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Dysbiotic oral biofilm accumulation is associated with many prevalent oral diseases, including caries, gingivitis, and periodontitis. One out of every four adults (26%) have untreated tooth decay,1 and approximately 42% of American adults older than 30 years of age have destructive periodontal disease.2 Oral hygiene practices performed diligently on a daily basis are crucial in preventing these oral diseases and maintaining treatment outcomes. Oral healthcare professionals commonly recommend daily toothbrushing and interdental cleaning to prevent the accumulation of plaque. Other commonly used adjuncts include mouthrinses and gingival irrigation devices. The global oral care market was estimated at $31.7 billion in 2020 and is expected to grow approximately 5.9% per year through 20283; it has also been speculated that the COVID-19 pandemic may contribute to an increased demand for oral hygiene products owing to more frequent detection of halitosis related to facemask wearing.3 Yet despite increased consumer spending on oral care products, a high prevalence of dental biofilm-induced disease persists, suggesting that, for many individuals, the performance of oral hygiene practices is generally inadequate. This article explores commonly recommended and effective oral hygiene practices and adjunctive oral hygiene aids that should be used by patients as part of their home care regimens to improve oral health.
ROLE OF DYSBIOTIC ORAL BIOFILM IN THE PATHOGENESIS OF ORAL DISEASE
Dysbiotic oral biofilm is a key initiating factor in the pathogenesis of many common oral diseases, including caries, gingivitis, and periodontitis (Figure 1 and Figure 2).
Dental caries has a multifactorial etiology. Carious lesions develop as a result of the presence of fermentable dietary carbohydrates and cariogenic bacteria.4 Acid produced by cariogenic microbes in dental biofilm reduces the pH of the oral cavity, inducing demineralization and dental caries.5 If left untreated, dental caries can lead to cavitation, pulpitis, and tooth loss.
Gingivitis is a nonspecific inflammatory lesion of the gingival tissues. The severity of gingival inflammation seen in patients with gingivitis is generally proportional to the amount of biofilm that accumulates at or just below the gingival margin.6 Gingivitis is characterized by the host immune response to dysbiotic biofilm, resulting in localized signs and symptoms of inflammation, eg, erythema, edema, and bleeding on probing.7 Furthermore, gingivitis can lead to periodontitis and is in fact a necessary precursor for this gum disease (although not all cases of gingivitis necessarily progress to periodontitis).8
Periodontitis is initiated by dysbiotic biofilm and is characterized by host response-mediated destruction of tooth-supporting hard and soft tissues, resulting in clinical attachment loss.9 Untreated periodontitis can lead to tooth loss over time, and it has been associated with myriad systemic diseases/conditions, including diabetes mellitus, rheumatoid arthritis, chronic kidney disease, adverse pregnancy outcomes, dementia, and atherosclerotic cardio- vascular disease, among others.10
ADJUNCTIVE ORAL HYGIENE AIDS
Given the critical role that dysbiotic biofilm plays in the development of these and other oral conditions, the importance of biofilm removal cannot be overstated. Individuals who follow home care recommendations, including at least once-daily toothbrushing, daily flossing, and regular attendance at dental appointments, are more likely to retain their teeth over the long term.11Further, patients with tooth surfaces that are 80% plaque-free and who maintain these low plaque levels tend to have consistently better periodontal health compared with patients in whom plaque is detected on more than 20% of their tooth surfaces.11,12 Thus, oral hygiene may be considered analogous to other wellness practices, such as exercise and diet, as a method for managing chronic conditions.11 The utilization of adjunctive oral hygiene aids (eg, mouthrinses, powered toothbrushes, interdental brushes, dental floss, oral irrigation devices, and dentifrices) can improve oral hygiene home care regimens and promote oral health.
Toothbrushing is the most common method to remove plaque from teeth.13 Current toothbrushing guidelines from the American Dental Association (ADA) promote twice-daily toothbrushing using a soft-bristled toothbrush and a fluoride-containing dentifrice for a minimum of 2 minutes.14 It is also recommended that toothbrushes (or toothbrush heads on powered toothbrushes) should be replaced every 3 to 4 months.14 Despite these recommendations, compliance with toothbrushing is low. One study reported that as many as 32% of individuals brush their teeth only once or less often per day.15Furthermore, these numbers may actually be inflated, as patients tend to overestimate brushing time and self-reporting of oral hygiene practices may introduce bias.
