Product recommendations for the most common dental issues

A patient very often has many a woe that they wish to share once reclined in the dental chair. Be it marital, gynaecological, psychological or spiritual. It is fairly difficult to recommend a mouthwash to help with genital itching, although at a push I would recommend Listerine. Mainly because the burning sensation as it melts the soft tissues of the mouth are bound to cause a distraction from the pain of itching elsewhere.

The top five most commonly complained about mouth problems are recession, bleeding gums, sensitivity, bad tastes and staining. The most commonly asked questions are what toothpaste would I recommend, should they be using a mouthwash and are there actually any benefits to using an electric toothbrush.

Some of these issues I have already tackled in previous blogs. Oral vibration or manual stimulation tackles the electric versus manual conundrum. Why breath can smell like death and there’s a lot to worry, about the interdental slurry answers the questions about bad tastes, bad breath and how to tackle it. Oral explosion anyone? Don’t mind if I don’t is a whistle stop tour of mouthwashes and their worth. If that lot doesn’t get you brushing your heart disease away, I don’t know what will.

What are we left with? Let’s start with recession.

As I am all out of funny banter about the UK’s economy, I’ll stick with gum recession. Although there are a number of reasons why recession occurs, the two main ones are over-brushing and gum disease.  Gum disease is normally associated with gum bleeding, gum soreness and bad breath. The gaps between the teeth can widen and the teeth can drift out of their original alignment. If you think you have gum disease, visit a hygienist. Pronto. If you think you’re brushing too hard, this is what you might see.

My crudely drawn on lines show where the gum line should be. Recession from overbrushing tends to have more on one side. If you’re right handed, you’ll overbrush the left hand side and vice versa.

Is there a toothpaste that can grow back gums? No. But there is a toothpaste I would recommend that can avoid exacerbating the recession. Sensodyne Pronamel. I recommend it because it is the least abrasive toothpaste on the market so when used alongside an electric toothbrush that senses you’re brushing too hard or a Wisdom Click Manual toothbrush that bends back with too much pressure, you can minimise damage. Oh, and stop being a scrubber. 

As an added bonus to those health conscious out there, Sensodyne Pronamel doesn’t contain Sodium Lauryl Sulphate, the foaming agent in everything that gets a lot of bad press. It can also help with associated sensitivity caused by gum recession. Which moves us nicely onto sensitivity.

Tooth sensitivity is a big problem and has many causes. If you notice hot and cold sensitivity, or sensitivity when eating sweet things, pop along to see your dentist to rule out decay. If you’re getting sensitivity and have noticed your teeth starting to flap about a bit, pop along to see your hygienist. If you get the kind of sensitivity that makes you want to remove your own head when the weather turns cold or because some inconsiderate bastard put ice in your drink, then there are a few products that may help.

Patient feedback suggests Colgate Pro-Relief and Sensodyne Repair and Protect (recently rebranded as Sensodyne Complete) are the market leaders in helping with sensitivity.  There is also a toothpaste available on prescription called Duraphat 2800 which contains double the amount of fluoride available in over the counter toothpastes.

Whichever one you decide to try, follow these very important rules: Brush morning BEFORE breakfast and at night, DO NOT rinse your mouth out with water after you brush (don’t do it with any toothpaste as you’re rinsing the active ingredients away) and before bed, rub the toothpaste around the sensitive teeth and leave it on.

Here’s the one thing that everyone wants to know. Do whitening toothpastes work? Yes and no. They don’t physically whiten teeth but they are abrasive so can lift the stains that make the teeth appear darker. Are they worth using? There is an argument that whitening toothpastes improve oral health because the users brush better with it as they want to improve their smile. However, I don’t tend to recommend whitening toothpastes; they’re more expensive and because they’re more abrasive, they can worsen pre-existing recession and sensitivity or start to cause it.

If you don’t suffer with sensitivity or gum recession and want to know what toothpaste to use, just look along the bottom shelf.

And if the Listerine hasn’t helped with the genital itching by the end of the week, perhaps pay your GP a friendly visit.

How to brush your child’s teeth

Most commonly, advice will be to brush for two minutes, twice a day.

In the real world, the tolerance level for such an activity for a full two minutes, is equivalent to teasing a lion with a piece of meat…it’s only a matter of time before you get your head removed from it’s neckstand by the unnatural strength a toddler can muster from nowhere when it really doesn’t want to do something.

My husband goes to martial arts classes to be taught techniques my two year old was born with. The Boy can miraculously turn to liquid, melt on the floor and slide out of my grip with an ease most Houdinis would envy, all to avoid a) putting a coat on, b) getting into a pushchair, c) being stopped from running into the path of a speeding vehicle.

He uses his melting technique for toothbrushing also, however, there are five main tricks that can help even the most reluctant of brusher comply with a bit of pre-breakfast/bedtime brushing.

#1 Monkey see monkey do

Most children will be glued to your ankles especially if you venture anywhere near the toilet, so will be happy to accompany you to the bathroom. This is also because the bathroom provides an endless supply of drinking/splashing water available from the strange shaped bowl, a brilliantly fun paper roll that makes a white mountain on the floor and an oversized brush in it’s own container, perfect for cleaning the walls with.

The earlier they can see you brushing and be included the better. Get them to ‘help’ put the toothpaste on your brush and then offer them their own so it feels like they’re being included in something exciting and special. If you have a bathroom mirror, hold them so they can see you brush whilst they ‘practice’ and once you’re finished you can take over. If they’re walking, use a stool for them to stand on next to you, so they can see their reflection and feel like they’re being included in something grown up and interesting.

#2 Make lots of noise

Not only can you teach your child phonics whilst brushing, you can also make yourself sound like a complete moron. It’s all for a good cause. It’ll also likely make you improve your oral hygiene to as it teaches a more methodical technique as opposed to random scrubbing like a maniac.

