j m
A
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P E R S P E C T I V E S
Looking behind closed doors W ilm er B. Eam es, D D S
I n g iv in g som e p ro fe ssio n a l a d vice to a neighbor, I com m ented: “Y o u are 64 years old and obviously have good teeth. D o you use toothpicks regularly ?” “No, I ’ve never used toothpicks. I sure do h a ve g o o d teeth. T h e d e n tis t th a t you recom m ended m ade them fo r m e— I lo st m y teeth w h e n I w as a b o u t 40, because they were so loose I could w iggle them w ith m y tongue. ”
here is n o th in g in dentistry th a t is m ore w o rth w h ile fo r o u r patients, nor more fulfilling for us as p ro fe ssio n a ls, th a n to p ro v id e instructions for oral hom e care. Failure to augm ent clinical procedures w ith patient education may greatly reduce the effectiveness of the dentist. T h e ravages of periodontal disease may be in e v ita b le w ith o u t h o m e o ra l care to ensure routine massage of su p p o rtin g tissues and thorough cleaning of all the surfaces of the teeth. It was an aw akening to read the re p o rt in T h e J o u r n a l o f the Am erican Dental Association on “T he prevalence of interdental gingival in flam m a tio n : a re p o rt fro m th e 1986 ADA a n n u a l h e a lth s c re e n in g .” It w as an ex cellen t d o c u m e n ta tio n of an alm o st u n b eliev a b le lack of basic k n o w led g e and interest in one of the m ost frequently seen diseases know n to m odern m a n — g in g iv itis—a precursor to serious p e ri odontal problems. D uring the 1986 ADA H ealth Screen ing, balsa wood toothpicks (Stim -U -D ent Interdental Cleaners, Johnson & John so n Products) were forced between the teeth
T
of 1,050 dentists: this induced bleeding in o n e o r m o re sites o f 81% o f the p a r tic ip a n ts , th ree o r m o re sites b led in 53%, an d seven or m ore sites bled in 23%.’ T h ese are a m a z in g sta tis tic s . T h ese dentists were p robably n o t u sin g in te r d e n ta l h o m e care th e m se lv es, as w ell as not encourag in g their patients to use this beneficial hom e care. In practice, I reluctantly h ad to learn from the advice of several experienced dentists an d especially from my skilled colleague, M iles M arkley (M. M arkley, DDS, p e rso n a l c o m m u n ic a tio n , 1945) th a t “gum s” bleed interdentally, because th e tissu es are n o t m assag ed forcibly. I have taught tissue massage an d effective b rushing, as p art of hom e care ro u tin e for m any decades, an d I th in k th a t there is n o other p a tie n t teach in g procedure th at is so neglected.
Fig 1 ■ Interdental stim ulators from left to right, the m ost co m m o n ly used round to o th p ic k , a new birch wood product from Norway; the older and readily available standard balsaw ood stim ulator; and convenient p la stic p icks that also reach from the lin gual aspect.
Hemorrhaging gingiva G ingiva hem orrhage occurs w hen to o th picks or other devices are used because to o th p ic k s are n o t u se d r e g u la rly . A p atient w ho finds bleeding an d soreness after using toothpicks m ust be reassured
th a t this is from lack of m assaging an d stim u la tin g these susceptible areas. We were ta u g h t in dental school th at stiff b ru sh e s a n d to o th p ic k in g cau sed b le e d in g tissues. It to o k a c o n v in c in g arg u m en t to get m e to try the ap p aren tly
E ditor’s note: We th o u g h t everything that could be said about oral hygiene m ethods has been said. N o t true. T w o professionals involved w ith dentistry th ro u g h o u t th eir d istin g u ish e d careers report th ere’s s till ro o m fo r debate on the best m e th o d s to ke ep m o u th s h e a lth y . Dr. W ilm e r E a m es o ffe rs evidence fro m h is lo n g , c lin ic a l, and a ca d em ic career to sh o w th a t g u m massage and use of to o th p icks have w orked fo r h im and his patients. Dr. Irw in M andel, fro m his m any years o f research, advocates the kinder, gentler b ru sh in g m e th o d s m o re concerned w ith te c h n iq u e th a n vig o r. W e’re n o t taking a p oll, but w e’ll be interested in and w ill p u b lish readers’ responses to these differing views.
