Oral hygiene

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Proper oral hygiene requires regular brushing and flossing

Oral hygiene is an important part of a daily routine. It is the practice of keeping one's mouth clean and free of disease, by regular brushing and cleaning in between the teeth. It is important oral hygiene is completed on a regular basis, as it can prevent dental disease from occurring. The most common types of dental disease is dental decay (also known as dental caries), gingivitis and periodontitis.[1] Regular brushing consists of brushing twice a day after breakfast and before going to bed. Cleaning in between your teeth is called interdental cleaning and it is equally important as tooth brushing.[2] This is because a toothbrush cannot reach between your teeth, therefore only cleaning 50% of the surfaces. There are many tools to clean between the teeth, these include floss, flossettes, interdental brushes, wood sticks and gum picks. It is generally up to each individual to choose which tool they would prefer to use.

A healthy smile


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.

Tooth decay is the most common global disease.[3] Over 80% of cavities occur inside fissures in teeth where brushing cannot reach food left trapped after every meal or snack and saliva or fluoride have no access to neutralise acid and remineralise demineralised teeth, unlike easy-to-clean parts of the tooth, where fewer cavities occur.

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 thus halting the decaying 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.[4]

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 were recovered. Many people used different forms of teeth cleaning tools. 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]

Generally, dentists recommend that teeth be cleaned professionally at least twice per year.[6] 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) publicly stated in 1998 that there is an absence of evidence that scaling and polishing provides therapeutic value.[7] The Cochrane Oral Health Group reviewed nine studies but found them to be of insufficient quality and not enough evidence to support the claims of the benefits of regular tooth scaling or tooth polishing.[8][needs update]

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 to prevent accumulation of plaque on the teeth.[9] Powered toothbrushes reduce dental plaque and gingivitis more than manual toothbrushing in both short and long term.[10] Further evidence is needed to determine the clinical importance of these findings.[10]

Dentist and dental hygienist are about preventing tooth loss and gum disease. The patient needs to be aware of the importance of brushing and flossing their teeth daily. New parents need to be educated to promote a healthy life and mouth for their children. At any age; a person should be notified about how to take care of their teeth and how they will be able to keep their teeth and not need dentures.


Plaque is also widely 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 influences the make-up of plaque. Sugar (fermentable carbohydrates), is converted into acid by the plaque. The acid is then responsible for the breakdown of the top layer of the teeth, eventually leading to tooth decay [11].

If plaque is left on the tooth 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 [12][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 is required to be removed by a dental professional [1]. If this is not treated, the inflammation will lead to the bone loss and eventually lead to the effected teeth to become lose [13]. That is why it is important to clean away the plaque and prevent it from staying on the tooth surface for a long period of time.

Tooth Brushing[edit]

Routine tooth brushing is the principle method of preventing many oral diseases, and perhaps the most important activity an individual can practice to reduce plaque buildup.[14] 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 in the world.[15] The average brushing time for individuals is between just over 30 seconds to just over 60 seconds.[16][17][18][19][20][21] Many oral health care professionals agree on the consensus that tooth brushing should take a minimum of 2 minutes, and be practiced at least twice a day.[22] Brushing for at least 2 mins per session is optimal for preventing the most common oral diseases, and removes considerably more plaque than brushing only for 45 seconds[14][22]

Dental dentifrices (toothpaste)‍‌‍‌ 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 remineralise already affected enamel.[23][24] In preventing gum diseases, the use of dental dentifrices toothpaste does not assist the effectiveness of the activity with respect to amount of plaque removed.[14]

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 (mouth). The tooth brush is arguably a person’s greatest tool at removing plaque from teeth, gums and the tongue, 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 that is most effective against removing plaque without damaging the surrounding tissues [25].

Technique is crucial to the effectiveness of tooth brushing and its influence on disease prevention [25]. Back and forth brushing is not effective in removing plaque surrounding the gum line. Brushing teeth should include systematic approach, whilst angling the bristles at a 45-degree angle towards the gums, and doing small circular motions at that angle [25]. This action increases the effectiveness of the technique with respect to 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 include the sonic range which has a vibrating head, and the oscillating-rotating range where the bristle head makes constant clockwise and anti-clockwise movements.

Sonic toothbrushes emit a high frequency of vibrations with a small amplitude, and a fluid turbulent activity that aids in plaque removal [26][27]. The movements of the bristles and their vibrations help break up chains of bacteria up to 5mm below the gum line [26]. The oscillating-rotating electric toothbrush on the other hand uses the same mechanical action 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 conditions that may inhibit them from full dexterity. The bristle head should be guided from tooth to tooth slowly, following the contour of the gums and crowns of the tooth [25]. The independent motions of the toothbrush head will take away from the need to manually wiggle the brush or to do circles.