Making the “e” sound whilst hanging upside down off the edge of the bed

The two main sounds I use are “eeeeeeeeeeeeeeeeeeee” and “arrrrrrrrrrrrrrrrrrrrrrrr”. Smaller ones can also start to associate the noise with an action which makes it easier than saying “open your mouth” or “close your teeth together” when they might be too young to understand. Plus, by the end of the day, you’re so fed up with hearing the sound of your own voice, it’s nice to not have to use actual words.

So, on your own teeth, start with your front teeth touching edge to edge and make the “e” sound. Be sure to show the little ones what you are doing when you make that noise. Then methodically and slowly work your way around, using small and gentle scrubbing movements from bottom left to right, starting at the back. When you swap sides, make sure you don’t automatically go straight to the back again. Start at the front where you finished and work your way back. Repeat at the top.

Using the “ar” noise, open wide and scrub the biting surfaces like your life depends on it.

Keeping the “ar” noise going, use the same left to right technique for the inside surfaces.

Don’t forget the tongue! Poke you tongue out and give it a good scrub.

NB. I have mentioned before about brushing BEFORE breakfast. Bacteria present on the teeth, especially first thing in the morning metabolises your breakfast, uses it for fuel and then produces acid as a by product. Translation: the bacteria eats your breakfast and poos out acid. This acidic environment softens the enamel which then if you brush, can damage the enamel further. Tongue brushing is another good reason for saving breakfast till after. If tongue brushing makes you gag, you’ll only dry retch and won’t come face to face with your cornflakes, avoiding having to use your finger to push the lumps down the plughole.

Once you’ve shown the kiddies your noisy technique, you can get them to copy whilst you brush theirs.

#3 Experiment with locations 

Doing a good “arrr” whilst being distracted by Iggle Piggle. Or possibly about to attack.

It doesn’t have to be in the bathroom. It can be anywhere, because the amount of toothpaste you use for a 0-4 year old is such a small amount, they shouldn’t foam at the mouth like a rabid dog. I have always used adult toothpaste from the word go but just varied the amount. It is literally just the tiniest smear to begin with and then three years and over, they can graduation to a little blob. However, I still use a smear with my four year old just because I know I get better compliance if we brush her teeth in the bedroom and it saves having to spit out any froth.

The telly can sometimes come in useful if they tend to sit in front of it like a sedated zombie. Distraction can sometimes be key.

#4 Role play

This is my favourite because children love to play doctors and nurses but rarely a dentist. It is an equally viable career path to pursue as long as they aspire to only work in the private sector. It can also help alleviate fears of visiting the dentist because they already know what to expect.

Hanging their head off the edge of the bed is handy because it allows you to have a good look round their gnashers, especially the top ones.

This, as well, means they get to brush your teeth too.  All’s fair in love and war and it will all go towards getting compliance if they’re allowed to brush yours first.

You may need to have your answers prepared to the, “urrrggghhhhhh, why have you got grey bits in your teeth?” I suggest something along the lines of, “when I was little, every time I didn’t do as my mummy and daddy told me, the tooth fairy would come and hammer holes in my teeth in the middle of the night whilst hundreds of tiny, snarling pixies held me down. The grey stuff is the toxic metal they filled the holes with, that slowly melts the brain.”

#5 Time doesn’t really matter

If you know you are on limited time due to tiredness (theirs and yours) or you can see their fist rising, ready to knock your block off, then try and prioritise giving the biting surfaces a good scrub as this is where all the nooks and crannies are in little teeth.

Also, let’s be sensible; if they only have their two front teeth, brushing them for two minutes is likely to lead to brushing the teeth into dust. Teeth, when newly erupted, have softer enamel initially so don’t be too overzealous. As long as they’ve had a methodical brush round and been touched by some fluoride, then time is irrelevant until they’re preschoolers.

Something else important to remember, the first adult molars to erupt do not have a baby tooth predecessor and appear out of nowhere around the age of 6, so keep supervising until a child becomes proficient at handwriting. Although, ironically, if they do become a dentist, their handwriting will likely remain appalling.

There you have it. All I can do now is wish you good luck! Not that you’ll need it with my fool-proof guide, of course.

There’s lots to worry about the interdental slurry

A little while back, I wrote a blog post on oral offenders.  You know, those people that make your face fall off when they talk to you.  I recently had the pleasure of sitting next to an oral offender on the train.  Every time she nodded off, she started to mouth breathe, polluting the air with unsavoury bacterial characters from her cesspit of a mouth.

I have thoroughly enjoyed lovingly sharing with you the wonderments of the microbial monstrosities that reside in our mouths, but have not gone into much detail about how to keep the buggers in check.  Until now.

Today, I removed this stinking, interdental slurry from a patient with relatively good oral hygiene.  The patient accessed all areas decently with their toothbrush.  However, they were a bit lackadaisical when it came to cleaning between the teeth and this is what I found:

But then a little while later, I saw another patient with horrendous toothbrushing skills and they had shit all over the place.  However, their smelly slurry looked like this:

Not a great deal of difference.  Perhaps that’s because the interdental spaces make up 40% of the total surface area of the teeth, so no matter how appalling or brilliant you are with a toothbrush, interdental slurry will form in similar amounts.  Ergo, it doesn’t matter if you use an electric toothbrush that vibrates your teeth into an alternate universe, you need to get in between those teggers too, otherwise you run the risk of offending. Orally.

What can you use to clean between the teeth?

Tape versus floss:

Floss is cheap and cheerful.  However, it can feel like cheese wire and cut into the gums with overzealous use.  It also snags on filling ridges and tears. Very annoying.

Tape is a lot thinner and flatter so can feel more comfortable than floss.  It tends to snag and tear less too. Win.

When you use floss/tape to clean between the teeth, you should NOT see-saw backwards and forwards as this is effectively sawing into the gum.  Once you click past the contact point of the teeth, glide it gently under the gum and then slide it up and down the surface of the tooth.

Flossing/taping around back teeth can be tricky.  Most of the time you end up gagging and dribbling everywhere because your mouth is so full of fingers, you’re bereft of the ability to a.) breathe and 2.) swallow.

