Oral hygiene is the practice of keeping one's mouth clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and cleaning between the teeth. It is important that oral hygiene be carried out on a regular basis to enable prevention of dental disease and bad breath. The most common types of dental disease are tooth decay (cavities, dental caries) and gum diseases, including gingivitis, and periodontitis.
General guidelines suggest brushing twice a day: after breakfast and before going to bed, but ideally the mouth would be cleaned after every meal. Cleaning between the teeth is called interdental cleaning and is as important as tooth brushing. This is because a toothbrush cannot reach between the teeth and therefore only removes about 50% of plaque from the surface of the teeth. There are many tools to clean between the teeth, including floss and interdental brushes; it is up to each individual to choose which tool they prefer to use.
Sometimes white or straight teeth are associated with oral hygiene. However, a hygienic mouth can have stained teeth or crooked teeth. To improve the appearance of their teeth, people may use tooth whitening treatments and orthodontics.
Tooth cleaning and decay
Tooth decay is the most common global disease. Over 80% of cavities occur inside fissures in teeth where brushing cannot reach food left trapped after eating and saliva and fluoride have no access to neutralize acid and remineralize demineralized teeth, unlike easy-to-clean parts of the tooth, where fewer cavities occur.
Since before recorded history, a variety of oral hygiene measures have been used for teeth cleaning. This has been verified by various excavations done throughout the world, in which chew sticks, tree twigs, bird feathers, animal bones and porcupine quills have been found. In historic times, different forms of tooth cleaning tools have been used. Indian medicine (Ayurveda) has used the neem tree, or daatun, and its products to create teeth cleaning twigs and similar products; a person chews one end of the neem twig until it somewhat resembles the bristles of a toothbrush, and then uses it to brush the teeth. In the Muslim world, the miswak, or siwak, made from a twig or root, has antiseptic properties and has been widely used since the Islamic Golden Age. Rubbing baking soda or chalk against the teeth was also common; however, this can have negative side effects over time.
The Australian Healthcare and Hospital Association's (AHHA) most recent evidence brief ) suggests that dental check-ups should be conducted once every 3 years for adults, and 1 every 2 years for children. It has been documented that dental professionals frequently advise for more frequent visits, but this advice is contraindicated by evidence suggesting that check up frequency should be based on individual risk factors, or the AHHA's check-up schedule. Professional cleaning includes tooth scaling, tooth polishing, and, if tartar has accumulated, debridement; this is usually followed by a fluoride treatment. However, the American Dental Hygienists' Association (ADHA) stated in 1998 that there is no evidence that scaling and polishing only above the gums provides therapeutic value, and cleaning should be done under the gums as well. The Cochrane Oral Health Group found only three studies meeting the criteria for inclusion in their study and found little evidence in them to support claims of benefits from supragingival (above the gum) tooth scaling or tooth polishing.
Dental sealants, which are applied by dentists, cover and protect fissures and grooves in the chewing surfaces of back teeth, preventing food from becoming trapped and thereby halt the decay process. An elastomer strip has been shown to force sealant deeper inside opposing chewing surfaces and can also force fluoride toothpaste inside chewing surfaces to aid in remineralising demineralised teeth.
Between cleanings by a dental hygienist, good oral hygiene is essential for preventing tartar build-up which causes the problems mentioned above. This is done through careful, frequent brushing with a toothbrush, combined with the use of dental floss or interdental brushes to prevent accumulation of plaque on the teeth. Powered toothbrushes reduce dental plaque and gingivitis more than manual toothbrushing in both short and long term. Further evidence is needed to determine the clinical importance of these findings.
Patients need to be aware of the importance of brushing and flossing their teeth daily. New parents need to be educated to promote healthy habits in their children.
