Sometimes I am not sure if this saying meant an English pound (or dollar) or a metaphorical weight measure. Let’s briefly explore how this applies to your dental health.

I was recently attending one of my study clubs and listening to an excellent case presentation involving a complete overhaul of someone’s teeth. The complexity, extractions, implants, lengthy time involvement, the number of specialists consulted, and of course the price tag (which was in the neighborhood of $70,000) was almost overwhelming.

This very extensive treatment and investment was a result of advanced periodontal disease that required extractions of all the teeth. Regretfully, all of this could have been prevented.

We know that periodontal disease or “gum and bone disease” starts as a gum infection that can spread to the underlying tooth-supporting bone. Statistically, this is the major reason for tooth loss as an adult.  The severity and speed of this painless disease depends on the populations of certain bacteria and the your immune system’s response.

Prevention includes at least twice daily effective tooth brushing, flossing, and regular dental visits. Your dentist can help by prescribing anti-microbial rinses, antibiotics, prescription strength fluoridated toothpastes, and specialized cleaning aids for at home use. I recommend the electric toothbrushes made by Oral-B Braun, Sonicare, and Rotodent. Each brand has it own individual mechanism of cleaning action. If you use a manual toothbrush, brush thoroughly but gently to prevent tooth and gum injury.

If you smoke, you can stop reading this article. The damgaging effects of smoking throw all the meaningful statistics and studies out the window. Systemic diseases such as diabetes can also complicate the fight against periodontal disease. Your general dentist or periodontist will consider all health factors and medications when diagnosing the state of health of the supporting structures of teeth (the periodontium) before recommending treatment alternatives.

Dentists can help control the damage caused from periodontal disease by removing the causative agents that collect below the gum line that the toothbrush is not reaching. Interrupting the daily life of a bacterium is critical. Of course a bacterial lifetime may only be twenty minutes so you must adhere to a daily habit of brushing. Think of it as an investment that cannot be taken from you in uncertain economic times.

Regaining some lost periodontal tissues may be possible with advanced laser treatments, tooth recontouring and frequent hygiene visits. A periodontist can perform surgical correction of the gum contours as a result of periodontal disease. Also, teeth can be extracted and replaced with implants. Sometimes this is necessary and not anybody’s fault. Most of the time it is preventable.

Prevention means good daily diet and home care. Have regular dentist visits so early signs of periodontal disease can be treated and stopped. Unfortunately, once we have periodontal disease we are never cured. However, it can be controlled before it becomes very costly to treat.

Is it possible to reverse a cavity once it starts eating a hole in the tooth? Do we just wait until a small cavity becomes “big enough to fill”? What causes a cavity to form and why do some people get cavities and others do not? These questions have been around long before I became a dentist. However, there now may be some answers on the horizon.

At the recent California Dental Association Spring Scientific Session in Anaheim I had the pleasure to once again listen to Dr. Brian Novy who is a self avowed cariologist (one who studies cavities). It is a puzzling phenomenon that some people who don’t brush do not get cavities. Their breath reeks, gums inflamed, and teeth covered in plaque but they do not have cavities. Dr. Novy wants to know how this can happen.

How is it that a tooth can still be intact after death for thousands of years, yet it can rot away before puberty? The answer lies in our mouth while we are alive. If some bacteria do not cause decay and other types are very harmful it is the duty of the dental community (research, development, and clinical) to identify the harmful bacteria and be able to economically test for the presence of these bacteria and the factors that allow for them to survive and flourish.

As of this publication there are four means of testing your mouth for microbes in the dental office. Costs may vary from $60 to $100. Some tests can give results in minutes and others may take overnight. How do we get harmful bacteria and what can we do about them?

It is known that bacteria are transmitted from the primary care giver in the first 12 months of life. Diet can promote the increase or decrease in populations of harmful bacteria.

Last week I was in my office on break and eating a peanut butter cracker snack. As I was chewing the cracker got caught in the back on my throat and I was beginning to wonder if I was ever going to be able to swallow. At that very moment my mouth began to water up and the food bolus slid easily down to make room for another cracker. Once again saliva came to the rescue.

