Who Should Premedicate with Antibiotics Before A Dental Appointment?
One of the most confusing topics for dentist’s over the last 10 or so years has been the practice of premedication with antibiotics prior to dental visits. For a while there it seemed like the guidelines changed every year or two. The basic idea behind premedication with antibiotics is that when certain dental procedures are performed, bacteria in your mouth are released into your bloodstream (also known as a transient bacteremia). For people with certain medical conditions, these bacteria can latch on to various parts of your body such as heart valves, joint replacements, etc and cause infections.
In the last couple of years several studies have been completed that show a very minimal risk of these types of infections with a couple of exceptions.
Joint Replacements
For a while there, the recommendation was that patients with joint replacements of any kind should premedicate their entire life. Then the recommendation was changed to only two years afterwards, and now it has been changed to not being recommended in most cases at all. The only people who should be pre-medicated are those who are severely medically compromised and at the highest risk of developing an infection. This determination should be made by the orthopedic surgeon who did the surgery.
If you’ve had a joint replacement, discuss this issue with your dentist and orthopedic surgeon. Odds are you likely don’t need to continue premedicating for your dental appointments.
Heart Problems
Just like with joint replacements, there used to be a huge list of heart conditions in which premedication was recommended. That list has shrunk down significantly under current recommendations. These include patients with the following…
- Previous history of infective endocarditis
- A prosthetic heart valve or a heart valve repaired with prosthetic material
- Unrepaired cyanotic congenital heart disease
- A completely repaired heart defect with a prosthetic device (for the first 6 months afterwards)
- A repaired heart defect with a defect near the prosthetic part
That’s it. All other heart issues and you don’t need to premedicate. Again, if you are concerned please discuss with your dentist and cardiologist.
Should I Get My Amalgam Fillings Replaced?
For almost as long as dental amalgam fillings have been used, there has been some controversy about their health consequences. On one side you have people who state that they are unequivocally safe while on the other side you have people who say that they lead to a whole host of health problems that will resolve if the amalgams are removed. They claim it can cause Alzheimer’s Disease, multiple Sclerosis, fibromyalgia, autism, kidney problems, behavioral problems, and various other health issues. So which side should you believe? As with anything, follow the evidence.
What are Dental Amalgams Made Of?
First, what are amalgams made of? They are a combination of mercury (approximately 50% of the total), silver, tin, copper, and a couple of other trace metals. The type of mercury used in dental amalgams is known as elemental liquid mercury. It is poorly absorbed by the body except in vapor form. The main concern with amalgams is the mercury content. Exposure to certain kinds of mercury is known to cause brain, liver, and lung problems with high exposures enough to cause death. Childhood exposure to certain types and amounts of mercury can cause neurological deficits for a lifetime.
Exposure to Mercury From Dental Amalgams and Other Sources
We do know there is some minimal exposure to mercury vapor from dental amalgams. When amalgams are placed and when they are removed you are exposed to the highest levels. We also know that when you chew, a minute amount of mercury vapor can be released. Interestingly enough, you receive far less mercury exposure over the lifetime of the fillings if you leave them in place vs having them removed. The levels that are released are very minimal as compared to what is considered a safe amount of daily exposure (approximately 1% of the maximum allowable exposure per day). You actually get far more mercury exposure from environmental sources such as eating fish than you’ll ever get from your dental amalgams.
The Evidence
A lot of studies have been done over the years to find out whether this small exposure to mercury can cause any health problems long term. The most well known groups to study this issue have been the New England Journal of Medicine and the Cochrane Collaboration. The New England Journal of Medicine completed a long term study and found that the number of surfaces of amalgams in a person’s mouth did not correlate with any other health problems. The Cochrane Collaboration does reviews of various topics that have been studied in the scientific literature. They took on the dental amalgam controversy and after going through all the literature did not find any evidence to support the claim of health problems associated with dental amalgam.
