J. Peter St. Clair, DMD Blog

It is common for a patient to ask what kind of toothpaste they should use. The concept of toothpaste and mouth washes is pretty old – almost as old as the Egyptian toothbrush. In fact, the earliest known toothpaste was created by the Egyptians. It was said to contain rock salt, mint, dried iris flowers and 20 grains of pepper, all crushed and mixed together to form a powder. It wasn’t until the 18th Century that the next recorded version of toothpaste showed up. That recipe was interesting as well.

The 19th Century saw a lot of toothpaste innovations, although many of them would be repulsive compared to what we are used to today. Charcoal, for example, was popular. Most of the toothpastes of this time were powders that became a paste when introduced to saliva. A lot of these different toothpastes were designed to both clean teeth and give the user better breath.

It wasn’t until the 1900s that toothpastes evolved into what we know now. Colgate, and many other toothpaste companies, worked to design toothpastes that tasted better while cleaning the teeth and not causing gums to bleed. Many ingredients now show up in toothpastes, with fluoride being one of the most common. There are a wide variety of “herbal” toothpastes as well, which don’t contain any fluoride. The variety of toothpastes available is designed to fit the needs and wants of every type of person out there. This high level of choice is the modern age’s primary contribution to toothpastes.

So, where does toothpaste go from here? Research continues to develop different ingredients that will benefit different problems. One of those ingredients I recently came across is green tea.

The oral health benefits of green tea are getting increasing attention in scientific literature, and now the authors of a new study suggest that it should be added to dentifrices as an active ingredient for managing periodontal disease.

The study authors, who are associated with various medical institutes in India, reported that it is a beneficial adjunct to nonsurgical periodontal (gum) therapy. “Green tea is known to possess anti-inflammatory, antibacterial, and antioxidant activities,” the authors wrote. “Antioxidants have a protective effect on periodontal tissues by reducing the oxidative stress in periodontal tissues.”

The study compared the effectiveness of great tea vs. triclosan. If you remember, triclosan, an antimicrobial which used to be found in some toothpastes, came under scrutiny for its overall safety. It is also found in some hand soaps, skin cleansers and detergents and has been shown to help with gum inflammation. “On comparison with fluoride-triclosan dentifrice, green tea showed greater reduction of gingival inflammation and improved periodontal parameters,” the authors wrote. “This can be attributed to the antibacterial, anti-inflammatory, and antioxidant properties of green tea.”

These results showed enhanced outcomes with the use of green tea dentifrice as an adjunct to routine professional periodontal care during the active and healing phases. Long-term clinical trials should be conducted to validate the results of this pilot study, the group added.

The great thing about green tea is that it is a natural product. Something to watch.

For decades, the American Heart Association (AHA) recommended that patients with certain heart conditions take antibiotics shortly before dental treatment. For those with these certain heart conditions, this was done with the belief that antibiotics would prevent infective endocarditis (IE), previously referred to as bacterial endocarditis. IE is an infection of the heart’s inner lining or valves, which results when bacteria enter the bloodstream and travel to the heart. Bacteria are normally found in various sites of the body including on the skin and in the mouth.

In 2007, the AHA’s revised guidelines were published in its scientific journal, Circulation, and there was good news: the AHA recommended that most of these patients no longer needed short-term antibiotics as a preventive measure before their dental treatment. This saved a lot of patients from taking antibiotics prior to dental appointments. However, those with replacement joints were still required to take the medication prior to dental visits.
These revised guidelines back in 2007 were based on a growing body of scientific evidence that showed the risks of taking preventive antibiotics outweigh the benefits for most patients. The risks included adverse reactions to antibiotics that range from mild to potentially severe and, in very rare cases, death. Inappropriate use of antibiotics can also lead to the development of drug-resistant bacteria. Scientists also found no compelling evidence that taking antibiotics prior to a dental procedure prevents IE in patients who are at risk of developing a heart infection.

