Monthly Archives: August 2015

E-cigarettes – finally some guidance…

At Northway Dental Practice we have like many people in healthcare been considering how we should advise our patients about e-cigarettes also known as vaping.

This issue has been one of common sense versus the available evidence. We felt, as I am sure most people in healthcare who have considered it also did, that e-cigs are less likely to be harmful to our health than smoking tobacco. They do not contain carcinogenic (cancer causing) chemicals, although some products have nicotine which is addictive. But the evidence was lacking to say that they were less harmful, and like many things which are new there tends to be a natural apprehension.

However when we look at the harms of smoking which are very real such as cancer, heart disease, stroke, emphysema as well as the dental implications such as gum disease, mouth cancer, stained teeth and bad breath, it seems that moving over to anything less harmful is the right thing to do on the way to quitting altogether.

It seems the government have now decided it is time to clarify the situation in a press release this week ( the conclusion drawn by Public Health England is that e cigarettes are 95% less harmful than smoking tobacco. My strong suspicion is that the remaining 5% is the unknown risk since this is a new phenomenon and this 5% will become clearer in time. It might even reduce in light of new evidence. They also determined that e-cigarettes were not a gateway or enabling route to more harmful behaviours, and they were not encouraging smoking in non-smokers.

So the message seems clear, if you smoke – quit. If you cannot quit – vape (as a way of lessening the harm or a help to quit).

I have had some personal experience of this having been a tobacco smoker in the past. I first tried an early version of an e-cigarette back in the late 2000’s and was fairly unimpressed, it did not taste like a cigarette, I felt no effect from the nicotine content and it seemed fiddly to use. At that point I decided perhaps they were just a fad.

It is much later and these products have developed into the wild array of devices and gadgets now available, which do provide to smokers the same sensation (minus 95% of the harm, it now seems) as smoking tobacco did, with the added benefit of a wide range of pleasant flavours. They also provide the nicotine smokers crave. Having tried one of these devices it seems that technology might offer the smoker who has tried everything to quit a chance to get away from the harms of tobacco.

It seems 2.6 million people in the UK are already convinced.

UPDATE 10-12-2015

So it seems there is a little more information to consider. One article I recently read (Harvard Gazette Article) links the disease commonly called popcorn lung, a serious and irreversible lung disorder to a chemical called Diacetyl. It also goes on to suggest that since 74% of e-liquids tested contained Diacetyl there may be a risk which was previously unknown.

Whilst this sounds worrying there are obviously several angles from which to view any given piece of information. My objection to the article is that it is titled on-line “popcorn-lung-seen-in-e-cigarette-smokers” however the study it quotes did not find any cases of popcorn lung in e-cigarette users, to the best of my knowledge there have been no cases. Instead it found a chemical which has been linked to this disease in a different context – 8 individual industrial workers exposed to the chemical in considerably higher doses developed the disease.

Another article (The Truth about Diacetyl) suggests that the evidence that diacetyl causes this disease might be questionable and also further goes on to point out that the chemical diacetyl is present in cigarette smoke and in much higher levels, but no cases of popcorn lung have been attributed to smoking tobacco cigarettes, something the world does have a great deal of data about.

So my advice would be if you vape it might be best to buy eliquid that does not contain diacetyl, a number of brands currently advertise as definitely free from this chemical and I suspect given this is likely to be newsworthy and induce a degree of panic the majority of the remaining main brands are likely to move to remove this chemical in their products.

In other news it appears that with e-cigarettes due to be regulated in 2016 they may be available on the NHS as a aid to quitting smoking.

Update 28th April 2016

The Royal College of Physicians have released a joint statement about e-cigarettes

In which they recognize that e-cigarettes are the best choice for smokers to switch to if quitting altogether is not possible, or as a way of quitting.

Prevention is better than cure but is it always easier?

Here at Northway Dental Practice we have always been heavily involved in prevention of dental diseases. People use the phrase ‘prevention is better than cure’ so much that we often don’t think about this phrase and what it means, it has become a throw away line.

