The popular media often portrays people with eating disorders as vain young women obsessed with their appearance. But that’s a dangerous stereotype, as anorexia nervosa and bulimia nervosa affect males and females across every demographic, often as the result of complicated psychological causes. Yet dentists can play a significant role in helping those who suffer from them begin their road to recovery by identifying their symptoms and initiating communication.
“If somebody is looking like they’re losing a lot of weight, you may be able to make ways to have a conversation because you’re going to be seeing them twice a year in theory, and so maybe you can see changes more clearly than somebody who is seeing them every day,” said Martha Levine, MD, director of the Intensive Outpatient and Partial Hospitalization Eating Disorder Programs at the Penn State Health Milton S. Hershey Medical Center.
The Physical Signs
In addition to the differences in weight, patients with eating disorders present very specific physical symptoms in the oral cavity that dentists should be able to note. For example, there may be signs of physical harm to the soft palate such as bruising as these patients with bulimia nervosa use their fingers or other objects to induce vomiting, Levine said. Plus, these patients will have worn enamel, particularly on the backs of their teeth, due to the vomiting.
The continued exposure to acid also may lead to dental caries or an increased susceptibility to cavity development, a chronic sore throat and hoarse voice, painful or bleeding gums, difficulty or pain in swallowing, a dry mouth, decreased saliva production, abnormal jaw alignment, broken or cracked teeth, chewing difficulties, reversal of previous dental work, and damage to the esophagus, according to Eating Disorder Hope, an organization that serves these patients.
“The other thing we see a lot is enlarged salivary glands because they get stimulated with all of this activity. So a lot of our patients have almost a chipmunk look, with very large parotid salivary glands,” said Levine. “Sometimes, and dentists wouldn’t necessarily be noting this, but there’s a sign called the Russell’s sign that shows a lot of callousing, usually on the back of the index finger, from people going over their teeth and getting rubbed and calloused.”
Patients with anorexia nervosa display similar symptoms, as their limited diet leads to nutritional deficiencies. Insufficient calcium and vitamin D may yield tooth decay and gum disease, while insufficient iron can foster the development of sores in the oral cavity, reports the National Eating Disorders Association (NEDA), an advocacy and support group. Also, insufficient vitamin B3 or niacin can produce bad breath and canker sores. Dry mouth and swollen and bleeding gums are possible as well.
Additionally, NEDA reports, the temporomandibular joint may develop degenerative arthritis. Pain in the joint area may follow, along with chronic headaches and problems chewing and opening and closing the mouth. Levine notes that osteoporosis is possible as well due to poor overall bone health, with a decrease in bone mass in the jaw area. And, there are signs beyond the oral cavity that dentists may be able to spot too.
“When individuals struggling with anorexia are very thin, oftentimes they have just an overall unhealthy thinning of their hair,” said Levine. “Sometimes they develop very fine hairs, called lanugo, on their arms because the body is trying to keep itself warm as they start to lose a lot of weight.”
The Demographics and Causes
According to NEDA, 20 million women and 10 million men in the United States suffer from a clinically significant eating disorder at some point in their life, including anorexia nervosa, bulimia nervosa, binge eating disorder, or other specified feeding or eating disorder. Eating Disorder Hope reports that 1.0% to 4.2% of women will experience anorexia nervosa and up to 4% of women will have bulimia nervosa in their lifetime.
“By and large, we see a lot of women,” said Levine. “But there are times that men will not want to admit that there’s an issue because it’s seen very much as a women’s disease. While our sense is that it really is in large part about women, you really need to be aware of it in any gender. Sometimes we are seeing challenges within the LGBT population.”
For example, Levine said, there is an elevated risk in those who are trying to appear attractive to males, including homosexual males and heterosexual women. Transgender individuals may suffer from an eating disorder as they try to control their body and shape it towards the gender that they identify with. And overall, patients with eating disorders tend to develop them during times of transition or times of stress.
“Women, if they are going through puberty, especially early puberty, can see an increase in anorexia for a number of reasons. They may get a lot of bullying, or negative comments from family or friends, because they’re now looking different. Those comments can trigger a lot of the eating disorder thoughts and focus on shape,” Levine said.
These adolescents may begin to be the subject of sexualized comments but they may lack the emotional ability to deal with these expectations, Levine said, particularly if they are young. The eating disorder, then, is driven by a need to be smaller and return to a pre-pubertal shape. Similarly, child abuse and sexual assault may affect these patients’ views of themselves and prompt a need for control, manifesting in the eating disorder.
“The other time we sometimes see an increase is when women go off to college, and it’s a big change with less support. For a lot of individuals, this change is very difficult. There’s suddenly a wide variety of food and food expectations, so you can often see a spike in eating disorders at that time,” Levine said.
Middle-aged patients may experience an eating disorder during a divorce, which will affect how they view themselves, Levine added. Or, patients who are trying to improve their health may go too far and “can’t get off of the dieting treadmill,” Levine said. And while popular culture may have an effect, the home environment may matter more.
