Dental plaque must be eliminated. Its continuous formation makes us have a constant and systematic method of getting rid of it.
The elimination of dental plaque is done at two levels:

At home by keeping daily brushing and at the dental clinic using different systems described in the next paragraphs.

Dental Brushing

The most efficient, simple and comfortable method to eliminate dental plaque at the individual's level is brushing, avoiding the most frequent diseases caused by plaque: cavities and periodontal sickness.

The majority of methods used to eliminate dental plaque are based on a mechanical effect. Plaque is eliminated by sweeping or by friction of the different systems used.

On the other hand, there are toothpastes and mouthwashes that help fight against bacterial plaque.
It is very common to use toothpastes while brushing, although some techniques do not recommend this.

Dental Brushes

In Europe, around the XVIII century the use of mechanical or electrical instruments to eliminate dental plaque begins, these act on the dental pieces, sweeping the adhered plaque adhered top the dental faces, and secondly it eliminated the food remains that host between the teeth.

Traditionally, manual brushes were used, in recent years different kinds of electric toothbrushes have been developed, and they improve day by day.

A manual toothbrush is made of two parts: a handle and a head. The handle can have different designs, there are no known studies to show which kind of handle is better, there are straight handles, curved handles or bend handles which make the head stand at a different level, commercial brands state that curved handles reach better the posterior teeth.

Manual Brush: handle and head

Straight and curved handles

There are handles with a flexible shoulder that according to its designers reaches better the mouth's hardest to reach places.

Flexible handle

The most important part of a toothbrush is the head, it is the active part, it is made up of a tuft of threads, and opposite to the handle, here the differences between heads is very important.

The heads can have different sizes and it is recommended to use a head according to the size of the mouth.

Toothbrushes of 3-4 rows

The threads or filaments that compose the head are the most important part of the toothbrush.

The first toothbrushes were made with natural threads, hence the name, until they started to be manufactured using synthetic fibers, and nowadays nylon threads or polyester fibers are employed.

The natural threads, no longer in use, were traumatic since the technology did not allow a perfect round ending, and actually the filaments caused continuous micro traumas to the gums and teeth. Also they did not dry as fast and this facilitated the accumulation of bacteria between the filaments.

The filaments developed today have rounded endings or fusiform, they are not harmful to the teeth, therefore the only way to damage the gums or teeth is by applying a bad tooth brushing technique.

Technology has allowed the making of head filaments with diverse diameters, and according to the overall diameter used the hardness of the head will vary, another factor that is involved here is the length of the filaments, the longer they are the softer the brush and vice versa.

This is the reason behind the different kinds of hardness in toothbrushes: soft, medium and hard; although some commercial brands have increased this classification, adding the ultra soft, toothbrushes for sensitive teeth, after surgery toothbrushes, etc.

Actually there are no mutual agreements or studies that indicate how should the ideal toothbrush be, but in general, dentists recommend medium hard toothbrushes, considering there are no dental pathologies that require the use of a softer toothbrush.

Generally speaking, the use of hard toothbrushes is not prescribed, since in the long run they cause injuries, although some patients prefer them for a wide range of reason. One of these is that when a toothbrush is soft it tends to wear out faster and this implies having to change it frequently, instead harder toothbrushes last longer.

Toothbrushes should be changed frequently, although its effectiveness will depend, as mentioned before, on the hardness and on the brushing technique.

Another factor to consider is the number of rows of filaments on the toothbrush. These can vary between 2 and 6 rows and the reason for this is summarized next.

Considering the prescription of each kind of toothbrush at different times, the same brushing technique is not prescribed for a person with a healthy mouth than for a person with a periodontal disease (gum disease and other components that hold the teeth in place, known as pyorrhea - described in another page).

Different kinds of periodontal diseases

Toothbrushes that present 2 or 3 rows of filaments are used by patients with periodontal disease, these are called periodontal toothbrushes or sulks, and have the objective of removing dental plaque deposited under the gums (sub gingival), which is the worst kind.