Something to help with this problem is a floss pick, or a floss holder.

Floss holder. Cost effective as reuseable. Good for accessing back teeth.
A load of wank. Don’t waste your money on these.
Single use floss pick. More expensive but quick and easy, as long as you don’t have big ridges on fillings/crowns.

Interdental brushes

Another useful aid is the interdental brush. Particularly if you have bridgework or fixed braces. Tepe is the leading brand and are generally pretty good.  You need the right size for it to be effective – a nice snug fit, without having to use too much bicep to push it through. I have seen someone fully pierce their gum with a Tepe brush so gently does it.

For accessing between back teeth with an interdental brush, you can buy long handled versions which can make it a lot easier.

If you’re unsure of any of this, just visit your hygienist. Simples. They’ll be more than happy to show you the error of your ways.

But for now, remember my motto to avoid being an oral offender…

If you’re always in a hurry, you’ll forget to clean that slurry.  You dirty bastard.

The tooth, the whole tooth and nothing but the tooth.

There a lot of changes afoot in NHS dentistry and I sincerely hope they are for the better because the current system is seriously failing you and your children.  There, I’ve said it.  But this is only my very humble opinion, of course.

Every ten years, a dental health survey on children and young adults is carried out by The Office of National Statistics.  The last one in 2003, showed that 57% of children aged up to fifteen had experienced tooth decay.  That means the latest statistical report will be due out this year and I predict it to have changed very little and probably worsened in some categories, especially in the under fives.

Since 2006, the previous government changed the way dental contracts worked in the UK.  Dentists in the NHS now have to work to a unit of dental activity (UDA) scheme. Each UDA is worth approximately £20 to the dentist.  This system was brought in to encourage preventative dentistry and to eradicate ‘over treatment’. It has been very successful in achieving that goal.  Unfortunately, it now encourages ‘under treatment’ and prevention is at the bottom of the list.

Many of you may think that dentists earn a lot and won’t feel sorry for them, however, with the incidence of oral cancer, heart disease, diabetes and obesity all on the increase, which all have a direct effect on your oral health and are intricately interlinked (angina and other serious cardiac symptoms can manifest as dental pain), dental professionals play a crucial role in prolonging your life.

The current system puts so much strain on finances that it may mean that you and your children are not getting the standard of care you deserve.  More dentists are opting out and moving to the private sector. To cover the deficit, dentists that were trained outside the UK, to an unstandardised level of practice, are being brought in to work for NHS dental corporates.

A dentist is expected to carry out an examination which includes a risk assessment for tooth decay, gum disease and oral cancer, as well as take radiographs, carry out a basic scale and polish (should it be deemed clinically necessary – staining is a cosmetic issue), apply fluoride varnishes and give oral health advice, all for 1 UDA.  They have to work to NICE guidelines and under the Care Quality Commission delivering standards of cross infection more fastidious than hospitals.  They have to document everything from the batch numbers on each individual local anaesthetic cartridge to print out reports on every cycle of sterilisation.  Obviously, to protect the patient from infectious diseases but mainly to avoid litigation in case a patient decides that the check up they had 6 months ago was responsible for their Hep C infection.

The advantage of UDAs is a guaranteed income but someone else decides how many UDAs the dentist needs to achieve in a year in order to get funding to treat patients on the NHS.  This means should they fall short of their UDA targets then they have to pay the deficit back. This encourages an influx of treatments in the months running up to April.  Why is it that all service provider sectors that are budgeted each year are rewarded for spending all the money?  Schools, councils etc have to spend any money left over otherwise they lose it the following year.  That doesn’t make sense.  Why not reward the ones that saved the taxpayer’s money?  If you are a dentist working to brilliant preventative measures then your UDAs will decrease.  Surely that’s a good thing and should be rewarded?

A dentist wishing to deliver a high standard of preventative care for your child would ideally take 10 minutes to thoroughly examine them, take radiographs if necessary, apply fluoride varnish and send them for a session with the oral health educator to give them instruction on diet and oral hygiene.  This is what research shows significantly decreases the incidence of tooth decay in children.  For all this, the dentist would receive 1 UDA.  A lot of dentists take no more than five minutes per person for examinations in order to reach their targets and absorb the more costly, time consuming treatments such as root canal fillings.  It appears it just simply isn’t financially viable for a dentist to carry out the full scope of preventative dentistry and remain in business or maintain integrity or sanity.

On the subject of root fillings, it’s unlikely they’ll even bother with root fillings that are generally loss leaders.  Tooth extractions rose by 18% in the two years following the new dental contract in 2006.  And what if patients are exempt from NHS charges?  In the last quarter to June 2013, 60% of non-paying patients received treatment in the third band category (12 UDAs) as opposed to 28% of paying patients. Does this mean that patients that are exempt from charges are more likely to be on a lower socioeconomic scale, smoke and drink more and look after their teeth less?  Possibly.  Or does it mean that dentists can carry out more expensive treatment plans without the patients complaining about the costs (£214) and therefore work towards actually achieving their targets?  Probably.

Dentists may also split treatment between check ups.  You arrive for your check up needing two fillings – one is causing pain, the other is not and you are unaware of its existence.  It is not uncommon for the dentist to just do the important one and claim 3 UDAs.  When you attend your check up in 6 months, the dentist will then identify the second filling and carry out treatment for another 3 UDAs.  Why not just do both together?  Because the dentist would only get 3 UDAs regardless of whether you had to have 1 filling or 10.  So ‘splitting’ occurs.  I have been reprimanded many times for pointing out a cavity to a patient that the dentist had been ‘saving for later’ – nothing was in the notes of this cavity’s existence so no one is none the wiser.  Is this fraudulent or illegal? Not always and it’s a stupidly grey area.  “There are no specific rules forbidding dentists from splitting up courses of treatment into separate claims for component elements, although it does demonstrate sharp practice on behalf of the dentist who earns more UDAs and collects more patient charge income than is necessary.”  Fraud does, of course, take place.  Dentists create ‘ghost’ patients to make false claims and claim for treatment that hasn’t taken place.  Not to increase their salaries mind, just to meet targets.

