Hang on, let me put my teeth in

I am hoping that this will be a short blog post but I seem to have an innate ability to waffle for extended periods of time about the most simple of topics and have in fact been penalised many a time for going over word limits so I will try my best!

When I started smiles—better, I decided I would only discuss subjects that I thought would be helpful to people rather than it just being another site of definitions/a rip off of Wikipedia, and so I had planned to stay away from the basics ins and outs of dentistry however after seeing possibly the most horrific and misleading piece of advertising since L’oreal used Cheryl Cole in a full face of make-up to promote their “no need for make-up” skin care, I decided that the topic of dentures needed to be approached.

I hereby call upon the British Dental Health Foundation:

What is a denture? (they even did the heading for me!)

“People wear dentures to replace lost or missing teeth so they can enjoy a healthy diet and smile with confidence”.

Now, my idea of the picture of health involves many green crunchy foodstuffs (I’ve always wanted to use that word) such as apples/celery and high protein items like nuts and steak. Now granted, I have only had 6 and a bit years of experience listening to people WHINGE AND COMPLAIN about their dentures, but I can pretty much guarantee that no one with a denture can successfully eat any of the aforementioned food products unless they are put in a blender first. Herein lies the first major flaw of dentures.

Sadly, adverts such as the one I spoke about in the intro, and that awful one where the man and the woman go apple bobbing and you have to guess who is wearing the denture (I wish they would tell you, or write it upside down at the bottom of the screen like in magazine puzzle pages where you have to spot the difference between the 2 pictures of Miley Cyrus, it continues to bug me that I don’t know the answer) are extremely deceptive and lead to people thinking that dentures are in fact an adequate replacement for natural teeth. At this point, I feel the following statement would help.

DENTURES ARE NOT REAL TEETH. THEY ARE PLASTIC. THEY DON’T HAVE ROOTS. THEY HAVE PLASTIC BOTTOMS WHICH REST ON GUM. (METAL IF YOU HAVE A DENTIST THAT IS FEELING PARTICULARLY RICH THAT UDA YEAR more on that later). THEY BASICALLY FLOAT IN YOUR MOUTH AND THUS ARE IN NO WAY LIKE YOUR NATURAL TEETH FROM “BACK IN T’DAY”

Annnndd exhale.

Time for everyone’s favourite bit; some anatomy/theory.

This is what mouths look like when teeth are lost. The picture on the left shows only some teeth missing whilst the gentleman (I’m assuming it’s a gentleman otherwise it’s a very stubbly lady) has sadly lost all of his teeth and is what we call, edentulous.

What I am trying to demonstrate here, is that a plastic pre formed surface fits against your gum. Your gum is squishy. In some people (usually those who have lost their upper teeth but still have some lower front teeth) their gum is particularly squishy. We call this “flabby ridge” (seriously, its in text books and everything). It is for this reason that the advert I mentioned right back at the start made me so furious. I have inserted the link below should any of you wish to subject yourself to some irritating American advertising.

What makes me most angry is that she suggests using Fixodent will stop your denture moving ENTIRELY. This is of course absolute rubbish. It will be “stuck” to gum, which will move. Similarly, she is suggesting that this will work wonders in the lower jaw. Do a quick test for me, have a feel of the bottom of your mouth – the bit under your tongue. It is pretty much covered in saliva if not pooled in the stuff. Sadly Fixodent is not waterproof. Thus, you can put layers of the stuff on your denture and within minutes it will be washed away and so you might as well just squirt some of the tube in your mouth and swallow it and save yourself the hassle.

While denture fixatives are extremely helpful for things like upper dentures they are pretty much useless on partial dentures particularly in the lower jaw.

Back to the British Dental Health Foundation:

Why should I wear dentures?

“Full dentures, to replace all your own teeth, fit snugly over your gums.”

Misconception number 1: They should indeed fit snugly over your gums however the fitting surface of the denture is made of a hard plastic material, and your gums are not. They are soft. Especially if you suffer from my aforementioned favourite dental condition, “flabby ridge”. 

Thus as I explained above, you need to accept that no denture will ever fit you “snugly” in every position your mouth will ever be in. If we make the denture fit when you are biting full force, they won’t fit when you have your mouth relaxed because the gum will be a different shape – imagine pinching your cheeks. The shape your cheeks go when pinched is dramatically different to the shape they are naturally. The same applies to your gums.

