What is a Dental Cavity

A cavity or dental caries is nothing more than a hole that has formed in the tooth by dissolving an area of the outer layer: enamel.  Enamel is the second hardest compound on earth, second only to diamonds.  A cavity can form when three things are present: a tooth, food and bacteria.

Firstly, a tooth must be present for a cavity to form.  I promise I am not trying to sound silly, but babies could have the bacteria and eat food, and not get cavities because there is not a tooth for the bacteria to attach.

Secondly, food must be present for cavities to form.  Certain foods can lead to cavities more frequently than others.  Foods that are high in processed sugars, such as candies, starches, and fruit juices, are more easily processed by the bacteria that live in our mouths.  Foods that are less likely to create cavities are things such as cheese, nuts, and apples. 

Thirdly, bacteria or “sugar bugs” as I call them, must be present for a cavity to form.  The mean sugar bug’s name is Streptococcus mutansS. mutans can adhere to teeth and if left to his own devices, can produce an acidic byproduct that can breakdown the protective enamel exposing the softer dentin below.  S. mutans loves starchy foods because it is easier for them to breakdown.  And guess what its byproduct is.  That’s right!  Acid.  S. mutans has an interesting quality in that it thrives in an acidic environment and every time we eat or take a sip of a beverage other than water; the oral cavity becomes acidic.  Now, it’s okay!  Our saliva attempts to counterbalance the acidic environment and bring the mouth back to neutral.

But, when food and plaque sit on teeth, the environment underneath the plaque is acidic, it can stay stuck to the enamel until we remove it from the teeth with a toothbrush or floss.  In the acidic environment, the minerals that make enamel so strong, can get broken down and is unable to recover.  At that time, a cavity will form. 

The last thing needed to form a cavity is time.  It takes time for the acid to break through the enamel and reach the underlying layer of dentin.  Can I give you some bonus information?  Did I hear you yell an emphatic “YES”?  I’m so glad you did.  Research studies show that it takes approximately six months for a cavity to break through the enamel layer.  It is for this reason that insurance companies cover a cleaning every six months and one day.  And not a moment sooner!

What Does a Tooth, Cake, and an Ogre Have in Common?

I know you remember the scene where Shrek is explaining to Donkey that ogres are more than the frightening fairy tale lore they are known for.  “They have layers.  Onions have layers” explains Shrek huffily.  Donkey thinks for a minute and replies, “Not everybody likes onions.  CAKE!  Cake’s got layers.  Everybody likes cake.” Teeth, like cake, have layers. 

The white outer layer is called enamel.  Enamel is the second hardest compound in the world, preceded only by one of my other favorite things, diamonds!  Enamel protects the inner tooth layers from extreme temperature changes and normal wear and tear from chewing food.  Enamel is densely mineralized and is constantly responding to changes in its environment.

The middle layer is called dentin.  It is less mineralized than enamel and has a yellow hue.  Dentin is amazing because it can sense if a cavity is forming, and it will lay down more dentin to wall off the cavity and protect the nerve and blood supply inside the tooth.

The innermost layer is called the dental pulp which contains the nerve and blood supply to the tooth.  This is why a tooth can feel cold, heat, and pain.  If a cavity comes close to or reaches the pulp, it can allow a pathway for bacteria to proliferate and cause an infection.   

Each layer has its unique purpose.  It is amazing how a tooth can fight a cavity without a single action from us.  Whether it be a cake, an ogre, or a tooth, I am a fan of layers, and you should be too.  Now, please pass the cake!

What is Conscious Sedation?

To sedate or not to sedate, that is the question.  Dental sedation has been brought to light by the media in the past few years and the light has not been very complementary.  Sedation is when medications are administered to create a relaxed or peaceful state.  It is a spectrum, and depending on the patient’s needs, the provider will decide what level of sedation is necessary to accomplish the desired goal.

Dental sedation can be used for adults, but I will be focusing on sedation for children since that is my area of expertise.  When I was in residency, in our first sedation class my professor said, “Children are not little adults!  Do not sedate them like they are an adult.”  At the time, I did not know what he meant.  When working with adults, there is more standardization as far as prescribing medications.  With a child, typically, prescribing should be based off his weight and not his age or maximum dosage.  Young children do not have mature respiratory systems, do not have a large oxygen reserve, and can become overly sedated quickly.

