Brushing, Flossing, and Xylitol
The greatest mistake is to continue to practice a mistake.
—Coach Bobby Bowden
The oral health of almost everyone in the United States deteriorates with age, even those who brush, floss, and have regular dental cleanings. Obviously, our current methods of tooth and gum care may slow the damage, but eventually, in most mouths, disease wins this game. Most of us begin brushing our teeth as children, but we may never have an assessment of the effectiveness of our technique for the rest of our lives. Confusion from mixed messaging and stakeholder advertising makes it difficult to know what works and what does not; plus, we do not have adequate methods to measure mouth health, especially when someone has crowns and cosmetically improved teeth that can camouflage festering gums, hide discolored teeth, and mask the ongoing dental damage in an infected mouth. Dentists obviously don’t want patients to feel bad about their smile, so many dental problems are blamed on old teeth or fillings, bad genetics, lack of saliva, an enamel defect, or a theory that somehow gums deteriorate and teeth become weaker with age.
However, don’t think you have to accept deterioration; remember, gum disease and cavities are completely preventable with effective strategies. You may be proud of your meticulous brushing habits, but it may be time to take a closer look and see if they are effective enough to defend you from dental and gum problems. In this chapter, we will discuss the importance of brushing and pairing this with preventive oral-care products that really work. We will also explore the many benefits of xylitol and shed some light on how flossing may not be the priority you once thought.
IMPROVING YOUR BRUSHING HABITS
Key nutrients and cells in saliva are the true workhorses that maintain our gums and teeth by providing constant healing and repair. This is why it is so important to give our mouth adequate time to interact with this major contributor to our oral health. Never blame yourself or think you have incurable dental problems. I hear sad stories of people who continue to use an ineffective ultrasoft toothbrush, because it was suggested by their specialist as he or she simultaneously informed them they would need ongoing periodontal treatments for the rest of their lives. Instead of a soft brush, why not try a firmer medium brush and a new system of care? Who knows? Maybe you can surprise your periodontist with improved mouth health at your next visit!
Toothbrushing can be difficult, especially if you have reduced arm movement because of arthritis or a stroke, which can make the essential gum brushing movements difficult. Medical conditions like diabetes or habits such as smoking reduce circulation to the body’s extremities, which include the gums, and this is why some patients are at increased risk for gum disease. Cortisol, a body hormone released when we experience stress, also changes the quality of saliva in our mouth and stifles circulation to our gums, which is why stress can be a risk factor for many oral health problems, including bone loss and periodontal disease.
But don’t give up! First, buy some new toothbrushes, and ensure they are not too soft. You’ll want to concentrate on reaching all the areas of your gums: even higher above, on the inside areas, and below your teeth in the areas of the teeth’s roots. A good gum massage will work wonders if it brings healthy nutrients and cells to fight any cavities or gum problems. In some cases, a battery-operated brush can be useful, since the vibrations help to stimulate circulation when dexterity or access to the mouth is difficult. In other situations, when the vibrations are not tolerable, cleaning the gums with a manual brush or even a sponge or cloth may be your best option. The tool you use is not as important as your method and the results you achieve from using it.
Gum massage brings blood and an associated lymphatic flow to help resolve any infection and brings healing nutrients to the teeth and gums. Brushing teeth per se has little influence on whether or not you have cavities, especially if you have a mouth teeming with harmful bacteria and are using an infected brush or bad toothpaste. You can brush many times a day and yet continue to experience bad breath, bleeding gums, and dental decay. Conversely, if you have healthy saliva, a good diet, and smart eating patterns, you may decide not to brush as often and still be able to enjoy a cavity-free mouth. I do not suggest you abandon brushing, but it is important to know that brushing is never a guarantee for a cavity-free mouth.
Brushing with an infected toothbrush can transfer harmful bacteria from external sources, such as from people who have flossed above your brush, leaving bacteria that can multiply in its bristles. Brushing with an inaccurate aim can cause erosion in a tooth’s surface if your mouth is acidic or if you use abrasive toothpastes. Brushing techniques that target teeth and do not reach your gums will leave plaque at the gum margins in an infected mouth. The fresh-tasting minty paste can create the illusion that your mouth is clean, but don’t be fooled. Many toothpastes, including apparently healthy ones, often contain ingredients like glycerin that may inhibit remineralization and products like baking soda or peroxide that can be problems or strip teeth of a healthy biofilm. This is why selecting appropriate products, toothbrushes, and using good gum-massage techniques are important.
