MDDr. Alžběta Kršáková studied oral medicine at Palacký University in Olomouc. She currently works at a clinic in Bratislava, where she focuses on complex dental care. Externally, she also takes part in educating dental hygienists at SZÚ – National Institute of Public Health in Czech Republic. She has been working as a dentist since 2011.
Why did you decide to become a dentist?
Alžběta: Medical care was always a natural choice for me, considering my interests. I was drawn to oral medicine by the idea of being able to work with my hands. On top of that, I always had a vision of creating a comfortable environment for my patients, where they won’t have to be afraid, and I hope I was able to do that. Dentistry is a difficult job to do, both mentally and physically, but it fulfils me.
What makes a good dentist?
Alžběta: A good dentist should be professional. Someone who is ready to keep educating themselves for their whole life, to be able to offer the best possible care. They should know how to create a feeling of trust and a pleasant atmosphere in the emergency clinic, and they should also be empathetic.
Should they also be a teacher and explain how and why we should brush our teeth for example?
Alžběta: A prevention of many diseases in the oral cavity stands on the technique of denture cleaning. A dentist should know how to illustratively show all of the techniques to patients. They should be able to explain the role of biofilm (also called dental plaque) in the development of the most common diseases such as tooth decay and periodontitis. Dentists like me often get help in this matter from professionals – dental hygienists, who are trained to motivate and instruct patients in good dental hygiene. Dental hygienists have more time to devote to the problems of teeth brushing. A thorough demonstration takes more than a minute or five, hence it is impossible with the current number of dentists for every patient to go through it at full length.
When should we start brushing our teeth, I heard it should be as soon as the first tooth grows?
Alžběta: We should start brushing the teeth which come through first already, which is from about 6 months to one year of age of the baby. The focus is mainly on dental hygiene before main night’s sleep, possibly even after repeated breast feeding, so that the food does not dry on the teeth and therefore doesn’t remain stuck during a period when natural self-cleaning mechanisms are not in effect – such as salivating and cleaning surfaces in oral cavity with lips and tongue movement etc. Even before the teeth come through, the parent should start getting the baby used to getting their teeth brushed, for example by massaging the gum with a silicone finger brush. Along with anatomical chew toys, this can also help the teeth to come through the gum and alleviate the symptoms of teething.
The best and fastest way for the parent to clean their baby’s first teeth is by using a single-volume toothbrush without toothpaste. Its bristles are very delicate and effective. If the baby has only a few teeth and is fed repeatedly at night, it is good to wipe the milk off with at least damp gauze. It is good not to get discouraged if the baby is not cooperating – we must be persistent and thorough. Other activities are also accompanied by crying and protests and yet we still have to do them.
Preventing tooth decay in children includes dietary counselling as well. It is ideal to avoid sugar and sweetened beverages, the very worst being sweetened drinks given to a baby in a baby bottle.
And what about brushing the teeth of older children, preschool children, and schoolchildren? Do you have any way to motivate them? Do you have any advice for parents?
Alžběta: At this age, it is needed to actively build up the habit of brushing the denture and make a ritual of it. There are various books, instructional videos, and fairy tales which are talking about a given problem available on the market nowadays. We have to recognise that the child is a mirror, which copies the actions of their parents, so it is best when they see that we too, take good and regular care of our teeth. Let the child watch, repeat and help us. Already young children like to play with their toothbrush by putting it in their mouths – they are curious.
A correct toothbrush to play with should be colourful and with soft bristles, and the parent then brushes the teeth with a single-volume brush. We teach older children simple brushing technique – circle movements – and show them how to clean all the little facets of their teeth. Their toothbrush should have a smaller head and soft bristles. Let the child choose the colour of the toothbrush. Long-handled brushes are also suitable. Such a toothbrush can be held by the child and their parent at once. It is still the case that the parent finishes the brushing process with a single-volume toothbrush and even with dental floss, if the gaps in the distal section are closed. Older children from school age can brush their teeth quite well, and after proper practice, they can also use a floss-pick. However, the parent must still finish brushing their children’s teeth and not rely on the child. From this age, fluoride toothpastes and possibly local mineralization are used as a preventive measure. Plaque detectors in the form of pills or water can be used to help with coating visualisation and showing of poorly cleaned areas.
Why are milk teeth so important, when they are going to fall out anyway?
