Within minutes after eruption or after all surfaces have been thoroughly cleaned, pellicle begins to form and is fully formed within 30-90 minutes.4 Biofilm accumulation occurs when bacteria attach to pellicle. Biofilm becomes increasingly more difficult to remove the longer it is attached to the tooth surface, and eventually hardens into a calcified dental biofilm known as calculus. A regimen that is used to control this biofilm accumulation consists of basic toothbrushing and interdental cleaning/flossing.
Toothbrushing is the mechanical removal of biofilm and debris from the tooth structure and oral structures such as the gingiva and the tongue. The process of care is a standard that dental professionals should follow in the treatment of patients and includes an implementation phase to provide patients with education and recommendations, such as choosing the best type of toothbrush, brushing method, frequency, and duration of brushing. Two toothbrushes that are given as options for patients are manual and power toothbrushes. When choosing a manual or power toothbrush, a soft bristled toothbrush is usual for most patients due to the risk of trauma with harder bristled brushes. While there are many different brushing methods, the method commonly recommended to healthy patients is a sulcular brushing method known as the Bass method. The Bass method is widely accepted as an effective method for dental biofilm removal.4 The procedure for this method includes directing toothbrush bristles apically at a 45° angle to the long axis of the tooth into the gumline, pressing lightly, and using vibratory strokes. For the occlusal surfaces of the teeth, a 90° angle is recommended. It is also standard to recommend brushing at least 2 times per day for at least 2 minutes each session.
Flossing is the standard recommendation for interproximal cleaning for many patients but is most effective when interdental papillae are present and there has not been loss of attachment with root surface exposure.4 Although there are several different types of dental floss, research shows that there is no difference between waxed and unwaxed floss on the effectiveness of biofilm removal.4 The method for flossing that is typically recommended is to use 18 inches of floss wrapping it around the middle fingers of both hands and using index fingers and thumbs to gently guide the floss past each contact area without causing trauma to the interdental papilla. Once the floss has passed the contact area, the floss should be adapted to both tooth surfaces one at a time using a C-shape then sliding up and down over the tooth surface at least twice. It is recommended to floss at least once per day prior to toothbrushing.