| The Necessary Personal Oral Hygiene For Prevention of Caries and Periodontoclasia* |
WIDESPREAD PREVALENCE OF PERIODONTOCLASIA
Periodontoclasia is practically a universal disease. There are suppurating lesions about some or all of the teeth of all people except those who have learned and follow the necessary personal oral hygiene to prevent the disease. Anyone who is interested can confirm this by examining, as indicated above, material from his own interproximal gingival crevices, and from those of others.
Inflamed and ulcerated inner surfaces of the free gingiva bleed easily from the slightest force or manipulation. Uninflamed epithelial surfaces do not bleed. Therefore "bleeding gums" can be considered practically diagnostic of inflammation and ulceration-the early stage of periodontoclasia. In view of the widespread prevalence of this disease it is hardly necessary, for diagnostic purposes, to make microscopic examinations for pyorrhaea, as suggested above. It can be assumed to be present about some of the teeth of practically an adults and most younger people. During a period of several years the author has examined a considerable number of people, mostly medical students and other university personnel. In no instance has he failed to find pus from some of the gingival crevices, and also one or more demonstrable lesions where some receding of the gingival attachment has taken place. This experience, which will be confirmed by those who employ appropriate technic, indicates the extensive prevalence of the disease, the inadequacy of the oral hygiene procedures presently in general use and the need for a better method.
NECESSARY PROCEDURE
We may now state the fundamental facts to which the necessary oral hygiene procedure must conform and specify the procedure required. One of these facts is the time honored saying "a clean tooth does not decay." The other, more recent, is "periodontoclasia does not occur about a clean tooth"8. The author has formulated one sentence which comprehends what every person must know and do to save his teeth from these diseases and to maintain reasonable personal oral cleanliness. It is used as a slogan in teaching personal oral hygiene to others. Anyone who undertakes to teach others how to take care of their teeth (after learning how to take care of his own) will find this sentence of instruction useful and helpful. "You must clean your teeth right with the right kind of both toothbrush and dental floss every night before retiring." No part of this sentence may be changed or omitted without impairing its completeness. In the light of present information, no part of these instructions may be disregarded or neglected by anyone except at the jeopardy of his dental health.
All other supposed preventive measures which conflict with, or are intended to supplement, what is comprehended in the above sentence, tend to confuse or detract from the personal oral hygiene that is essential for maintaining oral health and cleanliness. If the teeth are also cleaned partially or well at other times, this contributes to greater oral cleanliness, but under no circumstances may such cleaning at other times of the day take the place of the essential cleaning at night before retiring. Heretofore the individual has not known exactly how to clean his teeth right and the right kind of toothbrush and dental floss have not been available. Therefore he must be taught by someone who does know.
RIGHT KIND OF TOOTHBRUSH
The function of the toothbrush is to dislodge and remove from any and all areas on the teeth that are accessible to the application of the bristles of the brush as much as possible of the decomposing food and bacterial material that has accumulated and is retained there since the previous cleaning. This material is soft, often microscopic in amount and composed of microscopic particles (bacteria and food elements). Its presence and character can be ascertained only by appropriate microscopic examination. The most important places to be cleaned with the brush are (a) the occlusal pits and fissures, (b) the proximal surfaces in the sulci between teeth as far as the bristles may go and (c) the surfaces of the teeth within the gingival crevices wherever they are accessible to the application of the bristles of the brush.
Material is dislodged and removed by the digging action of the ends of the bristles when the brush is applied firmly against the places to be cleaned and moved back and forth with short strokes ("vibratory motion"). The brush must be pressed down hard enough to force some of the bristles into the pits, fissures, sulci and gingival crevices as far as their diameter will allow them to go. The bristles must be flexible enough to allow those that do not enter the deeper spaces at the moment, to be deflected and not prevent others from entering. They also must be flexible enough so they bend and do not injure the gingival tissue when applied directly to the gingival crevices, and manipulated so as to secure the necessary digging action to dislodge the foreign material on the tooth within the crevice. For the same reason the ends of the bristles must be round and smooth instead of sharp, jagged, chisel shaped and rough, as the bristles of so many current toothbrushes are (Figure 14). The shape, size and form of the brush must be such as to adapt it to the most practical and effective application and manipulation for the purpose for which it is used (Figure 15).