Whilst I seem to be a painting a negative picture, it is only to emphasise that dentures do not stay in by how they are made. This is of course a factor, and if you have shoddy dentures then no amount of practice will help you, however it is all about how you control them. Just as people take time to adjust to an artificial limb, it takes time to adjust to artificial teeth. Fortunately the muscles of your mouth – including the cheeks and tongue – are extremely powerful. Over time, your tongue adapts to gently rest against the denture and hold it in place. I have seen people function with broken dentures because of their muscular control. Yes, someone came to me with their denture split into 2 pieces and they were continuing to wear and eat with it just fine. However it takes perseverance.

Partial dentures replace teeth that are missing and can sometimes be supported by the teeth you have left. If you have gaps between your teeth, then your other teeth may move to take up some of the space, so you could end up with crooked or tilted teeth. This could affect the way you bite and could damage your other teeth”

Another misconception was brought to my attention by the website link for the above info from the British Dental Health Foundation. http://www.dentalhealth.org/tell-me-about/topic/older-people/dentures. 

Those eagle eyed readers amongst you will notice the highlighted phrase “older people”. Firstly, what is “old”. There are many people I could offend by attempting to put an age on it, and therefore I shall play the “don’t shoot the messenger” card and allow someone else to take the flack. CBS Statistics Netherlands seem to define “old” as over 65. 

They reckon that 6 out of 10 denture wearers fall into this over 65 category. Which means that 4 out of 10 people with dentures are under 65 which is a fairly significant number to me.

The United States National Health and Nutrition Examination Survey, 1999–2004 has a slightly different slant.

Age	Mean Number of Permanent Teeth
20 to 34 years	26.90
35 to 49 years	25.05
50 to 64 years	22.30

The normal number of permanent teeth is 32 (including wisdom teeth which wouldn’t be replaced on a denture because as mentioned in previous blogs, they are fairly useless) and so let’s work on a total of 28 teeth. There is not really a minimum number of teeth to be lost before a denture is provided – sometimes a denture may be provided to replace one tooth, for instance if a front tooth is knocked out. Therefore, as you can see in the table, the figure for the 20-34 age group shows an average loss of at least 1 tooth. By age 49, the average amount of teeth lost goes up to just under 3.In the final category of 50-64 year olds the average tooth loss is slightly under 6 teeth. Which means that anywhere from 20-64 i.e. before hitting the ripe age of 65 (aka old), depending on the person and how many teeth they are happy to live without, any of these people could be provided with/be wearing a denture to replace the average 1-6 teeth they have lost.

Let’s view it another way

Characteristic	Percentage with no Remaining Teeth
Age
20 to 34 years	(not enough data)
35 to 49 years	2.63
50 to 64 years	10.13

The above table shows us how many of each age group have no teeth left and so are almost definitely wearing dentures. Again, as expected the largest percentage of people with no teeth is in the 50-64 age group, however this is still only 7/8% higher than the same figure for the 35-49 age group.

These are USA figures, but the UK percentages are fairly similar. The table below is from the most recent Adult Dental Health Survey conducted in 2009.

 

Again, whilst it shows that between 15 and 45% of those aged 65 and over have no teeth, 6% of people under 65 also had no teeth, which out of several thousand surveyed means several thousand people likely to be wearing dentures. Of course those with no teeth may also choose to have no dentures, and there are a variety of areas in between where there are some teeth missing and some teeth still present and therefore dentures would still be a viable option. In fact this idea is nicely summarised by the aforementioned survey “13 per cent [of people included in the survey] had natural teeth and dentures; 6 per cent were edentate with dentures; and less than 0.5 per cent were edentate with no dentures”

Now of course, I am not denying that the majority of denture wearers are in fact “getting on a bit” it is a horrible bias that leaves us dental folk in a very difficult position when we advise someone that their best option is to have a denture made for them, because they imagine the things their granny used to put in a cup by the side of her bed at night and the reality is that we can make things now that look pretty damn good. The problem is that dentures – however they are made and however fancy the practice you go to looks (imagine lots of glass panelling and flat screen tv’s) – are lumps of plastic. For this reason they will never be like the teeth you lost but as you will know from reading my implant post (which I’m sure all of you did) sometimes it is the only option left to you.

See next subheading.

Eating – or at least trying to.

Back to my favourite dental resource (the British Dental Health Foundation). They claim that dentures “will help you to eat comfortably”. Generally any dentist will tell you that pretty much every new denture patient they see will return within a fortnight saying “I just can’t eat with them in” or my favourites “oh the dentures are wonderful, I just take them out when I have to eat” which amuses me as why bother having dentures at all in that case?

