The Harvard Medical School Family Health Guide
Teeth, Mouth, and Gums
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Preventing Tooth Decay and Plaque

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Manual vs. Powered Toothbrushes

Good news — you don’t have to buy an electric toothbrush to get clean teeth. As more power toothbrushes hit the store shelves, you may feel pressure to buy one. More expensive is better, right? Not necessarily. According to the American Dental Association (ADA), a manual toothbrush can clean teeth just as well as a power toothbrush. The secret lies in how the toothbrush is used.

By following the tips below you can ensure a good brushing:

  • Brush the inner, outer, and chewing surfaces of the teeth with short (teeth-wide), back and forth strokes.
  • Place the brush at a 45-degree angle against your gums when brushing along the gum line.
  • To clean the inside surfaces of the front teeth, use gentle up and down strokes with the tip of the toothbrush.
  • Use a soft touch. Vigorous brushing won’t get more plaque off and can irritate your gums.
  • A set time is not necessary; just make sure you are cleaning all the surfaces of your teeth thoroughly.
  • Be sure to replace your toothbrush once the bristles have become frayed or every three to four months.

An electric toothbrush may be the right choice for you, however. People with arthritis or other conditions that impair motor skills may need the relative ease of a powered toothbrush to do an adequate job of brushing their teeth. You should talk with your dentist or hygienist to determine which type of toothbrush is best for you.

When purchasing a toothbrush, look for the ADA Seal of Acceptance. To take part in this voluntary program, dental product manufacturers must prove their product meets ADA criteria for effectiveness and safety. Also, scientific studies must support the claims of any packaging or advertising of products bearing the ADA Seal.

December 2002 Update

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Periodontitis and Heart Disease

The question of whether gum disease is associated with heart disease is controversial. The first research to suggest a connection, published in 1989, found that even after controlling for such cardiovascular disease risk factors as smoking and diabetes, heart-attack patients had significantly worse dental health than control subjects. Since then, several studies have also suggested a link, but the nature of the relationship — is it causative or coincidental? — remains in question.

In 2001, researchers sought an answer to this question, examining data from 4,027 people who participated in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. During 17 years of follow-up, there were 1,238 cases of heart disease, 538 of which proved fatal. The rate of heart disease was three times higher in those with periodontitis than in those with healthy gums.

However, the connection became less prominent once investigators adjusted the numbers to account for other risk factors for cardiovascular disease — smoking, cholesterol levels, high blood pressure, and diabetes. After this adjustment, the heart disease risk among people with and without chronic dental infections was similar.

In fact, even those people who had eliminated any potential of dental infection through extraction of all teeth didn't have a lower heart disease risk when compared to those diagnosed with periodontitis (inflammation of the gums). The risk of developing CHD didn't decrease over time among those with no dental infections or increase over time among people with periodontitis.

A higher rate of other heart-disease risk factors among people with periodontitis might explain this relationship between gum disease and heart disease. For example, those with periodontitis were more likely to have high blood pressure and diabetes, and to smoke cigarettes.

These findings support the theory that the presence of periodontitis may occur coincidentally with increased cardiovascular risk but it is not its cause.
March 2002 Update

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Sugar and Tooth Decay

"If you eat too much candy your teeth will rot!" We've known about the link between sugar consumption and tooth decay for centuries. The bacteria in dental plaque feeds on sugar, and the acid produced by the bacteria attacks the protective enamel surface of the teeth, allowing for tooth decay to proceed. But since the advent of fluoride in water, toothpaste, dental treatments, and even processed foods, do we still need to restrict how much sugar we eat?

A recent review answers this question. Researchers examined the results of 36 studies conducted in countries where fluoride exposure is widespread. Only two of the studies showed people who consumed high amounts of sugar had a high risk of tooth decay. The remaining studies showed only a moderate to weak association. Does this mean we can eat all the candy we want and not have to worry about tooth decay? Not quite. Moderation is still key, because while the risk is much less than it was during the pre-fluoride era, consuming sugar was still found to be a moderate to mild risk factor for tooth decay.

If sugar has a role in tooth decay, can sugar substitutes have a role in the prevention of tooth decay? A review of fourteen studies showed a 30 to 60 percent decrease in the rate of tooth decay among study participants who used sugar substitutes compared to participants using sugar. In the studies, participants chewed gum or used toothpaste containing either sugar or the sugar substitutes xylitol or sorbitol. Xylitol gave the largest decrease in tooth decay. Sugar-free gums, particularly those containing xylitol, may help prevent tooth decay by decreasing acid production and promoting the flow of saliva to clear sugars from the mouth.
January 2002 Update

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