Oral Hygiene Instructions

Visiting a dentist regularly is not the most important part of your oral health.  While it is still very important to see a dentist for cleanings and check-ups at least once or twice a year with x-rays as needed, it is far more important to practice proper oral hygiene at home daily.  Our office loves to help if you have problems with your teeth and gums, but we feel strongly that helping to improve your personal oral hygiene is a higher priority, and will prevent problems before they begin.  The following is a fairly comprehensive list of some tips we feel can help in your daily dental home-care.  This is not all-inclusive of everything available, but anyone interested in preventing oral health problems should read this entire page and may find some interesting new ideas as well.  Or simply use this as a reference.  Our plan is to update this page if any new information becomes available or brought to our attention. 

Why is There a Problem?

Understanding the problem will help to understand the importance of daily prevention, and how to use preventive methods to target the risk factors for disease.  Cavities and gum disease are largely a bacterial problem that can be prevented by controlling certain risk factors.

At all times, bacteria are roaming your mouth seeking out places to bind and colonize into “plaque”.  Most bacteria are normally present and some possibly even help us to stay healthy.  But some are harmful and too many harmful bacteria will cause problems.  Plaque is made up of bacteria, debris from the food that you eat, and bacterial by-products like lactic acid.  If soft plaque is not broken up and cleaned, in as little as 24 hours it can become “tartar” (also called “calculus”).  Tartar is hard and mineralized and is not easy to remove with normal home care accessories.  It requires a professional dental cleaning to remove completely.

Bacteria tend to hide in the hard to reach areas of your teeth, gums and tongue – especially between the teeth, in the grooves and pits of the teeth which are formed by normal tooth development, and also in the pockets formed by your gums around the teeth.

 It should also be understood that the harmful bacteria involved in oral disease are contagious and can be passed to family members or others whenever saliva is shared.  This includes kissing, sharing drinks, etc.  If you are working hard at your oral hygiene, but your spouse or family members are not, you may still experience problems.  Treating everyone in the family is important.  Even well-intentioned parents who sacrifice their own care to take care of their kids may be re-infecting their children and counteracting the treatment their kids receive.

Bacteria are one of four necessary ingredients for tooth decay.  As seen in this diagram, “Caries” in the center is the disease process that causes tooth decay.  Decay leads to a hole in the tooth, which is called a “cavity”.  These ingredients are also involved in gum diseases like gingivitis or periodontitis.  Poor oral health has even been linked to systemic diseases like Diabetes, Heart Disease, Osteoporosis, etc.  The cause of this correlation has not been identified yet, but it may be due to increased harmful bacteria or the inflammatory response itself.

Teeth are fairly obvious because without teeth we would never get cavities.  Of course, there are other problems associated with going toothless, so we don’t advise removing teeth in order to prevent cavities.  There are plenty of ways to protect teeth from caries, which will be discussed later on this page.

Food is more of a factor than many people may realize.  Everyone knows that sweets are bad and lead to cavities, but truthfully there are many foods other than “sweets” which still can promote tooth decay.  Any sugars or fermentable carbohydrates can be metabolized by bacteria to produce acid, which is what erodes enamel and allows bacterial colonies to burrow deeper into the tooth and/or gums.  Acidity is usually represented by a number on a “pH” scale, where 7 is neutral like distilled water; lower than 7 is acidic; and higher is “alkaline” up to 14.  Battery acid is very acidic and would be around pH 1.  It has been shown that when the pH in the mouth is below 5.5 enamel dissolution can occur.  Root surfaces can dissolve at an even higher pH of 6.0 - 6.5 if you have gum recession that exposes the tooth roots.  Therefore, acidic foods and drinks are also bad (even diet soft drinks) because they lower the pH and allow harmful bacteria to thrive. 

Time is also important to consider because whenever you eat or drink anything acidic or that bacteria can metabolize into acid, the acidity can remain in your mouth for 20-30 minutes even after you stop eating – and it can last even for hours if heavy plaque is present.  The amount of time may vary depending on your genetics, nutrition, medications, saliva production, etc., but in general the more frequently you snack or sip something with carbohydrates (especially sugar) or acid, the more prone you are to tooth decay (cavities) and gum disease (gingivitis/periodontitis).  Saliva works as a buffer, and it takes time for saliva to neutralize the acidity in your mouth.  If you suffer from dry mouth, which is due to low saliva production, then you are more prone to these diseases also.

