Oral How-giene

This may sound like a very broad and very obvious topic. Sadly over my relatively minimal tenure in the dental profession I have come across many abominations of the aforementioned topic.

The problem usually begins with a simple question: “so, how often a day do you brush your teeth”. At the beginning of my studies I believe my emphasis was on “a day” assuming that most people would abide by the twice a day brushing rule. Sadly these people were in the minority.

 I then reassessed my questioning technique and modified to “how often do you brush your teeth”. I was met frequently with, “errr I’d say around twice a week”.

Just to put this into some sort of context a have created a week-to-view calendar of this patient’s oral hygiene habits.

Again, just to emphasise the point this would involve, going to bed, waking up, going to bed, waking up, going to bed, waking up, going to bed and waking up WITHOUT CLEANING YOUR TEETH.

Of course there are many combinations of the above diary and I have just highlighted one, of course said patient may have a special gathering on a Wednesday so they may rummage behind the sofa and whip out their brushing implement (I avoid using the word toothbrush for reasons described later) for this exceptional event upping their weekly mouth cleaning total to 3.

I realise sadly I am a special breed of person who struggles to have a glass of water without feeling like my teeth are covered in fur, but surely this must feel AWFUL. What is often shocking is these people are in attendance of their dental appointment with a partner. Someone who presumably gets within a close vicinity of said mal-brusher. I will leave your mind to fill in the rest.

After realising that the majority of people neither brush twice daily, nor use a toothbrush I have modified my questioning to “so, what is your cleaning routine for your teeth” which usually gets me the response I am after.

I have also encountered a realm of instruments and methods used for cleaning teeth. From sticks (“Jesus used a stick so must be good enough for me”) to brushes which only could have been designed for horses.

As I have mentioned before, I am not sponsored by anyone or anything (I can’t imagine why) and so my advice comes not from a monetary fuelled avenue. Whilst I enjoy a gadget and thus use a Sonicare toothbrush, this was given to me free are charge during University when our young student minds were easily swayed by freebies. You can pick up toothbrushes for 9p. Yes that’s right, 9p. I just checked. Look. http://www.tesco.com/groceries/Product/Details/?id=256420940. They do pretty much the same job. Strangely enough saying this, I have only encountered one person who used cost as an excuse for not brushing.

A few of my personal favourite excuses, alongside those I have borrowed from other colleagues’ horrific reports are recorded below.

“I used to have great teeth but they wouldn’t let me take my electric toothbrush to jail”

“My previous dentist told me brushing damaged the gums so I don’t bother anymore”

“My gums bleed when I brush” This excuse isn't so comical and I will cover later on in another post.

“My brother flushed my toothbrush down the toilet” (which warrants the question how powerful is your toilet flush!?)

“My toothbrush broke”

“I get up very early and the sound of my electric toothbrush wakes up the kids”

Apparently the excuses don’t stop at the brushing implement itself.

“I just don’t like the taste of toothpaste”

"My dad took the toothbrush to work so I couldn't use it"

“I’m allergic to fluoride”

"No one told me I was supposed to clean my teeth"

“I don’t have time” – this is often said by a woman wearing make-up so thick that could only be removed using a wallpaper stripper

There are some people who get away with not adequately cleaning their teeth. Sadly the majority of poor mouth-cleaners are those who also believe losing a filling and leaving it for 5 years won’t cause any detrimental effect. Please refer to previous blog post for my feelings on this. These people of less-than-socially-acceptable plaque carriage are also the ones who enjoy the following rant:

“I don’t understand why my teeth are so rubbish. They just aren’t formed right I don’t think. When I was pregnant they just crumbled/I fell off a bike when I was 37 and they’ve never been right since/they just fell apart. My sister/brother/dog has lovely teeth and I just don’t understand why I’m so unlucky”.

Post-rant actual advice

1. Brush twice a day. Yes. Brush. With a toothbrush. If you use the right technique which any dentist or hygienist will be able to show you it doesn’t really matter whether you use a manual or electric toothbrush

• I personally feel electric toothbrushes are easier to use. You can’t apply too much pressure and for people with manual dexterity problems or who suffer from laziness it does the work for you. At this point I could insert various studies and "clinical trials" showing results of manual vs electric toothbrush contests. Sadly 99% of these are sponsored, conducted, altered and generally biased by the dental trade. I.e. Oral B pay for studies to be done about Oral B. Same for Sonicare etc etc. Therefore it is not wise to read to much into this. As a general guide, it is what feels comfortable to you. Some people despise sonic toothbrushes, I personally very much enjoy mine.
• If however you are going to venture into the world of dental gagettery, then I would recommend the following. Invest. This does not mean spending a fortune. In fact Boots and the like have offers on the Oral B brushes all the time and do an extra special offer around Christmas time (generally knocking off 50p more than in all previous months). In saying this, I mean stay away from the toothbrushes that are basically a manual brush with batteries in. They will do nothing more than your normal brush but cost a lot, and the toothbrush heads also cost a lot more. 
• With the example of Oral B brushes, the Oral B 1000 does pretty much what the Oral B 5000 (and I've just noticed they have added the word "Triumph" to their latest brush name - fancy). The difference is a clock with a smiley face - something I'm sure a little home arts and crafts could conjure up, and a few "free" brush heads. Considering the difference in price is about 70 pounds, these free brush heads seem to have a significant mark up to the ones you can buy separately.

