Ban Triclosan!

My five year old likes to taunt me sometimes by telling me that he used hand sanitizer at school. I'm certain there are worse forms of rebellion in his future so I don't react much. But the truth is that hand sanitizer, which often includes the active ingredient triclosan, is pretty nasty stuff.

In addition to hand sanitizers, the antibacterial and antifungal ingredient triclosan can be found in many soaps, deodorants, mouthwash, toothpaste, and other products. But Google triclosan, and you're likely to find just as many articles about the dangers as you do about the products. Oh, and the other thing? If you're washing your hands or body with a triclosan-containing cleanser, it doesn't even work any better than regular soap and water.

Personal care products containing triclosan
Source: Beyond Pesticides

Triclosan History

Triclosan (also called triclocarban) is a synthetic antbacterial and antifungal pesticide that has been around since 1969, and was first used in hospital settings in the 1970s. For those of you with a chemistry background, it's a chlorinated aromatic compound with functional groups of phenols and ethers. Triclosan is fat-soluble and can easily cross cell membranes. Once inside the cell, triclosan poisons a specific enzyme that many bacteria and fungi need for survival.

In addition to its uses in personal care items, triclosan is also used in institutional and industrial equipment applications where it is incorporated into conveyor belts, fire hoses, dye bath vats, ice-making equipment, and HVAC coils.

Triclosan is also used as a preservative in many products including adhesives, fabrics, vinyl, plastics, toys, toothbrushes, floor wax, footwear, clothing, sealants, carpeting, and many others.

Triclosan 101

• Typical triclosan concentrations in personal care products are 0.15 to 0.3%. Most triclosan is absorbed into the human body through the skin and lining of the mouth.
• Worried about cold and flu season? Keep in mind that those are usually caused by viruses; triclosan is an antibacterial and has no effect on viral illnesses.
• 75% of humans have triclosan in their bodies; it is found in human blood, urine, and breast milk. People who use it in personal care products have higher levels. 

Human Health Effects

• Allergies: killing "good" bacteria can open the door to the development of allergies. This finding is tied to the broader "Hygiene hypothesis," which purports that early childhood exposure to common pathogens is essential in building healthy immune responses. Lack of such exposure, according to the theory, can lead to an overactive immune system that misfires against harmless substances such as food proteins, pollen or pet dander. Killing bacteria with synthetic pesticides such as triclosan may disrupt the delicate balance between good and bad bacteria and lead to dysregulation of the immune system.
• Asthma: triclosan may make asthmatics even more sensitive to environmental allergens.
• Hormone disruption: animal studies show that these chemicals can interfere with hormones critical for normal development and function of the brain and reproductive system. Triclosan has also been associated with lower levels of thyroid hormone and testosterone, which could result in altered behavior, learning disabilities, or infertility. Triclocarban has been shown to artificially amplify the effects of sex hormones such as estrogen and testosterone, which could promote the growth of breast and prostate cancer.
• Cancer: animal studies show a possible relationship between triclosan and breast cancer and liver cancer. This great overview discusses the evidence and makes the point that research into triclosan's potential to cause cancer in humans is needed.

• Antibiotic resistance: some studies have reported that the use of triclosan contributes to making bacteria resistant to antibiotics. This is because antibacterial products do not kill all bacteria and germs they come into contact with; the strongest survive, mutate, and become more and more resistant to treatment. 

Who Regulates Triclosan?

• The Food and Drug Administration (FDA) regulates triclosan-containing products if they will be used on the human body. Products are considered to be drugs if they make a health claim such as "kills germs;" if they make a claim like "improves skin" they are considered to be cosmetics.

• The Environmental Protection Agency (EPA) regulates other products like bathroom cleaners.  

In light of questions raised by recent animal studies of triclosan, both agencies are reviewing evidence of this ingredient's safety in consumer products. In December 2013, the FDA issued a news release stating that manufacturers of triclosan-containing personal care products must provide data showing safety and efficacy if they want the products to stay on the market. (For a great overview of the inadequacies of the regulatory process, read this article from Bloomberg.) 

In the meantime, the official regulatory stance is that "triclosan is not known to be hazardous to humans (and) FDA does not have sufficient safety evidence to recommend changing consumer use of products that contain triclosan at this time." 