A lot of different medical groups have also studied this issue and almost unequivocally they have stated that dental amalgam is a safe an effective filling material with no known associated health problems. Some of these groups include The American Dental Association, The Food and Drug Administration of the US Government, The Mayo Clinic, The American Academy of Pediatrics, The Autism Society of America, The US Environmental Protection Agency, The New England Journal of Medicine, and Consumer Reports. Most European countries have also stated that dental amalgams are safe and effective.
You might hear some people say that dental amalgam has been banned in some European countries. While this is somewhat true, it isn’t for the reason you would think. Dental amalgam is known to contaminate water sources when it is removed and it is for these environmental reasons that it has been highly limited. Most dental offices today install a device known as an amalgam separator that removes the amalgam before it can go into the water system.
The Conclusion
I don’t recommend having dental amalgams removed until they actually need to be replaced for legitimate dental reasons. I am perfectly OK with having them in my own mouth or in the mouth’s of my family.
Despite all this evidence, there still continue to be quite a few dentists and people who claim the contrary. They think dental amalgam is a huge cover-up or conspiracy. The important thing to remember is that if we found out tomorrow that all dental amalgams needed to be removed for health reasons, it would be a huge financial boon for dentists. It is not in a dentist’s best financial interest to recommend you leave amalgams in place. The American Dental Association has gone so far as to say that a dentist who recommends they be removed for health reasons is acting unethically. If your dentist recommends you have all your amalgams removed for health reasons, think long and hard about whether it is something that should actually be done.
How Often to Go to the Dentist
Most dentists recommend that you automatically schedule an appointment to see them every 6 months. They do this for a couple of main reasons. Your dental insurance usually covers a visit at this frequency and the majority of people today should be seen every 6 months. What they generally don’t tell you is that some people would do better with a more customized schedule for cleanings and x-rays! Read below to see what I recommend and then bring it up with your dentist.
Previous or Active Periodontal Disease
You should be seen anywhere from every 3-6 months depending on how healthy your mouth currently is. Your dentist is really the only who can make this determination. If you aren’t seen this often you run the very real risk of losing additional bone around your teeth and eventually losing teeth to this. Generally you’ll also need a full mouth set of x-rays at your visit, bitewings every year, and a new full mouth series every 3-5 years.
High Risk (Any of the below)
- Recent cavities in the last year or two
- You drink soft drinks, sweet tea, or any other sweetened beverage on a consistent basis.
- You snack on simple carbohydrates or candy throughout the day.
- You brush sporadically or don’t floss
- You smoke or use chewing tobacco
- You have diabetes
- You are pregnant
Most people today fall into this category. You should see your dentist every 6 months and have x-rays every year. You are at high risk for additional cavities and periodontal disease and these can progress rapidly if not detected early.
Medium Risk
- No cavities in the last 3-5 years.
- You brush morning and night and floss occasionally but not consistently.
You should be seen for cleanings every 6 months and x-rays once every 12-24 months.
Low Risk
- Good diet – Rarely drink sugary drinks and don’t snack throughout the day
- Minimal history of cavities
- Consistent brushing and flossing every single day.
If you’re one of these rare people (I’d estimate only about 1% of people fall into this category) you will likely be fine with seeing your dentist for a cleaning once a year and x-rays once every 2 years. If they mention you have a lot of build-up on your teeth, you should consider seeing them more often.
Burning Mouth and Tongue
Burning mouth syndrome literally causes a burning sensation or scalded feeling in your mouth, usually on the tongue, but can also be anywhere else. Oftentimes this is accompanied with a metallic taste or sometimes a loss of taste. This sensation varies from a constant problem to one that comes and goes. Burning mouth syndrome (BMS) has a lot of different causes and it can be very difficult to figure out exactly what the source of it is.
Primary burning mouth syndrome is caused by a dysfunction in the nerves that supply sensation and taste to your mouth and tongue. There is no test for this and is usually diagnosed when all other causes have been ruled out.
Secondary burning mouth syndrome is related to a specific cause… of which there are a lot!
