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Who can forget January 1st, 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
A noted medical researcher was recently asked what we will likely see first: a cure for cancer or a cure for bacterial infections. While confident that cancer will eventually be defeated, he believed the battle against bacteria may never be won. He explained that cancer cells begin when healthy cells mutate, and may even evolve as they grow and spread, but die when the patient is cured or succumbs to the disease. Their evolutionary path ends there. *
Bacteria, on the other hand, have the ability to pass from one individual to another, allowing them to continue their evolutionary journey. In fact, many of the bacterial species we are facing today didn’t exist twenty years ago, and the bacteria of the future will be even more evolved, and more difficult to defeat. Antibiotics have served as a potent weapon, but the war is far from over.
The history of antibiotics started in 1928 with the discovery of penicillin by Alexander Fleming. Although groundbreaking, it wasn’t widely produced until America’s entry into WWII. With memories of WWI soldiers dying almost as much from infection as they did from gunshot wounds, production methods were rapidly increased after the attack on Pearl Harbor in 1941.
Interestingly, Fleming’s later discoveries turned out to be equally as crucial, and prophetic as well. In 1945 Fleming noted that when too little penicillin was used, or for too short a time, the bacteria would adapt and survive. This ‘antibiotic resistance’ as he called it was observed early on in his clinical studies and rendered his penicillin useless.
Of course today we’re well aware of resistant bacterial species, and despite continued development of new antibiotics, some have evolved beyond our ability to treat. Perhaps the most notable example is MRSA, which stands for Methicillin Resistant Staph Aureus. MRSA and other resistant species are referred to as ‘superbugs;’ in the US they are responsible for one death every 15 minutes. And just as Fleming predicted, it was irresponsible prescribing, overuse, and poor patient compliance that led to their emergence.
Recognizing the potential epidemiological effects, the medical community is working diligently with prescribers to be much more judicious in their use of antibiotics. No longer do you get penicillin for the common cold, or amoxicillin for the flu. These are, after all, viral infections. Changes such as these were easy to adopt, but others have been much more difficult due to conflicting evidence, patient demands, and old-fashioned stubbornness.
For patients undergoing dental procedures, the medical community has long recommended premedication with antibiotics for conditions such as joint replacements, certain heart disorders, and for those with a compromised immune system. The rationale is that dental procedures can cause bacteria in the mouth to enter the bloodstream and lead to infection susceptible areas. However, as research continued to broaden our understanding of these processes, we learned that joint and heart infections weren’t caused by bacteria from the mouth, and prostheses developed a protective layer around them soon after implantation.
Over time, the recommendations for premedication were periodically scaled back, reducing the amount of antibiotic taken, conditions for which coverage is recommended, and timeframe of susceptibility for certain procedures. In fact, in a 2014 report conducted jointly by the American Dental Association and the American Academy of Orthopedic Surgeons, a panel of experts concluded that “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.” 1
If your healthcare provider is recommending antibiotics prior to dental procedures, it is important to understand why. A prior joint or heart infection can be an indication, but also are contributing health conditions (comorbidities) such as diabetes which can affect healing. Your provider should be able to provide a lucid explanation as to why he or she is prescribing them. “Well, that’s the way I’ve always done it” just won’t cut it any more.
Our knowledge will continue to evolve as more research comes in, and the evolution of the bacteria that seek to thwart our efforts will continue too. Bacterial evolution is unencumbered by dogma, bias, politics or profits. Can we do the same on our end of the fight? Can we make the right decisions regardless of conflicting pressures? Can we outsmart the bacteria?
*There are rare exceptions to this, such as the spread of Devil Facial Tumor Disease in the Tasmanian Devil population.
1 The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients With Prosthetic Joints: Evidence-Based Clinical Practice Guideline for Dental Practitioners—A Report of the American Dental Association Council on Scientific Affairs. JADA. 2015;146:11-16
“So we beat on, boats against the current, borne back ceaselessly into the past.”
Fitzgerald, F. Scott, 1896-1940. The Great Gatsby. New York :C. Scribner’s sons, 1925.
