Oral Hygiene Dental Plaque and Caries

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Oral Hygiene, Dental Plaque and Caries Michelle Bourassa, BPharm, MSc, DMD Date of Revision: January 2015

Dental Plaque Pathophysiology

Dental plaque is defined as a gelatinous deposit that adheres to the tooth surfaces, fillings or dental prostheses and is not removed by rinsing with water. Plaque is composed of aerobic and anaerobic bacteria in a matrix of bacterial or salivary glycoproteins and dextrans. Dental plaque is also referred to as “biofilm.”1,2 Deposition of plaque may occur on all surfaces of the teeth and may be recognizable within 24 hours. The area with the highest predilection for accumulation of plaque is the interproximal space of the molars and premolars, followed by the interproximal space of the anteriors and finally by the facial surfaces of the molars and premolars. Other areas of accumulation are the gingival margins along with pits and fissures.2 For an illustration of dental anatomy, see Teething, Figure 1. When freshly cleaned teeth are exposed to saliva, a layer of salivary glycoproteins adheres to the surface of the teeth. Oral microorganisms can attach to the glycoproteins or to the tooth enamel itself. Sticky dextrans and levans produced by the bacteria constitute the matrix that permits colonization and aggregation of more bacteria. Initially, plaque is made of gram-positive cocci and rods; with time, gram-negative rods and spirochetes join the existing microorganisms and the volume of plaque increases.3 Dental plaque can be divided into 2 types based on its location relative to the gum (supragingival or subgingival). Supragingival plaque is usually white to yellow in colour. When present in small amounts, it can be detected around the collar of the tooth with a probe or disclosing solution. When the volume is large, the eye can easily identify it.3,4 Subgingival plaque is a key factor in the development of periodontal diseases. On the tooth surface of subgingival plaque, the initial constituents and stages of plaque formation may be the same as for supragingival plaque. The plaque surface adjacent to the gingiva is, however, somewhat different. The structure appears less dense; the matrix is reduced and bacteria are more free.

Microbiology of Plaque

The microbiology of dental plaque varies greatly on an individual basis and from one area to another in the same mouth. Gram-positive bacteria predominate and are mainly from the Streptococcus and Actinomyces species. In most dental plaque, Veillonella, Neisseria and some gram-positive organisms and filaments are also found, to a lesser extent. Facultative anaerobic streptococci represent a significant proportion of bacteria encountered in plaque. The type and the relative amounts of microorganisms evolve with time, eventually producing an ecologic environment favouring anaerobes.3,5,6,7 With progression of periodontal disease, anaerobic gram-negative bacilli become more dominant.3,4

Consequences of Plaque

The presence of plaque plays an important role in 2 pathologic processes in the mouth, the development of caries (cavities) and periodontal diseases.4,5,8,9 Therefore, effective removal of supragingival dental plaque on a continuous daily schedule is essential to dental and periodontal health throughout life.10 Subgingival plaque can be removed only with a professional cleaning.

Cariogenic Effect

Dietary sucrose increases plaque formation and the resulting plaque is more cariogenic. Studies have shown that

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ingestion of sucrose favours the colonization and aggregation of microorganisms on teeth and prosthetic devices. Streptococcus mutans and lactobacilli play a primary role in cariogenic plaque. They act by metabolizing sucrose into an acid that causes demineralization of the enamel and, with time, tooth decay.5,8

Periopathogenic Effect

In order to initiate and maintain periodontal disease, plaque has to be present at the tooth surface. The pathogenic role of dental plaque is described in Periodontal Conditions: Gingivitis and Periodontitis.

