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Chapter 17: The Combination Approach

We've talked about ingredients. We've talked about formulations. We've talked about mechanical disruption and pressurized delivery. Now let's weave it all together into something coherent—protocols that put theory into practice.

I want to give you daily routines that are evidence-based, ecologically sound, and—critically—sustainable. The best oral hygiene protocol is useless if you won't actually follow it. These routines should fit into real life.

The Core Principles

Before the specific protocols, let's establish the principles that guide them:

Mechanical first. Biofilm disruption precedes chemical intervention. This isn't optional.

Fluoride in its place. For most people, fluoride remains the most evidence-supported caries prevention tool. Use it strategically—and don't immediately wash it away.

Ecological rinses as complement. Your salt/baking soda rinse works with the fluoride strategy, not against it. Use them at different times.

Timing matters. When you do things affects how well they work. Acid exposure, brushing timing, fluoride contact time—these details add up.

Consistency beats intensity. A sustainable routine done daily beats an elaborate protocol done sporadically.

The Foundation Protocol

This is the minimum effective routine—what I'd recommend to someone who wants to do the basics right without overwhelming complexity.

Morning

  1. Water flosser OR string floss (1-2 minutes)
  2. Disrupts overnight biofilm accumulation

  3. If using water flosser, plain water is fine for morning use

  4. Brush with fluoride toothpaste (2 minutes)

  5. Modified Bass technique

  6. Cover all surfaces systematically

  7. Spit, don't rinse1

  8. Spit out excess toothpaste
  9. Do NOT rinse with water

  10. Leave fluoride residue on teeth for continued exposure

  11. Tongue cleaning (30 seconds)

  12. Scrape from back to front
  13. Address the coating that accumulates overnight

After Meals/Snacks

  1. Water rinse or baking soda rinse
  2. Swish plain water to clear debris, OR
  3. ¼ teaspoon baking soda in water for pH buffering

  4. Quick rinse (15-30 seconds)

  5. Wait 30 minutes if you want to brush

  6. Especially after acidic foods
  7. Let saliva do its buffering work before mechanical brushing

Evening

  1. String floss (2-3 minutes)
  2. Physical scraping of interproximal surfaces

  3. This is when your dedicated flossing happens

  4. Brush with fluoride toothpaste (2 minutes)

  5. Same technique as morning

  6. Spit, don't rinse (again)

  7. Overnight is the longest period of low saliva flow

  8. Fluoride reservoir helps protect during this vulnerable window

  9. No food or drink after brushing

    • The fluoride film on your teeth needs to stay undisturbed
    • Overnight remineralization is maximized when you go to bed with clean, fluoride-coated teeth

This protocol takes perhaps 10 minutes per day total. It's not exciting, but it's effective.

The Enhanced Protocol

For someone who wants to incorporate ecological rinses, water flosser delivery, and a more comprehensive approach:

Morning

  1. Water flosser with dilute salt/baking soda (2 minutes)
  2. ¼ tsp salt + ⅛ tsp baking soda in reservoir
  3. Mechanical disruption + solution delivery

  4. Flush device with plain water afterward

  5. String floss interproximal surfaces (1 minute)

  6. Physical scraping that water flosser doesn't fully replicate

  7. Brush with fluoride toothpaste (2 minutes)

  8. Now that surfaces are clean, fluoride can contact enamel directly

  9. Spit, don't rinse

  10. Tongue scraper (30 seconds)

Midday (After Lunch)

  1. Baking soda quick rinse
  2. Neutralizes post-meal acid

  3. Prepare in advance and keep at work

  4. Xylitol gum or mint (optional)

  5. Stimulates saliva
  6. Xylitol starves S. mutans
  7. Non-fermentable sweetener

Early Evening (After Dinner)

  1. Salt/baking soda swish (30-60 seconds)
  2. Full-strength formulation

  3. Used hours before bedtime brushing

  4. Optional: Xylitol gum

Before Bed

  1. String floss (2-3 minutes)

  2. Brush with fluoride toothpaste (2 minutes)

  3. Spit, don't rinse

  4. Optional: Fluoride mouthrinse

    • If at elevated caries risk
    • Products like ACT (0.05% sodium fluoride)
    • Use after brushing if you choose to rinse

This protocol adds perhaps 5-7 minutes to your daily routine compared to the foundation protocol. The key additions are the water flosser delivery of your ecological rinse, the midday buffering, and the evening pre-bedtime swish.

The Therapeutic Protocol

For someone dealing with active gum issues, recovering from periodontal treatment, or experiencing a flare-up:

Morning

  1. Warm salt/baking soda swish (60 seconds)
  2. Soothing, osmotic reduction of inflammation

  3. Before mechanical cleaning when gums are tender

  4. Gentle water flosser (2 minutes)

  5. Low pressure
  6. Dilute salt/baking soda solution

  7. Focus on inflamed areas without traumatizing

  8. Soft-bristle brush with fluoride toothpaste (2 minutes)

  9. Gentle technique

  10. Don't aggravate tender tissue

  11. Spit, don't rinse

Midday

  1. Sage tea rinse (60 seconds)
  2. Anti-inflammatory botanicals
  3. See Chapter 19 for preparation

After Dinner

  1. Salt/baking soda + propolis swish (60 seconds)
  2. Enhanced wound healing support
  3. See Chapter 21 for propolis formulation

Before Bed

  1. Gentle string floss or interdental brush

  2. Skip if too painful; resume as healing progresses

  3. Soft brush with fluoride paste

  4. Optional: Chlorhexidine rinse (if prescribed)

  5. Short-term use only (2-4 weeks)
  6. The nuclear option for acute situations

  7. Transition back to ecological rinses as healing completes

  8. If not using chlorhexidine: dilute essential oil rinse

    • Thymol/eucalyptol for antimicrobial support
    • See Chapter 12 formulation

This protocol prioritizes gentleness while maximizing therapeutic support. As the acute situation resolves, transition back to the Enhanced Protocol.