The specifications for the right kind of toothbrush are:
1. Plain straight-handle design; over-all length about 6", width about 7/16"; 3 rows of bristles, 6 tufts to the row, evenly spaced (Figure 16).
2. High quality nylon bristles, about 80 per tuft, .007" diameter, straight trim, finished to 13/32" length.
3. Ends of bristles ground and finished to hemispherical shape or at least so as to eliminate all sharp points and rough edges.
4. A similar brush of reduced size for the use of young children should have an overall length of about 5", .005" bristles, finished to 11/32" length.
Based upon much study of the spaces to be cleaned, the character of the material to be removed, and the conditions to be met, the author has specified elsewhere3 the optimum characteristic of toothbrushes for personal oral hygiene, giving the reason for each of the characteristics specified. The specifications laid down meet the requirements indicated above. This, and no other, is the right kind of toothbrush. In the light of present information any brush that deviates from the characteristics specified is less effective and less appropriate for the purpose, to the extent it so deviates.
BRUSHING THE TEETH
All the surfaces of all the teeth to which the brush can be applied, should be brushed. A good system is to brush the buccal and labial surfaces of all teeth first, then the occlusal and lingual surfaces of the grinders in all four quadrants and -finally the lingual surfaces of the anterior teeth. The bristles of the heel of the brush can be applied most effectively to the lingual surfaces and the gingival crevices of these latter teeth. The bristles of the distal end or toe of this right kind of brush can be applied most effectively back of the last tooth in each quadrant by tilting the brush for this purpose at the same time the occlusal and lingual surfaces of the grinders are brushed. Anyone should be able to brush all of these teeth well enough for all purposes in less than one minute.
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| Fig. 14. |
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| Fig. 15. |
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| Fig. 16. |
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DENTIFRICES
The question of dentrifices necessarily arises. If one's hands are soiled with food and other objectionable material, he washes them with soap and water. A touch of soap (toilet soap) on the brush helps to clean similar material from the teeth. Nothing else is necessary for routine purposes.
The teeth of many people become stained with various substances such as tobacco, tar, certain stains in food and beverages, sometimes stains produced by chromogenic bacteria. Such stains are retained by the bacterial film but do not pass through it into the tooth. They may be removed and minimized by a mildly abrasive powder on the brush. Ordinary prepared chalk is effective. When used with the right kind of brush here suggested, it is harmless. It may be used as frequently as the individual requires. The teeth of some individuals stain much worse and in shorter time than others. Each person should use prepared chalk as often as necessary to prevent objectionable discoloration of his teeth. Some will require it every day, others only once in several days or longer.
The sweetening and strong mint or other flavors which most dentifrices contain serve no useful purpose and are more or less harmful.
CLEANING THE PROXIMAL SURFACES
No matter how much or what kind of brushing is done, it is not possible for the bristles to reach and clean the proximal surfaces between the teeth. It is simply imagination to think otherwise. At the contact point the teeth are in direct contact and there is no space between them. For a variable distance extending outward from the contact plane in all directions there is a gradually widening space which is filled with a pack of bacteria, mostly long rod and filamentous type. This material has the form of a somewhat irregularly outlined biconcave disc (Figure 10) with the center corresponding to the contact point. When heavily inoculated food material is lodged upon the outer part of this biconcave disc where there are large numbers of growing ends and fruiting heads of the rods and filaments of which it is composed, acids may be produced there and may be carried, as if by a sponge or wick, deeper into the space. If the acid production continues long enough, ultimately there is partial decalcification - early stage caries - and later perhaps breaking down, cavity formation - advanced stage caries. In order to surely prevent these events it is absolutely necessary to clean the proximal surfaces of the teeth in this area every night before retiring. When done right this removes most of the bacteria and the food material in which they could grow and produce acids. There is not sufficient time from the time food is put in again the next day, for maximum growth of bacteria and for production of harmful amounts of acid, before time to clean the teeth again at night before retiring.