Still, some companies, like Proctor and Gamble, are banning triclosan from its personal care products. Others like Colgate Palmolive (makers of Colgate Total, the only toothpaste with triclosan and the topic of much debate) maintain that the benefits outweigh any potential risks, and that the research is inconclusive. 

And for my friends in Minnesota, triclosan will be banned in 2017!

Here's a great timeline...you can also see it here.

Source: Bloomberg

What You Can Do...

• Well your mom was right...wash your hands. Here's a quote directly from the FDA: 

"At this time, FDA does not have evidence that triclosan added to antibacterial soaps and body washes provides extra health benefits over soap and water. Consumers concerned about using hand and body soaps with triclosan should wash with regular soap and water."

• Read the labels: Triclosan is also called Microban, Irgasan, Lexol, Ster-Zac, Cloxifenolum, and Biofresh. 

• Avoid products that say "antibacterial" or "antimicrobial"

• Use alcohol-based hand sanitizers if you do not have access to soap and running water (but be careful your little ones don't drink it or lick it!).

Air Fresheners: The Sweet Smell of Phthalates

Ahhh...island breeze, fresh waters, cranberry pear bellini. No, I'm not on vacation. Just taking a look at some air fresheners.

I've had pets for most of my life (two dogs and two cats at the moment) and I used to use plug-in and other types of air fresheners sometimes to combat animal odors. But when I was pregnant with my son, I went cold turkey on a lot of household chemicals and this was one of them. 

So how safe are these products? The answer might surprise you.

Source: thetravelingpraters.com

Types of Air Fresheners

The fragrance industry is big business in the United States, with sales estimated to reach $2.4 billion in 2014. Approximately 75% of American households use air fresheners. 

There are many different types of air fresheners on the market today. One thing they all have in common? Lots of chemicals...

• Continuous release (outlet and battery-operated) air fresheners
• Sprays
• Reed diffusers
• Hanging car air fresheners
• Solid gel dispensers
• Scented candles
• Incense

What's in These Things Anyway?

Good question! Unfortunately, there are no standards or regulations governing the ingredients in air fresheners. The makers of air fresheners aren't required to list their ingredients on their packages or on the material safety data sheets.

As you might imagine, ingredients vary depending on the product type. But according to the Environmental Protection Agency (EPA), there are four basic ingredients in air fresheners:

• Formaldehyde
• Petroleum distillates
• P-Dichlorobenzene
• Aerosol propellants

Here's a picture of the back of a Febreze Air freshener (link here). Sure enough, no ingredient list (nothing on the front either).

Source: soap.com

Independent Study: Phthalates

In 2007, the National Resources Defense Fund (NRDC), a non-profit environmental action group, conducted a study of air fresheners to determine which ingredients are present. The most concerning finding was the presence of phthalates (pronounced thal-ates).

Phthalates are used in many different products including cosmetics, scented items, vinyl items, furniture, and medical supply items. In air fresheners, phthalates are used to dissolve and carry the smell of the fragrance. Phthalates have been linked with the following health issues:

• Animal studies link prenatal exposure to decreased testosterone, reduced sperm production, and malformed genitalia.

• Human studies show changes in hormone levels, poor semen quality, and changes in genital development.

• Indoor phthalate exposure is also linked with allergies and asthma.

In the study, the NRDC tested 14 commonly used air fresheners and found that 12 of 14 (86%) contained phthalates. Here's the breakdown:

Source: NRDC

Other Chemicals

While the NRDC study focused on phthalates, other dangerous chemicals are also lurking in air fresheners. 

A 2005 European Consumers Union study found ingredients such as benzene, toluene, styrene, and formaldehyde in air fresheners; these have been linked with various health problems including cancers of the upper airways, leukemia, neurotoxicity, headache, and nausea (to name just a few). 

Research out of Berkeley in 2006 that looked at air fresheners and other cleaning products found potentially dangerous levels of terpenes and ethylene-based glycols. Ethylene-based glycols are classified as hazardous air pollutants by the EPA. Terpenes are not dangerous on their own but react with ozone to produce toxic compounds such as formaldehyde, which is also classified as a carcinogen. The authors present several real life examples, including this one about using an air freshener in a bedroom:

"Air freshener and ozone in a child's bedroom. This scenario could occur when people use both air fresheners and ozone-generating devices simultaneously in a room. This could lead to exposures to formaldehyde that are 25 percent higher than California's guideline value. Because other sources of formaldehyde could also be present in the room, exposure to formaldehyde would probably be even higher, the report states."   

