
Surprisingly little evidence for usual wisdom about teeth - wallace_f
https://www.nytimes.com/2016/08/30/upshot/surprisingly-little-evidence-for-the-usual-wisdom-about-teeth.html
======
lurquer
Anecdotal comments, in my opinion, are particularly unhelpful when it comes to
dentistry. Many people have teeth prone to all kinds of problems despite
perfect hygiene and brushing. Others have, essentially, indestructible teeth.
The last time I went to the dentist was 27 years ago. I was told I had three
cavities that needed filling. Never got it taken care of. Nearly 30 years
later, teeth are working great. But, like I said, I don’t draw conclusions
from this as there are others — apparently — who brush twice a day, see the
dentist regularly, and nevertheless have a mouthful of problems.

~~~
partiallypro
I have largely stopped trusting dentists, unless I have pain. When my lifelong
dentist fell out of network I went to a new dentist and they pushed all kinds
of procedures and nonsense, saying I needed 3 fillings, etc. I've been to
another dentist and they said things completely different. I don't understand
how two professionals can draw polar opposite conclusions. It really seems
they recommend needless procedures to fill their books of business and fleece
costumers.

It's visible cavities and decay, it's not like you're diagnosing based on
symptoms someone is describing to you, which I can understand for general
doctors or specialists drawing blanks or different conclusions.

~~~
jmartinpetersen
An old acturian at my current job usually tease new developers that they are
just like dentists - never satisfied with anyone elses work and always
suggesting serious rework that is critically important.

~~~
close04
Living with a dentist I learned that the single most important factor (by far)
in the health of teeth is the genetic factor. Some people do not brush their
teeth for years, never floss, have bad diets, etc. and still barely have a
cavity. Others do it "by the book" and yet their teeth are a ruin. This is not
to say that brushing teeth or flossing won't help. It will just not compensate
if you pulled the genetic short straw.

But as in every job dentists also feel pressured to point out other people's
lack of quality work to promote their own. You'll see this in the IT guy who
immediately recognizes that whatever the previous one did on your computer was
amateurish and they can do it better, same with the electrician, the plumber,
the mechanic, the plastic surgeon, etc.

------
paulsutter
Bogus headline, article confirms basic beliefs are true:

> brushing with fluoride toothpaste that matters, not the brushing alone.
> Doing that doesn’t just prevent gingivitis and plaque formation; it also
> prevents cavities, which is the outcome that we care most about.

> powered toothbrushes reduce both plaque and gingivitis more than regular
> toothbrushes

> toothbrushing with flossing versus toothbrushing alone most likely reduced
> gingivitis, or inflammation of the gums

Article seems to miss that gingivitis is a bigger concern than cavities for
adults

~~~
mikeash
I guess people wouldn’t click on “Most of the standard advice about dental
health is spot on but there’s some doubt around the edges.”

I wonder how many people will toss their toothbrushes after only reading the
headline and develop problems as a result. Seems like journalistic
malpractice.

~~~
gist
> Seems like journalistic malpractice.

It's not 'malpractice' and it's a mistake to think that what you consider
journalism is anything other than a vehicle to sell advertising in the end.
There seems to be this assumption that what is written (especially and
actually in the NY Times (which I do read and pay for)) is pure and good and
the people writing spend untold hours to get the story right and fairly
balanced. My anecdote is when I was interviewed a few times in the past by the
NYT the writer fed me conclusions and it was very easy to figure out what to
say in order to get my name printed. (A contrary position to the point and
stated vehemently was almost certainly the way to go..)

~~~
mikeash
You’re talking about what is. I’m talking about what should be. It’s not
somehow ok to harm people in the pursuit of advertising money just because
it’s the norm.

~~~
gist
> I’m talking about what should be.

What about journalism to you means it should have some kind of a higher
calling? The people working in that industry have jobs and families to feed.
If they simply did the right thing they wouldn't be employed very long if
their competitors didn't follow the same path.

When 'journalists' write either left leaning or right leaning pieces are they
being circumspect and covering all angles with fairness? Or are they just
making sure they have food on the table and/or ensuring that readers continue
to patronize the paper (or broadcast) that they work for?

It's nice to think that someone else who has to earn a living and feed their
family should be 'above it all' but in reality that is never going to be the
case.

Maybe a better idea is to teach children in school over and over that what you
read and what is reality are two different things. Don't believe what you
read.