Sources of problems
Dental plaque, also known as dental biofilm, is a sticky, yellow film consisting of a wide range of bacteria which attaches to the tooth surfaces and can be visible around the gum line. It starts to reappear after the tooth surface has been cleaned, which is why regular brushing is encouraged. A high-sugar diet encourages the formation of plaque. Sugar (fermentable carbohydrates), is converted into acid by the plaque. The acid then causes the breakdown of the adjacent tooth, eventually leading to tooth decay.
If plaque is left on a subgingival (under the gum) surface undisturbed, not only is there an increased risk of tooth decay, but it will also go on to irritate the gums and make them appear red and swollen. Some bleeding may be noticed during tooth brushing or flossing. These are the signs of inflammation which indicate poor gum health (gingivitis).
The longer that plaque stays on the tooth surface, the harder and more attached to the tooth it becomes. That is when it is referred to as calculus and needs to be removed by a dental professional. If this is not treated, the inflammation will lead to the bone loss and will eventually lead to the affected teeth becoming loose.
Routine tooth brushing is the principal method of preventing many oral diseases, and perhaps the most important activity an individual can practice to reduce plaque buildup. Controlling plaque reduces the risk of the individual suffering from plaque-associated diseases such as gingivitis, periodontitis, and caries – the three most common oral diseases. The average brushing time for individuals is between 30 seconds and just over 60 seconds. Many oral health care professionals agree that tooth brushing should be done for a minimum of two minutes, and be practiced at least twice a day. Brushing for at least two minutes per session is optimal for preventing the most common oral diseases, and removes considerably more plaque than brushing for only 45 seconds
Toothbrushing can only clean to a depth of about 1.5 mm inside the gingival pockets, but a sustained regime of plaque removal above the gum line can affect the ecology of the microbes below the gums and may reduce the number of pathogens in pockets up to 5 mm in depth.
Toothpaste (dentifrice) with fluoride is an important tool to readily use when tooth brushing. The fluoride in the dentifrice is an important protective factor against caries, and an important supplement needed to remineralize already affected enamel. However, in terms of preventing gum disease, the use of toothpaste does not increase the effectiveness of the activity with respect to the amount of plaque removed.
Manual tooth brush
The modern manual tooth brush is a dental tool which consists of a head of nylon bristles attached to a long handle to help facilitate the manual action of tooth brushing. Furthermore, the handle aids in reaching as far back as teeth erupt in the oral cavity. The tooth brush is arguably a person's best tool for removing dental plaque from teeth, thus capable of preventing all plaque-related diseases if used routinely, correctly and effectively. Oral health professionals recommend the use of a tooth brush with a small head and soft bristles as they are most effective in removing plaque without damaging the gums.
The technique is crucial to the effectiveness of tooth brushing and disease prevention. Back and forth brushing is not effective in removing plaque at the gum line. Tooth brushing should employ a systematic approach, angle the bristles at a 45-degree angle towards the gums, and make small circular motions at that angle. This action increases the effectiveness of the technique in removing plaque at the gum line.
Electric tooth brush
Electric toothbrushes are toothbrushes with moving or vibrating bristle heads. The two main types of electric toothbrushes are the sonic type which has a vibrating head, and the oscillating-rotating type in which the bristle head makes constant clockwise and anti-clockwise movements.
Sonic or ultrasonic toothbrushes vibrate at a high frequency with a small amplitude, and a fluid turbulent activity that aids in plaque removal. The rotating type might reduce plaque and gingivitis compared to manual brushing, though it is currently uncertain whether this is of clinical significance. The movements of the bristles and their vibrations help break up chains of bacteria up to 5mm below the gum line. The oscillating-rotating electric toothbrush on the other hand uses the same mechanical action as produced by manual tooth brushing – removing plaque via mechanical disturbance of the biofilm – however at a higher frequency.
Using electric tooth brushes is less complex in regards to brushing technique, making it a viable option for children, and adults with limited dexterity. The bristle head should be guided from tooth to tooth slowly, following the contour of the gums and crowns of the tooth. The motion of the toothbrush head removes the need to manually oscillate the brush or make circles.
