Preventive Care at Home - 80% of the Battle

Professional care in the dental office discussed above constitutes about 20% of the battle against caries. The remaining 80% of the war must be fought on the home front. Remember, the hygienist can only "bring your teeth down to baseline" on the day of your appointment. Between appointments, it is the patient's responsibility to maintain baseline. Baseline is accomplished by the mechanical disruption of the pellicle, namely brushing and flossing.

Tooth brushing

The objective of tooth brushing is simple, disrupt and brush away from the teeth the sticky pellicle that contains the acid-producing bacteria. Tooth brushing should be performed two to three times per day, and should take at least 2 minutes. The big debate today is manual toothbrush versus electric.

Theoretically (emphasis on theoretically), a person can brush their teeth as effectively with a manual brush as they can with one of the two recommended electric brushes. However (emphasis on however), in order to achieve the results of the electric brush, the person must (emphasis on must) maintain perfect technique during the entire two minute brushing procedure. The brush must be held at a 45 degree angle to the teeth and gums, and the brush must be gently turned in a circular motion to loosen the pellicle, and then the brush must sweep gently down the tooth away from the gums to remove the plaque from the teeth. This process must be repeated again and again over every tooth surface, until the entire dentition is clean. This is called the Modified Bass Technique.

Quite frankly, I am incapable of performing this redundant task twice a day for the rest of my life! I have other things to think about. While I brush my teeth, my mind wonders to yesterday's problems, then to today's problems, and then to the problems I will have to face tomorrow. Pretty soon, my modified Bass degenerates into Scrub-a-Dub. The problem with scrub-a-dub, is that it is not effective in removing plaque, and if I am not careful, I will apply too much force, causing tissue damage to my teeth and gums, referred to as toothbrush abrasion.

Fortunately for people like me, as well as for the vast majority of my patients, there are two excellent electric brushes presently on the market. They are the Sonicare and Braun Oral-B. Both brushes mechanically disrupt and remove the pellicle using a proper technique that does not harm the teeth or gums. Furthermore, like any automated machine, these brushes are able to consistently repeat the redundant process of proper brushing, so that we do not have to.

Recently, an article appeared in the Tucson paper discussing manual versus electric brushes. It did not mention any brand names. A similar article ran in the Washington Post on 1/12/03. The Post article did mention brand names and stated that a study from England showed that the Braun was superior to both manual brushing and the Sonicare, that the Sonicare was no better or worse than manual brushing, and that many American dentists and patients prefer Sonicare over Braun.

My recommendations are as follows: It is very rare for any person to practice ideal manual brushing technique 100% of the time. Therefore, I recommend one of the two above-mentioned electric brushes to all of my patients. As to which brush is superior, there is no absolute scientific information presently available that settles the turf war between the two manufacturers. Some periodontists swear by Sonicare, others prefer the motion of the Braun. Personally, I use the Sonicare. More importantly, I have seen tremendous results with my patients who use the Sonicare. I have also seen positive results with my patients who use a Braun. Therefore, if a patient is happy with the Sonicare, then I recommend that he or she continue to use it. If a patient likes the Braun, then I advise them to continue to use it as well. Quoting from the Post article, "Electric toothbrushes generally are better than conventional toothbrushes. Patients tend to brush longer. And since they invested in the toothbrush, they tend to be more committed to their oral hygiene."

Toothpaste

Patients often ask which brand of toothpaste to use. Please use any toothpaste that caries the Seal of the American Dental Association (ADA). This seal insures that the product contains fluoride, and that the fluoride is in a form and an amount that is beneficial to your teeth. Sonicare recommends using a gel form of paste that does not contain baking soda, only because the baking soda can clog the machine.

It should be emphasized that the ADA Seal is awarded to a toothpaste because of the fluoride it contains, and not for any other reason. Additives such as baking soda, whitening agents, and tarter controls have never been proven to provide any benefit in the disruption of plaque and or calculus. In fact, studies have shown that brushing without toothpaste is as beneficial as brushing with toothpaste. Remember, it is the mechanical disruption of the pellicle or plaque layer by the motion of the brush that minimizes caries, not any action of the toothpaste.

Flossing

No toothbrush, electric or manual, can disrupt the pellicle or remove plaque in between teeth. Therefore it is imperative that we all floss at least once per day. Flossing will minimize the probability of interproximal caries (in between the teeth caries). Early research indicated that unwaxed floss was superior to waxed floss, however this has been disputed in recent years. The important thing is to floss at least once per day. If you have difficulty with unwaxed, use waxed floss. If you cannot accommodate floss, try dental tape.

