Oral Probiotics for Dental Health

Bias disclosure: I started taking oral probiotics because my doctor told me to and I have vaguely positive feelings about probiotics.  I kept taking them because simple inspection with my tongue showed I was developing fewer dental plaques.  But the friend I recommended them to wanted actual data, so I did some digging.  The results were overwhelmingly positive.  They reduced not only cavities, but in the study that checked, total antibiotic usage.  In your face, friend who asked for data.

But only one of those tested a probiotic lozenge, the rest were milk products supplemented with Lactobacillus rhamnosus.  Not all Lactobacillus species scored so well, so I went to check what my supplement had.  Turns out it has no Lactobacillus at all.   So I went back to google scholar and checked the bacteria I was actually taking (Bacillus coagulans and Streptococcus salivarius).  Luckily the news was still good: in head to head trialsBacillus coagulans was found to be as effective as a mix of Lactobacillus rhamnosus and Bifidobacterium species, and Streptococcus salivarius also performed well.

Then I found the motherload: someone did a comparative survey.  This was less helpful to my cause.  Oral probiotics were almost universally found to be helpful to children, but results in adults were mixed.   My first argument is “well, yeah, adults develop fewer cavities per unit time than children, so you’d need a bigger sample over a longer time period to detect a difference.”  But the studies looked at intermediate results like “bad” bacteria presence, and even the 15 month trial in older and elderly people didn’t see a difference.

My conclusion is that oral probiotics are definitely good for children, and in light of the additional data for my personally, good for me, but possibly not for all adults.  I still feel confident recommending other people try them, but not that they stick with them if they don’t see results.

ETA 12/24/19: I’m currently using Florassist (affiliate link).

The Kitten Pain Scale

I very briefly flirted with Quantified Self and then jumped off the bandwagon because it was making my personal signal:noise ratio worse.  But my neuroendodontist* has given me several drugs, and he wants to know how they work.  Allow me to give you a brief list of things that make measuring this difficult

  • Treatments are all on varying schedules- some daily, some daily with a build up in blood stream leading to cumulative effects, some as needed to treat acute pain, some on my own schedule but hopefully having longer running effects.  Some are topical and some are systemic.
  • I have several home treatments like tea and castor oil.  I’m not going to not take them in order to get more accurate assessments of the drugs, both because ow and because pain begets pain.
  • Taking treatments as needed + regression to the mean = overestimate of efficacy.
  • Pain is affected by a lot of non drug things: sleep, stress, temperature, how ambitious I got with food, amount of talking, number of times cat stepped on my face in the night, etc.
  • We are hoping some of these drugs will work by disrupting negative feedback loops (e.g. pain -> muscle tension -> pain), which means the effect could last days past when I take in.  In the particular case of doxepin it might have semi-permanent effects.
  • Or I could develop a tolerance to a drug and my response to a particular drug will attenuate.  That is in fact one reason I was given so many choices as to medication: to let me rotate them.
  • We have no idea how these drugs will interact with each other in me.  We barely have an idea how the interact in people in general.
  • If I believe something will help my pain will lessen as soon as I take it, long before it could actually be effective.  Not because I’m irrational, but because my brain reinforces the self-care with endorphins, which lessen pain.
  • At the same time, having more pain than I expected to feels worse than the exact same pain level if it was anticipated.
  • Side effects: also a thing.

“I think I feel better when I take this one” was not going to cut it.

Then there was the question of how to measure pain.  Ignoring the inherent subjectivity of pain, neuralgia is a weird beast.  I already hate the 1-10 pain scale because pain has threshold effects and is exponential.  I could create a single pain number at the end of the day, but my pain is not constant: it spikes and recedes, sometimes for reasons, sometimes not.  What I would ideally like to track is area under the curve of pain**, but that requires polling, which would create horrible observer effects.  If I ask myself if I’m in pain every 15 minutes, I will increase my total pain level.  I could poll less often, but the spikes are random and short enough that this was not going to be accurate enough to evaluate the treatments.  I could count pain spikes, but that ignores duration.  Determining duration requires polling, so we’re back where we started.  I could deliberately poke a sore spot and see how bad the resulting pain is, but

  1. Ow
  2. A treatment that doesn’t affect sensitivity but does keep me from spontaneously feeling pain because the nerve is bored is a success.  If we wanted me to be numb we would do that.