Tooth brushing alone will not remove plaque from all surfaces of the tooth as 40% of the surfaces are interdental. One technique that can be used to access these areas is dental floss. When the proper technique is used, flossing can remove plaque and food particles from between the teeth and below the gums. The American Dental Association (ADA) reports that up to 80% of plaque may be removed by this method. The ADA recommends cleaning between the teeth as part of one's daily oral hygiene regime.
- Unwaxed floss: Unbound nylon filaments that spread across the tooth. Plaque and debris get trapped for easy removal.
- Waxed floss: less susceptible to tearing or shredding when used between tight contacts or areas with overhanging restorations.
- Polytetrafluoroethylene (Teflon): Slides easily through tight contacts and does not fray.
- Floss length: 15–25 cm wrapped around middle fingers.
- For upper teeth grasp the floss with thumb and index finger, for lower teeth with both index fingers. Ensure that a length of roughly an inch is left between the fingers.
- Ease the floss gently between the teeth using a back and forth motion.
- Position the floss in such a way that it becomes securely wrapped around the interdental surface of the tooth in a C shape.
- Ensure that the floss is taken below the gum margins using a back and forth up and down motion.
There are a few different options on the market that can make flossing easier if dexterity or coordination is a barrier, or as a preference over normal floss. Floss threaders are ideal for cleaning between orthodontic appliances, and flossettes are ideal for those with poor dexterity.
Interdental brushes come in a range of color-coded sizes. They consist of a handle with a piece of wire covered in tapered bristles, designed to be placed into the interdental space for plaque removal. Studies indicate that interdental brushes are equally or more effective then floss when removing plaque and reducing gum inflammation.
- Identify the size required, the largest size that will fit without force is ideal, if necessary more than one size can be used.
- Insert the bristles into the interdental space at a 90-degree angle.
- Move the brush back and forth between the teeth.
- Rinse under water to remove debris when necessary.
- Rinse with warm soapy water once complete, and store in a clean dry area.
- Replace once bristles are worn.
The tongue contains numerous bacteria which causes bad breath. Tongue cleaners are designed to remove the debris built up on the tongue. Using a toothbrush to clean the tongue is another possibility, however it might be hard to reach the back of the tongue and the bristles of the toothbrush may be too soft to remove the debris. Some may find it easier to use a tongue scraper instead because it does not tend to cause a gag reflex as readily as a toothbrush. Steps of using a tongue scraper:
- Rinse the tongue scraper in order to clean it and remove any present debris
- Start at the back of the tongue and gently scrape forwards
- Be sure to clean the sides of the tongue as well, not just the middle portion
- After the cleaning is completed, rinse the tongue scraper and any debris that is left behind
- Rinse the mouth
Single-tufted brushes are a tool in conjunction with tooth brushing. The tooth brush is designed to reach the ‘hard to reach places’ within the mouth. This tool is best used behind the lower front teeth, behind the back molars, crooked teeth and between spaces where teeth have been removed. The single- tufted brush design has an angled handle, a 4mm diameter and rounded bristle tips.
Toothbrushes with pointed rubber tips at the ends of the handles have been available for many years, and have more recently been replaced by a standalone tool called a gum stimulator designed to massage the gum line and the bases of the areas between the teeth. Such stimulators help to increase circulation to the gum line and to clear away bacteria which might not be removed by brushing and flossing alone.
Food and drink
Eating a balanced diet and limiting sugar intake can help prevent tooth decay and periodontal disease. The Fédération dentaire internationale (FDI World Dental Federation) has promoted foods such as raw vegetables, plain yogurt, cheese, or fruit as dentally beneficial—this has been echoed by the American Dental Association (ADA).