~~~
mikeash
You could write almost the same thing about doctors, yet we have no problem
using the term “malpractice” with them, to the point that it’s just assumed
you mean medical malpractice if you don’t qualify the word.

~~~
gist
Doctors take an oath and it is very clear what they are expected to do. (Some
of them stray of course but it is atypical). Additionally 'Physicians' (if
that is what you mean by 'Doctors') are a more homogeneous and generally
trustworthy group than 'journalists'.

------
thedentist1
Dentist here, AMA

By the way: \- there _is_ scientific evidence in dentistry just like any other
branch in medicine \- there are good and bad dentists just like in any other
profession \- the good ones tend to be very scientific and evidence-based (I
know I am, everything I recommend and do is based on solid evidence, and I
provide links to pubmed to any patient that asks for information) \- a good
dentist should be able to answer any of your questions or doubts in a split
second, I often draw simple sketches to explain concepts to patients \- please
use your common sense: even though it might be hard to prove with 3 standard
deviations that flossing makes a big difference (for all sorts of reasons that
statisticians know very well, including the difficulty of tracking a large
group of patients), it's pretty obvious that removing rotting food from your
gums is _good_ and leaving it there to putrefy is _bad_ , don't you think?
same goes for all the other claims...a powered toothbrush is better simply
because it does more iterations per minute than a manual one...again, common
sense

~~~
kstenerud
"it's pretty obvious that removing rotting food from your gums is good and
leaving it there to putrefy is bad, don't you think?"

But is that actually true? Has anyone actually confirmed it with replicable
scientific studies? Did early human teeth rot to hell over the first 10 years
of their lives? Why don't cats and monkeys need to brush and floss?

"please use your common sense"

The problem with common sense is that it can be deceptively nonsensical, and
we tend to ignore that we haven't proven it because we "know" it's true
already.

~~~
erikgaas
Pets, cats, and dogs only live until they're 20. AND pets DO have lots of
problems with dental health. What is with all these people questioning
flossing here? Floss your damn teeth. Worst that can happen is the poor guy
you work with doesn't have to smell the decomposing food coming out of your
mouth. JFC

~~~
village-idiot
We’ve changed pet food just like we’ve changed our own food. Notice how pets
and animals that eat human food (like raccoons) are all getting fat together.

Looking at modern dog dental hygiene to learn about how wild animals’ teeth
work is as silly as looking at our dental hygiene to see how a hunter
gatherer’s teeth work.

------
rdiddly
Good dental hygiene does what it's supposed to, but the biggest factor is
basically luck - you either "have good teeth" or you don't.

There's evidence that your mom's prenatal diet (and not strictly genetics) may
be a salient factor.

[https://www.amazon.com/Nutrition-Physical-Degeneration-
Westo...](https://www.amazon.com/Nutrition-Physical-Degeneration-Weston-
Price/dp/0916764206)

This book is eye-opening. A dentist traveled the world in the early 20th
century when there were a lot more indigenous people to visit who had had no
previous contact with modern processed flours etc. Those still on their
traditional diets almost all had excellent teeth, without ever owning a
toothbrush. But when modern foods were introduced, their teeth went to shit
within a generation. Probably some epigenetics playing a role, though they
didn't know about that then. Also I believe this may have been before flours
started being fortified, so you would probably see a less pronounced decline
if you somehow did this today. But the takeaway seems to be that a high
protein paleo-ish diet kind of takes care of everything.

~~~
taeric
I don't know. Chalking things to luck seems... like an admission that we don't
actually understand the causal factors that well. Especially combined with
your other evidence that there was a clear delineation between folks with
good/bad teeth.

Actually, your point about flour heavy diets basically sending folks that used
to have perfect teeth to cavities sounds very not luck based. Which is it?
Genetically some folks have cavities, or that common modern diets lead to
cavities?

~~~
rdiddly
The luck aspect, under this particular hypothesis, would be that either your
mom ate well or she didn't.

~~~
taeric
But it literally goes against the other argument. That isn't luck, that is
prior choices having a larger impact than current choices.

If diet of the mother is important, we can start educating future mothers to
have diets that help. Sure, there is no panacea for people with bad teeth
today, but that is true for a lot of things we take corrective action on.

~~~
rdiddly
Getting into the existential weeds a bit here with free will and all, but
that's OK with me. I'm not using a strict definition of purely random luck
here. I'm using a looser colloquial definition under which choices by yourself
or others can affect your luck. Like if the dictator chooses to chop off all
heads with my hair color today, that's bad luck for me, even though he caused
it. Or if I choose to drive drunk, and hit a utility pole, that's bad luck for
me, even though I caused it!

Here's a trans-generational example: My dad makes a bunch of awesome choices
that result in his becoming rich. Then I get born, and someday inherit that
fortune. I'm much more inclined to describe my own outcome as luck than his,
probably because my own decisions had less to do with it.