A FEW TIPS
There are a few things you can do to improve your daily brushing habits. They include:
•Using a clean and appropriately sized brush that is not too soft
•Learn how to brush with techniques that generate circulation in the gum area to promote tooth and gum health
•Use a helpful paste that ideally delivers benefits to teeth and does no harm; dry brushing without any toothpaste is a better option than using a harmful product
Everything would be so much easier if toothbrushing had been called gum brushing or gum massage. Our toothbrushing description was born in the 1900s when people thought brushing was to remove food from teeth. At this time, no one knew that cavities were caused by a bacterial infection or that toothbrushes could, in fact, be a part of the problem. The idea of brushing and cleanings—and eventually the idea of floss—was to mechanically and meticulously remove particles from every surface around a tooth. The problem with this method is that if your mouth and saliva are infected, this is inadequate care. This is why cavities and gum disease are so prevalent today, as this basic technique does not address the bigger whole-mouth problem of an infected oral ecosystem and the bacterial transmission in saliva. Scorched-earth tactics with strong fluoride or antiseptics disable both the bad and good bacteria, and brushing does not correct an imbalance of the mouth’s ecology. Effective strategies, on the other hand, must be designed not only to control any infection but must simultaneously nurture healthy bacteria and their associated biofilm if we are to achieve ultimate success and sustainable mouth health.
Our immune system is a powerful ally for improving bodily health. Good circulation throughout the body is vitally important for the health of all our tissues, and our gums are no exception. Blood transports many cells and nutrients, and important immune cells are carried in the lymphatic system, which flows around our body and can remove harmful bacteria. The blood transports minerals and healing nutrients, so tissues can heal themselves after the immune system has cleared and resolved any area of infection. Without an adequate blood flow, neither cleanup nor healing processes can occur, and without assistance, our gums do not normally receive a sufficiently vibrant blood flow.
Hospital personnel are familiar with wounds that never heal, often in the elderly or patients with diabetes or poor circulation. The secret to mouth health lies in stimulating and encouraging blood flow to the areas of the gums and teeth, using a bacterially clean toothbrush and a good brushing technique. Young children and dynamic adults may jump around enough to naturally stimulate gum circulation, but as we slow down (or in the case of injury or disability), our toothbrush may become our mouth’s only ally.
Gum tissues are extremely vascular and filled with tiny capillaries, so when we stimulate circulation in this area, the results can be positive and quick. Yoga inversions that lower your head below your heart can also help gum circulation. If anyone suddenly becomes diabetic, sedentary, or confined to a wheelchair or hospital bed, even for just a few days, their risk for developing gum problems, without appropriate care, can increase.
The goal of gum brushing is to actively stimulate circulation around every tooth, front and back, and on the inside and outside of both jaws. This kind of stimulation will bring blood to the roots of your teeth in these areas and also to the surrounding gums. The blood supply will carry cells to fight infection and nutrients for the wound-healing process. This is why a very soft brush will usually be inadequate or even a waste of your time. Soft brushes were originally fashionable in the era when dentists encouraged patients to oscillate the bristles inside tiny gum pockets around teeth to remove food particles.
The toothbrush now has a different purpose in our fight for gum health. Currently, there is no scientific measurement to categorize toothbrushes as to their stiffness, softness, or hardness. Almost all brushes today are labeled soft, and it may be a challenge to find a brush firm enough to help, but it is worth the effort. If your brush is too soft, you may not be aware of how ineffective it is. On the other hand, if your brush feels too hard, you can always soften the bristles under warm water.
With the exception of electric toothbrushes, many brush heads are too big and difficult to maneuver around your mouth. In general, a toothbrush head should be small, and the handle should be comfortable to grasp. You might think that a larger head means more bristles, but access in difficult areas is probably more important, specifically on the upper outside and lower inside areas along your back teeth. For some of my clients, I suggest a brush designed for teens or young adults. Basically, you want a brush that fits your mouth. And brushes with small heads are generally easier, especially if you have crowded teeth.
The United States sells about five million kilometers of floss per year, and I suggest that few dentists have dared to dispute or reject flossing because of an underlying fear that this appears heretical. When I began to voice flossing concerns years ago, many people were surprised, but they were not aware of the science about how cavities form, and they often believed cavities were random phenomena or were caused by food stuck between teeth. Today, we know that cavities are a biofilm infection and that a healthy mouth depends on nurturing healthy bacteria and healthy saliva in the ways I have discussed in this book.
There are no studies to support flossing as a method of protecting teeth. Anyone with cavities, gum disease, or plaque buildup may have been told to floss more, but I suggest you use caution and begin instead by using xylitol and my Complete Mouth Care System for at least 6–8 weeks before you begin flossing or have a dental cleaning appointment. I suggest this because flossing cannot help you improve your mouth ecology, and there is risk that flossing and cleanings could push bacteria into the blood from your infected mouth. If you have a problem with food being stuck between your teeth, this will gradually resolve as your mouth becomes healthier; in the meantime, small interdental brushes may be useful for extra plaque control in problem areas.
Researchers at the University of Applied Sciences in Amsterdam searched the scientific literature to check the effectiveness of flossing and compared it to brushing. Using meta-analysis, the researchers evaluated the data and showed no benefit of flossing over brushing alone when they measured plaque or gingivitis and that flossing without toothbrushing had no benefit at all. Two of the studies involved dental students—whom, one imagines, should have had an improved knowledge of flossing—yet this group did not show any better outcome than the general population.
