Treatment

Tooth decay is the most common global disease. Over 80% of cavities occur inside fissures in teeth where brushing cannot reach food left trapped after eating and saliva and fluoride have no access to neutralize acid and remineralize demineralized teeth, unlike easy-to-clean parts of the tooth, where fewer cavities occur.

Teeth cleaning is the removal of dental plaque and tartar from teeth to prevent cavities, gingivitis, gum disease, and tooth decay. Severe gum disease causes at least one-third of adult tooth loss.

Since before recorded history, a variety of oral hygiene measures have been used for teeth cleaning. This has been verified by various excavations done throughout the world, in which chew sticks, tree twigs, bird feathers, animal bones and porcupine quills have been found. In historic times, different forms of tooth cleaning tools have been used. Indian medicine (Ayurveda) has used the neem tree, or daatun, and its products to create teeth cleaning twigs and similar products; a person chews one end of the neem twig until it somewhat resembles the bristles of a toothbrush, and then uses it to brush the teeth. In the Muslim world, the miswak, or siwak, made from a twig or root, has antiseptic properties and has been widely used since the Islamic Golden Age. Rubbing baking soda or chalk against the teeth was also common; however, this can have negative side effects over time.

The Australian Healthcare and Hospital Association’s (AHHA) most recent evidence brief ) suggests that dental check-ups should be conducted once every 3 years for adults, and 1 every 2 years for children. It has been documented that dental professionals frequently advise for more frequent visits, but this advice is contraindicated by evidence suggesting that check up frequency should be based on individual risk factors, or the AHHA’s check-up schedule. Professional cleaning includes tooth scaling, tooth polishing, and, if tartar has accumulated, debridement; this is usually followed by a fluoride treatment. However, the American Dental Hygienists’ Association (ADHA) stated in 1998 that there is no evidence that scaling and polishing only above the gums provides therapeutic value, and cleaning should be done under the gums as well. The Cochrane Oral Health Group found only three studies meeting the criteria for inclusion in their study and found little evidence in them to support claims of benefits from supragingival (above the gum) tooth scaling or tooth polishing.

Dental sealants, which are applied by dentists, cover and protect fissures and grooves in the chewing surfaces of back teeth, preventing food from becoming trapped and thereby halt the decay process. An elastomer strip has been shown to force sealant deeper inside opposing chewing surfaces and can also force fluoride toothpaste inside chewing surfaces to aid in remineralising demineralised teeth.

Between cleanings by a dental hygienist, good oral hygiene is essential for preventing tartar build-up which causes the problems mentioned above. This is done through careful, frequent brushing with a toothbrush, combined with the use of dental floss or interdental brushes to prevent accumulation of plaque on the teeth. Powered toothbrushes reduce dental plaque and gingivitis more than manual toothbrushing in both short and long term. Further evidence is needed to determine the clinical importance of these findings.

Patient need to be aware of the importance of brushing and flossing their teeth daily. New parents need to be educated to promote healthy habits in their children.

Tooth brushing

Routine tooth brushing is the principal method of preventing many oral diseases, and perhaps the most important activity an individual can practice to reduce plaque buildup. Controlling plaque reduces the risk of the individual suffering from plaque-associated diseases such as gingivitis, periodontitis, and caries – the three most common oral diseases. The average brushing time for individuals is between 30 seconds and just over 60 seconds. Many oral health care professionals agree that tooth brushing should be done for a minimum of two minutes, and be practiced at least twice a day. Brushing for at least two minutes per session is optimal for preventing the most common oral diseases, and removes considerably more plaque than brushing for only 45 seconds.

Tooth brushing can only clean to a depth of about 1.5 mm inside the gingival pockets, but a sustained regime of plaque removal above the gum line can affect the ecology of the microbes below the gums and may reduce the number of pathogens in pockets up to 5 mm in depth.

Toothpaste (dentifrice) with fluoride is an important tool to readily use when tooth brushing. The fluoride in the dentifrice is an important protective factor against caries, and an important supplement needed to remineralize already affected enamel. However, in terms of preventing gum disease, the use of toothpaste does not increase the effectiveness of the activity with respect to the amount of plaque removed.

Manual tooth brush

The modern manual tooth brush is a dental tool which consists of a head of nylon bristles attached to a long handle to help facilitate the manual action of tooth brushing. Furthermore, the handle aids in reaching as far back as teeth erupt in the oral cavity. The tooth brush is arguably a person’s best tool for removing dental plaque from teeth, thus capable of preventing all plaque-related diseases if used routinely, correctly and effectively. Oral health professionals recommend the use of a tooth brush with a small head and soft bristles as they are most effective in removing plaque without damaging the gums.

