by Nancy W. Burkhart, RDH, EdD
[email protected]
Your patient today is 11–year–old Hunter, and he arrives for a six–month maintenance appointment. Hunter is currently under care for orthodontic treatment and has a spacer. The indentations from the spacer are evident on his tongue (see Figure 1). Hunter is producing a suction effect between the palate and the tongue. Normally, the indentations will subside when the spacer is removed, and the tissue will recover. The indentations would not cause a problem unless he developed some tissue ulceration.
Hunter is accompanied by his mother, and she mentions the indentations on his tongue. You reassure her that the indentations are temporary and that it would be beneficial to discuss her concerns with the orthodontist. Making Hunter aware of the pressure that he is exerting on the tongue may help to alleviate some of the tissue indentations. At this point, he probably has developed a habitual problem of sucking on the spacer.
Secondly, Hunter was cautioned by you during his last visit regarding the amount of plaque he had, and you reviewed his brushing technique with him. Hunter's mother was concerned that he was not cleaning his teeth adequately, so she purchased a small powered toothbrush hoping to resolve the plaque problem. Her rationale was that he might brush longer with the powered brush and be able to reach difficult areas.
Figure 1: The patient causes indentations on his tongue because of suction on an orthodontic spacer. Figure 2: Loss of gingival tissue on No. 24 occurs because of the placement of an electric toothbrush and applied pressure. Figure 3: A child was allowed to “play” with a manual toothbrush throughout the day. Note the recession and the tissue trauma on all anterior teeth. Courtesy of Dr. T.D. Rees, Baylor College of Dentistry.
The mother informs you that she is concerned about tooth No. 24. She noticed that the tissue around the tooth appeared to be receding (see Figure 2). As you begin to examine Hunter, you realize that the tissue appears to be approximately 2mm recessed , but does not appear to be inflamed or clefted at the gingival margin. Tooth No. 23 is not fully erupted making the appearance of No. 24 even more noticeable.
The mother also tells you that Hunter would sometimes brush in front of the computer and the television. After she noticed the difference in the tissue level, she started to watch him more closely. She noticed that he would hold the brush longer in the lower incisor area and sometimes would forget to move the brush until she mentioned this to him. As you begin to assess the area of concern, you recall that Hunter is right–handed and this angle would allow him to place the brush comfortably on the tissue of No. 24 and perhaps apply pressure. The small round head of the toothbrush allowed a defined placement right into the labial sulcus area of No. 24. Hunter's mom had him discontinue the use of the brush after witnessing the behavior.
Hunter is eleven years old and would understand the use of the electric toothbrush when properly instructed by a dental professional. Since his mother bought the toothbrush and did not provide any instructions or guidance in its use, the child did not properly use the brush.
Parents sometimes buy the inexpensive brushes for children and provide little to no instruction in their use. Children who become engrossed in a television show may not pay attention to the time that they leave the brush in one area of the mouth. Children may also brush longer than necessary when they are not supervised. Unfortunately, parents may believe that the longer the child brushes, the more plaque they will remove and the better their dental visits will be long–term. Younger children may apply pressure that could cause damage to the teeth and to the tissue.
Many studies have been conducted on the use of both manual and powered toothbrushes. Variables such as the amount of pressure the user applies, the toothbrush's structure of bristles and the related hardness, the rotation or speed of the brush, and the type of toothpaste with regard to abrasiveness produce varying results in most studies evaluating gingival recession.
The result of all the above factors is controversial and somewhat subjective, depending on each individual profile. For example, a patient who is applying more pressure to the gingival area may produce both trauma and possibly abrasion leading to recession (Addy and Hunter, 2003). Retrospective studies report very controversial and unclear findings regarding prior studies on toothbrush damage (Rajapakse, et al. 2007).
The case presented here is a good example of damage to the tissue related to pressure applied to a specific tissue area over time. Small children are sometimes given a toothbrush and allowed to play with the brush and keep it in the mouth for long periods of time. Documented damage has been reported (see Figure 3).
Parents should be cautioned to supervise children, provide specific instructions regarding brushing, and closely monitor children while using any toothbrush — specifically, electric/battery operated or powered toothbrushes. This is extremely important with small children who may have difficulty with motor skills. Dental professionals should always provide basic instructions in the use of such toothbrushes during dental appointments when children are using any type of powered or manual toothbrush.
References
Addy M, Hunter ML. Can tooth brushing damage your health? Effects on oral and dental tissues. International Dental Journal 2003; 53:31 177–186.
Rajapakse PS, McCracken GI, Gwynett E, Steen ND, Guentsch A, Heasman PA. Does tooth brushing influence the development and progression of non–inflammatory gingival recession? A systematic review. J Clin Periodontol 2007; 34: 1046–1061.
About the Author
Nancy W. Burkhart, BSDH, EdD, is an adjunct associate professor in the department of periodontics, Baylor College of Dentistry and the Texas A & M Health Science Center, Dallas. Dr. Burkhart is founder and co–host of the International Oral Lichen Planus Support Group http://www.bcd.tamhsc.edu/outreach/lichen/ and coauthor of General and Oral Pathology for the Dental Hygienist. Her Web site for seminars is www.nancywburkhart.com.
