Improving Your Mouth Health
We stand at the proverbial crossroads. We have medicines
and practices that have served us well but have had
unintended consequences. . . . The practices that endanger
our children are at the core of modern health care.
—Martin J. Blaser, MD, Missing Microbes
Many people have never contemplated their teeth, and only a few know they are alive. Inside a tooth’s thin outer shell are layers of living tissue that contains cells, lymphatic liquids, and a network of blood vessels that link directly to the blood flowing around our body. The outside of teeth may feel hard to your tongue, but teeth are not a row of indestructible pebbles. In fact, the best description may be that they are like a coral reef, covered in delicate crystals that are nurtured or damaged by the saliva and liquids that flow around them, in the way that ocean waters flow around and influence the health of a coral reef.
Mouth bacteria are a big part of the mouth’s ecosystem, and the good ones help keep the mouth healthy. Similarly, saliva delivers minerals to teeth, but not if saliva is acidic, too viscous, too diluted, or sparse. Like the ocean swirling over a coral reef, everything we eat, drink, or put in our mouth becomes mixed with saliva and circulates to help or harm teeth and influence the mouth’s ecosystem. Drinks are particularly influential. Even water dilutes saliva and makes it thinner and less able to support tooth health, which is why we must consider the effect of meals and snacks but more importantly the frequency of eating and drinking. Everything that enters our mouth can affect saliva’s pH levels and potentially improve or damage the mouth’s ecosystem. Other influences we need to consider are the drying and acidic conditions that are caused by mouth breathing and influences from the products we use to care for our teeth on a daily basis.
DETERMINING MOUTH HEALTH
In the United States, many people think they have good teeth. Their arbitrary assessment is often based on the fact that they have not had cavities in a while, or they simply think their teeth look good. Fillings, crowns, root canals, and implants are repairs for problems that are usually caused by dental disease. How do you know if your mouth remains infected or if it is getting healthier or less healthy? And how do you know if your tooth enamel is getting stronger or weaker? Any softening or sensitivity should be a red flag, because it shows minerals are leaving your teeth faster than they are being replaced. Excessive mineral loss is the cause of tooth sensitivity, which should be recognized as your teeth crying for help. Sadly, sensitivity pastes artificially block these important symptoms without addressing the underlying mineral imbalance, as they “fix” the symptom but ignore the underlying reasons for sensitivity.
Refusing to recognize gum disease is a problem for many patients. For years, gum disease has been tolerated or ignored in the United States, and detailed diagnosis of periodontal pockets has only recently become part of the routine at dental examinations. Gum pockets and periodontal disease are usually painless, and many dentists trained in the 1980s and 1990s were never taught how to identify this disease, despite the fact we have long known the damage that gum disease can cause and its potentially catastrophic impact on health. This situation is changing, and more physicians are now aware of the link between gum health and bodily health, although many do not understand how to advise patients who want to improve their home care. Be aware that, when dentists or physicians discover pathogens, they will usually want to prescribe antibiotics, strong antiseptics, or bleach combined with more frequent and deeper cleanings. My advice is to empower yourself and consider how you can first improve your mouth health with effective home care and potentially avoid antibiotics and aggressive strategies.
Many people assume they have a healthy mouth because they eat a good diet, exercise daily, and visit their dentist at regular intervals. When they experience cavities or gum disease, it can be shocking and make them feel angry, confused, or even depressed. If you consider the AAOSH Challenge results described in the preface, you will remember that even conscientious dentists had unhealthy periodontal pathogens in their mouths. This is why it is a good idea for anyone over the age of ten to have their saliva checked and, if they discover high levels of pathogens, begin using strategies to balance and control them to reach acceptable levels. Many of my clients have seen drastic improvements and a reduction in all their pathogens by simply following my recommendations for twelve weeks.
Good Mouth Bacteria
A healthy mouth is populated by a diverse variety of bacteria, and the broader this diversity, the healthier the mouth appears to be. In contrast, an unhealthy mouth will usually have a sparse and limited variety of bacteria, characterized by high levels of a few dominant pathogens. Current studies indicate that about ten billion bacteria live in the mouth, on teeth, on gums, and on the surface of the tongue. The Human Microbiome Project is focused on investigating these microbial communities and documenting how they influence health and the development of disease. This project reveals there are at least nine hundred strains of healthy mouth bacteria and that they have integrated systems to cooperate and communicate with each other, working in a harmonious way to protect our mouths from mechanical, chemical, and thermal damage.
In a healthy mouth with a wide variety of bacteria, there are usually about thirty to seventy families or species that are slightly more dominant than the others. Mouth bacteria float in saliva and move around until they find a habitat or location that will support their needs. This method of bacterial migration is called colonization. The dominant bacterial species in any mouth will therefore have a strong influence, and the most prevalent bacteria, be they good or bad, will usually determine the mouth’s overall health. In the late 1970s, we learned that dominant mouth bacteria are most often the kind or strain that is the first to gain access and colonize occlusal grooves in molar teeth, areas that provide stable footholds for these bacteria, nestled in the anatomy of the tooth’s flat biting surface.
In contrast to the nine hundred kinds of healthy mouth bacteria, there appear to be only about twenty bacteria that cause problems and can become destructive and harmful when they multiply. Some of these harmful bacteria are adapted to colonize teeth, but the majority, and some of the most destructive, breed in the depths of gum or periodontal pockets. The most infamous of mouth bacteria is a wild strain from a species called S.mutans. These bacteria have specific needs and flourish in acidic conditions, especially when they are undisturbed and are attached to a hard surface on which they can multiply. S. mutans are sticky by nature, and the firm, nonshedding platform of a tooth provides them with a perfect location to form thick layers, especially when they are able to feed frequently on sugar or carbohydrates in our diet.
