The Journey of Oral Hygiene: The Past, the Present, the Future.

2.1 Toothbrush

The history of toothbrushing is spanning thousands of years and encompassing numerous iterations of similar designs using a variety of materials [11]. The English word “toothbrush” first appears in the autobiography of Anthony Wood, who, in 1690, recounted purchasing a toothbrush from J. Barret. Yet, evidence indicates that various devices were used for oral cleaning prior to recorded history [12]. The earliest known tooth-cleaning tools, dating to around 3000 BC, were used by the Babylonians and Egyptians, who frayed the ends of twigs to create brush-like instruments. Such tooth sticks were considered important enough to be placed in Egyptian tombs. By 1600 BC, the Chinese had developed aromatic chewing sticks that freshened the breath and provided mechanical cleaning. One end was chewed to form bristles, while the other was fashioned into a toothpick. Similar chewing tools were described in ancient Greek and Roman writings.

Among traditional devices, the miswak, derived from Salvadora persica, became dominant across the Middle East, Africa, and Asia [13, 14]. Its roots, twigs, and stems have been used for centuries for oral hygiene, including the cleaning of teeth, gingival tissues, and the tongue. In Islamic tradition, its use was strongly encouraged by the Prophet Mohammed. In some populations, miswak use occurs up to five times daily as part of ablutions, although usage varies among different Muslim populations. A typical miswak is 15–20 centimeters long and 1–1.5 centimeters in diameter. One end is softened in water and chewed until the fibers splay, creating a natural brush. Experimental and clinical studies have shown that, when proper technique is used, miswak can remove plaque effectively. Its design, however, makes access to lingual surfaces and interdental spaces more difficult, and overuse has occasionally been linked to gingival recession in children [15, 16]. S. persica contains a variety of biologically active compounds, some with antimicrobial properties, and is increasingly studied for broader ethnopharmacological and biomedical applications, although many research gaps remain [17, 18].

The first true bristle toothbrush, featuring a handle with bristles inserted, was developed in China during the Tang dynasty (618–907 AD) [12]. These brushes used hog bristles set into bone or bamboo handles. By the 15th century, bristled toothbrushes resembling modern designs were common in China, and they reached Europe via trade routes in the 17th century. European users initially found the Siberian boar bristles too stiff and abrasive and therefore preferred softer horsehair, although its hollow structure harbored bacteria and degraded more quickly. During the 18th and early 19th centuries, toothbrushes in Europe were often made from bone, ivory, or ebony, sometimes with replaceable heads, and remained accessible only to the wealthy.

In 1780, William Addis developed a brush resembling modern toothbrushes. The brush had a carved bone handle into which hog bristles were secured with wire [8]. He conceived the idea while imprisoned. Addis observed that the prison floor was swept clean with a broom and realized that the prevailing method of cleaning teeth with a cloth was inefficient and could be improved. Driven by boredom and necessity, he took a small bone left over from one of his meals and drilled holes into it. A guard provided him with some bristles, which he tied into small tufts and inserted through the holes in the bone. He then sealed the perforations with glue. After his release, Addis established a toothbrush manufacturing company. His enterprise, later known as Wisdom, continues to produce toothbrushes to this day.

In the United States, the first toothbrush patent (Patent No. 18653) was granted in 1857 to H. N. Wadsworth. His brush, which featured a bone handle and Siberian boar bristles, entered mass production in 1885. Toothbrush use in the United States became widespread after World War II in the 1940s, when returning American soldiers who were forced to brush their teeth as part of the U.S. Army’s strict hygiene and readiness standards, brought their new habit home with them [19].

The 20th century was marked by advances in materials and manufacturing. Bone handles were gradually replaced by celluloid in the early decades of the century, especially as shortages during World War I constrained the supply of natural bristles and bone. The most transformative innovation occurred in the late 1930s, when Wallace H. Carothers and colleagues at DuPont invented nylon [20]. In 1938, Dr. West’s Miracle-Tuft, produced by the Weco Products Company, was the first toothbrush to use nylon filaments. These nylon filaments, being solid rather than hollow, did not absorb water and were more durable, more hygienic and more uniform in diameter and stiffness than animal hair. Their tips could also be end-rounded to reduce gingival trauma. By the 1940s, wood and plastic handles had largely replaced bone, and toothbrushes became widely affordable.

As the 20th century progressed, growing awareness of toothbrush abrasion and gingival recession shifted professional recommendations away from the hard nylon brushes initially popular under the assumption that harder brushing meant cleaner teeth [21]. Softer bristles became the norm by the 1960s. Also, electric (powered) toothbrushes were introduced during this period.

2.2 Powered Toothbrush

Although manual toothbrushes have remained the most widely used oral hygiene devices since their inception, the need for more effective alternatives has been recognized for more than two centuries. Historical patents from the mid-19th century document early mechanical toothbrush designs intended to address the limitations of manual toothbrushes. The development of mechanical and powered toothbrushes evolved through several stages, reflecting ongoing efforts to improve oral hygiene. In 1882, Hermann Heuschmann described twisted brushes with a cylindrical longitudinal section designed to clean entire rows of teeth [22]. Heuschmann mounted these brushes rotatably in partially open protective hoods, representing early precursors of mechanical toothbrushes. Various modifications were introduced, including the “Rotary Tooth Brush” combined with water rinsing, advertised in 1903. In 1885, Fredrick Tornberg, a Swedish clockmaker, patented the first mechanical toothbrush [8].

The modern powered toothbrush developed from these early prototypes. The earliest powered toothbrush, the Motodent, was developed by Tomlinson Moseley, with a patent filed by Motodent Inc. on December 13, 1937 [12, 23]. The earliest commercially marketed powered toothbrush, the Broxodent, was invented in Switzerland by Dr. Philippe-Guy Woog in 1954. Initially manufactured in Switzerland and later in France by Broxo S.A., the Broxodent was primarily designed for patients with limited motor skills. The device became commercially available in the United States in the 1960s by E.R. Squibb and Sons Pharmaceuticals and later marketed under the Broxodent or Broxo-Dent brand, with distribution eventually shifting to Somerset Labs, part of Bristol-Myers Squibb. An operational limitation of these early designs was their dependence on AC electrical outlets, which was inconvenient and raised safety concerns. Subsequent designs transitioned to low-voltage operation using step-down transformers to improve safety and usability in bathroom settings.

In the early 1960s, General Electric introduced a bulky, cordless automatic toothbrush powered by rechargeable NiCd batteries. While offering mobility, these early devices were limited by short battery life, the “memory effect” of NiCd batteries, and sealed battery units that rendered the entire toothbrush disposable upon battery failure, leading to economic and environmental inefficiencies. The size of the GE Automatic Toothbrush, comparable to two D-cell flashlight handles, further limited user convenience [23].

First-generation powered toothbrushes, such as the Broxodent and the GE model, featured brush heads that moved back and forth to mimic manual brushing, a design now categorized as conventional powered toothbrushes. Their brush heads typically operated in one of three movement patterns: reciprocating (back-and-forth motion), arcuate (up-and-down movement), or elliptical (a combination of reciprocating and arcuate motions). They were largely targeted at special populations, such as individuals with impaired manual dexterity. Their limited evidence of clinical benefit constrained wider use. Early experimental studies showed these devices performed similarly to manual toothbrushes in plaque removal, with mixed effects on gingivitis. The 1966 World Workshop in Periodontics concluded that “electric” toothbrushes could offer superior plaque control in individuals who were less motivated or had difficulty mastering manual brushing techniques [24].

Subsequent technological enhancements led to the availability of multiple powered toothbrush models, so that today a wide variety of types are available on the market.

