Redhead Dread Part II

A couple of months ago, I wrote an extensive blog post about my experiences as a general dentist treating redheads.  I called it Redhead Dread to suggest that redheads dread going to the dentist.  The post was based upon research which found that individuals with red hair required more local anesthesia than non-redheads.  A natural conclusion from that research was that redheads would avoid dental care and/or be fearful of the dentist because of a greater likelihood of a past, painful experience in the dental chair.

Joan on Mad Men is a Redhead - does she dread the dentist

Joan (Christina Hendricks) plays a sassy character on Mad Men. But would she secretly dread a trip to the dentist? (image from fanpop.com)

A research paper released just last month by the Journal of Endodontics detailed the findings of a well designed study which looked at the effects of dental local anesthesia on women with red hair.  This study had a control group of women with dark hair in order to observe the differences. Some of the findings were surprising. Key conclusions were:

  1. In standard injections for the lower teeth using lidocaine (not novocaine), there was no difference in the success of the local anesthesia between redheads and dark haired females.
  2. Redheads felt more pain on needle insertion than dark haired females.
  3. Redheads experienced “significantly higher levels of dental anxiety” when compared to dark haired females.

Considerations for Dental Patients

The first conclusion stunned me, as it contradicted both previous research as well as my own experiences treating dozens of redheads over the past several years.  This was a well designed study but there was a relatively small number of study subjects.  Could the small number of participants explain the unexpected response? Possibly.  But I am not going to doubt or second guess the authors.  Nevertheless, a follow-up study with more participants would be beneficial.

In my own observations as a general dentist, conclusions 2 and 3 are closely linked and were expected. The anticipation of pain can make anyone, regardless of hair color, either amplify a minor pain stimulus into a very painful one, or create a perception of pain when no pain should have occurred.  Stated another way, an expectation of pain can create pain out of nowhere!

Because the first conclusion was a surprise, I do expect there will be additional research on this topic, which I will write about. Until then, we can conclude:

Redheads will have greater anxiety when it comes to receiving dental care. If you are a redhead, don’t be afraid to tell your dentist about any fears you may have!

Tooth Tattoo

Small Sensor May Help Dentists Assess Dental and Overall Health.

As a dentist in Orange, Connecticut, one of the things I enjoy most is watching and following all the exciting research developments in the dental field. It is amazing the creativity and ingenuity that goes in to developing these innovations.  The research spans all areas, from better local anesthetic delivery systems, stronger crowns, new surgical techniques, more esthetic restorative materials, etc.  Some products are still many years away from market release.  Other dental innovations are “cool” but will never be feasible as commercial products.  Some products are ready to be released and placed into the hands of dentists today!

To stay abreast of these dental developments, I subscribe to different email lists and participate in various online forums about dentistry.  I do this so that I can incorporate newer technologies into my daily practice.  I came across the following article just a couple of days ago. The article describes a device that can attach to a tooth and provide information about the types of bacteria present in the mouth.

Tooth Tatoo Diagram

Tooth Tatoo – The Sensor (A) attached to the tooth (B) binds with bacteria (D) and sends radio signals (C). Image courtesy of Manu Manoor/Nature Communications.

Researchers at Tufts University have developed this technology.  In the prototype, there is a sensor with a width less than a piece of paper that attaches to a tooth.  Outside the mouth there is a receiver that continuously “pings” the sensor providing it with power as well as allowing the sensor to send data back to the receiver.  The sensor will send back different types of data based upon the presence or lack of bacteria as well as the types of bacteria that are adhering to the sensor.

Strep Mutuans, the cocci bacteria found on teeth that cause cavities or dental decay

Strep Mutans – the bacteria responsible for cavities

Dental caries (also known as dental decay or dental cavities) are caused by specific bacteria, aided or hindered by certain dietary habits.  Periodontal disease (which includes periodontitis and gingivitis) is caused by specific bacteria as well and is affected by numerous other factors (smoking, certain systemic diseases, etc).  The presence/absence as well as the amount of these different types of bacteria are directly linked to the current disease process as well as the future possibility of disease.  So a device such as this would be beneficial in diagnosing both current and future cases of cavities and periodontal disease.

Dr. Gerard Kugel from Tufts University School of Dental Medicine mentions in the article examples of how this technology could be used in an everyday dental practice.  If a patient is experiencing a spike in bacterial loads associated with dental caries, the patient could be given a prescription for high strength fluoride and be instructed to chew xylitol gum multiple times throughout the day.  Or if the sensor is detecting a surge in one of the 3 main bacterial species associated with periodontitis, the patient could be notified and be recommended to have a cleaning soon or to start on a mouth rinse containing chlorhexidine.

