Why Does Poor Oral Health Remain Such a Problem?

Every so often, a new story comes out about the American struggle with oral health. Not long ago, for instance, we heard about how 20% of Americans have untreated decay and most have some history of cavity repair: 40% of children, 52% of teens and 75% of adults. Other studies say that by the age of 65, as many as 90% of adult Americans have experienced decay in their permanent teeth.

Why is it such an ongoing problem?

For one, there’s the standard American diet, which is chock full of sugars even before factoring in the sodas, juices and other sweet beverages we’ve come to drink more of. These, along with refined grains and other processed carbs, feed the pathogenic (disease-causing) microbes involved in oral disease. Sugar has other negative health effects, too, and makes us more susceptible to illnesses of all kinds.

Add to this lifestyle factors such as limited physical activity, high stress, poor and insufficient sleep, high drug use (including prescription drugs, alcohol and tobacco) and the like: all these factors similarly weaken the body’s innate self-regulating abilities. We become prone to illness – or at least suboptimal health.

Then there’s the matter of lack of knowledge about dental health and hygiene – a point made quite vividly by survey findings released by the American Dental Association last week. The headline on their press release?

Americans Score a D
on National Oral Health Quiz

The “quiz” was a series of true/false questions answered by nearly 1500 adults. Here’s what the ADA found – and the correct answers:

• 90% think you should brush after every meal.
  Twice a day is the usual recommendation. And as mentioned, you should usually wait about a half hour after eating or drinking anything before you brush.
• 65% think you should replace your toothbrush twice a year.
  Every three months is more like it.
• 75% don’t know when a child should have his or her first dental visit.
  It should happen as soon as their first tooth erupts or no later than their first birthday.
• 81% think sugar causes cavities.
  Only part true. As mentioned above, sugars feed pathogenic microbes in the mouth, but it’s the acidic waste they produce that actually damages the teeth.
• 59% don’t know that those microbes can be passed from person to person.
  Like other infectious agents, oral bacteria can be passed along from one person to another – through things like kissing or sharing utensils.

Taking good care of your health – dental and systemic alike – means understanding how your body works. That’s why you may find your dentist or hygienist always explaining and teaching at your appointments – teaching that, unfortunately, some patients tune out for various reasons. But the teaching does matter, so we keep doing it. It’s central to our work. As I wrote before,

I can’t speak for all dentists, of course, but as a dentist, it’s important to me that you understand what we’re doing and why we’re doing it, as well as what you can do to gain and sustain more optimal oral health in general. After all, dentists are doctors, too – physicians whose specialty involves the teeth and oral cavity. You know how the word “doctor” came about? The English word comes from the Latin word docere, which means “to show, teach or cause to know.”

Teaching is part of our job.

Image by Jacob Barss-Bailey, via Flickr

Care of the Body = Care of the Mouth = Care of the Body

No doubt, mercury is a threat to human health. Yet more than 2/3 of all dentists still use it on occasion. One thing that can make it easier to justify is a consequence of that that doctor/dentist division I wrote about a couple weeks ago: the tendency to treat teeth as though they were separate from the rest of the body. If that were true, it would seem impossible that mercury fillings could harm other organs, such as the brain.

But of course they can. And do.

The mouth/body split also supports more benign ideas, like the belief that brushing and flossing are enough to ensure healthy, disease-free teeth and gums. They’re important, of course – but so are nutrition, exercise, limited or no drug use (including tobacco and alcohol) and the rest.

For all the things you do to keep your body healthy help keep your teeth and gums healthy, too. And vice versa. And just as keeping your body clean is one part of preventing illness – for instance, washing your hands after using the toilet – keeping your teeth clean is one part of preventing oral disease.

Recently, a pair of Swedish studies made the news for one startling fact they found: 90% of Swedes don’t brush their teeth effectively. I imagine US results would be similar.

Most Swedes regularly brush their teeth with fluoride toothpaste. But only few know the best brushing technique, how the toothpaste should be used and how fluoride prevents tooth decay.

Of course, even scientists aren’t entirely sure how fluoride works. We do know it does little to remove biofilm (the colonies of pathogenic microbes, or “bad bugs,” we call “plaque”). In fact, at least one study has shown that non-fluoride toothpaste is actually more effective at removing biofilm than toothpaste with fluoride. What matters most is the mechanical action of brushing. Toothpaste provides grit to help remove the sticky biofilm.