During the past thirty years, I have helped thousands of patients and clients improve their oral health, yet I have never once recommended flossing as the answer to oral health problems. Many of us who grew up outside the United States never considered flossing important. Working as a dentist in other countries during the 1970s, I saw patients who enjoyed amazing oral hygiene but who never flossed. Conversely, I have witnessed hundreds of patients in the United States who are paranoid about flossing and carry devices and floss everywhere, yet their oral health remains poor.
There is obviously a debate over the subject of flossing, but we should all agree about the danger of flossing if we have infected, swollen, or inflamed gums. I also believe flossing may cause sensitivity and contribute to gum recession, and I suggest that people with gum recession or sensitive teeth take a two-week (or longer) abstinence from flossing that I call a flossing holiday. It is remarkable how this change can improve gum recession and sensitivity. As mentioned, the other concern is the danger of flossing in an unhealthy mouth. This is why, if you are told by your dentist or hygienist that you need to floss more, I suggest you begin with xylitol and my other strategies to improve your mouth health before you begin flossing. You may also want to take a salivary test to find out if you have any periodontal pathogens breeding under your gums. For anyone with a healthy mouth who really wants to floss, I suggest the best time for flossing is at the toothpaste stage of my Complete Mouth Care System, because flossing will move a little toothpaste between your teeth into the interproximal areas, where the toothpaste could provide some extra benefit.
Never allow yourself to be blamed for cavities because of a lack of flossing. Dental statistics suggest that 5 percent of patients floss correctly and enjoy healthy mouths, but I believe it is more likely that this population group has naturally balanced mouth chemistry, healthy saliva, and good habits to support mouth health anyway.
In 2012, Helen Rumbelow, a reporter for the London Times, called me on the phone while searching for an expert on oral health. She was writing an article about flossing and wanted to pick my brain on the subject. It didn’t take long for me to explain my heretic thoughts about floss and the complete lack of scientific support for flossing—not at all what she had expected to hear. I gave Helen the details of my Complete Mouth Care System, and she decided to give it a try. Prior to our conversation, she had flossed avidly. Before making the change, she visited her dentist for a report on her mouth health. She was given a six out of ten. Then, Helen asked what her hygienist believed would happen if she gave up flossing. As you can imagine, the description was pure disaster: plaque, calculus, bleeding, and the demise of her mouth.
Helen was a brave reporter who wanted a good story, so she began to use my regimen with interest and a certain degree of fear. Four weeks later, she returned to her dentist’s office for review, without telling them about the changes she had made. Her hygienist was amazed by the state of her teeth, which showed dramatic improvement and now had no bleeding spots and no sign of plaque or inflammation. Helen followed up by talking with the chief of the British Oral Health Foundation and the professor emeritus of dental public health at University College, London. Both dentists agreed that xylitol was a wonderful adjunct for oral health and that it could prevent accumulation of plaque. They agreed that dentists should be aware of the power of xylitol but said that dentists get “bogged down” in the mechanics of dentistry. These experts also corroborated that flossing was not supported by science and is almost completely useless. Needless to say, Helen’s article ignited a firestorm and created a flurry of questions on both sides of the Atlantic.
I was interviewed by the BBC World Service and discussed flossing with a number of eminent dentists, who all agreed with me, yet they concluded by saying we must continue to support flossing. In the summer of 2016, an article was published in the United States by the Associated Press, commenting again that there is no proof flossing works. The article created a similar volcano of reaction, with the dental associations and periodontal experts unable to accept these findings. One professor even blamed the poor flossing results that had been documented in the studies on patients who did not floss properly.
RINSING TEETH
Rinsing teeth with a well-selected liquid seems to be a far superior adjunct for oral care than floss, and it will usually yield better results than flossing. Rinses will travel all over your mouth, between teeth, and to all the places that mouth liquids travel. This means that mouth rinses can access grooves in teeth, move around difficult areas behind wisdom teeth, and even get into cavities and under crowns if those are problem areas in your mouth.
Rinses can be great for oral health, but not all rinses are the same or equally effective. In fact, they vary dramatically, and some offer benefits for teeth, others, for gums; some are flavored water, and the worst ones can even be very harmful and upset your mouth health even after one rinse. All these good or bad outcomes depend on the specific ingredients, textures, and acidity levels of each rinse. This is why we need to select mouth rinses for a particular purpose and adjust our method of using them to maximize the desired results.
For example, a rinse like chlorine dioxide is very useful, because it will create oxygen in the small spaces where periodontal bacteria live. Oxygen can disrupt the dangerous anaerobic bacteria that cause gum disease but only if we allow adequate time for the rinse to work; otherwise, the benefits will be lost or reduced. It is also necessary to know where you may have problems; if, for example, you have periodontal problems around your lower front teeth, you must tip your head to ensure the rinse has time to bathe this area of your mouth.
