Old-School Oral Health: Exploring the Efficacy of Traditional At-Home Care Methods

Joy D. Void-Holmes, RDH, BSDH, DHSc

June 2023 Course - Expires Tuesday, June 30th, 2026

Inside Dental Hygiene


No two patients are the same. Each individual presents with a unique set of circumstances. Maintaining optimal oral health requires not only regular hygiene visits but patient compliance between appointments as well. When it comes to at-home routines and product choices, some patients need more guidance than others. New technology abounds, but power toothbrushes and water flossers are not practical options for many patients. It is therefore important for dental hygienists to stay up to date on manual toothbrushes, traditional dental floss, and mouthrinses. These basic, easily available products are invaluable tools in the reduction of biofilm and achieving the best possible periodontal health

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Dental hygienists play a vital role in the arena of promoting preventive oral health care. Achieving desirable outcomes following periodontal instrumentation requires patients to consistently and efficiently remove biofilm before their next recare visits. Current research indicates that a standardized oral health education approach may not be universally applicable, as individuals exhibit diverse oral health needs.1 As such, a key aspect of oral health education involves conducting a thorough evaluation of a patient's oral health status and subsequently incorporating personalized adjustments to the guidance and instruction provided. Before recommending oral care products, dental hygienists need to evaluate various factors to deliver personalized education tailored to each patient. This approach ensures that patients receive customized recommendations that address their unique needs.

Over recent years, substantial progress has been made in the field of oral health care technology, including improved designs with power toothbrushes and water flossers. While these innovative products offer potential benefits like enhanced biofilm removal and ease of use, they might not be suitable for all patients due to factors like cost or sensory issues. It is important for dental hygienists to recognize the ongoing significance of manual toothbrushes and traditional dental floss in maintaining good oral hygiene. Manual toothbrushes and traditional dental floss remain effective tools for promoting good oral health practices without relying on advanced technology. The goal of this article is to explore the key factors dental hygienists should consider when recommending oral care products. The discussion will focus on the continued effectiveness of traditional manual toothbrushes and dental floss, along with the latest advancements in mouthrinses.

Manual Toothbrushes

Among the various mechanical aids available, toothbrushing stands as the primary and most universally accepted method for biofilm removal and has consistently played a vital role in daily oral hygiene routines across various cultures from ancient times to the present day.2 Throughout the years, the development and introduction of several types of manual toothbrushes have reflected the ongoing advancements in dental care techniques, education, and professional practice.2Manual toothbrushes possess the capability to effectively eliminate biofilm, provided that patients employ the appropriate technique and allocate a sufficient duration for brushing.3,4,5 The traditional manual toothbrush design primarily comprises three key components: head, bristles, and handle.6 The ideal manual toothbrush design should be user-friendly, facilitate efficient plaque removal, and prevent any detrimental effects on the soft or hard oral tissues.7 When dental hygienists undertake the task of selecting a suitable manual toothbrush for their patients, it is essential to evaluate the following desirable characteristics:3,7,8

1. Ability to accommodate individual needs regarding size, shape, and texture

2. Ease and efficiency in manipulation during use

3. Simple cleaning and aeration processes, with resistance to moisture

4. Durability and cost-effectiveness

5. Emphasis on functional properties such as bristle or filament flexibility, softness, and diameter, as well as handle strength, rigidity, and weight

6. A design that prioritizes utility, efficiency, and cleanliness

The ADA outlines the following specifications for manual toothbrushes:8

1. Brushing surface dimensions: Length of 1 to 1.25 inches and width of 5/16 to 3/8 inches

2. Surface area: 2.54 to 3.2 centimeters

3. Number of rows: 2 to 4 rows of bristles

4. Number of tufts: 5 to 12 tufts per row

5. Number of bristles: 80 to 85 bristles per tuft

It is essential to evaluate the size and shape of a toothbrush head. Toothbrush heads are available in various forms, including rectangular, oblong, oval, near-round, and diamond-shaped. The diamond-shaped toothbrush offers convenience for cleaning posterior teeth due to its narrower head compared to conventional designs. Meanwhile, round or oblong-shaped heads facilitate easier guidance around orthodontic brackets and wires.9 Toothbrush head sizes typically come in three variations: medium, large, and small. The selection of the head size is generally based on the dimensions of the individual's oral cavity.6 For adult users, large or medium-sized heads are deemed appropriate. Conversely, small-sized heads are recommended for children, as their teeth and mouths are characteristically smaller in comparison.9 The bristle type and design arguably represent the most critical design features of a manual toothbrush, as these elements directly interact with both hard and soft oral tissues. Table 1 illustrates the various bristle types and their corresponding design features.