It’s just really hard to measure something when your goal is for it to be unnoticeable, and measuring it creates it.

So I came at it from the other side.  What happens when pain is unnoticeable?  I enjoy life more and I get more things done.  Could I measure that?  Probably.  They have the bonus of being what I actually care about- if something left me technically in pain but it no longer affected my ability to enjoy or accomplish things, that would be a huge success.  If something took away the pain but left me miserable or asleep, it is not solving my actual problem.**

So one metric is “how much I get done in a day”.  Initially this will be the first number between 1 and 10 that I think of when I ask the question at the end of the day, but I’m hoping to develop a more rigorous metric later.  You’d think enjoyment of life couldn’t ever be rigorously measured, since it’s so heavily influenced by what is available to me in a given day, but I say that brave men can make it so.  And so I introduce to you: the kitten pain scale.  Kitten videos vary a little in quality, but I think my enjoyment of any single video reflects my internal state more than it does the video. Three times a day (shortly after waking up, shortly before screen bed time, and sometime mid-day that can vary with my schedule but must be selected ahead of time to avoid biasing the data), I will watch a cute kittens video and record how much I enjoy it.  The less pain I am in the more I should enjoy the video.  This will give me a (relatively) standardized measure of pain without risking inducing it.

This is still not what you would call a rigorous study.  An individual choosing what to take among known options never will be.  But I seriously think the kitten pain scale could be a contender to replace the stupid frowny faces.  My first draft is available here.  Right now it’s set to measure over the course of a day, because that’s the scale I expect from these meds, but you can add bonus measurements at set times after taking meds if you like.

Possible additions: cups of tea drunk in day.  Right now that seems like too much work to measure, but when tea is available it’s a pretty good indicator of how much pain I’m in.

*I am still angry that I know what that is, much refer to one using possessive case.  But given that, I am extremely grateful I live within biking distance of a world class research facility in the discipline.  Even if the physical facility could be a case study in how economic insulation leads to bad user experience.

**This is why none of my treatment options are opioids.  Strong ones technically reduce pain, but they also leave me miserable.  The fact that some people take them for fun is all the proof of human variability I could ever need.

Adventures in Dentistry and Neurology

I forget if I mentioned it, but I had nerve damage from the first dental surgery, way back in June.  Everything else healed up more or less all right, but that one kept hurting.  Actually it felt like two damages- one that was healing, albeit slowly, and one that was staying static or getting worse.  The prospect of living with that pain for the rest of my life was really daunting.  Medical marijuana, which had been so helpful at first, was having more side effects with fewer desirable effects every day.  It eventually became clear my surgeon had no idea what was going on or how to fix it so I went to a neuroendodontist, a subspeciality I really wish I wasn’t already familiar with.

toenailectomy looks awful but feels like nothing at all.  A neuroendodontal exam is the exact opposite.  It looks like some guy very gingerly touching around your mouth, but he is not only deliberately provoking pain, he needs you to pay attention to the pain and report on in it excruciating detail, while you remind yourself that inaccurate reporting leads to inaccurate diagnoses.

For all that pain, I actually got very good news.  Even though it feels like I have two distinct damages, it’s actually only one, and it is healing.  Nothing is guaranteed in neurology but existing data is consistent with this eventually healing itself.  And in the meantime, he gave me new and different medicines.  We’ll see what the side effects are, but at the very least I have options to rotate through.

What doctors can learn from day care workers

So if being fat is bad for people, than doctors should tell them not to be fat, right?  Or at least tell them to eat vegetables and hit the elliptical, right?

Well, maybe.  But sometime around age two humans realize that they are independent beings who do not physically have to do everything an authority tells them to do.  Unfortunately, most doctors’ patients are over the age of two, and those that aren’t have their own issues.

vomiting baby
They’re gross

Telling people to do things they already know they need to do has mixed results.  Scott Alexander suggests alcoholism could be decreased by as much as 13% if doctors would spend five minutes telling alcoholics it was bad for them.  What this doesn’t capture is how lectures change the doctor-patient relationship.  It is very difficult to give a non-judgmental lecture when your billing model gives you 10 minutes per patient.  Patients might avoid or delay visits for problems- alcohol related or not- in order to avoid the lecture.  This is a pretty big issue with overweight patients, and apparently without upside: patients lectured by their doctors are more likely to attempt weight loss but no more likely to achieve it.

