Don't ease up!

Oct. 16, 2014
It's been about five years since I last visited family in northern England.


It's been about five years since I last visited family in northern England. So much has changed since then, including the provision of dental hygiene services. My niece Bethany and her boyfriend, Rik, are both millennials, and they are always eager to discuss their oral hygiene with me. They are very particular about their self-care. They love powered toothbrushes and Rik told me his hygienist (pronounced hy-GEE-nist in the UK) recommended a Philips Sonicare with smaller brush head for hard-to-reach areas, but he uses Bethany's electric Oral-B when he spends the night at her family home.

I asked them all kinds of questions about their hygiene visits and always came away impressed with their hygEEnist's suggestions and their overall commitment to good oral health. "Bad British teeth" is still the butt of jokes among those who stereotype people but I know through personal experience that many Brits practice excellent oral hygiene.

Powered toothbrushes offer statistically significant benefits when compared to manual toothbrushes.1 Here are some comparison figures (based on comparing mean scores for manual and powered toothbrushing):

• A 2014 Cochrane Review showed an 11% reduction in plaque/biofilm for the Quigley Hein index at one to three months of use, and a 21% reduction in plaque when assessed after three months of use.

• For gingivitis, there was a 6% reduction at one to three months of use and an 11% reduction after three months (Löe and Sillness index).1

The evidence was considered to be of moderate quality. The review included studies published from 1964 to 2011, which compared powered to manual toothbrushes. Over 50% of the studies used a powered toothbrush with rotation oscillation mode of action.

After manual toothbrushing, the overall plaque score reduction was estimated to be about 42% and was influenced not only by duration of brushing but by bristle design.3 A manual toothbrush with a "flat-trim" bristle design removed less plaque than a toothbrush with multilevel and angled bristles.3

Brushing efficacy

Brushing efficacy is more important than we sometimes realize. Individualized instruction with disclosing agents and a mirror can make a difference between a plaque score of 27% after one minute of brushing compared to 41% after two minutes.3 Application of additional hygiene tools for interdental cleaning and an appropriate dentifrice with plaque/biofilm growth-inhibiting ingredients are needed.3

Many U.S. adult patients (even young adults) are presenting with noncarious cervical lesions (NCCLs), which are controversial and not always well understood.4 Many of these NCCLs may have a multifactorial etiology and have been called abfraction, abrasion, erosion, and corrosion.4

In children and in young adults, the erosive potential of soft drink consumption, including energy drinks, is also a growing problem. In the case of dental erosion, chemical, biological, and behavioral factors need to be considered, and saliva is probably the most important biological factor affecting the progression of dental erosion. NCCLs (which are different from dental erosion) trap plaque/biofilm.

Instead of telling patients to "ease up on brushing horsepower," it's important to customize plaque/biofilm removal instructions to make sure the plaque/biofilm is being adequately disrupted. Adults with NCCLs and clinical attachment loss are sometimes told by dentists and hygienists to ease up on brushing. It's often the wrong message.

When I see new adult patients who have received this message from their dentist or hygienist in the past, many of them are no longer removing enough supragingival plaque/biofilm. In "going easy" in areas of clinical attachment loss or NCCLs, there is more gingival inflammation and additional loss of attachment. I have also seen an increase in demineralization near the CEJ as a result of manual toothbrushing using a light roll (Modified Stillman technique) with an emphasis on "gingival stimulation." This is where the advantage of powered toothbrushing is clear.

The CEJ is a plaque/biofilm and calculus trap.5 Inflammatory periodontal diseases (with the exception of aggressive periodontitis) develop and progress slowly, and there's a direct correlation between increasing probing depth, CAL, and the presence of residual biofilms and calculus.5 Post scaling and root planing reveals residual biofilm at the CEJ as a common area.5

Anatomical relationships of enamel, dentin, and cementum vary, and four relationships have been reported:

• Enamel overlapping cementum

• Cementum overlapping enamel

• End to end (butt) joint

• A gap between enamel and cementum that exposes underlying dentin (An ouch for our younger adult patients that often requires restoration with an appropriate restorative material.)

When viewed with a scanning electron microscope, it is clear that these irregular contours facilitate retention of biofilm and dental calculus.5 Professional instrumentation in these areas is difficult due to several factors. The irregular topography permits biofilm to accumulate in depressions that would require significant root planing to remove. Because the CEJ is in close proximity to restorative margins, these margins may inhibit adequate instrumentation due to overhangs and overcontouring at the gingival margin.5

More importantly, clinicians who "let up" on scaling and root planing in this area due to lack of, or inadequate, local anesthesia (which is all too common in today's dental practices) are leaving residual biofilm and calculus. Enamel at the CEJ is also reported to be thin and fragile; with aggressive instrumentation, enamel may sometimes fracture and result in irregular contours that may also contribute to biofilm and calculus retention.5

When plaque/biofilm attaches to the cervical enamel or root surface and matures, it is a key precursor to inflammatory periodontal disease.5 Because biofilm adherence is greatly influenced by surface texture and topography, irregular topography results in faster biofilm growth.5

In studying the relationship of supragingival biofilm to the recolonization of subgingival biofilm following periodontal treatment, microbes can have two origins: incomplete subgingival instrumentation or extension of a growing supragingival biofilm. These repopulated subgingival biofilms are characterized by a dominant population of gram-negative anaerobes and motile bacteria that are commonly associated with periodontal disease.5

For all clinicians who regularly evaluate a patient's plaque/biofilm control, the CEJ remains a significant clinical challenge - too much or too little instrumentation, too much or too little toothbrushing. The abrasive potential of toothpastes and need for dentin hypersensitivity medicaments require thoughtful consideration.

My message to all clinicians is to customize recommendations and therapy and to seriously consider high-end powered toothbrushes for improved plaque/biofilm removal. More effective cleaning at the gum line helps to preserve attachment by eliminating toxins and connective tissue-damaging proteases from the sulcus.6 High-end powered toothbrushes offer so many advantages over manual toothbrushing today, and important features are often overlooked. Interval timers and different brushing modes, especially instructions for "gum" care, can make a difference if the hygienist engages the patient in the appropriate manner.

Powered toothbrushes offer a significant advantage over manual toothbrushes for this obvious reason: With a manual toothbrush, it is necessary to educate the patient on how to hold the toothbrush and how to manipulate it in different areas of the mouth. The powered toothbrush takes away a lot of the uncertainty associated with manual brushing because it's moving continuously and can even reach areas that a manual toothbrush cannot.

When instrumenting or providing self-care instructions along the CEJ, keep in mind the surface irregularities and topography. For patients with gingival recession, exposed root surfaces are frequently missed during brushing because they do not follow the regular pattern of brushing along the teeth. Disclose these anatomical areas including the CEJ regularly and don't rush professional instrumentation. Easing up on toothbrush horsepower as a recommendation for patients who present with NCCLs and CAL is often a big mistake. RDH



LYNNE SLIM, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or