Quality & Affordable Dentistry in Malaysia

How To Avoid 90% of All Dental Disease in Selangor, Malaysia

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Bill (not his real name), a patient of ours since his first dental visit ever, was a fortunate child, adolescent, and now adult. His parents are professional family- oriented people, who always made sure that Bill went to the dentist every six months for check-ups and cleanings. Through primary school, he never had any serious dental problems. However, in secondary school, he came to our clinic with swollen gums on the lip side of his two lower front teeth. Plaque had built up there due to his missing this area with his tooth brush, and the bacteria from that plaque caused the gums to swell, bleed, and exude some puss. I cleaned it up and instructed him how to clean his mouth, teeth and gums. Bill was attentive, went home, and followed instructions; and the problem did not recur. He also had no wisdom teeth problems and his teeth were straight with no malocclusion or bite problems.

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Bill eventually left for university out-of-state with his teeth in good condition. As parents know, kids change their habits when they leave home for the first time. Diets change, new habits are acquired, oral hygiene regiments are often altered or even mostly ignored, and if in college they are preoccupied with their studies and other activities. And as Bill was on a sports scholarship, this was ever so true. Parents are not present to exert their influence and physicians and dentists to which students are accustomed are not around. In Bill’s case, one of probably several bad habits he acquired was using smokeless tobacco. This was cool! Most of the other team members chewed or snuffed tobacco, and the “little round can” was proof that this new college ball player had arrived and was an adult.

For the next four years, Bill was busy pursuing his university degree, practicing and playing with his team, and working. He didn’t have time for dentists, but more importantly, didn’t take the time for proper oral hygiene. And, oh yes, the tobacco took its toll as abscesses (infections) showed up on the ends of the roots of those same two lower front teeth. That, of course, is the exact spot where ball players place smokeless tobacco, in the valley between the lower front teeth and the lower lip, just opposite the ends of their roots.

I did not see Bill in my clinic for three or four more years, and other than an emergency visit to a dentist at university, he had received no preventative or other dental care. During a holiday of his senior year and with time on his hands, Bill rather sheepishly and apologetically presented himself at my clinic for a cleaning and checkup. He said that he had been having tooth discomfort off and on in different areas of his mouth, and that he was embarrassed to have me examine him. I assured him that his mouth wouldn’t be the worst that I had seen and that we would work together to ensure that it would never happen again. He relaxed a bit and we started the exam.

When I completed the examination and established a treatment plan, I had to inform Bill and his parents that he needed four root canals, one extraction, five crowns, three inlays, one bridge, and seven regular fillings, as well as two cleanings. Quite a bit of dental work for anyone, let alone a 21-year-old senior. We performed the treatment, intensely reviewed oral hygiene home-maintenance regiment, and placed him on a regular six-month recall for check-ups and cleanings. It is now more than 10 years later and because Bill practices preventive maintenance techniques religiously and has regular recall appointments, he requires very little maintenance and treatment.

Another patient, Sarah (not her real name either), had been coming to us for about 3 years, when at the age of 39, she became clinically depressed. Her most recent check-up prior to her depression revealed a very healthy mouth with only a few well-placed restorations (fillings) and no new decay. Her gums were healthy and her most recent x-rays exhibited no bone loss from the supporting areas of the teeth. Years passed before I saw her again.

After a two-year recovery period from depression, Sarah was finally strong enough to get to her normal routines, which of course included going for a regular dental exam. She warned me that it wouldn’t be a “pretty sight” in there and that several of her teeth were loose, that she had discomfort, and that she had a bad taste and smell in her mouth.

My cursory exam of her teeth revealed most of them to be fairly loose. A complete series of x-rays revealed severe periodontal disease around virtually all of her teeth. The gums were puffy and swollen. Their texture was a smooth glossy sheen rather than the orange peel stippling that indicates good health. Upon probing, they bled and were pussy. The probe fell to a depth of five to eight millimeters, whereas a probe of healthy gums would normally only go from one to at most three millimeters. The x-rays clearly revealed that there was bone loss varying from two to four millimeters around all of the teeth. We also found many thriving colonies of bacterial soft plaque, and there was a moderate amount of hard plaque, commonly known as calculus or tarter. Remarkably, there was no new decay or defective fillings or broken teeth, nor were there any abscesses (infections) at the roots of any of the teeth.

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What is the difference between Bill and Sarah? The same bacteria responsible for causing decay are the same that cause periodontal disease in many cases. What happened here is that during the entire four-year period of Sarah’s depression, she was eating a fairly healthy diet with virtually no refined carbohydrates or sugar. She also brushed the surfaces of her teeth that were exposed above the gum line. Sarah’s only error was not brushing below the gum line and in the areas just above where the upper most portion of the bacterial colonies were growing. Bacteria alone are not enough to cause tooth decay; however, bacteria plus soft plaque can cause periodontal disease.

