Introduction
Commercial Dental Products
What is Periodontal Disease?
What Causes Periodontal Disease?
Tools and Methods to Prevent Plaque Buildup
Toothbrushes
Dental Floss
Interdental Cleaners
Flexible Rubber Tips
Toothpastes
Antimicrobial Rinses
Oral Irrigators
Conclusion
Recently, I recommended a powered toothbrush to my patient, Mr. S. A few hours later, he frantically called me from the drugstore. There were nearly half a dozen toothbrushes on the shelf that met the description of the one I recommended. Was it the one with the three-minute timer, the easy-grip handle, the two-minute timer, the water-jet attachment? I calmed him, provided him with the advice he needed, and chuckled to myself as I hung up the phone. When I started practicing 20 years ago, a trip to the drugstore to buy a toothbrush was one of life’s simple chores. Today, it can be a daunting experience. As a consumer, I too, find myself bewildered and almost immobilized by the choice of consumer dental products. There are motorized brushes, manual brushes, round ones, rectangular ones, sonic brushes, toothpastes that fight plaque, whiten teeth, and reduce tartar—not to mention flossers, water jets, dental picks, and an ocean of mouth rinses. What is even the most well-educated consumer to do?
Surveys confirm that the oral health of most Americans has been improving over the past 30 years. There have been significant declines in caries (tooth decay) and periodontal disease. Tooth loss has also declined considerably, along with the percentage of people who have lost all of their teeth. We can attribute these great successes in the fight against oral disease to several factors. Better access to dental care and fluoridation of public water supplies are two significant factors. But credit must also be given to greater public awareness of dental health, created in part by advertising by the dental products industry.
As a dentist specializing in periodontics, I am secretly glad about this explosion of dental products and the extensive advertising campaigns mounted by their manufacturers. My explanation to patients about dental plaque, tartar, gingivitis, and periodontal disease used to produce glazed looks and furtive glances at watches. Now my patients respond with knowing nods and smiles. They imagine devilish animated figures climbing onto giant teeth and attacking their teeth and gums. They visualize the bristles of a huge toothbrush or the bubbles of a mouthwash magically washing the little devils away. I no longer have to work so hard to convince my patients of the importance of healthy teeth and gums. They have learned it all, simply by watching television. (Ahh, if only everything was so easy!)
Health
Even though you have seen and heard all of those commercials, a few basic definitions are in order. Periodontal disease is really a phrase that includes a large number of clinically and biologically distinct diseases. For our purposes, we will refer to gingivitis and periodontitis. Gingivitis is inflammation limited to the gingiva—the gums that surround the teeth. In health, this tissue should be pale pink in color and firm in texture. As gingivitis occurs, the tissue becomes red and swollen. Bleeding may occur spontaneously or with gentle pressure, such as when brushing. Periodontitis is a more serious condition because it spreads to the tissues that support the teeth. This can lead to loss of bone and subsequent loosening of the teeth. For some people, periodontitis results in loss of some or all of the teeth. Even without tooth loss, periodontitis presents several risks, including painful gum abscesses, bad breath, and reduction of chewing function.
There is now convincing evidence that periodontal disease may place people at greater risk of developing serious problems in parts of the body very distant from the mouth. When you consider that every day, millions of bacteria from dental plaque enter the bloodstream through infected gum tissues, the link between periodontal disease and systemic disease is not surprising. Studies suggest that periodontitis is a significant risk factor for heart disease, stroke, and low-birth-weight babies. The headline of a recent newspaper article about this subject read, “Floss or Die!” This stern admonition was meant to be taken with a dose of humor. Nevertheless, a Web site devoted to computing expected longevity, developed by Dr. Michael Roizen, includes flossing as one of the most important simple daily activities that can extend life span.
What Causes Periodontal Disease?
Periodontal disease is initiated by dental plaque. As the plaque collects, it stimulates an inflammatory response in the surrounding tissues. The response of our own defense cells to the plaque alters the local tissues and creates periodontal disease. As the disease progresses, the tissues that support the teeth are weakened, and the shallow crevice between the teeth and the gums becomes progressively deeper. These pockets become filled with more plaque, and a cycle of plaque accumulation and tissue destruction continues until teeth are lost.
Plaque is a soft mass of millions of bacteria and their products that stick to the surfaces of the teeth. Tartar (the correct term is calculus) is plaque that has become calcified. Plaque bacteria are picky about where they choose to live. They don’t like the nice smooth surfaces of the crowns of the teeth—the large area that you can easily see. They are easily removed from these surfaces by the actions of the cheeks and tongue. Instead, the little devils like the parts of the tooth that are hard to get to: the gum crevices and pockets, the grooves on the biting surfaces, and in between the teeth. To plaque bacteria, these are heavenly places, where they can multiply and where even more harmful species can thrive. Only a dentist or dental hygienist can remove plaque from deep pockets and irregular root surfaces. Calculus must also be removed by a dental professional. Your job, by maintaining effective oral hygiene, is to remove the plaque on a daily basis, thereby preventing it from accumulating and becoming more destructive.
