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INSIDE HEALTH

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Programme 5. – Chickenpox in pregnancy, Club foot, Test for Conn's syndrome, Teeth brushing

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TX:Ìý 09.02.16Ìý 2100-2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý FIONA HILL

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Porter

Coming up in today’s programme: Cleaning your teeth in the morning – should you do it before or after breakfast?

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And club foot – how a new treatment has transformed the lives of those affected.

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Clip

This is Lucas’s foot, the crazy foot as we call it, as you can see he’s got lovely normal feet with a bit of a curvy toe.Ìý Which one’s your crazy foot Lucas?Ìý That one and he’s got a little bit of a thinner leg on the right but that is it.Ìý And you can’t tell at all.

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Porter

More from Lucas later.

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But first Zika – almost unheard of until recently, the virus is now making headlines across the world; not least because of it being linked to microcephaly in the babies of women who caught the infection while pregnant.

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Dr Margaret McCartney has been following the latest developments and is in our Glasgow studio. Margaret I say linked because we don’t know for sure do we that the recent rise in children with microcephaly is definitely due to Zika.

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McCartney

We do not and the official line from the World Health Organisation is that they’re agreed there’s a causal relationship as in that Zika causes microcephaly, it’s strongly suspected but not scientifically proven.Ìý And the World Health Organisation, along with many other agencies, are working pretty hard I think to try and work out what is cause and what is effect here.Ìý But the situation’s quite confusing, there’s been media reports that in Brazil it’s been quite hard to work out indeed how many children have been affected by microcephaly because of the measurements that have been taken.Ìý Smaller children are going to have smaller heads, not necessarily microcephaly, so it’s been quite difficult I think to sort out really how much of a problem this is.Ìý And then the next problem is going to be to work out how that is related to Zika virus or whatever else.

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Porter

So it is complicated.Ìý I mean one of the things is this figure of 4,000 plus new cases in Brazil is being questioned isn’t it.

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McCartney

That’s right…

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Porter

Only a small proportion of those are actually confirmed.

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McCartney

That’s right, there’s a very small proportion of those have been confirmed.Ìý And the bigger problem is the measurements that have been taken it’s not clear how many of these children do have a genuine microcephaly and then the next problem is how many of these children have microcephaly caused by being affected by Zika virus when they were – in pregnancy and utero.

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Porter

So in view of all of this uncertainty what should pregnant women or women planning on starting a family or considering travelling to affected areas do, what’s the current advice?

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McCartney

The advice from the NHS is quite clear.Ìý If you are currently pregnant and you don’t need to go to Brazil or Central America or the Caribbean countries where there is a current outbreak don’t go.Ìý So that’s the safest thing to do.Ìý And if you do have to go then protect yourself against mosquito bites.Ìý So that’s the fundamental advice that’s been given.Ìý And it’s a bit more complicated than that.Ìý So they go on to say that if you have experienced Zika symptoms during or within two weeks of returning back home it’s recommended that you wait at least six months after a full recovery before you try to conceive.Ìý And even if you haven’t been unwell they recommend 28 days before you start trying to conceive.Ìý And a similar situation for men – if a man has returned home with no Zika symptoms he should wait for 28 days before trying to conceive and six months to try and conceive after returning home if he did experience Zika symptoms during his period away in an infected country.

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Porter

And to add even more confusion most people who have Zika don’t even get any symptoms, so they wouldn’t know.

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McCartney

Yes exactly, it’s a very mild virus for many people – mild fever, rash, muscle aches, a little bit of conjunctivitis – could easily be confused with many other viral infections that people get.Ìý So if you are pregnant or have a history of a travel to a country with an ongoing Zika virus outbreak the advice from the NHS is to speak to your midwife or your GP and mention your travel history and you will be accommodated usually with growth scans in pregnancy, if you choose to have them.

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Porter

Thanks Margaret.

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Andrew Shennan is Professor of Obstetrics at King’s College and St Thomas’ Hospital in London and he’s in our Millbank studio. Andrew, have women in your clinic been concerned about Zika?

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Shennan

Yes absolutely, the sort of eruption of cases that have happened in Brazil have been quite alarming, especially when they hit the media and women are obviously coming and asking questions, even if they have just the vaguest association with friends or travel and so on.Ìý So it’s something that is real in people’s minds.

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Porter

Zika may be in the headlines but of course as regards pregnancy, in terms of viruses having an effect on the developing baby, there are bigger threats much closer to home.