Back in 2002, a government document deemed that ‘scaling and polishing’ was a more cosmetic procedure and could save the NHS £70 million by not offering it as a separate entity as 50% of scale and polishes were crudely deemed to be carried out unnecessarily. So the new UDA system places very little value on scaling and polishing.

“Undiagnosed and untreated gum disease is one of the fastest growing areas of litigation and complaints in dentistry.”  It is nigh on impossible to treat gum disease on the NHS.  I regularly see patients with gum disease that require initial treatment plans of four to six appointments.  This totals 2-3 hours of my time and that is just the first stage of treatment.  A dentist on the NHS would be expected to do this for 3 UDAs.  Therefore, your 2-3 hours privately is likely to equate to 30 minutes on the NHS and that’s presuming they’ve actually identified any gum disease in the five minutes allocated for the examination.

Dentists, hygienists, therapists or oral health educators are not generally remunerated for visiting your child’s school and giving an oral health talk, despite government apparently setting aside additional budgets for schools to spend on health.  In order for a dentist to check your child’s teeth in school, each child has to have had consent from an adult given in the form of a signature and even then, the dentist cannot inform the parent if decay has been noted as they wouldn’t be present at the examination and confidentiality means a third person such as a teacher could not be informed.

It’s crazy to think that tooth decay is one of the most preventable diseases in the UK. But for preventative dentistry to work, they have to reward prevention in the first place.  There has to be routine use of hygienists, therapists and oral health educators and financial rewards for dentists that apply fluoride varnish and place fissure sealants.  Oral health professionals must be utilised to provide regular oral health messages in schools.

But let’s not lay all the blame and responsibility at the government’s door.  Parents must take responsibility for their child’s diet and oral hygiene habits.  If you expect your child to be responsible for their toothbrushing at the age of 5, then expect them to do an insufficient job and get tooth decay.  If your child regularly drinks anything other than milk or water, then expect tooth decay.  If you give your child sweets to keep them quiet/reward them/cheer them up, then expect tooth decay.

So, if you are lucky enough to have a dentist that nags you and your children when you see them, that makes you feel defensive because they question your dedication to your child’s oral health and advises you on how to make things better, don’t ignore them.  Just be grateful they still give a shit in the crappy system they’re having to work in.

In the meantime, I’ll be keeping my fingers crossed that this government make a few positive changes to help oral health professionals deliver a better service.  I won’t be holding my breath though.

The truth behind those ‘treats’

Image taken from this rather marvelous webpage

Food guilt is quite high on my guilt list, only marginally underneath Shouting At Them Guilt and Watched Too Much Telly Guilt.  How often the children eat.  How much they eat.  What they should eat. What they shouldn’t eat.

I have BIG guilt over what I don’t allow them to eat or drink due to my profession – saying that, my 3 year old daughter still eats 3 times over the recommended daily sugar intake just from sugars in food and an occasional bit of chocolate – that’s how easy it is to consume sugar in our diets today.

I know that there will come a time that I can no longer control it and instead of rebelling by smoking and getting pregnant at 15, my kids will probably start a sugar-only campaign until their dentition resembles that of a crack addict.  Just to spite me.

Tooth decay in children is a bit of a bugger though.  It contributes to days off at school, can cause disruption to how adult teeth develop and erupt and fillings in permanent teeth can reduce the life expectancy of that tooth quite drastically. Here’s a little paragraph from my resident dental expert, Dr Al Ginate explaining how:

So, basically it’s down to the size of the filling.  The bigger it is, the more chance the pulp gets damaged, thus decreasing it’s life expectancy. Ability to keep it clean is also important because if bacteria gets in between the filling and the tooth it won’t last long and a new filling will need to be placed, thus increasing the size of the cavity and decreasing the prognosis further. A filling badly done also decreases the life span of the tooth. If it’s improperly sealed, the bacteria will race in. If it’s not smooth around the gum line, the bacteria can get stuck under the ledge and inflame the gums, causing gum disease, bone loss and loss of tooth support. Bye bye tooth!

In my training we had to learn about The Vipeholm Study.  We had to study it with such intensity that if we weren’t able to randomly recite Vipeholm fact like Father Jack politely requesting an alcoholic beverage, then we were coshed over the head and our lifeless bodies dragged to the ‘probe’ room. I exaggerate slightly. Only slightly.

It was a pivotal 10 year study between 1945-55 that took place in Sweden, in a home for the “uneducable mentally deficient”.  It was one of the first taxpayer funded scientific studies and no official consent was obtained to experiment on the residents.  It would never be allowed today and caused a huge outcry at the time (or after the data was released) but what it discovered, to the detriment to many of the 436 residents involved, paved the way for tooth decay theory which is still of paramount importance in oral health education today.

Sugar was added in a variety of ways to the diet of 436 patients.  It was dissolved in drinks, baked into bread and added to plain chocolate. Other methods of administering sugar was via varying amount of toffees or caramels over the course of a day, either with a meal or in between meals.  Control patients were given fats instead of sugar to compensate for calorie consumption.  Saliva samples were taken every 15 minutes through the day and analysed for sugar and acid levels.

I dread to think what havoc all the extra calories had on their weight, and the sugar crashes on their mental wellbeing, when all of them were already classed as “mentally inept”.  The amounts of sugar being added to their diets were between 12 teaspoons to 75 teaspoons per resident, per day, depending on which group they belonged to.

Sadly, it is estimated that 2,125 tooth cavities were induced in a time when there was no dental care available to the residents.  No doubt then, they also experienced a lot of pain and probably went on to develop type II diabetes.

