Oral care instruments like toothbrush, floss, tongue cleaner etc are very important for maintain good oral health and hygiene. Human tongue harbors highly diverse bacterial population, Bass method of tooth brushing is widely followed and prescribed by dental professionals, but the proper brushing technique would vary with the brush used. Twice a day brushing with proper brushing technique combined with once daily use of an inter-dental cleaning aid is sufficient for the prevention of dental problems. Optimum plaque removal as well as reduction of caries causing bacteria may be obtained with at least two minutes of brushing twice a day. Studies have demonstrated that the efficacy of a toothbrush decreases over time. Thus, a toothbrush should be changed at least once every three months, Rinsing of toothbrush with tap water after brushing removes residual toothpaste and debris. Toothbrushes should neither be covered nor stored in a closed container and a toothbrush should never be shared due to the risk of infection.


Importance of Oral Care Devices

Toothbrushes are the most common device of oral health care and hygiene. It is also the oldest method of cleaning teeth and the toothbrushes have been known to be discovered around 5000 years also. Since their early discovery in most primitive form, toothbrushes have been evolutionary stage since then and are undergoing continuous changes in design, technology and materials. They have changed from manual to electric. Toothbrush is most important for oral health and daily oral hygiene and it checks the deposition of plaque, caries and can do tongue cleaning and if done properly can keep you free from most of dental problems. Most important function of a toothbrush is to keep you free from plaque and the toothbrush of whatever design, is able to do that is considered to be best. Most people do daily brushing but many lack the knowledge of selection of toothbrush, proper technique of brushing teeth. So it is very important to know and use correct toothbrushes and to know whether the toothbrush you are using is meeting the standards set in this regard by dental organizations and may not be effective inspite of your continuous usage.


Oral Disease Affected Parts of Mouth

The surfaces involved in oral diseases may include teeth, gingiva, tongue, and cheek mucosa. Soft tissue constitutes majority of the total oral surface area (80%). The bacteria present in the mouth are associated with hard and soft tis-sues. Thus, the conventional toothbrushes which only remove plaque and calculus from the teeth are less efficacious, Kazor et al had estimated that more than 700 bacterial species are present in the oral cavity, and human tongue harbours a highly diverse bacterial population.

Approximately 40% of the tooth surfaces are not readily accessible with a manual toothbrush, especially large inter-dental spaces. These regions may be responsible for the initiation of dental diseases. Thus, mechanical plaque control should be a part of any preventive strategy along with chemical control. Studies have demonstrated that amount of tongue coating is directly proportional to the degree of halitosis and reduction in tongue coating reduces halitosis.


Mechanical Cleaning of Teeth

Mechanical cleaning refers to removal of dental plaque as well as bio-film from hard and soft tissues, which may be achieved by either tooth brushing with a manual or electric toothbrush, inter-dental cleaning and tongue cleaning.


 

Inter Dental Cleaning Devices

 

Inter-dental cleaning devices may be classified as: inter-dental brush, dental floss, dental stick and water-pik. The choice of inter dental cleaning device is usually dependent upon the size of inter-dental space and manual skills.

 

Inter-dental brush is efficiently able to clean large inter-dental spaces, root surface concavities, and cleans beneath the orthodontic brackets. It has a high compliance. Dental floss  is most effective for narrow inter-dental spaces as well as below the contact points. Water-pik is very effective in removing food-debris especially after it is loosened with the floss or inter-dental brush.


Importance of Brushing Technique

Bass method of tooth brushing is widely followed and prescribed by dental professionals, but the proper brushing technique would vary with the brush used. Bass technique involves placing the brush at 45° to the axis of the tooth and pressing lightly against the tooth and gum margin. This is followed by about 10 small vibratory back-and-forth Movements over the width of approximately half of the tooth. Then the brush is gently taken towards the occlusal or incisal surface. These movements are repeated with all teeth and all surfaces of teeth present in the oral cavity. Bass technique is indicated for use in adolescents or adults with healthy gums. The advantages of bass technique include removal of plaque for supragingival area and gum margins in a targeted manner. Experimental studies6 had demonstrated that use of scrubbing method of toothbrush was associated with greater gingival recession as compared to rolling or bass method.


Reasons for Changing Toothbrush

Toothbrush is not a planned purchase. India has lowest per capita toothbrush consumption. Toothbrush is usually changed after signs of visual damage, occurring after 8-10 months. Other reasons for changing a toothbrush may Include: brush looks dirty, bristles starting to come out, breakage of toothbrush handle, change of handle color, damage to gingiva due to rough bristles, getting fed up of using the same brush for long-period of time.