Dentists have a love-hate relationship with saliva. While saliva is always “in the way” during dental procedures we wish there was more saliva for our patients with dry mouth.  Let’s look at the functions of saliva to get an appreciation of this important lubricant and discuss ways of dealing with dry mouth.

During chewing the saliva is lubricating the movement of food from our mouths to the esophagus. Salivary enzymes (amylase and lipase) begin the digestion of starch and fat in our foods (remember the peanut butter crackers?). Saliva also aids in taste by trapping the thiols (flavor chemicals) contained in food and allowing taste buds to operate. Mucous is the ultimate body lubricant and is especially important to facilitate food movement. Interestingly, mucous is not digestible and once swallowed will pass through with the feces.

Saliva also protects and buffers the teeth from food acids and harmful bacteria. Dry mouth promotes bad bacteria because the pH levels become acidic. As it turns out a high acidic level turns on the bad bacteria and the incidence of cavities dramatically increases.

Other enzymes include lactoferrin, lysozyme, lactoperoxidase, and immunoglobulin A which aid the body’s immune response system. Furthermore, since saliva reflects what is going on in the rest of the body doctors can use saliva as a diagnostic medium. Wouldn’t it be great if you can spit into a vial rather than having blood draws or spinal taps to screen for disease? Saliva tests may ultimately be used to determine biomarkers for Alzheimer’s and heart disease. Research is continuing in this area.

Xerostomia is a condition of inadequate salivary output. It is characterized by an excessively dry pasty feeling in the mouth, difficulty with chewing and swallowing, burning oral tissues, and increased cavities and gum disease. Xerostomia is brought about by a lack of production from the salivary glands due from age, disease, radiation therapy, and medications (to name a few).

Unfortunately, there is no cure-only treatment. Occasionally, discontinuing certain medications will reverse the condition. Otherwise, your dentist will recommend over the counter remedies to help stimulate salivary output. For more serious cases a prescription of pilocarpine mg in a lollipop  can be provided. This lollipop can be sucked on for 10-20 seconds and be placed back into its case for future use. The pilocarpine stimulates the tiny salivary glands to pump out more saliva. This has been very satisfying for my chronic dry mouth patients.

Many of us have experienced canker sores. Where do they come from, what are they, and what do you do about them?

In a nutshell we do not know exactly what brings on a canker sore. They appear in young adults more often and frequently arise during periods of emotional or physical stress.

The sores typically occur on the cheek lining, under the tongue, around the uvula, bottom of the mouth and in front of the tonsils. It is not uncommon to have several sores appear near each other. They are very painful and can reoccur without any warning.

They appear first as tiny “bubbles” or red spots. The middle of the lesion becomes necrotic and a grayish-white covering or scab covers the wound. The nerve endings are exposed and the underlying tissue is very raw. Pain is the primary feature and will last for 5-7 days. These sores will typically run their course in 14 days. They can reappear with extreme and exasperating frequency.

Under the microscope scientists have noticed an intense infiltration of inflammatory cells leading to the theory that these sores are an immunologic defect in the cellular immune mechanism. In other words a small patch of cells cease performing the functions that maintain their life.

What can you do about them? Since we do not exactly know what will create a canker sore you really cannot prevent them from occurring.  If one does pop up the pain can be relieved with Aphthasol or Kenalog ointments. These are prescription medications that your dentist can prescribe. They are anti-inflammatory and are locally applied to the wound. More severe sores can be treated with high potency steroids such as Decadron.

Otherwise, you can wait until they subside. In the meanwhile keep them clean with hydrogen peroxide and covered with Zilactin (an over the counter oral wound dressing). I like Zilactin with Benzocaine since it numbs the sore and seals it off from spicy and irritating foods. Keeping the wound free of secondary infection is important so your dentist may prescribe an oral antimicrobial rinse such as chlorhexidine.