What was learnt from this?  Well, they confirmed that sugar caused tooth decay but it wasn’t the amount of sugar, it was the frequency of sugar that really created cavity carnage.  Not just that though, but the consistency of sugar also made a significant contribution to the decay rates.  Those that were eating toffees and caramels suffered the most because the stickiness meant it increased contact time on the teeth.

As well as the caramels and toffees already mentioned, here is my top five contributors to tooth death list:

1.  Lolly pops.  They take a long time to eat, are sucked and kept in the mouth for considerable amounts of time and when crunched get stuck in all the fissures of the teeth.  Perfecto tooth destroyers.

2.  Jelly sweets.  Loaded with sugar, a few mood enhancing E numbers with an added bit of sticky.  Hello bacteria poo. Bye bye enamel. Hello holes.

3.  Boiled sweets.  Sucked and held in the mouth for long periods, and usually in one particular area.  If crunched, bacteria food heaven will be deposited in all the nooks and crannies.  Nom nom nom.  Big, fat, acid-shitting bacteria.

4.  Biscuits.  When eaten, they become a bolus of squidgey, sugary goo, that cakes itself all over the teeth and gets stuck in all the places it shouldn’t.  Yup, acidic faecal matter spreading itself all over those beautiful pearly whites.

5.  Soft drinks.  Full of crap.  Makes bacteria crap. Makes your tooth enamel look like crap.  Just crap.

WARNING: The next paragraph is going to be the most guilt-laden words ever written on EBT&T.  I’m sorry but I’m going to have to say it…

Next time you ‘treat’ your little one to tooth death, think about how much of a ‘treat’ it actually is.  Their lives won’t be left lacking without it and there are lots of other things that can be used as bribes/treats/thankyous/rewards.  Just have a look in the craft section of your local Pound shop to find inspiration.  Cheap, tacky but kids love that kind of tat and so do their teeth.

Make all the pain and suffering caused by the unethical experiment worth it and shun those sugary snacks….too far?  Ok, perhaps just save them for a mealtime instead.

(*Whispers* For more toothy blogs, check out the TEETH archive.)

Mercury declining

Something very interesting came to my attention today.  After rifling through a bunch of discarded dental magazines, I came across the August edition of the British Dental Journal.  Yeah and…?

In it was an article, “Managing the phase-down of amalgam”.  What what what??? They’re phasing out metal fillings, after years of defending the use of mercury filled…well, fillings? That doesn’t look good.

I recently blogged about mercury in boob milk and speculated on what this means for concerned mothers.  So does this new bit of revelation-ary news make any difference?  I think it does but let me expand on the article more.

The Minamata Convention has agreed a world wide ban on the production, export and import of products that contain mercury such as batteries, switches, toys, soaps and cosmetics (I had no idea mercury was in some soaps and cosmetics!  Scary!) and, of course, dental amalgam.  Dental amalgam will be ‘phased out’ and opposed to overnight stoppage.

The Minamata Convention was brought about after an a public and environmental disaster occurred in Japan following the second world war.  Chemical and heavy industry flourished and with it mercury was being discharged into the surrounding environment from a factory called Minamata.  It polluted the waters and the fish.  The local population that ate the fish become ill with severe damage to the nervous system causing symptoms such as paralysis, sudden inability to eat or talk, impaired hearing and vision.   Minamata disease was born.  60 years on, The Minamata Convention has agreed on a legally binding document between 147 governments on the Minamata Convention on Mercury.  In a nutshell.  From what I can fathom.

Various national and international dental organisations maintain that the use of mercury in dental restorations is safe, however, the time has come when dental practice has to move towards more preventative, minimally invasive methods, rather than a ‘drill and fill’ workforce.

Techniques in dentistry are changing from a ‘cavity-preparation-drill-everything-out-plus-a-bit-more-and-make-a-nice-retentive-undercut’ to just ‘scoop-out-the-soft-shit-and-seal-it-in’.  What they have discovered is that you don’t have to drill all the gunge out, in fact you can leave a large amount of it in, because properly sealed with a ‘white’ filling, the bacteria become entombed, lacking a nutrient supply and therefore die a slow and painful death.   Yes, this does mean you’ll have lots of microscopic dead bacteria in your tooth but it will also mean that you won’t have to endure a large portion of time having your tooth drilled out and fillings will become tooth coloured.

This is so much more important in paediatric dentistry – not only is it scary for children to have a tooth drilled and filled, a large number of them have to be done under GA or sedation.  Minimally invasive dentistry, more freely available to both NHS and private patients, will (hopefully) mean less scary experiences, which will equal less phobias, which will equal more adults accessing dental care, which will equal better oral health, which will equal better overall health. That’s my equation anyway.

It is only be a good thing to phase out dental amalgam, whatever the reason may be.

Who is the real NME?

The ‘Elite’, as they have now been reclassified, have a lot to answer for in the history of tits and teeth.

Sugar first started being imported in Britain in the 1300s.  Only the rich could afford it and would literally dine out on it; having it shaped into liquid receptacles to drink their beverages from and then eating it in a manner that would excite Heston Blumenthal to his very core.  This led to the occurrence of rotten teeth on quite a large scale so the cavity-less poor would sell their teeth to the rich.  Extracted without anaesthetic and implanted into the bacteria-poo infested wealthy, it didn’t have a high rate of success.   

In the 50’s, boobing was reported in Women’s magazines to be a practice of the poor – those that couldn’t afford formula, breastfed and were seen as peons.  Yet, in today’s society, it seems that those that are low on the socio-economic scale are less likely to boob even though it’s free.

Back to teeth.  Sugar is now consumed at ridiculous levels even though we are aware of it’s implications with diabetes, obesity and tooth decay.  It has 50 different aliases including, sucrose, fructose, maltose, dextrose, glucose, sorbitol and molasses.

