Dr. Fink and I recently collaborated on a blog post for Bipolar Beat entitled “The Effects of Chronic Stress on Bipolar Genes.” It focuses on a potential epigentic connection to bipolar disorder. If you’re wondering what “epigenetic” means, you’re not alone. I first encountered the word a couple days ago. Dr. Fink defines it like so:

The prefix epi- means outside, above, over, or on top of. The term epigenetic refers to factors outside the fundamental gene structure that affect a gene’s expression.

With bipolar disorder, what happens is that when a person experiences chronic stress, the body releases stress hormones that attach themselves to certain genes and alter their function. In other words, environmental factors can “flip the switch” on a gene to make it function one way or another. This change in genetic functioning may then be passed along to any offspring.

I find this fascinating because it helps explain the connection between nature and nurture and goes further in explaining the mechanics of evolution and why we see such diversity in nature. It is also likely that this will revolutionize the diagnosis and treatment of genetic diseases, including mental illness.

If you find this interesting, you may want to read “Understanding epigenetics” by Robert D. Sheeler, M.D.

People who’ve grown up in Crawfordsville, Indiana like to refer to this small town in Central Indiana as “The Athens of the Midwest.” Perhaps it is, and from what’s been going on lately, this might just be the place where the battle lines are drawn between physicians and the health insurance companies, where debate over national health insurance finally gains enough momentum to make a difference.

Over the past couple months, I’ve heard some discussion about Anthem Health Insurance not covering treatment provided by St. Clare Medical Center – the only hospital in Crawfordsville. Apparently, the two parties settled whatever dispute they were having, and the issue kind of faded as a topic in the local gossip chains.

The other day, however, my wife received a letter from Athens Medical Group, where her primary care physician practices. (You can view a PDF version of the letter – 1 meg.) In his letter, CEO of Athens Medical Group, Brett Spencer, MD informs patients that Anthem Insurance Companies are dropping Athens as an “in network” provider. For anyone who’s dealt with health insurance, this is a biggie, because you pay a premium for “out of network” care.

The conflict could affect my family through my wife - forcing her to pay out-of-network if she wants to continue seeing her current providers or to drive a half hour or more out of town to obtain in-network care. My health insurance is even worse. I pay over $2,000 per year for a $10,000 deductible policy to a company (American Medical “Security”) that simply sends me statements explaining why it’s not paying any claims.

What I’m waiting for is the doctors to get totally fed up with the status quo and launch their own national health insurance company through the AMA (American Medical Association). Get rid of the middleman! They could standardize all the forms, so they wouldn’t have to deal with multiple insurance companies and forms, streamline operations, and increase efficiency. Who better to oversee what insurance companies should and should not pay for than the doctors themselves?

And if that doesn’t work, why don’t we just go back to paying cash – out of pocket? Require each doctor to do a set amount of pro-bono work, and get rid of health insurance altogether? What we have now just isn’t working.

Until this gets fixed, I’ve left strict orders with my family. If I have a serious illness and can’t get myself to the hospital, they’re to take the wallet out of my pocket, drive me up in front of the hospital emergency room, and roll me gently out onto the pavement. This is the only way I’ll be able to get the treatment I need without going bankrupt.

If anyone has any detailed information about what’s going on between Athens Medical Group and Anthem Health Insurance Companies or any other similar dispute, please leave a comment. Or just weigh in on the current state of health insurance in the United States.

Shelley, a visitor to this blog who also experienced tooth staining when using Crest Pro Health Mouth Rinse submitted a complaint to Proctor & Gamble and received a response back from them. Here is Shelley’s original letter of complaint, followed by the Crest Team’s response, followed by how that response made Shelley feel and my own comments.

Shelley’s Complaint to P&G

I purchased this Crest Pro Health Rinse. It was packaged with Crest White Strips, which I always buy. After a few weeks of use, I noticed brown in the spaces between my lower teeth. I did not know this was caused by the rinse and I have been flossing aggressively to get it out. I’ve never had this kind of problem before – I usually have nice white teeth. I found out that this may have been caused by the rinse and now I’m afraid to use any Crest products. I will see if my dentist can get this brown out of my lower teeth.

Crest Team’s Response

Thanks for contacting us.