More recently The American Dental Association (ADA) finally weighed in on the controversy about prophylactic antibiotics prior to dental visits for those who have had artificial joint replacement:

“In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use. As part of the evidence-based approach to care, the clinical recommendation should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.”

While the ADA’s statement is not an outright cancellation of all prophylactic antibiotics, it is reassuring to know that we (dentists and patients) have more flexibility, and are able to make these decisions without having to always hunt down the orthopedic surgeon. People who have had previous complications with infected joints or have compromised immune systems may still be required to pre-medicate.

For those patients who have been swallowing all those pills prior to your dental appointments, I would suggest having a discussion about this with your dentist. Patients with artificial joints have become accustomed to pre-medicating and I can understand if there is hesitation about stopping this routine. Have the conversation with your dentist and decide what makes sense for your specific situation.

It is not uncommon for me to get a strange look when I ask a patient about snoring. After an explanation about some of the reasons I include this on my medical history form, the patient will often say, “Well, I don’t snore but my spouse does. In fact, we sleep in separate bedrooms.”

Asking a patient about snoring is really asking, “Have you been told you snore?” Snoring can be a huge nuisance to the bed partner and is actually very detrimental to both people. For those without a bed partner, snoring can be assessed with apps such as Snore Lab, which measures snoring levels throughout the night.

Snoring is a sign of a restricted airway, which means that there is a possible depletion of air getting into the lungs and thus the brain. You spend approximately one third of your life sleeping, which means if you live to 90 years old, you may have spent 30 years sleeping. Oxygen depletion during sleep has both short-term and long-term consequences. I have read multiple studies which suggest a reduction of oxygen to the body can take 6-10 years off of your life. Sleep is one of the most mysterious states of being – we don’t know a lot about what is going on during sleep without it being recorded. Wouldn’t you want to know if your body wasn’t being oxygenated properly?

A restricted airway can be caused by numerous different factors. Many times it is developmental and starts early in life. I will discuss this more in a future column. As we age, this risk for developing a restricted airway increases with things like gaining weight, muscle tone laxity, and even sleep position. Snoring is a fluttering of soft tissue in the back of throat due to there not being enough space for air to pass through. Not only does snoring have the potential to affect your brain and the way you feel on a day-to-day basis, it also disturbs the sleep of the person sleeping next to you….and in some cases, people in other rooms.

Snoring does not mean you have sleep apnea (a serious disorder measured by a sleep test,) but is a significant risk factor. If you do have sleep apnea, you need to know this so that it can be treated and you can live a better quality of life. If you don’t have sleep apnea and just snore, this can also be treated, and you may be able to make it back into your own bedroom.

Aside from snoring, if you have any of the following: familial history of sleep apnea, history of daytime drowsiness, history of clenching/grinding, history of TMJ disorder, history of mood disorders/depression, witnessed apnea events (gasping at night), large tongue with ridges on the sides, tooth wear, high blood pressure, gastric reflux, large neck (Males >17 / Females>16) – you should discuss this with your physician and/or your dentist.

There are different ways to treat snoring and/or sleep apnea including positional therapy (sometimes a wedge pillow strapped to your back so you can’t roll onto your back), a CPAP device (positive air pressure through the nose to keep the airway open), or a dental device (to keep the jaw and tongue from falling back).

Just like exercising and good eating habits are good for the body, quality sleep vital to good health. Just because you get 7-8 hours of sleep doesn’t mean it is good sleep. Don’t hesitate to talk with your doctors about your sleep issues…..and encourage the loud person sleeping next to you to do the same.

Dentists play a key role in screening patients for many disorders relative to nutrition and in providing appropriate referrals into the health care system. Although the importance of integrating diet and nutrition guidance into dental care has been advocated for decades by educators, it continues to be ignored except by a handful of prevention-oriented practitioners.

Many of the world’s most significant health problems are linked to poor dietary practices, including over-nutrition and under-nutrition. Nutrition plays a fundamental role in health, and dental professionals have the opportunity to be a critical link between discovery and wellness.

