Oral Hygiene FAQ.

Or: Cleanliness is next to Godliness

Dull, uninspired, boring--yes, but a properly implemented home oral hygiene program will do more to promote and maintain the oral health of our readership than anything else. ANYTHING! Now listen up!

Q: What would you say is the best toothpaste that doesn't injure the teeth or gums and whitens?

A: Most dentists agree that toothpaste does little more than improve "mouth feel" and provide flavor while brushing the teeth. Far more important is the way the teeth are brushed, and the type and condition of the toothbrush.

Some toothpastes make claims of brightening the teeth, but they do so only to the extent that they help remove adherent stain. Oxygen-based bleaching agents are not chemically stable enough to be included in toothpastes in sufficient concentration to bleach to any degree.

Some toothpastes are specifically made to remove heavy stain, and are frequently referred to as "smoker's toothpaste" or "tooth polish". This is a red flag that the toothpaste may be excessively abrasive, and may cause progressive wearing away of the tooth and supporting tissues. These toothpastes are to be avoided.

Some toothpastes have therapeutic agents added, such as fluoride (sodium fluoride, stannous fluoride, sodium monofluorophosphate), or desensitizing agents (potassium nitrate, strontium chloride), and may be of additional use for those prone to either decay or dental hypersensitivity. These products may be endorsed in the U.S. by the Council on Dental Therapeutics of the American Dental Association. There may be other sanctioning bodies in other countries, but I am not knowledgeable about them. Likewise, different toothpastes may only be commercially available in certain locations. It is more practical simply to consult your local dentist for recommendations. In most cases, though, it's more effort than the issue merits; toothpaste, for the most part, is simply toothpaste.

Q: I am a second year dental student at the University of Glasgow in the UK and have been asked to research the basis of action of mouthwashes. Could anyone give me any information to help me or tell me where I might look. Thanks.

A: Mouthwashes may be broadly divided into several therapeutic groups:

  • antiseptic rinses for oral malodor or periodontal disease
  • fluoride rinses for decay prevention
  • anesthetic or analgesic mouthrinses

Most antiseptic rinses are of limited effectiveness, since their antimicrobial effect is of very short duration. The exception to this is chlorhexidine gluconate, which has a persistent effect.

Fluoride rinses are considered an adjunct to other decay prevention measures.

Analgesic mouthrinses are appropriate for palliation of symptoms of oral inflammatory conditions.

A useful online research tool is the Pub Med interface for the U.S. National Library of Medicine. You can do research queries on any health related topic, which will yield reports of published studies on the topic; many abstracts from journal articles are available. They are located at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

Q: Since marrying and moving to my wife's home state 3 years ago, I've been plagued with constant canker sores. My most recent has been on the floor of my mouth. When I examined the sore, I was shocked to find that my gums had changed from a healthy pink to a dark red! Since both of my gums exhibit this new color, I doubt that it is related to the canker sores. I brush at least once daily, though I rarely floss. Is this darkening of the gums an early signal of gum disease, or could it be linked to the sores?

P.S. - Another quick question. A professor at college taught our class that because bacteria in plaque need 24 hours to begin to decay teeth, brushing teeth once a day was sufficient. Any thoughts on this? Thanks for the help!

A: Darkening of the gums is a sign of periodontal disease, though not necessarily an early one. It is most probably unrelated to the canker sores.

Not flossing can be considered a major omission in your oral hygiene regimen. At least you know where you need to apply more effort! If the discoloration doesn't go away, I would bring up the issue to your dentist at your next appointment.

The process of decay is not an all or none mechanism; there is a chemical equilibrium between the dental enamel and saliva. The decalcification and recalcification of enamel goes on all the time, and any shift toward one or the other can produce a net change in mineral density. There is no one moment when decay can be said to start. Why take chances? Besides, there are other benefits to oral hygiene besides decay prevention. Isn't a clean mouth a worthwhile objective in itself?

Q: Is it better to floss before you brush your teeth or after you brush your teeth? My dental hygienist says either way is OK. Is she correct or is one way better than the other?

A: I think most of my colleagues would agree that we're happy when our patients floss and brush; we can't afford to be too fussy about the sequence.

There is a rationale for recommending that flossing be done first if you are using a fluoride toothpaste applied to a toothbrush. Fluoride can only provide a benefit to tooth enamel if it comes into direct contact with enamel. While you brush with the fluoride toothpaste, the bristles remove the plaque covering the surfaces accessible to the toothbrush, which can then benefit from the fluoride. The same can't be said for the surfaces between the teeth, which are covered by a thin film of dental plaque which serves as a barrier to the fluoride. However, if you have flossed before application of fluoride toothpaste, these surfaces between the teeth can benefit from the fluoride as well.