“Families should look around to see what messages we are sending. If we have a lot of fashion magazines, or if moms are worried about dieting or their size, that’s going to get passed on to their daughters. But if we can be more concerned about being healthy, without worrying about a certain look all the time, that could be more protective,” Levine said.
Dentists who believe a patient may have an eating disorder should initiate a conversation about their suspicions, but these discussions must be handled very discretely. Patients with eating disorders strive to keep their condition a secret, and bringing it up may lead to defensiveness and denials. The patient also might not return for further treatment, eliminating the possibility for help. And if the discussion is perceived as an accusation, the negative feelings the patient may have may further drive the needs that compel the disorder in the first place.
First, dentists should make sure they have a private area such as their office or an individual operatory where they can close the door before they begin such a conversation, Levine said. Patients will not want to talk about their struggles if they can be overheard by other patients or dental personnel. Next, dentists should realize that it’s not going to be a quick chat.
“Make sure you have time to talk about it. It’s not something that you’re going to want to dash off and say, ‘Hey, I think you might be having some struggles with your eating. Here’s a card of an eating disorder clinic.’ Because they’re not going to follow through with that. So make sure you have that kind of time and a good space to really have a conversation,” said Levine.
Once the conversation begins, it should be open-minded and open-ended, without judgment, blaming, or shaming. The discussion shouldn’t necessarily begin with the eating disorder, either. Dentists should approach it indirectly and see if the patient is willing to bring it up.
“Just say, ‘I’m really worried with what I’m seeing with your teeth. And there can be a lot of different reasons for it. I’m noticing that there’s a lot of damage. Do you have any thoughts about what might be causing it?’ They might not open up at that point. You can continue with, ‘Some of the things that we’ve seen that cause problems like this are chronic vomiting or stomach acid. Are you having any problems like that?’” Levine said.
“Open-ended questions are a great way to get patients to talk with us, rather than going down a checklist, because people will tell us as much as they think we want to hear sometimes. If they think all we want to hear is ‘Yes, I have a problem’ or ‘No, I don’t have a problem,’ then that’s all we’re going to get, and we probably won’t really find out what’s going on. But if we really say ‘I’m interested in helping you. Can you tell me what might be going on?’ they will often provide much more information and really feel somebody is interested in helping them.”
If the patient is willing to discuss the disorder, then dentists should be prepared to provide referrals to specialists who may be able to help. Dentists also should ask if they can discuss the issue with the patient’s primary care provider. But some patients will rebuff the topic and even deny there is a problem in the first place. It may take multiple visits before the patient is willing to open up, if it happens at all.
“Put it in your chart or in your notes that you’ve had this conversation, and try again at the next appointment, especially if things are getting worse in any way,” Levine said. “Again, don’t be judgmental or shame the person. Just say, ‘I know we’ve talked about this before, but you’re still having a lot of these issues here, and I’m really worried about it. Let’s go through it again and really think about if there is something going on.’ That would be the main way I would say to approach it.”
Some of these patients may be adolescents, complicating matters in terms of confidentiality and parental permissions. Regulations vary and must be followed, though Levine notes that in adolescent medicine, she and her colleagues often start their conversations with the adolescents first and later bring in their parents. In some areas, patients as young as 14 or 16 years old may be able to make their own decisions about psychiatric treatment, she said.
“We never want to violate that, but we also want to make sure that we bring in the parents,” Levine said. “A lot of times it could be approached with the adolescent, and then just say, ‘You know, I think this is an important conversation to have. Let’s bring your mom or dad in to talk about what’s going on.’ But you’re going to have a lot more buy-in from the adolescent if you start with them first and then say, ‘This may be a tough conversation to have, so let’s bring your mom and dad in, and we can all do this together and help provide some support.’”
Levine also acknowledges that age and gender gaps may be difficult to overcome in these discussions. Young women, for example, may not be comfortable opening up to older men no matter how compassionate they are in bringing up their concerns. In those situations, younger female members of the staff may be better suited for initiating the communication, bringing others into the conversation as necessary.
“The most important thing is to have a basic understanding and approach the conversation in a calm way and not be judgmental, because a lot of these patients have already faced a lot of judgment from other people, including their families, who say, ‘I don’t understand it. Just eat,’ or ‘Just stop throwing up.’” Levine said. “They get a lot of criticism at times from other places. So if they feel like somebody is really worried about them and is willing to talk and is not going to judge them, they will be much more willing to open up about it.”
For More Information
There are many resources available for dental professionals who want to learn more. For example, Levine’s chapter “Communication Challenges Within Eating Disorders: What People Say and What Individuals Hear” from Eating Disorders—A Paradigm of the Biopsychosocial Model of Illness is available online. Levine also recommends “Communicating Effectively With Patients Suspected of Having Bulimia Nervosa” by Burkhart et al from the August 2005 issue of the Journal of the American Dental Association.
Access to oral healthcare remains a problem across the nation. Many patients today turn to their local hospital’s emergency department (ED) when they have problems as a last resort simply because they can’t afford a dentist—or because there’s no dentist practicing in their area. The ADA reports that most of these patients suffer from dental decay that could have been prevented with regular checkups.
