Melissa Kaplan's
Chronic Neuroimmune Diseases
Information on CFS, FM, MCS, Lyme Disease, Thyroid, and more...
Last updated January 1, 2014

Dentists in general have found that medical doctors are, for the most part, ill-informed about the interplay between infections in the mouth and gums and overall health, and how other health conditions can affect - or be affected by - the mouth (including teeth, gums, and jaw/joint). (I've had first-hand experience with this: The medical doctor decided I was faking being sick to get out of work. After months of fierce headaches, generalized pain in my face and head, and periodic raging fevers, I finally figured out the problem. When poking around trying to find where the source of pain was coming from, my pinkie finger slid into a finger-tip sized hole in one of my molars. This was followed by a trip to the dentist who proceeded to do a root canal without anesthesia, but that's another story…)

Frequently, many people who are disabled and chronically ill do not have dental insurance, nor do they have much money to spend on dental work. That, in combination with a lack of understanding of how to properly care for the teeth and mouth results in many people not going to the dentist until what could have been a small, easily (and often less invasively) resolved problem has become a big, expensive problem.

Prevention Is Paramount
Cavities and gum disease are both caused by infections, the former in the teeth themselves, the latter in the tissues and bone of the jaw. Even if you are not experiencing any pain or discomfort from these infections, they are still affecting your health, challenging your immune system to try to fight it. When your immune system isn't up to the challenge, you may begin to experience pain, fever, and other symptoms that may not feel like they are related to any particular tooth. As time goes on, you may become increasingly ill, not realizing that your symptoms are due to tooth/gum disease. Since medical doctors don't check your teeth or gums as a dentist does, you may never be properly diagnosed until you see a dentist.

Plaque
The key to preventing a wide range of mouth problems - and immune system challenges - is to remove plaque. Plaque is the sticky film on your teeth which, if not removed, will harden into those calculus (tartar) deposits the dental hygienist clucks her or his tongue over as they scrape it off the tops and sides of your teeth.

The mouth is normally an alkaline environment that keeps the many types of bacteria living in the mouth at bay. When we eat, the environment turns acid. Since many of acid-causing foods that favor these bacteria are our favorites, too, the balance all too often shifts in favor of the bacteria: breads, grains, and other starches, and sweets. If you eat more often each day than you are brushing, all that acid builds up in the mouth, attacking your teeth.

The bacteria in your mouth, especially those that find nice, cozy pockets in tiny cavities and pockets in the gums around your teeth, do what happy bacteria do: live, eat, produce wastes, reproduce themselves, and die. In your mouth, the same mouth that has highly vascularized sublingual and other tissues making them so conducive to taking many medications sublingually, since they are able to get into your bloodstream so easily. Handy, too, to your esophagus, down which they go when you swallow.

Along with building up on the teeth, antagonizing your immune system, and creating complications for people with other health problems (such as heart valve prolapse), plaque and the substances it produces can irritate the gums, causing gingivitis (reddening, bleeding). Over time, the gums start receding and pulling away from the teeth, providing more nooks and crannies for bacteria to colonize. Eventually, left untreated, the underlying bone may be invaded and destroyed. Teeth loosen and may require extraction. This is a serious - and extensive - enough of a problem that it is the main cause of adult tooth loss.

So, how do you combat plaque? Most of us are already pretty careful about what we eat, but in case you aren't, a diet high in veggies and low in refined sugar and starch is best. If you need to eat between meals, mouth-friendly snack foods include sugar-free yogurt, raw vegetables, cheese, or fruit.

Other proven plaque fighters? Proper brushing, flossing, and the right mouthwash.

Brush
Brushing removes some of the bacterial on the teeth and gums. Brushing properly removes even more and helps stimulate the gums. Apply the brush at a 45-degree angle on the gum and top of the tooth, and gently brush back and forth. Bush the surfaces of the teeth - all of them! Along with the outside of every tooth, don't forget to brush the inside surfaces, the chewing surfaces, and use the front end of the brush to brush the ends of the back teeth.