Calculus

Dental calculus (tartar) is defined as the calcification of existing plaque deposits on the teeth or any other hard surface in the mouth (fillings, fixed or removable prostheses).3 It can be located supragingivally or subgingivally. When visible, it has a yellowish colour that may be darkened by dietary or exogenous pigmentation (e.g., coffee, tea, red wine, nicotine). Its formation starts in areas close to the salivary gland openings, i.e., lingual (tongue) side of the inferior incisors and the buccal (cheek) side of the upper molars. When located under the margin of the gingiva, the calculus often takes on a dark colour and is very adherent to the cementum of the tooth. The surface of the calculus is usually rough and favours plaque retention, subsequently leading to irritation and periodontal inflammation. The presence of dental plaque is a prerequisite for calculus formation. In most patients, calcification occurs within 48 hours in newly formed plaque. The amount of calculus being formed varies greatly from one individual to another, and depends on many factors such as the composition of saliva and the concentration of certain enzymes. Therefore, control of calculus formation begins with controlling plaque formation. Calculus requires removal by a professional, with ultrasonic, sonic or sharp instruments. In contrast, supragingival plaque can be controlled with good oral hygiene.

Plaque Control Mechanical Methods

Mechanical removal of plaque may be achieved by brushing the teeth after every meal and at bedtime, and by flossing once a day, preferably at bedtime. Plaque removal is more effective when toothpaste is used;8,9 fluoridecontaining toothpaste is recommended for caries prevention. In some patients, tools such as interproximal brushes, dental sticks (wood or plastic), interspace single-tufted brushes, handles with a rubber tip or wide spongy floss (e.g., Superfloss) may be helpful for removing plaque from areas difficult to access with a toothbrush and floss.2,9,11 These devices can also be useful for patients with orthodontic braces, dental implants, wide spaces between teeth or fixed dental prostheses such as bridge work. Irrigating devices (e.g., Water-pik) can also be useful for patients with bridges, orthodontic appliances or after oral surgery or for patients who do not have good manual dexterity. They can remove food debris and possibly some plaque.12 Therefore, they can be recommended as adjunctive devices only. Some studies suggest that a greater reduction of gingival inflammation may result from subgingival irrigation with chlorhexidine by the dentist.13,14 Table 1 presents a nonexhaustive list of devices and their role in removing plaque. Table 1: Dental Cleaning Devices

9,15,16

Device

Role

Toothbrush

Removes plaque from buccal (cheek) and lingual (tongue) sides and occlusal (biting) surfaces of the teeth

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Device

Role

Dental floss

Removes plaque from interproximal surfaces (between the teeth)

Interdental brush, interproximal brush Toothpick

Removes plaque from concave root surfaces when attachment loss (detachment of the gingiva due to bone loss) is present, and from other difficult-to-reach areas

Stimulator (rod curved at one end with a sharp rubber tip)

Removes plaque by applying contouring pressure to hyperplastic gingival papillae (noninflammatory enlargement of the gingivae)11

Rubber tip

Tooth Brushing The most recommended tooth brushing technique is the sulcular method, which focuses on removal of the plaque adjacent to and within the sulcus (see Teething).8,14,16 It is a very effective method for the removal of plaque, particularly from the gingival area of the tooth and gingival crevice (sulcus). Three to 4 minutes is probably the minimum time required to perform an effective plaque removal.8,15,17 The tongue should be brushed as well. The technique is described in detail in the patient information section at the end of the chapter.

Toothbrushes A suitable toothbrush is one with soft or extra-soft, flexible, rounded bristles that can penetrate into the gingival crevice to effectively remove plaque without causing trauma to soft and hard tissues. It should also be small enough to easily reach all areas of the mouth.13,14,16 Replacement of a toothbrush is recommended every 3 months, or as soon as the bristles start to splay.16 Studies have found no consistent superiority of one design over another for either plaque removal or gingival inflammation reduction.2,15 Mechanical/powered toothbrushes simulate manual tooth brushing in various ways, such as side-to-side or circular motion. A Cochrane systematic review found that only rotation oscillation, where brush heads rotate in one direction and then the other, is superior to manual toothbrushes at removing plaque and reducing gum inflammation, and is not more likely to cause injuries to gums. Long-term benefits of this for dental health are unclear.10,18 The use of a mechanical brush may be beneficial when manual technique has failed, for patients with limited dexterity or for patients with orthodontic appliances.2,13,15

Dentifrices Dentifrices (toothpastes, gels, pastes) aid in:17 Minimizing the accumulation of plaque and tartar

Strengthening the enamel against caries (fluoride-containing products) Cleaning the teeth by removing food debris and some stains Freshening the mouth

Dentifrices contain various combinations of the ingredients found in Table 2.19 Toothpaste with an attractive appearance and flavour encourages prolonged and regular use.17 The market is overwhelmed with toothbrushes and toothpastes. Products that have obtained the Canadian Dental Association (CDA) seal respond to the needs of most patients. Particular needs should be discussed with the patient's dentist or dental hygienist.