Sometimes, the bacteria that live collectively in a defined space will be referred to as a bacterial flora. Our mouth flora can be imagined as resembling a flower-garden ecology. Weeds represent the harmful bacteria; flowers and grasses represent the beneficial ones. This analogy explains why aggressively clearing or stripping away weeds with harsh chemicals may remove weeds and clean up the garden, but it will also uproot good flowers and grass, which is why this not the best way to cultivate a healthy garden. Without nurturing healthy vegetation, a barren ecology will quickly become a home to more weeds, which may become even more invasive.
A healthy mouth needs a lush landscape with a wide variety of healthy bacteria that blend with each other and thrive with minimal care. This should be the goal for our mouth’s ecosystem, especially since many bacteria offer us health benefits, especially the ones that grow in the grooves of molar teeth in healthy mouths. These healthy bacteria produce enzymes that are important because they initiate the digestive processing of gluten and carbohydrates in the foods we chew. Blocking molar grooves with plastic sealants, fillings, or artificial crowns removes this natural habitat and potentially decreases the population of these bacteria and the digestive help they provide. Helpful bacteria losing their habitat to sealants could be at least partially responsible for gluten or carbohydrate intolerance, weight gain, and digestive issues, and this concern must become a research priority before we seal all the molar grooves of children in America, which is the mission of the American Academy of Pediatric Dentistry.
BACTERIAL TRANSMISSION
Healthy saliva washes over your teeth and gums and carries many bacteria floating in it. These planktonic microbes are a mix of all kinds of bacteria, including kinds that are healthy and some that are potentially pathogenic. Saliva facilitates the bacterial transfer from one tooth to another in your mouth and also from person to person as you kiss your family members and share food. A baby’s mouth is quickly colonized as soon as the first baby tooth erupts, and this occurs as bacteria travel and are shared from the mouths of people who interact closely or frequently with him or her.
Baby and adult molar teeth share a similar anatomy with crinkled biting surfaces. As soon as these teeth erupt, bacteria will colonize all the tooth surfaces and occupy every crevice, pit, and fissure to gain a foothold in an ideal location where they will become the dominant bacterial strain in a young child’s mouth. Baby molars erupt before a baby is two years old, and adult molars erupt around age five. Droplets of saliva transfer as we talk and share food, cups, straws, silverware, or toothbrushes. Bacteria transfer from spouse to spouse; between siblings; among friends at school, babysitters, and caretakers; and even from the mouths of pets to their owners. Bacterial transfer may sound scary at first, but it is how a baby’s mouth and body health is gradually strengthened. It is important to understand that having a wide diversity of healthy bacteria in your mouth will be healthful for you. In correct mouth conditions, these microbes will develop into a strong network and be able to protect your mouth from cavities and gum disease. This is why we should embrace bacterial transfer to a point and avoid the use of too many damaging antiseptics, antibiotics, and disinfectants whenever possible.
Infection on Toothbrushes
Unsanitary toothbrushes are a contributor to poor oral health, and I believe they may have played a much greater role in the explosion of tooth decay than has ever been considered. Today, we know toothbrushes pick up mouth bacteria during a single use. This may not be a problem if you have a healthy mouth, but it makes sense to be concerned if your family members have cavities or gum disease.
In New York, a state-mandated program in preschool and kindergarten classrooms insists children brush their teeth after lunch. The problem is that classroom brushes are often stored together in a large box or bag, potentially spreading infection from the children with cavities to those with healthy mouths. It seems equally wrong to suggest to communities or patients with poor oral health that a toothbrush per se will be helpful. There are superior ways to protect teeth from cavities, and toothbrushes have enormous potential to spread dental disease. Studies on toothbrush contamination are shocking, because they show the ease of contamination and how bacteria breed in toothbrush bristles. Brushes pick up the entire array of mouth bacteria, viruses, yeasts, and fungi, and some of these microorganisms remain viable on brush bristles for 2–7 days if the brush remains damp.
A few studies have examined the efficacy of products for decontaminating brushes. During a 2001 study, the researchers were amazed to find that 70 percent of the brushes in their study were heavily contaminated after one use. Placing a cap over the brush head appeared to encourage virulent opportunistic pathogens, like one called Pseudomonas aeruginosa, a species of bacteria that is adapted to low-oxygen environments. This is important information for anyone who travels or keeps their toothbrush in a gym bag, drawer, or confined space.
In 2007, researchers investigated the contamination levels for new brushes compared with older, worn brushes to see if older brushes would trap more bacteria. Three well-known brands of toothbrushes with soft nylon bristles were used: a brush with an oval head, a brush with flat bristles, and a brush with an average head design. The researchers used many brushes of each type. Half of the brushes were worn against metal brackets, whereas the rest of the brushes were unused. All brushes were immersed in a solution of S. mutans for five seconds. The brushes were then rinsed with water, and the first bacterial count was taken. The count was repeated twice, with the brushes being allowed to air-dry between the tests.
Immediately after immersion, all the brushes were heavily contaminated. After eight hours, there was contamination on all the brushes. After twenty-four hours there were varying levels of contamination on all the brushes. The researchers were surprised that there were differences in contamination among the brands and that these differences exerted an influence on the bacteria collected in the bristles. Even more surprising, the new brushes appeared to harbor more bacteria than the worn ones at every time interval. This study indicates how easily brushes become contaminated and that rinsing with water does not adequately decontaminate an infected brush.
If you have cavities or gum disease, brushing may dislodge infected plaque, but your brush will be contaminated with harmful bacteria, and so it must be disinfected before you use it again. I suggest twenty-four hours of air-drying any toothbrush, but I also suggest you decontaminate the bristles of your brush after each use by swishing the head of your brush in an essential oil rinse like Listerine®. Then rinse it with water, and allow it to air-dry in a clean environment away from any toilet contamination.