More important than whether the handle bends or the bristles are cut to various levels or arranged in different patterns is that you brush properly - and brush long enough. When you're tired or in pain, standing at the sink a couple of minutes brushing your teeth can be unbearable or so taxing that you have to head back to bed to rest for another couple of hours. Nonetheless, brushing is a deed that must be done. So, work out ways that you can do it at least twice a day. If your bathroom is big enough, put a stool or chair in there where you can sit while you brush. Or, take your toothbrush with the toothpaste on it and go sit someplace. Since just sitting or standing somewhere can be pretty boring and more likely to result in a too-short period of brushing, watch TV, read a book, enjoy the view outside your window, in short, do something that makes the time a little more enjoyable. If you tend to end up with a mouth uncomfortably full of saliva-diluted toothpaste before you are done brushing, spit it out (go ahead, bring a cup or bowl with you when you go sit), spit it out, and continue brushing.

Once you are done brushing, rinse your mouth out thoroughly, swishing the rinse water through your mouth and around your teeth.

Try to brush at least twice a day. Three times is better. If you indulge yourself with a sugary or starchy snack, try brushing after that, too.

What type of toothbrush is best?
The one that you will use the most and that lets you brush properly. When I grew up, there were just a couple of brands of toothbrushes and they came three ways: soft, medium, and hard. No Disney characters, no cool colors with groovy rubber handles. Now there is a bewildering array of brush head, bristle and handle styles, each proclaiming to be better than all the rest. But are any of them really any better than the basic, old-fashioned toothbrush?

Not really. Again, since toothbrushes are considered to be cosmetics rather than drugs, there's no requirement that claims be backed by hard research. So, what should you use? Find the brush that feels most comfortable for you, in terms of brush head size, hardness (soft or medium is best for most people), and handle. The best place to buy toothbrushes? Overstock stores such as GroceryOutlet and Big!Lots. Name brand (well somewhere, if not here!) brushes at bargain basement prices. The best thing is that you can buy two-four brushes for the price of one fancy one, so you can toss them out and replacement every couple of months. (To make mine last longer, I always have 4-5 brushes sitting in my holder, using them on a rotating basis each time I brush.)

Interested in an electric toothbrush? According to Dr. Salmon, the ones that tested out the best, in terms of cleaning teeth, are the Braun Oral-B and sonicare.

What type of toothpaste is best?
Toothpaste, like mouthwashes and OTC tooth whiteners, are considered to be "cosmetics" and so the FDA does not regulate the claims made on the packaging or advertising of these products.

Dr. Salmon says that, thus far, fluoride is still the best cavity fighter. Research questioning the safety or efficacy of fluoride is questionable, he states, due to poor study design. So, if you can tolerate fluoride, use toothpaste that contains fluoride. Toothpastes with ingredients such as peroxide or baking soda that do not contain fluoride have not been proven to be as effective as fluoride in fighting cavities. Another proven effective cavity and plaque fighter is triclosan, a bacteriostatic. [Read about problems associated with the use of triclosan in household products.]

Fluoride needs to be in contact with the mouth surfaces for three minutes for it to be effective, so if you are not using a mouthwash that contains fluoride, then be sure to get comfy and brush long enough.

Any toothpaste that contains fluoride will help fight cavities and plaque. You needn't buy the most expensive brand out there - any brand that contains fluoride will work.

Floss
As with brushing, how you floss is important. Flossing incorrectly won't do much more than waste precious energy.

Start with about 18 inches of floss - whatever type you like best (waxed, flavored wax, unwaxed). If you are unable to comfortably use your fingers as the floss holder, there are lots of products out there, from holders you thread with floss yourself, to disposable holders already fitted with pieces of floss. If you have fixed dental work that doesn't permit you to floss between each tooth, you can use a floss threader that you insert between each tooth at the gum line.

Move the floss gently between the teeth: don't ram it into your gums. Once you get the floss next to the gums, use your fingers to pull the floss, or reposition the floss holder so that the floss forms a C-shape around the base of one of the teeth. Holding the floss tightly against the tooth, gently slide the floss up and down along that tooth. Reposition your fingers, and do the same to the adjacent tooth. Work this way between each tooth. Advance the floss, or use several disposable pre-threaded floss holders, each time to floss so that you aren't using the same bacteria-laden section throughout your entire mouth. When you get to your back molars, don't forget to floss the back side of each one.

Floss at least once a day. Dr. Salmon says, "If you only floss once a week, that's better than never flossing at all." So, if you forget a day, or don't feel up to it, skip it, but don't let flossing drop completely from your list of things to do.

Mouthrinse (Mouthwash)
There are two types of mouthrinse, each fighting different types of bacteria. As indicated in the comment above about types of toothpaste, many are the claims, little is the hard, well-constructed research on many of the products sold.

