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Brushing and flossing isn't just about keeping your smile pearly white. Oral health is linked to whole-body health, which means problems with your teeth and gums can lead to concerns like heart disease, stroke and more. Periodontist Sasha Ross, DMD, MS, explains how to practice good dental hygiene and why it’s so critical to your overall health.

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Keeping Your Mouth Healthy with Dr. Sasha Ross

Podcast Transcript

Speaker 1: There's so much health advice out there. Lots of different voices and opinions, but who can you trust? Trust the experts, the world's brightest medical minds, our very own Cleveland Clinic experts. We ask them tough intimate health questions. So you get the answers you need. This is the Health Essentials Podcast brought to you by Cleveland Clinic and Cleveland Clinic Children's. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

Kate Kaput: Hi, and thank you for joining us for this episode of the Health Essentials Podcast. My name is Kate Kaput, and I'll be your host today. We're talking to periodontist, Dr. Sasha Ross about oral health, including the role that it plays in your overall health. You know that you're supposed to brush and floss every day, but it's not just about keeping your smile pearly white — oral health is linked to whole body health, which means that problems with your teeth and gums can lead to other health concerns like heart disease, stroke and more. So keeping your mouth healthy is an important part of your overall health and well-being. Dr. Ross is here today to talk to us about the connection between oral health and the rest of your body, and to tell us how we can practice good dental hygiene. Dr. Ross, thanks so much for being here with us.

Dr. Sasha Ross: Thank you, Kate.

Kate Kaput: So I always like to start by having our guests tell us a little bit about themselves. What kind of work do you do here at Cleveland Clinic and what kind of patients do you typically see?

Dr. Sasha Ross: So I grew up here in Cleveland. I did my dental school training at Harvard School of Dental Medicine. And then I did my periodontics residency at University of Illinois at Chicago College of Dentistry, where I received my certificate in periodontics and my masters in oral sciences. So I'm a periodontist, I'm a gum disease specialist. So I manage patients who have gum disease, gum recession, lesions on their gums, or who need teeth removed and dental implants placed. Part of my field is, we really love to save teeth when possible. So I work on trying to regenerate bone around teeth. I also work on trying to save dental implants that are failing.

And as far as who I see, I see employees at the Cleveland Clinic. I see patients before they have major operations like heart surgery or head and neck radiation for head and neck cancer. And I also can see anybody from the community or in private practice for all of these procedures. I work as a team with your general dentist and sometimes, other specialists, and very often manage patients with complex dental disease and complex medical conditions.

Kate Kaput: Wow, there's a lot in there. So it sounds like you're the perfect person to talk to us today about all of the above. I'd love to jump right in and have you explain to us why is oral health so important and let's go from there.

Dr. Sasha Ross: So the mouth is really an extension of the whole body. And I think a lot of times, we see them as separate entities because of the way our insurance system works here in the United States, where dental insurance and medical insurance are completely separate. But by looking in a person's mouth, I often get a sense of what their overall health is. And I believe, as we'll discuss, treating your oral health can often impact your overall health. The act of eating, which is really essential for our survival, really depends on having teeth in your mouth and healthy teeth and gums. And it makes eating so much more pleasurable. And your smile really is your everything. I mean, feeling confident about your smile goes so far in your workplace and socially. Other things to be aware of: untreated cavities in kids can lead to poor nutrition and stunted growth in development and — worst case scenario — an untreated cavity can lead to facial swelling and cellulitis, which can land you in the hospital, potentially require surgical intervention and large expenses.

Kate Kaput: So it sounds like there's a lot that we need to keep in mind. Tell me a little bit more about that point that you talked about at the very beginning, that when you look into someone's mouth, you can get a sense of their overall health. How is our mouth so closely related to everything going on in our bodies? What is the rest of the connection there?

