Essential Elements of Oral Care: Brushing, Flossing, and Rinsing

Gains in oral health have been considerable in the last 50 years. However, by adolescence 68% of people have tooth decay and gingivitis is also prevalent, with 50% of US adults experiencing this around a minimum of three to four teeth. Brushing and flossing are typically considered to be the basic procedures required for good oral hygiene; yet oral hygiene is generally inadequately performed. Patient compliance issues related to brushing and flossing are well documented and well recognized. Rinsing offers an opportunity to reduce plaque and gingivitis, incremental to the reductions obtained by brushing and flossing alone. Use of a chemotherapeutic mouthrinse together with brushing and flossing as a three-step program may help to reduce plaque accumulation and prevent the formation of mature plaque and the onset of disease. Introduction and Overview Gains in oral health, together with the wider variety and improved designs of oral hygiene aids, have been considerable in the last 50 years. However, oral health statistics indicate that there is still room for improvement. Gingivitis is prevalent, with 50% of US adults experiencing gingivitis around a minimum of three to four teeth.1 Gingivitis is a preventable and reversible disease, provided that adequate oral hygiene measures are in place and dental plaque is diligently removed. Gingivitis presents with gingival inflammation and redness and bleeding upon probing. Left untreated, gingivitis may progress to periodontal disease with soft and hard tissue destruction. Advanced periodontal disease occurs in only a small proportion of patients, affecting between 5% and 15% of adults. The presence and progress of periodontal disease depends on the host response and other factors. In the absence of periodontal bacteria and gingivitis it would not occur.2 Recent decreases in caries have been slight, based upon data from the 1999–2002 NHANES study in comparison to the previous NHANES study in the early 1990s. By adolescence, 68% of people have tooth decay, 90% of adults over the age of 40 have coronal caries, and 32% of adults over age 50 have root caries.3 Brushing and flossing are typically considered to be basic procedures for good oral hygiene. The first modern toothbrush with nylon bristles was available by 1938, and use in modern times of a floss-type oral hygiene aid was first addressed by Parmly in 1819 when he recommended that patients with gingivitis use “waxed silk” to clean their teeth interdentally.4 By the mid-1900s clinicians were recommending both toothbrushing and flossing for effective oral hygiene.5,6,7 More recently, electrically driven devices (first the electric toothbrush in 1960, followed later by electric interdental devices and oral irrigators) have become available as alternatives to manual devices. Chemotherapeutic pastes and rinses have been added to the arsenal of home care oral hygiene aids since 1914 (Figure 1). Standard oral hygiene techniques Brushing and flossing are commonly known by the general population to be important, and they have significantly contributed to improved oral health. Clinical trials in the 1960s demonstrated the importance of toothbrushing in preventing and reducing gingivitis in children and students.8,9 The classical study by Loe et al. demonstrated that cessation of brushing induces gingivitis.10 Regular removal of dental plaque before it matures will prevent the development of anaerobic-rich subgingival plaque. Until the third day of development, plaque is mostly streptococcal and rod species. The streptococci are acid-producing, resulting in the initiation and progression of caries, and dominate plaque from between two and six hours after the plaque starts to form until anaerobic bacteria appear in increasing numbers from day three onward.11 This corresponds with the findings of Lang et al. that experimental gingivitis can be induced by avoiding brushing for more than 48 hours.12 Immature plaque removal helps prevent the development of gingivitis associated with anaerobic microbiota and prevents the development of a thick, well-differentiated supragingival and subgingival plaque (Figure 2). Brushing alone has not been found to be effective in reducing caries unless done in combination with anticaries agents — predominantly as 1,000–11,000 ppm fluoride in regular dentifrices. Brushing without flossing — and without use of an alternative interdental oral hygiene aid such as interdental brushes — is ineffective at removing plaque interdentally. Flossing in addition to brushing was found to reduce the incidence of interproximal caries by 50% in one study of Figure 1. Evolution in Oral Care