Never keep brushes in a drawer, inside a travel case, or under a plastic cap. Do not rely solely on UV sanitizers either as they may not be as effective as portrayed by their marketing. Even antibacterial toothbrushes need to be cleaned with some frequency, especially if you have an unhealthy mouth. Finally, be wary of reusing a brush after you have packed it during travel. Consider purchasing inexpensive brushes for travel and use them as throwaways. A ten-dollar investment can buy you a handful of brushes and may save you thousands of dollars in periodontal treatments in the years ahead.
DANGERS TO MOUTH HEALTH
Our mouth and teeth are always under attack from our eating and drinking habits and from things that abrade, heat, chill, acidify, or dry them. This is why it’s important to limit snacking, especially with acidic or sugary foods or drinks, and to protect our mouth from acidity as much as possible. There are a few foods that may nurture the protective coating in our mouth known as biofilm, and there are some foods that offer some dental benefits and protection. Xylitol is one of the most convenient of these foods, and it works in various ways. It is especially useful in our modern diet, because it can quickly help control mouth acidity. Alkalizing the mouth to a pH of around 7.4 will not only promote healthy mouth bacteria but will also prevent post-meal demineralization of teeth and any potential acidic damage to healthy biofilm.
If you have cavities or gum disease, you have harmful mouth bacteria that have infiltrated and likely become resident in the biofilm of your mouth. Unless you make changes, these bacteria can cause ongoing damage for decades of your life, possibly forever. Frequent dental cleanings, however deep, cannot clear away these bacteria completely from your mouth. Antibiotics or strong antiseptics may eradicate bacteria, but they are not selective and do not prevent harmful ones from returning, sometimes more aggressively than before. It’s nice to think your hygienist is cleaning your teeth, but the terminology oversimplifies the situation.
Mouth bacteria float in saliva, and the diverse mix is made up of residents from the mouth and other areas, namely the sinuses, nose, and throat. A dental cleaning cannot change your saliva, nor does it promote healthy mouth bacteria. To change your mouth’s ecosystem requires strategies that limit mouth acidity daily and improve the quality of saliva that washes over your teeth. Too frequent cleanings can in fact be a problem, especially for someone with a dry mouth who may have difficulty maintaining or developing healthy biofilm. Frequent cleanings can make teeth sensitive and possibly more prone to cavities if the protective biofilm is cleaned away. If you lack saliva, you will lack the salivary proteins that are the foundation of biofilm, so you will have difficulty building back the mouth’s basic protection after it has been stripped from your teeth. Fewer cleanings and using techniques to nurture healthy bacteria will be beneficial for you and will help you to restore comfort to your mouth.
Any aggressive antiseptic, like chlorhexidine, or the use of an antibiotic can abruptly kill all mouth bacteria (good and bad) simultaneously. This may give you short-term clinical improvements, but these products can damage the beneficial bacteria in your mouth and create new problems, like candida overgrowth, gum recession, tooth abrasion, or sensitivity. The best way to develop sustainable oral health is to gradually improve your mouth health little by little. Along this progressive journey, you should ask your dentist about your mouth health and if you need dental cleanings. When cleanings are no longer required because they are no longer necessary, you will know that you have achieved healthy, stable, and sustainable conditions in your mouth—something I call ultimate oral health.
Gingivitis: Initial Gum Damage
When the gum around a tooth is tight and healthy, there is no risk of a pocket forming and no place for low-oxygen disease bacteria to multiply. This is why some kind of incident is necessary to cause the gum to be stretched and lose its grip on your tooth. Usually this occurs if the gum is irritated and becomes swollen. This can be the result of injury, but often it follows a small infection in an area. A wounded gum will, like any wounded body part, swell and bleed, especially if the area is rubbed or pricked. You may notice your gum bleeds easily but not remember the incident that caused the harm, possibly some lodged or abrasive food, a flossing cut, or toxins from infected biofilm (plaque) that irritated the area. Quickly resolving this infection will end the condition, which is called gingivitis. If your gums bleed when you brush or floss, it is likely you have gingivitis.
Often, gingivitis occurs when your body’s immune system is weak or compromised, such as during pregnancy, a period of stress, hormone fluctuation, menopause, or if your mouth is dry from the side effects of taking certain medications or using an asthma inhaler or antihistamine drug. When you notice bleeding, it is important to take action immediately to resolve this, since leaving gingivitis unchecked can allow the gum band to loosen and the door to open for the next stage of gum disease.
While we will discuss the specific strategies of my Complete Mouth Care System in chapter 9, here are some things you can do to support healthy gum tissue: Use xylitol gum or mints after every meal, snack, and drink to alkalize your mouth and support the development of healthy biofilm. You should also use a clean toothbrush and massage this area, especially around the site of bleeding. The idea is to stimulate circulation of blood and lymphatics in this area and recruit healing help from the nutrients that the blood flow will bring to the tissues. You should also try to ensure that you support your body’s immune system by eating healthy foods, especially fruits and vegetables with vitamin C, and other foods that provide a good mix of nutrients to benefit wound healing. These simple strategies can resolve gingivitis easily and stop more serious gum disease from developing. If gingivitis is untreated for more than a few days, deeper damage can occur, and a gum pocket may form that is much more permanent and difficult to resolve.
Gingivitis affects at least one in seven adults, even in the mouths of people who routinely visit their dentist. Few people realize how easy it is to treat this condition with good brushing, attention to nutrition, and the use of my Complete Mouth Care System to support healing. If your gums bleed as you brush them, this is a signal to brush the area more thoroughly, not less, since the improved circulation you will create by brushing will help the swelling go away before any permanent damage happens to your gums.
If cold water makes your mouth sensitive when you brush, use warm water on your toothbrush. If brushing is painful, try to clean the area initially with gauze or a cloth, wiping and massaging around the teeth. Once the area is clean, it will begin to heal quickly. Most people avoid brushing when they see bleeding, but this is exactly the wrong thing to do as it allows more bacteria to accumulate in the area and gingivitis to progress into a disease that can cause tooth loss. If you have previously noticed bleeding gums but they stopped bleeding, this may not be a good sign. This could signal that gingivitis progressed and became the next stage, which is a painless, nonbleeding, more serious gum problem called periodontal disease.