There are hundreds of medications that can be used to sedate children and as some would say, “many ways to skin a cat.”  I will not discuss specific medications, but each provider has their “go to” medications that they use depending on the situation and the desired goal.  When the term “conscious sedation” is used, I am referring to minimal sedation.  My goal for a child is that he be awake but relaxed for the procedure.  The child should be able to follow my instructions and have all his normal reflexes intact.

Conscious sedation is safe when practicing within the guidelines set forth by the American Academy of Pediatric Dentistry.  This is not to say that there should not be some level of healthy fear anytime medications are introduced.  As I stated before, sedation is a spectrum and a child can easily slip further down the sedation spectrum than may be intended.  Whenever a child is sedated, it is important to keep in mind where the child is on the spectrum, and as a provider, “Am I comfortable with how this child is responding?”  If not, what is the causing the problem and how do I fix it quickly. 

When I was in dental school, I had several patients that were terrified of the dentist.  Many of these patients had a bad experience as a child and have carried these fears into adulthood.  Sedation was not a common practice even twenty years ago.  At that time, it was not uncommon to use restraints or behavioral techniques that are not as acceptable at this day in time.  Children are impressionable creatures and do remember bad experiences that may affect them for the rest of their life.  This is one of the reasons why I decided to go into pediatric dentistry.  If I can give a child a good dental experience, then that child will carry this mindset to adulthood and is more likely to seek dental care on a routine basis instead of waiting for an emergency to arise. 

I am not going to lie, sedation appointments are not my favorite, but if it will give a child a good experience, I will do it.  During residency, I completed over double the amount of sedation cases required and feel comfortable with the medications I prescribe.  I maintain my Pediatric Advanced Life Support certificate.  All my staff is certified in Basic Life Support.  I complete an inventory of our crash cart monthly to make sure I have everything I need on the off chance I run into a situation where I may need to rescue a child.  We have staff meetings weekly where we discuss various office emergencies, and how we will handle them.  I hope to always maintain a healthy fear that I may need to use my advanced training.  Sedating a child is never something to be taken lightly, but it can be a useful tool in creating an enjoyable dental experience for some children.

What is Infant Tongue Tie?

Infant tongue tie is something that has come to light in the past few years as more and more of us mommies are breastfeeding our babies. I have been getting questions at an increasing rate on this topic. Does my baby have tongue tie? Is it a problem? Do I need to do something about it?


What is tongue tie?
Tongue tie is when the tip of the tongue is attached to the floor of the mouth. There are varying degrees of tongue tie from minimal attachment to the full length of the tongue being attached to the floor of the mouth.

What problems can it cause?
In infants, it can cause difficulty feeding/latching and for momma, it can cause nipple pain upon feeding.

Do I need to do something about my infant’s tongue tie?
This is the process I use to decide if my patients are candidates for the surgical procedure to relieve the tongue: I ask parents if it is causing a problem?” If the parents say no, it is usually something they have noticed visually and not noticed problems. These children are not a candidate. If the parents say “yes,” then I ask what problems they are experiencing. If the parents say the child has colic or gastric reflux and is fussy, they are not typically a candidate. These issues are best brought up to the child’s pediatrician and once GI issues have been ruled out, they may be a candidate. If the parents say the child is having difficulty eating, is in a low weight class, or the mom is having pain on feeding, then the surgery may be helpful. Notice, I said MAY be helpful. This is the controversial part! Scientific research has found a correlation between the surgical removal of the attachment and better feeding/less nipple pain. Is it a relatively harmless procedure? Yes. Is the recovery difficult? Not typically. Is it helpful in some cases? Yes. Is it 100% effective? No. Am I going to recommend it to all of my patients with tongue tie? No. A serious discussion needs to occur between the provider and the parents where the pros and cons of the procedure are weighed to determine if it is the right course of action. A good clinical evaluation is important. Sometimes the tongue is not the main source of the problem. Occasionally, the top lip can be attached firmly and is not allowing the baby to latch effectively.

Who performs this type of procedure?
Due to its controversial nature, only a select few doctors perform it. The best place to start in most cases is a lactation specialist. Although they do not perform the procedure, usually they know who in your area does. Among the list may be Ear, Nose and Throat physicians, Neonatologists, Periodontists (dentists who specialize in gums), Pedodontists (children’s dentist), and Oral Surgeons.