- Dry Mouth – Consistent use of a mouthrinse specifically formulated for dry mouth can help in these cases.
- Thrush – See our section on thrush for more information on it’s causes and how to treat and prevent it.
- Allergies to certain products – Products can include certain toothpastes, dyes, food colorings, and food additives. The only way to figure out what is causing it is to remove one thing from your routine at a time.
- Nutritional deficiencies – The most common deficiencies are the B vitamins (B1, B2, B6, B9, and B12) as well as iron and zinc. Taking a supplement, especially one with a B vitamin complex will often help resolve this type of burning mouth condition
- Acid reflux – Acid that comes up from the stomach can irritate the tissues in your mouth leading to the burning sensation.
- Lichen planus – This is a type of autoimmune disease in which your body attacks certain cells. The most common thing you’ll see in the mouth is a spiderweb like pattern of white lines.
- Geographic tongue – Geographic tongue is something you are usually born with and occasionally it can cause some burning.
- Some medications such as high blood pressure medications
- Acidic drinks – As with acid reflux, the acid in these drinks can irritate the tissues in your mouth.
- Heavily abrasive toothpastes
- Ill fitting dentures
- Stress or anxiety
How to Treat Thrush
This is not a topic most people like to talk about and understandably so. That’s probably why you’re here and not asking someone else what to do! Before we get to how to effectively treat thrush, let’s take a look at exactly what thrush is.
What is Thrush?
Thrush is an overgrowth of a yeast / fungus known as candida albicans in your mouth. Most cases of thrush involve your tongue but can also involve other areas of your mouth. It is very similar to vaginal yeast infections. It usually causes a burning or itching sensation, a bad taste in your mouth, and white patches on your tongue and throughout your mouth. If you have some of the previous symptoms and are able to wipe the white areas off your tongue with a piece of gauze or a paper towel then it is likely thrush.
What Causes Thrush?
Yeast thrives in dark, moist environments such as your mouth. Most of the time your body has no problem keeping the yeast cells in check in your mouth, however, certain situations can cause the yeast to grow rapidly leading to the condition known as thrush.
- Taking antibiotics. This kills the good bacteria in your mouth and allows the yeast to take over.
- Weakened immune system (such as in HIV). Your body can no longer effectively fight the yeast cells.
- Taking corticosteroids. These usually weaken your immune system.
- Taking medications that suppress your immune system such as medications for rheumatoid arthritis or after an organ transplant.
- Wearing dentures.
- Inhaled steroids (usually for asthma sufferers).
How To Treat and Prevent Thrush?
Thrush is usually treated with medications but there are also a lot of other things you can do to keep it in check.
- Standard medical treatment is usually with a Nystatin rinse or clotrimazole lozenges (prescription only). If these don’t work your doctor or dentist will usually prescribe Fluconazole which is an anti-fungal medication that you take as pill.
- Oftentimes a chlorhexidine mouthrinse can be helpful. This is by prescription only.
- If it is related to antibiotics, it will usually resolve on its own after you have stopped the antibiotics.
- If you wear a denture, it is important that you take it out at night and clean it. Never wear it 24 hours a day. A dirty denture can be the source of a thrush infection.
- Don’t use alcohol based mouthrinses.
- Brush / Scrub your tongue well when brushing your teeth.
- If you’ve had thrush in the past, throw out your toothbrush and get a new one. Your toothbrush can also be a source of infection.
- If you take inhaled steroids, rinse out your mouth with water after each use.
- Limit sugars and simple carbohydrates in your diet. Yeast cells feed primarily on this.
- There is some limited evidence that probiotics can be helpful. You can get these in pill form or by eating yogurt or other lactofermented foods.
- If you don’t have access to a doctor or dentist, you can use over the counter products with clotrimazole in them. Make sure it is only clotrimazole and no other ingredients. I’d recommend making a liquid suspension with them and swishing for several minutes a couple of times a day before spitting out. These formulations aren’t usually made for oral use so only do this if you have no other options and the previous suggestions haven’t worked.