Alžběta: Milk teeth are very important. It performs all functions of a permanent denture until it’s replaced – aesthetic function, mastication function (i.e. chewing and biting), phonic function (voice formation) and its presence greatly influences the correct development of the jaws and correct arrangement of the permanent dentures. If we allow a child’s temporary teeth to grow wrongly, the child may face many troubles. Decaying, rotten, black, and missing front teeth often mean issues with pronunciation and problems in a collective matter (mockery from other children), in addition to pain and the need for treatment. If the tooth does not hold in place in the dental arch, and therefore doesn’t “hold space” for its successor in physiological tooth replacement, then teething disorders, orthodontic defects, etc. may occur. Temporary molars are not replaced until the age of 10 to 12. Children’s toothache is also a major problem – consequential food refusal, possible swelling, or other health complications. Treating already painful milk teeth is more complicated and not always possible.
What does a correct process of teeth brushing look like?
Alžběta: It is necessary to clean all tooth facets so that they are smooth and free of plaque. Some areas are accessible for a regular toothbrush – those are the outer, inner, and chewing areas of teeth. We use a single-volume toothbrush to clean facets that are more difficult to reach with a normal toothbrush. However, brushing our teeth doesn’t stop there. It is also necessary to mechanically clean areas in interdental spaces – for this we use dental floss and interdental toothbrush. These tools should be used every day.
How do we choose the right toothbrush?
Alžběta: There are many types of toothbrushes on the market. It is important to choose a toothbrush which is going to make brushing our teeth more effective and pleasant. We choose toothbrushes from certified companies, because the bristles have to be high-quality in order to be able to clean the teeth properly, while being comfortably soft. We also choose toothbrushes with smaller heads, as those are easier to manipulate. The bristles should all be the same length for better cleaning efficacy.
And what is your opinion on “natural“ bamboo brushes, miswaks (a.k.a. siwak) and so on?
Alžběta: The material of the brush handle doesn’t play all that much of a role – it can be made of wood if the manufacturer has mastered the fibre-fastening technology so that the fibres don’t fall out. The fibres have to be delicate, resilient and able to withstand some stress. The problem with wooden brushes is storing them. If we typically put it in a glass with other brushes, where the moisture accumulates, then the wood can become a breeding ground for bacteria and fungi. The same is true for Miswak (which comes from the Salvador Persico tree) – we use it in a same way as we would single-volume brush, so you have to expect that you will need a longer period to fully brush your teeth (I personally tried it and I have no objections to its cleaning ability). And again, beware, it stays moist after use and could become mouldy if not stored properly.
What about super modern cleaning with the help of a sonic or electric toothbrush?
Alžběta: Sonic brushes offer a reduction in the time needed to clean accessible areas of the tooth. At the frequencies with which they operate, they remove the coating of the tooth quickly and effectively. However, they won’t guarantee a complete cleaning. Even when using a sonic toothbrush, it is needed to finish the brushing process with flossing of the interdental areas. It is a good idea to pick a pressure-controlled sonic toothbrush, so that we don’t damage the teeth when cleaning them. Sonic brushes are preferred to rotary brushes.
After how long should we replace our toothbrush? My dental hygienist told me that I should change it after 1 year. The replacement of the toothbrush after 3 months is said to be a marketing tool by companies and if I brush my teeth well, I will not destroy the toothbrush just like that.
Alžběta: A toothbrush should be replaced when worn out. Bristles are effective only if they are not bent or broken. A tool with flattened and bent bristles is inefficient and we may be more likely to injure ourselves with it. If we do not use too much force on the brush and if we use it correctly it can last longer, but some people are able to destroy a toothbrush in three weeks already. I have some doubts about whether a toothbrush will last a year if used daily – I would have to see such a toothbrush after a year of being used – but it can definitely last longer than 3 months.
Which tools are truly necessary to brush our teeth, and which are unnecessary? Interdental toothbrush / floss / dental shower.
Alžběta: A dental floss and an interdental toothbrush are necessary. A dental shower can be useful in some cases – for example in larger prosthetic interventions, but it doesn’t remove the coating on its own. It is needed to first disrupt the coating i.e. by a dental floss or interdental brush.
Toothpastes make it more pleasant for people to brush their teeth and they refresh the breath. Many contain fluorides and other active substances which can positively affect the state of the enamel and gums. I do not recommend mouthwash in usual dental hygiene at all, as it does not have any effect on the condition of the plaque, and it can paradoxically cause a false feeling of freshness and cleanliness. Mouthwash is suitable in specific cases – for example as a support for healing after oral procedures. Some contain ingredients that inhibit bacterial growth and support good hygiene under difficult hygienic conditions, however, such products are not to be used in the long term. The mechanical cleaning of the teeth is the most important factor, which toothpaste or any other product won’t mediate.
