DentalBuzz: a jolt of current

trends, innovations, and quirks of dentistry

Crest toothpaste embeds plastic in our gums

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This is polyethylene:

bottlesandbags

Did you know that polyethylene is the most common plastic in the world? It is used primarily for containers and packaging, such as these bottles and plastic grocery bags, and has been a concern for the environment because polyethylene lasts practically forever and isn’t biodegradable. It only breaks down into smaller and smaller particles until you can’t see it anymore. That’s why a couple of states are trying to ban it in body scrubs and dental products.

This is also polyethylene:
PeasizedTPaste

Well, not all of it. Most of it is toothpaste. But do you see those blue specks? That’s plastic. This is the suggested pea-sized amount that you should use when you brush your teeth. Yes, there is plastic in this toothpaste.

Want to see how many pieces of plastic are in this exact sample?

PasteSmear

Not that I’m counting the bits but that seriously looks like A LOT of plastic… err…high density polyethylene. That’s what plastic trash cans are made from! If you throw away the box like most people do, the ingredients aren’t actually listed on the tube (sneaky, sneaky, Procter & Gamble!) However, I was able to track down the box here at this link. We’re not talking about polyethylene glycol, which is soluble in water. This stuff won’t dissolve in water, or even acetone or alcohol for that matter. How do I know it won’t dissolve? Because I put on my little scientist hat and tested it.

Like many of you, we often let our daughter pick out her own toothpaste at the store. She liked the tween vibe of this particular product so much that she chose it twice, but eventually the squeezed-out tubes ended up in the back of her toothpaste drawer.

Crestforme

When I first got wind that plastic was in some toothpastes, it was kind of exciting to realize that we had some on hand! And a bit concerning, because, after all, this is in my own home, used by my own child. Able to confirm that, sure enough, there was polyethylene in this toothpaste, I squirted out a pea-sized sample, mixed it up with some water, strained out the undissolved particles and let them dry on a paper towel. Oh, and I used a hair dryer to speed things up because I’m impatient. Then I shook approximately half of the sample into each of two pyrex bowls and added some household solvents:

acetonealcohol

They didn’t dissolve in the acetone, (nail polish remover) or in the alcohol either. I even left the samples in the solutions overnight, then re-hydrated them. No change in the particles.

specks1polyethylenefinger

So it has been established here that polyethylene will not dissolve in the mouth, or even in household products. It is an inert substance, which means that it doesn’t change at all. You know, that’s pretty good in some ways, because at least it’s probably not morphing into big blobs of plastic evil cancer bait.

Here’s where the story gets scary, though.

You see, I’m not just a concerned mom. I’m also a dental hygienist. And I’m seeing these same bits of blue plastic stuck in my patients’ mouths almost every day.

Around our teeth we have these little channels in our gums, sort of like the cuticles around our fingernails. The gum channel is called a sulcus, and it’s where diseases like gingivitis get their start. A healthy sulcus is no deeper than about 3 millimeters, so when you have hundreds of pieces of plastic being scrubbed into your gums each day that are even smaller than a millimeter, many of them are getting trapped:

plasticingums

The thing about a sulcus is that it’s vulnerable. Your dental hygienist spends most of their time cleaning every sulcus in your mouth, because if the band of tissue around your tooth isn’t healthy, then you’re not healthy. You can start to see why having bits of plastic in your sulcus may be a real problem, sort of like when popcorn hulls find their way into these same areas. Ouch, right?

Like I said, I’ve been seeing these blue particles flush out of patients’ gums for several months now. So has the co-hygienist in our office. So have many dental hygienists throughout the United States and Canada who have consulted with each other and realized that we have a major concern on our hands.

This is what an actual polyethylene speck looks like when it’s embedded within the sulcus, under the gumline:

gingival specks

I am not saying that polyethylene is causing gum problems. I’d be jumping too soon to that conclusion without scientific proof.  But what I am saying definitively is that plastic is in your toothpaste, and that some of it is left behind even after you’re finished brushing and rinsing with it.

