A Prosthodontist Answers All Your Questions About the Right Way to Brush Your Teeth

WORDS DR ZETHY HANUM MOHAMED KASSIM

FEATURED EXPERT
DR ZETHY HANUM MOHAMED KASSIM
Senior Lecturer and Prosthodontist
Faculty of Dentistry
Universiti Teknologi MARA (UiTM)

The health of your teeth and their supporting structures can be compromised by decay.

Indeed, tooth decay affects an estimated 2 billion adults and 514 million children worldwide, while gum disease affects 19% of the world population.

The following are answers to some common questions commonly received by dentists, related to the maintenance of healthy teeth and gums.

WHAT ARE THE CAUSES OF DENTAL DISEASES?

The main culprit is plaque.

Plaque is a sticky white substance found on the surface of a tooth. It contains bacteria, proteins, bacterial by-products, and food debris.

Tooth decay

Bacteria in plaque ferment sugar into lactic acid, the latter can cause the tooth to lose important protective minerals via a process called demineralization. Over time, this process will lead to tooth decay.

Gum disease

The presence of bacterial products can also trigger an overt response from your immune system. This could result in gum disease that, if left untreated, will eventually cause the destruction of the ligaments and bony socket that keep the affected tooth in place.

Tooth loss

Over time, when left untreated, both gum disease and tooth decay can lead to the loss of teeth.

WHY IS TOOTHBRUSHING IMPORTANT?

The act of brushing your teeth can disrupt plaque that is present on the surfaces of your teeth.

This will thus help to prevent tooth decay and gum disease.

HOW OFTEN SHOULD I BRUSH MY TEETH?

Currently, evidence suggests that how often you brush your teeth does not greatly affect your chances of developing tooth decay.

However, it is commonly accepted that you should brush your teeth at least twice a day—after meals and before going to bed.

SHOULD I USE A MANUAL TOOTHBRUSH OR A POWERED TOOTHBRUSH?

Both can be used, but research found that powered toothbrush—also known as electric toothbrush—is more effective in removing plaque (65% compared to 41% using a manual toothbrush).

HOW LONG SHOULD I BRUSH MY TEETH?

2 minutes is the recommended duration for effective plaque removal.

HOW SHOULD I BRUSH MY TEETH?

Use the modified Bass technique. Click on the image below for a larger, clearer version.

  1. Angle your toothbrush at 45° to your gum margin.
  2. Brush gently using a short circular scrubbing motion.
  3. Sweep your toothbrush toward the occlusion surface of the teeth.
  4. Do steps 2 and 3 for the top, outer, and inner surfaces of all your teeth.
  5. Clean your tongue as well in the same short circular scrubbing motion.

Compared to the horizontal scrub method—you drag the toothbrush across your teeth in a horizontal right and left manner—this is a preferred method for effective plaque removal while reducing the incidence of gum recession.

HOW DO I CHOOSE MY TOOTHBRUSH?

Evidence points to toothbrushes with angled bristle tufts being more effective when compared to flat-trimmed or multi-level bristles.

The stiffness of the toothbrush bristles can affect the effectiveness of plaque removal. However, stiffer bristles may lead to more gum recession overtime. Therefore, most dentists would recommend the use of toothbrushes with soft bristles.

SHOULD I PRACTICE INTERDENTAL CLEANING?

Interdental cleaning refers to the cleaning of the areas between the teeth to remove food particles and plaque that are ‘caught’ in those areas.

Toothbrushing alone cannot reach those areas, hence interdental cleaning aids have been introduced for such a purpose.

Interdental cleaning aids

Evidence suggests that the use of interdental toothbrushes and flosses leads to more consistent plaque removal and a reduction in gum inflammation, compared to the use of oral irrigators and wooden or rubber sticks.

When it comes to gaps between teeth, the use of interdental toothbrushes, which are available in various sizes, would be more effective compared to floss.

HOW DO I CHOOSE MY TOOTHPASTE?

Toothpaste must contain fluoride with a minimum of 1,000 parts per million (PPM).

Fluoride helps to mineralize teeth, which is important to help prevent tooth decay.

This substance is usually present in toothpastes in the form of sodium fluoride and sodium monoflourophosphate, so if you are unsure, you can check the package of the toothpaste for the presence of these active ingredients.

