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Eat Happy!

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Tuesday, August 19, 2014

Reflux and Erosion from a “Dental Hygienist Mommy” Point of View

Reflux and Vomiting can cause a lot of pain, signal medical conditions, and open the door to new problems…. one of them being oral disease. The focus of this post is to discuss how children and adults with frequent acid reflux or vomiting are predisposed to tooth erosion and dental decay. As a dental hygienist, I see a lot of children who struggle with preventable dental problems… And when you have a child with special gastrointestinal needs, as I do, oral health becomes a daily struggle. In today’s world, dental acid erosion is causing a large health concern; some would argue it is a larger problem than dental decay. As a hygienist, and a mommy of a child with a history of severe reflux and frequent vomiting, this is a topic that has a very special place in my heart!

  



OK....... We need a little background first ~ ~ ~ ~ ~

WHAT IS DENTAL EROSION?

The minerals in the enamel (the hard white cover of your teeth) can become soft from extrinsic and intrinsic acids (acids from other sources than bacteria). This is called erosion. The minerals become weak and loose, allowing disintegration and destruction. The enamel is then “washed” away by the acids. Saliva can help neutralize the acid and protect teeth; however, if the attacks happen frequently, enamel doesn’t have a chance to repair. Once gone, enamel cannot “grow-back” or be regenerated. Erosion often affects all of the teeth and does not typically isolate and attack a particular tooth.

Healthy Tooth Enamel
Tooth Enamel Damaged by Acid Erosion

HOW DOES EROSION AND DECAY HAPPEN?

The enamel on your teeth is about 90% calcified. As a point of reference, bone is 50% calcified. This means that enamel is much stronger/harder than bone. Just as bone can lose minerals and become weak, so can your teeth. Dental erosion and decay are caused by weakened minerals in enamel from low (acidic) pH levels. Decay is weakening caused by bacteria and erosion is weakening caused by external and internal acids. The acids produced when eating and drinking lower the pH in the mouth. The pH measurement scale runs from 0 (most acidic) to 14 (most alkaline). I have included a few photographs to help understand the pH scale. A neutral pH is 7.


The mouth has a slightly acidic pH of about 6 to 6.5. The critical pH, when bad things start happening inside the mouth, is around 5.5. That isn’t a lot of wiggle room before acid starts causing what could quickly become permanent damage.


This first image is a great visual diagram. The lower portion of the tooth is being damaged, demineralized, by low pH acid. The top portion of the tooth represents the stable state of the mouth. It also indicates that while acids can cause demineralization (weakening of minerals), safe levels can contribute to “remineralization” (the depositing of mineral back into the enamel). This is *NOT* the same as “regrowing” enamel. Remineralization strengthens the existing enamel, but does not bring back lost enamel. The second image, below, is a great depiction of a sliding pH scale. I particularly like how the 5.5 is shown to the left of the neutral pH marked.



CAUSES OF EROSION

There are numerous extrinsic and intrinsic acids that can cause enamel erosion. Many foods and beverages cause dissolution of minerals. While some of these have healthy contributions for the body, they can be harmful for your teeth. Here are some examples:

Beverages: alcohol, coffee, energy drinks, fruit juices of all kinds including grapefruit juice and orange juice, sodas, sports drinks (Powerade, Gatorade), tomato juice, wine, and so on. Beverages typically have a pH of 4.0 or lower. Many of them are 3.0 or lower.


Foods: tomatoes, citrus fruits, lemons, vinegar. Fruits tend to be between 1.7 and 4.7, while vegetables are usually above 2.5.


Reflux: stomach acid (passively refluxed)


Vomiting: stomach acid from illness, eating disorders, morning sickness during pregnancy



Here are some charts of extrinsic and intrinsic acid values. Of course, we want the mouth to be as close to 7.0 as possible.




SIGNS & SYMPTOMS

(signs are objective, measurable facts, and symptoms are subjective, patient relayed opinions)

~ SIGNS ~

The first signs of erosion are usually smooth, flat surfaces of wear on the teeth. This is typically seen on the front and back surfaces of the front teeth. There can also be pitting (dimples) on the chewing surfaces of the back teeth (molars). These can deepen over time and form cup-like craters. Another sign is the thin, yellow appearance of the teeth. As the enamel erodes, the underlying layer of the tooth, called dentin, is exposed. The dentin is much yellower than enamel. This is why teeth with a lot of erosion appear yellow. Te edges of teeth appear very jagged and irregular as the thin enamel can begin to crack and chip.