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Table 2: Ingredients of Toothpastes

For product selection, consult Compendium of Products for Minor Ailments. Dental Products: Dentifrices. Ingredients

Role

Comments

Detergents, e.g., sodium lauryl sulfate, sodium-N-lauryl sarcosinate

Foaming action may increase the solubility of plaque during brushing

Adverse effects (e.g., development of aphthous ulcers) in small percentage of patients may necessitate switching to a toothpaste without these agents.

Flavouring agents, e.g., sweetening agents

Improve palatability

Humectants, e.g., glycerol, propylene glycol, sorbitol

Prevent toothpaste from drying out

Thickening agents, e.g., mineral colloids, natural gums, seaweed colloids, synthetic celluloses

Stabilize the formulation

Abrasive agents, e.g., calcium carbonate, dehydrated silica gels, hydrated aluminum oxides, magnesium carbonate, phosphate salts

Remove debris and residual stains; whiten teeth

May cause burning sensation, drying of mucous membranes, taste alteration, gingival abrasion or enamel erosion. Tooth powders contain about 95% abrasives compared to 20–40 % in toothpastes and gels.

Peroxides, sodium triphosphate

Whiteners

May work by breaking down pigments that accumulate on or in the tooth enamel. Some stains cannot be removed by toothpastes containing these whiteners, e.g., tetracycline staining, mottling.

Pyrophosphates, triclosan, zinc citrate

Prevent supragingival calculus (tartar) formation. Do not affect subgingival or existing calculus.

Mechanism not established. One hypothesis is the reduction of crystal growth on the tooth surface through chelation of cations.

Stannous fluoride, triclosan, zinc citrate

Prevent gingival inflammation

Reduce plaque accumulation through antibacterial activity. Stannous fluoride (and other toothpaste ingredients) may interact with chlorhexidine mouthwash, rendering both agents less effective. Use them 30 min apart.

Fluoride

Reduces caries formation

At a concentration of 1000–1100 ppm, fluoride makes enamel more resistant to demineralization. Excess amounts can cause fluorosis (see Caries: Fluoride).

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Flossing Dental floss and tape, waxed or unwaxed, are equally effective for cleaning proximal surfaces. Individual factors such as contacts (where 2 adjacent teeth come together), restorations, tooth alignment and manual dexterity determine the type of floss used. The floss should slip easily between the teeth and pass the margin of the fillings without tearing and becoming lodged in the interproximal spaces. Unwaxed floss is suitable for most people; if it does not slide easily between the teeth, a waxed floss can be used. For persistent problems with tearing or fraying, brands such as Glide, Colgate Total or Eez-Thru can be tried. Floss-holding devices have proven effective for some patients who have difficulty guiding the floss with their fingers.14 Flossing should be performed every 24 hours along with brushing at least twice a day to prevent plaque formation and subsequent caries and gingival inflammation.2,20

Chemotherapeutic Methods Mouthwashes In addition to plaque removal by brushing and flossing, chemical plaque control agents may be desirable in some circumstances, and the use of a mouthwash has shown some benefits.21 A number of commercially available mouthwashes may be good adjuncts to help control the development of supragingival plaque and reduce subsequent gingivitis (Table 3). Oxygenating agents (e.g., hydrogen peroxide, carbamide peroxide) are not recommended because of lack of efficacy and potential adverse effects such as chemical burns of oral mucosa, decalcification of teeth and black hairy tongue. 19,21,22

Table 3: Mouthwashes

For product selection, consult Compendium of Products for Minor Ailments. Mouth Products: Mouthwashes. Active Ingredient(s)

Plaque and Gingivitis Reduction

Comments

Cetylpyridinium chloride 0.05%

Moderate

Less effective than chlorhexidine. May cause staining of teeth.

