by Trisha E. O'Hehir, RDH, MS
Despite what you're hearing about immune response and genetic predisposition, the primary etiologic factor
for both caries and periodontal disease is still bacterial biofilm. Bacterial biofilm accumulates in areas that are well
protected, specifically between the teeth and under the gums. Areas between the teeth, just below the contact point
are also the places carious lesions begin. The bacteria metabolize sugars and produce lactic acid that melts the
enamel. Caries is as much about pH as it is about bacterial biofilm. Periodontal tissue under the contact, called
the col area, is less keratinized than facial and lingual tissue and thus more susceptible to the toxic waste products
released by the bacterial biofilm. The toxic waste products trigger the immune response and white blood cells are
dispatched to the area to attack the bacteria, but on the way to the sulcus, they destroy connective tissue and bone.
Caries and periodontal disease are still significant problems that can be prevented.
According to text books authored by Dr. Per Axelsson, both caries and periodontal disease are more prevalent
between the teeth than on facial or lingual surfaces. Despite this fact, oral hygiene instructions of the past
put greater emphasis on brushing surfaces than on interproximal surfaces, the surfaces at greatest risk of disease.
Brushing was always taught first, followed by flossing. Occasionally an interdental brush was recommended,
rarely was oral irrigation suggested and xylitol was a well-kept secret. To this day, many think oral
hygiene instruction means brushing and flossing. That was the standard of care, until today.
Today is the dawning of a new standard of care for oral hygiene
instructions. This is the new prevention, where brushing comes
last, not first. Prevention is no longer simply a stick with bristles
and a piece of string – both of these require skill by the user. What
about children, teens, the elderly, nursing home residents, people
with arthritis or those in hospitals? Prevention needs to work even
when individuals don't have skills or dexterity to brush and floss.
The new standard for prevention controls bacterial biofilm first
with xylitol and oral probiotics and then with sticks, picks, interdental
brushes or water between the teeth and brushing comes last.
Bypass Mechanical Skills with Xylitol
and Oral Probiotics
Brushing and flossing require skill and dexterity to effectively
remove bacterial biofilm. Reviewing the research, Dr. van
der Weijden reported a 50 percent reduction (at best) in plaque
and gingivitis scores with oral hygiene instructions and prophylaxis.
This is not a very good success rate, primarily because of a
lack of dexterity and accuracy with a toothbrush and dental
floss. Also lacking is a way to measure if the plaque is successfully
removed.
There is a way to reduce plaque levels 50 percent without
relying on the skill and technique needed for brushing and flossing.
According to research published in the 1970s by Drs.
Scheinin and Makinen, five exposures of xylitol each day will
reduce plaque levels up to 50 percent. That's comparable to the
effect of daily brushing and flossing. Introducing xylitol five
times daily will change the bacterial environment by blocking
the metabolism of sugar. Xylitol is a natural sweetener, but it is
a five-carbon molecule rather than a six-carbon molecule like
fructose, glucose and sorbitol. The smaller molecular size allows
the xylitol to pass through the bacterial cell wall. However, the
bacteria is unable to metabolize the xylitol and has to use its own
membrane pump to pump out the xylitol molecule. The xylitol
molecule simply turns around and goes back inside the bacteria,
creating a cycle of energy use by the bacteria with no energy
being derived from the xylitol molecule. The bacteria cannot
produce more acid, cannot communicate with neighboring bacteria
and therefore no polysaccharide slime is produced to keep
the biofilm intact. The biofilm dissolves and the bacteria simply
slides off the teeth and down the digestive tract. At the same
time, the oral pH is elevated.
Oral probiotics are now available to change the balance of
bacteria in the mouth to a balance that favors health. The bacterial
make-up of a healthy mouth is much different from a
mouth full of cavities or periodontal disease. By studying the
healthy mouths as well as those with disease, researchers have
identified bacteria present in healthy mouths that are missing
from diseased mouths. Oral probiotics deliver the missing bacteria
in a xylitol mint or candy to be dissolved in the mouth,
thus delivering millions of colony-forming units of the missing
bacteria to change the balance of bacteria in the oral cavity.
Creating a healthy mix of bacteria in the mouth prevents caries
and periodontal disease. Xylitol and oral probiotics provides reliable
measures to reduce bacterial biofilm without depending on
manual dexterity skills to mechanically remove bacterial biofilm
with a toothbrush and dental floss.
The first two steps in the new standard for prevention
require no skill on the part of the user, simply use xylitol products
five times daily and oral probiotics twice daily. Xylitol is
available in many forms – gums, candies, gels, baby wipes,
toothpaste, mouth rinse and packets for eating. Xylitol is also
used to sweeten oral probiotics. Look for products like those
from Spry that are 100 percent xylitol-sweetened and available
in health food stores or online. Evora probiotics provide the
missing oral bacteria to establish a healthy oral flora.
Mechanical Disruption
With the bacterial biofilm reduced significantly with xylitol
and the bacterial balance shifted toward health, it's time
for the mechanical disruption of the remaining plaque
biofilm. Since disease begins between the teeth, it makes sense
to start the mechanical disruption of biofilm between the
teeth, using sticks, picks, interdental brushes or oral irrigation.
Flossing statistics from Drs. Steward and MacGregor
confirm what dental professionals already know – two to 10
percent of people actually floss on a daily basis. It seems the
only people who floss regularly and effectively are hygienists
and dentists! Patients are skillful at putting floss between their
teeth without ever touching the plaque or going below the
gingival margin. Offer other alternatives that are easy to use
and comfortable. The most overlooked option for interdental
plaque disruption is oral irrigation; it's like flossing with
water. Oral irrigation is effective in blasting off huge sections of biofilm both supra and subgingivally.