The problem is that under the denture is squishy gum, and the teeth are plastic. The combination of these 2 things means that 1) when you bite into something the dentures move so you can’t apply the same chewing force that your natural teeth could apply 2) we all know how near impossible it is to eat with disposable plastic cutlery let alone try and cut into a steak and the same applies for plastic teeth.

Of course, there are exceptions to the rule like this fellow from a wonderful dental forum

“jroantree: I have just had top set 7 days ago. 10 teeth out, fitting 7 days before. follow up today with dentist 320 pounds, all done. I’m staying near Cape Town, come for a holiday and get your teeth fixed cheaper than UK. Eating chicken bread etc already."

Generally it takes practice. The same goes with speaking. Expect to lisp and slobber for a good few weeks after having your dentures fitted. If you are having your dentures fitted immediately after having teeth out (these are called immediate dentures funnily enough) then this will be increased because you are putting force and rubbing on a delicate area. This leads to soreness and an increase in saliva making it all more difficult so just give it time.

Now you have all the background info, I think that is quite enough waffling for today so I shall leave you with another of my favourite quotes from a dental forum.

"if any of you get a chance go have a look at the conditions some dental technicians work in, you might be shocked, particularly the cheaper/NHS part of the dental market. A lot is said of the poor, stressful working conditions of NHS Dentists, but dental technicians are a hidden, down-trodden profession”

Now before you all call the dental technician equivalent of the RSPCA I can assure you that I have met many of these poor down trodden fellows, and they are a wonderful breed and generally do not work in atrocity and squalor. Some of them even have radios on while they create their dental masterpieces.

Stay tuned for the next instalment when I go through how dentures are made and what to expect.

Reading and that

http://www.dentalhealth.org/tell-me-about/topic/older-people/dentures

http://www.cbs.nl/en-GB/menu/themas/gezondheid-welzijn/publicaties/artikelen/archief/2005/2005-1852-wm.htm

http://www.whatprice.co.uk/dentist/dentures.html

http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/ToothLoss/ToothLossAdults20to64

http://www.hscic.gov.uk/catalogue/PUB01086/adul-dent-heal-surv-summ-them-eng-2009-re11.pdf

http://www.steinerlabs.com/images/pre_op_arch.jpg

http://cdeworld.com/images/graphics/4469/lg/figure_23.jpg

http://www.youtube.com/watch?v=Sx4T7-V4wu0

My current rant topic: E Cigarettes

Even the writing of the above “product” as a title offends me. For those who have managed to bypass the tsunami of people walking the streets/sitting on public transport/your favourite restaurant with what looks like a tiny musical flute sticking out of their mouth, e cigarettes are the new “cool” way to smoke.

They are advertised as being the best thing you can do for your health and from the sheer volume of marketing bumph surrounding them you would think they were some sort of miracle that purified even the finest mountain air.

In this blog post I will therefore attempt to work out

1)      What the hell they are

2)      What the hell is in them

3)      Why the hell people think it is acceptable to use them like a lollipop

The premise of the e cigarette is that it is supposedly a healthier alternative to regular cigarettes because they do not contain tobacco. This sounds all well and good as we know the damage that tobacco can cause – in particular reference to my area of “expertise” it can lead to a whole range of oral cancers which can involve not just the areas of your mouth visible when you yawn but a whole realm of other areas in the head and neck. Most brands of this device also claim that they do not contain tar. Another benefit of course unless of course you wish for your lungs to look like the surface of the M6.

They were primarily designed as an addition to the realms of nicotine replacement therapy (NRT) alongside patches, gum, medication like Champix etc and therefore used to cut down smoking.

All of this sounds very positive, so much so that one lady who switched to using a certain brand of the e cigarette to write the poem below:

No more cigarettes for me
What could I do, I liked the taste
Went to e-cigarette with much haste

Cigarettes without the bad bits
Made it easy to kick the habit
They come in lots of different flavours
For me to try and quickly savour

The prices are great
Delivery is never late
So give Smokers Angel a go
And try their range of Halo

Now that is quite a gushing testimonial. Similarly, the woman below appears extremely pleased with her e cigarette. It has even managed to get her a gentleman willing to photobomb her holiday snaps.  What could possibly be so bad.

 

On that note, let’s see if we can find any information at all about what is in them. Now trust me, I spent a good few hours trying to research this and the only thing I consistently came across was marketing BS. So I turned to the BMA (as I so often do)

What are they?