Thus, in the cases of Bill and Sarah, Bill was particularly victimised by the first formula, while Sarah was susceptible to the second. In the worst scenario, some individuals are attacked by both.

So, what can you do to prevent decay and gum disease?

It is actually very simple and can be summed in one short sentence: Do something at least every 24 hours to keep bacteria from forming into colonies. That’s it. In fact, that’S all there is to it. Of course, many people do not know what that something is or even if they do know, they may not have the ability and will power to consistently take care of their teeth and gums.

I have a feeling that if you are interested enough in dentistry to be reading this book, you have probably been instructed many times in the past on proper oral hygiene methods. I do not have any secrets to relate, but I will attempt to explain oral hygiene in a simple way that you may not have heard of before.

First, let’s select a. toothbrush that will be kind to the gums, yet thoroughly cleanse the teeth. The ends of the bristles on the brush should be rounded and polished (through a microscope, that’s exactly what you would see). They should also be soft, not medium or hard. Many of the leading toothbrush manufacturers today produce just such a brush. I do not advise my patients to use toothbrushes with an angle on the head as I believe that they give patients a false sense of security. While these brushes do a good job on the cheek surfaces of the very back two or three teeth, they tend to skip over teeth in front of those. So, in general, I advise that you use a straight-headed brush with four rows of bristles of approximately a dozen tufts per row. Nothing fancy. At least not for a relatively healthy mouth with no bridges, braces, or other appliances.

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Now, what do you do with this scientifically-produced instrument called a “toothbrush”? You must direct the bristles of the brush down under the gum line. Think about what it felt like the last time you had you teeth cleaned. You may recall that the practitioner used a small rotating rubber cup with a cleaning agent on it, and how it felt going considerably under your gum line. For relatively healthy gums and teeth, the dentist or hygienist was probably all the way down into the crevice where the gum actually attaches to the tooth (one to two-and-one-half millimetres) under what appears to be the gum line. This is the depth to which you must reach to thoroughly cleanse the teeth and prevent bacteria from forming colonies. Bacteria float around in everyone’s mouth, as it naturally occurs, but they do their damage and create havoc to your teeth, gums, and mouth when they get organised and clump together.

So, what are the specific procedures for properly using your toothbrush? It’s best to have a routine which can be consistently followed. I suggest starting on the cheek side of the upper right side of your very back teeth. Place the brush at an approximately 45-degree angle to the teeth. (See figure 3.a.)

Once the bristles are fixed and you feel them all the way down as far as they will go before the attached gums stop them, move the brush horizontally from front to back several times. Do not move the toothbrush more than the width of one tooth. Then, overlapping the area, go to the next group of teeth, and so on, until finished. Now continue with this until you have finished with the upper left back teeth, always overlapping as if you were cutting the grass on your lawn to ensure not missing a blade. The implications for the teeth are obvious.

Now, move on down to the lower left, starting at the back, and directing the bristles downward into the gums at the same 45-degree angle used for the upper teeth. Continue around, overlapping as you go until you have finished all of the cheeks and lip sides of the lower teeth.

The next step is a most important one that most people forget: the inside or palate side of the upper teeth and the tongue side for the lower teeth. Again, start in the upper right portion of your mouth, at the back, then work forward and around, again utilising the 45-degree angle and overlapping method. Then, jump down to the lower left inside, and work forward and around.

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At this point, you will have finished the gum portion of the brushing part of all of your teeth.

Now, the final part of our brushing experience is to cleanse the biting surfaces, the  deep groves (known as pits and fissures in dental terminology) which are present as part of the normal dental anatomy. This is also where sticky substances, such as sugars, combine with bacteria to form decay on the biting surfaces. Again, start at the top right of the biting surfaces in the back, but this time brush even more vigorously and over a wider surface, about the width of two teeth forward and backward. Move around and back to the upper left, finishing on the lower right.

But what about the areas in between the teeth where the teeth touch one another, the so-called “contact areas”? These areas are sometimes open or not touching, and a space exists between the teeth. This undesirable situation is found more often than one might think. Other teeth touch one another and are sometimes very close and tight, making it difficult to perform the next most important procedure: flossing.

Flossing or interdental brushing is the solution to cleaning those contact areas that the toothbrush cannot reach. And it is often the procedure that people resist the most or just cannot do. However, flossing or interdental brushing is indeed most important.

The mouth is bathed 24 hours a day in food, saliva, and bacteria, and there can be a small organised world (microcosm) of bacteria waiting to take advantage of it. That’s all it takes for interproximal (areas between the teeth where they meet one another) decay and gum disease to occur. And that is precisely why it is absolutely essential to learn how to floss your teeth at least daily. Not flossing would be like taking a shower and not cleaning between your toes. Just imagine how that would be after a few weeks or months.

