These basic types of toothpaste are available:

• non-fluoridated
• fluoridated
• highly fluoridated
• sensitive formula
• tartar control formula
• whitening
• with or without sodium lauryl sulftate soap

All toothpastes have pretty much the same ingredients, but try to make themselves stand out in various ways.  The most common ingredients are:

Abrasives: Abrasives are what do the cleaning in toothpaste.  They take off yellowish plaque and scrub off stains.  The most common abrasives are calcium phosphate, silica, calcium carbonate and alumina.  Toothpaste abrasives should be strong enough to remove plaque and stain, but should not be so abrasive that they damage the tooth enamel.

Coloring Agents: Coloring agents make toothpastes more attractive and more palatable.  White toothpaste has titanium dioxide and other artificial dyes make other toothpaste colors.

Detergents: Detergents cause toothpaste to foam. Foam helps keep toothpaste inside our mouths instead of running out as we brush. Sodium lauryl sulfate (SLS) is the detergent used most commonly. Unfortunately, detergents are believed to contribute to formation of  canker sores (ulcers) in some people. Detergents are bad-tasting so strong flavorings are used to hide the bad taste.

Flavoring Agents: Flavors are added to toothpaste so you enjoy using them. Most toothpastes have strong flavors to cover up the bad tasting detergents.

Fluoride: Fluoride is the active ingredient in toothpaste.

Fluoride incorporates itself into tooth enamel making your teeth more resistant to acids produced by plaque bacteria, as well as acids found in fruit juices, soda (both regular and diet) and certain foods.  Fluoride in toothpaste can be in the form of sodium monofluorophosphate, stannous fluoride, or sodium fluoride. Prescription toothpastes (for people that need more cavity fighting help such as those with dry mouth or after cancer radiation treatment, etc.) have a much higher concentration of sodium fluoride than regular over-the-counter toothpastes.

Humectants: Humectants are moisturizers and also provide smooth texture to toothpaste. Glycerin is a common humectant and sorbitol acts as both a sweetener as well as a humectant. Xylitol acts as both a humectant and as a sweetener but it is less common although it seems to be a great cavity-fighter.

Preservatives: Preservatives stop toothpaste from growing germs so you can keep the tube on your sink counter instead of in the refrigerator.  Common preservatives are methylparaben, ethylparaben. and sodium benzoate.

Sweeteners: Sweeteners also improve the taste of toothpaste. Most toothpaste sweeteners are artificial and contribute very little to cavity formation. Saccharin is a common toothpaste sweetener.

Thickeners: Thickeners, of course, determine how ‘thick’ the texture of toothpaste is. Cellulose gum, carrageenan, and xanthan gum are often used for thickening.

So what do I recommend?

• Since most toothpastes have similar ingredients, I recommend prescription 5000 parts per million Fluoride toothpaste for most people over the age of six with the caution that the reason it is prescription is that you must keep it out of reach of children (who may eat it all and get very sick).
• For kids under age two, I recommend non-fluoride toothpaste or regular toothpaste and use very little, a dry grain of rice size.
• Kids between two and six can use regular toothpaste.
• People who frequently get canker sore ulcers in their mouths should try one of the toothpaste brands without SLS such as Rembrandt.
• I recommend avoiding tartar control toothpastes because they are more acidic and can actually soften teeth as well as soften tartar.
• Sensitive teeth can be helped with one of the several sensitive toothpastes, such as Sensodyne, or come to the dentist for application of fluoride varnish on the sensitive areas.
• All toothpastes whiten teeth by removing yellowish plaque and surface stains.  Tooth whitening is best accomplished with bleaching gels rather than with toothpastes.

Just remember that cleaning teeth well has more to do with brushing technique and the use of floss than the brand of toothpaste!

Post from: Great Grins

The Best Toothpaste

In addition to regular sucrose sugar, she also used Stevia - a very sweet plant with leaves 300 times sweeter than regular sugar!  Now that got my attention.

Well, I was taken aback because I have  never heard this before and I do not know that it is valid at all.  How did she learn about this and how could I find out more?  Looking online is tricky because many of the things said about fluoride (something I have experience with) are wrong online.  Carefully looking for articles that have been reviewed by scientists seems the best approach.  Wikipedia seems like a pretty reliable source most of the time.