Dentistry (and opthalmology) have always had an advantage over general medicine (i.e the GP), in that we are able to make a very thorough examination of our patient’s mouth without too much specialist equipment. Our GP colleagues by comparison often have to request expensive tests such as blood tests and scans to confirm their diagnoses. Because we have a relatively accessible part of the body  to examine, we have always been able to give advice on preventing disease. Rather than fixing things when they are broken, we stop things breaking by taking  preventative action. You need good information to do this well,  a dental check-up and occasionally a short follow-up appointment will usually gather enough information to do this.

The majority of prevention is about lifestyle. Although its not always a popular message, it is your choices  that determine much about your health i.e. you are responsible for it.

Because of this we need to find out about a person’s diet, habits, how they brush, what they brush with, how often they do it and the state of their general medical health; as many illnesses affect the mouth, including the consequences of stress. With this information which must be truthful and accurate, we can suggest ways to change things to improve health. The changes don’t always have to be big. It would surprise most people to know that having sweet food or drinks just 5 times per day (for example tea or coffee with sugar) can cause tooth decay whereas having it 4 times per day or less will usually cause no problems. The key to prevention is about changing our behaviour.

Prevention is however not as easy to do as it sounds. On paper it is quite straightforward. Make some changes and over time things improve. But in reality we are asking people to take responsibility for their own health and change their lifestyle, which is often a difficult message. Accepting this message requires taking personal responsibility for one’s own health, not something everyone we meet is willing to do.

Lets think about it in terms of a machine such as a car (or motorbike). We know that taking one for a service every year or certain number of miles, is an good way to achieve three things. 1) It is inspected by an expert who can advise if anything isn’t safe or might need attention. 2) Important things are replaced such as oil, brake fluid, brake pads etc.. which are items that wear out and degrade. 3) we get piece of mind and reassurance. This makes sense to most people, we know that a machine or a system needs maintenance, and we maintain it so that it doesn’t break down.

The mouth is essentially a system partly biological and partly mechanical, evolved to enable us to chew, speak, swallow (and smile). It is a biological system rather than a machine, but it is a system nonetheless which requires maintenance, cleaning and repair. Whilst many people see the logic of undertaking prevention and maintenance of this system, some others do not, perhaps feeling that it should maintain itself.

One group who do not follow preventative advice are those who have a severe anxiety about, or phobia of, dentistry. This group rarely attend and when they do they often have pain or swelling due to dental problems, this is often so bad that attendance is no longer optional. This can require complicated or difficult treatment which can be expensive. Once the problem is solved its easy to breathe a sigh of relief and not return until there is another serious problem. As such this behaviour reinforces the belief that what dentists do is always big, complicated, expensive (and often in their experience) – painful. As such they elect to avoid this experience by convincing themselves that everything is okay. This rarely works out as toothache or infection generally returns. It returns as lifestyle changes are not put in place, and other minor problems are not addressed.

There is another group of people who are even more puzzling to the dental profession some of this group have mild anxiety, others none, but when offered preventative advice say “if its not broken, don’t fix it” or words to that effect. Why is this? For some its financial – money is tight and they are trying to cut costs. It is doubtful whether this saves money in the long term. TO use the car analogy saving money on a service, might result in a costly and inconvenient breakdown. The problems which could have been avoided or at worst treated in a minimal-way return later and often are more serious.They also cost more to sort out later, both in terms of money, time and inconvenience. For some there is no belief that prevention is going to work. I often encounter people who seem almost fatalistic. They believe that things are predetermined. A belief that what we do or they do themselves, will not make a difference. Maybe they feel that their parents had bad teeth, so they will have bad teeth too. They do not think that using more fluoride, eating sugar less often and brushing better will decrease the amount of tooth decay they will suffer from, despite these measures being very effective. Because of this prevention seems like a load of  trouble that should be avoided.

The interesting  thing is that when dentists see healthy people who hardly ever have any trouble with their teeth, we do not think- ‘this must be a lucky person’! Almost always that healthy person is healthy because they made choices which are more compatible with health, and they have fewer problems. Fate, I am afraid, has nothing to do with it. If it did how would we explain that many people undergo a big turnaround in their health? Going from poor dental health to excellent in the space of a few years, by making small changes based on sound knowledge.

