Brushing Best: How to Brush Your Teeth

We’ve come a long way, baby, in taking care of our teeth. There are excellent brushes and toothpaste readily available, and if for no other reason than to avoid the social fail of bad breath, most of us brush pretty often. Still, we can do better.

WHY MUST WE BRUSH?
We brush our teeth to remove the transparent layer of bacteria, plaque, that continuously forms over the entire surface area of our teeth. We must brush frequently because this biofilm hijacks the minerals in our saliva and hardens, first becoming tartar and then calculus. By then it’s too hard to remove effectively by brushing and is home to bacterial colonies assaulting the teeth, causing decay and gum disease.  

WHAT SHOULD WE USE TO BRUSH OUR TEETH?
Not a frayed twig, thankfully, as in days of old. Consumers today are faced with a seemingly infinite variety of toothbrushes, and making a good choice does matter. The best toothbrush is one that can reach and clean as much of the teeth’s surface area as possible while minimizing wear to the enamel, and maximizing comfort and ease of use. We shouldn’t scoff at those last criteria, because human nature being as it is, we are more likely to brush if it’s pleasant.
 
The size and shape of a toothbrush’s head and bristles have a significant influence on the user’s ability to access and clean the less reachable dental surfaces. The interdental spaces between teeth are mostly out of direct reach of any brush, leaving only about two-thirds of total dentition surfaces cleanable by tooth brushing. There are other solutions for those inaccessible areas, but in choosing a brush, we should make reaching all brushable areas a priority. Smaller is better. A smaller brush head is more maneuverable and can better get bristles to bear on hard-to-reach surfaces.  
 
In the old days, people liked the cosmetic results and sense of accomplishment provided by very stiff, hard toothbrush bristles. Not unreasonably, their approach to scrubbing teeth was about the same as their way of scrubbing pots: hard and rough. Elbow grease. It certainly got their teeth clean, but we now know it also eroded their enamel and made worse their exposure to decay. For this reason, and to minimize damage to gums, the American Dental Association (ADA) recommends soft-bristle toothbrushes. We don’t want to treat our teeth like dirty pots.  If we brush regularly, so that the bacterial film doesn’t have time to harden, there’s no need for hard bristles or for brute force. The ADA also has advice regarding bristle designs (multi-level, angled) which may be helpful.  Look for the ADA Seal of Acceptance on any manual brush you consider buying.   
 
The problem of interdental cleaning leads us to the world of electric toothbrushes. The ADA’s position is that both manual and powered toothbrushes are effective at removing plaque. There’s evidence that sonic brushes are better than manual brushes at removing plaque from the hard-to-reach surfaces, probably by the action of forcing vibrating fluid between the teeth and so dislodging the biofilm there. There’s evidence, too, that powered brushes remove plaque much more quickly than manual brushing. People with dexterity or range of motion issues and those with orthodontic appliances often prefer powered toothbrushes for ease of use.  A useful discussion of powered vs. manual toothbrushes is available online here.
 
Toothbrushes have a useful lifetime, after which they should be replaced. Every three months, four at the outside.

AND WHAT SHOULD WE BRUSH WITH?
We should choose a dentifrice, toothpaste or powder, that we find pleasant to use and whose formulation suits our individual conditions.  
 
The primary function of a dentifrice is to help the physical agitation of the toothbrush to remove plaque. Two types of ingredients get this job done, abrasives and surfactants. Nowadays we know that abrasives pose a risk of enamel erosion, and so we inform consumers of toothpaste’ abrasive effect with an RDA value in the labeling. Most dentists recommend an RDA value below 50.
 
Another dental hygiene function of toothpaste is performed by ingredients added to strengthen teeth. Flouride and remineralizers like calcium phosphates are common examples.  Some toothpaste includes antibacterial agents like zinc chloride, which the ADA says reduces tartar and prevents gum disease.
 
Zinc chloride also has a cosmetic benefit, according to the ADA, in acting against bad breath. Other aesthetic duties, whitening and brightening, are performed by surfactants such as sodium lauryl sulfate  (SDS).  These are detergents! They’re what make your toothpaste suds when you brush.
 
Other specialized ingredients address sensitive teeth or focus on enhancing tartar control. Whiteners, such as hydrogen peroxide, are intended to remove stains and discoloration chemically.  

WHEN?
The ADA recommends brushing twice daily, for two minutes each time. Some dentists advise brushing a third time, that is, after each of the three daily meals. Plaque, as we noted, forms continuously and becomes tartar and then calculus if allowed to. By the way, that after-lunch brushing while at work will still be very beneficial without toothpaste, and certainly more convenient. After eating certain foods, it’s actually better to wait at least 30 minutes before brushing. And yes, there is such as thing as brushing too often, wearing away enamel.

HOW?
Those of us in the Baby Boomer generation can remember being taught all sorts of things about the right way to brush, and they seemed to change every so often. The American Dental Association has settled on standard recommendations which are believed to be both effective and do-able by the greatest number of people.
A key feature of the ADA technique is that instead of holding the brush flat on our teeth, we’re advised to keep it at about a 45-degree angle. For example, if you plant your brush head flat against your lower front teeth, then rotate your wrist a quarter-turn, you’ll be where the ADA suggests.  
 
Brush with short horizontal strokes, applying very gentle pressure, just maintaining contact between brush and teeth. Be sure to cover all surfaces: outer, inner, and chewing.  The entire process should last two minutes so it may be helpful to divide the mouth into four quarters and spend 30 seconds brushing each. Don’t forget to brush your tongue! This is helpful in controlling bacteria that cause bad breath.  
 
Powered toothbrush manufacturers recommend variations on brushing technique based on the technology and designs of their products. The instructions provided with the powered brush are the best guide to effective use.
 
After brushing, to rinse or not to rinse?  That is the question. Thorough rinsing with water certainly gets rid of most of that aftertaste, but research finds that along with it go some of the benefits of fluoride or other therapeutic ingredients in the toothpaste.  One compromise is to “slurry rinse,” that is, take in a small amount of water, swish once, and spit. There may be individual issues involved in the rinse/no-rinse decision, so a consultation with your dentist is in order.

BUT THAT’S NOT ALL…
Brush like a boss, but don’t forget to floss. Brushing is not a substitute for flossing. Not even the most high-tech ultrasonic brush can remove plaque from those tight crannies between our teeth as effectively as flossing does. Yes, it’s one more thing to do, but after all the effort put into disciplined brushing with the right hardware, dentifrice, and technique, what a shame to leave the door open to decay.