Laughing Gas
Nitrous oxide (N2O), more commonly known as laughing gas, is the most common sedative used in dental offices to help patients deal with anxiety and make treatment more comfortable. It was first discovered by a dentist named Horace Wells in 1844 and slowly came into more common usage over the years.
What Effect Does Laughing Gas Have?
The most important effects of laughing gas are it’s anxiolytic (anxiety reducing) and analgesic effects (reducing the sensation of pain). The maximal effects are reached within 3-5 minutes after breathing it and fade in about the same amount of time after stopping the flow of the gas. You can drive yourself immediately afterwards unlike all other sedative medications.
What Does Laughing Gas Feel Like?
There are a range of sensations you might experience with laughing gas. Everyone’s body processes it a little differently so your experience might be a little different than someone else. The most common sensations are a floating feeling, sleepiness, a tingling or numb feeling of your lips, hands, or feet, and distortion of sounds.
Who Is A Good Candidate For Laughing Gas?
Laughing gas is arguably one of the safest sedative medications used today and there are very few situations in which it absolutely can’t be used. When administered by a health care provider it is always delivered with a minimum of 30% oxygen. For comparison, the air at sea level contains about 20% oxygen.
Children and adults with mild to moderate anxiety about dental procedures usually benefit the most from the effects.
People with severe claustrophobia may not be able to tolerate it because several hoses attached to a nose breathing apparatus are placed over your nose.
Pregnant women shouldn’t have laughing gas (see below).
Are There Any Short Term Dangers With Laughing Gas?
Women who are pregnant shouldn’t have laughing gas or be in the same room when it is being administered. Some older studies showed an increased risk of miscarriage with exposure to it. A lot of these studies were done in operating room environments before nitrous oxide scavenging systems were developed. The scavenging systems significantly reduce the amount of nitrous oxide that is released into the air.
People with a vitamin B12 deficiency shouldn’t have laughing gas. Nitrous oxide deactivates a certain form of B12 in the body. Significant deficiency of B12 can cause degeneration of the nerves in your brain and the rest of your body. This isn’t a danger for most people because they have an excess amount of B12 built up in their body. Occasional use of nitrous oxide for dental or medical procedures isn’t enough to deplete normal stores of B12.
Are There Any Long Term Dangers With Laughing Gas?
As with people with a B12 deficiency, long term abuse of nitrous oxide depletes stores of B12 in the body and can lead to serious neurological damage. This usually starts with tingling in your extremities and progresses to tremors, muscle weakness, and brain damage over time. The treatment of a B12 deficiency is with IV administration of vitamin B12. Even with treatment, recovery from the effects can be very slow and some of the damage can even be permanent.
Why Do Dentists Recommend Different Things?
Dentists joke that if you were to show ten dentists the same tooth, you’d get ten different answers on the best way to treat it. When most people hear that they have a cavity, they think it is one of these black and white things, where you either have a cavity or you don’t. The truth of the matter is that cavities are a process. What one dentist may consider a cavity that needs to be filled, another dentist may consider it to be a cavity that just needs to monitored for the time being. Dental treatment recommendations are a highly gray area because there are so many factors that go into the process. These factors include…
- The size of the cavity
- What tooth
- What shape the tooth is in
- Age of the patient
- Teeth around it
- Risk factors for getting additional decay
- Dry mouth
- Medications
- The dentist’s treatment philosophy
- Diet
- Other health conditions
- Finances
The dentist tries to take all of these things under consideration and make the best treatment recommendations that they can. As you can imagine, with this many things involved, dentists are going to have differences of opinion.
Next time you see one dentist and then another who recommends something else, please remember why this happens. It’s not necessarily because one dentist or the other is dishonest. They just have a difference of opinion. Have the dentists explain their reasoning and choose what you think sounds right. In many cases, either treatment option can be successful as long as it is done well.
What Is A Cavity?
While most people know that they don’t want their dentist to find any “cavities” during their check-ups, they oftentimes don’t know what a cavity actually is. The word “cavity” literally means “a hole”. A cavity in the dental world, also known as dental decay or caries, is when the structure of a tooth starts breaking down as a result of acid formed by certain types of bacteria. Over time this will end up causing a hole in the tooth.
Let’s take a look at all the different stages of cavities…
Early Decay
Teeth are made up of several different layers. The outer layer, known as enamel is where cavities start. Sugar on your teeth acts as food for certain types of bacteria. The most common is known as streptococcus mutans. When the bacteria feeds on this bacteria it grows, multiplies, and creates acid. This acid slowly starts to eat away at the enamel of the tooth. In the very early stages, there isn’t a hole in the tooth but just a loss of the minerals that make up the enamel structure. These areas turn very white and tell us that a cavity is starting. As long as the cavity is confined to the enamel, nothing needs to be done. It can be reversed at this point by avoiding sugar and brushing with fluoride toothpaste.
