The Right and Wrong Ways to Brush
Mary Beth Kensek, RDH, RF, BS
Most people start brushing their teeth as toddlers, so one might think that by the time we reached adulthood, we’d be professionals at it. Assuming one brushes twice a day for 20 years, that’s approximately 14,600 practice sessions. But each of us has probably seen our share of patients whose teeth make it evident that those 14,600 brushings have been done the wrong way. We are often asked about sensitive teeth and what can be done to manage the condition. Excessive tooth wear and gingival recession, which can lead to dentin hypersensitivity, are just a few of the problems we see resulting from overzealous brushing. How can such a seemingly simple act trip up so many people? How can we help our patients learn and maintain the proper technique?
We know there are multiple factors in brushing that can contribute to tooth wear, and it is not always evident which factor, or combination of factors, is responsible when we see a patient with obvious abrasion or recession. In these cases, hygienists should review the list of possible causes with the patient in order to identify the culprit(s). The list can be difficult to remember, but we can give our brains a helping hand with a simple mnemonic device: “Make Brushing Feel Truly Fantastic Again.” Each of these words corresponds to a factor in the proper toothbrushing checklist.
The brushing motion most associated with tooth wear is the horizontal technique,1 which seems to be the default setting for many patients. This can be a difficult factor to correct, since it becomes so ingrained in muscle memory after years of daily repetition. It can also give patients the very satisfying feeling of cleaning their teeth extra thoroughly. But this action has been found to cause two to three times more wear on the dentin than an up-and-down motion.2 Demonstrate a rolling, circular motion at a 45° angle to the tooth for patients who brush side-to-side, and emphasize that brushing this way can help prevent gingival recession. This motion can be described as the combination of the benefits of both side-to-side and up-and-down techniques. It also lessens the chance of applying too much force. Make sure gentle contact is made with the gum tissues, being mildly assertive but not aggressive with the brush. If the patient does not floss regularly, this also presents a good opportunity to suggest flossing as an additional way to get that extra-clean feeling.
New evidence has surfaced in recent years that challenges the advice many of us have given patients regarding bristle stiffness and the importance of using a soft-bristled toothbrush. A study in the United Kingdom revealed that soft-bristled toothbrushes actually cause more abrasion than hard bristles. The study’s authors theorize that soft bristles retain more toothpaste than hard bristles, and dentifrice may cause most of the tooth wear. However, the researchers also state that the differences they found between the brushes were “probably of little clinical significance,” and did not recommend the adoption of hard bristles, especially considering the damage they may cause to soft tissues.3
To compare, brushing with harder bristles is similar to using an abrasive cloth to wash your car—it would certainly clean the car, but damage will be done to the finish as well. Soft bristles, then, still seem to be a safe choice for most patients, particularly when proper brushing protocol is observed. Using warmer water when brushing can help soften brush bristles, and cause a less sensitive feeling in the teeth.
Estimates vary as to the ideal amount of force to apply when brushing. Not surprisingly, the optimum brushing force for efficacy in plaque removal does not necessarily correspond with the optimum force in preventing gingival abrasion. At least one study has questioned whether there is a strong link between brushing force and gingival abrasion.4
In light of these conflicting findings, the simplest step hygienists can take to identify problem brushers is asking what the patient’s toothbrush looks like. If the bristles have been flared out to the sides of the brush, the patient is applying too much pressure. Scrubbing is not necessary as plaque is soft. Hygienists can recommend the use of a power toothbrush, which has been shown to reduce brushing force.5 Some are designed to stop moving if too much pressure is applied.
Patients can also use a manual brush with a flexible neck designed to prevent excess force. Encourage patients to hold the brush gently with a few fingers, not using a strong-fisted grip on the handle.
Experts recommend brushing teeth for 2 to 3 minutes, but studies have found the actual average for most patients to be about 60 seconds.6 Because of this, time spent brushing is unlikely to be a causative factor for tooth wear in most patients. However, if a patient makes the other suggested changes to her brushing regimen and feels she is not getting her teeth as clean as she used to, the hygienist or assistant can suggest she compensate by increasing the amount of time she spends brushing. Patients can use this extra time to make sure all surfaces are being brushed, including gently brushing the tongue. Some patients find it helpful to use an egg timer to correctly gauge their brushing time.