Hot off the press, research has shown sugar to have an inflammatory effect on the human body thus turning the theory of gum disease on it’s head.  It was once thought that quite simply, bacteria arrives first which leads to inflammation that causes destruction of the gums. This is still true but also the consumption of sugar can lead to inflammation first; the inflammatory cells ‘feed’ the bacteria, helping them thrive thus also causing gum disease.  This has meant a whole new category of gum disease has been created.  Food-induced gum disease.  These people tend to have good standards of oral hygiene but still have bleeding gums.  (Before you self diagnose, go and see a dental hygienist!)

In dental decay world, non-milk extrinsic sugars (NMES) are classed as the most cavity-creating.  They include the sugar we add to our tea/coffee, the sugar added to food, honey and syrups.  Fructose (fruit sugars) and lactose (milk sugars) can still cause tooth decay if the exposure is frequent enough and long enough, but for the simplicity of this blog, I’m going to stick to NMES otherwise we’ll be here all bloody day.

 10g of sugar is about two and a half level teaspoons.  The guideline daily amount of sugar for children over the age of 5 is eight and a half times that – 85! That’s about 21 teaspoons of sugar a day.  That seems like quite a lot.  There are no clear guidelines on recommended amounts prior to age 5, but the AHA recommend no more than 16g – 4 teaspoons.

Rice Krispies, a seemingly plain cereal, contains 9g of sugar per 30g portion.  Coco Pops contains about 17g.  Frosted flakes about 18g.  Tinned beans/pasta in a faux tomato sauce contains between 8-10g.  A pack of chocolate buttons is about 21g. Two pots of Petit Filous yoghurts contains about 12g – that’s 3 teaspoons of sugar in those teeny, tiny pots which we forcibly spoon into our baby’s teeny, tiny mouths.

If I analyse the sugar intake of my daughter on an average day, it’s probably around 40g which is quite over the AHA guideline.  She has chocolate but doesn’t eat sweets and doesn’t have sugary drinks.  But that’s still about 10 teaspoons of NMES.  Great.  Now I have sugar guilt.

However, as much as it saddens me to say, research suggests that sugary foods eaten at mealtimes, especially sugar-laden breakfast cereals, do not increase the incidence of tooth decay as they are eaten at a mealtime when acid attack is already going to happen.  But before you breath a sigh of relief that you’re able to relieve yourself of breakfast cereal guilt, we still have to consider the big picture – the health effects of sugar consumption on body weight and diabetes.  Uncontrolled diabetes can ravage the supporting structures of the teeth and gums and 16.3% of children, aged 2-15, in England were reported as obese in a health document published in 2012.  I’m really keeping it light today, People.

So, let’s look at drinks.  These, are what I personally think are quite damaging.  Heinz have a baby juice which has no added sugar and has quotes from some dental association on it.  All natural sugars but using the wonderful medium of litmus, you can see how acidic it is.  This is also marketed for babies.  BABIES! When their newly erupted enamel is still soft and fragile. Perfecto.

Fruit Shoots flavoured water is equally as acidic and so is a glass of cordial, no matter how dilute it is.  These also tend to be sipped at regular intervals throughout the day, especially if put into beakers and something named ‘hydro’ which is basically water may lull you into a false sense of security.  Don’t be lulled.  Be the opposite of lulled.

Something even more controversial though, which brings up debates similar to water fluoridation, is the use of sweeteners as a sugar substitute.  Aspartame is meant to be one of the most researched sweeteners on the market and has been deemed safe.  And yet there is research out there that suggests it has a profoundly negative effects on the nervous system, causes memory loss, allergic disease development when consumed in pregnancy and can cause hyperactivity and aggression in children.

However, some sweeteners are anti-bacterial, especially against the critters that cause tooth decay and eating sugar on an empty stomach can equally cause a child to become an aggressive, hyperactive, hyperventilating beast.

I don’t know about you but my brain just fell out.

Let’s take some deep breaths, poke our brains back in to our ears and try to make sense of this.  Let me tell you what I am going to do with my children (90% of the time):

  • Stick to sugary snacks at mealtimes only
  • Limit acidic drinks, even natural fruit juices, to mealtimes only
  • Try to only choose things with naturally occurring sugars as much as possible
  • Avoid anything with aspartame because (in my opinion) there ain’t no smoke without fire
  • Carry litmus paper with me every where to randomly dip as much as possible
  • If the kids are ever diagnosed with diabetes, blame the Father
Chocolate? What Chocolate?

Thank you to the brilliant Maria Dragan for letting me use her ‘candy’ photo.

Oral vibration or manual stimulation?

One of the most common questions I get asked is electric toothbrush versus manual toothbrush.   Studies are massively varied, some showing a significant difference in reducing the infamous, acid-defecating bacteria and others showing no significant difference whatsoever.  Nothing unusual there then.

Other problems with these studies are that there is such a huge selection of electric toothbrushes and manual toothbrushes that which ones do you trial together?  The basic electric toothbrush with the boring, round head or the electric toothbrush with 1400 buttons that not only vibrates the bacteria into another dimension and but also increases the size of your bicep by 27% due to the strength needed to keep it from vibrating out your hand and destroying the bathroom?  Do you use a little manual toothbrush with bristles all perfectly in line like a military haircut, or a bristle brush that has bits of coloured plastic jetting off in every direction like a festival goer’s hairdo?  Too many choices.

A small study with children aged 4-5, using four different types of manual and electric toothbrushes “showed there were no clinically meaningful differences found between any of the toothbrushes tested during either of the trials with regard to plaque removal or improvement in gingival health. ”

Another study with children aged 5-8, using three different kinds of manual toothbrushes, showed there were no significant differences in the cleaning efficiency between the three toothbrushes. “Significant improvements in plaque removal in children can be achieved following good brushing instructions regardless of the toothbrush design used.”

However, in usual contrast, a study in adults, one group using a battery toothbrush and the other using a manual toothbrush, showed a significant difference between the effectiveness of plaque removal.  That might be because adult biofilm is a little more complicated than child biofilm.  I have no evidence of that.  Just speculating because it makes me sound intelligent.  And I like the word biofilm.

