How to brush your teeth properly: toothbrush, fluoride toothpaste, floss and tongue, according to current guidance

How many times a day should you brush your teeth, and for how long?

Teeth should be brushed at least twice a day: last thing in the evening, before bed, and once more at another time of day. That is the recommendation of Delivering better oral health (DBOH), the UK prevention toolkit prepared for dental teams by the UK health department, and it carries the highest strength of recommendation.

Each brushing should last about 2 minutes. According to DBOH, that is how long it takes to clean all tooth surfaces thoroughly, and people with gum disease may need longer. The NHS, the UK’s public health service, gives the same time.

Do not skip the evening brush even after a long day, because it is the only one the guidelines name specifically. The second brush can be in the morning or at another time that suits your day.

How do you brush your teeth properly, step by step?

Brushing your teeth properly is a few simple steps in a fixed order. The list is based on the recommendations of DBOH, the NHS and the American Dental Association (ADA); the guidelines do not prescribe a single brushing technique, so it is worth adapting yours with a hygienist or dentist.

• First clean between your teeth with an interdental brush or floss, reaching just under the gum line.
• Apply fluoride toothpaste in an amount suited to age; adults use toothpaste with 1,350 to 1,500 ppm fluoride.
• Brush all tooth surfaces: outer, inner and biting surfaces, paying particular attention to the gum line.
• Move the brush gently, without scrubbing hard, for about 2 minutes.
• Spit out the foam, but do not rinse with water, so as not to dilute the fluoride left on the teeth.
• If you use a mouthwash, use it at a different time of day, for example after lunch, not straight after brushing.
• Replace your toothbrush every 3 to 4 months, or sooner if the bristles are visibly splayed or frayed.

Which fluoride toothpaste, and how many ppm at each age?

Adults should use fluoride toothpaste with 1,350 to 1,500 ppm, and children toothpaste with 1,000 ppm up to the age of 6 and 1,450 ppm after that, in an amount that grows with age. The fluoride concentration is given on the packaging in ppm, parts per million.

The recommendations for children come from the guidelines of the European Academy of Paediatric Dentistry (EAPD, 2019), which also advises that a parent should supervise toothbrushing until at least the age of 7. Prevention in young children is covered in more detail in the article on tooth decay in children.

Toothpastes with a higher fluoride concentration, 2,800 or 5,000 ppm, are recommended by a dentist for people with active decay until it is under control. They are not meant for use on your own initiative.

For adults at increased risk of decay, DBOH also recommends fluoride varnish (2.26% sodium fluoride), applied at the surgery twice a year. It supplements daily fluoride toothpaste rather than replacing it.

Electric or manual toothbrush: what does the research say?

An electric toothbrush removes plaque slightly more effectively than a manual one, but both, used properly, are enough for daily hygiene. A 2014 Cochrane review (56 studies, 4,624 participants) found that after 1 to 3 months electric toothbrushes reduced plaque by 11% and gum inflammation by 6% more than manual ones; after more than 3 months the differences were 21% and 11%.

The review’s authors rate the quality of the evidence as moderate and write that the clinical importance of these differences remains unclear. Most of the data concern toothbrushes with a rotating-oscillating action, and side effects were localised and temporary.

DBOH recommends a manual or electric toothbrush, in most cases with a small head and medium-textured bristles. The NHS considers both types equally good, so the choice can come down to comfort, price and which brush you actually use for the full 2 minutes.

Flossing or interdental brushes?

To clean the spaces between the teeth, use interdental brushes where they fit and floss or tape where the gaps are tight. That is the DBOH recommendation, which advises cleaning between the teeth every day, reaching just under the gum line, before brushing.

A 2019 Cochrane review (35 studies, 3,929 adults) reports that floss or interdental brushes added to toothbrushing may reduce gum inflammation or plaque, and that interdental brushes may be more effective than floss. The certainty of this evidence is low or very low, and the effects may not be of great clinical importance.

DBOH adds that in people with gum disease, interdental brushes may work better than floss. The NHS also lists single-tufted brushes, with one small tuft of bristles, as a possible alternative to floss, especially where there are gaps between the teeth.

An interdental brush is chosen to match the width of the gap, and the gaps between different teeth can vary. A hygienist or dentist can help with the first choice.

Can a water flosser replace floss?

A water flosser’s effect is not as well documented as that of floss or interdental brushes, so it is better treated as an addition than as a substitute. The 2019 Cochrane review rated the evidence for water flossers and toothpicks as limited and inconsistent.

If you find a water flosser convenient, you can use it, but not instead of floss or an interdental brush wherever these can be inserted.

If you find floss hard to use, for example because of tight gaps or limited hand dexterity, talk to a hygienist about other tools. Interdental brushes with a handle or single-tufted brushes can be easier to use, and interdental brushes have a better-described effect than a water flosser.

Why clean your tongue, and should you rinse after brushing?

Cleaning the tongue with a scraper or a brush is recommended mainly for fresh breath. However, the current 2019 Cochrane review found only a small improvement in breath as assessed by a dentist and judged this evidence very uncertain; the causes of bad breath are described in a separate article.

Rinsing with water after brushing is a common habit that weakens the effect of the toothpaste. DBOH and the NHS recommend spitting out excess toothpaste and not rinsing, so as not to dilute the fluoride, and the NHS adds that for the same reason a mouthwash, including a fluoride one, is not used straight after brushing.

Mouthwashes do not replace brushing. The Cochrane review on bad breath (44 studies) did not find that any method, mouthwashes included, worked clearly better than the others, and the certainty of all the results was low or very low.

The most common toothbrushing mistakes

Toothbrushing mistakes rarely come from the choice of toothbrush and more often from habits. These are worth checking in your own routine.

• Skipping the evening brush, the one the guidelines name specifically.
• Rinsing with water or mouthwash straight after brushing.
• Brushing for less than 2 minutes and missing the inner surfaces of the teeth.
• Scrubbing hard, which wears away the necks of the teeth and can lead to sensitivity.
• A toothbrush with splayed, worn-out bristles.
• Skipping the spaces between the teeth, which a toothbrush cannot reach.
• Toothpaste without fluoride, or with a lower concentration than recommended for adults.

How it works at DentalBlue

At DentalBlue in Białystok, preventive care includes hygiene treatment, fissure sealing and fluoride application, and the clinic’s team includes dental hygienists. In the clinic’s price list, “Kompleksowa higienizacja (skaling, piaskowanie, fluoryzacja)” (comprehensive hygiene treatment: scaling, air polishing, fluoride) costs 350 zł, “Fluoryzacja” (fluoride application) 100 zł and “Kontrola po higienizacji” (check-up after hygiene treatment) 50 zł. At the visit, it is worth asking for help choosing an interdental brush and for the places you miss when brushing to be pointed out. The final scope and cost are agreed at the visit, and prices may change.