I have had a few patients ask recently about the order of oral hygiene activities. Does it matter if you brush or floss first, and should this be done before or after breakfast? Based on available research, it seems opinion matters as much as scientific facts.

A spokesman for the American Dental Association and a professor of restorative dentistry at the University of California, Los Angeles, recommends flossing first. His rationale? Get the unpleasant task out of the way to avoid the temptation to not do it. “Let’s face human nature, if you’re going to skip one, which one will you skip?”

By contrast, a professor of oral health sciences at the University of Washington in Seattle, advises her patients to brush with a fluoride toothpaste, then floss. She says that way your mouth will be awash with fluoride as you are maneuvering the floss.

So, what’s my opinion? I was taught and have always maintained that flossing before brushing is better. The rationale behind this is that plaque and other debris is dislodged during the act of flossing allowing toothpaste and the mechanical action of brushing to better penetrate the different surfaces of the tooth. Does it really matter? I don’t think so.

Have you heard your dental hygienist or dentist tell you to floss to prevent cavities between your teeth? Based on research, the main reason for flossing is not for prevention of cavities. Rather, flossing’s main benefit is stimulation of tissue to reduce gum inflammation known as gingivitis. Gingivitis can lead to more advanced gum disease and things like bad breath. That is why I believe that regular use of a water pik and an electric toothbrush is most ideal.

A review of 12 randomized controlled trials found that people who brushed and flossed regularly had less gum bleeding than the brush-only camp. No surprises there. There have been no studies, that I am aware of, reporting a reduction in cavities from flossing. Of course, these are difficult studies to conduct. There are many factors that contribute to decay occurring between the teeth.

There are also different schools of thought whether to brush and floss before or after breakfast. I don’t know about you, but I cannot eat or drink anything (especially orange juice) after I brush my teeth. So, although you might expect the solution to be brushing after breakfast, there is some risk with that.

If you eat or drink something sugary or acidic—like the fruits, juices, and other breakfast foods many of us eat in the morning— the mouth is in an acidic environment for at least 30 minutes after consumption. These acids weaken tooth enamel, and brushing too soon can cause damage to the enamel. If you know you’re going to eat or drink something very acidic ahead of time, you may want to brush your teeth first.

Alternatively, you can wait 30 minutes after you eat for your saliva to neutralize the pH of your mouth. Or, re-balance your oral pH right away with an alkaline mouth rinse and then brush. In the end, it depends a little on what you eat. Take stock of what you’re eating for breakfast and judge when you should brush based on its sugar or acid content.

Everyone, well…..almost everyone, can stand some improvement with their oral hygiene. Many dental problems are completely avoidable with excellent home care, which is in your control. Ask your dentist or hygienist how to improve your home care. Strive for constant improvement.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. He has a special interest in treating sleep apnea and TMJ problems. If there are certain topics you would like to see written about or questions you have please email them to him at jpstclair@stclairdmd.com.

If you travel frequently, it’s easy for your nightly routine to change, which means you might forget about your sleep apnea treatment. It’s essential you continue your treatment, even if you’re away from home. No matter if you’re traveling for business or pleasure when living with sleep apnea in Rowley, here are the tips you need to make your journey easier.
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Dental hygienists love it when they make suggestions to patients about home care and their dreams are answered when the patient returns 6 months later with noticeable improvement. It might be as simple as adding a good electric toothbrush or waterpik to the patient’s regimen. I would like to say that we are amazed daily by the fruits of our counseling, but that isn’t the case. For whatever reasons there are, changing routines is often difficult.

Over 10 years ago I wrote a column about an article I saw in a magazine, which is apparently also a book, entitled “Change or Die”. What if you were given that choice? What if the doctor said you had to make tough changes in the way you think and act – or your time would end soon? Could you change? Here are the scientifically studied odds: nine to one. That’s nine to one against you. I don’t think we have made much headway on this over the past 10 years.