What does the surgery entail?
There is a section of gum tissue under the tongue that attaches to the floor of the mouth. This tissue is called a “frenum” or “frenulum.” The frenum is cut with either scissors, a scalpel, or a soft tissue laser to allow the tongue to move freely. Sometimes it is necessary to place stitches to allow the tissue to heal, but it is not always required.

Will my baby have to be put to sleep?
This depends on the surgeon you are using. Typically these babies are less than 6 months of age and general anesthesia is not required. Some ENT physicians may combine this procedure in with another surgery, for example, if your child also needs ear tubes. Most of the time, these procedures can be completed with your baby awake.

Will my child feel pain?
Babies are like adults. They do feel pain just like anyone else. But, there are risks to giving infants numbing medication because they are so small, and it is easy to give them too much. Some practitioners are of the school of thought that the child will not remember the procedure, so they do not give the baby numbing medicine. This is a topic to discuss with your surgeon and decide how you would like to proceed.

What is the recovery like?
Typically, following the procedure, the provider will give the baby to the mom to begin breastfeeding and help soothe the child. Yes, unless your child was put to sleep, your baby will scream throughout the procedure. This is normal and is not necessarily indicative of pain. Most babies do not like to have their mouth messed with, and their only known way of responding is to cry. Before you leave with your baby, you may be given instructions to do tongue and lip exercises at home. Typically the surgeon will schedule a follow up exam a week to a month following the surgery. This will allow them to monitor the healing and make sure the procedure was successful. In the meantime, Tylenol/Motrin can be used for any post-operative pain unless the pediatrician recommends otherwise.

I hope this is helpful and not overwhelming. I am attaching links to this post with more information on the topic.

http://www.aapd.org/assets/1/25/kupietzky-27-1.pdf

https://www.ncbi.nlm.nih.gov/books/NBK299106/

What is Dental Fluorosis?

“You’ve got what?!?  Dental fluorosis?  That sounds serious.  I hope it’s not catching.”

 Fluorosis is a dental condition that occurs during the years that a tooth is developing.  Excess fluoride is absorbed through the gut and can be stored in bones and teeth.  It is noted clinically as white striations but can appear brown that may be attributed to dietary staining of the effected enamel.  Severe fluorosis can present as pitted enamel.  Microscopically, the enamel layer is more porous and thus, weaker in nature. 

The age that fluorosis occurs is during the time the permanent teeth are forming, but it is not seen clinically until the teeth erupt into the mouth.  The top front four teeth are where fluorosis is the most commonly visible.  These teeth are affectionately called the central and lateral incisors.  The incisors begin forming early in a child’s first year of life and the visible portion of the tooth (crown) completes forming when the child is 4-5 years old.  Teeth begin forming at the bottom edge and form upwards until the root has been completed.  As you can see in the picture above, the staining occurs in lines.  The fluorosis is seen in the tooth layer that was forming at the time the child received excess fluoride. 

For example, in the picture above, the central incisors have a brown line near the top third of the tooth.  The lateral incisors have brown staining in the bottom third of the tooth.  It is likely that the fluorosis occurred at the same time, but the centrals and the laterals were at different stages of crown development.

Fluorosis is more common in the southwestern United States due to its higher naturally occurring fluoride levels.  Typically, fluorosis occurs from a long-term ingestion of excess fluoride and is not noticeable if a child has an acute fluoride toxicity event from eating a tube of toothpaste.  One instance that can cause fluorosis is using fluoridated water to mix infant formula.  Since this is the basis of the infant’s diet, especially early on, fluorosis can occur if fluoridated water is used on a regular basis. 

