Toothbrushes

The American Dental Association recommends brushing teeth twice a day for two minutes using a fluoride toothpaste. Brushing for two minutes has been shown to achieve clinically significant plaque removal³ and use of a toothpaste containing fluoride enhances fluoride concentration levels in biofilm fluid and saliva, and is associated with decreased risk of caries and remineralization of teeth.⁴

There are a number of techniques for brushing teeth; any of which may have advantages depending on a patient’s particular needs.⁵ In general, the American Dental Association suggests that people place the toothbrush against the gumline at a 45-degree angle to remove plaque from above and just below the gingival margin, and move the toothbrush gently back and forth in short strokes.⁶ To clean the inside surfaces of the front teeth, they should tilt the brush vertically and make several up-and-down strokes. 

Regardless of the technique used, brushing should touch upon all surfaces—inner, outer and chewing. Also, when brushing, the ADA recommends that people use a soft-bristled toothbrush and apply gentle pressure, both of which may help reduce the risk of gingival injury.^{7, 8}

SEM images comparing new and used toothbrush bristles (Used with permission from Applied Science Accessed April 25, 2016).

Here are some toothbrush care tips to share with your patients:

• Toothbrushes should not be shared.  Sharing a toothbrush could result in an exchange of bodily fluids and microorganisms between people.⁹
• Rinse the toothbrush thoroughly after each use to remove any remaining paste and debris.⁹
• Store toothbrushes in an upright position after use and allow them to air dry.  Storing a moist toothbrush in a closed container promotes microbial growth more so than leaving it exposed to the open air.¹⁰
• Toothbrushes should be replaced approximately every three to four months or more often if the bristles become matted or frayed.  The effectiveness of the brush decreases as the bristles become worn.¹¹

Toothbrushes have been shown to harbor bacteria (including fecal coliform bacteria that can be released into the air when the toilet is flushed or can be spread to the toothbrush when the owner touches a contaminated surface before handling his or her brush).¹²  While toothbrushes have been shown to harbor bacteria, there is no evidence that these bacteria cause adverse health effects.  Nonetheless, some patients may be interested in sanitizing their toothbrushes.  While there is little data in the literature regarding toothbrush sanitizing, one study indicates that soaking a toothbrush in 3 percent hydrogen peroxide or Listerine mouthwash greatly reduces (i.e., 85 percent) bacterial load.¹³  Microwaving or putting toothbrushes in the dishwasher is not recommended as such high heat may damage the brush.  Toothbrush sanitizer devices are available. Patients should look for a device that has been cleared by the U.S. Food and Drug Administration (FDA).

A myriad of toothbrush head design options are available.¹⁴ One systematic review found that toothbrushes with either multi-level bristles or angled bristles perform better than the conventional flat-trimmed bristles in removing plaque.¹⁵ Although toothbrushes with medium bristles have been shown to be effective at biofilm removal, the ADA recommends use of a toothbrush with soft bristles because they minimize the risk of gingival abrasion.⁸

The ADA Seal Category section on ADA.org provides a list of manual toothbrushes that currently have the ADA Seal of Acceptance. The Seal of Acceptance indicates that the toothbrush is both safe and efficacious for the removal of plaque and reduction of gingivitis. In addition, ANSI/ADA standards are used for testing the safety of manual toothbrushes.¹⁶

If a toothbrush differs significantly from previously accepted toothbrushes, the Council may request clinical studies to demonstrate that the toothbrush could be used without supervision by an average adult to achieve a significant decrease in mild gum disease and plaque over a 30-day period.¹⁶

Both manual and powered toothbrushes are effective at removing plaque.^{15, 17} While the powered toothbrushes can be more expensive than most manual toothbrushes, some people prefer the powered version. People who have dexterity problems—like the elderly, people with disabilities, or children—or those who have dental appliances, like braces, may find a powered toothbrush easier to use.

The ADA Seal Category section on ADA.org provides a list of powered toothbrushes that currently have the ADA Seal of Acceptance. The Seal of Acceptance indicates that the toothbrush is both safe and efficacious for the removal of plaque and reduction of gingivitis. In addition, ANSI/ADA standards are used for testing the safety of powered toothbrushes.¹⁸

A variety of powered toothbrushes that use a different types of head movement (e.g., side-to-side, counter oscillation, rotation oscillation, circular, ultrasonic) are available.

Look for the ADA Seal—your assurance that the product has been objectively evaluated for safety and efficacy by an independent body of scientific experts, the ADA Council on Scientific Affairs. The ADA Seal Category section on ADA.org provides a list of manual and powered toothbrushes that currently have the ADA Seal of Acceptance. A manual or powered toothbrush earns the ADA Seal for toothbrushes when the manufacturer provides scientific evidence demonstrating safety and efficacy in the removal of plaque and reduction of gingivitis. Toothbrushes with the ADA Seal have had data reviewed by the ADA Council on Scientific Affairs and have met the recommendations for both manual and powered toothbrushes.