~ ~ FRONT TEETH ~ ~

Top Front test shown from the back- mild erosion

Top Front test shown from the back- severe erosion

~ ~ Molars ~ ~
Left - Mild & Right - Severe

      

 ~ ~ Cracking & Chipping ~ ~

Top Front teeth shown from the back- chipping from erosion

Front teeth- breaking from erosion

As the teeth are eroded, the enamel becomes very thin and translucent. Below, you can see how the edges are much thinner than the center of the tooth.

Teeth become translucent from erosion

Sadly, children are not immune to this horrible condition. Primary teeth (baby teeth) eroded just as easily, if not more easily, than adult teeth. This is a picture of a ten year old with severe erosion. Since eroded enamel is very soft and weak, it decays much faster.

Child's teeth damaged by erosion

~ SYMPTOMS ~

The major symptom of erosion is sensitivity. Sweets and hot-cold liquids tend to create a “zing” sensation. As the severity of erosion increases, so does the pain and sensitivity. In a way, the enamel protects the teeth from sensitivity. When enamel is destroyed because of erosion (or other various reasons), the tooth becomes more sensitive because nerve impulses can travel to the nerve of tooth much faster. There are a few things you can use to help relieve sensitivity, such as toothpastes, rinses, and dietary adjustments.

TREATMENT & PREVENTION

The same types of products are used to help treat an prevent acid erosion. In addition to the products and ideas listed below, sometimes, fillings must be placed where tooth enamel is lost or decayed from erosion. Filling and crown placement is decided upon by the dentist.

Of course the ideal thing is to prevent erosion before it begins. I feel very blessed to have had the knowledge I did when Ian was vomiting, his whatever 1200+ times it has been by now. Ian began having reflux problems the week after we brought him home from the NICU. I immediately began giving him xylitol. I wrote a previous post all about xylitol and its wonderful health benefits. It is a very natural ingredient that comes from birch trees and corn and can be found in many products around the world.



We have used a few products with Ian that I feel very strongly about. I have been fortunate enough to speak with the companies, access their research as a dental professional, and put them to personal use.

~ ~ IAN’S PRODUCTS ~ ~

Tanner’s Tasty Paste: fluoride or fluoride-free

  

[ Child, could be used by adult ]

Tanner’s Tasty Paste is Ian’s toothpaste. We use both one with fluoride (bedtime) and one without fluoride (morning). We only use the fluoride toothpaste once a day to prevent him ingesting too much fluoride since his spitting skills are still a work in progress.

********* 
I will not be getting into a fluoride discussion in this post. Everyone has their own opinion about fluoride and I will easily get onto my soap-box, or shall I say “fluoride-box” if I don’t avoid the discussion entirely. 
*********

The xylitol in the toothpaste (both kinds) helps increase the pH in the mouth. The nice thing is, xylitol doesn’t just increase the acid for the immediate brushing, but for quite a while afterward. While the research differs on the exact amount of time. It seems that the pH is stabilized for at least 30 minutes..... or until eating or drinking again. 


Ian really likes the Tanner’s Tasty Paste. It comes in fun flavors and the tubes are bright and fun. We purchase it from his dental office, but it can also be purchased online. This pediatric xylitol toothpaste cannot be purchased in the stores..... but it is not a prescription.

You can purchase them directly from their website, or online stores like Amazon.


CariFree CTX 3 Gel: fluoride-free
CariFree CTx3 Gel



[ Child, could be used by adult ]

We have been using this product since the second week Ian came home from the NICU. It has been our LIFESAVER in my wholehearted opinion. I absolutely cannot recommend this product enough. CariFree is a company that makes an entire line of adult and child dental products: tooth gels, mouthwashes, and even candies and gum..... all made with xylitol. This product happens to be fluoride free. This means that the child (or adult) does not have to spit it out. It is safe to swallow. This product’s xylitol acts the same way as the Tanner’s Tasty Paste. The xylitol helps neutralize the pH in the mouth to help protect against decay and erosion causing acids.

We use this gel at bedtime. After Ian has brushed his teeth, and is getting ready to climb into bed, we take a pea-sized amount and rub it around on his teeth. As it gets thin and watery in the mouth, it reaches all the nooks and crannies. You don’t need to worry about covering every itty-bitty surface. It comes in grape and mint flavors. There is also a special one for adults. Ian swallows this small amount of product. It gives him erosion protection from acid reflux at night while he is reclined and sleeping. 


Ian does sleep in a semi-upright bed called a ComfyLift bed, but we still feel strongly about using this product overnight. This is not a cheap product (about $15 for a 2 ounce tube) but it will last you six months or so. It is some of the best money I have ever spent. This product also needs to be purchased on their website, or on a store such as Amazon. Once again, it isn’t available in stores, but is not a prescription product.


