Oral Health Topics

Home Oral Care

Introduction

Spending the right amount of time engaged in appropriate home oral care is
undoubtedly essential to helping minimize the risk of caries and periodontal
disease. An individual who visits the dentist twice a year for an oral exam and
dental prophylaxis will spend approximately two hours per year in the dental
chair. The time for that same person to brush and clean between his or her teeth
each day might be estimated to be around 30 hours per year. Considering the
amount of time that should be devoted to daily oral hygiene, it is important to
understand the scientific evidence that supports home oral care
recommendations made to patients.

In 2017, the ADA Council on Scientific Affairs identified three aspects of home
oral care that dentists should discuss with their patients:

1. General recommendations that are applicable to most people;

2. Personalized recommendations specifically targeted to meet the needs
of the individual patient, especially patients at increased risk of caries
and/or gingivitis; and
3. Lifestyle considerations to enhance oral health and wellness.

The general and personalized recommendations were developed in accordance

with a rapid evidence assessment methodology,1 meaning that the evidence
examined was derived from existing systematic reviews. Lifestyle considerations
comport with current ADA policy. This Oral Health Topic page is an executive
summary of that work and relevant ADA policy.

 General Recommendations for the Prevention of Caries and Gingivitis

1) Brush your teeth twice a day with a fluoride toothpaste

While a seemingly simple statement, the guidance for brushing twice daily with a
fluoride toothpaste weaves together a number of discrete components.

Toothbrushing frequency
Review of the scientific literature, along with guidance from governmental
organizations and professional associations found sufficient evidence to support
the contention that twice-daily brushing, when compared with lower frequencies,
was optimal for reducing risk of caries,2-4 gingival recession or periodontitis.5-7 It
is important to recognize that in these studies, it was the frequency of tooth-
brushing with a fluoride toothpaste that was evaluated rather than tooth-brushing
alone.

Fluoride toothpaste
Although the measures used to assess the benefit varied, studies examining the
effect of over-the-counter (OTC) fluoride dentifrice on caries incidence in children
and adolescents found the fraction of caries prevented ranged from 16% per tooth
to 31% per surface versus placebo or no dentifrice, and concluded that fluoride-
containing toothpaste was effective in caries control.4, 8, 9 In addition, high level
evidence shows that 5,000 ppm fluoride (available with a prescription) results in
significantly more arrest of root caries lesions than use of OTC levels of fluoride
(1,000 - 1,500ppm).10

Toothbrushing duration
Data examining the question of optimal duration of daily tooth-brushing
encounters relies on plaque indices which are surrogate measures rather than
direct measure of caries or gingivitis. Understanding that the use of surrogate
measures decreases the certainty with which a recommendation can be made,
the available systematic reviews found a brushing duration of two minutes was
associated with bigger reduction in plaque than brushing for a single minute. 11,
12 Two minutes per whole mouth can also be expressed as thirty seconds per

quadrant or about four seconds per tooth.

2) Clean between your teeth daily, While cleaning between teeth is important
to maintaining oral health, it is a concept that must overcome several barriers to
adoption. ”Flossing” is often used as a shorthand, common term for interdental
cleaning, which can become problematic in the real world where many report a
strong distaste for that particular activity.13 Some people presume flossing as
ineffective or unnecessary, which can also make it harder for them to adopt the
daily habit. Flossing is a technique-sensitive intervention14 as exemplified by the
disparity in benefit observed when comparing study designs involving self-
flossing and professional flossing.15 Where patients do not see positive results
from flossing, they may not continue to do so.

Using flossing as shorthand for interdental cleaning can also be problematic in

that patients may be unaware of alternative devices that may be more pleasant
or effective for them. A meta-review, which included the available devices
developed for this purpose (i.e. dental floss, interdental brushes, oral irrigators,
and woodsticks), addressed the question “What is the effect of mechanical inter-
dental plaque removal in addition to tooth brushing on managing gingivitis in
adults?” The strength of the evidence on the benefit ranged from weak to
moderate depending on the device in question.16
 Thus, there may not be one “best” interdental cleaning method; rather, the best
method for any given patient may be one in which they will regularly perform. A
guiding principle which is relevant to interdental cleaning is: “best care for each
patient rests neither in clinician judgment nor scientific evidence but rather in the
art of combining the two through interaction with the patient to find the best option
for each individual.”17

3) Eat a healthy diet that limits sugary beverages and snacks

While eating a healthy diet is important for overall health and well-being, a review
of the literature found little in terms of the effects of micronutrients on the risk of
caries or periodontal disease. However, the conclusion of numerous systematic
reviews on the effect of the macronutrient content of the diet, specifically of sugar,
is that there is an association between sugar intake and caries. 18-20 A review of
the evidence supporting nine international guidelines recommending decreased
consumption of sugar found consistent recommendations from all the groups
while noting that they relied on different data and rationales. 18

4) See your dentist regularly for prevention and treatment of oral disease
Viewed through the prism of the primary prevention of caries and/or gingivitis, a
systematic review of the literature failed to arrive at consensus regarding optimal
recall frequency to minimize either caries21, 22 or periodontal disease risk23 in part
due to limited availability of studies addressing this topic. Nonetheless, in terms
of the balance between resource allocation and risk reduction, it can be
concluded that there is merit in tailoring a patient’s recall interval to individual
need based on assessed risk of disease. 21, 24

Previously, the ADA Healthy Smile Tips advised people to “Visit your dentist
regularly.” However, dentists are doctors of oral health, which encompasses both
the prevention and treatment of oral disease. The current recommendation goes
a step further than its predecessor in articulating the duality of the dental
visits. Dental care includes actions to reduce disease risk, as well as the
formulation and execution of a treatment plan when disease is present.

