Bite Point

138 Years of Caries Knowledge

"The researches of the late Professor W.D.Miller, published about 1880, finally gave to the world the true explanation of the process of tooth decay."

"Briefly stated, Miller, as the result of a long and exhaustive experimental study of the subject, found that the destruction of the hard structures of the tooth by dental caries was accomplished by the agency of a certain class of microorganisms which had the characteristic function of fermenting certain of the sugars and converting these sugars into lactic acid, which acid in its turn attacked the solid tooth structure wherever it came into contact with it, dissolving out its mineral matter which caused the structure to disintegrate, forming a cavity which gradually enlarged until it eventually included the entire crown; indeed, if unchecked, the whole tooth may in this manner become disintegrated and lost."

--Edward Cameron Kirk, DDS, UPenn Dean from 1895-1917, writing (with rather less periods than we would use today) in Alfred Fones' remarkable text Mouth Hygiene. This is my original 1916 edition.

Dr. Kirk goes on to say,

"Dental caries is a characteristic disease with a well-marked and definite group of symptoms and within certain limits it has a known causation, which is the localized destruction of the hard tissues of the tooth by the solvent action of lactic acid generated at the point of decay by the agency of bacteria acting upon carbohydrate foodstuff."

*

And so. Although Dr. Kirk and others had a little further to go in terms of understanding the dynamics of the frequency of refined sugars consumption, we had the answer to the total prevention of dental caries ***138*** years ago, with Dr. Miller's astonishing insightful research.

Why did, and does, caries remain such a widespread public health problem?

For one, the sugar lobby in the U.S. is extraordinarily powerful. Labeling foods and drinks for their cariogenicity potential will likely NEVER happen in the U.S. Which is a shame, because it really needn't decrease sales of high cariogenic foodstuffs. I positively love chocolate, more than I can put into words. I only eat it around meals, though, and usually only once a day. I dig raisins, sugary little beasties that stick in tooth grooves for hours, on cereal in the morning. But that's the only time I eat them, and I brush afterwards. Frequency matters with sugars, even natural ones. We can still safely enjoy cariogenic foods and drinks--just not via grazing.

The other reason that dental caries is still so widespread is that the industrialists who run things discovered long ago that foods high in sugar, fat and salt sell very well in the U.S. Across our nation, healthy foods are expensive and unhealthy foods are cheap--as well as designed to be maximally addictive via the enticements (powerful ones, that speak directly to our species' lean evolutionary past) of sugar, fat and salt. This makes me angry. You can't tell me that it costs more to ship a head of lettuce from California to Philadelphia than it does to make a pack of Twinkies, with all the processing and ink and packaging that a pack of Twinkies entails. And yet routinely, the vegetables cost more than the high-carb snack foods.

It's maddening.

Most maddening of all, though, is the inherent and rather unfair paradox that has been built into our foods, beverages and oral health care patterns in recent decades.

What I have noticed--and perhaps you have too--is that well-educated patients with a sound economic life often have few caries. (Most of the new patients we see between ages 21-40 have good educations, great jobs and no caries. Minimal existing restorations as well.) In contrast, less educated patients with less economic means, in my experience and perhaps in yours, tend to have more caries. Industrialists are more than happy to market and sell unhealthy foods to the most susceptible segments of our society. Hence the inherent unfairness--

Today, those who can least afford to treat dental caries generally have the most dental caries.

This is a markedly different situation than the one that existed from at least the 1920s to the 1980s, in which captains of industry, wealthy businesspeople and Hollywood celebrities often had mutilated dentitions. Nowadays, I doubt there's even one CEO of a Fortune 500 company who has posterior bite collapse due to the effects of severe dental caries. Or from periodontal disease, for that matter.

In my view, this epidemiological challenge--not the latest, greatest, costly means of restoring multiple implants, nor the finer nuances of "digital workflow"-- is the key challenge in American dentistry today.

And so a pair of vital questions arise.

How do we practice prevention in the face of what the industrialists of the food and beverage businesses are doing?

And how do we reach those many potential patients, those often at-risk patients who believe--mistakenly--that they cannot afford us, and therefore do not seek care?

Please Be Aware: Werther's Original Contain Sugar!

We have now seen our third patient in the past few months who has wrecked their dentition with one overwhelming specific cause--overuse of Werther's Original Hard Candies. Thus, I wish to post a warning about this product.

And that warning is: Werther's Original Hard Candies contain sugar! Lots of it. This would seem self-evident, but each patient was totally surprised by the fact, and their surprise may spring from Werther's marketing. "The Classic Candy made with Real Butter and Fresh Cream" is a fine tagline, but we never see the word "sugar," the main ingredient, in there at all.

