Meditative toothbrushing

Introduction

The concept of holistic health (harmony of the mind, the body, behaviour and the environment) is well recognised and deeply rooted in Vedic culture, which has been explained in the Ayurvedic literature. Contemporarily however, health practice and recognition of health-related quality of life (holistic health) began only after the World Health Organization (WHO) expanded the definition of health to “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” in 1948.1 This resulted in the paradigm shift of health and disease from a medical model to a biopsychosocial model. It is simple to understand and logical to think that any disease that can interfere with the activities of daily life may have an adverse effect on general quality of life. It is evident from the literature that the notion of health-related quality of life started to emerge in the late 1960s and slowly impacted the oral health industry as well. Hence, the concept of oral health-related quality of life is a relatively new but rapidly growing phenomenon that has emerged over the past two decades.2 Several authors have explored the evolution of oral health-related quality of life and documented the circumstances that have led to its prominence.2–4 Oral health-related qual-monise with the ecology of commensal bacteria, fungi, and viruses, but also should be able to defend against pathogenic microbes. In fact, the oral microbiota is altered in situations when the immune system is dysregulated.14 There are a number of human diseases or conditions that disturb the balance of the host immune system and have an effect on the host’s oral microbiota.

The human oral cavity is an ecosystem, and like all ecosystems, the oral ecosystem is a combination of many different components (e.g. bacteria, fungi, metabolic compounds, host cells and salivary constituents), and in one way or another, this system maintains a balance. It is important to note that the bacterial communities can vary between different collection sites in the oral cavity. Variations in oral microbial diversity in different oral sites, especially between the mucosal and dental sites and between saliva and dental sites, have been observed.15 A recent study demonstrated that the buccal mucosa, gingivae and hard palate had similar microbiota, whereas the saliva, tongue, tonsils, throat, and supra- and subgingival plaque each had distinctive communities.16 To date, saliva serves as the best oral compartment to look for differences in the microbial com-position in a variety of human diseases, as it captures the closest true representative microbiota in the oral cavity.17–20

When we talk about the healing capacity of biological tissue, we need to understand that interactions between saliva, diet, the oral microflora, tooth surfaces and the oral mucosa support a dynamic state of equilibrium (healthy condition)21, 22 in the oral cavity as an integral part of an ecosystem. Oral health and disease are influenced by balances or imbalances between these components (Fig. 1). Consequently, preventive and treatment strategies should aim to maintain or re-establish balance with a more holistic view of preventive, diagnostic and treatment strategies in contrast to the traditional methods that focus on a limited number of pathogenic factors.23

Global oral health burden

Caries and periodontal disease pose an enormous burden on mankind as non-communicable diseases. A high proportion of the world’s population (approximately 90%) suffers from oral disease at some point in their lives,24 and caries and periodontal disease are the most common chronic dis-eases causing severe pain in the later stages.25, 26 It has been estimated that almost 100% of adults and 60–90% of schoolchildren worldwide suffer from caries (Fig. 2) , and about 20–50% of the global population suffers from periodontal disease.27 Severe periodontitis (Fig. 3) is the sixth most prevalent disease in the world and may lead to tooth loss.27, 28 Moreover, growing research is showing that there is a strong correlation between oral disease and major non-communicable diseases such as diabetes and cardio-vascular disease.24, 29 A strong interaction has been shown to exist between oral health and mental health that has been well documented in the literature.30–40 Hence, oral disease is considered the most significant global oral health burden.25

The impact of oral disease on the global economy involves direct and indirect treatment costs41, 42 and can have a huge negative economic impact on society. WHO estimated that oral disease is the fourth most expensive disease to treat in most industrialised countries.43 In addition to the direct and indirect treatment costs and economic impacts, oral disease has a large impact on people’s daily lives and is re-sponsible for the yearly loss of millions of school and work hours around the world.41–45 Hence even from an economic point of view, the improvement in the oral health of the population may be highly beneficial and could further increase people’s well-being.42

The concept and methods regarding the treatment of caries are changing in light of new research evidence based on the fact that caries is a behaviour- and diet-dependent disease with bacterial participation, and the treatment plan should consider the healing capacity of biological tissue.46–49 Pre-venting the occurrence of carious lesions should remain the primary aim of any oral care plan, and treating caries as an infectious disease with the unnecessary removal of sound tissue and replacement with restorative mate-rials is no longer acceptable within the field of dentistry. The author advocates the Vedic Smile concept,50 which focuses on preventing disease early on with an effective self-performed oral hygiene method, enforcement of regular dental check-up and a minimally invasive approach to early diagnosis of oral disease, its timely prevention and intervention with a patient-centric holistic care approach.