I’m sorry to hear of your experience when using Crest Pro-Health Rinse. I appreciate the time you’ve taken to bring this to our attention and I’ve shared your report with our specialized representatives.We conducted comprehensive studies on Crest Pro-Health Rinse to prove its safety and effectiveness. The active ingredient in Crest Pro-Health Rinse, Cetylpyridinium chloride (CPC), has been recognized as safe and effective by an FDA advisory panel. The label meets current FDA standards.My Comment

Like all mouthwashes that effectively fight plaque and gingivitis, Crest Pro-Health Rinse can contribute to temporary, surface-level brown tooth discoloration, which is reported by a very small percentage of people. Less than one-tenth of 1% of people who have purchased Crest Pro-Health Rinse have raised this concern. In some people, tooth discoloration could actually be one indication your mouthwash is working. After it kills germs in your mouth, the dead germs could collect on the tooth surface and create the appearance of a brown stain. The discoloration could be exaggerated by many other factors, such as existing tartar on teeth, tobacco use, certain prescription medications, and/or drinking red wine, tea, or coffee. Brown tooth discoloration from use of mouthwashes that effectively fight plaque and gingivitis is not harmful. It is reversible – and largely preventable – through options like brushing with a power toothbrush and tartar-control/whitening toothpaste, flossing, and visiting the dentist regularly.

Since the amount of help I can offer via email is limited, I’m following up with you by postal mail. Please allow two to three weeks for delivery of my letter. For answers to medical questions, we recommend you speak with your doctor who will be able to give you the best advice.

Thanks again for getting in touch.

Crest Team

Shelley’s Comments

It almost makes it sound like it’s my fault.  I’m going to stop using Crest and P&G
products.  It sounds like a canned response and is very smug.  How about the statement
that discoloration is actually an indication that the mouthwash is working?

The Crest Team is careful when quoting statistics, claiming “Less than one-tenth of 1% of people who have purchased Crest Pro-Health Rinse have raised this concern.” They don’t say less than one-tenth of 1% of people who have used Crest Pro-Health Rinse experience this problem, they highlight only the small percentage of people who report it. Granted, they cannot possibly know how many people experience these problems if people are not reporting it, but I believe that many people who are having problems are not reporting it for one of the following reasons:

• They don’t realize that the mouthwash is the cause.
• They simply stop using the product and don’t report anything.
• Some consumers simply don’t file formal complaints – it’s like patrons who have a bad experience at a restaurant and decide never to eat there rather than complain to the manager.

The comment that the staining is “largely preventable – through options like brushing with a power toothbrush and tartar-control/whitening toothpaste, flossing, and visiting the dentist regularly” is baloney. I was doing all this at the time and it did not succeed in preventing the stains caused by Crest Pro Health Mouth Rinse. This is insulting to anyone who experienced this staining.

I’d like to see a controlled clinical study.

I also think P&G should be proactive in adding a warning label to the product regardless of whether the FDA requires it. It would demonstrate P&G’s commitment to its customers’ health and well being.

USA Today has published its own report on Crest Pro Health mouthwash entitled “Crest rinse fights off customer complaints.” Items to note:

• “P&G says ’99.99%’ of users have had no complaints and that any discoloration or aftertaste is temporary.” How did they arrive at this figure? I used several bottles of this stuff before I finally discovered that it was staining my teeth.

• “Brinker said temporary discoloration can be a sign that the product is killing harmful germs, which can be brushed away, or reflect the user’s eating, drinking and brushing habits.” Oh, so the deep dark brown stains are a good sign that the product is working as designed? Is Brinker saying that I could brush the stains away and that they’re probably caused by my eating, drinking, and brushing habits? If so, that’s flat-out wrong. After getting the stains cleaned from my teeth, I stopped using Crest Pro Health Rinse and have not changed my eating, drinking, or brushing habits. Guess what – No stains.

• “Brinker said P&G doesn’t see a need for a warning label because the number of those affected is very small.” I doubt they know the real number.

I’m not saying that P&G should issue a product recall and pull the product off the shelves or that everyone should stop using it. For some people, Crest Pro-Health Rinse may play a valuable role in their oral hygiene. What I want to see is a warning label, so if staining or loss of taste does occur, consumers will have an easier time identifying the cause.

You can read Dr. Gerlach’s letter to consumers on the Crest Pro-Health website to gain a better understanding of Proctor & Gamble’s official stand on this issue.

I just watched the piece about Crest Pro Health Mouthwash staining teeth on NBC’s Today Show. The report was great and will certainly do some good in warning people about the possible negative side effects of the product. What really ruffled my feathers the most were some of the soundbites from Proctor & Gamble’s spokesperson, the overly smug dental researcher Dr. Robert Gerlach (following each quote is my commentary):

“The question really isn’t ‘Should there be a warning?’ The question is ‘What’s the need?’ The overwhelming majority of people don’t experience these problems at all.