Periodontal Disease
There are only a few kinds of mouth bacteria able to thrive in the narrow space between a tooth and its surrounding and supporting bone—a place called a gum pocket. These bacteria are collectively known as periodontal pathogens. These pathogens are aggressive and flourish anywhere they find seclusion and a low-oxygen environment. They cause harm to the gum fibers that connect the root of the tooth to the bone, and some of these pathogens can open up wounds on the inside of the gum pocket, which can potentially allow them to gain access into the blood and travel to distant areas in the body.
Periodontal pathogens have individual names, specific characteristics, and each kind appears to target one or more specific areas of our body. Most of them cause a low-grade chronic inflammation in the gum tissue where they multiply. This small nucleus of trouble below the gums can work like a burning ember, and as the inflammation or infection is distributed by blood, it can ignite far more serious inflammation elsewhere in the body. Periodontal pathogens adapt to low-oxygen environments, and eleven species have been identified and found in pockets around teeth. Some periodontal pathogens cause a low-grade infection in the gums, others cause erosions inside the pocket, and some produce toxins or poisons. All periodontal pathogens initiate a reaction from the body’s immune system, and the body responds by sending fighting cells to the area in an effort to control them.
In most cases, the body’s immune system is unable to overcome these periodontal attackers, and a chronic battle ensues. Unresolved, chronic gum disease can continue with progressive, ongoing destruction and attachment loss, until the jawbone dissolves in the area around the tooth, which allows the tooth to loosen and possibly fall out. These problems are hidden under the gums, but they are serious, even though they rarely cause any swelling or pain. Certainly the most dangerous consequences occur when invasive periodontal pathogens get into the blood or when they create sufficient inflammation to ripple from the mouth to other places in the body, which can put you at risk for a stroke or heart attack.
Periodontal disease has never hit the news headlines or been publicized, because it is an invisible disease that doesn’t cause toothache, bleeding, swelling, or the pain of other dental infections. Shocking statistics indicate that half of the young adults in America today are heavily infected with periodontal pathogens before the age of thirty. It seems unfortunate that carriers of gum infection often do not know the dangers of harboring high levels of these pathogens or how they are transferred from person to person by kissing and close contact.
Periodontal disease used to be called periodontitis, and it was thought to be a gum problem caused by food particles that were allowed to accumulate around and between teeth when patients were “bad” about brushing or flossing. The theory was that this debris caused damage, which led to pocketing, and when the pocket became too deep to be cleaned by a toothbrush, cleaning became impossible, so the situation escalated to eventual tooth loss. This was why a “critical pocket depth” was determined to be the length of a toothbrush bristle: 4 millimeters. Once a pocket was greater than 4 millimeters, dentists believed you would not be able to clean your gums adequately, and the prescribed treatment was then to cut the gums and reduce the pocket depth to less than 4 millimeters, so the toothbrush bristles could once again reach the bottom of the pocket.
Cutting the gums was a painful process that removed several millimeters of gum tissue, and as it reduced the pocket depth, it exposed several millimeters of the tooth’s root, which made teeth sensitive and look exceptionally ugly. Dentists did not know the bacterial nature of periodontal disease at the time and could not understand why this disfiguring process, called gingivectomy, never stopped the problems. No one knew about the transmissible nature of periodontal disease and that reinfection from the mouth of a spouse or friend was possible. People often used old infected toothbrushes after this surgery, sometimes keeping them for months and even years, never considering it a risk. Patients were usually blamed for inadequate mouth care, because nothing seemed to stop the disease, and these unfortunate people often ended up with dentures as their teeth fell out.
In 1978, Paul Keyes, a researcher working at the organization now called the National Institute of Dental and Craniofacial Research, caused a dental uproar when he suggested bacteria were to blame for periodontal problems in gum pockets. He suggested the revolutionary idea to stop cutting gums; instead, he applied a mixture of baking soda and hydrogen peroxide plus systemic antibiotics, creating a nonsurgical treatment for gum pocketing. Dr. Keyes was a trailblazer, but today we know more, and even this therapy was less than ideal, leaving patients with gum recession and sensitivity. Some dentists have built on Dr. Keyes’s original concept but with strong mouth disinfectants, antibiotics, aggressive antiseptics, or surgical-type cleanings aimed at removing biofilm and killing bacteria along the side surfaces of teeth (this process is called root planing). Dentists usually find it difficult or impossible to believe a pocket can heal naturally without this treatment or imagine that hard debris under the gums can dissolve in the correct mouth conditions and go away without root planing or antibiotics.
Root Sensitivity after Gum Disease
We have discussed how gums hug the tooth tightly at the place where the root meets the part covered by enamel in a healthy mouth. This area is called the cement-enamel junction. Healthy gum tissue is like a tight elastic collar, and it grips the neck of the tooth at this location to keep bacteria, liquids, and food particles from going below the gum surface. This mechanism protects the tooth’s root from any damage by acidic or abrasive foods that could harm its delicate surface.
A tooth’s root is covered with a soft, porous material called cement, which offers a perfect surface texture for the attachment of microscopic hairs that span between the tooth and bone. But this surface is not a shield and is easily damaged if it is exposed to the mouth, which is something that may happen as your gum recedes down to the root of your teeth or if a pocket opens up and allows liquids in this area. When gum tissues are damaged or if the gum loosens, root cement can come in contact with foods and liquids in the mouth. With no protection from acidic assaults and temperature changes, these sensations can travel through the tooth surface in the root area and are often perceived as sharp or even excruciating dental pain.