The best - and proven - bacteria fighter that combats the bacteria causing cavities and plaque - is Listerine. There are now many knock-off of Listerine, some of which are store brands you may find locally in stores such as Raley's, Alberton's, and Walgreen's. The active ingredients in these products are the essential oils found in small amounts. The one I use, Today's Health Antiseptic Mouth Rinse from Raley's, contains thymol (from thyme/oregano), eucalyptus, methyl salicylate (something for those on the guaifenesin protocol need to watch out for), and menthol. The inactive ingredients are water, alcohol, preservatives, flavoring (in Mint and other flavored rinses), and preservatives. Listerine and Listerine-based mouthrinses are bactericidal, killing bacteria.

Alcohol and the essential oils provide the "bite" or slight stinging (or invigorating, depending on how your brain interprets the signals it receives), something not pleasing to everyone. If this is your feeling about it, keep in mind that a minute or less of swishing this stuff around is, in all likelihood, preferable to spending a couple of hours in the dentist's chair, not to speak of considerably less expensive. (See Xerostomia below)

Use a mouth rinse at least once a day. Follow the directions on the bottle as to the amount to use. Swish it vigorously around your mouth and teeth, then spit out.

Kid Concerns
Sonoma County's municipal water supply is not fluoridated, so dentists or pediatricians may prescribe fluoride tablets for young children. If your child's dentist has done so, make sure to supervise the children when they are brushing: if they are swallowing their toothpaste regularly, talk to the prescribing doctor and ask how you should modify your child's dose. Dr. Salmon, by way of illustration, says that you may end up giving the child the tablet every other day, rather than every day. Too much fluoride can be just as harmful in its own way as too little, so do supervise children until they have consistently shown they are both brushing and rinsing properly.

Xerostomia (Dry Mouth)
Many of us suffer from chronically dry mouths. The cause may be illness-related, as in Sjögren's, or due to one of the many medications we take: asthma and allergy medicines; anti-depressants and anti-anxiety drugs; and antihypertensive drugs are some common culprits of drug-induced xerostomia.

But the annoyance or discomfort of dry mouth isn't the least of it. Medical doctors seem to downplay xerostomia, as if it was just an annoying little side effect, rather than recognizing it for the health problem it causes in the mouth. The usual advice is "sip some water. Unfortunately, while sipping water may help wet the mouth a bit, you can't be sipping all the time, and it is during the times you aren't sipping that another bacteria gets to work, working away at your teeth just at the gum line, because there is not enough saliva to wash the sugars and bacteria away from the teeth.

The most effective fighter of gum-line caries bacteria is fluoride. Along with using fluoride toothpaste twice a day, you may want to use a mouthrinse containing fluoride once a day. The fluoride is bacteriostatic, inhibiting the growth and replication of these organisms.

When asked which mouthrinse to use - a Listerine-type bactericidal or a bacteriostatic fluoride rinse, Dr. Salmon replied that he uses both, one in the morning, the other in the afternoon. Mouthrinses with alcohol can temporarily make xerostomia worse, so you might want to use it in the morning rather than before bed.

Other Mouth-Related Issues

Local Anesthetics
There are many local anesthetic products out now, some without epinephrine (adrenaline) that can cause adverse reactions in some people. Epinephrine is added to the anesthetic to prolong the anesthesia's effect: it contracts the capillaries in the area which in turn delays the dispersal of the anesthetic out of the area. You may find that different areas of your mouth react to anesthetic agents differently. If you take a lot of drugs, or have a history of substance abuse, your liver (specifically, the monomine oxidase and cytochrome P450) may break down anesthetics faster, leading to loss of numbness sooner rather than later during prolonged procedures.

Late Effects From Previous Dental Work/Surgery
Not everyone responds to dental procedures in the same way…and not all dentists are equally careful in their work. If you are having problems with old implants, root canals, or fixed or removable dental work, get it checked out by, if you can, the dentist who originally did the work. If your dentist is dismissive of your pain or other problems associated with the work, it might be time to get another opinion - and another dentist. See the Suggested Resources at the end of the article for dentists and clinics.

Temporomandibular Joint Syndrome (TMJ)/Orofacial Pain
The nerves, joints and bones of the face and head may cause a wide range of symptoms, from impaired mechanical function of the jaw and chewing, to headaches, severe wide-spread pain, tinnitus, and more. Bruxism (clenching, grinding) can cause many of the same symptoms as well as literally wear down the chewing surfaces of the teeth to the point where the bite is thrown off, causing additional difficulties and health problems.