Do you want plastic in your toothpaste? So far the only mention of polyethylene on the Official Crest website at this link is that it is added to your paste for color, not as an aid in helping to clean your teeth or to disperse important anti-plaque or anti-cavity ingredients. [Note: as of 9/3/14 Crest took down the link about polyethylene, but I saved a copy of it here in case this ever happened.]

In other words, according to Crest:

Polyethylene plastic is in your toothpaste for decorative purposes only.

This is unacceptable not only to me, but to many, many hygienists nationwide. We are informing our patients. We are doing research separately and comparing notes. And until Procter & Gamble gives us a better reason as to why there is plastic in your toothpaste, we would like you to consider discontinuing the use of these products.

Here are some of the brands (click each to see their ingredient list and labeling) that we currently are aware of which contain polyethylene:

What you can do

At this point, it’s probably best if you leave your flaming torches back in the barn. We’re not going after witches or Frankenstein here; you’re using your power as a consumer to send a message that you do NOT want plastic in your toothpaste. Heck, you might even be worrying about what may happen if you or your children swallow some of it.

1. If you’ve already purchased one of these toothpastes you can take it back to the retailer where you bought it, make sure that the manufacturer knows why you’re returning it, and ask for a refund.

2. Lodge a Crest consumer complaint at (800) 959-6586 and report an adverse health effect, namely, that you’re concerned that plastic pieces may be getting trapped in your mouth.

3. Click here to send an email to Procter & Gamble, the makers of Crest.

4. Share this! Let your friends and family know that you are also concerned about the plastic in their toothpaste by clicking on your favorite social media link below and getting the word out.

Response to criticism

Procter & Gamble’s current party line? “We will discontinue our use of PE micro plastic beads in skin exfoliating personal care products and toothpastes as soon as alternatives are qualified.”

And your response then may be, “I will discontinue MY use of Crest toothpaste until there are no more decorative microplastics entering my mouth.”

Trish Walraven RDH, BS is a mom and practicing dental hygienist in the suburbs of Dallas, Texas. She is also the co-creator of BlueNote Communicator, the top selling intra-office computer messaging system for dental and medical offices.

References and acknowledgements

Plastic Trades Industry: http://www.plasticsindustry.org/AboutPlastics
US National Library of Medicine: http://dailymed.nlm.nih.gov/crest
HygieneTown: http://www.hygienetown.com/blue-dots-in-patients-mouths

And a HUGE thank you goes out to my friend and colleague Erika B. Feltham, RDH for bringing this problem to our attention and for her extensive research. Erika is dedicated to providing the best possible care for her patients. She has been active in the dental profession for over 30 years, is a recipient of the 2008 American Dental Hygiene Association/Johnson and Johnson Hygiene Hero Award, the 2010 RDH Sunstar Americas (GUM Dental)Award of Distinction, lectures extensively about the harmful effects of sour candies, energy and sports drinks, and along with her San Diego component, she is responsible for presenting the resolution on sour candy labeling at the 2009 CDHA House of Delegates.

Update on 9/10/14:

As requested, here’s a quick video I made today that demonstrates polyethylene microbeads becoming embedded after brushing. This is for real; I didn’t poke the plastic in my gums (although I may have brushed a little more rough than normal!).

Update on 9/20/14:

This story got picked up nationally over the past week, with these notable entries:

The American Dental Association issued this press release regarding the safety of plastic in toothpaste and whether or not to remove the ADA Seal of Approval on Crest products.

FDA says that plastic is not approved as a food additive: NBC National News – Today Show

Interview in Phoenix, AZ  mentioning the influence of DentalBuzz on Procter & Gamble:

Trish’s interview on Good Morning America:

http://abcnews.go.com/video/embed?id=25560562

Brian Williams on NBC:

http://player.theplatform.com/p/2E2eJC/nbcNewsOffsite?guid=nn_09_bwi_toothpaste_140917

A concise writeup at the Washington Post

And a final word on why we shouldn’t even be so preoccupied with toothpaste in the first place:

https://www.dentalbuzz.com/2014/12/30/toothpaste-can-do-more-harm-than-good/

An interview with the Duck Dynasty dentist

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Courtesy of A&E Television Network.