The Traveling Protocol

When you're away from home and can't access your full routine:

What to Pack

  • Travel toothbrush and fluoride toothpaste
  • Concentrated dry salt/baking soda mix (in small container)
  • Floss picks or interdental brushes
  • Xylitol mints or gum
  • Optional: Small bottle of portable water flosser

The Minimal Travel Routine

Morning: 1. Brush with fluoride toothpaste (2 minutes) 2. Spit, don't rinse

After meals: 3. Pinch of dry mix, sip of water, swish, spit 4. Xylitol mint

Evening: 5. Floss picks for interproximal cleaning 6. Brush with fluoride toothpaste 7. Spit, don't rinse

This is stripped-down but covers the essentials. You're maintaining mechanical disruption and fluoride exposure even when your full arsenal isn't available.

Timing Considerations

Some additional notes on when to do things:

The 30-Minute Acid Rule

After consuming acidic foods or beverages (citrus, wine, tomatoes, vinegar, carbonated drinks):2 - DON'T brush immediately - DO rinse with plain water or baking soda solution - Wait 30 minutes, then brush if desired

This protects softened enamel from abrasion.

The Fluoride Contact Window

The longer fluoride stays in contact with teeth, the more effective it is.3 This is why "spit, don't rinse" matters. The residual fluoride film continues to:

  • Participate in remineralization
  • Incorporate into enamel as fluorapatite
  • Inhibit bacterial metabolism

If you must rinse after brushing, at least wait 10 minutes. But if you can tolerate not rinsing at all, do that.

Separating Fluoride and Ecological Rinses

Your salt/baking soda rinse would wash away the fluoride film. This is fine—you just shouldn't use them back-to-back.

Good separation strategies:

  • Ecological rinse after meals (midday, after dinner)
  • Fluoride brushing at morning and bedtime
  • At least 30 minutes between ecological rinse and fluoride brushing

This way, each intervention can work without interfering with the other.

Pre-Sleep Priority

Overnight is the most vulnerable period:4 - Saliva flow drops dramatically during sleep - Acid buffering capacity is reduced - Remineralization potential is diminished

This is why the bedtime routine matters most. Go to sleep with:

  • Mechanically clean teeth
  • Fluoride film in place
  • No food residue available for bacteria to ferment

The morning routine cleans up what accumulated overnight. The bedtime routine protects you during the night.

Building Habits

The best protocol is one you'll actually follow. Some suggestions for building sustainable habits:

Start with the foundation. Don't try to implement the enhanced protocol immediately if you're currently not flossing at all. Build habits incrementally.

Link to existing routines. Oral hygiene happens in the bathroom, often tied to other activities (showering, getting dressed). Link new habits to existing triggers.

Prepare in advance. Have your salt/baking soda mix ready. Have xylitol mints in your bag. Reduce friction for the behaviors you want.

Track initially. For the first few weeks, use a simple checkbox to track whether you completed each step. Habit trackers work.

Forgive lapses. Missing a day doesn't undo weeks of progress. Just resume the routine the next day without self-flagellation.

Notice improvements. Pay attention to how your mouth feels. As gum health improves and plaque accumulation decreases, you'll notice cleaner-feeling teeth, less bleeding when flossing, fresher breath. These natural rewards reinforce the habit.

What This Accomplishes

When you follow these protocols consistently, you're achieving:

  1. Mechanical biofilm disruption twice daily, preventing mature plaque formation

  2. Fluoride delivery to clean enamel surfaces, optimizing remineralization

  3. pH buffering after meals, reducing acid exposure duration

  4. Ecological support for beneficial bacteria through environmental modification rather than biocidal warfare

  5. Subgingival irrigation reaching zones that passive rinsing cannot access

  6. Consistent routine that becomes automatic with practice

This is a comprehensive approach—but it's also practical. The enhanced protocol adds perhaps 5-7 minutes to your day. In exchange, you're doing something meaningful for your long-term oral health.

And you're keeping more of your teeth in your mouth, where they belong. Which means I get to collect fewer of them—and that, as I've told you, is what I really want.

  1. The "spit, don't rinse" recommendation comes from Public Health England (2014) and is based on evidence that rinsing immediately after brushing reduces the caries-preventive effect of fluoride toothpaste. ↩

  2. Attin, T., et al. (2004). Toothbrushing abrasion of softened enamel. Caries Research, 38(6), 567-571. Demonstrated that brushing acid-softened enamel causes significantly more enamel wear than brushing remineralized enamel. ↩

  3. Zero, D. T. (2006). Dentifrices, mouthwashes, and remineralization/caries arrestment strategies. BMC Oral Health, 6(Suppl 1), S9. Extended fluoride contact time enhances uptake into enamel and prolongs antimicrobial effects. ↩

  4. Xerostomia — Wikipedia. Saliva production decreases significantly during sleep, reducing its protective buffering, antimicrobial, and remineralization functions. ↩