2.3 Interdental Cleaning

The use of tools to clean between the teeth dates back to prehistoric times. A jawbone excavated in northern Spain, dated to approximately 1.2 million years ago, displayed an interdental groove containing fragments of non-edible wood, representing early archaeological evidence of toothpicking [25, 26]. Implements resembling toothpicks have also been uncovered in other prehistoric sites, suggesting that toothpicking occurred in multiple prehistoric populations.

In Mesopotamia, toothpicks (wooden interdental cleaner) became more refined and ceremonial [27]. Excavations at Nigel Temple, Ur, revealed decorated gold toothpicks, and a Mesopotamian king’s tomb contained a golden toothpick housed in a conical, richly ornamented case. Toothpicks were included in personal care kits alongside tools such as depilatory tweezers and ear wax scoops [11]. The Romans frequently provided toothpicks for their guests, and archaeological evidence shows finely crafted toothpicks in the bedrooms of upper-class women. Practical toothpicks made from the mastix tree (Pistacia lentiscus) were also used throughout the day, earning some Greeks and Romans the nickname “toothpick chewers” [28]. In China, toothpicks were sometimes made as cast bronze pendants for personal use, while in Europe, from the 15th to the 19th centuries, ornate toothpicks of gold or silver were used in some contexts as status objects. For most people, however, toothpicks remained primarily utilitarian tools for comfort and hygiene [9]. In 1872, Silas Noble and J. P. Cooley patented the first machine designed for the manufacture of toothpicks. Some historical accounts suggest that dental care professionals promoted toothpicks as “gum massagers” to massage inflamed interdental papillae, reduce inflammation, and promote keratinization of the gingival tissue [29].

The systematic cleaning of interdental spaces using floss emerged much later [11, 28]. Levi Spear Parmly (1790–1859), a dentist from New Orleans, is widely recognized as the inventor of dental floss. In the 19th century, he emphasized the importance of cleaning between teeth with silk floss to remove debris that toothbrushes could not reach, recognizing this as an important factor in preventing dental caries and calculus accumulation. In 1882, the Codman and Shurtleft Company in Randolph, United States, began mass-producing floss for commercial home use. In 1898, the Johnson & Johnson Company from New Brunswick (USA) became the first company to patent dental silk. Early floss, made from cotton or silk, was less durable, but it introduced the concept of systematic interdental cleaning. Nylon dental floss became available after World War II, offering greater strength, more resistant to fraying and usability, though its adoption remained limited due to the technique’s inherent difficulty. Dr. Charles C. Bass is considered the person who established flossing as an essential component of oral hygiene. In Europe during the same period, toothpicks were still commonly used after meals, often crafted from goose feathers, silver, or copper, while floss adoption progressed gradually into everyday oral hygiene practices.

The origins of interdental brushes, also known as twisted or spiral brushes, are somewhat obscure, but they appear to have been developed by the late 18th or early 19th century during industrialization [22]. Twisted brushes were adopted for medical purposes early on, such as for tracheotomy care in 1827 and for cleaning the chemical apparatus of Franz von Soxhlet in 1879, which led to their naming as “Soxhlet brushes.” Early 20th-century developments included single-tufted and spiral brushes for cleaning hard-to-reach dental areas and partial denture clasps. Initially handmade using hand cranks, brush production evolved with natural bristles later replaced by nylon. By 1975, Ulrich Zahoransky developed specialized machines for producing cylindrical IDBs. The first experimental study on interdental brushes was published in 1970 by Gjermo and Flötra in Oslo, demonstrating greater plaque removal compared with toothpicks and floss [30]. Subsequent studies in 1976, including Waerhaug’s seminal work, provided detailed analyses of interdental brush dimensions and effectiveness in plaque removal, demonstrating effectiveness in cleaning coronal and subgingival surface, and providing the basis for the modern use of interdental brushes in periodontal care [31].

2.4 Dentifrice

Toothpaste, a widely utilized component of modern oral hygiene practices, possesses a history spanning multiple civilizations and time periods [32]. Toothpaste, from its rudimentary origins in ancient civilizations to the carefully formulated products currently used in dentistry, has continuously evolved as a standard adjunct to mechanical plaque control. Although its composition may appear simple, toothpaste has an established role in promoting oral health by preventing caries and supporting periodontal health. The term “toothpaste” broadly refers to a product used in conjunction with a toothbrush to clean and polish teeth. The French and English equivalent is “dentifrice,” derived from the Latin dentifricium, combining dens or dentes (tooth or teeth) and fricare (to rub). Toothpaste is not a modern invention but has a millennia-old history.

Archeological and textual evidence provide insight into early dentifrice-like formulations. Babylonians and Assyrian clay tablets of the great library of Ashurbanipal (king of Assyria) include a number of remedies, such as “if a man’s teeth are loose and itch a mixture of myrrh, asafetida and opopanax, as well as pine-turpentine shall be rubbed on his teeth until blood comes forth and he shall recover” [27]. Ancient Egyptian powders, dating to around 5000 BC, were composed of powdered ashes of oxen hooves, myrrh, burnt eggshells, pumice, and water. Pumice remains a component used by dental hygienists today in professional prophylaxis. The tooth-cleaning powders were likely rubbed onto the teeth using the fingers, as the toothbrush had not yet been invented. The Egyptian Ebers Papyrus (approx. 1500 BC) includes early recipes for tooth-cleaning preparations. For fresh breath, incorporation of mint, peppercorn, and dried iris flowers was advised.

The ancient Greeks and Romans improved tooth powders by adding abrasives such as crushed bones, oyster shells, and powdered charcoal to remove debris and whiten teeth. They also included flavoring agents and therapeutic additives like myrrh. In India, Ayurvedic practices promoted herbal tooth-cleaning mixtures with ingredients like ginger, salt, and pepper. The Chinese added ginseng, herbal mints, salt, and even ammonia derived from urine to prevent caries and whiten teeth. Some of these recipes spread to the Western world via trade routes like the Silk Road.

Hippocrates (460–377 BC) recommended dentifrices using burnt hare heads and mice to clean teeth and freshen breath, reflecting the belief that animal properties could transfer to humans. Celsus suggested rubbing teeth with a mixture of pounded rose leaves, gallnuts, and myrrh to remove stains. Pliny the Elder (23–79 AD) recommended ashes of a hare’s head, sometimes combined with aromatic plant extract. Scribonius Largus (47 AD) described barley flour, vinegar, honey, and sun-dried radish skin for dental care. Records from Persia (c. 1000 AD) advised against harsh abrasives and suggested softer powders from burnt hartshorn, snail shells, and gypsum. Recipes also incorporated herbs, honey, minerals, and animal products. In the medieval Islamic world, Avicenna (980–1037 AD) warned against hard powders and recommended burnt gypsum for calculus removal.

Historical accounts suggest that European dental care practices in the Middel Ages were influence by limited empirical knowledge, and toothpaste recipes sometimes contained sugar, which is now recognized as detrimental to oral health. By the 17th century, European tooth powders included ground china, coral, pumice, crab shells, or cuttlebone. Charles Allen’s formula even combined powdered pearls, coral, dragon’s blood (a natural resin obtained from the sap of several different plants), and rosewater. The 18th century saw the rise of tooth powders with bicarbonate (baking soda) and sodium borate (borax), which were used for their cleansing and mild abrasive properties. Charcoal powders promised whitening and odor removal. Thomas Berdmore and Pierre Fauchard warned against overly abrasive powders.

