I happened across a great article in the New York Times (readers of this blog may have come to the realization that I’m an avid reader of this publication) that sang the praises of the dental sealant. It still comes as a shock to me to hear of members of my own profession who still don’t place sealants on a routine basis. At our practice, most of our patients have sealants placed; the rare instances when we elect not to place them are for patients with extremely shallow grooves, easily cleaned teeth and a history of no cavities. Otherwise, we are HUGE believers in the value of sealants.
Consider this – most members of the Silent Generation, and even Boomers have a mouthful of fillings, crowns, implants, partial dentures and even full dentures. One of the unheralded medical discoveries of the past century, was that of fluoride, and it’s role in the prevention of dental cavities. In fact the Centers for Disease Control and Prevention (CDC) named the fluoridation of drinking water as one of the Ten Great Public Health Achievements in the 20th Century. And its impact has been seen in the substantial decline in dental disease in both the USA and around the world. However, there are still pockets of resistance in certain population groups (ie. low income communities, individuals with poor access to dental care) where dental caries is still prevalent. Surveys by the CDC show that 21% of children between 6 and 11, and 58% of adolescents have had cavities. So there is still work to be done in decreasing caries especially among the younger members of our population.
That’s where sealants come in. Sealants are a plastic-like tooth colored coating which is easily applied, fills in all the grooves and pits of a tooth where food tends to stick, is cost effective, and has been shown in countless studies to prevent cavities. Where fluoride works well in preventing what’s known as smooth surface (parts of the teeth that are smooth such as in between teeth) caries, it is less effective for preventing caries in the pits and fissures of teeth. It is these areas that are found to disproportionately develop cavities in the teeth of adolescents. And that’s exactly where sealants do their anti-cavity work.
I won’t bore you with the numbers, but the takeaway from the Cochrane study (which looked at 34 well designed sealant studies involving 6000 plus children/adolescents) is that in a population of cavity-free children with a 40% chance of getting a cavity in the next two years without sealants, application of sealants would reduce the rate to just 6%. (For those interested in more scholarly evidence, click here.) Admittedly not zero, which is every dentist’s goal but pretty darn close.
If Evidence-based dentistry is the use of current scientific evidence to guide decision making in dentistry, one should clearly be a believer in the important role sealants play in reducing cavities.
What if you, as a parent who has a very young child with a cavity, is told that instead of a 30 minute long appointment consisting of the dreaded shot, drilling, and no small amount of drama, that we could very simply, in less than a minute paint a magic substance on your child’s cavity, and voila, cavity is taken care?
Well, what if we told you that such a substance has been used in Japan for the past 80 years, can apparently basically ‘freeze’ cavities in place eliminating the need for placing a filling, and that the cost of such treatment is fairly low. Sounds good doesn’t it?
That magic substance is Silver Diamine Fluoride (SDF). It is a colorless liquid consisting of 24-28% silver and 5% fluoride. The FDA recently approved this for use as a cavity varnish placed on enamel to reduce tooth sensitivity. Though it hasn’t been technically approved for use in the treatment of cavities, some dentists have started using SDF ‘off-label’ (which is allowed) for management of the aforementioned cavities.
As we alluded to in the introduction, the dentist simply dries the tooth with the cavity, swabs a small amount of the SDF liquid on the tooth, allows it to dry (1-2 minutes), and you’re done – the cavity is arrested (which means it kills the bacteria causing the cavity, hardens dentin, and promotes re-mineralization or hardening of the surrounding enamel).
Of course, as with any treatment option, there are some downsides to this treatment. The most significant is that any tooth treated with SDF will turn black in color. To be completely fair, only the cavity turns black, but when we say black, we mean BLACK. Not a slight discoloration, or graying. Black.
It also requires multiple applications for complete success, cannot be used in individuals who have silver allergies, can cause irritation to gum tissue, and has a slight metallic taste when first applied.
While SDF has been used for decades in not only Japan, but also Brazil, Peru, Australia, Thailand and a slew of other Asian countries, studies looking at its efficacy, and safety in the U.S. are limited. To date, there have only been 14 reputable studies on SDF; 7 of which have been completed, 5 that are recruiting, and 2 that have not yet begun recruiting.
Despite it’s drawbacks, there is probably a place for SDF in dentistry. Patients who are unable to tolerate extensive or any dental treatment such as the very young, very old, and/or medically compromised seem like candidates who would benefit from this very non invasive treatment. However, it needs to be understood, that this is not a cure for cavities – it is simply managing a disease process until such time that more definitive treatment (ie. filling, crown) can be completed. Furthermore, more research need to be done around issues of effectiveness, long term safety and treatment protocols.
(Click here for a recent New York Times article on this issue)
Lest we be accused of not being afraid of wading into controversial topics, a recent article in the Wall Street Journal caught our eye. Not that it had anything to do with dentistry per say, but the title “Can You Sleep Train Your Baby At 2 Months” was tantalizing none the less.
