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.

Why Teeth with Root Canals Often Need Crowns

When we do a root canal on a back tooth, we nearly always recommend a crown. Many of our patients will naturally ask us why? Frequently, the last thing a patient wants to do after they have recently had a root canal is to then sit in the chair for a crown! We certainly wouldn’t want to either. So why?

A picture is worth a thousand words, and we think this photo of one of our patients tells a descriptive story:

broken or cracked or split tooth high quality photo

This premolar on one of our patients literally split in two! After the root canal, we had recommended a crown, but he declined. The patient lost the tooth and needed an implant. Photo and subsequent dentistry by Dr. Nicholas Calcaterra.

As described in the photo above, this tooth cracked into two pieces with a fracture going deep beneath the gum tissue. If he had a crown, this would not have occured. He lost the tooth and needed a dental implant.

Brittleness + Great Forces = Tooth Failure

When a tooth has had a root canal, it becomes brittle. It loses the ability to flex slightly under loads. In addition, there is less natural tooth structure remaining, typically because of a past history of dental decay. When you put that all together, you have a very weak tooth.

The jaw muscles, specifically the masseter, are generally considered to be the strongest muscles in the human body. In one test, the masseter was able to generate a force of 975 pounds!

When you apply a force of several hundred pounds to a weak and brittle tooth, the following will likely happen:

Fractured tooth high quality photo and picture

Fractured lower left molar. In this case, the tooth could be saved, but not without heroic efforts. Photo and subsequent dentistry by Dr. Nicholas Calcaterra

This lower molar fractured after root canal treatment. In this case, the tooth was able to be saved by doing a special procedure called crown lengthening and then placing a crown.

How Crowns Protect Teeth

dental crown photo showing a reflection in the mirror

This crown will slide over the tooth, protecting it.

A dental crown, often called a “cap”, is a custom fabricated combination of either porcelain or metal that covers the entire surface of the tooth above the gumline. When you chew, the powerful forces that hit the crown are then directed down the long axis of the tooth.

In addition, the chewing forces cannot exert a splitting force onto the tooth, because the entire tooth is covered. As a result, catastrophic fractures like the ones seen above are avoided.

The photo to the right shows a crown for one of our patients. It will fit completely over the tooth. Not only will it prevent fractures but it will make the tooth look much more natural and esthetic.

Below are before and after photos of we preserved two badly broken down teeth with crowns:

Before and After photos of all ceramic and porcelain dental crowns

The above teeth had large silver fillings and both fractured. We were able to protect them with beautiful all ceramic crowns! Photos and dentistry by Dr. Nicholas Calcaterra

We hope that the narrative and the photos show you that teeth can break. And when they do break, the results can be catastrophic! So if/when you need a root canals on a back tooth, you should strongly consider getting a crown if your dentist recommends it.

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.


OB-GYNs: Dental Care OK During Pregnancy

Approximately 4 months ago, we published a blog post describing a relationship between tooth loss and pregnancy. The theory was that pregnant women avoided dental care due to fears over the possible impact of dental treatment on their pregnancy.  The findings of the study confirmed a greater incidence of tooth loss in women with children .

American College of Obstetricians and Gynecologists Logo OK for dentist visit during pregnancy

New Guidelines

In a recent issue of Obstetrics and Gynecology, the American College of Obstetricians and Gynecologists (ACOG) published recommendations regarding dental care during pregnancy. These recommendations were based upon years of research on the impact of oral health on pregnant and post-partum individuals.

Key findings from the committee included:

Pregnant Woman Photo - OK to see the dentist

Routine dental care is important

  • OB/Gyns should discuss oral health with all patients, especially those who are pregnant.
  • Pregnant women should be advised by their OB that by improving her oral health, she is less likely to transmit the cavity producing bacteria to her infant.
  • OBs should inform patients that diagnosis of oral conditions, including dental x-rays, are safe during pregnancy.
  • OBs should inform their pregnant patients that certain conditions (dental abscesses, dental caries, pericoronitis, etc.)  may require treatment during the pregnancy. In general, delaying treatment may result in more complex problems.
  • Patients who experience morning sickness are at a greater risk for dental decay.

The Committee writes:

“Oral health is an important component of general health and should be maintained during pregnancy and through a woman’s lifetime. Maintaining good oral health may have a positive effect on cardiovascular disease, diabetes, and other disorders.”

Our clinical team at Calcaterra Family Dentistry

Our dedicated clinical team

We have had the privilege of caring for hundreds of pregnant and post-partum women over the years.

In most cases, we simply perform a routine cleaning and inform the patient of our findings. By doing so, we have been able to educate on the importance of oral health as well as help prevent future  tooth loss.

If you are expecting and have a dental question, feel free to call us for an appointment.