Dr. Sasha Ross: So there's a lot of reason that oral health and systemic health are so connected. One of them is the two share common risk factors. So people who use tobacco products, people who drink excessively have a poor diet or a diet high in sugary foods, who are stressed out — all of those things can cause periodontal disease or cavities. And they can also cause systemic disorders. Another reason that the two are so connected is because of our genetics in the way that we're born. Certain people are predisposed to developing periodontal disease or systemic diseases. And in line with that certain people, the way their bodies respond to bacteria are different. And, for instance, our bodies actually mount this huge response to bacteria that can often cause the destruction that we see and the inflammation in periodontal disease and systemic disorders. So we often see molecules like C reactive protein or CRP in fibrinogen. These are molecules you may have heard of that are inflammatory molecules that are elevated or high in both periodontal disease and systemic disease.

Kate Kaput: I think that's really interesting. I think a lot of people don't even realize that oral health is related to their overall health, possibly, like you said, because they're sort of set up that way through insurance, but research actually shows that gingivitis and periodontitis can contribute to other health issues. I'd love for you to tell us a little bit more about some of the health conditions that are linked to oral health.

Dr. Sasha Ross: Yeah. So the first one is cardiovascular disease. So cardiovascular disease is a term that's used by the American Heart Association. And it describes a group of disorders that includes stroke, congenital heart disease, which is what you're born with. Rhythm disorders, subclinical atherosclerosis, coronary artery disease, heart failure, valvular disease, venous diseases and peripheral disease. In the United States, cardiovascular disease is incredibly costly to treat across all age groups. And that's the number one leading cause of death. Cardiovascular disease and periodontal disease share a number of the same risk factors. So diets that are high in cholesterol, older age, male gender, hypertension, diabetes mellitus, smoking and low levels of the good cholesterol HDL are things that they both have in common.

Now this relationship between cardiovascular disease and heart disease has been studied for over 20 years. And what we've found is the vast majority of the studies show significantly higher rates of atherosclerotic cardiovascular disease in people who have periodontal disease. And specifically in people who have severe periodontal disease, which is about 10% of the cases. Peripheral arterial disease has not been as extensively studied. And it isn't as strongly linked to periodontal disease. The thing to keep in mind with cardiovascular disease is that even though the two are associated with each other, we haven't been able to prove that one causes the other. So we can't say for sure that periodontal disease causes cardiovascular disease or vice versa.

Kate Kaput: Got it. And when we talk about cardiovascular disease, does that include stroke — is stroke separate, is stroke related to oral health?

Dr. Sasha Ross: Great question. So stroke is one of the subcategories of cardiovascular disease and it is related to periodontal disease. Just a little background on stroke. So stroke refers to sudden onset neurologic symptoms that persist because the tissue is damaged and this is different than transient ischemic attack, or TIA, where you get these neurologic symptoms, but they resolve because there's no tissue damage. There are two types of stroke. There's ischemic stroke, which is the more common one. It comprises 80% of the cases. And it includes when a blood vessel becomes occluded and prevents oxygen from getting to the brain. There's the less common type, which is hemorrhagic stroke, which is around 20% of cases. And that's where a blood vessel ruptures and causes bleeding into the brain. Now, amongst the ischemic strokes, there's four types of those. There's the atherothrombotic type, which is 20% of cases; cardio embolic, which is also 20% of cases; lacunar, which comprises 30% of cases; and includes patients that have atrial fibrillation and cryptogenic, which is also 30% of cases and it's stroke of unknown origin.

So there's not a ton of recent studies about the link between periodontal disease and stroke, but there are a few key ones. The Aric Study, ARIC stands for Atherosclerotic Risk in Communities, and this showed a strong association between people who had periodontal disease and developed strokes, specifically the atherothrombotic or the cardio embolic types. Now, there's a different study that looked at in cases where people had severe periodontal disease — they were more likely to develop a second stroke. So 40% of those cases developed a second stroke within a two-year period compared to only 20% in cases where people had no periodontal disease or just mild disease. Newer studies show a stronger connection between periodontal disease and lacunar strokes in interestingly treatment for periodontal disease, meaning cleaning your mouth better. Seeing your dentist more regularly has been shown to decrease your risk for developing a stroke. There's a study going on right now where they're looking at really big interventions as far as treating periodontal disease and whether that will impact the risk of developing a second event after your first stroke. So the results of that are still pending.