JADA, Vol. 121, July 1990 ■ 125
PERSPEC TIVE S
distasteful chore of toothpicking. P atients com plain only for a little as th ey so o n fin d th e ir m o u th s to be com fortable. If this regim en is followed, they w ill enjoy lifetim e benefits of ou r c a rin g . G ra n u la tio n o ccurs an d tissue fo rm s in te r p r o x im a lly , w h ere p la q u e is norm ally found. We have know n about “ p la q u e ,” th a t has become a catchw ord a n d a p lague of this era—by way of heavy p ro m o tio n a l efforts. We alm o st created a new h ealth hazard. We are besieged by p la q u e-rem o v in g m o u th r in s e s a n d d e n tif ric e s —we ju s t d o n ’t h e a r a b o u t th e m e c h a n is m of c le a n in g by b r u s h in g a n d in te rd e n ta l stim u lation. Ju st rem oving p art of the p la q u e w ith flo ss is n o t e n o u g h . W ith th o r o u g h to o th p ick stim ulation, the soft, bleeding tissue is soon replaced w ith tough and h ealthy epithelial tissue, so patients are a lm o st u n c o m fo rta b le u n til they have c le a n e d a n d m a ssa g e d “ b etw e en th e teeth .” T h e rew ard is w atch in g a practice of g ra te fu l p a tie n ts m a in ta in th e ir teeth, th ro u g h thorough m assaging an d clean
ing, w ith professional supervision; w ith o u t this care, p eriodontal disease, req u ir in g s u rg ic a l tre a tm e n t, m ig h t h av e attacked these vulnerable areas. T h e philosophy is n o t new: it is sim ply overlooked. And, it works. The importance of home care T here is alm ost no universal agreem ent on th e need fo r in te r p r o x im a l s ti m ulation. T h e floss en th u siasts h arken back to th e B arkley days. T h e effectiv en ess is directly p ro p o rtio n al to convenience and tim e spent. Avid flossers som etim es add im pact by tying knots in their tape. W hen used regularly, the m ost effective and convenient im plem ent is the ro u n d toothpick, or variations show n in Figure 1. T h e en th u sia sm for th is reg im en is the readily available toothpick. P atients are urged to keep th em in co n v e n ie n t p la ce s, su ch as in th e ir s h ir t p o ck e ts to use w hile driving, and for handy use w hile w atching television. W ith m oderate p erio d o n tal involve
F ig 2 ■ L eft and r ig h t, rad iograp h s o f a 75-year-old in d iv id u a l, s h o w in g little b on e lo s s as
m e n t, th e use of to o th p ic k s w ill fre q u e n tly red u ce in te r d e n ta l so ft tissu e to a m o re d e s ira b le p la n e , w ith o u t surgery. T h e norm al alveolar h eig h t for the in d iv id u al w ith p erio d o n tal disease may be som ew hat less th an the average healthy m outh, an d this interdental space may be filled w ith hy p ertro p h ied g ra n u la tio n tissue. C lean in g an d m assaging th e se are as w ill c o n s id e r a b ly in h ib i t alveolar recession. I now know , from my lo n g years of c lin ic a l ex p e rien c e, th a t if to o th p ic k s are used in early a d u lth o o d , the daily p u m p in g a c tio n d u r in g in te r d e n ta l s tim u la tio n ca n p re v e n t p e r io d o n ta l d ise a se —even th o u g h to o th p ic k in g is n o t th o u g h t to be ac ce p ta b le socially, except “ behind closed doors .” 2 T h e r ig h t a n d left b ite w in g s of my m o u th (F ig 2) sh o w o n ly m o d e ra te alveolar recession, after nearly 50 years of toothpick massage an d the use of extrah ard n a tu ra l bristle brushes. T h e wellfo rm e d c o rtic a l la y e r of th e a lv e o la r s u p p o r tin g tissu e is e v id e n c e of th e im p a c t of g o o d o r a l h y g ie n e , w ith vigorous interproxim al stim u latio n .
