Welcome to the Big Grins blog page! Blog makes me think of inkblot which makes me think of the Rorschach test that analyzes your personality. Just write something! Then post it on the web for others to make conclusions about you! Sure!
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X rays and the HULK posted by greg on 09/08/09
Mouthguards for Kids posted by greg on 08/20/09
Cankers and Cold Sores posted by greg on 03/12/09
Canker and Cold Sores
Oral pathology was a subject I loved in dental school, so abstract, so much to remember. I don’t like it so much now; now it happens to real people. For my patient population, I can thankfully say that almost everything I see falls into the category of minor nuisance (no pun intended!) Since I see TWO oral lesions frequently, I thought a brief review of them would be a good topic for a blog. With that should come a warning. Nothing having to do with us humans ever presents as black and white, easily categorized or easily described. The internet is a good place to get general health information, but a lousy place to get good health advice. If you have questions, as always, call me. If I can’t answer something I know the right person in Fort Collins who can. Yours, Greg Evans cell 481-6728
Aphthous Ulcer, common name Canker Sore. These very distinct sores are a surface ulcer that is round or oval, white and surrounded by a very red border. The little sores , 1x1mm, are often unnoticed, but the usual sized sore, 4x5mm, are extremely painful for one to two weeks after onset. They happen almost exclusively on the moveable tissues of the inside of the mouth: bottom of inside lip, soft palate, underside of tongue or cheek in that order of likelihood. They are thought to be an over-response of the immune system to some irritation or insult to the mouth. Sometimes the cause if obvious like new braces, but most often the irritating agent is unknown. Because they are immune related, they do not respond to any antibacterial or antiviral medicine. Identifying them and treating the symptoms, with Tylenol or topical anesthetic like orajel, will help in the short term. Some over the counter products that cover and coat the lesions will help for 24-48 hours. Zylactin is one over the counter product, but it stings on application. Older folks may remember cauterizing them with silver nitrate, but that causes excess tissue damage that may scar. Our immune systems are funny things, but usually getting one Aphthous Ulcer will mean you get them repeatedly. They tend to peak in frequency around puberty. In extreme cases, a steroid rinse ( that suppresses the immune response in your mouth) can be prescribed to lessen the severity and prevent more from occurring. More or less, these lesions are a bummer but not cause for concern. For immuno compromised, ill children, I have a few other tricks that may help.
Recurrent Oral Herpes Simplex, common name Cold Sore. These sores usually happen on the OUTSIDE border of the lip, start as fluid filled vesicles (tiny blister) that rapidly appear and crust over. They are often preceded by an itchy prodrome on the lip by those who can recognize the feeling. These lesions are from a type of herpes virus that lives inside the trigeminal nerve cells of the face. Just like herpetic chicken pox infects the nerves of the trunk and comes out later in life as shingles or herpes zoster, once infected with the virus, it stays in your cells forever. There is currently a vaccine for chicken pox, but none for oral herpes. Almost 90% of the population is exposed/ infected by the virus by about age 3-4 (preschool!) and about half the population converts the virus to the chronic condition of infected nerve cells. This conversion results in recurrent cold sores throughout a person’s life, usually holidays and wedding days. Most initial infections are like a common cold, but sometimes children can get vesicles all over the inside of their mouth and throat resulting in a very painful week. This is call herpes stomatitis. A variety of antiviral medications have been developed which will lessen symptoms and speed healing from cold sores, but nothing cures the disease, because we can’t get the virus out of the nerve cells. The most common drug, Acyclovir, is generic and comes in a cream (best for young children), liquid (older children), or tablets for adults. A combination of cream and pills can be used and the drug does not cross react with other medications. Call me for a prescription for you or your child!
Bad Breath and Children posted by greg on 01/11/09
Bad Breath and Children
In my practice, I get questions from parents about their child’s bad breath almost everyday. Ironically, I also talk to parents with bad breath almost everyday. In reality, I suppose parents and children also talk to a dentist with bad breath, me! That’s why I don’t have onions on my subway sandwich at lunch. Regarding bad breath, the questions are where does it come from? What can we do about it?
Bad breath or Halitosis can come from a variety of sources including food odor, tobacco products, and oral injury. Rarely will bad breath be noticeable from a large cavity that packs food or an abscessed tooth. Bad breath can also come from dehydration of the oral tissues, as in when a person sleeps with their mouth open all night or is a chronic mouth breather. Draining congestion into the throat or infected tonsils are also significant sources of malodor, albeit usually temporary. These sources of bad breath can be addressed through medication, therapy, removal of tonsils or possibly braces. Oh yeah, don’t wrestle your brother with a toothbrush in your mouth like my daughter did!
