The ongoing debate about the absolute necessity of traditional brushing and string floss has simply got to stop. A remarkable number of clinicians fervently cling to the notion that these primary tools are essential to combat or halt biofilm-based oral infections. While these tools can offer a measure of effectiveness, it is time to examine other options.
Before you decide to stop reading, consider how innovative, targeted, and meaningful home-care strategies might be just what a patient can, or will, implement. The ultimate goals are preventing, stopping, or reversing oral disease. Our eyes need to be on the prize—
stable oral health.
Four factors affecting health
Long-term oral health is an interplay of four specific factors:
- a unique oral microbiome
- effective biofilm disruption
- immune system strength
- a healthy, sustainable ecological environment
The critical skill: Evidence-based decision-making
Many strategies and products exist that help us achieve stable oral health. A targeted plan should include using an evidence-based decision-making (EBDM) process. EBDM support contains three segments: a clinician’s clinical expertise, best external evidence, and, finally, a patient’s values and expectations. Each part plays a critical role. A cookie-cutter approach simply will not work.
Clinical expertise is not a fixed point. Academic education lays the foundation. Graduation is the first step, and over time, we observe potential outcomes derived from recommending different products and techniques. We also learn that what might work well for a particular patient/personal challenge may be the wrong strategy for another. Asking questions and troubleshooting with other clinicians are wonderful ways to deepen expertise and hone one’s assessment skills.
Best external evidence
Best external evidence is more than what published research says about disease progression, or which products or techniques stop disease and potentially restore health. External evidence includes conversations with colleagues in your practice setting, online discussions, and continuing education activities. While anecdotal evidence does not have the research strength of a double-blind, randomized clinical trial, observations at this level can be quite valuable. What we learned in school about patient home care may not be relevant or accurate in today’s world. Keeping abreast of observations at many levels is a must. Over time, prevailing thoughts can change as evidence mounts.
Patient’s values and expectations
The third piece of the EBDM process factors is the patient’s values and expectations. It is easy to offer a cookie-cutter plan, but that strategy rarely works. Every patient is different. Over time, a patient’s expectations and values can be refined or even changed as we guide them toward health.
More by the author:
- Outcompeting microbes: Understanding the future by looking at the past
- Muddy flooding and sinkholes: Understanding the difference between caries and erosive tooth wear
Sticking to health
Discussions can heat up very quickly when the chat comes around to home care or self-care products and strategies. Some adamantly insist that traditional toothbrushing and string floss are critical to achieving stable oral health. Scientific studies do not support this position. Research indicates that biofilm disruption is the first line of attack, and with continued disruption over time, a healthy microbiome can be established and maintained even when the immune system is severely challenged.1,2
Again, before you start turning the page, let me share an interesting observation. The miswak, or chew stick, is an oral cleansing tool commonly used in many African and Middle Eastern countries. Traditional miswaks are dried branches from a small evergreen tree called Salvadora persica. Miswaks are typically 8–10 inches long and 0.5–0.33 inches in diameter. The fibrous branch has numerous antimicrobial properties. The fuzzy end gently cleans tooth surfaces and stimulates gingival tissues.3
This tool has been used for thousands of years with great success. Miswaks are sold in bundles at local markets. Years ago, a wonderful patient generously gifted me with two different versions. One bundle came from Dubai and the other from Nigeria. During this same period, a large influx of people from the Middle East and Africa moved to my city. I treated people who had grown up using miswaks. Their oral hygiene was impeccable, and their periodontal health was stable. From that point on, it was abundantly clear that there were many ways to achieve oral health.
The chemo-mechanical strategy
Mechanical biofilm disruption is important. What we were trained to call plaque may be a biofilm or it could be leftover food debris that is superimposed over a biofilm complex. What if there is no visible “plaque” but the patient has ongoing bleeding, which is indicative of disease? Whether or not the microbial mass is visible to the human eye, it still needs to be disrupted and removed.4
Mechanical disruption includes both the supra- and subgingival disruption and removal of biofilm. This can be accomplished with hand toothbrushes and power toothbrushes, interproximal brushes, picks and sticks, string floss, water flossing, and devices that use a hydrated air puff to dislodge biofilm.5-8
Physically scraping debris off a tooth structure is not the only tactic. The force of fluids in motion uses hydraulics to create shear force. Biofilm is torn from its moorings on a microbial level, and pathogenic cell walls are breached. Fluid mechanics is particularly beneficial in disrupting subgingival biofilm in areas that can’t be reached by direct mechanical scraping.9
Chemical warfare also comes into play when dealing with biofilm-based periodontal conditions. Most options are available over the counter and come in the form of rinses, pastes, and gels. When making a recommendation, pricing, efficacy, taste, and ease of use all come into play.