Crude tooth-cleaning powders persisted until the industrial age when doctors, dentists, and chemists developed more refined tooth powders containing. Glycerine was introduced in the early 19th century to create smoother pastes, and strontium was added to strengthen teeth and reduce sensitivity. In 1824 Dr. Peabody combined soap with dental powder, followed by John Harris in 1850, who added chalk. In the 1850s, charcoal dentifrices and a red liquid dentifrices Sozodent were promoted in the United States. The latter contained 37 percent alcohol and became the first dentifrice to be featured in a national advertising campaign. Mass production of toothpaste began in 1873 with Colgate selling toothpowders in jars [9]. In 1892, Dr. Washington Sheffield of Connecticut introduced the collapsible tube, influenced by artists’ paint tubes, making toothpaste more hygienic and convenient [33]. He called it “Doctor Scheffield’s Crème Dentifrice.” It was his son, Lucius Sheffield, while studying in Paris, who had observed painters using collapsible metal tubes for their oil paints and suggested the same type of packaging for his father’s dental cream [9].

Willoughby D. Miller’s chemoparasitic theory of tooth decay (1890) influenced modern preventive dentistry, linking caries to acid produced by bacteria acting on fermentable carbohydrates [34]. This scientific understanding spurred the growth of dentifrice formulations with alkaline bases, often containing sodium bicarbonate or salts.

Early 20th-century toothpaste emphasized cleaning, fresh breath, and aesthetic appeal. Advertising played an important role in popularizing toothpaste and educating the public about the importance of oral hygiene. After World War II there were several developments in the formulation of toothpaste. Synthetic detergents replaced the soap with emulsifying agents, such as sodium lauryl sulfate. The first fluoride-containing oral care products, including toothpaste, tooth powder, and mouthrinse, were marketed starting in 1895 by the Karl Friedrich Toellner Chemical Company of Bremen, Germany, under the brand name Tanagra [35]. Fluoride use in oral products was patented in 1915 and formally recognized for caries prevention, although initial adoption was slow due to concerns about toxicity [36]. The American Dental Association initially criticized its introduction. After decades of research, fluoride use in toothpaste was approved and widely adopted by the late 1950s [28]. Crest fluoristan toothpaste, launched in 1955, was among the first dentifrices containing stannous fluoride, which marked the beginning of modern therapeutic dentifrices, with provisional ADA approval following in 1960.

2.5 Mouthrinse

The use of mouthrinses can be traced back thousands of years [11]. The earliest documented reference appears in Chinese medicine around 2700 B.C., where rinsing with a child’s urine was recommended for the treatment of gum diseases. During the Roman period, mouth rinsing was popular among the upper classes as an adjunct to mechanical cleansing. The Romans also perfumed the mouth with mixtures containing saffron, rose water, fennel, myrrh, and Arabic gum [9]. Pliny advised rinsing with salty water in uneven mouthfuls, while Hippocrates recommended a mixture of salt, alum, and vinegar. Other historic formulations included blends of honey, oil, beer, dill, anise seed, myrrh, and white wine. Mouth rinsing also held a religious dimension. For example, the Talmud prescribes rinsing the mouth between meals to remove food particles and prevent the mixing of meat and milk.

In the 12th century, the German philosopher Saint Hildegard von Bingen advised rinsing the mouth with pure cold water to prevent plaque and calculus formation [37]. The Zene Artzney (“Medicines for the Teeth”), published in Germany in 1530, the first printed work dedicated exclusively to dental therapeutics, included instructions for rinsing with burnt alum mixed with vinegar or myrrh boiled in wine, as well as a recommendation to rinse after meals with wine or beer to remove adherent debris [38, 39]. Its popularity is reflected in fifteen editions published between 1530 and 1576. During this period, mouth rinsing was primarily used to freshen breath, although some remedies, such as urine, were believed to have therapeutic properties due to their salt content.

Late 19th-century research introduced bacteriological understanding. Louis Pasteur established causal connections between bacteria and disease, providing a basis for antiseptic oral care. Willoughby D. Miller (1853–1907), often called the “Father of Dental Prevention,” conducted research demonstrating the importance of controlling oral bacteria. He furthered the knowledge on oral rinsing by distinguishing between bacterio-static effects (inhibiting the metabolism or reproduction of a bacteria) and bactericidal effects (killing the microbes) [40].

Among early antiseptic mouthrinses, Listerine emerged as an early example of an antiseptic mouthrinse [41]. Developed in 1884 by Joseph Lawrence and Jordan Wheat Lambert, the original, amber-colored formula combined essential oils (thymol, menthol, eucalyptol, and methyl salicylate) and was named in honor of Sir Joseph Lister, the pioneer of antiseptic surgery. Early advertisements promoted Listerine for a wide range of uses, from treating dandruff to curing diseases such as dysentery and gonorrhea. Although profitable, this “multipurpose approach” did not reflect the company’s intended image. The identification of halitosis as a key focus shifted Listerine’s marketing strategy toward combating bad breath, establishing its role as an oral hygiene product. Initially marketed as a general antiseptic, Listerine was promoted to the dental profession in 1895 and, by 1914, had become one of the first widely available over-the-counter oral care products [42–44].

In the latter half of the 19th century, the empirical use of various substances for mouth rinsing became increasingly evidence based. W.D. Miller described Listerine as a “very useful and active antiseptic” [44]. Miller himself developed a mouthrinse using a “Colorado Claro” cigar, which demonstrated antibacterial activity, though it contained substances later identified as hazardous, such as formaldehyde, arsenic, and cyanide. According to his own accounts, he used this preparation himself without observing any adverse effects. Home remedies such as rinsing with saline solutions or chamomile tea are continuously being used, though evidence is limited [45]. These historical developments highlight the longstanding recognition of mouth rinsing as both a cosmetic and therapeutic measure.

3.1 Manual Toothbrush

At the beginning of the 20th century, oral hygiene practices were not widely adopted (See Figure 1). In the early 1900s, only about 7% of Americans brushed their teeth. It was not until the 1930s that toothbrushing became more common among the general American population. Around the same time, toothbrushes became more widely accessible as their design and manufacturing methods evolved and inexpensive plastic handles and nylon filaments became available. Historically, bristles were cut bluntly and often had sharp tips [21]. In 1948, Bass observed that these blunt-ended filaments could injure soft tissues. Although his research did not meet contemporary clinical trial standards, his recommendations established an emphasis that persists in current recommendations on end-rounded bristles, which remain an important quality marker.

By the 1940s through the 1980s in the United States, most manual toothbrushes shared a similar flat, multi-tufted design [47]. During the 1990s, toothbrush designs were characterized by increasing diversity in both design and function, as manufacturers introduced brushes with varied head shapes, bristle configurations, and handle designs, all claiming improved performance. Toothbrushes are produced in multiple sizes (large, medium, small, or compact) to match different oral anatomies, and bristle stiffness varies from hard to extra soft. Adjustments in filament length, stiffness, and angulation enabled more effective access into the sulcus and interproximal areas. Ergonomic handle designs were introduced to assist individuals with different levels of manual dexterity. Some models even incorporated multiple heads to simultaneously clean buccal, lingual, and occlusal surfaces [48]. Technological advances in molding allowed bristles to be integrated directly into the handle rather than stapled, allowing a wider range of design configurations. The result was a substantial increase in the variety contributing to a large, competitive global marketplace. Although premium manual brushes have become more expensive, their unit cost typically remains lower than that of family-sized toothpastes or mouthrinses. Furthermore, toothbrushes benefit from low shipping costs, minimal breakage, and long shelf-lives, making them particularly profitable products within the oral care industry.

Early scientific comparisons of toothbrush efficacy often yielded inconsistent or contradictory findings, largely due to methodological limitations. Standardized and quantitative measurements of plaque removal were not yet established, and tested brushes varied widely in size, shape, and bristle configuration. More recent research has focused on evaluating modifications to bristle characteristics and placement. Modern innovation in bristle engineering has resulted in a variety of bristle shapes. Tapered [49], feathered [50], diamond-shaped [51] have been shown in laboratory studies to enhance plaque removal compared to conventional round-end bristles.