Education and prevention

Prevention is better than cure, and this can be applied in lowering the oral health disease burden in society. It has been documented that effective self-performed regular oral hygiene has been identified as a key attribute in oral disease prevention.51, 52 During dental visits, the dental care team normally provides advice and instruction on oral health to patients based on the results of their clinical ex-aminations, to develop oral self-care skills for maintaining good oral hygiene.53 However, multiple studies have shown that patients’ adherence to a proper daily oral hygiene regimen generally remains poor,54–56 and even a large number of adults clean their teeth less than the recommended number of times and duration57 and have been shown to have problems achieving oral cleanliness through self-performed oral hygiene. This demonstrates that aware-ness and cultivating self-compassion plays a major role in achieving optimal oral health. Increasing adherence to oral hygiene behaviour is regarded as essential in the prevention of caries and periodontal disease.58, 59 A lack of oral health awareness, self-compassion and self-regulatory skills is associated with a disinclination to change health behaviours to approach effective self-performed regular oral hygiene. Hence, we need to think of a smart approach to oral care that is healthy, reliable, simple and affordable to adopt as a daily routine in life. Scientific studies have already shown that toothbrushing is regarded as a key practice for self-performed oral care, and it depends on effective behavioural change interventions that can enhance an individual’s ability to perform self-oral care as well as long-term dental habits critical for the maintenance of oral hygiene, which are the key factors for achieving good oral health.58, 60 Multiple research findings have already shown that self-care, behavioural change and diet modification play a vital role in achieving a healthy mouth for the reduction of the global burden of oral disease.61–64

Empowerment over persuasion is the key to successful oral health promotion while achieving good oral health.65 Moreover, oral health education has been considered one of the fundamentals in oral health promotion,66, 67 and a strong interaction between oral health and mental health has been well documented in the literature.68–78

With education, a child receives training and encouragement specially to stimulate the development of skills, formation of aptitude and creation of values, which lead to acting positively in relation to his or her oral health and other people’s oral health on a daily basis. The importance of oral health education programmes in schools (Fig. 4) is reported predominantly in the form of positive learning and behaviour in children.79–85 Hence, is necessary to promote new empowerment strategies to modify oral health habits based on the patient’s age, knowledge, attitudes, practices and abilities, and self-monitoring. Thus, there arises a need for inculcating healthy oral health habits as a daily life routine. With this notion in mind, a unique technique has been formulated that encompasses the mind, the body and be-haviour to achieve a better quality of life by improving the oral health-related quality of life via a method as simple as toothbrushing. The meditative toothbrushing (MTB) technique, as I like to call it, is a consciousness-based oral hygiene practice and is a component of holistic healthcare.

Meditative toothbrushing

MTB is based on the Vedic Smile Dentistry50 concept (Fig. 5) of holistic care and focuses on the harmony of the mind, the body, behaviour and the environment (in this case, the oral ecosystem) of the person so that the person apprehends the core benefits of MTB and adopts it as a health and happiness promotion habit. The MTB action emphasises the mind–body connection and combined mechanical act of toothbrushing with the simplified meditative approach in order to keep the mouth healthy and release mental stress. The fundamental aim of MTB is to be self-aware, nurture compassion and practise good oral habits as a behaviour. The concept of incorporating awareness, compassion and practice in the MTB process is briefly explained below.

Awareness

Awareness is one of the key components of well-being. The importance of enhancing well-being and reducing mental distress is more apparent today than ever. Distractibility, loneliness, depression and anxiety are all on the rise, creating an emerging crisis in mental health and a growing deficit in our collective well-being.86–88 Research has studied interventions that improve well-being through the use of various forms of self-regulation,89 including psycho-therapy,90, 91 positive psychology interventions92, 93 and contemplative practices like meditation.94–100 Hence, MTB emphasises mindfulness in order to lower the harmful effects of distraction, which has been shown to impair executive function101 and to increase stress, anxiety102 and attention-deficit/hyperactivity disorder symptoms.103, 104 It is to be noted that being informed and being aware are two different things at the level of the mind. For example, a smoker may be fully informed about the negative consequences of smoking tobacco on overall health and well-being in the long term; however, if this piece of information is not synthesised at the conscious level of mind, then the person cannot quit smoking easily.