Periodontal toothbrushes used for treating periodontal diseases.

Toothbrushes with 4 to 6 rows of filaments are the most common ones, people with no buccal problems use these, and the variation on the number of rows is justified by each commercial brand without a unified criterion among them.

Nowadays toothbrushes, which do not belong to the categories mention before due to the irregular distribution of rows, are also manufactured.

Current distributions filament rows (OralB)

An effective toothbrush is designed for those patients using orthodontics with fixed appliances like bands and brackets; the central row is shorter so it can clean between the brackets without deteriorating the toothbrush.

Orthodontics toothbrush

Fixed appliances with high plaque index

There are toothbrushes that have a protective cover and others do not, this is a polemic subject and currently there are two tendencies.

The ones that have a protective cover are isolated, from a hygiene point of view, and the toothbrushes' shape is conserved. The tendency against is that according to some authors, the covers, no matter how many respiration holes they have, do not allow the toothbrush to breathe.

Toothbrush with cover and toothbrushes close to each other, possible contact (not hygienic)

Toothbrushes should be changed when the filaments are no longer straight, this will depend on the hardness and on the way the brushing is performed, reason why the durability of a toothbrush varies from person to person. En general, though, it is recommended changing toothbrushes every 2 to 6 months.

There are a wide variety of toothbrushes available in the market today, with different designs and special shapes with no scientific reason known, only marketing reasons.

Some of the ones shown in this document have been discontinued.

Toothbrush with springs at the head base, which loosen with excessive pressure

Toothbrush with fruit flavor	Toothbrush for cleaning removable prosthesis

Folding toothbrush for traveling

Toothbrushes with filaments that with one movement clean 3 dental faces at the same time

Toothbrush with sand clock to remind brushing time

Toothbrush with an electric music chip that plays a melody that indicates brushing time.

Toothbrush with switching heads

Luxury toothbrush with wooden handle

Toothbrush with an appliance to install and use dental floss

Toothbrush with rounded head for circular motion on the teeth

Different designs on the length of the filaments, each commercial brand abides by the advantage of its shape

Toothbrush with few rows of filaments for those hard to reach places and to clean fixed prosthesis

Brushing Techniques

There are many brushing techniques, some very complicated, but here is the easiest and most practical one referring to what the patient should and should not do.

A person can brush how he pleases as long as the dental plaque is removed without damaging the gums or the teeth, and as a dentist this should be respected since is very hard to change a person's brushing habits, even harder is to teach someone who has never brushed.

First, let us consider those patients with good dental health. As a dentist you should indicate that no excess force should be applied to the toothbrush while brushing, something helpful is to teach them to eliminate bacterial plaque previously tinted with revealer, so that the patient can see how easily plaque is removed with an adequate brushing technique.

Also it is recommended to tell the patient to use vertical movements, always from the gums at the edge of the tooth, in other words, in the upper jaw from up to bottom and on the lower jaw from bottom up.

It is better to start by leaning the toothbrush against the gum and then move to the face of the tooth, giving the gum a little massage stimulating blood circulation, and emptying the gingival groove (in the space between the tooth and the loose gum, there is a small bag where plaque and food remains accumulate).

Space between the tooth and the loose gum - gingival groove

Vertical brushing technique (drawings by Prof. Dr. Peter Reithe)

There are many patients that use vertical brushing techniques like the one shown above, but directing the toothbrush from the edge of the tooth to the gum, in this case the surface is cleaned but plaque is introduced to the gingival groove.

Horizontal brushing: allowed in children and in the chewing faces of the teeth (Scheme by Prof. Dr. Peter Reithe)

A different technique is the one called Stillman Technique, which is basically the same but adding to the movement from the gum to the tooth a vertical movement and making the toothbrush rotate forward.

Stillman Method. Vertical movement from the gum at the edge of the tooth, making at the same time a toothbrush rotation.

Toothbrush in adequate position for the Bass Method

Brushing until all the dye is removed, this indicates that all the plaque has been eliminated.

