Oy! So your teenager wants to get a piercing. And not just a cute little earring, but a cool one that expresses her individuality, and wait a minute, she wants it in her tongue. What’s a parent to do?
It’s a well known fact that teenagers don’t think like adults – they are impulsive, narcissistic and aren’t capable of thinking about the effects of their behavior on other people (or themselves for that matter). Their frontal lobes aren’t quite developed, so since their insight is impaired, it makes perfect sense to them that getting a tongue piercing is completely normal and safe.
One should know that oral piercings (tongue, lip, and cheek), are associated with a number of adverse oral and systemic conditions. Parents should inform their teenagers of the risks of piercings which are significant. In fact, the American Dental Association opposes the practice of intraoral/perioral piercing.
Piercing related risks include:
- Infectious Disease transmission: Oral piercing has been identified as a possible factor in the transmission of hepatitis B, C, D and G.
- Infection: The mouth is filled with millions of bacteria and oral piercing creates an opportunity for these bacteria to infect the piercing site. These infections can be quite serious, leading to swelling, inflammation, cellulitis and even endocarditis.
- Nerve and blood vessel damage: The tongue has lots of blood vessels and nerves. One can puncture a nerve leading to temporary and even permanent numbing of the tongue. This damage can affect your sense of taste and ability to move your tongue.
- Injury to gums: The metal bars and caps in oral jewelry can cause gum recession and damage leading to long term sensitivity and potential bone loss.
- Tooth damage: Metal jewelry can lead to tooth fracture, abrasion, increased sensitivity, cracking of fillings and tooth wear.
- Airway obstruction: Oral piercings have many parts that can come loose, leading to inadvertent swallowing or aspiration (when foreign objects go into the lung)
- Allergic reaction: A hypersensitivity reaction — called allergic contact dermatitis to the metal (nickel) in the jewelry can occur in susceptible people.
- Compromised Dental Care: Oral piercings can prevent dentists from taking clear x-rays and not allow proper treatment to be recommended.
And while your teenager typically does not think adults know what they are talking about, it is important to inform them of the dangers associated with oral piercing. Sometimes they do hear what you are saying.
Sometimes the old is new again. Or it can take decades for an idea to come to fruition. Then again, maybe a fresh reboot on a concept that has been percolating for a long time is what’s needed to get things going.
What am I going on about?
When I was accepted into dental school, one of the things that attracted me to the school was it’s philosophy that the oral cavity is but just one part of the entire body, and in order to gain an understanding of how to manage and treat oral diseases, one needed a broader study of the entire body. Hence, the first two years of my dental school education were at the medical school, taking all of the same courses as my medical colleagues – biochemistry, gross anatomy, microbiology, genetics, immunology, patho-physiology and so on. It was fantastic and helped me broaden my understanding of medicine in general.
Dentistry does not exist in a vacuum. On a daily basis we treat patients in the dental chair with complex medical conditions, allergies and who may be on a variety of medications. As pediatric dentists, we are often referred patients with chronic diseases that necessitate coordinating care with other medical specialists. It is crucial that we develop a global medical expertise which gives us the skill set to recognize how medical conditions can impact the dental care we recommend.
The dental/medical community is still asking ourselves what role the dentist should have in diagnosing and managing medical conditions such as high blood pressure, diabetes, asthma and depression. Studies have shown that a lot of people see a dentist more often than their primary care medical doctor. If that is true, we are missing a tremendous opportunity in improving the overall health of our patients.
Fast forward 20 odd years, and the dental-medical community is still struggling to reconcile the mouth-body gap, and the role of the dentist in our patient’s overall health. A recent article “Fluoride and a Physical: Patients see Docs at the Dentist” reviews changes being implemented at the Harvard School of Dental Medicine is hoping to address this challenge. Primary Care Physicians and Nurse Practitioners are now actively involved in the clinical care of patients alongside dental students.
Hopefully this initiative will stick, be picked up by more dental schools and be transformative in the way we deliver health care. I’m hopeful that eventually this will come to be, but I’m still waiting (ergo my first paragraph of this article). Because 24 years ago I was a first year student at Harvard School of Dental Medicine and despite having this concept of holistic care ‘drilled’ into me, this idea of “putting the mouth back in the head, and putting the head back in the body” is still trying to gain traction in the broader community.
“I don’t want my child to have any x-rays!”