Tongue Ring Dangers
I’ve seen a lot of patients over the years who have had tongue rings. Without fail, they all had one thing in common… chipped and broken teeth. Let that sink in for a moment. Chipped and broken teeth on pretty much all of them. The second thing they all had in common… They wish they hadn’t gotten a tongue ring!
Chipped and broken teeth happen because the tongue whips the tongue ring around with the force of a wrecking ball. Your tongue moves every single time you swallow, speak, or chew food. Every single one of these movements, all day long, has the potential to cause significant damage to your teeth. Your teeth can only take so much trauma before they break. The teeth that are most often damaged are the bottom front teeth. These teeth are some of the most difficult for a dentist to fix because they are the smallest teeth in the mouth. Bonding on these teeth struggles to stay in place and crowns are also very challenging to do without breaking the teeth or hurting the nerve of the tooth.
If you’ve got a tongue ring, I’d highly recommend removing it and never putting it back in. Lip rings, multiple-earrings, nose rings… totally OK from a dental perspective. Tongue rings, not so much.
If you’re considering getting a tongue ring, please just don’t do it! They just aren’t worth the potential damage to your teeth.
How to Get Kids to Brush Their Teeth
Getting your kids to brush their teeth can be a very challenging process! Here are some tips on making it easier on you.
Ages 0-2
From the time they get their first teeth in until they turn three, you will have to do all the brushing. They just don’t have the coordination at these ages to be able to brush effectively at all. Some kids will be very cooperative for you to brush their teeth while other kids won’t be cooperative at all. Two out of three of my kids were really easy. The other was really challenging. I found that turning it into a game or distracting them while brushing was the best way to get it done. The toothbrush as an airplane or a tickler were really popular in my house.
Ages 3-7
Around age 3 they get quite a bit better at brushing their teeth and will continue to improve over the next four or so years. During this age range you’ll almost always need to go back behind them and brush again. They are usually trying to assert their independence around this time and will give you a lot of push-back but you definitely still need to help them out. At this age you also want to start using a small amount of fluoride toothpaste and start teaching them to spit it out. There are a couple of easy things you can do to make brushing easier at these ages.
- Sing a song or play a song that is right around two minutes long.
- Make it into a game.
- Comment after they brush about how “shiny” their teeth are and that they are blinding you. Kids are usually very proud of their shiny teeth!
- Use a fun electric toothbrush with their favorite character on it. An electric toothbrush will help them brush better too.
- Make it part of their bedtime routine. Kids at this age really value routine and will be more cooperative if it is a daily, expected thing that is done.
Ages 7+
At around age 7 you can usually let them brush on their own entirely if you feel like they are up for it.
- Make sure you continue to check their brushing from time to time.
- Find a new age appropriate song for them to brush to. Brushing for the right amount of time is really critical.
- Buy some disclosing tablets and have them use them before brushing. These will stain any plaque on their teeth red and give them a visual goal to shoot for when brushing.
- Continue to have them use an electric toothbrush.
Why Teeth Break
In my dental practice I probably see at least one or two people every single day who come in with a broken tooth. Many times they’ll tell me that they were chewing on something soft and then all of sudden it just broke. They’re often confused about how it even happened. We’ll take a look at the most common reasons teeth break and what you can do to prevent it. Just before we get to that here’s a quick primer on how a tooth is set up.
This is a rough diagram of a tooth. It shows the outermost layer of enamel, an inner layer of dentin, and the innermost layer is the pulp space
The enamel layer of the tooth is the hardest but also the most brittle if it doesn’t have something to support it. It’s main purpose is to provide an extremely durable surface for chewing and protection of the rest of the tooth.
The dentin layer is softer than the enamel but still very hard. It similar to how hard a bone is. It’s main purpose is to support the enamel.
The pulp contains the cells, blood vessels, and nerves needed to keep your tooth healthy.
