Japanese Dental Science Review (2014) 50, 69—77

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Tooth brushing for oral prophylaxis

Haruaki Hayasaki DDS, PhDa,*, Issei Saitoh DDS, PhDa,
Kuniko Nakakura-Ohshima DDS, PhDa, Mika Hanasaki DDSa,
Yukiko Nogami DHa, Tsutomu Nakajima DDSa,
Emi Inada DDS, PhDb, Tomonori Iwasaki DDS, PhDb,
Yoko Iwase DDS, PhDa, Tadashi Sawami DDS, PhDa,
Katsushige Kawasaki DDS, PhDa, Nozomi Murakami DDSa,
Tomoya Murakami DDSa, Mie Kurosawa DDSa,
Masami Kimi DDSa, Akiko Kagoshima DDSa,
Miki Soda DDSa, Youich Yamasaki DDS, PhDb

a
Division of Pediatric Dentistry, Department of Oral Health Science, Course of Oral Life Science,
Graduate School of Medical and Dental Science Niigata University, 2-5274, Gakkocho-dori, Chuo-ku,
Niigata 951-8514, Japan
b
Department of Pediatric Dentistry, Graduate School of Medical and Dental Science, Kaghosima University,
8-35-1, Sakuragaoka, Kagoshima 890-8544, Japan

Received 23 November 2013; received in revised form 8 April 2014; accepted 25 April 2014

KEYWORDS Summary Control of plaque and debris is essential for the prevention of inflammatory
Tooth brushing; periodontal diseases and dental caries, because plaque is the primary etiological factor in the
Oral prophylaxis; introduction and development of both of these infection-oriented diseases. Plaque removal with
Dental plaque; a toothbrush is the most frequently used method of oral hygiene. Powered toothbrushes were
Toothbrush developed beginning in the 1960s and are now widely used in developed countries. The bristles of
a toothbrush should be able to reach and clean efficiently most areas of the mouth, and recently
the design of both manual and powered toothbrushes has focused on the ability to reach and clean
interproximal tooth surfaces. An individual’s tooth brushing behavior, including force, duration,
motivation and motion, are also critical to tooth brushing efficacy. Dental floss and the type of
toothpaste play additional important roles as auxiliary tools for oral prophylaxis. Dental profes-
sionals should help their care-receivers’ meet the requirements of oral hygiene to maintain their
QOL. This article reviews these topics.
# 2014 Japanese Association for Dental Science. Published by Elsevier Ltd.
Open access under CC BY-NC-ND license.

* Corresponding author. Tel.: +81 25 227 2908; fax: +81 25 227 2908.
E-mail address: hayasaki@dent.niigata-u.ac.jp (H. Hayasakia).

http://dx.doi.org/10.1016/j.jdsr.2014.04.001
1882-7616/# 2014 Japanese Association for Dental Science. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
70
1. Introduction
Oral prophylaxis is the foundation of oral health, and daily
plaque removal is considered important for oral health.
Specific oral bacteria, generically known as ‘‘dental plaque’’
are the primary cause of gingivitis (gum disease) and caries.
The removal of dental plaque is thought to play a key role in
the maintenance of oral health. There is some evidence that
electric toothbrushes, other than those with a counter-rotat-
ing movement, are more effective than manual brushes for
tooth brushing [1]. One explanation might be the varying
dexterity of the participants in the different studies. Clear
deficiencies in manual tooth brushing have been recognized
both from epidemiological and clinical researches [2—5]. This
article reviews the contemporary literature to provide an
overview of present knowledge concerning tooth brushing.
2. Dental plaque
A great diversity of microorganisms–—over 700 species–—has
been detected in the oral cavity [6], and evidence shows that
the investigation of specific microorganisms or associations of
microorganisms as etiological agents of periodontal diseases
and caries is a simplistic approach. Instead, dental plaque
must be studied as a biofilm (i.e., as communities composed
Figure 1 Examples of typical bristle profiles [8].
H. Hayasaki et al.
of microorganisms not individual pathogens) in order to
understand its biology and functional implications [7]. The
clinical presentation of these dental diseases is a net result of
the cross-talk between the pathogenic dental plaque biofilm
and the host tissue response. In the healthy state, both
plaque biofilm and adjacent tissues maintain a delicate
balance, establishing a harmonious relationship between
the two. However, changes occur during the disease process
that transform this ‘healthy’ dental plaque into a ‘patho-
genic’ biofilm. Recent advances in molecular microbiology
have improved our understanding of dental plaque biofilm,
producing numerous clinical benefits.
