Oral hygiene

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Proper oral hygiene requires regular brushing and flossing

Oral hygiene is the practice of keeping one's mouth clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and cleaning between the teeth. It is important that oral hygiene be carried out on a regular basis to enable prevention of dental disease and bad breath. The most common types of dental disease are tooth decay (cavities, dental caries) and gum diseases, including gingivitis, and periodontitis.[1]

General guidelines suggest brushing twice a day: after breakfast and before going to bed, but ideally the mouth would be cleaned after every meal. Cleaning between the teeth is called interdental cleaning and is as important as tooth brushing.[2] This is because a toothbrush cannot reach between the teeth and therefore only removes about 50% of plaque off the surface.[3] There are many tools to clean between the teeth, including floss, flossettes, and interdental brushes; it is up to each individual to choose which tool he or she prefers to use.

Sometimes white or straight teeth are associated with oral hygiene, but a hygienic mouth may have stained teeth and/or crooked teeth. For appearance reasons, people may seek out teeth whitening and orthodontics.

A healthy smile

The Global Epidemic of Poor Oral Health

Oral diseases are a critical public health concern because of their extremely high prevalence and the enormous potential effects on an individual's quality of life (QoL) (WHO, 2018a; CDC, 2018). The etiological factors leading to oral diseases include issues around oral hygiene, poor genetic predispositions and even traumatic incidents (WHO, 2018a; CDC, 2018). Dental caries, severe periodontal disease, edentulism (no natural teeth), cleft lip and palate, teeth loss, and oral cancer are some of the common oral conditions (Galloway et al., 2002). A study by Nazir (2017) on WHO data found that severe periodontal (gum) disease was very common making it the 11th most prevalent disease worldwide (Nazir, 2017; WHO, 2018a). Besides gum disease, severe tooth loss and edentulism were among the ten leading courses of Years Lived with Disability (YLD) in some high-income countries in North America, Latin America and Europe (WHO, 2018a). Among children , the most prevalent condition is tooth decay ranked at position 36. 2% of the population worldwide. The incidence is between 60% -90% of the school-going children . Approximately 2.4 billion persons and 486 million children worldwide are affected by dental caries on permanent and primary teeth respectively. Although dental practice has permeated the whole world, statistics illustrate that there are gaping differences in availability and quality of care (Bahramian et al., 2018) . Figure 2 below illustrates country differences in care. Oral health is one of the most costly medical treatments, accounting for 20% of out-of-pocket health expenditure and 5 per cent of all total health expenditure per person in most high-income countries in Europe and America (Nazir, 2017; WHO, 2018a). Ultimately, OH care places its greatest strain on the restricted capacities of the healthcare systems of low- as well as middle-income countries as shown in figure 1 below (LMICs; Nazir, 2017)

Measuring Oral Health and General Wellbeing

Research has shown that health and quality of life cannot be measured by mearre absence of disease longevity and life expectancy (Foundation Health Measure, 2010). Matrices such as “health-related quality of life and oral health” (OHRQoL) have been developed for better appreciation of the interrelationship between oral health and overall wellness. The tool is able to measure health in its multidimensional format that looks at the physical, mental, social and emotional status of a human being. The tool has been adopted as a means of objective measure especially among patients with multiple illnesses, long and short termshort-term disabilities. Some researchers have expanded the questionnaire to capture patients self evaluateself-evaluate their oral health, functional and emotional status and their feedback with regards to quality of care (Sischo and Broder, 2011). The tool also captures the effects of cosmetics improvement to teeth or oral cavities such as fixed cleft palate or artificial teeth. The questionnaire has also been used to provide feedback on how comfortable a person is while eating or drinking using new devices. Given that this is a subjective evaluation, OHRQoL offers lessons for the qualitative design that will be discussed in the next chapter. Oral diseases are correlated with NCDs such as such as diabetes, hypertension and cancers are given that they share risk factors; smoking, drinking and eating meals with free sugars and fats (Wagner et al., 2017). It can affect the psychological wellbeing of a person by lowering their self-esteem due to missing teeth.