A 2006 study detected the presence of a volatile organic compound (VOC), called 1,4 dichlorobenzene (1,4 DCB) in many air fresheners linked it to modest reductions in lung function.

In two national studies, approximately 20% of the U.S. population, and 40% of asthmatics, report headaches, breathing difficulties, or other health problems when exposed to air fresheners or deodorizers. 

Regulations and Research

Chemicals from air fresheners get into the body by inhalation, absorption, or accidental ingestion. The NRDC explains that there is no simple way to know how many of these toxins get into our bodies, or how much might pose a health hazard. Furthermore, the lack of listed ingredients and misleading claims of "natural" or "non-toxic" on some products make it difficult for consumers to evaluate the safety of products. Here's what the NRDC has to say about the difficulties of ascertaining just how dangerous these products might be:

Source: NRDC

In 2008, the NRDC called for a ban of phthalates but this was rejected by both the EPA and the consumer Product Safety Commission (CPSC), citing insufficient evidence. However, the EPA did ask the seven largest companies to voluntarily submit product ingredients, concentrations, and other information (most companies have not). 

One thing just about everyone agrees on? More research is needed.

What You Can Do: Alternatives to Air Fresheners

• Open a window! (But you probably already knew that one.)

• Choose soy or beeswax candles scented with essential oils (most others release benzene and toluene)

• This website suggests using vodka as an air freshener and coffee grounds or kitty litter for absorbing odor.

• There are a lot a lot of things you can do to freshen your air using essential oils.

• You can also use baking soda and vinegar for many stinky things around the house!

• Simmer cinnamon, cloves, or other natural spices on the stove.

• Don't be fooled by misleading product labels! Even some products labeled "all natural" contain phthalates. 

Dental X-Rays: Worth the Risk?

I've had two dental X-rays in my life, both times as an adult because I was in pain. My mom never let my brothers and me get dental X-rays when we were kids because she was concerned about potential health effects. My mom told me recently that her misgivings came from working with dental students many years ago; they told her that the only thing dental X-rays were good for was paying for the X-ray machine. 

My son had his first dental appointment over the summer and the dental assistant told me they would be doing bitewing X-rays on my son. I told her that I didn't want him to have them and explained that I wasn't comfortable with their safety. She responded by saying, "An X-ray has less radiation than a microwave. Do you use a microwave?" "Not on my head," I told her. We left it at that.

Benefits of Dental X-Rays

A dental X-ray provides your dentist with a picture of the hard and soft tissues of the mouth. While at least one study shows that findings on clinical exam alone agree with findings on dental X-rays over 90% of the time (in other words, your dentist can usually see problems just by looking in your mouth and examining it); there are times when X-rays help to diagnose issues not always visible to the naked eye such as: 

• Cavities between teeth or under fillings
• Diseases in the bone
• Gum disease and infection
• Tumors

Professional Guidelines

The American Dental Association (ADA) says that radiation exposure from dental X-rays represents a "minor contribution" to a person's total exposure from all sources. But the group does recognize that dental X-rays are not without risk and that the effects accumulate over time. Furthermore, the group recommends that dentists should perform an examination and use their clinical judgement before making the decision to get an X-ray. Here is an excerpt from the guidelines, and you can read the full booklet entitled Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation here.

Source: ADA

Though the ADA does not regulate dental x-rays, they do make recommendations regarding how often a patient should have them done, based on age and dental history. In general, dentists are expected to follow the "ALARA" principle when performing X-rays: ALARA stands for "as low as reasonably achievable."  

• For low risk-patients:

• Adults should have bitewing X-rays every 2 to 3 years.

• Teens should have bitewing X-rays every 1½ to 3 years.

• Children should have bitewing X-rays every 1 to 2 years.

• For people who have tooth decay or are at high risk of getting cavities:

• Adults should have bitewing X-rays every 6 months to 1½ years.