This issue is particularly acute in Nebraska, which saw 9,943 dental-related ED visits from 2011 to 2013, according to the State Emergency Department Database. Also, 39% of these visits were by patients who were self-financed or uninsured. Plus, 20 of Nebraska’s 93 counties don’t have a dentist, and 9 of these counties had more than 50 visits per 10,000 population. The mean and total ED charges for these visits were $934 and $9.3 million, respectively.
Researchers at the University of Nebraska Medical Center and the University of Iowa recently examined these disparities with an eye on identifying risks and improving care. According to their research, patients who are uninsured, aged 25 to 44 years, covered by private insurance, and living in urban areas are at more risk. Sankereeth Rampa, MBA, MPH, of the University of Nebraska Medical Center, recently shared his insights about their work.
Q: Would you say that the number of ED visits for dental problems is increasing, decreasing, or staying level?
A: Based on the 2 studies we have conducted using state-level specific ED data, we found ED visits for dental problems increasing. In California, dental-related ED visits increased over the study period, from 44,516 in 2005 to 70,385 in 2011. In Nebraska, dental-related ED visits increased from 3,243 in 2011 to 3,495 in 2013.
Q: What were the most common oral health problems that drove patients to the ED?
A: The most common oral conditions leading to ED visits are dental caries and pulpal or periapical lesions.
Q: How did the ED doctors treat these problems? And how effective was this treatment?
A: Typically, dental conditions are treated in dental clinics. EDs are ill-equipped to treat dental conditions. Also, it is only occasionally you find actual specialized oral care treatments in hospital settings. Most of the time, they are just given prescription medicine. Hence, it is very unlikely a patient receives an effective treatment for dental problems in the ED.
Q: Could these problems have been prevented? If so, how?
A: Many dental problems can be easily avoided or minimized with timely preventive oral health treatment. If dental conditions are not treated in a timely manner, they could pose severe problems at a later stage and may necessitate visits to hospital-based EDs and even subsequent hospitalizations.
Q: What are the biggest obstacles to these patients getting that preventive treatment?
A: Lack of access to timely dental care due to uninsurance and out-of-pocket dental expenses, for example, is an important barrier to seeking preventive care. Many private health insurance plans do not include dental coverage except at an additional cost, and dental coverage of adults is not included as an essential benefit under the Affordable Care Act. Dental insurance plans are very costly and unaffordable for low and mid-level income families. People without any dental insurance are less likely to seek preventive dental care and may suffer poor oral health as a consequence.
Q: The study noted that 20 counties do not have a dentist. What is causing this shortage?
A: These counties include inner cities and rural areas. Dentally uninsured and low-income families live more in inner cities and rural areas. Dentists are unwilling to lend their services to those who are uninsured and those covered by Medicaid because of the low reimbursement that they receive in return. For this reason, most of the dentists prefer not to practice in inner cities and rural areas.
Q: What impact is this shortage having on the state’s oral health?
A: The shortage of dentists could further contribute to worsening oral health care and perpetuating the disparities in dental care access.
Q: What could be done to recruit more dentists to practice in underserved areas?
A: Increase scholarship and loan repayment programs for dentists. These programs could aid the dentists in paying their education expense in exchange for service in underserved areas for specified number of years.
Q: In the short term, what can today’s dentists do to improve access to dental healthcare?
A: I don’t think dentists can do any more than what they are doing now to improve access to care. Insurance (including Medicaid) reimbursements must be increased.
Q: In the long term, what could be done to improve this access?
A: To improve access to dental care, more emphasis should be on dental-related preventive programs for vulnerable groups. It is also very crucial that significant awareness be created among the general population on dental care and related outcomes. The reason many people ignore dental problems is a lack of knowledge about these issues. Also, there is a need to expand the current dental care workforce and increase the use of dental hygienists or dental therapists for routine preventive dental care.
Lasers will continue to play an expanding role in dental treatment as their global market grows at a 10.71% compound annual growth rate (CAGR) through 2021, according to Research and Markets. This increase will be driven by advances in technology, which have had a particular impact on cosmetic dentistry.
Also, the use of laser technology for hard- and soft-tissue applications has resulted in a high state of refinement with improved care and safety, according to the research company. Most lasers used in dentistry target small-end procedures, and dentists are gaining their benefits in a variety of fields, including oral surgery, periodontics, endodontics, and aesthetics.
The prevalence of orthodontic demands and periodontal diseases also are driving the market. In fact, Research and Markets expects the orthodontic supplies market to see an 8.0% CAGR through 2021 to reach $4.71 billion. Meanwhile, the American Academy of Periodontology reports that 47.2% of adults over the age of 30 years in the United States have periodontitis.
However, the high cost of laser equipment and procedures remains an obstacle to greater growth. Though many end users prefer laser systems for treating a wide range of dental disorders, many healthcare institutions classify them as capital items, and procurement often requires budget procedures and allocation considerations.
Dental implants are becoming more commonplace in prosthodontic treatment. In fact, the American Academy of Implant Dentistry reports that 3 million people in the United States have dental implants, and that number is growing by 500,000 each year. Also, these implants have a 98% success rate. And since these procedures are surgical in nature, infection is a key concern, prompting many dentists to include antibiotics as part of the treatment.
