Brushing: how long is long enough?

This article will consider why, for patients with periodontitis, the universal recommendation to brush twice daily for at least 2 minutes with a fluoridated toothpaste is likely to be insufficient, as well as investigating why there remains an apparent gap in at-home preventive care and how to bridge it.

The Adult Dental Health Survey (2009) suggests that only 17% of dentate adults in England, Wales and Northern Ireland have very healthy periodontal tissues and no periodontal disease. This is defined in the survey as no bleeding, no calculus, no periodontal pocketing of 4mm or more, and, in the case of adults aged 55 or above, no loss of periodontal attachment of 4mm or more anywhere in their mouth. With three-quarters of respondents claiming to brush their teeth at least twice a day, there seems to be an unmet need when it comes to at-home oral care.1

Focusing on periodontal disease,Group B of the 5th European Workshop in Periodontology deemed gingivitis and periodontitis to be a ‘continuum’ – part of the same long-term process – of the same inflammatory disease.2

Building on this picture, Chapple and colleagues (2017) considered periodontal disease to be multi-factorial, in that, ‘[…] there is a symbiosis between a health-associated biofilm and a proportionate host immune inflammatory response. Periodontitis develops following the emergence of a dysbiosis in susceptible individuals which is associated with dysregulation of the immune-inflammatory response, and which leads to host mediated connective tissue damage and alveolar bone loss.’3

It has been recognised that disrupting plaque biofilm in the mouth is the most effective way both to treat and prevent gingivitis and periodontitis.2 However, evidence also suggests that brushing and interdental cleaning alone may not be enough for the majority of people when it comes to controlling periodontal disease.

Looking beyond mechanical cleaning

Recognising this potential limitation, Working Group 2 of the 11th European Workshop in Periodontology systematically reviewed, ‘[…] the evidence for primary prevention of periodontitis by preventing gingivitis via four approaches:

• 1) the efficacy of mechanical self-administered plaque control regimes;

• 2) the efficacy of self-administered inter-dental mechanical plaque control;

•3) the efficacy of adjunctive chemical plaque control; and

•4) anti-inflammatory (sole or adjunctive) approaches'5

Their results led the group to reach the following conclusion: ‘We support the almost universal recommendations that all people should brush their teeth twice a day for at least 2 min. with fluoridated dentifrice. Expert opinion is that for periodontitis patients 2 min. is likely to be insufficient, especially when considering the need for additional use of inter-dental cleaning devices. In patients with gingivitis once daily inter-dental cleaning is recommended and the adjunctive use of chemical plaque control agents offers advantages in this group.’5

The Group further suggested: ‘When used as an adjunctive therapy to conventional manual tooth brushing with a fluoridated dentifrice, the use of chemical anti-plaque agents in mouth rinses or incorporated into the fluoridated dentifrice, alone or in combination, offers clear and significant improvements in managing gingival inflammation and preventing plaque accumulation.’5

The need for an adjunct

Barnett (2006) also suggested that this gap in preventive care provides: ‘[…] a clear rationale for incorporating effective antimicrobial measures, such as use of an antimicrobial mouthrinse, into daily oral hygiene regimens.’6

He wrote that the basis for making use of an antimicrobial mouthrinse is two-fold:

• 1. Since mechanical methods performed by the majority of people is inadequate, an adjunctive antimicrobial mouthrinse may help to reduce plaque levels

• 2. It offers a way to deliver antimicrobial agents to mucosal sites throughout the mouth that are unaffected by mechanical methods and would otherwise serve as ‘reservoirs’ for plaque bacteria.6

Marsh (2012) further considered the limitations of mechanical cleaning and offered a possible solution, writing: ‘Mechanical plaque control can be effective, but needs to be meticulous and patients have to be highly motivated and with an appropriate lifestyle (that is, an appropriate diet, avoid smoking, etc). Consequently, oral care products have been formulated that contain antiplaque or antimicrobial agents to augment conven­tional mechanical plaque control activi­ties and interfere with biofilm composition and metabolism, especially at sites that are difficult to clean and are commonly missed during self-performed mechanical plaque control.’7

He continued: ‘The maximum length of time recommended for people to brush their teeth is in the order of two minutes, followed by flossing and rinsing with a mouthwash for 30‑60 seconds. A major requirement of the antiplaque for­mulation, therefore, is to deliver sufficient concentration of the active ingredients to have an effect on the biofilm in that short period of time. Alternatively, the formula­tion should ensure the prolonged retention of the active components on dental and mucosal surfaces in the mouth so that they can be released over time at levels that will still deliver biological activity.’7

The evidence of efficacy

In 2015, Araujo and colleagues (2015) produced a meta-analysis demonstrating the clinically significant benefit of using an essential oil mouthrinse as an adjunct to mechanical cleaning over a six-month period.8

They evaluated, ‘[…] the combined effectiveness of mechanical methods with essential oil-containing mouthrinses (MMEO) versus mechanical methods (MM) alone in achieving site-specific, healthy gingival tissue and reducing plaque […]’.8

The researchers were able to determine that: ‘[…] after 6 months of use, clinicians could expect that approximately […] 37% of participants would have at least 50% of sites without plaque (PI = 0 or 1). In addition, the implementation of a long-term oral care routine that provides 7 times greater odds for plaque-free sites […] can be compelling information for the clinician when educating patients on the appropriate oral care routine.’8

Placing their results in context, Araujo and colleagues (2015) revisited Gunsolley’s 2006 meta-analysis, when mouthrinses containing essential oils, ‘[…] were determined to have beneficial antiplaque […] effects when used long-term, and in conjunction with other oral hygiene measures such as brushing and flossing.’8

They also cited the Boyle et al (2014) and Gandini et al (2012) research papers focusing on the use of mouthrinse in tackling common oral conditions.8 These reviews focused on large studies looking at the patterns, origins and consequence of oral conditions in defined populations, finding that using mouthrinse is beneficial when it comes to reducing the threat posed by dental plaque, to help protect against gingivitis.8

Looking atBoyle et al (2014) in more depth, it was concluded that when a mouthwash is used for fewer than three months, those containing chlorhexidine are the most effective of the preparations considered.9 However, when used for six months or longer, essential oil mouthwashes were shown to equal or exceed the effect of chlorhexidine in controlling plaque as an adjunct to standard care.9 It was also found that mouthwashes containing cetylpyridinium may also be effective, but less so than chlorhexidine and essential oil formulations.9

Taking all of this into account, current evidence appears to support the use of an antimicrobial mouthrinse for any patients who need to achieve greater plaque control despite twice-daily brushing and interdental cleaning in line with current recommendations.5,8,9



  1. Adult Dental Health Survey 2009. The Health and Social Care Information Centre
  2. Kinane DF, Attström R. Advances in the pathogenesis of periodontitis. Group B consensus report of the fifth European Workshop in Periodontology. J Clin Periodontol 2005; 32(Suppl. 6): 130-1
  3. Chapple ILC et al. Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: consensus report of group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol 2017; 44 (Suppl. 18): S39-S51
  4. Sharma N et al. Adjunctive benefit of essential oil-containing mouthrinse in reducing plaque and gingivitis in patients who brush and floss regularly: a six-month study. J Am Dent Assoc. 2004; 135: 496-504
  5. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. Clin Periodontol 2015; 42 (Suppl. 16): S71-S76
  6. Barnett ML. The rationale for the daily use of an antimicrobial mouthrinse. JADA 2006; 137: 16S-21S
  7. Marsh PD. Contemporary perspective on plaque control. BDJ 2012; 212(12): 601-606