Chlorhexidine 0.12%

High

Gold standard. Requires prescription.

e.g., Cepacol e.g., Peridex

Limit use to once or twice daily; prolonged use may cause tooth staining, taste disturbances and discoloration of tongue. Other adverse effects include local irritation or allergic reactions.

Essential oils (thymol, menthol, eucalyptol and methyl salicylate), e.g., Listerine

High

Use for 30 seconds twice daily; high alcohol content in some products; may cause burning sensation, bitter taste or mucosal drying; not recommended for children because of alcohol content.

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Dental Caries

Dental caries is a localized and progressive dissolution and destruction of the calcified tissues of the teeth resulting from an infectious process.8,23 Bacteria from dental plaque (predominantly S. mutans and Lactobacillus) are capable of producing organic acids from the metabolism of dietary carbohydrates as well as from proteolytic enzymes. In response to the decrease in pH at the tooth surface, calcium and phosphate ions diffuse out of the enamel, and demineralization takes place. With an increase in pH, the process may be reversed. With time, disintegration of the mineral component of enamel and dentin occurs, with subsequent formation of a cavity on either the enamel surface or root surface. Patients with xerostomia (dry mouth) have a higher risk for and incidence of caries (see Dry Mouth).24

Early Childhood Caries

Any preschool-age child presenting with one or more decayed, missing (due to caries) or filled tooth surfaces in a primary tooth is considered to have early childhood caries (ECC), a complex and chronic disease. To reduce the risk of ECC, the Canadian Dental Association recommends dental assessments of infants within 6 months of the first tooth erupting and at least by the age of 1 year.25 Healthcare practitioners who identify children with ECC should refer them to a dental professional for further assessment and care.

Enamel Caries

Initially, the lesion appears as a white spot due to demineralization of the enamel. With repeated exposure to acid, the surface changes from smooth to rough and may become stained. If left untreated, pitting and then cavitation occurs.8

Arrested Caries

Under favourable conditions, the lesional process in the enamel may stop, become inactive and may even regress. Most of the time, arrested enamel caries have an opaque or dark appearance.8

Dentin Caries

In the dentin, demineralization is followed by bacterial invasion. Dentin has the ability to produce secondary dentin in an attempt to protect the pulp, but its proximity to the pulp also represents a risk of bacterial invasion into the tooth structure.8

Susceptible Sites

The sites on the tooth where plaque can accumulate are more prone to decay: pits and fissures (occlusal surface for the posteriors and palatal surface for the anteriors), smooth enamel surfaces that shelter cariogenic biofilm (proximal and cervical areas) and the root surface. Susceptibility is also dependent upon host factors such as the volume and composition of the saliva.8,23

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Prevention of caries can be achieved by:8,23 Protecting the teeth or strengthening the tooth structures

Reducing the amount of substrate available to the bacteria

Removing plaque and calculus through mechanical or chemical procedures A combination of the following interventions can facilitate the goals of caries prevention:8,23,24,25,26 Dental assessment of infants within 6 months of eruption of first tooth and no later than 1 year of age Regular professional dental care

Good, regular oral hygiene methods

daily mouth cleaning or tooth brushing for all infants, including those who are breastfed27

Diet low in sugar and dietary acids Topical and/or systemic fluorides Control of salivary flow

Caries Treatment Depending on caries risk and incidence, some therapeutic modalities may be recommended:8,26,28,29 Modification of the diet in order to limit the substrate, e.g., favouring a noncariogenic diet and limiting exposure to sucrose Modification of microflora, e.g., antibacterial mouthwash, topical fluoride

Plaque disruption, i.e., good oral hygiene involving brushing, flossing, use of other aids

Modification of tooth surface, e.g., topical or systemic fluoride, smoothing of tooth surface Stimulation of salivary flow, e.g., sugarless gum, xylitol-containing gum, medications

Restoration of tooth surfaces, e.g., sealing of pits and fissures at risk for caries, restoration of cavited lesions, correction of defects

Pits and Fissures Sealants

The Canadian Dental Association supports the appropriate use of selective sealants based on an individual caries risk assessment and diagnosis by the dentist, along with nutritional counselling, good oral hygiene optimal fluoride exposure and regular dental exams.30,31

Role of Saliva Saliva plays various protective roles against tooth decay:6,8,24 Acts as a reservoir of calcium, phosphate and fluoride ions and therefore favours remineralization Contains IgA, lysozyme and peroxidase, which provide some antibacterial action Decreases plaque accumulation and helps eliminate food debris

At high flow rates it has an alkaline pH, which helps buffer against organic acids.