Canker sores can be confused with herpes and traumatic ulcers. Although herpes is reoccurring it typically does not appear inside the mouth. Likewise, traumatic ulcers usually have a memorable start date and do not reoccur (unless you repeatedly bite the same area).

I advise people with troublesome canker sores to seek pain relief from their dentist.

As dental students we were taught the skills to repair, extract and replace teeth afflicted with cavities. It seems like we were always one step behind the forces that cause decay. We recommend brushing twice daily, watch sugar intake, and seeing your dentist on a regular basis as our way of preventing cavities from forming. Current research suggests this may not be adequate.

Research shows that dental decay is a chronic disease and that it is a result of individual behavioral patterns. We know of 32 types of bacteria that cause cavities. These bacteria thrive when the mouth saliva is acidic or at a low pH level. Behavioral effects range from how sugar is consumed, how effective we brush, how medications alter the mouth, how we respond to bacteria and how we utilize proper home remedies.

Dentists first look at one’s risk of getting cavities.  I can look at a twenty year old with one or two cavities and confidently say their risk is low. What about the 1 year old? Dentists will ask questions and analyze the primary care giver to determine the child’s exposure.

Mothers can transmit oral bacteria to the baby in the first year. If the mother has a lot of cavities the baby is a high risk. We must look at the mother’s behavior and evaluate the child when the first teeth come popping through.

If the caries risk assessment is high we can do bacteriological tests through cultures that will tell us the levels present. Treatment of dental disease then becomes individualized to each person depending on the evidence at hand.

I mentioned pH factors for cavities. There is a growing awareness to “convert” the pH level to a more neutral level to select against harmful bacterial. There are regimens of toothpastes and mouth rinses designed for short-term use to convert the biofilm to a neutral state. Saliva tests can be performed to determine the need for these treatments and measure changes.

Recalcification or remineralization toothpastes (such as Recaldent) are available to harden eroded teeth so fillings aren’t required. Fluoride varnishes are recent additions to the dentist’s bag of tools to resist decay of high-risk teeth. I use these varnishes both in all children and seniors who are prone to root decay.

Xylitol is a sweetener added to some chewing gums. It appears to reduce the biofilm or plaque index thus lowering the decay and gum disease rates. In the past I have not recommended chewing gum due to long term wear on the teeth and jaw joint. Since the addition of xylitol I now prescribe this as an over-the-counter therapeutic.

The challenge is to change dietary behavior and not consume foods that create an acidic mouth. This is especially true for preschool children. Dental decay is unfortunately on the rise in this age group. I will discuss the effect of diet upon the health of the mouth in the future.

Fearful that communists were fluoridating our water supply General Jack D. Ripper in the movie Dr. Strangelove started a nuclear war with Russia. The absurdity is that it reflected the public controversy at the time over the addition of fluoride to our water to help lower the incidence of dental decay. I would like to discuss the brief history of fluoride and the impact it has made.

Modern dentistry came into it’s own early in the 20^th century. It was observed that people who lived in areas of the country with naturally higher levels of fluoride in their water had fewer cavities. Research after World War II confirmed that optimal levels of fluoride (0.7-1.0 ppm) reduced cavities by 20%-40%. Furthermore, fluoride was relatively inexpensive and could be safely added to water much like chlorine for general consumption.

Consequently, other formulations (NaF)) of fluoride began to appear in dentifrices and rigorously advertised as anti-cavity agents. This reduction of decay proved especially true in European countries that did not add fluoride to water. Fluoride continues today as one of the great advances in preventing tooth decay.

The public outcry over fluoridating water was eased with announcements from public health agencies like the World Health Organization and professional societies like the ADA that optimal levels of fluoride were safe. There are still those who would believe otherwise.

When I went to dental school it was believed that ingestion of fluoride during childhood was most beneficial. The fluoride was “taken up” in the developing tooth enamel before it erupted and, hence, made the enamel more decay resistant. Although this was somewhat true it proved to be only part of the story. It is now acknowledged that topical applications of fluoride are more effective with the interference of cavity formation.