When it comes to manual toothbrush designs, no single design appears to be superior to the others.16 Similarly, no single brushing technique has been shown superiority to the others in reducing plaque and gingivitis.15 When using manual toothbrushes, patients should be instructed to focus on the cervical and interproximal areas, since these areas are prone to greater plaque accumulation and are also the areas where such accumulation can be most harmful.16Many brushing techniques have been described that may be applicable in a variety of different clinical scenarios. In the Bass technique, the brush head is angled at a 45-degree angle towards the gingiva and short back-and-forth vibratory strokes are used, with the bristles inside the gingival sulcus.17 An adaptation of the Bass technique (ie, the Modified Bass technique), in which circular motions are used instead of back-and-forth strokes, is the most commonly recommended toothbrushing technique.17Using the Modified Stillman technique, the brush is angled towards the gingival sulcus, with the brush head progressively turned in the occlusal/incisal direction.18 The Modified Stillman technique may be appropriate for post- operative oral hygiene and/or in areas prone to gingival recession.
Powered vs Manual Toothbrushes
Some research has shown that powered toothbrushes provide superior biofilm removal compared with manual toothbrush use.16Powered toothbrushes improve patients' ability to remove supragingival plaque and are at least as effective as manual toothbrushes in reducing plaque indices and gingivitis.11 Current recommendations from the ADA suggest that powered toothbrushes may be especially advantageous for individuals with poor dexterity or other reasons (eg, cognitive impairment) for reduced ability to perform toothbrushing effectively as part of their home care.19 The "financial investment" that a patient has made in purchasing an electric toothbrush may also serve as a motivator to perform toothbrushing more regularly. It should be noted, however, that the brushing techniques used with powered toothbrushes differ from those used with manual toothbrushes, and oral healthcare professionals should therefore instruct patients on the best practices for the use of the different types of toothbrushes.
Mechanisms of Action of Powered Toothbrushes
Powered toothbrushes vary depending on their mechanism of action. Meta-analysis suggests that powered toothbrushes that employ rotation/oscillation brush strokes provide super- ior reductions in plaque accumulation and gingival inflammation compared with those that have other mechanisms of action.11 Additionally, while both sonic toothbrushes and rotation/oscillation brush strokes have demonstrated superiority over the brush stroke movements used with manual toothbrushes, other mechanisms of action, including rotation, side-to-side, or counter-oscillation, have not been found to be superior to the brush stroke movements used with manual brushes.20
Toothbrushing is necessary but not sufficient to achieve biofilm removal on all tooth surfaces. Effectively cleaning the interproximal surfaces of teeth with a toothbrush is difficult if not impossible. Because interproximal access is challenging to attain and failure to use interproximal cleaning techniques is common for many patients, interproximal areas are frequently affected by gingivitis and perio- dontitis.16 For this reason, daily interdental cleaning is endorsed by the ADA as an essential oral hygiene practice.21 It has also been determined that toothbrushing and flossing sequence is important, with flossing prior to brushing having been shown to be more effective than flossing after brushing.22
Dental floss has several advantages, including that it is inexpensive and readily available. However, many patients report difficulty with flossing, as it requires significant manual dexterity. In a systematic review of studies comparing toothbrushing versus toothbrushing plus flossing at three time points (1, 3, and 6 months), the addition of flossing to a toothbrushing regimen was found to provide significant benefit in reducing gingivitis at all study time points.23 Flossing can also be performed to clean contact points between teeth. In children with low exposure to fluoride, professional flossing has been found to be highly effective in reducing interproximal caries risk.24
While flossing can be effective, the number of individuals who floss daily is quite low, and therefore additional interdental cleaning methods should be recommended to improve interproximal biofilm removal and increase compliance. In one systematic review, interdental brushes (IDBs) were superior to dental floss in reducing plaque.25 IDBs are also more likely to be accepted by patients owing to their ease of use.20 However, IDBs are capa- ble of traumatizing the interdental papilla and leading to gingival recession at sites without adequately open embrasure spaces.20 For these reasons, professional selection of the size/shape of IDBs and educating patients about their proper use is recommended.20
Dentifrice (toothpaste) is widely recommended for use with toothbrushing. Dentifrice can include various ingredients, including those with anticaries and antimicrobial agents (which prevent gingivitis), among others.26
