Many different oral hygiene aids/tools are available and can work well. However, the certainty of the evidence to support the use of each individual aid/tool varies. Dental professionals are well placed to provide patients with information about which oral hygiene aids/tools will be of benefit to them.
Toothbrushes
Key recommendation
Advise patients to regularly clean their teeth and gums, using either a manual or rechargeable powered toothbrush, and that an effective technique should be employed.
(Strong recommendation; moderate certainty evidence)
The BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3) guideline6 and the Delivering Better Oral Health (DBOH) toolkit7 recommend the use of either a manual or powered toothbrush, with both considered to be effective provided that the correct technique is employed (see figure: Toothbrush heads).
A simple manual toothbrush with a small head and medium texture (left) and a simple head for a powered toothbrush (right).
Research suggests that, for the general population powered toothbrushes can remove more plaque than manual toothbrushes but the size of difference is small and its clinical benefit unclear.56, 60-63 The evidence is considered to be of moderate certainty; despite the significant risk of bias in some studies due to methodological and reporting issues, there was consistency of findings for improved plaque removal in favour of powered toothbrushes. However, manual toothbrushes can remove plaque effectively and it is likely that the skill and technique used during tooth cleaning is more important that any particular difference between manual and powered brushes.
Both guidelines note that the choice of toothbrush should be made on an individual patient basis, taking into account the patient’s abilities, needs, preferences, and manual dexterity.
Further details on the development of the recommendations in this guidance can be found in Methodology.
Factors to consider when discussing toothbrushes include toothbrush head size, mode of operation, general design, cost, environmental impact and patient preference. DBOH recommends a small toothbrush head with medium texture, as there is low certainty evidence that hard textured brushes can result in gingival lesions.64
Irrespective of brush type chosen, an effective toothbrushing technique is required and this should be taught as part of oral hygiene instruction. In situations where a patient is struggling to clean effectively with a manual toothbrush, suggesting the use of a powered toothbrush might be of benefit.
Advise patients that to prevent or control gingival inflammation (bleeding gums) they need to remove plaque with a toothbrush.
- Highlight that to control inflammation, plaque should be removed from their teeth and from the margin where the gum and tooth meet.
Advise patients to regularly clean their gums and teeth, using either a manual or rechargeable powered toothbrush, using an effective technique.
- Discuss with the patient the most appropriate type of toothbrush to use, taking account of their abilities, needs, preferences and manual dexterity.
- Manual and rechargeable powered toothbrush heads for daily use should be small, medium textured and of a simple design and should be changed when obvious signs of wear appear.
Advise patients to brush all tooth surfaces and where the tooth and the gum meet twice a day for at least 2 minutes.
- Adopting a methodical approach, cleaning the outside, inside and biting surfaces of the teeth, will ensure all surfaces are cleaned.
- Spitting toothpaste out and not rinsing after brushing is beneficial for caries prevention.
- Leaving an interval of at least 30 minutes between consuming acidic or erosive foods and/or drinks and toothbrushing will reduce the risk of enamel loss.
Advise patients with gingival inflammation, periodontitis, orthodontic appliances and/or complex restorations, that effective toothbrushing is likely to take longer than two minutes.
Advise patients that bleeding on brushing is a sign of gingival and periodontal inflammation and that they should not stop brushing if their gums bleed.
- If bleeding on brushing has been present, resolution of this signifies a reduction in inflammation.
Interdental cleaning
Key recommendations
Advise patients with a diagnosis of periodontitis to clean interdentally every day, using appropriately sized interdental brushes where the interdental space allows, and floss in interdental spaces too small to allow interdental brush use.
(Strong recommendation; moderate certainty evidence)
Advise patients without a diagnosis of periodontitis but who have gingival inflammation to clean interdentally as required to control their inflammation. The method and frequency of cleaning should be tailored to individual patients.
(Conditional recommendation; low to very-low certainty evidence)
As toothbrushing does not adequately clean the approximal tooth surfaces, cleaning interdentally is important to ensure effective plaque removal. A systematic review65 found that interdental cleaning using floss or interdental brushes may be more effective than toothbrushing alone to reduce gingivitis or plaque but noted that the overall effect sizes observed may not be clinically relevant. The authors observed that interdental brushes may be more effective than floss. The evidence is considered to be of low to very-low certainty due to risk of bias, substantial unexplained heterogeneity, and lack of precision in the effect estimates. Accordingly, DBOH recommends that patients clean interdentally daily, using an interdental brush where space allows, with dental floss/tape recommended for smaller spaces (see figure: Interdental cleaning aids). DBOH also suggests that interdental cleaning takes place before toothbrushing, as there is some evidence that doing so can help patients form a lasting habit.66
Images showing various interdental cleaning aids. The choice of aid should be customised to the patient and the area to be cleaned, for example interdental brushes with longer handles and working brush (top left of image) may be more suitable for posterior teeth.