There are certainly other factors involved, but these four seem to be the most significant and the easiest to effectively control.  Whatever role genetics plays, there is nothing we can currently do to modify it, so it’s best to focus on what we are able to control. 

The whole process can be thought of as a tug-of-war battle between disease and healing processes.  Enamel is demineralized and re-mineralized depending on the oral environment.  Cavities and gum disease form when the disease process is given more time.  At first, these problems may not seem detrimental, but, if not treated early or prevented, they can lead to expensive procedures, loss of teeth, systemic diseases, or even life-threatening infections.

Now let’s look at some ways to attack these factors of disease progression and share some tips for prevention.

Brushing and Flossing

The most basic and one of the most important parts of your home care includes brushing at least twice daily for two minutes and flossing at least once daily.  You can certainly do more, but this is the minimum recommendation.  Here are some tips to follow.  Some are not commonly known, but they are important and can help in your daily dental hygiene routine.

Brushing Technique. 

 This is how Dr. Albertoni used to get his "Mr. Clean" smile!

This is how Dr. Albertoni used to get his "Mr. Clean" smile!

Use only soft or extra soft bristles for your brush.  Medium and hard bristles are too stiff and can damage your gums, causing gum recession followed by abrasion of the exposed roots of your teeth.  This causes sensitivity and sometimes the damaged roots need to be filled to stop further injury and sensitivity.  If the damage is already done, don’t panic – Just stop brushing hard and the sensitivity should resolve itself with some time.

Electric or manual toothbrush?  Both are fine.  An electric brush (like Sonicare or Oral-B) is great and many dentists and hygienists recommend everyone to use them, but the ones worth using can be expensive.  Manual toothbrushes work fine if you use proper technique.  However, people with dexterity problems should use an electric toothbrush.

Light pressure.  Do not press hard or brush aggressively or too fast.  Doing so can cause the same damage seen with medium or hard bristles, and will make you think the softer bristles are not cleaning as well.  If the bristles of your brush are frayed, then you are probably brushing too hard.  Slow down and take your time.  Hold your brush with your fingertips instead of a fist to utilize fine motor control. 

 
 Don't hold your brush forcefully with a fist.  This uses larger muscles and can be too abrasive.

Don't hold your brush forcefully with a fist.  This uses larger muscles and can be too abrasive.

 Hold your brush gently with your fingers in order to use smaller muscles and have better control.

Hold your brush gently with your fingers in order to use smaller muscles and have better control.

 

Brush with short, gentle strokes up and down each tooth or in small circles.  Long strokes along the gum line can cause gum recession and abrasion to the enamel and root surfaces.

Angle the brush about 45 degrees toward the gums, and sweep away from the gums along the tooth.

Spend a full 2 minutes.  Use a timer if you have to, but the key is not to rush and to make sure you clean every surface of every tooth.  Start in one area and work your way slowly around your entire mouth.

 Angle at 45 deg toward gums

Angle at 45 deg toward gums

 Clean the biting surfaces

Clean the biting surfaces

 and the front and back sides

and the front and back sides

 turn the brush to fit.

turn the brush to fit.

Brush your tongue also.  Bacteria can hide in the fissures of your tongue, so it is important to brush the top of your tongue, or you can use a tongue scraper – a specialized tool made for cleaning your tongue.

Replace your toothbrush every 3 months or sooner if it is damaged or frayed. 

Flossing Technique

 This X-ray shows decay (the dark areas on the teeth), which often starts between the teeth at the contact where bacteria can hide from brushing.  To the right of the top arrow is a cavity.  To the left of the bottom arrow is a smaller area of tooth decay that may be maintainable and may not need a filling yet.

This X-ray shows decay (the dark areas on the teeth), which often starts between the teeth at the contact where bacteria can hide from brushing.  To the right of the top arrow is a cavity.  To the left of the bottom arrow is a smaller area of tooth decay that may be maintainable and may not need a filling yet.