OTHER BENEFICIAL ACTIVE INGREDIENTS TO LOOK OUT FOR IN A TOOTHPASTE
  • Stannous fluoride, effective for the reduction of gum disease.
  • Nano-hydroxyapatite and arginine to help reduce dentine hypersensitivity.
  • Hydrogen peroxide and blue covarin colorant produce the best tooth whitening with continued use.
  • Abrasives such as silica, alumina, and calcium carbonate to remove stains. Those with a value below a unit of 250 radioactive dentine abrasion (RDA) are considered safe to prevent progressive tooth surface abrasion.
HOW MUCH TOOTHPASTE SHOULD I USE?

When using regular strength fluoride toothpaste (1,350 to 1,500 PPM), a pea-sized amount is recommended for all individuals and children aged 2 years and above.

A smear is recommended for children under the age of 2, as these children are more likely to swallow their toothpaste—something that can increase their risk of developing mottled teeth or fluorosis.

Fluorosis is caused by ingestion of large amounts of fluoride by children before eruption of their permanent teeth. A common sign of fluorosis is tooth discolouration.
SHOULD I USE MOUTH RINSES?

Mouth rinses may be useful to increase the availability of fluoride for individuals 8 years and older who experience difficulties in brushing their teeth. For example, children that wear braces.

Mouth rinses with active ingredients such as chlorhexidine, acetyl pyridinium chloride, and essential oils may be useful to prevent gum disease.

To improve their effectiveness, mouth rinses should be used at different times from toothbrushing.

Experts Explain Why Thumb Sucking Can Be a Damaging Habit for Children Over 5

WORDS DR NIK MUKHRIZ NIK MUSTAPHA & DR MOHD AMIR MUKHSIN ZURIN ADNAN

FEATURED EXPERTS

DR NIK MUKHRIZ NIK MUSTAPHA
Lecturer and Specialist Orthodontist
Centre of Paediatric Dentistry and Orthodontic Studies Faculty of Dentistry
Universiti Teknologi MARA (UiTM)
DR MOHD AMIR MUKHSIN ZURIN ADNAN
Lecturer and Specialist Orthodontist
Centre of Paediatric Dentistry and Orthodontic Studies Faculty of Dentistry
Universiti Teknologi MARA (UiTM)
5 QUICK FACTS ABOUT THUMB SUCKING
  1. Thumb-sucking—a repetitive behaviour of sucking the thumb—is one of the behaviours referred collectively as non-nutritive sucking habits (NNSH).
  2. This behaviour has the potential to adversely affect the dentition, occlusion, and facial structures.
  3. It is prevalent among young children, particularly girls, and its occurrence tends to decrease with age. Approximately 70% to 80% of children exhibited this habit before the age of 5, with the incidence reducing to 12.1% and 1.9% beyond the age of 7 and 12, respectively.
  4. Interestingly, a higher percentage of mothers with thumb-sucking children had received some college education in comparison to mothers of children that don’t have this habit.
  5. It was also reported that the prevalence of thumb-sucking was least common among children that had favourable breastfeeding opportunities.
THUMB-SUCKING COMFORTS & SOOTHES INFANTS

The thumb-sucking reflex is one of the first sophisticated patterns of behaviour in infants, appearing around the 29th week of age.

Such reflex is considered normal, harmless, and comforting.

It helps infants to fall asleep easier as well as provide a sense of comfort, happiness, and security when they feel distressed.

COMMON FACTORS, EMOTIONS & SITUATIONS ASSOCIATED WITH A BABY’S THUMB-SUCKING HABIT
  • Fatigue.
  • Boredom.
  • Hunger.
  • Anger.
  • Fear.
  • Excitement.
  • Tooth eruption.
  • Insufficient sense of satisfaction.
  • Physical and emotional stress.
WHAT STARTED OUT AS AN EMOTIONAL COPING MECHANISM CAN BECOME A HABIT WHEN THE CHILD IS OLDER

Because thumb-sucking is a comforting coping mechanism, a child may eventually develop a strong attachment to this habit that persists at an older age.

This is the point at which problems begin to arise.

There is a direct link between the destructive effects of thumb-sucking habit and the intensity, frequency, and duration of the habit.

Having the habit for a short period will not leave much of an impact on the child.

However, continuous thumb sucking more than 6 hours daily often lead to the development of significant destructive outcomes.