Our need for escape has been around ever since our ancestors first scrawled images on a cave wall to depict a recent hunt. Primitive as they were, they told a story, and that allowed our minds to leave our current reality and briefly live another one.
Escape has taken on a myriad of forms over the millennia, and technology has contributed to its volume, availability, and format. One genre that actually owes its existence to current technology, specifically the advent of the computer, is video games.
Video games have grown to be so popular that they sometimes lead to addiction, referred to as “gaming disorder” in the WHO medical reference book, the International Classification of Diseases. It’s easy to see why they’re so alluring, offering the player an interactive experience and a challenging gameplay. But video games also offer something you won’t find anywhere else: a reset button.
Did your player get killed? Hit the reset button. Stuck in an area and can’t find the way out? Hit the reset button. Want to try to get more points on the last level? Hit the reset button. How glorious it would be to have a reset button for any situation, to relive a moment in time where you can make different decisions and get a better outcome.
If only reality had that option. I think most of us would have reset 2020 back to January 1st and had another go at it. And yet we steam forward like a ship into the night, where an uncertain future has us wary of icebergs.
All of this uncertainty has served as a great source of anxiety for many people, and compounding the problem is that our usual sources of escape have been taken away. Movie theaters? All closed. Take a vacation? No airplane flights. Go out to eat at your favorite restaurant? Takeout only. Go get some exercise? Gyms are shut down. Unfortunately, many have turned to alcohol or drugs to provide the escape they so desperately seek, while doing nothing for stress relief.
Stress shows up in many forms. From a dental perspective, the most common are headaches, sore jaw muscles, pain in the jaw joint, worn and broken teeth, and joint noises like popping and clicking. This is a result of the clenching and grinding of the teeth, called bruxism, an unconscious behavior that usually occurs while sleeping.
The signs of bruxism are fairly obvious for a dentist to spot, and when I notice them I like to have a conversation with the patient. Some are aware they are bruxing, but about half have no idea, and some even flat out deny it, despite ample evidence to the contrary. For those of you suffering from higher stress levels, here are some things to look for in the morning:
- Sore jaw muscles, or pain with finger pressure on the jaw muscles
- Inability to open wide
- Individual teeth that elicit pain with biting pressure
- Pain with finger pressure on the jaw joint
If you notice any of these, the first step is to call your dentist to set up an appointment for an evaluation. In the meantime, here are some things you can do at home:
- Moist heat – use a washcloth with very warm water and apply to the jaw muscles
- Active stretching – move your jaw open and closed, left and right without using your hand for additional pressure
- Avoid tough, chewy foods and caffeine
- Practice the relaxed position – with your teeth slightly apart and your tongue touching the roof of your mouth
Your dentist can offer some solutions to help with the symptoms and even reduce the bruxism itself. Common is a hard plastic appliance called a nightguard that fits over the teeth and keeps the jaws slightly separated. They take some getting used to, but most people achieve relief with regular use.
Unfortunately no one can make this COVID-19 situation go away, and reducing stress levels is always easier said than done. The best I can offer is a piece of advice from the Navy SEALs when dealing with high-stress situations:
“You can’t calm the storm so don’t try. Just calm yourself and the storm will pass.”
Here’s to a better 2021!
Postscript – Interestingly, The Great Gatsby was set in the 1920’s, also known as the ‘Roaring Twenties’ due to rising personal wealth, growth of the automobile, development of radio and film, birth of the aviation industry, and widespread optimism. These golden years came to a screeching halt with the stock market crash of 1929 and the beginning of the Great Depression. The 2020’s started with a pandemic, stock market crash, double-digit unemployment, and an explosion of civil unrest. Only time will tell if the decade can come ‘roaring’ back with the prosperity of the past.
In an episode of the TV show Mad Men, one of the characters is at the doctor’s office for an exam. Set in the 60’s, the physician is shown with no safety glasses, no mask, and no gloves. While I found this amusing, the doctor then leans back and takes a puff from his cigarette. Now that was truly shocking, but my parents assured me that’s the way it was back then. The example served as a reminder of how safety, knowledge, and personal protection in healthcare have evolved, along with the pathogens we face.