Kate Kaput: That's big. So it sounds like in that case, oral health does seem to be directly related, right?

Dr. Sasha Ross: Yes.

Kate Kaput: Like possibly. OK. What about pneumonia? Another thing that I've heard is that your oral health can contribute to pneumonia. Is that one true?

Dr. Sasha Ross: Yeah. So just to define what pneumonia is: pneumonia is an acute condition that can be either community acquired — so something when you're out every day or hospital acquired, which occurs after 48 hours of being in the hospital — and hospital-acquired pneumonia is a big deal. It's about 15% of all infections in the hospital. Its urinary tract infections are the most common hospital-acquired infections. People in the ICU who are on mechanical ventilators are more prone to developing pneumonia. And there's the thought that bacteria from the mouth can aspirate into the upper airway and into the lungs and be related to causing pneumonia. In addition, they make it easier for some of the bacteria that cause respiratory infections to stick in the lungs.

So oral health has been associated with pneumonia. It's less so with periodontal disease, though, and more so with people who have cavities or more strongly linked to development of pneumonia. There was a study that was done in Brazil in 2014 that showed that the chance of having hospital-acquired pneumonia was about 3 times more likely if you had periodontal disease. But there's also been a lot of evidence, like there was a systematic review, which is one of the highest levels of evidence done in 2006, that really only showed fair evidence, linking oral health to pneumonia. The main link I'd say between the two, interestingly, is that treating oral health — and by treating, I mean using a rinse or topically placing chlorhexidine, which is a very strong prescription strength, antimicrobial, antibacterial that connect actually help prevent pneumonia specifically in the hospital setting. So even though there's only weak evidence treating, it seems to really help.

Kate Kaput: Are there any other health conditions that you can sort of acquire or that you're more likely to acquire based on your dental health? Anything that we haven't talked about yet?

Dr. Sasha Ross: Yeah. There's a couple big ones. Pregnancy is one of the big ones, at least as far as periodontal disease is concerned. So pregnancy complications, there's a lot of them. There's low birth weight, which is being born at less than five and a half pounds preterm birth, which means being born at 37 weeks or less. Preeclampsia, which means high blood pressure and protein in the urine in the mom after 20 weeks of pregnancy. Miscarriage, stillbirth, fetal growth restriction and gestational diabetes. So these things are important because they comprise about 10% of all pregnancies in the U.S. And they are the number one cause of neonatal death. So there was a landmark study that was done in 1996, by Offenbacher, that showed that you are 7 times more likely to have a preterm low birth weight baby, if you have periodontal disease in pregnancy. And there's newer studies like the OCAP Study, the Oral Conditions and Pregnancy study that was done in 2004 in over 900 pregnant women, it showed that African American women were more likely than Caucasian women to have periodontal disease and pregnancy and periodontal disease that was progressive.

So the studies, even the newer ones, really support the association between periodontal disease and these pregnancy complications. The thought being that oral bacteria can, again, travel into the bloodstream, get to where your fetus and placenta are located and wreak havoc. Unlike for stroke, though, when they've tried to do intervention studies, meaning the common treatment for periodontal disease is a deep cleaning or scaling and root cleaning, where we numb you up and clean tarter beneath your gums. When that was done in pregnant women in the second trimester, it was found to be very, very safe for them, but it didn't create a big effect in preventing some of these complications. So more research in this area is recommended.