Tooth brushing alone will not remove plaque from all surfaces of the tooth as 40% of the surfaces are interdentally [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) even reports that up to 80% of plaque may be removed by this method [28]. The ADA suggested cleaning between your teeth as part of a daily oral hygiene regime [28].

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

  • Unwaxed floss: Unbound nylon filaments that spread across the tooth and plaque/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 (PTFE): 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 the proper technique, research has shown that it may not be effective[29]. The correct technique to ensure maximum plaque is as follows:[1].

  1. Floss length: 15 – 25cms wrapped around middle fingers.[1].
  2. For flossing on the maxilla, grasp the floss with thumb and forefinger, and with both forefingers when flossing the mandible. Ensure a length of roughly 2.5cms is left between the fingers[1].
  3. Ease the floss gently between the teeth using a back and forth motion[1].
  4. Position the floss in such a way that it becomes securely wrapped around the proximal surface of the tooth in a C shape[1].
  5. Ensure that the floss is taken below the gingival margins using a back and forth motion apico-coronally[1].

There are a few different options on the market to choose from 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 flossetts are ideal for those with poor dexterity[1].

Interdental brushes[edit]

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

The steps in using an interdental brush are as follows:

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

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:

·      Rinse the tongue scraper in order to clean it and remove any present debris

·      Start at the back of the tongue and gently scrape forwards

·      Ensure to clean the sides of the tongue as well, not just the middle portion

·      After the cleaning is completed, rinse the tongue scraper and any debris that is left behind

·      Rinse the mouth [30]

Oral irrigation[edit]

Some dental professionals recommend oral irrigation as a way to clean teeth and gums.[31][32][33][34]

Single-tufted brushes[edit]

Single-tufted brushes are a tool in conjunction with tooth brushing.[35] 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.[36] The single- tufted brush design has an angled handle, a 4mm diameter and a rounded bristle tips.[36]

Food and drink[edit]

Foods that help muscles and bones also help teeth and gums. Breads and cereals are rich in vitamin B while fruits and vegetables contain vitamin C, both of which contribute to healthy gum tissue.[citation needed] Lean meat, fish, and poultry provide magnesium and zinc for teeth.

Eating a balanced diet and limiting snacks can prevent tooth decay and periodontal disease.[dubious ] 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).[37][38]

Beneficial foods[edit]

Some foods may protect against cavities by naturally containing fluorine, from which fluoride is derived.[39] Fluoride is naturally present in all water. 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). One ppm is the equivalent of 1 mg/L, or 1 inch in 16 miles.[40] Fluoride is a primary protector against dental cavities. Fluoride makes the surface of teeth more resistant to acids during the process of remineralisation. 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 remineralisation. All foods increase saliva production, and since saliva contains buffer chemicals this helps to stabilize the pH to near 7 (neutral) in the mouth. Foods high in fiber may also 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 carbohydrate like sugar, neutralise acid and remineralise tooth like 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 sugars by salivary amylase (an enzyme in the saliva) first.[citation needed] 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 seem equally likely to cause cavities.[citation needed]

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[citation needed], 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]

Chewing Ice[edit]

When it comes to chewing ice, many might think it will do no harm since ice is made from water, and as many might know, water is great for the body. However, chewing on solid objects such as ice can have catastrophic consequences for your teeth. Chipping may occur and this can lead a pathway for greater teeth 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 not so white smile. Dryness is also another aftereffect of alcohol consumption leading to a dry mouth, preventing 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 mouthwash; saline (salty water), Essential Oils (Listerine, Colgate Plax, 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) post 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)

Essential oils, found in Listerine mouthwash, contains Eucalyptol, Menthol, Thymol, Methyl Calicylate. CPC containing mouthwash contains CetylPyridinium 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 can only be used in 2 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]

Denture care[edit]

Dentures, retainers, and other appliances must be kept extremely clean. It is recommended that dentures are 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 in an alkaline-peroxide denture cleansing tablet, as they have been proven to reduce bacterial mass and pathogenicity [55] [56]


To become a dental hygienist, one must attend a college or university that is approved by The Commission of Dental Accreditation and take the National Board Dental Hygiene Examination. There are a few degrees one may receive. An associate’s degree after attending community college is the most common and only takes at least two years to obtain one. After doing so, one may work in a dental office. There’s also the option of receiving a bachelor’s 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 potential risk factor for serious systemic diseases, such as:[57][58]

See also[edit]


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