Now that we understand all that, let’s take a look at why exactly teeth break.
Reasons Why Teeth Break
Teeth, especially the ones in the back of your mouth, take a tremendous amount of force. An average man can exert nearly 150 pounds of pressure on his back molars and nearly 70-80 pounds on his front teeth. Teeth are much like the foundation of a house. Even with great care, over time they will develop cracks and wear from the the constant everyday pressure they are under. It is actually pretty incredible that teeth are able to hold up so well over the course of your lifetime considering how much punishment they take.
- Cavities
- Cavities are the most common cause of broken teeth. Cavities start at the surface of your teeth and then spread out through the dentin. When enough of the dentin has been destroyed, the enamel no longer has any support under it and will easily fracture if pressure is applied to it.
- Imagine two pieces of glass. The first one is resting on a flat piece of plywood. The second is resting on just two small pieces of wood on each end. If you apply pressure downwards, which one do you think will break? Obviously the second one right? It has no support underneath and is easily broken. The first piece of glass on the other hand has good support underneath all of it and will be almost impossible to break. Your teeth are the exact same way.
- Weak after a previous filling
- Even if you have your cavities taken care of, fillings can leave your teeth weaker than before. Over time the process of chewing creates small cracks in these teeth. Once these cracks have made it all the way through your tooth, you end up with a tooth that cracks.
- Having fillings are still always better than leaving cavities. Fillings help to rebuild that support for the tooth.
- Wear from grinding
- Grinding speeds up the wear on a tooth tremendously. Most people’s teeth only touch for a fraction of a second when they swallow or chew. People who grind generally spend an entire night with their teeth grinding together. If you couple this with a weak tooth from a cavity or filling and you’ve got all the right ingredients for a broken tooth.
Prevention
- The most important thing you can do to prevent your teeth from breaking is to not get cavities. Teeth that have never had dental work very rarely break, unless you are a very serious grinder.
- If you are a grinder, you should seriously consider wearing a nightguard. You can either have a nightguard made at your dentist’s office, have one made for you by a dental lab, or you can use our guide to make your own custom nightguard at home. A nightguard will take take all the force created by your grinding and distribute it more evenly as well as wearing itself instead of the teeth.
- Don’t regularly chew on ice or other extremely hard things like nuts. Your teeth just can’t stand up to that kind of consistent force.
- See your dentist regularly to check for cavities. It usually takes a pretty large cavity before a tooth will break.
- If you have a large filling or cavity on your tooth (or both) and your dentist recommends a crown, you should probably get it done. A crown slides over top of the tooth and helps hold everything together. This prevents your teeth from breaking.
The Effects of Acid Reflux On Teeth
Acid reflux (also known as GERD or heartburn) occurs when acid from your stomach moves upward through your esophagus. This causes a burning pain in your chest that can spread all the way up into your throat. Some of this acid can make its way all the way up in your mouth where over time it can cause damage to your teeth.
In the early stages, the enamel on the back side of your top teeth will start to lose it’s glossy appearance and take on a more chalky look. This is a result of the breakdown of the top layer of enamel. Over time the surface of the tooth will continue to wear away. If you grind, this process will oftentimes progress much more quickly. Let’s take a look at some of the ways you can help control this process…
Diet and Lifestyle Changes:
- Avoid eating meals three hours before bedtime.
- Don’t lay down after eating.
- Eat small meals more frequently throughout the day. Large meals stimulate more acid production.
- Avoid alcohol
- Lose weight
- Stop smoking
- Avoid certain foods which are greasy, spicy, fatty, or acidic as well as caffeine, chocolate, citrus, and tomato based foods.
Medications:
- Antacids – Tums and other similar medications contain calcium carbonate which helps neutralize the excess acid in your stomach. You shouldn’t use these daily for more than three weeks as they can cause the build-up of certain minerals in your body.
