Dental Problems Following Weight Loss Surgery

weight loss surgery diagram which leads to decay

One variation of weight loss surgery. Courtesy WebMD.

We’ll begin this post with a story. It involves one of our patients – we’ll call her Deb.* Deb had weight loss surgery (specifically gastric bypass) approximately two years before coming to our dental office. She did not initially disclose this to us (perhaps out of embarrassment?).

On examining Deb, we noticed significant dental decay on almost all of her teeth. Some of the decay appeared to be from acid – similar to what we see in bulimic patients. Other areas of decay followed the pattern commonly seen in patients with xerostomia (chronic dry mouth).

Her condition was of great concern to us. How could this relatively young woman who appeared to take good care of her teeth have so many dental problems?

We spent significant time trying to figure out why this was happening. She finally told us about the weight loss surgery. It was at this point when everything made sense…

How Bariatric Surgery Works

gastric band procedure causing dental cavities

Gastric Band. Image courtesy ASMBS

Many of you reading this probably know how the procedures work. Some of you may have actually had the procedure and are now researching why you are having dental problems. But either way, a refresher is beneficial.

To summarize, bariatric surgery is a group of similar procedures performed on the stomach. The procedures will accomplish one of two objectives (or both):  restrict the amount of food the stomach will hold and/or affect the quantity and quality of nutrients absorbed.

In either case, weight loss follows the procedure, and resolution of many obesity-related conditions ensues. However, a complex set of physiological changes also occur, and in nearly all cases, dental problems emerge as a direct result.

Significant Dental Findings After Weight Loss Surgery

Let’s look at some key findings observed in patients who’ve had the procedures:

  1. 56% of patients vomit at least once per week six months after the surgery.
  2. Nearly all patients experience a decrease in the flow of saliva.
  3. While nearly all obese patients experience GERD (gastroesophageal reflux disease), many patients still have GERD post-surgically. And with the ABG procedure, 33% reported having severe reflux – worse than before the surgery.
  4. Many patients snack repeatedly throughout the day, leading to a constant barrage of sugar on their teeth and causing an increase in plaque accumulation.
  5. 37% of patients report eating increased amounts of sugary foods after the surgery than before.
dental decay photo on a weight loss surgery patient showing cavities

Decay seen on a male patient of ours who had bariatric surgery. He suffered from dry mouth after the procedure. Photos and subsequent dentistry Dr. Nicholas Calcaterra.

So, we basically have a perfect storm here: acid on the teeth due to GERD and vomiting, reduced saliva, increased frequency of eating, and increased sugar consumption.

The end result is an increased rate of dental decay, often requiring fillings, root canals, and sometimes even extractions followed by dentures and/or implants.

What You Should Do?

Tell your dentist (assuming you haven’t done so already)!

In our office, we’ve treated Deb and many others like her who’ve had gastric bypass or other weight loss surgical procedures. We manager each and every case differently, but examples of how we address these challanges include:

  1. Customized trays to wear at night with high fluoride toothpaste (these are similar to whitening trays people will wear – except that you place fluoride in them instead of whitening gels).
  2. Acid reflux medications to reduce GERD.
  3. More frequent dental cleanings.
  4. Daily use of high fluoride toothpaste such as Prevident.
  5. Recommend chewing sugarless gum and or candies to increase salivary flow.

If you have had weight loss surgery and are struggling with dental issues, we can help. Call us at (203) 799 – 2929 if you would like to make an appointment.

* Deb’s name was changed due to privacy concerns.

Nail Biting Can be Hazardous to your Teeth

single tooth photo

You are more than just a tooth!

We treat every single one of our patients as unique individuals with unique needs. Many have healthy gums and teeth and rarely have any treatment needs. Others will come in needing fillings or crowns. Some will need their wisdom teeth out. Others will need dental implants.

Occasionally, a patient will come in with a unique and unexpected finding causing us to have to “think outside the box” to determine what is going on.

One patient came in just recently. Everything was unremarkable except for a very unique wear pattern with her front teeth. We spent over five minutes interrogating her in our attempts to find out what was going on! We finally identified the culprit:

Detailed photo showing wear of teeth from nail biting

Her front teeth showing a highly unusual wear pattern; the culprit is her finger! You can see how her fingernails fit perfectly into the newly created groove on her two lower front teeth.

On questioning, she admitted to obsessively biting her nails. This was a new habit as she had recently started a stressful graduate program. Not surprisingly, all 9 other digits looked exactly like this!

Why Nail Biting is Bad for your Oral Health

Even though it took us time to properly diagnose this patient, we were already well aware of the detrimental effects that nail biting (the technical term is onychophagia) has on your teeth. Some of these include:

  • Significant wear of the front teeth as seen above. If the wear is bad enough, it can lead to thousands of dollars in treatment needs.
  • Your nails are very unsanitary – it is estimated they harbor twice as much bacteria as your fingers. This can introduce new bacteria into your mouth. It can also lead to nail infections (see below).
  • Repeated nail biting can actually move your teeth. The forces are much stronger than braces.

Nail biting is bad for your overall health too. According to the American Academy of Dermatology, bacterial infections from nail biting can and do happen quite frequently.

How to Stop Biting your Nails

This is not necessarily easy. It comes down to two approaches:

  • Just stop yourself when you put your finger(s) in your mouth.
  • Buy one of the many over the counter products that you paint on your nails. They taste horrible! But they’re supposed to. That’s how they work. Just Google it or look at this one product.

We’ll post more photos from nail biting once we see more!

Hydrocodone Reclassified as Schedule II

Hydrocodone and acetominophen tylenol combination prescribed at the dentist

Hydrocodone and Acetaminophen (brand name Vicodin).