Fig 3 ■ T oothpicking is a valuable daily practice.
a result of vigorous daily interdental stim ulation and cleaning, and stiff-bristle brushing.
Fig 4 ■ Detailed and specific brushing instruc
Fig 5 ■ From left to right, the extra-hard natural
tions are aided by the patient-held mirror. The
bristle is a longstanding favorite, a new V-tufted
tufted bristles “nestle” under the gingival tissues,
brush from Sweden; a standard flat soft nylon
Fig 6 ■ The brush stick, hand-crafted, and sold
and interproxim ally.
bristle brush for “ tender gum s” ; and a sin gle
in Saudi Arabia. Even th o u g h p rim itiv e, the
126 ■ JADA, Vol. 121, July 1990
tufted interproxim al brush that som e w ill find
users open the fibers w ith their teelh to form
useful around fixed prostheses.
fairly effective toothbrushes.
PER SP ECT IVE S
Wildlife in the Orient A toothbrush m anufacturer for m ore than half a century tells of the o rig in of hog bristles, w hich are still avail able, alth o u g h nylon bristles are m uch less expensive to produce. Domestic hog bristles were of poorer quality; and so, from the cold clim ates of C h in a a n d S iberia, b o a r b ristle s are preferred. T h e boars ru b bristles from th eir backs and necks on the sides of trees, an d w hen the b ristles are gath ered , they are ab o u t 6 in long. T h ey are sorted in to hard, m edium , an d soft,
a n d w ashed, bleach ed , treated , a n d c u t to 4-in le n g th s for s h ip p in g to our m anufacturers. P roponents of the “Save the Boar” m ovem ents can be m o llified in th a t th e id e n titie s of w ild C h in e se a n d Siberian boars are w ithheld in respect for their rig h ts for privacy, an d any u n p ro te c te d ov ert acts for co m m er cialism . T h e tree-ru b b in g h ab its are n o t to be construed as a n y th in g b u t casual an d com forting, an d there may be some sim ilarity to those eccentric itie s , seen as h a b its ( s c ra tc h in g in those places), of the h u m an race. W ilm er B. Eames, DDS
b r u s h fo rw a rd , o n e o r tw o te e th , th e m o tio n s a re re p e a te d . . . a n d so o n aro u n d the m outh. “ A lw ay s try to feel th e tip s o f th e b ris tle s n e s tle d u n d e r th e g u m s a n d betw een the teeth. If the bristles a re n ’t there, they c a n ’t clean an d m assage the g u m s.” T h e in fo rm atio n is given w hile dem o n s tr a tin g in v a rio u s c ritic a l areas of the m o u th , such as the lin g u al surfaces o f th e lo w e r a n te r io r te e th , a lw a y s em phasizing the need for “ n estlin g ” the tips of the bristles. Several available bru sh types are show n in F igure 5. Figure 6 shows a prim itiv e in s tru m e n t used in S au d i A rab ia, an d it is sold in suks (m arketplaces). Epilogue
Instructions for interproximal devices In a d d itio n to b r u s h in g in s tru c tio n s , a dem onstration in the p a tie n t’s m o u th is made (Fig 3). T he p atien t learns the technique of the insertion of a toothpick or c o m m e rc ia l in te r d e n ta l s tim u la to r w hile looking in a m irror. T h e p atien t inserts the stim ulator through the spaces b etw een th e te e th , u n til it is w ed g ed tig h tly , a n d th e n m assages the tissues w ith a p u m p in g m o tio n , in a n d o u t several times. T h is sho u ld be done for 3 to 5 m inutes each day, at the conve nience of the individual. T h e first dem onstration of the to o th p ic k p ro c e d u re m ay be p a in f u l a n d produce hem orrhage, and it is im p o rtan t to re a ssu re th e p a tie n t th a t th is is a n o rm a l in it ia l re a c tio n . T h e sw o lle n tissues are stim ulated to repair themselves to a n o rm a l a n d h e a lth y to n e w ith in a few days or weeks. The soft bristle brush Most den tists are convinced th a t u sin g a soft bristle brush is less likely to cause bleeding an d dam age to inflam ed gingiva. In fact, it is difficult to find stiff-bristled brushes, b u t they can be ordered. T h ro u g h experience, I have found that “gum s bleed” because they need vigorous stim ulation, and after a few weeks, w ith su p e rv isio n , p a tie n ts re sp o n d d r a m a t ically to this effective and proved m ethod of hom e care. Stiff bristle brushes stim ulate epithelial re p a ir; b le e d in g com es fro m te n d e r, diseased g ranulated tissue that is destruc tive, an d is sustained by plaque, accu-
