Teeth Care

(There are highly-abbreviated notes loosely based on "Kiss Your Dentist Goodbye". Read the book or google for clarifying details.)

• Tooth decay could be called an epidemic 
• widespread, not really treated
• almost all adults, even those flossing regularly, eventually get dental disease
• 1/5 Americans rate dental health as fair to poor
• 1/4 of young people have gum disease
• tooth decay 5x more common than asthma in childhood
• All sorts of diseases have been linked to it: cancer, acid reflux, heart problems, high blood pressure, stroke, insulin instability, infertility, premature birth, pancreatic cancer, bowel problems.
• Health care systems mostly suck, incentivize expensive treatments instead of prevention - good for research (and researchers), bad for the people involved

Identifying a good dentist

Despite name of the book (implying that you never need see your dentist again), she's a dentist and still recommends you see one occasionally.

A good dentist:

• prevents problems, avoids drilling; if treatment is necessary, chooses minimally invasive procedure
• avoids the common error of filling a perfectly sound tooth
• Identifies fillings when damaged by acidity (tooth around it erodes, comes loose) - can offer array of options, avoids using toxic chemicals such as mercury
• ideally: screens to help you prevent cavities, does not handle treatments or fillings directly (thus no conflict of interest)
• compare "drill, fill, cover" vs. leaving it in place and covering w/ porcelain pastes
• is skeptical of industry claims, communicative, source of info, experienced, knowledgeable, caring, effective, etc.
• believes in prevention, remineralization
• "mouth fitness trainer"
• interviews patients regularly to discover cause of dental damage
• has special equipment
• ultrasound depth testing, Inspektor dental light, digital imaging fiber-optic trans-illumination (DIFOTI), DIAGNOdent laser (kavo usa), inspektorpro, x-rays, ...
• see cavities, weakened areas
• measure tooth strength/thickness
• see at regular intervals
• provides advance warning/praise
• uses blunt instrument to check for rough spots, not explorer - see article "Should a Dental Explorer be Used to Probe Suspected Carious Lesions?"
• explorer - pushing sharp point into weakened area makes it harder for tooth to repair itself
• sticky spots not reliable diagnosis for cavity - only 24/100 w/ cavity in one study
• hunts for new dental ideas or methods to stop dental problems
• at least: dental school, journals, and education programs
• attends lectures on preventative care
• interacts with other dental professionals
• reads (some of) Dentistry Journal, J of ADA/Calif DA, J of D Education/Research, General/Pediatric Dentistry, Caries Research, Archives of Oral Biology, FEMS Microbio Reviews,  J of Clinical Microbio, Infectious Immunology, J of Clinical Pediatric Dentistry, oral health and preventative dentistry, Micro-organisms of human mouth, J of Clinical Periodontology, A J Epidemiology, J of Endodontics, Annals of Pharmacotherapy, 
• Cleanings make bacteria attach more easily, but also remove a significant amount of them. Unclear if they're beneficial, if you have a good home care routine. (if you don't take care of your teeth then of course they help...) 

old method of fillings - cut grooves into tooth to retain filling
new method - etch, fill pores w/ plastic resin ("sealant")
sealants useful for small cavities, pits, grooves - worry about bacteria though

Minitutorial on teeth and how they decay

Structure of tooth is similar to egg - shell corresponds to enamel - immerse in vinegar, shell turns to rubber (but does not vanish; just breaks really easily)
soft teeth look dark or yellowish, just need time/care to harden/lighten - don't use bleaching agents
note that fluorescent lights make teeth look yellow regardless

tooth parts (outside to inside):

• Plaque - mesh/biofilm of protein strands, many bacteria types, and other substances, fluids, and cells; can have a protective or harmful effect on teeth
• enamel - continuously changing mesh of watery film and mineral crystals (calcium hydroxyapatite - key elements calcium and phosphate)
• in presence of fluoride, crystals form faster, structure is calcium fluorapatite - larger, stronger, smoother, more symmetric, and shinier crystals
• acid dissolves both types, some is normal but too much is bad
• porous teeth are sensitive, fragile, and temperature-sensitive
• demineralization/remineralization - shrinkage/growth of crystals -acid demineralizes, saliva remineralizes
• usually clear, like glass
• dentin - softer than enamel, very porous, creamy white, tubes
• pulp - soft living tissue w/ blood supply - odontoblasts
• gum - seals roots off from rest of mouth, protects roots