“E-cigarettes are battery-powered products designed to replicate smoking behaviour without the use of tobacco – some look like conventional cigarettes, while others appear more like an electronic device”  They consist of a cartridge containing liquid nicotine, an atomiser (heating element), a rechargeable battery, and electronics.

E-cigarettes have been marketed as cheap and healthier alternatives to cigarettes as well as to look and feel like cigarettes for use in places where smoking is not permitted since they do not produce  smoke. E-cigarettes are products operated by a single use or rechargeable battery that heats a liquid based solution (often containing nicotine) into a vapour. This is then inhaled by the user, simulating the effect of cigarette smoking.

They are primarily used (apparently) as a means to quit smoking and therefore the major studies conducted on e-cigarettes have analysed nicotine content, as addiction to this apparently why people cannot quit smoking. “An analysis of the total level of nicotine generated by e-cigarettes which vaporise nicotine effectively found that the amount inhaled from 15 puffs was lower compared with smoking a conventional cigarette”. Please note the extremely vague wording used by the usually extremely un-vague British Medical Association. Another study analysed sixteen e-cigarette brands and found the total level of nicotine in vapour generated by 20 series of 15 puffs varied from 0.5 to 15.4 mg. Again, there is no regulation, nor any standard or reproducible results that can be produced from e cigarette testing.

In 2009, the United States Food and Drug Administration (FDA) released results of an analysis of some e-cigarette product, it showed that the tested e-cigarette cartridges contained carcinogens and toxic chemicals. Analysis of two leading brands by the FDA also revealed:

• • diethylene glycol (a toxic chemical) in one cartridge at approximately 1%
• • tobacco-specific nitrosamines (which are human carcinogens) in half of the samples
•  tobacco-specific impurities suspected of being harmful to humans (anabasine, myosmine, and ßnicotyrine) in a majority of the samples

The tests also suggested that quality control was inconsistent or non-existent:

• • cartridges with the same label emitted a markedly different amount of nicotine with each puff
• • one high-nicotine cartridge delivered twice the amount of nicotine compared to a nicotine inhalation product approved by the FDA.

 i.e. the biggest food and drug regulatory body in the world cannot conclusively say that is in the products or what they give out.

See next subheading.

E cigarettes – the new enemy?

Whilst I absolutely cannot deny that any improvement on smoking normal cigarettes is beneficial to health in general and therefore oral health, e cigarettes are a dangerous realm to enter into.

The reason they are cheaper is because they are not taxed in the same way as regular cigarettes. Hurray, I hear you shout. Sadly, these taxes pay my wages in the NHS, they also put people off smoking because it makes it so darn expensive. Without this deterent what is to stop people continuing to pump dangerous chemicals into their bodies. Similarly, they are not regulated in the same way as normal cigarettes. For cigarettes to be sold they have to go through rigorous quality control, the same does not apply for e cigarettes. Due to this, we have absolutely no clue what is in them.

All that can be said is that they are not licensed as a medicine in the UK, and there is no peer-reviewed evidence that they are safe or effective for the purpose of helping to cut down smoking, as a “healthier” alternative to smoking or in fact any other reason except making you look like you’re smoking a marker pen.

The World Health Organisation document (which is 50 pages long I might add); WHO STUDY GROUP ON TOBACCO PRODUCT REGULATION raises further concern about the use of these products as nicotine replacement therapy. “Delivery of nicotine to the lung raises concern about safety and addiction that go beyond that related to currently approved NRT, concern…is associated with the probable exposure of the lung to repeated dosing, perhaps hundreds of times a day for many months, if these products are used as a smoking cessation aid, or for years, for smokers who use them as long-term cigarette substitutes”. That is to say, the delivery of nicotine directly to the lungs has never before been studied, and whilst manufacturers get away with using certain chemicals in e-cigarettes because they approved for human consumption, we have no idea of the effect they have when inhaled.

Most people who purchase and use e-cigarettes claim they do so as a means to cut down on smoking i.e. smoking cessation, instead of things like patches, gum and so on. Sadly, the World Health Organisation(WHO) who govern most of what we do in terms of medication, health choices, prevention etc state that “as of July 2013, the efficacy in using electronic cigarettes to aid in smoking cessation has not been demonstrated scientifically”. They tend to err on the side of caution as they are such a huge body of people of differing backgrounds and motivations that having a strong unified opinion on something is a difficult task. However, so unified was their opinion in this case that they recommend "consumers should be strongly advised not to use" electronic cigarettes until a reputable national regulatory body has found them safe and effective”. Nuff said.