Higher magnification studies have shown that not all bristles labeled as rounded are uniformly smooth. A scanning electron microscope analysis of eight commercial toothbrush brands found wide variation in acceptable end-rounding, with values ranging from 22% to 88%, indicating that some brushes had the potential to cause gingival injury [52]. A later comparison of ripple-profile and flat-profile brushes revealed that nearly 90% of the ripple brush bristles were end-rounded, compared to only 52% in the flat brush, suggesting that end-rounding quality depended more on manufacturer standards than on brush design [53]. A broader survey of 31 toothbrushes found that only four had more than half of their filaments end-rounded, with many products exhibiting extremely poor rounding quality [54]. In a clinical experiment involving professional brushing, it was found that 40%–50% or greater end-rounded filaments provided a significant reduction in gingival abrasions compared to non-end-rounded filaments [55].

The firmness of nylon toothbrush bristles is generally consistent but influenced by material, diameter, length, filament count, and factors such as temperature, water exposure, and brushing frequency [56]. Adult bristles are typically 10–12?mm long, with diameters of 0.007–0.015?inches. Bristle texture labeling is not standardized, so a “soft” brush from one brand may be firmer than another’s “medium.” ISO testing procedures, supported by the ADA, provide objective measures to ensure consistency, enabling dental care professionals and consumers to select brushes based on standardized stiffness rather than brand-specific terminology [57]. To address safety and performance variability, the American Dental Association (ADA) established the Seal of Acceptance. Their guidelines require manufacturers to demonstrate proper bristle end-rounding, adherence to good manufacturing practices, and, when applicable, clinical equivalency data showing plaque and gingivitis reductions comparable to an ADA control toothbrush. Standard manual brushes with conventional shapes can meet these standards with laboratory data alone, while novel manual designs and all powered toothbrushes must undergo clinical testing to qualify.

Toothbrushes can be classified by lateral profile as concave, convex, flat, multilevel, or cross-angled. Slot et al. systematically reviewed 59 studies comprising 212 independent brushing experiments with 10?806 participants to assess the effect of a single manual brushing session [58]. The large sample and study heterogeneity strengthened the generalizability of their findings to routine daily oral hygiene. Using pre- and post-brushing plaque scores, they calculated a weighted mean plaque reduction of approximately 42%. Evidence showed that bristle tuft arrangement (e.g., flat, multilevel, or cross-angled) and brushing duration influenced efficacy. Among designs, cross-angled bristles showed the highest mean plaque reduction within the included comparisons, a finding supported by meta-analytic evidence from short-term studies demonstrating a statistically significant, medium-sized effect favoring this design [59].

The development of the manual toothbrush cross-angled filaments illustrates a design approach involving researchers, designers, engineers, and marketers from the outset [60]. A collaborative, research-driven approach from ergonomics, kinesiology, perceptual analysis, and observational studies informed bristle performance, grip security, accessibility, and ergonomics. Observations also informed handle geometry, grip texture, and storage compatibility. The final design combined criss-cross bristles, ergonomic contours, and color-coded grips to enhance cleaning efficacy, accommodate diverse hand sizes and grip styles, and improve usability. With the Introduction in 1993 there were, however, some challenges. Following the launch, Dr. Paul Warren from Oral-B reported in an interview with the New York Times that many consumers found the toothbrushes convenient, but that they did not fit into standard bathroom toothbrush holders. To address this, a toothbrush holder was developed resembling a cigar case, which could be left on the counter or packed for travel [61].

As toothbrushes are used, the mechanical forces of brushing gradually alter bristle shape and form, which may influence their cleaning efficiency [62]. Bristle wear is influenced by brushing force, the amount of dentifrice applied, and the thickness of the bristles themselves. Normal use tends to make bristles smoother and more rounded but can also cause the tufts to splay outward [63]. In a secondary analysis of a controlled longitudinal oral hygiene study with a 3-month toothbrush replacement protocol, toothbrush wear varied considerably between individuals. While wear was consistent within individuals across brushes, participants exhibiting extreme toothbrush wear had significantly higher plaque scores than those with little or no visible wear, suggesting reduced cleaning efficacy in severely worn brushes [64].

3.2 Powered Toothbrush

In 1986, an international workshop on oral hygiene concluded that (See Figure 2), up to that time, neither powered nor manual toothbrushes had demonstrated superior plaque removal, regardless of brushing method [65]. But since the 1980s, powered toothbrush technology has advanced substantially, a period that also marked a resurgence of interest in these devices [66]. Over the subsequent decades, more advanced powered brushes emerged, representing a significant departure from conventional manual toothbrushes. One early example was the Rotadent, introduced in 1986, which featured a 360° rotary brush head designed to maintain constant contact with all tooth surfaces. Rotadent offered different brush-head types (Hollow-tip, Short-tip, and Long-tip), representing what is often regarded as the second generation of powered toothbrushes. One of the earliest published studies, from 1989, reportedly concluded that the Rotadent was “as effective for plaque removal and control of gingival inflammation as a combination of conventional toothbrushing, flossing, and toothpicks,” at least among patients undergoing periodontal maintenance [67].

A major technological step followed in 1987 with the introduction of the Interplak, which used a motor-driven brush head in which each tuft rotated independently. This was followed in 1993 by the Braun/Oral-B oscillating–rotating design, featuring long-life rechargeable batteries. Unlike earlier brushes with long, narrow heads, it employs a small, round head that oscillates and rotates to enhance plaque removal. The design of this brush head has a design conceptually similar to prophylaxis handpieces used by dental care professionals for professional plaque removal in the dental office. More recent innovations, such as the Oral-B iO, utilize a linear magnetic drive, of which recent studies report increased plaque removal compared with traditional oscillating–rotating technology [68].

The introduction of sonic toothbrushes in 1992 marked the beginning of a third technological generation. These devices operate at sufficiently high speeds to produce vibrations in the audible range, with typical frequencies ranging from 200 to 400 Hz, or 24?000–48?000 movements per minute. Sonic toothbrushes rely primarily on sweeping motions, and these movements are generally high in amplitude, meaning that the sweeping strokes cover relatively long distances across the tooth surfaces. Clinical studies indicate that these devices are effective, although the magnitude of effect varies, and they are generally well tolerated, particularly among users who prefer a brushing experience similar to manual toothbrushing. Ultrasonic toothbrushes use ultrasonic waves to disrupt and remove plaque. To be classified as ultrasonic, a toothbrush must emit vibrations at a minimum frequency of 20?000 Hz or 2.4 million movements per minute. Ultrasonic toothbrushes produce high-frequency, low-amplitude vibrations. Some ultrasonic models rely solely on ultrasonic motion, while others combine ultrasonic vibrations with additional sonic movements ranging from 9000 to 40?000 strokes per minute to provide sweeping action that further facilitates plaque removal.

However, technological aspects alone do not guarantee clinical effectiveness. The benefits of powered toothbrushes depend on good compliance and continued use. While novelty may initially motivate users, long-term adherence is required to maintain plaque reduction. Prospective observational and interventional clinical studies have shown that switching from manual to powered brushes improves long-term compliance, even in patients with persistent poor oral hygiene habits [69, 70]. Surveys of dental care professionals indicate that power brushes have been associated with improvements in brushing behavior, patient satisfaction, and selected clinical outcomes [71]. The availability of interchangeable brush heads allows individualization of care, and patient surveys indicate high levels of compliance and satisfaction [72]. Patient motivation remains an important determinant of adoption and sustained use. Surveys conducted by the American Dental Association on powered toothbrush ownership reported that, among 139 users, 21.6% used their devices regularly, 25.2% used them occasionally, and the remaining 53% could not be clearly classified with respect to usage frequency [73]. Initial adoption of powered toothbrushes is often associated with increased brushing frequency, especially when professional instruction and guidance are provided in the first 6?months [74]. Nevertheless, a follow-up survey of a randomized controlled clinical trial indicates that many users fail to maintain twice-daily brushing over time [75]. In an ultimate evaluation professional powered toothbrushing was compared to professional polishing in 90 non-dental students [76]. Two minutes of powered toothbrushing removed plaque as effectively as a 10-min professional polish, while 10?min of powered toothbrushing achieved the highest plaque reduction, especially on approximal surfaces and molars. The findings suggest that under experimental conditions the powered toothbrush may achieve plaque removal comparable to professional polishing.