The only way now known, and the only way likely to ever be known, whereby the bacterial film on the proximal sides of the teeth can be removed is by the proper use of the right kind of dental floss. Elsewhere4 the author has specified the optimum characteristics of dental floss for personal oral hygiene, indicating the necessity or basis for each characteristic specified. This right kind of dental floss consists of 170 very fine filaments of high tenacity nylon. It is not waxed, and is only slightly twisted (3 turns to the inch). When drawn across the surface of the tooth, each of the 170 separate filaments is potentially capable of mechanically dislodging and removing some part of the microscopic bacterial material thereon. Also the bundle of loosely held together filaments is capable of receiving and holding in the spaces between the filaments (Figure 17), large numbers of microscopic particles (bacteria).
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| Fig. 17. |
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NECESSITY FOR CLEANING THE TOOTH WITHIN THE INTERPROXIMAL GINGIVAL CREVICES
So far as proximal caries of the enamel is concerned, it is only necessary to clean the proximal surfaces of the tooth above the gingival margin or the papilla. We have seen that from the very earliest stage of periodontoclasia there is bacterial film and other foreign material on the surface of the tooth within the gingival crevice (Figure 12) and that this material is responsible for the initiation of the very earliest lesion and for the continued progress of the disease. To prevent the beginning and progress of the inflammation and suppuration which characterizes the disease it is necessary to clean these areas of the teeth within the crevices. This can be done well enough with the right kind of dental floss mentioned above but it cannot be done in any other practical way now known. The surfaces of all teeth within the interproximal crevices of contacting teeth, and those within the distal or mesial crevices where there are no contacts, must be cleaned. This is accomplished by carrying the floss down to the very bottom of the crevice, holding it against the tooth and drawing it slightly endways and outward so as to scrape the surface. The bacterial material is dislodged and much of it is held and removed within the spaces between and around the filaments (Figure 17) of the floss.
DETAILED DIRECTIONS FOR CLEANING THE TEETH RIGHT WTTH THE RIGHT KIND OF DENTAL FLOSS
While different people may develop their own technic and manipulations for cleaning their teeth with dental floss, the following procedure is probably the most practical and effective:
1. Cut off a piece of floss about 2 to 3 feet long.
2. Wrap one end with 2 or 3 turns around the first phalanx of the right index finger, for the purpose of anchoring or holding it. (Figure 18).
3. Bring the floss over the end of the right thumb which is also held against the finger around which the floss is anchored. (Figure 18).
4. Grasp the floss with the left hand and bring it over the end of the first finger of that hand. Thus a length of floss, about 1 inch long, is held between the thumb of the right hand and the first finger of the left hand. (Figure 18 (l)).
5. Now with the thumb inside of the cheek and the finger inside of the mouth, the floss is carried to the very bottom of the gingival crevice back of the last right upper tooth, drawn slightly endways through the crevice and crossways outward across the distal surface so as to scrape off and dislodge the soft bacterial material on the tooth within the crevice and outwards.
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6. Holding the floss in the same way, pass it into the next interproximal space. Carry it to the bottom of the posterior gingival crevice and clean the mesial surface of that tooth. Now, before withdrawing the floss from this interproximal space, clean the distal surface of the other tooth in the same way. Then withdraw the floss and move on to the next interproximal space, etc., until the proximal surfaces of all teeth have been cleaned.
7. In passing the floss between contacting teeth it is not forced directly in and out. It should be held over the contact and drawn gently and slightly back and forth endways. This allows the low-twist, unwaxed floss to flatten and pass between the contacting teeth with the greatest ease.
8. After cleaning 2 or 3 teeth the part of the floss used is somewhat soiled and loaded with bacterial material. It is desirable to move along the string to a new place by taking another turn around the anchoring finger. This should be repeated from time to time as needed.