While it's easy to find Werther's ingredients online, there's a sort of burying of this information in all their marketing messages. And of course nowhere is there any warning like, "This product contains straight sugar; overuse of sugar-containing food products leads to tooth decay."

But that's the truth. Of any food, liquid or solid, that contains refined carbohydrates.

Here are the ingredients in a Werther's Original Hard Candy:

Ingredients: Sugar, Glucose Syrup (from Wheat or Corn), Cream, Condensed Whey, Butter, Cane Sugar Syrup, Salt, Soy Lecithin Emulsifier, Artificial Flavor.

Translation: Sugar, sugar, milky sugar, more milky sugar, butter, sugar, salt, chemicals, chemicals and sugar.

I mean, damn. It's like the beloved old Monty Python Spam skit, only with sugar.

https://www.youtube.com/watch?v=anwy2MPT5RE

Please, please, folks, if you enjoy Werther's, or Life Savers, or hard candies of any kind, watch the frequency! Have them once a day. Each and every time you put a miniature hockey puck made of sugar into your mouth, you're bathing your teeth in sugars and acids for the entire time the thing takes to dissolve, plus about half an hour afterwards. Thus, the nightmare scenario for your teeth is to pop another one in every hour or so. Or right before you fall asleep. Your teeth never get a chance to recover from the acids. They WILL rot out of your head. It's only a matter of time.

This may sound like an odd warning to many, but each of these patients said the exact same thing once we identified that hard candies were the cause of the destruction in their mouths:

"Oh! I carry a bag of them around with me everywhere."

Words to send a shiver down every dentist's spine.

In the photos, the red arrows point to the serious cavities (darker areas on the images) that were caused, so far as I can tell, by interviewing each patient in detail about their diet, mainly by the overuse of one product--in these cases, Werther's Original Hard Candies.

Please, folks. Use any and all hard sugar candies sparingly and infrequently. Certainly never more than twice a day outside of mealtimes. And when it comes to cough drops--only use them while you actually suffer from a cough, not after it has passed.

The Great Dupe: Bottled Water

For April 1st, rather than the usual satire-posing-as-reality I felt like some straight-up poking fun, in this case at The Bottled Water Crowd. Oh, bottled water has its place I suppose. Mostly when thirst strikes in a theme park, or when one is out and about and wishes to avoid the empty calories of sugar-laden sodas. But I still routinely see people buying cases of the stuff at the supermarket, and I always wonder two things:

-Do they realize how much this costs? and,

-How do they really know what taps the bottled water came from, and how do they know those taps are better, somehow, than their own?

Join me then as we examine what the industrialist is thinking when it comes to bottled water. The industrialist who has duped all these millions of people.

This is an excerpt from The Virtue Polarization, a short story I'm writing. It's set in the fictional universe of The Man Who Wore Mismatched Socks, my novel which will shortly be on Amazon in both print and eBook formats.

Here's the page for the evolving short story, and the rest of the site concerns the novel:
https://sites.google.com/site/tmwwmms/home/the-virtue-polarization

And here you go with the water excerpt.

*****

 

    He was already considering the notion of expanding into non-alcoholic beverages such as soda water. Perhaps, in the fullness of time, the public could even be coerced into buying water itself, in little disposable bottles, rather than drinking it out of their tap. Hudeler had always been maddened by the notion that water, one of the most basic necessities of life, was almost free to the average man. Yes, of course it was plentiful, but it was also extraordinarily valuable. Just ask the fellow dying of thirst in the Sahara. Or those crews of becalmed ships during the age of sail—water rations running out, throats in unspeakable pain, yet surrounded by more water than the human mind could ever comprehend—all of it salt and undrinkable. And water had, further, to be clean! The chap suffering from cholera or dysentery was the very one to ask about the value of water’s cleanliness.

    Giving thoughtful consideration to the total absence of a thing was, in Hudeler’s view, the best way to learn its true worth.

    Yes, all one needed was just the right set of marketing messages, delivered over long periods of time and with savage consistency, and, so Hudeler was convinced, one could induce the rabble to fear the very taps in their own homes, and to buy an endless stream of bottles and cans of expensive water instead. It was his secret and grandest dream, as the volume of such water sales would make Slore’s output of beer seem as a mere eyedropper in comparison.

 

The Bottle Project

On a recent trip to California- my first, and on which I met the redoutable writer Tom Bentley in person- I was astonished when my wife said, "Hey Rick, look at this bottle!"

It wasn't plastic!

It was made from plant material, not petroleum.  This will change the whole game.  Plastics in our garbage stream are especially problematic since they never really go away, they just degrade into smaller and smaller pieces.

