Graphic Effects of Sucking Fentanyl Patches

As a dentist, I have seen many patients over the years who have abused heavy drugs. In many of those cases, their oral hygiene took a back seat to their addiction, and their teeth and gum tissue suffered as a result. Nearly all dentists have seen cases like this:

Photograph of decayed teeth from a drug addict of opiates percocet and vicodin

This patient suffered from narcotic addiction for many years. This led to extreme teeth decay as seen above.

Graphic photo of rotten teeth from years of narcotic and opiate drug abuse

The same patient as above.

I had a very long and candid conversation with this patient who opened up to me about his past. In addition to abusing prescription painkillers such as Vicodin, Lortab, and Percocet, he also admitted to sucking fentanyl patches. He said that he would feel the effects almost immediately upon putting the patches in his mouth.

On exam, the broken down, rotted teeth did not surprise me – I had seen that many times before. What was surprising were the linear lesions all across his palate (the roof of his mouth) as seen here:

Photo and picture on gums from sucking fentanyl patches

Linear patches on his palate on one side only. This is where he used to suck the fentanyl patches. Clicking on the image will yield a larger, high resolution version.

I had never seen anything like this before over my entire career. Are these lesions scar tissue from the constant placement of fentanyl patches against the soft tissue in the mouth? It is hard to tell. I have shown these photos to several colleagues and no one has seen anything like this before.

Regardless of the origin, it is safe to say that chronic abuse of narcotic painkillers – consumed orally or by sucking on them – can have disastrous results for both the teeth and the soft tissue of the oral cavity.

A Divorce over Bad Breath?

Picture of person with bad breath aka halitosis

Halitosis or Brad Breath. Image courtesy Flickr Commons.

Bad Breath, more formally known as halitosis, is a condition that affects tens of millions of people worldwide. It is defined as a persistent malodor coming from the mouth. Bad breath is primarily caused by conditions affecting the teeth or gums but other anatomical areas such as the nose, throat, and GI system can also be causes.

The annoyance of bad breath has been noticed for centuries – it is not just a recent development. But did you know that in some cultures, you could divorce your partner over it?

Bad Breath in the Talmud

The Talmud is an important text in Judaism and dates back to more than two thousand years. This text serves as the basis for Jewish law and customs.  Surprisingly, halitosis is discussed in great detail in more than one part of the Talmud.

In this great summary by Shira Goldstein, she outlines the details of halitosis and how it was addressed in the Talmud:

  • According to the Talmud, halitosis is considered a “serious disability.”
  • In Jewish marriage, the ketuba is the marriage contract between the husband and wife. If a husband discovers his wife has bad breath, he has the ability to cancel the ketuba over it.
  • Women were able to divorce their husbands over halitosis too. The smell from bad breath was even comparable to the smell from collecting dog dung!
  • There was significant discussion in the Talmud over whether nasal odor and oral odor were equivalent. They were later deemed to be comparable.

So this means that over 2000 years ago, people were gravely concerned about bad breath!

Bad Breath and the Dentist

Photo of teeth with gum disease showing halitosis or bad breath

Would you divorce your spouse if his/her teeth looked like this and the odor was comparable to dog dung?

As a dentist in Orange, CT, patients typically look to me to help them with their real or perceived halitosis. Many people actually suffer from a perception and/or fear that they have bad breath. This is referred to as halitophobia.

But most cases of perceived halitosis are legitimate. Research shows that 85 to 90% of cases of bad breath are oral in origin with the remaining 10 to 15% originating elsewhere. So that means I can help the vast majority of patients with real (or perceived) cases of halitosis. The techniques for treating bad breath are beyond the scope of this post but in general we focus on improving oral hygiene. For the other 10 to 15%, I typically refer to the correct physician specialist for evaluation and diagnosis.

What NOT to do if you have halitosis

I’ve had a great number of patients come to me for assistance and advice on many dental and non-dental issues. These have ranged from whether the Tooth Fairy should come for Wisdom Teeth (no!) to whether used dental floss can be flushed down the toilet (no!) to how do I tell my significant other they should see the dentist (firmly but delicately).

I have yet to field a question regarding bad breath and the status of a patient’s marriage. But I can confidently say:

Do not divorce you partner if he/she has bad breath!

Your dentist and hygienist can help. Just call them.

Dental MythBuster #9 – You can’t get a cavity under a crown

This is one dental myth that I wish I did not have to see.  The myth typically plays out like this:

“Mrs. Jones, I can see both on the x-ray and upon clinical exam that there is decay on this particular tooth.”

She will typically respond by saying:

“How can I have a cavity on that tooth? It has a crown!”

After years of practicing dentistry, I can say that this happens about 98% of the time when there is decay on a tooth which already has a crown. So this dental myth definitely needs to be busted!

Photograph of a cavity under a crown

Seeing is believing, so let’s take a look at a photo I took of a patient in my dental office in Orange, CT.

Photo showing a cavity, also known as dental decay, under a dental crown

A cavity, known more formally as dental decay, evident underneath a crown on a lower molar on a patient of mine in Orange, CT.