Community water fluoridation is the addition of fluoride to adjust the natural fluoride concentration of a community's water supply to the level recommended for optimal dental health, approximately 1.0 ppm (parts per million). Fluoride is a primary protector against dental cavities. Fluoride makes the surface of teeth more resistant to acids during the process of remineralization. Drinking fluoridated water is recommended by some dental professionals while others say that using toothpaste alone is enough. Milk and cheese are also rich in calcium and phosphate, and may also encourage remineralization. Foods high in fiber may help to increase the flow of saliva and a bolus of fibre like celery string can force saliva into trapped food inside pits and fissures on chewing surfaces where over 80% of cavities occur, to dilute carbohydrates like sugar, neutralize acid and remineralize teeth on easy to reach surfaces.
Sugars are commonly associated with dental cavities. Other carbohydrates, especially cooked starches, e.g. crisps/potato chips, may also damage teeth, although to a lesser degree (and indirectly) since starch has to be converted to glucose by salivary amylase (an enzyme in the saliva) first. Sugars that are higher in the stickiness index, such as toffee, are likely to cause more damage to teeth than those that are lower in the stickiness index, such as certain forms of chocolate or most fruits.
Sucrose (table sugar) is most commonly associated with cavities. The amount of sugar consumed at any one time is less important than how often food and drinks that contain sugar are consumed. The more frequently sugars are consumed, the greater the time during which the tooth is exposed to low pH levels, at which point demineralisation occurs (below 5.5 for most people). It is important therefore to try to encourage infrequent consumption of food and drinks containing sugar so that teeth have a chance to be repaired by remineralisation and fluoride. Limiting sugar-containing foods and drinks to meal times is one way to reduce the incidence of cavities. Sugars from fruit and fruit juices, e.g., glucose, fructose, and maltose can also cause cavities.
Sucrose is used by Streptococcus mutans bacteria to produce biofilm. The sucrose is split by glucansucrase, which allows the bacteria to use the resulting glucose for building glucan polymer film and the resulting fructose as fuel to be converted to lactic acid.
Acids contained in fruit juice, vinegar and soft drinks lower the pH level of the oral cavity which causes the enamel to demineralize. Drinking drinks such as orange juice or cola throughout the day raises the risk of dental cavities tremendously.
Another factor which affects the risk of developing cavities is the stickiness of foods. Some foods or sweets may stick to the teeth and so reduce the pH in the mouth for an extended time, particularly if they are sugary. It is important that teeth be cleaned at least twice a day, preferably with a toothbrush and fluoride toothpaste, to remove any food sticking to the teeth. Regular brushing and the use of dental floss also removes the dental plaque coating the tooth surface.
Chewing gum assists oral irrigation between and around the teeth, cleaning and removing particles, but for teeth in poor condition it may damage or remove loose fillings as well. Dental chewing gums claim to improve dental health. Sugar-free chewing gum stimulates saliva production, and helps to clean the surface of the teeth.
Chewing on solid objects such as ice can chip teeth, leading to further tooth fractures. Chewing on ice has been linked to symptoms of anemia. People with anemia tend to want to eat food with no nutritional value.
Smoking is one of the leading risk factors associated with periodontal diseases. It is thought that smoking impairs and alters normal immune responses, eliciting destructive processes while inhibiting reparative responses promoting the incidence and development of periodontal diseases.
Saline (warm salty water) is usually recommended after procedures like dental extractions. In a study completed in 2014, warm saline mouthrinse was compared to no mouthrinse in preventing alveolar osteitis (dry socket) after extraction. In the group that was instructed to rinse with saline, the prevalence of alveolar osteitis was less than in the group that did not.
Essential oils (EO) or cetyl pyridinium chloride (CPC)
Essential oils, found in Listerine mouthwash, contains eucalyptol, menthol, thymol, and methyl salicylate. CPC containing mouthwash contains cetyl pyridinium chloride, found in brands such as Colgate Plax, Crest Pro Health, Oral B Pro Health Rinse. In a meta-analyses completed in 2016, EO and CPC mouthrinses were compared and it was found that plaque and gingivitis levels were lower with EO mouthrinse when used as an adjunct to mechanical plaque removal (toothbrushing and interdental cleaning).