Oral Health Care Models

OH is a subset of the overall system of health care that may either be private or public according to Cristina and Chaves (2012). In their study of the BrazillianBrazilian health system, the two adopted a hegemonic approach. The private medical care model was mainly curative in nature with specialised dentists who practised in isolation as a business entity providing services on demand. To attract more clients, doctors in private practice ensure that they have the latest technology, knowledge, equipment, and materials that would satisfy a potential client (Cristina and Chaves, 2012) . The public health model, on the other hand, is understood to go beyond curative services to include public oral health campaigns such as ‘community-supervised teeth brushing activity '. The objective of the public oral health model is not to respond to client demand but to carry out campaigns that will encourage the public to act to reduce risk factors for dental diseases. The public model would also encourage the use of fluoride to prevent tooth decay or the use of ionomers to improve the oral environment (Adeniyi, Sofola, and Kalliecharan, 2012; Cristina and Chaves, 2012). Access to high standards of dental care increases QoL (WHO, 2018a). Such access is heavily impacted by a client’s ability to utilise OH care (WHO, 2018a). In some countries, Universal Health Coverage (UHC) has helped breach the gap in funding for health (Fukushima, Adami and Palme, 2010; Joel et al., 2011; Goodwin et al., 2014). However, in some developed countries, UHC has not managed to be effectively implemented due to reasons such as a lack of goodwill, political interference, or resource constraints (Cristina and Chaves, 2012) . Donor-funded programs such as the "Non-Communicable Disease Prevention and Health Promotion (NPH)" department under WHO operates a Global Oral Health Program (ORH) are based mainly on the overall disease prevention and health promotion’s global strategies (Alfaqeeh et al., 2017; Petersen, 2003). In countries where the programme exists, oral health is looked at in a wholesome manner combining a variety of interventions that would not have been possible with the line basedline-based budgets of most countries.

Challenges of Oral Health care in PHCs

Financial challenges

There is a relationship between the level of income and access to quality healthcare services. A study by Velez et al. (2016 ) shows the percentage of people based on age and the level of income who sighted financial barriers as an impediment to oral care. The percentage of children declined from 10% to 6.8% in the years 2003-2004 to 2011-2012 respectively. The report shows that in the duration all the participants of all ages were likely to complain of financial barriers being the reason they did not access proper healthcare. One in five healthcare users cannot afford oral treatment in the United States of America (Brown et al., 2009). In support of the finding by Velez et al. (2016), the statistics by Brown et al. (2009) show the disproportionate burden poor Americans suffer from, oral disease. However, the information provided does not accurately show the latest trends, between 2010 and 2018 when the Affordable Care Act was fully implemented to increase access to health insurance coverage. Nevertheless, as per the assertions of Harnagea et al. (2017), the cost of dental treatment remains a significant barrier to accessing dental care . 2.7.2 Lack of perception of the need for oral health services The felt need for care translates into demand for healthcare services . Majority of people rarely present for routine dental checkups and will only present for dental services when in pain (Freeman, 2016). Oral health campaigns have helped increase awareness about dental conditions and encouraging people to present for a checkup (Shankar et al., 2017) . The Institute of Medicine and National Research Council (2011) reported that the lack of OH knowledge often leads to a poor understanding of the significance of OH. This includes misconceptions about OH. Public awareness of oral health is a prerequisite for better oral health choices. Public awareness campaigns have been shown to increase the perception of the need for service. (A lmutlaqah et al., 2018; Mahmoud et al., 2017). However, there is inadequate research in Saudi Arabia on public awareness of oral health (Almutlaqah et al., 2018). There is a need for a media campaign to educate people on the importance of OH . Saudi people do not frequently utilise preventive techniques against oral diseases. As a result, more initiatives are required in Saudi Arabia so that they can be aware that the prevention of oral diseases. Prevention is better than cure. The perception of need can also help the leaders to allocate more funding to oral health in the UHC system (Almutlaqah et al., 2018; Jaber and Da’ar, 2016). Thus, it is possible that addressing the gap of knowledge about the lack of information in Saudi Arabia about OH practice could promote OH promotion programmes, in turn reducing the prevalence of oral diseases.