m u la tio n s of food deb ris, m u cu s, an d atten d a n t bacteria. F o rtu n a te ly , th e m o u th tis su e s do respond favorably, when m assaged vigor o u sly . I h av e o fte n p re p a re d p a tie n ts for gingivectom ies by first teaching them good hom e oral care. Often, the crevices n e e d in g su rg ic a l tre a tm e n t re sp o n d e d so th a t surgery was not needed. Brushing instructions T h e dentist can present b ru sh in g in stru c tions by saying, “T h is is a n atu ral bristle b ru s h , m a d e fro m th e b ris tle s of the C hinese boar. T h e n a tu ra l b ristle may be preferred, because after the bru sh has been used a few tim es, the ends of the b ristle s fe a th e r-o u t, a n d becom e little brushes in themselves. T hey drag against the surface of the tooth an d clean better than synthetic bristles, w hich are slippery. “ We are trying to sim ulate a n atu ral c h ew in g action. As we chew , the food pushes again st the tissues th a t su p p o rt th e te e th , m a s s a g in g th e m . N a tu re intended that we should eat tough, fibrous foods. A lth o u g h m ost of o u r foods are co o k e d a n d so ften e d , a n d we h av e to su pplem ent o u r eating w ith a stim u latin g b ru sh in g techniq u e.” At th is p o in t, the p a tie n t is given a h and-held m irror to follow the in stru c tions by d em on stratio n : “T h e b ru sh is carried in to the m outh nestling the tips of th e b ris tle s u n d e r th e g u m s a n d between the teeth, (Fig 4), usually startin g w ith the back teeth first. After p o sitio n in g the bristles, we m assage the teeth w ith an u p -a n d -d o w n a n d c irc u la r m o tio n for 15 or 20 strokes. T h en , m oving the
I am n o t so naive as to believe th a t the readers w ill necessarily agree w ith a ll or any of my experiences or advice. B ut, I do know th a t it took years of ex p e rien c e befo re I b ecam e co n v in c e d th a t the best oral care was often considered “ tr a u m a tic .” A m u ltitu d e of p o s itiv e case histories are n ot en o u g h evidence, by scien tific stan d ard s. “ E p iso d e s” are n o t v alid statistically . In th e th ro es of controversy, a study needs to be u n d er taken of a large p o p u la tio n w h o have, a n d w h o h av e n o t u se d in te r d e n ta l stim u latio n . Do we have any volunteers for the sacrificial control group?
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In deference to discretion and n on partisansh ip, manufacturers of products illustrated are not given, but w ill be furnished by the author at the request o f readers e n c lo s in g a self-ad d ressed , stam p ed envelope. Essays of o p in io n on current issues in dentistry are published in this section of T h e Jo u rn a l. T he o p in io n s exp ressed or im p lie d are strictly th ose o f the authors and d o n ot necessarily reflect the op in io n or official policies of the American Dental Association. Dr. Eames is professor emeritus, Emory University, and clinical professor, School of Dentistry, University o f C olorado H ealth Sciences Center. Address requests for reprints to Dr. Eames, 14390 E Marina Dr, no. 501, Aurora, CO 80014. 1. Kohut BE, Baron HJ, Yost KG, B ouw sm a OJ. T h e prevalence of interdental gingival inflam m ation: a report from the 1988 ADA Health Screening. JADA 1989;118:463-5. 2. Eames WB. G oing for the ideal. J O h io Dent Assoc 1989;63.