Chlorhexidine gluconate is an antiseptic mouthrinse that should only be used in two-week time periods due to brown staining on the teeth and tongue. Compared to essential oils, it is more efficacious in controlling plaque levels, but has no better effect on gingivitis and is therefore generally used for post-surgical wound healing or the short-term control of plaque.
As mentioned earlier, sodium hypochlorite, a common household bleach, can be used as a 0.2% solution for 30 seconds two or three times a week as a cheap and effective means of combating harmful bacteria. The commercial product is 5% or 6%, so this requires diluting the product by a factor of about 30 (half a tablespoon in a full glass of water). The solution will lose activity with time and may be discarded after one day.
Dentures, retainers, and other appliances must be kept extremely clean. It is recommended that dentures be cleaned mechanically twice a day with a soft-bristled brush and denture cleansing paste. It is not recommended to use toothpaste, as it is too abrasive for acrylic, and will leave plaque retentive scratches in the surface.
Dentures should be taken out at night, as leaving them in whilst sleeping has been linked to poor oral health. Leaving a denture in during sleep reduces the protective cleansing and antibacterial properties of saliva against Candida albicans (oral thrush) and denture stomatitis; the inflammation and redness of the oral mucosa underneath the denture. For the elderly, wearing a denture during sleep has been proven to greatly increase the risk of pneumonia.
It is now recommended that dentures should be stored in a dry container overnight, as keeping dentures dry for 8 hours significantly reduces the amount of Candida albicans on an acrylic denture. Approximately once a week it is recommended to soak a denture overnight with an alkaline-peroxide denture cleansing tablet, as this has been proved to reduce bacterial mass and pathogenicity.Duyck J, Vandamme K, Muller P, Teughels W (December 2013). "Overnight storage of removable dentures in alkaline peroxide-based tablets affects biofilm mass and composition". Journal of Dentistry. 41 (12): 1281–9. doi:10.1016/j.jdent.2013.08.002. PMID 23948391.</ref>
To become a dental hygienist in the US one must attend a college or university that is approved by the Commission on Dental Accreditation and take the National Board Dental Hygiene Examination. There are several degrees one may receive. An associate degree after attending community college is the most common and only takes two years to obtain. After doing so, one may work in a dental office. There is also the option of receiving a bachelor's degree or master's degree if one plans to work in an educational institute either for teaching or research.
Oral hygiene and systemic diseases
Several recent clinical studies suggest oral disease and inflammation (oral bacteria & oral infections) may be a risk factor for serious systemic diseases, such as:
- Darby M, Walsh MM (2010). Procedures Manual to Accompany Dental Hygiene: Theory and Practice. St. Louis, Mo.: Saunders/Elsevier.
- Claydon NC (2008). "Current concepts in toothbrushing and interdental cleaning". Periodontology 2000. 48: 10–22. doi:10.1111/j.1600-0757.2008.00273.x. PMID 18715352.
- Lee DW, Moon IS (June 2011). "The plaque-removing efficacy of a single-tufted brush on the lingual and buccal surfaces of the molars". Journal of Periodontal & Implant Science. 41 (3): 131–4. doi:10.5051/jpis.2011.41.3.131. PMC 3139046. PMID 21811688.
- "Dental Caries (Tooth Decay)". Centers for Disease Control. 12 December 2018.
- "How to Whiten Your Teeth". WebMd.
- Gussy MG, Bracksley SA, Boxall A (27 June 2013). "How often should you have dental visits?" (PDF). Deeble Institute.
- "American Dental Hygienists' Association Position Paper on the Oral Prophylaxis" (PDF). American Dental Hygienists' Association. 29 April 1998. Retrieved 28 June 2012.
- Worthington HV, Clarkson JE, Bryan G, Beirne PV (November 2013). "Routine scale and polish for periodontal health in adults". The Cochrane Database of Systematic Reviews (11): CD004625. doi:10.1002/14651858.CD004625.pub4. PMID 24197669.
