This information on home oral care, developed by the ADA, is a summary of the ADA recommendations and can help facilitate discussions with your patients about their home oral health care habits.
Spending the right amount of time engaged in appropriate home oral care is 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 for patients.
In 2017, the ADA Council on Scientific Affairs identified three aspects of home oral care that dentists should discuss with their patients:
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.
While a seemingly simple statement, the guidance for brushing twice daily with a fluoride toothpaste for two minutes 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 greater 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.
While cleaning between teeth is important in maintaining oral health, it is a concept that includes several barriers people encounter on the way to adoption. ”Flossing” is often used as a common, shorthand term for interdental cleaning, which can become problematic in the real world where many people report a strong dislike for that particular activity.13 Some people presume flossing is 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 differences in benefit observed when comparing study designs involving self-flossing and professional flossing.15 Patients who do not see positive results from flossing 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, which 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 toothbrushing 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 will be the one that they will regularly perform. A guiding principle that 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
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
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. 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 ADA recommends that dentists:
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:
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 a fixed combination of four essential oils (eucalyptol, menthol, methyl salicylate, and thymol) or cetylpyridinium chloride,26-28 and toothpastes containing triclosan or stannous fluoride, 29-31 were associated with decreased risk of gingivitis and periodontal disease.
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 However, all of the products available in the market that display the ADA Seal of Acceptance have been shown to have fluoride levels that are safe and effective.
Like their manual counterparts, powered toothbrushes provide effective removal of dental plaque and reduction in gingival inflammation when used appropriately.11, 12, 33-37 Some patients may find powered toothbrushes easier to use.38-43
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.44 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.45 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.
Dentists can provide, promote or direct patients to information about lifestyle behaviors and/or services that can aid in reducing the risk of problems and improving overall oral health.
Beyond the general and personalized recommendations above, specific ADA policies that address lifestyle considerations to help reduce risks to oral health. Four policies are discussed below:
At-home orthodontic treatments, such as direct-to-consumer (DTC) and do-it-yourself (DIY) orthodontia are both forms of orthodontic treatment discouraged by the ADA due to patient safety concerns. DTC orthodontic treatment services allow consumers to order teeth straightening kits directly from a supplier and often rely on patient-supplied impressions or photographs. Unlike impressions and radiographs taken by an experienced, licensed dental professional, patient-supplied impressions may be more likely to result in user error, which can ultimately lead to an improper fit of orthodontic appliances. A poor fit can cause the gum tissue to be impinged or stripped, and may also increase the chances of tooth loss or misalignment; or problems with the temporomandibular joint (TMJ). In addition to assuring proper fit, dental professionals can provide pre-treatment dental evaluations and take radiographs. These play an important role in planning treatment and identifying underlying problems, such as periodontal disease, which can impact both oral health and orthodontic results.46 For example, while patients who undergo orthodontic treatment are more likely to experience root resorption than those who do not, 47 the process may be exacerbated by periodontal disease.48 The importance of regular dental visits is greater during orthodontic treatment to ensure the well- being of the teeth being treated. Regular dental visits, including radiographs, as part of the orthodontic treatment plan can help identify tooth structure loss or other problems as they occur and address the problem in real time.
The use of rubber bands and paper clips to adjust teeth is ill advised. DIY orthodontia commonly involves using household items and can result in permanent damage and/or require corrective measures to avoid adverse results, such as tooth loss or misalignment.49 Citing concern about patient harm and the importance of dental oversight throughout orthodontic treatment, the ADA passed a resolution discouraging the use of DIY orthodontic treatment in 2017 (Do-It-Yourself Teeth Straightening (Trans.2017:266)).50
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 1980s. 51 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 that 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. 52 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. 53The ADA’s most recent resolution supporting community water fluoridation was passed in 2015 (Operational Policies and Recommendations Regarding Community Water Fluoridation (Trans. 1997:673; 2015:273)).50
While the various forms of tobacco have a variety of health consequences, the oral consequences of cigarette smoking 54 and use of smokeless tobacco products 55 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 (Policies and Recommendations on Tobacco Use (Trans.2016:323))50 and practice levels.
The literature on the oral consequences of oral piercings show tooth fracture, tooth wear and gingival recession among the commonly reported adverse events, and the ADA established policy discouraging oral piercing in 1998 (Policy Statement on Intraoral/Perioral Piercing and Tongue Splitting (Trans.1998:743; 2000:481; 2004:309; 2012:469; 2016:300; 2021:164).50
Related Oral Health Topics
The following related Oral Health Topic pages contain current scientific reviews of subjects that relate to home oral care, including:
Information Sheet on pH of Home Oral Care Products
ADA Seal of Acceptance
Search for related products with the ADA Seal of Acceptance, including:
Patient Education
For the Dental Patientis a JADA column that is geared toward patient education and intended to facilitate discussion between dentists and patients. The following items can help facilitate conversations related to the ADA’s home oral care recommendations:
Additional ADA Resources
Search the following databases for additional resources related to home oral care:
Last Updated: December 30, 2022
Prepared by:
Department of Scientific Information, Evidence Synthesis & Translation Research, ADA Science & Research Institute, LLC.
Disclaimer
Content on this Oral Health Topic page is for informational purposes only. Content is neither intended to nor does it establish a standard of care or the official policy or position of the ADA; and is not a substitute for professional judgment, advice, diagnosis, or treatment. ADA is not responsible for information on external websites linked to this resource.