• Children and teens should have bitewing X-rays every 6 to 12 months.

Source: Dimensions of Dental Hygiene, reprinted from ADA

Radiation Exposure in Humans

There are two types of radiation: "non-ionizing" radiation such as sound waves, visible light, and microwaves; and "ionizing radiation," which is the type people typically think of when they refer to radiation. Non-ionizing radiation uses include electric power generation, lasers, and manufacturing processes.

During an X-ray, an X-ray machine sends this radiation through the body. Some of the radiation emerges on the other side of the body, where it exposes film or is absorbed by a digital detector to create an image. And some of it is absorbed in body tissues. It is the radiation absorbed by the body that contributes to the "radiation dose" a patient accumulates.

In the US, the unit of measurement for a radiation dose is the rem (Roentgen Equivalent Man); doses are most commonly reported in millirem (mrem). (Most other countries use the metric "milliSievert" unit of measurement.) According to the National Council on Radiation Protection and Measurement, the average annual radiation dose per person in the US is 620 millirem (6.2 milliSieverts).

Radiation exposures come from natural and man-made sources. Radiation dose per person from medical X-rays has increased almost 500 percent since 1982, from 11% to around 35-36%.

Source: US Nuclear Regulatory Commission

General Health Effects of Radiation

According to the EPA, "there is no firm basis for setting a 'safe' level of exposure" to radiation. Children are at a particular risk for effects from ionizing radiation because their cells are rapidly dividing and there is more opportunity for radiation to disrupt the process. In setting limits, EPA "makes the conservative assumption that any increase in radiation exposure is accompanied by an increased risk of effects."

Long-term, low-level exposure to radiation is known to cause cancer, birth defects, and genetic mutations (those last two are the reason that a female patient is always asked if she is pregnant before an X-ray is administered). (Acute high-level exposures like those experienced by Chernobyl victims carry a whole other set of serious health effects like internal bleeding, nervous system damage, and even death; these are not relevant to this topic.)

Types of Dental X-Rays

There are quite a few different types of dental X-rays used for different things. 

• Bitewing X-rays are taken with the patient biting down on film. Bitewing X-rays are used to detect decay between teeth and changes in bone density caused by gum disease, to determine the fit of dental crowns or restorations, and to inspect integrity of tooth fillings.

• Periapical (limited) X-rays show the whole tooth from the crown to beyond the root tips to the supporting bone in one area of either the upper or lower jaw. These X-rays aid in treating conditions such as periodontitis, advanced gum disease, and detecting abscess.

• Panoramic (Panorex) X-rays require a machine that rotates around the head and show the entire mouth in one image. Panoramic X-rays are used to plan treatment for dental implants, detect impacted wisdom teeth and jaw problems, and diagnose bony tumors and cysts. 

• Multi-slice computed tomography (MCT) shows a particular layer or "slice" of the mouth while blurring all other layers. This type of X-ray is useful for examining structures that are difficult to see clearly.

• Cephalometric projections, which show the entire head, help examine teeth in relation to a patient's jaw and profile. Orthodontists use cephalometric projections to develop their treatment plans.

• Sialography uses a dye injected into the salivary glands to visualize them on the X-ray film. A sialography typically is used to identify salivary gland problems, such as blockages or other problems.

• Cone beam CT scanners show the body's interior structures as a three-dimensional image. CBCT — often performed in a hospital or imaging center, but increasingly being used in the dental office — is used to identify facial bone problems, such as tumors or fractures. CT scans also are used to evaluate bone for dental implant placement and difficult tooth extractions to avoid possible complications during and after surgical procedures.

As you might expect, different types of X-rays come with different levels of radiation exposure. Below is a chart that details exposures from some types of dental x-rays, and compares the exposure to other common sources of radiation. Amounts of radiation received from dental X-rays is relatively low.

Source: Dear Doctor, Inc.

Dental X-Rays & Cancer Risk

Dental X-rays are the most common way Americans are exposed to radiation. But there is surprisingly little research on the effects of dental X-rays on humans. As noted above, children are particularly susceptible to radiation's effects. The Society for Pediatric Radiology reports that children are at an approximately 3 to 5 times higher radiation-induced cancer mortality risk than adults.  