The history of personal protective equipment, or PPE, began in the first century with a Roman named Pliny the Elder developing a breathing filter for dust particles. In the 16th century Leonardo Da Vinci improved on this early respirator to create a device that was more effective and filtered a broader range of particles. In these early stages the goal was simply to remove irritants, the existence of bacteria and viruses was still unknown. A tragic example is the Black Death which killed up to 200 million people in the mid-14th century, caused by bacteria that spread primarily through unsanitary conditions. It’s interesting to think how handwashing and clean water, things we take for granted today, could have changed the course of human history.
Further improvements in PPE came slowly as we learned more about the microscopic dangers around us, and it wasn’t until 1970 that the CDC codified its use in a seminal document titled “Isolation Techniques for use in Hospitals.” Similar to kindergarten, it was pretty basic, but it was a good start. Not surprisingly, also that year Congress created the Occupational Safety and Health Administration (OSHA). Why? The CDC only makes the guidelines; OSHA was created to enforce them.
The early 80’s saw the emergence of antibiotic-resistant pathogens, and then with the emergence of HIV in the US in 1981, the CDC realized that a more robust system was needed. In 1985 they introduced Universal Precautions which included not only protective clothing and devices, but also safety protocols and procedures. In essence, universal meant that all patients are to be considered infectious.
In 1996, the universal precautions were further enhanced and given the name standard precautions, and that’s the system we have today. (The terminology may seem rather generic, but hey, they’re scientists, not writers). The requirements are thorough and well-reasoned, but in the age of coronavirus, the question is: Are they still good enough? The simple answer is: We don’t know.
Governmental agencies like the CDC, OSHA, and state licensing boards are all weighing in on what they believe is necessary to protect the public and healthcare workers alike. Given the rapid onset of the pandemic, their advice isn’t always consistent. To a degree, healthcare workers are therefore relied upon to use their own professional judgment to determine what level of PPE, protocols, and devices are necessary to ensure the safe delivery of their services. The general rule right now: More is better.
What does this mean for you? First of all you may notice slight differences from one facility to the next. That doesn’t mean that one is right and one is wrong, just that each facility is different, offering different services and conferring different levels of transmission risk. Also, getting through your visit may take longer than usual, so plan extra time both before and after. Lastly, if you fall into a high-risk category or simply have additional concerns, contact your provider and they likely will have the flexibility to accommodate your needs.
The good news is that seeking healthcare services is still very safe, so certainly don’t wait if you’re due for a dental visit, a medical exam, or any other regular appointment. All healthcare facilities have been routinely observing standard precautions, so these additional measures have been fairly easy to implement. In fact, as of this writing, both the World Health Organization and the CDC say there have been no confirmed cases of COVID-19 transmitted in a dental office1.
Remember, this isn’t going to last forever. As we learn more about the COVID-19 virus, and as more medications are developed to treat and prevent infections, many of these extra precautions will be scaled back. What is considered “normal” in the future will certainly look different than our pre-coronavirus “normal,” but it’s all part of the evolutionary process.
1Kritz, F. The dentist will see you now. But should you go? MPRnews, July 6, 2020
In the movie “This is Spinal Tap,” a fictional English rock band is followed through their tour of America and the viewer is given an insight into the highs, lows, and head-scratching commentary of the band. In one scene, Nigel, the lead guitarist, is explaining that his amplifiers go up to 11, not 10 like everybody else’s amplifiers. In his words, they’re “one louder.” When the interviewer asks “why don’t you just make 10 a little louder and make that the top number,” Nigel stares at him for a second and explains “These go to 11.”
Making an amplifier “one louder” might only require a labeling trick on the dial, and making your teeth “one stronger” may be just as easy to do. Normal tooth structure is composed of a mineral called hydroxyapatite (pronounced like hydroxy-appetite). Calcium and phosphorus make up the “apatite” portion, and a single hydrogen and oxygen make up the “hydroxy” portion. Hydroxyapatite is good at resisting acids, but not great. How do we make it better? Add fluoride! A single fluoride atom comes in, bumps off the hydroxy portion, bonds to the apatite portion, and now you have fluoroapatite, or simply fluorapatite.
