Oral Hygiene: Methods, Assessment, and Patient Education

Core Review

Toothbrushing Methods

Multiple toothbrushing methods exist, each with specific indications. The NBDHE emphasizes the Bass and modified Bass techniques:

Bass Technique (Sulcular Brushing):

• Indication: All patients; particularly those with periodontal disease. The gold standard for biofilm removal at the gingival margin and within the sulcus.
• Technique:
  1. Position the brush at a 45-degree angle to the long axis of the tooth, with the bristle tips directed into the gingival sulcus
  2. Apply gentle pressure until the tissue blanches slightly
  3. Use short, vibratory (back-and-forth) strokes — approximately 10-15 strokes per area
  4. The bristle tips should remain in the sulcus during the stroke
  5. Move to the next group of 2-3 teeth and repeat
  6. For lingual surfaces of anterior teeth: hold the brush vertically and use the toe of the brush
  7. For occlusal surfaces: use a scrubbing motion

Modified Bass Technique:

• Same as Bass with one addition: after the vibratory strokes, sweep the bristles occlusally (away from the gingiva) in a rolling motion
• This combines sulcular cleaning (Bass) with a sweeping motion that removes plaque from the embrasure areas
• More widely recommended than pure Bass because it provides both sulcular and general cleaning

Stillman Technique:

• Indication: Gingival massage and stimulation; patients with gingival recession
• Technique: Bristles positioned partly on gingiva and partly on the cervical portion of the tooth, angled at 45 degrees. Vibratory strokes then sweeping motion.
• Less effective for plaque removal than Bass; primarily for tissue stimulation

Charters Technique:

• Indication: Orthodontic patients, patients with provisional restorations, cleaning interproximal areas from the facial and lingual
• Technique: Bristles angled at 45 degrees toward the occlusal surface (away from the gingiva). Vibratory strokes direct bristle tips into interproximal spaces.
• Also useful for cleaning around fixed prostheses and orthodontic brackets

Fones (Circular) Technique:

• Indication: Young children learning to brush; patients with limited manual dexterity
• Technique: Teeth closed together; brush moved in large circular motions covering both teeth and gingiva
• Simplest technique to teach and perform; least effective for sulcular plaque removal

Roll Technique:

• Bristles placed at the gingival margin, then rolled occlusally
• Gentle on gingiva but less effective for sulcular cleaning than Bass

Comparison of Brushing Methods:

Toothbrush Characteristics

Manual Toothbrush:

• Size: Handle should fit comfortably; head should be appropriately sized for the patient's mouth (smaller heads provide better access to posterior areas)
• Bristle texture: Soft or extra-soft nylon bristles recommended by the ADA. Medium and hard bristles damage gingiva and may cause recession and abrasion.
• Bristle pattern: Flat, rippled, or multi-level — evidence does not strongly favor one pattern over another. The technique matters far more than the bristle pattern.
• Replacement: Every 3-4 months, or sooner if bristles are splayed. Splayed bristles are less effective.

Powered Toothbrush:

• Indications:
  • Patients with limited manual dexterity (arthritis, stroke, Parkinson disease, developmental disabilities)
  • Caregivers brushing for dependent patients
  • Orthodontic patients (some powered brushes have orthodontic heads)
  • Patients who are poorly compliant with manual brushing (some patients are more motivated by powered brushes)
  • Any patient who prefers a powered brush — compliance is more important than the brush type
• Types:
  • Oscillating-rotating (round head rotates back and forth) — most evidence for effectiveness
  • Sonic (side-to-side vibration at high frequency; fluid dynamics may enhance cleaning slightly beyond bristle contact)
  • Ultrasonic (very high frequency)
• Advantages over manual:
  • Easier to use (reduced dexterity requirement)
  • Built-in timers promote adequate brushing duration (2 minutes)
  • Some evidence for modestly superior plaque removal compared to manual brushing
• Disadvantages: Cost, need for charging/batteries, may require multiple head sizes for different family members

Interdental Cleaning

Toothbrushing alone cleans only approximately 60% of tooth surfaces. Interdental cleaning is essential for removing biofilm from proximal surfaces and is a critical component of oral hygiene.

Dental Floss:

• Indication: Normal to tight interproximal contacts; most universal interdental aid
• Technique:
  1. Use approximately 18 inches of floss, wrapped around middle fingers
  2. Guide floss between teeth with a gentle sawing motion — do NOT snap through the contact (traumatizes the interdental papilla)
  3. Curve the floss into a C-shape against one proximal surface
  4. Slide the floss up and down, extending slightly below the gingival margin
  5. Repeat on the adjacent tooth surface
  6. Use a clean section of floss for each interdental space
• Types: Waxed (easier to pass through tight contacts), unwaxed (may be more effective for biofilm removal), PTFE (monofilament — shred-resistant, good for tight contacts and rough restorations), tape (wider, for larger embrasure spaces)

Interdental Brushes (Proxabrushes):

• Indication: Open embrasure spaces, exposed furcations, orthodontic patients, areas of gingival recession with open interproximal spaces
• Advantages: More effective than floss in open embrasures; easier to use for patients with limited dexterity
• Selection: Various sizes available; the largest brush that fits comfortably through the interproximal space should be used

