This guidance is issued jointly by the Department of Health and Social Care, the Welsh Government, the Department of Health Northern Ireland, Public Health England, NHS England and NHS Improvement and with the support of the British Association for the Study of Community Dentistry.
Delivering Better Oral Health has been developed with the support of the 4 UK Chief Dental Officers.
Whilst this guidance seeks to ensure a consistent UK wide approach to prevention of oral diseases, some differences in operational delivery and organisational responsibilities may apply in Wales, Northern Ireland and England. In Scotland the guidance will be used to inform oral health improvement policy.
Oral hygiene practices in the UK
Oral hygiene practices include toothbrushing and the use of other aids for cleaning teeth. Toothbrushing is widely practiced across the UK. In a 2009 national survey of adults (1), more women reported cleaning their teeth at least twice a day than men (82% compared with 67%). Three quarters (76%) of dentate adults reported using toothpaste with 1,350 to 1,500 parts per million level of fluoride and a further 18 per cent used a brand with a medium (1,000 to 1,350 parts per million) fluoride level. Most dentate adults (58%) used additional products as well as a standard toothpaste and brush, the most common of which were mouthwash (31%), powered toothbrushes (26%) and dental floss (21%). Women and middle-aged adults were more likely to use additional products than men, younger and very old adults (85 years and over).
A 2013 national survey (2) found that only a quarter of children benefited from having their teeth brushed before they were 6 months of age, whereas about 50% had commenced between 6 months and one year of age. Overall about 90% of children (aged 5 to 8 years) are reported as having started toothbrushing by 2 years of age (2). Overall, 77% of 12-year-olds and 81% of 15-year-olds reported that they brushed their teeth twice daily or more. Mouthwash was the most common aid other than a toothbrush (manual or powered) and toothpaste. As expected, the use of mouthwashes, dental floss (the only interdental cleaning method investigated) and sugar-free gum was generally higher in older children. Approximately 40% of the school children surveyed used a powered toothbrush.
Oral hygiene principles for oral health
Toothbrushing is important throughout life. The overall goal is to achieve and maintain good oral hygiene as follows:
- clean all tooth surfaces, and the gum line, thoroughly with a toothbrush and fluoride-containing toothpaste at least twice a day (last thing at night or before bed and one other time), spitting out the excess toothpaste
- use additional cleaning aids to reach interproximal surfaces, as appropriate
The risk of dental caries (Chapter 4) and periodontal diseases (Chapter 5) can both be reduced by the practice of regular careful oral hygiene involving toothbrushing with fluoride toothpaste. The particular benefit in preventing dental caries, relates to the fluoride in toothpaste (Chapter 9). Good oral hygiene reduces the risk of periodontal diseases; however, periodontal health also requires effective interproximal plaque removal. Oral hygiene advice for the population in general, and specific advice for those at higher risk, are presented below for each oral condition.
For caries prevention, it is the application of fluoride in toothpaste that is the most important aspect of brushing, as fluoride helps prevent, control, and arrest caries (Chapter 2: Table 1). Higher concentration of fluoride in toothpaste leads to better caries control. Family or standard fluoride toothpaste at 1,350 to 1,500 parts per million fluoride (ppmF) is recommended, although in very young children, where the ability to control swallowing is limited, a toothpaste containing a lower amount (at least 1,000 ppmF) can be used (3, 4). Frequency of brushing is important. Brushing should occur twice daily as a minimum, the guidance being to clean teeth last thing at night or before bed, and at least one other time each day. The term ‘before bed’ may be used as an alternative to ‘last thing at night’ for shift workers to sleep at another time of day.
Early introduction to the habit of toothbrushing is important. Parents should brush their children’s teeth as soon as they erupt. From 3 to 6 years of age there is a transition with the child and adult both brushing. Adult involvement ensures the correct amount of toothpaste is used, enables them to prevent children eating or licking toothpaste from the tube and that all teeth are brushed thoroughly. From 7 years of age, many children can brush their own teeth but will still require prompting, supervision, and motivation. Parents may still need to provide help with toothbrushing for some children, depending on risk and capability.