ANSI/ADA standards are used for testing the safety of manual¹⁶ toothbrushes. To qualify for the Seal of Acceptance, the manufacturer of a manual toothbrush must provide evidence that:

• All toothbrush components are safe for use in the mouth
• Bristles are free of sharp or jagged edges and endpoints
• Handle material demonstrates durability under normal use
• Bristles won’t fall out with normal use.
• The toothbrush can be used without supervision by the average adult to provide a significant decrease in mild gum disease and plaque

If a toothbrush differs significantly from previously accepted toothbrushes, the Council may request clinical studies to demonstrate that the toothbrush could be used without supervision by an average adult to achieve a significant decrease in mild gum disease and plaque over a 30-day period.

To earn the Seal, a powered toothbrush goes through tests based on the ANSI/ADA standards for testing powered toothbrushes.¹⁸  These tests evaluate qualities like electrical safety, tuft retention, mechanical strength and chemical resistance.  The Seal program also requires powered toothbrushes to complete a clinical study demonstrating that they are safe for use on oral hard and soft tissues as well as restorations and that they meet the requirements of a safety laboratory such as Underwriters Laboratories, Inc.

1. American Dental Association Council on Scientific Affairs. Fluoride toothpaste use for young children. J Am Dent Assoc 2014;145(2):190-1.
2. American Academy of Pediatric Dentistry. Guideline on Infant Oral Health Care. Ped Dent 2011;33(6):124-8.
3. Creeth J, Gallagher A, Sowinski J, al. E. The effect of brushing time and dentifrice on dental plaque removal in vivo. J Dent Hyg 2009;83(3):111-16.
4. Newby EE, Martinez-Mier EA, Zero DT, et al. A randomised clinical study to evaluate the effect of brushing duration on fluoride levels in dental biofilm fluid and saliva in children aged 4-5 years. Int Dent J 2013;63 Suppl 2:39-47.
5. Darby ML, Walsh MM. Dental Hygiene: Theory and Practice. St. Louis: Saunders; 2010.
6. For the dental patient ... methamphetamine use and oral health. J Am Dent Assoc 2005;136(10):1491.
7. Cifcibasi E, Koyuncuoglu CZ, Baser U, et al. Comparison of manual toothbrushes with different bristle designs in terms of cleaning efficacy and potential role on gingival recession. Eur J Dent 2014;8(3):395-401.
8. Zanatta FB, Bergoli AD, Werle SB, Antoniazzi RP. Biofilm removal and gingival abrasion with medium and soft toothbrushes. Oral Health Prev Dent 2011;9(2):177-83.
9. Bunetel L, Tricot-Doleux S, Agnani G, Bonnaure-Mallet M. In vitro evaluation of the retention of three species of pathogenic microorganisms by three different types of toothbrush. Oral Microbiol Immunol 2000;15(5):313-6.
10. Frazelle MR, Munro CL. Toothbrush contamination: a review of the literature. Nurs Res Pract 2012;2012:420630.
11. Cooper AM, O'Malley LA, Elison SN, et al. Primary school-based behavioural interventions for preventing caries. Cochrane Database Syst Rev 2013(5):Cd009378.
12. Alber L. Dissertation: An Epidemiological Survey of Toothbrush Contamination in Communal Bathrooms at Quinnipiac University; 2015.
13. Beneduce C, Baxter KA, Bowman J, Haines M, Andreana S. Germicidal activity of antimicrobials and VIOlight Personal Travel Toothbrush sanitizer: an in vitro study. J Dent 2010;38(8):621-5.
14. Voelker MA, Bayne SC, Liu Y, Walker MP. Catalogue of tooth brush head designs. J Dent Hyg 2013;87(3):118-33.
15. Slot DE, Wiggelinkhuizen L, Rosema NA, Van der Weijden GA. The efficacy of manual toothbrushes following a brushing exercise: a systematic review. Int J Dent Hyg 2012;10(3):187-97.
16. American National Standards Institute/American Dental Association. Standard No. 119 Manual Toothbrushes. Chicago, IL: American Dental Association; 2015.
17. Rosema N, Slot DE, van Palenstein Helderman WH, Wiggelinkhuizen L, Van der Weijden GA. The efficacy of powered toothbrushes following a brushing exercise: a systematic review. Int J Dent Hyg 2016;14(1):29-41.
18. American National Standards Institute/American Dental Association. Standard No. 120 Powered Toothbrushes. Chicago, IL: American Dental Association; 2009.

Professional Resources:

• ADA Oral Health Topic: Home Oral Care

Patient Resources:

• Toothbrushes with the ADA Seal of Acceptance
  
• How to brush (PDF)
• MouthHealthy.org: Brushing Your Teeth
• Quick Facts: Toothbrushing