Wednesday 12th December 2018

Dental Care

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Dental health & oral hygiene

We've all been advised by our dentists to avoid eating sugar for the health of our teeth. But many questions remain. Does that mean avoiding just sugary foods like sweets and cholocate? The problem is that in fact many foods which are essential for health in general like fruit and vegetables contain carbohydrates such as sugars and starches. Besides and even worse, all foods have the potential to be converted in the mouth into tooth-destroying acids.

The authoritative National Institutes of Health of the USA sums up the problem in this way:

Carbohydrates (sugars and starches) increase the risk of tooth decay. Sticky foods are more harmful than nonsticky foods because they remain on the surface of the teeth. Frequent snacking increases the time that acids are in contact with the surface of the tooth.

But there is good news on this front, in the form of a shift of focus on what can most effectively prevent tooth decay. Although avoiding high-sugar products remains advisable, diet can turn out to be not as important as regular dental care and hygiene.

Recent evidence points in that direction when we consider that in most European countries dental caries' incidence in children and adolescents has continuously decreased in the last three decades, although the average sugar intake has remained more or less the same. So what is the cause of this good trend? It seems likely that better oral hygiene, like more tooth brushing and using dental floss, and the use of fluoride are both the causes.

We need a bit of explanation.

Teeth can be damaged by many different things, among which dental caries (tooth decay), dental erosion, attrition (through tooth grinding, for instance), trauma, and abrasion; they can also be lost through periodontal disease, i.e. disease of the tissues surrounding the teeth, such as gums, bones, ligaments and cementum, the calcified substance covering a tooth's root.

Of all these, dental caries and inflammatory periodontal disease are the most common diseases of the mouth, and both are caused by the activity of dental bacterial plaque. In fact, tooth decay is one of the most common of all diseases, second only to the common cold. Tooth decay is probably the most prominent health risk linked to the consumption of sugar.

For tooth decay to develop, several factors must be present. First, a tooth must be susceptible to caries, for genetic or other reasons. Second, there must be dental plaque (see below). Third, there has to be enough time for tooth demineralisation (dissolution of the hard enamel surface of the tooth) to happen and not enough time for the body's mechanism of natural defence that remineralises the tooth to remedy the damage.

These factors can be affected and overturned by other factors, for instance: the presence of fluoride changes the tooth structure, helps remineralisation and makes the tooth more resistant to decay; eating and drinking more often gives the bacteria more opportunities to ferment carbohydrates but the converse is also true; saliva production is good because saliva provides minerals for teeth remineralisation, neutralises acid and helps clear food from the mouth.

Fluoride is particularly important for tooth health. The British Medical Association, the British Dental Association, the World Health Organisation (WHO) and the FDI World Dental Federation are all in favour of fluoridation of water, that is the addition of fluoride to a public water supply in a quantity low enough to be well below the threshold of safety but sufficient to prevent or reduce tooth decay. The FDI World Dental Federation states:

"Over sixty years of research and recent systematic reviews have shown that water fluoridation is an effective and efficient public health measure for the prevention of dental decay."

Despite support of water fluoridation by major public health and dental organizations, and although all the evidence shows no adverse effects of water fluoridation except mostly mild fluorosis (tiny white specks or streaks on teeth, often unnoticeable), water fluoridation has been controversial and opposed by segments of the public.

Nevertheless, two systematic reviews, one in 2000 and a more comprehensive one in 2007, both found that water fluoridation was linked to a reduction in children of dental cavities and of missing, filled and decayed primary teeth.

Water fluoridation efficacy was discovered in the US and today this method of tooth decay prevention is used mainly in the United States, where approximately two-thirds of the population on public water systems receive it.

Another way to deliver fluoride to the teeth is by applying it topically by means of varnishes, mouth rinse, gels, and most commonly toothpaste or other dentifrices. Today in the developed world most toothpaste contains fluoride.

The risk of fluoride toxicity that is sometimes mentioned is not a real hazard in the small or trace amounts contained in toothpaste, which is the amount also found in many foods. People often forget that toxicity is always a question of dose: even water can be poisonous in great quantities. The danger is so low that the use of full-strength fluoride toothpaste is recommended for all ages (with smaller amounts for young children and a smear, the size of a rice grain, of toothpaste for children up to 3 years).

 

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Dental plaque

Dental plaque may lead to dental caries, tooth decay.