On the other hand it's not really so straightforward, because so many
occurrences are attributable partly to random chance and partly to free will
by somebody or somebodies. Maybe my rich dad benefited from luck, like not
being crippled by polio or war, or not being born into a repressed social
group. And of course my own "good luck" is a result of dad's explicit choices
(your point), plus it also hinges on my own actions, such as not doing
anything particularly atrocious to alienate him such that I get written out of
the will. So is he a genius or just lucky? Probably a bit of both. Am I lucky
or just shrewd/a good son? Probably a bit of both.

~~~
taeric
Ok, I was following "luck" as in "non-deterministic."

Pulling it back to what I think you are saying, though; there are still some
obvious points that need more exploration for a causal factor. And if it can
be found, then it should be exploited more.

So, if there really is a link between mother's diet and bone health, we should
find out what that link is. If it is diet related, we should find out what
about the diet leads to it.

I'll note my bias. I have the best teeth of my siblings. I likely have the
worst brushing habits. Even in grade school, when I had braces, I would brush
the night before the dentist, and would generally chew gum/whatever whenever I
wanted. Easy to say I got lucky genetically. But what if there is more to it
than that? What if my genetic luck was my allergy to damned near all food
which knocked out some specific food that caused issues? (Would be almost
poetically ironic if it was milk or some such.)

So, colloquially, I don't disagree that luck is a big factor. I just don't
think luck should rule out looking for causal factors that can be exploited.
Pretty sure that is standard for exploration/exploitation strategies in any
learning scenario, no?

~~~
rdiddly
Yep it is, and we should most definitely nail it down with further study.
Especially since, as you kind of hinted, it's so hard to isolate or control
all the variables when you're dealing with people just living their lives.

------
dazc
As a 20-something I often skipped brushing, never flossed and would rather
have a leg amputation without anesthetic than visit a dentist.

In my thirties, I experienced a lot of dental problems such as toothache, bad
breath and gum disease. Eventually it got the point where I was in so much
daily pain that visiting a dentist didn't seem such a bad idea after all.

For the past 18 years or so I've followed a strict regime of brushing twice
daily, flossing and three-monthly sessions with my hygienist.

My hygienist is fastidious and is always disappointed in me, no matter how
hard I try she'll always find a spot I'm missing or not cleaning thoroughly
enough.

Regardless of this though, my dentist checks me over every 12 months, I have
x-rays every 18 - 24 months and there are seldom any problems.

I've had a couple of treatments for chipped enamel over the past 18 years but,
apparently, that's a result of aging rather than poor hygiene. Nothing else.

So, yeah, the scientific evidence for regular brushing my be lacking but I'll
take my personal experience any day of the week thanks.

~~~
drewg123
As a 20-something, I moved away from home and neglected to find a new dentist.
I kept putting it off, but to make myself feel better, I brushed more
aggressively and more often (after every meal and snack). After 8-10 years of
this, I didn't have any cavities, however I had the start of gum erosion. This
grew worse, and I eventually had to have a gum graft. That's a procedure that
I would not recommend to anybody.

~~~
wozniacki
Did your dentist or doctor posit a reason why your gums started eroding? Is it
hereditary? What else could you have done to prevent the erosion?

~~~
SECProto
Aggressive/harsh brushing is generally what is identified as causing gum
recession, and that matches their story.

------
thedentist1
Also, regarding the guy that doesn't trust dentists that posted
below...consider this \- You had a very good dentist for several years that
never suggested you do unnecessary procedures

This dentist had the balls to drop out of network, probably because he's good
and has enough patients to not cave in to the absurd demands of insurance
companies (they pay far less than a FFS practice, just FYI)

So you decide to drop your good dentist, and go to lower quality ones, just
because they are in-network (guess what? these guys actually need to drop
their fees because they don't have enough patients otherwise)...and then you
find out that these new dentists _are_ lower quality and need to prescribe
unnecessary procedures to make ends meet

Solution: like in any other field, value quality over price, go back to your
old dentist.

It's like Apple charging more for an iPhone simply because it's higher quality
and is time-tested, of course if you buy cheap cell phones they are worse and
screw you up some other way.

The real problem is insurance companies here, they are screwing both dentists
and patients extracting money in a place where they shouldn't be (why do you
need a middleman between a doctor and a patient anyways?)

~~~
Someone1234
> why do you need a middleman between a doctor and a patient anyways?

I agree, we don't.

Problem is right now if I pay for dentistry via "insurance" then it is pre-tax
dollars and or my employer pays some/all of the premium. If I pay it
completely out of pocket, I am now using post-tax dollars and my employer
isn't picking up a percentage.