But antimicrobial resistance also is a potential danger. The Centers for Disease Control and Prevention (CDC) notes that at least 23,000 people in the United States die each year due to bacteria that are resistant to antibiotics. A team of Australian researchers, then, set out to see if there is any consensus for antibiotic prescriptions for healthy patients undergoing implant placement, finding that such usage does not improve clinical outcomes.
In their study, “Is There a Consensus on Antibiotic Usage for Dental Implant Placement in Healthy Patients?” published by the Australian Dental Journal, these researchers concluded that implant practitioners should apply principles of antimicrobial stewardship and not use antibiotics as a routine measure in healthy patients. Alex (Joon Soo) Park, BPharm, one of the researchers and a student at the University of Western Australia School of Dentistry, recently shared their insights with Dentistry Today.
Q: Generally speaking, what are the risks of antibiotics overuse?
A: The risk of antibiotic overuse not only results in compromised health, it also could result in financial burden. A review published by Ventola summarized that overzealous usage has reached the antibiotic resistance era.1 As a result of this, healthcare providers are required to use second-line treatment, which may be questionable in terms of efficacy, is more costly, and may come with greater adverse reactions. Furthermore, the longer time period it takes to treat the infection will consequently lead to unnecessary hospital admission, which is cost-economically inefficient. Nevertheless, more than 70% of dentists on a global scale are likely to prescribe routine antibiotics during implant placement on a routine base approach.
Q: What are the key infection risks in implant surgery?
A: Dental practitioners are mostly concerned with the possible infiltration of oral microbiota into the bloodstream via the surgical site, which could potentially result in bacteremia. This requires hospital admission under intensive care.2
Q: Are there alternatives to antibiotics in addressing these risks?
A: The most important measure to limit these risks would be to adhere to meticulous infection control guidelines, as set out by the dental practitioners’ associations in their respective countries. The clinician’s experience may strongly influence the outcome of implant treatment, and utilizing antibiotics seems to be a form of reassurance for many clinicians.3 However, risks could also be avoided by effectively communicating with patients to ensure the optimum maintenance of implants by practicing good oral hygiene.4
Q: How do dentists distinguish between “healthy” and “unhealthy” patients before deciding whether antibiotics are necessary?
A: Dental practitioners play an important role in determining whether patients are medically compromised prior to any treatment.5 In addition to extensive oral examinations, having a comprehensive medical (and social) history is imperative to ensure the success of invasive procedures such as placing implants. Patients that are considered to be “unhealthy” predominantly have health problems of a systemic nature, and they normally disclose that before the consultations. Smoking, diabetic (especially uncontrolled), and immunocompromised patients are considered to be categorically predisposed to developing infection as a result of delayed healing.
Q: What are the best practices for using antibiotics for these “unhealthy” patients?
A: Adhering to proper antimicrobial stewardship is essential to ensure minimization of antibiotic resistance.6 As dental practitioners, it is important to determine whether antibiotics are absolutely necessary. Signs of systemic malaise are a good indicator to utilize antibiotics. Narrow spectrum is preferable, but broad spectrum is an alternative for dental practitioners who are not sure about the microbiological nature. If it is necessary, utilizing the smallest effective dose for the shortest effective duration is the key. Antibiotics should not be used for other microbial infections such as fungal, protozoan, or even viruses. Both the prescriber and the dispenser should be educating patients to take antibiotics for the entire duration that they have been prescribed for regardless of whether infection has subsided or not.
Q: Where can dentists go for more information about proper antibiotic usage?
A: The CDC provides online resources for the quality use of antibiotics. Patients who want information about prescriptions also can find it online. Furthermore, dental practitioners should utilize the evidence-based guidelines set out by their dental association in their respective countries, as guidelines may vary in different countries.
- Ventola CL. The Antibiotic Resistance Crisis: Part 1: Causes and Threats. P&T. 2015;40(4):277-283.
- Piñeiro A, Tomás I, Blanco J, et al. Bacteraemia following dental implants’ placement. Clin Oral Impl Res. 2010;21:913-918.
- Nolan R, Kemmoona M, Polyzois I, et al. The influence of prophylactic antibiotic administration onost-operative morbidity in dental implant surgery. A prospective double blind randomized controlled clinical trial. Clin Oral Implants Res. 2014;25(2):252-259.
- Klinge B , Meyle J. EAO Consensus Report: Peri-implant tissue destruction. The Third EAO Consensus Conference. Clin Oral Impl Res. 2012;23:(suppl.6):108-110.
- Manor Y, Simon R, Haim D, et al. Dental implants in medically complex patients—a retrospective study. Clin Oral Invest. 2017;21:701.
- Using medication: Using antibiotics correctly and avoiding resistance. ncbi.nlm.nih.gov/pubmedhealth/PMH0087079/. Accessed on June 7, 2017.
Nitrous oxide is essential to many dental procedures, though safety is a sometimes overlooked concern. The National Institute for Occupational Safety and Health (NIOSH) recently conducted its online Health and Safety Practices Survey of Healthcare Workers among 284 dental professionals in private practice to assess how well they meet best practices for using nitrous oxide and protecting themselves and their patients.