Eames : BEHIND CLOSED DOORS ■ 127
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P E R S P E C T I V E S
Looking behind closed doors W ilm er B. Eam es, D D S
I n g iv in g som e p ro fe ssio n a l a d vice to a neighbor, I com m ented: “Y o u are 64 years old and obviously have good teeth. D o you use toothpicks regularly ?” “No, I ’ve never used toothpicks. I sure do h a ve g o o d teeth. T h e d e n tis t th a t you recom m ended m ade them fo r m e— I lo st m y teeth w h e n I w as a b o u t 40, because they were so loose I could w iggle them w ith m y tongue. ”
here is n o th in g in dentistry th a t is m ore w o rth w h ile fo r o u r patients, nor more fulfilling for us as p ro fe ssio n a ls, th a n to p ro v id e instructions for oral hom e care. Failure to augm ent clinical procedures w ith patient education may greatly reduce the effectiveness of the dentist. T h e ravages of periodontal disease may be in e v ita b le w ith o u t h o m e o ra l care to ensure routine massage of su p p o rtin g tissues and thorough cleaning of all the surfaces of the teeth. It was an aw akening to read the re p o rt in T h e J o u r n a l o f the Am erican Dental Association on “T he prevalence of interdental gingival in flam m a tio n : a re p o rt fro m th e 1986 ADA a n n u a l h e a lth s c re e n in g .” It w as an ex cellen t d o c u m e n ta tio n of an alm o st u n b eliev a b le lack of basic k n o w led g e and interest in one of the m ost frequently seen diseases know n to m odern m a n — g in g iv itis—a precursor to serious p e ri odontal problems. D uring the 1986 ADA H ealth Screen ing, balsa wood toothpicks (Stim -U -D ent Interdental Cleaners, Johnson & John so n Products) were forced between the teeth
T
of 1,050 dentists: this induced bleeding in o n e o r m o re sites o f 81% o f the p a r tic ip a n ts , th ree o r m o re sites b led in 53%, an d seven or m ore sites bled in 23%.’ T h ese are a m a z in g sta tis tic s . T h ese dentists were p robably n o t u sin g in te r d e n ta l h o m e care th e m se lv es, as w ell as not encourag in g their patients to use this beneficial hom e care. In practice, I reluctantly h ad to learn from the advice of several experienced dentists an d especially from my skilled colleague, M iles M arkley (M. M arkley, DDS, p e rso n a l c o m m u n ic a tio n , 1945) th a t “gum s” bleed interdentally, because th e tissu es are n o t m assag ed forcibly. I have taught tissue massage an d effective b rushing, as p art of hom e care ro u tin e for m any decades, an d I th in k th a t there is n o other p a tie n t teach in g procedure th at is so neglected.
Fig 1 ■ Interdental stim ulators from left to right, the m ost co m m o n ly used round to o th p ic k , a new birch wood product from Norway; the older and readily available standard balsaw ood stim ulator; and convenient p la stic p icks that also reach from the lin gual aspect.
Hemorrhaging gingiva G ingiva hem orrhage occurs w hen to o th picks or other devices are used because to o th p ic k s are n o t u se d r e g u la rly . A p atient w ho finds bleeding an d soreness after using toothpicks m ust be reassured
th a t this is from lack of m assaging an d stim u la tin g these susceptible areas. We were ta u g h t in dental school th at stiff b ru sh e s a n d to o th p ic k in g cau sed b le e d in g tissues. It to o k a c o n v in c in g arg u m en t to get m e to try the ap p aren tly
E ditor’s note: We th o u g h t everything that could be said about oral hygiene m ethods has been said. N o t true. T w o professionals involved w ith dentistry th ro u g h o u t th eir d istin g u ish e d careers report th ere’s s till ro o m fo r debate on the best m e th o d s to ke ep m o u th s h e a lth y . Dr. W ilm e r E a m es o ffe rs evidence fro m h is lo n g , c lin ic a l, and a ca d em ic career to sh o w th a t g u m massage and use of to o th p icks have w orked fo r h im and his patients. Dr. Irw in M andel, fro m his m any years o f research, advocates the kinder, gentler b ru sh in g m e th o d s m o re concerned w ith te c h n iq u e th a n vig o r. W e’re n o t taking a p oll, but w e’ll be interested in and w ill p u b lish readers’ responses to these differing views.