There is a great deal of evidence linking oral infections, including periodontal disease, nutrition and immunological response. We have clear evidence linking oral disease with adverse pregnancy outcomes, diabetes, cardiovascular disease and stroke. In addition, obesity, which is an epidemic facing our country, is significantly affecting the incidence of diabetes, cardiovascular disease and overall lifespan. We know there are direct connections between these problems and oral disease. What is the role of the dentist? Should the dentist just be a tooth fixer?

As the body of data linking systemic health conditions and oral infection grows, the expanding understanding of the gene-nutrient reaction may result in more profound discoveries. As of now, many dentists fail to fully appreciate that the scientific bridge between oral disease and systemic health is often mediated by diet and nutrition.

The beneficiary of this profound evidence should be you, the dental patient. It should not only be the responsibility of the physician or specialized nutritionist to incorporate this information into practice. The dentist should be playing a key role.

For the most part, the dentist is the only one who examines the mouth. It used to be that the dentist only looked at the teeth and only fixed problems when they arose. By now, most dentists screen for periodontal, or gum, problems as well as oral cancer. The trend is to address these problems earlier than ever before.

People tend to have ingrained in their head that the dentist just looks at the teeth and treatment should be the same as 25 years ago. The fact of the matter is, things change. As I have said in numerous previous columns, there are no two dentists who practice identically. Each individual’s philosophy of care comes from personal experience, review of literature and the type and amount of continuing education taken. One thing we all hope is that our health care provider, dentist or physician, has our best interest in mind. There is room for improvement in the communication between all health care providers.

As science continues and evidence grows, preventative care and treatment will change with the times. It is the responsibility of all health care providers to work towards a more integrated health care system.

There are five major reasons that people do not get the necessary dental care they need. They are money, time, lack of concern, fear and trust. Let’s take a quick look at each one and see what dentists try to do to overcome these obstacles for patients.

Although you may think that money would be the number one reason people avoid ideal dental treatment, it is not. Even in tougher economic times, money, although a significant barrier for many, is still not the number one issue for most. Yes, dental care in some cases can be a significant investment. With insurance company’s unwillingness to raise the bar, as I have talked about in previous columns, patients often get stuck with large dental bills. Unfortunately, as of now, we have to face these facts but it should not mean avoiding the dentist.

Many dentists offer payment plans through third party carriers so patients can pay for treatment over an extended period of time. Ask your dentist if they have such an option. The point here is to get a plan. Once a plan is established, your dentist can work with you to prioritize and sequence your treatment. This way, if you need to spread your treatment over a period of time to make it affordable, you can pick away at a well thought out plan.

Time is an excuse. We all use time as an excuse for many of the things in our lives we want to avoid or procrastinate on. The reality is, however, if we place something high enough in our value system there is always time for it. In order to move something higher up in our value system, we must be educated and come to realize that this particular thing is of benefit to us. If you want better health/quality of life and to avoid the pitfalls of neglect, make the time.

The most common reason people avoid ideal dental care is lack of concern. Lack of concern about dental health is prevalent in our population for a few reasons. Absence of pain is one. Other than “nerve gone bad” need for a root canal, there few things that actually cause pain. Gum disease is a perfect example. About 75% of the population has some form of this disease but only 50% of the population goes to the dentist. Why? No pain. This doesn’t mean it is healthy and there are not problems down the road like loss of teeth. It is up to the dentist to educate patients on these types of issues, but people have to actually go to the dentist to get this information.

Some people fear going to the dentist….and for good reason, due to bad past experiences or bad information. However, dentistry today should be a comfortable experience most of the time. For those who are still fearful, there are different medications dentists can use to ease the experience. Avoidance cannot make the situation better. Most fearful patients are cured by finding the right dental team.

The last barrier to ideal treatment is trust. For a patient to move forward with treatment, it is essential the patient both like and trust the dentist. Although I am sure that the skills of your dentist are important to you, I am willing to bet that you would not stay with a dentist that you did not like or trust. Find someone you can connect with and build a strong doctor-patient relationship.