Our incentives themselves are irrational. You're essentially forced to go
through insurance/your employer, and punished if you don't.

I'd love to see both dental + health insurance "unbundled" from employment,
and a large HSA-like pre-tax savings account which can be used on premiums,
that employers can choose to contribute to (in cash dollars). That way if you
wanted to skip dental insurance, and pay per-treatment you could (and pick any
health insurance plan you liked, including ones that could include dental
benefits).

PS - The reason the existing HSA structure doesn't work for well for dental is
two fold: It requires high-deductible health insurance, and the cap is low
when you start using it for other areas (vision/dental).

------
barbegal
I tried to find studies for the effects of teeth brushing frequency but the
only ones I could find were cohort analyses as opposed to randomised trials.
It seems like despite a lack of evidence, it would be very hard to ethically
approve a randomised trial of teeth brushing over a long period. I honestly
believe brushing teeth twice a day is very much a ritual which achieves very
little on a per effort basis.

Reducing our intake of sugary and acidic foods and drinks would have a much
greater effect with much less effort. The problem is that the profit margins
on carbonated flavored water are massive so the opposition to such change will
be huge.

~~~
abtinf
> It seems like despite a lack of evidence, it would be very hard to ethically
> approve a randomised trial of teeth brushing over a long period.

This is the exact same argument that was used to evade studying the effects of
low doses of aspirin on heart disease. Everyone “knew” it worked, so it was
thought to be unethical to put people at risk of heart disease into a control
group. Many millions of people spent money for years to consume a constant
supply of aspirin.

When the question was finally studied, it all turned out to be nonsense. In
fact, it turned out to increase death rates from higher cancer risk. All that
money could have been spent on actually improving health.

[https://utswmed.org/medblog/aspirin-heart-
disease/](https://utswmed.org/medblog/aspirin-heart-disease/)

~~~
whycombagator
I am pretty sure that low dose aspirin has some benefits for some
people/conditions. At least I remember reading studies that suggest as much.

So naturally I was curious about it being “nonsense” for heart disease.

A quick skim of the article + a quick search shows it’s not as clear cut and
conclusive as you suggest.

Interestingly, neither is the increased risk of cancer discussed in the
article. Aspirin has been shown to have the opposite effect too.

I found it hard to glean what dosages where used in the studies mentioned in
the article but the couple I saw were 100mgs per day. I didn’t see mention of
if they were enteric coated or taken with meals.

In the US baby aspirin is 81mg and in the UK there are 75mg available. Both
are enteric coated. In Australia it seems 100mg might be considered low dose
and widely available.

It would be interesting to see more studies on this topic using lower dose,
coated, aspirin taken with a meal. The US/UK low dose aspirin are 19-25% lower
than at least a couple of dosages the studies mentioned. Those lower dosages
may help mitigate bleeding risk.

Seeing as some of aspirins effects are longer lasting, perhaps alternative
dosing schedules could also be looked at (every other day etc.) - this may
further help mitigate the bleeding risk whilst still providing benefit.

~~~
Scoundreller
The doses were different for legal reasons. Aspirin for children is
unnecessarily risky in most cases but different countries set different
cutoffs for restricted doses vs. unrestricted adult doses.

But ya, dosing is underrated. Something that's bad at X dose may be beneficial
at 1/Yth the dose.

------
js2
A similar article in The Atlantic was submitted a few days ago:

[https://www.theatlantic.com/magazine/archive/2019/05/the-
tro...](https://www.theatlantic.com/magazine/archive/2019/05/the-trouble-with-
dentistry/586039/)

There's even less evidence for pulling wisdom teeth:

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1963310/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1963310/)

("The Prophylactic Extraction of Third Molars: A Public Health Hazard")

I'm lucky like the author. 47. Zero cavities. Gums are healthy. Brushed
infrequently as a kid and never flossed. Teeth were treated with fluoride by a
dentist as a kid. Didn't start brushing daily till high school. Didn't start
flossing daily till my thirties. Skipped going to the dentist at all for maybe
5 years in my mid-twenties. Typical western diet. Never had braces. Straight
teeth.

Both parents, both sisters, and my brother all have several to many fillings.

No smokers.

I see my dentist twice a year but they only take x-rays every 18 months.

~~~
nickpeterson
I'll add one. I had bad cavities and several root canals by the time I was 22.
Dentist told me to start using a fluoride mouthwash. I use it occasionally
(few times a week?), no new cavities for 10 years straight. Seriously no other
change.

~~~
ricardobeat
No change in diet at all?

~~~
nickpeterson
Nope, if anything it's worse.