Caries

• bad bacteria transferred by contact w/ infected saliva on food, utensils, hands, etc.
• There are ~700 species of bacteria, mostly competing for resources in the mouth. Their functions are still an active research area, but it's clear that some are worse than others in terms of cavities, and you want to get rid of those, e.g. Streptococcus mutans and some lactobacilli. Yeast is another possibility.
• bacteria attach to a hard, non-shedding tooth surface
• eating - bacteria process some of the sugar and produce acid
• acid eats away at the nearby portions of tooth, weakening it and eventually causing cavities
• bacteria cause gum disease too, attach near gum/tooth line instead of on tooth

Signs that you have a problem (from bad to worse):

• gingivities - mild inflammation of gum, 1/7 adults
• enamel on outside surface of back molar teeth chips away (where teeth bend and flex)
• back teeth are sensitive
• bleedings gums
• periodontis - severe inflammation of gums
• periodontal pockets form
• fillings fail and need replacement
• gums need extra cleaning
• gum recession, exposed roots showing cementoenamel junction
• root-canals and crowns
• extractions, implants, bridges, dentures

Ways to prevent:

(all of these happen naturally, but you can help the process by being conscious of it and using various products)

1. Control which bacteria you have - don't share saliva, remove infected clumps of bad species, eat clean food
2. Prevent bacteria from attaching to teeth - brushing, flossing (questionable), chew gum, protective sealants, fillings
3. Kill the bacteria - xylitol, antiseptic rinses, less mouth sugar/food, immune system
4. Protect teeth - fluoride, pH, minerals, saliva flow (gum, ...), protective rinses

 Methods

Fluoride

• strengthens teeth. benefits mostly when in direct contact w/ outside of tooth, for as long as possible
• good for teeth in moderation (toothpaste!)
• extreme amounts can cause fluorosis in anyone
• fluoride before age 3 can poison ameloblasts (teeth cells) and cause even more problems
• breast milk has low fluoride, infant formula might have high fluoride - bad
• types:
• sodium fluoride - well studied, pretty safe, more expensive than other types
• stannous fluoride - reduces gum inflammation, but brown/black staining of teeth
• silicon fluorides - not well studied (commonly found in fluoridated water)
• fluoride sources - foods, sodas, beer, infant formula, powdered iced tea, ...
• Fluoride rinse - last thing before bed, first thing in morning; spit at least twice to remove extra stuff
• recommendation: dilute ACT 0.05% fluoride, with no alcohol
• very little is needed, just enough to coat the tooth surfaces (a few drops)
• rinsing more often w/ fluoride gives better results
• Topical high-concentration rinse doesn't do much for healthy teeth.
• Fluoride gels/foams only effective when applied for >4 minutes on disease-laden teeth
• fluoride varnish - recent option for low-dose fluoride, numerous studies touting effectiveness
• Fluoridated water... but:
• tends to use less-studied (cheap) fluorides, which might have adverse health effects (e.g. heavy metal poisoning)
• can't control - it's better to filter your tap water and buy your own (sodium) fluoride

Behavioral Saliva /  PH Control

• Probably the most effective, after fluoride.
• Measure saliva pH (litmus, special probe), also amount (saliva buffer kit)
• To take mouth acidity reading: 
1.  Spit saliva into spoon
2.  Test w/ pH detector
•  do when you wake up (base pH, should be neutral or alkaline, close to 7, <6 is worrying), then 10-minute intervals over course of day to see how drinks/foods change the pH - typically return to normal takes ~30min, quicker is better
• Know pH of liquids you commonly drink (e.g. the water)
• Saliva contains minerals for rebuilding teeth (remineralization), lubricates teeth so they don't grind while eating; normal saliva contains all the needed minerals, specifically rinsing w/ minerals is generally unnecessary
• dry mouth is related to dry esophagus, leaving it open to bacteria or fungi which could give symptoms of acid reflux
• healthy saliva is neutral or alkaline; should return acidity to safe levels ~30 minutes after eating
• saliva flow increases at mealtimes and reduces during sleep, varies according to person and situation
• stress thickens saliva and make your mouth dryer - go to sauna/beach, practice meditation/relaxation, frequent exercise

Good foods:

• potatoes, asparagus, broccoli
• fresh veggies/fruits, veggie juices
• herbs
• vitamins/minerals, and waters with them
• whole grains
• bananas, almonds, fresh apples, pineapple
• milk, cheese, other dairy products
• tea, coffee
• chocolate, licorice, pure cranberry juice - intense sweeteners
• alkaline soups/broths/water