For more, have a look at my previous post:
http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2011/05/plastic-versus-plant-based-beverage-bottles.html

After admiring this simple consumer product for a few weeks- come on, you would too- I decided to start The Bottle Project.  I've placed two bottles into my garden, a conventional plastic one and this new plant-based bottle.  I'm going to take a picture once a week until one biodegrades completely.  Exposed to whatever elements Pennsylvania throws at them, we shall see in a most Visceral way what happens to each material, and at what rate.  Half of each bottle is in the dirt, exposed to soil microorganisms.  Half is exposed to sunlight.

Don't worry, I won't post each and every picture here.  But from time to time I will update you all on this important change in our consumer culture.

May the best bottle win!

 

*Updated photo, from 7/22/2012:

Not much degrading yet, ya know? But let's give it time. I've taken 1 pic a week since I started, so the record is thorough.

Our Caries Clock- Avoiding Cavities

Some time ago, we posted our magnificent Caries Clock for anyone to use in order to educate themselves and their families about how to avoid getting cavities:

http://www.smilephiladelphian.com/clock/Caries.php

Tooth decay is certainly one of the most common diseases in humans.  Worldwide, most children and an estimated ninety percent of adults have experienced tooth decay, or dental caries.  This is upwards of 6 billion people.

Some of the effects of dental caries are:

-Soft spots in teeth, loss of softened tooth structure as it breaks off or is removed during repair.

-Pain. 

-Infection if the decay progresses into the center of the tooth, the living dental pulp.

-Endondontic (root canal) treatment can eliminate this pain and infection if the tooth is still intact enough to be restorable.

-Esthetic challenges, as many cavities are visible when a person smiles; also gaps show when teeth are lost due to cavities.

-Loss of time from productive work as teeth and possibly infections related to decayes teeth are treated.

-Emotional trauma expecially in children from the treatment of what is by definition a complex and sensitive medical problem.

-Cost.  Tremendous cost can be incurred in treating extensive decay and it's all preventable.

We need three things for a cavity to occur in a tooth.  We need the person, who has to have teeth, we need simple sugars, and we need a particular germ.  Unlike gum disease with its many possible causitive germs, with cavities there are only two main bad guys.  There is primarily Streptococcus mutans, and there is Lactobacillus acidophilus who is kind of like Best Supporting Actor here.  I know, I know, they should name them something a lot simpler, like Elmo and Big Bird or Hall and Oates.  But they don't...  Something involving Latin taxonomies and large quantities of micro-brewed beers at scientific conferences.

What happens is actually pretty simple.  Any time we ingest simple sugars in either liquid or solid form- any time, any sugar- Herr Mutans, in particular, steals some of it from us.  The millions of germs in our mouths (Gack!) grab on to this food like starved football players after practice.  The problem is that Strep mutans happens to kick out insane levels of acid waste products when it metabolizes sugars.  The next problem is that the more we feed sugar to these little beasties, the more of them there are- giving them just what they want increases their population in the plaque in our mouths.  The acid eats into the teeth, both in the grooves on top and on the smooth sides.  Cavities result.  Then, the more cavities there are, the more Strep mutans there is in all those holes... It's a snowball rolling down hill at that point.

Our defenses:

-Keep the plaque in our mouths down to a minimum.  Brushing thoroughly, flossing, using Soft Pics if you don't like floss- all keep the numbers down on Strep mutans and for that matter everyone else in there too.  Fringe benefit- better breath.

-Fluorides strengthen the enamel against this form of acid attack.  Topical fluoride in toothpaste is appropriate for adults whose teeth have already grown.  Not all water supplies have fluoride, so for kids with their teeth still forming a careful check is needed to ensure that they are getting the optimal levels.

-Eating with some regard to frequency of carbohydrate intake is important, and is what our Caries Clock is all about.  We can snack, we can have our chocolate- we just shouldn't have it too darned often.

Here's a neat graph of the acid curve over time:

Sucrose is a common simple sugar, it's table sugar actually, and pH is a measure of acidity.  (Just in case you've protected your psyche by blanking out all memories of high school chemistry class.)  As you can see from the graph, your teeth need time to rest after an "acid attack".

And watch out for what really contains carbohydrates.  People always seem to be aware of the risk from sodas but not from sports drinks.  If it's liquid and tastes really sweet and there's any other ingredient besides sucralose or aspartame in there, it can cause cavities:

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2009/12/how-sweet-it-is.html

So can otherwise healthy foods like raisins and dates and most fruit.  These are excellent things to be eating- just don't graze.  And try to clean your mouth after you're finished.