'Shortage of qualified OH care providers

One of the critical challenges that PHCs face is the unavailability of professional dentists and dental staff. Almutlaqah et al. (2018) carried out research in Abha city, Saudi Arabia where they concluded that although there has been an increase of dental graduates in Saudi Arabia, the field still lacks enough professionals to cater to the whole population. The necessity and reliance of professionals in the health field limit the potential of other officers. In a clinic-based pilot study among Saudi adults, Al-Ansari (2016) noted that these are the clinicians who are constantly in contact with the patient and, although the health standards and ethics are against some, those officers could help reduce the big patient-doctor ratio. However, according to a study by Alshahrani and Raheel (2016), in KSA , on the availability of dental resources, professionals as well as level of their experience and skills are key to ensuring the quality of care for all patients. The five-year plan initiated in the KSA by the Ministry of Health has led to improvements and equitable redistribution of dental resources and facilities throughout the kingdom (Alshahrani and Raheel, 2016). Alfaqeeh (2015) in his study on “Access and utilisation of primary health care services in Riyadh Province, Kingdom of Saudi Arabia” stated that the primary care in oral health in KSA is currently provided by moiré than 2400 facilities along with specialised centres and clinic owned or linked to universities. However, Al-Jaber and Da'ar (2016) in the research on PHCs in Riyadh reported that 28% of the participants were unsatisfied by OHC services in primary care due to lack of enough dentists to serve them. They further established that unavailability of OH care providers in PHC was associated with the high percentage of patients who prefer private clinics . Similarly, other studies have identified the shortage of OH clinicians and caregiver as a major barrier in PHCs (Almutlaqah et al., 2018; Al-Ansari, 2016 ).

Time constraint

In any medical service, waiting time is a crucial indicator of the outcome quality of any medical service; therefore , OH providers should ensure the patients are served appropriately in the shortest time possible (Saddki, Yusoff, and Hwang, 2010). Extended waiting times for patients at clinics may lead to inadequate healthcare which scares the patients away; this means that there would be an increase in the cases of oral healthcare to be solved which would have been prevented (Saddki, Yusoff, and Hwang 2010). A study carried out in Abha city, Saudi Arabia by Almutlaqah et al. (2018) on "factors affecting access to oral health care among adults" established that the most common hindrance of dental services in KSA is the time constraint. Similarly, a study carried out in Jazan, KSA by Quadri et al. (2018) found that the long waiting periods in the OH made the patients avoid dental services in KSA; the more patients waited for the appointment, the more they became anxious to the extent that they no longer wanted to get treated. Another factor is the lack of specified time required between the dental visits (Allegranzi et al., 2009). Most practitioners recommend the six-month gap between the appointments; however, researches research on the subject shows that clinicians are not keen on the patient's risk as an individual (Allegranzi et al., 2009).


Culture is a key determinant of access to quality OH in primary health centres (Butani et al., 2008). In their study, carried out in the United States Butani et al. (2008) state that culture determines the health status of the mouth and teeth . Oral hygiene practice and the criteria used to tackle oral problems vary with different communities. For instance, the use of herbs and traditional plants in oral hygiene is part of the Islam culture and is passed down to generations; in their clinical trial, Bhambal et al. (2011) stated that Miswak is a chewable stick that is characterized by some content of Salvadora persica and is widely used for flossing and brushing in Islamic communities. Equally, the practice has been a part of KSA culture and is highly respected by the majority of the people. Many believe that it was passed down by Prophet Mohammed; however, the benefits of this hygiene technique do not come out clearly (Allegranzi et al., 2009). Use of Miswak prohibits access to modern dental hygiene and services . According to Almutlaqah et al. (2018), a study carried out in Abha city, Saudi Arabia, traditional practices and cultural beliefs about health are more common amongst the older and uneducated people; it influences their attitude towards modern practices . In their study on “Use of dental clinics and oral hygiene practices in the Kingdom of Saudi Arabia”, El Bcheraoui et al. (2016) noted that dietary habits also affected the incidence and prevalence of dental problems especially increased intake of foods that have high sugar content, and other sweetened products. Indeed, high sugar content ; it is a significant cause of the high record of dental caries, periodontitis, and gingivitis in KSA . Culture dictates how people respond to problems; in this regard, oral health problems are not taken as a serious issue in many communities including the KSA population (Bhambal et al., 2011). A significant percentage of KSA residents do not pay attention to regular dental appointments and only visit the clinic when there is an emergency or intolerable pain (Almutlaqah et al., 2018 ).