It is important to know the pH value of any product that will be used for a long period of time. This is particularly critical if the patient has root exposure. Low-pH (below 6) products affect dentin and cementum surface microhardness.10 Low-pH products also affect restorative materials and cement integrity.11 When a low-pH product is recommended, balance the risk with a product or strategy designed to reduce erosion risk.
Adding a new perspective
Most patients are not oral experts. Marketing efforts can make people believe that removing “stuff” with a particular brush or paste, or swishing with the latest rinse, will either cure their condition or stop the disease progression. The effectiveness of what we do every two, three, or six months in the clinical setting pales in comparison to how an individual deals with microbes daily. The real outcome is dependent on what happens 365 days a year and the individual’s immune system.
For decades, home-care recommendations have focused on a basic chemo-mechanical approach to outfox pathogenic biofilm microbes. There are valid reasons for this approach; however, current science supports a more precise, customized approach.8
Ongoing research classifies periodontal conditions as dysbiotic, a classic environmental imbalance in which the microbes are winning, and the human body’s inflammatory response is in overload. Articles by Marsh1 and Hajishengallis2 support the concept of dysbiosis, which focuses on creating a healthy environment that is ecologically stable over time. Ideally, conversations can shift from a list of tasks to a customized plan focused on creating a healthy, balanced oral ecology.12-14
Looking at the challenge through a different lens allows everyone flexibility. An adjunct is a task performed in addition to a primary tool. If an individual does not include string flossing in their home-care routine but, rather, chooses a water flosser or a custom prescription tray to deliver a medicament subgingivally, these approaches are primary tools rather than adjuncts. This mind shift takes practice but is a welcome approach for those who are tired of the same old discussions that never result in change. This new perspective allows clinicians to veer away from tradition and redirect attention to alternatives.
Changing the ecology one parameter at a time
Antibiotics wipe out pathogens with drug warfare. Over the long term, ecological approaches to microbial ecology are far different. Initially a surgical or nonsurgical therapy may be indicated to jump-start the process, but sustainable tactics are ongoing. To change the microbial environment over the long haul, the discussion needs to be different than the tried, but not necessarily true, traditional floss and brush talk. New conversations should be different but scientifically supported. The emphasis can shift to creating
oxygen-rich environments, supporting favorable pH ranges, reducing bioburden in deep pockets, using probiotics to supplement natural oral flora, or evaluating prebiotics to support the growth of healthy commensal microbes.
Stories can convey new information or ideas. Consider using a well-understood analogy such as how to prevent cardiac disease. A sample dialogue might begin like this: “Typical risk factors for preventing or modifying cardiac disease are well understood—e.g., smoking cessation, dietary modifications, stress reduction, regular exercise, and weight control.” It is easy to substitute new periodontal disease controls into a similar discussion framework.
Tweaking the basics
Primary periodontal pathogens have specific requirements. Why not make the environment less supportive of their noxious activities? The biggest challenge is debriding the sulcular area beyond the point reached with a traditional toothbrush or string floss.
Effective, daily use of an oral irrigator—now called water flossing—reduces the microbial bioburden. A recent research study brought forth an alarming finding. Virulent periodontal microbes use dead microbes as a nutritional source, which increases their microbial virulence and cytotoxicity.15 The impact of water flossing is powerful.16 Not only does pulsated water flossing under pressure disrupt biofilm, but the forces of fluid in motion flush out thousands of microbes and their cytotoxic waste products.9 Water flossing plays a huge role in turning the tide toward homeostasis, especially around implant devices,9,17,18 and also can result in a high level of patient satisfaction.9
The Waterpik brand is the device used in most significant research studies. When making recommendations, be mindful that findings from any study reflect the actual product used in the research.
Prescription tray therapy
It is well understood that hydrogen peroxide is a component of healthy saliva and an effective agent against anaerobic microbes. However, the amount found in saliva is insufficient to combat the microbial assault found in a dysbiotic community.19 Based on this understanding, it is reasonable and prudent to recommend an FDA-cleared custom prescription tray as an entirely different strategy to disease management.
The patented PerioProtect method uses a custom-fabricated tray with an inner hydraulic seal to deliver a stable 1.7% hydrogen peroxide gel subgingivally. The patented hydraulic seal prevents dilution during the daily 15-minute wear time and allows the gel to penetrate up to 9 mm, both factors that substantiate a disruption in the integrity of plaque biofilm and allow the chemistry to create high levels of oxygen that can kill anaerobes.20
Periodontal pathogens can’t survive in a high-oxygen environment. Research has demonstrated that subgingival biofilm degrades in the first 10 minutes, while the maximum oxygen potential continues for another five minutes. The daily kill of pathogens and the high-oxygen concentration sets the stage so that healthy aerobic microbes can proliferate and predominate. Studies demonstrate custom prescription trays successfully support positive outcomes in conjunction with nonsurgical periodontal therapeutic treatment.21,22 Some cases require an initial addition of doxycycline to achieve a positive outcome.23 Regular use results in two compelling side effects: whiter teeth and fresher breath.