MI Paste (GC America): fluoride or fluoride-free 


[ Child or Adult.... monitor Child usage of PLUS product ]

This is an entirely different type of product. MI paste has milk casein in it (milk protein). This is not for children/adults with milk allergies. Lactose intolerance is not a milk allergy. Those who are lactose intolerant can safely use MI Paste. MI Paste come with (PLUS) or without fluoride. We used the fluoride-free product with Ian because it was safe to swallow. We have been using this product less now, as Ian seems to like using the CariFree gel better. For a while we were using the MI Paste in the morning, and the CariFree gel at bedtime, after toothbrushing. 

MI Paste - No Fluoride

MI Paste PLUS - with Fluoride

The MI Paste is manufactured by a dental company called GC America. They only sell to dental offices and companies, so it makes it harder to come by. Your dentist would need to purchased this product and then sell it to you. I have been unable to find it available online for patient’s to buy directly other than eBay. If you feel comfortable checking with your dentist and purchasing it there, power to ya!

The tube is just over an ounce, but will last you three to six months depending on how much you use. Once again, we only used a small pea-sized amount and applied it exactly the same way as the CariFree gel. This is a cream-like consistency and takes longer to liquify and dissolve in the mouth. Some patients report a thick-feeling coating on the teeth. However, I feel it is always important to weigh the pros and cons. you can decide for yourself. 


The technology of the product is ingenious! It uses a technology called Recaldent. Recaldent is a combination of the milk protein casein product (casein phosphopeptide (CPP)) and calcium (calcium phosphate (ACP)). Together they are called CPP-ACP. This technology binds calcium and phosphate particles to the tooth surfaces to not only help protect against acid, but it even goes as far as to help restrengthen enamel and mineralize it again. (A side FYI, Recaldent technology can also be found in Trident Xtra Care chewing gum- hence the old TV commercial of kids chewing gum and saying they are fighting cavities. Older children could also chew this gum to help prevent erosion and remineralize enamel).


Xlear Nasal Spray: fluoride-free


[ Child or Adult ]

Xlear is a very large company. They make a variety of products including sprays, candies, gums, toothpastes, and even xylitol packets (a sugar substitute) that can be used for teas, cooking, etc. They also manufacture Spryy, Spark, and Xylosweet. We have always used their nasal spray for Ian. It is the same spray that the adults use. It is a mixture of xylitol and saline. We have been using this with him for years.

It is a multi-purpose product for him. We even use it to keep his nasal passages and throat clear of mucus and congestion. It even helps minimize the excessive mucus produced by his vagus nerve damage from his fundoplication. We do use it for minimal dental benefits. Inevitably, as the spray passes through his nasal cavity and down his throat, some of it travels into his mouth. Ever notice how you can taste your nasal sprays when you use them? ....... exactly! The xylitol in his throat also helps minimizes acid as it refluxes up into his mouth. By using this product for respiratory benefits, it also helped considerably with his ear infections and glue-ear. Parents who use this product swear their kids practically never get sick, have ear infections, or allergies. Under normal circumstances, I would agree with them....... for Ian, it made an enormous improvement, but couldn’t keep in completely in the clear (haha, pardon the pun!). 


* Small Squeeze Bottle & Small Pump Spray *


* Child Friendly Package of Small Squeeze Bottle *

* All three of these bottles are the same product * 

Ian has shown great improvement in oral and respiratory health with Xlear. We plan to continue using it even if he does not show clear signs of reflux. You never know what acid may be creeping up.



** Any of these above listed products could be used by adults or children **


~ ~ OTHER PRODUCT OPTIONS ~ ~

CariFree’s CTx4 1000 gel toothpaste or
CariFree CTx4 5000 gel (not a toothpaste):
both have fluoride 

[ Adult ]



These products work in the same manner as Ian’s CTx3 gel


Sensodyne Pronamel: fluoride


[ Adult version or Child version ]

Pronamel helps prevent erosion through a better availability of fluoride to strengthened weak enamel (which I am still waiting on a verification phone call about). Availability of fluoride in a toothpaste is just as important as the amount of fluoride. Without access to research however, it is practically impossible to know which toothpastes have higher availability (usable fluoride) fluoride. 

Adult Pronamel

Think of it this way... your body can only absorb 600 mg of Calcium at a time... women need 1200 mg or so a day... you cannot take all 1200 mg at one time because only 600 mg of that is “available” to you... you pee the other 600 mg out... so you took 1200 mg, but you really only got 600 mg... you need to take 600 mg or less at least 4 hours apart. The topical/surface availability of fluoride on the tooth surface is the same, although I am not sure about the numbers and timing on fluoride. This does not mean that fluoride is absorbed systemically throughout the body.  I believe Pronamel allows for a greater available delivery of fluoride to the tooth surface at one time to help prevent acid erosion.