Fluoride The use of fluoride to prevent and control dental caries is well documented, safe and effective.26,32,33,34 Systemic fluoride improves the crystallinity and decreases the acid solubility of enamel formed in the pre-eruptive phase of tooth development. In addition, it may affect tooth anatomy and reduce the risk of caries associated with pits and fissures in the teeth. Locally administered fluoride benefits the enamel by reducing demineralization and promoting

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remineralization of early caries. The resulting remineralized enamel has improved resistance to acid attack. In the presence of fluoride, acid production by bacteria in plaque is decreased, as is the synthesis of extracellular polysaccharides.8,22 The addition of fluoride to drinking water is recognized as a cost-effective public health measure.26 In areas where the water is not fluoridated, supplemental oral fluoride may be considered.30,34 For caries prevention in children, the monitored use of fluoridated dentifrice (for a child between 3 and 6 years old a pea-sized amount on the toothbrush; for a child younger than 3 only a smear of toothpaste, and the teeth should be brushed by an adult) is recommended until the child is able to expectorate the dentifrice, which is around the age of 6.26,30,32 To minimize the risk of fluorosis, it is important for the caregiver to ensure the child does not swallow the toothpaste. A nonfluoridated dentifrice may be considered until the age of 3.32 In some cases, based on the individual child's risk of caries, professionally applied fluoride may be indicated. For children considered at high risk for caries, home protocols may be recommended by the dentist on an individual basis.26,34 CDA does not recommend the routine use of fluoride supplements before the eruption of the first permanent tooth. In individual cases where the benefits outweigh the risk of dental fluorosis, practitioners may recommend supplements to young children at appropriate doses. To minimize the risk of dental fluorosis, all other sources of fluoride should be carefully assessed to ensure that total fluoride intake does not exceed 0.05–0.07 mg/kg body weight.26 After the eruption of the first permanent tooth the risk of dental fluorosis is decreased and fluoride supplement in the form of lozenges or chewable tablets could be considered as the fluoride would be delivered locally (intra-orally). Lozenges and chewable tablets should be used preferentially over drops for their local action. A lozenge or chewable tablet containing 1 mg of fluoride delivers the same amount of fluoride as 1 g (average amount used) of a 1000 ppm fluoride toothpaste.26 Excessive amounts of fluoride may result in dental fluorosis, which manifests as white specks on the child's teeth. It is a permanent cosmetic alteration of the enamel; there is no evidence that it affects the health of the child. It affects mainly younger children.24 To minimize the risk of fluorosis, the total daily dose of fluoride should not exceed 0.05–0.07 mg/kg of body weight.34 Fluoride mouthwashes could be recommended to patients at high risk of developing caries, as a preventive measure. The CDA does not recommend this measure for patients under 6 years of age.26 Other forms of fluoride may be applied professionally (fluoride gels, foams and varnishes) in infants and adult patients at high risk of developing caries.26,33,34 For most Canadians the other forms of fluoride supplements (chewable tablets, lozenges, drops) are not recommended. They may be indicated for high-risk individuals in nonfluoridated communities when fluoride is not obtained in other forms (toothpaste) and after a careful analysis of the total amount from all other sources has been completed.26 Children who may be at higher risk for caries due to orthodontic or prosthodontic appliances or reduced salivary function, or children with high caries activity, should be considered for fluoride supplements.32 Gastric distress, headache and weakness have been reported in cases of excessive ingestion. Allergic reactions such as rash and other idiosyncratic reactions have been rarely reported.32 When taken as directed, no adverse effects have been reported.32 To prevent overdoses, no more than 120 mg of fluoride should be dispensed per household at one time.32 Fluoride tablets should be taken with a glass of water or juice. Calcium from milk or other dairy products may bind with fluoride causing both to be poorly absorbed.32