In this TED talk, Thomas Goetz talks about a study of dental patients (no cite, unfortunately) that found that scaring them had no effect, but patients’ belief in their own ability to floss had a large one.  It’s impossible for me to separate my personal experience from this data.  Multiple dentists and hygienists told me my pain was my fault for terrible oral hygiene, and if I brushed and flossed it would go away.  This turned out to be untrue on a couple of levels.  The pain was caused by structural damage and internal infection, which may have been made incrementally worse by oral plaques but wasn’t caused by it.  And I was actually brushing pretty regularly, it just wasn’t do anything.  Then I started treating a completely unrelated digestive problem, and suddenly my teeth were cleaner.  I didn’t even tell my dentist anything had changed, she asked spontaneously.  So I guess, yeah, patients belief in their own ability to effect change matters, and if they don’t believe it, maybe consider that they’re correct and investigate why.

But let’s go one step farther.  Crum and Langer did an interesting experiment on two groups of hotel maids.  Both were told exercise is good for you.  One was given additional information about the intensity level of the work they did all day, and told just by going to work they were exceeding the surgeon general’s RDA of exercise.  Four weeks later, the informed group was slightly thinner (they even checked body fat %.  I am so pleased) and had lower blood pressure .  Not astoundingly lower(10 points on diastolic BP), but it was only four weeks, and a pamphlet is even less work than a doctor lecture.

This suggests that one of the more helpful things public health officials can do is reinforce the good things people are already doing.  You did a stretch?  Hurray for you.  Check parking lot twice before accepting a far out spot?  Still counts.  It would not shock me if part of the health improvements attributed to standing desks turned out to be simply a halo effect of feeling like you made a healthy choice.  Which coincidentally is how you turn a two year old into a civilized human being.

Wish me luck

Fourth dental surgery (this year) is today (not counting when they snapped that extra bone off).  I’ve buffered with some content but it’s going to be kind of grab bag for a bit, possibly even the rest of the year.  I have two different multi-book reviews in the pipeline but apparently other people use the library too, so neither is done.  I loved doing that HAES deep dive but it was seriously tiring and there was no way I was finishing another before this surgery.  So enjoy my forthcoming waffle mix review and have a happy solstice celebration of your choice.

Contempt and Complacency

My current surgical dentist recommended some things fairly far outside the mainstream.  I went to my old dentist for a second opinion, and she very solemnly informed me that his recommendations were outside the mainstream.  I explained that mainstream medicine had had nine years with this problem and only made it worse, whereas his one operation had made things better.*  She repeated that conventional treatment for my symptoms was to do something else.  I explained his specific hypothesis about the root cause of my symptoms, which had a coherent narrative and made specific testable predictions.  We had tested it once and the predictions were upheld.  She repeated that conventional treatment for my symptoms was to do something else.  I asked her what her explanation was for the problem, accounting for  the symptoms, imaging, failed treatments and the one successful one.  I asked her if she would have recommended the surgery I already had, which had been conclusively proven necessary.  I would have eventually died without it.  She repeated that conventional treatment for my symptoms was to do something else.

This woman wasn’t evil, or trying to profit.  She didn’t even charge me for the visit.  She followed up with other practitioners and with some additional data I sent her afterwords.  When her words failed to convince me, she was was genuinely sad and worried that I was going to hurt myself.  But she was simultaneously completely unable to wrap her head around the actual evidence in front of her.  And while her concern for me is touching, the fact that it centered on a treatment that was helping and not any of the treatments that made it worse is pretty damning.

This is one of many examples of why it pisses me off when people deride medicine outside the mainstream (including but not limited to eastern and “natural” medicine) and mock those stupid enough to believe or even try it.  Conventional medicine does some things very well.  If I get in a car crash, take me to the hospital.  But if something is consistently failing, the smartest, most scientific, most rational thing to do is look at other options.  And if those other options succeed based on the scientific method (ideally with large studies, but scaled down to n =1 if necessary), that is evidence in their favor.