9. The floss is held and manipulated with the same fingers as indicated above until after the surfaces of the teeth in the interproximal space between the left central and lateral have been cleaned.
10. In cleaning the rest of the upper teeth, it will now be found more convenient and practical to hold the floss over the ends of the thumb of the right hand as before and over the thumb (instead of the index finger) of the left hand. (Figure 18 (2)).
11. All the lower teeth now should be cleaned in the same way. Most people will find that they can carry out the necessary manipulations most successfully with the floss held over the ends of the second finger of each hand instead of the thumbs or the thumb and first finger as in cleaning the upper teeth. (Figure 18 (3)).
12. After cleaning all the teeth with dental floss, the mouth should be thoroughly rinsed by forcing water vigorously back and forth between the teeth in order to remove material that has been loosened or dislodged but not removed by the floss. After a little experience one can clean all his teeth well with dental floss in from 2 to 3 minutes.
13. It gives a pleasurable sensation of cleanliness to hastily brush the teeth again after cleaning them with dental floss. But this is not essential.
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RESULTS
The author has instructed and had under observation, a sufficient number of subjects to be able to state positively the beneficial effects that result from the personal oral hygiene herein specified.
1. No new caries lesions develop.
2. Early stage lesions (mostly unrecognized "white spot" partially decalcified enamel that has not broken down) do not progress further or break down.
3. Small shallow cavities do not progress but usually become inactive.
4. Correctly made fillings do not undermine or break down.
5. No new periodontoclasia lesions occur.
6. All early stage periodontoclasia lesions heal promptly. It is almost dramatic the way in which the bleeding from the gingival crevices stops entirely after the first few days. Pus (even microscopic quantities) is no longer present in material from most of the crevices, and greatly diminished in that from others. The delayed or incomplete healing in such lesions is usually due either to calculus or scale on the tooth within the crevice or to irregularities or other conditions on the surface of the tooth which prevent accurate application of the floss. In most such instances, removal of the foreign material from the surface of the tooth at, and within, the gingival crevice by the dentist, followed by the right personal oral hygiene, results in prompt subsidence of the disease.
7. Each advanced stage periodontoclasia lesion and deep "pyorrhaea pocket" is a separate problem. However, cleaning off the tooth at and within the lesion by the dentist at suitable intervals together with faithful application of the personal oral hygiene described herein usually will yield most gratifying results. The beneficial results will depend largely upon the extent of the lesion and the damage already done. In favorable instances suppuration and inflammation of periodontal tissues subside, and loose, drifting teeth usually stabilize.
8. Foul odors from the mouth due to decomposition of food material about the teeth, to putrefaction of inflammatory tissue exudates within the crevices and to the growth of certain microorganisms (especially spirochetes) in the blood enriched material in the crevices, is avoided.
9. Much satisfaction is derived from the sense of oral cleanliness which one enjoys, after he once understands the conditions and learns how to clean his teeth effectively.
COMMENT
Every person who has teeth to save and everyone who desires to maintain reasonable oral cleanliness must learn and follow the personal oral hygiene procedure herein described. People go to dentists for treatment of the advanced stage of caries and periodontoclasia from which nearly all loss of teeth results. They do not know or properly evaluate the fact that the lesions, representing more or less irreparable damage, could have been prevented. Neither do they recognize the presence of existing earlier stage lesions, further progress of which can be prevented by personal oral hygiene. They need to be instructed.
Dentists should be interested in teaching this necessary personal oral hygiene to their patients not only for the purpose of prevention but also to greatly improve the success and durability of their treatment of existing lesions and conditions. To fill a cavity without making certain, at the same time, that the patient knows how to maintain the necessary cleanliness of the area in the future reduces, on the average, the usefulness and success of the work done. To clean the accumulations of foreign material from the teeth or to treat his periodontoclasia without, at the same time, teaching the patient how to keep his teeth clean in the future, greatly reduces the value of the service. The value of the periodical visit to the dentist for check up and "prophylaxis" is very greatly increased if the patient is also taught this necessary personal oral hygiene.
