Dreading a visit to the dentist is a tried and true tradition – along with the age old question that every patient is asked – ‘Have you been brushing and flossing?’

I get asked more commonly than ever about when, how, and what my patients should be brushing with.

Electric or manual?

What type of toothpaste should I use?

Am I brushing too much?

When it comes to these questions there’s many answers. Ultimately, it’s important to be brushing with a soft-headed toothbrush and any old toothpaste works (as long as it contains fluoride). You can find numerous resources that recommend the use of fluoride, but for this post I want to focus on when you should brush your teeth. For the ‘fluoride debate,’ please reference the American Dental Association’s guidelines – Fluoride: Topical and Systemic Supplements. I often times recommend an electric toothbrush, though a manual will work just fine¹. In the study cited, a manual and electric toothbrush were found to reduce plaque effectively but the electric toothbrush was found to have a greater reduction. All of this being said, one of the questions above can get a little more complicated – Are You Brushing Too Much?

Why Do I Need To Brush?

In our post last week, I mentioned that there are various factors that may cause cavities – including diet, bacterial load, saliva, and frequency of brushing. When we brush our teeth, we are removing plaque consisting of food and bacteria. This plaque contributes to gum disease as well as releasing acids that cause tooth decay. So what is actually happening to our teeth when decay occurs, and why do we need to brush to stop it?

When we eat sugars and other foods (don’t just think of traditional sugars – bread and other carbohydrates are essentially the same), bacteria in our mouth break them down and use them as fuel. This results in acids released from the bacteria that leach minerals from our teeth, like calcium. As our teeth lose minerals, decay sets in². So what does brushing your teeth have to do with this?

The physical act of toothbrushing mechanically removes plaque and food material. What many individuals may not understand is what fluoride in toothpaste does to your teeth. While minerals are lost when we eat, fluoride helps reverse this process. The fluoride elements bind to calcium and aid in what is called remineralization. Fluoride has other uses, as well, such as helping prevent the demineralization of teeth and acting as an antimicrobial³. This is why brushing with fluoridated toothpaste is so important. Again, this is a long-debated subject and the systemic and topical use of fluoride can be supported by numerous resources but won’t be discussed further in this post (but look for it in the future).

When Do I Need To Brush?

Now that we understand why we need to brush, when we need to brush gets a little more complicated. We’ve always been taught that brushing twice a day for two minutes is the golden standard. I think it’s a good starting place for all patients to understand – but this is an over-simplified approach to something we do everyday. Over-brushing or under-brushing can lead to issues down the road with your teeth.

Let’s begin with the basics – you should brush your teeth each morning and night for two minutes. The two minute standard is easy to remember, but may seem like an eternity to patients. In fact, it was found that the average time patients spend on brushing their teeth is actually closer to 46 seconds⁴. With the two minute standard, you can count on placing 30 seconds in each quadrant of your teeth. Remember – over-brushing can lead to complications, so there’s no need to go above two minutes. Angle that brush head at 45 degrees, so you can properly clean in between your gums, too.

What Complications Are You Talking About?

A lot of times my patients think that the more you brush, the healthier your teeth and gums will be. Unfortunately, I often have to slow them down – brushing more than twice a day has shown to have negative effects on both the teeth and gums.

When you brush more than twice day, you may be contributing to abrasion on your teeth. Abrasion is usually found on the buccal surface (cheek side) of teeth and appears as notches along the cervical portion of the teeth (near the gums). The cause of abrasion is usually due to over-brushing – toothpaste is a natural abrasive that removes surface stains but isn’t meant to be overused. Studies show that the benefits of toothpaste do not outweigh the negatives of repeated use (more than twice a day). Overuse has also attributed to gum recession, as well, resulting in sensitivity and an unpleasant appearance⁵.

And Finally… Should I Brush After I Eat?

This is what I like to think of as ‘The Silent Killer’ – more studies show that brushing after you eat can have detrimental effects on your teeth – and it’s why I always recommend a mouth rinse after lunch or dinner, not brushing⁶.

