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Profile in Oral Heath By Trisha E. O’Hehir, RDH, BS, Editorial Director, Hygienetown Magazine

More by this author (282)
Nearly everyone brushes their teeth, but very few people clean between their teeth. The question with brushing is not “if” people brush, but “how many times” they brush each day. It’s just the opposite with cleaning between the teeth. Not “how many times” each day, but “if” they do it at all. Is this the best way to prevent dental disease?
Toothbrushing is the most common form of oral hygiene in the world today, with 90 percent of all children and adults reporting daily toothbrushing. A Google.com search of the term “toothbrush” brings up more than nine million hits compared to just under two million for “dental floss.” Despite this enthusiasm for the toothbrush, dental disease is still a significant problem. It is estimated that 52 million hours of school are lost each year due to dental visits and oral health problems, according to the National Institute of Dental and Craniofacial Research/Dental, Oral, and Craniofacial Data Resource Center’s Web site(http://drc.hhs.gov/report17_1.htm). Adults lost 164 million hours of work in 1989 due to dental visits or oral health problems. If so many people are brushing daily, but they’re still missing so much school and work due to dental problems, it is clear that daily toothbrushing alone is not preventing dental disease.

Plaque accumulation is greater between molars and premolars than anterior teeth. The wider the interdental space, the more protected the bacterial biofilm will be. Molars and premolars provide the perfect interdental space for bacterial biofilm formation and maturation, without disruption by chewing or toothbrushing.

Reduced salivary flow, high intake of fermentable carbohydrates and gingival inflammation will all increase the rate of bacterial biofilm formation. Mature three-day-old bacterial biofilm shows a critical drop in pH following exposure to sucrose, while newer biofilm does not. Blood byproducts associated with gingival inflammation provide a substantial nutrient source for subgingival bacterial biofilm. As the volume of gingival exudate from inflammation increases, the rate of biofilm formation also increases.

According to the research, dental disease on smooth surfaces begins between the teeth. Mutan streptococci counts are higher on posterior interproximal surfaces than anterior surfaces. Posterior interproximal surfaces have the highest rates for decayed, missing or filled surfaces. Disease starts between the teeth and the bacteria in these areas are protected from the reach of the toothbrush.

Despite the fact that dental disease starts between the teeth, toothbrushing has traditionally received more attention than cleaning between the teeth. Toothbrushing is taught before interdental cleaning, sending a message to patients that brushing surfaces are more important to clean than surfaces between the teeth. Rubber cup polishing, which many patients believe to be the “cleaning,” focuses on brushing surfaces and not on interdental surfaces, reinforcing the message to patients that brushing surfaces are more important to clean than surfaces between the teeth.

Because of these traditions, changing the oral hygiene message is difficult and can test belief systems. While substituting in a dental office, I told an 18-year-old, just out of orthodontic bands, that he didn’t need to brush his teeth any more, but he absolutely had to clean between his teeth every day. I presented the information this way to get the attention of the young man whose eyes were glazed over since he sat in the dental chair. Telling him he didn’t need to brush his teeth anymore really got his attention. He was now listening and whatever I said next, he would hear. This approach also got the dentist’s attention. He was in the next operatory and heard me tell this patient he didn’t need to brush anymore. He left his patient and rushed into my room to find out why I was telling his patient something so crazy. I explained that this patient had interproximal demineralization between all his molars and premolars and daily interdental cleaning was essential to stop this disease process. Toothbrushing would not help. I also needed to capture this young man’s attention since according to the chart notes, routine oral hygiene instructions including flossing hadn’t worked in the past. My extreme approach did get his attention and he did engage in the discussion about interdental cleaning, asking questions and commenting that he never realized before that cleaning between his teeth was important. The dentist agreed, grudgingly, to go along with the recommendation that daily interdental cleaning was essential for this patient and brushing was secondary, based on his risk factors. It was very difficult for the dentist to accept this change from tradition. Yes, he wanted the patient to clean between his teeth, but telling a patient to forgo toothbrushing to achieve that goal went completely against his traditional education.

I’m not advocating abolishing the toothbrush completely, but if telling patients they “don’t need to brush,” but that they “absolutely have to clean between their teeth” gets their attention, go ahead and do it. Chances are they will still brush their teeth, but the message to start cleaning in between will be taken seriously. Toothbrushing is such an ingrained habit; it won’t be given up easily.

Ideally we want people to clean all surfaces of their teeth, but based on scientific evidence, interproximal surfaces of posterior teeth are at greater risk for both caries and periodontal disease than surfaces reached by the tongue, chewing and the toothbrush. If we add dry mouth, high sugar intake and gingivitis to this equation the risk increases considerably. “Start cleaning in between” should be the message to prevent caries and periodontal disease.