The array of rinses available in the United States today is difficult to navigate, and most dentists are overwhelmed by advertising, sponsored studies, and insufficient time to explore these products or document long-term outcomes. Some professionals accept free samples to give away, and this can confuse patients and derail them from an effective to a less effective product.
One shocking fact is that many rinses today are acidic, with a pH low enough to damage root cement and even tooth enamel. The only acidic rinse that is safe for teeth is one containing dilute sodium fluoride, since the benefits of the fluoride are enhanced in a slightly acidic solution. A number of well-advertised and often esteemed non-fluoride and “natural” rinses are as acidic as a can of soda with pH scores between pH 4.0 and 3.3. Another shock is that rinses recommended for dry mouth are often sufficiently acidic to pull minerals out of tooth enamel and root surfaces. Acidic rinses are particularly damaging in a dry mouth. I believe everyone should check products they use regularly, possibly using an inexpensive pH-testing meter.
If you have any cavities or gum disease or are at risk for developing them, certain mouth rinses can be helpful, particularly when used in a special sequence, which we will cover in chapter 9. The rinses I suggest work in harmony with each other and also with the toothpaste I recommend. The choice and order of these rinses is exact and important, and the outcome of the routine depends on using the correct products in the correct order to enable harmonious interactions between the products.
CLEANING YOUR BRUSH
Toothbrushes need twenty-four hours between uses to dry in open air. Many years ago, I looked at an infected toothbrush under a microscope, and I still remember seeing crawly bacteria on the brush and how they completely disappeared when the brush was cleaned for a few seconds in bleach or Listerine, then rinsed and allowed to dry. After a single use, all the bacteria in the mouth are transferred to a toothbrush. Even the latest designs of toothbrushes are easily infected, and studies show it makes no difference if you use a new brush: The brush becomes infected after one use.
My recommendation would be to store your brushes in a dry, clean area away from the toilet and to consider a rigorous routine for toothbrush cleaning and replacement, particularly if you are fighting gum disease or cavities. Simply swish the bristles of the brush daily, preferably in a drop of an undiluted essential oil antibacterial rinse, like Listerine, for a couple of seconds. Rinse the brush under running water and then store it—bristles up, in a cup or holder—so it can air-dry completely for twenty-four hours between uses. Remember that bacteria lodged inside biofilm will die when they dry. This means that in order to brush twice a day you will need, at a minimum, two brushes. I think it is often a good idea to select two brushes that are different designs, to make brushing feel a little different each time you brush.
If your bathroom conditions are damp, mold or bacteria can grow on your brush, especially if you store it under a cover or inside a bag. Storing your brush close to another one could allow transfer of bacteria from one brush to another. Carrying any toothbrush in a plastic case, in the carry compartment of your vehicle, or in a gym bag is a recipe for disaster. UV toothbrush sanitizers may seem a good idea, but even the manufacturers admit they only kill 99 percent of bacteria. From my clinical experience, I worry that this 1 percent they fail to kill may be an aggressive periodontal pathogen, a frightening microbe called Aggregatibacter actinomycetemcomitans. This particular pathogen can cause a rapid form of periodontal disease in adolescents and has been implicated in infective endocarditis. It is also the periodontal pathogen identified in atherosclerotic plaque, which can block arteries and cause heart attacks and stroke. The ADA’s position on the cleanliness of your toothbrushes is surprisingly nonchalant, which seems strange considering the fact that so many adults in America have gum disease. The ADA does, however, recommend people susceptible to infections should use “a higher level of vigilance.”
XYLITOL
In addition to proper brushing and care of your brushes, I believe that xylitol is a key part of any healthy mouth program. This is because xylitol can quickly bring saliva into your mouth, limit acidity, and help control plaque growth. Xylitol also nurtures and supports good mouth bacteria and appears to aid mineral absorption into tooth enamel and the transfer of minerals into deeper parts of a tooth for more complete mineralization. Xylitol also helps make harmful plaque bacteria slippery, so these bacteria are more easily rinsed away during oral care. Finally, by using xylitol as your ally, you can nurture healthy mouth bacteria and develop a healthier and more protective mouth biofilm.
For many years I lived and worked as a dentist in Rochester, New York. During this time, I co-owned a restaurant quite famous in the 1980s as one of the first to offer cappuccino coffees. Our restaurant made Swiss cakes and European pastries, and the staff were provided with a constant supply of broken cookies, pieces of cake, and treats to taste, along with coffee and limitless soda from a fountain in the waiters’ area. To freshen their breath, the staff consumed breath mints, multiple times a day. Familiar with xylitol from my career in Europe, I asked why they did not eat xylitol mints. When no one had any idea what I was talking about, I decided to start making xylitol peppermints and put them in a dispenser at the back of the restaurant. Every waiter was able to purchase a small handful for a quarter and nibble them over the course of his or her shift. Quite rapidly, the staff noticed improvements in their oral health, and many became so interested that they began using my other mouth care strategies and the rinses and toothpaste I recommend. Now, over twenty years later, many of these individuals stay in touch and let me know how much they enjoy their ongoing oral health success.