Let’s revisit the process of getting a cavity. When we eat foods, acid is released as a byproduct by bacteria in our mouths. This causes a rapid decrease in pH of our mouth – meaning it becomes more acidic. This is the process that minerals are lost in our teeth – it takes our saliva to neutralize this acid over time and protect our teeth (remember how ‘saliva’ was a key factor in cavities?). Reference the ‘Stephen’s Curve’ that was posted above.

‘Upon exposure to an acid, the saliva has the ability to achieve remineralization with time, but teeth are vulnerable to abrasion before completion of this action.’

Oral and Maxillofacial Pathology, 4th Edition

If we immediately brush our teeth after we eat, we are applying an abrasive on an already weakened tooth structure due to the acid produced. This is especially important for those patients who suffer from acid erosion such as that seen with GERD, or gastroesophogeal reflux disease.

You can do a lot, instead, rather than brushing. I always recommend my patients to rinse with water after they eat a meal, and if the meal happens to be a bit on the smelly side, a quick rinse with Listerine should do the trick. You can remove surface plaque without abrading your teeth and still get the benefits of a fresh-feeling mouth. If you really feel like you need to brush your teeth, wait at least one hour before you do!

All of these complications happen after long-term, repeated overuse of brushing incorrectly. There’s no need to worry now if your gums will recede or if your teeth are in harms-way, it’s just important to do everything you can to maximize the longevity of your teeth as you age!

To Summarize:

• Use a toothpaste with fluoride
• Fluoride helps remineralize teeth that lost minerals due to acid caused by bacteria
• Brush for two minutes, twice a day, at a 45 degree angle
• Overbrushing can lead to gum loss and wear down teeth
• Don’t brush after you eat – wait at least one hour

References:

¹Ccahuana-Vasquez, R. A., Adam, R., Conde, E., Grender, J. M., Cunningham, P., Goyal, C. R., & Qaqish, J. (2019). A 5-week randomized clinical evaluation of a novel electric toothbrush head with regular and tapered bristles versus a manual toothbrush for reduction of gingivitis and plaque. International journal of dental hygiene, 17(2), 153–160. https://doi.org/10.1111/idh.12372

²The Tooth Decay Process: How to Reverse It and Avoid a Cavity. (n.d.). Retrieved January 25, 2021, from https://www.nidcr.nih.gov/health-info/tooth-decay/more-info/tooth-decay-process#how-does-a-cavity-develop

³Buzalaf, M., Pessan, J. P., Honório, H. M., & Ten Cate, J. M. (2011). Mechanisms of action of fluoride for caries control. Monographs in oral science, 22, 97–114. https://doi.org/10.1159/000325151

⁴Creeth, J. E., Gallagher, A., Sowinski, J., Bowman, J., Barrett, K., Lowe, S., Patel, K., & Bosma, M. L. (2009). The effect of brushing time and dentifrice on dental plaque removal in vivo. Journal of dental hygiene : JDH, 83(3), 111–116.

⁵AEGIS Communications, B. (2010). The Right and Wrong Ways to Brush. Retrieved January 25, 2021, from https://www.aegisdentalnetwork.com/ida/2010/06/the-right-and-wrong-ways-to-brush

⁶Jaeggi, T., & Lussi, A. (1999). Toothbrush abrasion of erosively altered enamel after intraoral exposure to saliva: an in situ study. Caries research, 33(6), 455–461. https://doi.org/10.1159/000016551

⁷The Stephan Curve. (n.d.). Retrieved January 25, 2021, from https://www.wrigleyoralhealthcare.co.uk/research-and-evidence

⁸Chi, A., Neville, B., Damm, D., Allen, C. (052015). Oral and Maxillofacial Pathology, 4th Edition. [VitalSource Bookshelf 9.4.0]. Retrieved from vbk://9781455770526

Liability Statement:

The medical advice given in this blog should only be utilized by a medical professional who has received a medical degree. I am not responsible for the medical advice given in this blog and each case should be reviewed extensively with sources outside my blog. This blog is for education purposes only and is not meant as a substitute for an academic institution.