Non-food stuff:

• propolis (bee product)
• chewing gum
• plant fibers/leaves - even chewing sugarcane is good

Bad stuff:

• acidic food
• acidic drinks (worst to OK)
• frozen fruit juice
• lemon juice, lemonade
• citric, apple, and grape juices - even diluted they still cause problems
• soda, sports drinks, coffee, beer
• sugar/carbohydrates (if bacteria present)
• Halloween candy - best to eat it all at once (unless you're diabetic)
• corrosive, abrasive, or whitening oral care products 
• includes Listerine, don't leave it in your mouth
• bleaching - horrible - damages enamel - sensitive teeth, inflamed gums, gum recession, etc.
• sugarless products (diet soda, sugarless cookies)
• sorbitol causes gastric problems and feeds the bacteria too
• gastric acid
• grinding teeth stresses them and causes problems

Ellie's 3-Rinse Care Procedure

(2x / day, once before sleeping and once ~12 hours later)

1. Prerinse with pH-balanced/stabilized unflavored chlorine dioxide rinse (Closys/Retardex)
• salt water probably would work too
• baking soda,peroxide - sensitize gum, don't work
2. Brush teeth, in particular gum-tooth edge, all the way around the mouth
• Use toothbrush - head <1 inch in length, easily-grasped handle, soft/giving bristles w/ round ends, should be able to reach upper outside and lower inside easily
• Toothpaste - old-fashioned, boring, low-chemical, low-tech, no abrasives, few additives, no whitening, "gentle", sodium fluoride, ADA seal
• dicalcium phosphate dehydrate- abrasive 
• recommend Crest Regular Cavity Protection
• Brush bleeding gums, heals in a few days if bacteria are removed
• use warm water/prerinse + soft cloth instead of toothbrush if sensitive
3. Disinfect toothbrush (1x/day)
• Swish bristles in 0.5oz undiluted antiseptic/antibacterial rinse (Listerine) for 30 seconds
• Rinse off w/ tap water
• Alternatively: use UV box
4. Store toothbrush w/ head upright, in cup, allowing bristles to dry completely before using again
• ensure head doesn't touch other brushes to avoid contamination
5. Use antiseptic rinse (listerine), swishing around everywhere in the mouth
• should have ADA seal, good taste, no whitening/abrasives - can dilute if needed
• Spit out, don't rinse
6. After antiseptic, immediately use protective anticavity rinse, esp. before sleeping
• 0.05% sodium fluoride ACT
• goal is to rebuild teeth
• don't wash off afterwards, keep on as long as possible
• swishing toothpaste around your mouth w/ a small amount of water can be used instead of a rinse, but does require spitting it out again

The toothbrush breaks up plaque films and rinsing afterwards mechanically removes most bacteria. Flossing breaks up plaque as well, but it's not particularly effective (it's mostly good for removing food particles). However, the toothbrush is inadequate for periodontal pockets, only goes ~4mm deep. A Waterpik works but breaks far too easily; the antiseptic mouthwash works pretty well for gum pockets. Also see Periogen, not mentioned by Ellie but seems effective at periodontal restoration / prevention (it has a cult internet following, although it's overpriced). Similarly sodium hexametaphosphate inhibits calculus and loosens extrinsic stains, and in general there are lots of interesting rinse additives to explore.

Xylitol

wood sugar, available in specialty stores
Sciency mumbo-jumbo:

• antibacterial effects
• less buildup of plaque for some reason
• 5g had strong effects, even with a 3 month break
• 6.5g a day - after 5 wks, reduced; afer 6 months, bacteria gone. for 2 years, plaque reduced significantly - no buildup at all.
• past 10g/day, no generic effects, but some suggest for calcium absorption
• xylose + other 8 sugars precursors to some important proteins
• also reduces ear infections
• stimulates saliva flow like other foods 
• 15g naturally produced by body (though not in saliva)
• 100g/day eaten w/out obvious ill effects

Ellie's website (Zellie's) sells xylitol wipes, gum, mints, rinses, etc., obvious conflict of interest. She recommends 6-10g/day in 3-5 doses. Buying in bulk from her website, the cost per day ranges from 75 cents (gum) to 48 cents (mints) to 13 cents (granular xylitol). For comparison, the general recommendation is to use 1g of toothpaste and brush twice a day, so your typical $3 232g tube of Crest Regular Cavity Protection toothpaste is only 2.5 cents a day, and 20ml of $5/L Listerine mouthwash once a day is 10 cents a day.