My spouse brushes his teeth daily and uses a mouthwash regularly. Despite these efforts he seems to always have bad breath. What do you think we should do?

If your spouse has not had a dental examination within the last 6 months I would urge you to have him do so. More often than not what you are describing is a result of gum and bone disease. As mentioned in an earlier column, this is normally very treatable and predictable. The odor could be due to the presence of plaque (broken down food particles) on his teeth and below his gums. If this is the case, having his teeth scaled is all he may need. A scaling in combination with good home care instructions can bring his mouth to a healthy state. Once healthy, all you need do is thorough home care and regular visits to your dentist.

If after your spouse sees his dentist, he or she does not feel the reason for the odor is in his mouth,  I would encourage you to see your family medical doctor. He or she will do an examination and run some tests that may uncover the reason for the bad odor.

Is there a particular toothbrush that you recommend? How about floss and mouth rinse?

The main thing to look for in a toothbrush is the bristles. Contrary to what some people may believe, it is important that the bristles be soft so as not to damage both the gum tissue as well as the enamel. There are so many tooth brushes on the market today with different shapes, head sizes and angles. However, none of these features are as important as your brushing technique.

In my practice I find that rechargeable electric toothbrushes can make a large difference in some patient's overall oral hygiene.

Floss also comes in many different types. Your choice of floss should depend on the size of the space between your teeth. For those of you with extremely tight contacts there are Teflon Coated Flosses. For those with larger spaces between their teeth I find that dental tape works very nicely. Most patients find that waxed floss is easier to use and some prefer the taste of flavored floss. As with toothbrushes, the technique is more important than the type of floss.

Mouth rinses are an important part of your home care routine. I suggest that my patients rinse with a stannous fluoride rinse. This happens to be a prescription, however, it is by far the best rinse to use. Among its benefits are its ability to kill some of the bacteria that cause both gum disease and decay. It will also help harden the outer surface of the tooth, thereby decreasing the possibility of decay. It also tightens up the tissues, making your mouth a healthier environment.

My daughter is a hygienist and she was telling me about a special program that she and her dentist have for people with gum disease. Can you explain this to me?

During a new patient examination, your dentist will be taking measurements of what we call a "pocket" between your tooth and gums. These measurements are in millimeters and start at 1 and can go as high as 10 to 12. If you have pockets greater than 4 millimeters there is a good chance you have periodontal disease. When detected early, like many diseases, there are a lot of things that can be done to treat it. One of these things is probably what your daughter is talking about. In broad terms, it can be called non-surgical periodontal treatment. You may also hear it referred to as a "soft tissue management program" or "root planing and scaling." All of these terms refer to the treatment of your gums when affected by periodontal disease or, as called in the past, pyorrhea. To follow is a brief explanation of what a dentist and hygienist might do for you. They will typically get you numb and clean out all the areas around your teeth in two to four sessions. Depending on the severity, you will be treated by quadrant (1/4 mouth) or by half mouth. These sessions will take between 3 and 4 hours collectively. In many cases, you will return for some additional sessions to review proper home care and to check that you understand what the hygienist expects of you at home. This understanding and ability to perform good home care is critical to the success of the treatment. The hygienist will also review the use of many different home aids - all of which depend on your particular circumstance. Some of these aids might be a toothbrush, floss, an electric toothbrush, fluoride, gum stimulators, special toothbrushes for between your teeth and many more. At the end of these sessions, you will be re-evaluated by re-recording the measurements that were taken at the start of treatment. You should see a decrease in the depths of the pockets around the teeth. If this didn't occur to the satisfaction of your dentist and hygienist, your dentist will probably make some additional suggestions for you. I hope this helped clear up what you and your daughter were talking about.

What is the best technique for brushing?

There are a number of effective brushing techniques. One effective, easy-to-remember technique involves using a circular or elliptical motion to brush a couple of teeth at a time, gradually covering the entire mouth. Place a toothbrush beside your teeth at a 45-degree angle and gently brush the teeth in a circular motion. Brush the outside of the teeth, inside the teeth, your tongue, and the chewing surfaces and between the teeth. Using a back and forth motion causes the gum surface to recede or can expose the root surface or make the root surface tender. You also risk wearing down the gum line.

Should I use soft or hard bristles?