It’s a pretty common theme. As Americans, we’re dying at a rapid rate from five basic self-induced health problems. We eat too much. We drink too much. We smoke too much. We have too much stress. And, we don’t exercise enough. These five poor choices, manifested in scores of ailments, consume the vast majority of the nation’s healthcare budget. The article is an outpouring of concern from healthcare experts and doctors, all looking for a way to change the behavior of people who love their lifestyle so much that they literally die from it.

In a Johns Hopkins study a while back, 9 of 10 heart surgery patients chose to return to their unhealthy lifestyle, rather than make the changes needed to live longer. Only a few are convinced by their doctors to make radical daily changes. One of the more successful doctors with this is Dr. Dean Ornish, founder of the Preventive Medicine Research Institute. He says NO to meat, fatty dairy products, alcohol and oil. His vegetarian diet is low-fat, high-maintenance and strict. And, it has been shown to reverse heart disease and other factors in patients who were destined for quadruple bypasses – or worse, eternal sleep.

When 90% of patients are back to their old tricks within weeks of open-heart surgery, his program is the one making a difference. How does he do it? Well, it’s easy, really. Dr. Ornish coaches his patients to make changes strictly for the benefit of making them. Instead of telling them they must change or face death, he encourages them to change so that they can enjoy the endless beauty of living. With dedicated support, three-quarters of his patients are still going strong three years into their drastic lifestyle shift. I’m sure it is deeply gratifying to know that it only takes words said a certain way to make a true change in someone’s life.

Why is it so difficult to get people to change? Well, it depends. You have to be sick and tired of being sick and tired, usually, before you’ll make the leap and let go of whatever the resistance is to change. For many, doing more preventively never happens. We wait for chest pain to strike or a toothache to occur before seeking help to solve our crisis problem. Then we hope, and many times expect, that our problem can be solved easily and not too much will have to change to prevent it from happening again.

Dr. Ornish would tell you the change must be profound. He would tell you to never have another cheeseburger. Your hygienist would say you need to follow a new strict homecare routine, radically different than what you currently do. Making changes like these has to mean more to you than the change itself. You must be invested in improving the quality of your life.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. He has a special interest in treating sleep apnea and TMJ problems. If there are certain topics you would like to see written about or questions you have please email them to him at jpstclair@stclairdmd.com

In an online report I recently read in a journal that was forwarded to me by a patient, they listed 9 “healthy” habits that they claim are a waste of time. Three of them had to do with oral health. Let’s take a look.

The first on the waste of time list was to see your dentist twice per year. I have seen this reported somewhere else in the media recently. According to the authors, close to 30 studies have apparently found no conclusive evidence supporting a need to see a dentist every 6 months. They went on to say, “If your teeth and gums are healthy, once per year is enough to catch developing problems.”

I absolutely agree. There are definitely people who only need to see a dentist/hygienist once per year. Most dentists use a classification system to rate a patient’s periodontal (gum) health. Type I patients are the ones that only need to see a dentist once per year. They are healthy, they have good homecare habits and are low risk for disease. In the average dental practice, I would say this is about 10-15% of the population.

Type II patients are those with gingivitis and should be seen twice per year. This group makes up about 50% of the typical dental patient population. Many of these patients could move into the Type I group if they had better homecare habits and technique.

Type III & IV patients are the remaining 30-35% of the population who should be seen every 3 or 4 months, and in some cases even more frequently. Because of genetics and/or bad habits, this group has active disease and is at high-risk for problems.

Let’s also not forget the other 50% of the population who don’t even visit a dentist once per year. While I think there are people who can be healthy and see a dentist once per year, it is irresponsible to make it seem that it pertains to everyone. The only one who can determine how healthy you are is your dentist. It should be up to you and the dentist you trust.

The #7 waste of time reported was to use a hard toothbrush. According to the report, a soft one cleans your teeth just as well and is less damaging to your teeth and gums. This is old news and is true.