Compassion

Kindness is a key component in enhancing mental health that helps to maintain quality of life. A person lacking in self-compassion for his or her health or body parts could easily become a victim of multiple diseases in a lifetime and may cause self-harm to health and happiness. It is the author’s long-term clinical findings that a person who neglects his or her oral hygiene generally neglects his or her overall health, and oral hygiene status can be a good indicator in understanding a person’s self-compassion level towards his or her quality of life. Hence, the MTB technique is designed to cultivate self-compassion towards the teeth, gingivae, and other parts of the mouth and body and to help patients to keep their mouths healthy and minds happy, thereby improving quality of life. Teaching self-compassion at an early age could be a smart approach to self-care, and by cultivating kindness towards each tooth as an individual “being”, this MTB practice encourages children to keep their teeth clean and adopt good oral hygiene habits.

Practice

Toothbrushing is a behavioural daily habit; hence, it is not easily altered, even after professional oral hygiene instruction in the clinical setting, and multiple studies have shown that patients’ adherence to a proper daily oral hygiene regimen generally remains poor,54, 55 and even a large number of adults clean their teeth less than the recommended time56 and have been shown to have problems achieving oral cleanliness through self-performed oral hygiene. The act of toothbrushing is a science-based skill that requires at least basic oral hygiene education and suitable skill training, which must teach the art of toothbrushing with the right protocol. Moreover, from the movement science viewpoint, skill training requires many repetitions of the same movements to incorporate them into an individual’s habitual motor programme. In this regard, one needs to understand the role of practice (repetition) with the aware and com-passionate mind in the act of toothbrushing. An aware and self-compassionate mind can easily realise the importance of learning the right skill of toothbrushing and using it properly as a lifelong responsibility. The MTB concept encour-ages the user to continue practising good cultural oral hygiene habits that exist in his or her society. For example, rinsing the mouth two to three times vigorously after each meal with water is a deeply rooted oral hygiene practice in Nepal. The author has been recommending to his patients to keep on practising such good cultural habits.

MTB: Three-step oral care

The MTB protocol has simple three steps to keep the mouth clean and relax the mind, namely prepare, clean and protect (Fig. 6). Awareness of these three steps is the key to successful toothbrushing.

Prepare

The mind is like a monkey, and taming this monkey mind while brushing one’s teeth is the key idea of this preparation step. The monkey mind becomes calm and relaxed if we are able to instruct it with awareness and compassion by giving it some tools to employ. Before starting toothbrushing, the practitioner should fully be aware of the right instruction to be given to the mind so that for the next three to four minutes the mind–body connection is achieved. MTB suggests following simple steps to tame the monkey mind:

– Look into the mirror and have a quick glance into your mouth.

– Check the condition of tooth surfaces by rolling your tongue all over tooth surfaces.

– Be compassionate and grateful to your teeth for serving you since birth.

– Give a happy smile and be ready to brush.

– These simple steps help to focus the mind on the brushing movement and interrupt any distraction, thereby reducing stress and anxiety and bringing calmness within, such that the action of toothbrushing becomes enjoy-able and thus successful.

Clean

Various studies have shown that the main objective of tooth-brushing is to meticulously remove food debris and dental plaque from tooth surfaces and help to maintain the oral ecosystem. The process of cleaning by toothbrushing is a mechanical action that demands basic cleaning skills and proper tools. It is recommended that both the toothbrush (MTB recommends a toothbrush with soft and tapered bristles with a small head; Figs. 7a & b) and brushing motion should not harm the hard and soft tissue of the mouth and should be capable of removing food debris and dental plaque from the flat tooth surfaces as well as the interdental areas effectively. MTB recommends cleaning all the interdental areas first. Once they are cleaned properly, the mouth should be rinsed vigorously with water and then other tooth surfaces should be brushed completely. Regarding the toothbrushing motion, MTB suggests being logical and considering that the aim of brushing is to remove dental plaque from all interdental and flat tooth surfaces. There-fore, vertical strokes from the gingivae towards the teeth are recommended for cleaning the interdental area and brief scrubbing in circular motion for the flat surfaces. To keep a person fully aware and compassionate during the tooth cleaning process, MTB emphasises using a silent MTB mantra, “I LOVE you”, which helps to confine the mind to the toothbrushing movement and reminds the brusher to clean all the interdental, lingual, occlusal and vestibular surfaces of each tooth meticulously. MTB recommends not using toothpaste or tooth gel during the cleaning step because the basic notion of this step is to focus on the mechanical cleaning effects of toothbrushing, increase the toothbrushing duration, stimulate the salivation mechanically, increase the visibility of tooth surfaces during brushing, and clean the tooth surfaces properly, such that they are ready to receive suitable chemical protection for its optimal effects.