Care of Prostheses

Any removable prosthesis should be cleaned after eating and before going to bed. Plaque and tartar can

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accumulate on artificial teeth as on natural ones. A soft toothbrush may be used to clean the prosthesis using a regular toothpaste. The gums and the remaining teeth should be cleaned carefully as well, with a soft tooth brush. For patients who wear a partial denture, special attention should be paid to cleaning the teeth under the denture's metal clasps as plaque may become trapped which would increase the risk of tooth decay.30 The toothbrush is not sufficient to remove debris; therefore, immersing the device in a commercial denture cleaning solution is helpful. The patient should soak the dentures for 15 minutes once daily in the cleaning solution, then brush them with a dentifrice. Sodium hypochlorite solutions are effective denture cleaners; however, they should be avoided for dentures with metal parts since they have a tendency to cause corrosion of the metal. Household products should be avoided because they are too abrasive for use on acrylic resin surfaces. Dentures should be cleaned over a basin filled with water so that if they are accidentally dropped, the water will prevent breakage. In spite of proper cleaning techniques, calculus may build up on some prostheses. Calculus should be removed in the dental office with an ultrasonic cleaner. Dentures should not be worn at night unless recommended by the dentist. They should be placed in a container and soaked (completely covered) in lukewarm water to prevent dehydration and subsequent dimensional change. If the patient is not able to brush the dentures after the midday meal, they should at least thoroughly rinse the dentures and mouth. A Health Canada advisory in February 2010 alerted denture wearers to serious health risks associated with excessive use of zinc-containing denture adhesives. Zinc is absorbed systemically when small amounts of zinc-containing adhesive are swallowed during normal use. When these adhesives are applied too frequently or in excessive quantity, over-exposure to zinc can lead to copper deficiency with possible blood dyscrasias and/or neurologic symptoms. Caution patients to use adhesives only according to the manufacturers' instructions and to consult their physician if they may have been exposed to excessive amounts of zinc through over-use of these products. Implants should be brushed and flossed carefully every day. All sides of the implant should be brushed, and floss used with caution where the implant meets the gum line.30,35,36

Resource Tips

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Canadian Dental Association. Available from: www.cda-adc.ca. Perry DA. Plaque control for the periodontal patient. In: Newman MG, Takei HH, Klokkevold PR et al., eds. Carranza's clinical periodontology. 11th ed. St. Louis: Saunders; 2012. p. 452-60.

Suggested Readings

Ritter AV, Eidson RS, Donovan TE. Dental caries: etiology, clinical characteristics, risk assessment, and management. In: Heymann HO, Swift EJ, Ritter AV, eds. Sturdevant's art and science of operative dentistry. 6th ed. St. Louis: Elsevier/Mosby; 2013. p. 41-88.

References 1. Flemmig TF. Periodontitis. Ann Periodontol 1999;4:32-8. 2. Claydon NC. Current concepts in toothbrushing and interdental cleaning. Periodontol 2000 2008;48:10-22. 3. Manson JD, Eley BM. The oral environment in health and disease. In: Manson JD, Eley BM, eds. Outline of periodontics. 4th ed. Oxford: Wright; 2000. p. 26-33. 4. McHugh WD. Dental plaque: thirty years on. In: Newman HN, Wilson M, eds. Dental plaque revisited : oral biofilms in health and disease : proceedings of a conference held at the Royal College of Physicians, London, 3-5 November 1999. Cardiff: BioLine; 1999. p. 1-4.