There is a clear link between gingival recession and the frequency of toothbrushing.7 It is recommended that patients brush twice a day, which is particularly true in the case of patients using an anti-sensitivity toothpaste. However, patients who brush more than twice a day should be instructed that the practice is likely to do more harm than good, since studies have found few benefits from increased brushing frequency that would outweigh the additional abrasion.8 If a patient likes to “freshen up” after a meal or before going out, hygienists or assistants can suggest swishing with mouthwash. Patients also should be instructed not to brush immediately after consuming acidic foods and beverages, as this can lead to increased risk for tooth wear and erosion.
Patients often think only of their toothbrush as a cause of abrasion, but dentifrice can also contribute to enamel loss.9 Studies have shown that brushing without dentifrice can adequately clean teeth, but dentifrice is the agent that prevents staining. All toothpastes must have some degree of abrasivity to function, but it can be difficult to determine just how abrasive a toothpaste is by looking at the package. Hygienists or assistants also can suggest patients simply use a smaller amount of their current dentifrice. Patients should also be advised to alternate the place in the mouth they begin brushing, so as to limit any one area’s exposure to undiluted dentifrice.10
Addressing Existing Wear
Often, incorrect brushing technique does not come to our attention until there are already visible signs of tooth wear. By this point, it is quite likely that dentin has become exposed and the patient is at risk for dentin hypersensitivity. Inquire if the patient ever experiences pain when consuming common trigger foods, such as hot and cold beverages. Hygienists and assistants can also ask if the patient avoids specific foods because they cause tooth sensitivity. If the patient is in fact a sensitivity sufferer, a potassium nitrate dentifrice such as Sensodyne® (GlaxoSmithKline Consumer Healthcare, https://www.gsk.com), Tom’s of Maine Natural Toothpaste for Sensitive Teeth (Colgate-Palmolive Oral Care, https://www.colgateprofessional.com) or Orajel® Sensitive Pain Relieving Toothpaste (Del Pharmaceuticals, https://www.orajel.com) can help reduce the pain.
Some patients who brush incorrectly are often surprised to learn there is a problem. Ironically, it is the extra attention and care they give to keeping their teeth clean that causes the trouble. Hygienists as well as assistants are in an ideal position to identify patients with poor brushing technique, and to help them learn to “Make Brushing Feel Truly Fantastic Again.” Often, the same conscientiousness that leads patients to overzealous brushing can aid in their attention to proper technique. Explain that often all that is necessary is a minor technique adjustment.
Being Proactive About Dentin Hypersensitivity:
You Can’t Help if You Don’t Ask
Consider the following: It is estimated that 22% of American adults suffer from dentin hypersensitivity, and of these, 42% don’t bring up the issue with their dental professional.1 Many patients may feel hesitant to talk about the problem because they are unaware that there is often a simple treatment for their pain, or they may fear a more serious condition. Therefore, it is important for dental professionals to proactively question patients about hypersensitivity. Your interest and advice can make a significant difference for patients who have previously suffered in silence.
Identifying a Sufferer
Hypersensitivity can affect people at any age, but it is most frequently reported by people between the ages of 20 and 50, particularly those in the 20- to 30-year-old range.2 Additionally, women report hypersensitivity more often than men.3 Patients undergoing whitening procedures, either at home or in the office, are at high risk as well; between 55% and 75% of whiteners experience sensitivity.4 This wide range of sufferers highlights the importance of asking each patient, particularly whiteners and young women, if they experience tooth pain.
How Do You Ask?
These questions can help you spark a conversation about hypersensitivity:
- Do you avoid specific foods or beverages that cause tooth sensitivity or pain?
- Do you experience discomfort from cold, hot, sweet, or sour foods, or beverages?
- Have you recently undergone a whitening or bleaching treatment? If so, did you discontinue or interrupt treatment because of tooth sensitivity?
- Are you considering using whitening or bleaching treatments in the future?