With the fluoride now added to your enamel, your teeth are now ‘one stronger,’ at least on the pH scale. Regular hydroxyapatite starts to dissolve at a pH of 5.5, whereas fluorapatite dissolves at a pH of 4.5 (remember that a lower pH means more acidic). However, since the pH scale is not linear, but logarithmic, like the Richter scale for measuring earthquakes, a one-point change from 5.5 to 4.5 actually represents a tenfold increase in resistance to acid attack.
How significant is this? Let’s let millions of years of geology be our guide. It turns out both hydroxyapatite and fluorapatite occur in nature, as components of different types of rock. While hydroxyapatite is quite rare in nature, fluorapatite is rather common. Since one is formed from the other, it stands to reason that this conversion process is the key to withstanding the destructive forces of mother nature.
Certainly the inside of your mouth can’t compare to the forces of nature, but there are similarities. Heat, pressure, abrasives, acids and bacteria, all present to break down whatever is in their path. While smaller in scale and compressed in time frame, your mouth is no less unforgiving than the natural environment.
The Centers for Disease Control and Prevention considers public water fluoridation as one of the ten greatest public health achievements of the 20th century, right up there with immunizations, food safety, and reduction in tobacco use. The CDC notes that fluoride can also slow down the activity of the bacteria in your mouth, and recent evidence shows that it can actually help teeth heal after a small cavity has started. This is a process called remineralization and is the primary benefit of fluoride exposure after age eight.
Fluoride is not without its detractors, and certainly too much fluoride can lead to various health problems. But at normal therapeutic levels, the benefits of fluoride are without question and the negatives are simply without scientific support. So take a tip from Nigel and make your teeth ‘one stronger.’ With the ubiquitous nature of sugar in today’s foods, habits of clenching and grinding being commonplace, and the costs of dental care continuing to rise, our teeth need all the help they can get.
The technology we are using today would have been considered futuristic just ten years ago, and science fiction twenty years ago.
I view dentistry as a blend of science and art, and with the care I provide I strive to satisfy both disciplines. Dental school provides a rigorous scientific training to assure that our work is durable, functional, and bio-compatible, while our artistic training drives us toward results that are as unnoticeable as possible. In other words, I strive for restorations that are natural-looking, not attention-grabbing. I want your friends to think “Wow, what a beautiful smile!” not “Wow, look at all that dentistry!”
Almost no other profession seeks to be as ‘invisible’ as the dental profession. Just as you want your restorations to be seamless and harmonious with the rest of your smile, the process of making those restorations is often just as inappreciable. This is where advancements in technology have had their greatest impact, operating behind the scenes to give us results that are more predictable, longer lasting, and more esthetically satisfying than ever before.
Here is a story that represents a typical situation of replacing a missing tooth, demonstrating several of the newest technologies at work in the background: 3D imaging (X-ray), 3D printing, dental implants, digital scanning, and CAD/CAM (Computer Aided Design/Computer Aided Manufacturing).
After losing a tooth recently, our patient decides to replace it with a dental implant. The first step is to make sure there is enough bone in the area to support an implant and that there are no anatomic structures in the way (nerves, tooth roots, etc.). This is done by taking a 3D X-ray using Cone Beam Computed Tomography, or CBCT. Standard X-rays only show us two dimensions: up/down and right/left. CBCT gives us the third dimension, front/back, that is essential for proper implant planning. While CBCT has been around for a while, only recently has it become compact and affordable enough to install in a private dental office. The resulting image allows us verify that the area is suitable for implant placement, and then with the associated software, we can virtually place the implant in the desired spot.
With the planning complete, we send the CBCT image to the 3D printer to make a surgical guide. The guide is designed to fit over the adjacent teeth and orient the handpiece so that the implant goes exactly where we want, meeting our three criteria of proper placement: insertion point, orientation, and depth. The 3D printer uses a laser to cure a liquid resin and build the guide layer by layer. Thirty minutes later our guide is printed and cleaned, and we are now ready to place our implant.