What most people mean when they talk about bad breath is the chronic unpleasant odor children or adults have, often called “morning breath.” Morning breath is caused by the bacterial breakdown of saliva proteins and the bacterial metabolites. Some of these metabolites contain volatile sulfur or amines. In lay language, that means bacteria in a person’s mouth are feeding off protein in the saliva and producing waste products that smell like rotten eggs (sulfur) or ammonia (amines.)
These bacteria live on the soft tissues of the mouth, mainly the tongue. On the tongue, the bacteria that produce most of the problem are gram negative anaerobic bacteria. They like the deep grooves and papilla of the posterior dorsum of the tongue, way in the back. You know, near your child’s carefully protected gag reflex!
Because the cause of bad breath is bacteria, we can treat chronic bad breath like a bacterial infection and fight it with antimicrobials. These antibacterial products come in several varieties: antibiotics, general antimicrobial prescription rinses, toothpaste products and cosmetic rinses. Don’t forget the toothbrush to physically remove bacteria either!
In general, unless a child has and underlying systemic infection, antibiotics are not used to treat halitosis because of the possible side effects, diarrhea, yeast infection, or drug resistance. Physical debridement or posterior tongue scrapping remains the gold standard for fighting bad breath. Lessening the bacterial load by frequently brushing the posterior tongue with a toothbrush or a tongue scraper should be part of the daily routine. The gag reflex will get better over time, and it often helps if a child can brush their own tongue.
Recently stannous fluoride has been reintroduced into toothpaste as the active ingredient. Crest originally used this form of fluoride but switched to sodium fluoride because of the taste and short shelf life of stannous fluoride. These problems have been worked out and there is good evidence to show the stannous ion (tin) is antibacterial and will help fight bad breath as well as gingivitis. We have a stannous fluoride gel in the office and Crest Pro Health toothpaste is now on the market.
A host of mouthrinses have been part of a billion dollar industry to fight bad breath and make us all paranoid. Most mouthrinses are categorized as cosmetic, in that they MASK bad breath rather than fight the underlying causes. Scope is a good example, its active ingredient is a weak bacteriostatic, but the alcohol gives the soft tissue a zing and the mint smells fresh, at least what we have come to accept as fresh in our society.
Listerine is more of a therapeutic mouthrinse in that the proprietary essential oils will stick to tissues for long periods of time and actually kill bacteria. It is also high in alcohol so a caution for unsupervised use by children. Consistent use of this product will help to reduce halitosis.
Another over the counter product that is effective is marketed as Closys II ( the original name Retardant was not a hot seller!) It contains chlorine dioxide which will kill bacteria and bad breath for up to eight hours. It is particularly effective on those bacteria which produce the volatile sulfur and amine compounds.
Prescription rinses are available, most have the main ingredient of Chlorhexidine. While
Other rinses, including ACT, Listerine tooth sluth and smart rinse do not contain ingredients that will fight bad breath. If you have questions about who should use what and when, don’t hesitate to email me at greg@biggrinswithdrgreg.com . In conclusion, brush the back of that tongue, use rinses appropriately and remember when you were first married morning breath wasn’t a big deal! Just give your kids a smooch on the forehead before breakfast. Dr. Greg
Overnight Malodor Effect of with a 0.454% Stabilzed Stannous Fluoride Soduim Hexametaphosphate Dentifrice. Farrell et al. Compendium, Dec 2007:28(12):658-662
Microbiology and Treatment of Halitosis. Loeshe, Kazor. Periodontol 2000. 2002;28:256-79
Infant Dental Care posted by greg on 11/06/08
My father, the junior high teacher of 30 years, had a favorite saying: “Children don’t change, only their circumstances.” That has been one of my guiding principles as a pediatric dentist. I have found that all kids are good kids if you can build the right environment for them to excel in. That being said, today’s world is a lot different for children than even a decade ago. In order to meet the challenges of today’s circumstances, dentistry has changed. In the specialty of Pediatric Dentistry, some changes have been dramatic. Keeping up with the specialty is, well, like keeping up with my children!
The latest buzz in pediatric dentistry is what is happening to our mindset. We are weaning from the antiquated notion that we can surgically repair teeth. Lately, we have begun to confront dental caries as a ‘chronic disease process’ much like asthma or diabetes. Paradigm shifting research out of California’s San Francisco School of Dentistry is teaching pediatric dentistry to manage this bacterial disease process long term in order to keep it in remission, and we are focusing on prevention with new fervor. A movement is now happening in Colorado, the first in the nation, to incorporate medicine and dentistry together to attack dental caries before it starts.