What is dental plaque? Plaque is a biofilm, i.e. an aggregate of microorganisms that forms on teeth. There are bacteria normally present in the mouth. These organisms, mainly Streptococcus mutans, convert all foods, but especially sugar and starch, into acids. Particles of chewed-up food, acid, bacteria and the enzymes in saliva combine in the mouth and form plaque, a sticky, noxious substance that adheres to the teeth and corrodes their enamel surface. Plaque build ups mostly along the edge of gums, between teeth, on back molars, in cavities, and around fillings.

Plaque starts to form on teeth within 20 minutes after eating: this is also the time when most bacterial activity happens. If this plaque is not removed completely on a regular basis, dental caries will start and then flourish.

The acids in the plaque destroy the enamel and create holes, or cavities, in the tooth. Most cavities form over a period of months, or even years. They are usually painless until they grow very large and then affect nerves or provoke a tooth fracture. If left without treatment, this may lead to a tooth abscess. Untreated dental caries also destroys the tooth's softer internal structures, dentin and pulp, and eventually causes the loss of the tooth itself. It's plainly obvious that tooth decay should be prevented.

If plaque is not removed regularly, the bacteria develop and plaque may calcify and harden, forming tartar (calculus).

Whereas plaque can be removed by regular dental care at home, tartar is more resistent and needs scaling and root planing by a dentist in order to be removed. Both plaque and tartar contain acids which may over time erode the tooth's protective coating of hard enamel, producing cavities, or holes. Plaque and tartar also irritate the gums, resulting in gingivitis, or inflammation of the gums, and eventually periodontitis, a disease of the supporting tissue, mostly gums and bone, surrouning the tooth, which can be so serious that the tooth loosens and fall outs.

 

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What to do to help tooth health

It's also important how you clean your teeth. Use a toothbrush with a small head, so that you can get to those parts of the mouth most difficult to reach, especially the back of the teeth. Apply on your toothbrush fluoride toothpaste no more than the size of a pea, don't brush too hard because that can have adverse effects and damage your gums. During their cleaning, the toothbrush should adhere very firmly to the teeth.

A good method of cleaning inner, outer and biting surfaces of your teeth and removing plaque is the following. Place the head of the toothbrush against your teeth, angle it against the gumline, and brush by moving it in small circular movements several times on all surfaces of each tooth: outer, upper and lower surfaces, always keeping the bristles angled against the gumline. Then do the same on the inside surfaces of each tooth; for the inside surfaces of the front teeth, place the toothbrush vertically and make several small circular strokes with its front part. Then brush the biting surfaces of the teeth. Additionally you can brush your tongue: that cleans your mouth, removes bacteria and helps make your breath fresher.

Brushing your teeth should take at least 3 minutes. Change your toothbrush every 2-3 months or sooner if you see signs of filaments becoming worn, because worn-out toothbrushes may damage your gums and don't clean teeth properly.

All this is not as difficult as it sounds when you apply the overall advice to your life in gradual steps and these things start becoming habits. In the same way as not caring for your teeth becomes a routine, similarly looking after your oral hygiene can become a new routine too.

In addition, if you are a parent, begin your baby's dental care early by brushing its teeth with a fluoride toothpaste as soon as they appear, which is normally between 4 and 6 months but can be as late as 12 months of age. For children up to 3 years only apply a smear of fluoride toothpaste on the toothbrush. Clean your baby's teeth regularly twice a day by using a small, soft toothbrush. Do not habitually let babies fall asleep while drinking from a bottle of anything except pure water. The sugars in the liquids remain on the infant's teeth for a long time and may result in what is known as "baby bottle tooth decay".

Use artificial sweeteners in your coffee or tea, and use foods and drinks containing them rather than sugar: for example xylitol, saccharin, sorbitol, aspartame, mannitol, and many others.

The use of sugar-free chewing gum is tooth-friendly because it stimulates salivary flow.

New evidence indicates that xylitol, a sweetener used in alternative to sugar in chewing gum and other products, is beneficial to teeth. Sugar-free chewing gums, after meals for instance, can also be useful because they stimulate the production and flow of saliva which has a protective role against tooth decay, although they are by no means a replacement for toothbrush and dental floss. Saliva has many positive functions for teeth health, the most important of which are its abilities to neutralize acids, to cleanse the tooth surface, to clear bacteria and food debris, to control demineralization and mineralization, and its antibacterial activities.

The American Academy of Pediatric Dentistry in its Policy on the Use of Xylitol in Caries Prevention document says:

"The American Academy of Pediatric Dentistry (AAPD) recognizes the benefits of caries preventive strategies involving sugar substitutes, particularly xylitol, on the oral health of infants, children, adolescents, and persons with special health care needs."

 

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