Told You So

You think the floss is effective? In most cases it is not.

I couldn’t hide my satisfaction when I read the news in the US about effectiveness of the floss. Finally something I have been preaching about is out and in the open for everyone to read.

You see I have met many dental professionals who have doubted my way of giving oral hygiene instructions especially regarding the floss. I have met so many of them that I have stopped explaining the reasons behind my recommendations.

My hope has been that some day they would get enough experience to notice that the floss isn’t doing a proper job. Or that they would start using the disclosing solution (I use Rondell Disclosing Pellets) which would definitely prove it.

We’ll see what happens. My fear is that many will stubbornly stick to their old ways. Change will always bring along resistance.

If you haven’t read my blog before, please take a look at this page about my recommendations.

And click this link if you haven’t read the news about the effectiveness of floss yet.

Do You Recommend Toothpick?

Toothpick or no toothpick, that is the question!

I will once again return to the times when I was a student in dental school and knew only little of the dentistry.

We were learning about cariology and were advised to bring in dental radiographs (x-rays) if we had any. I had had a panoramic radiograph taken recently and the teacher – a specialist in cariology – took a look at it. He said to me:

“You should use a toothpick”

I was very surprised and said to him that there is no way I can fit the toothpick in between the teeth. He showed me from my x-ray that there is enough space between the teeth for the toothpick. But I was not convinced (thought that he was wrong) and carried on using a floss for many years to come.

The reason why this occasion came to my mind was that I was reading through health and dental blogs to get ideas for my next topic and I ran into several blogs that wrongly advice people against using a toothpick. I got this certain annoyed feeling inside of me and I knew I had to write about it.

Toothpick Widens the Gaps Between the Teeth and So It Is Supposed To

I have worked with many periodontists and learned that floss is not – by far – the right tool when we try to tackle the gum disease. It does no massaging for the gums which is needed when we try to make the gums firmer around the teeth (plus it won’t remove all the bacteria). When the gum gets firmer it shrinks and leaves less space for the bacteria to hide and cause the disease.

When I moved abroad I very quickly understood that a toothpick was not considered to be a good tool for cleaning between the teeth. I received wondering commentary from my colleagues when they realised I am recommending it. It was considered to be old-fashioned, ineffective and even harmful to the gum. I had to explain the reasons for recommending it again and again:

“The toothpick – the triangle-shaped wooden one – works well initially when the patient has inflamed and swollen gums. It is cost-effective, easy to use and effective in massaging the loose gum. Once the gums have healed and firmed up we can determine better which sizes of interdental brushes are the best ones to use.”

The patients often fear that whatever they are using to clean between the teeth will widen the gaps. I tell them that it might actually happen but in that case it is only a good sign. I explain to them – with their x-rays – that the bone levels will determine how much the gaps between the teeth will widen.

If the bone around the tooth has receded as a result of the bacteria presence and inflammation and there is swollen and loose gum on top of it, it is an unhealthy situation and will result in more bone loss eventually. The gum needs to be firm on top of the bone so that it can better resist the bacteria.

And the only way to get firm gum is by massaging it. This can be done with the triangle-shaped wooden toothpick by pushing it gently but firmly between the teeth as far as it goes and repeat it couple of times. If there is bleeding at first it is also a good sign – the toothpick is doing its job. The bleeding will stop if the toothpick is used for a week in every between the teeth every night.

Suspicion

People often leave the practice unconvinced of the advice they were given. But the ones that do as they were told despite being sceptical are gobsmacked by the way the bleeding (and hurting) stopped.

I recall having a phone conversation with a patient who had an advanced gum disease and who had recently seen me for the first visit of the course of treatments. I had advised him to use purple interdental brush (1,1mm) but he wasn’t convinced about it and this was the reason for to phone call. He thought the brush was too big as it hurt. I told him that the only thing he can do is to try to prove me wrong. To follow my advice and see if I’m wrong.

He carried on using the interdental brush and about week later I received another phone call from the patient. He wanted to share his amazement and joy about his gums that had stopped bleeding. He was thankful for the correct advise and said that he had suffered from bleeding gums for all his life and only now – at his fifties – he managed to stop the gums bleeding.