There are various devices that can be worn in the mouth at night to reduce or eliminate the effects of bruxism. These devices (night guards, splints, etc.) keep the chewing surfaces from touching. This sends a message to the brain that the jaws aren't masticating anything, which makes the muscles relax and the tooth surfaces are about three millimeters apart, about as far apart as they normally are (or should be!) when you are awake and doing something other than eating or talking.

Many people who clench or grind, during the day or night, are not aware they are doing so. Instead, they suffer through headaches (that may not respond to analgesics) and other pains and problems, until the condition is diagnosed by a dentist, who can tell there is a problem by the abnormal wear on the cusps and valleys of the individual teeth.

While there is no cure for most instances of TMJ, patients can be evaluated to see if there is anything that may help relieve their symptoms.

The Orofacial Pain clinic at the University of the Pacific's Dental School (see Suggested Resources below) is an excellent resource for situations in local dentists are unable to resolve, as the dentists at the clinic are working with the latest in clinical and pathology information and materials and procedures technology.

Note: If you are thinking about going to the UOP ADG or UCSF dental clinic, you might want to see Dr. Salmon first. Because of the physical hardship of repeated trips to San Francisco, he may be able to do some of the preparatory work up here, thus reducing the number of trips you will need to make to San Francisco clinics.

Dental Check-ups
Next to gynecologists or urologists, dentists seem to rank way down on the list of health care providers with whom patients want to spend time. A healthy person can usually get away with an exam and prophylaxis (cleaning) once a year, though twice a year is better, or necessary if there is a lot of fixed dental work in place. For those of us with compromised immune systems or health problems putting them at higher risk for dental disease (such as xerostomia, diabetes), we should be seeing the dentist every 3-4 months.

While the mouth may be smaller than other organs and systems of the body, it is nonetheless an important - and complicated - place. The mouth, with its complement of teeth, gums and assorted other structures and tissues, doesn't exist in a vacuum. It can cause health problems affecting other parts of the body, can exacerbate other health problems, and can be affected by other health problems.

Proper oral hygiene has always been important, from the time we cut our first teeth. When you're sick and debilitated and getting out of bed every morning requires a Herculean effort of will, tending properly to one's teeth seems way down on the scale of priorities of things to be accomplished every day. But, as we can see from some of the topics covered in this article, the mouth isn't a place we can afford to ignore. So, if you aren't already being good to your mouth, work on developing and incorporating a better oral hygiene routine into your day. Your mouth will be happy you did.

Toothsome Bits
If reading the above doesn't motivate you to pay a little more attention to your mouth, read on.

Oral Cancer - Oft Overlooked Risk
Every year, there are more than ten thousand deaths due to oral cancer, many of which might have been prevented had diagnosis been made earlier. A good dentist will examine your mouth for any signs of oral cancer. Everyone should regularly check their gums and other mouth tissue for any red or white spots that don't go away, lesions that don't heal, or small lumps to don't go away. Denture wearers, a group that tends to not get dental checkups as often as they should, should go at least annually to have their gums examined - and to catch oral cancers while they are still small. At risk: over 40, tobacco smokers and chewers, especially the smoker also drinks heavily.

Dental problems can boost pneumonia risk in elderly
Aspiration pneumonia is an infection that occurs after bits of food or stomach contents are inhaled into the lungs. In a study of the records of 402 patients aged 57 to 98, the investigators found patients were at higher risk for this type of pneumonia if they had dental plaque or certain types of mouth bacteria. Overall, patients who had a stroke, chronic obstructive pulmonary disease (which includes emphysema and chronic bronchitis) or needed help eating were at risk for the ailment. (From Reuters Health, 5/14/2002)

Age No Protection Against Caries
As the population lives longer and more seniors are keeping most or all of their own teeth, dentists are now seeing more carries and other dental disease in a population that, a generation ago - when death was at an earlier age and tooth loss extensive - was much less common. Reasons for the increasing decay problem include physical difficulties brushing and flossing leading to plaque and receded gums, and medication-induced xerostomia. In addition, seniors tend to drink less tap water, and so are not getting much in the way of fluoride supplementation in areas where water is fluoridated. Denture wearers are at risk, too, as dentures may be ill-fitting and so cause gum abrasions, or the gums themselves may be unhealthy, both of which cause stress and challenge the already at-risk immune system.