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Shennan

Yes I mean I think it’s worth keeping it in context because actually the mother copes incredibly well with most viruses and actually her own immunity and so on protects the baby.Ìý However, there are some situations and some viruses that can be problematic, particularly very early on when the baby’s developing rapidly in the first few weeks of development and also later on just before it’s delivered when the mother may not have had time to develop the immunity to protect the baby and the baby then becomes exposed, so that can be dangerous.

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Porter

So can we look at some examples of that?Ìý I mean chickenpox is one, a very common child infection, a lot of women who are pregnant will be exposed to children who’ve got chickenpox.

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Shennan

Absolutely.Ìý And this obviously is a common scenario when women come to us when they’ve had exposure or they’re worried they have had it.Ìý It’s one of those viruses that is quite infectious and therefore we do worry when people are susceptible.Ìý The good news is that 90% of women actually are immune in this country and therefore fortunately we can reassure most of them.Ìý What we often do is go back to their blood tests that we have stored from when they first presented in pregnancy, when they booked with us, and then we just see that they are immune and we can reassure them.Ìý So we only need to worry about that 10% who are still susceptible and I think when they are exposed and if they get ill that’s when it becomes an issue.

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Porter

So when’s the danger period Andrew for pregnancy?

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Shennan

Well first of all the biggest danger actually is for the mother not the baby and that danger can be anytime in pregnancy, the mother’s susceptible to the virus and her immune system isn’t quite the same when she’s pregnant.Ìý So our biggest concern is actually the mother’s wellbeing and if she’s exposed and may be getting it we do want to see her and we do want to do things.Ìý I think for the baby it’s dependent on when you get it, so if the mother gets it in very early pregnancy there’s a higher chance that the baby will be infected but fortunately, even in the first half of pregnancy, that’s only about a 2% risk.Ìý The bigger worry for the baby is if the mother gets exposed in the last month of pregnancy when she hasn’t really had time to develop her immunity and then the baby’s born and then is exposed to the virus without her protection, so that’s the major worry with the baby.

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Porter

So what should a woman do if she’s not sure she’s had chickenpox and she thinks she’s been exposed to the virus?

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Shennan

Well the best thing she can do is find out if she’s immune.Ìý We don’t people who are spreading virus to come into the hospital but if she contacts her midwife she can often contact the laboratory and we can just find out by a simple test whether she’s got antibodies and then we can ring her back and reassure her that it’s not an issue.Ìý If she’s then susceptible then we’ll make arrangements to see her and possibly offer her what we call passive immunity is we actually give her immunoglobulins to protect her at the time she’s likely to be sick.Ìý If she actually gets symptoms we want to see her quite quickly because giving drugs, antiviral agents like acyclovir, has to be done very quickly to make a difference, certainly within the first 24 hours.

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Porter

What’s the threat to baby, what does the virus actually do?

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Shennan

Well the virus can be quite devastating, so actually in the first exposure, in the first trimester for example, when the baby’s developing, the baby can have multiple problems.Ìý One of the problems is eye problems.Ìý So what we’ll do is scan the baby and make sure that there’s good ophthalmic examination, eye examination, in the newborn period.Ìý Fortunately after 20 weeks foetal problems are very, very rare indeed and so we can pretty reassuring, we’re more worried about the mother, it’s just that last four weeks if the baby became seriously ill.

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Porter

Historically the virus that we used to worry about a lot of course was German measles, now widely vaccinated against, do you see many cases of German measles or Rubella in pregnancy still?

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Shennan

Well we don’t actually, we do see people who are still susceptible, fortunately the sort of vaccination programmes in this country, with the MMR, have been incredibly successful.Ìý But there are a few people who don’t react to the vaccine so we do need – we do automatically check every pregnant woman and we do see people who are susceptible.Ìý So occasionally if a woman has been exposed, because it’s such a devastating infection in early pregnancy, we do take it very seriously.Ìý But it’s something that I personally haven’t seen for more than a year for example.

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Porter

Professor Andrew Shennan. And there is more information on chickenpox in pregnancy, and the latest advice regarding the Zika virus, on the Inside Health page of the Radio 4 website.

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Now have you ever met a school age child or teenager with congenital talipes - or club foot as it’s better known? ÌýWell even if you had you probably wouldn’t notice thanks to treatment that has transformed the outcome, and enabled those affected to lead perfectly normal lives. The therapy involves stretching the foot into the right position, and holding it there in a plaster, and once completed should leave the child with no limp, no deformity and no pain. And it’s all thanks to the pioneering work of one man … with a little help from the internet. It’s a remarkable story, but before we reveal the doctor behind the revolutionary treatment, let’s meet Claire Medeiros and her four year old son, Lucas.