So another disease that we haven't talked about that is very, very strongly linked with periodontal disease is diabetes. So diabetes affects 300 a million people all across the world. And that number is just expected to rise. We know that there are three types of diabetes: Type 1, which is the autoimmune condition where the pancreas can't make insulin; Type 2, which is where the pancreas both really can't make it, but it also is resistant to insulin, often seen in people who are obese; and then gestational diabetes, which is diabetes during pregnancy. The relationship between diabetes and periodontal disease has been studied for many, many years. And it's a very, very strong relationship. So people who have diabetes, like kids with Type 1 diabetes or people with poorly controlled diabetes, have a significantly greater risk of developing periodontal disease and of having that periodontal disease progress and be more severe in nature.

What's really interesting about this, too, is that there's a number — some of you may heard of called the hemoglobin A1C. So this is where sugars or glucose in the blood bind to hemoglobin. And this is a blood measurement that they essentially stay bound for the lifetime of the red blood cell, which is 120 days or three months. So this number is looked at every three months by your physician or endocrinologist. If it's below six, you're not a diabetic, it's above eight, you're an uncontrolled diabetic. What we've found is that the glycemic control and diabetes is very strongly linked to periodontal disease, such that worse-controlled diabetes leads to more severe periodontal disease. And treating the periodontal disease in some studies has shown that you can decrease that A1C and vice versa, controlling the diabetes can help control your oral health. So this really has been studied, and we actually believe that periodontitis should be classified as a classic complication of diabetes.

Kate Kaput: We've also learned that there's a significant connection between COVID-19 and oral health. What can you tell us about what we know there?

Dr. Sasha Ross: So this is obviously all new and these studies are just coming out, but there are a number of studies that are really showing that the presence of periodontal disease and how severe your disease is can be linked to COVID-19 severity and outcomes. So the idea is that worse periodontal disease correlates with higher rate of COVID-19 complications, ICU admissions having to be ventilated and even dying. So the idea again is this link that periodontal disease and COVID-19 are both linked to inflammation throughout your body. And more studies on this are needed.

One final thing to consider is that oral health and specifically periodontal disease, there's many, many more studies on that out right now, showing connections between periodontal disease and osteoporosis, fibromyalgia, rheumatoid arthritis, HIV, Alzheimer's disease. There's so many things — prostate cancer. There's just more and more data coming out to show a linkage between the two.

Kate Kaput: And so related to that, we've talked about the way that your oral health can impact some other health conditions. But I know that the reverse is also true that having some health conditions can negatively impact your teeth and gums. What are some of those conditions that can have an impact on your oral health? That if you have these conditions, you really need to pay close attention to what's happening in your mouth.

Dr. Sasha Ross: Yeah. So like I mentioned before, osteoporosis is one of those that has been studying. We know that osteoporosis is linked to low bone mineral density throughout your body. And the thought is, well, if you have low bone mineral density or bone resorption throughout your body, maybe you have it in your jaws as well. And there are a lot of studies that really do suggest that linkage. We know it's linked to decreased estrogen levels in parathyroid levels in women, mostly in women who are around menopause age or older. So I think treating osteoporosis will be, or at least recognizing it can be something of importance.

Kate Kaput: And so if you have a kind of condition that is going to impact your mouth, something like osteoporosis, is there anything that you need to do to keep an eye on ensuring that you're keeping your mouth as healthy as possible? Like anything extra, just to make sure that you're staying as healthy as you can.

Dr. Sasha Ross: Great question. And I would say, first of all, I just can't say enough about the power of oral hygiene at home. So cleaning your teeth. And I think we can talk about this more, but brushing at least twice a day, flossing once a day, using other tools like Waterpik® or mouth rises, that can go such a long way for helping your oral health and your systemic health. You want to see your dentist at least twice a year, your periodontist as well. And common things — see your doctor regularly, follow up with your doctor or your endocrinologist about how often you need to get that hemoglobin A1C level checked, you may need it checked every three months. See your cardiologist and manage your heart health. And then the other things we always hear, you want to exercise daily, eat healthy and avoid things like smoking and drinking to excess.