Chemical Solutions to Fighting Caries-Fluoride

Brushing and flossing involve the mechanical disruption of the pellicle and plaque. There is one chemical that when used in addition to brushing and flossing, will make your teeth more resistant to caries, fluoride.

Enamel is composed of a mineral called hydroxy-appetite. Over time, the acid produced by the cariogenic bacteria can dissolve or demineralize hydroxy-appetite crystals, initiating the caries process. It turns out that appetite crystals have a higher affinity for fluoride ions than they do hydroxy ions. Therefore, when fluoride is applied to enamel, the hydroxy-appetite crystals are converted into fluoro-appetitie crystals.

Guess what? Fluoro-appetite is much stronger and more resistant to caries than hydroxy-appetite. Therefore, by applying fluoride to teeth, we are making them more resistant to decay. In other words, fluoride is like vitamins for the teeth. We recommend a 1.1% neutral sodium fluoride paste, applied to teeth at bedtime, after brushing and flossing.

In summary, in order to minimize and control caries, see your dentist regularly for exams, x-rays and cleanings, brush and floss regularly, and use a prescription fluoride paste at bedtime after brushing and flossing.

Diet

Obviously, reducing the intake of foods and beverages that contain sucrose helps to minimize caries. Remember, without sucrose, the bad bacteria cannot produce the acids that destroy teeth. If you have an uncontrollable "sweet tooth" like me, try to brush immediately after eating something naughty.

Products That Do Not Work

Every year, this country spends $4 billion on colored water. We call this colored water mouthwash. With the exception of over-the-counter fluoride rinses formulated primarily for children (brand names ACT and Fluoroguard), scientific research has proven that flavored mouthwashes, referred to as cosmetic mouth rinses by the dental profession, are no more effective in removing plaque than plain water. Therefore, there is no reason for us to waste our money buying them. Mouthwash has no positive effect in fighting tooth decay.

As always however, there is one possible exception to this statement, Listerine. Listerine has been classified as a therapeutic mouth rinse, as the active ingredient in Listerine has been shown to have a marginal (emphasis on marginal) impact on killing cariogenic bacteria in supra-gingival (above the gum-line) plaque. In other words, Listerine can kill some of the bacteria that cause tooth disease. In order for Listerine to work however, it must be used full-strength for 30 seconds, twice per day. It is not easy to swish with full-strength Listerine for 30 seconds, as it has a high alcohol content and tends to burn the inside of your mouth. If you dilute the Listerine, or use it for less than 30 seconds, then it will not kill the cariogenic bacteria, and therefore there is no need to use it.

My recommendations are as follows; brushing, flossing, and using a prescription strength fluoride paste after brushing and flossing, are the most effective, scientifically proven ways to minimize caries and gum disease. No mouth rinse should ever be used as a substitute for any of these procedures, unless instructed to do so for a short period of time after a dental procedure by a dentist. Listerine provides such a marginal benefit, that I rarely recommend it for patients. There are more effective prescription rinses that can be used short term under specific conditions should the need arise.

Mother product on which we like to waste money is the water pick. As Americans, we like to see results. We know that our lawnmower works, because we can see the cut grass and clippings before our eyes. Our razor works because our beard disappears down the sink. Therefore we think our water pick works because we see big chunks of food fly out of our mouth when we use it.

Remember, it is not big chunks of food that cause caries. Caries develops when we fail to remove the pellicle containing cariogenic bacteria from our teeth. Scientific research has proven that water picks have no impact on removing the pellicle, plaque, or calculus from our teeth. Furthermore, it has been shown that water picks can actually damage gum tissue attachment to the teeth. Water picks have also been shown to cause bacteremias, a process in which bacteria ifs forced into the systemic circulation. This is of particular concern to patients with certain types of heart conditions. Finally, water picks force bacteria down into periodontal pockets around the tooth, worsening periodontal disease. Therefore, I strongly recommend that patients refrain from using a water pick. If a patient is physically unable to brush and floss, then I prefer to have the patient or caregiver brush the teeth with a Sonicare toothbrush, as opposed to using a water pick.

I hope you have found this article interesting and informative. More importantly, I hope it has provided you with the information that you need to select the best dental care for you. Until next time, please brush, floss, and use a fluoride paste.

Dr. James S. Sidd, Jr., D.D.S.