The British Medical Association have also been forced to offer up an opinion on the damn things and their summary is not much more positive than the WHO. They state that “four out of five e-cigarette users continue smoking, and use e-cigarettes primarily as a substitute where smoking is not allowed” thus completely defeating the object of switching to e-cigarettes for a smoking cessation purpose. Again, the BMA agree, expressing their concern that e-cigarettes may undermine smoking prevention and cessation, as their use is likely to reinforce the normalcy of the smoking behaviour”.

This normalcy was nicely illustrated just last week when I walked past a patient sitting IN THE DENTAL HOSPITAL WAITING ROOM smoking one of these devices, regarding me with confusion at my anger with her behaviour. Similarly, the fact that the e cigarettes are generally quite aesthetically pleasing and gadgetty-looking means that people are far more likely to openly smoke them, and thus consume more nicotine than they would should they smoke their normal cigarettes, thus negating the intended purpose of switching.

Our Australian cousins also echo this. “Other unintended consequences of e-cigarette use include the potential to induce nicotine addiction in non- smokers or maintain addiction in current smokers who might otherwise quit. Furthermore, concerns have been raised that e-cigarettes may undermine the comprehensive indoor  smoking restrictions and smokefree air policies” and making it generally acceptable for people to be seen smoking after years of hard work aiming to make them feel as embarrassed about smoking in public as public urination – people still do it but its few and far between, although maybe I grace the wrong areas of town at the wrong time of night.

The National Institute for Health Care and Excellence (NICE) recently published new public health guidance backing the use of licensed nicotine products to help people cut down as well as stop smoking. However, these guidelines did not cover e-cigarettes. Again, without having to say it, I imagine several suited men sitting round a table and laughing at the concept of e-cigarettes even being considered in this category of something that they would advise or recommend as something of health benefit.

Now of course, I cannot complete an analysis of the use of this product without referring to the superpowers of the USA – namely the Food and Drug Administration department (FDA). They basically regulate everything that is consumed, injected or applied by our friend across the pond and thus you could argue, have probably become fairly used to seeing products come and go, and are unlikely to have any emotional response related to items they are asked to assess. So strongly therefore did the FDA feel about e cigarettes that way back in 2010 long before the e cigarette phenomenon reached our shores, they issued warning letters to a grand total of 5 electronic cigarette distributors for various violations of the Federal Food, Drug, and Cosmetic Act (FDCA) including unsubstantiated claims and poor manufacturing practices. What is more worrying is that the FDA only regulates products intended for therapeutic use i.e. as a nicotine replacement therapy, and therefore, if a company decides to purely register their e cigarette product as recreational, or a hobby based item, then it completely negates all regulation by any drug agencies. Still fancy puffing away on one of them?

Dental Impact

What most people don’t consider is the effect that smoking has on their mouth. Whilst smoking e cigarettes should technically reduce risk of oral cancer, the presence of carcinogens in most of the leading brand’s e cigarettes negates this benefit. Similarly, the main causative factor of smoking related gum disease is nicotine. As the e cigarettes are rammed with the stuff, they offer no benefit in terms of “the leading cause of tooth loss” (thanks Corsodyl). That is to say, puffing away on your e-cigarette is just as harmful to your gums as smoking regular cigarettes and so your path on the road to dentures is just as speedy. In fact the WHO state that 90% of the nicotine that people smoking e-cigarettes are so desperate to get into their lungs, is actually deposited in the mouth.

In Summary.

The Medicines and Healthcare Products Regulatory Agency in the United Kingdom reported that it planned to regulate e-cigarettes as medicines from 2016 when new European tobacco laws come into force so until then, it remains that we have no idea what e-cigarettes are. In my mind, used as a nicotine replacement therapy, i.e. to smoke less and less over a set period until smoking has been stopped, completely, is fine, so long as they smoke it miles away from me, not around children, and that the whole thing stops being glamorised.

What I trawled through in order to write this blog:

BMA, E-cigarettes in public places and workplaces A briefing from the BMA Occupational Medicine Committee and the Board of Science, March 2012

BMA calls for stronger regulation of e-cigarettes

March 2012 (updated January 2013) A briefing from the Board of Science and the Occupational Medicine Committee

http://www.cancerwa.asn.au/resources/2013-11-13-ecigarettes-position-statement.pdf

http://www.ecigarettedirect.co.uk/

http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm

http://whqlibdoc.who.int/publications/2009/9789241209557_eng.pdf

WHO "Questions and answers on electronic cigarettes or electronic nicotine delivery systems (ENDS)". World Health Organization. 9 July 2013.