So how to brush your teeth effectively?

First, despite what you’ve likely been told, you shouldn’t brush your teeth immediately after eating. Instead, wait a half hour or so – especially after acidic foods and beverages, which include those with a lot of sugar or other refined carbs. This gives oral conditions time to return to their usual alkaline state. Otherwise, you’re essentially brushing acids into your teeth, raising the risk of damaging the enamel, which in turn can lead to tooth sensitivity and decay.

Then, when you do brush, follow the technique shown and described here.

And don’t forget to floss. (Even better, clean with a proxy brush, which research suggests may be even more effective than floss. Really.)

Image by rachel a.k., via Flickr

A Mouth Full of Bacteria, a Tablespoon of Oil

Did you know that there are more bacteria in your body than human cells?

Yes, really. Microbes outnumber them, 10 to 1.

That’s not a bad thing. For not all “bugs” are bad (despite what you see and hear in some ads). Some are essential to human health, doing things like

• Synthesizing and excreting vitamins
• Preventing colonization by pathogens (“bad bugs”)
• Inhibiting or destroying pathogens
• Stimulating tissue and antibody development

The human mouth alone contains an estimated 10 billion bacteria. Yet most of us grow up thinking that a “clean” mouth is a germ-free mouth. As professor of oral microbiology Dr. Phillip Marsh puts it,

What we’ve been brought up with is “Plaque is bad – get rid of it.” But it’s actually too much plaque and plaque in the wrong places that are bad for us. We want to prevent the buildup of levels of organisms, particularly in hard-to-reach places of the mouth, that could lead to disease. Pushing to have an ultraclean mouth isn’t beneficial to us; we should be trying to maintain our natural microbiota at levels compatible with oral health in order to preserve their beneficial activities.

Dr. Aaron Weinberg, dean of the School of Dentistry at Case Western Reserve, agrees:

You don’t want a sterile mouth; you want a mouth that has primarily good bacteria in it, in order to keep exogenous microorganisms out and prevent them from colonizing the mouth.

Seems common sense, doesn’t it? Keep the good, control the bad. And that’s what dental hygiene is really about: not eliminating but controlling bacteria, especially those that contribute to tooth decay and gum disease. As mentioned before, the mechanical actions of brushing and flossing are crucial in this, breaking up microbial colonies. Mouthwash, on the other hand, is often meant to kill – or at least slow down the proliferation of – pathogens, whether by chemicals or herbal extracts and essential oils. While rinse is seldom necessary, it can be a help, especially when periodontal (gum) disease is an issue.

But there are traditional, natural alternatives for controlling oral flora, as well – practices such as oil pulling.

Oil pulling comes to us from Ayurveda, a system of traditional medicine developed in India thousands of years ago. Often described by Western holistic practitioners as a way to “pull out toxins,” it effectively cleanses the mouth by controlling oral bacteria, especially along the gumline and in the periodontal pockets. Vitamins and minerals in the oil are absorbed, while pathogenic microbes are bound up in the oil and ultimately removed from the mouth. The natural balance of oral flora is restored, which allows tissues to regenerate.

Research (PDF) has demonstrated a marked decline in levels of decay-causing microbes after oil pulling. Other studies have found oil pulling to be at least as effective as chlorhexidine in controlling bad breath.

We’ve seen remarkable results in patients who have turned to oil pulling to take control of their periodontal health – much healthier gums, much smaller pockets.

Although some recommend using coconut or other oils, sesame oil is often preferred. According to a short paper published in the Indian Journal of Dental Research,

The sesame plant (Sesamum indicum) of the Pedaliaceae family has been considered a gift of nature to mankind because of its nutritional qualities and its many desirable health effects. The seeds of the plant are commonly known as ‘gingelly’ or ’til’ seeds. Sesame oil has a high concentration of polyunsaturated fatty acids and is a good source of vitamin E. The antioxidants present in it are mainly sesamol, sesamin, and sesamolin. Sesamin has been found to inhibit the absorption of cholesterol as well as its production in the liver. It reduces lipogenesis and exhibits an antihypertensive action.

