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Oral Hygiene: Here We Go
Michael Rethman, DDS, MS
Excellent oral hygiene can prevent or limit the harms associated with the most common oral diseases, namely caries and the periodontal diseases. Furthermore, optimal oral hygiene is often critical to the success of clinical procedures aimed at halting or reversing the damages caused by oral diseases.
Oral hygiene includes professional (eg, prophylaxes, fluoride treatments, etc.) and self-care endeavors. The term self-care consists of oral hygiene endeavors performed by individuals on themselves or as caregivers for others, eg, invalids. All serve patient-centered goals, namely oral comfort, adequate function, and esthetics—including pleasant breath odor.
Oral Hygiene: Past and Present
Early in human history, oral self-care targeted impacted food and problematic teeth. Although the ancients knew nothing about the biology of oral diseases, rudimentary self-care tools included chewing sticks, twigs, feathers, and animal bones. Over the past century, efforts to optimize oral hygiene as a means to enhance prevention or to limit disease progression have increased.1
In the 1930s “See your dentist twice a year” and “Brush your teeth twice a day” became popular aphorisms. Nearly a century later, no quality evidence exists to support such claims. However, it now seems clear that some people need frequent professional care and intensive self-care, while others need less.2
Increased societal interest in dental health was an indirect effect of World War II, when many military draftees were rejected because of extremely poor oral health. This led to the creation of the National Institute of Dental Research in 1948. Research later confirmed that the “dental film” (aka, dental plaque and more recently termed dental biofilm) played an important role in the etiologies of dental caries and periodontal diseases. Once dental plaque was identified as causal for caries and the periodontal diseases, the biological rationale for optimal oral hygiene became clear.3
Pre- and post-WWII advertising by dentifrice companies encouraged patients to improve self-care, and also encouraged professionals to increase professional oral hygiene services. Eventually, it became clear that the amount of dental plaque did not always correlate with the likelihood or severity of dental diseases. Rather, it became evident that the bacterial makeup and the anatomic location of the plaque were more critical determinants of oral health or disease.4 It also became clear that undisturbed dental plaque changes in character over time, typically becoming more harmful.5
Dental calculus (ie, tartar) has long been linked to poor esthetics and the periodontal diseases. Calculus removal was often a key focus of early dental hygienists and dentists. Later came evidence that calculus per se was not causal, but rather the bacteria that populated it could cause periodontitis. This led to confusion regarding the importance of preventing or removing calculus. It now appears that the frequent removal of all macroscopically visible calculus, whether supragingival or subgingival, is part of any regimen aimed at ensuring optimal oral health.6
By the 1930s, epidemiological studies reported lower caries rates in some localities. Higher concentrations of fluoride ions dissolved in municipal water supplies were implicated. Although technically not self-care, beginning in 1945, low concentrations of fluoride were added to more municipal water supplies. Unfortunately, the enamel component of teeth tends to become undesirably mottled if dietary fluoride is too high.7 Some experienced mottling, even in cities where fluoride concentration was held to only 1 part per million. Therefore, the recommended concentration of fluoride in water supplies is now 0.7 parts per million.8
Dentifrices (toothpastes) began replacing dental powders in the 1920s and 1930s. Diluted sodium lauryl sulfate detergent became a popular component of dentifrices because a sudsy mix contributed to patients’ post-brushing perceptions of cleanliness.
In recent years, the addition of specific ingredients to dentifrices and rinses has been found to better mitigate existing caries and gum diseases, especially when those maladies are addressed in their nascent stages. In the 1960s, fluoride was added to dentifrices (later to mouthrinses) to inhibit caries. Agents (eg, pyrophosphate) were added to inhibit the formation of dental calculus. The antiseptic triclosan was compounded in some dentifrices; it promptly kills bacteria and is substantive, meaning it remains active for hours after its application. All of these additives have been shown to be at least somewhat beneficial. Some dentifrices include more than one active ingredient and show efficacy against both caries and gingivitis.