Clinical trials involving (powered) toothbrushes inherently involve human participants, and this fact introduces a range of practical and methodological considerations that can influence both the conduct and the outcomes of such studies. The very act of carefully examining individuals for the presence of plaque and gingivitis can alter behavior and improve oral hygiene practices [77]. Exposure to clinical trial procedures may therefore lead to improvements that arise not from the physical effects of the test device, but from psychological influences. This phenomenon, known as the Hawthorne effect, has been recognized in numerous clinical investigations. When controlled clinical trials are properly designed and balanced, this effect should not result in systematic differences between test and control groups.

A further methodological challenge in toothbrush research is that true double-blinding is virtually impossible [78]. Consequently, the novelty effect associated with powered toothbrushes must be carefully considered in study design. This novelty effect, also referred to as “gadget appeal,” may initially be driven by curiosity, but patients generally demonstrate increased interest in powered toothbrushes and often show greater willingness to use them. One practical strategy for minimizing this effect is to conduct studies over longer periods, allowing the initial enthusiasm to diminish. Short-duration studies are particularly vulnerable to bias arising from novelty effects [79].

Early research at ACTA included one of the first systematic comparisons of oscillating–rotating powered toothbrushes with manual toothbrushes [80]. In a split-mouth study involving sixty students, a standard manual toothbrush was compared with the conventional powered toothbrush Braun D3 and the newly developed Braun D5, which featured an innovative oscillating–rotating round brush head. After a 24-h period of brushing abstinence, professional brushing demonstrated greater plaque removal by both powered brushes compared with the manual toothbrush. When participants brushed without prior instruction, plaque removal was, however, similar across all brushes. Yet, following professional instruction, the Braun D5 achieved plaque reduction comparable to professional brushing. These findings highlighted the role of brushing technique in maximizing the benefits of powered toothbrush technology and contributed to the development of the oscillating–rotating concept.

Short-term gingivitis studies present additional methodological difficulties. To obtain maximum benefit from a toothbrush, professional instruction and training in its correct use are generally required [81]. Such instruction unavoidably affects gingival status, as participants are likely to improve their oral hygiene and become clinically healthier. To address this issue, a model was subsequently proposed that incorporated a phase of experimental gingivitis within short-term study designs, with the objective of re-establishing gingival inflammation following the training period [82]. This model made it possible to maintain a sufficient level of gingivitis in adequately trained subjects and provided a realistic framework for evaluating toothbrush effects on gingival health. Study results demonstrated that gingivitis was resolved within four weeks after resuming toothbrushing, confirming that this design represents a useful methodological approach for testing toothbrush efficacy in relation to gingival outcomes.

Further investigations examined the relationship between brushing duration and cleaning efficacy [83]. These studies demonstrated that optimal plaque removal was achieved with two-minute brushing sessions. The findings emphasized the importance of patient education, as typical brushing times in everyday practice are frequently <?45?s. Longitudinal clinical studies further demonstrated that regular use of oscillating–rotating powered toothbrushes improved gingival health and reduced plaque accumulation over periods of several months, supporting the role of both technological features and professional instruction.

Subsequent innovations focused on improving brushing mechanics and enhancing user compliance. Later models expanded on these concepts by incorporating vibrating and reciprocal movements, as well as built-in pressure sensors and timing devices. The introduction of integrated two-minute timers supported adequate brushing duration and improved adherence to recommended oral hygiene practices. Research into brushing force led to the development of pressure sensors, which provide real-time feedback has been associated with a reduction in the risk of hard- and soft-tissue trauma. If excessive force is applied, the user is alerted to reduce pressure. This training mechanism may support safer brushing behavior [84].

The implementation of light, perpendicular tapping motions in the brush head forming the first generation of the so-called “3D Plaque Remover” further enhanced plaque disruption [85, 86]. This design development was inspired by simple mechanical principles observed in everyday activities. Peter Hilfinger, who led the development of the Braun/Oral-B powered toothbrush, observed that while clearing his snow-covered driveway, tapping a broom against compacted snow facilitated its removal. This repetitive tapping motion disrupted the adhesion between the snow and the underlying surface, thereby improving removal efficiency of residual material. By analogy, the incorporation of light, perpendicular tapping movements into the brush head was intended to disrupt the adhesion of plaque to the tooth surface, thereby enhancing the mechanical efficacy of plaque removal.

Multiple studies conducted over the past decades have demonstrated that contemporary powered toothbrushes are associated with greater reductions in plaque and gingivitis than manual toothbrushes. Oscillating–rotating powered toothbrushes from Braun/Oral-B and sonic powered toothbrushes such as Philips Sonicare are among the most commonly used powered toothbrushes in the current marketplace. Evidence from systematic reviews supports these effects [87–89]. A systematic review and meta-analysis including 21 randomized clinical trials found a standardized mean difference (SMD) of 0.86 for plaque reduction, 0.47 for gingival index, and 0.92 for bleeding index compared with manual brushes. This corresponds to a moderate effect size (Cohen’s d ??0.5), which may translate into clinically meaningful improvements in gingival health over time [89]. Emerging evidence also highlights their potential for optimizing interdental cleaning, an area often challenging to manage [90].

A systematic review and network meta-analysis synthesized the available clinical evidence on the efficacy of powered toothbrushes with oscillating–rotating (OR) or high-frequency sonic (HFS) technology compared with manual toothbrushes for plaque removal after a single brushing episode [91]. Analyses of changes in plaque scores showed a significant benefit of powered toothbrushes over manual brushes, with ranking probabilities indicating a modest advantage of OR over HFS technologies. This observation aligns with findings from a participant-level meta-analysis of studies with follow-up periods of up to three months which showed that oscillating–rotating brushes produced the highest proportion of participants achieving gingival health (72%) compared with manual (21%) and sonic brushes (54%) [92, 93]. Longitudinal evidence also provides supportive evidence for powered toothbrush use. An 11-year longitudinal study within the Study of Health in Pomerania (SHIP) cohort evaluated the effects of powered toothbrush use on periodontal health, caries, and tooth retention in adults. During the study period, powered toothbrush use increased from 18.3% to 36.9% [94]. Long-term use was associated with reduced mean probing depth, less clinical attachment loss progression, and a higher number of teeth retained. Although these observational findings cannot establish causality and may be influenced by confounding factors such as oral hygiene behavior, socioeconomic status, and dental attendance, the data suggest that powered toothbrush use may be linked to reduced gingival inflammation and improved oral health. A recommendation of powered toothbrush usage in dental practice may contribute to long-term oral health outcomes, but guidance should be provided alongside patient education [95].