The worst thing you can do for your teeth- and your pancreas, for that matter- is to "graze" on refined sugars all day long.  Eat, then give your mouth time to rest.

Mr. mutans will be very angry about this, but that's his problem.

Gatorade- Open. Gulp. Repeat.

Ah, Gatorade.  There you go again...

Those of us who are of a certain age can well remember "There you go again":

http://www.youtube.com/watch?v=t3GnWTy8Ebg

In this instance, the Gatorade folks have devised a remarkable slogan: "Open. Gulp. Repeat".  Oh my.  Where do I even start on this one?

(Notice where I noticed it- pumping that other culturally charged liquid, gasoline...)

-By "open", I suppose they mean both the bottle and the mouth.  So far, so good.

-"Gulp".  Which means "Gulp 14 grams, 7 teaspoons of refined sugar, 125 calories."

-Repeat.  This is the dodgy part for us dentists, as repeating small intakes of refined carbohydrates over a period of time is by far the biggest risk factor for getting cavities:

http://www.smilephiladelphian.com/Clock/Caries.html

Bottom line: the Repeat part leads to tooth decay, and the Gulp part increases the chances that you'll end up with Type II Diabetes.  No kidding.  Human beings don't do well when we shock our insulin system too hard and too often.  We simply weren't designed for it.

Yes, Gatorade replaces lost electrolytes.  Yet just so you know, it takes about 2 hours of hard exercise, I mean pedal to the metal, to lose enough electrolytes in sweat to warrant replacement in a healthy young athlete.  And at that point the sugars will be useful too, especially if the event isn't over yet.  I'm thinking swim meet with multiple heats, cycling a century, running the Iditarod.  That kind of thing.  In these cases, go for it.

When you're exercising for under an hour though, or playing a sport like softball where the action is intermittent, please consider water.  Your pancreas and your teeth will thank you.

*More on "Vitamin G":

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2010/02/2010-super-bowl-gatorade-shower.html

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2009/12/gatorade-selling-the-sizzle-not-the-slake.html

What does "sweet" really mean, sugah?

Our "Caries Clock" is ready!  It's a graphic representation of how our daily eating and drinking habits can lead to cavities if we take in sugary foods and liquids too frequently.

It's here:

http://www.smilephiladelphian.com/Clock/Caries.html

 
"Caries" is the technical word for "cavities"; it just seemed to us that "Caries Clock" sounded snazzier than "Cavity Clock".

I would really like to review what types of foods are worse than others in terms of leading to tooth decay.  This is difficult though.  Supposedly there was work being done on a "Cariogenic Index" or cavity-causing rating system for common foods.  I cannot find any such thing at the moment.  I thought that some European countries had made that a part of their food labeling back in the 90's.  I'll keep looking and asking.

Essentially, if something (liquid or solid) tastes sweet, and if it has refined sugars as part of its substance, then it has a high potential for causing cavities.  So we're talking a range of foods all the way from candy to Twinkies to soda and sports drinks to tea with honey in it to ketchup to granola cereals to fruits of all kinds to raisins- it's a big range.  Many of the final foods that I listed are very healthy for us.  Yet as a separate issue they can cause cavities if eaten too often throughout the day on a regular basis. 

 

Fruit juices provide an excellent example with which we can learn some of the principles involved in thinking about sugars and our health.  Let's take a minute and examine them.  Fruit juices contain a number of simple sugars, especially fructose.  Fructose is a sugar found all over the place in nature.  (The most common sugars are fructose, sucrose (table sugar) and glucose.  There are many though.  These are different than high fructose corn syrup, which is controversial because the corn industry is powerful and has been responsible for putting it into everything.  And corn syrup has a lot of calories per gram.)

 

http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/C/Carbohydrates.html

 

So fruit juices contain many valuable nutrients and vitamins.  The negative aspects are that they do have calories, they do have these simple sugars that can cause cavities if taken with too much frequency, and if ingested quickly with no exercise following they might add to Type II Diabetes risk because they shock our insulin system.  So- my interpretation of the science is as follows:

 

-Fruit juices provide essential vitamins and nutrients;

-To avoid cavities they should not be sipped at over long periods of time;

-To avoid increasing diabetes risk they should not be ingested quickly too often without being followed by at least moderate exercise, and;

-To avoid weight gain their calories should be considered as balanced against exercise and overall calorie intake for the day.

 

Finally, the less high fructose corn syrup added, the better.

 

Keep these principles in mind for all foods that contain simple sugars and you will minimize your risk of diabetes, weight gain and tooth decay, and yet can still enjoy the wonderful range of fruits, vegetables, sauces and desserts which we have access to these days.

 

I mean, I love chocolate...