Why does flossing work?  Brushing does not reach every surface of your teeth.  If your teeth contact each other, then the bristles cannot clean adequately between your teeth.  Flossing works by physically breaking up plaque that accumulates just below the contact of your teeth and in the crevices of your gums between your teeth.  It also works by allowing oxygen to reach those areas, which disrupts the anaerobic (oxygen intolerant) bacteria that cause gum disease and caries.

Do your gums bleed when you floss?  Bleeding is not normal.  Your gums are bleeding because they are unhealthy and inflamed in response to the amount of plaque and/or tartar that has accumulated.  You might need a professional cleaning in order to remove the tartar, but your gums will only heal if you commit to regular flossing.  Your gums will continue to bleed for a while, but in about 4-6 weeks they should heal and healthy gums do not bleed or hurt when brushing or flossing. 

Hold the floss tightly.  With string floss, a good technique is to wrap it around one finger (eg. index fingers) on each hand so you can pull it tight.  (About 18 inches of floss is a good length to allow you to wrap it around each finger and to slide the floss to use a clean section for each tooth.)  Then use another finger (eg. thumbs or middle fingers) from each hand to hold it close to your teeth while still pulling tight.  Then you can gently and easily saw the floss through the contact without an uncomfortable snap.  (Click on the following pictures to view larger.)

1. Pull the floss tightly between two fingers.  Try either your index fingers or middle fingers.

2. Then, using two other fingers or thumbs guide the floss close to the teeth.  The closer you get, the easier it will be to floss gently.

3. Angle the floss between the teeth and slowly rock back and forth until it slides through the contact.

4.  Floss up and down the sides of each tooth and gently into the gums.  Shape to floss along the contour of the tooth so it can clean as much plaque as possible.

Floss gently.  There is no need to snap the floss through the teeth and jam it into the gums.  Just hold it tight and gently saw it through the contact at an angle that works best for your teeth.  Shape the floss along the side of one tooth and floss softly up and down and slightly below the gum-line, then along the other tooth, then pop it back out through the contact.  With a little practice flossing becomes very easy and takes about 1-2 minutes.

There are many types of floss to choose from.  You can get waxed, unwaxed, braided, mint, cinnamon, unflavored, floss picks, reach flossers, etc.  The one you choose is a personal preference.  The regular string floss is probably slightly superior to the floss picks since it can be shaped along the tooth better, but the convenience of floss picks makes it easier for some people to commit to flossing, and they work much better than no floss at all.  For braces or under bridges you can find special floss threaders to help you thread the floss through braces.  Super Floss has one stiff end that helps to thread it.  For braces you could also try Platypus Flossers, which are made to fit without having to thread the floss under the wire.

Don’t forget behind the back teeth.  There may not be two teeth contacting in the very back, but it is still hard to brush back there and some spots are missed.  It is important to run the floss back there to clean the tooth, and it’s pretty quick and easy too.

If you find it hard to start flossing, try starting small and working your way up.  Not many people can hit the ground running and keep it up long term.  Start flossing once or twice a week to get used to it.  Gradually work up to a daily routine of flossing at a certain time that works for you.  Make it a priority and use reminders.  Maybe even reward yourself, and eventually you will be successful. 

Water flossersWaterpik is the most well-known brand, but there are others available.  These are tools that spray a jet of water aimed between your teeth and toward your gums.  The jet is strong enough to disrupt plaque without doing damage to your teeth or gums.  A Waterpik can be very useful in cleaning around braces, under bridges, and for patients with periodontal disease it can clean deeper into gum pockets than normal brushing and flossing.  Further studies will need to show effectiveness in preventing caries, so for now we only recommend these in addition to regular flossing.  Although, for patients who don’t floss, using a Waterpik could help improve your oral health.

Air flossers.  The Philips Sonicare AirFloss uses a very small amount of water to blast air and water droplets to disrupt plaque between teeth.  These also are effective, however may not be quite as effective as regular flossing.  For patients who do not floss, these may be an alternative that will help improve gum health.  Its ability to prevent cavities at the contact of the teeth is yet to be proven, so regular flossing is still recommended over air flossers.