Tools and Methods to Prevent Plaque Buildup
There are several ways to remove plaque and maintain proper oral hygiene.
Toothbrushes
All toothbrushes should be manufactured with soft nylon bristles with rounded tips. To effectively remove plaque, the tips of the bristles should extend slightly into the crevice between the gum and the tooth. The mechanical movement of the brush should allow the bristles to sweep in to this crevice and remove the plaque. The soft nylon gives the bristles just the right amount of flex, while the rounded tips reach gently in to the gum sulcus (the groove between the gum and tooth) without damaging the tissue. Hard brushes can injure the gum tissue and, if used improperly, can abrade the teeth. I do not recommend them to anyone. Very soft brushes, whether made of nylon or natural materials, lack the flex of nylon and are less effective. I sometimes recommend ultra-soft brushes to patients who have very sensitive teeth, or who tend to brush very hard. Most of the brushes on the drugstore shelf today are made with soft nylon bristles with rounded tips.
How to brush your teeth
The inner and outer surfaces of the teeth should be brushed separately. The brush should be placed so that the angle of the bristles to the teeth is approximately 45 degrees. The bristles should be on the teeth, and their tips should be inserted slightly into the gum line. Move the brush back and forth in a gentle jiggling motion against the gum line. Be sure you are reaching the gum line of each tooth, and changing the position of the brush to compensate for changes in the gum position. I tell my patients to think of massaging the gum line, rather than brushing their teeth, although in the process, the teeth are being brushed. Whether you use a manual or a powered toothbrush, this basic concept of gently brushing against the gum line should be followed. It takes about three minutes to brush properly. It is best to divide the mouth into quarters, and spend an equal amount of time brushing each quarter.
Manual versus powered brushes
A recent article in the Journal of Clinical Periodontology reviewed more than 30 studies comparing manual and powered brushes. The conclusion was that statistically, the powered brushes showed greater plaque removal efficiency than the manual brushes. However, the clinical superiority of powered brushes was not demonstrated, and further studies were suggested. In some of the studies, many of the subjects who were given powered brushes returned to their manual brushes when the study was over. The articles reviewed did not show any significant superiority of sonic brushes when compared to motorized brushes.
In my practice, I usually recommend manual brushes, and that is what I use myself. I find the powered brushes too cumbersome because of their weight and size. They take up extra space on the bathroom shelf, some prohibit the use of certain toothpastes, and they can break. For most of my patients, I don’t feel that the negligible benefit justifies the significant difference in cost.
Of course, there are some people who do benefit from use of a powered toothbrush. I recommend them to patients who have very crowded teeth, who have problems with manual dexterity, or who are simply more motivated to brush if they have the latest in power technology. When I do recommend a powered brush, it is one with a round head (e.g., the Braun-Oral B), which I find better for cleaning areas that are hard to reach.
The choice of which manual brush to buy is a more individual one. It is often decided on the basis of look and feel. My personal choice is a brush on which the inner rows of bristles are shorter than the outer rows, creating a groove through the center. When the groove is placed over the cusps of the teeth, the outer bristles are almost automatically placed where they should be, at a 45-degree angle to the tooth, with the tips inserted into the gum line. My favorite brush is called the Improve, but it is hard to find.
Dental Floss
Everybody brushes their teeth, but flossing is what really separates the men from the boys. To me, brushing without flossing is like washing your hands but not your face. The simple fact is that most plaque tends to accumulate between the teeth, and that is where periodontal disease and decay often start. Floss should be used in an up and down motion against the in-between surfaces of the teeth. Never floss in a saw-like motion on the same spot on your teeth or gums.
The major choice in selecting floss is waxed versus unwaxed. In theory, waxed floss slips through tight tooth contacts more easily. In theory, unwaxed floss is better because the fibers spread on contact, and create more friction against the tooth. In practice, the choice is one of individual preference. I have never heard of, nor detected, wax buildup on a tooth due to floss. A more common problem is that some flosses tend to shred or break more easily due to tight contacts or rough fillings. For this problem, I recommend Glide floss. It is made of synthetic fibers that glide more easily past tight contacts, and it is more resistant to shredding or tearing.
A wide variety of floss holders are available. These usually look like tiny bows, or like slingshots. I prefer manual flossing, because patients have more control. However, many of my patients enjoy the convenience of these products and I gladly recommend them.