The next one shocked me. The #8 waste of time – brushing and flossing twice per day. According to the authors, everyone only needs to visit the dentist once per year and brush and floss one time per day. They recommend brushing for at least 2 minutes before you go to bed and flossing one time per day. They also mentioned that people who did not floss frequently (whatever that means) are 3 times more likely to develop stomach cancer. I am assuming the author is relating lack of flossing to getting periodontal (gum) disease. More recent research is showing that, “Risk factors for precancerous lesions and gastric cancer are being identified, one of which may be periodontal disease”. Although lack of flossing does not automatically cause gum disease, poor oral health is clearly a risk factor for other health problems.

Here’s the bottom line:

1. Establish a relationship with a dentist you are comfortable with and trust. Determine with that person how frequently you should be seen.
2. Use a good quality soft electric toothbrush. Get instructions on proper use from your hygienist.
3. Brush at least twice per day, preferably at least 30 minutes after meals. Floss at night before you brush.

It is as simple as that.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. If there are certain topics you would like to see written about or questions you have please email them to him at jpstclair@stclairdmd.com. You can view all previously written columns at www.jpeterstclairdentistry.com/blog.

It’s one of those things like Kleenex® or Ziploc®…..you know…when you think of a tissue or a resealable bag you think of these. The same goes for Waterpik®. There are different oral irrigators on the market. There are the ones made by Waterpik® and many others; even ones that attach to your sink or showerhead.

I had never really recommended oral irrigators to my patients. The clinical research that I have seen never showed that these things were any more effective than flossing and brushing. I recently noticed that the packaging on the Waterpik® brand said that oral irrigation was 3X more effective than floss. So, I went back to the literature.

The claims made by Waterpik® are from “independent” studies. This basically means that their own research shows they are more effective. While flossing is good, if you don’t use floss, any other aids used to clean teeth are better than none at all. Although, having experienced the Waterpik firsthand, I do feel there is more benefit than just for those with braces.

Stimulation of the gum tissue is essential to a healthy mouth. It is also essential to remove bacteria both above and below the gumline. Oral irrigators do a great job of this. Like anything else, it takes a little getting used to. I realized quickly that you can actually experience tickling and pain at the same time with one of these things. It takes a little time to build up tolerance and be able to increase the pressure of the stream of water. Once you get used to it, it seems to be very effective in stimulating healthy tissue.

Oral irrigators are essential for both kids and adults with braces. They are also great for those with crowns, bridges, larger spaces between the teeth, people battling periodontal disease, or anyone trying to achieve healthier gums. The units come with an assortment of tips for different applications.

Waterpik® has both counter models and cordless hand-held models. The counter models have a wider range of pressure settings and a larger tank to hold water. The cordless models are very convenient for obvious reasons but the water compartment is very small. You typically have to fill the thing up about four times for each use.

Here is the bottom line. If you brush and floss impeccably and your dentist or hygienist says your gum tissue is as healthy as it could be, a “water flosser” is probably overkill. In my experience, that is a very small portion of the population. Most people have room for improvement with their homecare.

The newest research I have seen, which was not done by a product manufacturer, shows that using a water flosser is significantly better than brushing alone. So, if you don’t floss, have braces, have any type of implants, any crowns, bridges, or veneers, have diabetes, or have been told you have gingivitis or any other type of periodontal disease, this product will most likely improve the report you get when you visit the dental office.

Like anything, compliance is the key. Research shows that only 2-10% of the population flosses regularly and effectively and that the average brushing time is 37 seconds. Improvement comes with the effective use of the tools you have. You can get healthier and have good check-ups, but you have to put the time in.

Dr. St. Clair maintains a private dental practice in Rowley and Newburyport dedicated to health-centered family dentistry. He has a special interest in treating sleep apnea and TMJ problems. If there are certain topics you would like to see written about or questions you have please email them to him at jpstclair@stclairdmd.com