How do we treat a tooth with dental fluorosis?  Back in the day, the only treatment options were to use a high-speed handpiece to remove the stained tooth structure and place a filling or a crown.  I’ve said it before and I’ll say it again, I love the day and age we live in because we have more conservative options at our disposal.  I will list the options from most conservative to most aggressive:

  1. Tooth whitening – no tooth structure will be removed, but the discolored tooth may blend with whitening treatments.  Follow up treatment is usually required.
  2. Resin infiltration: a treatment option where the enamel is opened with an acid to release staining, apply a bleaching agent to the tooth, and apply a sealant to protect the tooth and prevent future staining.
  3. Microabrasion: the top layer of the enamel is removed with an abrasive to reveal a more esthetic layer of the tooth (not always an option for fluorosis, due to it affecting the entire depth of enamel)
  4. Remove the stained portion with a dental handpiece and apply a filling
  5. Remove tooth structure to allow for an esthetic crown to be placed

To summarize, causes of fluorosis can be atributed to long-term fluoride ingestion such as, drinking fluoridated water at levels higher than recommended by the CDC or using fluoridated water to mix infant formula.  Fluoride varnish is the most commonly placed dental fluoride at cleaning appointments.  Research studies do not support a correlation between increased dental fluorosis and fluoride varnish application.

References:

Dental fluorosis:

https://pdfs.semanticscholar.org/0fb5/28d4b7a7e193e90bd533b5ea54f816b04375.pdf

Dental Tooth Formation Chart:

https://www.aapd.org/globalassets/media/policies_guidelines/r_dentalgrowth.pdf

Correlation of fluorosis and fluoride varnish placement:

https://www.aapd.org/assets/1/7/Fluoride_varnish.pdf

American Academy of Pediatric Dentistry Fluoride Guidelines:

https://www.aapd.org/media/Policies_Guidelines/P_FluorideUse.pdf

What is Silver Diamine Fluoride?

You mean you’ve never heard of silver diamine fluoride?  It is hot, hot, HOT, right now!  I’m surprised it is not trending on Twitter.  Silver Diamine Fluoride, known among dentists as SDF, is a liquid with a high concentration of fluoride that is applied to a cavity to prevent it from getting larger. 

You may ask, why would one apply this to a tooth instead of just getting a filling?  A filling or crown would be a more permanent fix, but what if the child is two years old and is unable to behave for a filling?  What if the child has special needs that make it dangerous to sedate or have the fillings done under general anesthesia?  What if the child is eight years old and will lose the tooth in a year or two and the parents insurance benefits have been maxed out for the year?  These are all reasons to consider SDF in a dental treatment plan.

As costs increase and dental insurance benefits stay the same, it is becoming more and more of a struggle for parents to pay for their children’s dental needs.  SDF may not be long term treatment, but if there is a need to defer treatment, it can be applied to the teeth to prevent the cavity from becoming larger.  Typically, SDF needs to be applied every six months until the final treatment can be completed, or the tooth falls out.   Some practitioners will place it once and follow up a week later to add another coat.  Some practitioners will place the SDF and add some type of temporary restoration to further protect the tooth from breakdown. 

It sounds too good to be true, right?  There is always a catch, isn’t there?  The downside to SDF is, it turns the cavity black.  When I say black, I mean black!  It not only turns cavities black, it turns anything it touches black, as well.  If it were to touch a child’s cheek, the soft tissue would be black for a week.    For some children, if they cannot follow instructions and will be fighting the treatment, they are not candidates for SDF.  For some parents, the esthetics would eliminate SDF as a treatment option completely.  Attempts have been made to make SDF more esthetically pleasing, but at this time, they do not look as natural as a traditional filling. 

If SDF is placed and a white filling is indicated later, the dark staining can be removed with a dental handpiece, but it is not always completely successful.  This is one reason why SDF is not commonly used on adult teeth.  It is great for baby teeth, because they fall out in a few years and you get a “do over.”  In the past when treatment needed to be delayed, the cavity sat exposed for six months or a year until treatment could be completed and what originally needed a filling now needs a crown or extraction.  SDF prevents cavities from getting larger, so in theory, a cavity that requires a filling should still require a filling in six months following SDF application.  SDF is not recommended on teeth that have been deemed non-restorable and need to be removed to prevent the risk of infection. 

What are the advantages of SDF?

  1. No injection is required
  2. Sedation can be prevented or delayed as the child matures
  3. Lower cost than a filling
  4. Promotes a positive dental attitude for the child

I hope you found this post informative.  I love working in this time period because we are blessed to have so many treatment options at our disposal, and we can customize it to the needs of the individual.  I am happy to have this option in my wheelhouse, but I very much hope it does not put me out of business!