The article centered on the sleep philosophy of a prominent pediatric group in Tribeca (that would be a neighborhood in the center of the universe, otherwise known as Manhattan) which advocated ‘ferberizing’ infants at 2 months of age so as to improve their nightly sleeping habits.
The Ferber method, or Feberization, is a technique invented by Dr. Ferber who promoted the idea of letting babies ‘cry it out’ and develop the ability to self-soothe and fall asleep on their own.
The basic idea is to leave the baby in the room, leave, and return at progressively increasing intervals to comfort the crying baby (without picking him or her up). With each night, these intervals increase until the baby is asleep. Dr. Ferber felt that by age 6 months of age, this technique is appropriate as most babies are capable of sleeping through the night by that age and don’t need night feeding.
The WSJ article profiled a practice that goes one step further, and their recommendation is to sleep train babies at age 2 months. Of course, in the interest of a balanced informed article, both advocates and detractors of this method discussed the pluses and minuses of sleep training at so young an age. This is a highly emotionally charged issue with both sides accusing the other of being absolutely wrong. I suspect this debate will go on for the foreseeable future.
So why was this article on how to put your baby to sleep of interest to a pediatric dentist? Simply put, we face a similar conundrum on a daily basis at our practice and that is the issue of pacifier use. Pacifiers certainly have their place in soothing very young infants, and parents (myself included) would be quick to say that they work well in getting that fussy baby of yours to calm down, even fall asleep. However, pacifiers do become a problem when used for too long, especially once baby teeth start growing in. Long term use of a pacifier can cause significant malocclusion, specifically distorting the position of the front teeth, causing large overbites, failure of the front teeth to be able to close, and even impeding in the widening of the palate – all ingredients for orthodontics at an early age.
Most children be getting weaned off the pacifier starting by age 2, and our recommendations is that they stop by age 4. Anything beyond can cause the developmental problems listed above.
The takeaway from the WSJ article for this pediatric dentist is that one CAN train your child be it to fall asleep or stop using the pacifier. The basic technique(similar to that of Dr. Ferber) is that of being consistent and over time decrease the amount of time your child is allowed to use the pacifier. Our thought is that the earlier one starts (or if you never start at all!), the easier the pacifier removal will be. Clearly if some parents can train their 2 month old to sleep through the night, pacifier removal should be a cinch!
The New York Times is always a good read. Recently, in honor of April Fools Day, it ran a series that highlighted common misconceptions and sought to debunk some of these common myths. Check out misconception #5.
The misconceptions (in no particular order) are:
- Exercise builds strong bones
- In an asteroid belt, spaceships have to dodge a fusillade of oncoming rocks
- The universe started somewhere
- Spree killers must be mentally ill
- Baby teeth don’t matter
- Climate change is not real because there is snow in my yard
- Migranes are psychological manifestations of women’s inability to manage stress and emotions
I certainly can’t claim to be an expert on osteoporosis, the mysteries of space, psychosis, the environment or migranes, so I’m in no position to rebut or support any of these common myths. But it is fair to say that I know a few things about Baby teeth. And yes, they do matter!
We’re always on the lookout for the latest in dentistry, and this newish entry to the world of burgeoning oral health products caught our eye. Developed by an orthodontist, it is a patented disclosing toothpaste (Plaque HD) which is designed to help patients with braces to brush better.
One of the greatest challenges when it comes to braces (especially the traditional metal ones) is brushing. Food and plaque tends to build up very easily, causing significant gingivitis to the point where the gums can grow over the braces and cover one’s teeth completely. This can also lead to extremely significant cavities, the cost of repair approaching the cost of the braces themselves. We’re talking thousands of dollars. Gulp!
But how does one know that you are doing an adequate job? For our younger patients who don’t brush well, we give out disclosing tablets (there are also mouth rinses). These tablets, which are chewed after an initial round of brushing, get incorporated into plaque that hasn’t been brushed off, turning these areas pink. Hence, one can actually see the areas that are being missed, and can go back and brush the pink off. Aside from a great educational tool, it is great fun for the kids to see their teeth turn pink.
Plaque HD incorporates this disclosing agent in their fluoride cavity preventing toothpaste. Instead of pink, it turns teeth green in areas that haven’t been brushed well (ie. plaque is accumulating) and serves as a visual cue for patients to go back and brush in those areas. The benefit of this toothpaste is that it’s a one step process – simply brush, look for green areas and then brush again until removed.
This is a fabulous idea that is a long time coming. It’s applications are not limited only to patients with braces but can be used by anybody who brushes poorly. It is a vast improvement from the traditional disclosing tablet route which is more labor intensive, messy and takes more time. The toothpaste retails for $21 (direct to consumer) which may seem like a lot, but keep in mind that even one small white composite filling costs significantly more. Think of the toothpaste as an investment for not only a beautiful smile, but a healthy one. We think this is a win-win for all.
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.