The pain makes people think that something they use is not right for them. That’s why it is important to advise patients that when they have a gum disease (any stage from gingivitis to severe periodontitis) it will be painful at first when they begin using the interdental brush or toothpick – there’s no way around it. I always tell patients that for about week they need to suffer from tender and sometimes very painful gums. But if they persevere with the use of interdental brush/toothpick as advised they will notice it won’t hurt after a while.

Conclusion

I have said this before and I am saying it again – do not believe everything you read from the internet. I have run into several sites that offer wrong advise on oral health. Even dental professional offer wrong advise. Here’s one example about advise against the use of toothpick

The sharp surface area might destroy the polish of the tooth, damage the gums or perhaps create the voids in between the teeth to broaden.

A correct technique of any product recommended needs to be established at the dental practice before patient leaves the practice. Toothpick can cause harm to the gum if used incorrectly but so can floss, interdental brush and toothbrushes. I have pointed out two times in this post that the toothpick needs to be the triangle-shaped one if it is used in between the teeth. Never use cocktail sticks!

Also a toothpick should be used only temporarily as it won’t remove all the bacteria from between the teeth for the same reasons as the floss doesn’t. Neither one of them cannot get into the grooves of the teeth (area where the roots start to separate) and the grooves of the fillings.

I will emphasise that a toothpick is perfect in the beginning of the periodontal treatment when the swelling of the gum needs to be reduced.

Finally back to my teacher who advised me to use toothpicks. He was right. Of course he was – he had decades of experience. I was just a cocky rookie in dentistry and thought I knew better.

It wasn’t until I had periodontists as colleagues when I realised that I need to use something else than a floss. My bone level around the teeth was naturally that low that I could fit in a toothpick and later I moved on to the interdental brushes (size 0,7mm). I have used them for over a decade now and haven’t used floss since – and no, I have not developed any decay in the contact point of the tooth.

Compilation of Excuses

After being so serious for a while it is time to lighten up for a moment.

People are funny creatures. You can tell all sorts of tales of them and their funny ways. This time I will tell you about people’s creativity when they put a blame on so many other things than their own indolence when it comes to oral hygiene routines.

I’ve collected a list of the answers we get to two of the very common questions we ask. Let’s see if you recognise yourself?

So Are You Using Your Electric Toothbrush?

lost in a house move
it’s still in an unpacked box after a house move (moved a year ago)
out of battery and haven’t got around to charge it
it’s malfunctioning
can’t find brush heads from the shops
I don’t have a plug-in in the toilet
it makes me feel dizzy
it’s too vigorous.. I’m nervous about loosing a filling
dropped it and it broke
the manual toothbrush is quicker
it takes too long
it’s too noisy.. I’m afraid of waking up the kids/wife/neighbour/partner
I don’t like the feeling in my head
it tickles too much
it makes my gums bleed
it hurts
the bristles feel too hard
don’t have batteries in the house (battery operated electric toothbrush)

How About Are You Cleaning Between The Teeth?

too difficult
too tired
floss gets stuck/shreds
my gums bleed
I lost a filling once
it hurts
my teeth are so close together that the floss/interdental brush/toothpick is impossible to use
I use a mouthwash instead
I use the water pick
I rinse with water after every meal
I use chewing gum
my gaps between the teeth are so wide that nothing gets stuck there
I push the bristles of the toothbrush between the teeth
I use a toothpaste that says it cleans between the teeth
I run out of floss/interdental brushes/toothpick (last year) and never got round to buy new ones
can’t be bothered
it makes the gaps between my teeth wider
I don’t have time for it
don’t know which one to use
is it harmful?
is it needed? I never see anything coming out when I floss
are you?

Feel free to add more excuses on the comment box!

Do You Recognise the Gum Disease?

Be careful next time you open your mouth in the bus. I might be sitting next to you.

Many people have gum disease without knowing it and it often comes as surprise when they are told about it at the dentist. Even bigger surprise would be if they knew how many dentists do not recognise the gum disease or know what a comprehensive treatment is for it.

I have seen countless amounts of patients in my career whose gum disease has gone undetected. It’s astounding! I’ve had patients who have visited the hygienist and the dentist every six months but still there is massive amounts of subgingival calculus around every teeth. And it is deep and tough to remove.