The safety of powered toothbrushes was initially a concern among dental care professionals. Poor control of brush movements or excessive brushing force could theoretically damage the gingiva and increase the risk of gingival recession. A systematic review evaluated the effects of oscillating–rotating and manual toothbrushes on hard and soft oral tissues [96]. Thirty-five original articles were included and grouped by study design: randomized controlled trials with safety as the primary outcome, studies where safety was a secondary outcome, investigations using surrogate safety parameters, and laboratory studies. Although the parameters varied too widely for pooled statistical analysis, the overall findings indicated no significant safety concerns. In their systematic review, Rajapakse et al. found no evidence that powered brushes cause more tissue damage than manual brushes [97]. These findings are consistent with observations from clinical studies, in which only minor or transient adverse events were reported [98]. A recent 36-month randomized controlled trial evaluated a newly developed powered toothbrush with a linear magnetic drive versus a manual toothbrush in participants with pre-existing gingival recessions [99]. The powered toothbrush group showed a small but statistically significant reduction in mean recession at index teeth compared with the manual group. While the number of stable or improved sites was similar between groups, fewer sites worsened in the powered toothbrush group. These findings support earlier work suggesting that, in individuals at high risk for gingival recession, powered brushing may help limit further progression without increasing adverse events [100, 101]. Similarly, a cross-sectional, examiner-blind study compared gingival recession and gingival abrasion in users of manual and oscillating–rotating powered toothbrushes during a single brushing exercise [102]. Nearly all participants had at least one site of mild gingival recession, with no significant differences between groups. Powered toothbrush users exhibited significantly less post-brushing gingival abrasion than manual toothbrush users, and no association was found between gingival abrasion and recession in either group. These findings indicate no increased risk of gingival recession. Tooth and gingival abrasion is associated with excessive brushing, with contributing factors including frequency, duration, force, and filament stiffness.

3.3 Interdental Cleaning

Interdental cleaning should be integrated into daily oral care based on early clinical signs of caries or periodontal disease [4, 8] (See Figure 3). Selection of the appropriate interdental cleaning device should consider individual preferences, manual dexterity, and the morphological situation of the interdental spaces (see Table 1).

For open interdental spaces, woodsticks seem to be appropriate. Woodsticks are generally simple to handle and are composed of biodegradable materials. A pointed, triangular woodstick when placed interdentally maintains a plaque-free region for at least 2–3?mm subgingivally [103]. A 2008 systematic review including evidence from controlled trials, most of which were also randomized showed that triangular woodsticks used as an adjunct to toothbrushing improve interdental gingival inflammation and reduce bleeding, although they do not significantly affect plaque levels [104].

Dental floss or dental tape is traditionally recommended for interdental cleaning when the papillae completely fill the interproximal embrasures. Under ideal conditions, flossing can remove up to 80% of (inter)proximal plaque, including plaque located 2–3.5?mm subgingivally [105]. Various types of floss exist, monofilament and multifilament including waxed and unwaxed versions. A randomized crossover experimental study did not demonstrate clinically meaningful differences in their effectiveness [106]. Unwaxed floss is generally preferred for normal contact points, whereas waxed floss may facilitate passage through tight contacts. The effectiveness of flossing depends heavily on technique. Many individuals struggle with the fact that flossing is time-consuming and technically demanding, and inadequate instruction contributes to poor performance and low adherence. Although floss holders and powered flossing devices have been introduced, these aids do not consistently improve plaque removal or gingivitis outcomes, despite being preferred by some users. Limitations of floss are shedding and tearing, inefficient cleaning of larger embrasures, inaccessibility in areas with deeper pockets and furcation involvements [107].

Despite its theoretical benefits, robust evidence supporting routine flossing in adults with healthy gums is lacking. While flossing is widely promoted, systematic reviews consistently show that the supporting data are limited, indirect, or methodologically weak. Floss may still be recommended when other interdental devices are unsuitable, but its routine use as a universal guideline is not supported [5]. A 2008 systematic review found no meaningful effect of flossing, when added to toothbrushing, on gingivitis [108]. Subsequent systematic reviews, including Cochrane analyses, have largely confirmed that the available evidence is weak, inconsistent, or of very low certainty [109]. Meta-analyses indicate that most studies fail to demonstrate significant plaque-removal benefits, and that floss often performs less effectively than other interdental cleaning devices [110]. While professionally performed flossing may reduce approximal caries risk in children, this benefit does not translate to self-performed flossing [111].

This gap between practice and evidence gained widespread attention in 2016, when Associated Press journalist Jeff Donn requested documentation from U.S. federal health agencies to substantiate their long-standing recommendation to floss daily [112]. The inquiry was prompted by a remark from his son’s orthodontist, who suggested that there was “no solid evidence” supporting flossing. Upon reviewing the literature, the journalist identified a genuine scientific concern. His subsequent requests revealed that, despite inclusion in national dietary guidelines since 1979, the flossing recommendation had never undergone the legally required scientific evaluation. After repeated unanswered inquiries, a formal Freedom of Information Act request was submitted. Six months later, a revised edition of the Dietary Guidelines for Americans was released, with the flossing recommendation removed without explanation. Only thereafter did the Department of Health and Human Services acknowledge that no supporting evidence could be identified and that flossing had never been systematically reviewed by the responsible guideline committees.

The removal of flossing from federal guidelines also triggered considerable public and professional debate, ranging from media narratives of a collapse of conventional wisdom to statements from professional organizations defending flossing on pragmatic or biological plausibility grounds, while acknowledging the scarcity of robust evidence. This episode, often referred to as “Floss-gate,” illustrates discrepancies between longstanding clinical recommendations, public health messaging, and supporting evidence [113]. More broadly, it underscores a recurring challenge in preventive dentistry that clinical practices may persist despite limited empirical support, reinforcing the need for transparent, evidence-based recommendations.

In a recent roundtable consensus meeting clear clinical recommendations and future research priorities were established through structured, pre-formulated questions and guided group discussions [4]. These encompassed specific considerations for interdental cleaning and concluded that overall, interdental brushes (IDBs) are generally the preferred method. Between 1980 and 1990, clinical research demonstrated the efficacy of IDBs in plaque removal [22]. Early randomized clinical trials showed that these devices were more effective than woodsticks for spaces without adjacent teeth and more effective than waxed dental floss in open interdental areas, with no differences between brush types or surfaces [114, 115]. From 1991 onward, IDBs became recognized oral hygiene aids. A 2008 systematic review confirmed that IDBs combined with toothbrushes improved plaque, bleeding, and probing indices compared to floss [116]. Appropriate interdental brushes are available today for the smallest to the largest interdental spaces. Interdental brushes are commonly recommended for patients with periodontitis, based on evidence of their efficacy. A systematic review concluded that the majority of the test study individuals preferred the IDB as they found the process to be simpler when compared to flossing [117].

Brush design factors influencing performance include overall diameter, filament length (1.1–7.0?mm), filament thickness, and longitudinal/cross-sectional shape. While evidence for optimal filament length-to-thickness ratios remains lacking, proper selection of interdental size and shape, as well as matching to individual interdental spaces contributes to maximizing cleaning efficacy [118]. Cylindrical, conical, and waisted IDB designs all reduce plaque effectively. Though cylindrical [119] or waisted shapes [120, 121] may improve cleaning in some conditions.

The IDB should be inserted obliquely into the interdental space, with a back-and-forth motion. They should be used without dentifrice except in special cases and then only short-term [122]. They can be used to apply fluoride or chlorhexidine into the interdental space to prevent caries or the recolonization of residual pockets [123].

The most recent interdental cleaning aid is the rubber or silicone toothpick. Interdental spaces in many adults are sufficient to accommodate these. The sticks have a firm but flexible conical plastic core covered with small filaments or soft rubber or silicone lamellae. Although they resemble an IDB, they function like a toothpick. These devices are available in multiple sizes, and selecting the appropriate size improves cleaning efficacy. Terminology for these devices is inconsistent across the literature. They are variously referred to as non-wired interdental cleaners, rubber-bristle interdental cleaners, or interdental rubber picks.

The first product was GUM Soft-Picks (Sunstar Europe S.A., Switzerland). This rubber toothpick was designed to massage the gums and dislodge food debris. The manufacturer promoted the rubber toothpick as “more pleasant than floss,” potentially improving adherence to interdental cleaning routines. Later, similar silicone products are EasyPick (TePe Munhygienprodukter AB, Sweden) and Vitis Flexpick (Dentaid, Spain).