3. Toothbrushes
3.1. Manual toothbrush design
During the 18th century, the bristle toothbrush came into
use. Forerunners of today’s brushes were developed in the
1930s. These nylon toothbrushes with plastic handles were
easy to manufacture and therefore more affordable, making
tooth brushing a common practice in Western society. Ever
since, much imagination and inventiveness has been applied
to toothbrush design, and now numerous models of manual
toothbrushes are available [8] (Fig. 1), with more than 450
Tooth brushing for oral prophylaxis
kinds in Japan. However, there is still insufficient evidence
that any specific toothbrush design is superior to another.
Modern toothbrushes have various bristle tuft arrange-
ments (e.g., flat-trim, multilevel, angled) that are designed
[9] to enhance plaque removal from hard-to-reach areas of
the dentition, particularly from interproximal areas. The
degree of hardness and stiffness of a toothbrush depends
on the filament characteristics such as its material, diameter
and length. Today many manufacturers vary the length or
diameter of the filaments mounted in a single head. Tooth-
brushes with thinner filaments are softer while thicker fila-
ment diameters are stiffer and less flexible. The number of
filaments per tuft also determines the hardness of a tooth-
brush, which in turn has an effect on the cleaning perfor-
mance.
Robertson and Wade [10] showed that subjects cleaned
significantly better with medium and hard brushes than with
a soft-bristled brush. Berdon et al. [11] found that a tooth-
brush with 0.18 mm diameter filaments was significantly less
effective (P < 0.05) in cleaning than were five brushes with
larger diameter filaments from the same manufacturer. Gib-
son and Wade [12] observed that a toothbrush with 0.2 mm
diameter filaments tended to clean the marginal gingiva
more effectively than another with 0.18 mm diameter fila-
ments. In a crossover study, Vowles and Wade [13] tested the
differences between 0.13 mm and 0.28 mm filament dia-
meters and found that plaque removal was significantly
better (P < 0.001) with the thicker filaments when used with
the roll technique for brushing the facial and interproximal
areas. It appears, therefore, that filaments must have a
degree of stiffness to dislodge plaque deposits.
Designs are based on the premise that the majority of
persons in any population use a simple horizontal brushing
action. Over time, the design of the brush head has evolved
and multiple tufts of bristles, sometimes angled in different
directions, are now used. Today, prospective users can read-
ily find a toothbrush with a handle size appropriate to their
hand size, and much emphasis has been placed on new
ergonomic designs [14]. Toothbrush manufacturers have
made great effort in considering many different aspects
when designing new models to meet the challenge of enhan-
cing plaque biofilm removal through improved tooth brushing
efficacy. A few toothbrush manufacturers have also made the
effort to evaluate tooth brushing efficacy.
Product design changes can yield genuinely improved
performance characteristics [15]. A major shortcoming of
conventional flat-trim toothbrushes has been a ‘blocking
effect’ of tight bristle tufts, preventing individual tufts from
reaching interproximal areas. Multilevel toothbrushes have
been developed with alternating rows of longer and shorter
bristle tufts acting independently, uninfluenced by adjacent
Table 1 Reported comparisons of plaque removal efficiency between powered had manual toothbrushes.
Authors Year Manual brush (MB)
Nathoo et al. 2003 Oral-B Cross Action
Singh et al. 2005 Oral-B Indicator
Ghassemi et al. 2013 Oral-B Indicator 30 CS
MB: manual toothbrush, PB: powered toothbrush.
71
bristles during brushing. Once independent motion is
achieved, the longer bristles can effectively reach farther
between the teeth [16].
A recent systematic review [9] indicated that, depending
on the plaque index used, a 7—9% improvement in efficacy
(with the Navy index and Q&H index, respectively) can be
achieved with a multilevel bristle tuft configuration com-
pared to the traditional flat trim. The most recent develop-
ment of angled (‘‘angle bristles’’ in Fig. 1) rather than
vertical bristle tuft arrangements appears to have made a
significant contribution to interproximal plaque removal.
Clinical studies have consistently demonstrated that a brush
with an angled bristle tuft configuration is significantly more
effective [8,17,18]. Slot’s review also showed that depending
on the plaque index used, a 12—15% improvement in efficacy
(with the Q&H index and Navy index, respectively) can be
achieved with this particular bristle tuft configuration com-
pared to a flat-trim design. Angulation appears to be an
efficient innovation of brush head design, based on the
results of a review by Cronin et al. [19].