Just guess the surprise of the patient when instead of having a 15 minute check-up and 30 minute hygienist visit like normally, she will now need three 60 minute visits to remove the calculus thoroughly and a 4th visit in three months time. To be honest, this upsets me often. It’s not that difficult to diagnose the gum disease. It’s not rocket science for crying out loud!

I have spent way too many hours explaining why my colleagues have not noticed the gum disease. And my efforts for not sounding too annoyed at my fellow professionals sometimes fail miserably. Luckily, most of the patients take it relatively easy and do not demand compensation from the previous dentist. Instead they are normally very grateful that somebody caught the condition.

There will be information for professionals next but the patients benefit of reading it too. If you are a patient you can move on to the end of this post if you want to skip the professional part.

So Why Don’t You Recognise the Gum Disease?

There are five probable reasons (add more to the comment box if you wish).

Lack of time. In 15 minute check-up the dentist should go through the medical history of the patient, check the teeth (loose fillings, decay, fractures etc.), the soft tissues (inside the cheeks, tongue, lips, roof and floor of the mouth and the throat) and the gums. Plus there might be need for the x-rays. Fifteen minutes simply is not enough for this considering that the disinfection business before the next patient should be done as well. Even 30 minute appointment might not be enough.

The X-factor. By X I mean money and it is related to the time issue. Dental practices have 15 minute check-ups because instead of having two patients in an hour that pay X amount for the visit they can have four. Four times X is better than two times X. At least for the practice.

Lack of basic skills. We have an instrument which finds any gum disease from any patients mouth when used correctly. Or when used. It is not by default that this instrument, perio probe finds it’s way to the check-up tray. I have seen dentist doing the check-up by using the sharp explorer only. And even if the perio probe is used, it is used incorrectly and the gum disease goes undetected. Even a gum specialist (periodontist) has failed at this and I will tell you more about it later in this post.

Lack of experience. When you are an experienced dental professional (either a dentist with a great interest in the gum disease or a hygienist) you can recognise gum disease from a distance. I will give you an example.

You sit in a bus on your way home and somebody sits next to you. He yawns and 3 seconds later your nose detects an odour you rather not smell on your free time. Periodontitis (aka gum disease)! Thank goodness the bus has a good ventilation and the odour is soon gone and you hope he keeps his mouth closed for the rest of the journey. Then the guy’s phone rings and it’s his mother…

I can often recognise the gum disease by just looking at the patients mouth. The gums have a certain look on the sites of the pockets. Even if there is only one deep pocket in a healthy mouth, you can spot it out by the looks of the gum. It is difficult to explain how they look so I won’t even try. Anyone experienced know what I mean. The point is that the more you examine the gums and find the sites where the deep pockets, subgingival calculus and gingivitis (bleeding of the gums) are, the more you learn to tell what looks normal and what doesn’t.

But do not worry if you are a newbie. Just learn to use the perio probe correctly and you will be fine!

Forgetting how smoking hides the gum disease. Heavy smoking can make the gum disease invisible to the eye and often the dentists and hygienists are misled by the looks of the heavy smoker’s gums especially if the oral hygiene is good at that very moment. Heavy smoker’s gums look healthy and pale. There’s no sign of the red and swollen gums. No sign of the bleeding after probing. And yet the disease is there.

Even if the gum disease is not visible to the eye with the smoker, it is still there for the perio probe to find but with the smokers you really need to master the technique. Often the smokers gum line is very tight and it is difficult to find access to the pocket (once you do, don’t let it out until you have probed the whole side of the tooth).

Use of the Periodontal Probe

When I was at dental school learning the arts of the dentistry, one of our teachers (a periodontist) said one day annoyingly “They didn’t even know how to use a perio probe!” At that moment we were practicing scaling in the school’s clinic but this outburst was not addressed to us students (thank god as the teacher was scary as hell) but to a group of dental hygienists who had come to revise perio skills at the dental school. This one sentence has stayed in my memory for some reason and only until now I understand what she meant and why she was so annoyed.

Not only the hygienists fail in the technique of the perio probe but also the dentists and even the periodontists. I will tell you about one periodontist who saw one of my patient.