Many kids who have had braces for several years find that they have these white spots on their teeth after getting their braces off. This is usually a result of bad diet as well as not cleaning their teeth as well as they should while having the braces on.
Medium Size Decay
Once the cavity extends past the enamel and into the second layer of the tooth known as dentin, you need treatment. Often at this point, the enamel will start to break apart and the underlying dentin will become very soft. In this stage you usually only need a filling to take care of the decay, unless you already have large filling in the tooth. When you’re having a filling done, the dentist will remove the outer enamel layer and the softened dentin underneath. Once the dentist gets back to solid, hard tooth structure they can place a filling material into the tooth to build it back up again.
Large Decay
Once decay gets very large it can cause several different problems. The first problem is that it weakens the tooth significantly. This can cause the tooth to break. Large decay usually needs a crown on the tooth to keep the tooth from breaking anymore.
When the decay reaches the nerve of the tooth it can cause a toothache or it can kill the nerve and you’ll eventually get an abscess. At this point you need a root canal and a crown on the tooth to fix it.
Avoiding Cavities
Avoiding cavities is actually pretty simple, but hard to do.
- Avoid sugary and acidic drinks on a regular basis.
- If you do drink sugary or acidic drinks, don’t sip on them over a long time period.
- Avoid snacking on carbs or sugary foods throughout the day.
- Brush twice a day with fluoride toothpaste and floss.
- Chew sugar-free gum or use sugar-free mints especially if they contain xylitol
DMD vs DDS
In the United States, dentists are either awarded a DMD or DDS degree at the end of their training. DMD stands for Doctor of Medicine In Dentistry while DDS stands for Doctor of Dental Surgery. DDS was the original dental degree established by the Baltimore College of Dental Surgery. This was the only degree for dentists until Harvard decided they wanted to award the DMD degree instead. Today approximately half of dental schools award the DMD degree while the other half award a DDS.
While they sound like they would have different training requirements, in actuality the training between the two is identical. The requirements for dental education are set by the American Dental Association and each school must follow these requirements. Both DMD and DDS dentists can perform the same procedures and are equally well qualified to perform dentistry. This is different than in medicine where physicians are awarded either an MD or DO degree. MD and DO programs have different treatment philosophies.
I personally think it is just confusing having both DMD and DDS degrees without any distinction between the two. Hopefully one day they’ll pick one over the other and be done with it… That’s if they can convince all the old, cranky dentists who run dental schools to agree on it.
There are a lot of different ways to go about picking a dentist (see our guide on finding a dentist), but fortunately this is one less thing you have to worry about.
Do Straws Reduce Cavities?
A lot of people drink sugary drinks through straws because they believe that this will help them avoid cavities. Is this actually the case? Researchers have studied this very topic and came to the conclusion that drinking through a straw can slightly reduce the number of cavities of a person gets depending on where the straw is placed and the person’s drinking patterns.
The researchers followed people over a several year period. They found that people who positioned the straw right behind the front teeth, tended to develop more cavities in that area. They found that people who positioned the straw near the back of their mouth tended to get cavities on the back teeth. The best place to position the straw was so that the drink went directly onto the back of the tongue and down the throat. People who didn’t use a straw at all tended to develop more cavities especially on their back molars.
Now it is important to remember that even though a straw can reduce cavities, if you are drinking sugary or acidic drinks on a regular basis, you will still continue to develop cavities. Ideally you’d like to not get any cavities at all. This is not possible with a high level of consumption of sugary drinks.
Some other tips that can help reduce cavities when drinking sugary and/or acidic drinks…
- Rinse your mouth out with water after drinking them but don’t brush. Brushing soon after having an acidic drink can cause more damage to the tooth enamel.
- Brush twice a day with a fluoride toothpaste.
- Use a fluoride containing mouthrinse.
- Drink it all in one sitting as opposed to sipping on it throughout the day. Remember that for your teeth, its more important how often they are exposed to sugar rather than how much sugar total you are consuming. I find that having your drink in a can forces you to do this unlike a drink in a bottle that you can put a cap on.
- Don’t hold the drink in your mouth. Swallow it immediately. Some people like to let it sit either around their front teeth or back teeth and this is also linked to higher levels of teeth decay in those areas.
- Don’t drink sugary drinks before bed.