Abnormal Pattern of Teeth Formation

The constant pressure and sucking motion exerted by the thumb on the teeth may interfere with a child’s normal path of tooth eruption and cause teeth to shift unnaturally. The position of the thumb within the oral cavity determines the pattern of the deformity.

A study has indicated that the incidence of tooth misalignment (malocclusion) is 3 times higher among children that exhibit thumb-sucking behaviour and other unhealthy oral habits, compared to those who do not have any such habits.

Asymmetrical Open Bite

The child’s front upper and bottom teeth do not come in contact when biting. This is usually worse on the side that the digit is sucked.

In turn, this may interfere in biting, speech, and to some extent, prevent closing of the lips.

Asymmetrical Facial Appearance

The narrowing of the palate associated with strong buccal musculature contraction and low position of the tongue can lead to the development of a posterior crossbite.

This can potentially impede the establishment of a proper bite and cause the jawbone to shift to one side, resulting in an asymmetrical facial appearance.

Increased Overjet

The tongue may push the upper front teeth forward, resulting in a ‘sticking out’ appearance while the lower front teeth is backward. The combination of these movements will result in an increased horizontal gap between the upper front and lower front teeth, a condition referred to as increased overjet.

Children with an increased overjet usually are at a greater risk of dental trauma due to the prominence of the teeth.

Speech Difficulties

Pronouncing certain words using tip of the tongue may be difficult, often with the child developing a lisp.

Skin Problems

Prolonged thumb sucking can cause skin irritation, cracked skin, and callus formation along the thumb.

Fingernail infection and eczema of the thumb may also develop.

WHEN SHOULD PARENTS BE CONCERNED ABOUT THEIR CHILD’S THUMB SUCKING?

The American Dental Association recommends intervening before a child turns 4 or, at the latest, by the time the permanent front teeth are about to erupt at the age of 5.

If the habit continues into the mixed dentition stage, past the age of 6, problems with the position of teeth might occur.

These problems can still self-correct and the child experience normal tooth growth if the habit is stopped by the age of 7.

After this age, the positions of the child’s teeth become more established and self-correction is less likely to occur. Complex orthodontic treatment is needed at this stage.

Hence, parents should aim to help their child stop the habit as early as possible, such as during preschool.

HOW TO WEAN YOUR CHILD OFF THUMB SUCKING
Psychological or Behavioural Approaches

Identify triggers. Determine the situations or times that would most likely drive your child to suck their thumb. By identifying these triggers, you can redirect their attention or provide them with alternative forms of comfort.

Positive reinforcement. Celebrate your child’s thumb-free moments. Consider setting up a reward system like a sticker chart that allows your child to visualize their progress and earn treats for sustained periods without thumb-sucking.

Communicate. Engage your child in age-appropriate discussions about thumb-sucking. Help them understand why they need to stop, while at the same time addressing any of their anxieties that lead them to suck their thumb.

Use visual reminders such as a band-aid on their thumb or a colourful bracelet on their wrist as a visual cue to remind them not to suck their thumb.

Distraction and substitution. Help your child find alternative ways to comfort themselves or keep their hands busy. Offer items like a soft toy, a soothing blanket, or even a stress ball. Keeping their hands occupied can divert attention away from thumb-sucking.

Seek professional help. If your child’s the thumb-sucking habit persists despite your efforts, consider consulting a child psychologist or counsellor. They can help identify any underlying emotional or psychological issues contributing to the habit and provide appropriate guidance.

Non-orthodontic Strategies

Thumb guards are devices that fit over the thumb and make thumb-sucking less enjoyable.

Other forms of physical barriers that can be used include bandages and gloves, but parents will have to monitor the child as these barriers can be easily removed by the child.

Taste-based deterrents. Apply bitter-tasting products to the child’s thumb as an immediate and often effective deterrent.

Orthodontic Strategies

Palatal crib is a dental appliance attached to the upper teeth. It prevents the thumb from comfortably resting against the roof of the mouth. Dentists often recommend the use of this appliance if the child’s thumb-sucking habit is causing dental issues.

Bluegrass appliance is designed to redirect thumb-sucking behaviour. It includes a roller or bead that the child can play with using their tongue, instead of sucking their thumb. Over time, this can help break the habit.