Protect

Depending on the possibilities of exposure of the oral ecosystem to disharmony risk factors (Fig. 1), a suitable protective plan needs to be adopted. Use of fluoridated toothpaste and antimicrobial mouthwash, application of fluoride varnish, bioactive protective barriers for tooth sur-faces, pit and fissure sealants, protective mouth guards (to protect against possible tooth damage due to mechanical forces), and diet modification are a few examples of the protection approach and should be followed according to the dental professional’s recommendation. However, during self-oral care, tooth cleaning should be followed by oral massage of the teeth, gingivae and tongue using the recommended toothpaste, tooth gel, mouthwash, etc. in order to provide extra and effective bioactive protection against caries, periodontal disease and other oral diseases, as well as halitosis. For the prevention of caries, regular use of a small amount of fluoridated toothpaste has been recommended by multiple scientific and clinical studies.105–116 Hence, brief scrubbing and a circular toothbrush motion with a little toothpaste or tooth gel are recommended. The mouth should not immediately be rinsed after oral mas-sage with fluoridated toothpaste; however, the excess toothpaste or tooth gel can be spat out properly. Regular toothbrushing and oral massage using protective tooth-paste or mouthwash generally helps in biological repair (remineralisation or healing) of the hard and soft tissue in the oral cavity. However, if the oral ecosystem disharmony factors are on the higher side, then signs and symptoms of disharmony, like bleeding gingivae, dental hypersensitivity, halitosis, demineralised white spots, micro-decay and non-carious tooth lesions, such as erosion, abrasion and attrition, become evident, and this requires professional care for repair and maintenance. Vedic Smile always emphasises the use of smart technology and materials, such as bioactive restorative materials and non-invasive or microinvasive techniques, for the repair and maintenance of such early defects by dental professionals.

Teaching the right protocol in the right approach at the right time is necessary for any cognitive skill training that involves the movement of body parts or motor skill. Tooth-brushing activity as mentioned is an art and science of keeping the mouth healthy and the mind relaxed. The art component of toothbrushing requires skills for correct movement of the hand and brushing motion for long-term oral health benefits. The skill learned with awareness and proper practice (repetition) at the right age is easily con-verted into behavioural habits. The efficacy of toothbrushing depends on multiple factors, such as age, awareness, motivation, quality of the toothbrush, brushing frequency, brushing duration, brushing force and toothbrushing motion. It is to be noted that the aim of MTB is not limited to keeping the mouth clean and healthy, but extends to helping to brush up the mind by reducing day-to-day anxiety and stress, making it fresh and happy.

MTB: Hands-on training programme and appeal

Over 30 years of clinical dentistry, the author has found that the patients visiting his dental clinic lack self-compassion for their oral structures and are not very familiar with the proper brushing technique. Moreover, it is also difficult to teach correct brushing skills in the busy clinical setting with only quick professional instruction. As mentioned earlier, toothbrushing is a skill-based behavioural habit and is dificult to change for the majority of individuals in their teens or adults. Therefore, the author has designed an exclusive MTB hands-on training programme targeting schoolchildren who are at an early stage of their lives. The hands-on training focuses on the idea that any hand skill teaching requires proper motor skill training, along with ongoing follow-up, evaluation and monitoring. It is a well-established fact that repetition is the key approach to converting a good health protocol into a habit, and early school age is the best time to foster healthy oral habits among children. MTB hands-on training is designed as a package of a basic dental check-up, caries risk assessment, oral hygiene awareness, and a step-by-step hands-on training pro-gramme in a small group with the aim of engaging and encouraging the children to regularly practise MTB at home and at school and to develop a habit of keeping in touch with their dentist at least once a year. The MTB certification system is incorporated into the programme to make the children feel proud and happy about participating and learning good habits.

To help promote this oral hygiene mission, the author has also established the Chetu kids’ club, which has the monkey Chetu as a mascot (Fig. 8) to symbolise that we need to tame our monkey minds first and only then will it be easy to convert any good health practice into a habit. The silent MTB mantra “I LOVE you” is used during toothbrushing so that kids start adopting the art of self-compassion and gratitude in their lives. The author appeals to all schools, dental colleges, and dental clinics to incorporate the MTB hands-on training programme as an inbuilt curriculum and support service. In this regard, the author, in joint collaboration with the Oral Health Innovation Center of the Punyaarjan Foundation in Nepal, is in the process of developing a comprehensive MTB hands-on training manual to support schools, oral healthcare organisations and dental clinics around the world to conduct well-organised MTB hands-on training. A copy of the training manual will be freely available at www.punyaarjanfoundation.org.np after October 2021.

Editorial note: A list of references is available from the publisher. This article originally appeared in Smart Oral Care, Vol. 1, No. 1 (March–August 2021), and an edited version is provided here with permission from the publisher.