Dentists have been using topical fluoride rinses (acidulated phosphate fluoride-APF) for years. They come as liquid rinses, gels, or foams and have been very effective in reducing cavities on the smooth surfaces of teeth. I have been most impressed with newer fluoride varnishes (5% NaF). They are extremely safe and are used in adults and children under 1 year. Stronger prescription toothpastes (1.1% NaF) are dispensed as an at-home adjunct for some people.

Are you getting tired yet? Unless you have a lot of time on your hands don’t try to remember this information. Let your dentist and especially your hygienist recommend the best prevention program for your needs. Some of the newer dentifrices are more costly than standard toothpastes. However, when only costs are compared you could buy a three-year supply for less than the cost of one filling.

Back to General Jack D. Ripper. Concern and over reaction are two different beasts. It is smart to be concerned and informed when making health choices. Over reaction is usually based on fear and mistrust. It is ironic that dentists are basically trying to work themselves out of a job by eliminating the very thing they are paid to fix.

The California Dental Association completed its annual spring scientific session in Anaheim. The lecture offerings were outstanding and very pertinent to your dental care. I will cover some of these topics in other articles. I want to report interesting innovative dental solutions discovered while “walking the floor”.

People have been devising filling materials for the cavities in teeth since the dark ages.  Over the past thousand years various concoctions of silver paste, stone chips, resins, cork, turpentine, soft lead and gold leaf have been used to fix holes in teeth. In 1883 two Frenchmen introduced amalgam into the United States. It has since been modified, improved and placed in millions of teeth.

Because amalgam has mercury the public has been very concerned about effects upon our health. Where do we now stand with amalgam?

Amalgam contains silver, tin, copper, zinc and mercury. Upon mixing the paste hardens very quickly and within an hour you can chew on your new filling. Unfortunately, the material will wear and degrade releasing some of these elements into your body. The FDA has published a regulation this year reclassifying amalgam as a moderate risk material due to the mercury content. However, they concluded that most mercury exposure is incurred during placement and not after the mixture hardens.

There is no hard science that can show harm from amalgam fillings. The FDA is correct in demanding good studies before issuing a more severe regulation. In my opinion the regulation appears vague and unhelpful. Some European countries have banned amalgam. Fortunately, there are extremely good alternatives to silver-mercury fillings that are safer and definitely look better. The question becomes “why do some dentists still use amalgam”?

Amalgam can be placed easily in moist environments. It has a slight anti-bacteria effect due to its corroded black layer of silver-oxide. It seems to take a beating pretty well and it can be delivered very economically. If you ran a military or public health clinic this would be your material of choice. For decades it was the only alternative to gold and it was placed in all cavities. At first glance amalgam has done very well.

Over time they will corrode, blacken, crack, and expand creating splitting forces on the sides of the tooth. I have seen gross discolorations “bleed through” the enamel of the tooth as a result of these developments impairing our smiles. These adverse changes have prompted dentists to question why they include amalgam fillings in their services.

Well, good news! In the last 20 years many of my fellow dentists and I have been dropping amalgam from our offices. Composites have taken over as the “go-to” filling material. They are a little more demanding and require a very controlled delivery process. Also, they take a little longer to finish, however, they are bonded to the tooth, do not swell, and look like your tooth. They are proven materials and wear at about the same rate as silver-mercury fillings. There is no mercury present to be a health concern.

Should all your amalgam fillings be replaced? Eventually, most all fillings materials will fail and need replacement. If the current controversy over the silver-mercury filling concerns you, I suggest that you consider the composite filling at replacement time

Does it seem like you go to bed early, get your eight hours of sleep and still feel tired?

Perhaps you are not getting the sleep you think you are. Many of us suffer from obstructive sleep apnea or OSA.

Sleep apnea is characterized by pauses in breathing from a few seconds to a minute. These pauses can occur a few times during the night or over a hundred times an hour. It can allow a low oxygen saturation level in the blood resulting in oxygen starvation of the tissues and organs. It can result in strokes, hypertension, heart disease and death.