According to the survey, the use of primary engineering controls such as a nasal scavenging mask and/or local exhaust ventilation was nearly universal, reported by 93% of respondents treating adults and 96% of respondents treating children. However, 41% of those who treated adults and 48% of those who treated children did not check their equipment for leaks, while 13% of those who treated adults and 12% of those who treated children started the gas flow before the mask was applied to the patient. Other key lapses were noted as well.
The NIOSH recommends the use of properly fitted nasal scavenging masks, supplemental local exhaust ventilation when necessary, adequate general ventilation, regular inspection of gear for leaks, standard procedures to minimize exposure, periodic training, ambient air and exposure monitoring, and medical surveillance. James M. Boiano, MS, a member of the survey team, shared his insights and further recommendations with Dentistry Today.
Q: What are the primary dangers to both dental personnel and patients in nitrous oxide administration?
A: Acute exposure to nitrous oxide may cause lightheadedness, eye and upper airway irritation, cough, shortness of breath, and decreases in mental performance and manual dexterity. Chronic exposure to high levels of nitrous oxide among female dental assistants who worked in offices where scavenging equipment was not used was associated with an increased risk of spontaneous abortion and reduced fertility. Occupational exposure to nitrous oxide has also been associated with an increased risk of neurologic, renal, and liver disease.
Anesthesia machines are designed to deliver up to 70% (700,000 ppm) nitrous oxide with oxygen to patients during dental surgery. However, they are restricted from delivering higher concentrations to protect the patient from hypoxia, or deprivation of adequate oxygen supply at the tissue level.
Q: Are there national guidelines and standards for safe usage?
A: Yes. NIOSH and the Occupational Safety and Health Administration (OSHA) have developed guidelines for the safe administration of nitrous oxide. To protect dental healthcare workers from exposure to excessive levels of nitrous oxide, NIOSH recommends an exposure limit of 25 ppm as a time-weighted average during the period of anesthetic administration. OSHA does not currently have an occupational exposure limit for nitrous oxide.
Q: What are some of the most important best practices for safe usage?
A: Best practices for safe administration of nitrous oxide include the use of a patient nasal scavenging mask, regular inspection of the nitrous oxide delivery and scavenging equipment for leaks, and adequate room ventilation. Periodic monitoring of the air in the worker’s breathing zone and in the dental operatory is recommended to ensure nitrous oxide levels are kept below 25 ppm.
Q: How do dental personnel typically get trained in nitrous oxide usage?
A: Dentists, dental hygienists, and dental assistants receive training on nitrous oxide sedation practices in their school’s curriculum and/or by completing continuing dental education (CE) courses. Curriculum content and length of the CE courses as well as permit/certificate requirements vary by state. In some states, dental hygienists and dental assistants are not permitted to administer nitrous oxide to patients.
Q: Is there certification or CE required?
A: Yes. CE is required for dental practitioners who administer nitrous oxide to patients. National accreditation standards for dental education programs have been established by the Commission on Dental Accreditation. Accreditation standards have been developed for education programs in dental anesthesiology, dental hygiene, and dental assisting.
Q: The survey listed several types of breaches. Typically, who is responsible for ensuring such breaches don’t happen?
A: Although the owner of the dental practice is ultimately responsible for ensuring breaches don’t occur, all practitioners in the practice who administer nitrous oxide to patients are responsible for ensuring that proper safeguards are implemented to keep exposures to nitrous oxide as low as practicable.
Q: What should dentists do to ensure they meet best practices for safety?
A: Dentists and other dental practitioners who administer nitrous oxide must comply with state-specific dental board or regulatory agency regulations and training requirements.
Q: Where can dentists go for more information?
A: Dental practitioners who administer nitrous oxide can obtain additional health and safety information on the safe administration of nitrous oxide from NIOSH and OSHA. The ADA also offers recommendations for administration.
Sugary drinks are repeatedly named as one of the biggest culprits when it comes to poor oral health, particularly in young children. Packed full of sugar and sweeteners and containing empty calories, or calories with no nutritional impact, they have been demonized by many associated with the beverage and health industries.
Back in March of 2016, Chancellor George Osborne of the United Kingdom announced in his budget a plan to introduce a levy on drinks containing more than 5 g of sugar per 100 ml. Effectively, the decision created a tax on sugary drinks.
Although the tax doesn’t come into force until April 2018, it already has been generating a lot of interest. Figures are not confirmed, but some experts suggest that the amount of the tax could be as much as 20% of the sale price. But is the tax a good thing?
A Positive Message
For anyone dealing with people’s teeth, encouraging the reduced consumption of sugary drinks has become a key step in improving oral health. In terms of supporting that sentiment, the new tax really adds weight to the idea that consuming these drinks isn’t a good idea. So, it’s a positive move for the government to stand up and hit the manufacturers producing beverages with such high levels of sugar where it will hurt them the most—in their profits.