Caring for Colorado, a private, non-profit foundation in conjunction with the Rose Foundation and Delta Dental is sponsoring a statewide, multi-million dollar initiative called “Cavity Free at Three.“ Its emphasis is on treating pregnant women for dental disease, which in turn, may lessen infant morbidity. Further, infant dental care is instituted with the pediatrician to identify high-risk children or behaviors and stop the cycle of mother –to-infant bacterial transmission and caries. Linda Reiner, director of the initiative, is hopeful this prevention based initiative will spread beyond community clinics and eventually save tax payers millions of Medicaid dollars as well as preventing missed school and needless suffering.
New research has conclusively shown that dental treatment during pregnancy and education in infancy can significantly reduce dental caries (tooth decay) throughout a child’s life. The New England Journal of Medicine reported in 2006 that dental treatment was safe during pregnancy, did not hurt the unborn child, and may reduce stillbirths. The Journal of the American Dental Association published a landmark study showing pregnant mothers who rinsed with an anti-bacterial mouthwash for the last three months of pregnancy not only reduced the bacteria counts and cavities in their own mouths after birth, but they reduced the bacteria in their infants’ mouths as well. Cavities are not genetic, but the specific bacteria that cause them are passed from parent to child. Infant dental care is the key for parents to understand and stop this cycle from occurring. And the timing is crucial, at or before the arrival of the first baby tooth!
The strategy is a simple one. Cavity Free at Three is now educating our medical colleagues to prevent dental caries in infancy and recognize the signs a disease process may be starting. This effort begins at those well established well-baby checks. During this window of opportunity, both the high risk mother and child can receive Medicaid insurance, and the mother is motivated to learn and help her baby. Education on bottle use, infant toothbrushing, the timing and use of toothpaste, and referral to a dentist can all be covered in a proactive, positive light.
It is then the partnership with dentistry comes into play. Pediatric dentists are leading the call to see children below age three to prevent disease, not just when they have enough teeth to clean and can sit still. Both the American Academy of Pediatrics and the American Association of Pediatric Dentists advocate for children to establish a “dental home” by age one. Examining children on the laps of parents fosters involvement, educates them about a child’s oral anatomy and growth, and anticipates development , both mental and physical. These tools equip parents to raise a cavity free child. And for those children where disease is immanent, interceptive strategies can take place before the child ever gets the end-game toothache.
Far too often my dental colleagues and I treat children with toothaches or abscessed teeth before their third or fourth birthdays. When extensive or invasive treatment is required to ward off pain in young children, nobody thinks dentistry is fun. And, it is difficult to bring a child back around to a positive dental attitude later. For those high risk kids who also have language and access barriers, it is nearly impossible to overcome bad dental experiences. So they continue!
The popular press, with little argument from organized dentistry, misinterpreted census results in the late 1980’s and lured us into believing cavities were decreasing. In fact the opposite is now true. Pediatric dentistry is seeing a reemergence of high rates of cavities in children across the country and across all socio economic lines. That is where we have to emphasize our role as teachers and establish long term relationships built on trust with families. The challenges are great. Our children eat more convenience foods and drink more pop than ever before. Rising obesity and rising dental caries are symptoms of the same problem. Here’s one you may not have thought too obvious; cavity rates also are on the rise in response to our love affair with bottled water! Most bottled water does not contain adequate amounts of fluoride which will strengthen permanent teeth as they form or topically remineralize them in the mouth. Some areas in the country are returning to the days of pre- water fluoridation due to widespread use of bottled water, and cavity rates are skyrocketing. That is the kind of nostalgia we don’t need! No, this is not the same old same old; children’s lives have changed as much as their parents’ have. Prevention may not be flashy or text easily, but certainly we must use the technology and knowledge we have gained recently to change those circumstances for our children. They deserve it!
Xylitol Gum and Mints (Will they stop cavities?) posted by greg on 09/05/08
Xylitol is a sugar substitute or food sweetener that is derived from birch bark. It is has been around since the 1960?s. While it has been used for a long time as a sweetener in various foods, it has lately come into mainstream focus as a sweetener for children?s candies and gums. While it is perfectly safe and approved by the FDA, relatively recent research has shown that Xylitol may actually be able to prevent cavities and suppress cavity causing bacterial growth!
Recently, a few new gums and mints have hit the American market and some of them are hitching a ride from this research and promoting Xylitol as a cavity preventer. What are the facts?