Recently, Voelker et al. [20] compared various commercial
manual toothbrush and powered heads to characterize the
following: bristle size, shape, diameter, number of tufts,
number of bristles per tuft and surface characteristics. There
were significant differences for toothbrush bristle diameter
and bristle shape. In contrast, there were no significant
differences between powered toothbrushes and manual
toothbrushes in bristle diameter, bristle count and tuft
count. The results suggest that although there are wide
variations in toothbrush head designs, significant differences
are found only in bristle diameter and shape.
3.2. Powered toothbrushes
Powered toothbrushes were first introduced commercially in
the early 1960s [21,22] and have become established as an
alternative to manual methods of tooth brushing. As a rule,
the advantage of the powered brush is both clinical and
statistical improvements in overall plaque scores. Powered
toothbrushes offer an individual the ability to brush the teeth
in a way that is optimal in terms of removing plaque and
improving gingival health–—conferring good brushing techni-
que on all who use them, irrespective of manual dexterity or
training [23]. Results showed that, powered brushes were
always better than manual brushes (Table 1).
There are two published Cochrane systematic reviews
comparing the efficacy of powered toothbrushes and manual
toothbrushes [5,24]. The first suggested that the rotation/
oscillation type of powered tooth brushing is superior to
manual tooth brushing for the removal of plaque and reduc-
tion of gum inflammation. However, that review did not allow
Powered brush (PB) No. of subjects Differences
MB < PB (%)
Colgate Motion 126 42.1
Colgate MicroSonic 39 52.9
Spin brush GLOBRUSH 103 12.8
72
direct comparison between different types of powered
toothbrushes, due to the small numbers of trials using other
types of powered brushes. Therefore, no definitive conclu-
sions can be drawn regarding the superiority of one type of
powered toothbrush over another. Only minor and transient
side effects were reported, and cost and reliability of the
brushes were not reported. Further trials of good quality will
be required to establish if other types of powered tooth-
brushes are better at reducing plaque and gingivitis. These
findings were not advanced much in the second review.
Another systematic review for powered toothbrushes pro-
posed the necessity of methodological homogeneity in future
studies in this field to enable quantitative comparison of
results [25].
4. Tooth brushing behavior
4.1. Techniques for manual toothbrushes
To identify the most effective methods of tooth brushing in
children, Muller-Bolla and Courson [26] carried out a sys-
tematic review to evaluate the children’s ability to remove
dental plaque. The horizontal technique was found to be the
most effective up to 6—7 years of age [27—29]. Advantages of
the horizontal Scrub are that it is easy to learn and practice
and is effective at plaque removal [30,31]. However, this
tooth brushing method is less effective for cleaning in the
proximal and gingival sulci of permanent teeth and may
results in gingival recession and tooth abrasion [32]. For
older children, there was no statistical difference between
the Bass and Fones techniques. Bergstrom et al. suggested
that the horizontal technique should be advised in younger
children. For adults, the modified Bass technique is often
recommended by dentists and in textbooks and used in
clinical studies [33—35]. However, the Fones technique is
often recommended in patient brochures in Germany, and its
efficiency recently was proved by Harnacke et al. [36]. In
general, these brochures, recommendations and instructions
of tooth brushing technique are very helpful for improving
oral hygiene. However, for serious improvement in a patient’s
oral hygiene, the dentist should first evaluate the patient’s
hand-skill motion before giving instructions. Each individual
has poor (or weak) or favorite (or strong) hand-skill motion
for each of the brushing techniques. From this point of view,
toothbrushing technique is still an open question.
As for the effectiveness of tooth brushing instruction along
with practicing a particular tooth brushing method, Slot et al.
[9] summarized in their systematic review that tooth brush-
ing practice reduces plaque from baseline plaque scores by
42% on average, with a variation of 30—53%, dependent on
the plaque index used. In addition, they suggested that
bristle tuft arrangement (flat-trim, multilevel, angled) and
brushing duration were factors that contribute to the varia-
tion in observed efficacy.
Recently, several studies have tried to evaluate brushing
techniques in terms of brushing motion, brushing action or
both [33,37—40]. One study developed and evaluated the
efficiency of a smart digital toothbrush monitoring and train-
ing system in terms of correct brushing motion and grip axis
orientation in the at-home environment [41]. Their analyzing
software allowed calibration of all parameters individually.
