Microbial biofilm begins to form within seconds of thorough debridement of tooth surfaces and owing to the complexity of bacterial biofilms, biofilm associated infections are a challenge to treat.69,70 Well-organized biofilms grow within hours after cessation of oral hygiene measures and biofilm must be completely removed at least every 48 hours in experimental settings to prevent inflammation.71 Current ADA recommendations14,15 for oral hygiene include:
Several methods for interdental biofilm removal will be reviewed, along with evidence of their effectiveness. It should be noted that all of the interdental cleaning methods presented here should be combined with toothbrushing and are not stand-alone therapies. Because individual patients demonstrate differences in dexterity, motivation, and intraoral anatomy, coaching provided by dental healthcare providers should seek to evaluate current toothbrushing methods, frequency, and duration and their effectiveness in plaque removal for each patient to allow for delivery of an individualized oral home care plan to optimize oral health and hygiene efforts.
Proper toothbrushing with both manual and power brushes, is effective for plaque removal on tooth surfaces, but may be limited in the removal of interproximal plaque.72,73 Toothbrushing duration in periodontally healthy individuals is associated with a significantly greater amount of biofilm removal up to approximately two minutes.74 It has also been suggested that for patients with periodontal disease, longer toothbrushing duration may be necessary.7 Patients also generally brush for significantly less time than the recommended two minutes, even in instances where they are asked to brush for a full 120 seconds.75,76 Selection of toothbrushes is important for optimal biofilm removal. While patients’ perception indicates that harder toothbrush bristles and brushing force are more effective, in reality, the use of toothbrushes with softer toothbrush bristles results in superior plaque removal both subgingivally and interproximally.77,78 Softer toothbrushes also result in less gingival recession and abrasion to oral soft tissues than hard toothbrush bristles.77,78 Patients should be counseled that excessive force can cause trauma to hard and soft tissues in the mouth and is not required for optimal biofilm removal.76 Finally, regular replacement of toothbrushes improves clinical outcomes. Even normal use over a period of 9 weeks can decrease the efficacy of biofilm removal!77
Power toothbrushes are often considered as a part of the oral hygiene armamentarium and are equally effective as manual toothbrushes when both are used properly.79,80 Furthermore, power brushes with oscillating rotating action have been shown in several systematic reviews conducted by the Cochrane Collaboration, to remove significantly more plaque and reduce gingival bleeding than manual toothbrushes.79,80 Acceptance of powered toothbrushes among patients of all ages has been reported to be high,81,82 and thus recommending a power toothbrush to patients may lead to improved delivery of oral hygiene. Individuals who demonstrate difficulty in motivation or dexterity issues may also see an additional benefit from powered toothbrushes.82,83 Powered toothbrushes have been shown to improve gingival health and biofilm removal when compared to manual brushes for 1) children and adolescents, 2) children with physical or mental disabilities, 3) hospitalized patients, including elderly adults with caregiver-delivered oral hygiene, and 4) patients with fixed orthodontic appliances.82,83
While no randomized controlled studies demonstrate that toothbrushing itself is effective in caries prevention, observational studies demonstrate that biofilm accumulation is associated with increased rates of caries and proper toothbrushing has been shown to reduce these biofilms and improve gingival health.2,56,71,72