“I think my child is getting too many x-rays and I’m worried about radiation”
These are just a few of the comments that we hear on a daily basis at our office. Parents are extremely concerned about the amount of radiation that their child is being exposed to, and instead of running from these important questions , our practice welcomes them and we spend a lot of time discussing their concerns.
Parents, like most individuals, have heard about the dangers of excessive exposure to radiation. They have most certainly heard about the high levels of exposure when taking a chest x-ray, CAT scan, or MRI. They have probably also heard that radiation exposure accumulates over a lifetime; hence, the more one is exposed, the greater the amount of lifetime accumulation.
The simplest explanation I usually give parents is that the amount of radiation a bite-wing x-rays emits is extremely , extremely low – about 10 times less than that of a chest x-ray and 1000x less than a CT scan. One of the more important things to consider is that for we are also all exposed to radiation from natural sources all the time. The average person in the U.S. receives an effective dose of 3 mSv (millisieverts is the scientific unit for radiation dose) from naturally occurring radioactive materials and cosmic radiation.
Radiation Type Radiation Amount
Daily background radiation 0.008 mSv
Single Digital Bitewing 0.005 mSv
Digital Panorex 0.01 mSv
Cross Country Flight 0.03 mSv
Chest X-ray 0.1 mSv
Chest CT 7 mSv
Head CT 2 mSv
To put things in perspective, a single typical dental x-ray is less than a day of usual background radiation, and a panoramic x-ray is 3 times less than flying a plane cross country. One chest CT is the equivalent of 1400 dental x-rays. In fact, if one lived in higher altitudes such as in Colorado, you are exposed to 50% (1.5 mSv) more background radiation than those of us at sea level (that’s the equivalent of 300 dental x-rays for those of you keeping count). Click here for more information.
The takeaway from this data and the multitude of studies done on x-ray safety is one should not worry about the amount of exposure one gets from dental x-rays. As shown, the amount of exposure is low, and the estimated additional risk of developing cancer as a result is negligible.
All things in life are about considering the cost:benefit ratio. The cost of not taking a dental x-ray is the inability to diagnose disease (dental caries) and allowing it to progress to a point where one is put at risk of pain, localized and systemic infection, and extensive treatment which could have been avoided. The cost of taking an x-ray is…..well, as we have seen, is less than a day outside. One should note that people who live in Colorado get 50% more background radiation than those of us in Boston, are deemed some of the healthiest people in the United States, with cancer rates not being any higher.
Certainly, if you do have concerns about the need to take x-rays, I would encourage you to speak with your dentist. There is a recommended schedule for taking x-rays – the key word here is recommended. There are certainly reasonable cases to be made for not taking x-rays routinely (ie. low caries risk, exfoliating baby teeth) which should be made on a case to case basis.
So the super geeky, jet propulsion lab, MIT wanna be, engineering side of my personality (isn’t there an engineer in all of us?) was fascinated by this video produced by google engineer Ben Krasnow, which in illuminating, exhaustive detail shows the effects of brushing on the bristles of a toothbrush. Google is famous for it’s search engine, but a little known fact is that Google engineers are encouraged to spend 20% of their time to work on things that personally interest them (and which may have an application for Google). Apparently, engineer Krasnow has a fascination with microscopes and toothbrushes. And so do the 280,000 who have viewed the video.
It is common knowledge that one should change a toothbrush every 3 months. Ben’s project showed that after 3 months when viewed through a scanning electronic microscope, the bristles on the end of your toothbrush are worn smooth. In order for brushing to be effective, the tips of the bristles need to be ‘microscopically’ rough which not only aids in abrading away plaque but increases the surface area of the bristle contacting the tooth.
Ben also scans toothpaste, specifically looking at the coarse grains of di-calcium phosphate di-hydrate which is in toothpaste, and which acts as an abrasion agent to aid in the cleaning of teeth. Think baking soda or sand. These grains are 20 microns in diameter, similar to 600 grit sandpaper which is actually surprisingly coarse. He does reveal that in a pinch, one can use toothpaste to clean dirty car headlamps.
The video which is over 8 minutes in length is a nerdy scientist’s dream and is appropriate for anybody who enjoys watching detailed explanations of how things work. It is full of words like zoom ratio, vacuum desiccation, aspect ratios and silver vaporization. I give it a strong 2 thumbs up.
If you need a good excuse to change your toothbrush after 3 months, I highly recommend this video!