Toothpaste

Toothpaste is not required.  Toothpaste is great and improves the flavor and mouth-feel of brushing.  It also usually includes ingredients that help fight caries and gingivitis, and removes stains.  But toothpaste is actually not absolutely necessary.  You can simply use a toothbrush and water, and the physical action of the bristles will break up the majority of plaque.  It has been suggested that without toothpaste, brushing alone will not abrade enamel… however gum recession can still occur.  We still recommend using toothpaste, but if you can’t tolerate the taste, or if you find yourself without toothpaste, just brush without it.

Whitening toothpastes should be avoided.  We all want white teeth, or at least not dark or yellow teeth.  But whitening toothpastes are generally highly abrasive, which is how they work.  By removing layers of your enamel it may remove the staining and whiten in the short run, but eventually you may wear through to the darker dentin layer of teeth and whitening may not help anymore.  It will also increase sensitivity of your teeth and gums.  If you really want to whiten your teeth, we recommend either trying white strips (over the counter), or we can make bleaching trays at our office for you to use at home.  Any whitening will cause sensitivity, but it should not be done daily for more than a couple weeks, which is likely how whitening toothpastes would be used.

Fluoride is important.  Topical fluoride has been shown to be very effective in protecting enamel from dissolution.  It works by replacing hydroxyl groups in hydroxyapatite crystals (the crystalline structure of enamel), and forms fluorapatite – a related structure that is less prone to dissolution by acids.  Fluoride protects your enamel and can also re-mineralize early lesions of decayed enamel.  This is why fluoridated toothpaste is recommended, and if you have many early lesions we may even recommend prescription strength fluoride toothpaste to help prevent cavities.

Spit, but don’t rinse after brushing, and don’t eat or drink anything for an hour.  It’s true that a high amount of the fluoride in toothpaste should not be swallowed, but a small amount is perfectly safe, so spit the excess out but don’t rinse.  Rinsing will dilute and wash away most of the fluoride that you just brushed onto your teeth, which is meant to be beneficial.  If you don’t like the flavor or the grittiness and you must rinse, go ahead, and you can try rinsing with a fluoride mouth rinse, which may be more tolerable.

Desensitizing Toothpaste.  If you suffer from sensitive teeth then check your brushing technique and see if you are doing something wrong that is causing the sensitivity (see above).  Your teeth should eventually desensitize themselves, but you can use Sensodyne or other anti-sensitivity toothpastes to help the process along, or you can try brushing without toothpaste for a while to avoid the abrasives.

ADA Seal of Acceptance.  When you see the ADA Seal on a product, you can be confident that it is good.  However, a product without the seal does NOT necessarily mean it is inferior.  In order to earn the seal, a brand must submit to additional rigorous evaluation above and beyond FDA requirements, and it must meet other quality standards.  They also must pay a submission fee and maintenance fee in order to get the endorsement.  That is all fine, but some products may not have the seal even if they are great products and worth using.

Nutrition and Diet

Probably as important as brushing, if not more so, is paying attention to the foods you eat and drink, and how often you eat them.  Here are some tips to help you reduce your risk of caries and gum disease.

Time and frequency may be the most important concept to understand about nutrition and oral health.  Every time you snack or sip something with acid and/or sugar your teeth will be under acid attack until about 20-30 minutes after you stop eating.  This means that if you snack frequently throughout the day, you may not be giving your teeth and gums any time to recover.  Sticking to three meals a day and only one or two snacks is a good way to limit the time that your teeth are bathing in acid. 

This figure shows the effect of time on eating and snacking.  Red bars indicate the amount of time the mouth is exposed to acid.  Each sitting assumes 20 minutes for eating and 20 more minutes until the acid is neutralized by saliva.  By snacking multiple times a day,  Ike's teeth are bathing in acid about twice as long as Mike's, who eats 3 meals and 3 snacks.  (Click the figure to view larger).