JADA, Vol. 121, July 1990 ■ 125
PERSPEC TIVE S
distasteful chore of toothpicking. P atients com plain only for a little as th ey so o n fin d th e ir m o u th s to be com fortable. If this regim en is followed, they w ill enjoy lifetim e benefits of ou r c a rin g . G ra n u la tio n o ccurs an d tissue fo rm s in te r p r o x im a lly , w h ere p la q u e is norm ally found. We have know n about “ p la q u e ,” th a t has become a catchw ord a n d a p lague of this era—by way of heavy p ro m o tio n a l efforts. We alm o st created a new h ealth hazard. We are besieged by p la q u e-rem o v in g m o u th r in s e s a n d d e n tif ric e s —we ju s t d o n ’t h e a r a b o u t th e m e c h a n is m of c le a n in g by b r u s h in g a n d in te rd e n ta l stim u lation. Ju st rem oving p art of the p la q u e w ith flo ss is n o t e n o u g h . W ith th o r o u g h to o th p ick stim ulation, the soft, bleeding tissue is soon replaced w ith tough and h ealthy epithelial tissue, so patients are a lm o st u n c o m fo rta b le u n til they have c le a n e d a n d m a ssa g e d “ b etw e en th e teeth .” T h e rew ard is w atch in g a practice of g ra te fu l p a tie n ts m a in ta in th e ir teeth, th ro u g h thorough m assaging an d clean
ing, w ith professional supervision; w ith o u t this care, p eriodontal disease, req u ir in g s u rg ic a l tre a tm e n t, m ig h t h av e attacked these vulnerable areas. T h e philosophy is n o t new: it is sim ply overlooked. And, it works. The importance of home care T here is alm ost no universal agreem ent on th e need fo r in te r p r o x im a l s ti m ulation. T h e floss en th u siasts h arken back to th e B arkley days. T h e effectiv en ess is directly p ro p o rtio n al to convenience and tim e spent. Avid flossers som etim es add im pact by tying knots in their tape. W hen used regularly, the m ost effective and convenient im plem ent is the ro u n d toothpick, or variations show n in Figure 1. T h e en th u sia sm for th is reg im en is the readily available toothpick. P atients are urged to keep th em in co n v e n ie n t p la ce s, su ch as in th e ir s h ir t p o ck e ts to use w hile driving, and for handy use w hile w atching television. W ith m oderate p erio d o n tal involve
F ig 2 ■ L eft and r ig h t, rad iograp h s o f a 75-year-old in d iv id u a l, s h o w in g little b on e lo s s as
m e n t, th e use of to o th p ic k s w ill fre q u e n tly red u ce in te r d e n ta l so ft tissu e to a m o re d e s ira b le p la n e , w ith o u t surgery. T h e norm al alveolar h eig h t for the in d iv id u al w ith p erio d o n tal disease may be som ew hat less th an the average healthy m outh, an d this interdental space may be filled w ith hy p ertro p h ied g ra n u la tio n tissue. C lean in g an d m assaging th e se are as w ill c o n s id e r a b ly in h ib i t alveolar recession. I now know , from my lo n g years of c lin ic a l ex p e rien c e, th a t if to o th p ic k s are used in early a d u lth o o d , the daily p u m p in g a c tio n d u r in g in te r d e n ta l s tim u la tio n ca n p re v e n t p e r io d o n ta l d ise a se —even th o u g h to o th p ic k in g is n o t th o u g h t to be ac ce p ta b le socially, except “ behind closed doors .” 2 T h e r ig h t a n d left b ite w in g s of my m o u th (F ig 2) sh o w o n ly m o d e ra te alveolar recession, after nearly 50 years of toothpick massage an d the use of extrah ard n a tu ra l bristle brushes. T h e wellfo rm e d c o rtic a l la y e r of th e a lv e o la r s u p p o r tin g tissu e is e v id e n c e of th e im p a c t of g o o d o r a l h y g ie n e , w ith vigorous interproxim al stim u latio n .