The decay is visible in the above photo at the gum line. Treatment will most likely involve a new crown. Without treatment, this patient will lose his tooth eventually.

By looking at the photo, you can see that it is possible to get decay under a crown. So the myth is busted! But let’s look at how it happens.

What are dental cavities?

Dental decay photo showing a cavity on an upper canine tooth

Decay on an upper canine near the gum line.

Dental decay (known less formally as dental cavities) occurs when bacteria inside the mouth ingest certain foods and then attack the teeth. This leads to a weakening of the tooth and can ultimately lead to an actual hole (a.k.a cavity) in the tooth.

Decay can occur on any part of any tooth in the mouth. It can occur on teeth that have never had a filling before. Or the decay can start on teeth that have had fillings, crowns, or root canals.  It can start at age 2 or age 100! For a more detailed explanation, you can refer to a page I authored on my main practice website.

How teeth with dental crowns can develop decay

As stated earlier, decay can develop on any tooth. But cavities are more likely to occur in certain areas.

Dental x-ray radiograph showing decay or cavities under or below a dental crown

The red circles indicate the decay at the margin of two different crowns.

When it comes to teeth with crowns, the area most susceptible to developing decay is the margin. The margin, as you would guess, is where the crown meets the tooth. It is the weak spot. It is the Achilles Heel.

Food and other debris can collect right at the margin. A crown that was poorly made will collect even more food. If you combine this with a diet rich in sugar or acid, along with home hygiene that is not ideal, you have a perfect storm. That perfect storm affected the two crown to the upper right on the x-ray, resulting in decay.

Another Dental Myth Busted

The above photos, descriptions, and x-ray show that even with a crown, a tooth can still develop a cavity. So it bears repeating:

Crowns will protect an already weakened tooth but you still need to brush and floss sensibly. If you don’t, you can develop decay just like you would on any other tooth.

 

Dental MythBuster #6 – My baby stole the calcium from my teeth!

As a general dentist practicing in Orange, CT, I have the privilege of treating patients of all ages, including both expecting and postpartum mothers.  The number one dental myth I hear from these patients is the following:

Drawing of baby who stole the calcium from his mother's teeth leading to dental cavities

“I didn’t have any cavities until I became pregnant. Then my baby sucked the calcium out of my teeth which is why I have all these new cavities now!”

This is always a difficult dental myth to “bust.” First, the concept of losing calcium from bones is well established and patients frequently assume bones and teeth are similar.   Secondly, this dental myth is so widely circulated among pregnant and new mothers that many don’t want to believe me when I try to “bust” it!

About Calcium, Teeth, and Bone

Teeth, like bone, are comprised of hard minerals, with calcium being one of the key components. Tooth enamel is harder than bone and is actually the hardest substance in the body!  Adult teeth begin to develop at a very young age and continue to mature until approximately age 16 (except for wisdom teeth).  By age 16, your teeth are no longer developing and the strong enamel layer no longer requires nutrients from your bloodstream.   So at this point a deficiency of calcium in your diet will not affect your teeth, because your teeth are no longer forming.

Picture of Bone in Thigh. Unlike teeth, bones are constantly being broken down for calicum.

Bone is used as a source of calcium.

This is in direct contrast to bone which is constantly being reformed in response to dietary, hormonal, and other factors. Every single day, small parts of your bones are naturally dissolved and then re-formed.  Calcium is needed for this process and a deficiency of calcium can lead to weaker bones.  This is one of the main reasons why older patients frequently take Vitamin D and Calcium – it is to enhance the strength of their bones.

So, many patients assume that because bones constantly require a source of calcium, then teeth must as well. And with a growing baby in utero and/or nursing baby taking nutrients from the mother, people assume their teeth are having nutrients taken away. Not true!

New Mothers and Tooth Cavities

So this brings up the question: do new mothers have greater amounts of tooth decay? And if so, why?  Well, the answer to the first question is Yes! New mothers do have higher rates of dental decay.

Tooth with a cavity or decay in a new mother, not because the baby stole her calcium

Photo of a tooth from one of my patients with an 8 month-old little one. The cavity is NOT because the baby “stole” calcium from her teeth!

There are several reasons for why new mothers have more cavities. I have observed all 4 of these personally in my private practice.

  1. Morning Sickness: not all pregnant patients experience this. However, even occasional vomiting in the morning brings up very acidic stomach contents which can quickly erode your teeth, leading to decay.
  2. Acid Reflux: pregnant women are more likely to experience acid reflux due to the pressure on their stomach from the growing baby. This can also lead to stomach acid entering the mouth to erode the teeth.
  3. Changes in Oral Hygiene: let’s face it, being a Mom is hard work! Many new mothers spend so much time focusing on their new child that they neglect to brush and floss consistently. This can easily lead to new cavities.
  4. Changes in Diet: with pregnancy and nursing, some women will start eating sugary foods they did not typically consume before.  Increased sugar intake can lead to increased decay.

In addition to dental decay, pregnant and nursing mothers are also at risk for Pregnancy Gingivitis which will be covered in a future post.