- H-2 Blockers – These include Tagamet, Pepcid, Zantac, and Axid. They work by temporarily stopping acid production in the stomach and must be taken at least one hour before meals. They don’t reduce acid that is already in your stomach.
- Proton pump inhibitors – These include Prilosec, Nexium, Prevacid, Aciphex, and Protonix. These are the most effective heartburn medications but must be taken consistently in order to work. They work by blocking an enzyme that produces acid in your stomach.
Remineralizing Your Teeth
- The acid works to demineralize your teeth. Your goal is to add those minerals back, usually in the form of fluoride.
- Brush twice a day for two minutes with a non-abrasive fluoride toothpaste.
- Ask your dentist for a prescription strength fluoride toothpaste such as Prevident.
- Use a fluoride containing mouthwash either 30 minutes before or 30 minutes after brushing and flossing.
- Ask for a fluoride treatment at each 6 month dental visit. This can come in several forms including a varnish, a gel, or foam.
Avoid Damage to Your Teeth
- Any episodes of reflux will make your mouth an acidic environment. Avoid brushing immediately after these episodes as the enamel is temporarily weaker and toothbrushing can speed up the loss of surface enamel.
- If you grind, wear a nightguard. Grinding can also accelerate the tooth wear.
- Have the dentist fix any chips or worn areas if possible.
Dental Sealants
Updated 04/16/2018
What are dental sealants? 
Many of your back teeth come in with deep grooves. Bacteria can get down in these grooves and cause cavities. Sealants work by sealing over these grooves and making the biting surface of the tooth more of a smooth surface. This is much easier to clean and doesn’t allow bacteria and food to get stuck in the grooves.
Do dental sealants prevent cavities?
Study after study has shown that dental sealants help reduce occlusal (biting surface) decay in children by nearly 80%. They don’t replace the need for fluoride or good brushing and flossing. You can still get decay in a different spot on a tooth or around the sealant if you aren’t taking care of your teeth.
What are sealants made out of?
Sealants are made out of a very similar material to what is used for white dental fillings. It is basically a plastic type material.
When should sealants be done?
The teeth that benefit most from sealants are the permanent molar teeth. Your first set of four molar teeth come in around age 6 and you have a second set that come in around age 12. Ideally sealants should be done as soon as the tooth comes in. Some offices will also do sealants on the premolar teeth (the two teeth in front of your molars). These teeth usually come in around age 10-12. Sealants on these teeth aren’t nearly as beneficial as on molars because they don’t have as extensive grooves.
How long do sealants last?
A well done sealant will often last 5 years and occasionally up to 10 years. Poor oral hygiene and diet can contribute to the sealant being lost early.
How are sealants placed?
A dentist, hygienist, or dental assistant can all place sealants. No numbing or drilling is necessary. The tooth is cleaned with a special type of toothpaste and then rinsed off. Then an acid gel is placed on the tooth to “etch” the enamel allowing the sealant material to bond the tooth. The gel is then rinsed off and the sealant material flowed into the grooves of the teeth. A special dental curing is then used to harden the material in place. Most sealants only take a couple of minutes as long as the tooth can be kept dry during the procedure.
Are there any concerns about sealants?
There are two major concerns. The first is that the sealant material, being made out of plastic, does contain small amounts of BPA. BPA is known to have some estrogen type effects on the body and there has been some concern in the medical community recently about it’s effects. Fortunately, studies have shown that the exposure to BPA in sealants is extremely minimal as compared to your other daily exposures to it (approximately .001% of the total). The second concern is that if the sealants aren’t done well and don’t seal the tooth it can trap plaque and bacteria under the sealant material. This can create a cavity that won’t be able to be seen until it is large.
This infographic from the American Dental Association shows exactly how much BPA you get from sealants vs other sources. You literally get 100 times more BPA just from breathing the air than from a sealant. 250x more from cosmetics such as make-up or sunscreen. 1500x from touching a receipt. And finally 65,000x more from food and drink. I don’t have any problems recommending sealants to patients even if they are concerned about BPA.