References:

American Academy of Pediatrics:

https://www.aappublications.org/news/2016/08/05/SilverDiamine080516

https://www.healthline.com/health/silver-diamine-fluoride#cost

Jeanette MacLean Placement of SDF between teeth:

https://www.youtube.com/watch?v=nPyYpZYfrHQ

Help! My Child Ate Toothpaste!

A common reason for parents to call Poison Control is because their child ate an unknown amount of toothpaste containing fluoride.  And who can blame them?  Toothpaste, with its sweet flavors, is quite tempting to some kids. 

We have discussed in previous blog posts that fluoride is an ion that wants to bind to another ion.  When it is used correctly, it binds to the enamel ions to make fluoroapatite which makes enamel less likely to get cavities.  When it is swallowed, the fluoride binds to hydrogen in the stomach creating hydrofluoric acid.  The acid is corrosive and can cause an irritation to the stomach lining, presenting as nausea, vomiting, and diarrhea.  Typically, this is the extent of the episode.  But what if we could have the fluoride bind to something besides stomach acid?  The treatment of choice when your child has eaten a small to moderate amount of fluoridated toothpaste is to give your child a milk-based snack, i.e. a glass of milk or bowl of yogurt.  The calcium in the milk binds the fluoride to make an inert salt (CaF2) that is excreted from the body.

 I have attached a chart that Georgia’s Poison Control uses to determine if a child needs a trip to the emergency room:

In rare cases, a child can ingest a larger amount of fluoride than is safe to treat with milk or yogurt.  Usually, when this occurs, a young child is involved.  It does not take much toothpaste to cause a problem in a very small child.  For this reason, it is extremely important to keep toothpaste out of reach of small children and behind childproofed drawers or cabinets.  The symptoms that follow are nausea and vomiting that progresses to seizures and muscle spasms.  It can potentially lead to death if left untreated.  Poison Control will let you know if inducing vomiting is recommended.  Once the child is admitted to the emergency room, activated charcoal may be given to help bind the fluoride and the child will be treated by physicians who will be monitoring the child’s vital signs until they have recovered.

When dealing with children, emergencies can happen in a heartbeat, and if you find yourself in this situation, I hope you find these resources helpful.

References:

Poison Control: 1-800-222-1222

https://www.poison.org/articles/2015-dec/toothpaste

http://kidemergencies.com/toothpasteingestion.html

Water Fluoridation: To Drink or Not to Drink

In my last post, What Is Fluoride, I discussed what fluoride is and how it affects our enamel.  It aids in remineralizing enamel and prevents the demineralization of enamel.  It can also prevent bacteria from producing cavity enhancing acid. 

Community water fluoridation began in the 40s because studies showed that residents with higher naturally fluoridated water had fewer dental cavities.  To this day, it is touted as the most equitable and cost-effective method of delivering fluoride to all members of most communities.  Over the years, a significant decrease in dental cavities has been seen.  In the United States, the amount of fluoride in the water is from a range of 0.7-1.2 mg fluoride ion/L part per million (ppm). 

There are several classes of people that I run into:

  1. Those that believe fluoride works and is beneficial
  2. Those that think fluoride is toxic and harmful
  3. And people who do not care either way

I get asked on a regular basis if I actually believe in fluoride.  It’s almost the same as if someone asked me if I believed apples came from apple trees.  Through my four years of college, I learned about the how fluoride effects our teeth at an atomic level.  During my four years of dental school, I read countless articles that have undergone meta-analysis and systematic reviews (highest level of validated research).  And during my two years of pediatric dental residency, I have seen how fluoride has been beneficial to one of the poorest and most underprivileged communities in the nation.  I believe in fluoride because I have seen its benefits first-hand.  But I do understand that not everyone has had the same experiences I have had so it is normal to be skeptical.  Is it possible that I live in the Truman Show and everything I have learned is a big hoax?  I sure hope not!

To the people who believe that fluoride is toxic and harmful, all I can say is, “You are absolutely right.”  Just about anything in excess is not good for you.  Even drinking too much bottled water when drunk too fast at a large amount can cause your sodium levels in your blood to drop and be fatal.  It is well known that when a small child ingests too much fluoride (typically by eating toothpaste from a full tube), the side effects can affect their gastrointestinal system by causing nausea, vomiting, diarrhea, and abdominal pain.  If a very large amount is ingested, it can affect the central nervous system and symptoms of convulsions, numbness, and possible cardiovascular collapse.  So, yes, I would say it is toxic and can be harmful when used outside of its recommended guidelines.