I had referred the patient to the specialist with all the relevant documentation (x-rays, perio chart etc). When I saw the patient 6 months later a course of treatment was finished with the periodontist. I examined the patient’s gums and found a 10 mm pocket on one of the molars. The depth was the same as before referring. The patient told me she was going to have a control visit soon with the periodontist so I wrote letter about the persistent pocket.

Three months later I saw the patient again and nothing was done to it. A periodontist had said to the patient that there is no pocket.

No pocket! I’m going to show you the pocket!

I took my DSLR and put a perio probe into the pocket and fired away. The patient got the photo on cd and gave it to the periodontist on the next visit. I’m afraid my story ends there. I never saw this patient again as she got retired and was not able to see me as we were too expensive.

Ten millimetres deep pocket and it went unnoticed by the specialist even when the location was pointed out. What chances do the rest of us less-educated ones have if the one wearing the black belt in our industry is not able to do it?

Note to all dental professionals who examine patients gums: Please check your perio probe technique. There are plenty of information about the use of the perio probe on the internet plus hands on courses at the dental schools. And those who are not using a perio probe, shame on and start now!

What Is the Gum Disease?

I won’t go much into details about the gum disease but I will tell you the warning signs when you should visit your dentist:

your gums bleed when brushing/flossing/eating or they bleed spontaneously
your gums hurt when brushing/flossing/eating
your teeth have become longer over the years or they have tilted/rotated/moved
your teeth feel loose
you have wider gaps between the teeth than before
somebody has told you often that your breath smells. Gum disease doesn’t always produce bad breath especially in the early stages. It is the advanced periodontitis when the smell can be obvious to everyone else except to the bearer. But how many of you tell the other person that their breath stinks? Not many, unless it is your spouse in concern

The gum disease is always caused by the bacteria in your mouth. When the bacteria is removed effectively and regularly the chances for you getting a gum disease are minimal. But even if you are looking after the teeth well (brushing thoroughly twice a day and cleaning between the teeth once a day with a product that was recommended by the hygienist) go to see your dentist if:

you are a heavy smoker (here‘s why)
you have a diabetes
you are pregnant

If the gum disease is left untreated it will result in loss of tooth. It is also associated with certain illnesses so your general health is to be concerned as well.

If you want to find out more please visit American Academy of Periodontology’s site which provides lots of useful information for the patients.

How Is It Treated and Can I Do It Myself?

The gum disease is treated by simply removing the bacteria (both soft bacteria, plaque and hardened bacteria, calculus) and teaching the patient the correct techniques for removing the soft bacteria regularly by themselves.

Anyone can start better oral hygiene routine at home without seeing a dentist. Getting rid of the daily build up of bacteria effectively may cure the gum disease. This means brushing twice a day with electric toothbrush and cleaning between the teeth preferably with something else than a floss (floss is better than nothing of course). You could try Gum Soft Picks at first. Aim to the size that feels slightly tight between the teeth.

But remember, you are not able to remove the hardened plaque (calculus). Also if the calculus has build up below the gum, you will need to see dentist (for an assessment) and hygienist (for scaling) to stop the gum disease progressing.

A revelation:

There is no easy way out of the gum disease. It will most probably hurt like hell and the gum will bleed (in some cases heavily) in the beginning when you brush and clean between the teeth. If you at this point stop e.g. using an interdental brush that was recommended to you or you use it every second night because you think you are harming the gums, the gums will keep on bleeding and hurting. You will never get out of the vicious cycle. So persevere, be brave and have a faith on us professionals.

Sometimes if the gum disease has advanced to severe stage, you might need surgery on your gums (performed by the periodontist).

Can You Trust the Recommendations given to You by a Dental Professional?

Too Many Options

Floss, tape or ribbon? Soft, medium or hard brush? Manual or electric? Fluoride or herbal toothpaste? Whitening, double-action, triple-action or all-in-one? Mouthwash or not?

These questions are endless in the mind of a common consumer. So no wonder they rely on the advice of a dental professional. Why wouldn’t they? Us professionals have the latest information and studies. We have tested the products ourselves. We have seen them in use amongst patients with good results before recommending them.

Not.

As some of us might have, most of us haven’t. Let me tell you how a product gets recommended.

Annual Dental Show Case

Every year dental professionals gather at dental show cases where manufacturers of dental equipments and oral health care products have set up impressive stands to lure dentists, hygienists and nurses to discuss about the new products.