Last week we discussed the role and effect that diabetes has on oral health. It is not something that should be taken lightly. If you missed this column, please visit www.thetowncommon.com.

After reading last week’s column, it may seem frightening that there is no way out of the partnership of horrors between diabetes and severe gum disease. There are solutions. Just as poor oral health can compound a diabetic’s plight, proper oral health can come to the rescue.
Clinical studies confirm that treatment of gum disease reduces oral inflammation, which removes the factor that triggers the body’s inflammatory response which, in turn, plays a major role in compounding the effects of diabetes.

Dental treatments that fight gum infections also help improve control of blood sugar levels in diabetics.

If you are pre-diabetic, your dental team may actually be able to help prevent diabetes. If you already have diabetes, your dental team may be able to help you keep it under control, improve your quality of life and reduce the risk of premature death.

There’s even better news. It’s never too late to improve oral health care. Even if you already have severe gum disease or other dental problems, proper treatment can help stop it in its tracks. In many cases, this treatment can even reverse the damage done to your teeth and gums as well as manage the metabolic elements of diabetes. And, if you haven’t yet developed any symptoms of diabetes-related oral health problems, your dental team can start a prevention program that will help you stay in control of your diabetes, maintain better health and enjoy a better quality of life.

This is not something that requires exercise, taking a pill, giving yourself a shot of insulin, or sticking to a special diet, although some or all of these things may be necessary to also help control diabetes. From an oral health perspective, all you need to do is to start seeing your dentist and talking to him or her about your particular situation. Through the guidance of an exceptional dental team, you will be put on a path to better health. It will require you to alter your routine, but change is what is needed.

There may be varying degrees of participation from dental teams, depending on their knowledge or “philosophy” of care, when it comes to partnering with you and your physician to manage the oral health issues in regards to diabetes or pre-diabetes. The best team approach is between the doctor, the patient and the dentist (including the hygienist). If one of these team members does not participate, the battle cannot be won.

Sometimes it is the patient who is not doing the things that he or she needs to do to properly manage the problem. There needs to be open discussion on where things are falling short and follow-up to assess progress. If the dental team doesn’t seem too concerned about your diabetes, and isn’t giving you feedback at every visit on the status of your oral health, it might make sense to find a more progressive dental team.

Diabetes and pre-diabetes is a serious issue. You can take control of it but it needs to start with you wanting the improvement in your life. Your medical and dental teams are there to help make it happen.

With more than 24 million diabetics and 57 million pre-diabetics in the United States, nearly a quarter of the nation’s population has already been affected by this disease. The connections between dental health and diabetes have never been more critical.

As an indication of our general health, the rapidly rising rate of diabetes should be ringing alarm bells everywhere. The litany of health implications from diabetes is a long and grisly list. It is the sixth leading cause of death in the U.S. That is probably vastly understated because as many as 65% of deaths from diabetes are attributed to heart attack and stroke. People with diabetes have about twice the overall risk of death as those who don’t have the disease.

Complications from diabetes cuts years off productive lives and interfere with the quality of those lives through a host of debilitating health effects. Heart disease and stroke rates are as much as four times higher among diabetics. Nearly three-quarters of diabetics have high blood pressure. Each year, diabetes causes blindness in as many as 24,000 Americans. It is the leading cause of kidney failure, nervous system disease, amputations – the list goes on.

This isn’t meant to be a scare tactic. These are simply the facts and, yes, they are sobering. But if you have diabetes or are pre-diabetic, you may want to brace yourself. Because we are going to talk straight about oral health and diabetes, two diseases that can twist each other into a tight downward spiral of amplifying negative health effects. Unless they are halted by your physician and your dentist working in tandem as a health care team, together with your commitment to hold up your end of the bargain, these effects can continue to compound.

The facts about the connections between oral health and diabetes are even more alarming than those about diabetes alone. Here are just a few:

Diabetics are twice as likely to develop gum disease. This is especially true if your diabetes is not under control. The gum disease then worsens your diabetes through an automatic response that your uses to fight the infection.