I used to express this as “Yeah, and you said Mesmer was a danger because his patients stopped blood letting” or “You don’t get an opinion until you start washing your hands“, but now I have an even better example.  The American Academy of Pediatric Dentistry’s position on soda used to be “Are you kidding me?  Of course kids shouldn’t have soda.”**  But when Coca-Cola gave them a million dollars, the president defended it by saying “Scientific evidence is certainly not clear on the exact role that soft drinks play in terms of children’s oral disease.”***  I’m not saying alternative practitioners are all brilliant bastions of moral purity.  Some are idiots, some hurt people for money.  I’m just saying that “hypothesis that passed many tests” is a better proxy for correctness than “recommended by large medical association” is.

This is highly related to Scott Alexander’s cowpox of doubt.  If you spend too much time on easy problems you start to believe all solutions are obvious, and anything new must be not only wrong, but dumb.  It breeds a contempt for uncertainty that is inimical to discovery.  And this is why I’m considering a broad anti-contempt stance, even though contempt is really fun and a fantastic group bonding exercise.

*Of course it’s too soon to know if this will last forever, but none of the conventional treatments had worked even briefly.

**Exact words: “…frequent consumption of sugars in any beverage can be a significant factor in the child and adolescent diet that contributes to the initiation and progression of dental caries.”

***Original source: Health at Every Size, which I am side eyeing for implying that this was an official change in policy.  The position paper on the AAPD’s website still condemns soda, juice, and even formula.

Cannibidiol for pain: a partial retraction

Earlier I described CBD as having absolutely no effect on cognition.  This turns out to be wrong.  I’ve subsequently found that CBD does impair cognition somewhat relative to optimal, it just does so less than pain.  And at least for me, it doesn’t wear off quickly: if I take it at night I’m in less pain the next day, but I also have trouble focusing for long periods and doing truly complex work.  It feels like I can’t get far enough away from problems to see the whole of a thing.  If my choices are “in pain and dumb” or “not in pain and dumb”, I choose door 2, but this does make me more forgiving of NSAIDs.

In other news, they finally took my bone spur out and wow, I’m in a lot less pain.

…and the Wisdom to Tell the Difference

I haven’t gotten too much into my own dental stuff because I spend enough time thinking about it as is, but the current count is:

  • 3 completed surgeries
  • 2-5 more planned, depending on what you count as a surgery
  • painful nerve damage on the lower right
  • a hole in my lower left gum.  You can see a good chunk of bone if you look in my mouth.

After the last surgery (wow, two months ago now), my pain level actually dropped significantly.  We took out a major part of the problem, which not only helped on its own merits, but meant I stopped clenching/grinding, which made the nerve damage on the other side stop hurting continuously.  It was still touch sensitive, but I can handle that.  My ability to focus skyrocketed, limited only by my exhaustion.  I dropped CBD in favor of naproxen, and then didn’t need anything at all. I read a book a day for a month.  You can roughly see this increase in focus in my blogging, although the signal on your end is a little messy because publish can come long after writing, unless wordpress screws up, which it usually does.  I went on forays to the library to practice thinking around other people.  I even started to program a little bit.*

Then the surgery site started to hurt.  And my upper right (which needs surgery but hasn’t had it yet) began to ache from the sudden chewing burden.  I saw myself faced with two possible paths: a life where the pain just kept increasing and no amount of treatment could keep up with it, and I was never able to accomplish anything because it rendered me stupid, or a life where I was never in pain and I went on to be Brene Brown’s more medical second coming.   Obviously future #2 is better than future #1, and in future #2 I don’t take pain medicine, so I needed to just keep not taking pain medication and everything would be fine.

Causality does not work that way

If you’d tracked self reported pain it probably wouldn’t have gone up that much, because I have a lot of practice pushing dental pain out of conscious awareness.  But my reading rate plummeted, and I stopped going to the library.  Blogging which had felt like a thing I needed to do to clear my head a week before now felt like a chore.

I had just started to give in and take more CBD when I had a follow up appointment with my dentist, who explained that there was a hole in my gum where the jaw was growing in order to push out an infection.  I started crying the minute he said it.  I went home and took real pain meds.  A few days later, when I didn’t have to drive anywhere, I took twrugs o days and took way more pain medication than I consciously thought I needed.  Since then I’ve continued taking more-than-forebrain-thinks-is-necessary at night, but NSAIDs only during the day.  My reading and writing productivity has picked up significantly, talking barely hurts anymore, and I feel safe being in touch with my pain level again.