In children and in adolescents the use of horizontal techniques is allowed, they are easier but with excessive force can produce injuries to the gum and tooth.

The horizontal technique is allowed when cleaning the occlusal sides (chewing sides of molars and premolars), also on these sides the circular technique is used, this is using circular motion.

In patients with buccal problems or periodontal disease, the technique, which for most professional is the best brushing technique, is recommended. This is the Bass Method.

Its' objective is to eliminate the sub gingival bacterial plaque, the one stored inside the gingival groove. It can be done with any toothbrush, but the ideal and most recommended are the ones called sulks or periodontal toothbrushes (2 or 3 rows of filaments).

The toothbrush is placed at 45º in relation to the tooth's axle inside the gingival groove, and a vibrating movement is done, not a displacement of the filaments, it is like if the filaments are moving without variation the position of the extreme end of the filaments. This movement is done approximately for 10 seconds in each group of 2 -3 teeth.

Bass technique. 45º toothbrush placement in relation to the teeth. (Scheme by Prof. Dr. Peter Reithe)

OTHER METHODS OF ELIMINATING BACTERIAN PLAQUE

The interdental embrasure and dental faces that are in contact, accumulate a great amount of dental plaque and it is very difficult to eliminate it using the type of toothbrushes described before, this is why there are other instruments for this explained ahead.

Dental Floss

This method helps to eliminate plaque on the proximal faces, this are the teeth's faces that touch each other, and that next to the gum, form the interdental spaces. At the beginning floss made of natural silk was used, but currently they are made using synthetic fibers, it is introduces in the interdental space and with up and down movements the dental face is cleaned.

Dental Floss. The arrows show how the movement is performed. Photograph: Prof. Klaus H. Rateitschak

Dental Floss is presented in various forms:

• Dental Floss is rounded, with or without wax. It is said that the wax allows a better penetration on the interdental gaps. Some manufactures also add flavor like mint and impregnated it with fluoride so it deposits on the teeth.

• Dental Thread is flat and harder to introduce interdentally but has the advantage of increasing the surface of performance therefore eliminating more bacterial plaque.

• Thread with nylon or foam (Floss), it has an initial hard section without nylon, that helps introducing it into the interdental gap. It eliminates a great amount of plaque and it is highly recommended to clean fixed prosthesis and implants. Since it is wider than the rest, when the interdental gap is small it is better to use any of the other two kinds of floss described above.

Floss. Thread with nylon, it is introduced by the hardest section.

Dental Floss in posterior dental pieces.

In the posterior mouth's segments, it is difficult to introduce the dental floss between the teeth, that is why nowadays in the market there are different types of floss supports.

In irritated gums, the use of dental floss is recommended, but it is very possible that the mere contact may cause them to bleed, this will continue until the degree of inflammation decreases. If while applying the dental floss there is an excess of force, this can lead to gum lesion and bleeding.

Interproximal Toothbrushes

Dental floss is effective but a little troublesome, not all patients achieve the habit of using it daily, this is why, when possible, it is best to use interproximal or interdental toothbrushes.
Interproximal toothbrushes are easier to use, but the problem lays in that not everyone can use them, since if the interdental gap is to small the toothbrush does not fit.

Interproximal Toothbrushes, with central axle laminated

The shape of the toothbrush can be conical or cylindrical and some brand names also make them in different sizes.

Toothbrushes in different size and shape

Toothbrush placed in the interdental gap

Toothbrush movements. Photo by Prof. Dr. Klaus H. Rateitschak

Interproximal toothbrushes are indicated also for patients with fixed prosthesis, implants or patients with fixed orthodontics apparels.

Interdental Toothpicks

These are special toothpicks, made with wood that does not chip (abedul), that once placed in the interdental gap eliminate, by means of friction, bacterial plaque located in the tooth's faces. They are available in different shapes: rectangular, rounded, squared, they are effective, but in Spain they are difficult to find.

If not used properly they can lead to gum lesions.