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Medeiros

This is Lucas’s foot, the crazy foot, as we call it. ÌýAs you can see he’s got lovely normal feet with a bit of a curvy toe.Ìý Which one’s your crazy foot Lucas?Ìý That one.Ìý And it’s got a little bit of a thinner leg on the right but that is it.Ìý And you can’t tell at all that anything ever happened.Ìý But we’re still keeping an eye on you.Ìý Put your sock back on?Ìý Yeah okay.

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We had our standard 20 week anomaly scan and we could tell that something wasn’t quite right because they kept going back over certain areas on the scan and they told us not to worry and were quite categorical about that.Ìý But they said we would need a further scan with a consultant to look for talipes or club foot.Ìý And then life got complicated.Ìý And we kind of forgot about it a bit until he was born and then it was like, aha right there’s definitely a problem.Ìý It was completely inverted on the right hand side, turned inwards, tip down and just from then on got called his crazy foot.

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Porter

Well to find out more about the modern management of club foot I’ve come to the clinic where Lucas was treated at the London Hospital to meet orthopaedic surgeon Manoj Ramachandran.

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Ramachandran

Club foot is a broad term and most children are born with a foot position where their foot is turned downwards and inwards.Ìý But a true club foot is completely fixed in that position, so there’s no way you can manipulate that foot to make it straight.Ìý So that’s a diagnosis we tend to make either antenatally, ultrasound scan, or once the child is born.Ìý And at that stage we differentiate between what we call a flexible club foot, which needs a few stretches and then it gets better by itself, or a fixed club foot.

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Porter

If it’s fixed what happens if you don’t do anything about it, if it’s missed?

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Ramachandran

You can still walk but you tend to walk on the top of your foot rather than the bottom of your foot, so your foot’s turned so far inwards and downwards that you really can’t get your foot up flat. Eventually you start getting blisters, sores, calluses, on that part of the foot but you can still get around but your foot’s not very functional.

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Porter

Do we know what causes it?

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Ramachandran

No. ÌýHypocrites first described it over 2,000 years ago and he thought that it was to do with pressure in the womb during pregnancy.Ìý We now realise that a fixed club foot has already happened by the end of the first trimester, so the first 12 weeks, so it’s not a pressure effect, it’s something that you develop with as your organs and your limbs form.Ìý What we don’t really know was what the contribution of genetics is to it versus some sort of environmental trigger.Ìý And we think now there is something in your genes plus some kind of trigger that activates the club foot.

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Porter

How quickly do you need to see them ideally?

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Ramachandran

The treatment relies on this stretchability of the tissues and when you’re first born there are hormones, particularly a hormone called relaxin, that comes across from the mother into the child that keeps all your tissues really flexible.Ìý So the earlier we start treatment the easier to correct the club foot, so ideally we’d like to start in the first couple of weeks after birth and start the casting then.

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Porter

At least 30 children come to this club foot clinic at the Royal London every week.Ìý Hannah McKay is here with her baby daughter.

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This is?

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McKay

This is Penelope.

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Porter

How old’s Penelope?

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McKay

She’s eight weeks and one day now.

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Porter

So she’s in plaster.

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McKay

Yeah she’s had the cast on last week.

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Porter

Right, was that the first – were they the first ones or…?

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McKay

First ones yeah, she has them first put on last week.Ìý So she’s been a bit grumbly this week.

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Porter

And to describe the position – I mean she’s lying on her back.Ìý It’s the sort of position babies would often have their legs in anywhere – it’s knees bent, isn’t it, drawn slightly up.Ìý But the plaster goes right up to the groin almost.

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McKay

Yeah.

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Actuality

Doctor

We cut these off using a little mechanical saw.Ìý It just vibrates.Ìý Very, very quiet and controlling my hand….

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McKay

Not going to cut through her skin.

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Doctor

No not going to cut through the skin.Ìý And she may not like the vibration.Ìý Okay, so a little bit of noise, it does get a little bit noisy when I cut.Ìý

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Porter

So the theory, put simply, is that you’re gently bringing the foot back to the normal position, sequentially increasing that as you use different plasters over a five, six week period of whatever.

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Ramachandran

Correct and you’re taking the foot from down and in to up and out slowly.Ìý But the last bit of up might not work because the muscle at the back’s really tight so we do a little cut of the muscle in clinic and it is generally a small cut and the scar is negligible.