Kate Kaput: Perfect. So I think that leads us really well into the next section, where we talk about some mouth problems and how we know what's going on in there and what to do about it. So what kind of warning signs might indicate that you're having some oral health problems?

Dr. Sasha Ross: So the obvious one is pain. Pain in your gums and in your teeth, but oftentimes, there can be problems without you having pain. So things like loose teeth, broken teeth, gums that bleed, bad breath, bad taste in your mouth, ulcers in your gums. If you have swellings anywhere, receded gums or cracked teeth, these are all things that can indicate that there's a problem.

Kate Kaput: And so I want to talk a little bit about tooth pain. I know that you're not a dentist, but can you walk us through some of the most common causes of tooth pain? You mentioned some of them there, but when your tooth hurts, it's not always a cavity, it could be a cavity. What else could it be? What are some of the other common causes of that kind of pain?

Dr. Sasha Ross: Cavities are a common cause of tooth pain. And when they get severe enough and get close to your nerve, they can cause significant pain that may require seeing an endodontist or a root canal specialist to do a root canal. It may require having to have the tooth removed. Gum disease, ironically rarely causes pain in the mouth. So even if it's very, very severe, I rarely see this as a cause of pain where patients have to come in on an emergent basis. Other sources of tooth pain could be a root fracture — and root fractures are really difficult to diagnose because we don't see them in your mouth or under your gums. And if we take a two-dimensional X-ray in the office, it's very rare that it'll show. The way that we kind of figure out that you have a root fracture, oftentimes, if we suspect it, we will send you to a root canal specialist, an endodontist who will do some tests on the tooth.

And they will also take what's called a cone beam, CT scan. So it's a very low radiation, much lower than the medical grade CT scan, but it's a three-dimensional X-ray. And if there's bone loss in a certain way around a tooth, that can be indicative that the root is fractured. And if that's the case, the tooth does need to be pulled. Now, other causes of tooth or gum pain, there are autoimmune conditions like lichen planus that can cause pain in your gums. Herpes simplex virus and aphthous ulcers, both can create ulcerations on the gums that can be very painful.

In addition, there are non-tooth related issues that can cause tooth — what you think is tooth pains. So trigeminal neuralgia is a facial pain disorder that can often mask as tooth pain, but that's really treated by a neurologist or a pain management specialist. And the other thing that comes to mind are TMJ disorders. So your jaw joint, those, and actually the muscles related to the jaw joint. If those spasm, those can create pain around your mouth that really can mask and make you think that it's tooth pain. So it's really important to see your dentist to identify is this tooth pain or is this something else?

Kate Kaput: Yeah. Ooh, makes my mouth hurt just to think about it. So that's actually, my next question is how do you know when it's time to see a dentist or periodontist about pain versus when it's something that might go away on its own? Are there kinds of pain that are less worrisome than others?

Dr. Sasha Ross: Yeah. Good question. So with regard to this, I would say it never hurts to call your dentist and go in and see them. If you feel like the pain is tolerable and you kind of want to wait it out, I would say, watch it for maybe about two weeks. And if it hasn't gone away, I would call your dentist. Things that would make me say to call your dentist sooner — if the pain is increasing in frequency, so becoming more common, or if it's becoming more severe over time, don't wait, call your dentist.

Kate Kaput: OK. So I want to talk a little bit about cavities. There are a lot of myths out there on the internet. The internet is a place full of myths. A lot of myths about how to get rid of cavities on your own. Can you weigh in on whether there are any effective home remedies for cavities?

Dr. Sasha Ross: Great question. I guess I'll preface this by saying I’m a periodontist, I'm not typically the one to treat cavities. That being said, when I spoke to other dentists at the Cleveland Clinic, we are all in agreement that we really don't support home remedies to treat cavities. To treat cavities and at least prevent them, we recommend using fluoridated toothpaste. And sometimes, that can be prescription strength. We support brushing your teeth several times a day, especially after you eat. And if you're eating, eat in one sitting rather than little bits throughout the day — if you're doing the little bits throughout the day, you need to be brushing your teeth more often to prevent cavities from occurring.