People with gum disease are 270% more likely to suffer a heart attack than those with healthy gums. People who have diabetes and severe gum disease have a premature death rate nearly eight times higher than those who do not have periodontal disease.

Those who have gum disease and diabetes together are more than three times likely to die of combined heart and kidney failure. In people who have type 2 diabetes, gum disease is a predictor of end-stage kidney disease.

In people who have pre-diabetes – blood glucose levels that are higher than normal but not in the diabetic range – gum disease makes it more likely that they will become diabetic. Once established in a person who has diabetes, the chronic infection that causes gum disease makes it more difficult to control diabetes, and increases damage and complications in blood vessel disease.

We will continue this discussion next week and talk about some things you can do to help this problem.

Dental caries (cavities, decay) is still very prevalent in today’s society. There are many factors that contribute to dental decay. In addition, there are some people who are more susceptible to decay than others. In a recent article in the Journal of the American Dental Association (JADA), sugar-sweetened beverages, one of the main culprits for dental decay, was discussed.

Dental decay is a multifactorial disease characterized as an infectious process during which carbohydrates are fermented by specific oral bacteria at the tooth surface. This results in acid production and enamel breakdown. It should be noted that the beverages described in this column are not the only things that lead to dental decay. Anything rich in carbohydrates or with high acidity can lead to decay. In addition, the right bacteria, genetics, insufficient home care, and salivary flow are all contributing factors.

With regard to beverages specifically, as described in the JADA article, the main carbohydrate additives to note are sugar, lactose, high-fructose corn syrup, sucrose, fructose, glucose, maltodextrin, and honey. The beverages to watch for containing these are milk – yes milk, flavored milk, 100 percent fruit juice and vegetable juice, soda, juice drinks, sports drinks, flavored water, flavored tea and coffee, energy drinks, smoothies, and nutritional supplements.

People usually consume multiple beverages daily. As I have described in past columns, one of the worst things you can do is to drink these kinds of beverages slowly throughout the day. Constant introduction of carbohydrates over a prolonged period feed bacteria and never allow the saliva to neutralize the oral environment. If you have decreased salivary production this makes the situation much worse.

Here is a list of recommendations as stated in the JADA article:

1. Consume these types of beverages at meals only
2. Limit these types of beverages to once per day and to 12 ounces
3. Consume these beverages within a 15-minute time frame
4. Using a straw is preferable
5. Replace these sugary beverages with artificially sweetened or unsweetened beverages. ** I would add to that preferably non-carbonated
6. Brush teeth with fluoridated toothpaste 20 minutes after intake
7. Chew sugar free gum immediately after intake
8. Rinse mouth with water immediately after intake

Dental decay is preventable. Following the guidelines above and practicing good oral hygiene can prevent the most common reasons for decay. It is important to note that most people have plenty of room for improvement with their oral hygiene. Brush your teeth before your next dental appointment and ask your hygienist or dentist to assess how well you are doing at plaque removal. You will be surprised at what you may be missing.

In a recent study published by the American Dental Association (ADA), visits to the emergency room (ER) for dental related issues have doubled nationwide over the last decade. Last year, over 2.1 million people visited the ER for a dental “emergency”, most of which could have been prevented with regular dental visits.

In another recent collaborative study between the Rutgers School of Dental Medicine and the Rutgers Center for State Health Policy, they confirmed that most of these ER visits were for dental pain and infections that were not related to trauma. This is an increasing burden on the taxpayer and the healthcare system. ER visits can be 10 times more costly than if the treatment was performed in a dental office.

Dr. Cecile Feldman, dean of the Rutgers School of Dental Medicine, recently said the following in an ADA publication:

“The most disturbing aspect of the rise in ER dental visits is that treatment is often ineffective. In emergency rooms, there is a lack of diagnostic equipment and tools – such as dental X-ray machines – and ER physicians aren’t trained to identify and treat oral health problems. Often, they prescribe painkillers and antibiotics for infections while the underlying problem remains.”

