Should the message to patients be changed to emphasize interproximal cleaning?

Feb. 1, 1998
As I have written in this column and elsewhere, we understand the value of brushing the inside of the bottom teeth first. Now let`s put that finding into perspective. In the whole picture of plaque removal, where should patients` efforts actually begin?

Trisha E. O`Hehir, RDH, BS

As I have written in this column and elsewhere, we understand the value of brushing the inside of the bottom teeth first. Now let`s put that finding into perspective. In the whole picture of plaque removal, where should patients` efforts actually begin?

Research done by RDH readers confirmed the effectiveness of brushing the inside of the bottom teeth first. Reductions in both bleeding and calculus accumulation were impressive. Calculus was reduced by more than 60 percent and bleeding was reduced by 50 percent. Focusing on the area of the heaviest supragingival calculus formation was a sure way to succeed in this effort. We simply combined scientific findings, common sense, and experience.

Scientific findings point to the mandibular lingual surfaces as the area of heaviest calculus formation, as well as the area receiving the least attention during toothbrushing. Common sense tells us that the area with the greatest buildup should be brushed first. Our experience as hygienists tells us that the area where people start brushing usually receives more time and attention. Our experience also tells us that brushing first without toothpaste results in:

* Longer brushing time.

* Self-examinations in the mirror.

* Objective evaluation of effective brushing by feeling for plaque with the tongue.

This combination of scientific findings, common sense, and experience leads to a simple message for patients, where the results are tremendous. Simply telling patients to dry brush the inside of the bottom teeth first can practically eliminate supragingival calculus formation in that area.

How does this finding fit into the big picture of daily plaque removal? Reducing calculus formation certainly makes our job easier, but does it actually prevent disease? It does. During the dry-brushing technique, bacterial plaque, the primary etiologic factor in periodontal disease, is reduced. In addition, gingivitis is reduced, since sulcular bleeding is also reduced.

However, these advantages are limited to the mandibular lingual surfaces. Based on scientific findings, common sense, and our own experience, we know that periodontal disease begins between the teeth - not on the facial and lingual surfaces. The architecture and width of the interproximal area lead to greater plaque accumulation. At the same time, plaque removal is more difficult. The tissues in the col area are not keratinized and, therefore, break down more quickly than facial and lingual tissues. It is not a naturally cleansed area and instead requires specific attention. The more complicated the interproximal anatomy, the more difficult plaque removal will be.

It is only common sense that areas further back in the mouth will be more difficult to access. With that in mind, it is not surprising that more disease is measured in molar interproximal areas than anterior areas. Knowing that interproximal areas are more susceptible to periodontal disease, the primary focus of plaque control should be interproximally.

Our experience certainly tells us that the majority of people will brush their teeth every day, but few of them will effectively remove plaque interproximally. Even when people report daily use of dental floss, we see their lack of effectiveness. Many people still think they clean between the teeth to remove food and don?t understand the value of removing bacterial plaque from interproximal areas. It is not enough to just use floss or toothpicks or irrigation; it must be done effectively.

Putting these facts together leads us to our next bit of advice for patients: start in-between. It just makes sense. I?m sure many of you are already doing this. If a patient complains they don?t have enough time to do all the plaque removal recommended, you simply say: O...well, in that case, skip the brushing and only clean in-between your teeth. That?s the most important area anyway.O

I don?t think we have gotten to the point where we routinely tell patients to skip brushing in favor of interproximal cleaning, but maybe we should give it a bit more consideration. If we know that disease starts interproximally and progresses there faster than facial and lingual, shouldn?t our message to patients reflect our knowledge?

This may not sound too comfortable. You may even think that by shifting the emphasis from brushing to interproximal cleaning we might risk losing whatever plaque control we now have. It is hard to believe that people who don?t do any interproximal cleaning now would start simply because we told them to and explained it in a new way. After all, we?ve been telling them for years, haven?t we? It?s risky, but the potential outcomes are far greater than what we have now. It only looks like we have to give up what we have now in order to achieve greater gains in the end.

Begin the process yourself. Simply start in-between, if you don?t already. Just because you floss first or use toothpicks first or use oral irrigation first, you will undoubtedly also pick up a toothbrush. Telling them that brushing isn?t important, cleaning in-between is, will change their perception and understanding of the value of cleaning in-between. You can bet they will also brush afterwards without being told to do so. Sometimes we just need to change the message in order to get people?s attention.

The toothbrushing message is brush inside first, but the overall message should be start cleaning in-between.

Trisha E. O`Hehir, RDH, BS, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics.The Web site for Perio Reports is Her e-mail address is trisha