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.

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.


7 Habits of Highly Effective Brushers

I get tooth brushing questions all the time from my patients in private practice in Orange, CT. What toothpaste should I use? Should I listen to Dr. Oz? Am I brushing too hard? Should I brush after every meal?

After many years of observations, the following was born: The Seven Habits of Highly Effective Brushers.

1.  They use a Power Toothbrush

Power toothbrush used by highly effective brushers as observed by Orange, CT dentist Nicholas Calcaterra DDS

Oral-B Toothbrush with a timer

Electric toothbrushes, if properly used, are far more effective in removing plaque and other debris than a manual toothbrush. Regardless of the brand used, the vibrations and movements produce cleansing actions that cannot be reproduced manually. Removal of more plaque and tartar reduces the likelihood of gum disease and dental decay. The most effective brushers I have encountered always use power toothbrushes.

Besides cleaning the teeth more effectively, power toothbrushes also can have other important features. One is a timer indicating you should move to another area of the mouth. Another feature tells you when you are brushing too hard. This is especially important as brushing too hard is addressed in Habit #5.

2. They ask for personalized feedback from their dentist or hygienist

I spent 9 years after high school training to become a dentist with 5 years focusing primarily on the oral cavity. Dental hygienists spend a minimum of 2 years after high school studying the gum tissue and supporting structures. Your dentist and hygienist know more about the oral cavity than your physician, Dr. Oz (see Habit #3), WebMD, or any other resource.

Highly effective brushers always ask me or one of my hygienists for feedback.  Certain power toothbrushes are better for some than for others. Some toothpastes are better for decay (cavities) than gum disease and vice versa. We are there to give you information and advice.  Just ask. Your teeth and gums will thank you for it!

3. They do NOT listen to Dr. Oz for dental advice

Dr. Mehmet Oz is a great surgeon but gives bad dental advice

Dr. Mehmet Oz. Image courtesy wikipedia

Dr. Oz is an accomplished cardiothoracic surgeon and TV personality. His training in the dental field is likely limited to the 2 hour lecture on teeth and gums he received as a second year medical student back in the 1980s. But that has not stopped him from presenting some questionable and even frightening solutions regarding oral health.

In his post on home teeth whitening, he suggests mixing lemon juice (an acid) and baking soda (an abrasive). You apply it to your teeth, let it sit for a minute, and then brush it off. In doing so, your teeth will become whiter. But you will be actively wearing away your teeth! This is the equivalent to swishing with Mountain Dew for 2 minutes and then rubbing your teeth with sandpaper!

Highly effective brushers do not turn to Dr. Oz for dental advice. They rely on their dentist and hygienist for professional advice.

4. They don’t brush immediately after every meal

Some people rush to the bathroom after every meal to brush. This is either ineffective or in some cases counterproductive. After an acidic meal, such as one with orange juice, the acids in the juice will have temporarily weakened the enamel. If you rush to the bathroom to brush, you will be slowly brushing away the weakened enamel!  Do this over a period of years and you will have lost enough enamel for the teeth to be permanently weakened.

Highly effective brushers typically brush 2 to 3 times per day, and never immediately after a meal. After an acidic snack, they are more likely to rinse their mouth with water than to brush.

5. They don’t brush too hard

Photo of receded gums from brushing too hard teeth and recession

Gum Recession and abrasions from an overzealous tootbrusher!

Some people think that the harder they brush, the better. Wrong! Brushing too hard can lead to recession of the gum tissue, as seen in the photo to the right. Over time, the tooth loses the critical gum and bone tissue supporting it.

Another side effect from brushing too hard is that you can wear away the outer layer of the tooth. The beginning of this can be seen in the photo on the right. I’ve had patients brush so hard that they wore all the way into the nerve of the tooth so that they needed a root canal!

Highly effective brushers do not brush too hard. This is because they have been properly instructed by their dentist or hygienist (see Habit #2) or they have a power toothbrush which tells them when they are brushing too hard (Habit #1).

6. They use a fluoridated toothpaste

Fluoride has been proven by hundreds of studies to reduce dental decay. The CDC called fluoridation of public water supplies one of the 10 greatest public health achievements of the 20th century. But some still attempt to link fluoridation to a Communist Plot.

A fluoridated toothpaste is much less controversial than public water fluoridation. I can say from my personal experience that people who use a non-fluoridated toothpaste get more cavities. I’ve seen this hundreds of times. Fluoride works. Highly effective brushers use fluoridated toothpastes sensibly.

7. They Floss

Dental floss used by highly effective tooth brushers

Effective Brushers also floss!

The seventh and final habit of highly effective brushers does not deal with brushing teeth. It address flossing.

Highly effective brushers also floss. They know that brushing only cleans 60% of the tooth surface. The other 40% of the tooth can only be reached and cleaned by dental floss or similar device. Without flossing, even the best brusher in the world will still be susceptible to getting cavities (dental decay) as well as gum disease.

Other Habits?

Do you have other ideas on the habits of highly effective brushers? If so, leave a comment!

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.