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.
If Gwyneth Paltrow does it should you?
One of the hottest trending items found out there in the twitterverse and social blogging world, is the practice of ‘Oil pulling’ (swishing oil in the mouth) which is purported to have numerous systemic and oral health benefits. If you google ‘Oil pulling and teeth’ you will find more than 2 million search results discussing the oral health benefits of swishing sesame, olive, sunflower or coconut oil. Oil pulling claims to prevent tooth decay, halitosis, gingivitis, throat dryness, and cracked lips. Some practitioners of the practice also think it helps whiten teeth and aids in the strengthening of teeth, gums and the jaw.
The practice of oil pulling has its roots in traditional Indian medicine. It is mentioned in the Charaka Samhita, one of the key texts in the practice of Indian medicine known as Ayurveda. Ayurveda is a holistic system of natural healing which evolved in India some 3000-5000 years ago, a system of traditional medicine native to the Indian subcontinent, now practiced in other parts of the world as a form of complementary medicine. It is a complex and individualistic form of medicine which carefully prescribes different forms of therapy depending on the individual. “Oil pulling” is but one part of this traditional medicine, and besides from it’s oral benefits, it is claimed to cure about 30 systemic diseases ranging from migranes to diabetes and asthma, weight loss, clear skin and improved kidney function.
“Oil pulling” involves placing a tablespoon of your edible oil of choice in your mouth, then sipping, sucking and pulling between the teeth for up to 20 minutes or longer. The exact mechanism of the action of oil pulling therapy in the oral cavity has not been clarified. It is thought to prevent plaque from binding to teeth by inhibiting bacterial adhesion and plaque co-aggregation. It may also have a ‘soap-like’ action (or saponification) which can prevent inflammation and bacterial infection.
It is not clear why this traditional method of dental care has suddenly become such a darling of the social media world. Aside from celebrities and alternative/traditional medicine espousing it’s benefits, there has been relatively little in the way of critical, scientific peer reviewed studies done to either support or refute these claims. The few studies (mostly published in Indian Journals) that are regularly quoted by believers in ‘oil pulling’ have clear limitations. The American Dental Association found the following – “Existing studies are unreliable for a number of reasons, including the misinterpretation of results due to small sample size, confounders, absence of negative controls, lack of demographic information , and lack of blinding. To date, scientific studies have not provided the necessary clinical evidence to demonstrate that oil pulling reduces the incidence of dental caries, whitens teeth or improves oral health and well being.”
Evidence based medicine differs from Google based medicine, in that recommendations and guidelines are typically drawn from a large body of peer reviewed studies and committees which methodically, and some would argue very slowly, sort through the data before coming to a consensus opinion. While we all hope for a magic pill to cure cancer, or even a simple ‘natural’ way of preventing cavities, one needs to be patient when analyzing new alternative/holistic therapies. Our recommendations to all of our patients is based on sound scientific principles and demonstrated clinical safety and effectiveness – “Oil pulling” has yet to meet these critical standards, and hence, we would be hard pressed to recommend this practice for our own patients. As they say in the scientific world, more research is needed.
I guess it comes down to who you believe – movie stars make great movies, but I’m not sure I’d go to them for dental advice.
Overheard on the radio this morning was a fascinating piece on the ‘microbiome’. The microbiome is basically all the bacteria, viruses and fungi that live on our bodies, and researchers are slowly coming around to the realization that all these living organisms play a crucial part in ensuring that we are healthy.
The mouth, in fact, has hundreds of different kinds of bacteria, some of which is ‘good’ bacteria, necessary for helping with digestion and for priming our immune system. Other ‘bad bacteria’ such as streptococcus mutans produces acid in the presence of carbohydrates which leads to the development of cavities. Porphyromonas gingivalis is the bacteria found to cause periodontal disease. Interestingly enough, the tongue, the crevices of your teeth, the cheek and even the roof of the mouth all harbor different kinds of bacteria.
Harmful bacteria in the mouth can lead to a heightened perpetual state of chronic inflammation and heightened immune response. Both are not good, and the presence of certain bacteria in the mouth can act as initiators or even markers of diseases such as diabetes, obesity, alzheimers and even heart disease. Like we were taught in dental school, the mouth is the window into one’s overall general health.
