Local dentists offer tips for preventing oral health problems

GERM WARFARE: Oral probiotics can help counteract bad bacteria in the mouth, says dentist Kani Nicolls. Photo by Cindy Kunst

Maintaining a healthy set of teeth and gums is a goal pretty much everyone shares. For this special wellness issue, three Asheville-area dentists share some of their wisdom about the best ways to build strong teeth, prevent cavities and generally take good care of your choppers. Their recommendations range from regular brushing and flossing, limiting sugary foods and drinks, and using either fluoride-containing or alternative dental products to strengthen tooth enamel.

Dr. Kani Nicolls, a dentist who’s practiced in Asheville for over 20 years, explains that a big part of dental health comes down to a tiny but complex ecosystem of bacteria. “There are at least 700 different kinds of bacteria in our mouths,” she says. When those bacteria stick to one another and to teeth and gums, she continues, they create a “biofilm.” Even though it might not sound like it, that can be a good thing. “In a healthy biofilm the good bacteria keep the bad bacteria in check,” Nicolls says.

But without proper oral hygiene, the biofilm can take a turn to the dark side. In the absence of regular brushing and flossing, or if a person consumes a lot of sticky, sugary foods, the bad bacteria can overwhelm the good, Nicolls explains. When that happens, the bacteria mutate into a new form that secretes acids. Those acids can damage tooth enamel, leading to cavities and gum disease.

In addition to brushing, flossing and avoiding sugars, Nicolls says there are other ways to neutralize the acids that attack your teeth. Saliva contains bicarbonate, an alkaline substance that helps with normalizing the mouth’s pH after eating. Drinking water throughout the day or chewing sugar-free gum can help keep the salivary glands flowing, Nicolls says.

Another aid Nicolls recommends is sugar-free chews that contain the alkaline substances arginine, bicarbonate and calcium carbonate. In addition to the ingredients that neutralize acid, the calcium in the chews helps strengthen tooth enamel.

Oral probiotics can also serve as an ally in what Nicolls describes as a benign form of germ warfare. Studies have found that people with healthy mouths have a distinct culture of oral bacteria. So researchers have analyzed the composition of the healthy biofilms in those people and replicated it in a probiotic product, Nicolls says.

Now, sugar…

NOT SO SWEET: Sugar in liquid form, especially in sodas, is the worst thing for teeth, says dentist Mark Knollman. Photo by Cindy Kunst

As a college chemistry major, dentist Dr. Mark Knollman says he learned, “If your goal was to destroy teeth, you would take a mild acid and sugar and put them together in a container and say, ‘Drink this.’ And it would rot your teeth out.”

Based on that lesson, Knollman continues, he assumed during the early years of his career that those who formed cavities were eating large amounts of candy, cookies and cake. Now, after 28 years practicing dentistry, he says, “I don’t find many patients where that’s really the problem. Those are actually very few and far between.” The larger culprit, he explains, is the sugar people consume in liquid form.

In addition to sweetened sodas’ high sugar content, Nicolls says, these beverages generally include some combination of citric, carbonic and phosphoric acids.

“One sip of a soft drink can lower the pH in your mouth for up to four hours,” Knollman reveals. Therefore, people should limit sugary drinks as much as possible, he advises, noting that “water is healthy and cheap.

“For a lot of people that’s a big stretch — for them to switch from soft drinks to water. One option is to switch them to diet drinks. I’m not a big fan of artificial sweeteners because they come with their own set of problems, but they are slightly better for your teeth,” says Knollman.

The average 12-ounce can of soda contains over eight teaspoons of sugar. But ferreting out just what kinds and how much sugar a product contains can be challenging. Fructose, glucose, dextrose and maltose are just some of the names for sugar that show up on product labels, says Knollman. “The average consumer just isn’t educated about appropriate sugar portion sizes to understand how it impacts their overall health.”

How about fluoride?

Fluoride’s role in promoting dental health has been the subject of significant public attention — and controversy — since the U. S. first began introducing the chemical into public water systems in the 1950s.

Fluoride, Knollman explains, strengthens teeth by chemically changing the makeup of the tooth’s enamel. Natural, unsupplemented tooth enamel is made of a chemical crystal called hydroxyapatite, he says. The first part of that crystal, the hydroxide ion, can be replaced with a fluoride ion, creating a new crystal, fluorapatite — a substance that’s harder and “a lot more resistant to acid attack,” according to Knollman.