Physical removal of plaque is the important element of toothbrushing for preventing or controlling periodontal (gum) diseases for the general population (Chapter 2: Table 2). Self-care is important to maintain healthy gums and manage any gingivitis; it reduces inflammation of the gingivae. It is important to advise and instruct patients on good plaque removal from, and just into, the gingival crevice, including interdental areas, which takes around 2 minutes. There is no high-quality evidence regarding the best times of the day to brush in order to maintain healthy gums; however, it is good practice to suggest last thing at night or before bedtime and one other time in line with caries prevention (3).
Self-care is vitally important to prevent and manage plaque-induced periodontitis (5) (Chapter 2: Table 2). For people with periodontal diseases this becomes vitally important throughout the rest of life and good oral hygiene may take longer than the recommended 2 minutes. The patient’s existing method of brushing may need to be modified to clean all tooth surfaces systematically, maximise plaque removal and to brush the gum line carefully (6). No particular technique has been shown to be better than another (7). Disclosing tablets can help to indicate areas that are being missed. For people with extensive inflammation, it is good practice to start with toothbrushing advice, followed by interdental plaque control (8).
Cleaning between teeth, ideally with interdental brushes, is recommended prior to toothbrushing as a habit-forming approach, which is considered to be good practice (9), through adult life.
Based on current evidence, no strong conclusions can be drawn concerning any specific oral hygiene devices as adjuncts to toothbrushing for patient self-care in periodontal maintenance (5, 10), or method of providing oral hygiene advice (11).
General population advice
For the general population, advice on toothbrushing follows the generic advice on oral health for prevention of dental caries and periodontal diseases (Chapter 2: Table 4). Although concerns have been raised, there is no strong evidence to suggest that the timing of toothbrushing is of great importance in preventing tooth wear or that all patients should delay brushing until after meals involving erosive food and drinks (12).
Higher risk of tooth wear
For those at higher risk, changing to a low abrasive toothpaste or specially reformulated toothpaste for tooth wear alone may be considered, but will not be sufficient to fully address tooth wear (Chapter 7). There have been debates over whether to recommend manual or powered toothbrushes. Many brushes now have sensors to indicate when the user is brushing too hard. However, when it comes to tooth wear, there is no evidence to suggest that powered toothbrushes are any better, or worse, than manual toothbrushes (13). Patient preference is therefore the most important factor over whether a powered or manual toothbrush is used.
Oral hygiene advice
Effective toothbrushing with a fluoride toothpaste is important to support oral health. The physical action of brushing removes plaque, which prevents gingivitis and periodontitis, and the fluoride in toothpaste is effective against tooth decay. The following key messages for the population include when and how to brush, specific habits associated with brushing, and, where necessary, assistance with brushing. There may be adaptations of toothbrushes, such as special grip handles, that are helpful to people who have limited manual dexterity.