Fig 3 ■ T oothpicking is a valuable daily practice.
a result of vigorous daily interdental stim ulation and cleaning, and stiff-bristle brushing.
Fig 4 ■ Detailed and specific brushing instruc
Fig 5 ■ From left to right, the extra-hard natural
tions are aided by the patient-held mirror. The
bristle is a longstanding favorite, a new V-tufted
tufted bristles “nestle” under the gingival tissues,
brush from Sweden; a standard flat soft nylon
Fig 6 ■ The brush stick, hand-crafted, and sold
and interproxim ally.
bristle brush for “ tender gum s” ; and a sin gle
in Saudi Arabia. Even th o u g h p rim itiv e, the
126 ■ JADA, Vol. 121, July 1990
tufted interproxim al brush that som e w ill find
users open the fibers w ith their teelh to form
useful around fixed prostheses.
fairly effective toothbrushes.
PER SP ECT IVE S
Wildlife in the Orient A toothbrush m anufacturer for m ore than half a century tells of the o rig in of hog bristles, w hich are still avail able, alth o u g h nylon bristles are m uch less expensive to produce. Domestic hog bristles were of poorer quality; and so, from the cold clim ates of C h in a a n d S iberia, b o a r b ristle s are preferred. T h e boars ru b bristles from th eir backs and necks on the sides of trees, an d w hen the b ristles are gath ered , they are ab o u t 6 in long. T h ey are sorted in to hard, m edium , an d soft,
a n d w ashed, bleach ed , treated , a n d c u t to 4-in le n g th s for s h ip p in g to our m anufacturers. P roponents of the “Save the Boar” m ovem ents can be m o llified in th a t th e id e n titie s of w ild C h in e se a n d Siberian boars are w ithheld in respect for their rig h ts for privacy, an d any u n p ro te c te d ov ert acts for co m m er cialism . T h e tree-ru b b in g h ab its are n o t to be construed as a n y th in g b u t casual an d com forting, an d there may be some sim ilarity to those eccentric itie s , seen as h a b its ( s c ra tc h in g in those places), of the h u m an race. W ilm er B. Eames, DDS
b r u s h fo rw a rd , o n e o r tw o te e th , th e m o tio n s a re re p e a te d . . . a n d so o n aro u n d the m outh. “ A lw ay s try to feel th e tip s o f th e b ris tle s n e s tle d u n d e r th e g u m s a n d betw een the teeth. If the bristles a re n ’t there, they c a n ’t clean an d m assage the g u m s.” T h e in fo rm atio n is given w hile dem o n s tr a tin g in v a rio u s c ritic a l areas of the m o u th , such as the lin g u al surfaces o f th e lo w e r a n te r io r te e th , a lw a y s em phasizing the need for “ n estlin g ” the tips of the bristles. Several available bru sh types are show n in F igure 5. Figure 6 shows a prim itiv e in s tru m e n t used in S au d i A rab ia, an d it is sold in suks (m arketplaces). Epilogue
Instructions for interproximal devices In a d d itio n to b r u s h in g in s tru c tio n s , a dem onstration in the p a tie n t’s m o u th is made (Fig 3). T he p atien t learns the technique of the insertion of a toothpick or c o m m e rc ia l in te r d e n ta l s tim u la to r w hile looking in a m irror. T h e p atien t inserts the stim ulator through the spaces b etw een th e te e th , u n til it is w ed g ed tig h tly , a n d th e n m assages the tissues w ith a p u m p in g m o tio n , in a n d o u t several times. T h is sho u ld be done for 3 to 5 m inutes each day, at the conve nience of the individual. T h e first dem onstration of the to o th p ic k p ro c e d u re m ay be p a in f u l a n d produce hem orrhage, and it is im p o rtan t to re a ssu re th e p a tie n t th a t th is is a n o rm a l in it ia l re a c tio n . T h e sw o lle n tissues are stim ulated to repair themselves to a n o rm a l a n d h e a lth y to n e w ith in a few days or weeks. The soft bristle brush Most den tists are convinced th a t u sin g a soft bristle brush is less likely to cause bleeding an d dam age to inflam ed gingiva. In fact, it is difficult to find stiff-bristled brushes, b u t they can be ordered. T h ro u g h experience, I have found that “gum s bleed” because they need vigorous stim ulation, and after a few weeks, w ith su p e rv isio n , p a tie n ts re sp o n d d r a m a t ically to this effective and proved m ethod of hom e care. Stiff bristle brushes stim ulate epithelial re p a ir; b le e d in g com es fro m te n d e r, diseased g ranulated tissue that is destruc tive, an d is sustained by plaque, accu-