Sleep study tests can determine the incidence of breathing cessation. A medical doctor can confirm a diagnosis of sleep apnea after carefully reviewing the results of a sleep study test. These tests monitor the blood oxygen level, REM cycles, and the frequency of obstructive episodes per hour.

You can ask yourself these questions to see if you should seek help. What are my chances of dozing when I sit and read, watch TV, sit in public places, wait for red lights while driving or sit as a passenger in a car? What is the likelihood of falling to sleep after lunch? If you are tired or fatigued easily during the day it would be very prudent to consult with your physician for advice.

Sleep apnea can be initiated from the brain or from physical factors that obstruct and collapse the breathing space.  Exactly where the collapse occurs in the back of the throat can determine the treatment alternatives.

Treatments for OSA can vary from anti-snoring devices made by dentists, sleeping on specially tilted pillows, neck slings, or wearing facemasks attached to positive pressure air pumps (CPAP). As with all treatment options these CPAP pumps cannot be tolerated by everyone and may have a limited success with some individuals.

In severe cases where respiratory arrest is possible surgery may be the only option.  Surgical removal of excessive soft tissues in the throat and nasal sinus surgeries have been performed open up the airways with limited success. In the most severe cases skeletal surgeries are performed to open up airways. This type of surgery, although extensive, has had great success. It sounds like a lot of treatment, but we are talking about a life-threatening situation if left untreated.

Regardless, I hope that you can appreciate that snoring may be a sign of a more serious problem and that it should be discussed with your physician or dentist. Your dentist can do a quick airway analysis, ask a few questions, and refer you to a physician that specializes in sleep apnea. Depending upon the results you may just have a snoring problem that can be alleviated with a simple appliance. Remember that OSA is not condition about a lack of sleep, but a medical condition about a lack of oxygen.

It is estimated that almost 60% of adults have one or more sensitive teeth. Over zealous tooth brushing, using too abrasive toothpaste, clenching or grinding teeth, extensive dental cleanings, and a highly acidic diet can lead to the hypersensitive tooth. Let’s investigate this further.

All dentists and their patients know that when a dentist works on a tooth that is not anesthetized it may hurt. Although the dental work is well away from any vital structures inside the tooth, the tooth is very well aware that something is happening to it. This sensory mechanism sometimes acts without warning or “just cause”.

The sensory mechanism is essentially made up of thousands of tiny holes in the root that communicate with the nerve in the middle of the pulp. These holes house the nerve extensions that connect the inside of the tooth with the outside. In the normal tooth these holes are closed off to the outside world. However, when events happen that expose these holes and their nerve contents pain will result.

Daily events such as aggressive tooth brushing, acid diets, tooth wear (attrition, abrasion, erosion), bulimia, periodontal disease, dry mouth syndrome, gum recession, cracked teeth, dental work and cavities can cause a tooth to fire off. Let’s just examine the tooth that has no pathology and no restorative work yet signals us when things are too cold or is sensitive along the gum line. These teeth are commonly referred to as hypersensitive.

Dentists first look at possible exposed root surfaces due to recession. Does it hurt when brushing or drinking cold water? Does it hurt when touching with your fingernail or to sweets? Is the pain sharp and short? The doctor will rule out cracks, decay, and other things people do to their teeth. Once the hypersensitive tooth diagnosis has been confirmed several remedies exist that can alleviate the problem.

Our goal is to neutralize or close the exposed holes in the root to their original sealed state. Sensitivity toothpastes that contain potassium nitrate along with fluoride are the least expensive and pretty good. Brushing for several weeks will reduce if not eliminate sensitivity along the exposed root surfaces by depolarizing the nerve. For plugging the holes dentists can use fluorides in high concentrations, protein fixing agents, root bonding agents, or laser treatment.

This will provide solution to the present condition. The problem, however, is that the condition will change as a result of exposure to brushing, acid diets, and dental work. Hypersensitivity sometimes recurs as the root is worn away. Remember that it is just a signal your tooth (yes-it is always a pain signal) is sending to you warning of a potential problem down the road. Your dentist can assist you in choosing the right choice for treatment.