Toothbrush Techniques? EIOH Experts Weigh In

Only brush the teeth you want to keep, many dentists will quip.

But joking aside, how often and how well we brush our teeth can make a significantly positive or negative impact on our oral health.  A study published recently in the British Dental Journal and gaining wide media attention, showed that there is little agreement among experts around the world on the technique that is best to prevent cavities and gum disease.

Eastman Institute for Oral Health experts say the best technique for one person may not be the best approach for another.  

“Frankly, the best technique is whatever each person needs to do to for their particular dental situation,” stated Michael Yunker, DDS, EIOH assistant professor and assistant  program director for the Advanced Education in General Dentistry program. “Most people think the purpose of brushing and cleaning between the teeth is to remove food particles, when the real purpose is to remove dental plaque--the almost invisible layer of fluids, cells, food debris, and microorganisms that collects on the surfaces of the teeth and gums, leading to dental disease if left in place.” 

Because people are different, proper oral hygiene requires different approaches, depending on the oral conditions of each individual patient. In the past, Dr. Yunker said that patients were instructed to use the biggest, stiffest brush available and to brush hard.

“This is no longer the case,” Dr. Yunker explained. “A smaller brush will contact difficult-to -reach areas and the soft bristles are best for use against the delicate gm tissues.”

“Additionally, if there are spaces between the teeth that allow the bristles of the brush to extend to the areas between the teeth,” continued Dr. Yunker, “then more of the tooth surface can be reached by the toothbrush.”

However, if the teeth are crowded or at least touching, then the bristles are only able to contact the part of the teeth that is visible, no matter how well a person brushes.

“And then there are some who need an electric toothbrush because they have a disability or simply don't have the dexterity to use a regular toothbrush,” he added. “For some, another person may actually have to do the cleaning for them. You have to use whatever is easiest that still does the job. If the work becomes too hard or too time-consuming, a person's natural instinct is to not do it.”

After surveying dental association guidelines in the United States, Australia, Brazil, Canada, Denmark, Finland, Japan, Norway, Sweden and the United Kingdom, British researchers and authors of the study learned that six different methods of manual tooth brushing are recommended (described below). They also reviewed guidelines published by toothpaste and toothbrush companies, and textbooks at Eastman Dental Hospital in London, among other sources. Many, including the American Dental Association, recommend the Bass technique, holding the brush at a 45-degree angle to the gum and making very short back-and-forth movements.

“Generally, I suggest a scrubbing technique similar to the Bass Technique for brushing with the bristles directed toward the gum  and into the spaces between the teeth, trying to get the tips of the bristles to go into the area between the teeth and between the teeth and gums,” explained Dr. Yunker. “For the biting surfaces of the teeth, I suggest a back-and-forth scrubbing motion.”

Cleaning between the teeth depends on the condition of the gum tissues, and the size of the spaces between the teeth, Yunker added. “If there are minimal spaces between the teeth, then flossing is best, making sure to wrap the floss around the tooth to keep from cutting into the gum tissue.”

“If there are larger spaces between the teeth or the patient has bone loss from periodontal disease, I suggest Stimudents or other types of interdental picks or circular bristle brushes for interdental cleaning,” he said. “They are easier to use than floss and cover more surface area.”

Joseph Fantuzzo, DDS, MD, chair, Oral and Maxillofacial Surgery Division, also said that recommendations will vary per person, especially if they are recovering from oral surgery or for effecting hygiene around their dental implants, for example. “I recommend minimally brushing twice daily using a modified bass technique. I encourage my patients to spend 10 seconds per each tooth surface, and always remind them about the critical importance of flossing.”

Still, brushing is only part of an effective system of oral hygiene that will prevent and reduce dental problems, Dr. Yunker emphasized "An effective system of oral hygiene includes good nutritional habits, limiting snacks between meals, cleaning between the teeth, getting enough fluoride and visiting a dentist regularly on a schedule individualized for the patient. 

Toothpaste

So many options!  How does one know the best choice for a healthy smile?

Dr. Yunker suggests using fluoride-containing toothpaste that is not a tartar control paste, a stain removing paste, or a whitening paste. “These are too abrasive and if used by a vigorous brusher, will cause tooth and gum abrasion,” he said. “Some people are sensitive to the chemicals in tartar control toothpastes and notice gingival sensitivity and irritation after use.”

For more information about the wide range of toothpaste options, visit http://www.webmd.com/oral-health/guide/weighing-your-toothpaste-options

Toothbrushing Methods

Fones – this is the oldest method and is recommended mainly for children, using large sweeping circles over the teeth, with the toothbrush at right angles to the tooth surface.

Bass technique – emphasizes plaque removal from the area above and just below the gum line by holding the brush at a 45-degree angle to the gum and making very short back-and-forth movements.

Modified Bass – the bristle position and predominantly horizontal brush movements stay the same, but use vertical and sweeping motions to create circles

Stillman – similar to the Bass technique, but using vertical motions

Scrub – the simplest technique, the toothbrush is held parallel to the gingiva and horizontal motions are used to scrub the gingival crevice in an ordered fashion.

Hirschfield -circular motion is much smaller and concentrated

Other Brushing Tips

• Brush at least twice a day. One of those times should be just before you go to bed. When you sleep, your mouth gets drier. This makes it easier for acids from bacteria to attack your teeth.
• Brush lightly. Brushing too hard can damage your gums. It can cause them to recede (move away from the teeth). Plaque attaches to teeth like jam sticks to a spoon. It can't be totally removed by rinsing, but a light brushing will do the trick. Once plaque has hardened into calculus (tartar), brushing can't remove it. If you think you might brush too hard, hold your toothbrush the same way you hold a pen. This encourages a lighter stroke.
• Brush for at least two minutes. Set a timer if you have to, but don't skimp on brushing time. Two minutes is the minimum time you need to clean all of your teeth. Many people brush for the length of a song on the radio. That acts as a good reminder to brush each tooth thoroughly.
• Have a standard routine for brushing. Try to brush your teeth in the same order every day. This can help you cover every area of your mouth. If you do this routinely, it will become second nature. For example, you can brush the outer sides of your teeth from left to right across the top, then move to the inside and brush right to left. Then brush your chewing surfaces, too, from left to right. Repeat the pattern for your lower teeth.
• Always use a toothbrush with soft or extra-soft bristle. The harder the brush, the greater the risk of harming your gums.
• Change your toothbrush regularly. Throw away your old toothbrush after three months or when the bristles start to flare, whichever comes first. If your bristles flare much sooner than every three months, you may be brushing too hard. Try easing up.

Sources:   British Dental Journal   (www.nature.com/bdj)
                  Simple Steps to Better Dental Health (simplestepsdental.com)