Likewise, from the first study cited above,

Sesame lignans have antioxidant and health promoting activities (Kato et al., 1998). High amounts of both sesamin and sesamolin have been identified in sesame (Sirato-Yasumoto et al., 2001). Both sesamin and sesamolin were reported to increase both the hepatic mitochondrial and the peroxisomal fatty acid oxidation rate. Sesame seed consumption appears to increase plasma gamma-tocopherol and enhanced vitamin E activity which is believed to prevent cancer and heart disease (Cooney et al., 2001).

Even so, a good number of naturopaths advocate sunflower oil instead. It also contains vitamin E, as well as a number of nutrients key to good dental and oral health, including vitamin D, calcium, magnesium and trace minerals.

Sesame or sunflower, whichever you use, do be sure to use a good quality oil: organic, cold-pressed and unrefined.

The technique itself is simple:

1. Anytime between waking and breakfast, brush your teeth or scrape your tongue.
2. Put 1 tablespoon of oil in your mouth and slowly, gently work it around the oral cavity – like using mouthwash but in slow motion, less vigorously. Do this for 10 to 20 minutes.
3. Spit out the oil (which will look thin and milky white).
4. Rinse with warm salt water. (Optional)

The first time you try it, you may find the practice feels slightly uncomfortable. Don’t worry. Most people quickly get used to it. If it becomes too uncomfortable, though, just spit out the oil and try again.

One last note: Oil pulling can have detoxifying effects, so you might want to start off with just a few days a week and gradually work up to daily practice.

Images by wellcome images and FotosVanRobin, via Flickr

Managing the Halloween Candy Haul

Halloween is fast approaching – time for goblins and ghouls, haunted houses, scary stories, trick-or-treating…and the obligatory news items in which dentists give tips for avoiding decay through the candy glut.

Most are just common sense, seasonal variations on what we advise all year round:

• Avoid sour candies, as their high acidity can damage enamel.
• Avoid sticky or gummy sweets, which cling to – and between – teeth, feeding the microbes that cause decay.
• Don’t graze on candy and sweets through the day, as this also perpetually feeds those microbes.
• Rinse your mouth with water afterward, or chew a piece of sugarless gum to stimulate saliva flow that will help clean the teeth.

Notice the one I didn’t mention? Right: Toothbrushing – not because it doesn’t matter but because the conventional wisdom about it isn’t entirely accurate.

Consider this example of the standard line:

Mitchell said the key to preventing tooth decay lies in limiting not only the amount of candy children eat, but also how long the sugar remains in the mouth.

Brushing teeth as soon as possible after eating candy may keep harmful bacteria from developing, she said…. [emphasis added]

Unless “as soon as possible” means at least a half hour after eating the last treat, this actually isn’t the best advice in the world.

This is because when we eat carbohydrates – and candy is little but carbs and, often, fat – conditions in the mouth turn acidic. Brushing at this time can damage the enamel. Over time, this leads to enamel erosion and a higher risk of decay.

Oral acidity peaks at about 20 to 30 minutes after eating refined carbs and is usually back to normal within an hour. Consequently, it’s better to wait a while before brushing and flossing.

(The same dentist also recommends sealants as a Halloween “precaution,” but good diet and proper hygiene are usually precaution enough. And sealants themselves may not be all that effective anyway – or so recent evidence suggests. They’re also not as risk-free as proponents insist.)

Perhaps a bigger question for health-conscious parents and guardians is whether and how to moderate kids’ candy consumption. Some, seeing Halloween as a special time to indulge, have no qualms about letting the kids enjoy the gluttony. Others prefer to set limits – x number of pieces per day, for instance, or only after dinner – while others let their child choose a portion to keep and then get rid of the rest, perhaps through a local dentist’s candy buy-back.

Or parents may do buy-backs of their own. One of the most intriguing is from Dina Rose, whose blog is loaded with great tips for teaching children healthy eating behaviors. As she writes, “The “hidden” problem with Halloween is that it teaches kids to eat what they have, not what they want.” Thus, with her own daughter, she does a special kind of buy-back:

Instead of buying my daughter’s candy back with money, toys, or other non-consumables, I offered to buy back my daughter’s candy with…more candy. Not just any candy, though, better candy.

Yup. Instead of trying to de-candify Halloween I upped the ante. I allowed my daughter to swap any candy she didn’t absolutely LOVE for candy she adores.