On October 6th, hydrocodone containing medications will be re-classified as a Schedule II controlled substance. Hydrocodone is a high potency prescription level painkiller included in the combinations known as Vicodin and Lortab. Hydrocodone is considered a narcotic and is classified as an opioid type medication. In addition to relieving pain, hydrocodone can cause drowsiness and has the potential for addiction.

Many physicians and dentists, including our Orange, CT dental office, prescribe hydrocodone-containing products to treat pain. As a result, this change affects all dentists and many patients.

Why the Change?

In the past several years, a new epidemic of prescription drug abuse has emerged, with opioid pain killers being the most frequently abused drug. In fact, on average, narcotic painkillers cause or contribute to approximately 16,000 deaths per year in the U.S.

Map of Connecticut Prescription Drug Deaths

Prescription drug deaths in Connecticut. Fortunately there have been no deaths in Orange. Image courtesy the Connecticut Mirror.

In Connecticut, including the greater New Haven area, there has been an average of 272 drug overdoses per year, with many of them from painkillers such as Vicodin. Although there have been no deaths in Orange, our office has seen our fair share of patients who have had abuse problems with these types of medications.

In order to combat this epidemic, the DEA is now making it more difficult to obtain hydrocodone containing prescriptions. Some of the changes are listed below.

How it Affects Dental Offices

All dental offices that prescribe these types of medications are affected. In our office, where we do a significant amount of oral surgery such as tooth extractions, we will be adhering to the new requirements. These include:

  • We can no longer call in prescriptions.
  • In general, we can no longer give prescriptions with refills.

While this may pose a slight inconvenience to our patients, we hope everyone understands that this is not being done to annoy them but to reduce drug abuse in Connecticut and beyond.

Mouths of Prescription Drug Abusers

We all know how devastating prescription drug abuse can be on individuals. The abuse can lead to disastrous effects on the oral health. Below is a photo of a patient who had abused these medications for years:

Photograph of rotting teeth from abuse of percocet and vicodin

Teeth with untreatable decay due to abuse of Vicodin and Percocet. The only solution is a denture. Photo Dr. Nicholas Calcaterra.

We realize that the above photo is graphic and may be disgusting to people. However, it should hit home the point that prescription drug abuse is a serious problem.

By adhering to these new regulations, we hope to be part of the solution to our nation’s prescription drug abuse problem.


Dry Mouth Medications: A Recipe for Tooth Decay

Many prescription pills will cause xerostomia or dry mouth - dentist in Orange, CT

Is this causing dry mouth?

Many older patients in our practice in Orange, CT take medications as part of their daily routine.  However, many of these prescription drugs have an unwanted side effect: dry mouth, more formally called xerostomia.

In fact, the most commonly prescribed medication in the United States in 2012 lists xerostomia a common side effect!

Chronic dry mouth can have a profound effect on the oral cavity, leading to dental decay (cavities) as well as inflammation of the gum tissue.

Without treatment, the results of the dry mouth can be devastating: loss of some or all of your teeth!

Photo of Tooth Decay from Dry Mouth

Photo of teeth with decay from dry mouth or xerostomia from radiation treatment

Teeth with decay (cavities) from chronic dry mouth on a patient from Woodbridge, CT. Photo and subsequent treatment by Dr. Nicholas Calcaterra.

The above photo shows quite dramatically the decay (also known as cavities) that can occur due to dry mouth. We see decay both at the gum line as well as near the edges or tips of the teeth. This is the classic pattern of decay due to xerostomia.

Common Drugs which Cause Xerostomia

Medications and Drugs which cause dry mouth xerostomia leading to dental decay and cavities

The most widely prescribed drug in the U.S. is associated with dry mouth!

Older adults take many medications which can lead to dry mouth. Some of them include:

  • Medications for high blood pressure: ACE inhibitors, Angiotensin II Receptor Blockers, Diuretics, and others.
  • Anti-cholinergic medications used to treat a variety of conditions.
  • Many anti-depressant medications (Zoloft, Celexa, etc.).
  • Narcotic based pain relievers such as Vicodin and Percocet.

As previously mentioned, the most commonly prescribed pain medication in 2012 was Vicodin and is associated with xerostomia.

Why Dry Mouth Leads to Tooth Decay

Saliva has numerous qualities which help to reduce decay and gum disease. A partial list includes:

  • Contains buffers which help to neutralize acids from foods (soda, candy, fruits, etc.)
  • Possess several anti-microbial proteins which kill harmful bacteria.
  • Serves to mechanically cleanse and remove food debris.
  • Helps to remineralize damaged tooth structure.
  • Any many other functions.

As you can imagine, if the amount of saliva is reduced, the normal benefits of saliva are not realized.

photograph and picture of cavities from dry mouth with ropey saliva

Another photo of dental decay from chronic dry mouth from medications. This patient was from West Haven, CT. Photo and subsequent treatment by Dr. Nicholas Calcaterra.

Treatment for Chronic Xerostomia

Our patients are on medications for important reasons, so we can’t have them discontinue the medications solely because of the effects of dry mouth. But there are several options for either increasing the amount of saliva and/or protecting the teeth. These include:

  • High fluoride content toothpastes and rinses to reduce the likelihood of further tooth decay. An example is Prevident.
  • Chewing xylitol based gum. The chewing action stimulates salivary flow and the xylitol is proven to reduce tooth decay.
  • Various toothpastes, mouthrinses, gels and other products designed solely to moisten the soft tissue and help your mouth feel wetter. The products from Biotene are the most common.
  • Sucking on sugar free candies throughout the day, stimulating saliva flow.

You should work with your dentist and physician to determine if your medications are causing dry mouth and if so, the degree to which the dryness is affecting your overall oral health. From there, the appropriate treatment (if any) can be recommended.