Kate Kaput: That's such a good point. And that's one that I haven't thought of, our dietitians often talk about eating smaller meals throughout the day, but there's another piece of that, that you need to then add on. So good point.

So again, I know you're not a dentist, but speaking of dental care, is there anything that you can tell us about at home teeth whitening and whether it's safe and maybe if there are some ways that are safer than others.

Dr. Sasha Ross: So at home whitening is definitely safe. When you're choosing what type of whitening to do, you want to look for a product that has the ADA seal of approval on it. Most whitening products have the same base ingredient, which is hydrogen peroxide — I'm sorry — it is hydrogen peroxide or carbamide peroxide. You want to know that the at home whitening products are not going to give you as white a result is something that you would do in the office. Crest Whitestrips® are a really nice product that works for at home whitening. And just know that there can be side effects. So if these materials get onto your gums, they can cause your gums to burn and they can create sensitivity in your teeth or possibly over whiten your teeth.

Kate Kaput: OK. And I know that I've heard that if you have very sensitive teeth home whitening can make it worse or might not be the best move for you. If you feel sort of quite a lot of pain from home whitening, then I would imagine you should stop and talk to a dentist?

Dr. Sasha Ross: Exactly right. Yep.

Kate Kaput: All right. So let's move on to prevention, and you've given us some great tips already. How can we improve our oral hygiene? How often should we see a dentist? How often should we see a periodontist? What do people need to know about really taking care of their mouths before something happens?

Dr. Sasha Ross: So as far as improving your oral hygiene, you want to be brushing at least twice a day. One of the two times for two whole minutes, and electric toothbrushes are really what I recommend. Those actually have timers on them that can tell you when the two minutes are up. Floss is incredibly important because studies have shown that brushing just doesn't get to the area in between your teeth. And if you're not getting the plaque that's there, it can lead to cavities or periodontal disease. And the other thing that I'd say is a lot of us really have never been shown how to brush and how to floss properly. So just having your dentist or hygienist say, just do it, isn't enough. Ask the questions and say to them, “Can you watch how I'm brushing? Can you watch how I'm flossing? And can you show me what I need to do to be more effective at cleaning?”

Kate Kaput: That's so interesting. I have this very clear memory in my head of elementary school and a dentist came in and taught us how the right way to brush your teeth. And it has always stuck with me. What can you tell us about what is the proper way to brush your teeth? I love that idea of asking your own dentist and having your dentist kind of show you, but are there any tips that you can give folks who are listening about what they should be doing?

Dr. Sasha Ross: Sure. Well, as far as again, the type of toothbrush, electric toothbrushes, and this is studies going back 30, 40 plus years, just do a better job than the regular ones that actually you may get from your dentist office. There are two main brands on the market. There's the Oral-B®, the Braun, and the Phillips Sonicare®. The Oral-B works with oscillating rotating technology. The Phillips Sonicare works with sonic technology. Each of the companies says that they're better than the other one. And the truth is we don't have any real recent studies to say one way or another. I tend to be a little bit more partial to the Oral-B because the brush head is circular. Whereas the Sonicare is more oval. And I think the circular head can kind of get to some of those hard to reach areas without gagging you. And there was a study back done in the early 2000s that really looked at a ton of different studies and showed that the Oral-B was more effective with that kind of technology.

Now, the brush heads come in soft, medium and hard — hard toothbrushes do a better job cleaning. They will remove more plaque, but they also remove part of your tooth structure as well. So they really are too abrasive and I would stay away from that and really stick with a soft or a sensitive brush head. As far as toothpaste and your choice of that. Really a lot of them on the market, some say they're to help gum health, some say they're to help whitening or decrease sensitivity or prevent cavities. They all kind of have the same ingredients. The main thing that I believe is that you should have a toothpaste that's fluoridated, and you should stay away from toothpaste that have a lot of baking soda that are very abrasive.

