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Brushing Up on Oral Health

Get More From Your Brushing and Flossing

​How much you really need to floss, which toothbrush is best and why you may want to skip a rinse

toothbrush, dental floss and mouthwash

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Have you been brushing and flossing the same way for years? If so, it may be time to upgrade your routine.

Taking good care of your teeth is important at every age, but it’s especially essential as you get older. That’s because with age comes higher risk for dental decay and gum disease, says Diane Melrose, a dental hygienist and professor of clinical dentistry at the Herman Ostrow School of Dentistry at the University of Southern California.

Not only is keeping your mouth in tip-top shape important for holding onto your teeth; research shows that oral health is strongly connected to overall health. Untreated gum disease, for instance, is linked to conditions including heart disease, rheumatoid arthritis, dementia and type 2 diabetes. “Almost every systematic disease has a correlation with oral health,” Melrose says. “That’s why having good oral health habits is so critical.”

Here, dentists and hygienists answer your top questions about how to get the most out of your brushing and flossing routine — from the bottom line on flossing time to when an electric toothbrush (or water flosser) will be worth the investment.

Fine-tune your flossing

Q. Which should I do first: floss or brush?

Floss first. A 2018 study published in the Journal of Periodontology found that flossing before brushing was more effective at reducing plaque compared to brushing first. The study also found that more fluoride remained in the mouths of those who flossed first.

“When you floss, you get large debris out from between your teeth, and then when you brush you remove it from the mouth,” says Leonardo Marchini, a dentist who teaches geriatric and special needs dentistry at the University of Iowa College of Dentistry and Dental Clinics. “If you do other way around, some debris may stay in your mouth after you floss.”

Q. Do I really have to floss if I do a good job brushing?

Yes, the American Dental Association (ADA), National Institutes of Health (NIH) and other health agencies all recommend cleaning between teeth with floss or another interdental device at least once a day in addition to brushing. It’s a critical step to remove bacteria-filled plaque from areas your toothbrush can’t reach.

“Most periodontal disease starts in between the teeth,” Melrose says. “The bacteria are what cause disease and infection. In order to prevent that, we need to get that bacteria out.”

Q. Which type of floss is best?

Dentists and hygienists say the type of floss is less important than using it regularly and with the right technique. Whether it’s waxed, unwaxed, flavored or not, pick what you like best, Melrose says. “It has to feel comfortable, go in between your teeth easily and not break.”

A thicker floss makes it easier to pick up plaque and bacteria, but thinner ones are easier to get into tight spaces. If you choose a thin, slick floss because your teeth are close together, Melrose recommends using a few extra strokes to make sure you catch everything.

If you have dental bridges or implants, look for special floss that comes with a firm end, because it’s easier to guide through and under dental work.

Q. What’s the best technique?

Slide it gently between two teeth, form a C-shape around one tooth, and then slide it up and down five times, applying more pressure on the upward stroke. Repeat on the other side. “Try to do an up-and-down motion; don’t shoeshine the tooth,” Melrose says. 

Q. What if flossing is difficult for me?

Many dentists like the way traditional string floss wraps around each tooth, but it can be tough to manipulate for people with limited hand and finger dexterity. If that’s the case, you can try a device such as a floss stick or floss holder, an interdental brush or a water flosser. 

Interdental brushes, which have small bristled heads, are a great option if you have some space between your teeth — which is often the case with older adults because of gum recession, Melrose explains. The brushes are much easier to manipulate than floss, and they work well, she says.

Most people need a set of different-sized brushes because the gaps between their teeth are different widths. To figure out which brush to use, start with the smallest and work your way up until you find one that fills the gap between two teeth, Melrose says. Or ask your dental hygienist or dentist for help.

Q. Can I use a water flosser instead?

Water flossers, also called oral irrigators, spray a stream of water to remove plaque between teeth. Some studies show they remove plaque as well as or better than floss. However, a Cochrane systematic review of 35 different studies in 2019 found most evidence to be of “very low-certainty.”  

Michael Reed, a clinical dentist in Dallas and director of Mobile Dental Care, says an oral irrigator can be a good choice for patients who simply don’t like to floss or find it too hard to do. “Really, what is important is doing something to clean between your teeth daily,” he says.

Reed recommends choosing a device by Waterpik or Philips Sonicare because they are the only two water flosser brands that have earned the ADA Seal of Approval. That means they’ve undergone rigorous testing and meet the association’s guidelines for safety and efficacy.