Some studies have shown a relationship between dental X-rays and cancer. While more research is needed, the findings below suggest that patients and dentists should carefully consider the potential risks of exposing patients to radiation. 

Thyroid Cancer: 

A 2013 study in the journal Clinical Thyroidology found that repeated dental X-rays without a neck shield were associated with all types of thyroid cancer.

A 2010 study reported that men and women who had four or more dental X-rays had twice the risk of thyroid cancer; and those who had ten or more X-rays had 5.4 times the risk.

Salivary Gland Cancer:

Cancers of the salivary gland (parotid gland) have also been linked to dental X-rays, according to this National Cancer Institute publication. 

Brain Cancer:

A 2012 study published in the journal Cancer  made a lot of headlines when it found a possible relationship between dental x-rays and a certain type of brain cancer called a meningioma. In the study, researchers surveyed 1433 meningioma patients and 1350 healthy patients. The meningioma group was twice as likely as the control group to report ever having had a bitewing exam and more likely to report having had a panorex exam at a young age (under 10 years old) or on a yearly or more frequent basis. Though most meningioma tumors are benign (non-cancerous) and tend to grow slowly, some cause significant symptoms such as seizures, vision changes, hearing loss, weakness, and even death.

This study has been criticized due to certain limitations of the study, including the fact the reports were based on patient's memories, rather than on dental records. In addition, X-rays used today deliver less radiation than they did when the subjects of this study received them, so the results may not apply to today's patients. 

What You Can Do

Some people are at a higher risk of dental disease than others. You should understand your risk (and your child's risk) and ensure that your dentist follows the ALARA principle (as low as reasonably achievable) when administering X-rays. Some steps you can take:

• Make sure the dentist (not the assistant) performs a clinical exam before administering any X-rays. (Though apparently some dental professions feel that patients should get X-rays right away and that "it is best not to ask the patient's permission.")

• Always ask why the dentist is doing the X-ray. (And keep in mind the answer "because your insurance covers it" is NOT a good reason!)

• Be aware that some types of dental X-rays exposure you or your child to more radiation than others. Newer machines called cone-beam CT scanners are particularly high in radiation and should be avoided, according to some experts. And digital images expose people to less radiation. 

• Insist on a thyroid protector.

• Keep in mind that radiation exposure is cumulative (adds up over time with repeated exposures).

Final Thoughts

The relative lack of research on health effects means that I'll avoid dental X-rays for my son and for me, unless there is a really good reason to do them. And while I can't argue with the premise that an X-ray may turn up a hidden problem, the overall logic seems flawed to me. There are plenty of health problems that could be found with a scan if you went looking for it, but to me the potential risks associated with getting an X-ray "just in case" outweigh the benefits.

Some dentists tell you that they simply must do dental X-rays, because they could be sued for malpractice if they are not performed and a problem turns up later. I am unable to confirm or deny the truth of this claim, but I'd gladly sign a waiver absolving them from litigation. Some dentists even refuse to treat people who refuse X-rays, though I've never experienced this. 

And what about the two issues we started with? Do dentists perform unnecessary procedures for profit? Well, some do and some don't. There are no figures available that I could find, but I'm sure that for every horrifying case like this or fraudulent dentist like this, there are many more who are simply trying to give their patients the best care possible. 

And is my use of a microwave worse than a dental X-ray? It's apples and oranges, according to this article: these two things emit different types of radiation. 

MiraLAX: Miracle or Malpractice?

My son struggled with potty training, and once he did get with the program he was still having some trouble "staying regular" as they say in the commercials. I thought his issues were due more to fear of change and the newness of the situation, and less to his diet or to any sort of physical issue. We weren't at a crisis point (except that he became pretty cranky when he didn't go) but I brought it up with his pediatrician at his 5-year-old checkup over the summer. She pointed out that constipation can become a serious issue and quickly recommended that I start giving my son the over-the-counter laxative MiraLAX every night before bed in the hope that he would start to go potty on a daily basis. 

The next day I went to the drugstore to pick it up and I was surprised when I saw the active ingredient: polyethylene glycol 3350. Polyethylene glycol? Yikes! I put the product back on the shelf and decided to do some research.

So, What is Polyethylene Glycol Anyway?