------
BlackFly
That there are no randomized control studies is hardly surprising: nobody
would ethically assign a person into the "no dental care" control group.

I am reminded of the randomized control study they did on parachutes which
showed that parachutes were useless. Of course, to ethically allow people to
jump out of an airplane without a parachute, they made sure the jump was not
more than a meter and a half off the ground.

What that satirical study actually showed is that randomized control studies
don't always make sense.

~~~
BeetleB
>That there are no randomized control studies is hardly surprising: nobody
would ethically assign a person into the "no dental care" control group.

They're not saying "no dental care". They are saying "no dental floss", or "no
fluoride toothpaste", or "no fluoride in water", or "brush once a day". The
reality is that a significant percentage of the population falls into one of
these three categories (I was surprised you could by toothpaste without
fluoride, but you can - there's a market for it).

And yes, while you can't do true randomization, you can compare dental
outcomes between these groups.

And finally, saying it's "unethical" is a stretch. It's not unethical if there
is no good reason to believe these measures are good for health. Until there's
a clear study, these all fall into the same category as other traditional/folk
medicine. When I first went to my current dentist years ago, he said "Your
insurance covers two cleanings a year, and we'll give that to you. However,
I'll have you know that there's no evidence that twice a year is better than
once" and he proceeded to tell me a bunch of other common dental practices,
their origins, and the lack of studies on them.

It reminds me of the whole 8 glasses of water a day belief, which until about
10 years ago was commonly promoted by doctors. Then in about 2005-2007,
someone published a literature survey showing no studies had ever recommended
8 glasses with good reason. All my doctor friends knew of this survey and
promptly stopped recommending it.

~~~
BlackFly
I agree with everything you are saying. Let me rephrase what I was saying so
you can see we more or less agree.

The article is complaining that there are no randomized control studies and
using this to conclude that there is little evidence to support flossing. They
are simply disregarding other types of studies like the observational study
you are pointing out have value. These observational studies show such clear
benefits to flossing that directing a person to stop would be considered
unethical. I am pointing to a more facile example where you would never
imagine performing a randomized control study because it is obvious that the
no treatment control is dangerously unethical.

Doctors end up being susceptible to public misconceptions just as much as the
general public. Not everybody reads original research or health guidelines. So
someone hears that the official guide recommends 2.5 liters of water, with no
mention of the accompanying note that most of this comes through ordinary food
intake, and they misinterpret it as needing 8 glasses of water a day. That is
the case for the 8 glass a day myth: no scientific study ever recommended it,
but half readings of some literature seemed to imply it.

If you like myths like those, read through [https://www.snopes.com/fact-
check/water-works-2/](https://www.snopes.com/fact-check/water-works-2/)
especially when it gets to the diuretic effects of caffeinated beverages. I
mostly learned about this when I started talking to foreigners about it and
realized it just wasn't common knowledge outside of North America that
caffeine causes dehydration.

------
usgroup
I think individual dentists will often go on anecdotal evidence. A single
dentist may fix 10k+ teeth or more and treat the same patients over 20 years
or more and is therefore often well placed to consider what worked in their
practice.

This is often exactly what you want actually ... controlled trials typically
can’t take into account enough useful variation in patient conditions to be a
useful guide for any given patient. Meanwhile the dentists mental database can
be ... if your dentist is a good one.

~~~
majewsky
Anecdotal evidence is widely considered inferior to controlled studies, and
for good reasons: Confirmation bias, survivorship bias, etc. are incredibly
hard to avoid for a single person even if they're aware of them.

~~~
usgroup
Anecdotal evidence doesn’t have to have any of those qualities but I do think
that’s exactly right, yet most decisions just won’t have a basis in controlled
trials due to the variation in the patient group and because you just can’t
have controlled trials for most things .

For example, implant placement at a 45 degree angle are totally weird
mechanically speaking given that the biting force runs down but dentists may
do them to recruit better quality bone because they know that implanting into
low density bone or calcious mass will likely lead to an implant failing but
they just don’t see much failure due to weird angles ... this particular case
happens so often actually that some companies now recommend placement at 45
degrees.

Personally experience, conferences, etc . It’s not how the world ought to work
but it is how it mostly does.

------
blfr
_Surely the twice-a-year teeth cleanings matter? In 2005, Evidence-Based
Dentistry highlighted a systematic review on the effects of routine scaling
and polishing (you call it teeth cleaning)._

It very obviously works aesthetically, especially if you drink a lot of tea. I
had no idea it was even supposed to have any health benefits besides the free
check-up which some (my) dentists throw in.

