Oral health prevention and maintenance includes both daily habits that comprise oral hygiene practices, as well as routine care by oral healthcare professionals. Most of the products recommended for daily oral health maintenance are available over-the-counter, making pharmacists and other nondental health professionals valuable resources in providing oral healthcare and patient education.
It is widely recommended that patients brush their teeth with a fluoride toothpaste for a duration of 2 minutes twice daily. Brushing for a period of 2 minutes achieves clinically significant plaque removal, removing more plaque than when teeth are brushed for only 1 minute. Patients should also be counseled to divide each brushing session into 30 second segments for each quadrant of the mouth.13 Some toothbrushes have incorporated timers into the toothbrush design for this purpose. Although studies are lacking to evaluate the efficacy of built-in timers, these may be useful for patients who have difficulty brushing for the recommended amount of time.14
Toothbrushing technique is also important for plaque removal. Multiple toothbrushing techniques have been published, but studies have not reliably demonstrated one method to be superior for all patients. In general, the toothbrush should be placed at the gumline at a 45° angle to remove plaque optimally at the gingival margin. Patients should apply gentle force to insert the toothbrush into the sulcus. The toothbrush should be moved in a vibrating motion in short strokes while remaining in contact with the sulcus. All surfaces of the teeth (inner, outer, and chewing surfaces) should be brushed during each session.14,15
The choice of toothbrush bristles is important as well. Soft bristles minimize the risk of gingival abrasion or injury during brushing. While medium bristles are effective at plaque and biofilm removal, they carry a risk of gingival damage. This risk can also be minimized by educating patients to apply gentle pressure when brushing and to avoid overly forceful brushing.15 Multilevel or angled bristles remove plaque more effectively than conventional flat-trimmed brushes.14 Toothbrushes should be replaced every 3 to 4 months, replacing more frequently if bristles are visibly frayed or matted.15
Electric-powered toothbrushes are available in a variety of designs. Patients can be assured that electric toothbrushes are at least as effective as manual toothbrushes. Studies of electric toothbrushes have shown statistically significant improvement in dental plaque removal when compared with a manual toothbrush, but the difference may not be clinically meaningful. In general, electric toothbrushes are likely more expensive, but some patients may find them easier to use. It seems there may be meaningful benefit for using electric toothbrushes for those patients who may have difficulty with brushing technique. This may include patients with special needs, patients requiring a caregiver for activities of daily living, patients with manual dexterity deficits, as well as older adults, children, and those with braces. Electric toothbrushes are available with various types of head movements, including side-to-side, rotating oscillating, circular, and ultrasonic. A Cochrane review found that rotating oscillating and ultrasonic designs were more effective in reducing plaque than conventional manual toothbrushes. However, other studies have found conflicting results; choice of electronic toothbrush design remains largely based on patient preference.14,15
Toothbrushes can also earn the American Dental Association (ADA) Seal of Acceptance, indicating the toothbrush is safe and effective for the removal of plaque and reduction of gingivitis. The ADA Council on Scientific Affairs reviews data on defined parameters and grants the seal to those products meeting its requirements. While considering bristle softness, toothbrush shape, and manual or electric toothbrushes, patients can also examine whether or not the product has the ADA Seal of Acceptance. Overall, patients should be encouraged to choose the toothbrush they prefer and will be able to use most consistently in order to promote adequate brushing practices.15
Fluoride is anticariogenic, meaning it prevents tooth decay. Significant clinical studies support the use of fluoride in dental care, recommending that patients brush teeth twice daily with a fluoride toothpaste. Fluoride strengthens tooth enamel by both inhibiting the demineralization of enamel, as well as enhancing the remineralization of decalcified enamel in the early stages of tooth decay. When given systemically prior to the eruption of permanent teeth, the fluoride ion is incorporated into the apatite crystal of the bone and teeth, stabilizing and strengthening the tooth.16 Topical fluoride is also incorporated into the enamel structure, thus fluoride is still effective for caries prevention in children and adults with permanent teeth.17 Fluoride incorporated into the enamel increases the enamel’s resistance to acid, inhibiting the demineralization of enamel. Enamel with a greater concentration of fluoride has an improved structure and is more resistant to acid.18 In decalcified enamel, fluoride present in the oral cavity can be incorporated into enamel structure and promotes remineralization of enamel, protecting the tooth from decay.17 Additionally, fluoride inhibits the metabolism of carbohydrates by cariogenic bacteria, preventing the creation of an acidic byproduct that leads to demineralization of tooth enamel.18