A revelation:

Most of these professionals are not interested in what types of root canal files they have invented or the qualities of the new toothpaste.

What they are interested in (while acting as if they are listening the representative) is:

Are there any freebies?

Yes, I have seen highly paid dentists with their Louis Vuittons to run after freebies like they had no money to buy them. They sit in free 45 minute lecture sponsored by one of the leading oral hygiene product manufacturer to receive the latest model of an electric toothbrush which they already have. This new one they will either sell or give as a Christmas gift to a relative. They go from stand to stand to pick toothpaste, floss, chewing gum, sweets and reluctantly accept advertisement leaflets which will go straight into the bin when they reach home.

The most generous representatives are the ones whose product end up recommended the most.

Why?

Because they send boxes and boxes of free samples to the practices. Let’s say a dental practice receives 6 boxes of toothpaste samples, those handy travel sized ones, you know? Each box has 100 samples. So 600 tubes of toothpaste to give away. Will all of these be given to the patients? Nope.

300 of them will confiscated by the staff of the dental practice for personal use
200 of them the staff will give to the relatives and friends

And finally the rest will go to a small bowl on the side of the desk in the surgery and these samples are given one by one to a patient who has deserved it. Some might even hide them in a drawer to avoid being forced to give them to a patient that annoyed them (because it’s not good manners to say no if the patient asks for samples).

Salesmen of the Manufacturers

The leading oral hygiene manufacturers have salesmen who visit regularly the dental practices to promote their products. They are warmly welcomed to the practices but often only if they visit whilst the practice is having a lunch break. The reason for this is:

The practice does not want to lose any profitable surgery hours.
All dental professionals know they will bring something to go with a coffee. A cake, sweets, a swiss roll. They had better or the salesman will be faced with a grumpy audience.

When the dental professionals are happily sipping away their coffee or tea with the cake, the salesman goes through the new products. There might be a question or two but what everyone is thinking while the salesman talks is:

Are there any freebies?

We often meet quite aggressive salesmen who will defend their product to the death. Honestly, what happened to customer is always right? If you are actually listening to the salesman when he is telling you about all the impartial studies of how their pulsating electric toothbrush is better than a manual toothbrush and especially better than their competitor’s sonic toothbrush (their study actually says sonic toothbrush is as crap as the manual toothbrush – whaaaat?) you are urged to raise your hand to get a say.

You want to tell the salesman, that you are actually using the sonic toothbrush and that you have recommended it to the patients with poor oral hygiene and the results are great. If you are wise, you don’t say anything and carry on recommending the product you know is the best. But if you cannot keep quiet, you will soon learn to do so next time. The salesman starts to talk to you as if you are retarded or malpracticing when recommending something their study has shown to be ineffective.

Impartial study my arse (beg pardon my French).

Anyway, the salesman gives everyone toothpaste and promises to send samples later on. Boxes of samples. And they will. And you already know what happens then.

I must say that it amazes me how some of the dental professionals are stubbornly stuck on recommending the same electric toothbrush they are using themselves and have never tried another one. Or they might have tried it once (let’s say this leading sonic toothbrush) with incorrect technique and judge it by that. They refuse to see the good results that are clear with the patients who are using this sonic toothbrush. Where is professionalism in this?

Personalities and Professions Clash inside the Practice

The dentist is the ultimate Master of the Universe (by Universe I mean a dental practice) and if the Master has ordered certain toothbrushes, certain toothpaste, floss and interdental brushes to be sold in the practice, then the rest need to comply. Of course there will be some rebellion inside the closed surgery doors. But it needs to be done so that one does not get exposed as there will be consequences. So one must occasionally recommend the products the Master has chosen.

For some reason unknown to the writer the patients seem to consider the dentists as God. What the dentist says overwrites everything another dental professional has said, including oral hygiene recommendations. The hygienist cannot be right if the dentist said something else.

This leads me into temptation to step out of the subject for a little while as I remembered something that has puzzled me for ages and I think I might get an answer through this blog. Here it goes… Patients consider the dentists as God and bring gifts (wine, chocolate, flowers etc) to them when the treatment is done and the nurses, hygienists and the rest hardworking supportive staff get nothing. Gifts TO THE DENTIST who makes gazillion amount of money compared to the supporting staff! Why o why? Dear patients, please use comment box to enlighten me in this matter!