Considering the primary objective of toothbrushing, a suitable toothbrush would be one that adheres to ADA specifications, features a simplistic design, and grants access to all oral regions, as long as the patient employs the proper brushing technique. It is evident that motivated, well-informed individuals with adequate time and skill can achieve optimal oral health through mechanical plaque control measures.9 When choosing a manual toothbrush for a patient, several factors must be taken into account, including preference, design features, prescribed brushing method, intraoral characteristics, patient motivation, manual dexterity, and cost.

Dental Floss

Toothbrushing is insufficient in achieving comprehensive biofilm elimination from proximal dental surfaces and adjoining gingival tissues when compared to its efficacy on facial, lingual, and palatal regions. Consequently, incorporating interdental biofilm management is imperative for the optimization of a patient's oral self-care regimen.10The gingival and dental anatomy of a patient's interdental area serves to clarify the roles and objectives of various interdental cleaning devices along with their oral health, disease status, and risk for future recurrence.10While toothbrushing in isolation can considerably mitigate interproximal gingival inflammation, the impact is substantially enhanced when combined with the use of dental floss.11Dental floss serves as an efficient interdental aid for individuals exhibiting interdental papillae occupying the embrasure space, absence of attachment loss, and no exposed root surfaces.10 Consistent use of dental floss effectively eliminates biofilm, food remnants, and debris from interdental spaces.12It is important to acknowledge that dental floss can be employed for patients exhibiting gingival recession; nonetheless, successful deposit elimination necessitates increased time, effort, and manual dexterity.10There are several types of dental floss that are available on the market. Dental floss dates to 1819, when it consisted of silk fibers skillfully intertwined and enveloped in a wax coating.10,13The introduction of the first commercially available non-waxed silk dental floss came 65 years later. In the 20th century, the oral care industry experienced significant progress with the emergence of waxed and non-waxed versions of nylon and polytetrafluoroethylene (PTFE) floss. This advancement exemplifies the ongoing evolution of dental hygiene products, broadening the spectrum of options for individuals seeking to maintain the highest standards of oral health. It is imperative for dental practitioners to consider the various advantages and disadvantages associated with recommending waxed and unwaxed dental floss to their patients, taking into account the unique intraoral characteristics of each individual. A wax coating on dental floss provides a smooth surface. This feature facilitates its passage through interdental contact areas while potentially reducing the likelihood of tissue trauma. Furthermore, the presence of wax enhances the floss's mechanical properties, including strength, durability, and resistance to breakage and shredding. In contrast, unwaxed dental floss or thinner alternatives might be better suited for individuals with tight interdental spacing. An added benefit of unwaxed floss is the generation of an audible squeaking noise when gliding over a clean surface, potentially serving as positive reinforcement for patients.10 Over time, both waxed and unwaxed dental floss have been developed with a variety of textures, flavors, materials, and therapeutic agents to enhance their effectiveness. It is essential to recognize that the use of dental floss may be challenging or less effective for individuals with limited manual dexterity or advanced periodontal conditions. However, when used correctly, flossing can still be highly beneficial for patients with intraoral characteristics suitable for string floss and those who adopt the most effective flossing technique.


Mouthrinses play a vital role in complementing home care and dental hygiene therapy, assisting in biofilm management, particularly in cases where cognitive or physical impairments lead to poor oral hygiene. Serving as the predominant mode of topical delivery for chemotherapeutic agents, first-generation rinses exhibited low substantivity and limited therapeutic value; however, many modern rinses now offer high substantivity and demonstrate antibacterial properties. Mouthrinses can be categorized into two primary classes: cosmetic and therapeutic.

Cosmetic mouthrinses may provide temporary relief from halitosis, reduce oral bacteria, and facilitate the removal of oral debris. These solutions frequently incorporate whitening agents, which may contribute to teeth whitening over time.

There are various categories of therapeutic mouthrinses, including anti-tartar, anti-caries, and anti-plaque rinses. A predominant group among these is the antimicrobial rinses. Ideally they should inhibit microbial colonization on tooth surfaces and prevent subsequent plaque formation along with suppressing pathogenicity of existing biofilm. Common antimicrobial rinses include bisbiguanides, such as chlorhexidine. The mechanism of action involves attaching to bacteria and lysing the cell wall, effectively killing the microorganisms. However, bisbiguanides may have undesirable side effects, including supragingival calculus formation, staining, and altered taste perception. Another class of antimicrobial agents in mouthrinses is phenolic compounds, like those found in some Listerine formulations. These compounds function by significantly reducing plaque development through cell lysis via cell wall destruction. Due to their low substantivity, the duration of tooth contact is crucial for their effectiveness. Quaternary ammonium compounds, such as those in Scope and Cepacol, share similarities with chlorhexidine but exhibit lower substantivity. They are effective in plaque reduction and gingivitis control. Additionally, oxygenating agents and povidone iodine are present in some therapeutic mouthrinses, offering alternative mechanisms for antimicrobial benefits. Another promising alternative is molecular iodine rinses. Molecular iodine rinses employ the same biocidal form of iodine found in povidone iodine but at higher concentrations while suppressing other nonbiocidal forms of iodine. This results in highly effective, high-performance rinses with excellent safety profiles that do not cause staining and have pleasant flavors, such as cinnamon or mint. These rinses are well-suited for long-term, daily use at home.14 Alcohol-free mouthrinses, such as Therabreath, CloSYS, and Tooth and Gum Tonic, are increasingly favored by patients and practitioners due to their efficacy in addressing common oral issues like periodontitis, halitosis, and xerostomia.