* * *

You can only be truly satisfied by eating foods you love. Unfortunately, Halloween teaches kids to eat what they get. It’s a kind of scarcity-response, even in the face of abundance.

Eat what you LOVE, not what’s available.

If there were ever a message that kids needed to learn, this is it.

Instead, the real Halloween lesson goes something like this: eat as much candy as you can even if you don’t like it that much.

And if you have a kid who doesn’t get candy that often, the message goes something like this: you better take advantage of this candy because you’re not getting a lot more of it in the near future.

And who says that Halloween treats must be candy – or even food? There are plenty of kid-friendly alternatives – things like wax lips, temporary tattoos, sugarless gum, stickers, low-sugar trail mix or granola bars, blowing bubbles or other small novelties. So many times, I’ve heard people say kids consider their home the coolest precisely because they got something different – not just another candy bar.

Images by sean dreilinger, via Flickr

Does It Matter What Kind of Toothpaste You Choose?

 

Are today’s toothpaste ads really so different? Each brand still insists that it’s better than the rest – because it has fluoride or baking soda or peroxide or nanosilver or Xylitol or triclosan or whatever.

But truth be told, toothpaste doesn’t do all that much to keep your teeth and gums clean and healthy. In fact, one study, published in the Journal of Periodontology, actually found brushing without paste to be more effective than brushing with it.

Researchers concluded that brushing without toothpaste was more effective in removing plaque from the front surface of teeth. The mechanical action of brushing (moving the brush up and down or sideways) may have been the main factor in determining effectiveness of plaque removal, they said.

This is why cleaning technique matters. Brushing (and flossing) breaks up the biofilm (“plaque”) that forms on your teeth between cleanings – and that’s the key, not necessarily what you break it up with. Our ancient ancestors used things like chew sticks and twigs. Even today, at least one entrepreneur is marketing Miswak twigs as an eco-friendly alternative to regular brushing. In India, twigs of neem – which has antimicrobial properties – are still commonly chewed to clean the teeth.

What toothpaste does offer is grit – silica, calcium carbonate, chalk, alumina or other abrasive to help break up the biofilm. Abrasives can also help remove stains from the teeth, but sometimes at a cost to their enamel, as results of a recent study in the Journal of Clinical Dentistry suggest.

Anything with an RDA, (Relative Dentin Abrasion) score of about 100 is generally considered highly abrasive. Anything above 150 is considered potentially damaging to enamel.

Here’s how some of the popular whitening toothpastes stacked up:

• Crest White Vivid scored above 200.
• Rembrandt Intense Stains was only mildly abrasive with an RDA of 90.
• Ultrabrite Advanced Whitening from Colgate had an RDA of 260, one of the most abrasive.

Of course, toothpastes contain more than abrasives. Most mass market toothpastes contain fluoride, foaming agents, detergents, humectants, thickeners, flavoring and sweeteners. Not all of these are benign. For instance, sodium lauryl sulfate (SLS) – a common foaming agent also used in shampoo, dish soap and other products – has been shown to damage the soft tissues of the mouth.

Some also contain remineralizing agents, although there’s little evidence that they strengthen enamel as the ads say they do. Others tout antimicrobials such as nanosilver and triclosan. We still don’t know much about nanosilver’s biological effects, though early animal studies suggest cause for concern. Triclosan, on the other hand, is a suspected endocrine disruptor and probable carcinogen. The chemical reaction that occurs when it’s combined with chlorinated water (98% of the public water supply) produces chloroform.

Fortunately, it’s easier than ever to find gentle, natural alternatives – pastes made without detrimental ingredients, with essential oils and herbal extracts that support oral and dental health. This article from Natural Solutions contains some good tips on choosing one.

Images by Meanest Indian & Leo Reynolds, via Flickr

Do Natural Mouthwashes Work?

For most people, antimicrobial mouthwashes – “germ-killing” products such as Listerine – aren’t necessary for good oral hygiene, but they can be helpful. By controlling the growth of S.mutans and other microbes that contribute to oral disease, they can help you keep your gums healthy and get rid of bad breath. But so can effective brushing, flossing and rinsing with plain water.

However, when a person is already showing signs of gingivitis or periodontitis – “gum disease” – their dentist may recommend an antiseptic rinse to help reverse the disease and restore the gums to health.