But the extent of remineralization can only go so far, he continues. “You can’t make it twice as hard by giving people twice as much fluoride.”

Though fluoride is toxic at higher doses, the federal Food and Drug Administration does not regulate the substance at 1 part-per-million, the amount added to public drinking water supplies. At the same time, fluoride is also not regulated by the Environmental Protection Agency, which suggests appropriate levels for drinking water, since the substance is introduced during the treatment process rather than added directly to a body of water. The Centers for Disease Control and Prevention provides public education for fluoride uses.

All water is local

Since no one federal agency holds responsibility for adding fluoride to public water systems, the decision to fluoridate or not is made at the local level.

Asked about his position on Asheville’s fluoridation practices, local dentist Dr. Phil Davis referred Xpress to a summary of his concerns about water fluoridation in a Sept. 18, 2015, editorial in the Asheville Citizen-Times. “Exposure keeps adding up,” Davis wrote. “Fluoride has been added to toothpastes, mouthwashes, tooth sealants and other dental products. It’s in processed foods, commercial beverages made from fluoridated water, pharmaceuticals, pesticides and cigarette smoke. Today we know that nearly all of fluoride’s effect occurs via surface contact to teeth. Swallowing is not necessary. When fluoride is swallowed, healthy kidneys excrete about half. The remainder accumulates in the body over time.”

Critics of fluoridation point to a list of adverse health impacts of the long-term accumulation of the substance in the body, which they say include dental and skeletal fluorosis, lower cognitive function in children, hyperactivity disorders, and thyroid and other endocrine system disruptions.

Concerns also surround the type of fluoride used in community water treatment. The Asheville Buncombe Food Policy Council asked Asheville Mayor Esther Manheimer to stop adding fluoride to the local water supply in June 2015 (“Food Policy Council Urges Asheville to Stop Fluoridating Water,” Sept. 9, 2015, Xpress). In a letter, the ABFPC outlined its concerns: “The chemicals used to fluoridate water are not pharmaceutical grade (sodium fluoride). The form of fluoride added to the city water supply is hexafluorosilicic acid and is obtained from a chemical plant located in Spruce Pine. Industrial-grade fluoride chemicals are classified as hazardous wastes and may be contaminated with various impurities, including arsenic.”

The ABFPC’s letter contends that by putting fluoride in the water “the dose cannot be controlled, as people ingest varying amounts of water. This is of particular concern for infants and young children and especially those consuming infant formula made with fluoridated water. Infants who receive formula made with fluoridated water … may receive an estimated 175 times more fluoride than a breast-fed infant.”

Starting them young

According to the CDC, children under 8 years of age can develop a condition known as “dental fluorosis” from overexposure to fluoride while the permanent teeth are still developing under the gums. In its milder forms, the condition may appear as scattered white spots or thin white lines on the surface of a tooth. More severe forms can result in larger white patches or, rarely, a rough and pitted tooth surface. Once permanent teeth have erupted, the risk of dental fluorosis is past.

Those who wish to opt out of fluoridated public water supplies can use water from springs, wells or other untreated water sources. Pitcher and tap-style water filters don’t generally remove fluoride from water. Reverse osmosis whole-house water treatment systems can remove the substance, but they are costly.

To minimize fluoride exposure, some people use fluoride-free toothpastes that contain xylitol, a sugar alcohol that reduces plaque on tooth surfaces. Other alternative tooth products contain calcium and phosphate, which manufacturers say also strengthen tooth enamel.

Despite the controversy surrounding fluoridation in public water supplies, Knollman says he thinks the use of fluoride has had significant public health benefits. “I have made a career basically out of taking care of baby boomers,” he says, “people who grew up pre-fluoride, and they have a ton of cavities.”

By contrast, he continues, “Now I see a bunch of people under 40 who think the dentist is just a place where you get your teeth cleaned and you get a free toothbrush twice a year. … So this is my empirical evidence that fluoride has benefited this generation.”

While Nicolls says she respects the preferences of her patients who wish to avoid fluoride, she is on the same page as Knollman when it comes to the oral health benefits of fluoridation. “I don’t think that oral hygiene is any better now than it ever was,” she confides. “But I think the kids that have fluoride are definitely more resistant to cavities.”