It is evident that the practicing dentist should teach the necessary personal oral hygiene to his own patients. However, to teach it he must first know it himself. It is axiomatic that one cannot teach what he does not know himself. Except for anyone who may have already learned how to clean his teeth right, as here indicated, the dentist who still has teeth left now has more or less suppuration within the gingival crevices, and therefore active periodontoclasia, about some or many of his teeth. This will be confirmed by microscopic examination of properly collected material from his interproximal gingival crevices. He is losing his own teeth from the same conditions for which his patients need advice and treatment. Until he learns and practices the necessary personal oral hygiene to save his own teeth, he is not very well prepared to instruct his patients how to save theirs. Therefore he should first learn and practice the right method himself. Then he will realize how necessary it is for his patients also and can instruct them correctly and effectively.
SUMMARY
The necessary personal oral hygiene for prevention of caries and periodontoclasia has been presented in some detail. It conforms to the two fundamental facts: "a clean tooth does not decay" and "periodontoclasia does not occur about a clean tooth." The essentials are embraced in the teaching slogan which the author has formulated, uses, and recommends that others use:
You must clean your teeth right with the right kind of both toothbrush and dental floss every night before retiring.
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REFERENCES
1. Bass, C. C.: A demonstrable line on extractcd teeth Indicating the location of the outer border of the epithelial attachment. J. Dent. Research, 25 :401. 1947.
2. Bass, C. C.: The enamel cuticle. I, in relation to the early stage of caries; II, in relation to the early stage of periodontoclasia. To be published soon.
3. Bass, C. C.: The optimum characteristics of toothbrushes for personal oral hygiene. Dent. Items Int. 70 :697, 1948
4. Bass, C. C.: The optimum characteristics of dental floss for personal oral hygiene. Dent. Items Int. 70: Sept., 1948.
5. Bass, C. C. : The habitat of Endameba buccalis in the lesions of periodontoclasia. Proc. Soc. Exp. BioI. and Med., 61 :9. 1947.
6. Frisbie, R. E., Nuckolls, J. and Saunders, J. B.: Distribution of the organic matrix of the enamel in the human tooth and its relation to the histopathology of caries. J. Am. Col. Dent., 11 :243. 1944.
7. Malleson, H. C. : The histology or enamel caries. Brit. D. J., 46 :907. 1925.
8. Bodecker, C. F.: The bacterial invasion of the enamel in dental caries. D. Cosmos, 69:987. 1927.
9. Bodecker, C. F. and Bodecker II., W. C.: The bacterial destruction of dental enamel. J. D. Research, 9:37. 1929.
10. Bibby, B. G.: The organic structure of dental enamel as a passive defense against caries. T. D. Research, 12: 99. 1932.
11. Berke, J. D.: Studies in the histology and pathology of human enamel. D. Cosmos, 78 :700. 1936.
12. Ibid. New Finding in the histology and pathology of human enamel. J. A. D. A. :27 :1229. 1940.
13. Frisbie, H. E. and Nuckolls, J.: Caries of the enamel. J. D. Research, 26 :181. 1947.
14. Goltlieb, B.: Dental caries. Philadelphia, Lea and Febiger. 1947.
15. Stephan, R.M., and Miller, B.F.: A quantitative method for evaluating physical and chemical agents which modify productivity of acids in bacterial plaques on human teeth. .J. D. Research, 22 :45. 1943.
16. Riggs, J. W.: Suppurating inflammation of the gums and absorption of the gums and alveola process. Penn. J, D. Sci. 3:99. 1876.
17. Beust. Theo. Von: A contribution to the morphology of the micro-organisms of the mouth. Dent. Cos., 50 :594. 1908.
18. Bass, C. C.: Prevention of the loss of teeth. The Mississippi Doctor, 20:522. 1943.
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