In this case (as well as after oral surgery), dentists often recommend a solution of the chemical chlorhexidine – the active ingredient in products such as PerioGard, PerioRx and Peridex, which the University of Maryland Medicine Center says “reduces plaque by 55% and gingivitis by 30 – 45%.”

But despite claims to the contrary, one thing chlorhexidine may not do is prevent cavities.

According to a 2008 literature review, research outcomes have been mixed, with insufficient data to support the use of chlorhexidine to prevent cavities.

Since dental caries is a disease with a multifactoral etiology, it is currently more appropriate to use other established, evidence-based prevention methods, such as…diet modifications and good oral hygiene practices. Recent findings also indicate that the effect of an antimicrobial agent for reducing the levels of mutans streptococci or plaque reduction may not always correlate with eventual caries reduction.

Now comes a study which shows chlorhexidine to offer no real improvement over natural antimicrobials when it comes to managing oral biofilms.

For this Journal of Dentistry study, researchers tested the effects of herbal extracts and chitosan on oral biofilms in vitro – that is, outside the human body – using chlorhexidine rinse as a control. The natural antimicrobials

showed immediate killing of oral biofilm bacteria, comparable with chlorhexidine. Moreover, exposure of a biofilm to these supernatants or chlorhexidine, yielded ongoing killing of biofilm bacteria after exposure during re-deposition of bacteria to a matured 16 h biofilm, but not to a much thinner initial biofilm formed by 2 h adhesion only. This suggests that thicker, more matured biofilms can absorb and release oral antimicrobials.

Conclusions: Supernatants based on herbal- and chitosan-based toothpastes have comparable immediate and ongoing antibacterial efficacies as chlorhexidine. Natural antimicrobials and chlorhexidine absorb in oral biofilms which contributes to their substantive action.

Which raises the question: If the effects of natural substances on oral biofilms are at least as good as those of a chemical substance, why opt for the chemical?

Of course, this study doesn’t answer the question of whether this biofilm control actually prevent caries. And so we return to the earlier study and the knowledge that other actions – chiefly good hygiene and diet – are enough. (As I mentioned a couple weeks ago, fluoride as a preventative is questionable at best and, any benefits may not be worth the risks.)

In other words: why make things more complicated than they need to be?

Meantime, if you do like to use a mouthwash – and some do just for the extra fresh and clean feeling it gives – there are excellent natural products available. I prefer Natural Dentist Healthy Gums Mouth Rinse, which contains a blend of cleansing and soothing botanicals including echinacea, golden seal, grapefruit seed, aloe vera gel and calendula. It contains no alcohol, artificial sweeteners, dyes or preservatives, and will not stain the teeth (unlike chlorhexidine rinses).

We have this product available in my Glendale office. According to the manufacturer’s website, it is also available at CVS, the Vitamin Shoppe and Drugstore.com.

Top image by Nicole Lee, via Flickr

Fluoride Works…How, Exactly?

There’s an interesting double standard in medicine – dental and otherwise. Conventional practitioners can and do promote all sorts of treatments that haven’t been empirically proven or that work in ways we don’t yet understand. At the same time, many insist that “alternative medicine” isn’t valid because many of its treatments aren’t yet proven or understood. Yet when proof is provided, the tendency is to ignore it, discount it or move the goal-posts, holding traditional and natural healing practices to a higher standard than they hold their own. If we say there’s only one kind of medicine – that which works – then shouldn’t all of its premises and practices be held to the same standard?

Science is not a body of knowledge but a process – a way of understanding the world through what can be observed, measured and tested. The tools of science are also always evolving, letting us see more – or more precisely – than before. What can’t be proven in one era may be proved in another as knowledge and technology evolve. What seems like magic to one generation may come to seem common sense to later ones.

For decades now, conventional dentistry has put a large store of faith in fluoride. Fluoride toothpaste, fluoride supplements and fluoridated water have all been touted as important factors in preventing tooth decay. But research has helped our understanding evolve. We know now that ingested fluoride does little to prevent tooth decay yet contributes to a host of physical illnesses. We also see evidence that fluoride supplements may not be effective for children.

But what about fluoride in toothpaste? A new study published in Langmuir, the journal of the American Chemical Society, raises some questions.

In a study that the authors describe as lending credence to the idiom, “by the skin of your teeth,” scientists are reporting that the protective shield fluoride forms on teeth is up to 100 times thinner than previously believed. It raises questions about how this renowned cavity-fighter really works and could lead to better ways of protecting teeth from decay, the scientists suggest….