------
mathewsanders
This recent article on the Atlantic is more interesting read:
[https://www.theatlantic.com/magazine/archive/2019/05/the-
tro...](https://www.theatlantic.com/magazine/archive/2019/05/the-trouble-with-
dentistry/586039/)

Covers both lack of evidence-based science in dentistry, and also culture
(thankfully doesn’t seem to be the norm) of over treatment.

------
andrewl
For some history of teeth (not just human teeth) try the BBC _In Our Time_
podcast episode _The Evolution of Teeth_ :

[https://www.bbc.co.uk/programmes/m0003zbg](https://www.bbc.co.uk/programmes/m0003zbg)

Being a Melvyn Bragg podcast, it includes a reading list:

Barry K. B. Berkovitz, _Nothing But the Tooth: A Dental Odyssey_ (Elsevier,
2016)

John A. Long, _The Rise of Fishes. 500 Million Years of Evolution_ (The Johns
Hopkins University Press, 1996)

Neil Shubin, _Your Inner Fish: A Journey Into the 3.5-Billion-Year History of
the Human Body_ (Vintage, 2009)

T. M. Smith, _The Tales Teeth Tell: Development, Evolution, and Behaviour_
(MIT Press, 2018)

Peter S. Ungar, _Teeth: A Very Short Introduction_ (Oxford University Press,
2014)

Peter S. Ungar, _Evolution’s Bite: A Story of Teeth, Diet and Human Origins_
(Princeton University Press, 2018)

------
gerbilly
The main differences in outcome, like the anecdote the article leads with,
might be due to different micro-flora in the mouth.

I used to get plaque build up something awful, but since I started taking
probiotics a few years ago for another problem, I don't seem to have that
problem anymore.

------
mrob
There's also evidence that brushing with toothpaste ("dentifrice" in
scientific papers) does not remove plaque any more effectively than brushing
with plain water:

[https://www.ncbi.nlm.nih.gov/pubmed/27513809](https://www.ncbi.nlm.nih.gov/pubmed/27513809)

Toothpaste can also deliver fluoride, but I drink a lot of tea (which
concentrates fluoride from the soil) so I'm more concerned about excessive
fluoride exposure than too little. I've been brushing my teeth with plain
water for years and they are as healthy as ever.

~~~
notabee
You can use toothpaste with some of the other enamel supporting materials
popular overseas, like nano-hydroxyapatite.

------
tomohawk
Sample size of 1, but I've done several A/B tests to see what works better for
me.

Works:

Xylitol. Been trying this recently, and it is amazing. Using the Xlear sinus
mist has massively reduced snoring and sleep apnea issues. Using Xylitol as a
mouth wash - my teeth feel much smoother now. Go do the research and check it
out for yourself.

Apagard toothpaste. Its pricey, but switching to this dramatically reduced the
drama during dental visits.

~~~
balfirevic
> Its pricey, but switching to this dramatically reduced the drama during
> dental visits

What drama was there during dental visits? Found cavities? How often do you go
to dentist/how often did the drama happen before you switched toothpaste?
Sorry for blunt questions, I really don't know what that could mean.

~~~
tomohawk
No cavities since I found this toothpaste. Also, greatly reduced tooth
sensitivity. I go to the dentist every 6 months.

------
dwighttk
I had dental insurance a couple years back and went to the dentist for a
cleaning after probably 10 years and the dentist and the cleaning tech both
said my teeth looked about like I skipped my last 6month visit (before I told
them it had been a decade)

Now that I’m not spreading the cost out over the year it is harder for me to
get motivated to go and pay $250.

------
andai
Surprised to see nothing about carbohydrates in the article, nor here. I have
been following a diet very low in carbs recently, and one thing that surprised
me is that my teeth never hurt anymore. It wasn't the reason for my diet, but
it's a really nice benefit.

I noticed a causal relationship between eating eating sugary foods and
toothaches, so I cut out sugar a few years ago, which reduced the pain by 80%.
But there was still a subtle aching after every meal, sometimes even if I
immediately brushed my teeth (can't reach every single place).

But cutting carbs altogether, has _completely_ eliminated the mild background
toothaches (and not so mild ones) I just took for granted.

I heard recently that with the advent of agriculture, humans switching to a
carb-rich diet, cavities (in found skulls) increased by 500%.

------
gibolt
I've read similar articles before, and yet I still feel the need to follow all
the suggestions.

I floss daily and brush a little more than 2 minutes each time. Still get
dental issues, but I feel like it would be worse without it.

Maybe just doing something makes it feel like I have some control in the
process.

------
colordrops
I've found through personal experience that diet and general health are most
important for teeth. I used to get a cavity a year. Once I cut sugar out 100%,
reduced carbs, and started eating healthy, I've had no cavities for 10 years.
I don't even use a fluoride toothpaste, and sometimes forget to brush. The
dentist always compliments me on my teeth.

------
caprese
I met some dentists the other day that waterpicks may be doing more harm to
gum density, while still helping get food particles out to avoid plaque
building (which itself will do harm to gum density and cause other forms of
decay)

yeah well its not like my non-existent flossing habits will supplant my
waterpick half-solution. But I do wonder the support for any of this wisdom.

