The Four Pillars of Oral Health
A holistic approach that takes into account the impact that oral hygiene has on the whole body
Though bacteria are vital to human health and well-being, they are responsible for most of the damage done to teeth and gums, e.g. cavities, gingivitis and periodontitis. The starting point for these conditions is the uncontrolled growth of pathogenic bacteria in the mouth, which is the result of poor oral hygiene. The mouth is the door to the body, which means that pathogens don’t just cause oral disease, but they can have implications throughout the entire body if their growth within the mouth is not controlled. Long-term consequences of poor oral hygiene include stroke and heart disease (not to mention loss of teeth and jaw bone). This is why it’s important in the dental industry to shift focus from just the mouth to the entire patient, with all systems working together and not individually.
The four pillars of oral health form the foundation of a holistic approach to oral care. These are:
Diet
Cleaning
Prevention with fluoride
Professional control
Diet
Care of the Microbiome
Enamel is the hardest material in the human body, but its disadvantage is that once it is damaged, it cannot grow back. Demineralisation is the loss of essential minerals (i.e. calcium and phosphate) from the enamel in the presence of bacterial acids.
Stephen's Curve, first described by Robert Stephan in 1943, shows the pH of the mouth over time following sugar consumption.
The normal pH of the mouth is usually pH 7 (neutral). When one eats certain foods (e.g. fermentable carbohydrates, acidic drinks or sugar), the commensal acidogenic bacteria in the mouth metabolise these, creating acidic by-products in the process. These by-products bring the pH of the mouth below the “critical” pH of 5.5, at which point demineralisation of the enamel occurs.
Gradually, the acids are eliminated from the mouth, aided by the saliva (and fluoride-containing products) that acts as a pH buffer. Once the pH rises above the critical level of 5.5, repair of any demineralised enamel occurs (remineralisation) and the pH eventually returns to normal (pH 7). Repeated consumption of sugary foods and drinks means a lower pH is maintained for longer periods of time, therefore not allowing remineralisation to occur. A lack of repair of demineralised enamel eventually leads to tooth decay.
When it comes to Stephan’s curve, there are three factors to bear in mind:
Quality of food
To prevent tooth decay, a healthy diet is recommended. According to the Swiss Dental Association (SSO), there are certain enamel ‘superfoods’ (and drinks) that can have a protective effect on teeth.
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Quantity of food
The more sugar one eats, the more the bacteria have to metabolise, and the longer the pH of the mouth remains below 5.5. This means longer periods of demineralisation and therefore less of an opportunity for remineralisation, thus increasing the chance of tooth decay.
Time of consumption
Spacing sugary snacks out throughout the day again prolongs a low pH, maintaining the demineralisation period. It is therefore better to save sugary foods for meal-times in order to reduce the amount of time the pH of the mouth spends below 5.5 throughout the day.
The health of the entire body depends on a balanced diet, and that includes the mouth. Poor nutrition in the mouth can cause bad breath, tooth decay, gingivitis and periodontitis – all in varying degrees of severity. According to the UK’s National Health Service (NHS), bad diets are the cause of more deaths worldwide than tobacco. Not only can a poor diet cause mental health conditions, cardiovascular disease and diabetes, but it is also a risk factor for many types of cancer. A healthy mouth, a healthy body and a healthy mind are all linked and the importance of a holistic approach to dental care, starting with the diet, should not be overlooked.
Cleaning
Though it is the second pillar, cleaning for many is perhaps the most obvious starting point of oral care.
Mechanical cleaning (which is contact cleaning with a non-chemical product, e.g. a toothbrush) is the best way to remove plaque. Plaque is a cumulative soft, sticky mass of bacteria that grows on the surfaces of teeth and is easily removed with regular tooth brushing. If, however, its growth is not controlled, it can spread and harden to form tartar (which is less easily removed with a toothbrush). Plaque is responsible for tooth decay and gingivitis, so it’s best that it’s removed regularly.
Some bacteria settle in places in which they are less likely to be disturbed, e.g. between the teeth. 40% of each tooth is concealed in the hard-to-reach interdental spaces, so many people neglect to brush there. This is the equivalent of leaving 12 whole teeth uncleaned and is why 80% of cavities occur in the interdental region.
To ensure regular plaque removal and optimal oral health, establishing a thorough mechanical cleaning routine that includes the following is recommended:
Twice-daily tooth brushing
Once-daily interdental cleaning
Prevention with fluoride
The most important ingredient a toothpaste can have
Stephan’s curve describes the continuous fluctuation of pH throughout the day, which fuels the demineralisation-remineralisation cycle. Though the saliva plays a role in buffering pH to try and keep it at the normal level of pH 7, or to at least keep it above the critical pH 5.5, prevention of tooth decay needs the support of chemical products. While mechanical cleaning without chemical intervention can remove plaque, the addition of chemical products to one’s routine can protect teeth and gums, preventing tooth decay, gingivitis and periodontitis.
The most important ingredient a toothpaste can have is, inarguably, fluoride. Though consumption of this ingredient is a topic of much controversy, the concerns don’t have enough evidence to support them. The benefits, on the other hand, are vast and scientifically backed. Fluoride has been shown to prevent cavities via a number of mechanisms. Firstly, it stops the enamel from demineralising in the presence of bacterial acids and is also said to inhibit these acids, thus protecting the enamel from two different angles. Fluoride enhances the remineralisation by increasing the rate of the process and creating a material that is stronger and more resistant to subsequent demineralisation. Read more about fluoride here.
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Another chemical product that works prophylactically against tooth decay is mouthwash. Many mouthwashes have no therapeutic effect, but medical mouthwashes with low concentrations of fluoride can help reduce the occurrence of cavities by 30-50%. The use of medical mouthwash is particularly beneficial for young people.
Here are edel white's expert mouthwashes:
Professional control
Regular visits to a dental professional are essential for maintaining oral health
“90% of a person’s oral health is determined by what they do at home”, explains Dr Tracey Lennemann, RDH PhD. It is, however, important to check in with a dental professional to ensure the other 10% is being taken care of. As new products are developed and new techniques are defined, regular visits with a dental professional will ensure that the patient is kept up-to-date with the latest in oral care, so a high standard of oral health can be maintained at home.
Dental hygienists also assist patients in removing plaque from places that are notoriously hard to reach, such as the interdental spaces and gingival margin. A patient could be brushing twice daily and practising interdental cleaning, and can still be accumulating plaque asymptomatically. Regular visits to the dental hygienist can therefore ensure that no area is neglected, and no diseases are developing.
Aside from examining and cleaning teeth, a dental hygienist will also offer advice on staying healthy (particularly with regard to diet, smoking and drinking) and will look for early signs of oral cancer. It is therefore recommended to visit a dental professional for regular check-ups every 6-12 months.
Dr Tracey Lennemann, Periodontal Specialist
London / Washington DC / München