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Porter

So for a typical child the programme of treatment would be what?

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Ramachandran

So they would start their first cast in the first two or three weeks of age, they’d have a weekly cast, the plaster goes to above the knee.Ìý We soak the cast off and then we manipulate the foot.Ìý The next cast is put back on and the average number of casts is between four and six.

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Porter

And here’s baby Penelope with her mother Hannah just back from having a quick bath before her next plaster is put on.Ìý And here’s a sweet smelling Penelope, did she enjoy her bath?

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McKay

Not really no, she screamed with it but…

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Porter

Does she know what’s going to happen next though, she’s going back into the plasters.

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McKay

Oh god.Ìý

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Doctor

So just having a feel to see what position we’ll be able to take the foot into today.Ìý We’re keeping the foot down, so keeping the foot pointed, but just bringing it round to the side a little bit.Ìý Ready to go when you are.

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Porter

How long do you actually have to hold the foot in position for?

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Doctor

So it depends on a few variables, we need the plaster to set in the correct position and that depends how much water you use, that depends how much they kick.Ìý So we’ll see, we’ll see what happens here.

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Porter

I was just thinking it’s difficult enough having a new baby isn’t it, with all the things you have to do, and this has just added to your…

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McKay

Yes, definitely, it’s definitely a challenge.

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Porter

And you’ve got twins.

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McKay

Yes.

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Porter

My word, I’m impressed.

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McKay

I just think there’s a lot worse that she could have.

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Porter

Of course yeah.

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Depending on how Penelope’s foot responds she’ll have weekly casts for the next month of so, a final plaster cast for three weeks and then after that she’ll be put into a type of brace, known as boots and bars, all too familiar to four year old Lucas and his mother Claire.

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Medeiros

There you go there’s a banana for you, can you hold with one hand?Ìý There you go.

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The only way I can describe it is like a pair of shoes that look like bindings for a snowboard and the feet are twisted outwards, much like a snowboard, and then a metal bar representing the actual board itself that keeps the child’s feet apart and an angle away from their midline.Ìý And as the child gets older it becomes more difficult because the child vocalises their opinion more and more and then it’s just – you have to focus on the more positives of it’s amusing that my child associates going to bed with putting some shoes on – everyone else takes them off, we put ours on – but that’s the most amazing thing, the end result is your child will walk properly and will not be identified as the person who’s got a problem with their walking or with their feet in general.Ìý And thus far – so far so good.

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Porter

If all goes to plan and the parents do their bit as well what sort of success rate are you looking at?

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Ramachandran

Ninety five percent, so there’s only a 5% recurrence rate, as opposed to surgery where it’s about a 50% recurrence rate.

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Porter

Are these children completely normal?

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Ramachandran

Completely normal, the only thing you might be able to notice is that that foot is slightly smaller, the calf muscle is slightly smaller.Ìý We know that if they get through their first decade then the risk of recurrence after that is zero.Ìý They pretty much have a normal functioning foot.

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Porter

A success rate that is remarkable but it wasn’t always like this.

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Ramachandran

Until the 1980s, ‘90s, surgery was considered the gold standard treatment and pretty much every day in any children’s hospital at least one club foot was being operated on, that was the gold standard, and that was done about the age of walking, which is around a year.Ìý And then a gentleman called Ignacio Ponseti, who was an orthopaedic surgeon originally from Mallorca, he moved to Iowa in the Midwest of the US in the 1960s and he started really trying to work out why these children who had surgical treatment had pretty much a 50-70% recurrence rate and they needed more surgery and more surgery and eventually often a fusion of the foot bones by the time they were fully grown.Ìý And he started treating his children that came to him with club feet with casting, with five or six casts done on a weekly basis and then into a brace that holds you in the corrected position for around three to four years age.Ìý And he showed that the risk of recurrence was around 5%, so 10 times less, and the foot looked normal, it wasn’t scarred, it didn’t need any further surgery.Ìý But no one believed him and he toured Europe with his results, no one listened to him, they thought he was a crazy…

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Porter

A maverick, so often the case in medicine isn’t it.

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Ramachandran

Correct, working in the middle of America, even the Americans didn’t believe him.Ìý Till the children who he’d treated had grown up and they’d moved out from Iowa and started to say to clinicians they saw that I had a club foot, it was treated by Dr Ponseti and it’s completely normal.Ìý Clearly with the internet people were visiting the internet to work out what to do with their child newly diagnosed with club foot and as the story started to come out of Iowa that really helped it to spread like wildfire and it got to Europe very quickly as a result of that.Ìý So by the early noughties this became the gold standard treatment and now it’s recognised as the standard of treatment and we pretty much hardly operate on club foot now as a result.

