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  • Dr. David Alfaro

How often do you scrub the tub?

We have been having an awesome summer in Vancouver, and along with the warm weather has come plenty of outdoor dining. Somehow, as soon as people find out that I am a dentist, the topic of toothbrushing seems to come up, even at a bbq.

A recurring theme in these conversations has been the age old battle of Sonicare and it's fancy bubbles, versus the spinning Oral-B electric toothbrush. Everyone I have spoken to has been on team Sonicare because they love the foaming action. I am an Oral-B guy, but I admit, I haven't given the Sonicare a fare try.

Being the nerd I am....I decided to look at the research to see if one brush was better than the other. Once I started writing, however, I realized that before we talk about toothbrushing, we have to talk about gum disease, and WHY we brush our teeth.

Let us talk gum health.

What is a "pocket"?

I am sure that all of you have had your dentist (or the hygienist in most cases) poke your gums a million times whilst shouting out numbers, "2, 3, 2, 3.....9.....". What in the world are they doing?

A tooth has two parts, the crown, which is the visible part you chew with, and the roots, which you don't usually see because they are embedded in the jawbone and covered by the gums (gingiva). The gums also cover a bit of the crown, but they are not firmly attached it, thus leaving a little space between the gums and the tooth called the "sulcus", aka, the "pocket".

In a normal, healthy situation, the pocket is 2 or 3 mm deep and is easy to brush and floss.

What are "plaque" and "calculus"?

You know that slime that you have to scrub off of your tub after a while? Well, plaque and calculus are the same thing. They are a BIOFILM of living bacteria that make themselves a comfy environment to live in. At first this biofilm is loosly attached to the tooth and is easily removed by brushing and flossing. This is "plaque".

Over time, however, this biofilm picks up minerals from the saliva and becomes rock hard and very well adhered to the teeth and roots. At this point it is now "calculus". This stuff cannot be brushed away and must be removed professionally.

What is gum disease?

Plaque and calculus are pro-inflammatory. The bacteria within the biofilm secrete toxins and enzymes that break down the cells and connective tissue of the gums, and attract immune cells to the area. It is not healthy to have plaque around. It is actually pretty gross.

In the earlier stages of gum disease, the gums (gingiva) get inflamed, sore, and bleed easily during brushing, flossing and chewing. When the inflammation is limited to the gums, it is called GINGIVITIS.

Everyone has gingivitis because nobody brushes or flossess well enough.

If the plaque and calculus stick around long enough, the inflammation begins to attack the jawbone which surrounds the roots. The enzymes and toxins break down the bone, weakening the support for the tooth. The combination of the shrinking of the jawbone, and the inflammation of the gums, creates a deepening of the "pocket" of gums around the tooth. As the pocket gets deeper, it gets harder to brush and floss. Furthermore, the bacteria that get trapped down in the pocket are deprived of oxygen, thus selecting for nasty, anaerobic colonies that are really good at causing bone destruction, and smell horrible.

Once bone destruction begins, it is no longer called gingivitis, but PERIODONTITIS.

In periodontitis, the pockets are too deep to be properly cleaned by brushing and flossing alone, so a professional "deep cleaning" (root planing) is required to scrape off all of the nasty gunk that is stuck to the root surface way under the gums. Periodontitis causes bad breath, painful gums, loose teeth, gum infections, and can even lead to life threatening swelling if the infection goes the wrong direction. Eventually, gum disease can affect a tooth so severely that there is no treatment that can save it, and the tooth must be removed.

I have been removing a lot of teeth lately.

What treatments are there for gum disease?

The first line of treatment for gum disease is getting rid of the biofilm (professional dental cleaning) and then TRYING to implement behavioural changes that reduce the accumulation of biolfilm long term. It is harder to change someone's habits than to clean their teeth.

The goal of this approach is to reduce the inflammation. In some cases, a good professional dental cleaning is enough to reduce the "deep pockets", thus re-creating a healthy anatomy that is easy for the patient to take care of at home. If the patient brushes and flosses properly, the gum disease has a chance of being controlled.

In some situations, the "deep pockets" remain, even if the patient is maintaining good oral health. When this happens, the goal becomes the surgical elimination of the deep pocket. There are various approaches to the surgical management of periodontitis.

Who gets gum disease?

In Canada, gum disease is very prevalent. 20% of adults have moderate to severe gum disease, and this number is actually increasing. Part of the reason for this is that people are no longer losing all of their teeth. 50 years ago it was very common for people aged 65 and up to have no teeth. Now, in Canada at least, the rate of complete edentulism has gone down substantially. As people hold on to their teeth longer, periodontal disease rates go up.

The tough part about periodontitis is that different people have different succeptibilities to it. There is a small subset of the population that are just "prone" to gum disease. I feel really bad for these folks because if they have the tiniest lapse in their home or professional dental care, the disease returns and progresses quickly.

But realistically......most people get gum disease because they have bad hygiene practices. People just do not floss. Some do not even brush.

It is my job to help reduce oral diseases. I give people floss, toothbrushes and toothpastes for free, and I show them how and where to use them, and I even clean their teeth myself, only for them to go home and make a mess of it in a couple of months. I cannot fight gum disease and dental caries when people do not do something as simple as to take the 5 minutes a day to scrub the biofilm off of their teeth to ensure that they have clean mouths. The mouths they socialize with. The teeth they eat and speak with. They will spend 2 hours on the internet but maybe 30 seconds on oral homecare. Priorities?

It is ubiquitous too. People of all ages, all incomes, genders, sexes, professions, educational levels etc. have surprisingly horrible homecare practices. Yea, I am calling you all out.

People say dentistry is expensive. You know what isn't? Brushing your teeth. Flossing. Those two simple actions effectively combat the two most prevalent (and costly) oral diseases. My patients with good homecare spend the least amount of money in my office......which, well, is not good for my bottom line, but is what I want to see from, and is my goal for, every patient that walks through the door.

Thanks for reading!

Dr. Dave

Photo credits:

1. "Gingivitida" by D-institut - Own work. Licensed under CC BY 3.0 via Wikimedia Commons -

2. "Kriticke stadium parodontitidy" by D-institut - Own work. Licensed under CC BY 3.0 via Wikimedia Commons -

3. "Gingivitis-before-and-after-3" by Onetimeuseaccount - Own work. Licensed under CC0 via Wikimedia Commons -

4. By Zeron AGUSTIN ZERON (Own work) [Public domain], via Wikimedia Commons

5. "Zubni protezy" by D-institut - Own work. Licensed under CC BY 3.0 via Wikimedia Commons -

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