Patients may encounter fluoride from multiple sources, including toothpaste, mouthwashes, and fluoridated water. Fluoride exerts a topical effect when in direct contact with teeth, such as when drinking fluoridated water, brushing with a fluoride toothpaste, or using a fluoride mouthwash. Additionally, any ingested fluoride increases the fluoride concentration in the saliva, extending the protective effects.18
Fluoride is available in toothpastes as sodium monofluorophosphate, sodium fluoride, and stannous fluoride. Prescription strength toothpastes have a greater concentration than OTC toothpastes and result in a greater prevention of caries. However, studies with OTC toothpastes have still found them to be effective in caries prevention and control. Toothpastes may contain additional active and inactive ingredients. These are summarized in Table e15-2.18
Toothpaste Ingredients and Their Functions
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Toothpaste Ingredients and Their Functions
|Category ||Ingredients ||Indication/Purpose |
|Fluoride ||Sodium monofluorophosphate, sodium fluoride, and stannous fluoride ||Prevention of dental caries |
|Antimicrobial ||Triclosan, stannous fluoride ||Reduce gingivitis |
|Antimicrobial ||Pyrophosphates, triclosan, zinc citrate ||Reduce build-up of tartar |
|Anti-hypersensitivity ||Potassium salts, stannous fluoride, amorphous calcium phosphate, caserin phosphopeptide, calcium sodium phosphosilicate ||Reduce tooth sensitivity |
|Abrasive Agents ||Modified silica abrasives or enzymes (calcium carbonate, dehydrated silica gels, hydrated aluminum oxides, magnesium carbonate, phosphate salts, silicates) ||Whiten teeth by physically removing surface stains |
|Detergents ||Sodium lauryl sulfate, sodium N-Lauryl sarcosinate ||Foaming action. May help increase the solubility of plaque during brushing |
|Flavoring Agents ||Noncaloric sweeteners (sugar is cariogenic and is not found in any ADA-accepted toothpaste) ||Flavor |
|Humectants ||Glycerol, propylene glycol, sorbitol ||Prevents water loss in the toothpaste |
|Thickeners ||Mineral colloids, natural gums, seaweed colloids, synthetic cellulose ||Binding agents to stabilize toothpaste |
|Peroxides ||Hydrogen peroxide, carbamide peroxide ||Reduce extrinsic stains |
|Other ||Essential oils, fragrance, menthol, citric acid ||Flavor and fragrance |
Toothpaste ingredients may cause contact dermatitis. Common allergenic ingredients in toothpastes include essential oils, such as spearmint, peppermint, or cinnamon. It is important to note that specific essential oils may not be listed in the ingredients and instead may be mentioned as flavors. Other potential irritants include citric acid, menthol, fragrances, sodium lauryl sulfate (SLS), propylene glycol, parabens, and triclosan. As with toothbrushes, toothpastes may also carry the ADA Seal of Acceptance. Toothpastes must meet requirements created by the ADA Council on Scientific Affairs related to fluoride availability and absorption.18
Recommendations for toothbrushing and toothpaste for children are discussed in section "Pediatrics" of this chapter.
Flossing or interdental cleaning is recommended once daily in order to reduce the likelihood of gum disease and tooth decay. While patients may struggle to floss regularly, it is an essential part of daily oral health maintenance. The purpose of flossing is to remove debris and interproximal dental plaque, or plaque that collects between teeth. Plaque not removed from the teeth may harden into calculus, potentially leading to gingivitis.19
Dental floss is made of nylon or plastic filaments. Floss may have flavoring agents and is available both waxed and unwaxed. The best time of day to floss is whenever it will be performed most regularly. Flossing can occur before or after toothbrushing, or at a different time altogether.19 Flossing is a technique-sensitive intervention, and patients should discuss proper flossing technique with their oral healthcare professional.20 Proper flossing technique is included in Table e15-3.21 Other interdental cleaners available include prethreaded flossers, dental picks, wooden plaque removers, interproximal brushes, and water flossers.19 Not all interdental cleaners are appropriate for all patients, and patients should consult their oral health professionals for individualized recommendations.20
Proper Flossing Technique
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Proper Flossing Technique
Wind 18 inches (45 cm) of floss around the middle fingers of each hand