Dental implants are typically made out of titanium and are about the size of two tic-tacs lying end-to-end. Do they still make tic-tacs? Anyhow, it turns out that the body really likes titanium, so much so that bone will actually bond to it. This was discovered accidentally in 1940 and was termed ‘osseointegration’ by Per-Ingvar Branemark, a Swedish physician who actually placed the first dental implant in 1965. This discovery revolutionized the field orthopedics, paving the way for modern joint replacement components. Today, the vast majority of artificial joints are titanium-based (or cobalt-chromium). Titanium’s impact on dentistry has come along more slowly, but surely as dental implants are gaining acceptance with insurance companies and patients.
You may be wondering, “Today’s implants aren’t made out of the same stuff that was used in the 40’s, are they?” And in fact you’re right, just as we’ve moved on from polyester clothing and avocado green appliances, the implants themselves have evolved over time, both in design and composition. A buzzword you may have heard a lot lately is ceramic. Ceramic cookware, ceramic knives, ceramic watches, and of course ceramic dental crowns. At one time the term ceramic simply referred to mugs, dishes, and vases. Certainly our pans, knives, watches, and crowns aren’t made of the same material, which is basically clay baked in an oven. The distinction is the term porcelain, which generally refers to clay-based items, and the broader category of ceramics.
So what exactly is a ceramic? Ceramics form a rather nebulous category that includes many different materials, but for our purposes a ceramic is a combination of two or more elements that form a crystalline pattern when set and have certain common properties. By comparison, combining two metals together produces an alloy (like copper and zinc form the alloy brass), but modern ceramics are often a combination of a metal, such as titanium, tungsten or silicon, and a non-metal, such as carbon, nitrogen, or oxygen. Ceramics are also typically very hard and brittle. If you hit a metal or metal alloy with a hammer you will leave a dent, hit it harder and you will get a bigger dent. Hitting a ceramic will not leave a dent, but hitting it too hard will cause it to shatter.
Modern ceramics are all around us. Carbide cutting tools are actually tungsten carbide, a ceramic of tungsten (metal) and carbon (nonmetal). Titanium nitride is a combination of titanium (metal) and nitrogen (nonmetal) and is the coating used in the titanium ceramic cookware you see advertised. Borosilicate glass, a combination of boron (metal), silicon (metal), and oxygen (nonmetal) is more commonly known as Pyrex. Even though these ceramics contain a metal element, the ceramic itself is not considered a metal because its properties are often vastly different. In particular their appearance can range from metallic, to transparent, to white, as is the case with zirconium dioxide (a combination of zirconium and oxygen). Zirconium dioxide, or simply zirconia, is the material of which ceramic knives are made, and also represents a new class of dental implants.
In the spectrum of dental implants, pure titanium would be on one end and pure ceramic, such as zirconia, would be on the other. Most implants placed today fall in the middle, with the body of the implant made out of titanium and an outer coating of a ceramic material. The most common coating is hydroxyapatite, which is a ceramic of calcium (metal) and phosphorus (nonmetal). This coating enhances bone adhesion, decreases chances of an allergic reaction, and decreases healing time. These beneficial properties are due to the fact that hydroxyapatite occurs naturally in bone and teeth, and thus is referred to as a bioceramic.
Titanium with a hydroxyapatite coating gives us the best of both worlds, making it the preferred choice for dental implants as well as joint replacement parts and other uses. Pure zirconia implants have the benefit of being white, which may be helpful in situations where the implant may be visible through the gum tissue, such as when they are used to replace front teeth. The disadvantage is that, since they are a ceramic, they can be brittle and prone to fracture. A fractured implant that has already bonded to the bone can present a challenging and expensive situation to rectify.