Cracked Tooth Syndrome
So you’re happily eating dinner when all of a sudden you bite down and feel a sharp pain in your tooth. You think surely it’s broken but when you look at it in the mirror, it all seems to be there. Over the next several days the tooth randomly hurts, is sensitive, and you can’t bite into anything hard with it. What is going on?
Let’s imagine your tooth as a road (trust me, this will make sense in a moment). When a road is first paved, the surface is smooth and strong. Over time, the surface gets damaged from normal wear and tear. Potholes form which are patched over with asphalt. This holds up for a while but eventually the surface all around the pothole begins to crack and wear away until eventually something comes along, hits it just right, and bam… you’ve got a big crack, the surface starts moving slightly, and a pothole patch isn’t going to cut it anymore. The only option at that point is to repave.
Same thing with a tooth. Teeth take a lot of abuse. They often get cavities which have to be patched (fillings). These “patches” weaken the tooth until one day something hits it just right and bam, just like the road, you get a big crack. Sometimes the tooth will actually break but other times these cracks are invisible to the naked eye. These mostly invisible cracks lead to “cracked tooth syndrome”. The tooth moves imperceptibly leading to all sorts of random symptoms such sensitivity, pain when biting, and dull aches.
Like that road, once the tooth is cracked a “patch” is no longer going to cut it. At least not for any significant amount of time. The tooth needs to be rebuilt. In dental terms, this means you need a crown. The crown acts somewhat like “new enamel” for the tooth and helps hold everything together again. When the crack extends more deeply into the tooth, you may need a root canal. In some cases the crack goes all the way through the tooth in which case it can’t be saved and needs to be extracted.
So how do you know if you have a cracked tooth? It can be challenging, even for dentists. The most classic symptom of a cracked tooth is that you get a severe, sharp pain as soon as you release your teeth after biting down. Some other things that can mimic a cracked tooth are a tooth with a bite that is too high, a tooth that is irritated from grinding or clenching, a filling that has come loose, or a large cavity. With a cracked tooth, you should see a dentist as soon as possible. This isn’t something that will go away or get better with time. Cracks only get larger. Wait too long and you’ll end up needing to have the tooth extracted. Get a crown on that tooth as soon as possible and you give yourself the best possible chance of saving the tooth long term.
Should You Bother With Tongue Scraping?
Did you know that your tongue is estimated to be responsible for 50% of all cases of bad breath? Keeping your tongue clean is one of the best and easiest things you can do to reduce bad breath. Let’s take a look at your tongue, why it causes bad breath, and the most effective ways to clean it.
Your tongue is covered in tiny taste buds that retain little food particles. These food particles are fed upon by bacteria and produce compounds that lead to bad breath. The most common are hydrogen sulfide and mercaptans, which as a group are known as volatile sulfur compounds (VSC’s). Yep, the same sulfur responsible for the smell of rotten eggs. You definitely don’t want your breath to smell like that.
To clean their tongue, most people brush it with their toothbrush immediately after brushing. Interestingly enough, this isn’t the most effective way to clean your tongue. Researchers from the University of Sao Paulo compared tongue brushing with tongue scraping to see how each reduced those smelly VSC’s. Brushing alone reduced VSC’s by 48% while tongue scraping reduced them by a full 75%. Other small studies have backed up the conclusion that tongue scraping is more effective than using a toothbrush alone.
So final conclusion…Tongue scrapers are cheap and effective. If you struggle with bad breath, buy one and use it daily. Here is a link to one of the more popular tongue scrapers on Amazon…
Energy Drinks
Energy drinks have really taken off in the last five years. They are marketed heavily and are consumed by many people to get a quick pick me up during the day. Some of the most common brands include Red Bull, Rockstar, 5 Hour Energy, and Monster. What a lot of people don’t know about them is that they have really terrible effects on your teeth. I’ve personally seen a lot of my patients develop cavities after starting to drink energy drinks regularly.
Why are energy drinks so bad for your teeth?
- They are highly acidic. In fact they are some of the most acidic drinks out there due to their high concentration of citric acid. Studies have shown that they cause enamel breakdown on your teeth more quickly than just about any other kind of drink. Acidic drinks don’t just cause damage to your teeth when you first drink them. The acid lowers the pH in your mouth for 20-30 minutes at a time during which the enamel is broken down. Taking sips of an energy drink over the course of several hours is even worse because this keeps your mouth acidic all day long which quickly leads to cavities.
- They usually have a lot of added sugar. We all know that sugar is a huge factor in developing cavities. Constant consumption of energy drinks keeps that sugar sitting on your teeth.
What do I recommend for my patients who drink energy drinks?
