Let’s get a bit mouthy about the oral cavity.

Our oral cavity includes the lips, the bony front portion of the roof of the mouth (hard palate), soft palate (the muscular back portion of the roof of the mouth), retromolar trigone (the area behind the wisdom teeth), front two-thirds of the tongue, gingiva (gums), buccal mucosa (the inner lining of lips and cheeks), and the floor of the mouth (under the tongue).

There are three categories of the gingiva – basically arranged by the differing fibres that constitute these specialised tissues.

These are the fibres that work to protect against periodontitis, the world’s most common gum disease; suffered by up to 50% of adults. The difficulty with periodontitis is that once the gingiva is compromised, it cannot regenerate. This in turn increases the depth of the gingival sulcus – the natural space between the tooth surface and the surrounding gum.

Obviously then, more debris and bacteria remains in contact with the delicate sulcular and junctional epithelia – the part that attaches the connective tissue to the tooth.

Know your Gingiva! And not Gingerly.

There’s no point getting mouthy if you’re not at some point tempted to mouth off; and there’s no point doing that unless you have some facts and information. Without which you’re just a motor mouth instead of someone with the opportunity to spread some knowledge regardless of the number of g&ts you’ve had.

If nothing else, all rote facts’ll bring up the intelligence points temporarily nullified by the gin.

The reason the dentogingival unit is a group of three types of fibres is because of the intricacies involved in keeping your teeth in your head.

There are fibres that extend upward to the crest of the gingiva (the coronal portion of that surrounds the tooth).

There are lateral fibres that extend horizontally from the base of the tooth to the outer surface of the gingiva.

There are fibres that extend downward along the cortex of the alveolar; the bone ridge where tooth sockets live.

Then there is the group of circular fibres – completely unique because they exist entirely within the gingiva and yet have no contact the with the tooth.

Then there’s another group of more fibres; and by this time everyone gets the gist and will start to wander off if there’s too much further detail. So we’ll accept that there’s also the transseptal group, throw in the words ‘interproximal’, ‘semicircular’ and ‘cementum’, remember why our dentist is so important to us with a note-to-self of how very Harry Potterish ‘cementum’ is.

All this is part of the stuff of the periodontium. Its only function is to surround and support the teeth and keep them within the maxillary and mandibular bones; such is its marvellous biological engineering. One should no longer consider periodontists as souped-up dentists: their specialty is the care and maintenance of these delicate and specific tissues. They know all there is to know about maintaining functioning teeth, and the Google periodontal degree you may claim for yourself will never outweigh their knowledge and expertise.

So if you’re figuring to self-diagnose and treat your ailing gums, cut down on the g&ts.

All these connective fibres consist primarily of type I collagen, and healthy gingiva is described as ‘salmon’ or ‘coral pink’. The surface of gingiva is keratinised, and the width of attached gingiva can vary dramatically between people – from as little as 1mm to a centimetre.

This keratinised gingival is an oral mucosa which covers the gingiva and hard palate. Part of its job is to prevent receding gums. In terms of dental implants, the width is important because it’s tissue that plays a big role in the long-term support of the prosthetic tooth.

Of the mouth, the interdental space is the most neglected area and yet the most vulnerable. It’s the perfect environment for dental plaque to accumulate, and it’s perfectly inaccessible. It’s where great harm to the periodontium and therefore the teeth, happens.

We know what plaque is; we know it likes sugar. So while we’re talking about mouths, we’ll talk about diet.

Studies have determined that high carbohydrate consumption favours the development of periodontal disease. So when it was found by a German research team that a low-carb diet can significantly reduce gingivitis because of a notable decrease in inflammation, it seems like a grant grab really – until you understand that it also discovered that it’s a diet that has no influence on subgingival microbiota or inflammatory serological levels. (The fancy science of antibodies in bodily fluids.)

Factually, the most time intensive, complicated, and expensive therapy a dentist performs on a daily basis is because of the pathology of this interdental space. Neither toothbrush bristles nor mouthwash (and there’s a whole conversation to have about that) can effectively access and cleans this part of the mouth. Dental floss is the benchmark device. Ageing (becoming ‘longer in the tooth’) means embrasures and interdental spaces become larger and salivary flow decreases. More food debris accumulates more plaque, and the thinness of dental floss makes an inadequate method of removal, even if it had been perfectly suitable before.

Flossing is effective – and most people hate it. It’s highly technique sensitive, it involves two clean hands, manual dexterity, and reverse hand-eye coordination (thanks to the mirror). It can shred or tear the contact area, causing pain and bleeding.

And that’s discounting ‘blue finger syndrome’, as well as what happens to sewerage systems when you flush floss, and what happens to dogs when get to the bin that you’ve put it in. (Nothing deadly. Just unpleasantly hilarious, mostly.)

Dentists and hygienists are continually frustrated with advice to patients about daily flossing knowing full well that most will just not. Practitioners are tired of the spiel, and patients are tired of the nagging; research reveals that 25% of people routinely lie to clinicians about their flossing habits.

Like your dentist doesn’t know…

According to the American Dental Association, less than 30% of American adults floss daily. 20% have never flossed and are unlikely to. The interesting and amusing stats to pull out with the g&ts are that in preference to flossing, 14% would rather clean the toilet, 9% would rather sit in traffic for an hour, and 7% would rather be subjected to toddlers crying on a plane.

The presumption is that dental floss is a 20th century thing, because it’s hard to imagine a bloodied red-and-white poled barber flogging their traumatised patient a snap-lock gizmo with waxy string inside. It was in fact invented 1815 by American Dr Levi Spear Parmly (1790-1859), considered the Father of Dental Hygiene and Preventative Dentistry. With such a spearminty and parmigiany name you have to wonder about its ethereal significance.

The first dental floss patent was granted to J&J (now Johnson & Johnson of course) in 1898 made of unwaxed silk.

Certainly alternatives to dental floss in an attempt to address its problems and limitations have been introduced over the years.

Much of the interdental cleaning research is ambiguous, uncontrolled, and all too often, manufacturer-sponsored. Exhaustive reviews of available data conclude that motivation is the key element (d’oh!) with ease of use affecting motivation. (What a surprise.)

Most study participants prefer interdental brushes because they’re simpler to handle, require only one hand, are more time efficient and therefore encouraging for better compliance.

Maybe it’s time for the dental profession to accept that it is not enough to continue advocating for dental floss to patients who will simply refuse, no matter how many times they’re advised and instructed. It’s the cleaning of the interdental space that’s important. And if you want to do that with a tiny brush or a bit of balsa instead of a bit of string, the thing is to do it. Daily. As part of your oral health regimen along with regular visits to your dentist.

It’s those routine appointments with your dentist that is the only way you really know how your gingiva’s going.

Further References:

https://www.sciencedirect.com/science/article/pii/S0020653920365205
https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/gingiva
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gingiva
https://www.kenhub.com/en/library/anatomy/gingiva

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