Is our current system of informed consent making the situation worse or better? Informed consent is a process (not a piece of paper) whereby a dentist or doctor explains what the diagnosis or problem is to their patient. They explain what they recommend as a solution, in the case of dentists, it might be avoiding frequent sugars, getting more fluoride, or perhaps a treatment such as a filling or crown. They discuss the risks of this solution and how likely it is to be successful. They explain what might happen if this solution is not put in place, i.e. toothache might begin or an infection set in. Then they offer alternative solutions and finally they ensure their patient understands the information and has had a chance to ask questions. This system was put in place to ensure that each of us when we are accessing medical or dental care, are involved with our care, consulted about our wishes and offered choices.

Again like prevention, on paper it seems like a very good idea. Most of the time it is. Engaged and interested people find the process to be exactly that, engaging and interesting. However those who are not so interested will often say “you’re the dentist you do what you think is best”. Unfortunately the age when this was acceptable has passed. This would go back to the bad old days when “doctor knew best” and in today’s blame-and-claim culture, it is impossible to practise in this way. For most people, informed consent is the cornerstone of good dental care but for others it might act as a barrier. They are unwilling to undergo a procedure when they know the full ins and outs of it and all the risks. Maybe for some ignorance was bliss.

Another issue that we often face when we are successfully preventing problems is that prevention itself, unlike toothache, cannot be seen,felt or measured easily. It is hard to notice that something did not happen! Many patients who’s gum disease is being kept at bay by their good brushing, our scaling and polishing and other treatments may not realise that although the problem cannot be cured it would be much, much worse if these beneficial things were not taking place regularly. As such it is important when we prevent something to make sure we draw attention to it, otherwise it often goes unnoticed. A good example of this is the much lower rate of heart disease, as a result in part of treating high blood presure, high LDL (bad) cholesterol and diabetes management. We see the rate of heart disease falling but it is hard for someone who resents all the tablets to appreciate that the alternative might be a lot worse. For someone who has had a heart attack (due to a lack of prevention) then the medication afterwards is greatly appreciated, it was broken and so the acceptance of “fixing it” is greater.

A situation where we struggle to decide on the best way to help someone is that of the person who actually objects to prevention. This person has a firm belief that they only go to the dentist to have their teeth cleaned or to have a filling, and that they don’t want to hear anything else. This type of person is particularly challenging. On the one hand it is a tempting train of thought to ask them in future, if they are sure about this approach, to sign a form to say they do not wish to have any preventative advice and thereafter not to provide any. I’ve never heard of any dentist actually doing this, and certainly do not know if this would be legally binding if the patient later decided to make a complaint that they were not offered preventative information. Once problems have set in people often decide that they do want to do something done about it, and despite being anti-prevention before, they suddenly see the point of it, and forget that they chose to ignore the earlier advice. These are questions that would have to be asked in order to solve this problem in this way. Another solution is to offer the prevention in a very round-about way and very tactfully, but this is difficult and is not always effective. Dentists have to record when they recommend something such as recommending flossing, or a filling or crown, in the patient’s notes. If later a patient says that no-one ever told them that their tooth might decay, the notes will show this to be incorrect.

Measuring prevention is especially problematic for the government and the NHS. If you as an NHS commissioner want to get funding for a programme to prevent disease you have to be able to show results. Since it’s extremely difficult to measure cavities that did not form, or teeth that did not break, the approach adopted is often one of measuring treatments such as fillings, which are only being done because they weren’t prevented. This means that governments and the NHS often talk a good game about prevention but struggle to actually deliver it.

Despite being very difficult to do, I strongly believe that prevention is better than cure. Changing your behaviour might be hard  and certainly moves the responsibility for your health on to you as the patient, but it is by far the easier, cheaper and more convenient way to ensure good health in the long term. Prevention is healthcare being done right. In dentistry, some of the treatment only happens when prevention fails. So when people say, in a throw away fashion “prevention is better than cure” that’s because it is! Its up to you to decide what you are going to do about it. Prevention is an active process, it means doing things to prevent problems, instead of doing nothing and hoping for the best. The other throw away phrase “if it isn’t broken, don’t fix it” should read “just because it isn’t broken doesn’t mean we shouldn’t look after it”.

Northway Dental Practice has been caring for the oral health of people in the Midsomer Norton area for over 40 years.