Quad-helix with crib attachment is recommended for more severe dental complications arising from prolonged thumb-sucking. This device corrects dental misalignments while curbing the thumb-sucking habit.

Oral Health Tips From a Dentist for People With Diabetes

WORDS DR LAU LAKE KOON

FEATURED EXPERT
DR LAU LAKE KOON
Dentist
Koks Dental Surgery

Most people with diabetes or those that have someone close to them that have this disease will know that the disease can harm many organs in the body—such as the eyes, nerves, kidneys, heart, and more.

DO YOU KNOW THAT DIABETES CAN AFFECT THE TEETH AND GUMS AS WELL?

People with diabetes are more likely to have:

  • Periodontal or gum disease
  • Persistent bad breath
  • Tooth decay or cavities
  • Oral fungal infections
  • Oral ulcers
  • Loss of teeth
Diabetes can cause increased levels of glucose in the blood as well as saliva
Progression of gum disease, from gingivitis to the more serious periodontitis. Click on the image to view a larger, clearer version.

The increase of glucose in the saliva encourages the growth of bacteria in the mouth and together with food particles can build soft sticky whitish layer called plaque.

Plaque is the yucky smelly stuff that you can scrape off from your teeth if you haven’t been cleaning them properly. It is the main cause of bad breath.

If left unchecked, the persistent plaque buildup can cause tooth decay and harden to form tartar.

Persistent plaque or tartar buildup causes irritation to the gums

The gums can become red and swollen, and bleeding may occur.

This is the first warning sign that it’s time to visit the dentist.

Comparison of normal tooth and a tooth with periodontitis. Click on the image for a larger, clearer version.

Otherwise, the infection will go deeper under the gums, causing infection of the bone structure supporting the teeth. This is periodontitis, the second stage of gum disease.

The gums will start to recede, trying to pull away from the tartar formed. Over time the teeth will become unstable, and one may experience pain as a result.

At the final stage of gum disease, the teeth will become so infected and painful that it may need to be removed

In poorly controlled diabetic cases, the gum disease may progress much faster. The severity of the condition may be worse, which is why it is important to visit the dentist early to resolve the issues.

Diabetes and certain drugs can reduce the production of saliva in our mouth

Our saliva contains minerals to protect our teeth from tooth decay, mucin to keep the teeth moist and slippery, antibacterial substances to eliminate potentially harmful bacteria, and it also has the ability to neutralize the acids produced by bacteria in our mouth.

Without the presence of saliva, there is a higher risk of tooth decay and gum disease.

Dry mouth can increase the risk of developing fungal infections called thrush, which are painful white patches in the mouth.

In denture wearers, the dryness can decrease the suction effect of the denture and increase abrasion against the gums, leading to ulcers and mouth sores.

Smoking will worsen the condition further.

In severe uncontrolled diabetic cases, some people can develop burning mouth syndrome—a continuous burning sensation in the mouth that will alter taste and sensation.

HOW THE DENTIST CAN HELP YOU
Gingivitis or periodontitis

The dentist will need to carry out deep cleaning of the teeth and gums, in order to decrease the bacterial load and to allow the gums to heal.

However, the dentist can only do so much—you have to also keep good oral hygiene and use of mouthwash daily.

Fungal infections

Your dentist may prescribe some medications to kill the fungus responsible for the infection.

If you use dentures, they will be checked to ensure that they are still fitting properly. You must keep them clean in a disinfection solution at night.

Dry mouth

For most non-severe cases, the simplest solution is to keep your body well hydrated at all times. Drinking water regularly also moistens the mouth.

Only in severe cases are saliva substitutes prescribed.

Burning mouth syndrome is usually more complicated and will require specialist attention.

HELPFUL TIPS
  • A well controlled blood glucose level as well as a healthy diet and lifestyle are key to reducing and preventing oral health problems. Keeping your mouth healthy will also prevent diabetes-related health problems such as heart disease and kidney disease.
  • Good oral hygiene will keep your gums and teeth healthy. Brushing twice a day every day, and use a floss or water floss daily.
  • Visit your dentist regularly for a routine checkup. Please make sure you tell your dentist if you have diabetes. Keep your dentist updated about any changes to your health and blood sugar levels.
  • For denture wearers, make sure your dentures fit properly, and clean them by soaking them in denture disinfectant at night.
  • Quit smoking. Smoking will worsen gum condition and overall health.