H. Hayasaki et al.
Hence, movements of the toothbrush during different brush-
ing techniques could be characterized.
The most recent study developed a toothbrush-monitoring
system that provided information concerning the orientation
and linear displacement of the toothbrush actions [33].
Orientation and back-and-forth displacement of the tooth-
brush were measured by a combined three-axis acceler-
ometer.
Tooth brushing behavior is a daily habit, therefore, it is not
easily altered, even after professional instruction in the
clinic. First, teaching brushing technique is a complex and
time-consuming procedure. Second, from the perspective of
movement sciences, skill training requires many repetitions
of the same movements to incorporate them into an indivi-
dual’s habitual motor program.
4.2. Toothbrush force and pressure
The choice of toothbrush is usually a matter of individual
preference rather than a demonstrated superiority of any one
type [42]. The enthusiastic use of a toothbrush is, however,
not synonymous with a high standard of oral hygiene. Adults,
despite their apparent efforts, appear not to be as effective
in their plaque removal as might be expected. Most indivi-
duals reduce plaque scores by approximately 50% during
tooth brushing. A 1-min brushing exercise in participants
adhering to their customary brushing method, but all using
the same type of toothbrush, observed a plaque score reduc-
tion of approximately 39% [42]. These results indicate that
most people are not effective brushers and probably live with
considerable amounts of plaque on their teeth, despite
brushing at least once a day. What currently is lacking is a
systematic review that provides a reliable overview of tooth
brushing efficacy through the process of systematically locat-
ing, appraising and synthesizing evidence from individual
trials [9].
Professional recommendations for individual oral hygiene
mostly include tooth brushing at least twice daily [43,44] for
2—3 min with gentle force [39] using the Bass technique or
modifications of it [33,45] as suggested by American Dental
Association. However, ‘‘gentle force’’ is not defined clearly
enough to be used in the clinical situation.
When brushing force is increased, more plaque is removed
[46]. Numerous studies have reported brushing forces. Some
of these previously reported tooth brushing forces were
2.95 N [47], 2.61 N [46], 2.96 N [48], 3.23. N [42], 2.3 N
[39]. Force discrepancies might have been due to random
effects from using different measuring systems and tooth-
brushes, and different gender, age and dental characteristics
of the study groups. Burgett and Ash discussed the significant
variation in the magnitude of brushing force (from 1.04 N g to
11.3 N) when using different measuring systems, toothbrush
grips, toothbrushes and techniques [49]. In addition, no
systematic review or evaluation of brushing forces has so
far been performed that compares different sextants and
tooth sites or of the effect of instruction on brushing tech-
nique.
Very few studies have investigated the association
between brushing force and gingival recession. The available
evidence suggests that tooth brushing force should not
exceed 3 N to avoid gingival recession [50]. Tooth brushing
Tooth brushing for oral prophylaxis
abrasion is one factor in the multi-factorial process of tooth
wear. While tooth brushing is considered to be of minor
importance for abrasion of sound enamel and dentin [51],
it was shown to be a significant risk factor for the etiology of
erosive lesions [52—54], especially on eroded enamel and
dentin. Tooth-brushing abrasion is determined by the abra-
sive properties [55,56] and concentration [57] of the tooth-
paste, and is also modified by the kind of toothbrush [58] and
the brushing force [59,60].
Comparison of the brushing forces applied during in vivo
tooth brushing with manual and sonic toothbrushes and the
average brushing force of manual toothbrushes (1.6  0.3 N)
was significantly higher than for sonic toothbrushes
(0.9  0.2 N) [54]. These different brushing forces affect
the abrasive capacity of manual and sonic toothbrushes.
Recent systematic reviews also suggest that power tooth-
brushes produce less clinically relevant damage potential to
soft and hard tissues than manual toothbrushes [61,62].
Patients with clinically significant severe tooth wear and
exposed or eroded dentin surfaces should use sonic tooth-
brushes to reduce abrasion, while patients without tooth
wear or with erosive lesions confined to the enamel do not
benefit from reduced abrasion from sonic toothbrushes [54].
4.3. Duration of manual tooth brushing
Duration is one of the critical factors affecting the efficacy of
tooth brushing for dental plaque removal [63]. It has been
proposed that the main cause of insufficient oral hygiene in
the general population is too short a brushing time [64].