Health Benefits
Xylitol is a low-calorie and diabetic-safe sweetener, and it has been central to my strategies for mouth health for a long time. Xylitol is such an amazing product that I was stunned to find that it was virtually unknown in the United States as late as the 1980s. Xylitol was used in Europe over a hundred years ago as a natural diabetic sugar alternative and was used as an intravenous support for diabetic patients during surgery. It was chosen for its safety, its freedom from the insulin pathway, and its ability to keep the blood glucose of diabetic patients stable during stressful surgical procedures. Xylitol was commonly used as table sugar in homes during sugar rationing in Europe during the 1940s, and in the 1960s, it became popular to help cut sugar cravings and as a chewing gum for smoking-cessation programs.
Xylitol can be extracted from the woody fibers of birch trees, but it is also found in numerous vegetables, fruits, corn husks, and even the human body. In its granular form, xylitol looks and tastes like ordinary table sugar but with a slightly fruity overtone. The difference, however, is that xylitol’s effects are almost the exact opposite of sugar, so it nurtures the healthy mouth bacteria, makes plaque slippery, and is useful for digestive health. Xylitol should not be classified as either a sugar alcohol or an artificial sweetener, because its structure differs completely from other members of both these groups. Xylitol is a unique five-carbon (or pentose) sugar, and people are amazed how sweet and delicious it tastes. Some people, especially special-needs patients or dementia patients who are physically unable to eat mints or gum, may benefit from consuming xylitol in baked goods, such as puddings and custards; sprinkled onto foods or used in drinks; or even wiped over their mouths at the end of meals. The only setback to baking with xylitol is that it cannot be caramelized, and because it has antifungal properties, it inactivates yeast.
Xylitol is a prebiotic fiber food that supports mouth and intestinal probiotic bacteria, and in the colon, it digests to form butyrate, which is a compound that helps support and heal the cells of the colon lining. Xylitol does not dissolve in cold water, but it dissolves easily at room temperature, and once dissolved, it will stay dissolved, even when chilled. Adding xylitol to water may be helpful when higher doses of xylitol are used, as they are in Europe for women with osteoporosis. Doctors who believe in xylitol for bone benefits often suggest an amount of up to 20 grams of xylitol daily. Again, if you are diabetic and choose to replace all the sweeteners in your diet with xylitol, my suggestion is to begin slowly, gradually increasing the amount added to your diet (talk with your doctor before you begin). Any form of xylitol will benefit digestive health, although people with unhealthy digestion should begin using xylitol in very small amounts, maybe 1–3 grams per day in small, divided amounts at first. People with digestive imbalances will develop adequate tolerance to xylitol’s special hygroscopic effects, but this can take a few months. For people with a leaky gut, xylitol may allow body liquids to flow through the leaky gut lining and into the gut, which can cause loose stools. Anyone with leaky gut should begin slowly, as mentioned, using just one gram of xylitol at the end of one or two meals each day and then gradually adding more as they become tolerant and their digestive health improves.
Regular use of at least 3 grams of xylitol daily will improve the quality of the biofilm that covers your teeth and mouth, although less than this amount on a regular basis may not show these benefits, which is why some people do not see oral health improvements. Improvement in the oral biofilm may positively affect adjacent areas of confluent biofilm, such as areas in the nose, mouth, throat, and possibly the lungs, but if you struggle with nose, sinus, ear, or acid reflux issues, a xylitol nasal spray may be a useful adjunct as you improve your mouth health. For young children, just as xylitol reduces the number of sticky plaque bacteria on their teeth, it also appears to reduce the number of sticky bacteria in their eustachian tubes and reduce the incidence of middle-ear infections. As harmful bacteria disappear, healthier and nonsticky bacteria will take their place, which means that the ecologies of the mouth, nose, and middle ear will often improve together, and you may notice fewer ear, nose, and throat infections.
Recommended Daily Amount of Xylitol for Oral Health
The total quantity of xylitol consumed each day for oral health should be equivalent to 1 and 2 teaspoons of xylitol (1 teaspoon is about 5 grams). This is recommended for children and adults, but studies show that teeth benefit most from tiny, multiple exposures to xylitol each day—ideally 1–2 grams at each exposure to total between 6.5 and 10 total grams per day. This amount, used regularly, can radically change the profile of bacteria in an infected mouth within a year.
Of course, reducing harmful plaque is one goal, but feeding or supporting a healthy mouth ecology is another part of this strategy and works best when regular sugar and carbohydrates are restricted in the diet. Be aware that studies indicate that less than 3 grams of xylitol per day may not provide any oral health benefits and that, as the number of exposures per day increases, so do the clinical benefits. Over 10 grams per day may not give you any additional dental health benefits, and at this amount, oral health changes appear to plateau. Remember that increasing the frequency of xylitol consumption and considering the best timing will be your way to maximize its benefits. I suggest you strive for a 1-gram serving of xylitol (ideally as two 0.5-gram mints or a 1-gram piece of gum) five times each day after meals, snacks, and drinks.