- If you’re able to stop taking them, this is the best choice. If you need caffeine to keep you going consider taking a caffeine supplement instead.
- Don’t brush immediately after drinking them. You want to wait at least 30 minutes minimum before brushing as the acid makes the enamel softer and you can cause additional damage by brushing.
- Rinse your mouth with water after drinking energy drinks. This will help to start returning your mouth’s pH to a healthy level.
- Brush regularly with a fluoride toothpaste and use a fluoride containing mouthwash. This will help remineralize some of the damage done to your teeth by the energy drink.
Should You Floss?
The Associated Press came out with a story a couple of days ago with the headline, “Medical benefits of dental floss unproven”. Because flossing and dentist visits are such hated past-times, many media outlets seized on this story and claimed that you can stop flossing! Headlines like “Tell your dentist to suck it” abounded. Hey, don’t get me wrong. I’d be super excited if we actually had found out that flossing doesn’t work and nobody needed to do it too. One less thing for me to do and I could tell my hygienists to stop hounding my patients about it.
Here’s the funny little secret though. Unproven, doesn’t mean ineffective. Dentists have been notoriously behind the times in adopting evidence based practices. Certain topics just haven’t been studied well. The existing studies all had significant problems such as extremely short time spans, difficulties controlling variables, and no measurements on the actual important indicators of gum disease. Gum disease and decay is process that occurs over years and years, not days or months. Studying this can be extremely difficult because getting some to comply with flossing instructions over this time frame can be nearly impossible. All that said, one of the other main reasons it hasn’t been studied is because it’s benefits are so readily apparent to any dentist, hygienist, or any regular person who has taken the time to start flossing regularly.
Don’t believe me? Take this challenge. First look at your gums, brush them hard, poke them slightly and watch them bleed. If you don’t floss, this will more than likely be the case. Now, go ahead and floss for two weeks straight and then do the same thing. Guess what, they won’t bleed easily anymore! You literally have to stick a sharp instrument into them really hard to make them bleed. I’ve seen this in patient after patient after patient. I’ve seen this on myself personally. Ask any dentist or dental hygienist. They’ll tell the same thing. I know that personal experience doesn’t rise to the level of scientific evidence, but the professional consensus in the dentistry community is almost unanimous in support of flossing.
Bleeding of the gums with slight pressure (say from brushing or occasional flossing) isn’t normal. Any other area of your body that bled spontaneously or easily and you’d be off running to your physician. Why isn’t this the case with your mouth too? Flossing prevents this.
Here are some other common sense benefits to flossing that all dentists know…
- It cleans out food from between your teeth. Don’t floss for a couple days then floss again. You’ll pull a bunch of rotting food out from between your teeth when you do. You can easily see this on the floss. At best, this rotting food will cause you to have bad breath. At worst it can cause gum disease and cavities. I consistently see people develop cavities in areas where food gets stuck in between the teeth.
- Most people who don’t floss build up significant tartar between their teeth, under the gumline. Floss or a waterpik is the only way to clean the plaque out before it turns hard and calcifies into tartar.
- Tartar under the gumline causes additional inflammation of your gums and eventually leads to bone loss around your teeth. I’ve never seen anyone develop gum disease who flosses regularly (unless there was some other specific health problem at play).
- Gum health is linked to overall health. This includes diabetes, heart disease, and certain types of cancer. Unlike flossing, the literature on this is solid.
After all this, if you still don’t want to floss, by all means go ahead. I’ll see you in 10 or 15 years needing some serious dental work. You’ll wish you had taken the 30 seconds a day to floss instead of believing hyped up media stories meant to sell clicks and advertising space.
My Thoughts On Homeopathic Dentistry
I’m going to give you my honest thoughts on homepathic dentistry. I stand to gain or lose nothing from telling you this. I simply feel strongly that people seeing a homepathic dentist should be aware of the issues. I’m very much against people being misled and taken advantage of.
Homepathic dentistry, also known as “holistic dentistry”, “biological dentistry”, or “biocompatible dentistry” is a type of dentistry that philosophically claims to be concerned with your dental health as it relates to your overall health. In practice it usually means opposition to amalgam fillings, opposition to fluoride in any form, opposition to surgical gum therapy, ozone treatments, opposition to root canals, and limiting exposure to any dental materials with “toxins” in them.
Homepathic dentistry is big business. These dentists often charge several times what mainstream dentists charge because they market and believe they are providing a superior service. In reality they are often providing unnecessary and ineffective treatments at a premium price. Current evidence based dentistry has debunked many (but not all) of the claims holistic dentists make. As you can probably piece together from all this, I believe most holistic dentists are either liars or quacks.