It's also easy to do; simply aim the jet tip
90 degrees toward the interproximal
space and hold for a few seconds. Done.
The last step in the mechanical disruption
process is the toothbrushing. Working
with what people are already doing will
make this part successful. According to Dr.
Beals, people in the U.S. spend only 37
seconds brushing their teeth. Using this as
a starting place, the only toothbrush to
cover all surfaces in such a short time is the 30-Second Smile
power toothbrush. This brush is a car wash for the mouth.
Simply bite on the brush head and it will brush top, bottom,
inside, outside and biting surfaces all at once, taking only 30
seconds to cover the entire mouth. This brush removes the need
for skill in placing and moving the toothbrush correctly. Many
standard power toothbrushes now have two-minute timers to
ensure adequate time to move the brush around to all surfaces
of the teeth.
For those using a manual toothbrush, the short brushing
time is due to the foaming and bubbles of toothpaste. Without
toothpaste, people brush much longer and more evenly around
the mouth. Plaque biofilm levels are the highest on the lingual
of the lower teeth, especially the right side. This is where toothbrushing
should start. Instruct patients to start brushing on the
lower lingual surfaces and brush until all the teeth feel clean and
taste clean. When the biofilm has been removed, then add
toothpaste and brush once more around the mouth. Brushing
without toothpaste allows the patient to feel the bacterial
biofilm before and after brushing, something not possible when
using toothpaste due to the flavor and wetting agents.
Toothpaste makes the mouth feel clean when it's not yet clean.
Dry brush first until the teeth feel clean and taste clean, then
add toothpaste.
The tongue also needs to be cleaned to remove bacterial
biofilm and volatile sulfur compounds. No gold standard has yet
been identified for tongue cleaning, so recommend what you
prefer to use yourself. Some prefer a brush, others prefer one of
the many tongue scrapers now available. Gentle brushing or
scraping will remove tongue biofilm.
Self-tests for Prevention
Feeling bacterial biofilm on the teeth, testing the salivary
pH and checking for bleeding between the teeth are three easy
self-tests. Before any action to control the biofilm, teach
patients to feel the biofilm in their own mouth using their
tongue. Focus on the lingual of the lower posterior teeth along
the gingival margin and along the gingival margin on the facial
surfaces of the maxillary molars. Using the tongue they can feel
for biofilm before and after each oral hygiene session and
throughout the day as biofilm accumulates. Knowing where
the biofilm is before taking action will provide the feedback to
evaluate toothbrushing effectiveness. In
order for the tongue to evaluate bacterial
biofilm removal, toothbrushing needs to
be done first without toothpaste until the
bacterial biofilm is removed. After the
teeth feel clean to the tongue the toothpaste
can be added.
Testing salivary pH is easy using a piece
of litmus paper or a pH strip. Simply spit
into a spoon and then apply the pH strip
and check the color change. The pH strip
is also good for checking the pH of foods, drinks and oral
hygiene products. People are surprised that drinking coffee all
day will lower their salivary pH.
The Eastman Interdental Bleeding Index (EIBI) is a toothpick
test for interdental bleeding developed by Drs. Caton and
Polson. It was shown in a study by Dr. Bliedin to be more reflective
of interdental inflammation than bleeding on probing
scores. Where interdental space allows, insert a triangular
wooden stick from the facial and push in and out four times,
looking for bleeding within 15 seconds. This can be done in all
interproximal areas to check for bleeding, a sign of infection.
Although no research has been published using plastic sticks,
they just might provide similar information about interdental
infection when used to do the EIBI test.
Conclusion
It's time to move beyond brushing and flossing to the new
standard for prevention. Today prevention focuses first on
changing the oral environment with xylitol and oral probiotics
before cleaning between the teeth and eventually brushing and
tongue cleaning. Feeling plaque biofilm with the tongue before
and after brushing, testing pH of the saliva and checking for
bleeding between the teeth are easy ways to monitor success.
Giving patients the science, ingredients and tools to effectively
control bacterial biofilm and salivary pH is the new standard
for prevention.
References
- Axelsson, P.: Diagnosis and Risk Prediction of Dental Caries. Quintessence Publishing, 2000.
- Axelsson, P.: Diagnosis and Risk Prediction of Periodontal Diseases. Quintessence Publishing, 2002.
- van der Weijden G., Hioe K.: A systematic review of the effectiveness of self-performed mechanical plaque
removal in adults with gingivitis using a manual toothbrush. J Clin Perio; 32 (Suppl. 6): 214–228, 2005.
- Scheinin, A., Makinen, K.: The effect of various sugars on the formation and chemical composition of dental
plaque, Inter Dent J, 21:302–321, 1971.
- Scheinin, A., Makinen, K.: Effect of sugars and sugar mixtures on dental plaque, Acta Odon Scand 30:
235–257, 1972.
- Steward, J., Strack, S., Graves, P. Development of oral hygiene self-efficacy and outcome expectancy questionnaires.
Com Dent Oral Epid 25: 337–342, 1997.
- Steward, J., Wolfe, G.: The retention of newly-acquired brushing and flossing skills. J Clin Perio 16:
331–332, 1989.
- Macgregor, I., Balding, J., Regis, D.: Flossing behaviour in English adolescents. J Clin Perio 25: 291–296,
1998.
- Beals, D., Ngo, T et al. Development and laboratory evaluation of a new toothbrush with a novel brush
head design. A J of Dent 13, 5A–14A, 2000.
- Caton, J., Polson, A.: The interdental bleeding index: a simplified procedure for monitoring gingival health.
Comp of CE in Dent 6: 89, 1985.
- Bliedin, T., C
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