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5. Rolla G, Waaler SM, Kjaerheim V. Concepts in dental plaque formation. In: Busscher HJ, Evans LV, eds. Oral biofilms and plaque control. Australia: Harwood Academic; 1998. p. 1-17. 6. Marsh PD, Bradshaw DJ. Microbial community aspects in dental plaque. In: Busscher HJ, Evans LV, eds. Oral biofilms and plaque control. Australia: Harwood Academic; 1998. p. 43-55. 7. Jones CG. Chlorhexidine: is it still the gold standard? Periodontol 2000 1997;15:55-62. 8. Ritter AV, Eidson RS, Donovan TE. Dental caries: etiology, clinical characteristics, risk assessment, and management. In: Heymann HO, Swift EJ, Ritter AV, eds. Sturdevant's art and science of operative dentistry. 6th ed. St. Louis: Elsevier/Mosby; 2013. p. 41-88. 9. Perry DA. Plaque control for the periodontal patient. In: Newman MG, Takei HH, Klokkevold PR et al., eds. Carranza's clinical periodontology. 11th ed. St. Louis: Saunders; 2012. p. 452-60. 10. Perry DA. Plaque control for the periodontal patient. In: Carranza FA, Newman M G, Takei HH et al., eds. Carranza's clinical periodontology. 10th ed. St. Louis: Saunders Elsevier; 2006. p. 728-48. 11. West NX, Moran JM. Home-use preventive and therapeutic oral products. Periodontol 2000 2008;48:7-9. 12. Gorur A, Lyle DM, Schaudinn C et al. Biofilm removal with a dental water jet. Compend Contin Educ Dent 2009;30:1-6. 13. Forgas L. Plaque control. In: Fedi PF, Vernino AR, Gray JL, eds. The periodontic syllabus. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2000. p. 75-85. 14. Wilson TG, Kornman KS. Treating plaque-associated gingivitis. In: Wilson TG, Kornman KS, eds. Fundamentals of periodontics. Chicago: Quintessence Pub.; 1996. p. 319-47. 15. Handcock EB, Newell DH. Preventive strategies and supportive treatment. Periodontol 2000 2001;25:59-76. 16. Manson JD, Eley BM. Prevention of periodontal disease. In: Manson JD, Eley BM, eds. Outline of periodontics. 4th ed. Oxford: Wright; 2000. p. 132-44. 17. Forward GC, James AH, Barnett P et al. Gum health product formulations: what is in them and why? Periodontol 2000 1997;15:32-9. 18. Robinson PG, Deacon SA, Deery C et al. Manual versus powered toothbrushing for oral health. Cochrane Database Syst Rev 2009;(1):CD002281. 19. Mariotti AJ, Burrell KH. Mouthrinses and dentifrices. In: American Dental Association. ADA guide to dental therapeutics. 2nd ed. Chicago: ADA Pub.; 2000. p. 211-29. 20. Sambunjak D, Nickerson JW, Poklepovic T et al, Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database System Rev 2011;(12):CD008829. 21. Stoeken JE, Paraskevas S, van der Weijden GA. The long-term effect of a mouthrinse containing essential oils on dental plaque and gingivitis: a systematic review. J Periodontol 2007;78:1218-28. 22. Jackson RJ. Metal salts, essential oils and phenols–old or new? Periodontol 2000 1997;15:63-73. 23. Manton DJ, Drummond BK, Kilpatrick N. Dental caries. In: Cameron AC, Widmer RP, eds. Handbook on pediatric dentistry. 3rd ed. Edinburgh: Mosby Elsevier; 2008. p. 39-52. 24. Bourassa M, Perusse R. Making their mouths water: general principles for treating xerostomia patients. Canadian J Restorative Dentistry Prosthodontics 2008;1:24-7. 25. Canadian Dental Association. CDA position on early childhood caries. Ottawa (ON): CDA. Available from: https://www.cda-adc.ca/_files/position_statements/earlyChildhoodCaries.pdf. Accessed December 2014. 26. Canadian Dental Association. CDA position on use of fluorides in caries prevention. March 2012. Available from: www.cda-adc.ca/_files/position_statements/fluorides.pdf. Accessed January 28, 2013. 27. Canadian Dental Association. CDA position on breastfeeding and early childhood caries. Ottawa (ON): CDA. Available from: https://www.cda-adc.ca/_files/position_statements/BreasfeedingandECC.pdf. Accessed December 2014. 28. Deshpande A, Jadad AR. Impact of polyol-containing chewing gums on dental caries: a systematic review of original randomized controlled trials and observational studies. J Am Dent Assoc 2008;139:1602-14. 29. Splieth CH, Alkilzy M, Schmitt J et al. Effect of xylitol and sorbitol on plaque acidogenesis. Quintessence Int 2009;40:279-85. 30. Canadian Dental Association. Available from: www.cda-adc.ca. Accessed January 26, 2013. 31. Beauchamp J, Caufield PW, Crall JJ et al. Evidence-based clinical recommendations for the use of pit-andfissure sealants: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2008;139:257-68. 32. Burrel KH, Chan JT. Systemic and topical fluorides. In: American Dental Association. ADA guide to dental therapeutics. 2nd ed. Chicago: ADA Pub.; 2000. p. 230-41.