Squared Toothpick. Photo form Prof. Dr. Klaus H. Rateitschak

Toothpicks accepted by ADA (American Dental Association)

Incorrect toothpick use. Gingival Lesion

Toothpicks made with other materials. Rota - Point

Actually toothpicks made with synthetic materials, other than wood, are manufactured, they are cheaper and it seems that the elimination of bacterial plaque is effective.

Rubber Stimulators or Cones

These are instruments made with rubber or flexible plastic, in conic shape that are placed interdentally and help blood irrigation to the area favoring regeneration and desinflammation.

They are recommended in patients with big dental gaps and with implants, not in patients with healthy gums.

They can be used with the toothbrush or separately. As a secondary effect they eliminate bacterial plaque in proximal dental faces.

Rubber stimulator adapted to the end of a toothbrush

Stimulator placed in the interdental gap. In small gaps they do not fit. Photo form Prof. Dr. Klaus H. Rateitschak

Stimulator alone

Irrigators or Dental Shower

They are machines that project spurts of water with certain pressure, with the objective of eliminating food residue accumulated interdentally, in conventional fixed prosthesis, and in supported implants and in these cases they are highly recommended.

Even though commercial brands state that they eliminate bacterial plaque, the amount of plaque reduced is very little, reason why it is not very useful for this, since there are better methods and systems like the ones described above. In patients with periodontal diseases, irrigators are very effective specially when to the water is added an anti - plaque substance like clorhexidina, sanguinari

A point to be made is that this machine is recommended but not indispensable.

Currently they are used together with the electric toothbrushes, meaning that in the same machine you can find the toothbrush and the dental irrigator.

Today, in the market, there is a dental irrigator that combines water with air, so that the spurt of water comes out in micro bubbles that seem to increase the effectiveness of the irrigation.
This creates an effect of mini turbine that spins at 8000 rpm, and it also contains a microchip to regulate the water pressure.

Drawing of the irrigator nixed with air. Braun OralB

Electric Toothbrushes

Electric Toothbrushes date back 50 years, therefore they are not as recent as people think, even though they were not perfected until recent years.

During many years they were not very useful, but as they have been improving , their use has increased, today many dentists recommend them, although in some cases manual brushing is advised.

There are many designs and many different brands, it is very possible that the ideal head has not been developed yet, and therefore, from the ones available today there is a clear preference for the ones that are round and small.

Electric toothbrushes have different velocities and the most important characteristic is that they stop spinning if a lot of pressure is applied to the teeth, this avoids lesions and bruising to the gum and teeth.

Toothbrush with electric recharge. Different heads. Braun Oral B

The great majority comes with an electric recharge that feed the toothbrushes' battery, the recharge is left plugged into the wall and when the toothbrush is needed it is just pulled out of the charger.

There are other kind of electric toothbrushes that operate with regular batteries and do not need to be connected to an electric outlet.

Electric Toothbrush with batteries. Colgate Actibrush	Electric Toothbrush with charger. Rota-dent

These toothbrushes are indicated in patients with good dental health, in children and in physical and mental diminished persons, it is recommended for parents that brush their children's teeth since it is much easier.

Electric Toothbrushes eliminate bacterial plaque much faster, but subgyngival plaque is eliminated better using the Bass method, this is why in the case of patients with periodontal disease the combination of electric and manual brushing is advised.

One advantage is that the same toothbrush can be used by different people, the heads are interchangeable, therefore each person must have his own.

There are electric interproximal toothbrushes, they are very practical and maybe due to their novelty, patients tend to use them more frequently and with more persistence than the others.

Special heads for children, the filaments are softer and shorter

Different heads for dental faces and interdental spaces

Application in proximal faces. Rotadent

Toothbrushes' application in an interproximal space.

Some toothbrushes include a timer with memory, and they let the user know when 2 minutes have elapsed.

There are others that combine the circular effect with an increase in the beating per minute, providing a sonic effect similar to the one used by instruments in a dental clinic.