Xylitol is a sugar alcohol (the class of molecule) sweetener like sorbitol or mannitol. Like these common sweeteners, Xylitol tastes sweet like table sugar (sucrose) but cannot be absorbed and used by the body so don?t contribute calories. They also cannot be used by bacteria in the mouth to produce energy and therefore reproduce or produce acidic plaque, so Xylitol is considered non cariogenic. But here is where it gets interesting. Xylitol, unlike other sweeteners, is absorbed by the type of bacteria that causes cavities called Strep Mutans. Strep Mutans bacteria cannot help but absorb Xylitol, so the bacteria ends up spending a whole bunch of metabolic energy to push Xylitol back out. In doing so, the Strep Mutans cannot be as effective in causing cavities! Over the long term, Xylitol in the mouth will actually reduce Strep Mutans and will even select for the type of Strep Mutans that are the least virulent or harmful. Good stuff!
Yes, but as with anything there is a catch! And, as with any medication or nutrient, these effects are entirely dependent on DOSAGE. One or two pieces of Xylitol gum a day will not hurt Strep Mutans. It must be a dose of 6-10 grams/ day. That turns out to be a lot of gum! How much? Well, if Xylitol is the only sweetener in the gum or mints, you would have to chew 2 to 3 pieces, at least 4 times a day to get the anti cavity benefit. Some gums like Epic or Spry or Omni ?Theragum? or Hershey Carefree Koolerz Gum will get you to that level, but those gums are expensive at about a dollar a day or more. Most of them you can find online.
When Xylitol is listed as a second sweetener ingredient or listed in combination with other sweeteners, it will be very unlikely that a person could chew enough gum a day to produce an anti cavity effect. Gums such as Starbucks after coffee gum, Biotene Dental Gum or Trident with Xylitol or Trident for Kids Gum, simply does not have enough good stuff in it to make it practical to chew and prevent cavities. Those gums are still sugar free and better than sugar gum, but they don?t have the DOSAGE to be effective, despite what an ad might imply. Same goes with Xylitol sweetened toothpaste. Unless a kid is brushing four or five times a day with a toothpaste containing Xylitol, Xylitol will not become a clinically significant active ingredient.
I hope that helps those of you with questions about Xylitol and amuses those of you who are insomniacs or biochemistry nerds. A good review paper on Xylitol is in the Pediatric Dentistry Journal 28:2, 2006. I would be happy to send you a copy (for individual use only of course) or answer any questions you might have. Happy Blogging! Greg Evans
Amalgam Scare Update posted by greg on 08/25/08
In my last blog I promised to research a possible FDA warning regarding the mercury content of amalgam fillings. Here is the update: The FDA has not changed its position that dental amalgams are harmful nor is it likely to. The FDA was recently successfully sued by a non profit organization called Mothers Against Mercury which forced them to review the current science related to dental amalgams. While the vast body of scientific study points to no recent change in dental amalgam safety, the FDA must now produce a review on the matter to appease the court. For more on this story, please go to our links page and click on ADA. For more on dental materials used on our office, go to our Answers to Your Dental Questions section our of website!
Cavity Free at Three posted by greg on 08/22/08
Cavity Free at Three is a statewide, privately funded initiative by Caring for Colorado Foundation, Delta Dental and numerous other sponsors and participants. The initiative is concentrating on recent research by Dr. Francisco Ramos- Gomez and others that show early dental screening and treatment of infants by dental and medical professionals can greatly reduce dental caries disease later in life. In fact, the time to address early childhood caries disease is prenatally!
Much has come together in the last couple of years to bring this program to Colorado. Work out of New York is showing that pregnant women are at no more health risk from dental care than the general population, and their babies are benefitting in higher birth weights if mommy has better oral health. Added to that is the recent change in policy by the American Academy of Pediatricians. The AAP now recommends all children find a ?dental home? and are screened by age one by a dentist. This reverses a long held view that physicians could provide oral care for children up to age three. Now, the research is in to show the cavity process can start as the first teeth come into an infants mouth, and by age three children often have obvious and painful decay. How often? A study in 2000 by the state of Colorado found up to one third of all three and four years olds had untreated dental decay.
With dental decay occurring five times more often in our children than the asthma, and the best predictor of adult dental decay is decay in the primary teeth, this is an epidemic that needs addressed before the holes start. Cavity Free at Three is the initiative that is providing educational materials, cavity prevention kits and technical training to both physicians and dentists. They have begun to reeducate and realign both MD and DDS to see pregnant women and infants and to recognize early cavity trends and risk factors. Eleven community health sites around Colorado have been awarded grants and twelve technical advisors from the medical and dental fields have been hired to get this program up and running. For more information on this initiative go to our link under Cavity Free at Three. For more information on infant dental care, go to our website section under Services We Offer. You will be pleasantly surprised to find we think this issue so important we offer FREE Infant Dental Care Exams. Also, I am a technical advisor for Cavity Free at Three should you desire more technical training for your medical or dental office. Please call me at my numbers under Contact Us.