Non-wired interdental cleaners have been evaluated as an adjunct to toothbrushing for plaque and gingivitis control. Evidence from randomized trials shows that overall, these devices perform similarly to IDBs and dental floss in reducing plaque and bleeding, though in accessible sites non-wired interdental cleaners may achieve greater reduction in gingival inflammation [124]. Non-wired interdental cleaners require higher forces for cleaning compared to IDBs [125]. An in-vitro study showed that using artificial saliva halved the cleaning forces, especially in larger or convex interdental spaces, potentially improving effectiveness and patient comfort [126]. They are associated with fewer gingival abrasions compared to IDBs and are generally well tolerated, although the certainty of evidence regarding plaque and gingivitis reduction remains low [127].

While the 2015 European Federation of Periodontology workshop reinforced IDBs as the most effective interdental cleaning method, meta-analysis also shows that the oral irrigator (water jet) devices also rank high [46, 128]. The oral irrigator was developed by a hydraulic engineer, John Mattingly, and a dentist, Gerald Moyer, and was introduced in 1962. In 1964, external support enabled broader distribution. Within a few years, Waterpik devices became widely available in drugstores and department stores. In 2001, the American Academy of Periodontology stated that in individuals with suboptimal oral hygiene, supragingival irrigation, with or without antimicrobial ingredients, can further reduce gingival inflammation beyond what is typically achieved with toothbrushing alone. In 2017, the Waterpik Water Flosser (Water Pik Inc., Fort Collins, USA) received the ADA Seal of Acceptance.

There are several tip designs for varying patient needs, for example, the classic jet tip, orthodontic tip, and pik-pocket tip. The device is considered safe for systemically healthy individuals. An oral irrigator is not a substitute for toothbrushing but rather an adjunct to remove residual plaque.

A miniature pump delivers a (pulsating) jet of water through the oral irrigator tip to remove interdental debris and dental plaque. Oral irrigators primarily exert their effect through hydrodynamic shear forces that disrupt and thin the biofilm at the supragingival and marginal subgingival level. Penetration into deeper periodontal pockets remains limited. Their primary mode of action is mechanical biofilm disruption rather than a direct bactericidal effect. Other proposed mechanisms include mechanical gingival stimulation, interference with plaque maturation, and immune response stimulation. Oral irrigators can also deliver antimicrobial solutions such as low-concentration chlorhexidine into shallow periodontal pockets [129].

Scanning electron microscopy (SEM) images have demonstrated that the water jet can remove biofilm both above and below the cemento-enamel junction [130]. Studies have demonstrated that pulsating water systems may enhance fluid dynamics compared to continuous flow streams [131, 132]. The effect has been associated with cyclical compression/decompression action that enhances hydrokinetic flushing of interdental and subgingival areas, with pulsating devices shown to be approximately three times more effective than continuous-flow devices in laboratory and comparative analyses.

A systematic review evaluated the effectiveness of oral irrigation after toothbrushing on plaque and clinical parameters of periodontal inflammation compared with toothbrushing alone or routine oral hygiene [133]. Due to heterogeneity, only a descriptive analysis was possible. While no significant differences in plaque scores were observed, several studies reported significant improvements in gingival inflammation, bleeding indices, and probing depth when oral irrigation was used as an adjunct. A comprehensive secondary analysis of primary data showed that across 12 clinical studies in subjects with generalized gingivitis, the adjunctive use of an oral irrigator with toothbrushing markedly reduced bleeding on probing within 4?weeks [134]. Approximately two-thirds of participants achieved <?20% BOP and transitioned from generalized to localized gingivitis, with the greatest improvement observed when the oral irrigator was combined with a powered toothbrush.

Other designs, such as the Sonicare AirFloss, use microburst technology but appear less effective than conventional water irrigators [135]. In a randomized clinical trial, AirFloss Ultra with essential oils was compared to waxed dental floss as adjuncts to manual toothbrushing [136]. No significant differences in efficacy or safety were observed between the two interdental cleaning methods, indicating that both are equally effective and well tolerated in non-periodontitis patients.

3.4 Tongue Cleaning

The dorsum of the tongue, with its papillary structure, grooves, and crypts, forms an ecologically unique niche with a large surface area where microorganisms can persist and serve as a microbial reservoir, contributing to the bacterial composition of saliva [137]. Tongue bacteria can spread to other oral surfaces, potentially contributing to dental plaque formation. Tongue cleaning is included in oral hygiene practices in many regions and cultures, including Africa, the Middle East, South and East Asia, South America, and Europe, with historical references to its use in traditional Ayurvedic and other cultural systems [138]. In India, the tongue is traditionally scraped daily after tooth brushing, followed by rinsing with extracts of betel leaves, cardamom, camphor, and other herbs. Tongue cleaning is included in full-mouth disinfection protocols during non-surgical periodontal treatment [139].

Various tools are available for tongue cleaning, ranging from traditional long, curved metal or plastic scrapers to modern, compact tongue cleaners with handles. Comparative surveys have not identified a clearly superior design, although sharp-edged scrapers may cause discomfort during use [140]. Systematic reviews indicate that tongue scrapers and cleaners are more effective than toothbrushes and are better tolerated, as they provoke the gag reflex less frequently [141]. Accessing the posterior dorsum of the tongue is, in itself, technically challenging. Techniques such as tongue extension or nasal breathing may facilitate cleaning, and cleaning in the evening can improve compliance.

Clinically, tongue cleaning has been shown to reduce tongue coating and improve the subjective feeling of oral freshness. Regular tongue cleaning is associated with reduced tongue debris. The effect on dental plaque formation, however, is inconsistent; some studies report a benefit, while others find no difference in de novo plaque accumulation. This variability may partly be explained by the inherent difficulty of accessing the posterior dorsum of the tongue. In patients with periodontal disease or halitosis, tongue coating is significantly more extensive, suggesting that tongue cleaning may be particularly relevant in these populations [142]. While mechanical tongue cleaning can reduce tongue coating and contribute to subjective oral freshness, there is insufficient evidence to conclude that tongue cleaning reliably reduces halitosis. Further controlled clinical studies in patients with halitosis are required [143].

3.5 Dentifrice

Toothpaste plays a central role in modern oral hygiene and is used daily by billions of people worldwide (See Figure 4). Brushing is almost universally accompanied by toothpaste, making it reasonable for both toothbrush and dentifrice to be considered synchronized tools within an individualized oral care regimen. Brushing with toothpaste is also generally perceived as more pleasant than brushing without it [144, 145].

Although the form and formulation of toothpaste have evolved considerably, its purposes remain consistent: facilitating plaque removal, reducing extrinsic discoloration, providing a clean and fresh sensation, and delivering therapeutic agents throughout the oral cavity.

The American Dental Association’s 1953 conference on therapeutic toothpaste claims and the subsequent introduction of clinically tested fluoride toothpastes stimulated a surge of innovation [3]. Since then, manufacturers have progressively enriched formulations with diverse active ingredients designed to address specific clinical problems such as gingivitis, dentine hypersensitivity, halitosis, enamel erosion, and extrinsic staining. A continuing challenge for industry and researchers is ensuring that all active ingredients function effectively within the standard regimen of twice-daily brushing for two minutes.

In contemporary Western society, the toothpaste market has grown substantially in recent decades. For consumers, an overwhelming variety of toothpaste products is available, while dental care professionals must discern which products offer clinically validated benefits for their patients. Toothpaste is also available in many forms, including pastes, gels, powders, and more recently tablets [146].