Not too many dentists are portrayed positively in the media, we all pretty much know that. Even when something so routine as a third molar extraction becomes fodder for reality TV it becomes as heinous as possible. Oh, and thanks, sound teams, for when you add that special bone-cracking celery effect during tooth removal. You really help the cause there.

Want to know why I think that this dentist is truly one of the good guys? Not only was Dr. Kevin Finley, DDS gracious in accepting an interview request a few days after his appearance on the A&E Network, he was able to work it in amongst…get this!….fooling his whole dental team into thinking they were working, but he had secretly booked the day full of fake patients and instead thrilled all of them with a birthday party, complete with a shopping spree, a scavenger hunt, fine piano bar dining, board games (with big fat bills for winning!) and an early send-home. That takes heart. So thank you, Dr. Finley, for doing your best to make dentistry go well on TV, and for being the kind of dentist that everyone wants to work for.

With that said, here’s our conversation:

DentalBuzz: It’s intriguing to see a dentist doing a little bloodletting on unscripted television, especially on a show that’s as popular as Duck Dynasty. How long have you known the Robertson family?

Dr. Kevin Finley: I have known the Robertson’s for over 25 years. Phil has been a patient in the past. Korie has been a patient for over 10 years and her children have been patients since their first dental visit.

DB: So Willie’s not a patient? Why not?

KF: By his own admission, he does not like going to the dentist. Korie says that she is going to get him in sometime. They do seem to be very busy people.

DB: Maybe it’s time for a dental intervention! Or at least a postcard. Speaking of postcards, Wal-Marts all over the country seem to have postcards and everything else, for that matter, branded to Duck Commander this and Duck Dynasty that. Is the whole town of West Monroe like that too? How has their success changed your community?

KF: It is important to know that Phil is a great businessman. The Duck Commander and the Buck Commander have both been fantastic businesses long before Duck Dynasty. Don’t let the beards and accents fool you. Phil ( and the rest of the family) are really smart and VERY hard workers. (Filming my part of the episode was more work than i could have imagined).

It appears that the entire community is elated that they are so successful. The old adage that “a profit is not without honor, save in his own city”, does not apply here. We all love the Robertson family and they have brought nothing but positive influence to our community. It is no secret that they are Christians and they are not ashamed of who they are. They proclaim their love for God, their family and their country. They really are a phenomenal family. That being said– the business of Duck Dynasty has been great for our community. It is fantastic to see the local West Monroe police having to direct traffic in and around their store because people are coming here from all over the place.  Duck Dynasty has put West Monroe Louisiana on the map, so to speak.

As for Wal-Mart, it is not an easy thing to get your products in Wal-Mart, they, too, are great business people and they know what sells. I can honestly say that the success of the Robertson family has been a wonderful benefit to our community.

DB: It gives a whole new meaning to living one’s faith, huh? They get to be who they were meant to be and lift everyone else around them up in the process, including all their TV viewers and fans. Which brings us to how they’ve elevated your world for a while, at least. In last week’s episode you extracted the third molars of both John Luke and Sadie in the same day. That’s eight teeth in front of a camera crew! No pressure, right? What was that like?

KF: It is unique to human nature that if you know a celebrity, it kind of makes you feel special– sort of like a celebrity yourself. I got to feel famous for about 1 minute. As a side note, when I have gone to dental meetings and met other dentists and they find out I live in West Monroe, Louisiana, they all ask if I know the Duck Dynasty family. I tell them that I do and that some of the family are patients of mine–they usually look at me kind of sideways and say “that’s great”, but all the while thinking that I am lying.

I really love to see success stories, especially in person, and is even more of a thrill to be asked to participate in their story. You would have to know this family to really feel what I am saying. As to the treatment, I have been in practice for 29 years and the dentistry itself was quite normal for us. I remember from dental school reading in our oral surgery textbook that “wisdom teeth Courtesy of A&E Network. extractions are easy, except for those that aren’t”. I really didn’t know what that meant until I did my share of third molar extractions. They either come right out in a few minutes or it’s “hold on to your butts”, we are going to be here for a while. Usually on teenagers, the surgery goes very well, as was the cases for John Luke and Sadie.