Q. What if my gums bleed?

If you’ve just started a new flossing routine, it’s normal for your gums to bleed at first. Usually the bleeding stops after a week once your gums get used to your new routine. If the bleeding continues, that’s cause for a visit to your dentist. You may be flossing incorrectly, you could have a gum infection called gingivitis or you may have some tartar that needs to be professionally removed.

Brush up on your brushing

Q. Which is better: a manual or an electric toothbrush?

You can do a great job cleaning your teeth with a manual toothbrush, but a powered toothbrush has a few advantages, dentists and hygienists say. First, you’re less likely to hurt your gums by brushing too hard. In addition, electric toothbrushes are easier to use for those who have trouble with grip or manual dexterity.

Finally, research shows powered toothbrushes generally work better. A Cochrane review of 56 studies found that electric toothbrushes reduce plaque 21 percent more effectively than manual brushes after three months. They were also better at reducing gingivitis.

Q. Which powered toothbrush works the best?

Dentists and hygienists recommend looking for an electric toothbrush with the ADA Seal of Approval. Some studies indicate those that have a round, oscillating head reduce gingivitis and plaque more effectively than the ones with a vibrating head.

Q. What type of manual toothbrush is best?

If you use a manual toothbrush, choose one with soft or extra-soft bristles that are angled or at different levels, which are likely to remove plaque better than flat-trimmed bristles. “The medium and hard [bristles] can cause recession and trauma to your gums,” Melrose says. 

Q. How long should I spend at this?

No matter what type of toothbrush you use, you won’t be able to do a good job removing plaque and preventing gum disease if you brush for only 30 to 45 seconds — the average time that most Americans spend at the task. For a good clean, the ADA recommends spending a full two minutes, twice a day, taking care to reach all surfaces of your teeth, including molars in the way back. If you have less manual dexterity, it may take a little longer.


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Q. What is the best technique?

Never brush straight up and down or back and forth across your teeth, Melrose warns. Both techniques cause gum trauma and recession, when the gums pull away from teeth. Instead, hold your brush at a 45-degree angle and gently make small circles across the tooth. You should also have a sequence in mind when you brush: Start on one side and work around to the other, or do outside surfaces first and then the inside, Melrose suggests. Don’t forget to brush your tongue; it collects bacteria that cause bad breath.

Q. How often should I change my toothbrush?

If you use a manual toothbrush, the ADA recommends reaching for a new one every three to four months, or more often if the bristles become matted or frayed. “You don’t want a toothbrush where the bristles are all worn down — there’s a clear change in performance,” Marchini says. “It won’t be as effective removing plaque.”

If you use a powered toothbrush, follow the manufacturer’s instructions for how often to replace the brush head; many have an indicator that tells you when it’s time. Some dentists also say it’s a good idea to change out your brush after you’ve been sick.

Q. Where should I store my toothbrush?

Rinse your toothbrush thoroughly after you use it, then store it in an upright position so it can air dry, the ADA says. Putting a wet toothbrush in a closed plastic case or even in a medicine cabinet may promote the growth of mold and bacteria. It’s also a good idea to store your brush on the side of the counter farthest from the toilet, to keep fecal bacteria from settling onto it.

Q. What should I look for in a toothpaste?

Make sure you use a toothpaste that contains fluoride, which prevents cavities and builds stronger teeth, dentists say. Fluoride is especially important for older adults, who are at higher risk for cavities because they often take medications that cause dry mouth, Melrose says. All ADA-recommended toothpastes have fluoride.

If your teeth hurt when they’re exposed to heat and cold, a desensitizing toothpaste with ingredients such as potassium or stannous fluoride can help reduce this kind of discomfort.

Q. Should you use mouthwash?

Some mouthwashes contain antimicrobial ingredients that can help reduce plaque and gingivitis. Others contain fluoride to prevent cavities. Melrose says a fluoride rinse is often the best choice for most older adults because of their higher risk for decay. Ask your dentist or hygienist which type would be most beneficial for you.

Q. Any other tips for older adults when it comes to dental care?

To maximize the benefits of your toothpaste, try not to rinse after you brush, Marchini suggests. “It’s hard advice to give because people don’t like that strong taste in their mouths, but then you get the benefit of the fluoride staying on your teeth,” he says.

Michelle Crouch is a contributing writer who has covered health and personal finance for some of the nation’s top consumer publications. Her work has appeared in Reader’s Digest, Real Simple, Prevention, The Washington Post and The New York Times.

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