Prebiotics and probiotics
While these two strategies are not identical, both focus on supporting a healthy ecological environment. Probiotics are live bacteria and yeast. They are used to supplement the human microbiome. There are specific oral probiotic products, which are different in composition to products formulated to support digestive health. The FDA regulates probiotics like foods, not as medications. Unlike drug companies, makers of probiotic supplements don’t have to show that their products are safe or that they work.
Initial research on the effects of oral probiotics demonstrates positive outcomes in inhibiting the growth of periodontal pathogens and reducing the incidence of gingivitis.24-28 When considering probiotics, the focus needs to be on therapies designed for the oral cavity, not gut digestive health.
Prebiotics are substances that are used to support the growth of healthy microbes. The amino acid, arginine, plays a large role in the development of a healthy oral microbiome. Most of the prebiotic activity revolves around raising the oral pH, but arginine also interferes with the development of P. gingivalis biofilm and is implicated in the degradation of the EPS slime matrix in existing biofilms.29-30
Eighteen months ago, I was asked to look at how dental hygienists have dealt with periodontal disease over time. What seemed like a simple reflection turned into a deeper discussion with three distinct but overlapping components leading to this series. The first article focused on the scientific advancements in microbiology, the role of the immune system, and how inflammation exacerbates dysbiosis. The second discussion looked at dental hygiene treatments initiated in the clinical setting, and the final segment focuses on the hows and whys of the patient’s role in dealing with oral disease.
The bottom line is that we can do more, and so can our patients. Patients are better off for what we now know, compared to what was taught 50 years ago. When we are brave enough or open enough to evaluate and implement new ideas, the future is bright and better health is on the horizon. Good luck in your journey to provide better and better care.
Editor's note: This article appeared in the November 2021 print edition of RDH.
- Marsh PD. In sickness and in health—what does the oral microbiome mean to us? An ecological perspective. Adv Dent Res. 2018;29(1):60-65. doi:10.1177/0022034517735295
- Hajishengallis G, Chavakis T, Lambris JD. Current understanding of periodontal disease pathogenesis and targets for host-modulation therapy. Periodontol 2000. 2020;84(1):14-34. doi:10.1111/prd.12331
- Dahiya P, Kamal R, Luthra RP, Mishra R, Saini G. Miswak: a periodontist’s perspective. J Ayurveda Integr Med. 2012;3(4):184-187. doi:10.4103/0975-9476.104431
- Sakanaka A, Takeuchi H, Kuboniwa M, Amano A. Dual lifestyle of Porphyromonas gingivalis in biofilm and gingival cells. Microb Pathog. 2016;94:42-47. doi:10.1016/j.micpath.2015.10.003
- Drisko CL. Periodontal self-care: evidence-based support. Periodontol 2000. 2013;62(1):243-255. doi:10.1111/prd.12012
- Drisko CH. Nonsurgical periodontal therapy. Periodontol 2000. 2001;25:77-88. doi:10.1034/j.1600-0757.2001.22250106.x
- Ng E, Lim LP. An overview of different interdental cleaning aids and their effectiveness. Dent J (Basel). 2019;7(2):56. doi:10.3390/dj7020056
- Sälzer S, Graetz C, Dörfer CE, Slot DE, Van der Weijden FA. Contemporary practices for mechanical oral hygiene to prevent periodontal disease. Periodontol 2000. 2020;84(1):35-44. doi:10.1111/prd.12332
- Salles MM, de Cássia Oliveira V, Macedo AP, Silva-Lovato CH, de Freitas de Oliveira Paranhos H. Effectiveness of brushing associated with oral irrigation in maintenance of peri-implant tissues and overdentures: clinical parameters and patient satisfaction. J Oral Implantol. 2021;47(2):117-123. doi:10.1563/aaid-joi-D-19-00092
- Carvalho TS, Colon P, Ganss C, et al. Consensus Report of the European Federation of Conservative Dentistry: Erosive tooth wear diagnosis and management. Swiss Dent J. 2016;126(4):342-346.
