Dental hygiene in autoinflammatory conditions
By Daniel Radu, Dentist
As your friendly FMF dentist here, I wanted to share my knowledge of dental hygiene, FMF’s potential impact on gum inflammation and dental problems, and general tips on properly caring for your teeth, which is really very important.
Does FMF affect your gums/tooth health?
If you do some research online, the data you will find is that if the inflammation is ‘controlled’ (ESR and C-reactive protein are normal levels) and on colchicine, you are not going to have a high risk of gum/tooth disease. Just like with other diseases (diabetes, heart disease, etc), if your disease/inflammation is uncontrolled, it will cause issues.
The point either way, in my opinion, is to keep the levels of inflammation in your mouth as low as possible. It’s something that can be controlled. Even if you see a very small potential source of inflammation, try not to exacerbate it in any way.
Another oral condition associated with FMF sometimes are aphthous ulcers, or canker sores. Some of you may get these oral ulcers randomly, which can be really irritating. The triggers can be emotional stress, trauma or other unknown reasons. Some treatments your dentist can prescribe include Kenalog in Orabase or a chlorhexidine rinse. The ulcers shouldn't last more than 5-10 days, and they generally heal without any problems.
I would like to give you a few tips on how to keep your teeth and gums as healthy as possible.
You brush your teeth, and probably have done it for decades. So, you hopefully know what you’re doing, right?
Maybe! Let’s make sure that if we're going to do it twice a day, we clean our mouth as well as possible, without really adding any time or stress to the process.
Tip 1: DON’T BRUSH YOUR TEETH (Just clean the spaces)
But guess what. I know where plaque ends up sitting, I see it every day.
It’s at locations B (not location C!) - see figure 1 attached.
The spaces are 1) around the gingival sulcus (gum gap) and 2) between the teeth.
So, what ends up happening when the plaque sits there? Cavities between teeth happen (see location A).
Location A is showing the redness (inflammation) around the teeth. This is the source of most inflammation of the gums. This is a result of not focusing the cleaning at the right locations.
The toothbrush (electric or manual - although there is a slight difference in technique which shows in the attached video), should be inclined at 45 degrees into the gingival sulcus, so the bristles are cleaning those spaces. Figure 2 shows the space which is 360 degrees around each tooth, and how plaque, which turns into calculus, sits there for an extended period of time and will inflame the attached gum, leading to bone loss, more inflammation, loose teeth, infections, etc.
By the way - when you brush the spaces, you’ll inevitably brush the rest of the tooth (location C). But the focus should be locations B.
The curved line on the left (figure 1) shows how there’s a ‘bump’ of gum tissue (we called it rolled tissue). That bump should look pointed (as on the right in figure 1). The bump on the left is from inflammation.
Tip 2: Really more of a Tip 1b – FLOSS
Guess where most people get cavities? Between their teeth. Why? Because people either don't really brush between their teeth (you can’t really) or don’t floss, but usually both.
A brush won’t clean locations B between the teeth perfectly, but it will do ca. 75% of the job. The problem is that over many months, the plaque between your teeth just sits there and erodes away, causing major gum inflammation between the teeth and cavities. The cavities get bigger until they reach the nerve and then you need root canal work. This is expensive so you opt for having the tooth pulled out, but then you need an implant, which is even more expensive and even harder to clean. See the vicious cycle? So stop it and FLOSS.
I don’t like to floss either, but I try. Therefore, I usually use something called the Reach access flosser (figure 3), and I replace the tips every few days. This lets you get something between the teeth and wrap around each tooth at least a little bit.
This is the key to flossing - wrap the floss around the teeth to clean locations B as much as possible, on BOTH sides. You’re flossing one side of each tooth separately each time you ‘click’ the floss through.
Waterpiks (figure 4) - I have one or two. I mostly use a cordless Waterpik (figure 5) that I leave sitting in my shower, using shower water. Waterpiks are good for the super lazy flossers, but not a 100% alternative to flossing. BUT if you aren’t going to floss, at least use one of these bad boys, pointing the spray right into the same gingival sulci, and the same in-between areas, as mentioned before.
Figure 4 Figure 5
Tip 3: Get regular cleanings at your dentist (every 4-6 months), but you need to do the brunt of the work AT HOME. Yes, going regularly helps, sometimes tartar gets stuck in places where the dental hygienist needs to take care of it. However, what you do at home is the main event. You get to clean your teeth every day, twice, and if you do a good job, following my instructions above, I promise you’ll see improvements. Once you’ve had a good hygiene visit, the hard build-up is off. KEEP it off by doing proper home treatment.
Other quick titbits:
- I equate mouth rinses to an analogy: if you're standing in the shower, letting soapy water go to your feet, and consider that ‘washing my feet.’ You didn’t. You have to bend down and scrub.
- Electric brushes generally are better, but you have to let them do the work - no scrubbing. Hold them in place. See the attached video.
- If you bleed when you brush or floss - that’s the inflammation in your gums. That means you haven’t cleaned them well. Don’t go gentle or avoid those areas. Brush and floss even BETTER there.
- Floss with string versus those sticks that cross contaminate bacteria between all the teeth.
- A tongue scraper is good to get rid of a huge source of bad breath.
In summary, clean the spaces, ideally use an electric toothbrush, ideally floss (but a Waterpik is OK).
As for children with inflammatory conditions, to fortify their teeth/enamel, I would recommend a higher strength fluoride toothpaste like Clinpro (a prescription one), not for children under 6. At least, it should be used at night. It will help ‘strengthen’ the enamel, as much as possible.
https://www.ncbi.nlm.nih.gov/pubmed/23557976 - oral health and oral quality of life
https://www.ncbi.nlm.nih.gov/pubmed/18973533 - if uncontrolled, bad gums
https://www.ncbi.nlm.nih.gov/pubmed/25126643 - not much difference if on colchicine