Pinch 1-2 inches (2.5-5 cm) of floss behind thumb and index finger, keep taut between fingers
Gently guide floss between the teeth, guiding with the thumb and index fingers
Gently wrap floss around the side of the tooth
Slide floss up and down against the tooth surface and under the gumline
Mouthwash may be used daily, offering further benefits in addition to brushing and flossing. Specifically, mouthwash may reduce bad breath, as well as reduce plaque and gingivitis. It is important to educate patients that mouthwash cannot replace brushing and flossing, but instead should be used in addition. Mouthwashes may also have the ADA Seal of Acceptance. Table e15-4 lists active ingredients that may be found in mouthwash.22
Active Ingredients in OTC Mouthwash
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Active Ingredients in OTC Mouthwash
|Active Ingredients ||Indication/Purpose ||Clinical Pearls |
|Cetylpyridinium chloride ||Reduce bad breath, plaque, and gingivitis ||Antimicrobial action |
|May cause brown staining of teeth, tongue, and/or restorations |
|Essential oils such as eucalyptol, menthol, thymol, methyl salicylate ||Reduce bad breath, plaque, and gingivitis ||May be a potential allergen or irritant for some patients |
|Fluoride ||Prevent tooth decay ||Effective topically to prevent dental caries |
|Peroxide ||Tooth whitening ||Present in whitening mouthwashes |
Mouthwashes may also contain alcohol. Alcohol consumption is a risk factor for oral cancers, although studies have not demonstrated an association between mouthwash use and oral cancer. Since alcohol may also worsen xerostomia, alcohol-containing mouthwashes should be avoided in patients experiencing xerostomia. Mouthwashes should not be used in children under 6 years of age because of the concern that they may swallow a large quantity.22
Chlorhexidine mouthwash is available only by prescription and is indicated for treatment of gingivitis and periodontitis.23 Chlorhexidine rinse may also prevent alveolar osteitis (dry sockets) after a tooth extraction. Potential adverse reactions include staining of teeth, dentures, and tongue, as well as altered taste.22
The ADA recommends all patients regularly visit a dentist or oral healthcare professional for the prevention and treatment of oral disease. The frequency of dental visits should be determined by an individualized case management protocol based on the patient’s caries risk level, age, and compliance or engagement with oral health preventive strategies. Frequency of visits range from every 12 months for a patient with low risk of oral disease to every 3 months for patients at high risk. Visits include regular cleanings, assessments for oral conditions, such as dental caries, periodontitis, and oral cancer, and guidance on oral health maintenance. Patients should expect their oral healthcare professional to design an oral health maintenance regimen that is tailored to the patient, provide education on lifestyle changes related to oral health, and provide guidance on the use of oral healthcare products.15 The chronic condition of oral disease dictates that oral health recommendations should focus on prevention and maintenance protocols.24
Edentulism, defined as the loss of all permanent teeth, affects an estimated 26% of the US population over 75 years of age.25 Many of these individuals wear complete dentures as a prosthetic to enhance esthetics and function. The oral health of a completely edentulous patient is a significant factor in their quality of life, nutrition, social interactions, and general systemic health.26 Dentures accumulate plaque, stain, and calculus similar to the natural dentition. In 2009, the American College of Prosthodontists developed evidence-based guidelines for the care and maintenance of complete dentures (see Table e15-5).27
Guidelines for Care and Maintenance of Complete Dentures
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Guidelines for Care and Maintenance of Complete Dentures
Careful daily removal of the bacterial biofilm present in the oral cavity and on complete dentures is important to minimize oral tissue irritation (denture stomatitis).
Dentures should be cleaned daily by soaking and brushing with an effective, nonabrasive denture cleanser. Afterward, they should be thoroughly rinsed before putting them back inside the mouth.
Commercially available denture cleansers use various active agents, including hypochlorites, peroxides, enzymes, acids, and oral mouth rinses to remove biofilm from dentures. Denture cleansers are not to be used inside the mouth.
Dentures should never be placed in boiling water.
Dentures should not be soaked in bleach, or products containing bleach, for periods of more than 10 minutes.
Dentures should be stored immersed in water when not in use.
Dentures should not be worn continuously (24 hours per day) as this can cause denture stomatitis.
Patients who wear dentures should see a dentist annually for maintenance of the denture and evaluation of the health of the oral cavity and associated tissues.