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Ponseti clip

The method did not really gain popularity until I published it in the internet and a few parents read it and then pushed the doctors really to change their technique.Ìý The doctors had followed what the parents demanded.

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Ramachandran

We eventually took a team, we went to visit Ponseti, in fact I was very lucky I was the last person to visit Ponseti, unfortunately he died at the age of 96.Ìý He’d been working all the way up to his mid-90s.Ìý But that was the only way to really understand what they did, was to be embedded in that unit for a week there and really understand how that practice worked because that’s a complete anathema to what we had before, which was see, operate, follow up, this was see, see, see, stay away from operate.Ìý But it is a sea change, particularly for a surgeons, because it’s not what we’re used to.

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Porter

Because you’re not operating, you’re not being surgeons.

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Ramachandran

Correct, but it’s the right thing to do.

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Porter

So presumably as an orthopaedic surgeon you’re coming across people who’ve just missed out on this treatment, they were treated in the old fashion way where the results weren’t that great.Ìý It must be awful to see them to know that you could have cured them effectively.

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Ramachandran

Yes it is difficult when you’re in a clinic where there are clearly older children there, teenagers, or I see young adults in their early 20s who’ve had lots of surgery who have unfortunately quite stiff scarred feet that are not very functional and right next to them are kids 10 years younger with pretty much normal feet.Ìý But that’s medicine, there’s nothing you can do, you know you do the best you can and you do what’s available and best practice in front of you at the time.Ìý So we’re just fortunate that there is a better treatment and who knows there might be an even better treatment down the line.

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Porter

Orthopaedic surgeon Manoj Ramachandran, one of the last people to visit Dr Ignacio Ponseti, the man behind the Ponseti technique. And there are more details on our website.

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Last week’s item on Conn’s syndrome – a potentially curable condition that could be responsible for as many one in 10 cases of high blood pressure – prompted some of you to get in touch concerned that we had glossed over the test for Conn’s. Our guest, Professor Morris Brown, advocated measuring levels of the hormone renin which are unusually low in people with the syndrome. So he’s back on the line from his office in London to explain more. Morris, how practical is it to test renin levels at a typical GP surgery?

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Morris

This test really is practical in general practice and we commonly ask patients to have their blood measured via their general practice before they come and see us, so I have the result ready for me at their first visit.

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Porter

A couple of listeners have got in touch concerned that the drugs that people are taking to lower their blood pressure may influence the test in some way.ÌýÌý Now these people, because they’ve got difficult to treat blood pressure, will often be on lots of different drugs, so what’s the ruling there?

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Morris

That’s a very good and important question.Ìý And fortunately we can reassure patients and doctors that almost all the drugs commonly used in the treatment of hypertension do not interfere with our interpretation of the result.Ìý There is one exception which is the beta blockers, drugs such as Atenolol or Bisoprolol, because these drugs actually work by suppressing the secretion of renin and we do advise that that type of drug is temporarily withdrawn before the blood test is done.Ìý But all other drugs either have no effect or actually increase the amount of renin in patients who do not have Conn’s syndrome.Ìý We find it very useful to have the blood measured on such drugs because if the renin is still low, despite the presence of a drug like an Ace Inhibitor, like Lisinopril or angiotensin blockers such as Losartan, then finding a low renin makes us even more confident that Conn’s syndrome may be present.

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Porter

Professor Morris Brown.

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Time now to settle a dispute between two of our listeners about the best time to brush your teeth in the morning? Howard brushes his before breakfast but his wife Katherine does it after breakfast. So who is right?Ìý A question I put to the scientific advisor to the British Dental Association, Professor Damien Walmsley.

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Walmsley

Well first off it’s good they’re brushing their teeth, that’s the most important part.Ìý And with the science what we’re looking at it depends on what you’re eating for your breakfast.Ìý So, for instance, if you’ve had a fruit juice and it’s got an acidic content there was evidence to show that the tooth might be slightly softer after you’ve had the fruit juice and therefore it’s best to wait probably half an hour to an hour after before brushing your teeth.Ìý And therefore…

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Porter

Otherwise you might be brushing your teeth effectively?

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Walmsley

Maybe, over time, not – it’s just like very small increments – but over time that could be the problem.Ìý So the idea is to brush your teeth before breakfast.Ìý But some people may want from a sort of a cursory sort of way just make sure they get rid of some of the debris and maybe a mouthwash can help on that sort of thing.

