Why Brushing and Flossing Not Enough?
The title of this post brings to mind something I hear at least every week from a patient who has just been diagnosed with some degree of gum disease, and that is, “I brush and floss every day. I couldn’t possibly have gum disease.” I can genuinely empathize with patients who didn’t know they had a systemic infectious disease with potentially serious health risks, and can easily understand their frustration upon discovering that their conscientious home-care efforts simply weren’t capable of keeping them healthy.
Having discussed what goes on under the gums, in the sulcus, we know how important it is to cleanse this space frequently enough to make sure the gum tissue remains a healthy barrier. This isn’t easy, especially if you are depending on brushing and flossing to accomplish this important task; you have to consider the sheer volume of food debris, living and dead microorganisms, odors, sloughed-off skin cells, and toxins that can build up around the normal complement of twenty-eight to thirty-two teeth in that space under the gums. In the majority of cases, this stew in the sulcus is the spark that sets off periodontal disease. While not pleasant to think about, all this is toxic waste that contains the rotted remains of literally trillions of dead microorganisms, all producing inflammation, and odor that is, for the most part, trapped in the sulcus. This stew can also contain various amounts of dead white blood cells (the cells that fight infection when they are living), with sulcular pus and periodontal abscesses containing very high amounts. Since these dead white blood cells also rot, as the infection progresses and the numbers of dead cells accumulate dramatically, their rotting contributes to the breakdown of soft tissue and the perpetuation of the disease process.
This moist mixture produces inflammatory components, such as leukotrienes, proinflammatory cytokines, and prostaglandins (each associated with inflammation anywhere in the body), as well as the volatile sulfur compounds (VSCs) hydrogen sulfide and methyl mercaptan. These two VSCs are known to activate collagenase, which breaks down collagen (unfortunately, in the sulcus, this collagen happens to be the sulcular wall in the gum tissue). As previously mentioned, hydrogen sulfide and methyl mercaptan are easy to recognize by their smell—rotten eggs and sewer gas, respectively.
The harmful effects of the toxic stew under the gums, which leads to the breakdown of the gum-tissue wall due to collagenase produced by VSC and other toxic substances, in turn, allows up to 400 types of microorganisms to spread throughout the body via the circulatory system. These microorganisms create myriad problems, including inflammation, and have been found in blood clots evaluated at autopsy. Perhaps the most serious effect of all is the inflammation-induced elevation of C-reactive protein. As discussed in (Should I Worry About Gum Disease?), this substance is produced by the liver in response to a wide range of chemical and microbiological causes. CRP circulates at low levels in healthy individuals but rises considerably in response to infection, inflammation, and injury, and gum disease is associated with all three of these stimuli. If you remember some of Bif’s problems, his CRP levels would probably be off the chart. A 1999 article in Diabetes Care described a study of 16,573 people in which about “90 percent of apparently healthy individuals have C-reactive protein levels (less than) 3 mg/L and 99 percent have (less than) 10 mg/L,” so we can assume that the lower the reading, the better. Gum disease, as we said, can elevate CRP levels to more than 1,000 times the normal healthy upper limit, and I have no doubt the CRP healthy upper limit is being reconsidered as the knowledge of its severe health consequences is becoming better known. CRP levels are directly related to circulating levels of inflammation-inducing blood elements. CRP has been responsible for causing clotting anywhere in the body, including the brain, heart, legs, and lungs.
Collectively, odors, circulating microorganisms, and elevated CRP can exact a terrible toll on a person’s health. In the Physicians Health Study that followed a broad range of lower-risk males, it was found that those with the highest CRP levels had triple the risk of a heart attack, as well as double the chances of having a stroke. So to be on the safe side, it is well to reduce all factors that can elevate CRP.
It is “estimated that more than 100,000,000 American adults have moderate to severe periodontal disease, not counting gingivitis or early stage periodontal disease,” so it doesn’t take too much guesswork to figure out what might be elevating CRP in much of the United States population. Even worse, the letter (in Dental Economics, August 2002) containing the statistics quoted above stated that only 3 percent of the population receives conventional dental treatment in a given year. That means about 97 percent of the population is either receiving “unconventional treatment,” or, more likely, no treatment at all. I would agree with that.
You have already read about the stew that builds up in the sulcus and its role in initiating inflammation, so one of the keys to keeping CRP at the lowest levels possible is to control what goes on in the sulcus. In some people, this stew buildup can be negligible and requires only minimal effort to control. These fortunate individuals manifest little or no evidence of disease, yet others can find it very challenging to maintain the cleanliness of the sulcus—and, to repeat, one of the keys to controlling the periodontal disease is to keep the sulcus clean. But what percentage of the population even thinks about keeping the sulcus clean on a regular basis?