I guess if I was going to have any anxiety it would be with the anesthesia–we all know that the unexpected can happen and we would not like it to happen while parents were in the room or while the filming was going on.  As it turned out, thanks to Delvin Price our Certified Registered Nurse Anesthetist, who is off the charts amazing, conscientious and caring, and our wonderful dental assistants, Frances and Kim, the Robertsons went to sleep, stayed asleep for their procedure and woke up when it was over, only slightly worse for the wear. I would call this quite a successful operation! Of course, after they woke up, then the real fun began, as you saw on the show. I can’t say enough good things about this family and my life has been enhanced just by knowing them—regardless of how famous they may be.

DB: Fame and good fortune sometimes goes to the right people, that’s what it sounds like you’re saying. As an insider looking out (because after all, you do live and work in the Beard Bubble there!) your experiences with the Robertson family seem to explain their phenomenal success to the rest of us: Duck Dynasty is not so much about characters as it is about character.  Thank you, Dr. Finley, for sharing a juicy little slice of what it’s like to be a dentist in the middle of reality TV.

So there’s a final serious answer everyone wants to know about working with the Robertson family: How have you and your team ever managed to do dentistry through all that facial hair?

KF: (crickets chirping).

 

 

Didn’t catch this episode of Duck Dynasty? You can watch it now in its entirety by clicking this link to the A&E website: John Luke After Dentist

 

Also a BIG hug goes to my friend Eva Watson, RDH for pushing the interview button. Thank you, awesome woman!

Why your fingers shouldn’t be in the picture

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handinmouth

“Just this once; it’s okay.”

Does that sound like your practice? You know, you have a gaggy, bouncy kid who’s just about to tongue-thrust their way out of having those radiographs taken, but here comes Amazing Assistant to help you get a diagnostically acceptable image. SCORE!

The problem is that this never happens “just once.” I’ve seen the same person holding sensors in patients’ mouths dozens of times, and that’s when it becomes a problem. Yes, radiation is safer now that we’ve dialed it down and collimators make sure that there’s nothing scattering beyond the focused beam, but that doesn’t mean that we should be flippant about limiting exposure to our patients and most importantly, ourselves.

My best friend from high school could tell you not to hold those films in people’s mouths, too. She was a dental technician in the Navy and also worked for years in pediatric dental offices and orthodontics as an assistant, calming nervous children, helping them to have good dental experiences, and when she was exposing radiographs, sometimes she admits that she would make it easier on everyone if she would stay with the child while the x-rays were beaming through her hand.

She doesn’t have to tell you not to hold the films, though. She can just show you why you shouldn’t:

KKBWhand2

This is her right hand. Several years ago when she was doing laundry her finger caught on the dryer and “snapped.” This is important, sort of like when your patient tells you exactly what they were eating when their tooth broke – don’t you pay that the most attention of all? Because it was the darn dryer that was the problem….(!) Let’s be serious, though. Like you, her doctor really didn’t care what broke her finger, he wanted to know why it broke.

Turns out that she had developed a giant cell tumor in the first (proximal) phalange of her ring finger that had eaten everything except a small sliver of bone and that was what had snapped. These are very, very rare in small bones like those found in our fingers; most osteoclastomas happen in the larger bones like femurs and such. Hmmm.

Even though the tumor was benign, because of the damage done, the possibility of regrowth and other factors, the decision was made for my friend to have her ring finger amputated. I would have had her flip you the bird for effect but she no longer has a middle finger either…! (think about it…!)

So she was fortunate enough to stay in dentistry as a patient care coordinator for a few more years as she recovered but is now working towards her master’s degree for speech pathology. While she doesn’t seem totally convinced that excessive radiation exposure caused her to lose her finger, she doesn’t count it out for even a second.

And neither do I.

Losing a finger may be anecdotal evidence about the dangers of radiation, but it’s enough for me to feel like enforcing what we already know to be true.
 