Importance of Soft Tissue Cleaning

 

Tongue cleaning is not practiced due to a variety of reasons including: discomfort. Lack of awareness on the part of dental professionals and patients. Bordas et all had concluded that regular tongue cleaning is able to reduce bacterial count for an overnight period. Casemiro et  al had recommended that mechanical cleaning of the tongue results in improvement in halitosis as well as reduction in bacterial count. The toothbrush with tongue cleaner as well as conventional tongue cleaner demonstrated similar efficiencies in reducing halitosis and bacterial count.


Frequency of Mechanical Plaque Control

The efficacy of a brushing technique is dependent upon the patient's long-term willingness to use the technique correctly and regularly. Twice a day brushing combined with once daily use of an inter-dental cleaning aid (dental Floss or inter-dental brush) is sufficient for preventing the onset of dental problems, which is also in accordance with the recommendations of American Dental Association (ADA). Optimum efficacy for plaque removal as well as reduction of caries causing bacteria may be obtained with at least two minutes of brushing with manual or electric tothbrush twice a day. Studies have demonstrated that the efficacy of a toothbrush decreases over time. Thus, a toothbrush should be changed after every three months which is also in accordance with the ADA guidelines.

Need based selection of toothbrush and proper tooth brushing technique is considered to be important for prevention of various dental problems including dental caries, hypersensitivity and gum Problems.

Dental caries is a disease of bacterial origin resulting in the cavity formation. Dental caries originating in inter-proximal areas are usually undiagnosed. In the absence of regular dental check-ups, patients visit dental professionals in the last stages where either a root canal therapy or tooth extraction is the only means of treatment. Dental caries bacterial activity is at its peak after consumption of acidic or aerated diet and drinks, and at night when the salivary flow is less. Thus, twice a day brushing coupled with once daily use of an inter-dental cleaning device is considered to be critical for the prevention of dental problems and night brushing is perceived to be most important for the prevention of dental caries.

Gum problems including gingivitis and periodontitis are commonly found in patients with high plaque accumulation. Studies have demonstrated that inter-dental brush coupled with the use of regular toothbrush is able to remove more plaque than compared to toothbrush alone and thus is beneficial for the control and prevention of gum diseases.

DentinaI hypersensitivity is a result of exposure of dentinal tubules. Results of the study by Iwakami et al had demonstrated that proper brushing technique and selection of correct toothbrush is important for good oral health. The results of the study had demonstrated that scrub method and hard bristles result in greater gingival recession and loss of attached gingiva as compared to either bass or roll method. The results of the study also demonstrated that increased bristle stiffness was associated with increased damage to soft tissues and tooth structure. Studies by Schiff et al had demonstrated that toothbrush with extra-soft bristles and tongue cleaner was efficient in preventing and reducing tooth sensitivity.


 
How Dentist or Hygienists Can Help In Oral Care Awareness
 

1.   Selection of correct need based toothbrush (super-soft toothbrush in patients with dentinal hypersensitivity, inter-dental cleaning devices in patients with caries or periodontal diseases, orthodontic brushes for patients under going orthodontic treatment, hard brushes for cleaning removable dentures).
2.   Demonstrate correct tooth brushing technique on models.
3.   Diet counseling.
4.   Stress on the damaging effects of not brushing at all, infrequent brushing, improper brushing techniques and not using inter-dental cleaning devices.
5.   Videos, printed leaflets concerning correct brushing technique and use of inter-dental cleaning device should be available in all dental clinics, hospitals and various sites on internet.
6.   Educating on the importance of brushing twice a day.
7.   Change the brush at least once every three months.
8.   Advise the patients for regular dental check-up every six months.
9.   Emphasis should be laid on the importance of night brushing


Toothbrush Contamination

Appropriate cleaning, storage and replacement of toothbrush are vital in preventing the spread of infection. A toothbrush may get contaminated from the environment. Rinsing of toothbrush with tap water after brushing removes residual toothpaste and debris Toothbrushes should neither be covered nor stored in a closed container.

Toothbrush should be stored in an upright position and should be allowed to air dry until using it again. It should be stored away from the toilet to prevent contamination due to flushing which spreads bacteria in the immediate vicinity. A toothbrush should be changed after at least once every three months or before bristle deformation. A toothbrush should never be shared due to the risk of infection.

The results of the study done by Mehta et al had demonstrated that overnight immersion of a toothbrush in 0.2% of chlorhexidine gluconate solution was highly efficient in preventing microbial contamination.

A toothbrush is an individual's basic tool in the prevention of dental diseases. Dental professionals educate patients about the advantages of correct tooth brushing technique and help the patient in the selection of the correct toothbrush. Twice a day brushing and once daily use of an inter-dental cleaning aid coupled with antibacterial mouth rinses is important for the prevention of dental diseases and particularly, night brushing is perceived to be more important. Efficacy of the brush decreases with time. A toothbrush should be changed after at least once every three months or earlier as needed. With all the above precautions the prevalence and severity of dental disease may decrease in the near future.


 

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