For maximum dental benefit, do not consume your daily xylitol at once—for example, do not put a teaspoon of xylitol in a cup of tea and expect to see results. Xylitol works in the various ways we have discussed, and we can maximize its effect when it is consumed after meals, drinks, and snacks. Mints, gum, and granules work equally well for reducing plaque, although mints and gum are more convenient and an easy way to count up your dosage to an effective level, especially if you are fighting cavities or gum disease. Check the amount of xylitol in the products you select, since the amounts vary, and companies are allowed to round up the amounts on their nutrition labels.
Correct use of xylitol can gradually eliminate plaque and help protect teeth from cavities. In the first five weeks of using xylitol, you may notice cleaner-feeling teeth, but it takes about six months of regular use to fully change your mouth ecosystem and for you to feel the benefits of having healthier bacteria in your saliva and mouth. Infants and toddlers without decay or plaque can benefit from xylitol, and they will develop a healthier mouth ecosystem even with very small amounts. An effective dosage of xylitol for infants and toddlers is between 1 and 3 grams per day (¼ to ½ teaspoon of granular xylitol).
The other thing to remember is that people with delicate digestive health or leaky gut may not tolerate larger amounts of xylitol at first, so be sure to work up slowly, introducing xylitol by using one mint or one piece of gum at the end of meals, two or three times per day, keeping the total amount to around 3 grams per day for the first month. Then, increase the amount gradually over several months until you reach the ideal amount of 6–10 grams per day (which would be 12–20 half-gram mints, or 6–10 pieces of gum).
Xylitol Gum and Candies
In its granular form, xylitol can be used for baking. It also tastes delicious as chewing gum and healthy, tooth-friendly mints and candies. Since the 1960s, it has been given to preschool children in Finland as part of a public oral health measure. Many studies have looked at xylitol’s dental health benefits, and a number of impressive studies were conducted in the 1970s by researchers at the University of Michigan.
Making xylitol a regular part of your daily routine is easy, and this is the best way to experience its benefits. You can eat it as candy, chew it as gum, or use it as a breath mint or spray. When you expose your mouth to a tiny amount with regularity, you will create major changes in the biological health of your mouth. Studies show that five or more exposures per day are ideal, and it appears xylitol’s benefits are greatest when it can alkalize your mouth at the end of meals or after snacks.
Granular xylitol can be eaten or used as crystals or made into a solution to wipe, rinse, or brush onto the teeth of babies, the elderly, bedridden patients, or simply to avoid commercial toothpastes and rinses. Xylitol used in this way is a good choice if you are simply looking for a harmless tooth cleaning product with no chemicals and providing you have no need of other ingredients that could offer enamel protection or remineralization help.
Here is a table that outlines why xylitol is a key part of my strategy for mouth health.
However, while xylitol is useful to control plaque and nurture healthy mouth bacteria, xylitol cannot eliminate periodontal pathogens from periodontal gum pockets, and it cannot eradicate immature plaque spores or certain other bacteria found in an infected mouth. This is why xylitol may not give you adequate protection when used by itself, especially if you are experiencing cavities or gum disease.
Xylitol is a great way to limit the damage caused by acidity after meals. Usually teeth are damaged for close to an hour, every time we eat or drink. Xylitol helps generate a flow of saliva, which will wash away acidity and can provide minerals to heal any damaged areas of tooth enamel. This effect is achieved because xylitol is hygroscopic, which means it attracts water to itself. When you consume xylitol as mints or gum, they pull some saliva into your mouth from small salivary glands in the roof of your mouth. In most mouths, this saliva is mineral-rich and alkaline, which is conducive to tooth health and repair.
Remember that this effect cannot occur if xylitol is added to water, because the hygroscopic effect is nullified. Drinking xylitol water can be useful, but it cannot contribute to remineralization and the reversal of cavities in the same way as is achieved by regularly eating some mints or gum. By consuming xylitol regularly, you will encourage natural tooth healing, and the more often you eat xylitol, the more help you will be giving your teeth and gums. Xylitol mints or gum will also help people with dry mouth by creating a flow of saliva, and studies have shown that using xylitol mints daily can reduce the amount of root decay in high-risk patients by 40 percent.
Please note: Xylitol should not be given to animals—particularly not dogs. There are many human foods that are dangerous for dogs—grapes, chocolate, and raisins, to name a few. Xylitol is another of these foods, and it’s best kept away from animals.
Xylitol is expensive and is often mixed with cheap but similar-sounding sweeteners. For example, xylitol is sometimes mixed with sucralose or other artificial sweeteners. Marketing on these packages often advertise the benefits of xylitol, and people wrongly believe that xylitol is another artificial sugar or a sugar alcohol similar to sorbitol, maltitol, or mannitol, which are all products well known for giving people stomach cramps, bloating, gas, and acid reflux symptoms. As xylitol emerged in America in the early 2000s, a major gum manufacturer sent large bags of sorbitol gum that contained a tiny amount of xylitol to every dentist in the country, advertising that this gum was “now with xylitol.” Dental staff chewed this gum, unaware it was mainly sorbitol. Many were disappointed at the lack of dental benefits, because there was insufficient xylitol. High doses of sorbitol also cause gastric upsets, acid reflux, and bloating, which many people incorrectly attributed to xylitol and not the real culprit, sorbitol.