Types of foods are important to consider.  As stated before, any carbohydrates can be converted to acid by bacteria, but some foods are still better than others.  Healthier foods like fruits contain sugar, although it rinses away easily.  Higher sugar content, like in candy, can be more problematic, but a more significant factor is the stickiness or the retention of the foods.  Starchy foods like chips, crackers, and cookies stick around longer on your teeth than foods like ice cream or milk chocolate.  Caramel and gummy candies can be sticky too, so they should be avoided, but they do seem to be cleared faster than starchy foods.

Acidic foods and drinks contribute to lowering the pH in the mouth, which allows enamel erosion or dissolution to occur.  Citric acid and phosphoric acid are common acids in many foods and drinks.  Anything with a pH below 5.5 is able to lower the oral pH below the threshold for caries and gum disease.  Note that diet sodas contain no sugar, but they are still acidic.  Also sports drinks like Gatorade are acidic and contain sugar, AND they are usually consumed when the mouth is dry and less able to clear the acid.  Water is a better choice for athletes, and keep in mind that replenishing electrolytes is really only necessary for very high performance athletes.

Acid Reflux can be a problem as well.  If you suffer from some level of reflux, bulimia or frequent vomiting for whatever reason, you are at higher risk of tooth erosion, caries and gum disease.  If you brush your teeth immediately after vomiting, make sure your toothpaste has an alkaline pH to buffer the acid, otherwise you should rinse with water and wait at least a half hour before brushing.  Brushing immediately after an acid wash can be abrasive and can do more damage than good.

Water is great to drink throughout the day.  Tap water is usually fine, and you can filter it if you prefer.  Be careful with bottled water, though, as some are actually acidic.  A few are alkaline, and some are neutral pH.  You can find charts and videos online demonstrating this phenomenon, but a good idea if you drink bottled water is to test the brand you like with pH test strips (can be bought online).  Otherwise, if you are drinking acidic bottled water throughout the day you run the same risks for cavities as with any other acidic drinks.

Saliva

Saliva is an important protective factor in preventing caries and gum disease.  It is useful for washing away food debris, buffering acidity, bringing minerals to teeth for remineralization, and other benefits for immunity and digestion. 

Chewing sugar-free gum is a great way to stimulate saliva production after a meal or snack.  The gum also helps to clean most of the food debris that sticks to your teeth.  Sugar-free candies can also be helpful.  The “sugar-free” part should be emphasized, though, because gum with sugar will only help if your goal is more cavities!

Xylitol is one of the sugar substitutes that has gained popularity recently.  It is a naturally occurring alternative sweetener and seems to interfere with bacterial growth and reproduction, therefore having an anti-bacterial property.  Current research is still weak in proving that Xylitol is better than other sugar substitutes and/or fluoride for caries prevention, so more and better research still needs to be done before getting a firm recommendation.  However it may still be beneficial, so if you’re interested in trying it, feel free.  What’s the downside?  Well, the recommended therapeutic dose is about 6g/day, which is a lot and can be costly to maintain.  Also, too much xylitol can have a laxative effect, especially during the first weeks of consuming it.  It has been shown to be toxic to dogs and must be kept away from pets.  Otherwise, Xylitol can be a great sugar substitute in gum, candy or anything else you want to sweeten.

Deficiency in saliva production is called “dry mouth” or “xerostomia”.  It is usually a side effect when taking multiple medications, but can also be caused by genetics, dehydration, mouth breathing, tobacco, radiotherapy, etc.  If you suffer from dry mouth, you should drink lots of water and try to keep your mouth hydrated.  Chewing sugar-free gum or sugar-free hard candies can help to stimulate your salivary glands to produce more saliva.  Biotene mouth rinses can be used to wet the mouth and stimulate saliva.  Fluoride rinses like ACT or fluoride trays from the dentist can be very helpful to prevent cavities since you are at a higher caries risk when you have lower salivary flow.  Prescription medications like Pilocarpine can help increase salivary production, however it may be contraindicated with certain medications or medical conditions.  Ask your doctor first if you can change some medications that are causing dry mouth.  If switching medications is not possible then ask if you can add Pilocarpine to your regimen.

While you are sleeping salivary flow is low.  You should avoid snacking immediately before going to bed.  We recommend brushing your teeth before going to bed and no “midnight snacks.”