In general, a toothbrush head should be small (1" by 1/2") for easy access. It should have a long, wide handle for a firm grasp. It should have soft, nylon bristles with round ends. Some brushes are too abrasive and can wear down teeth. A soft, rounded, multi-tufted brush can clean teeth effectively. Press just firmly enough to reach the spaces between the teeth, as well as the surface. Medium and hard bristles are not recommended.

How long should I brush?

It might be a good idea to brush with the radio on since I generally recommend brushing 2 minutes - the length of an average song. Using an egg timer is another way to measure your brushing time. Also, most rechargeable electric toothbrushes have 2 minute timers. You would be surprised how long 2 minutes is when you are actually timing it. Patients generally think they are brushing longer, but most spend less than a minute brushing. To make sure you're doing a thorough job I recommend you brush a good 2 minutes two times a day rather than 4 or 5 times quickly. You might also remember those little red tablets we used as children. I like to recommend that, for about two weeks after your hygiene appointment, you chew one of these disclosing tablets before brushing and then brush until you get all the red off. This will help teach you where you build up plaque. After 2 weeks I suggest you brush and floss as usual and then disclose with a tablet. Hopefully, you will have gotten all the red off and are doing a good job. If not, you will find the spots you need to work on. This can be used on all ages and, for the children, it can become a sort of game you play.

Should I brush at work?

Definitely, but most Americans don't brush during the workday. I would suggest that you keep a toothbrush at your desk, which will increase the chances that you'll brush during the day by 65 percent. Getting the debris off the teeth right away stops sugary snacks from turning to damaging acids, and catches starchy foods, like potato chips, before they turn to cavity-causing sugar. If you brush with fluoride toothpaste in the morning and before going to bed, you don't even need to use toothpaste at work. You can just brush and rinse before heading back to the desk. If you don't have a toothbrush, rinsing your mouth for 30 seconds after lunch also helps. The following tips may improve your work-time brushing:

  • Post a sticky note on your desk or computer at work as a reminder to brush your teeth after lunch
  • Brush your teeth right after lunch, before you become absorbed in work
  • Store your toothbrush and toothpaste at work in a convenient and handy place
  • Make brushing your teeth part of your freshening up routine at work.

What about those rechargeable electric toothbrushes - do you recommend them?

For some people, rechargeable electric toothbrushes are a must. Many of my patients use a rechargeable electric toothbrush dipped in a fluoride rinse. By not using toothpaste they do not get a lot of foaming and, therefore, get a better result. I have seen a significant reduction in the amount of plaque we see on recall as well as the occurrence of new decay in my patients that are faithful to this routine.

I have been looking at some of the rechargeable electric toothbrushes in the stores recently. Do you have any preferences on which is the best to use?

I am glad that you asked this question. I do in fact have a preference in choosing a rechargeable electric toothbrush. I have recommended various toothbrushes in the past but, presently, the one that I feel stands out above the rest is the Sonicare. The Sonicare has a rechargeable battery that sits in the base to keep it charged. Its head is the size of a conventional toothbrush and oscillates back and forth 31,000 times a minute. The professional model has a built-in timer that beeps every 30 seconds to signal you to move to the next quadrant of your mouth and turns off after 2 minutes. The head is replaceable making it ideal to share among a family. There are many other benefits to the Sonicare. If you would like a brochure on the brush I would be happy to send it to you. The Sonicare toothbrush is available in many department and discount stores. You can also get it at many dental offices. If you purchase it at a dental office you will get the professional model, as well as for instructions on its use. You should check with your dentist to see if he or she has the brush available. If you decide to get it I am sure that you will be thrilled. It is a great brush that I use every night.

The following is a question I received from someone in the audience at a Kiwanis meeting where I presented a brief synopsis on periodontal disease: Is it true that a gum graft can be done using your own gums, as well as tissue from a cadaver?

The most common use of a gum graft is to augment the gum tissue around the teeth that is attached to the bone below. If someone is deficient in this tissue a dentist can do a surgical procedure that replaces the lost tissue. The tissue is generally harvested from the patient's own mouth, typically from the palate or roof of the mouth. In the event that a lot of tissue is needed it may make sense not to take it from the patient's mouth and instead utilize tissue from a tissue bank. The tissues in this bank are generally taken from cadavers and processed in such a way as to make the procedure very safe and predictable. If there is any discomfort associated with a graft it is typically from the donor site. If the graft is from a tissue bank there will be no donor site and therefore less discomfort.

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