Denture adhesives can improve the retention and stability of dentures, helping prevent the accumulation of food particles beneath the dentures. However, evidence regarding the effects of denture adhesives on the oral tissues when used for periods longer than 6 months is lacking. Thus, extended use of denture adhesives should only be undertaken with periodic assessment by a dental professional.27
Denture adhesives are available in multiple forms, including paste, cream, powder, and pads. Prior to the application of any adhesive, the denture should be cleaned and dried. Creams and pastes should be applied in three to four pea-sized increments. Powder should be applied in a thin film to the tissue-contacting surface of the denture after wetting the denture base. Pad adhesives should be sized correctly by pressing the pad into the denture and removing any excess with a pair of sharp scissors. The necessary quantity of denture adhesive should be minimal and should be completely removed from the prosthesis and the oral cavity on a daily basis. Upper and lower dentures should be placed individually and held in place firmly for 5 to 10 seconds, after which any excess material should be removed. If increasing amounts of adhesive are necessary for the patient to feel comfortable, a dental professional should be consulted in order to evaluate the prosthesis and oral tissues.27
Temporomandibular disorders (TMDs) encompass a wide group of clinical problems involving the masticatory musculature, the temporomandibular joint, and the surrounding bone and soft tissue. TMD is a multifactorial disease process with various causes including parafunctional habits (bruxing, clenching, lip or cheek biting), instability or laxity of the temporomandibular joint, trauma to the jaw, and comorbidity with other rheumatic or musculoskeletal disorders. The prevalence of TMD is thought to be 6% to 12% of the population, with about 5% having signs and symptoms warranting treatment. TMD symptoms are more prevalent in women than men, with peak occurrence between 20 and 40 years of age. See Table e15-6 for common symptoms of TMD.28
Symptoms of Temporomandibular Disorder
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Symptoms of Temporomandibular Disorder
Muscle and joint pain, acute or chronic
Radiating pain to the ears, neck, and head
Joint noise (clicking, popping, crepitus)
Functional limitations such as decreased range of motion and jaw locking
Diagnosis of TMD requires a focused history and physical examination. The use of radiographs and magnetic resonance imaging may aid in determining degenerative changes. Images combined with clinical presentation, signs, and symptoms will allow the clinician to develop a diagnosis and treatment plan. Treatment should initially center on conservative, reversible, and evidence-based modalities. Only after failure of noninvasive options should invasive and nonreversible treatments be performed.28
A variety of bite guards, also known as occlusal splints, oral orthotics, and oral appliances, are available with differing designs and functions. Patients often seek them out to alleviate symptoms of TMD and bruxism. Bite guards can be custom made or bought OTC. They seem to be an effective treatment for many temporomandibular disorders and nocturnal use may improve sleep quality. Evidence also supports oral appliance treatment for sleep bruxism and protection of teeth, but it is insufficient to support its role in the long-term reduction of sleep bruxism activity. Therapeutic mechanisms of occlusal splints are not yet clarified; suggestions have been made that occlusal splints can reestablish symmetric activity in the temporal and masseter muscles. An occlusal splint may contribute to reducing myofascial pain, improving quality of life, and protection of teeth, although it does not cure temporomandibular dysfunction.29
There is little evidence to prove the theory behind any one bite guard design30; however, full coverage splints (covering the biting surfaces of all teeth of one arch) are often recommended to evenly distribute forces from the masticatory muscles to the teeth and to prevent unwanted changes in tooth or bite position.31 With the availability of OTC splints in the community pharmacy, patients may bypass their dentist, which can have many significant risks. Not least, it relies on the consumer to diagnose their condition without the help of a dental professional, which may be inaccurate and delay appropriate treatment. Additionally, there is little consistency across safety warnings or stated indications for use of OTC splints, which can result in confusion or improper treatment of a condition.
The use of poorly fitting appliances can have unintended consequences. Changes in the dentition, tooth movement, gingival trauma, and increased TMD symptoms are all possible risks of using occlusal splints.32 In general, patients should use caution in self-selecting OTC occlusal splints and consultation with an oral healthcare professional is recommended prior to purchasing an oral appliance for daily use.
Both the ADA Council of Scientific Affairs and the Council on Access, Prevention, and Interprofessional Relations recognize that dental injuries are common in sports and recreational activities. Nearly one-third of all dental injuries is sports related, with one-sixth of sports-related injuries being to the craniofacial area. Dental traumatic injuries can carry a hefty financial and physical burden over an individual’s lifetime. Numerous surveys of sports-related dental injuries have documented that participants of all ages, genders and skill levels are at risk of sustaining dental injuries in sporting activities, including organized and unorganized sports at both recreational and competitive levels. While collision and contact sports, such as boxing and football, have inherent injury risks, dental injuries are also prevalent in noncontact activities and exercises, such as gymnastics, bicycling, baseball, and skating. In limited-contact sports such as basketball, 14% to 34% of reported injuries are to the orofacial area. Mouthguards can be effective in reducing the incidence of dental injury in sport.33
Mouthguards are typically composed of a thermoplastic coploymer (usually ethylene vinyl acetate), and designed to fit over the upper teeth. There are three types of mouthguards: ready-made, mouth-formed “boil-and-bite,” and custom-made. An effective mouthguard should be resilient, tear-resistant, properly fitting, and comfortable. It should also be easy to clean. A mouthguard should be cared for similarly to any oral appliance. Prior to and after each use, it should be rinsed with cold water or mouthrinse. It may also be brushed gently with a toothbrush. Mouthguards should be stored in a firm, closed container allowing for adequate airflow. High temperatures should be avoided to prevent distortion of the device. Mouthguards that are loose or have holes should be replaced.33 Notably, when custom mouthguards were compared with other mouthguard types, injury rates did not differ. However, a properly fitted appliance can decrease discomfort and fatigue, which are often associated with noncompliance.34,35
It is necessary that mouthguards actually perform as required in order to keep teeth safe. Importantly, the ADA and the American National Standards Institute (ANSI) have developed a standard for Athletic Mouth Protectors and Materials. However, as recently as 2009, a study of commercially available products found none that met current ANSI and ADA standards for impact attenuation.36