Dental hygienists hold a critical position in fostering preventive oral health care and contributing to the overall well-being of patients. A personalized approach to oral health education, based on individual needs and circumstances, is essential in achieving optimal results. While advancements in oral health care technology have introduced innovative products that may offer enhanced benefits, it is crucial for dental hygienists to acknowledge the enduring effectiveness of manual toothbrushes and traditional dental floss as well as mouthrinses in maintaining good oral hygiene. By carefully evaluating each patient's unique oral health status and considering factors such as cost, accessibility, and personal preferences, dental hygienists can provide tailored recommendations that empower patients to take charge of their oral health. Ultimately, a balanced perspective that integrates both traditional and innovative oral care products will enable dental hygienists to deliver the highest quality of care, promoting improved oral health outcomes and overall patient satisfaction.


1.Bhaskar V, McComas M, Wang CW. Customized Oral Hygiene Therapy: A Personalized Approach. J Dent Oral Disord Ther. 2016;4(4):1-4.

2. Ng C, Tsoi JKH, Lo ECM, Matinlinna JP. Safety and design aspects of powered toothbrush-a narrative review. Dent J (Basel). 2020;8(1):15.

3. American Dental Association. Toothbrushes. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/toothbrushes. Updated October 7, 2022. Accessed June 8, 2023.

4. Kracher, CM. Manual versus powered toothbrushes-current concepts in preventive dentistry. Dentalcare.com website. https://www.dentalcare.com/en-us/ce-courses/ce334/ manual-versus-powered-toothbrushes. Updated July 26, 2022. Accessed June 8, 2023.

5.Kallar S, Pandit IK, Srivastava N, Gugnani N. Plaque removal efficacy of powered and manual toothbrushes under supervised and unsupervised conditions: a comparative clinical study. J Indian Soc Pedod Prev Dent. 2011;29(3):235-238.

6. Graveland MP, Rosema NA, Timmerman MF, Van der Weijden GA. The plaque-removing efficacy of a finger brush (I-Brush). J Clin Periodontol.2004;31(12):1084-1087.

7. Mehta S, Vyaasini CS, Jindal L, Sharma V, Jasuja T. Toothbrush, its design and modifications: an overview. J Curr Med Res Opin. 2020;3(08):570.

8. Claydon NC. Current concepts in toothbrushing and interdental cleaning. Periodontol 2000. 2008;48:10-22.

9. van der Weijden GA, Timmerman MF, Danser MM, Piscaer M, Ijzerman Y, van der Velden U. Approximal brush head used on a powered toothbrush. J Clin Periodontol. 2005;32(3):317-322.

10. Wilkins EM, Lyle DM. Oral infection control: interdental care. In: Wilkins EM. Clinical Practice of the Dental Hygienist.12th ed. Wolters Kluwer; 2016.

11. Londero AB, Reiniger APP, Tavares RCR, et al. Efficacy of dental floss in the management of gingival health: a randomized controlled clinical trial. Clin Oral Investig. 2022;26(8):5273-5280.

12. The benefits of flossing your teeth. Oral B website. https://oralb.com/en-us/oral-health/solutions/floss/the-benefits-of-flossing-your-teeth/. Accessed June 8, 2023.

13. The evolution of dental floss. Berquist Family Dentistry website.  https://www.berquistdentistry.com/blog/dentist-crown-point-the-evolution-of-dental-floss/. Updated August 11, 2021. Accessed June 8, 2023.

14. Moskowitz H. Antimicrobial rinses for at-home use. Dental Economics. https://www.dentaleconomics.com/science-tech/preventative-and-hygiene/article/14174032/antimicrobial-rinses-for-athome-use. Published May 1, 2020. Accessed June 8, 2023.

Table 1: Bristle types and design features of manual toothbrushes

Table 1

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SOURCE: Inside Dental Hygiene | June 2023
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Learning Objectives:

  • Describe the ideal design components for manual toothbrushes as tools to facilitate effective biofilm removal.
  • Explain the value of using traditional dental floss for the reduction of interdental biofilm.
  • ​Discuss the advantages of using cosmetic and therapeutic mouthrinses and their role in enhancing at-home care.


The author received an honorarium from BroadcastMed, LLC for this article but reports no conflicts of interest with any material in the article.

Queries for the author may be directed to justin.romano@broadcastmed.com.