If you are not yet willing to tell patients to forgo toothbrushing for inderdental cleaning, then consider where in the oral hygiene process you ask patients to clean between their teeth. Adding interdental cleaning works best if it’s added before toothbrushing, not after as has been the tradition. In the past we’ve asked people to add flossing after toothbrushing to their oral hygiene routine. They brush their teeth and simply forget to floss as instructed. Their habit is to brush and go on to the next thing, not flossing. When flossing or another interdental cleaning tool is used first, followed by toothbrushing, remembering is easier.
Interproximal Cleaning Tools
Dental Floss
AIT Dental, Inc. – www.aitdental.com
Alpine Oral Care – www.alpineoralcare.com
Colgate-Palmolive Co. – www.colgate.com
Discus Dental, Inc. – www.discusdental.com
Johnson & Johnson Oral Health Products – www.jnj.com
OMNI Preventive Care – www.omniipharma.com
Oral B – www.oralb.com
Oral Health Products (POH) – www.oralhealthproducts.com
Plak Smacker – www.plaksmacker.com
Proctor & Gamble – www.glidefloss.com
Prophy Perfect, Inc. – www.prophyperfect.com
Sunstar Butler – www.jbutler.com
TePe Oral Health Care – www.tepeusa.com
Tom’s of Maine – www.tomsofmaine.com
 		Interdental Brushes
AIT Dental, Inc. – www.aitdental.com – Proxi-Tip
Allpro, Inc. – www.allprodental.com – Pocket Dental Care
SquirtBrush CDMS – www.squirtbrush.com – SquirtBrush
Centrix, Inc. – www.centrixdental.com – Benda Brush
FlossTech – www.flosstechproducts.com – Micro Interdental Brushes
Oral B – www.oralb.com – Inerdental Brush
PHB, Inc. – www.phbinc.com – Interdental Brush
Plak Smacker – www.plaksmacker.com – Double Head Brush
Prophy Perfect, Inc. – www.prophyperfect.com – Interproximal Brushes
Sulca Brush – www.sulcabrush.com – Sulca Brush
Sunstar Butler – www.jbutler.com – Proxabrush
TePe Oral Health Care – www.tepeusa.com – Interdental Brushes
Emphasizing the importance of cleaning between the teeth before brushing reinforces the message that disease begins between the teeth.

Dental floss is another tradition that is hard to change, despite research showing low compliance and no better plaque removal than other tools. It’s not just a matter of using floss or not, effectiveness is essential. Effectiveness of plaque removal with dental floss is evident when an audible squeak is heard. In the United States and Canada, dental floss is recommended more than other interdental cleaning options. In Europe, wooden interdental sticks are used more than floss. There are many scientifically proven alternatives to dental floss for cleaning in between the teeth including sticks, picks, brushes and oral irrigation.

Triangular-shaped interdental sticks are designed to fill the triangular shape of the space between the teeth. The stick presses the interdental papilla down, reaching a couple of millimeters below the tissue. The friction of the sides of the stick rubbing against the proximal tooth surfaces removes the sticky bacterial biofilm. Round tooth picks work similarly, but do not fit the interproximal space as well. The tip of the round picks is used to remove the bacterial biofilm from both supra and subgingival surfaces.

Interdental brushes of varying sizes and shapes are available to fit a variety of interdental spaces. Interdental brushes are particularly effective for plaque biofilm removal in interdental flutings and root surface concavities. End tuft brushes are also effective in reaching in between the teeth.

Oral irrigation flushes the toxins out of the bacterial biofilm and may reduce the thickness of the plaque. Interproximal irrigation reduces the toxins associated with dental disease and promotes tissue healing in just two weeks of use. Safety studies have shown oral irrigation both safe and effective. Research studies have been done primarily with Water Pik devices that use pulsating fluid flow. No clinical research has been published comparing pulsating and direct flow oral irrigators. Clinical observations show effectiveness with both types of oral irrigators. Adding a magnetic component to an oral irrigator resulted in less supragingival calculus formation than irrigation without the magnetic aspect.

All of these tools are safe when used properly. Overuse or misuse can result in trauma to either tooth or tissue as has been demonstrated with toothbrush and toothpaste causing abrasion, and dental floss cutting into the papillary tissue or toothpicks wearing away tooth structure with extreme over use. When properly used, all of these interdental tools can clean between the teeth and prevent dental disease. Select specific interdental tools based on the patient’s age, risk for caries and/or periodontal disease, dental disease experience, manual dexterity, and motivation. There isn’t one interdental tool for everyone, just as there isn’t one toothbrush for everyone. Select from a variety of options to achieve interdental health for each individual person.

If you’re open to breaking from tradition, change your message to patients from “toothbrushing first” to “start cleaning in between.” Focusing on the interdental areas is based on scientific evidence. Dental disease begins between the molars and premolars. That’s where more plaque accumulates and is missed by brushing and chewing. Tell your patients to “start cleaning in between” to achieve better oral health.
Interdental Sticks/Piks
AIT Dental, Inc. – www.aitdental.com – Proxi-Stik
Alpine – www.alpineoralcare.com – Pocket Dental Care
Denta Distributing, Inc. – www.denta.com – Denta-PX
Johnson & Johnson Oral Health Products – www.jnj.com – Stim-U-Dents
Marquis Dental Mfg. Co. – www.perio-aid.net – Perio-Aid
Prophy Perfect – www.prophyperfect.com – Micro Sticks
Pro-Dentec – www.prodentec.com – Rota-Point
Sunstar Butler – www.jbutler.com – GUM Go-Betweens
The Doctor’s – www.brushpicks.com – Brush Piks
Ultradent Products, Inc. – www.ultradent.com – Opalpix
Oral Irrigators
Conair – www.conair.com – Interplak
H2Oral Irrigator – www.h2oralirrigator.com – H2Oral Irrigator
Oral Breeze – www.showerpik.com – ShowerPik
Oratec Corp. – www.oratec.com – Via-jet
Oxyfresh – www.oxyfresh.com – OxyCare 3000
Panasonic – www.panasonic.com – Oral Irrigators
ShowerFloss, Inc. – www.showerfloss.com – ShowerFloss
TheraBreath – www.therabreath.com – HydroFloss
Water Pik, Inc. – www.waterpik.com – Dental Water Jets
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