While the use of dentifrice alone may not provide a significant benefit compared with tooth brushing with water for improving gingival health, the use of fluoride-containing dentifrice has been shown to reduce caries rates.11,27 In fact, a linear correlation has been shown between dentifrice fluoride concentrations of up to 5,000 ppm and caries reduction.28Various compounds containing fluoride may be found in dentifrice, including sodium monofluorophosphate, sodium fluoride, and stannous fluoride.26Stannous fluoride has also been shown to have antigingivitis properties and act as a desensitizing agent for dentinal hypersensitivity.29
Additional Dentifrice Ingredients
Other ingredients incorporated in many dentifrices include pyrophosphate and zinc citrate, which act as anticalculus agents.16 Dentifrices that contain these ingredients may be desirable for patients whose teeth accumulate more calculus. Triclosan is another ingredient that may be found in certain dentifrices that works against both gram-negative and gram-positive bacteria to aid in preventing plaque accumulation.16 It should be noted that no commercially available triclosan-containing dentifrices are currently sold in the United States and there have been concerns about the systemic impact of triclosan on overall health.11Additionally, calcium sodium phosphosilicate (CSP), strontium, and potassium plus hydroxyapatite have been shown to help reduce dentin sensitivity.29 A novel 2.6% ethylenediaminetetraacetic acid (EDTA)-containing dentifrice has been found to have a significant benefit on plaque, gingival inflammation, and bleeding on probing.30,31 Furthermore, in patients with periodontitis who were receiving periodontal maintenance therapy, use of a 2.6% EDTA dental gel significantly reduced probing depth reductions, gingival inflammation, and bleeding on probing.32
Mouthrinses may be an effective adjunct to a patient's oral hygiene regimen. The common active ingredients of most mouthrinses are useful in reducing plaque and gingivitis, and their ease of use makes them ideal for home care.
Fluoride-containing mouthrinses may promote remineralization of enamel33 and can reduce the formation of carious lesions by as much as 20% to 25%.16A Cochrane systematic review demonstrated that fluoride-containing mouthrinses reduced caries rates in children, regardless of other fluoride exposure.33
In part due to the substantivity of chlorhexidine, mouthrinses that contain this ingredient are effective in reducing plaque and gingival inflammation.11 In a systematic review, it was reported that chlorhexidine reduced plaque by 33% and gingival inflammation by 26% compared with control mouthrinses.34Chlorhexidine-containing mouth rinses are available in concentrations from 0.1% to 0.2% worldwide, with 0.12% available in the United States. Multiple studies have concluded that higher concentrations do not seem to provide a significant clinical benefit over lower concentrations.35,36 Patients should be advised to brush prior to using a chlorhexidine-containing mouthrinse, since chlorhexidine is inactivated by the anionic surfactants found in many dentifrices.16
Essential Oil-Containing Mouthrinses
Essential oil (EO) mouthrinses, which contain thymol and eucalyptol, along with menthol and methyl salicylate, are widely used oral hygiene products.37 Unlike chlorhexidine-containing mouthrinses, EO mouthrinses do not stain the teeth, and they have been shown to be safe for long-term use without promoting bacterial resistance.37However, EO mouthrinses do not offer the prolonged activity provided by chlorhexidine substantivity and are therefore inferior to chlorhexidine mouthrinses in reducing gingival inflammation.11,37
Oral Irrigation Devices
In 2001, the American Academy of Periodontology (AAP) stated that adjunctive supragingival irrigation, with or without medicaments, improved gingival inflammation reduction compared with toothbrushing alone.38,39While irrigation devices designed for subgingival delivery have been shown to achieve up to 90% periodontal pocket penetration with probing depths of 6 mm,38,40 many commercial irrigators are able to penetrate only half the depth of pockets, with the greatest penetration occurring in shallower pockets.38,41Adjunctive use of oral irrigation may improve outcomes, but it is important to note that the use of an oral irrigator cannot replace primary mechanical plaque removal.
Appropriate oral hygiene practices performed daily by patients at home are critical to the prevention of oral diseases such as caries, gingivitis, and periodontitis, as well as for the maintenance of oral health after successful dental treatment. A wide array of adjunctive oral hygiene aids are available on the market, and oral healthcare providers thus have many tools at their disposal to recommend to their patients for improved oral hygiene practices. The importance of encouraging patients to perform daily oral hygiene practices cannot be overstated, and all oral healthcare providers should bear responsibility in educating patients about the optimal techniques and products that can be utilized to help improve their oral hygiene. Because improved oral health, which is easily and effectively achieved through home care prevention of caries and gingivitis, can have such a significant impact on patients' quality of life, providing effective and individualized oral hygiene recommendations affords dental healthcare professionals a wonderful opportunity to touch the lives of their patients.
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