Obesity and Oral Health
There is no getting away from the link between sugar-filled drinks, oral health problems, and obesity, particularly in children. The tax is largely thought to be a response to a report by Public Health England, which identified that 29% of 11- to 18-year-olds’ daily sugar intake comes from sugary drinks.
Many health and weight loss charities believe that the additional cost that the tax adds to the price of these kinds of drinks could have a direct effect on reducing consumption, as people respond to price. The British Dental Association is fully behind the tax as a way to reduce the impact of sugar on oral health, supporting its introduction via its Make a Meal of It campaign.
Spotlight on Really Sugary Drinks
Part of the battle with drinks that are high in sugar is that consumers often don’t realize just how much sweet content they have. One positive effect of the sugar tax is that drinks will become more expensive, drawing attention to the fact that they have been caught by the tax and perhaps motivating consumers to look at the label.
Estimates put the figure raised from the tax at around £276 million per year (or $339 million), which could be plowed back into the UK via government spending. Of course, this kind of revenue gathering can be quite controversial as it comes from the public. However, most experts predict that the tax would not disproportionately affect one income group over another, so there isn’t one social group that is being particularly squeezed.
Estimates put the figure raised from the tax at around £276 million per year (or $339 million), which could be plowed back into the UK via government spending. Of course, this kind of revenue gathering can be quite controversial as it comes from the public. However, most experts predict that the tax would not disproportionately affect one income group over another, so there isn’t one social group that is being particularly squeezed.
Inevitably, there has been backlash against the suggested tax, and plenty has come from soft drink manufacturers. Coca Cola and the British Soft Drinks Association have already spoken out against the introduction of the tax, denying any link between sugary drinks and obesity and calling the tax “ineffective.” Others have highlighted the impact that a tax like this could have outside of the direct effect on consumers.
The think tank Oxford Economics has produced a report stating that the tax will only reduce sales by around 1.6%. It also highlighted that this could result in job losses of around 4,000 and a drop of £132 million (or $162 million) in the contribution that the beverage industry makes to the British economy. It is, however, worth noting that Oxford Economics’ clients include Coca Cola.
Will a Tax Actually Work?
There’s no doubt that obesity levels and poor oral health do need to be tackled. But whether a tax is the right way to do it remains an unanswered question. Those who claim it isn’t cite the example of Denmark, where a controversial “fat tax” along similar lines was recently repealed. The tax was aimed at foods that contained more than a certain level of saturated fat (2.3%). After just a year, the Danish government decided to repeal the tax on the basis of it having a negative effect on business and consumer buying power.
Margo Wootan, director of nutrition policy at the Center for Science in the Public Interest in Washington, was quoted in The New York Times as saying she wasn’t surprised that the fat tax had problems and had been repealed. Interestingly, though, she was also quoted as saying, “It’s much easier to tax specific foods, say a tax on sugary sodas, than to tax at the nutrient level like a fat tax or a sugar tax.”
The sugar tax is due to come into effect in April 2018 with the taxable percentage announced just prior to that. It will be interesting to see whether the government goes ahead with its plans and, if it does, what kind of an impact it will have on both obesity and oral health.
Dentin does more than form the bulk of our teeth. It also may hold clues to evolution as mankind migrated from our earliest homes, thanks to a new methodology that examines the mineralization defects in dentin developed by an international research team. Plus, this methodology may have applications in improving health today.
“This is exciting because we now have a proven resource that could finally bring definitive answers to fundamental questions about the early movements and conditions of human populations—and new information about the importance of vitamin D for modern populations,” said Megan Brickley, PhD, an anthropologist and Canada Research Chair (Tier 1) in bioarcheology of human disease at McMaster University.
In 2016, the researchers first established that dentin carries a permanent record of vitamin D deficiency, or rickets, by examining teeth ranging from Predynastic Egypt that were thousands of years old to samples taken from the twentieth century. During periods of severe deficiency, new layers of dentin cannot mineralize, leaving microscopic markers that scientists can read like the rings of a tree.
“Interglobular dentin (IGD) is mineralization defects (bubble-like spaces) that form in bands where dentine fails to mineralize properly along incremental lines due to low levels of vitamin D,” said Brickley. “More pronounced spaces indicate a greater level of disruption of mineralization, and the position of the bands of defects relative to incremental lines indicates that age at which the deficiency occurred.”
The researchers prepared thin sections of teeth and used a microscope to observe the presence or absence of IGD and its severity. They also evaluated the number and size of the defects or bubbles within the dentin and used the percentage of a set microscopic view covered by IGD to provide one of 4 grades. For example, Grade 0 indicated an absence of interglobular spaces, while Grade 3 meant more than 75% of the area was covered by interglobular spaces.
“From our work with archaeological skeletons, individuals with clear signs of childhood rickets had at least Grade 2 IGD occurring during periods of rapid skeletal growth,” said Brickley.
These markers can tell the story of human adaptation as early man moved from equatorial Africa into regions with less sunlight. They also may explain changes in skin pigmentation to metabolize more sunlight or how indoor living has silently damaged human health. And, vitamin D deficiencies have an effect on health today.