A few years back, a study came out of Harvard University called Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis.  I have provided the link below for your reading pleasure.  This paper collected studies from around the world that compared children’s water fluoridation levels and their IQ.  “The results supported the possibility of an adverse effect of high fluoride exposure on children’s neurodevelopment.  Future research should include detailed individual-level information on prenatal exposure, neurobehavioral performance, and covariates for adjustment” (Choi 2012).  I reviewed the studies that were listed and the fluoride levels that are present in many of the studies are 3-4 times higher than the amount used in the United States water fluoridation.  It is very interesting that these studies are evaluating a long-term effect of fluoride on children’s brains.  This research paper was well conducted by a highly prestigious university and is something to be cognizant of.

With all of this said, it does not make a difference to me if someone “believes in fluoride.”  I do find it important that my patients are well informed so they can decide what is right for their family.  Fluoride is not essential to having healthy teeth, but it is a tool that can be helpful if there is an imbalance in the oral cavity where cavities are forming.  If you feel fluoride could be helpful for your child, drinking fluoridated water and brushing your child’s teeth with fluoridated toothpaste is a good place to start.  If you do not wish to have your child exposed to fluoride, drinking bottled or distilled water is always an option.  Newer refrigerators have reverse osmosis filtration systems which utilizes tap water but removes fluoride, as well as, other things like lead and chlorine. 

I hope this post was helpful in deciding what is right for your family.  And for those people who do not care one way or another if their water is fluoridated, keep doing what you are doing and thanks for reading!

References:

https://www.aapd.org/media/Policies_Guidelines/BP_FluorideTherapy.pdf

https://jada.ada.org/article/S0002-8177(85)02022-0/pdf

Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491930/

Link to Check Your Water Fluoridation Level:

https://nccd.cdc.gov/DOH_MWF/Default/WaterSystemList.aspx

What is Fluoride?

The short answer to this question is fluoride is an ion that bonds to enamel and hardens its chemical structure.  If you are curious about the chemistry behind it, keep reading.  If you are fine with the previous answer, there is no need to suffer through this one!

Let’s take a journey back to middle school.  Reach into the depths of your brain to find the periodic table.  The periodic table is a chart of elements.  Elements are building blocks for everything: trees, rocks, gases, skin, and food.  Everything is made up of elements.

Fluorine is an element and fluoride is the ionic (active) form of fluorine.  Most ions do not like floating around by themselves.  They bind with other ions to create molecules which are more stable.  For example, oxygen is not often found by itself.  It binds to another oxygen element to form an oxygen molecule.  Fluorine is a very special element.  It has the highest electronegativity of any of the ions, forming strong ionic bonds. 

Are you bored yet?  Let me get to the point.  Why is fluoride important in the dental field?  To answer this, I must explain what enamel is.  Enamel is the hardest substance in our bodies and is the white covering of our teeth.  Enamel, like anything else, is made up of elements, such as calcium, phosphorus, and hydrogen.  When our mouth becomes acidic after eating or drinking, the enamel releases hydroxide into the mouth to help bind the acidic ions and bring the mouth back to a neutral environment.  When this happens, the enamel has two courses of action: it can continue to breakdown further (demineralization) and result in a cavity, or ions/compounds can bind to damaged enamel to restore the structure (remineralization). 

When teeth are formed, the enamel is made up of interlocking molecules called hydroxyapatite.  The fluoride can replace hydroxide in the molecule to create a stronger substance called fluorapatite.  Fluoride changes the structure of the tooth at a chemical level to make it stronger.  Fluorapatite is stronger than hydroxyapatite and is less likely to breakdown.

I hope this post did not stress you out, because it sure stressed me out!  I am sorry it was dry and heavy in the sciences.  I am, ultimately, a scientist and am tasked with the burden of learning the “why” behind everything I do.  I am going to continue down the fluoride rabbit hole, but I think this is enough information for one blog post.  Soon I will address the sources of fluoride and its beneficial and harmful effects.  As always, I love your feedback and any additional questions you may have on this topic. 