Advice for the population (primary prevention)
- brush all tooth surfaces at least twice a day (last thing at night or bedtime and on at least one other occasion), with fluoride toothpaste
- ensure that every surface of each tooth and the junction between the gum and tooth (gumline) are cleaned carefully
- for young people and adults, the patient’s existing method of brushing may need to be modified to maximise plaque removal, emphasising the need to systematically clean all tooth surfaces
- both powered and manual toothbrushes are effective for plaque control (14)
- there is low-certainty evidence that medium and soft bristle brushes are less likely to cause gingival lesions than hard bristle toothbrushes (15); for most patients, an appropriate brush will be a small-headed toothbrush with medium texture bristles
- the type of toothbrush filament does not appear to be clinically important in plaque removal (15, 16)
- daily interproximal plaque removal should have started by age 18 years, or younger, if gingival inflammation is present
- thorough cleaning may take at least 2 minutes (3); the main rationale for this time period is to ensure that sufficient time is taken for all tooth surfaces to be cleaned effectively (17)
- timers, which range from simple ‘egg-timers’ to clocks incorporated into toothbrushes and downloadable ‘apps’, can be helpful to assist with the length of time toothbrushing (3, 17)
- disclosing agents can help to indicate areas of the mouth that are being missed and guide the person to more effective brushing
Advice for children in the population (primary prevention)
Advice should include the following:
- brushing should start as soon as the first primary tooth erupts using toothpaste containing at least 1,000 ppmF (3, 4)
- parents or carers should use no more than a smear of toothpaste (a thin film of paste covering less than three-quarters of the child’s brush) for children below 3 years of age (17)
- parents or carers should use no more than a pea-sized amount of toothpaste for children between 3 and 6 years (18)
- parents or carers should brush their young children’s teeth. In the absence of evidence from home settings, expert opinion suggests that they need to be helped and supervised by an adult, when brushing, until at least 7 years of age (based on findings from supervised brushing at schools which show significant caries reduction) (19)
- parental supervision in the early years can also ensure that children do not eat or lick toothpaste from the tube (or brush), use the correct amount of toothpaste, and brush in a systematic pattern around the mouth (20)
- as soon as they are able (usually around the age of 3 years), children should be encouraged to spit out excess toothpaste, and not to rinse with water after brushing
- from 7 years of age, many children can brush their own teeth but will still require supervision, motivation, and possibly assistance
- for children at higher risk of oral disease, a family fluoride toothpaste (1,350 to 1,500 ppmF) is indicated for maximum caries control, except where children cannot be prevented from eating toothpaste (3, 4)
Advice for those with evidence of periodontitis or higher risk (secondary and tertiary prevention)
Advice should include the following:
- cleaning at the gum level is particularly important for people with experience of periodontitis
- interdental cleaning aids help reach interproximal surfaces (8), and it may possibly be helpful to use them before toothbrushing (9)
- in general, people with, or treated for, periodontitis will have larger interdental spaces due to tissue loss, and should use interdental brushes, which are more effective than dental floss or tape (21)
- the interdental brush should fit snuggly in the interdental space; therefore, many people with periodontitis will require different sizes for smaller and larger spaces – where the teeth are closer together, floss or tape can be used for interdental cleaning (5)
- regular re-evaluation of oral hygiene will be helpful for some patients with appropriate level of support from dental professionals (5, 22)
- partially dentate older adults would particularly benefit from additional attention to oral hygiene, particularly those wearing partial dentures (23), as they increase plaque retention
- good denture hygiene is important for those with partial and/or complete dentures as demonstrated in mouthcare matters
Specific oral hygiene issues for vulnerable children and adults
Vulnerable children and adults, particularly those lacking manual dexterity and mental capacity, may require assistance and support with toothbrushing as part of their daily self-care. Oral hygiene care and advice for people who have learning disabilities should be based on professional expertise and the needs and preferences of the individual and their carers (24). They may benefit from using a powered brush (24), and some will require modifications such as a grip handle to assist with toothbrushing. The latter may also be useful for people with physical disabilities. There is low/very low certainty evidence for the effectiveness of triple-headed manual toothbrushes for reducing plaque compared to single-headed brushes (25). Carers of people lacking the ability to undertake their personal oral hygiene may consider some of these products helpful and they are likely to require training and support from the dental team. It is worth noting that some studies reported participant difficulties with, or fears of, using the powered or the 3-headed manual toothbrushes (24); thus, they won’t be helpful for some patients.
NICE guidance on oral health for adults in care homes stresses the importance of ensuring care staff provide residents with daily support to meet their mouth care needs and preferences, as set out in their personal care plan after their oral health assessment (26).