The increase in dental ER visits supports the fact that many Americans have inadequate knowledge about the consequences of not getting regular dental check-ups. Many view dental care as a luxury and if their teeth don’t hurt and appear visually acceptable, they do not feel the need to visit a dentist.

Dental decay is the underlying cause of most ER dental visits. Dental decay does not hurt until it has affected the nerve of the tooth. Dr. Feldman states, “Tooth decay, which is almost entirely preventable, is the most common chronic illness among school-age children. Left untreated, it can result in infection, unbearable pain, loss of teeth and acute systemic infection, which in some cases can lead to death. Yet nearly one in four American children has untreated tooth decay.”

So, what are some of the underlying reasons for the increase in ER visits?  Dr. Feldman says, “For many, a visit to the dentist is unaffordable and inaccessible. More than 85 million Americans have no form of dental insurance. For those who have Medicaid, finding a dentist who accepts it can be challenging. Many dentists don’t because the reimbursement payments are a fraction of the cost of care and there is a very high administrative burden.”

I have seen many suggestions for helping address this problem. Some push for more community water fluoridation, others for dental coverage for all – such as under the Affordable Care Act (ACA). While children do have coverage under the ACA, it does not extend to adults. I’m not so sure that is the answer anyway, mainly due to the cost.

Dental insurance, in general, is a broken system. Unless there is some major overhaul in the way dental care or dental insurance is delivered in this country, the ER stats will continue to rise. For now, personal responsibility and budgeting for basic preventive dental care is your best defense against future dental problems.

Over the course of my 22 years in dentistry I have witnessed some significant changes in the materials that are used to restore teeth. In fact, most of the materials I use today were not in existence when I started to practice. The demand for materials that are tooth-colored have taken over. There are very few patients who ask for gold or silver fillings any more. And, while some of these newer materials are white, there are many factors which need to be considered in determining what material is appropriate for each individual situation.

As I said last week – The best dentistry is NO dentistry. Prevention of decay and other factors that require teeth to be restored is the best defense to not needing restorative dental work. Keeping up with maintenance cleaning appointments and listening to your dental team’s recommendations regarding diet, homecare and other forms of prevention such as nightguard use, is key to avoiding many dental problems.

One of my favorite quotes in dentistry comes from a pioneer dentist who was killed in a plane crash back in the 1970’s named Bob Barkley. He said, “The goal of dentistry is to make the patient worse at the slowest possible rate”. I think about this quote all the time when making recommendations and treating patients. Sometimes it leads me to recommend extensive treatment and other times it leads me to not recommend any treatment at all, even despite apparent need.

Dr. Barkley also coined the phrase “co-diagnosis” which refers to the patient taking an active role in their dental health. It is the role of the dentist to not only educate the patient on their specific situation and different options for care, but to also extract (no pun intended) from the patient their goals for their dental health. It is so important to think beyond the immediate fix sometimes. Taking the time to talk to patients about why things are happening and about their choices for prevention and treatment allows patients to become active participants in their health.

However, there are many barriers to this model including the patient’s lack of interest or concern, time involved, lack of trust, money and even fear. The dentist can also be a limiting factor depending on their philosophy of care. And one of the biggest issues facing both dentists and patients today is the role of patient’s dental benefit companies. This broken system is often responsible for patients choosing less than ideal care, thereby setting themselves up for more problems down the road.

My simple suggestion is to take a more active role in your own dental health. Think forward and ask your dentist or dental hygienist about things that can make your situation worse at the slowest possible rate. You very well may be doing fine or just need a couple tweaks to your home care regimen. Or maybe it’s time to consider preventive treatment or re-consider your dental team’s suggestion for an increase in the number of times you visit your hygienist a year.

Unfortunately, lack of pain is not a good indicator of lack of problems. Put your health first, find a dental team that listens to your concerns and takes the time necessary to establish a plan that makes sense and you are on board with.

I strayed from my original intention of discussing more on CAD/CAM dentistry that I introduced last week. However, as you will see next week, CAD/CAM dentistry often aligns perfectly with making your situation worse at the slowest possible rate.