~~~
BeetleB
When I first discovered Waterpiks a year ago, I was extremely frustrated at
the fact that all dentists hate it, and that there were very few studies on
it. The universal belief, found all over the Internet, is that Waterpik is
good for removing food particles, but is ineffective at removing the film,
which regular floss does.

This _really_ should not be hard to validate.

The only study I could find showing this was done in the late 70's. Waterpiks
have changed a lot since then. And you'll find _plenty_ of studies showing how
effective Waterpiks are at removing that film. All these papers were funded by
Waterpik.

Why are dentists insisting Waterpiks are bad when there is no independent
study comparing modern Waterpiks with regular floss? And why doesn't anyone do
the damn study?

~~~
nickjj
My dentist and his team of hygienists are big fans of waterpiks, but not as a
substitution to anything. You would still brush and floss (with string) as
usual.

A waterpik used incorrectly may cause gum problems, so maybe that's why
dentists don't like them across the board. If you put the thing on the highest
setting and aim it so it pushes your gums up that may cause damage.

But if you keep it at a low / medium setting (a lot of waterpiks go from 1 to
10 in terms of pressure) and aim the water straight at your teeth and trace
your gums then you should be good (there's videos showing how to do it). Not
only does it remove all sorts of food particles, but it also stimulates your
gums.

~~~
BeetleB
>My dentist and his team of hygienists are big fans of waterpiks, but not as a
substitution to anything. You would still brush and floss (with string) as
usual.

Same as mine. Well, sort of. They never recommend Waterpiks, but they all say
"Cool! You use a Waterpik! I hope you're still flossing with string, though".

>A waterpik used incorrectly may cause gum problem

Evidence?

Also, are there incorrect ways of using string floss that can cause dental
problems?

>If you put the thing on the highest setting and aim it so it pushes your gums
up that may cause damage.

"May" is not good enough. What is the evidence? There are plenty of people who
use it at the full setting. It's not hard to study the topic. Of course,
Waterpik muddles the issue because the highest setting differs from product to
product - but when they publish their papers they specify a precise pressure,
which is easy to measure. The other reason I ask: Their papers showing that
Waterpiks are as good at removing film than string floss use fairly high
settings.

>But if you keep it at a low / medium setting (a lot of waterpiks go from 1 to
10 at 0.5 intervals in terms of pressure) and aim the water straight at your
teeth and trace your gums then you should be good (there's videos showing how
to do it). Not only does it remove all sorts of food particles, but it also
stimulates your gums.

If I do this, can you explain why I still need to use string floss? Do you
have any studies showing that string floss is more effective than Waterpik
when a Waterpik is used properly?

I appreciate your willing to share the information you have heard/read, and
please don't take this as an attack on you, but your comment is a classic
example of what I'm complaining about. Lots of claims, but not pointing to a
concrete study.

~~~
nickjj
> Evidence?

None, other than asking my hygienist which setting I should personally use,
and she told me don't go above 5. I trust her judgment so I left it at that.

Also one of the waterpik tips (mine came with like 6 different tips) literally
has a warning label that says "CAUTITION: Only use this tip on the lowest
setting". It's a much sharper tip and for fun I put the waterpik on 10 with
that tip and aimed it at my sink. The stream looked so powerful I'm surprised
it didn't cut the Earth in half. I can't say for sure what would happen if I
aimed that at my gums but I'm not trying.

> Also, are there incorrect ways of using string floss that can cause dental
> problems?

Yes absolutely. If you jam the floss into your gums as hard as you can sure
I'm sure you'll be able to do damage.

> "May" is not good enough. What is the evidence? There are plenty of people
> who use it at the full setting.

I think it's because everyone is different. I know people who are 70+ and
brush their teeth once a day, never floss, haven't visited a dentist in 20+
years and have little to no cavities and very little plaque build up. That's
with smoking too.

> If I do this, can you explain why I still need to use string floss?

From personal experience the waterpik I have on setting 5 with the standard
tip has a much different feel to it than string floss. String floss feels like
it cleans the side edges of my teeth better where as the waterpik seems better
for dislodging things that I have trouble getting out even with string floss.

> Do you have any studies showing that string floss is more effective than
> Waterpik when a Waterpik is used properly?

No, I'm not a medical doctor or dentist. I'm just a dude who brushes their
teeth.