Back to the subject.

Later on in this blog I will be writing more about the personalities and how it affects dental practice and the treatment given to the patient. But having mentioned it on the heading already I will write shortly here as well.

When a dental professional has a big ego it sometimes runs over the best interest of the patient. Lets say a dental hygienist recommended you a yellow interdental brush and she spent time and effort to get you to learn the technique by showing how to use it and by checking that you understood how and why to use it. You leave the practice happy because you learned a new skill to improve your oral hygiene.

Then you see a dentist the next week and he thinks the interdental brush is rubbish (as you lost a filling made by him when using the interdental brush) and advices you to use floss on your heavily filled teeth with wide gaps. He just casually says this without showing the technique. You try the floss as you have many times previously and it gets stuck, breaks and is difficult to use between the back teeth. You give up and stick to the toothbrush only.

Who wins? Nobody. Especially not the patient. And to be honest, you would be wasting your money anyway as the floss is not the right tool for you.

A revelation:

The dentist is not in the area of the best knowledge when it comes to recommending the oral hygiene products. They are far better drilling and filling the teeth. And doing all sorts of other nasty (from patient’s perspective) things that requires higher and longer academic education than hygienist’s.

Old Habits Die Hard

“I have always recommended floss and it’s been fine”

Oh, dear. Lets start from the basics of oral hygiene.

Patients are all different, our teeth and bones are different shapes. They have teeth that have no fillings, some fillings or mouth full of fillings and other restorations (crowns, bridges, implants). Some restorations are well made, some not. Patients have different motoric skills.

So you cannot recommend something out of custom.

To find out the best product to recommend to the individual patient, we should always use disclosing liquid (the one that dyes the plaque red/blue). If not used, it is impossible to tell what works and what doesn’t. You would be surprised to find out how ineffective the common floss or tape is. I do recommend floss every once in a while but only 3 certain types of certain brands (you will find out from here which they are, plus correct technique for the sonic toothbrush).

How It Should Be Done

This chapter is especially useful for the dental professionals but the patients benefit of reading this as well. You know you are in good hands when a dentist or hygienist is as thorough as I describe.

This is a short version of upcoming post about what recommendations should be based on. It is last on the list because there are not many dental professionals who are this thorough.

The most important thing is to interview the patients about their current oral hygiene habits and reasons behind them. E.g. if the patient is not cleaning between the teeth, ask why? without sounding or being judgemental. Laziness, ignorance, stress, depression, difficult life situation, too hard… there are as many reasons as there are patients.

The next you need to find out where the problem areas are in patient’s mouth and decide the right tool for the patient to use. Test it, show it to the patient and let the patient try. Remember to say, it won’t be an easy ride at first even if looks easy when I do it.

Tell the patient where she can find them and where they are the cheapest to buy (do your research).

Give leash and don’t be overenthusiastic. By this I mean you should encourage patient even if there has been only small improvement, but also same time encourage to do better next time. Change the tool if it’s not working. Small steps!

In my experience it takes 12-18 months on average until you get it right if the patient is responsive. So don’t give up after the first visit.

Also worth remembering

the products sold in the practices are not necessarily the best ones like electric toothbrushes of certain makes and models. They are normally just the owner’s way of making more money on the counter. Use the products recommended by an experienced hygienist.
some of the products might even be a health risk like mouthwash which contains alcohol (now this is an issue that divides dental professionals. Some agree with me, some don’t. I will be writing about this later on in this blog).
some of the products might not be suitable for you like toothpaste containing soap if your mouth is sensitive (sodium lauryl sulfate).
some dental professionals are not revising and open to a new information and studies about dental products. They stick to the old knowledge despite the fact that the new information is indisputable. This happens especially if the new information is delivered by the lower rank colleague in the practice.
fillings, when well-made, do not come out with any oral hygiene product. The fault is always in the filling and in it’s maker if the filling is relatively new.

Conclusion

It was a long post, hopefully you made through it. To sum up all 2000+ words, only two words come to my mind that defines us dental professionals these days. Greed and pride. Two out of seven of deadly sins.

But there is hope.

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Do You Recommend Toothpick?