This should include:
- providing daily oral care for full or partial dentures (such as brushing, removing food debris, and removing dentures overnight)
- using their choice of cleaning products for dentures if possible
- using their choice of toothbrush, either manual or powered
- daily use of mouth care products prescribed by dental clinicians (for example, this may include a high fluoride toothpaste or a prescribed mouthwash or rinse (27)
Powered versus manual toothbrushes
There is moderate-certainty evidence to suggest that powered toothbrushes reduce plaque and gingivitis more than manual toothbrushing in the short and long term, and supporting their safety (28). Findings are consistent across reviews, favouring powered brushes but the clinical relevance of the results is unclear (14), (29 to 31). This is particularly important to note as many people will not be able to afford a powered toothbrush and it should be stressed that teeth can be cleaned effectively with either type of toothbrush (32). Additionally, the evidence is insufficient to conclude that any particular mode of action of powered brush is superior (for example, sonic, rotatory) (33). There is no evidence regarding the role of powered versus manual toothbrushes in preventing caries.
There is low to very low-certainty evidence that using some dental cleaning aids in addition to tooth cleaning (for example, interdental brushes and floss) reduce gingivitis and plaque, but the clinical importance of the effect sizes is uncertain (8). The findings suggest that interdental brushes may be more effective than floss and the evidence for tooth cleaning sticks and oral irrigators is limited and inconsistent (8). Daily cleaning is recommended between the teeth to below the gum line (8). Ideally this should take place throughout adult life and start earlier if there are signs of gingivitis. Since toothbrushing is a daily routine for the majority of people, carrying out interdental oral hygiene first may help to link these activities and develop regularity (9).
Recommendations relating to interdental brushing and flossing are based on trials at unclear or high risk of bias that focus on the reporting of plaque and/or gingivitis, rather than caries. Thus, there is no evidence to determine whether interdental cleaning aids reduce caries, or not, when compared with toothbrushing alone (8).
The sustainability agenda, which is an important aspect of public health action, has implications for the prevention or oral diseases. It is increasingly influencing the nature of new products arriving on the market, some of which have relatively little underpinning research.
For example, switching from traditional plastic toothbrushes to replaceable-head plastic or bamboo has been suggested as being environmentally more sustainable. However, all choices have trade-offs which should be considered carefully. Bamboo toothbrushes are manufactured in different parts of the world, and although they have been shown to have a reduced carbon footprint (34), they have also been shown to have high planetary harm, due to the need for land, and volume of water required to grow the product. Furthermore, there is currently little evidence on their effectiveness. On the other hand, plastic has been considered the most hygienic option for decades. Additionally, all toothbrushes, whether normal plastic, bamboo, and biodegradable plastic (PLA or polylactic acid), have brush heads containing metal and/or nylon, so it is currently not possible to recycle the heads.
Further innovative new products will emerge, and it will be important for health professionals to be aware of these changes and consider the clinical effectiveness of sustainable products. Integrating oral health and sustainability is attractive, and continually recycled plastic, rather than bioplastic or bamboo, will be the most environmentally sustainable toothbrush model (35). Practices may wish to encourage patients to recycle toothbrushes as best as possible. As a compromise, it may be possible for people to remove or chop off the brush head and recycle the handle. Some dental practices already have an arrangement with companies to recycle any type of toothbrush and toothpaste tubes.
Oral Hygiene TIPPS video. Oral Hygiene TIPPS is a behaviour change strategy which aims to make patients feel more confident in their ability to perform effective plaque removal and help them plan how and when they will look after their teeth and gums.
Scottish Dental Clinical Effectiveness Programme. Prevention and Management of Dental Caries in Children: SDCEP; 2018 (Second Edition).
How To Clean a Denture Animation:
NHS apps library. Includes Brush DJ which plays two minutes of your music so you brush your teeth for the right amount of time. The app has short videos on how to brush your teeth and how to clean in between them using an interdental brush or floss.
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