitol actually has 2.43 calories per gram (sugar has 3.87) but is considered safe for diabetics because its effect on blood sugar is minimal.  The best part of xylitol is that the bacteria in your mouth can’t process it, and it actually inhibits the growth of certain bacteria, providing a one-two punch in the battle against tooth decay.  The reason you don’t see it much in toothpaste is because it’s fairly expensive, but if you can find it it is an excellent choice.

One word of caution: xylitol can be fatal to dogs.  Come to mention it, fluoride is harmful to dogs too.  If you have a dog that will actually let you brush his teeth, they make toothpaste specifically for pets which can be found at most pet stores, in exciting flavors like poultry and bacon.

Whitening agents

As mentioned above, the primary method by which whitening toothpaste makes your teeth appear whiter is removing surface stains.  It accomplishes this through abrasives and other ingredients meant to dissolve common stains from foods and beverages.

The main ingredient in any true whitening product, or “bleaching” product, is hydrogen peroxide (or its more stable cousin, carbamide peroxide).  Toothpaste contains no peroxide (at least the ones I’ve seen) and therefore doesn’t do any true “whitening” of the teeth.

Tartar control agents

Names of tartar control agents take the form of __Sodium __Phosphate, such as pentasodium triphosphate or tetrasodium pyrophosphate.  Sometimes Calcium Phosphate is used instead.  Basically they act like the rock salt in your water softener.  Here’s how it works:  Your saliva contains a lot of minerals like Magnesium (Mg) and Calcium (Ca) that like to build up on your teeth, forming tartar (or calculus as it’s known in some circles).  Tartar makes a perfect home for bacteria, allowing them to set up shop and wreak havoc in your mouth.  Controlling tartar = controlling bacteria.  The __sodium __phosphate will interact with these minerals and prevent them from building up on your teeth, just like your water softener interacts with the minerals in your water and washes them down the drain, making your water “soft.”  Thus you could say that tartar control toothpaste is like “saliva softener.”  It works pretty well, too, if you can get past the taste.

Here’s the rub.  The minerals in your saliva, specifically calcium, play a role in “repairing” teeth in areas where a cavity is getting started.  The decay process starts when acid removes minerals from your tooth enamel, and the calcium in your saliva can bond back on and “heal” the spot.  However, if you’re using tartar control toothpaste, you’re removing calcium from your saliva and limiting your ability to heal those areas.  My recommendation: for patients who are more cavity-prone I usually try to steer them away from tartar control toothpaste.  For the rest of us it’s fine and probably helpful.

Polyethylene

Polyethylene is a fancy name for plastic.  Some manufacturers used to put tiny, colorful plastic beads in the toothpaste to enhance its appearance.  I’m not sure any of them do anymore.  You probably have the following questions:  Q: Do I need plastic beads in my toothpaste?  A: No, they serve absolutely no purpose.  Q: Then why are they in there?  A: To make your toothpaste look pretty.  Q: Does my toothpaste need to look pretty?  A: No, unless you’re using it to decorate a cake.  Q: So I can use toothpaste to decorate a cake?  A: No, toothpaste is not a food (see above).

Coloring Agents

The most common coloring additive is Titanium Dioxide (TiO2).  Although listed as Generally Recognized as Safe (GRAS) by the FDA there has been some controversy as to it possibly being a carcinogen (cancer-causing).  Titanium Dioxide starts off as a white powder and performs two main roles in the food and healthcare industry.  For food products it makes things white and opaque (non- see through) and is often used in frosting, powdered sugar and other candies and sweets.  It turns out that titanium dioxide also reflects the sun’s UV rays quite well so it is included in skin creams and sunscreen.    However we don’t want to be walking around with white, opaque lotion on our skin (I’m just making an assumption here) so they grind the powder into very, very small particles, called nanoparticles.  In this nanoparticle form the titanium dioxide still blocks UV rays but is now transparent (invisible) on the skin.

The nanoparticle form is also the potential cancer-causing form, but only when it’s a powder and inhaled into the lungs.  Bottom line, titanium dioxide is only potentially dangerous (speculation, not proven) in a powder form (which toothpaste isn’t) of nanoparticles (not used in toothpaste).  More research is needed and is currently underway, but at this point I just can’t justify being concerned about it.

If your toothpaste isn’t plain white then it’s probably some shade of blue, in which case the likely other color additive is FD&C Blue No. 1, also known as Brilliant Blue FCF, a very common food colorant.  The only concern ever noted by the FDA regarding its use is the potential for an allergic reaction in people with asthma.

Others

Flavorants: Various natural and synthetic additives, such as mint oil (often listed just as “flavor”).