This is what I call the “nuke if from orbit” pain medication option, and it really seems to work.  Catching the pain before it “settles in”, or sending a surge against it, moves the baseline pain level back significantly, and lets you use less drugs over all.  The reluctance or inability to do this is another casualty of our awful attitude towards pain, where medication is essentially viewed as a failure of the individual to tough it out.

But nuke it from orbit doesn’t always work either.  Right now I’m in a tiny bit of pain.  It would take a lot of drugs to get that to zero, possibly an infinite number.  I faced a stronger version of this problem right before the last surgery, where the nerve damage side just kept upping the pain level to keep up with whatever amount of drugs I took.  In that case, I was better off simply accepting that pain was the state of being I was in right now.  The most helpful thing to do was meditate, except that while meditation often helps by relaxing the jaw, meditation for the goal of pain relief doesn’t.  Since most of the emotional impact of the pain was frustration and fear over my ability to think (read/write/plan) while in pain, practicing thinking while hurting would definitely lead me to look back more fondly on the experience, although it probably would have led to more distress at the time.

The first lesson here is to treat for the pain level you have, not the pain level you wish you had.  The second is to aggressively counteract pain at the first peep of its head.  The third is to learn to live with pain instead of fighting it.  I guess this is one of those “wisdom to tell the difference” situations.

*Fine, I started to set up a dev environment and that took two weeks because I was still very sleepy and android development studio is stupid.

Monday morning quarterbacking

The infection in my jaw has been growing for either 1.5 or 6 years, depending on how you count the first surgery to remove it.  I was already practiced at ignoring dental pain because I’d had trigeminal neuralgia on the other side for even longer.  In retrospect it’s obvious the pain had been life altering for at least several months, but I either didn’t consciously notice the effects or didn’t link them to the cause.  Now I’m looking over the last six months or so and analyzing what else might have been a side effect of the pain.  I’ve already talked about my concentration and focus, but today it occurred to me my relationship with alcohol had changed too.

I’ve always been a very, very light drinker, a drink or two every few months, because that was the frequency with which it was fun.  It wasn’t a conscious decision, and the frequency was highly variable- I might drink twice in one month if two drinking occasions came up, and then go six months without when none did.  It’s a matter of social environment, and I don’t have a good definition of what the “right” time is, I just know it when I see it.

So it wasn’t really weird that the last drink I remember having was at New Years.  Except it was. My reason for not drinking at a given event was no longer “eh, this is not the day” but “no, that will take something I can’t spare.”  I couldn’t have told you what it was, but I knew I didn’t have enough.  And this isn’t just me applying 20/20 hindsight, I told someone this exact thing before the new infection was diagnosed.

Looking back now, it seems entirely plausible that alcohol would be competing for the cope that was being used to cushion the pain, or would have weakened one of the systems that was fighting the infection (immune,  liver).  I would expect chronic infection to be a drain on the immune system and alcohol to be a tax on the liver, which means one of them has to be crossing over in order to see this effect.  Eyeballing it, I find the liver the more likely crossover point.  I definitely wasn’t drinking enough to have even a marginal effect on the liver of a healthy person, and while I was not healthy, I also wasn’t drinking hardly anything.  If the liver was the shared resource, that implies the infection (and/or the parasite I may have) was kicking out enough toxins to tax my liver.  That’s pretty concerning, given that the liver is enormous and however impressed the dentist was, the absolute volume of the infected tissue was just not that big.

“But look how much bigger it is” is not an actual medical argument, even if you could fit all of my gum tissue in the liver many times over.  A quick googling reveals that bacterial periodontitis leads the liver to produce more C-reactive protein.  I had “cardiac” CRP, which I believe is the same thing, tested a month after my last surgery (timing is a coincidence) and it was low normal.  I don’t have any numbers for the intervening period.  There are several studies showing an association between liver damage and periodontitis.  Most are mostly small, retrospective, and unable to distinguish cause and effect, but this one used both animal models and treatment to demonstrate that bacterial gingivitis taxed the liver.

There’s no way to prove the liver is what I was keying in on, but it certainly looks plausible.  And in a situation where I’ve had almost no information or control, I’m kind of proud of myself for listening and protecting myself, even when I didn’t know from what.