Bioactive agents have also been introduced into appliqués and mouthrinses. Among these ingredients are fluorides, essential oils, quaternary ammonium compounds (eg, cetylpyridinium chloride), and chlorhexidine. Many offer better means to assist certain patients, especially caries-prone children and the elderly.9, 10
Rinses are popular; a rinse containing “essential oils” has been advertised as a germicide for a century. It is somewhat effective against the mildest of the periodontal diseases, namely gingivitis. Chlorhexidine rinses are substantive and highly potent antimicrobials, but stain teeth and may affect taste sensation. Such shortcomings make chlorhexidine rinses appropriate for brief intervals, eg, after certain types of periodontal therapy.
Powered toothbrushes were first introduced in the 1960s. When properly used, ample evidence exists to support their superiority. However, manual toothbrushes can achieve similar results but with more effort.
Tongue cleaning has gained popularity in recent years based on the observation that the tongue’s rough dorsum harbors bacteria that can facilitate the microbial re-population of newly cleaned teeth. Data also suggest effectiveness against halitosis.11
Oral Hygiene: The Future
Some of what follows may seem fanciful. The key to widespread implementation is whether each makes sense from a cost (risk)-versus-benefit standpoint.
Individualized diagnostics, including genetic tests, will better identify those who need more intensive oral hygiene interventions. Ideally, such information would be available and acted on early enough in life to prevent or limit caries and the periodontal diseases. Delta Dental of Michigan recently introduced a program in which patients at lower risk of oral disease are benefited for fewer periodic prophylaxes and examinations. Those who test at higher risk are benefited for additional professional interventions. Although notionally sound, this effort is based on averages and confounded by an administrative bias against tobacco users. Thus, the risk is that some who are examined less often may incur otherwise-avoided oral health problems.
As the average age of Americans increases, oral hygiene emphasis will be multi-modally enhanced for invalids and those for whom better oral health may translate into decreased risk or morbidities for systemic diseases. Also, technologies that make interdental cleaning easier will become mainstream.
There will be improved understanding (both professional and patient) of preventive care aimed at the completely or partially edentulous, with or without osseointegrated implants. Those with complete dentures infrequently visit dental professionals, thereby putting themselves at a greater risk for less common oral diseases, such as advanced squamous cell carcinoma. Similarly, it is unclear whether or how oral health may be linked to the growing incidence of oropharyngeal cancer caused by sexually transmitted human papilloma virus.
After 35 years of osseointegrated dental implants, dentistry is now more widely addressing implant maintenance issues. It should come as no surprise that the same patient-specific causes of natural tooth loss may also put implants at risk. Indeed, it has become increasingly clear that oral hygiene tactics designed for implants are critical to their maintenance.
The causal links between oral health and systemic health will become better-known by the public, thereby driving increased attention to optimal oral hygiene.
Improved availability of Internet-based services will improve the average information technology capabilities of tomorrow’s patients. Tactics to guide users to reputable sources of information will become better and more successful.
Optimal self-care regimens will be refined. For example, it may make no difference to the oral health of some patients if they perform self-care once, twice, or more times each day. It may also matter little if brushing times (2 minutes is today’s general recommendation) are cut or increased in duration. Also, efforts to make self-care easier will gain in popularity.
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8. US Department of Health and Human Services. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for Prevention of Dental Caries. Federal Register. April 30, 2015. https://federalregister.gov/a/2015-10201. Accessed September 4, 2015.
9. Weyant RJ, Tracy SL, Anselmo TT, et al. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc. 2013;144(11):1279-1291.
10. Rethman MP, Beltrán-Aguilar ED, Billings RJ, et al. Nonfluoride caries-preventive agents: executive summary of evidence-based clinical recommendations. J Am Dent Assoc. 2011;142(9):1065-1071.
11. Slot DE, De Geest S, van der Weijden FA, Quirynen M. Treatment of oral malodour. Medium-term efficacy of mechanical and/or chemical agents: a systematic review. J Clin Periodontol. 2015;42(Suppl 16):S303-S316.