- "Submission 9(b)—SuperTooth" (PDF). Archived from the original (PDF) on 27 February 2015. Retrieved 22 August 2014.
- Curtis J (13 November 2007). "Effective Tooth Brushing and Flossing". WebMD. Retrieved 24 December 2007. Cite journal requires
- Yaacob M, Worthington HV, Deacon SA, Deery C, Walmsley AD, Robinson PG, Glenny AM (June 2014). "Powered versus manual toothbrushing for oral health". The Cochrane Database of Systematic Reviews (6): CD002281. doi:10.1002/14651858.CD002281.pub3. PMID 24934383.
- Fejerskov O, Kidd E (2015). Dental Caries (2nd ed.). Chichester, West Sussex: Wiley Blackwell. p. 4.
- Porth C, Porth C (2011). Essentials of Pathophysiology (1st ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
- Julihn A, Barr Agholme M, Modeer T (June 2008). "Risk factors and risk indicators in relation to incipient alveolar bone loss in Swedish 19-year-olds". Acta Odontologica Scandinavica. 66 (3): 139–47. doi:10.1080/00016350802087024. PMID 18568472.
- Creeth JE, Gallagher A, Sowinski J, Bowman J, Barrett K, Lowe S, Patel K, Bosma ML (2009). "The effect of brushing time and dentifrice on dental plaque removal in vivo". Journal of Dental Hygiene : JDH. 83 (3): 111–6. PMID 19723429.
- "Oral health". World Health Organization. 2012. Retrieved 7 May 2017.
- Dahl LO, Muhler JC (1955). "Oral Hygiene habits of young adults". J Periodontol. 26: 43–47. doi:10.1902/jop.19126.96.36.199.
- Van der Weijden GA, Timmerman MF, Nijboer A, Lie MA, Van der Velden U (August 1993). "A comparative study of electric toothbrushes for the effectiveness of plaque removal in relation to toothbrushing duration. Timerstudy". Journal of Clinical Periodontology. 20 (7): 476–81. doi:10.1111/j.1600-051X.1993.tb00394.x. PMID 8354721.
- Van der Weijden FA, Timmerman MF, Snoek IM, Reijerse E, Van der Velden U (July 1996). "Toothbrushing duration and plaque removing efficacy of electric toothbrushes". American Journal of Dentistry. 9 Spec No: S31–6. PMID 9002786.
- Saxer UP, Barbakow J, Yankell SL. "New studies on estimated and actual toothbrushing times and dentifrice use." J Clin Dent 1998;9(2):49–51
- Robinson HB (September 1946). "Toothbrushing habits of 405 persons". Journal of the American Dental Association. 33 (17): 1112–7. doi:10.14219/jada.archive.1946.0156. PMID 21000167.
- Beals D, Ngo T, Feng Y, Cook D, Grau DG, Weber DA. "Development and laboratory evaluation of a new toothbrush with a novel brush head design." Am J Dent. 2000;13:5A–13A
- McCracken GI, Janssen J, Swan M, Steen N, de Jager M, Heasman PA (May 2003). "Effect of brushing force and time on plaque removal using a powered toothbrush". Journal of Clinical Periodontology. 30 (5): 409–13. doi:10.1034/j.1600-051x.2003.20008.x. PMID 12716332.
- Slots J (October 2012). "Low-cost periodontal therapy". Periodontology 2000. 60 (1): 110–37. doi:10.1111/j.1600-0757.2011.00429.x. PMID 22909110.
- Marinho VC, Higgins JP, Logan S, Sheiham A (2002). "Fluoride varnishes for preventing dental caries in children and adolescents". The Cochrane Database of Systematic Reviews (3): CD002279. doi:10.1002/14651858.CD002279. PMID 12137653.