Another sweetener that is less expensive than xylitol is erythritol. Xylitol is often mixed with erythritol to create a cheaper product. Recently Cargill, the largest privately held global corporation in the United States in terms of revenue, became involved in the erythritol supply chain, so you can expect to hear more about erythritol. Erythritol is derived from corn, and because the body does not recognize this product, it will be touted as calorie-free. Like all zero-calorie products, this may not be a healthy attribute, and I do not promote erythritol or suggest you mix it with xylitol or allow yourself to be swayed by research that asks you to believe that erythritol is superior to xylitol.
BAD BREATH
People often worry that they have halitosis or bad breath, and this can seriously affect someone’s confidence and quality of life. Often, these folks are obsessed with cleaning their teeth, and frequently they use oral care products that are not helpful, because they are either acidic or mouth-drying, which can make the situation worse. No one with an acidic or dry mouth will ever find relief from halitosis by brushing and flossing, even if they do so ten times per day. This is because the problem is an imbalance in their mouth ecology, and constant cleaning, rinsing, and flossing—especially with aggressive antiseptics or antibacterial products—will only create a more destabilized situation and more embarrassment, expense, and frustration.
Scorched-earth tactics are common in dentistry, which is why patients assume it is correct to scrape the tongue or use prescription products for bad breath. When you appreciate the delicate bacterial balance in our mouths, which includes our tongues, you understand why scraping and killing will not promote the desired outcome. Consider the coral reef analogy, and remember that planktonic or floating microbes will never be controlled by scraping or flossing. The mouth ecology communicates with the nose, ears, and throat, and it may be more useful to consider the health of these areas and add a xylitol nasal spray to your daily xylitol regimen if you suspect allergies or postnasal drip could be involved in your halitosis problems.
Don’t sabotage your mouth health by trying to eliminate all your mouth bacteria, because this could allow yeasts or aggressive mouth pathogens an opportunity to develop. The best approach is to minimize periods of acidity in your mouth and develop habits—like ending meals with xylitol—that will frequently alkalize your mouth. Selecting oral care products is always difficult, but this daily mouth care routine must be an integral part of your strategy for a balanced and healthy mouth.
Research in 2007 by V. Haraszthy et al. from the University of Buffalo, and research in 2010 by Takeshita in Japan looked at the relationship between oral malodor and bacteria found on the tongues and in the saliva of people with and without bad breath. These studies showed that the bacteria of people with halitosis was distinct, especially the bacteria on the top surface of their tongues. These bacteria and the bacteria found in saliva were different from bacteria found on the tongues and in saliva of people with inoffensive breath. They also noted that their mouths had limited bacterial diversity. In other words, these sufferers had the opposite of a healthy ecology. In the case of halitosis, there is often an initial bacterial upset following antibiotic exposure or a digestive upset, and then the vulnerable ecosystem can be further exacerbated by any allergies, chronic sinus or nasal problems, acidity from the stomach or throat, or even constant cleanings with incorrect products.
Many people with bad breath do not like the taste of water, and some are almost addicted to soda drinks and juices. Unfortunately, even diet or sugar-free versions of these acidic drinks perpetuate an unhealthy ecology and create conditions that favor periodontal pathogens and other harmful mouth bacteria. Some of these bacteria secrete liquid poisons or toxins, which can become dissolved in any water that you drink, giving it a foul taste. When children or adults say that they do not like the taste of water, consider mouth health may be part of their taste problem. My strategies for mouth health, which we will discuss fully in chapter 9, can usually eliminate harmful mouth bacteria in about twelve weeks and potentially enable you to enjoy drinking water again.
The first step to stop bad breath is to control periods of mouth acidity, and if you are addicted to soda, try to drink it only at meals, and finish the meal with xylitol gum or mints to alkalize your mouth. Don’t allow yourself soda outside mealtimes, and if you need to drink between meals, try water sweetened with some xylitol. To make this, add 1 teaspoon of granular xylitol to 3 cups of room-temperature water, and when the granules have dissolved, you can refrigerate this xylitol water, and the xylitol will remain dissolved. Xylitol will not dissolve in cold water. Remember, you will not have the same benefits from drinking xylitol dissolved in water as from a mint or piece of gum. This is because xylitol’s hygroscopic effects are nullified by dissolution in the water. Drinking xylitol water can still be useful, especially for people with halitosis, and it can be an alternative to sweet or acidic drinks as your taste buds learn to appreciate the taste of water again.
Combatting Bad Breath
Following are my top six suggestions for combatting bad breath:
1.Control mouth acidity by eating xylitol mints or gum, especially after every meal, snack, or drink.