So before I bore you too much, I’ll skip straight onto the advice I give – some based on teachings at dental school, and other advice based on looking in several thousand mouths over the last 9 years:

Taken from a funny comic blog
Taken from a funny comic blog
  • It’s, in a nutshell, down to personal preference.  A manual toothbrush used well is just as effective as an electric brush.  It’s what you do with it that counts.  A toothbrush used badly, whatever it is, will be as effective as trying to access your mouth via your anus.  The bacteria will be the same though (not quite, but smell the same).
  • Only bother with battery-operated brushes if you’re unsure whether you’ll like the gummy stimulation of a vibrating brush.  This way you get to try it out cheaply before making up your mind.
  • Don’t bother with expensive sonic brushes.  Some dental professions swear by them.  Some patients swear by them.  They require such a specific technique, that in my opinion, do not improve gum health because they are rarely used correctly.  Plus, they splatter the bathroom mirror with mouth debris with such vigour, it’s like a bloody scene from a Tarrantino film by the time you’ve finished.
  • Regardless of how new-fangled your toothbrush claims to be, along with your mouth exploding mouthwash and miracle, enamel growing toothpaste, you will only be cleaning 60% of the tooth surfaces, so if you do not get in between the teeth, you could end up with breath like death.

Tips for electric toothbrushes:

  • Always get one with a two-minute timer as a basic feature
  • Always get a round-headed brush as opposed to rectangular
  • Always stick to the basic head it comes with – forget the heads with plastic gum massagers and polishers.  Pointless and expensive
  • Always get a rechargeable as opposed to battery
  • Spend at least £30 (unless you see one half price but the original price was more than £30!)
  • DO NOT use it like a manual toothbrush.  You will need to tilt the bristles towards the gums and hold it for a couple of seconds on each tooth.  If you move it too quickly, you’ll just skim past the proudest parts of the teeth and miss the nooks and crannies
  • DO NOT be tempted to use it when it has lost it’s charge.  Please refer back to my shoving toothbrush up arse comment earlier
  • Change the heads as soon as the blue bristles start to fade or start to splay
  • Do not rinse with water after you have finished brushing as you will wash away to antibacterial agents of the toothpaste

Tips for manual toothbrushes:

  • Keep it small and simple – no more than 2cm in length
  • Keep bristles fairly uniform and boring
  • Medium textured bristles
  • Brush for at least two minutes
  • Point the bristles towards the gums and use small, jigging movements
  • Use a bathroom mirror so you can actually see where you’re brushing and if any areas bleed.  If they do, call an ambulance.  Not really, just brush the bleedy area again.  Gums are like the soles of your feet; the more you walk around without socks on, the harder the skin gets.  The more effectively you brush your teeth, the tougher the gums get.
  • Change the toothbrush at least three-monthly or when the bristles start the splay and feel soft
  • Again, do not rinse with water after you have finished brushing as you will wash away to antibacterial agents of the toothpaste

So, the next time you find yourself standing in front of the sea of toothbrushes at the local supermarket, hopefully you’ll feel less like stabbing yourself in the head with an organic parsnip and be more equipped to picking the right brush. Just keep it simple.

I’ll leave you now with Charlie Brown – he will make you so knowledgeable about toothbrushing, that you can put it on your CV when applying for my job.

Why breath can smell like death…

If people generally become nauseous in your company, you may be an oral offender

We all know an oral offender.  I’m not talking about the office bigot with the liberal use of foul language.  I’m talking about the person that has a three metre radius of fetid fog emanating from their face hole.

Everyone gets morning breath.  I often cringe at Hollywood sex scenes that involve an impromptu morning rendezvous   It’s one thing to exchange genital fluids at that time in the AM but sharing their mouth inhabitants’ excrement makes me feel a bit queasy. Who said romance was dead. But I’m not talking about run of the mill morning breath, I’m talking about having-to-hold-your-breath-so-you-don’t-gag-whilst-they-talk-to-you breath.

So why do some people get bad breath and what can we all do to avoid it?  I think understanding the tiny inhabitants of our mouths and their habits might help so here goes…

What was once called plaque is now termed as a biofilm.  This is because it is far more highly organised than they once thought.  Once upon a time they discovered two different groups of bacteria – ones that lived above the gums and ones that lived below it.  The ones that lived above the gums liked lots of oxygen and the ones that lived below didn’t like oxygen.  They quickly realised that the ones that liked O2 were the Notting Hill, high society-type bacteria and the ones that loathed Owere quite a volatile bunch that caused a lot of damage and did a lot of murders.  The two didn’t have a lot to do with each other and it was generally thought that if you were unlucky enough to have the thuggish lot living in your oral cavity then you had evict them pretty damn quick. 

Now, however, they have discovered that the two sides are actually complexly intertwined like a well scripted Guy Ritchie movie.  Instead of being like an episode of Downton Abbey where the upstairs never mingles with the downstairs, it’s more like the drug industry where the dirty lowlifes are supplying the socialites their fix of narcotics – they never consort but are very much dependant on one another.

Most of the bad breath smell is created by bacteria turd, but other more disturbing compounds can also be found.  Candaverine and putrescine are what makes dead bodies smell.  Skatole is the smell of human bum waste.  Isovaleric Acid is the smell of sweaty feet.  All these things can also be found in the mouth.  I often have patients say to me that they didn’t have time to brush their teeth before they left the house.  Does a lady ever go for a smear test and forget to wash her chuff? Does a bloke, hoping to cop off on a night out, forget to give his knob a good scouring? I bloody hope not.

If you have an inquisitive mind and a strong stomach, you can look at a video of the inhabitants of a healthy mouth and the boisterous, defacating party goers of an unhealthy mouth.  If that doesn’t make you scrub and floss your toothy pegs, I shall also be doing a future post on good toothbrushing techniques.