- Bonner BC, Clarkson JE, Dobbyn L, Khanna S (October 2006). "Slow-release fluoride devices for the control of dental decay". The Cochrane Database of Systematic Reviews (4): CD005101. doi:10.1002/14651858.CD005101.pub2. PMID 17054238.
- "Brushing – Your Dental Health". Australian Dental Association. Retrieved 16 May 2017.
- Hashizume LN, Dariva A (December 2015). "Effect of sonic vibration of an ultrasonic toothbrush on the removal of Streptococcus mutans biofilm from enamel surface". American Journal of Dentistry. 28 (6): 347–50. PMID 26846041.
- Re D, Augusti G, Battaglia D, Giannì AB, Augusti D (March 2015). "Is a new sonic toothbrush more effective in plaque removal than a manual toothbrush?". European Journal of Paediatric Dentistry. 16 (1): 13–8. PMID 25793947.
- Deacon SA, Glenny AM, Deery C, Robinson PG, Heanue M, Walmsley AD, Shaw WC (December 2010). "Different powered toothbrushes for plaque control and gingival health". The Cochrane Database of Systematic Reviews (12): CD004971. doi:10.1002/14651858.CD004971.pub2. PMID 21154357.
- Accepted Dental Therapeutics. Section III (40th ed.). Council on Dental Therapeutics.
- Schmid MO, Balmelli OP, Saxer UP (August 1976). "Plaque-removing effect of a toothbrush, dental floss, and a toothpick". Journal of Clinical Periodontology. 3 (3): 157–65. doi:10.1111/j.1600-051X.1976.tb01863.x. PMID 1067277.
- Wiley C (2017). "Using a Tongue Cleaner for a Cleaner Mouth". Colgate. Retrieved 16 April 2017.
- Cobb CM, Rodgers RL, Killoy WJ (March 1988). "Ultrastructural examination of human periodontal pockets following the use of an oral irrigation device in vivo". Journal of Periodontology. 59 (3): 155–63. doi:10.1902/jop.19188.8.131.52. PMID 3162980.
- Greenstein G (April 1988). "The ability of subgingival irrigation to enhance periodontal health". Compendium. 9 (4): 327–9, 332–4, 336–8. PMID 3073855.
- Ciancio S (1988). "Oral Irrigation: A Current Perspective". Biological Therapies in Dentistry. 3: 33.
- Flemmig TF, Newman MG, Nachnani S, Rodrigues A, Calsina G, Lee Y, et al. (1989). "Chlorhexidine and irrigation in gingivitis: 6 months correlative clinical and microbiological findings". J Dent Res (68 (spec issue)).
- Slot DE, Dörfer CE, Van der Weijden GA (November 2008). "The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review". International Journal of Dental Hygiene. 6 (4): 253–64. doi:10.1111/j.1601-5037.2008.00330.x. PMID 19138177.
- Prevention Magazine Editors (2 March 2010). The Doctors Book of Home Remedies: Quick Fixes, Clever Techniques, and Uncommon Cures to Get You Feeling Better Fast. Potter/Ten Speed/Harmony/Rodale. p. 442. ISBN 978-1-60529-160-4.CS1 maint: extra text: authors list (link)
- Staff (2011). "Prevention". British Dental Centre. British Dental Centre. Retrieved 28 June 2012.
- "Fluoride Facts" (PDF). American Dental Hygienists Association.
- "Gingivitis". June 2017.
- "Symptoms and causes - Mayo Clinic". Mayo Clinic. Retrieved 7 May 2017.
- "The cold, hard truth: Chewing ice and teeth". Go Ask Alice!. Retrieved 7 May 2017.
- "What Does Alcohol Do to Your Teeth?". Healthline. Retrieved 8 May 2017.
- Dietrich T, Maserejian NN, Joshipura KJ, Krall EA, Garcia RI (April 2007). "Tobacco use and incidence of tooth loss among US male health professionals". Journal of Dental Research. 86 (4): 373–7. doi:10.1177/154405910708600414. PMC 2582143. PMID 17384035.