Nicolls recommends establishing oral care habits when a child’s first tooth appears. “As soon as children’s teeth begin to come in is the time to brush and clean them and begin healthy, positive dental experiences,” she advises. Parents shouldn’t wait until something hurts or a problem arises, she continues. “It is all about developing positive habits and a healthy oral health program.”



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9 thoughts on “Local dentists offer tips for preventing oral health problems

  1. Ok, let’s look at some of the misleading and misinformation within this article:

    1. While it is the decision of local and state officials as to whether to adjust the existing fluoride level in public water supplies, they can only do so to the extent allowed under EPA mandates. The EPA has maximum allowable levels of safety for fluoride and any contaminants in drinking water. So, while the fluoride level in local supplies can be raised to the optimal level, that level is well below the maximum allowable by the EPA, and must not, by law, exceed the EPA mandated maximum.

    2. The effects of fluoride are both topical and systemic. The systemic effect is clearly evident in mildly fluorosed teeth. Mild dental fluorosis is a barely detectable effect which causes no adversity on cosmetics, form, function, or health of teeth. Peer-reviewed science has demonstrated mildly fluorosed teeth to be more decay resistant. Mild dental fluorosis can only occur systemically through ingestion of fluoride.

    Additionally, incorporation of fluoride into saliva enables a consistent bathing of the teeth in a low concentration of fluoride throughout the day, a very effective means of decay prevention. This incorporation into saliva occurs systemically.

    3. There is no valid, peer-reviewed scientific evidence of any adverse effects from “accumulation in the body over time” of optimal level fluoride from fluoridated water.

    4. The only dental fluorosis which may be attributable to optimally fluoridated water is mild to very mild, a barely detectable effect which causes no adversity on cosmetics, form, function, or health of teeth.

    5. If skeletal fluorosis was in any manner attributable to optimally fluoridated water, in the nearly 75% fluoridated US, this disorder would be rampant by now. Skeletal fluorosis is so rare in the US as to be nearly non-existent.

    6. Hexafluorosilic acjd (HFA) is not a “form of fluoride”. Fluoride is the anion of the element fluorine. An anion is a negatively charged atom. HFA is a compound containing the fluoride ion.
    A compound is not a “form” of an atom.

    7. Once introduced into drinking water, HFA immediately releases its fluoride ions. After that point, HFA no longer exists in that water. It does not reach the tap. It is not ingested. It is of no concern, whatsoever. The fluoride ions released by HFA are identical to those released by NaF, or any other compound. These ions are identical to those fluoride ions which already exist in water. A. fluoride ion is a fluoride ion, regardless its source.

    8. Substances produced for specific purposes, such as is HFA, are not classified as “toxic waste” by anyone.

    9. “Pharmaceutical grade fluoride” is not only far more expensive than HFA, but it has the potential to release into water more of the “various impurities including arsenic”, than HFA. As the fluoride ions released by “pharmaceutical grade fluoride” are identical to those released by HFA, the only difference between the compounds is the amount of contaminants in each. “Pharmaceutical grade fluoride” is produced to use in one shot applications such as toothbrushing, mouth rinses, etc. While the amount of contaminants in that “pharmaceutical grade fluoride” is entirely safe for these one shot applications, when used in the high volumes necessary to fluoridate entire water systems, the amount of arsenic and other contaminants may very well be significantly higher than that from HFA, which is produced for high volume use, and is remarkably pure. The amount of impurities in fluoridated water at the tap are in such minuscule amounts that they are not even detectable unless ten times the manufacturer’s recommended single use amount of HFA is utilized. Even then, the contaminants are so barely detectable that it’s not a certainty that those detected aren’t those that exist in water already.

    A complete list of the contents of fluoridated water at the tap, including precise amounts of any detected contaminants, and the EPA maximum allowable level for each, may be found on the “Fact Sheet on Fluoridation Substances” on the website of NSF International.

    10. There are no “dose” concerns with optimally fluoridated water. When the maximum amount of a substance which can be ingested does not reach the threshold of adverse effects, then dose is not an issue. Before the threshold of adverse effects could be attained from the 0.7 mg/liter fluoride in optimally fluoridated water, in combination with fluoride intake from all other normal sources, water toxicity would be the concern, not fluoride.