The implant placement procedure is systematic; the guide removes any guesswork and allows the procedure to move along swiftly. From anesthesia to the final suture (if needed), the whole process takes about 45 minutes. Our patient is given a prescription for ibuprofen and an antibiotic mouthrinse and the implant is allowed to heal, typically four to six months. During this time a temporary crown can be placed, or another method can be used to ‘fill the gap’ while the implant heals.
The implant itself is only one of three components. A final crown must be placed later to fully represent the missing tooth, and between the implant and crown is the third component called an abutment.
Once adequately bonded to the bone, the implant is now ready to have the final crown made. Up until this point the implant has been hidden under the gum tissue, nearly invisible except for a small healing cap. The healing cap is removed and a small post is attached for the digital impression. Our intraoral camera is a wand-like instrument with a lens at the end, we hold it over the implant site and it takes a series of images to generate a 3D representation of the area. The post is removed, the healing cap is replaced, and the 3D ‘impression’ is sent to a dental lab for fabrication of the abutment and crown.
Even dental labs have moved into the 21st century with their technology, utilizing CAD/CAM to streamline their processes. The digital impression is loaded into a software package to design the abutment and crown. What technicians used to do by hand they now do on a PC; the same skills are at play, but a different medium is used to deploy them. Once designed, the parts can be created in a computer-controlled milling machine from different materials: the abutment is often a gold alloy or zirconia (if it might be visible), and the crown can also be made from zirconia or another type of ceramic. The crown starts out as a rectangular block and diamond-tipped cutters mill away the extra material until a crown emerges ten minutes later. The technician then adds custom shading, polishes everything up, and returns the components to the dental office.
The big day has arrived! Usually without needing any anesthesia, the healing cap is removed and the abutment and crown are attached and checked for proper fit and bite. Our patient is ready to immediately start using the new tooth, and in fact our instructions are to treat it as if it were a natural tooth: brush, floss, chew, smile! With proper care an implant can potentially last the rest of one’s life.
The materials, techniques, and instruments of tomorrow are being developed today. Dental implants will continue to evolve, giving us even easier placement, quicker healing, and more reliable results. Someday we may not even need implants; research is currently being conducted to regrow a new tooth right in the patient’s jaw. Sound like science fiction? Maybe today, but one day it might be science future, and soon after become science fact.
Patrick McGann, DDS
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:
- 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.
- 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.
* 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.
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.
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.
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.
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.
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?
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.
When I first went into business for myself I had to meet with a lot of different service providers in order to get everything set up; people from banking, legal services, insurance providers, suppliers, and so on. I can’t say the meetings were all that fun, but they went smoothly enough and I learned a lot as the process went on. It wasn’t until I was in business for a short while that I got in touch with an accountant to help with the bookkeeping and taxes. This is something I should have done right away, but I will admit it was the one I was least looking forward to.
Why would this be? It’s just tracking expenses and balancing columns, right? The truth is the accounting end of the business was the part that I knew the least about. I had taken some accounting classes in college, but it was all debits and credits and no practical application. Socrates once said “The one thing I know is that I know nothing.”* Ever the master of paradox he was, but I guess that would have described my situation pretty well, even if somewhat generously.
The meeting went more or less as I had expected, there were some things I knew, some things I didn’t, and a lot of things I didn’t know I didn’t know, and that’s probably what frightened me the most. It’s hard to admit you don’t know something, and then to ask for help from an expert. Doing so can leave one feeling vulnerable and at risk of being judged. It is this aversion to judgment that I believe is the number one fear of dental patients; more than pain, more than expense.
I remember an episode of ‘The Simpsons’ where a sign outside the Springfield dental clinic reads “No matter how you’re flossing you’re doing it wrong.” It’s classic ‘Simpsons’ humor, and as with any successful comedy, the jokes all have a grain of truth to them. There probably is a significant portion of the population that views dental teams as bossy and lecturing, but heaven forbid we’re viewed as judgmental. Even if only a small percentage of dental offices are belittling patients with a judgmental tone, I see it as a black eye on the profession and the rest of us have to work that much harder to change the perception.
Let’s leave the judging to those who are highly trained to do so: judges. For the rest of us, an approach of respect and professionalism is the right way to go. As for my accountant and me, we’ve become good friends and he is now a patient in the practice.