Now, as far as how to brush your teeth, the idea is to angle your brush at 45 degrees to the gum. So where the gum meets the tooth, angling it down and using some short overlapping strokes. And you want to make sure that you're getting on the cheek side, on the biting side and on the inside, near your tongue or the roof of your mouth when you're brushing.

Kate Kaput: So really hitting it from every angle. When you talked about the hard bristles, I'm sort of imagining power washing a house, right? It's like a little bit too hard. It gets everything off, but it maybe also takes the paint off the house.

Dr. Sasha Ross: Well between abrading your tooth and maybe needing to see your dentist to get a filling, it can abrade your gum tissue as well. And I see many, many patients for gum recession that are caused by using hard toothbrushes over a period of many years.

Kate Kaput: OK. So lots of great tips here. This is something I've always wondered about. Is there a right order to cleaning your teeth? Do you floss before or after you brush, do you use mouthwash? Do you use a tongue scraper, when? What should the kind of right order of things look like?

Dr. Sasha Ross: Good question. And the truth is I think in our field, we don't really know. There's one newer study that I don't think was the best study that maybe suggests flossing before brushing is the way to go. And I'd say that's usually what I tell my patients. Mouth rise you would use at the end. And I generally recommend something like Listerine that not only targets bad breath, but also is antibacterial and antigingivitis. And as far as the tongue scraper goes, I personally am not a huge proponent of it. And I don't know many colleagues of mine that are. The thought is that it can maybe help bad breath by scraping away some of the bacteria that can release things like sulfites that cause bad breath. But I'd say in the majority of cases, it maybe isn't necessary.

Kate Kaput: OK, good to know. So we've mentioned flossing in passing, but I would love to kind of delve a little bit deeper. What can you tell us about flossing? Why is it so important? And we'll go from there.

Dr. Sasha Ross: So flossing is the thing that most people that I encounter hate doing, find very difficult to do, but really is truly so important because the string floss, the type that you hold and wind around your fingers, is able to get under the gum line a little bit. And the idea is that you wrap a piece, do it about shoulder length apart and kind of cup it around the tooth up and down a few times on either side of the triangle of gum, which is called the papilla and making the C shape around the tooth. It really can be so effective. Studies have shown no difference in unwaxed or wax floss. I personally like the unwaxed one a little bit more. I think it's a little bit more effective.

And the other thing to know is your gums may bleed when you start doing it. And if you've never done it before, and that's because they're inflamed. The thought is, “Oh, they're bleeding. I need to stay away and not do this because I'm going to hurt them.” In most cases, if you continue with it and do the right technique, that bleeding will stop even after a week or so, you just want to make sure you're not traumatizing your gum tissue and pressing too hard or at the wrong angle and causing the bleeding that way. You can always talk to your dentist or periodontist or hygienist about that.

Kate Kaput: That's really good to know, that the bleeding is almost because you're not flossing often enough. And if your gums sort of get used to the floss, then it won't happen anymore?

Dr. Sasha Ross: Correct. It should decrease.

Kate Kaput: And so you talked about the kind of floss that you wrap between your fingers. Those little floss picks, right? They're like plastic and there's a little piece of floss between them. They're super convenient, but I've also heard that they're not as good for your teeth as actual floss. What can you tell us about those?

Dr. Sasha Ross: I'd say they're better than nothing, but the truth is they aren't as effective as a string floss when you're using the string floss correctly, it being able to wrap around the teeth and get under the gums in the right way.

Kate Kaput: My dental hygienist told me, like, they're good to keep in your car. You keep a couple in your cup holder or whatever for when you've eaten on the go and you need to just get something out of there, but they're not a replacement for real floss.