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4851520/

https://pdfs.semanticscholar.org/d18f/c15a17a82c5a89acd3023decec0b578f7fcb.pdf

Can My Baby Use Orajel for Teething Pain?

Orajel is a topical numbing agent that’s uses range from relieving pain from canker sores, tooth and gum pain, as well as for cold sores.  The active ingredient in Orajel is 20% Benzocaine which is a topical local anesthetic (pain reliever).  Some formulations also contain Menthol which is obtained from mint oils.  Menthol increases blood flow to the area and provides at cooling sensation. 

Benzocaine has been used for decades to relieve oral pain temporarily.  Dentists most commonly use it to place on their patient’s oral tissue prior to an injection of numbing medicine.  How does it work?  Pain is caused by stimulation of specific types of nerve endings.  Benzocaine stops the nerve from being stimulated temporarily by blocking the uptake of the molecule that stimulates the nerve.

Like any drug, we must be aware of its potential side effects, especially when we are talking about young children.  It is generally safe and non-toxic when applied topically.  So, what’s the problem?

Benzocaine has been associated with an uncommon, but serious condition called Methemoglobinemia (pronounced Met–hemo– globe-in-emia).  I found out it was one of my husband’s pet peeves when it is called METH-hemoglobinemia.  To avoid a lengthy and yawn-inducing discussion over its chemical formula, and why it is called METhemoglobinemia, I am stressing its pronunciation.  Please!  Not again!

I will try to keep my “sciency stuff” to a minimum.  Bear with me.  Let me start with explaining what hemoglobin is.  Hemoglobin is the oxygen carrying molecule in red blood cells.  It delivers oxygen to the tissues in the body.  The oxygen bond with hemoglobin is not strong.  Some may say, it’s down-right weak!  It sounds terrible, but it is actually a great thing.  The weak bond of hemoglobin is what allows oxygen to be released to the oxygen-depleted tissues.  Methemoglobin is a different chemical formula of a hemoglobin molecule that binds strongly to oxygen, thus not allowing for its release to the body.  When this occurs, the body is unable to function well due to the decreased oxygen availability.

What is methemoglobinemia?  When benzocaine is applied to the tissue and is absorbed into the blood stream, it can convert normal hemoglobin to methemoglobin and cause an oxygen depletion.  It has been found to be severe, especially in children ages 2 and younger.  Unfortunately, this age group most often suffers from teething discomfort.

What are the symptoms of methemoglobinemia?  Pale, gray, or blue skin color, shortness of breath, fatigue, headache or lightheadedness, and rapid heart rate.  These symptoms can occur in minutes to hours after Benzocaine’s application.

What is the treatment to reverse methemoglobinemia? The child would be placed on oxygen and given a substance called methylene blue through an IV.  The improvement is typically rapid.

Methemoglobinemia is well known by the Orajel company, so they have come out with a children’s version without Benzocaine.  In fact, they have two kinds: daytime and nighttime teething gel.  It is called Orajel Non-medicated Cooling gels for Teething.  The active ingredient in the daytime gel is Simethicone.  It is commonly used to relieve colic in babies.  Simethicone drops allows for smaller gas bubbles to come together in the stomach and become one big bubble to aid in the baby burping.  I have been unable to find how it aids in relieving teething pain.  The nighttime active ingredient is chamomile in addition to the simethicone.

I love a good cup of tea and chamomile is one of my favorites, but I also have the unfortunate quality of being a skeptic when it comes to homeopathic remedies.  Some research out of the University of Michigan supports the use of crushed chamomile tablets mixed with water and given in a dropper to your child can relieve diarrhea associated with teething.  Many herbalists suggest that chamomile has anti-inflammatory and calming properties to alleviate teething pain, but currently there is not enough research I have found to prove or disprove this theory.  The bottom line is, chamomile has not been found to be harmful for children.  One way that it can be used is by making a cup of chamomile tea, dipping a corner of a washcloth in the tea then freezing it for your child to chew on.  The rule of thumb with anything is “Everything in Moderation.”

References:

https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-reports-rare-serious-and-potentially-fatal-adverse-effect-use-over

http://www.med.umich.edu/yourchild/topics/paininf.htm