Root sensitivity is most often a symptom of gum problems, but it is usually felt as radiating pain in teeth, especially as you breathe or drink something hot or cold. Tooth roots are not good candidates for fillings, and sensitivity toothpaste will only cause additional discomfort, including a furry feeling on your teeth or the sensation of a dry mouth. My suggestion is to avoid peroxide, whitening products, oil pulling, or baking soda, which may lead to recession. Sensitivity will disappear naturally as your gum and tooth health improves.
Dentin Problems
The center of a tooth is alive, and it is called the pulp. Pressure-sensitive cells called odontoblasts are located in the pulp, and they have extension arms that radiate from the pulp and traverse across the main part of the tooth that is called the dentin. The arms of odontoblast cells run inside a small hollow tube, known as a dentin tubule. The cell’s arm floats in this tubule bathed in lymphatic fluid that is in osmotic balance with the chemistry of your body and blood. This fluid provides a transport system for minerals from the body to supply internal areas of the tooth, keeping them hydrated, pliable, and healthy. Any sensation that upsets an odontoblast will be communicated to the nerve cells in the tooth pulp. Nerve cells transmit the problem sensations to your brain, where they are interpreted as pain. You feel such sensations when an odontoblast senses that bacteria are attacking a tooth or sometimes during dental treatment. To clean and shape a tooth for a filling, a dentist will drill out damaged areas, and if the drill cuts dentin, part of an odontoblast’s arm can be severed. This creates alterations in fluid pressure in the tubule and sends an urgent signal to your brain, where this is perceived as intense pain.
Odontoblasts secrete a material that solidifies to become new dentin, and this is a process that can repair the walls of their tubule, even decades after a tooth has erupted. This mechanism continues slowly over time, and the internal walls of dentin tubules thicken gradually as you age. In a crisis, the odontoblasts use this attribute to barricade and close off one or more tubules to stop bacteria from reaching the live center of the tooth. This defense mechanism can be extremely effective if decay progresses slowly, but it is unable to compete with a bacterial attack that occurs rapidly. Odontoblasts are unique, and they appear to have a vital role in tooth health. Sadly it is your friendly odontoblasts that are most damaged by peroxide and when you treat teeth carelessly with bleaching or whitening products or chemicals.
How do you know when tooth pain is telling you something serious or if it is sensitivity that can be reversed naturally? The rule of thumb is that a painful sensation that lasts fewer than two minutes usually indicates the problem is reversible. You should consider this pain as a warning, but the situation may not be a disaster. Usually, the longer the pain continues, the more serious it is. When tooth pain is felt as you press on a tooth, this is usually a call for more urgent dental help, as this kind of pressure is normally caused by fluids accumulating from a bacterial infection inside the tooth or an abscess in or around the tooth’s root.
Over half of the US population is now suffering from tooth sensitivity, which should be a warning that we are being careless in the way we care for teeth. In most cases, this pain is probably reversible with kinder and more preventive home care. Of course, pain from an abscess or dead tooth is serious, and if you are in pain and unsure of the cause, make an appointment with your dentist. If you want to try to determine a little more about sensitivity, consider what may be causing the problem. Here are some questions to ask yourself:
When you feel pain from hot or cold—
•Is the pain immediate, as if directly on the outside of the tooth?
•Is the pain delayed, or does it persist for more than two minutes, with it feeling like a throbbing inside the tooth?
When you eat or drink—
•Does the pain appear to come directly after food or drink?
•Does the pain start as you begin chewing or when pressing down on the tooth?
When you look at your teeth—
•Do you have thin enamel or a groove at the sides of the gum, all along your back teeth?
•Do you have a piece of tooth missing, a large old filling, or a cavity (hole) in the area?
If you answer yes to the first questions in each grouping but not the second, the problem is generally reversible. Everyone with sensitivity should take preventive action, but if you gave affirmative answers to the second questions, your problems are more likely to be caused by infection—either in your gums or in a tooth—so you should seek treatment sooner rather than later. If a tooth dies, bacteria will invade the pulp, causing a buildup of fluid that creates pressure inside the tooth. Unless dental care relieves this pressure, it will eventually push into the bone, forming an abscess, which can be painful and dangerous.
Many people have embraced white fillings as an alternative to silver ones, but patients often experience sensitivity and pain from a white filling and wonder why this happens. Silver filling material is a paste-like metal that solidifies after it is packed into a tooth to become a block known as an amalgam filling. The shape of this filling block is critical and complex, and dentists need to follow defined engineering rules if the filling is to stay in place. White filling materials are easier to use, because they can be glued to teeth, and less engineering design is required. This seemed great at first, but dentists discovered these white filling materials often set hard before they were correctly positioned.
New materials have been developed that remain fluid until they are cured with a light beam. It was a perfect solution until dentists discovered that this light caused the filling material to pull away from the tooth surface and move toward the light. This problem produces tension on the adhesive glue at the base of the filling and causes it to stretch like chewing gum, pulling away from the tooth’s dentin surface and then bouncing back each time the filling is pressed by eating or clenching. Constant stretching and pulling changes the fluid pressure in the dentin tubules and can upset the odontoblast cells, which notify you with a signal that is felt as pain.
Fortunately, the Academy of Biomimetic Dentistry (ABD) has worked tirelessly to perfect placement techniques for white fillings and has taught ABD members how to properly adhere fillings, and they also teach a method where the filling is cured outside the mouth with a technique called CEREC. This group of dentists has also developed excellent methods to harden white fillings incrementally, sometimes interspersing and weaving fine mesh fibers between the layers to prevent any movement or shrinkage.