While we're on the subject of flossing, we should mention how remiss many dentists are in their responsibilities as regards the coaching of proper oral hygiene. In the service of rectifying this transgression, we have made available a short video clip demonstrating the technique of proper flossing. To view the video, please choose one of the following links:

View with Apple QuickTime  --1.92 MB--
(download latest version of QuickTime here)
View with Microsoft Windows Media Player  --1.65 MB--
View with Macromedia Flash Player  --334 KB--
(download latest version of Flash Player here)

Q: Are there any improvements that can be made in the use of triclosan in Colgate Total?

A: The use of triclosan in toothpaste (and other common household products) is a somewhat controversial issue. Studies have demonstrated that bacteria can develop resistance to the antimicrobial effects of triclosan, as they do in the case of antibiotics. This not only limits the long-term effectiveness of triclosan, but has implications for the development of pathogen resistance to similar chemical antimicrobials in treatment of more serious conditions.

Q: Does the Braun 3-D plaque remover really remove plaque? Does this do a better job of cleaning your teeth than a regular toothbrush?

A: Electric toothbrushes can be useful for those with physical disability or poor manual dexterity. I resist recommending these devices otherwise, since they do not produce an improvement in oral hygiene commensurate with their expense and complexity. This is always important to consider in a routine that has always demonstrated poor patient compliance.

In short: keep it simple! There's nothing these modern-day wonders can do that conventional brushing and flossing can't at a fraction of the cost and complexity.

Q: I am in a quandary: tartar builds up very quickly (in a matter of a week or so despite careful brushing and flossing twice or three times a day and the use of a water pik) at the bottom of my lower front teeth on the tongue side. Obviously I cannot go to the dentist for a cleaning every week or so. Therefore my choice is between leaving it until my regular cleanings at the dentist every 6 months or removing it myself from time to time with the type of metal toothpick sold in drugstores (it comes out easily in one piece and I am careful not to do myself any harm, but I still have to scrape a bit). What I am worried about is that this very minimal scraping could cause my gums to recede further (they are already receded on those teeth in a V shape); on the other hand, if I wait for my regular cleanings at the dentist (even if I increase the frequency of my visits to every 4 months) the tartar could cause caries to begin. There seems to be no good solution; so the question is which option is preferable and why?

While on this subject I have another question, I have read that a dry toothbrush is more effective in removing plaque probably because a dry brush is less soft than a wet one; but isn't this advantage offset by the risk of receding gums when the brush is less soft?

A: We discourage patients' use of sharp metal dental instruments on their own teeth; there is the potential for injury. Interestingly, tartar does NOT cause caries, although it may seem intuitively that it would. The tartar may, however, contribute to periodontal (gum) disease, so it should be removed periodically.

Every dentist has encountered the problem you describe, and there is no one good solution. Patients under the care of a periodontist (gum specialist) are now typically given a recall interval of every 3 months. This does,of course, present the question of whether the disease or the cure is worse for some people.

In our experience, patients who form a lot of tartar will form it regardless of the effort they claim to employ in its prevention. We do find though, that there is almost always room for improvement in a patient's oral hygiene technique.

In the matter of a wet versus dry brush, it's probably not important. The brush will become wet with saliva and soften soon after being placed in the mouth. What correlates more closely with tooth abrasion and gum recession is the hardness of the brush bristles, the abrasiveness of the toothpaste, and the technique used in tooth brushing. Ask your dentist or dental hygienist to instruct you in the proper approach. It's the most important thing you can do yourself to improve your oral health.


A: Gagging is a normal protective reflex. It serves the purpose of ejecting a foreign object that threatens to fall into the respiratory tract, which would be a grave occurrence. People vary in the irritability of their gag reflex. This is a problem that we as dentists must deal with on a daily basis when we take x-rays, take impressions, etc.

It is impractical to abolish the gag reflex. Regardless of just how active a person's gagging may be, they usually can only brush a small portion of their tongue before inducing gagging. The tongue extends quite a bit behind the part which is readily visible, and nearly all will gag if its posterior regions are stimulated.

Your attention to oral hygiene is commendable, and brushing of the tongue will reduce the total bacterial count in the mouth. The consensue among dentists is, however, that the bulk of your hygienic efforts should be reserved for the teeth themselves. This will reduce your susceptibility to both decay and periodontal disease. Brush your tongue if you wish, but don't worry if you can't brush the whole length of it. None of us can!

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