Oral Hygiene, Toothpaste, & Toothbrushing

Introduction to Oral Hygiene

toothbrushing1Patients should understand that proper homecare is important for dental health.  In fact, assuming non-surgical or surgical periodontal treatment is not needed, the care that every individual provides to themselves while at home will outweigh the impact of professional dental hygiene visits.  Healthy patients are usually seen two times per year, because they are not viewed as currently susceptible to gum disease.  In the United States, the most frequent (intensive) dental hygiene schedule in which a patient would be maintained is four visits per year.  In this situation, four professional cleanings in a calendar year would still render a patient with 361 days per year on their own.  In looking at it this way, one can quickly determine why perfect homecare is so essential.

Patients should floss at least one time per day, before brushing their teeth.  In addition, patients should brush two or more times per day with a soft toothbrush, preferably after meals.  Some patients use mouthwashes that are beneficial if they are able to kill harmful bacteria in the mouth.  Examples of such mouthwashes include Listerine and Crest ProHealth rinses (over the counter), and Peridex (Chlorhexadine) prescription mouth rinses.  Finally, modern products do exist that can actually rebuild the enamel on the teeth and/or make the teeth much more resistant to cavities or gum disease.

Flossing Teeth

When flossing, it is essential to view the teeth as curved surfaces that the floss must engage to properly squeegee off the accumulated plaque in between the teeth and just below the gumline.  It is not correct to accelerate with the floss in between the teeth and strike the gums below the contact point—this can actually cause harm.  Rather, it is ideal to bend and curve the floss to clean the proximal areas of each tooth.  Floss threaders, while better to use then no floss at all, are much less beneficial as compared to traditional flossing techniques, as traditional floss can be manipulated more easily than the tight floss threaded through the floss threader.  If used aggressively, floss threaders can damage the gingival tissues or possibly contribute to floss cuts or even gingival recession.  After removing the plaque in between the teeth by flossing, brushing should commence.

Brushing Teeth

Brushing should be completed every day, at least two times per day, or ideally after every meal.  A soft bristled toothbrush (or softer) is recommended to lessen the abrasive capabilities of the brush against the teeth.  Brushing should be completed with a technique named the “Modified Bass Technique,” which essentially advises angling the bristles toward the gumline at approximately a forty-five degree angle and moving back and forth.  The majority of the plaque accumulation that causes harm to the teeth in terms of gum disease is harbored at the gumline—therefore all of these areas should be cleaned effectively.  In Dr. Engelberg’s opinion, most patients brush too hard for too short of a time period.  In fact, the exact opposite is preferred, with gentle brushing for at least two minutes multiple times per day.  A Sonicare toothbrush (electric toothbrush manufactured by Philips), in fact, has a timer that does not allow the brush to shut off for a minimum brush time of two minutes.

Choosing a Toothpaste

Dentifrice (toothpaste) selection is a very important choice today.  Any marketing company paired with a dental company will recommend a line of whitening toothpastes.  Today, if you walk into a pharmacy it is not uncommon to see over one hundred choices in the toothpaste section!  How do you select the right brand, flavor, size, and ability to whiten?  The fact is that nearly all whitening toothpastes do not actually whiten your teeth.  They are actually simply more abrasive, and therefore more aggressively remove surface stains from the teeth, which is why they claim themselves to be whitening toothpastes.  The downside, and it is substantial, is that continuous use of these toothpastes will actually abrade away the enamel and dentin on the teeth at a much more rapid rate then most non-whitening toothpastes.  Over time, this can cause problems with your teeth.

The Hefferren abrasivity test is the recommended test by the American Dental Association (ADA) to determine exactly how abrasive a toothpaste (or any oral healthcare product) is to the teeth.  The procedure for this test is actually quite complex, although accurate.  This testing starts when extracted teeth are bombarded with neutrons, which labels the teeth with radioactive phosphorous.  When the teeth are abraded away with brushing or toothpaste, the resulting slurry can then be quantitatively measured in terms of a radiation count per minute in each gram of slurry.46 The results of this test can be used to gauge how abrasive particular toothpastes actually are, and therefore how potentially damaging they could be long term when used on your teeth.  The results of a study by Glaxo Smith Kline, the manufacturer of Sensodyne toothpastes, are in the table below.  You can see that many of the whitening toothpastes are listed with larger (more abrasive) numbers than those toothpastes registering lower (less abrasive) numbers.46


How abrasive is your toothpaste relative to others?

The above chart illustrates the abrasive nature of some of the more popular whitening toothpastes.  Excessive use of these abrasive toothpastes over a long period of time may cause serious negative consequences—including the need for more dental work!  When combining these toothpastes with acidic foods and beverages, the results can be alarming.

The Impact of Foods

Below is a table which illustrates the acidity of popular foods and beverages.  The words “acid” and “base” are opposites of each other that chemically define a range across a spectrum from one through fourteen.  This range gives the “pH” of a food or drink.  The most acidic portion of the spectrum is 1, and the most basic portion of the spectrum is 14, and the number 7 is considered totally neutral.  Water, for example has a pH of 7.3.


In general, the more acidic a food or beverage, the more harmful it is for a tooth.  Teeth are comprised of minerals, such as calcium or fluoride, and when we ingest an acidic food or beverage, we are initially demineralizing the tooth surfaces and causing an injury.  The demineralization is usually offset by re-mineralization that happens when our saliva, which acts as a buffer, and/or dental products work to rebuild the tooth structure.  This is one reason why dental patients with dry mouth tend to have a greater propensity for tooth decay.  Cavity-causing bacteria release acids during metabolism that demineralize teeth, and can cause havoc in the oral cavity.  Likewise, patients should be cautious when consuming items listed at the top of the above chart which have a lower pH and are therefore acidic and also may cause harm to the teeth.