In patients with a diagnosis of periodontitis, there is evidence from a systematic review that using interdental brushes in addition to manual toothbrushing is more effective at plaque removal than manual toothbrushing alone and that using interdental brushes in larger spaces where they fit is more effective than using dental floss.67 The evidence is considered to be of moderate certainty; the review employed a network meta-analysis so some of the comparisons were indirect, most studies included in the review were at high risk of bias but there was consistency of results across studies. Accordingly, the BSP-S3 guideline recommends that tooth brushing should be supplemented by the use of interdental brushes (where there is space for them) for patients in supportive periodontal care. It does not recommend floss as the first-choice method of interdental cleaning for these patients.
Further details on the development of the recommendations in this guidance can be found in Methodology.
Advise patients with a diagnosis of periodontitis to clean interdentally every day.
- Appropriately sized interdental brushes should be used where the interdental space allows, with floss used in interdental spaces too small to allow interdental brush use.
- To be effective, the interdental brush should fit snugly into the interdental space without the wire rubbing against the tooth. More than one size of interdental brush may be required depending on the sizes of the interdental spaces present.
- Patients with negative architecture of the papillae should be advised to press gently into the shallow craters. A larger interdental brush may be required to clean effectively.
Advise patients with gingival inflammation but who do not have a diagnosis of periodontitis to clean interdentally as required to control their inflammation.
Instruct patients in the use of interdental aids appropriate to their particular situation, including their level of manual dexterity and ability to use each type of aid.
Toothpaste
Key recommendation
Advise all patients to use a toothpaste containing 1350-1500 ppm fluoride to prevent dental caries.
(Strong recommendation; moderate certainty evidence)
There is insufficient evidence to support the use of toothpastes with additional additives to control gingivitis and periodontitis on a routine basis.
While there is moderate certainty evidence (as assessed within DBOH) supporting the value of toothbrushing with a fluoride-containing toothpaste for the prevention of dental caries,68 the evidence to support the use of specific toothpastes with additional additives to control gingivitis and periodontitis is less certain.
The BSP-S3 guideline includes a conditional recommendation that adjunctive antiseptics, delivered either by toothpaste or mouthrinses, may be considered in specific cases to help control gingival inflammation for patients in maintenance care. However, no specific recommendation was made on the most effective toothpaste due to a lack of evidence.
Further details on the development of the recommendations in this guidance can be found in Methodology.
Advise the patient that mechanical removal of plaque is of primary importance in the control of plaque biofilm and gingivitis. Toothpastes are considered an adjunct to this process and deliver fluoride, which is important in caries prevention.
- Advise the patient to use a toothpaste containing 1350-1500 ppm fluoride and to ‘spit, don’t rinse’ during tooth cleaning.
Advise the patient that there is no evidence to support the adjunctive use of antiseptics in toothpastes to control gingival inflammation and periodontitis on a routine basis.
Anti-plaque mouthwashes
The best way for patients to remove supragingival plaque is by effective use of a toothbrush and interdental cleaning aids.
Anti-plaque mouthwashes have bacteriostatic and bacteriocidal activity and inhibit the development of plaque biofilm. However, they have much less effect on established plaque biofilm and cannot prevent the progression of periodontitis. There is also no evidence that sporadic use has any benefit to patients. Anti-plaque mouthwashes can be used as a temporary primary oral hygiene measure or as an adjunct to toothbrushing and interdental cleaning for acute conditions as outlined below.
Note that chlorhexidine has been associated with a number of adverse effects, such as dry mouth and tooth staining. In addition, although rare, allergic reactions, including anaphylaxis, are a recognised adverse effect.
The BSP-S3 guideline states that adjunctive antiseptics may be considered, specifically chlorhexidine mouth rinses for a limited period of time, in periodontitis therapy, as an adjunct to mechanical debridement, in specific cases. It also states that it is necessary to optimize mechanical plaque control before considering chlorhexidine as an adjunct to subgingival instrumentation. The guideline notes that the 0.2% formulation is intended to be used for a limited period (typically 1-2 weeks) for specific clinical reasons, such as following periodontal surgery or other situations where mechanical plaque control is compromised.
DBOH also notes that chlorhexidine mouthwash is advised for short term use only.
The BSP-S3 guideline also states that antiseptic mouth rinses to control gingival inflammation in patients in supportive periodontal care can be considered. If used, formulations containing chlorhexidine, essential oils or cetylpyridinium chloride are suggested.
Consider prescribing 0.2% chlorhexidine gluconate for patients where pain limits mechanical plaque removal (e.g. for patients with desquamative gingivitis or patients with necrotising gingivitis/periodontitis) or where toothbrushing should be temporarily avoided (e.g. following periodontal surgery).*
N.B. Prescriptions should be short-term and for no more than 14 days.
Advise the patient to leave an interval of 30 minutes between using the mouthwash and toothbrushing.
*Refer to the SDCEP Drug Prescribing for Dentistry guidance95 for further details.
Other oral hygiene aids
Other oral hygiene aids, such as oral irrigators, woodsticks and rubber/elastomeric cleaning sticks, are available but the evidence to support their use is minimal and low certainty at best.65, 67