Several good scientific studies have looked at sugar replacements and one of the best is xylitol.  Xylitol is a “sugar alcohol”, like sorbitol, that has nothing to do with getting drunk, just explains the chemical structure of the molecule.  Xylitol, unlike sorbitol, was initially derived from birch bark and it has some very diverse and potent health benefits.

One of the best things that xylitol can do for your teeth is to stop the bacteria that eat it from growing well and this prevents tooth decay and cavities.  Xylitol gum is effective in stopping cavities in people who chew gum sweetened with xylitol, but only if they eat at least one gram each day.  Xylitol has specifically been shown to reduce the transmission of cavity-causing bacteria from mothers to their babies.

One gram a day is about two packs of gum; and xylitol gum is not cheap.  Fortunately, it is cheaper than fillings!

There are other health benefits from xylitol sweeteners such as reduced blood sugar so diabetics can use it, reduced infections, and reduced osteoporosis in women. 

I try to have an open mind about medical issues and I love the idea of using naturally occuring plants that are low calorie and provide that sweetness that we all crave while offering other health benefits too!  I have used xylitol gum for years  and I will have to try the Stevia too.

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Dietary Supplements for Dental Health

These parents love their babies and want them to have all the good things in life.  Juice is sweet and delicious and healthy too.  Right?

Fruit juice is definitely sweet and babies love it but it is not very healthy for them.  Some babies will get diarrhea from apple or grape juice and many will get cavities from drinking juice in their bottle at night.

Fruit juice has some small amount of vitamin C but it is better to get the vitamins from a slice of fruit than from the juice only.  This is because the fruit has lots of fiber with the juice that fills them up and takes the sugar to the stomach without damaging the teeth.

Juice recommendations for my Portland parents:

• Definitely no juice before 6 months.
• Children should only drink milk or water before age 3.
• Juice should only be in a cup, not a bottle or sippy cup.
• Limit juice to avoid overweight kids.
• Fruit juice in a bottle causes cavities.
• Diarrhea is caused by excessive fruit juice.
• Calcium-fortified juice should not be mixed with fluoride drops.

I joke that babies have to wait until 21 to drink beer but only wait until 3 to drink juice.  This helps drive home the message that it is ok to wait for maturity for many things in life.

Although this article is specifically about fruit juice for babies, it also applies to all other sweet drinks such as Kool Aid, sport drinks like Gatorade, and especially soda.  These sweet drinks all cause cavities and are especially bad if given to children in bottles.

Soda is one of the worst because it is sweet and fizzy.  The carbonation fizz in any drink makes them acidic and acids dissolve teeth to cause cavities.  Simply put, soda causes cavities.

Just remember that milk is the best for almost all children and that water is a wonderful drink that is healthy, cheap, and delicious!  Just remember that water from your tap is the best: safe and environmentally responsible.

Post from: Great Grins

Baby Juice Bottles

• crossbite
• cross-bite
• cross bite

An anterior crossbite involves the front teeth and a posterior crossbite involves the back teeth.

Rarely, the upper posterior teeth bite completely outside the lower teeth in a condition called a scissor bite. 

A posterior crossbite can involve either one side, called a unilateral crossbite, or both sides, called a bilateral crossbite.

Now that all the definitions are out of the way, lets look into why they are a problem.

All crossbites cause a shifting of normal chewing patterns.  The lower jaw works best to chew food if it is free to move not just up and down but side to side and front to back.  Think of a cow chewing its cud with the exaggerated jaw movements and you will get the idea.

When the upper jaw has one or more teeth that hang down inside the lower teeth, the full movement is not possible and a more up and down chewing movement results. 

Upper front teeth can also look bad if they are in crossbite and the lower teeth rub the front of the upper teeth.

Most seriously, the lower front teeth are much more likely to have gingival recession or other gum and periodontal problems if they are pushed forward by upper teeth in crossbite.

How can crossbites be corrected?

Anterior crossbites are corrected with an appliance that attaches to the permanent molars and pushes or pulls the upper front teeth forward.  Usually this is a rather quick procedure that might take a few months. 

Once an anterior crossbite is corrected, it will usually stay corrected if the upper teeth cross over the lower teeth enough vertically.