~~~
BeetleB
>> Do you have any studies showing that string floss is more effective than
Waterpik when a Waterpik is used properly?

>No, I'm not a medical doctor or dentist. I'm just a dude who brushes their
teeth.

I hope you realize that the whole discussion, and submission, is about the
lack of scientific evidence to back these claims. Everyone is welcome to do
whatever makes them feel better, but medical professionals should not give
guidance that is not based on much evidence. Unfortunately, the dentists do
not appear to have any more information than you do. Some have literally told
me "Oh, we were just taught that in dental school" (regarding Waterpiks).

~~~
nickjj
I just go by the results I see with my own eyes.

I see food particles that come out of my mouth after using a waterpik (even
after string flossing and brushing). Normally I waterpik first but during the
testing phase I did it last because I was skeptical on what it would actually
do for me.

None of the staff at the place I goto say they learned it in dental school or
hinted at doing it for the sake of doing it. They've been in practice for 20+
years and have seen a lot of patients. I'm guessing they have a large enough
sample size to come up with something. In my opinion experience is often a
good deciding factor when you have nothing else to work with.

------
wsdfsayy
When I switched to a low/no carb diet my gums were much less inflamed and
stopped experiencing bleeding in my gums (w/ regular flossing). I also stopped
getting that "filmy" feeling in my mouth when I'd occasionally sleep/take a
nap before brushing after a carb-heavy meal.

------
paulpauper
It's mostly genetic. George Washington took fastidious care of his teeth yet
they still all fell out anyway

------
HocusLocus
How come no one has mentioned that image?

That QUIVERING image?

That SWAYING image?

That WOBBLING image?

I cannot accept we now live in a world where such things go without saying.

~~~
flycaliguy
These quirky, looping 3d renders have become fashionable in the illustration
world.

------
nobrains
"To recap, there’s good evidence that brushing twice a day with fluoride
toothpaste is a good idea, especially with a powered toothbrush. For children,
there’s good evidence that the use of fluoride varnish or sealants can be a
powerful tool to prevent cavities. The rest? It’s debatable."

------
ufo
I have read that one of the reasons for the lack of evidence is that it is
really hard to run randomized the trials for these things. Getting a cohort to
brush or floss exactly according to instructions fof a long period of time can
be challenging.

------
ashton314
I have never seen so many ads for tooth-related things on a single web page.

------
thedentist1
Dentist here, 35yo, ask me anything.

~~~
Scoundreller
Why the huge variation in interventions for the same inputs?

If the same software was giving different outputs for the same inputs in 2
different locations, everyone here would see that as a concern to be
addressed.

~~~
thedentist1
A software analogy would be: if a client asks for a simple website with a
shopping cart and a newsletter, and you ask 10 programmers, you're almost
guaranteed to get 10 different platforms (different CMS, different language
like PHP vs Ruby vs .net)

It's kind of the same thing with dentists: a good surgeon will tend to lean
towards surgery, and there are usually at least 2-3 different ways of solving
a particular problem

------
hn_throwaway_99
At least with flossing, regardless of whether there are double-blinded
controlled studies for it, it makes my mouth feel much cleaner when I do it, I
can see a lot of plaque coming out when I floss, and there certainly doesn't
seem to be any evidence against it.

With twice yearly dental X-rays, though, even though the doses are really
small, all X-rays carry a risk of cancer, so it seems close to malpractice to
request these X-rays without evidence to back it up. Try refusing X-rays at
your dentist's office because you've done your own research, though, and they
look at you with the "Oh I bet you don't vaccinate your kids either" look.

~~~
pbhjpbhj
[Please check my numbers.]

The Banana Equivalent Dose (BED) of a mouth xray is apparently 15 for 2 xrays.

Personally I hate bananas (well, just the smell, taste, look, and texture).

Aeroplane flights (4 hrs of flying is about 2 xrays) might be a greater
exposure source for people who travel a lot.

~~~
projektfu
Banana equivalent doses assume that the radiation is distributed over the
body. This is true for backscatter and other nonspecific radiation. It is not
true for collimated radiation such as an x-ray. One explanation for "cell
phone cancer" is that people who have annual dental radiographs have develop
neuromas which are then (probably incorrectly) blamed on cell phones.

[https://www.ncbi.nlm.nih.gov/pubmed/23211211](https://www.ncbi.nlm.nih.gov/pubmed/23211211)