m u la tio n s of food deb ris, m u cu s, an d atten d a n t bacteria. F o rtu n a te ly , th e m o u th tis su e s do respond favorably, when m assaged vigor o u sly . I h av e o fte n p re p a re d p a tie n ts for gingivectom ies by first teaching them good hom e oral care. Often, the crevices n e e d in g su rg ic a l tre a tm e n t re sp o n d e d so th a t surgery was not needed. Brushing instructions T h e dentist can present b ru sh in g in stru c tions by saying, “T h is is a n atu ral bristle b ru s h , m a d e fro m th e b ris tle s of the C hinese boar. T h e n a tu ra l b ristle may be preferred, because after the bru sh has been used a few tim es, the ends of the b ristle s fe a th e r-o u t, a n d becom e little brushes in themselves. T hey drag against the surface of the tooth an d clean better than synthetic bristles, w hich are slippery. “ We are trying to sim ulate a n atu ral c h ew in g action. As we chew , the food pushes again st the tissues th a t su p p o rt th e te e th , m a s s a g in g th e m . N a tu re intended that we should eat tough, fibrous foods. A lth o u g h m ost of o u r foods are co o k e d a n d so ften e d , a n d we h av e to su pplem ent o u r eating w ith a stim u latin g b ru sh in g techniq u e.” At th is p o in t, the p a tie n t is given a h and-held m irror to follow the in stru c tions by d em on stratio n : “T h e b ru sh is carried in to the m outh nestling the tips of th e b ris tle s u n d e r th e g u m s a n d between the teeth, (Fig 4), usually startin g w ith the back teeth first. After p o sitio n in g the bristles, we m assage the teeth w ith an u p -a n d -d o w n a n d c irc u la r m o tio n for 15 or 20 strokes. T h en , m oving the
I am n o t so naive as to believe th a t the readers w ill necessarily agree w ith a ll or any of my experiences or advice. B ut, I do know th a t it took years of ex p e rien c e befo re I b ecam e co n v in c e d th a t the best oral care was often considered “ tr a u m a tic .” A m u ltitu d e of p o s itiv e case histories are n ot en o u g h evidence, by scien tific stan d ard s. “ E p iso d e s” are n o t v alid statistically . In th e th ro es of controversy, a study needs to be u n d er taken of a large p o p u la tio n w h o have, a n d w h o h av e n o t u se d in te r d e n ta l stim u latio n . Do we have any volunteers for the sacrificial control group?
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In deference to discretion and n on partisansh ip, manufacturers of products illustrated are not given, but w ill be furnished by the author at the request o f readers e n c lo s in g a self-ad d ressed , stam p ed envelope. Essays of o p in io n on current issues in dentistry are published in this section of T h e Jo u rn a l. T he o p in io n s exp ressed or im p lie d are strictly th ose o f the authors and d o n ot necessarily reflect the op in io n or official policies of the American Dental Association. Dr. Eames is professor emeritus, Emory University, and clinical professor, School of Dentistry, University o f C olorado H ealth Sciences Center. Address requests for reprints to Dr. Eames, 14390 E Marina Dr, no. 501, Aurora, CO 80014. 1. Kohut BE, Baron HJ, Yost KG, B ouw sm a OJ. T h e prevalence of interdental gingival inflam m ation: a report from the 1988 ADA Health Screening. JADA 1989;118:463-5. 2. Eames WB. G oing for the ideal. J O h io Dent Assoc 1989;63.
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