Sensitivity can occur intermittently, so when questioning patients, inform them that the pain could have been earlier today, yesterday, or last week. Some patients may be able to list foods, beverages, or circumstances that always trigger pain, while others may experience sensitivity seemingly at random. For intermittent sufferers, the unpredictability of the pain can make it just as much a nuisance as it is for regular sufferers.
The Next Step
If a patient’s answers to any of your questions indicate that he or she experiences sensitivity, a review of the patient’s habits may reveal improper brushing techniques or other factors contributing to the pain. You can also perform a clinical examination to exclude secondary causes of dentin hypersensitivity such as dental caries, pulpitis, cracked or chipped tooth syndrome, and/or changes in restorations.
Once any serious problems are ruled out, you can discuss available treatment options with your patient. Commonly used treatments include desensitizing dentifrices, such as Sensodyne® (GlaxoSmith-Kline) to depolarize nerve endings in the tooth, and in-office desensitizing treatments to occlude the tubules. For especially sensitive patients, some practices recommend both treatments; as the in-office treatment brushes off over time, and the dentifrice takes time to build to maximum effectiveness.
Remember that while the triggers, frequency, and severity of dentin hypersensitivity can vary by patient, the most effective way to identify sufferers remains the same: ask.
1. Data on file, GlaxoSmithKline, Research Triangle Park, NC.
2. Gillam DG, Aris A, Bulman JS, et al. Dentin hypersensitivity in subjects recruited for clinical trials: clinical evaluation, prevalence and intraoral distribution. J Oral Rehabil. 2002: 29(3):226-231.
3. Addy M. Dentine hypersensitivity: New perspectives on an old problem. Int Dent J. 2002;52(5):375-376.
4. Haywood VB. Contemporary Esthetics and Restorative Practice. 1993; 3(Suppl):2-11.
1. Piotrowski BT, Gillette WB, Hancock EB. Examining the prevalence and characteristics of abfraction-like cervical lesions in a population of U.S. veterans. J Am Dent Assoc. 2001;132(12):1694-1701.
2. Manly RS, Shickner FA. Factors influencing tests on the abrasion of dentin by brushing with dentifrice. J Dent Res. 1944;23:59-72.
3. Dyer D, Addy M, Newcombe RG. Studies in vitro of abrasion by different manual toothbrush heads and a standard toothpaste. J Clin Periodontol. 2000;27(2):99-103.
4. Danser MM, Timmerman MF, IJzerman Y, et al. Evaluation of the incidence of gingival abrasion as a result of toothbrushing. J Clin Periodontol. 1998;25(9):701-706.
5. Van der Weijden F, Danser MW. Toothbrushes: benefits versus effects on hard and soft tissues. In: Addy M, Embery G, Edgar M, Orchardson R, eds. Tooth Wear and Sensitivity: Clinical Advances in Restorative Dentistry. London: Martin Dunitz; 2000.
6. Hunter ML, West NX. Mechanical tooth wear: the role of individual toothbrushing variables and toothpaste abrasivity. In: Addy M, Embery G, Edgar M, Orchardson R, eds. Tooth Wear and Sensitivity: Clinical Advances in Restorative Dentistry. London: Martin Dunitz; 2000.
7. Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc. 2003;134(2):220-225.
8. Hunter ML, West NX. Mechanical tooth wear: the role of individual toothbrushing variables and toothpaste abrasivity. In: Addy M, Embery G, Edgar M, Orchardson R, eds. Tooth Wear and Sensitivity: Clinical Advances in Restorative Dentistry. London: Martin Dunitz; 2000.
9. Addy M. Dentine hypersensitivity: Definition, prevalence, distribution and aetiology. In: Addy M, Embery G, Edgar M, Orchardson R, eds. Tooth Wear and Sensitivity: Clinical Advances in Restorative Dentistry. London: Martin Dunitz; 2000.
10. Van der Weijden F, Danser MW. Toothbrushes: benefits versus effects on hard and soft tissues. In: Addy M, Embery G, Edgar M, Orchardson R, eds. Tooth Wear and Sensitivity: Clinical Advances in Restorative Dentistry. London: Martin Dunitz; 2000.
About the Author
Mary Beth Kensek, RDH, RF, BS
Past President, Minnesota Dental Hygienists Association
St. Paul, Minnesota