The toothpaste? Original formulation perhaps. Original formulation Colgate. There’s no magic in toothpaste as long as it has the fluoride in it. That’s the biggest benefit in a toothpaste. It’s the soap and the fluoride.
Student: What if you’ve got where your gums have receded and maybe there is some sensitivity there because enamel [inaudible]
You can. You cover those if it gets you screaming. I had to put fillings over that exposed tooth structure. Normally we try using potassium…it’s in the toothpaste, desensitizing toothpaste… Sensodyne. It’s a potassium ion… potassium chloride… my mind…it escapes me but it’s a…potassium nitrate. Forms a plug at the end of the tubule. Your tooth is an enamel, enamel covering with the dentin underneath it. The dentin is just a bunch of hallowed pipes. It’s just a bunch of hollowed tubes with the cell body in the middle of that tube and so if the end of the plug of that tube becomes open, anything that rubs across it or osmotic gradients change – a really sugary solution or really acidic solution, it tugs on that cell body and it transmits impulse to the tooth. So if you plug up that tubule, then that little cell body is happy. That’s where the desensitizing toothpaste is trying to form a plug in that tubule. You can do it with fluoridine, you can do it with potassium nitrate.
Student: How long does it take, I think you said acid is what starts eating away at the tooth? How long does it take for it to?
Student? 17 minutes? And acid can form that quickly?
That quickly. So if you have something sugary and acidy, you got to brush your teeth immediately. An hour later, too late.
Student: So this brushing twice a day really doesn’t make sense if you are going to eat anything sugary. You’re going to have to brush right afterwards or rinse your mouth.
Rinse your mouth. When you’re brushing twice a day, you’re trying to brush the plaque off your teeth. So if there’s no plaque on your teeth then there’s no bacteria and sugar is not going to be harmful.
Student: And how long does it take for the plaque to build up?
Student: [inaudible] If you don’t have the plaque buildup do you get the acid?
There’s no acid. The plaque doesn’t form the acid. Now if you have a really acidic drink. But plaque takes in the sugar and uses a Krebs cycle and byproduct of that is acid. That’s the acid that demineralized the tooth. And then when it demineralizes the tooth, it gets soft and the bacteria can penetrate in and then the worse it gets the faster it gets worse.
Student: So you should be okay if you are brushing twice a day and getting rid of the plaque?
If you’re getting a hundred percent of it off but nobody gets 100 percent of it off.
Student: So what is plaque?
Plaque is a biofilm. It’s a biofilm. It’s a bacteria and a bunch of polysaccharides that the plaque…that the bacteria excretes and becomes adherent. It becomes a matrix for more bacteria to form and grow. It becomes its own environment to harbor itself.
Student: Almost like a barnacle.
When it calcifies from the minerals in your saliva, then we call it calculus. But plaque is a biofilm. I don’t know if you’ve ever seen the inside of the pipe that’s got that slime layer on it? That’s a biofilm there. that’s just loaded with bacteria that populated that surface. Well, that’s what happens in your mouth when you get a biofilm. And it’s mostly strep mutant. And there’s different strains of strep mutant, and some strains are more virulent and are more decay producing than others. Brushing twice a day helps with the plaque forming. 24 hours…you dislodge it, knock it off your tooth, just not going to get back on it for 24 hours. But you literally… if we all brushed our teeth for 4 minutes and we took disclosing tablets, chewed them up and we looked in each other’s mouths we ‘d go “Whoa!” There is still biofilm layer on there. It’s difficult. It’s not easy to clean your teeth. But so, okay. On to bisphosphonates: Actonel, Fosamax, Boniva and those drugs. Active osteonecrosis of the jaw. ONG. It’s a significant problem. The drug companies report that it happens very, very, very, rarely. 1 in 100,000 patients. well, if that was the case, Santa Maria has 100,000 people living in it. My oral surgeon would see only 1 case of it. Well that ain’t true. He sees quite a few cases. In osteonecrosis of the jaw…In a treatment of osteoporosis basically the drug you take stops bone turnover. When you turnover bone, you reabsorb bone and you lay more of the bone down. Well, to build bone, it stops the bone resorptive process. So you are getting bone deposition process so the bone density goes up. The key question is, is this bone any stronger? Or is just like adding a plaster veneer to a broken down wall? It looks good but it’s still a weak bone. That’s what I always wondered. Just because it’s dense bone does it really mean less prone to fracture? But that’s a whole different discussion. The unique thing about… there’s a difference in the mouth. The jawbones turnover 17 times more frequently than your femur. So this drug because of the way it works, it gets concentrated in jawbones. So it will stop bone turnover. It stops. So if you extract a tooth of somebody who has been on Fosmax or Boniva or Actonel for a period of time that wound never heals. And when I mean never heals I mean never heals. And it’s nasty and it’s ugly and it smells and it looks terrible and gets painful and it has to go in and bigger areas die and they go in and scrape out that area and it never heals back in. Hyperbaric oxygen doesn’t work on it. They’ve gotten a few cases to resolve but once it’s dead gone daddy gone there’s no turnover. It will never heal. So these patients are left with unhealed wounds in their mouth and sections of their jaw that will die and sometimes they cut that section out and put a graft in and then that section dies and it’s just…it’s horrible. It’s really debilitating. And sometimes it’s just a small one and it just never heals. Patients that have been on the bisphosphonates therapy for a period of time, before we do sometimes even a deep cleaning, they have to go off of it for a while. There’s a bone turnover marker. The CTX bone marker. I used to know what the CTX stood for. But it’s a bone turnover marker that not too many people are familiar with. And if I ordered the test, the insurance company won’t pay for it. So I have to have a physician order it. You know, and I hate to say it but I had physicians asking go “I don’t know what it is. What is it?” So just order and it’s got to be above 150 otherwise we can’t take out a tooth from this patient, we can’t do periodontal surgery, we can’t do deep cleaning. They have to go off the drug for a period of time and let the bones start turning over in the mandible and the maxilla and lets remodeling occur. And if the count seems to be above 150 on the CTX test then it’s safe. It’s safe. And then, the very potent drugs like that are used in the treatment of lymphoma and leukemia, bone cancers and those patients, once they have [inaudible] there are real problem. There’s a patient who gets sent to me and say “Dr Kirk you got to do all the dentistry on this patient in 2 weeks” Because in 2 weeks they are going to start their Zometa and after that you can’t touch them because they are worried about osteoporosis of the jaw.