Interdental cleaners
While floss is the gold standard for interdental cleaning, many people cannot or will not use it. For these people, I recommend a variety of products. My favorite is the interdental brush. They are made by several manufacturers, and can be found in most drugstores. They are simply inserted between the teeth, and the handle is moved in and out about four to five times. Interdental brushes work well if there is sufficient space between the teeth. If the teeth are too close together, the brushes will not fit in between them. Since the bristles are attached to a metal wire, improper placement can injure the gums. Never try to force an interdental brush between the teeth.
Another compromise for non-flossers is wooden interdental cleaners marketed as Stimudents. Stimudents are shaped to be inserted between teeth. They function well for the front teeth, but cannot be angled properly to clean the back teeth. To reach the back teeth, there are plastic handles designed to hold the tip of an ordinary toothpick at an angle (e.g., Perio-Aid). The toothpick can then be gently moved along the gum margin, and in between the teeth.
There are powered interdental cleaners that extend a small nylon filament between the teeth (Oral-B). In my experience with patients, they are awkward to use and not very effective. As a last resort, however, they are better than nothing.
Flexible rubber tips
Flexible rubber tips were developed many years ago when it was believed that physical massage of the gums stimulated circulation and contributed to gingival health. This theory is no longer accepted. Rubber tips may feel good, but they do not effectively remove plaque. There is no harm in using a rubber tip, but not as a substitute for a plaque removing device.
Toothpastes
The most important ingredient in all toothpastes is fluoride, to help prevent tooth decay. In addition, they contain mild abrasives to remove stain. In recent years, specialized toothpastes have been introduced to fight tartar, gum disease, and to whiten teeth. The manufacturers of these toothpastes have spent millions on clinical and laboratory studies to prove the efficacy of their products. Once again, the question of statistical efficacy versus clinical efficacy must be raised. For example, several whitening toothpastes lighten tooth color by one to two shades of standard dental guides, but will this be noticeable when you smile? Tartar control toothpastes may interfere with the formation of new calculus, but they do not remove calculus that has already formed. An anti-gingivitis toothpaste is effective against plaque, gingivitis, and calculus in clinical studies, but is not a substitute for professional care.
In fairness, the manufacturers have not made claims for their products beyond those that are substantiated by research. If you have one of the problems listed above, use of an appropriate toothpaste is a safe and inexpensive measure, but only as an addition to professional treatment. The only toothpastes I recommend to my patients for therapeutic use are desensitizing toothpastes. These should be used twice a day for two to three weeks. The teeth should be exposed to the paste for at least two to three minutes. After brushing at night, a small dab of the paste should be smeared on the offending teeth and left there while you sleep.
Antimicrobial rinses
There are two mouth rinses that are approved by the FDA to reduce plaque bacteria. One is chlorhexidine gluconate, which is a prescription rinse (Peridex and PerioGard). The other is a mixture of essential oils (Listerine), which is sold over the counter. Both products are useful as assistive agents to control periodontal disease. Neither is effective as a treatment for periodontal disease. Essential-oil rinses are also useful for patients who prefer using a mouthwash on a daily basis.
I prescribe chlorhexidine as a post-treatment rinse for patients who have received periodontal or oral surgery, and as an in office irrigating solution for infected areas. It is also useful for new patients who present with severe gingival inflammation or bleeding to reduce the symptoms until treatment commences. I have used it for longer periods to control periodontal disease for patients who are severely disabled.
Oral irrigators
Although the organisms are very different, dental plaque is similar to the “slimes” we encounter on other surfaces such as bathtubs, toilets, rocks in a stream, or the lining of water pipes. These microbial films must be removed by physical disruption. Just running water over them doesn’t do anything. For this reason, I rarely recommend irrigating devices (e.g., Water Pik). Improper use of irrigators can make the problem worse, by pushing food particles and plaque deeper in to periodontal pockets.
There are indications for oral irrigators in selected cases. Perhaps the most common is for patients with braces. There may simply be no other way of removing food particles other than blasting the braces with an irrigator. Some periodontists recommend irrigation of periodontal pockets with antimicrobial solutions. If you do use an irrigator, you must take care not to direct the tip in to the gum sulcus. I recommend that you consult your dentist before using any oral irrigating device, and have him or her demonstrate and monitor proper use.
The choice of dental consumer products ultimately depends upon what works best for you. Fortunately, purchasing products for oral health does not involve huge sums of money and the use of the wrong product is unlikely to have serious consequences. Of course, your own dentist or dental hygienist is the best resource for advice. Now that you are armed with some knowledge, you don’t have to be intimidated by all those products. Purchase what makes sense to you, and in the words of the commercial, “Just do it.”