2.Clean your toothbrush every time you use it, and allow it to airdry—away from any toilet—for twenty-four hours between uses.
3.Stop drinking—even water—for at least a few hours in the afternoon.
4.Follow my Complete Mouth Care System twice or three times (maximum) daily. Do not overclean your tongue or mouth.
5.If you travel, take inexpensive throwaway brushes. Never store a brush in a bag or under a cover.
6.Try to improve your digestive health by including a wide variety of vegetables in your diet, and consider if digestive enzymes and colon probiotics could improve your nutritional status and the quality of your saliva.
7.Foods that boost your immune health include mushrooms, onions, garlic, and pomegranate. Try adding small amounts of these foods to at least one meal each day.
ORAL CARE PRODUCTS
Today, we are faced with an incredible selection of pastes, rinses, and products for tooth care. Many products claim to stop sensitivity, whiten teeth, and prevent bad breath, yet the oral health of America continues to deteriorate. The problem is that few of these products are designed for oral health, but instead they are targeted as a temporary fix for the superficial symptoms. For example, they may give you instant minty breath, less sensitivity, or whiter teeth—but the real solution is to control the underlying problems of an imbalanced or diseased mouth. Of course, toothpaste companies are trying to give you, the consumer, what you want. However, it’s important to realize that the kind of toothpaste you put on your toothbrush is important as it can help or harm your efforts to achieve oral health.
Toothpaste marketing is alluring, so be sure you are an educated shopper. A toothpaste’s ideal ingredients would be nonabrasive silica, enough sodium fluoride to strengthen teeth, and no glycerin. In the late 1950s, the original Crest formulation passed randomized clinical trials and showed it could stop cavities before they start, which means it was shown to prevent cavities. It has been my toothpaste of choice for three decades, despite the fact it contains color and some ingredients I wish were not there. A good toothpaste has value, especially when it is combined with effective brushing techniques. A toothbrush cannot strengthen your teeth or heal a cavity, but the toothpaste that you put on your brush can contribute to this process if it contains ingredients that stimulate remineralization and tooth healing. If your mouth is not as you want it to be, consider your toothpaste, and make a simple change.
If your teeth are pristine, healthy, and have never had a single cavity, filling, sealant, or crown at any time in your life, you probably have a wide selection of toothpastes that will work for you. You may enjoy one that contains activated charcoal, one that is chocolate-derived, xylitol gel, or xylitol crystals sprinkled on a damp toothbrush. These are choices that do no harm, and they are also good choices for children who are at no risk for cavities.
On the other hand, if you have gum recession, be sure to avoid any toothpaste that contains glycerin, salt, peroxide, coconut oil, or baking soda, since these can upset biofilm health by dissolving its foundational proteins. If you have a dry mouth or sensitivity, my advice is to avoid all the pastes advertised for sensitive teeth and dry mouth and consider the strategies in this book that address mouth acidity and tooth demineralization problems. Many mouth rinses are acidic, which can make your mouth feel as if they are covered in wool, and they can also cause teeth to become brittle. If you have had fillings in any tooth—even years ago— you will need a toothpaste that can help repair the microscopic enamel cracks that occur on the sides of these teeth. If your mouth needs help, or if it is sensitive or dry, or if you have already had one or more fillings, be sure to consider using xylitol and my Complete Mouth Care System, which helps to strengthen your teeth and will stop enamel from chipping around fillings and from the sides of your teeth.
DAILY MOUTH CARE
Ninety-five percent of people living in the United States have infected mouth biofilm. These people can probably identify the substance known as plaque on their teeth and may have even noticed it as a white foamy material, which is actually biofilm heavily infected with harmful mouth bacteria. Statistics show that a trained hygienist who carefully brushes and flosses teeth can only remove 40 percent of infected plaque from someone’s mouth. This is because the remaining 60 percent of problematic bacteria are floating in saliva or attached to other areas of the mouth, nose, or throat, which are inaccessible to a toothbrush. Brushing and flossing cannot turn bad bacteria into healthy ones, which is why we need a new approach.
At night, our mouths become drier than during the day and everyone’s saliva becomes more acidic. This makes the night a high-risk time for everyone’s teeth, which is why it is vital to adequately prepare your mouth before sleeping. Before bed, I recommended preparing your mouth for this difficult time. My routine can help anyone with weak teeth, dry mouth, darkening teeth, or sensitivity. If you feel you are at risk for cavities or gum problems or if you are someone with a dry mouth, here are four basic suggestions:
1.Use the Complete Mouth Care System described in chapter 9 twice daily and always before sleeping at night.
2.Disinfect your toothbrush, and allow it to air-dry for twenty-four hours between uses.
3.Use xylitol to protect your teeth after every meal, snack, and drink.
4.Give your teeth as much time as possible to interact with saliva, especially during the afternoon. Drink mainly at mealtimes and control sipping (even water), which dilutes saliva’s supersaturated status and will reduce its healing power.