DBSmile1
 
 
Please share this story with those you care about, even if it makes you feel like the Radiation Nazi.

A plea to use DMG Icon infiltrant

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Don’t you think that this is the WORST part of orthodontia? You take off the brackets and voila! Straight teeth… with fugly white squares where acid beat the $#!† out your patients’ anteriors. And NOW you have to go drill on their teeth, destroying what you so carefully tried to perfect.

Once you’re here there’s no use in blaming the patient; it’s not like they’re going to get the brackets put back on to cover the white spots and then get more decalcification there. Yes, you should help them with their lifestyle choices (less energy drinks and voluntary mouth breathing, please) but at this point you have to do something to make them look better.

As a hygienist I’ve been totally itching for about the last four years to get the go-ahead to use a relatively new product called an infiltrant. There’s only one, it’s made by DMG and it’s called Icon. This infiltrant is placed on the tooth where it seeps into smooth-surface lesions that haven’t fully cavitated (although if you ask me the ones in the “Before” picture above look way gnarled out) and pretty much does a little remineralization voodoo.

I’d hoped that it would be classified as a sealant because Yay! I can do sealants. There’s no drilling done, right? There’s nothing taken away, right? There is, however, some irreversible improvement made to the tooth though and that (plus a significant etch time) means that when the CDT recognized that an infiltrant needed a code, where did that boom fall? Smack dab into Composite Land as a D2990. I know. The wording says “placement of an infiltrating resin restoration for strengthening, stabilizing and/or limiting progression of the lesion” and that SCREAMS prevention. Alas there’s the other word. Restoration.

Dangit.

Another problem is that this stuff is very expensive. See what it costs here for the mini kit for a maximum of six lesions?

That’s at best, $27 per tooth just for the kit (not including your other overhead or minusing the limited-time Amex card!). The suggested cost to a patient should be somewhere between your one surface composite fee and a sealant fee, and conservatively it takes at least 20 minutes of intense doctor time to place an infiltrant on a single tooth. Composites don’t cost that much or take that long to place so you know what that means, right? THE FEASIBILITY OF ICON SUCKS.

I really hope I’m wrong, but to most doctors, what’s a few millimeters of drilled-away tooth structure? Minimally invasive dentistry is for anal retentive freak dentists anyway. And every hygienist who has ever had a passion for preserving tooth structure, including me.

So yeah, this is bad news for Icon and for DMG, really. Sure, they got a CDT code this year but it’s not like anyone is going to use it. There’s like one dentist in a 5o mile radius that’s even ordered it around here. I know this because you can look on the DMG patient portal here and find a dentist that offers Icon in your area.

I have a challenge then. Actually two challenges – one for dentists, and the other for those who want to see this service added to the hygienist’s scope of practice in every state.

•If you’re a dentist and you love saving teeth, JUST DO THIS. Charge what you must, you’re not going to get rich, but you will have the warm fuzzy feeling that you’re doing the right thing by preserving tooth structure. We all know composites and amalgams eventually fail around their margins. There are no margins with an infiltration, just a lovely, arrested half-moon where an incipient lesion never progressed if you follow up with radiographs two decades from now (I may be exaggerating, but maybe not!). Go here, learn more, buy some.

•Those of you who are frustrated with dental hygienists wanting to become these mid-level providers that are supposed to help in low-access areas but will probably just come take your job away from you (I keed! I keed!) please support the use of infiltrants by hygienists. You will still need to diagnose that the treatment is needed but the service should be able to be delegated because of the very nature of the care being provided and the labor intensity needed for this smaller ROI.

As a realist, I don’t see squat happening as a result of this challenge. What can one blogger do? I have these silly dream glasses, when I put them on and see the future, well, there are no more cavities, on anyone, except arrested ones, and all the dentists are happy because all they have to do is play on the computer and nod their head every so often while their hygienists prevent all dental infirmities for ever and ever. Then I take them off again, and I see white spot lesions on teeth.

And I say…..dangit.