The technique is crucial to the effectiveness of tooth brushing and disease prevention. Back and forth brushing is not effective in removing plaque at the gum line. Tooth brushing should employ a systematic approach, angle the bristles at a 45-degree angle towards the gums, and make small circular motions at that angle. This action increases the effectiveness of the technique in removing plaque at the gum line.

Electric tooth brush

Electric toothbrushes are toothbrushes with replaceable moving or vibrating bristle heads. The two main types of electric toothbrushes are the sonic type which has a vibrating head, and the oscillating-rotating type in which the bristle head makes constant clockwise and anti-clockwise movements.

Sonic or ultrasonic toothbrushes vibrate at a high frequency with a small amplitude, and a fluid turbulent activity that aids in plaque removal. The rotating type might reduce plaque and gingivitis compared to manual brushing, though it is currently uncertain whether this is of clinical significance. The movements of the bristles and their vibrations help break up chains of bacteria up to 5mm below the gum line. The oscillating-rotating electric toothbrush on the other hand uses the same mechanical action as produced by manual tooth brushing – removing plaque via mechanical disturbance of the biofilm – however at a higher frequency.

Using electric tooth brushes is less complex in regards to brushing technique, making it a viable option for children, and adults with limited dexterity. The bristle head should be guided from tooth to tooth slowly, following the contour of the gums and crowns of the tooth. The motion of the toothbrush head removes the need to manually oscillate the brush or make circles.

Flossing

Tooth brushing alone will not remove plaque from all surfaces of the tooth as 40% of the surfaces are interdental. One technique that can be used to access these areas is dental floss. When the proper technique is used, flossing can remove plaque and food particles from between the teeth and below the gums, The American Dental Association (ADA) reports that up to 80% of plaque may be removed by this method. The ADA recommends cleaning between the teeth as part of one’s daily oral hygiene regime.

There are different types of floss available, including:

• Unwaxed floss: Unbound nylon filaments that spread across the tooth. Plaque and debris get trapped for easy removal.
• Waxed floss: less susceptible to tearing or shredding when used between tight contacts or areas with overhanging restorations.
• Polytetrafluoroethylene (Teflon): Slides easily through tight contacts and does not fray.

The type of floss used is a personal preference, however without proper technique it may not be effective. The correct technique to ensure maximum plaque removal is as follows:

1. Floss length: 15–25 cm wrapped around middle fingers.
2. For upper teeth grasp the floss with thumb and index finger, for lower teeth with both index fingers. Ensure that a length of roughly an inch is left between the fingers.
3. Ease the floss gently between the teeth using a back and forth motion.
4. Position the floss in such a way that it becomes securely wrapped around the interdental surface of the tooth in a C shape.
5. Ensure that the floss is taken below the gum margins using a back and forth up and down motion.

There are a few different options on the market that can make flossing easier if dexterity or coordination is a barrier, or as a preference over normal floss. Floss threaders are ideal for cleaning between orthodontic appliances, and flossetts are ideal for those with poor dexterity.

Interdental brushes

Interdental brushes come in a range of color-coded sizes. They consist of a handle with a piece of wire covered in tapered bristles, designed to be placed into the interdental space for plaque removal.^[1] Studies indicate that interdental brushes are equally or more effective then floss when removing plaque and reducing gum inflammation.

The steps in using an interdental brush are as follows:

1. Identify the size required, the largest size that will fit without force is ideal Often more than one size is required in the mouth.
2. Insert the bristles into the interdental space at a 90-degree angle.
3. Move the brush back and forth between the teeth.
4. Rinse under water to remove debris when necessary.
5. Rinse with warm soapy water once complete, and store in a clean dry area.
6. Replace once bristles are worn.

Tongue scrapers

The tongue contains numerous bacteria which causes bad breath. Tongue cleaners are designed to remove the debris built up on the tongue. Using a toothbrush to clean the tongue is another possibility, however it might be hard to reach the back of the tongue and the bristles of the toothbrush may be too soft to remove the debris. Some may find it easier to use a tongue scraper instead because it does not tend to cause a gag reflex as readily as a toothbrush. Steps of using a tongue scraper:

1. Rinse the tongue scraper in order to clean it and remove any present debris
2. Start at the back of the tongue and gently scrape forwards
3. Be sure to clean the sides of the tongue as well, not just the middle portion
4. After the cleaning is completed, rinse the tongue scraper and any debris that is left behind
5. Rinse the mouth