Scientists long have known that fluoride makes enamel — the hard white substance covering the surface of teeth — more resistant to decay. Some thought that fluoride simply changed the main mineral in enamel, hydroxyapatite, into a more-decay resistant material called fluorapatite.

The new research found that the fluorapatite layer formed in this way is only 6 nanometers thick. It would take almost 10,000 such layers to span the width of a human hair. That’s at least 10 times thinner than previous studies indicated. The scientists question whether a layer so thin, which is quickly worn away by ordinary chewing, really can shield teeth from decay, or whether fluoride has some other unrecognized effect on tooth enamel.

We might also ask, is it really the fluoride at all? For toothpaste really isn’t the biggest factor when it comes to good oral hygiene – which isn’t to say that it has no role. Its main role is to act as a mild abrasive to help break up the biofilm (plaque) that forms on your teeth between cleanings. (Toothpastes that contain elements such as antimicrobials play a dual role in supporting oral health, but their main function is still as an abrasive.) More important are things like brushing regularly and well, flossing and/or using a proxy brush – both of which have a much bigger impact on oral health than brushing alone.

As a dentist, I do not use fluoride, nor do I recommend it to my patients. For hygiene products I do recommend, click here.

Image by alles-schlumpf, via Flickr

A Nanosilver Bullet against Tooth Decay?

We’re often overwhelmed by choice. Just think of your local supermarket and its aisles brimming with so many dozens of kinds of breakfast cereal, soup, crackers, cookies and other products. Most of the time when we do our shopping, we don’t pay attention to the plentitude. When we do become aware of it, it can be truly mind-boggling.

Of course, the matter of too much choice isn’t restricted to groceries but a whole array of consumer goods, from cars to computers, TVs to toothpaste. Anymore, it seems any innovation is glommed onto as quickly as possible to create new products that can stand out amidst the glut of old, familiar ones. And we all know newer is better, right?

Not necessarily. “New” isn’t always “improved.” And sometimes we rush to embrace new things without asking whether they’re really an improvement or what their potential drawbacks might be.

One new technology in dental care products that we may want to ask these questions about is the use of nanosilver in toothpastes.

The first question, though, is why nanosilver – very tiny bits of silver used to coat an item or be suspended in it? The answer is simple: it’s been shown to have antibacterial qualities. So considering that pathogenic microbes – “bad” oral bacteria – play a role in tooth decay and gum disease, it would seem to make good sense to use nanosilver to kill those “bad germs.”

But nanosilver – like other nanomaterials – has other qualities, as well. As noted in an article posted at The Wealthy Dentist,

Nanoparticles behave quite differently from their regular-sized counterparts. Their comparatively large surface area increases their biological activity. Moreover, the particles themselves are much smaller than cells. Nanoparticles can be absorbed through the skin, eyes or nose. They can even cross the blood-brain barrier.

For example, although titanium dioxide is biologically inert, nano-titanium dioxide particles have been shown to damage DNA. Nano-titanium dioxide is estimated to be in over 10,000 consumer products today, including cosmetics, medicines and toothpaste.

Another major nanotech invention, carbon nanotubes have amazing strength. Unfortunately, they can also cause more lung damage than asbestos.

What biological effects might nanosilver have? We don’t really know yet, though some animal studies – such as this one – have shown potential for harm. Much research remains to be done – not just on nanosilver but the full array of nanomaterials.

And what do dentists think about all this? According to a Wealthy Dentist survey, only 6% would recommend it, while 26% would recommend against it and 69% say they don’t know enough about it to say. But caution does seem to be called for. As one Texas dentist put it, “There is not enough scientific evidence that it is more efficacious than other more proven products, and there’s some disturbing evidence that it might do harm.”

Besides, in the world of too much choice, there are already plenty of effective, nontoxic toothpastes available – including ones that contain no fluoride or sodium lauryl sulfate.

What’s more, toothpaste itself plays a minor role in fighting tooth decay, serving mainly as an abrasive to help break up the biofilm (plaque) that forms on your teeth between cleanings. More important is how you brush, as well as whether or not you floss.


Image credits: 1) Toothpastes via Coming Home, 2) Nanosilver via NanotechnologyNow