DBSmile1

Thanks to Dental Products Report and The Catapult Group for this review of ICON from DMG America: http://www.dentalproductsreport.com/dental/article/review-catapult-group-delves-details-icon-dmg-america

Patients can keep on smoking?

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by Trish Walraven

Stanky Moufs, Stanky Moufs, I want to rid the world of Stanky Moufs. When a patient sits down in a chair with a freshly-stanked cigarette mouf, that smell hangs in the operatory longer than their jacket.

Is the American Lung Association with me? NO! Maybe it’s because they’re still getting a part of that $206 billion settlement from Big Tobacco back in 1998. Can’t put their sugar daddy out of bidness.

Well then, is the government with me? Not really. The government wants to tax those stanky moufs for recreational nicotine use, and they want to regulate the patches, gums, and lozenges being sold as medical devices designed for smoking cessation.

How many smoking patients do you have that don’t want to quit? They’re not supposed to admit to you that they really love smoking, now. Especially not to you. But more and more of them are coming into my practice, breaths a-bloomin’, tissues pinkin’, and when I ask them if they quit smoking, they don’t say yes. They say that they’ve switched to e-cigarettes.

RRRrrrRRT ( that record scratch stop noise that’s used too much in media but I can’t help myself). WHAT THE?  WHAT IS AN E-CIGARETTE?

I Gurgled it. Gurgling is kind of like Googling except that you ask your patient an open-ended question while they’ve got a little spit in the back of their throat that they really don’t have but they think they do and they want you to suck it out before they answer the question.

Best answer I got: “Well, everyone in our office either got a supply of E-Cigarettes if they would quit using regular cigarettes, or $200 to use on themselves if they weren’t smokers.” An employer has gone out of their way to get tobacco out of the bodies of their workforce. This sounded BIG.

That’s when the internet got much more handy than Gurgling. Here’s a great description of an E-Cigarette from AlterNet:

The e-cigarette was invented in China in 2004. It’s a cigarette-shaped tube that contains a rechargeable battery, a mini-vaporizer, a small reservoir, sensors and, in most cases, a light on the tip. The sensor notes when you take a drag on the tube and turns on the vaporizer, which more-or-less instantaneously turns the substances in the reservoir into a stream of visible water vapor that mimics the taste and feel of tobacco smoke. The tip glows like the end of a lit cigarette with each drag. It’s infused with the taste of tobacco – or tobacco combined with other flavors for those who are into that sort of thing – and nicotine, in various doses (including none at all). The refill cartridges – which look like the butt of the cigarette–give you about the same number of drags as a pack of cigarettes, but cost around $3 each – a bit more than half the national average and a third of what a pack of smokes go for in places like New York City.

The next question everyone asks is “Is it safer?” (I must stop with the Marathon Man references…this is only my second offense, sorry!). But really. Are e-cigs safer than tobacco? I for one am totally convinced that they will kill you much, much slower than tobacco, and far slower than water (if you’re drowning in it, of course). It’s the combustion that creates the majority of carcinogens found in cigarettes, which is why no real smoke is safe. The vapor ingredients in an e-cigarette – propylene glycol or glycerin – are Generally Recognized As Safe (GRAS) by the Food and Drug Administration. The problem arises when you don’t know what else is being added to the cartridges. Like Cialis. No joke. You can get some Cialis to smoke in an e-cigarette here. What about a dangerous, banned weight loss drug? They’ve got that too.

These extreme additives are all the excuse that e-cigarette opponents need to try to get them banned in the United States. That’s why no one will touch this issue, especially with the FDA coming down hard on new tobacco products in March. The federal courts are leaving it alone for now, but arising is a vast current of e-cigarette fanboys. They call themselves Vapers, and their recreation? Vaping.

What do you prefer? Stank Mouf or vape mouth? If your patients are committed to their cigarettes, it might not be such a bad idea to turn them on to something that may do less harm than their current habit.

I don’t know about you, but my ops are smelling better already. 

UPDATED 2/21/19: The CDC has an infographic with a few surprising current statistics about e-cig usage. You can view it here:

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-Cigarettes-Infographic-p.pdf

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