Mouth Rinses

There are many different types of rinses available.  None of them have been shown to be a substitute for brushing and/or flossing, however they can provide preventive benefits to complement brushing and flossing.  The benefit may be small, but not insignificant.  Listed here are some strategies that mouthwashes employ, and some even use combinations of two or more.

Antiseptic.  Examples of this type would be Listerine, Scope, Crest Pro-Health, etc.  Various ingredients are used for this purpose.  Some use alcohol as an inactive ingredient, but lately more alcohol-free products are becoming available.  Alcohol may have antiseptic properties, but it also can have a drying effect and acidic pH.  Other antiseptic ingredients may also have a low pH, and may have conflicting effects.  However, ingredients like chlorine dioxide in CloSYS or sodium hypochlorite in CariFree may be promising for antiseptic use as well as maintaining a high pH.

pH buffering.  These alkaline mouth rinses can help prevent caries and gum disease by lifting the oral pH to a safe level.  CariFree and CloSYS are some brands that are worth trying which use an alkaline pH along with other antiseptic and/or anti-cavity ingredients. 

Anti-cavity (Fluoride).  These rinses use fluoride to protect enamel and prevent cavities.  A common brand is ACT, but others are using fluoride now too.  Be sure to buy the smaller bottle even though the larger one is a better deal… there is a limit to the amount of fluoride one bottle can contain, so the concentrations are different.  The smaller bottle contains 0.05% sodium fluoride, while the larger one contains 0.02% and is less effective.  However, in dry mouth formulations, the fluoride may be lower since it will be used more frequently.

Saliva substitutes.  Some rinses are used frequently to moisturize the mouth and help relieve symptoms caused by dry mouth.  They might also contain enzymes that act as saliva substitutes, or to stimulate saliva production.  Biotene is a popular brand.

Anti-Halitosis.  Some rinses may simply be used to improve the smell of your breath.  By masking the smell with aromatics, these don’t necessarily solve the underlying cause of the halitosis.  Halitosis can be caused by a number of problems, but most of the time poor oral hygiene is the culprit.

Prescription Strength rinses.  There are some mouth rinses that are only available by prescription or dispensed by dental professionals.  If we feel that you need something stronger than is available over the counter, we will provide it or prescribe it for you.  

ADA Seal of Acceptance (worth noting again).  When you see the ADA Seal on a product, you can be confident that it is good.  However, a product without the seal does NOT necessarily mean it is inferior.  In order to earn the seal, a brand must submit to additional rigorous evaluation above and beyond FDA requirements, and it must meet other quality standards.  They also must pay a submission fee and maintenance fee in order to get the endorsement.  That is all fine, but some products may not have the seal even if they are great products and worth using.

Conclusion

Dental caries and gum disease are a serious problem, and the problem is getting worse.  There are many reasons listed above to take this seriously and take the time to care for your oral health as much as your health in general.  Much time and thought was put into this article to provide information that will help.  If you do see anything that is inaccurate (according to good evidence), confusing, or if you have questions or anything to add, please let us know at oakdalefamilydentalcare@gmail.com.  

Disclaimer: The links provided in this article are for your convenience in finding more information on certain products.  We have no financial arrangement with these companies, and we receive no financial benefit from endorsing any products.  

Why would a dentist give away this information that hurts their business, and why should I trust it?  This is a question we get occasionally, and it is an interesting one.  While it may hurt our business to offer advice on preventive care, we got into this business because we want to help people.  We are interested in healthcare, and our goal is to improve the lives of our patients and to make a difference in the community.  The incidence of dental caries today is rising and this is a problem that is not getting better on its own.  For us, it is upsetting to see so many people losing teeth because of a preventable disease, especially if they simply can’t afford the treatment needed to save the tooth.  As dentists, we are licensed and required to act as a fiduciary for our patients, which means we need to act in the best interest of our patients as a trusted advisor.  We swore an oath in school to live up to these standards, but above all that, we really do care about the health of our patients.  If you feel like your dentist doesn’t live up to these standards, you should leave and find a dentist you trust. 

References

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