Do teeth whitening products work? Should we whiten our teeth?
Alžběta: Professional teeth whitening products do work, I definitely wouldn’t recommend any other products. The whitening process belongs in the hands of experts, otherwise it can cause problems. Whether to whiten teeth there is no clear answer to that, but if the answer is yes, only teeth that are healthy and completely treated can be whitened, after a professional dental hygiene treatment and under the supervision of a specialist. Dental hygiene often times improves the appearance of the teeth sufficiently on its own, without the need for the whitening process.
What is your opinion on the presence of controversial fluoride in oral hygiene?
Alžběta: It is not the fluorine that is being used in toothpaste, but rather its compounds. The use of fluoride in controlled quantities in pastes has a positive effect on the development of tooth decay in the population. The efficacy of fluoride compounds on enamel mineralisation and also the increase in the resistance of enamel is proven. That’s how much science tells us on this subject at present, whether the attitude of the community experts will change in the future, I dare not to guess. I myself use a gel which contains fluoride. It is necessary to use the correct amount of toothpaste and the centimetre long strip from adverts is definitely not correct. For children, a little amount of toothpaste is only gently rubbed onto the toothbrush and in adults and older children a pea-sized amount is used.
What should we buy? Toothpaste, gel, powder or pill for brushing our teeth? How should we choose?
Alžběta: It depends on your preference, but it is always necessary to follow the manufacturer’s recommendations. As I mentioned earlier, toothpaste is only an addition to dental hygiene. Selecting it doesn’t have any major impact on the quality of teeth cleanliness – that is affected by the technique and precision of mechanical brushing. It can still make brushing our teeth simpler and more pleasant. We choose a toothpaste which offers us a bonus such as fluorides and other minerals, alternatively substances which reduce sensitivity of exposed tooth dentin. When choosing a toothpaste for children, we make sure they enjoy the taste of it.
If we haven’t mastered oral hygiene, there will be a decay. Fortunately, the bell tolls for the amalgam filling and it has been banned for children under 15 years of age, pregnant and breastfeeding women since 2018. Do you perceive in any way that people already know that the mercury contained in the amalgam filling is a strong neurotoxin dangerous to the environment and our health, and are asking for different teeth filling on their own?
Alžběta: Amalgam drilling is known to release mercury, which is inhaled by patients and dentists. Drilled amalgam fillers in wastewaters also damage the environment (mercury is toxic to aquatic animals and, of course, to us as a result of the food chain i.e. by fish and seafood consumption).
A question arises whether to get the existing amalgam filling redone, while they still function well?
Alžběta: If the filling still works well and it is not necessary, then I usually don’t redo it. However, we often see defective fillings. If the filling is no longer sufficient, alternatively if a secondary tooth decay occurs in connection with it, it needs to be redone. Dental kits are equipped with amalgam separators, capturing the amalgam filling rings before it would be washed away into the sewers. For treatment we use cofferdam insulating membranes and cooling, which minimises the fumes generated by overheating the dental drill. At the same time, we ensure that the amalgam scrub is not in contact with the patient’s oral cavity. We don’t use amalgam at the clinic where I work, so even though it is not banned yet, we do not do amalgam fillings and I don’t even remember a patient who would require an amalgam seal.
Today we luckily have other fillers. What are they made of? What is their lifespan?
Alžběta: White composite fillings are composed with multiple components. The base is made of filler, of which there is the biggest amount – it consists of tiny inorganic particles (you can imagine those as ceramic grains) in an organic matrix. The matrix contains monomers and photoinitiators, which ensure that the filler is connected throughout and that the plastic solidifies after illuminating it. The lifespan of the white filling depends on how it was done – whether a technological procedure has been followed, which is more demanding than the “amalgam procedure”, and how the teeth are subsequently cared for. White filling often fails precisely on the fact that a secondary decay forms in its surrounding area, if the area has not been sufficiently cleaned. A well-made white filling with proper dental care can last for decades.
Do you have any recommendations to conclude this interview?
Alžběta: Devote enough time to the prevention. If you don’t know how to brush your teeth correctly, or how to use the tools, undergo training and learn it – it’s never too late. Watch out for sugary and carbonated beverages and drink them as little as possible as they can quickly and irreversibly damage the enamel.