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33. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Am Dent Assoc 2006;137:1151-9. 34. Brearley Meser L, Mekertichian K. Fluoride modalities. In: Cameron AC, Widmer RP, eds. Handbook on pediatric dentistry. 3rd ed. Edinburgh: Mosby Elsevier; 2008. p. 53-69. 35. McGivney GP, Castlebeery DJ, eds. McCracken's removable partial prosthodontics. 9th ed. St. Louis: Mosby; 1995. p. 442-3. 36. American Dental Association. Available from: www.ada.org. Accessed January 26, 2013.

Healthy Teeth and Gums — What You Need to Know Dental Check-ups

See your dentist and hygienist at least once a year, or as often as they recommend.

Infants should be brought to the dentist for the first visit within 6 months of the eruption of the first tooth or by the age of 1 year.

Brushing your Teeth

Brush your teeth after each meal and before going to bed.

Use a toothpaste that you like and that has the seal of the Canadian Dental Association (CDA). Your dentist or hygienist may also recommend a toothpaste. Replace your toothbrush with a new one every 3 months or sooner if the bristles are frayed. Make sure you use a toothbrush with soft or ultra-soft bristles.

How to Brush Properly

Place your brush at a 45° angle to your teeth. The bristles should reach the place where the gum and the teeth meet. Move your brush in a gentle circle, starting at the gum and moving towards the top of the tooth. Do not scrub your gums hard. You could damage them and your gums could recede.

Use this gentle circle technique to clean each tooth on the cheek side and the tongue side. For the tongue side of the front teeth, use the tip of your toothbrush. Finish by cleaning the chewing surface of each tooth. Brush for about 3–4 minutes to make sure your teeth are clean.

Flossing

Flossing is very important because it removes plaque that you can't reach with your toothbrush, which is about 1/3 of the tooth surface. Flossing every day helps keep your gums healthy. It also prevents tartar from forming on your teeth. Tartar is like hardened plaque. You can't remove it yourself. Only your dentist or hygienist can do it.

How to Floss Properly

Take about 40–50 cm (16 to 20 inches) of floss (about the length between your hand and your shoulder). Wrap each end around your middle fingers, leaving about 8–10 cm (3–4 inches) between your hands.

Hold the floss between your thumb and index finger of each hand, leaving about 2.5–5 cm (1–2 inches) in between.

To clean the teeth of the lower jaw, use the index fingers of both hands to guide the floss between the teeth.

For the upper jaw, use the index finger of one hand and the thumb of the other to guide the floss. Never snap the floss into the gums.

Slide the floss between your teeth and when it reaches the gum line, wrap it into a “C” shape around the tooth

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and move it gently under the gum line.

Holding the floss tightly against the tooth, glide it up and down 2 or 3 times.

Floss both sides of each tooth. Don't forget the back of your last upper and lower molars. Change to a new section of the floss as it wears.

For a better result, brush your teeth after flossing.

Mouthwash

If your dentist prescribes a mouthwash for you called chlorhexidine (Peridex), this is how you should use it: Brush your teeth carefully.

Rinse your mouth well with water to remove any toothpaste that is still in your mouth. Measure the amount of mouthwash prescribed.

Swish it in your mouth for 30 seconds, then spit it out.

Repeat these steps as often as your dentist recommends.

Do not use the mouthwash for more than the number of days your dentist recommended. It can cause dark stains on your teeth and fillings if you use it for too long. CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-03-2016 02:06 PM] RxTx, Compendium of Therapeutics for Minor Ailments © Canadian Pharmacists Association, 2016. All rights reserved

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