 Personalized Recommendations for the Prevention of Caries and Gingivitis

While generalized recommendations for home oral care may be appropriate to

help optimize oral wellness for many patients, those found to be at elevated risk
of caries and/or gingivitis, may ask their dentists to provide guidance on additional
action steps that they can take to reduce their risk of oral disease. 25 To help
address this reality, the Council on Scientific Affairs recommends that dentists:
  Design a home care regimen with specific recommendations for oral
hygiene. This may involve consideration of not only the person’s
individual oral disease risk, but the needs and wants of the patient.
 Offer direction concerning lifestyle changes. This is addressed in the
next section, entitled “Lifestyle Considerations.”
 Provide guidance on dental products and mechanical devices.This
includes detailed suggestions that can help patients make decisions about
dental hygiene practices and products. Patients may look to their dentists
for guidance and recommendations to help discern among the plethora of
home oral care products and mechanical devices that lay claim to oral
health benefit. Dentists and patients can look to the ADA Seal of
Acceptance program as a source of validated information regarding the
safety and efficacy of many home oral care products.

After careful review of the available evidence, the Council on Scientific Affairs
provides the following rationale to inform decision-making between dentists and
patients on products and mechanical devices that can be considered as adjunct
therapies and modalities for the prevention of caries and/or gingivitis:

1) Antimicrobials
For individuals with increased risk for gingivitis or periodontal disease, there is
evidence that over-the-counter oral care products containing specific
antimicrobial active ingredients can decrease risk of gingivitis. Systematic
reviews found that mouthrinses containing an antimicrobial effective amount of
essential oil(s) (with or without alcohol) or cetylpyrdinium chloride, 26-28 and
toothpastes containing triclosan or stannous fluoride,29-31 were associated with
decreased risk of supragingival plaque and gingivitis.

2) Fluoride Mouthrinses
With regards to caries risk reduction, there is strong evidence supporting the use
of fluoride-containing mouthrinses by children at elevated caries risk; 32 and low
level evidence on the benefit of adults using fluoride mouthrinse to decrease their
risk of root caries.10

3) Power Toothbrushes
Powered toothbrushes provide effective removal of dental plaque and reduction
in gingival inflammation.11, 33 Though there may be statistically significant
improvement in dental plaque removal or gingival inflammation when comparing
use of a powered toothbrush with a manual toothbrush, the difference may not
be clinically meaningful.33 However, when brushing technique is a concern such
as for patients with special needs, those who require the help of a caregiver for
activities of daily living, or those with manual dexterity deficit, the use of a
powered toothbrush has been found to provide substantive benefit in plaque
 reduction.34-38

4) Interdental Cleaning Devices

Recent analysis using NHANES data found that adults who more frequently
reported using floss or other devices to clean between their teeth were found less
likely to have periodontitis.39 Because of the barriers to interdental cleaning, it
may not be effective to tell patients that they must floss and expect it to become
a regular part of their oral home care routine. Instead, dentists can support
effective home oral care by gauging their patient’s level of understanding,
learning about their motivation, and then serving as a “coach” by communicating
and promoting daily cleaning between their teeth.40 Discussing the various
interdental cleaning devices can help educate patients on available options and
provide them with some of the skills necessary to be effective stewards of their
own oral health.

 Lifestyle Considerations for the Prevention of Caries and Gingivitis

Dentists can provide, promote or direct patients to information about lifestyle

behaviors and/or services that can aid in reducing their risk.

Beyond the general and personalized recommendations above, there are three
specific ADA policies regarding aspects that fall under the rubric of lifestyle
considerations with roles to help prevent caries and gingivitis:

1) Consumption of Fluoridated Water

Much of the literature evaluated in systematic reviews examining the association
between consumption of fluoridated water and reduced levels of caries in primary
and permanent dentition derives from studies conducted before the
1980’s.41 One experiment, in which a Canadian community discontinued its
community water fluoridation to allow for the comparison of caries rates within a
socioeconomically similar, adjacent community which maintained its water
fluoridation demonstrated a significant increase in primary tooth decay and an
increasing trend for increased decay in permanent dentition 2.5 – 3 years post
cessation among residents who reported usually drinking tap water.42 In 2016,
the U.S. Surgeon General expressed the view that community water fluoridation
was an important component for developing a culture of disease prevention and
helping to ensure health equity for all.43

2) Use of Tobacco Products

While the various forms of tobacco have a variety of health consequences, the
oral consequences of cigarette smoking44 and smokeless tobacco products45 can
include adverse effects on gingival health, enamel discoloration and erosion, and
 oral cancer. For these reasons, the ADA has long advocated for smoking and
tobacco cessation initiatives both at the policy and practice levels.

3) Oral Piercings
The literature on the oral consequences of oral piercings show tooth fracture,
tooth wear and gingival recession among the commonly reported adverse
events,46 and the ADA established policy discouraging oral piercing in 1998.

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