End-Tuft/Single-Tuft Brushes:

• Indication: Isolated areas with difficult access — distal of last molars, furcation areas, crowded teeth, fixed prostheses, orthodontic brackets
• Small, concentrated tuft of bristles on a handle

Floss Threaders:

• Indication: Under fixed bridges, around orthodontic wires, under splinted teeth
• A flexible plastic loop that guides floss under an appliance

Wooden/Plastic Interdental Cleaners:

• Indication: Open embrasures, exposed furcations
• Triangular wooden sticks or plastic picks that clean interproximal surfaces

Oral Irrigators (Water Flossers):

• Indication: Adjunctive cleaning; patients with periodontal pockets, orthodontic patients, implants
• Mechanism: Pulsating water jet flushes debris and loosely adherent plaque from interproximal spaces and pockets
• Evidence: Reduces bleeding on probing and gingival inflammation as an adjunct to brushing, but does not replace flossing for plaque removal

Interdental Cleaning Selection by Patient Need:

Plaque Assessment: O'Leary Plaque Control Record

The O'Leary Plaque Control Record is the most widely used plaque assessment method and is heavily tested on the NBDHE.

Method:

1. Apply disclosing solution to all tooth surfaces
2. The patient rinses; disclosing solution remains on areas with plaque
3. Examine all tooth surfaces: facial, lingual, mesial, and distal (4 surfaces per tooth)
4. Record whether each surface has plaque at the gingival margin (present = 1, absent = 0)
5. Exclude missing teeth from the count
6. Calculate the score

Formula: Plaque Score = (Number of Surfaces with Plaque / Total Number of Tooth Surfaces) × 100

Example: A patient has 28 teeth. Total surfaces = 28 × 4 = 112 surfaces. Plaque is present at the gingival margin on 45 surfaces. Plaque Score = 45/112 × 100 = 40.2%.

Goal: Plaque score ≤10% is considered a reasonable goal. Some clinicians set the goal at <15-20% for patients with compromised dexterity.

Clinical use:

• Baseline: Establish the starting plaque score
• Motivational tool: Show the patient the disclosing solution results — visual feedback is powerful
• Monitoring: Reassess at subsequent appointments to measure improvement
• Research: Standardized measurement for clinical trials

Limitations:

• Dichotomous (present/absent) — does not measure plaque quantity
• Disclosing solution may not reach all interproximal areas
• Some patients find disclosing solution cosmetically unacceptable

Other Plaque Indices:

Silness and Löe Plaque Index:

• Scores 0-3 on selected teeth (Ramfjord teeth)
• 0 = No plaque
• 1 = Thin film of plaque visible only with a probe
• 2 = Moderate accumulation visible to the naked eye
• 3 = Abundant plaque filling the gingival crevice
• More detailed than O'Leary but more time-consuming

Patient-Specific Modifications

Arthritis/Limited Dexterity:

• Powered toothbrush
• Enlarged handle modifications (bicycle grip, foam tubing, ball grip)
• Floss holder or powered flosser
• Interdental brush with large handle

Caregiver-Assisted Oral Hygiene:

• Caregiver stands behind the patient (wheelchair or bedbound)
• Use a mouth prop if patient cannot keep mouth open
• Extra-soft brush
• Suction toothbrush for patients at aspiration risk
• Chlorhexidine rinse for patients who cannot perform mechanical plaque removal

Orthodontic Patients:

• Interdental brush, floss threader, or orthodontic floss for cleaning around brackets
• End-tuft brush for difficult areas
• Fluoride mouthrinse (increased caries risk during orthodontic treatment)

Dental Implants:

• Soft brush (avoid scratching the titanium abutment)
• Implant-specific floss (thicker, textured)
• Interdental brush with plastic-coated wire (to avoid scratching)
• Oral irrigator with non-metal tip

Clinical Application

A 65-year-old patient with rheumatoid arthritis presents with generalized moderate periodontitis and a plaque score of 78%. She states, "I try to brush, but my hands hurt, and I can't hold the floss."

Oral hygiene recommendations:

1. Powered toothbrush (oscillating-rotating) with a large, cushioned handle grip. Use modified Bass technique as tolerated.
2. Floss holder (Y-shaped handle) for interproximal areas with closed contacts
3. Interdental brushes (pre-sized handles) for open embrasures
4. Oral irrigator as adjunct for pocket irrigation (does not replace mechanical plaque removal but helps reduce inflammation)
5. Set realistic goals: reduce plaque score from 78% to <30% within 3 months, with long-term goal of <20%

Common Traps

• TRAP: Recommending the Fones technique for an adult with periodontitis. Fones is for children and patients with very low dexterity — it does not clean the sulcus effectively.
• TRAP: Recommending floss for a patient with open embrasures and exposed furcations. Floss is ineffective in open spaces; interdental brushes are superior.
• TRAP: Thinking a powered brush is always superior to manual. An excellent manual technique equals or exceeds a mediocre powered technique. The best brush is the one the patient uses correctly and consistently.
• TRAP: Calculating total tooth surfaces incorrectly for the O'Leary Index. Exclude missing teeth; count all 4 surfaces per tooth (facial, lingual, mesial, distal).