HEALTHY BIOFILM: A DEFENSIVE SHIELD
We’ve discussed how the mouth is home for hundreds of different kinds of bacteria, yeasts, fungi, and viruses—an invisible garden of life. The irony is that the healthiest mouths have the widest diversity of bacteria, and unhealthy mouths are dominated by a few aggressive and destructive kinds. In a healthy mouth, beneficial bacteria are woven into an invisible unit by thread-like strands of protein that form a transparent microfabric known as biofilm. The characteristics of a healthy biofilm are poorly understood, but it is more complex than the sum of the qualities exhibited by each individual bacterium that comprises the biofilm. For example, temperatures and chemicals that would harm individual bacterium subjected to a particular challenge suffer no harm or damage when they are meshed together as part of this biofilm. Two teeth in your mouth can host completely different bacterial species, but their communication systems, called quorum sensing, allow them to work in harmony and function as a coordinated unit to protect your gums and teeth in a powerful way.
A healthy tooth requires healthy biofilm to cover its surface if it is to attract minerals from saliva to enter into the tooth’s surface. Healthy biofilm also acts as a shield, offering protection from thermal damage, from hot or cold food and drinks, from infection by invader bacteria, and from chemical or mechanical damage that could wear away the tooth’s surface. Teeth devoid of biofilm will usually be easily weakened, more sensitive to hot and cold, more likely to decay, and more at risk for erosion and abrasive damage.
The first bacteria to land on a clean tooth will immediately begin to attract other bacteria and develop into tiny communities called colonies. The speed and type of colony that develops appears to be influenced and depend on the surrounding environmental conditions and by the type of bacteria that are first to initiate the colony. This happens because certain bacteria attract other specific kinds that may not be from the same family but appear to flourish in similar areas. This means we see certain kinds of bacterial groups in specific mouth neighborhoods, and these bacteria—good or bad—grow in numbers and become dominant. Acidic conditions, especially in mouths where sugar and carbohydrates are consumed, will promote aggressive cavity- and plaque-forming microbial communities, whereas alkaline conditions in mouths where carbohydrates and sugar consumption are controlled will promote a protective collection. Each colony is unique, yet through cellular communication they are never isolated, and they touch and interact with adjacent communities in every dimension. This is why bacteria in your mouth are biologically connected to biofilms that extend into other areas of your body.
The bacterial communities in your nose, for example, communicate with adjacent bacteria in the throat and sinuses. This is why children with plaque and cavities may also have frequent middle ear infections, postnasal drip, sinus problems, and even lung infections. As mouth health improves, the health of these adjacent areas may improve as well. This also means it’s important to consider nasal and sinus health if you are trying to improve your teeth.
Healthy biofilm protects your mouth from all kinds of damage, but biofilm can become infected if changes tip its bacterial balance and the environmental conditions offer more support to harmful microbes. Things that can tip the health of biofilm are acidity, high-carbohydrate or sugary diets, any mouth-drying conditions (including medications), challenges to the immune system, prolonged illness, chronic depression, chemotherapy, or poor digestive health. The most common bacteria to infect oral biofilm are S. mutans, which can change healthy biofilm into a sticky mass in less than three weeks of unhealthy conditions, especially when accompanied by improper mouth care. These invisible microbes inflate the biofilm and can expand it until it becomes a foamy mass that is visible in the mouth as a material commonly referred to as plaque.
S. mutans bacteria attach to a tooth’s surface by strands of a stringy, adhesive material they produce when they feed on carbohydrates and sugars from the foods we consume. These adhesive strands help S. mutans bind closely to the tooth’s surface and to each other, forming blankets of tube-shaped bacteria that layer one sheet on top of the next. In this way, the sticky mass covers the tooth surface and it grows upward and outward. As the bacteria multiply, they form acids, which collectively acidifies the entire mesh of biofilm in which they are lodged.
Sugar and carbohydrates energize the bacteria of infected biofilm and make it grow rapidly and produce more acids. To the eye, this thick mass is often seen as a cream-colored material close to the gumline or in other sheltered areas between your teeth. The acids in this infected biofilm damage the tooth surfaces in any areas where it is attached, and the greatest damage occurs on surfaces exposed to acids for the longest time. When plaque remains undisturbed for several days, these acids will remove minerals from the underlying tooth and leach into saliva to weaken teeth everywhere in your mouth. Generalized mouth acidity is particularly dangerous, since it encourages the growth of a particularly aggressive type of bacteria that secretes poisons called toxins. These toxins irritate the gums and cause gingivitis and bleeding around the margins of your teeth.
When plaque is visible on your teeth, it is already seething with harmful bacteria. The more infected it becomes, the more puffed up it will be. Eventually, this infected biofilm can become thick enough to be scraped from teeth as a white, foamy slime. An infected biofilm that grows more slowly can be equally problematic, since it can calcify and thicken as it absorbs calcium and phosphates, and this will create a hard, crusty product known as calculus or tartar.
One kind of bacteria, Corynebacterium matruchotii, occurs in certain individuals’ mouths and can increase the speed of calculus formation. These bacteria form a backbone or post-like structure, which becomes a support for bacterial film to grow more rapidly than in most other people’s mouths. People who have a rapid buildup of calculus should avoid acidity as much as possible by eating and drinking at mealtimes and ending meals with xylitol or something that can alkalize the mouth. Before a dental cleaning, try to balance your mouth ecology with xylitol, improved nutrition, and careful eating patterns. Many people struggle with their digestive health, and this has an influence on mouth health. My suggestion is to supplement with a digestive probiotic for a few weeks before and after your dental cleaning. You need to support these probiotics by eating a wide variety of vegetables as part of every meal. A healthy digestion will improve saliva quality and this, in turn, will encourage the development of healthy bacteria and their supporting biofilm in the mouth. Eventually good bacteria will crowd out plaque-building ones, but this transition is progressive and may take months or sometimes longer. The key is to realize that we must begin with digestive health as it is the only way to improve saliva quality and unlock a lifetime of sustainable oral health.