In the meantime, here are a few tips:

  • Brushing alone only cleans 60% of the total tooth surface area so that means 40% makes up the spaces in between the teeth.  Most bad breath can be eliminated by flossing or using an interdental cleaning aid of some kind.  If you need assistance on choosing the right in betweeny-cleany gadget then visit your dental hygienist.  (From May 1st, you should be able to see a hygienist without having the see a dentist first.)
  • Your tongue, especially near the back, can collect and harbour a lot of bacteria so tongue brushing is very important.  You only need to use your toothbrush at the end of your toothbrushing routine and if you brush before breakfast, it won’t matter if you gag a bit.  If you use an electric toothbrush, it might be worth having a manual toothbrush as well to brush your tongue with.
  • The average time spent brushing teeth is about 30 seconds.  To do a thorough brush, it really needs to be about two minutes.  First of all, time yourself to see how long you take and do it honestly.  Then do it for two minutes and see how much more you clean.
  • Be methodical.  Most of us are zoned out when we’re brushing, thinking about the next task or the day’s events so when you put that toothbrush down, you won’t be able to remember whether you brushed the back teeth or the left side as equally as the right.  Feel all the surfaces of the teeth with your tongue.  You have the insides of the top set and the insides of the bottom set, the outsides of the top set and the outsides of the bottom set, the biting surfaces of the top set and the biting surfaces of the bottom set.  Think about where you’re brushing and use a mirror so you can put the toothbrush down when you’ve finished and know that you have cleaned all the surfaces thoroughly.
  • If you notice bleeding, don’t worry.  It’s likely that you’ve just started reaching inflamed bits that you weren’t reaching before.  If your gums persistently bleed, then visit a hygienist so they can tell you why.

Gum disease is now being linked with heart disease, diabetes, respiratory disease and even some cancers so having a healthy mouth really will increase your life expectancy. Help your fellow (wo)man by sharing this blog…unless the oral offender you know is a complete cock in which case, just keep giving them a wide birth as they’ll hopefully die a lot sooner than you anyway.

Oral explosion anyone? Don’t mind if I don’t.

There is something I have been needing to get off my chest.  That advert.  The one with the exploding mouth whilst the bloke rinses with a well known mouthwash.  Bloody irritating.  Cleans 99.9% of bacteria *small print* in healthy mouths.  Oh, piss off.  It’s like those mascara adverts with the scandalous eyelashes.  79% of women agree *small print* from a study of 13 women.  The only scandalous thing is their misuse of the word scandalous.

So let’s discuss mouthwashes.  Do they have a place in our bathroom cabinets or should they be pushed aside for more important things like Rescue Remedy and emergency bottles of gin?  (I have tried to keep this evidence based without putting my own stuff in so if there are any other tooth botherers out there that disagree, please feel free to comment.  I may not include your comment but hey, I like the power.)

When researching mouthwashes apart from getting bored quite quickly, it was mainly the ‘treatment’ mouthwashes that were studied such as the chlorhexidine based ones.  So let’s have a few words on them first.

Pros: Good for treating symptoms of gum disease in the short term but not a cure (bleeding gums is the most common symptom…no you haven’t brushed too hard).  Has a very effective antibacterial and antiseptic action.

Cons: Can be high in alcohol.  Stains the teeth.  Affects the flora and fauna of the whole mouth.  Can affect taste.  Can increase tartar build up.  Not a long term solution.

There, a few words.

Next are the 14,367 fluoride rinses that are available on the market (an estimated guess).  The research papers I read seemed to be sponsored by Johnson & Johnson so I have taken the facts that I know to be true and summarised as follows:

Pros: Provides a topical application of fluoride.  Does have an antibacterial action.  Can help to remineralise enamel (harden soft bits).

Cons: Not a substitute for brushing.  Another expense.  Some are high in alcohol so watch out if using with kiddies (make sure it specifies alcohol-free).

How does this apply to the real world?  Well, fluoride works in two ways – the first is if it is swallowed, it can have an affect on the teeth whilst they are forming making the enamel harder and more resistant to acid.  It can also help the tooth form shallower pits and fissures so instead of looking like the grand canyon, it’ll look more like a smooth crater.  There are a lot more places to hide in a canyon, so having smooth craters means it’s easier for our toothbrushes to brush the bacteria away.  This doesn’t mean that it is a good idea to start eating toothpaste as too much fluoride can lead to fluorosis.  The second way is when the tooth has popped out, fluoride can have an affect on the bacteria’s ability to produce acid, or in other words, it gives them constipation.  It can also help the tooth surface to re-harden if it has been softened by bacteria turd.

Right, well, that still doesn’t answer the question of whether they’re worth it.  These are my thoughts:

Just a reminder of my beautiful diagram of how tooth decay occurs.
Just a reminder of my beautiful diagram of how tooth decay occurs.
  • I think if you have a high incidence of tooth decay in the family (which might be more diet related), or you are medically compromised in some way, elderly or have been told you are at higher risk of tooth decay by your dentist, then yes, a mouthwash is beneficial.
  • To the average Joe, I’d say the best way to prevent tooth decay is to limit sugar in between meals and DON’T rinse with water after you’ve brushed your teeth, especially at night.  That way you leave the fluoridey, foamy goodness on the teeth whilst your salivary bodyguard has gone away for the night.
  • For children, they don’t always have the ability to spit out so better to stick to just toothpaste but NOT to rinse with water afterwards.  If the dentist has advised you that little soft bits have started to appear on the teeth, get the dentist to show you where they are and you can topically apply the toothpaste (that goes for the grown-ups too), but most importantly cut down on sugar in between meals.

Of course, mouthwashes do have their place, but the reason I don’t like the adverts is because I feel they are misleading and give the impression they are more superior than they actually are (it’s the same with the baby milk adverts…oh come on, I had to crowbar a dig in somewhere!).  They give an impression that they are just as important as toothbrushing – it’s far easier to swill your mouth out for a few seconds than brush for 2 minutes so I think it can encourage laziness.  So what if your child hates toothpaste?  Well my friends, that’s a whole different blog altogether so watch this space.