Posterior crossbites are usually corrected by expanding the palate, but sometimes by just moving one or two teeth. See the article on Expanding Your Palate for more on this.

Correcting scissor bites are a bit more difficult and usually requires some braces, at a minimum on the involved teeth and the opposing teeth with  a rubber band stretched vertically.  More often, braces on all the top and bottom teeth  in the area are more effective.

As you can see, crossbites can be a problem but can also be fixed  with relatively little work.

Post from: Great Grins

Crossbites

The primary baby teeth are important for chewing and biting and speaking and especially for maintaining the space needed for the future permanent adult teeth.

Luckily, missing front teeth do not seem to have as much trouble with space loss as missing back teeth.  A gap-toothed grin in a kid is much cuter than in an adult!

But when a primary molar is lost by infection or trauma, the gingival gum fibers and the angle of the jaws closing together make for a strong tendency for the adjacent teeth to move into the newly open space.

In other words, the space will be lost.

While initially the loss of a primary tooth does not seem like such a terrible thing, the future consequences could be the loss of a permanent tooth, extensive and expensive orthodontic appliances, and even an uncomfortable bite that causes abnormal wear on the poorly positioned teeth.

We routinely make a small appliance that spans the gap to keep the the space open.  This is called a band – loop space maintainer.  It is made with a metal orthodontic band with a wire stretching across the missing tooth’s space.

Adults need to have an artificial tooth made to replace missing permanent teeth because the teeth on the other jaw can over erupt.  Children are growing so much and their adult teeth will come in soon enough that this is usually not a problem for them.  An artifical tooth is not needed.

If more than one tooth is missing, a better way to save the space is to use an appliance that goes from a permanent tooth on one side to one on the other side of the mouth.  These are called a lower lingual arch to replace bottom teeth or a transpalatal arch to replace upper teeth.

If teeth are crowded, sometimes teeth must be extracted to make room for the others to line up.  Often a lower lingual arch or transpalatal arch can keep the room that remains, and even stretch the space.

Taking care of them is easy with only minor restrictions of not playing with them and keeping them clean.  These appliances will stay in place until the permanent teeth erupt.  Usually braces are needed after all the permanent teeth erupt but the treatment will be easier.

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Saving Space

Usually dentists prefer to treat infected root canal pulps before they start to hurt because this is the most comfortable way to go.  Waiting for a tooth to hurt before starting root canal treatment is usually less comfortable.

Permanent teeth with infected pulps need root canal treatment. 

The steps of root canal treatment:

• Numb the tooth with local anesthestic, usually 4% articaine or 2% lidocaine instead of novacaine.
•  
• Stretch a rubber dam over the tooth to keep saliva from re-infecting the cleaned root canal.
•  
• Remove any decay with a handpiece drill and remove the infected pulp. 
•  
• Use extremely small wire files to scrape the tissue from the canals in the roots.
•  
• Measure the length of the files to know exactly how far it is to the end of the root.
•  
• Rinse the infected material from the root canals with disinfectants, often sodium hypochlorite.
•  
• Soak triple antibiotics in the cleaned, shaped, and smooth canals to fight infection.
•  
• Pack pink, rubbery gutta percha into the root canals all the way to the tip, with runny sealer to fill in any gaps.
•  
• Place a filling in the hole and plan on a crown to hold the weakend tooth together.

Primary teeth with infected pulps are treated differently than permanent teeth. 

Primary molars last until about age 11 or 12 so we like to save them with root canal treatment, if we can, instead of pulling them out and placing a space maintainer.

Because primary teeth roots need to dissolve away when the permanent teeth start to grow in, the root canal material used for baby teeth should be dissolveable or not go all the way down the root canals.

Most of the  time, primary teeth with infected pulps are treated with a partial pulp removal called a pulpotomy.

The pulpotomy procedure:

• Numb the tooth with 4% articaine or 2% lidocaine (almost always with 1:100,000 epinepherine).
•  
• Stretch the rubber dam around the infected tooth to seal out infected saliva.
•  
• Use a handpiece to drill away infected tooth and cut the infected tooth pulp in the top coronal pulp chamber. 
•  
• Stop any bleeding with ferric sulfate, then swab out the chamber with diluted formocresol.
•  
• The infection is often only in the top of the tooth so using medicines like formocresol or ferric sulfate will treat painful nerves and kill the germs in the remaining pulp tissue.
•  
• Fill the pulp chamber with zinc oxide and eugenol filling to form a tight seal and prevent bacterial entry.
•  
• Place a tightly fitting stainless steel crown or a composite filling.