“There are vitamin D receptors in 36 major organs, and maintenance of adequate vitamin D levels has an important effect on immune function,” said Brickley. “In particular, vitamin D is essential to build and maintain healthy bones. Low levels will lead to an increase in fragility fractures. Although less widely studied, vitamin D deficiency also appears to be linked to poor dental health. Low levels of vitamin D are associated with the development of some cancers.”
Until now, there has been no reliable way to measure vitamin D deficiency over time. As the researchers have shown with examples from ancient and modern teeth, the method is valuable for understanding a health condition that today affects more than 1 billion people, and it may have clinical applications in the future.
“Naturally exfoliated teeth and teeth extracted for clinical reasons could be analyzed for interglobular dentin,” said Brickley. “Our team has been working with donated teeth and medical information to start to link serum 25-hydroxyvitamin D levels to changes observed.”
The study, “Ancient Vitamin D Deficiency: Long-Term Trends,” was published by Current Anthropology.
The Center for Craniofacial Research at the University of Texas Health Science Center at Houston School of Dentistry needs people who are missing teeth that never formed for a research study. Associate professor Ariadne Letra, DDS, PhD, is studying the genetics of tooth agenesis, where one or more permanent teeth fail to develop.
A common craniofacial disorder, tooth agenesis affects about 10% of the general population. It can be mild, with up to 5 permanent teeth missing, or severe, with 6 or more teeth missing. If third molars are included, prevalence may be as high as 25%. Lower premolars and upper lateral incisors are the most frequently affected teeth.
“Individuals with tooth agenesis face both aesthetic and functional consequences, which increase in severity depending on the number of missing teeth,” said Letra. “In addition to affecting a person’s smile, tooth agenesis affects masticatory function, occlusion, and even maxilla and/or mandible development.”
There are financial consequences for affected individuals as well, and dental rehabilitation costs are high. While a few genes have been identified as defective in some cases, the cause of the condition is still unclear. There is no current treatment for avoiding tooth agenesis either. Palliative treatment involves replacing the missing teeth with a bridge or implants.
The study is looking to recruit 900 individuals or families missing one or more permanent teeth since birth. The large number is needed to achieve enough power to identify genetic variations that can contribute to the condition. Volunteers are required to come to one appointment lasting about 30 minutes.
“First, I explain the objectives and terms of our study,” Letra said. “Upon patient written consent, we collect some basic medical and dental information, perform a clinical and radiographic examination, and collect a saliva and/or blood sample as a source or DNA. Our study is completely voluntary and free of cost.”
Once the subjects have been examined, the researchers will conduct sophisticated genetic analyses of the DNA from subjects who have tooth agenesis and compare them to individuals or family members who do not have it.
“Along with numerous genes already identified, our research hopes to identify additional causative genes that can be targeted for use in future treatment and prevention strategies,” Letra said.
Dental professionals from around the world soon will be arriving at the Palais des Congrés de Montréal for the 47th Journées Dentaires Internationales du Québec, scheduled for Friday, May 26 to Tuesday, May 30. Presented by the Ordre des Dentistes du Québec, the 3-day conference will provide seminars and hands-on courses led by top dental experts.
Howard S. Glazer, DDS, will be there to present “I Have It… You Need It!” During his lecture for dentists and their staffs alike, Glazer will discuss materials, technologies, and techniques that make dentistry easier, more productive, and more fun, on Friday, May 26 from 8:30 am to 3:30 pm. The course will be worth 6 continuing education credits.
“These are products that I use almost on a daily basis in my practice. Nothing comes into my lecture unless I actually use and like the product, and if you came to my office, chances are you’ll find it,” Glazer said. “So it’s real dentistry by a real dentist using the products of today. I evaluate materials based on if they are faster, easier, and better for me, the doctor, and better for the ultimate end user, who is the patient.”
Before procedures can begin, dentists need to know what they’re looking at. Glazer will delve into digital radiography during his lecture, comparing and contrasting phosphor plates and sensors and explaining why he prefers the Intraoral Phosphor Plates from Air Techniques, which he calls much more tolerable for patients to hold in their mouth than hard, rigid sensors. The company’s CamX Spectra Caries Detection Aid is another valuable tool he will discuss.
“I can actually get a reading of the depth of decay before I even pick up a drill or an anesthetic syringe. If I have something that’s not very deep, why would I bother giving somebody an injection? It’s really ideal in being able to fully diagnose the patient’s problem,” said Glazer.
Sometimes, the restoration is necessary. Glazer will discuss composite resin materials for both anterior and posterior use such as Shofu’s Beautifil II, which lets dentists blend in the gingival tone and color while performing restorations on patients who have more root exposed and a higher gumline. He also will explore the new realm of bioactive materials from GC America and Pulpdent, which go beyond repair to restore the tooth.
“We can begin to heal the tooth and replace the missing ions that are lost during the decay process,” said Glazer. “They help the formation of secondary dentin so that you’re helping to protect the pulp to ensure the health of the tooth. And we have great materials too if you get very near the pulp or to a pulp exposure of some sort. There’s a whole wealth of materials out there that could be helpful.