Now that you are motivated to floss your teeth, how do you do it? The basic and simple way is to take a piece of floss about four feet long. Wrap all but about 24-25 cm around the middle finger of your left or right hand, and then wrap about 12-13 inches or so around the middle finger of the other hand. In any event, when you pull your hands apart as far as they will go, about 7 cm will remain. (See figure 3.b.) This serves as your supply-and-anchoring system. As you go around your dental arch, you will floss two or three teeth then unravel a fresh piece of floss from the bulk supply side to the less bulky finger. This process will thus be repeated a series of times until all of your teeth are flossed.

Start flossing in the upper right quadrant behind the very last tooth. Most people forget about that last, most distant surface because it is not next to another tooth. Nevertheless, it is a tooth surface and it must be cleansed just like all the others.

The anchorage system is now established and the supply of floss is on your fingers. You know where to start and how to reel off fresh floss from finger to finger as you move about your teeth. But how do you actually do it? Well, while working on your top teeth (upper arch), use your two thumbs as guides to actually place the floss where you want it. For bottom teeth, use your index fingers. (See figure 3.c.)

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When you floss your children’s teeth, the technique is just the opposite. And, you must floss kids’ teeth up to at least six years of age, or until they can do it on their own. The routine is simple. Just sit on your couch, place the child’s head in your lap, and proceed as you would on yourself, except now you are using your index fingers as guides while flossing their upper teeth, and your thumbs while flossing their lower teeth.

How do you enter the in-between areas of teeth? Just slide laterally from side to side and you will break through the contact areas of the teeth. Once through, go gently to the depth of the gum, as deep as the gum will allow. In other words, as previously mentioned in the brushing section, the gum is attached to the tooth at a level below the visible gum line-one to two-and-one-half millimetres below in a healthy mouth-and it is to this depth that you must go. Now what? Rather than the see-saw lateral movement, you must change the direction of movement: move the floss up and down at least five to 10 times per surface. (See figures 3. and 3.c.)

There is, however, another little subtle nuance here as well. Don’t forget that while the floss is between two teeth, there are two surfaces to attack: the most anterior tooth (front) or mesial (toward the mid-line of your face on the tooth farthest back) surface and the most distal (back) or posterior (away from the mid-line on the teeth closest to the front) surface. Thus, to reiterate, that’s five to ten strokes up and down on each of these two surfaces every time you go in between two new teeth. And, if you are not yet totally confused, there is one more consideration: don’t forget that there is a bit of anatomy here known as the gingival papilla. This is the gum which exists between all teeth. You must navigate around this when flossing on the mesial surface of one tooth and the distal surface of the next, without bringing the floss all the way out and breaking through the contact areas.

Now that you have the facts and the technology, move around your upper arch until finished, and then move to the lower back left side and around to the lower back right side. Finally, you are finished! At least for now.

To the uninitiated, this one-time flossing of your mouth may seem to have stretched to the millennium. To explain it, YES! But to do it the very first time won’t take even five minutes and I usually complete my own flossing within about 90 seconds while watching the news.

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One last point: should you use a mirror? You may want and need to at first, but because of the reverse images reflecting from the mirror, you will probably become confused and frustrated. I suggest that if you are using a mirror, use it as a checkpoint rather than as a guide as you go tooth by tooth. And, even if you start out using one, you will soon abandon it.

And, oh yes, when do you floss? Morning or night? It really does not matter. Remember, what we really are doing every 24 hours is preventing the bacteria from. organising into colonies. Theoretically, the evening would probably be better because you would be cleaning away the day’s food deposits. I floss in the morning because I like to start my day out fresh. So pick out your own time. Just floss at least every 24 hours.

Well, that’s it! Of course, flossing is more complicated if you have for example fixed bridges, braces, or have had periodontal surgery or some other degenerative condition. (See Chapters 8, 11, and 12.)

But, for now, if you want to prevent any and all dental disease from this day forward, you can do it all by yourself. These procedures work and are effective 99.9% of the time. JUST DO IT!

Figure 3.a. Proper angle of brush to teeth.
Figure 3.a. Proper angle of brush to teeth.
Figure 3.b. Proper finger position for holding floss.
Figure 3.b. Proper finger position for holding floss.
Figure 3.c. Proper finger position while flossing upper right
quadrant.
Figure 3.c. Proper finger position while flossing upper right
quadrant.
Figure 3.d. Movement of floss upward towards gums.
Figure 3.d. Movement of floss upward towards gums.
Figure 3.d. Movement of floss upward towards gums.
Figure 3.d. Movement of floss upward towards gums.

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