However, changing this seems to be very difficult [65].
Reported tooth brushing durations for children and adults
are shown in Table 2. Brushing’s major effect on plaque
reduction is reached after 30—45 s of brushing per quadrant;
accordingly, the commonly recommended tooth brushing
times vary between 120 s (USA) and 180 s (Europe) [66].
Manual brushing for additional time did not lead to any
significant improvement [66], and a brushing duration of
more than 3 min is usually not achieved [67]. On the other
hand, Schlueter et al. [41] reported that repeat motivation at
each recall, using leaflets, instructions and demonstrations,
were statistically effective in prolonging tooth brushing
duration and improving tooth brushing technique.
5. Clinical research for plaque removal
efficacy
The gold standard for clinical research is a randomized con-
trolled trial with large numbers of participants to test the
Table 2 Reported toothbrushing durations.
Authors Year Age (mean age or range)
Tesini and Perlman 1994 8.4
Das and Singhal 2009 9—11
Sharma et al. 2012 8—12
Macgregor and Rugg-Gunn 1979 11—13
Macgregor and Rugg-Gunn 1985 18—22
Dentino et al. 2002 Adults
73
efficacy and effectiveness of various types of clinical inter-
vention. Indices for the clinical evaluation of dental plaque
have been developed and are listed in Table 3. Each index has
its own characteristics, and each study selects the index best
suited for its purpose. However, this variety of indices makes it
difficult to compare them directly for a systematic review. In
addition, studies using these indices typically rely on clinical
examiners to assign index values as a means of determining
outcomes or for performing group comparisons. The quality of
the assigned values is dependent, to a large extent, on the
skills of the examiners and on the validity of the assessment
methods that are used. Therefore, much attention has to be
paid to the common sources of error and bias that can lead to
difficulties in standardizing examiners [68].
Personal oral hygiene is often combined with therapeutics
such as fluoride or xylitol, which have an effect on dental
diseases and possibly tooth loss, making the evaluation of the
pure effects of oral hygiene behavior difficult. Because the
evidence for the effectiveness of these chemo-therapeuti-
cals is sufficiently convincing that withholding them may be
considered unethical. However, alternative delivery mechan-
isms, such as chewing gum, may be viable, more practical,
and more reliable than personal oral hygiene tools. Another
possibility is to evaluate variations in the level of personal
oral hygiene (much like studying varying levels of fat intake,
physical activity, etc.).
6. Toothpaste and/or dentifrice
Advances in toothbrush technology are associated with more
effective plaque removal, but excessive plaque regrowth can
also be a problem for individuals. Therefore, there is a need
for products that not only help users achieve optimal plaque
removal, but also ensure that plaque levels remain controlled
overnight and throughout the day, thereby reducing the risk
of oral hygiene becoming suboptimal. The choice of denti-
frice had a significant effect on the inhibition of plaque
regrowth in a study with manual toothbrushes and may also
play an important role in optimizing the level of plaque
control achieved with power brushing.
The systematic review of the Cochrane database by Walsh
et al. [69] confirmed the benefits of using fluoride toothpaste
to prevent caries in children and adolescents, but only for
fluoride concentrations of 1000 ppm and above. The relative
caries preventive effect of fluoride toothpastes increases
with higher fluoride concentration. However, the choice of
fluoride level to use for children under 6 years should be
balanced with the risk of fluorosis. Haftenberger et al. [70]
reported that most 1—3-year-old children in Brazil are
exposed to a daily fluoride intake above the suggested
Mean Duration (sec)
57.8
76.2
85.8
78.0
33.0
14 out of 81 spent 120 or more
74
Table 3 Indices for the clinical evaluation of dental plaque.
Authors Year
Quigley and Hein 1962
Silness and Loe 1964
Turesky et al. 1970
Elliott et al. 1972
O’Leary et al. 1972
Lobene et al. 1982
Rustogi et al. 1992
threshold for dental fluorosis. The dentifrice alone was
responsible for an average of 81.5% of the daily fluoride
intake, while the diet, water and milk were the other most
important contributors. Although the efficacy of fluoride
paste has been confirmed, information about its risks should
be given more emphasis. Accordingly, detailed longitudinal
studies of fluoride intake during tooth brushing with tooth-
paste in large populations are still needed, especially of very
young children in various countries and areas.