    11. There is no valid, peer-reviewed scientific evidence of any adverse effects of optimally fluoridated water on “infants and young children”, or on anyone else, of any age.

    12. The amount of fluoride in human breast milk is of no relevance to optimally fluoridated water. Human breast milk is deficient in iron, vitamin k, and vitamin d, to the point of requiring supplements for breast-fed infants. By the “logic” of antifluoridationists, nature intends for infants to be anemic free-bleeders who develop Ricketts.

    Steven D. Slott, DDS
    Burlington, NC

  2. This article is accurate except for a few relatively insignificant details. I would disagree with the dentists who think fluoride, specifically fluoridated water, has played a role in the observed improvement of dental health of younger generations. That conclusion is anecdotal rather than emprical because, as a matter of fact, empirical epidemiological data shows no statistically significant difference in tooth decay rates between areas in the US and around the world that do not fluoridate their water and areas that do. Tooth decay rates have been declining at the same rate everywhere for the last half century, perhaps due better access to professional care, better nutrition, better oral hygiene practices or other unknown factors. Unfortunately poor “Doc” Slott cannot swallow that obvious truth, so he grasps at feeble talking points in an attempt to shore up a failed and foolish public health belief system. (Does he really think you’ll believe that the human race has survived some 10 million years on deficient mother’s milk? It is pretty much true, though, that there’s no difference between “pharmaceutical” fluoride and industrial grade fluoride. All fluoride ions are protoplasmic poison. ) Every court that has heard challenges to fluoridation has agreed that it is a violation of Constitutional protections of privacy and freedom from bodily intrusion. Those courts have allowed it, however, because they accepted the claims of public health “authorities” that it was a public health necessity. Now the empirical evidence shows that it’s no such thing and is just a Constitutional violation. So there’s really nothing to debate or hesitate about. Fluoridation is the only non-consensual public health policy in the US. It is not effective and, contrary to Doctor Slott’s flat-footed claim, there IS plenty of evidence that it is not safe. EPA scientists have been calling for a halt to fluoridation since 1999, but EPA administrators refuse to comply with the requirments of the Safe Drinking Water Act. Local water suppliers assume the responsibility for imposing this ignorant non-consensual treatment on their customers. No one makes them do it. They are free to stop at any time.

    • Steven Slott

      Janet Nagel

      1. The effectiveness of water fluoridation in the prevention of dental decay in entire populations is not a matter of what anyone “thinks”, it is a well established scientific fact. I will be glad to cite as many of the volume of peer-reviewed studies clearly demonstrating this fact, as anyone would reasonably care to read. That Janet believes the peer-reviewed science to be “anecdotal” is typical of the disdain antifluoridationists have for facts and evidence.

      2. The “empirical epidemiological data shows no statistically significant difference in tooth decay rates between areas in the US and around the world that do not fluoridate their water and areas that do.” to which Janet refers is not “empirical” anything, it is a meaningless, skewed misrepresentation of WHO data by personnel of the New York antifluoridationist faction, “fluoride action network”.

      3. In regard to deficiencies in human breast milk:

      A. “As vitamin K is undetectable in cord blood, the only other source in breast-fed infants is human milk. We found persistently low vitamin K1 plasma concentrations in these infants by 4 weeks, and vitamin K concentrations at 2, 4, 6, 8, 12, and 26 weeks averaged 1.18+/-0.99, 0.50+/-0.70, 0.16 +/-0.07, 0.20+/-0.20, 0.25+/-0.34, and 0.24+/-0.23 ng/mL, respectively (lower limit of adult normal = 0.5ng/mL). Vitamin K, in breast milk at 2, 6, 12, and 26 weeks was also very low, averaging 1.17+/-0.70, 0.95+/-0.50, 1.15+/-0.62, and 0.87+/-0.50 mg/mL, respectively. This may be secondary to low maternal vitamin K1 intakes or inability of vitamin K1 to penetrate human milk.”

      —Adv Exp Med Biol. 2001;501:391-5.
      Are breast-fed infants vitamin K deficient?
      Greer, FR

      B. “While breastfeeding is the recommended method of infant feeding and provides infants with necessary nutrients and immune factors, breast milk alone does not provide infants with an adequate intake of vitamin D. ”

      “Human milk typically contains a vitamin D concentration of 25 IU per liter or less. Therefore, a supplement of 400 IU per day of vitamin D is recommended for all breastfed infants.”