- Esquivel-Upshaw JF, Dieng FY, Clark AE, Neal D, Anusavice KJ. Surface degradation of dental ceramics as a function of environmental pH. J Dent Res. 2013;92(5):467-471. doi:10.1177/0022034513484332
- Ng E, Tay JRH, Ong MMA. Minimally invasive periodontology: a treatment philosophy and suggested approach. Int J Dent. 2021;2021:2810264. doi:10.1155/2021/2810264
- Rakic M, Pejcic N, Perunovic N, Vojvodic D. A roadmap towards precision periodontics. Medicina (Kaunas). 2021;57(3):233. doi:10.3390/medicina57030233
- Bartold PM. Lifestyle and periodontitis: the emergence of personalized periodontics. Periodontol 2000. 2018;78(1):7-11. doi:10.1111/prd.12237
- Rodriguez Herrero E, Boon N, Pauwels M, et al. Necrotrophic growth of periodontopathogens is a novel virulence factor in oral biofilms. Sci Rep. 2017;7(1):1107. doi:10.1038/s41598-017-01239-9
- Abdellatif H, Alnaeimi N, Alruwais H, Aldajan R, Hebbal MI. Comparison between water flosser and regular floss in the efficacy of plaque removal in patients after single use. Saudi Dent J. 2021;33(5):256-259. doi:10.1016/j.sdentj.2021.03.005
- Tütüncüog˘lu S, Cetinkaya BO, Pamuk F, et al. Clinical and biochemical evaluation of oral irrigation in patients with peri-implant mucositis: a randomized clinical trial. Clin Oral Investig. 2021. doi:10.1007/s00784-021-04044-x
- Bunk D, Eisenburger M, Häckl S, Eberhard J, Stiesch M, Grischke J. The effect of adjuvant oral irrigation on self-administered oral care in the management of peri-implant mucositis: a randomized controlled clinical trial. Clin Oral Implants Res. 2020;31(10):946-958. doi:10.1111/clr.13638
- Herrero ER, Slomka V, Boon N, et al. Dysbiosis by neutralizing commensal mediated inhibition of pathobionts. Sci Rep. 2016;6:38179. doi:10.1038/srep38179
- Dunlap T, Keller DC, Marshall MV, et al. Subgingival delivery of oral debriding agents: a proof of concept. J Clin Dent. 2011;22(5):149-158.
- Putt MS, Proskin HM. Custom tray application of peroxide gel as an adjunct to scaling and root planing in the treatment of periodontitis: a randomized, controlled three-month clinical trial. J Clin Dent. 2012;23(2):48-56.
- Putt MS, Proskin HM. Custom tray application of peroxide gel as an adjunct to scaling and root planing in the treatment of periodontitis: results of a randomized controlled trial after six months. J Clin Dent. 2013;24(3):100-107.
- Putt MS, Mallatt ME, Messmann LL, Proskin HM. A 6-month clinical investigation of custom tray application of peroxide gel with or without doxycycline as adjuncts to scaling and root planing for treatment of periodontitis. Am J Dent. 2014;27(5):273-284.
- Cantore S, Ballini A, De Vito D, et al. Clinical results of improvement in periodontal condition by administration of oral probiotics. J Biol Regul Homeost Agents. 2018;32(5):1329-1334.
- Laleman I, Teughels W. Probiotics in the dental practice: a review. Quintessence Int. 2015;46(3):255-264. doi:10.3290/j.qi.a33182
- Keller MK, Brandsborg E, Holmstrøm K, Twetman S. Effect of tablets containing probiotic candidate strains on gingival inflammation and composition of the salivary microbiome: a randomised controlled trial. Benef Microbes. 2018;9(3):487-494. doi:10.3920/BM2017.0104
- Kaz´mierczyk-Winciorek M, Ne¸dzi-Góra M, Małgorzata Słotwin´ska SM. The immunomodulating role of probiotics in the prevention and treatment of oral diseases. Cent Eur J Immunol. 2021;46(1):99-104. doi:10.5114/ceji.2021.104412
- Alanzi A, Honkala S, Honkala E, Varghese A, Tolvanen M, Söderling E. Effect of Lactobacillus rhamnosus and Bifidobacterium lactis on gingival health, dental plaque, and periodontopathogens in adolescents: a randomised placebo-controlled clinical trial. Benef Microbes. 2018;9(4):593-602. doi:10.3920/BM2017.0139
- Ikeda K, Ejima D, Arakawa T, Koyama AH. Protein aggregation suppressor arginine as an effective mouth cleaning agent. Int J Biol Macromol. 2019;122:224-227. doi:10.1016/j.ijbiomac.2018.10.158
- Li YY, Li BS, Liu WW, et al. Effects of D-arginine on Porphyromonas gingivalis biofilm. J Oral Sci. 2020;62(1):57-61. doi:10.2334/josnusd.19-0075
Editor's note: This article appeared in the November 2021 print edition of RDH.
Anne Nugent Guignon, MPH, RDH, CSP, has received numerous accolades over four decades for mentoring, research, and guiding her profession. As an international speaker and prolific author, Guignon focuses on the oral microbiome, erosion, hypersensitivity, salivary dysfunction, ergonomics, and employee law issues. She may be contacted at [email protected].