Dow Chemical's Polyethylene Glycol (PEG) chemicals "are water-soluble linear polymers formed by the addition reaction of ethylene oxide to an ethylene glycol equivalent. Sometimes referred to as polyglycols or polyols, their properties make them among the most versatile chemical ingredients and processing aids available to formulators and manufacturers of a wide range of products." It's been about 30 years since I took a chemistry class so I won't embarrass myself by trying to explain what exactly that means, but I can tell you that PEG works to alleviate constipation by drawing water into the colon to stimulate a bowel movement. 

In addition to laxatives, PEG is used in a wide range of products indeed. Below are a few:

• Agricultural chemicals
• Disinfectants (nonagricultural)
• Hairspray (non-aerosol)
• Herbicides for agricultural, garden and health service use
• Household dry automatic dishwashing detergents
• Laundry starch preparations
• Lubricating oils
• Other hair preparations, including heat setting wave solutions
• Other pharmaceutical preparations acting on the skin
• Pet flea and tick products, including collars
• Pharmaceuticals for veterinary use
• Eye drops
• Skin cream
• Rocket fuel
• Paintballs

Pediatric Constipation

As unpleasant as it is to discuss, constipated kids are common and the problems can be significant. A 2009 study reported an 8.9% worldwide prevalence in "functional constipation" (that is, chronic constipation with no known physical cause). Chronic symptoms are a source of great distress to children and their families, more behavioral problems are reported in these kids, and quality of life is negatively affected as well. In up to one third of children suffering with functional chronic constipation, symptoms persist into adulthood. Potty training is a common time for constipation to start, as children find themselves in a "test of wills" with their parents.

Laxative Sales

The Consumer Healthcare Products Commission reports that over the counter laxatives are a $1.3 billion dollar a year industry (2013). Bayer's MiraLAX products make about $180 million for the company per year. I was unable to find any figures showing how much of the market is driven by pediatric sales, but a New York Times article reports that a 2006 peer-reviewed study found 75 percent of about 350 pediatricians nationwide had suggested parents use MiraLAX or similar generics to treat childhood constipation. 

MiraLAX: Safe for Children?

Polyethylene glycol is generally considered to be a low toxicity agent and no studies have shown severe side effects, though there are concerns about organ system toxicity (i.e., toxicity linked one or more biological systems in the body through laboratory studies or studies of people). That being said, no studies have ever been conducted on children. Why is this? Because the drug is approved only for adults and only for seven days at a time. If you look at the product label above, note that for "children 16 years of age or under: ask a doctor." These so-called off-label uses of drugs in which a physician recommends or prescribes a medication not approved for a particular use or age group are common and perfectly legal. The Food and Drug Administration (FDA) regulates labels, not prescribers. 

But in 2009, the FDA took the issue of potential side effects of these products seriously enough to discuss it at its Drug Safety Oversight Board Meeting. Below is an excerpt from the agency's report:

The FDA also wrote "There is a perception that PEG is safe because it is minimally absorbed from the stomach and intestines. However, little is known about whether absorption in children differs from adults, especially in children who are constipated, have underlying intestinal disease, or are very young." In 2011 the agency listed polyethylene glycol on its Adverse Event Reporting System (AERS) to monitor "neuropsychiatric events," which means that the agency has identified a potential safety risk, but ultimately the FDA decided that because there is no evidence of severe side effects, no action would be taken.

There is also a vocal online community of parents complaining about side effects of MiraLAX. And this guy, who blames MiraLAX for a host of serious medical issues (but he also sells alternative competing products, so take it with a grain of salt. Or, if you're constipated, take it with a teaspoon of epsom salt as that is known to be a natural remedy.)

Outcomes (No Pun Intended)

I don't know what the answer is here. For me, the lack of research and potential for harm is enough to keep me away from this product. That being said, every parent does a cost/benefit analysis whenever they give their child anything to ingest. For your child, the benefits may outweigh the potential costs. The only advice I can give with certainty is read labels, ask questions, and do your homework!

I'm happy to say that after a couple months, my son became acclimated to the new routine and is now doing just fine without the use of medication. Initially, I stocked up on any sort of natural remedy I could find, like prune juice and probiotics. But I think what he really needed was time and patience.