      –Centers for Disease Control and Prevention.

      C. “Breast milk contains very little iron (~0.35 mg/liter). The Institute of Medicine recommends that infants 6-12 months old get 11 mg of iron per day [1]. By this age, most babies’ iron stores have been depleted, so this iron needs to come from complementary foods, in addition to breast milk or formula. ”

      —Institute of Medicine, Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. 2003, National Academies Press: Washington, D.C.

      4. There is no valid, peer-reviewed scientific evidence that fluoride at the optimal level at which water is fluoridated is “protoplasmic poison”.

      5. No court has ever ruled that water fluoridation “is a violation of Constitutional protections of privacy and freedom from bodily intrusion.” Janet is certainly free to provide such rulings if she cares to belabor this point.

      6. Countless peer-reviewed scientific studies clearly demonstrate the effectiveness of fluoridation in the prevention of dental decay in entire populations. I will gladly cite as many as Janet would reasonably care to read.

      7. There is no valid, peer-reviewed scientific evidence that fluoride at the optimal level at which water is fluoridated is, in any manner, unsafe……..as evidenced by Janet’s inability to provide any such evidence.

      8. The “EPA scientists” nonsense constantly attempted by antifluoridationists is in regard to the vote of a few members of a little EPA union of but 1500 of the 20,000 EPA employees, a decade and a half ago, shortly before that union went defunct. At one of its last meetings in 1999, this union, led by long time antifluoridationist, William Hirzy, the current paid lobbyist for the New York faction, “FAN”, declared the few members in attendance to be a quorum. This “quorum” then voted to support the antifluoridationist activities of its leader, Hirzy.

      Neither the EPA, nor the large EPA employee union which usurped Hirzy’s little union after its demise, have any position on water fluoridation.

      9. There are obviously no violations of Safe Water Drinking Act, by water fluoridation. Uninformed antifluoridationists who make the ridiculous claim that there are any such violations, are always conspicuously unable to provide any valid evidence, whatsoever, of any purported violations. Janet is certainly free to provide any such evidence if she cares to belabor the point.

      10. As has been demonstrated in this dismantling of Janet’s unsubstantiated claims, the ignorance lies not with fluoridation, but with her and other such uninformed antifluoridationists who seem not to understand that their personal opinions do not qualify as valid evidence of anything.

      11. There is nothing “consensual” required for local officials to approve the concentration level of existing minerals in public water supplies under their jurisdiction.

      Steven D. Slott, DDS
      Burlington, NC

  3. Also in response to Doctor Slott: The symptoms of mild skeletal fluorosis are the same as arthritis. Since physicians are all taught and expected to believe that fluoridation is entirely benign, they learn nothing about skeletal fluorosis. Since no one is looking for it there’s no way to know how many cases of skeletal fluorosis are misdiagnosed as arthritis.

    • Steven Slott


      Your unqualified personal opinion in regard to skeletal fluorosis, and your ridiculous unqualified opinion as to what is taught in medical schools, are, obviously, meaningless and irrelevant.

      If you have valid, documented evidence of any misdiagnoses by duly qualified, educated, credentialed, and licensed healthcare personnel, then feel to present it. Otherwise you have nothing but your own, unsubstantiated, libelous claims of incompetence of such personnel.

      Steven D. Slott, DDS
      Burlington, NC

  4. The Real World

    I’ll let people more knowledgeable that I debate the flouride issue. But, will pass on what my own dentist said about the #1 cause of tooth decay. It’s SUGAR. He said there are tribes in the world that consume no sugar as part of their diet, receive no sophisticated dental care and have virtually intact teeth with no decay.

    In American diets, where many virtually bathe their teeth in sugar daily in the form of sweetened drinks, ice cream, syrups (not to mention candy and bakery items), we voluntarily rot our own teeth. Ponder that one for a bit. Good teeth or bad teeth — it’s choice.

    • Snowflake (Social Justice Worrier)

      My dad said his dentist told him that when he couldn’t brush after eating, to swish and swallow (with water). Makes sense.

  5. Micheal Fernandez

    Hi there, from last 2 weeks I have a problem in my tooth and I have tried most of the home remedies to cure the pain. While discussing with my friend, he suggested me about http://caldentalgroup.com to have a visit for tooth pain. If you have any idea please tell me.

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