2. Use a toothpaste with fluoride. At least 1450ppm. It will say this on the side of the box - usually as something fluoride (the something usually being sodium or potassium). Even the really inexpensive toothpastes pretty much all have a good level of fluoride in. (N.B this is the recommended level for adults, children are a different matter. We can also prescribe much higher levels of fluoride if we think you are at a higher risk of getting tooth deca

3. DO NOT RINSE AFTER BRUSHING. The reason we recommend a fluoride toothpaste is because fluoride helps stop bacteria in its tracks. It also hardens the tooth structure. If you wash this off, you pretty much counteract using a toothpaste and so might as well just use a brush and water. Or a stick in fact

4. Mouth wash. This is a tricky one. I like to view mouthwash as a personal preference type thing. Unless we recommend mouthwash as an aid in fighting gum disease (in which case chlorhexidine is the only thing with any proven efficacy), for dry mouth (something I will happily write about if anyone wants advice) or for orthodontic patients (who require more meticulous oral hygiene because they have blobs of metal and Hanibal Lecter type head gear) there is no particular reason for using mouthwash other than to freshen breath.

• We would always recommend an alcohol free mouthwash purely because the less alcohol you can expose your delicate mouth to the better (due to its cancer inducing properties – I’ve put this in brackets so it hopefully makes the “cancer” word less terrifying)
•  If you’re going to use it, wait at least 30-60 mins after brushing for the same reason we say don’t rinse. Ideal would be to rinse at a completely different time of the day so that your teeth are getting another hit of fluoride. Its a bit like applying moisturiser straight after you've already put some on. Its not going to do any harm and it will probably make your skin feel nice, but not as nice as if you wait a few hours and reapply. 
• If you have been recommended to use chlorhexidine this is slightly tricky. Certain ingredients in toothpaste – namely the ones that make it foam – in-activate the stuff in chlorhexidine that makes it work. Sadly it also doesn’t work if there is too much of a plaque layer on your teeth. Therefore pinpointing a time to rinse when it will be effective is tricky but I would say if you are within the 30-60 minute window I mentioned before you should be safe
• For the aforementioned orthodontic (brace wearing) people, or for those who are deemed "high risk" for dental decay - which your dentist can discuss with you - there are a plethora of fluoride mouthrinses. Whilst your dentist can prescribe some which will have a higher concentration of fluoride, you can also pick them up over the counter.

5. Tooth brushes DO NOT clean in between teeth. Gum disease is caused by a build-up of bacteria in between the teeth and below the gum line. The bristles of your brush (or splinters of your stick if you are so inclined) are far too big to get to this area. Therefore to effectively clean your teeth you need to be flossing or using interdental brushes like TePe’s. (I will be writing a separate post about gum disease to explain this in more detail but you get the jist)

I hope this makes sense and that you have picked up some pointers amidst my general annoyance at the general population for their lack of oral cleanliness. In all honesty I should be grateful as it keeps me employed however it would be nice not to feel the need to wear 3 masks and hold my breath to protect me from the halitosis I encounter on a daily basis from whichever dental chair I am leaning over. This is of course not an exhaustive list. There are many other things you can do to get optimum oral hygiene. There is also a lot more you can do to reduce your chances of getting tooth decay and I can of course cover this at a later date. This post is more of a baseline for improving your hygiene rather than the be all and end all of dental decay prevention!

As always, please feel free to ask any questions about toothpaste, toothbrushes, brushing techniques etc etc.

Dental Prevention Toolkit. 

http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_102982.pdf 

This is a very long document aimed at toothworkers however if you have any confusion over what brand of toothpaste/mouthwash contains what ingredients then it is very helpful. 

Below I have provided a bit of a modified contents page of things that might be useful. 

Page number	What you’ll find there
20	Names of toothpaste brands with the amount of fluoride they contain
25	Diet related stuff to help reduce your risk of getting rotten teeth
29	Lists of sugar free medications – they usually say sugar free on the box and most good pharmacists will know which medicines don’t have nasty sugar in, but it is a helpful guide if you’re not sure
There is generally a lot of helpful information in this whole document but I’m hoping there will be very few of you that will rifle through all the jargon as it sort of invalidates the reasoning for me writing this blog so, for my sake, please continue to visit smiles—better!