What makes home-care efforts so vexing for the dentist or hygienist, and so frustrating for their patients who find out their efforts aren’t working, is that many people think that state-of-the-art home care is basically just brushing well two or three times a day, and flossing at least once a day. Most people now know to brush and floss after every meal, three times a day, and to floss thoroughly at least once a day, probably because this message has been drummed into their heads over the years in toothpaste or mouthwash advertisements that induce them to buy and use certain products. Unfortunately, the public has been grievously misinformed about brushing, flossing, and using some advertised product; they all still fall short of what’s required for genuinely effective oral (systemic) health maintenance, by far, even though together they make up the current standard for oral care.
Let’s begin with the shortcomings of brushing. The problem is, although brushing with a manual toothbrush can be very effective at cleaning the teeth from the point of the gum margin, this tool is incapable of doing much to clean down to any significant depth below the gum margins, and certainly not down to the probing depths most people have around their teeth, where the toxic stew resides.
Compounding the frequently ineffectual home-care regimen is the notion that flossing somehow cleans under the gums. It does, but only so far as the soft tissue on the tongue side and cheek side of the tooth will let it. The depth below this level is where most of the disease occurs (gingivitis excepted). While flossing has definite benefits for many who perform this important task, it has been said that only 2 percent of the population flosses every day. Even doubling that to 4 percent still leaves 96 percent of the public not flossing even once a day. And those who do floss can’t clean the stew out from under the gums. In fact, although flossing does move the plaque and food debris that builds up between the teeth, and does dislodge some of it so it can be cleaned out of the mouth, the balance of the debris is forced into the sulcus.
The pitfalls of home care can be made even worse if you use a toothpaste or mouthwash containing ingredients that carry warnings to “seek professional help or contact a poison control center immediately,” and are known to cause harm. And these are products that are supposed to help us get healthy? As mentioned in (Toxic Toothpaste and Scary Mouthwash!), my professional advice is to stay away from them. Products containing ingredients that can kill people, induce oral cancer, cause allergic reactions, burn, itching, redness, and soft-tissue sloughing, and degrade tooth-colored fillings and cosmetic dental bonding agents are not improving the health of the user. People with gum disease already have enough problems without adding toxic products to their oral health program.
The federal government has compiled much of this disturbing information (oral cancer statistics, alcoholic-mouthwash-ingestion deaths, and so on) and it is available to anyone who is interested in seeing it. Universities and independent research labs have done valuable work to determine other harmful effects of oral health products. ADA-approved or not, if a person is interested in his or her health, these products need to stay undisturbed in their respective tubes and bottles, as colorful displays on the store shelf where they can’t possibly do any harm. As far as I am concerned, oral health can best be accomplished by exclusively using healthy products and techniques.
I would like to make it clear, just for the record, that I am all for brushing and flossing. Both of these activities are fundamental oral health procedures, and both offer benefits if they are done frequently (brushing and flossing have to be done often enough to keep plaque, and other debris removed by these activities, at sufficiently minimal levels to ensure that the gum tissue remains healthy). I especially want a patient’s brushing and flossing efforts to be effective and non-injurious, but unfortunately, I often see just the opposite. It is extremely common for dentists to see toothbrush abrasion from improper brushing or the effects of the wrong kind of brush. As I said earlier, hard and medium brushes should only be used for cleaning small motor parts and boots, not teeth. As far as flossing is concerned, gingival clefts (cuts) are also quite common when this procedure is done improperly, and the daily inflammatory injury to the gums not only allows microorganisms into the body but also causes gum and bone recession, even occasional tooth loss. (For some reason, I’ve seen moderate to severe flossing damage almost exclusively in women, some of it requiring surgery to repair the damage.) These are very poor rewards for such vigorous efforts intended only to improve health. Brushing and flossing can both be performed effectively, and without injury, which I will cover in Chapter 7.
I hope the information here and in the previous posts has convinced you that your oral and systemic health can largely depend on how clean you keep your mouth—and that brushing and flossing can’t do it alone. Chapter 7 will outline much of the specific information that has proven beneficial, even lifesaving, in helping my patients recover from both oral and systemic disease. I said it before, but it bears repeating, that the mouth is intimately connected to the whole body, and I hope you can sense that we are entering a new era in which periodontal disease is viewed as a major cause of systemic disease, and gum disease and its inflammatory consequences is understood to cause even death in extreme cases.
The public’s perception of periodontal disease and its consequences are, unfortunately, still not yet in tune with the health consequences associated with what is, in fact, a systemic infection. Until those perceptions change on a widespread basis within the medical and dental professions, as well as in the public domain, we will continue to lose the battle. However, perceptions and concepts can occasionally change almost overnight, and I am encouraged that the public and the health professions may soon start viewing periodontal disease and its potentially lethal toll in a totally new light. Only then will any meaningful improvement occur. I don’t know if a person’s cause of death will ever be listed as gum disease since it was perhaps a heart attack or a stroke that ultimately caused the death, but I do know that it would certainly help elevate the public’s awareness of how serious this health problem is.