A 1930s poster from the Work Projects Administration promoting oral hygiene

Tooth decay is the most common global disease.[4] Over 80% of cavities occur inside fissures in teeth where brushing cannot reach food left trapped after eating and saliva and fluoride have no access to neutralize acid and remineralize demineralized teeth, unlike easy-to-clean parts of the tooth, where fewer cavities occur.

Teeth cleaning is the removal of dental plaque and tartar from teeth to prevent cavities, gingivitis, gum disease, and tooth decay. Severe gum disease causes at least one-third of adult tooth loss.

Since before recorded history, a variety of oral hygiene measures have been used for teeth cleaning. This has been verified by various excavations done throughout the world, in which chew sticks, tree twigs, bird feathers, animal bones and porcupine quills have been found. In historic times, different forms of tooth cleaning tools have been used. Indian medicine (Ayurveda) has used the neem tree, or daatun, and its products to create teeth cleaning twigs and similar products; a person chews one end of the neem twig until it somewhat resembles the bristles of a toothbrush, and then uses it to brush the teeth. In the Muslim world, the miswak, or siwak, made from a twig or root, has antiseptic properties and has been widely used since the Islamic Golden Age. Rubbing baking soda or chalk against the teeth was also common; however, this can have negative side effects over time.[5]

The Australian Healthcare and Hospital Association's (AHHA) most recent evidence brief [6]) suggests that dental check-ups should be conducted once every 3 years for adults, and 1 every 2 years for children. It has been documented that dental professionals frequently advise for more frequent visits, but this advice is contraindicated by evidence suggesting that check up frequency should be based on individual risk factors, or the AHHA's check-up schedule. Professional cleaning includes tooth scaling, tooth polishing, and, if tartar has accumulated, debridement; this is usually followed by a fluoride treatment. However, the American Dental Hygienists' Association (ADHA) stated in 1998 that there is no evidence that scaling and polishing only above the gums provides therapeutic value, and cleaning should be done under the gums as well.[7] The Cochrane Oral Health Group found only three studies meeting the criteria for inclusion in their study and found little evidence in them to support claims of benefits from supragingival (above the gum) tooth scaling or tooth polishing.[8]

Dental sealants, which are applied by dentists, cover and protect fissures and grooves in the chewing surfaces of back teeth, preventing food from becoming trapped and thereby halt the decay process. An elastomer strip has been shown to force sealant deeper inside opposing chewing surfaces and can also force fluoride toothpaste inside chewing surfaces to aid in remineralising demineralised teeth.[9]

Between cleanings by a dental hygienist, good oral hygiene is essential for preventing tartar build-up which causes the problems mentioned above. This is done through careful, frequent brushing with a toothbrush, combined with the use of dental floss or interdental brushes to prevent accumulation of plaque on the teeth.[10] Powered toothbrushes reduce dental plaque and gingivitis more than manual toothbrushing in both short and long term.[11] Further evidence is needed to determine the clinical importance of these findings.[11]

Patients need to be aware of the importance of brushing and flossing their teeth daily. New parents need to be educated to promote healthy habits in their children.