Dr. Sasha Ross: Yeah. That's really good advice. I'd also say in people who maybe have issues with hand dexterity, maybe any disorders that they really can't grip the floss well, they are a good alternative.

Kate Kaput: That's a great point. Anything else? Any other floss tips or things that our listeners should know about flossing? I know that flossing is something that quite a lot of people are resistant to, as we said. So anything that we can tell them to make it easier, make it more compelling.

Dr. Sasha Ross: I'd say practice makes perfect. And so don't give up if you're struggling initially and really use your dentist, your periodontist, your hygienist, look in the mirror when you're doing it and keep trying, because it really can impact your oral health and therefore your overall health.

Kate Kaput: And while we're talking about flossing, what can you tell us about those waterpiks or water flossers? How do those work and do they work?

Dr. Sasha Ross: So I have recently become a huge convert to believing in the power of the waterpik. Waterpik® brand specifically, I think does a phenomenal job. It's not a substitute for floss, but can be used in addition to it. And the people who really can benefit the most are people who have dental implants, people who have bridges in their teeth or people that have a lot of gaps between their teeth. The waterpiks, you simply put water from the sink in them, lean your head over the sink, turn it on and just kind of run the water along every gum line and let the water fall into the sink. A lot of times, you'll see chunks of food coming out, even after having flossed. And they really can help decrease the amount of bleeding and tighten the gum tissue. So I definitely think there is a benefit to them.

Kate Kaput: Wow, OK. So not a substitute for flossing, but a good thing to add to your arsenal to keep your mouth extra healthy?

Dr. Sasha Ross: Definitely. Yes. I've seen huge improvements in patients, periodontal health after switching to using the Waterpik.

Kate Kaput: Great. And so as we wrap up, I know that we've mentioned this in passing, but I'd love to just get you to reiterate for us. How often should you see a dentist and sort of when, or how often do you see a periodontist?

Dr. Sasha Ross: So seeing a dentist is so important, I would see a dentist at least twice a year, and that's for an exam, X-rays, cleanings. And a periodontist, you can also throw into the mix seeing us at least once a year, if not more. I think dental insurance, getting back to our first point, only covers it a couple times a year, but in some people you may need to see a dentist or periodontist more often. Some of these people that we've discussed are genetically prone or have periodontal disease. And so you may have to pay a little bit out of pocket using dental insurance as your crutch, not as the way that is guiding us to the correct treatment.

Kate Kaput: Got it. So, is there anything else that we haven't discussed today, that's important for people to know about their oral health?

Dr. Sasha Ross: I think just again, to know that it really is so important to take care of your teeth and your mouth, both for your health in your mouth, your health of your whole body and just your happiness in general. And we hope that, you don't use fear of the dentist as a reason to stay away because there's so many ways that we can help you to not be fearful when you go in and so much benefit to having regular dental care at home and in the dental office.

Kate Kaput: Yeah, as someone who is formerly afraid of going to see the dentist. I think that it's so important to even just mention to your dentist or your dental hygienist that you're a little scared of being there. It's something they hear all the time and they have ways to work with you. And even just to help you calm down a little. My dentist has a stress ball that you can hold while you're in there. And that really goes a long way.

Dr. Sasha Ross: Definitely. Definitely, definitely.

Kate Kaput: All right, Dr. Ross, thank you so much for being here with us today and for speaking with us on this important topic.

Dr. Sasha Ross: Thank you so much for having me and I encourage everybody to pay more attention to what's going on in their mouth and to see their dentist or periodontist regularly.

Kate Kaput: Perfect. Thank you so much. To all of our listeners, if you have questions about your oral health, talk to your dentist or call 216.444.6907 for an appointment at Cleveland Clinic. You can also find more information on oral health online at clevelandclinic.org/dentistry. Thank you so much for being here with us today.

Speaker 1: Thank you for listening to Health Essentials brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. You can also follow us on Facebook, Twitter and Instagram for the latest health tips, news and information.

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