These pulpotomies are very successful for teeth that have not infected the bone supporting the tooth.  If the bone gets infected, then all the pulp tissue must be removed, even the root canal tissue, in a pulpectomy.

A pulpectomy procedure is similar to the adult root canal treatment in that files are used to clean and shape but the filling is much different.

The root canal filling material for primary teeth must be resorbable or dissolvable.  I use a material called Vitapex (a mixture of calcium hydroxide, iodoform, and silicone lubricant) with great success healing abscessed teeth. 

Pulpectomy treatment  for primary teeth is mostly reserved for only the most important teeth: the second primary molars before the eruption of the permanent molars.

When faced with the options of a painful toothache, a root canal, or an extraction, most people will be pleasantly surprised that those root canals are the best option and not an “OUCH!” after all.

Post from: Great Grins

Treating Portland Pulps & Root Canals

Some orthodontists recommend treating crooked teeth or teeth that do not occlude (bite together properly) in two phases or treatment steps.  The first phase usually starts around second or third grade and a second phase around sixth grade.

Treating jaw problems early has not been well supported with excellent randomized controlled clinical trials.  These studies show that equivalent results are achieved with either one or two phases of treatment but that two treatment phases usually costs more and takes longer.

I believe that there ARE tooth alignment or spacing problems that are best treated early; before the back primary teeth come out. 

Reasons to treat early:

• Congenital problems such as cleft lips are best treated very early, then off and on for many years.
•  
• Thumb or finger sucking, pacificer use or tongue thrusting all can move teeth and even bend the jaw bones. 
•  
• Appliances to treat these problems early are very appropriate if other methods fail.
•  
• Upper teeth that stick out very far risk being broken in an accident so braces can help pull these back to safety.
•  
• Upper teeth that bite inside lower teeth are called crossbite teeth and should be treated early.
•  
• Narrow upper jaws are best treated early when the bones are most flexible.
•  
• Very crowded teeth may need to be extracted to make room for the others to straighten up.
•  
• Holding space is always a good idea with primary tooth loss.
•  
• Because the lower primary molars are usually much larger than the permanent premolars that replace them, holding this space with a metal wire appliance can usually save space for alignment without extractions.

Reasons to wait until later for orthodontic appliances:

• Two sets of braces costs more than one set.
•  
• The novelty of braces  wears off quickly so they are not so fun to wear any longer than necessary.
•  
• Putting braces on, getting straight, taking off, wearing retainers, putting braces on, getting straight, taking off, wearing retainers: just takes longer.
•  
• The longer braces are on, the more difficult it is to keep them clean and avoid cavities.
•  
• Braces come off when the second molars are straight, usually after age 12. 
•  
• Retainers for life follow orthodontic appliances so the sooner you start, the longer you will need to have retainers.

As you can see, there are some reasons to start early but if your child has crowded teeth and can wait until middle school, you and your child will be better off for waiting.

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When to Start Kids Braces?

We move teeth with brackets glued to teeth and wires between them.  The trick to moving teeth orthodontically is to have the gentle forces continue for a long enough time.

Wires are where the forces come from.  Orthodontic wires get bent into the crooked teeth and as they straighten, they pull the teeth straight also.

Relatively new super wires are able move teeth faster and more comfortably. They can be soft with cooler temperatures and stiffer with warmer temperatures.

The advantage of changing stiffness with temperature is that they can be cooled to bend them into the braces easily then they move the teeth more quickly as they warm up to body temperature.

These thermally sensitive orthodontic wires come in many different shapes:

• simple round wires
• braided round wires
• square wires
• combination wires with rectangular and round in others
• rectangular wires
• wires with different strengths in different areas

Orthodontic wires also come in several different materials and a huge variety of thicknesses.

Which super wire  to use is dependent on how crooked the teeth are and if teeth roots need to be moved or not.  Extremely crooked teeth will usually need small diameter braided round wires.  Less crooked teeth will use solid round wires.