Dental plaque, also known as dental biofilm, is a sticky, yellow film consisting of a wide range of bacteria which attaches to the tooth surfaces and can be visible around the gum line. It starts to reappear after the tooth surface has been cleaned, which is why regular brushing is encouraged.[1] A high-sugar diet encourages the formation of plaque. Sugar (fermentable carbohydrates), is converted into acid by the plaque. The acid then causes the breakdown of the adjacent tooth, eventually leading to tooth decay.[12]

If plaque is left on a subgingival (under the gum) surface undisturbed, not only is there an increased risk of tooth decay, but it will also go on to irritate the gums and make them appear red and swollen.[1] Some bleeding may be noticed during tooth brushing or flossing. These are the signs of inflammation which indicate poor gum health (gingivitis).[13][1]


The longer that plaque stays on the tooth surface, the harder and more attached to the tooth it becomes. That is when it is referred to as calculus and needs to be removed by a dental professional.[1] If this is not treated, the inflammation will lead to the bone loss and will eventually lead to the affected teeth becoming loose.[14]

Tooth brushing[edit]

Routine tooth brushing is the principal method of preventing many oral diseases, and perhaps the most important activity an individual can practice to reduce plaque buildup.[15] Controlling plaque reduces the risk of the individual suffering from plaque-associated diseases such as gingivitis, periodontitis, and caries – the three most common oral diseases.[16] The average brushing time for individuals is between 30 seconds and just over 60 seconds.[17][18][19][20][21][22] Many oral health care professionals agree that tooth brushing should be done for a minimum of two minutes, and be practiced at least twice a day.[23] Brushing for at least two minutes per session is optimal for preventing the most common oral diseases, and removes considerably more plaque than brushing for only 45 seconds[15][23]

Toothbrushing can only clean to a depth of about 1.5 mm inside the gingival pockets, but a sustained regime of plaque removal above the gum line can affect the ecology of the microbes below the gums and may reduce the number of pathogens in pockets up to 5 mm in depth.[24]

Toothpaste (dentifrice) with fluoride is an important tool to readily use when tooth brushing. The fluoride in the dentifrice is an important protective factor against caries, and an important supplement needed to remineralize already affected enamel.[25][needs update][26][needs update] However, in terms of preventing gum disease, the use of toothpaste does not increase the effectiveness of the activity with respect to the amount of plaque removed.[15]

Manual tooth brush[edit]

The modern manual tooth brush is a dental tool which consists of a head of nylon bristles attached to a long handle to help facilitate the manual action of tooth brushing. Furthermore, the handle aids in reaching as far back as teeth erupt in the oral cavity. The tooth brush is arguably a person's best tool for removing dental plaque from teeth, thus capable of preventing all plaque-related diseases if used routinely, correctly and effectively. Oral health professionals recommend the use of a tooth brush with a small head and soft bristles as they are most effective in removing plaque without damaging the gums.[27]

The technique is crucial to the effectiveness of tooth brushing and disease prevention.[27] Back and forth brushing is not effective in removing plaque at the gum line. Tooth brushing should employ a systematic approach, angle the bristles at a 45-degree angle towards the gums, and make small circular motions at that angle.[27] This action increases the effectiveness of the technique in removing plaque at the gum line.

Electric tooth brush[edit]

Electric toothbrushes are toothbrushes with replaceable moving or vibrating bristle heads. The two main types of electric toothbrushes are the sonic type which has a vibrating head, and the oscillating-rotating type in which the bristle head makes constant clockwise and anti-clockwise movements.

Sonic or ultrasonic toothbrushes vibrate at a high frequency with a small amplitude, and a fluid turbulent activity that aids in plaque removal.[28][29] The rotating type might reduce plaque and gingivitis compared to manual brushing, though it is currently uncertain whether this is of clinical significance.[30] The movements of the bristles and their vibrations help break up chains of bacteria up to 5mm below the gum line.[28] The oscillating-rotating electric toothbrush on the other hand uses the same mechanical action as produced by manual tooth brushing – removing plaque via mechanical disturbance of the biofilm – however at a higher frequency.