- Palmer RM, Wilson RF, Hasan AS, Scott DA (2005). "Mechanisms of action of environmental factors--tobacco smoking". Journal of Clinical Periodontology. 32 Suppl 6: 180–95. doi:10.1111/j.1600-051X.2005.00786.x. PMID 16128837.
- Ryder MI (2007). "The influence of smoking on host responses in periodontal infections". Periodontology 2000. 43: 267–77. doi:10.1111/j.1600-0757.2006.00163.x. PMID 17214844.
- Osunde OD, Adebola RA, Adeoye JB, Bassey GO (May 2014). "Comparative study of the effect of warm saline mouth rinse on complications after dental extractions". International Journal of Oral and Maxillofacial Surgery. 43 (5): 649–53. doi:10.1016/j.ijom.2013.09.016. PMID 24314857.
- Haas AN, Wagner TP, Muniz FW, Fiorini T, Cavagni J, Celeste RK (December 2016). "Essential oils-containing mouthwashes for gingivitis and plaque: Meta-analyses and meta-regression". Journal of Dentistry. 55: 7–15. doi:10.1016/j.jdent.2016.09.001. PMID 27628316.
- Strydonck DA, Slot DE, Velden U, Weijden F. "Effect of a chlorhexidine mouthrinse on plaque, gingival inflammation and staining in gingivitis patients: a systematic review." Journal of Clinical Periodontology. 2012;39(11):1042–1055.
- Van Leeuwen MP, Slot DE, Van der Weijden GA (February 2011). "Essential oils compared to chlorhexidine with respect to plaque and parameters of gingival inflammation: a systematic review". Journal of Periodontology. 82 (2): 174–94. doi:10.1902/jop.2010.100266. PMID 21043801.
- Harrison Z, Johnson A, Douglas CW (May 2004). "An in vitro study into the effect of a limited range of denture cleaners on surface roughness and removal of Candida albicans from conventional heat-cured acrylic resin denture base material". Journal of Oral Rehabilitation. 31 (5): 460–7. doi:10.1111/j.1365-2842.2004.01250.x. PMID 15140172.
- Iinuma T, Arai Y, Abe Y, Takayama M, Fukumoto M, Fukui Y, et al. (March 2015). "Denture wearing during sleep doubles the risk of pneumonia in the very elderly". Journal of Dental Research. 94 (3 Suppl): 28S–36S. doi:10.1177/0022034514552493. PMC 4541085. PMID 25294364.
- Stafford GD, Arendorf T, Huggett R (April 1986). "The effect of overnight drying and water immersion on candidal colonization and properties of complete dentures". Journal of Dentistry. 14 (2): 52–6. doi:10.1016/0300-5712(86)90051-5. PMID 3469239.
- Duyck J, Vandamme K, Krausch-Hofmann S, Boon L, De Keersmaecker K, Jalon E, Teughels W (2016). "Impact of Denture Cleaning Method and Overnight Storage Condition on Denture Biofilm Mass and Composition: A Cross-Over Randomized Clinical Trial". PLOS ONE. 11 (1): e0145837. doi:10.1371/journal.pone.0145837. PMC 4701668. PMID 26730967.
- Li X, Kolltveit KM, Tronstad L, Olsen I (October 2000). "Systemic diseases caused by oral infection". Clinical Microbiology Reviews. 13 (4): 547–58. doi:10.1128/CMR.13.4.547-558.2000. PMC 88948. PMID 11023956.
- Lai YL (August 2004). "Osteoporosis and periodontal disease". Journal of the Chinese Medical Association. 67 (8): 387–8. PMID 15553796.
- Hua F, Xie H, Worthington HV, Furness S, Zhang Q, Li C (October 2016). "Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia" (PDF). The Cochrane Database of Systematic Reviews. 10: CD008367. doi:10.1002/14651858.CD008367.pub3. PMC 6460950. PMID 27778318.
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