Beyond assessing a patient for dental caries or periodontal disease, I see many other applications of this future tool.  There are many biological markers in saliva that could be monitored and tracked. For example, proteins from the HIV virus can be found in saliva.  In addition, biological markers associated with Type II Diabetes, breast cancer, Alzheimer’s Disease, Sjogren’s Syndrome, and many other diseases can be found in saliva.  A great summary of the different markers can be found here.

This development is still many years away from being commercially available and viable. However, there are many possibilities beyond what has been described in this blog post.  But perhaps the greatest finding with this research is the further solidification that the mouth is a gateway to the body and that dentists and physicians should work together closely to manage their patients’ health.

Disclosure: I completed my undergraduate studies at Tufts University and I routinely take continuing education classes at Tufts University School of Dental Medicine. But I have no connection with this product or the research in practice in Orange, CT.

Redhead Dread

Do redheads dread a trip to the dentist?

Redheads dread the dentist due to resistance to local anesthesia

Redheads. Image courtesy The New York Times

When I stumbled across this article in the New York Times back in 2009, the conclusions seemed eerily familiar.  In my own personal experiences as a dentist in Orange, CT and elsewhere, patients with red hair seemed to be more apprehensive regarding dental care, and also seemed to have the dreaded “well, it looks like you’re not quite numb enough with the first shot, let me give you a bit more” phenomenon occur to them with much greater frequency than patients with darker hair and complexions.

As much as I would like to delve into the true scientific details, those facts go beyond the scope of this post.  But to summarize, redheads have a mutation (basically a change in their genetic makeup) that produces red hair and fair skin.  But that same mutation also affects receptors in the brain that govern pain perception.  Although the exact mechanism is not quite fully understood, studies show that redheads have resistance to lidocaine.  Lidocaine is the most commonly used dental local anesthetic used in the United States. Chances are, when you visit the dentist, and get “The Shot”, you are receiving lidocaine.

So if redheads have resistance to lidocaine, then they are more likely to feel pain during a dental procedure.  But does that translate into more dental anxiety?  Of course.  You don’t need published research to reach that conclusion!   However, in medicine and dentistry, we do like to have our conclusions backed up by sold research.  A 2009 article by the Journal of the American Dental Association did confirm that redheads have “increased dental-care anxiety” and exhibit “avoidance of dental care.”

As a practicing dentist, I always look at research and then ask myself how the findings apply to my patients, either past, present, or future.  This is true not just with this specific research finding but with all the developments that are continuously occurring in dentistry.  A lot of research doesn’t immediately apply. However, this is one case in which the findings have immediately impacted how I approach my patients – specifically patients with red hair.

Lidocaine also known as xylocaine is a dental local anesthetic used in the United States

Dental Carpule of Lidocaine with epinephrine. Redheads have a documented resistance to Lidiocaine.

No dentist is perfect and can get 100% of the patients 100% numb with the first injection.  Any dentist that claims that is lying. There are too many factors that come into play.  As a dentist, it is tempting to find something or someone to blame when your patient does not get numb with the first injection.  Blame the assistant!  The anesthetic must be expired!  The patient moved!  The sun was in my eyes!  The sun was in the patient’s eyes!  It was a full moon last night!  This happens to all dentists and to all patients – independent of hair color.

However, upon thinking back on my own patients who were “tough” to get numb, a disproportionately large percentage had red hair and fair skin.  These patients seemed to require 2 to 3 injections to get numb.  Another observation is that these patients always knew they would need more.  They were the first ones to say “Hey doc, I always seem to need 2 or 3 shots every time I get a cavity filled.”  But they never knew why they needed more local anesthetic.

In my experience, if you know a patient is going to be a challenge to effectively anesthetize, administering extra local anesthetic right off the bat is the best solution. The patient appreciates it.  The second injection, if done properly, will rarely hurt, and will almost guarantee that the patient does not feel any part of the procedure. Since this article was published in the New York Times in 2009, I’ve told numerous redheads about it.  Upon telling them, they nearly universally have an expression of “Wow!! Now I finally understand why I’ve always felt pain and dreaded coming to the dentist.”  And from then on, their fears are reduced, permanently.

So how do we approach redheads who avoid care because of past negative experiences?  This is a lot more challenging! Most redheads are unaware that their genetics are pre-determining them to have more pain in the dental chair (unless more local anesthesia is administered).  So they must be informed of this. Simply informing anxious patients of this genetic phenomenon and how we address it is enough for many patients.  More severe cases of dental anxiety require different approaches.  I have training in sedation dentistry which has allowed me to treat patients who have moderate to severe dental phobias. This has allowed me to personally treat hundreds of patients too scared for “regular dentistry.”  But unfortunately, very few dentists have the training, equipment, and staff to do sedation dentistry safely. I will try to describe other techniques in a future blog post.

Many redheads still do dread the dentist, but now they don’t need to anymore.  There are many dentists out there equipped with this knowledge helping redheads overcome their anxieties, one patient at a time.