Using electric tooth brushes is less complex in regards to brushing technique, making it a viable option for children, and adults with limited dexterity. The bristle head should be guided from tooth to tooth slowly, following the contour of the gums and crowns of the tooth.[27] The motion of the toothbrush head removes the need to manually oscillate the brush or make circles.


Tooth brushing alone will not remove plaque from all surfaces of the tooth as 40% of the surfaces are interdental.[2] One technique that can be used to access these areas is dental floss. When the proper technique is used, flossing can remove plaque and food particles from between the teeth and below the gums. The American Dental Association (ADA) reports that up to 80% of plaque may be removed by this method.[31] The ADA recommends cleaning between the teeth as part of one's daily oral hygiene regime.[31]

There are different types of floss available, including:[1]

  • Unwaxed floss: Unbound nylon filaments that spread across the tooth. Plaque and debris get trapped for easy removal.[1]
  • Waxed floss: less susceptible to tearing or shredding when used between tight contacts or areas with overhanging restorations.[1]
  • Polytetrafluoroethylene (Teflon): Slides easily through tight contacts and does not fray.[1]
A dental hygienist demonstrates dental flossing.

The type of floss used is a personal preference, however without proper technique it may not be effective.[32] The correct technique to ensure maximum plaque removal is as follows:[1]

  1. Floss length: 15–25 cm wrapped around middle fingers.
  2. For upper teeth grasp the floss with thumb and index finger, for lower teeth with both index fingers. Ensure that a length of roughly an inch is left between the fingers.
  3. Ease the floss gently between the teeth using a back and forth motion.
  4. Position the floss in such a way that it becomes securely wrapped around the interdental surface of the tooth in a C shape.
  5. Ensure that the floss is taken below the gum margins using a back and forth up and down motion.

There are a few different options on the market that can make flossing easier if dexterity or coordination is a barrier, or as a preference over normal floss. Floss threaders are ideal for cleaning between orthodontic appliances, and flossettes are ideal for those with poor dexterity.[1]

Interdental brushes[edit]

Interdental brushes come in a range of color-coded sizes. They consist of a handle with a piece of wire covered in tapered bristles, designed to be placed into the interdental space for plaque removal.[1] Studies indicate that interdental brushes are equally or more effective then floss when removing plaque and reducing gum inflammation.[1]

The steps in using an interdental brush are as follows:[1]

  1. Identify the size required, the largest size that will fit without force is ideal Often more than one size is required in the mouth.
  2. Insert the bristles into the interdental space at a 90-degree angle.
  3. Move the brush back and forth between the teeth.
  4. Rinse under water to remove debris when necessary.
  5. Rinse with warm soapy water once complete, and store in a clean dry area.
  6. Replace once bristles are worn.

Tongue scrapers[edit]

The tongue contains numerous bacteria which causes bad breath. Tongue cleaners are designed to remove the debris built up on the tongue. Using a toothbrush to clean the tongue is another possibility, however it might be hard to reach the back of the tongue and the bristles of the toothbrush may be too soft to remove the debris. Some may find it easier to use a tongue scraper instead because it does not tend to cause a gag reflex as readily as a toothbrush.[1] Steps of using a tongue scraper:

  1. Rinse the tongue scraper in order to clean it and remove any present debris
  2. Start at the back of the tongue and gently scrape forwards
  3. Be sure to clean the sides of the tongue as well, not just the middle portion
  4. After the cleaning is completed, rinse the tongue scraper and any debris that is left behind
  5. Rinse the mouth[33]

Oral irrigation[edit]

Some dental professionals recommend subgingival irrigation as a way to clean teeth and gums.[34][35][36][37]

Single-tufted brushes[edit]

Single-tufted brushes are a tool in conjunction with tooth brushing.[38] The tooth brush is designed to reach the ‘hard to reach places’ within the mouth. This tool is best used behind the lower front teeth, behind the back molars, crooked teeth and between spaces where teeth have been removed.[3] The single- tufted brush design has an angled handle, a 4mm diameter and rounded bristle tips.[3]

Food and drink[edit]

Foods that help muscles and bones also help teeth and gums. Vitamin C is needed for healthy gums, to prevent scurvy.