The need, Dr. Gerlach, is so people will know what’s going on when Crest Pro Health mouthwash stains their teeth and causes them to lose their sense of taste. They won’t have to do their own research to discover that it’s the mouthwash they’re using. As for the overwhelming majority of people not experiencing these problems, I question the accuracy of the data: How many people is this happening to who are unaware that their mouthwash is causing the problem? How many people simply stop using the product and don’t file a complaint? Is Proctor & Gamble giving us accurate data?

When asked, “For people who feel they’re misled because there are some side effects they didn’t know about, what do you say to that?”

We have to take everything we read on the Web with a grain of salt. We treat all of our consumer reports very seriously, whether they’re on the Web or elsewhere. Any rinse that fights plaque and gingivitis may cause these side effects in a small number of users.

Dr. Gerlach and Proctor & Gamble would prefer it if they could control all the data. Because they can’t censor blogs, the truth is going to get out despite their best efforts to cover it up. Gerlach wants consumers to take everything they read about Crest Pro Health Mouthwash on the Web with a grain of salt when, in fact, consumers need to take everything that Gerlach and Proctor & Gamble  say about their product with a huge block of salt. They’re the ones who can’t be trusted.

Gerlach paraphrased by interviewer: “He says judging by calls to P&G’s customer center, only a fraction of 1% report any problems.”

I filed my complain online. Are they counting only the phone calls?

This is a product that’s been very safe and effective, used by millions of people. If consumers are experiencing problems with our products, whether it’s stain or taste or anything else, they’ll call us. Wouldn’t you?

At this point, I wanted to punch the TV. Gerlach sounded so smug. P&G, wake up! Do the right thing. Stick a warning on the bottle just like you have a warning on your stannous (stain us) fluoride toothpaste. That way, if people do experience problems, they can tell immediately from reading the label what’s going on. In addition, as one of the consumers interviewed for this piece stated, a warning label would empower consumers with the information they need to make a well-informed decision.

One last thing – these stains aren’t as easy to remove as P&G would like you to think.

On March 14, 2008, I ran a post called “Crest Pro-Health Mouthwash Stains Teeth,” recounting my story of how the mouthwash I was using as part of my dental hygiene actually stained my teeth a dark brown.

Soon after posting that piece, someone from NBC’s Today Show contacted me about a story they were putting together on this very topic. I just heard today that the story is scheduled to run on NBC’s Today Show on Wednesday, May 7 between the hours of 7:30 a.m. and 8:30 a.m. EST. Tune in.

During my previous visit to the dentist, the dental hygienist said that my teeth had a lot of plaque, so I decided to put a real effort into caring for my teeth. I brushed after every meal, flossed once or twice a day, and started rising with Crest Pro-Health mouthwash.

After a couple weeks, I noticed that my teeth were stained worse than ever – dark brown stains particularly near the gum line. When I smiled, my daughter said that it looked as though I had algae growing on my teeth.

I assumed it was from the harsh cleaning I had received at the dentist office. I thought maybe the hygienist had scrubbed off a protective layer and that the first few cups of coffee I had after that cleaning had somehow soaked into my porous teeth.

Today, I visited the dentist for my six-month checkup. She looked at my teeth and noted how stained they were. She said, “You’re not a smoker, are you?” I told her no, I’m not a smoker.

The hygienist did her cleaning. She needed a special high-powered water pick to blast the stain off. She couldn’t finish. She scheduled me for another appointment.

I explained how discouraged I was. Here I was trying my best to care for my teeth, and this was the worst staining I’ve had in my entire life. How could that be possible?

The hygienist asked if I brushed with Crest Pro-Health. I said no, I don’t brush with it but I do use Crest Pro-Health mouthwash at least once a day and sometimes twice. I asked her why? She explained that Crest Pro-Health toothpaste uses stannous fluoride, which can stain some people’s teeth. She said she didn’t think the mouthwash had stannous fluoride. (I checked the label when I got home – no stannous fluoride. Sure enough, the toothpaste tube does have a warning “products containing stannous fluoride may produce surface staining of the teeth.” No such warning appears on the mouthwash bottle.)

When I got home, I Googled “crest pro health mouthwash stains teeth.” The entire first page of results contained links to articles and blog posts from people who reported that Crest Pro-Health mouthwash stained their teeth a dark brown soon after they began using it.

This really irritates me. I was using a product I thought would make my teeth healthier and whiter and make my gums stronger. Instead, it made my smile look like I was a two-pack a day smoker.