Preservative: Sodium benzoate  (a common food preservative).

pH neutralizer: Sodium hydroxide (lye).

Granted there are likely other ingredients that have made it into a tube of toothpaste from time to time that are not explicitly listed here, but whatever they may be they would fall into one of the above categories.  I hope this article has been informative and provided some clarity in what to look for in a toothpaste.  If you have any questions, I’m certain your dental team will be happy to discuss further!

Patrick McGann, DDS

McGann Family Dental

To floss or not to floss?

Flossing.  We all know we should do it but none of us like to.  “It’s messy, it makes my gums bleed, and it takes too long” are common objections.  And now with a recent report coming out that flossing hasn’t been proven to do any good, for some of us that’s all we need for an excuse to give it up completely.

But what did these studies actually say?  Basically that no conclusive study has been done that proves that flossing is beneficial to oral health.  That may seem a bit surprising since dental floss has been around since 1874.  I believe that there are two reasons for this: common sense and ethics.

Each tooth has five surfaces: the chewing surface, cheek/lip side, tongue side, and two sides that contact adjacent teeth (front and back).  Brushing effectively cleans three of these five surfaces.  That’s 60%.  Add flossing and you clean the other two.  That’s 100%.  For an analogy: what if you had a dishwasher that only cleaned 60% of each plate, fork, glass, etc.?  Would that be acceptable?  Common sense tells us “no” whether it’s our dishes or our teeth.

We all know that seat belts save lives, and studies have been done on crash-test dummies to show the benefits of wearing one.  But what about studies in the real world?  Why hasn’t anyone conducted a study where half of a group of people wears a seat belt all the time and the other half is required to drive around without wearing one.  Then when they get in accidents we can see which group suffers the most significant injuries.  A study like this has never been done because it would be unethical.  In a less dramatic sense, conducting a similar study on flossing/not flossing could be considered unethical too.  Thus for real-world results we rely on the observations of professionals.  Ask any police officer or EMT whether seat belts save lives and you’ll get an unequivocal “yes;” ask any dental professional whether flossing helps prevent cavities and gum disease and you’ll get a unanimous “yes” as well.

Ultimately the decision is yours, we just make recommendations, but those recommendations are made to give you the best chance for a healthy set of teeth for life.  Remember, we’re on the same team.  And as a final thought: whether you decide to floss or skip it, we can always tell.

I’m guessing there’s a number of people out there who would love the chance to stick a needle in their dentist instead of the other way around.  “I just hope he knows what it feels like so he can be extra careful with me” is probably the feeling they have.

While you may never get the opportunity to do so, plenty of other people do.  About once a month I need to submit a blood sample for the management of my Graves’ disease, a condition where the thyroid gland produces too much thyroid hormone.  I have definitely come to appreciate the skill and compassion of an experienced phlebotomist (blood-draw person).

On the other hand, I’ve had some experiences with an uncaring and inattentive provider that left my arm bruised and sore all day long.  Admittedly, managing Graves’ disease isn’t fun, but it’s relatively easy when compared to the management of other more serious medical conditions.  I’m not going to complain.

On the contrary, I’ve actually realized a silver lining through the whole process.  Once a month I get a reminder of what it’s like to be on the receiving end of a needle; a reinforcement of the importance of compassion, awareness, and empathy with what my patients are experiencing.  I’m hoping one day I can get my patients numb without a needle, but until then I will do my best to make it as comfortable as possible, as I hope others would do for me.

Dr. McGann

There’s an urban legend out there that claims a frog placed in a pan of boiling water will quickly jump out, while a frog placed in a pan of room-temperature water, with the heat then slowly increased, will just sit there until cooked.

While I have my doubts as to the scientific accuracy of this claim, it serves a useful analogy to your teeth.  No, I’m not kidding.  The key is the difference between an acute attack on a tooth and a chronic attack.  An example of an acute attack would be a large piece suddenly breaking off.  One second everything’s fine, the next second your tooth is screaming “Ahhhhhh!  Fix me!”

On the other hand, an example of a chronic attack would be a slow-growing cavity; this type of attack is sneaky and most often painless, sometimes even when the cavity gets into the nerve and kills it.  This happens because the body has a remarkable ability to adapt and avoid pain, for better or worse.  The difficulty is that many people believe if something doesn’t hurt it must be OK; unfortunately most dental issues are painless until it’s too late, and then the cost to fix it will typically go up by a factor of ten.

The old medical axiom “an ounce of prevention is worth a pound of cure” is particularly appropriate to your dental health, and this is the basis of our philosophy of care at McGann Family Dental.