Eating a balanced diet and limiting snacks can help prevent tooth decay and periodontal disease.[citation needed] The Fédération dentaire internationale (FDI World Dental Federation) has promoted foods such as raw vegetables, plain yogurt, cheese, or fruit as dentally beneficial—this has been echoed by the American Dental Association (ADA).[39]

Beneficial foods[edit]

Community water fluoridation is the addition of fluoride to adjust the natural fluoride concentration of a community's water supply to the level recommended for optimal dental health, approximately 1.0 ppm (parts per million).[40] Fluoride is a primary protector against dental cavities. Fluoride makes the surface of teeth more resistant to acids during the process of remineralization. Drinking fluoridated water is recommended by some dental professionals while others say that using toothpaste alone is enough. Milk and cheese are also rich in calcium and phosphate, and may also encourage remineralization. Foods high in fiber may help to increase the flow of saliva and a bolus of fibre like celery string can force saliva into trapped food inside pits and fissures on chewing surfaces where over 80% of cavities occur, to dilute carbohydrates like sugar, neutralize acid and remineralize teeth on easy to reach surfaces.

Harmful foods[edit]

Sugars are commonly associated with dental cavities. Other carbohydrates, especially cooked starches, e.g. crisps/potato chips, may also damage teeth, although to a lesser degree (and indirectly) since starch has to be converted to glucose by salivary amylase (an enzyme in the saliva) first. Sugars that are higher in the stickiness index, such as toffee, are likely to cause more damage to teeth than those that are lower in the stickiness index, such as certain forms of chocolate or most fruits.

Sucrose (table sugar) is most commonly associated with cavities. The amount of sugar consumed at any one time is less important than how often food and drinks that contain sugar are consumed. The more frequently sugars are consumed, the greater the time during which the tooth is exposed to low pH levels, at which point demineralisation occurs (below 5.5 for most people). It is important therefore to try to encourage infrequent consumption of food and drinks containing sugar so that teeth have a chance to be repaired by remineralisation and fluoride. Limiting sugar-containing foods and drinks to meal times is one way to reduce the incidence of cavities. Sugars from fruit and fruit juices, e.g., glucose, fructose, and maltose can also cause cavities.

Sucrose is used by Streptococcus mutans bacteria to produce biofilm. The sucrose is split by glucansucrase, which allows the bacteria to use the resulting glucose for building glucan polymer film and the resulting fructose as fuel to be converted to lactic acid.

Acids contained in fruit juice, vinegar and soft drinks lower the pH level of the oral cavity which causes the enamel to demineralize. Drinking drinks such as orange juice or cola throughout the day raises the risk of dental cavities tremendously.

Another factor which affects the risk of developing cavities is the stickiness of foods. Some foods or sweets may stick to the teeth and so reduce the pH in the mouth for an extended time, particularly if they are sugary. It is important that teeth be cleaned at least twice a day, preferably with a toothbrush and fluoride toothpaste, to remove any food sticking to the teeth. Regular brushing and the use of dental floss also removes the dental plaque coating the tooth surface.

Chewing gum[edit]

Chewing gum assists oral irrigation between and around the teeth, cleaning and removing particles, but for teeth in poor condition it may damage or remove loose fillings as well. Dental chewing gums claim to improve dental health. Sugar-free chewing gum stimulates saliva production, and helps to clean the surface of the teeth.[41]


When it comes to chewing ice, many might think it will do no harm since ice is made from water. However, chewing on solid objects such as ice can have catastrophic consequences for your teeth. Chipping may occur and this can lead to more tooth fractures in the future. Chewing on ice has been linked to symptoms of anemia. People with anemia tend to want to eat food with no nutritional value.[42][43]


Drinking dark colored beverages such as wine or beer may stain the teeth leading to a discolored smile. Drinking high-concentration alcohol can lead to a dry mouth, with little saliva to protect the teeth from plaque and bacteria.[44]


Smoking is one of the leading risk factors associated with periodontal diseases.[45][46] It is thought that smoking impairs and alters normal immune responses, eliciting destructive processes while inhibiting reparative responses promoting the incidence and development of periodontal diseases.[47]

Regular vomiting, as seen in bulimia nervosa and morning sickness also causes significant damage, due to acid erosion.