There is even a children’s version of this product (which we have never used). I believe the children’s toothpaste is much harder to come by and needs to be ordered from an online store. I have never seen it on the shelves.

Children's Pronamel


Tom’s of Maine products: fluoride or fluoride-free 


[ Adult or Child ]

Tom’s of Maine products typically have xylitol in them. Therefore, they would help prevent and treat erosion the same way that the Tanner’s tasty Paste and CariFree products do. Tom’s of Maine products also have other natural ingredients and rarely contain chemical compounds. I am not saying this is either good, or bad, just saying. Their children’s products do not have xylitol to prevent erosion in them, only the adult products. Both their adult and child products can be purchased with or without fluoride. 

Children's toothpastes come in Fluoride & Fluoride-Free Options

 




** There are too many other products to name them all. Speak with your hygienist or your dentist if you have questions about acid erosion and what products best help you. **



ROUTINE BRUSHING

All adults and children should brush their teeth twice a day (morning and night) for two minutes each time. Brushing after each meal is ideal. This provides enough exposure to manual bacterial removal and cavity-erosion preventing ingredients to be efficient. Most studies show an average brushing time of 30 seconds! There are so many toothbrushes, toothpastes, floss, and mouthwash out there that it is tough to make good decisions. It is important to always discuss your situation with your dental hygienist or your dentist. 

Sonicare for Kids Toothbrush:
Sonicare for Kids Toothbrush


We personally use a Sonicare Kids power toothbrush for Ian. I love the way the sonic technology reaches every possible crevice and space in his mouth. Ian’s sensory input craves the vibrations. he loves the brush. Regardless of what toothbrush you are using (adult or child), always remember to brush the inside of your cheeks carefully, as well as the roof of your mouth and your tongue. A lot of bacteria live there and can dirty your freshly brushed teeth!

Sonicare for Kids Toothbrush


***** If you ever have any questions about ingredients (because not all websites give lists of product ingredients), I have found Drugstore.com always has an ingredients tab on each product page. I often go there just to check on ingredients and the order they are in. Ingredients are always listed from highest quantity - to lowest quantity. In a perfect world, xylitol is listed in the top three ingredients. 


WAITING GAME

One more * very important * thing to mention about acid and the mouth. If you know there is or has been acid in the mouth at the given moment, wait five minutes before doing any brushing or rubbing. Do nothing that exerts pressure on the teeth! It is best to let the acid neutralize a bit first by swishing with water or placing on of the gels on gently. Do not rub, smear, or brush anything onto the teeth. All this does is scrub the acid into the teeth while you are trying to neutralize it. After five minutes or so, then brush your teeth with an acid neutralizing fluoride or xylitol toothpaste. This is especially true with vomiting. We have all been so ingrained to brush right after we throw-up, etc, that we instantly want to scrub all that nasty stuff out of our mouths. I know it is very tempting, but please try and refrain, for just five minutes.

This same thing holds true for severe reflux and high acid beverages. It would not be the smartest thing to finish a glass of wine and then immediately brush your teeth. Use some water, or one of the gels above to help neutralize the acid so you are not scrubbing it into your teeth.

~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~


THE BOTTOM LINE

If you take nothing else away from this incredibly lengthy post, please remember these few things:

1)  Reflux, vomiting, foods, beverages often drop the pH of the mouth below 5.5, which causes erosion of tooth enamel. Over time, this frequent exposure can do serious damage to teeth and cause sensitivity and decay. 

2)  There are products that can help prevent and manage tooth erosion. Xylitol, fluoride, and calium can help prevent erosion and even put minerals back in weakened enamel. (This is not regrowing enamel). 

3)  From a personal standpoint....... chronic, severe acid reflux can cause serious damage to the teeth. Once enamel is gone, it cannot be regrown. Even silent reflux can be very harmful. Please do what you can to help protect your child’s teeth at a young age if they are suffering from these issues. This goes the same for adults too. 

4)  This site provides a nice article overview or erosion. Even though it says for dental professionals, I believe we all can take away some good facts from this article.

Acid Erosion for Dental Professionals


When you have a child like Ian who vomits frequently and struggles with daily reflux, it is important to protect their teeth. We have been on this from day one, and it has made all the difference in the world. I am always happy to help answer any questions and I thank you for allowing me to be a small part of your medical journey!








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