Local Anesthesia
In selecting a local anesthetic for use in a dental procedure, the duration of the procedure is one of four key criteria that will determine your anesthetic choice. Local anesthetic formulations used in dentistry are categorized by their expected duration of pulpal anesthesia as short-, intermediate- and long-acting drugs. Alternatives to local anesthetics with epinephrine (used to prolong the effect of the anesthetic around the work site) exist, so talk to your dentist if you get reactions to epinephrine (such as rapid or pounding heartbeats).

Pre-Medicate!
If you have a heart valve prolapse, you should ask your doctor or dentist for a prescription for a pretreatment dose of antibiotics to take before your dental work. The old protocol of taking large doses of antibiotics before and after a dental procedure has been replaced by just one megadose before the visit for anyone with heart valve prolapse. For immunocompromised patients who have a total joint replacement, they should also talk to their dentist about taking a preventive dose of antibiotics before dental work, as there may be a greater risk of infection.

Gum Overgrowth
Gum overgrowth is when the gum tissue creeps up over and in between the teeth. Aside from the odd appearance, it poses a challenge in keeping the teeth clean. Proper brushing and flossing is essential. Some dentists recommend more frequent cleanings and exams (every six months for otherwise healthy people).

Researchers recently discovered what they think might be the gene linked to hereditary gum overgrowth, but medications may also cause gum overgrowth. In these instances, the condition may be referred to as gingival hyperplasia secondary to drugs. Why exactly this happens is presently unknown, but theories advanced to explain it include a greater synthesis of protein and collagen caused by the drug or its metabolites.

The common antiseizure drug, phenytoin (Dilantin), causes overgrowth, reddening, and bleeding in about half of its users, as do many cardiac medications. Cyclosporine, an immunosuppressant used in organ transplant recipients and for treatment of psoriasis, may cause overgrowth. So, too, can numerous calcium channel blocker agents (calcium antagonists), especially nifedipine. When nifedipine and cyclosporine are taken together, it increases the chance of overgrowth. When taking drugs, the dose of drug and the length of time on the drug may affect the development of or severity of the overgrowth.

People at risk for gum overgrowth include those with poor oral hygiene, leading to the presence of plaque which may enable the accumulation of cyclosporine or phenytoin. Those with deep periodontal pockets are also at higher risk.

University of the Pacific (UOP) School of Dentistry
2155 Webster Street (between Sacramento & Clay Streets)
Floor Level B
San Francisco, California 94115
Telephone (415) 929-6675
UOP's School of Dentistry's Advanced Education in General Dentistry (AGD) is one of several clinics at the school. Graduate dentists pursuing additional education provide the care at this clinic. Fees are generally lower than the prevailing fees in the area; Denti-Cal and Medi-Cal and most insurance plans accepted; fees may be discussed and payment arrangements made.

UC San Francisco (UCSF) Dental School
Parnassus Ave
San Francisco CA 94143
415-476-1891
UCSF's dental school has several clinics. Call or visit the website for information on the different clinics, directions, services, etc. Fees are competitive with those in the San Francisco area.

Sources, in addition to notes taken at the meeting, include the following:

American Dental Association including the following articles:
Asthma medications linked to xerostomia, caries
Seniors , Not Kids, are the Most Cavity-Prone
Inside Out: Oral Signs of Medical Problems
Drug-Induced Gingival Hyperplasia

There are numerous issues I have not addressed in this article, including amalgams/mercury toxicity and water/product fluoridation. There are numerous sites out there that addresses these often controversial topics in great depth.

From what I have learned in dealing with my own mercury issues, from intelligent doctors and others, is that just because one has mercury in one's mouth doesn't automatically mean that the mercury is causing a health problem, nor, if it is, that replacing each amalgam filling with composites is always necessary or therapeutic. Before anyone goes to get their amalgams removed, keep in mind that a number of the dentists recommending removal and replacement with composites neglect to mention that composites are significantly more expensive (the prevailing rate in our area is $800/tooth) and last a fraction of the that amalgams do.

If you do decide to get amalgams out, you might first want to consult a physician and/or biologic dentist who is experienced in mercury detoxing to discuss chelation and immune system support prior to, during and after the dental work.

If your only health problem is mercury toxicity due to the amalgams in your mouth, and if you have them removed properly (gradually, over a period of time, by a dentist who uses the proper equipment to prevent excessive inhaling of and contact with the mercury as the amalgams are removed, with liver and other systemic support), you have an excellent chance of near or full recovery. If extraction is not done properly you may get much sicker. If you have other health problems, you may feel better, though not fully recovered, after having the amalgams removed.

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