Healthy biofilm appears to contribute many general health benefits as it protects the integrity of your cheeks, gums, teeth, tongue, and overall mouth health. Removing healthy biofilm removes this special protection and can leave your mouth and teeth vulnerable to damage. Without healthy biofilm, the mouth and tongue may be more prone to ulcers, sloughing, and soreness, and teeth are more easily damaged, thinned, and eroded, leaving them sensitive to temperature changes.
Each of us has a unique biofilm fingerprint that has developed over our lifetimes, incorporating all kinds of bacteria into the mesh that forms from our unique salivary proteins. The composition of biofilm is usually well developed by age five and may remain mostly unchanged over the course of our lives. The only caveat is if biofilm is removed or is frequently influenced by mouth acidity or dryness, by taking antibiotics or by the use of products that damage its biology or chemistry. For example, you may be surprised to learn that biofilm can be seriously harmed by “plaque control” or “whitening” pastes that contain damaging abrasive or caustic ingredients like peroxide, which can destroy the protein matrix of healthy biofilm. Unexpected damage can happen suddenly or slowly, and even an apparently static biofilm that has offered your mouth ideal protection for many years can be rapidly changed by modifications in the products you use, your health, or your lifestyle—things like eating more often, different food quality or acidity, or the introduction of snacking or sipping between meals.
Once a healthy biofilm has developed, it should be respected and protected, as we need its protection for our mouth and teeth. Removal of healthy biofilm will leave teeth unprotected, and this may make your mouth feel uncomfortable, sensitive, or dry, and it can cause a bad taste or make your mouth feel slimy. During a professional dental cleaning, healthy biofilm is removed by the traditional process of cleaning teeth with pumice or abrasives. This is why you may want to ask in advance if you need a cleaning and opt not to have one if the answer to your question is “no.” A doctor’s prescription for antibiotics, perhaps for some unrelated infection in a distant part of your body, can also damage healthy biofilm in your mouth. In addition to reducing the number of cleanings and avoiding antibiotics whenever possible, I also suggest you avoid baking soda and peroxide, because these popular products can be problematic, especially if you have a dry mouth, a delicate digestive system, or protein-deficient saliva.
Developing Healthy Biofilm
My desire is that everyone should be able to enjoy natural and pristine teeth and gums, untouched by dentistry—for a lifetime.This is often seen as a laughable goal by dentists who usually see teeth deteriorate with age and may have never witnessed cavities and gum disease reversing. The process of breakdown and rebuilding our body’s skeleton is understood as a natural process that helps to keep our bones dense and healthy. There is a similar ebb and flow of minerals in and out of the outer layer of tooth enamel to maintain the health of teeth and basically keep them young and strong. Mouth health improves rapidly when two simple things are in balance: (1) when enamel breakdown is controlled by limiting mineral loss from acidic damage or mouth dryness and (2) when mineral deficits are replaced quickly and completely after any damage. When the amount of damage and repair are equal or if there are greater amounts of minerals deposited in teeth each day, a cavity cannot form, since as many minerals are entering the enamel as are leaving it. When extra minerals are provided to teeth regularly each day, any enamel weaknesses will slowly become more fully mineralized, cracks will heal, and the tooth should lighten in color naturally. During this process, any cavity will begin to repair and may even disappear completely.
This is why it is important to control prolonged periods of mouth acidity, and this may involve reducing habits like snacking, frequent sipping of drinks (even water), and allowing chronic stress to dominate your life. It is equally important to nurture the healthiest possible biofilm, ideally by keeping your mouth bathed in healthy saliva as much as possible. The health and pH of saliva is affected by diet, stress, changes in hormones and circulation, smoking, and the quality of nutrients absorbed from your food, which depends on the health of your digestive system. A mouth that is bathed in mineral- and protein-rich saliva will have the attributes and proteins necessary to form the foundation of a strong biofilm, which will provide an essential base for the absorption of minerals into teeth. These minerals that are absorbed into the outside of teeth are able to diffuse through the teeth and be used for natural repair and prevention of weak enamel and cavities. Minerals from saliva are attracted to a tooth by an ionic charge on the outside of it, and this charge, which is almost like a magnetic force, pulls the minerals toward and then into the tooth’s surface. The caveat is that this only happens in the presence of healthy biofilm and when the mouth is at a neutral or slightly alkaline pH.
After a tooth has been cleaned, healthy saliva will immediately coat its surface with proteins and form a hydration layer that protects the outer enamel crystals. This protein layer has a great influence on the amount and type of minerals and bacteria that are attracted to the tooth’s surface. Certain kinds of bacteria will be promoted, others will be rejected, and additional types of bacteria will be preferentially encouraged to join the developing community while others will be repelled from this developing community woven between the protein mesh.
In 2014, Dr. Erica Shapiro Frenkel of Harvard University and Dr. Katharina Ribbeck published a study in Applied and Environmental Microbiology, suggesting that bolstering the mouth’s salivary defenses may be a better way to fight cavities than relying on sealants and fluoride treatments. These researchers noticed that when the saliva proteins called mucins covered teeth, they had powerful abilities to manipulate microbial behavior and prevent cavity-forming bacteria from attaching to the teeth and causing cavities. In healthy biofilm, bacteria woven into the mesh contribute and communicate within their network, with positive and negative interactions between members of the community. Healthy saliva and biofilm promote the mineralization of teeth. Your gums will become healthy when your mouth no longer supports the bacteria that grow into thick plaque and produce toxins that cause gingivitis.
Many dentists despair and are frustrated, because they believe patients do not brush or floss adequately, and this is often a charge leveled at patients who are unable to develop healthy biofilm with their current oral care methods. Sometimes their dentist may suggest stronger toothpastes, more frequent cleanings, or even antibiotics, but these products and methods are aimed at killing mouth bacteria, a problem that could easily send someone’s mouth into an ever-deteriorating cycle.