Many of these dentists and the people that go see them believe mainstream dentistry has an on-going conspiracy to mask any evidence of harm from traditional dentistry. The truth is that most dentists have no financial incentive to mask harm. If everyone practiced dentistry the way holistic dentists did, there would be a lot more work removing and replacing amalgam fillings, complications from those removals, and a steep increase in cost. The only financial incentive is for holistic dentists to peddle these claims.
Let’s take a look at some of the major issues…
Amalgam fillings
Opposition to amalgam/mercury fillings is an almost universal belief of holistic dentists. They believe that the mercury in amalgam fillings is slowly leaked into the body causing a whole host of health problems. They claim that by removing these amalgam fillings, you can cure your fibromyalgia, headaches, etc. Here’s the problem… study after study has shown amalgam fillings to be effective and safe long term. This is one of the most studied topics in dentistry and no study has shown any type of harm from amalgam fillings. Any improvements in other health problems after removing amalgam fillings is likely related to the placebo effect (you think something will be better, so it actually gets better).
I wrote a whole other blog post specifically on this topic. Check it out for more information.
My favorite part about the whole thing is that they literally wear suits and gas masks while removing amalgam fillings for fear of exposure. I believe that this is all theater to justify their exorbitant prices. They actually look similar to this…
Fluoride
Opposition to fluoride is the other pillar of holistic dentistry. They believe that fluoride, in any form, should be avoided. This includes tap water and in your toothpaste. They claim that fluoride, like amalgam fillings, causes a whole myriad of systemic health problems including brain development issues. So what is the truth?
Fluoride is actually a naturally occurring mineral. It is found in many natural water sources and is found in trace amounts in your saliva. It plays a very important role in remineralizing and strengthening your teeth. The natural water sources were actually how it’s important role in tooth development were discovered.
This may surprise you but this is probably my one area of partial agreement with holistic dentists. Studies have shown that fluoride in drinking water can lead to substantial decreases in IQ in children. Systemic exposure to fluoride can have neurotoxic effects on developing brains. High levels of fluoride are also associated with a condition known as fluorosis in which brown spots develop on the teeth. Unsurprisingly, higher levels of fluorosis are also linked with lower IQ scores.
What do we do then? This is where I differ with the holistic dentist. More important than fluoride in your water source, is the topical application of fluoride by using toothpaste. Because it is a topical application and then spit out, you get almost no exposure to the rest of your body. This is why many dentists recommend brushing for two minutes a day. You want your teeth to have time to take up the fluoride.
So my conclusions on fluoride… I think it should be taken out of the water supply but more emphasis should be placed on fluoride toothpaste use and topical application of fluoride varnishes, etc at routine dental visits. It has a place in dentistry but I don’t think the current known risks justify leaving it in the water supply.
Root canals
Many holistic dentists also don’t believe in doing root canals. They claim that this seals dangerous bacteria in the area that can travel to other parts of the body and cause problems. Instead they just take the teeth out and place “biocompatible” implants, which are coincidentally far more expensive. Here’s the thing with bacteria in your body. They’re everywhere in trace (and not so trace) amounts. Your immune system usually keeps them in check. No evidence has linked root canals with any type of systemic health condition. Missing teeth on the other hand are linked to certain types of malnutrition and long term health problems. Even if there was a small risk, I believe that the benefits of root canals far outweigh any small risk.
BPA in white “composite” fillings
BPA is an ingredient present in many plastics that has been shown to cause estrogen type effects in high concentrations. The good news? Exposure to BPA from white fillings has been studied and has been shown to be 1% or less of your total daily exposure to BPA. This is insignificant in the overall picture. I’d be much more concerned about other types of BPA sources such as canned goods, plastic bottles, etc.
Ozone therapy
Now this is one of those really “quack” treatments promoted by holistic dentists. They claim that ozone can be flowed into cavities and diseased pockets around your teeth to clean and heal the area. They claim it works by undergoing a super-oxidative burst. The problem? Studies have consistently shown no benefit from ozone therapy. You know what has been shown to promote healing? Traditional dental approaches to treating gum disease such as scaling and root planing, antibiotic placement, periodontal surgery, and laser therapies.
OK. Big takeaways… Be careful if a holistic dentist tells you that you need all your amalgam fillings replaced. Use fluoride toothpaste. Avoiding fluoridated water in children may be wise. Root canals are safe. Don’t be that worried about BPA in white fillings. Ozone therapy is ineffective. Go to a regular dentist and get good care so that you aren’t scammed by a “holistic” dentist!