* Historians now believe this quote has been mistakenly attributed to Socrates by his pupil, Plato.
In a world of 3D video games, 3D movies, and 3D printing, we are thrilled to have 3D imaging at our office! We added this technology not because it’s trendy, but because it allows us to visualize your teeth and jaws with better clarity than ever before. Being able to see better helps us to diagnose better, which allows us to provide treatment plans that are more accurate, timely, and cost-effective!
The technology is called Cone Beam Computed Tomography, or CBCT. Computed Tomography has been around for a long time in the medical field but only recently has it come into use for dentistry. “Cone Beam” simply means it is capturing a relatively small area for the image, which is ideal for our purposes. A standard dental X-ray only shows us two dimensions: up/down (height) and right/left (width), but not front/back (depth). Using CBCT we can find things that often don’t show up on a standard X-ray, such as a cracked tooth or where an infection is coming from.
In addition, the CBCT allows us to “virtually” place dental implants on a patient as part of the treatment planning phase, which we then use to make a 3D-printed surgical guide. The actual implant placement appointment is therefore quick and systematic with no guesswork. Using this technology, most implant placement appointments take less than half an hour!
A CBCT scan is not appropriate for every situation as regular dental X-rays still do an excellent job and remain the standard imaging choice. However when the situation is warranted, a CBCT image can be taken to give us a more detailed view of a specific area. This image is then reviewed by Dr. McGann and the Oral Radiology department at the University of Minnesota. Once the reviews are complete the results are discussed with the patient and a treatment plan is created.
For more information you can check out the following article that answers many common questions: http://www.radiologyinfo.org/en/info.cfm?pg=dentalconect. We would also be happy to demonstrate the technology here at the office and answer any other questions you may have!
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:
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.
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.
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.
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.
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.
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 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.
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.
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 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).
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.
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
In 1804 a man by the name of Richard Trevithick built the world’s first fully-functional steam locomotive, ushering in the era of mass transit for people and goods. Ninety-nine years later the Wright Brothers were “First in Flight” with the launch of their flying machine, taking the world of mass transit across oceans and continents in record time.
Ever since the airplane came on the scene it was certainly “newer” than the locomotive, and I think anyone would agree modern airplanes are more “technologically advanced” as well. Terms like “state-of-the-art” and “high-tech” can also be used. So if modern airplanes are so much superior to the locomotive, the obvious question is why are we still using trains?
The reality is that trains still do an important job in our society and they do it very well. Just because a newer technology comes along doesn’t mean we automatically abandon previous one. When it comes to dental care, there are older technologies that are tried-and-true, newer technologies just being introduced, and future technologies to be anticipated. An example of an older technology would be the commonplace dental crown. While the materials have changed (ceramics, bonding agents) over the years, the basic principle is the same as it was decades ago. An example of a newer technology is the dental implant, a titanium post that is placed in the jaw to replace a missing tooth. I’m sure when dental implants first came on the scene some of the “experts” forecast the end of dental crowns. But the truth is that implants, while very reliable and often the preferred treatment option, are simply not appropriate for every person and every situation. The reality is that crowns aren’t going anywhere.
One possible future technology often discussed is the ability to grow a new tooth via stem cells. Obviously any time the future is discussed we can only guess as to when it will be available and how it will work. Given that, there are two predictions I can make rather confidently: first, growing a new tooth from stem cells implanted in your jaw will take at least a year (total treatment time), possibly much longer, and second, the total cost of this procedure will be well in excess of a crown or an implant.
If and when growing new teeth becomes a reality, it will be an exciting new option for patients to consider. But that’s all it will be, an option. Our current treatment options will remain an excellent choice, and often the preferred choice, as we continue to improve upon them with better materials and protocols. The future of dentistry is exciting, but the dentistry of today will continue to serve us very well for years to come.
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.
The number two dental fear patients have is pretty obvious, but may surprise some people that it’s not number one. I see it on the faces of many adult patients, but only the kids will actually blurt it out: “Is this going to hurt?”