There are three commonly used kinds of mouthwash: saline (salty water), essential oils (Listerine, etc.), and chlorhexidine gluconate.


Saline (warm salty water) is usually recommended after procedures like dental extractions. In a study completed in 2014, warm saline mouthrinse was compared to no mouthrinse in preventing alveolar osteitis (dry socket) after extraction. In the group that was instructed to rinse with saline, the prevalence of alveolar osteitis was less than in the group that did not.[48]

Essential oils (EO) or cetyl pyridinium chloride (CPC)[edit]

Essential oils, found in Listerine mouthwash, contains eucalyptol, menthol, thymol, and methyl salicylate. CPC containing mouthwash contains cetyl pyridinium chloride, found in brands such as Colgate Plax, Crest Pro Health, Oral B Pro Health Rinse. In a meta-analyses completed in 2016, EO and CPC mouthrinses were compared and it was found that plaque and gingivitis levels were lower with EO mouthrinse when used as an adjunct to mechanical plaque removal (toothbrushing and interdental cleaning).[49]


Chlorhexidine gluconate is an antiseptic mouthrinse that should only be used in two-week time periods due to brown staining on the teeth and tongue.[50] Compared to essential oils, it is more efficacious in controlling plaque levels, but has no better effect on gingivitis and is therefore generally used for post-surgical wound healing or the short-term control of plaque.[51]

Sodium hypochlorite[edit]

As mentioned earlier, sodium hypochlorite, a common household bleach, can be used as a 0.2% solution for 30 seconds two or three times a week as a cheap and effective means of combating harmful bacteria. The commercial product is 5% or 6%, so this requires diluting the product by a factor of about 30 (half a tablespoon in a full glass of water). The solution will lose activity with time and may be discarded after one day.[24]

Denture care[edit]

Dentures, retainers, and other appliances must be kept extremely clean. It is recommended that dentures be cleaned mechanically twice a day with a soft-bristled brush and denture cleansing paste. It is not recommended to use toothpaste, as it is too abrasive for acrylic, and will leave plaque retentive scratches in the surface.[52]

Dentures should be taken out at night, as leaving them in whilst sleeping has been linked to poor oral health. Leaving a denture in during sleep reduces the protective cleansing and antibacterial properties of saliva against Candida albicans (oral thrush) and denture stomatitis; the inflammation and redness of the oral mucosa underneath the denture.[53] For the elderly, wearing a denture during sleep has been proven to greatly increase the risk of pneumonia.[53]

It is now recommended that dentures should be stored in a dry container overnight, as keeping dentures dry for 8 hours significantly reduces the amount of Candida albicans on an acrylic denture.[54] Approximately once a week it is recommended to soak a denture overnight with an alkaline-peroxide denture cleansing tablet, as this has been proved to reduce bacterial mass and pathogenicity.[55]Duyck J, Vandamme K, Muller P, Teughels W (December 2013). "Overnight storage of removable dentures in alkaline peroxide-based tablets affects biofilm mass and composition". Journal of Dentistry. 41 (12): 1281–9. doi:10.1016/j.jdent.2013.08.002. PMID 23948391.</ref>


To become a dental hygienist in the US one must attend a college or university that is approved by the Commission on Dental Accreditation and take the National Board Dental Hygiene Examination. There are several degrees one may receive. An associate degree after attending community college is the most common and only takes two years to obtain. After doing so, one may work in a dental office. There is also the option of receiving a bachelor's degree or master's degree if one plans to work in an educational institute either for teaching or research.

Oral hygiene and systemic diseases[edit]

Several recent clinical studies suggest oral disease and inflammation (oral bacteria & oral infections) may be a risk factor for serious systemic diseases, such as:[56][57]

See also[edit]


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