If only the front teeth are twisted but the back teeth are not, then we consider using a wire with different stiffnesses in the front and the back.

Rectangular wires are used to move tooth roots.  The slot in the orthodontic bracket is rectangular so a rectangular wire will be able to twist and torque the tooth roots in the proper directions.

These super orthodontic wires are made of an alloy of  nickel, titanium, and copper.  Other wires are made of nickel and titanium but heat treated differently to make different metal crystals with different flexibility properties.

When we get close to the end of treatment, we need to bend the wires.  These wires are made of stainless steel or titanium alloys.  The bends compensate for the brackets being slightly out of position since it is impossible to get them perfectly placed when first glued on.

Orthodontic wires are hard to clean and sometimes pokey but they are the work horses that get your teeth straight.

Post from: Great Grins

Super Orthodontic Wires

Dental plaque is a thick sticky waterproof cream-colored coating that develops on teeth over time.  It is made up of bacteria and their wastes with saliva components. 

Sticky mucopolysaccharides are the mortar of dental plaque.  They protect the bacteria by gluing the whole colony to tooth enamel and making them resistant to washing off with normal eating and drinking.

If you start with perfectly clean teeth, very quickly a glycoprotein coating called pellicle will coat the enamel.  Because bacteria are still present in your mouth and will immediately stick to this pellicle on your tooth enamel. 

The bacteria grow and grow until there are literally trillions of them.  Usually it takes about 24 hours before there are enough to damage your teeth or gums.

After one to three days, another group of bacteria will stick to the first ones.  This makes the plaque more complex with the wastes of some being the food of others.

After plaque has been on teeth for about a week, the dental plaque changes color and texture.  Usually bacoming a dark yellow or light orange color, this plaque is very stiff and may need to be scraped off with a toothpick or dental instrument.

Lactic acid builds up in dental plaque and over time can dissolve the enamel surface of teeth.  Cleaning off the dental plaque gives the enamel access to the minerals present in saliva that can restore enamel strength.

Streptococcus mutans is the most prevalent bacterium in dental plaque.  This bacteria is especially good at converting sugars and starches into lactic acid and so it is responsible for most peoples cavities.

Other bacteria present in dental plaque above the gumline are:

• Streptococcus sanguis
• Actinomyces viscosus
• Actinobacillus actinomycetemcomitans
• Capnocytophypa species
• Eikenella corrodens

Bacteria only found below the gums to avoid oxygen are:

• Porphyromonas gingivalis
• Fusobacterium nucleatum
• Prevotella intermedia
• Bacteroides forsythus
• Campylobacter rectus

This links to an excellent discussion of dental plaque.

Post from: Great Grins

Plaque in Portland

Some parents tell me that they have heard that it is impossible to get cavities from mother’s breast milk.

My experience shows me that although nursing is the best way to feed your infant, it is possible to get cavities while nursing.  I have seen one year old children with cavities who have only drank mother’s milk.

All the infants with cavities on their upper teeth who never had a bottle did sleep with their mothers and nursed as often as they wanted, usually suckling all night long.

This continuous exposure to sweet milk can overcome the natural cavity-fighting abilities of milk proteins and allow bacteria to grow rapidly and help dissolve away the teeth.

Sleeping with your baby can be harmful to them in other ways too.  Sudden Infant Death Syndrome, SIDS, is also increased when infants sleep in the same bed as their parents.

The best way to nurse your baby is to keep them out of your bed, perhaps in a bassinet close by, and encourage them to feed very well with plenty of time to sleep and digest before another feeding.

Cavities can start forming as soon as the teeth erupt into the mouth.  Everyone has bacteria in their mouth that came from the people around them, usually their mother.

The type of bacteria that cause cavities (Streptococcus mutans) make a waterproof coating that sticks them to the tooth surface.

Because bacteria cause cavities, not sugar or milk, brushing the bacteria off of teeth is the most important of the cavity prevention strategies:

• brushing & flossing
• receiving optimum dietary fluoride
• limiting time exposed to sugar and starch

So make sure that you massage your baby’s gums with a soft cloth before they get teeth and use a soft bristle toothbrush to clean off their teeth when they erupt.

The La Leche League has some good articles and  I especially liked this one on preventing cavities while nursing your infant.

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Cavities from Breast Feeding?