At this point I’d like to relate a story about a survey I first heard about maybe 25 years ago. The survey asked people what their greatest fears are. Twenty five years ago the number one response was public speaking, not a big surprise there. Number two was going to the dentist. Out of curiosity I looked up the same survey recently and found that public speaking was still number one, but going to the dentist was not even in the top ten! Why is that? What caused this dramatic change in public perception over the last two and a half decades?
Quite simply, I think people have shed the idea of dentistry as a “necessary evil” and embraced the idea that dental care is an important part of their overall health and appearance. Instead of begrudingly showing up for their cleaning or fillings, people actually seek out dental care now. How has the dental profession participated in this paradigm shift in patients’ attitudes? By embracing new technology and new techniques that has made today’s patient experience vastly superior than even a generation ago. But the bottom line for most people is: the dental injection.
People know needles aren’t fun. But here’s the good news: by putting our focus on the best materials and techniques, we’ve been able to make the whole experience nearly or even completely pain free for most people. And here’s the better news: technology is still advancing at a rapid pace, and I expect the patient experience will continue to improve by leaps and bounds. I’m looking forward to treating a generation of patients who have never feared their dental visit, and I believe that generation is now upon us.
As far as the fear of public speaking, I don’t see that going away anytime soon.*
* Here’s my trick when speaking to an audience, don’t look at the whole audience, look at one person in the audience, as if you’re talking only to her or him. Finish your sentence, move to someone else and speak directly to that person. Speaking to an individual is much less intimidating than speaking to a group.
Dr. McGann explains how and why dental sealants work in this informative video. Check it out!
Throughout my years of practice I’ve always had the mindset of constant improvement: learning new procedures, improving on the procedures I already perform, adding new technology when it can improve outcomes, and many other avenues. While all of these are important to help achieve better clinical results, perhaps the most important skill I can seek to master is my ability to communicate with and understand my patients.
The fact that there’s still a great many people who have dental fear and anxiety is not going to surprise anybody. Everybody who sits in my chair has had a dental experience before (well, almost everyone), which means they also have feelings about it; good, bad or otherwise. Throughout my years of listening to what my patients liked and didn’t like I’ve been able to identify what I believe are the three main causes of dental fear and anxiety. If dental anxiety is something you’ve ever experienced, I encourage you to read on and see if any of these resonate. I’ll start with the third-most common.
Fear number three: Financial cost
I’m going to come right out and say it: dentistry can be expensive. And unless you just won the lottery, we know that the financial considerations of getting your dental work done will play a role in the treatment planning. I encourage you to check out our page on affordability where I outline the various services, discounts, and financing options we offer to make your dental care more manageable.
Beyond the immediate financial concerns of dental care there is another money-related concern many patients have; it’s what I call the “doctor-knows-best” experience, and it’s even more insidious and disconcerting. I can’t tell you how many times a patient has told me about an experience where their dentist said something like: “This tooth needs a crown, let’s get it scheduled in two weeks. See you soon!” And that represents the beginning, middle and end of the conversation. What the patient hears is “I don’t care about your thoughts on the matter” and “I just want to do the most expensive treatment.” While that approach may have been the norm for previous generations, today it’s as archaic as wooden dentures. It blocks communication and erodes trust, the two most important pieces of the dentist-patient relationship.
Our treatment plans are not a one-way communication, they are a discussion about what is right and what is recommended for treatment. They are a discussion of options, with nothing absolute, only the pros and cons of each choice. And there is one choice that is always an option but rarely mentioned, the choice of doing nothing. You are the final decision maker for your dental care, our job is to present findings, have a discussion on what is going on, make recommendations for treatment, and present the pros and cons of each choice. We will never presume to know what’s best for you and make your treatment decisions for you. In fact, I only want to proceed with treatment when you fully understand why we’re doing it and you request that it be done.
Money is a difficult topic to discuss. Trust us to walk you through the process in an understanding and professional manner. Coming up next: the number two dental fear. You may be surprised it’s not number one!
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.
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.