There is evidence that casein phosphopeptide-amorphous
calcium phosphate, CPP-ACP, can bolster the effects of
fluoridated toothpaste alone to prevent caries. The localized
CPP-ACP nanocomplexes in plaque and on tooth surfaces can
buffer the free calcium and phosphate ion activities, main-
tain a state of supersaturation with respect to tooth enamel,
prevent enamel demineralization, and promote reminerali-
zation [71]. Several studies have shown a synergistic effect of
CPP-ACP and fluoride in reducing caries [72,73]. Almost all
clinical trials have investigated the effectiveness of CPP-
ACP-containing products in caries prevention and enhancing
remineralization of initial caries lesions in the permanent
dentition of young adolescents [74—76].
Specially formulated oral care products containing stan-
nous salts (e.g., chloride, fluoride) have shown to effectively
protect enamel and dentin from erosive and abrasive wear in
vitro [77—79] and in situ [77,80,81]. It has been suggested
that the stannous ion can act either by precipitation on
dental surfaces forming a relatively acid-resistant mineral
layer or by incorporation into the eroded surface in a complex
demineralization and remineralization process [79]. While
these data are encouraging, it must be borne in mind that
erosion is highly influenced by biological factors, especially
those imposed by the acquired dental pellicle [82].
7. Oral care for elderly persons and persons
with disabilities
Good oral health is an important aspect of quality of life,
even for the elderly [83]. Teeth are important for chewing,
speech and appearance [84]. In recent years, people’s overall
health has improved, as is reflected in an increase in the
average life expectancy in developed countries. Today, the
elderly remain dentate to a greater extent than just a few
decades ago and have more teeth, often with extensive
repairs, crown and bridge work and implants. This places
high demands on satisfactory oral care for the elderly to
remain in good oral health.
Oral health is also affected by a number of general health
factors. Dementia and various mental and physical disabil-
ities, for example, can result in difficulties in maintaining
H. Hayasaki et al.
Method
Quigley and Hein (Q&H) plaque index
Silness and Löe plaque index
Turesky modification of the Q&H plaque index
Navy plaque index
O’Leary plaque control record
Lobene modification of the Q&H plaque index
Rustogi modified Navy plaque index
good oral health. Medications can induce hyposalivation,
which in turn, increases the risk of tooth decay and other
dental diseases [85,86]. Without support for regular oral
hygiene habits there is a risk that dependent residents will
develop oral diseases. Care involves not only caring for the
sick but also taking preventive measures to preserve good
overall health.
For individuals with disabilities, the dental health is gen-
erally worse than that of normal people of the same age
because their medical, physical, social, or psychological
disabilities limit their access to oral health care, including
diagnostic, preventive, interceptive and treatment services
[87,88]. Anders and Davis [89] concluded that patients with
intellectual disabilities have poorer oral hygiene than the
general population [90—95]. The above listed disadvantages
lead to poorer oral health, more untreated decayed teeth
and severe periodontal status [96—99]. However, some stu-
dies [100,101] have reported that the oral health of children
with disabilities can be improved to a similar or even better
status than that of normal children at the same age in spite of
their disadvantages. The main reasons for improvement can
be accredited to the practice of daily tooth brushing by
themselves or by their caregivers, and diet control by insti-
tutes and schools [100].
Dental care has been found to be the most common cate-
gory of unmet healthcare services for individuals with special
healthcare needs [102,103]. These individuals are at a higher
risk for more untreated caries, gingivitis and other periodontal
diseases, malocclusions secondary to abnormal development
and muscle function, problems related to poor oral hygiene
and dental/orofacial trauma, as well as inadequate access to
care. [102] More importantly, if adequate oral hygiene and oral
health care are not addressed the sequelae can be detrimental
to the overall health of the individual. The role of caregivers
and dental health professionals’ instructions to caregivers are
crucial for these disable persons.
8. Conclusion
In this paper we have discussed various aspects of oral
prophylaxis, especially, tooth brushing. This is a basic and
fundamental daily custom for almost all people, even in
developing countries, and its aim is to remove dental plaque.
However, more than 40% of plaque will not be removed, even
by a well-trained person. Because of the importance of
prevention of dental caries and periodontal disease,
improvement of the quality of daily brushing is indispensable.
In addition, combining more effective brushing with dental
floss, inter-dental brush and oral rinses, will provide better
oral health for all.
Tooth brushing for oral prophylaxis
Conflict of interest statement
The authors declare no conflict of interest.
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