Student: These guys who keep losing more and more bones once they go off their drugs to go of these drugs would they heal back or they are just too far?
Once the bone is dead, it’s dead. It does not a remodel. It’s a osteonecrosis of the jaw. And the Actonel Fosmax companies kind of got hit blindside with it and then they said “oh, these dentists are nuts!” It’s obviously the whole osteoporosis therapy regime has to be followed and that for the physician and their management. But there comes a point where if they need dental work they have to go off the drug for a period of time. They have to take a drug holiday. And let that CTX score bounce back, the bone turnover marker got to where they are turning over bones so when I take out a tooth that wound is going to heal because wounds heal, bones heal by remodeling. If you stop the remodeling process then it will never heal. And once you think of mandible and maxilla, it turns over so much faster the drug ends up being concentrated in there and it literally stops bone turnover.
Student: Do you know how long does it need to keep the person off?
Student: Kind of worried about those once a year shots.
Student: Most of people that are taking this stuff shouldn’t be taking it.
I can’t speak to that. I don’t… I wonder about…
Student: It’s called the broken bones business.
I wonder about, just because you’re plastering more bone…Because I was thought, you were thought, you know, bone remodels and bone remodels because the structure of the bone breaks down and factures and breaks down. So it always has to be rebuilt otherwise the bones get brittle and will break. So if you stop the bone remodeling process and you’re not breaking down and repairing that broken bone, you’re just slathering on more calcium hydroxylapatite over broken bone, are you really strengthening the bone enough to reduce hip fraction. The data they have shows that it does significantly reduce the risk of hip fraction. So I got to believe that it works. So, you know, that’s… I’m no physician. I just wonder about it.
Student: Been quite a few articles on it.
I just wonder about that treatment. Maybe… what’s your treatment? Would tey just blast you one time or is it just slow release drug?
Student: I don’t know. It seems scary if you have a problem.
You can’t stop it.
Student: Even if they stop Fosmax you still have that effect for years.
Student: [inaudible] something like radiation…
It’s just once a year so. Maybe in a sense it’s better because it could be that is stops bone turnover for 3 to 4 months and that [inaudible] build up and then slowly washes out and lets bone remodel again and build and build and then you get another injection and let the bone density fill back up. So maybe that…it could be working that way too.
Student: Current theory is that if you eat too much protein that the protein because of acidic amino acids then the body needs more to counteract the acidity so then it starts pulling calcium out of the bone to neutralize the amino acidity. Wonder is why countries like Western [inaudible] you get more osteoporosis than in Africa and Asia. They have much less osteoporosis because they mostly eat fruits and vegetables. Very rarely fish and meat. [inaudible] 500 mg of calcium. Why we need it so much is we need calcium to neutralize all these amino acid acidity but in Africa and Asia [inaudible] You see very little osteoporosis. You need some physical activity. But when you leave Asia and come here within a generation [inaudible] OS the diet is they key of preventing.Things like that.
I’m sure this has a lot to do with it. Bisphosphonate related osteonecrosis of the jaw…that’s why you’ll see on those commercials on TV. If you have jaw problems call your dentist right away. That got kind of on there because we started raising…but if you have jaw problem, it’s too late. “I got a wound here doc.” Well, guess what? It’s not like you can take a dive in hyperbaric oxygen chamber and it’ll heal. There’s osteoradio necrosis. Necrotic bone because of radiation exposure to kill a tumor. That bone will die but you can get it to come back and heal if you go into hyperbaric oxygen. High oxygen level. For a prolonged period of time you can get this bone to heal. Not so with the osteonecrosis of the jaw. Hyperbaric oxygen chamber does not appear to heal which is a scary thing, which means that’s it. And Dr Petrovski, he’s got a number of patients. When I say number…probably 10 to 15 Just one oral surgeon in town. The there’s his partner who’s got some. Then there’s the other surgeon in town. So you can’t tell me it’s 1 in a 100,000. It’s much more than that. But anyway. I hope you guys didn’t get too bored this evening and had a good time. I enjoyed myself.
Student: Any subject that we should’ve covered yet?
We hit everything. If we had any more subjects I would put them all to sleep.
Student: Here’s an article for you. I just haven’t looked at it yet. High school sweet tooth.
Yeah, that’s a big problem. All the sodas and sport drinks in school. The kids just suck on those things all day and they sip on them and…I got a high school athlete right now. I’m just doing a whole bunch of fillings on him and I’m just trying to figure out where is coming from, where is the sugar source coming from. And I do dietary questionnaire…