So getting back to the title of this piece. A Paleo Diet, commonly known as the caveman diet, eschews processed food, dairy products and refined carbohydrates (ie. the diet of a child), and subsists mostly of fresh meats, fish, seafood, fresh fruits, vegetables, seeds, nuts, and healthful oils (olive, coconut, avocado, macadamia, walnut and flaxseed). Skulls of our first ancestors reveal a significant lack of dental disease, both cavities and periodontal disease, are not present, and the current school of thought is that it was their diet which prevented these contemporary diseases.
Our dietary shift to include more carbohydrates, lead to a gradual but definite change in our digestive system microbiome, including the mouth. It doesn’t take much to imagine that this continuous change in our microbiome has some effect on our health.
Proponents of a paleo diet contend that hunter-gatherers typically were free from the chronic illnesses and diseases that are epidemic in Western populations, including:
- Cardiovascular disease (heart disease, stroke, high blood pressure, congestive heart failure, atherosclerosis)
- Type 2 diabetes
- Autoimmune diseases (multiple sclerosis, rheumatoid arthritis, Crohn’s disease, ulcerative colitis, etc.)
- Myopia (nearsightedness), macular degeneration, glaucoma
Granted, our ancestors faced other kinds of dangers, such as high infant mortality and a general lack of healthcare (and obviously low healthcare costs!) which made treatable illnesses/accidents a death sentence. But it is an interesting hypothesis that it is our modern day diet which is contributing to some of the chronic diseases of today.
While we are certainly not suggesting that one shift to a caveman diet (and we personally can’t live without our carbohydrate rich treats!), there is a takeaway message – We Are What We Eat or rather, We Are What Our Bacteria Eat.
I was recently asked an interesting question by one of our patient’s mother. Her 9 year old daughter had just been in for her routine 6 month preventive visit and was diagnosed with 5 cavities. She had never had a cavity before, and concerned, this mother asked, “Can asthma or her inhaler cause cavities?” Since her last visit, this young patient had been diagnosed with asthma and was now using a nebulizer.
Turns out there are a few scientific studies which suggest that there is an increased risk of dental cavities and gingivitis for individuals with asthma. A well researched 2011 study from dental researchers in Sweden (the Swedes are obsessed with the study of cavities) strongly examined asthmatics – ages 3, 6, 12-16, and 18-24 – and a control group of healthy youths of similar age and geographical background. The results were interesting.
- Only 5% of tested asthmatic teens were cavity-free, compared to 65% of “healthy teens.”
- Teens with “long-time moderate or severe asthma” had more gum inflammation than the control group.
- The 3-year-old asthmatics showed more dental caries than 3-year-olds in the “healthy” control group. This trend still existed in a follow-up exam three years later, when the kids were 6 years old.
- Adolescents with asthma had lower plaque pH than the control group, meaning their mouths were more acidic, making their teeth prone to decay and their gums vulnerable to inflammation.
Researchers think low saliva levels contributed to the gum irritation and tooth decay. Saliva washes food particles from teeth and minimizes the growth of bacteria that contributes to decay.
When an asthmatic child exercises or sleeps, he often will breathe through the mouth to get enough air. Subsequently, the mouth dries out. Medication (such as nebulizers) used to control asthma dries the mouth even more. In addition, some nebulizers use fructose in their delivery mechanism, increasing sugar exposure.
One usually drinks water when thirsty, however, interesting enough, children with asthma have been found to drink more sugary beverages than non-asthmatics. This combination can lead to a greater incidence of cavities.
There have also been studies showing that asthma, or even the use of nebulizers, does not increase one’s risk of cavities or gingivitis. In fact there continues to be some debate within the dental community about whether or not there is a true correlation between asthma and cavities. For another point of view, check out this article: http://www.sciencedaily.com/releases/2010/09/100916113420.htm
That being said, there are some common sense precautions one can take if you have asthma.
- Brush and floss on a regular basis
- Stay well hydrated. Drink plenty of water and avoid sugary or acidic drinks
- After using a nebulizer, make sure you drink some water to eliminate any dry residue that may stick to your teeth.
- See your dentist every 6 months and inform him/her of your concerns.
Happy Brushing and Flossing!