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Porter

But ideally you should be brushing your teeth before breakfast and if you are brushing afterwards, if you’ve had fruit juice, it pays to wait is what you’re saying – half an hour or so for the acids to be neutralised?

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Walmsley

Wait, yes.Ìý It’s just sensible advice on that.

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Porter

And I mean in the evenings it’s much easier isn’t it, presumably you brush it at the end of the day before you got to bed, is that standard?

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Walmsley

Well you’d be surprised, some patients will have something just before they go to bed, a nightcap, and that can be quite a problem.Ìý So if you have a nightcap or milk…

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Porter

Or a midnight feast.

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Walmsley

Or a midnight feast, because your mouth goes to sleep as well and dries up, so any food that you have before you go to sleep can stay in the mouth for a long time.

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Porter

When you say it goes to sleep, you mean the saliva production shuts down and that has a protective effect does it?

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Walmsley

That’s right.Ìý You’ve got bugs in the mouth and some of them if you keep your teeth really, really clean there are some that will remain there, won’t do anything unless you feed them sugar and if you feed them sugar they’ll cause dental decay.

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Porter

So to get dental decay we need a combination of lots of bugs in the mouth and the sugars as well.

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Walmsley

Yes.

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Porter

So if you brush your teeth before breakfast you’re reducing the bacterial load, so if you do have some sugars during breakfast it may have less of an impact on your teeth, is that scientific?

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Walmsley

Yeah I mean when you have sugar it’s the frequency, it’s not how much you have, it’s the frequency.

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Porter

Picking up on this juice thing, what about children and juices, there has been some concern that we’re perhaps given them too frequently?

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Walmsley

Yes I always get really upset when I go around a supermarket and I see young kids with their feeders and they’re full of fruit juice, that’s bathing the teeth continuously for hours or so with fruit juice which is acidic and is not particularly good.Ìý I mean water is very good, that’s the main thing to use.

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Porter

But from a dental point of view you don’t have a problem with fruit juices, it’s just that they should be restricted so perhaps once a day rather…?

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Walmsley

It’s the frequency yes.

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Porter

Can I ask you, as we’ve got you here, about another debate that you commonly hear about – manual versus electric toothbrushes?Ìý What sort of evidence do we have from that arena?

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Walmsley

Well first off technique is really important, so it’s how you brush your teeth and brushing your teeth should be for two minutes in a systematic way and you go around the whole mouth, making sure you clean all the surfaces, particularly the part where the tooth comes away from the gum. ÌýThen we get into the debate about manual and power toothbrushes.Ìý Now there is some evidence that power toothbrushes, especially with a small head, and that they move in a circular direction, may have some advantage.Ìý It’s a small advantage but the main thing I would advise patients, if they’re wanting to buy a power toothbrush and they like to use it and it makes them brush their teeth then I think that’s a good thing.

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Porter

But you and dentists in general are you pro or anti or equivocal?

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Walmsley

You get debate about it.Ìý I know it’s very important to industry whether a person buys a power toothbrush…

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Porter

Well it’s a huge industry.

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Walmsley

…a manual toothbrush and there is – certainly both of them are very effective.

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Porter

What about toothpastes?Ìý I’ve been around long enough to see different themes in the way toothpastes are marketed so when I was a youngster it was all about fresh breath, now it’s all about having – then it was all about dental decay and now it’s all about having sparkling white teeth.

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Walmsley

The most important ingredient in the toothpaste is fluoride because that strengthens the teeth.Ìý Then after that there’s different ingredients that manufacturers put in them but the most important thing is that people are brushing their teeth effectively and the fluoride in the toothpaste.Ìý After that all these have a sort of a…

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Porter

It’s marketing.

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Walmsley

They do have a small effect but it’s not an effect that will do – what you have to do is the cleaning of your teeth with a toothbrush and the fluoride.

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Porter

That’s 95% of the toothpaste, the rest of it’s the frills on…

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Walmsley

That’s most of the job being done with that.

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Porter

… the rest of it’s the frills on top.Ìý Professor Damian Walmsley, who sides with Inside Health listener Howard and brushing your teeth before breakfast.

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Just time to tell you about next week when we investigate whether the first licensed e-cig in the UK - manufactured by one of the world’s biggest tobacco companies - could soon be available on the NHS. It may be a clever business move to produce an e-cig that can be prescribed to patients trying to beat an addiction created by your other products but is it a welcome one from a health perspective?

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