As pediatric dentists, we are referred patients who are unable to tolerate procedures at their family dentist. Patients come to us for a variety of reasons – chief among them are anxiety, apprehension, inability to comprehend, fear of the ‘needle’, combativeness, shyness and stubbornness. With the vast majority of patients simple behavior management which involves a lot of talking on our part, and clear, child-friendly explanation of procedures enables us to transform a previously uncooperative patient into one who comes to the practice with a smile!
Patients on the autism spectrum experience all of the behavioral issues previously discussed and more. Autism Spectrum Disorder is an extremely complex disorder of brain development. Symptoms vary in severity but are characterized by difficulties in social interaction, communication and repetitive disorders. Autism can be associated with intellectual disabilities, difficulties in motor coordination, and sensory disorders.
The key to treating our patients with autism is understanding, patience and parental involvement. Parents help guide our understanding of their child’s ability to tolerate treatment and are invaluable in discussing tactics that may be effective in gaining their child’s trust. Mostly, it’s about understanding that one needs to be flexible in determining what qualifies as a successful visit. For some of our patients, the ability to sit in a chair for a short period of time may be enough for a first visit. On the second visit, introducing them to the high speed suction or other tools that we use in dentistry may be the next step to gaining their trust. Usually, what is needed is patience and the willingness to spend multiple visits to achieve what may typically be done in one visit.
Other things that we do that have been successful in the past include:
- Treating patients in the operatory alone – less noise and distraction is essential and gives the patients the chance to acclimate to their environment
- Having the same dentist/hygienist see the patient every time. This eliminates the chance of there being any surprises for the patient
- Doing procedures in smaller chunks ie. only clean the teeth in 10 second increments, taking only one x-ray, doing only one filling
- Discussing with parents beforehand what the plan for the day is
- Placing a heavy lead apron over the top of the patient which can be soothing for some patients
- Use of a picture chart with images that patient can point at to communicate
- Instead of using a loud handpiece for cleaning teeth, brush with a toothbrush only. Loud noises can be quite disturbing
- Having the parent bring an iPad/tablet with the patient’s favorite music, movie or show playing
This list is by no means exhaustive nor do these techniques work with every patient. But these techniques can help.
One of the joys of pediatric dentistry is seeing our patients grow up before our very eyes. Treating patients on the autism spectrum is no different. The only difference is that it may take a little longer to gain their trust. But the reward is always a High Five and a smile.
Click here for a New York Times article on children with autism and dentistry
Take a walk down the aisle of any supermarket or pharmacy and you will be shocked by the number of toothbrushes available. From different shapes, sizes, bristle type (soft, extra soft, medium), brand names, store brand, electric or manual, what’s a consumer to do? Well, to further add to one’s toothbrush confusion, one now has the choice of purchasing an eco-friendly, recyclable and compost friendly, design chic toothbrush.
If one considers that you should be changing your toothbrush every 3 months, that is a lot of toothbrushes in one’s lifetime (rule of thumb is if the bristles on your toothbrush are no longer standing upright, it’s time to change your toothbrush; furthermore, waiting to get a new free toothbrush from your dentist at your regular 6 month check-up should not be the only way you obtain a new toothbrush). Imagine throwing away 500 toothbrushes over your lifetime, multiply that by the global population, and that is a lot of trash.
This new toothbrush made by the folks from a small Portland based company called Goodwell aims to solve this problem by creating a toothbrush that is biodegradable. The handle is made from harvested renewable bamboo, and the bristles are made from binchotan. Binchotan is made in the Kishu region of Japan.. It is a charcoal activated by burning oak branches at extremely high temperatures for several days and then rapidly cooling them. This charcoal is incorporated into biodegradable bristles. Aside from being environmentally friendly, proponents of this product state that it prevents bad breath, deodorizes and removes plaque. Supposedly, this activated charcoal also gives off negative ions and prevents bacterial growth within the brush. However, this has not been independently verified or studied.
Clearly, this is a toothbrush designed with those who care greatly about both the environment and chic design. Priced at $14.99 for a 3 pack, it is reasonably priced considering it is not manufactured by one of the ‘big boy’ companies that have the advantage of scale and distribution. There is also a subscription based model which will ensure that one never runs out of toothbrushes.
It will be interesting to see if this model of direct to consumer sale will be successful in the long run or if the Crests and Colgates of the World will jump in once they see there is a market for internet distribution of toothbrushes. They may even determine that an eco-friendly toothbrush makes sense. In a way, they are lucky to have the benefit of waiting to see if this small crowd sourced company achieves some measure of profitability before spending any money of there own. Best of luck to Goodwell for trying to shake things up in the toothbrush world.