Quality restorations need more than the right materials, though, and Glazer will look at today’s leading tools. Ring systems from companies like Garrison Dental and Ultradent Products help dentists place composites without the composite sticking to the instrument. He is particularly partial to Ivoclar Vivadent’s OptraSculpt Pad. Plus, Glazer will examine how soft-tissue diode lasers can assist in restorative dentistry.
“You can only restore what you can see,” Glazer said. “Very often we have decay that’s subgingival. How do you plan to restore that and maintain a dry field when doing restorative dentistry? You need to use a laser to expose that tissue and decay and ablate some of that tissue.”
Curing lights have seen some big changes lately, with some powerful models on the market now. Glazer recommends Ultradent’s VALO Grand and DentLight’s FUSION 5. Handpieces are seeing equally innovative developments, such as Bien Air’s iChiropro, which can be controlled via an iPad application. And on the other end of the technological spectrum, Glazer notes, burs remain essential to dental work too.
“With moving decay, you’ve got to be able to just take the decay and leave healthy tooth structure. The best bur to help you do that, once you’ve gained access to the carious lesion, is the SmartBur II from SS White Burs. It’s basically used in a slow-speed handpiece at 5,000 or 10,000 rpm, with no water, and it will not cut hard tissue. It will only remove soft dentin, so you can’t really expose anything with it,” Glazer said. “In fact, you could run it on your hand, on your skin, and it wouldn’t cut it because it’s not soft dentin.”
Of course, Glazer encourages dentists to bring their staff members so they have a better understanding of the new gear that the practice may be purchasing after his presentation. He also promises a very useful and timely look at today’s dental products market, exploring a variety of additional products beyond those mentioned here.
“The things I talk about nowadays didn’t exist 5 years ago. A lot of them. And most of them will be replaced in 5 years,” Glazer said. “Dentistry is changing rapidly, and for the better.”
Recreational marijuana is legal in 8 states and the District of Columbia, while 28 more states permit medical marijuana only. Yet even in states where it isn’t legal, the stigma attached to marijuana use is fading, and advocates are pushing for legalization. Overall, 22.2 million people have used marijuana in the past month, according to the National Institute of Drug Abuse.
That means dentists may be seeing more people who use marijuana in their chairs. When they do, dentists also can expect to see some of the drug’s effects on the oral cavity. Like any other kind of smoking, reports Harold Crossley, DDS, MS, PhD, marijuana increases the potential for periodontal disease. But that’s just the beginning when it comes to marijuana’s most ardent enthusiasts, according to the clinician.
“Many marijuana smokers become dependent on marijuana, and so marijuana basically leads their life. So because of that, they’re not really taking care of themselves the way they should. They’re not brushing, they’re not flossing, they’re not taking care of their teeth,” said Crossley, who has written and lectured extensively on dentistry and pharmacology. “Maybe they don’t have the money to go to the dentist on a regular basis.”
Of course, not all marijuana smokers are so careless about their oral health, but it does happen, Crossley said. And aside from a possible stain on their teeth, there might not be any signs that these patients are marijuana smokers. In fact, Crossley notes significant differences between patients who may be under the influence of various drugs when they enter your office.
“We separate drugs into uppers and downers. Uppers pose the greatest risk because we use local anesthetics with a vasoconstrictor, which can raise blood pressure. If patients come in and they’ve used cocaine, methamphetamines, or ecstasy in the last 24 hours and you use a local anesthetic with a vasoconstrictor, you run a risk of having a stroke in the chair,” said Crossley.
“But somebody comes in that’s been snorting heroin, or smoking marijuana, or had a couple shots of whiskey, they’re not going to pose a threat. They’re going to be very compliant. They’re going to be very good patients,” said Crossley. “Say ‘Move your head over here,’ and there’s no argument.”
Still, marijuana may make IV and oral sedation more powerful, and Crossley says that’s a concern. Crossley also concedes that patients who are high during an appointment may be forgetful, so dentists may have to provide written instructions for anything that needs to be done once the patient has left the office.
Dentists additionally should be aware of the many different forms that today’s marijuana takes. Vaporizers pull the active ingredients including tetrahydrocannabinol (THC) from marijuana, so users can inhale the vapor without inhaling the smoke. Also, dabbing extracts THC-rich resins from marijuana for high dosages in products such as shatter, a hard, amber-colored solid.
“It looks like caramel. It’s translucent and very thin, and it’s called shatter because when you pop it, it shatters. That stuff is about 80% pure of marijuana,” said Crossley. “You take a little piece of that and you put it on a nail, and it’s heated. It will vaporize, and you inhale the vapors and get a high off of it.”
Overall, today’s marijuana is much stronger than the strains of decades ago, with THC levels rising from about 4% in 1995 to about 12% in 2014, reported a 2016 study from the University of Mississippi. Yet attitudes toward its use may continue to fluctuate, too. The University of Michigan’s 2016 Monitoring the Future project says that marijuana use remains high and has held steady for twelfth graders, but has been declining among tenth and eighth graders.
“There have been studies that show that in fact some of the younger generation is turned off by the marijuana. But right now we’re finding mostly marijuana being used between 25 and 43 years of age,” said Crossley. “Really, it’s based upon the generation.”