My approach may be the answer for you, if you have been unsuccessful with your oral health and if you want to enjoy the oral health you deserve. My strategies work to nurture and develop healthy saliva and biofilm by focusing on the development of the following:
•Healthy mouth bacteria and saliva and the development of healthy oral biofilm
•Supportive home care and habits to fully mineralize your teeth
•Improved digestive health to maximize absorption of nutrients from foods for the support of your immune system (i.e., your defense from disease)
•The consumption of a diverse whole-food diet (about 80 percent plant-based) to support digestive bacteria and provide the nutrients necessary for dental and salivary health
In addition, your choice of oral care products is vitally important. Many products can be problematic, and even some apparently healthy choices can have a negative impact. There are many features to consider, and if you have been loyal to a homemade toothpaste recipe, but your teeth and gums are not comfortable and healthy, you may want to reconsider what you are using, since many oils, clays, salts, and glycerin can interfere with tooth mineralization. Other ingredients, like baking soda and peroxide, can dissolve salivary proteins and leave teeth devoid of their essential biofilm layer, making them sensitive and rough to the tongue. This will explain why some apparently healthy products may stop disease, but they allow different problems to occur, such as gum recession, enamel erosion, sensitivity, weakened teeth, and fractures. A mouth that is not comfortable is not healthy. My greatest concern is that some of these products, especially the pastes and rinses that are specifically designed to strip biofilm, may allow viruses, chemicals, bacteria, or free radicals to damage skin cells in the mouth, working as precursors for oral cancer.
HEALING MOUTH TISSUES
If you have chronic health problems, you may show signs of inflammation, and your doctor may have discovered elevated levels of C-reactive proteins in your blood. Anyone who is trying to lower these levels should consider the impact of oral health on chronic systemic inflammation. Healing gum disease is similar to healing any wound, and this process is dependent on help from your body’s immune system. This is why anyone with gum disease must pay attention to their digestive health, the powerhouse that supports their immune system.
My clients work to improve their digestive health in a variety of ways. We consider foods, eating patterns, the use of colon probiotics (sometimes with additional digestive enzymes), and usually some vitamin and mineral supplements, at least for a limited time. Often, our body requires extra nutritional support to improve its chances of healing chronic health problems. I rarely recommend oral probiotics, which are probiotics targeted for the mouth. A healthy biofilm makes the addition of new bacteria difficult or impossible in the mouth, so oral probiotics will be of little use. On the other hand, oral probiotics can be useful in specific and extreme situations; for example, when people struggle with the development of healthy biofilm because they have a very dry mouth, are recovering from cancer treatments, or are in situations where their immune system is compromised and their mouth needs help. Regular use, along with xylitol at the end of meals and before bed, can help these patients greatly. It is important to check the quality of oral probiotics very carefully. Many are lozenge-type but are sweetened with harmful artificial sweeteners, including sucralose, which will negatively affect your digestive pH and potentially disrupt your digestive bacteria. You really want to try and find oral probiotics sweetened with xylitol if possible, since xylitol provides nutrition for these healthy bacteria to support them. Please check my website for more information about probiotics and products that my clients have found useful. When a good combination of supportive efforts are used for twelve weeks, most people notice changes in their saliva health, oral biofilm, and the health of their teeth and gums.
NEW UNDERSTANDING ABOUT ORAL HEALTH
This shift in oral health thinking is about developing a new awareness and respect for the community of helpful bacteria that support our mouth’s health. For many years, dentistry has tried to meticulously clean teeth, often with sharp instruments, powerful antiseptics, and even antibiotics, thinking that the eradication of plaque will somehow mechanically “clean” your mouth and keep it healthy.
Healthy biofilm can be our mouth’s best friend, but it is easily weakened by periods of mouth dryness, a variety of medications, antimicrobials, strong fluoride treatments, and even antibiotics taken to heal other parts of the body. If you have a balanced and healthy mouth, a strong biofilm is providing your teeth with an effective shield against sensitivity, staining, and cavities. Biofilm is your mouth’s natural defense from abrasion and erosion, two problems that can occur while brushing your teeth or grinding your teeth. Instead of buying a new brush or a bite guard, maybe first consider why you may have lost the protection of your natural healthy biofilm, and do what you can to restore it.
Many people have used my strategies and have completely resolved gum pockets without deep cleanings or any surgical therapy. I never prescribe chlorhexidine, peroxide, or strong antibacterials, as these can kill all the bacteria in your mouth. Chlorhexidine is particularly dangerous, because it can create a lethal allergic response.
Your dentist may want you to have a deep cleaning, laser treatments, bone grafts, irrigation, or use of special toothbrushes, strong antiseptic, or antibiotics rinses for your periodontal problems. I suggest that before you begin any of these potentially expensive treatments, you should consider an inexpensive at-home alternative for at least a few weeks. A few simple strategies could improve your mouth health and reverse some or all of your periodontal problems with minimal fuss and bother. You may be able to surprise your dentist, because the program I recommend will address the low-oxygen periodontal pathogens but will preserve the healthy bacteria that help establish mouth health and pocket healing.
Healing in the mouth occurs in exactly the same way as healing occurs elsewhere in the body. Healing is not possible until a wound is free of the infecting bacteria, and this explains why, in a diseased mouth, dental problems have caused so much frustration and confusion. Few dental strategies remove the offending infection without killing the bacteria that are necessary to establish mouth health. My epiphany occurred years ago, and for decades, I have focused on nurturing the mouth health of my patients before we pursued any proposed treatment plan. I often notice that damage can regress and may even disappear, almost miraculously, when you use this approach.
This is why I believe it is good, if possible, to implement my strategies and begin developing and maintaining healthy biofilm before you decide to have fillings, deep cleanings, or other treatments. Why not make improvements for a few months and use my Complete Mouth Care System, which we will explore in chapter 9, before you schedule your next dental cleaning? You may not be able to eliminate this first cleaning, but your improved state of mouth health will set you up for more success in the future and maybe help you to extend the intervals between cleanings, something that will only be possible if your mouth health improves.