Modern toothpaste formulations rely on a wide range of active and inactive ingredients, each contributing to specific clinical functions [32, 147]. Fluoride remains the cornerstone of caries prevention, with sodium fluoride, stannous fluoride, and sodium monofluorophosphate all enhancing remineralization and inhibiting demineralization. Its introduction represented one of the most important breakthroughs in dental public health. Fluoride toothpastes rapidly achieved global acceptance, contributing to substantial reductions in dental caries and improved population-level oral health. A Cochrane review evaluated fluoride’s preventive efficacy across various concentrations [148]. Most available studies compared 1000–1250 ppm formulations with placebo, leaving limited precision for less commonly used concentration ranges despite the application of network meta-analysis. Nevertheless, the evidence strongly supports the effectiveness of the fluoride concentrations most widely used worldwide. Optimal fluoride concentration, however, is not uniform and should be tailored to age and individual caries risk. In children, fluoride toothpaste is recommended in age-appropriate concentrations, with careful control of the amount used to balance caries prevention with the risk of fluorosis during enamel development. In adolescents and adults with increased caries risk, higher concentrations—up to 5000 ppm in professionally prescribed toothpastes—may be indicated to achieve enhanced preventive benefit.

Several active ingredients target biological processes related to oral diseases. Antibacterial agents such as stannous fluoride exhibit potent anti-plaque and anti-gingivitis effects, while zinc citrate offers antimicrobial benefits and contributes to halitosis control. Although triclosan was once widely used, its inclusion has decreased substantially due to regulatory restrictions related to systemic safety concerns.

For patients experiencing dentine hypersensitivity, desensitizing agents including potassium nitrate, arginine, strontium salts, stannous fluoride, hydroxyapatite, and calcium sodium phosphosilicate act either by reducing nerve excitability or occluding dentinal tubules. These agents are supported by evidence for reducing dentine hypersensitivity, though optimal usage regimens remain under investigation.

Abrasive agents, most commonly hydrated silica and calcium carbonate, facilitate plaque and stain removal. When formulated within controlled abrasivity limits, these compounds effectively clean the tooth surface without causing enamel damage. To address cosmetic concerns, whitening agents may incorporate mild abrasives or low concentrations of peroxide to remove extrinsic stains, whereas blue covarine pigments create an immediate optical whitening effect by altering perceived tooth color. In contrast, charcoal-based dentifrices are discouraged due to their high abrasivity and insufficient clinical evidence. Agents aimed at reducing oral malodor typically include zinc salts, sodium bicarbonate, or stannous fluoride, all of which reduce volatile sulfur compounds responsible for halitosis.

These active components are supported by “inactive components” in toothpaste that contribute to stability, consistency, and user acceptability. Humectants such as glycerin and sorbitol prevent dehydration of the paste, while binders maintain structural consistency. Flavoring agents improve the palatability of brushing, and surfactants, most notably sodium lauryl sulfate, facilitate dispersion of the dentifrice throughout the oral cavity, even though their characteristic foaming is not essential for cleaning efficacy.

Abrasive components of toothpaste facilitate the removal of surface stains, yet their efficacy depends on maintaining consistent granularity, particle shape, and crystallinity, which advanced production technologies help ensure. Ensuring that abrasives are compatible with fluoride salts is an important aspect of their selection. Slop (1986) employed an in-vitro model to assess enamel wear from brushing and found minimal risk of significant tissue loss [149]. Data on dentine abrasion remain limited for both manual and powered toothbrushes. Today, the most recognized laboratory measure of toothpaste abrasivity is the Radioactive or Relative Dentine Abrasion (RDA) method developed at Indiana University and approved by the American Dental Association to evaluate toothpaste abrasiveness [150]. The International Organization for Standardization (ISO) sets an RDA value of 250 as the upper safe limit for daily use, with lower values indicating low to moderate abrasivity and higher values indicating high abrasivity. However, translating RDA values from laboratory models to clinical practice requires caution, as in-vivo tooth wear is influenced by numerous factors including brushing technique, saliva composition, pellicle formation, diet, and acid exposure. Dentin wear in particular is modulated not only by the abrasive ingredient but also by the overall paste formulation, type of toothbrush, brushing pressure, and movement. Sharp edges of crystalline abrasives can be enveloped by other paste components, reducing their abrasive effect, while saliva may rinse away abrasives, paradoxically enhancing their action. Research consistently shows that the way a toothbrush is used plays a more decisive role in abrasion and brushing trauma than the toothpaste’s inherent abrasiveness. Clinical research reports no significant differences in abrasive gingival lesions or brushing trauma among individuals using toothpaste with varying RDA values [151].

The relative contribution of toothpaste abrasives to plaque removal, compared with bristle action alone, warrants consideration. Is toothpaste truly indispensable for effective plaque removal? A 2001 report from the Division of Science of the American Dental Association indicated that plaque removal is minimally influenced by abrasive agents. Instead, the efficacy of plaque removal during brushing appears to depend primarily on the ability of the bristles to retain the toothpaste, rather than on the abrasives themselves [152]. Moderate evidence further suggests that brushing with toothpaste does not significantly enhance mechanical plaque removal compared to brushing without it [153]. Despite this, toothpaste use is recommended for the delivery of therapeutic agents and potential benefits in oral hygiene, beyond mechanical plaque removal. Recommendations regarding toothpaste should be individualized to optimize oral health outcomes and appropriate use of active ingredients.

3.6 Mouthrinse

Daily brushing with fluoride-containing toothpaste remains the cornerstone of caries prevention (See Figure 5). Nevertheless, both scientific evidence and clinical experience demonstrate that many adults encounter considerable difficulties in achieving effective oral hygiene. The success of daily plaque removal is strongly influenced by the patient’s motivation and proficiency in mechanical cleaning techniques. This context motivates the evaluation of chemical adjuncts or other strategies to support mechanical plaque control. The inclusion of specialized antibacterial toothpaste and/or therapeutic mouth rinses may serve as valuable complements to routine oral hygiene practices. Mouthrinses may be indicated when mechanical plaque removal is insufficient or not feasible.

According to the EFP S3-level clinical practice guideline on the treatment of stage I–III periodontitis, adjunctive antiseptic agents may be reasonably recommended for specific patient populations rather than the general public [46]. At present, the evidence supporting routine use in the general population is limited. In the management of gingivitis and enhancement of plaque control, anti-plaque chemotherapeutic agents may be considered as adjuncts to mechanical oral hygiene. Likewise, in periodontal therapy, adjunctive antiseptics can be applied for defined periods alongside mechanical debridement in select cases. During periodontal maintenance, such agents may be employed to aid in controlling gingival inflammation, although their additional cost must be carefully weighed. For patients unable to adequately manage supragingival biofilm or gingival inflammation through mechanical methods alone, recommending a mouthrinse with a specific active ingredient should be based on individual clinical assessment. Patient sensory preferences, including taste and flavor, may influence adherence to mouthrinse use.

Mouthrinse formulations typically consist of a water base, flavoring agents, and colorants, with additional therapeutic ingredients such as fluoride, antibacterial compounds, and freshness enhancers. Alcohol is sometimes included to facilitate the dissolution of non-water-soluble ingredients, contribute to the formulation’s organoleptic properties, and provide a robust sensory experience that may improve user acceptance. The commercial market offers a wide array of products containing therapeutic agents intended to support plaque control. An extensive systematic review reported that mouthrinse formulations containing specific chemical plaque-control agents, irrespective of the active ingredient, were associated with statistically significant reductions in gingivitis and plaque scores, with variation in effect size among formulations [154]. Nevertheless, only a limited proportion of formulations and proprietary mouthrinse products have demonstrated convincing, clinically meaningful efficacy [3].

While mouthrinses can reach areas that are less accessible to mechanical cleaning, their penetration into subgingival spaces is minimal. Within minutes, gingival crevicular fluid flow dilutes the subgingivally applied antiseptic, and salivary proteins may further reduce the activity of certain active agents. Moreover, the oral biofilm constitutes a densely structured and highly protective community of microorganisms, which functions as a barrier and substantially limits the influence of external chemical interventions [40].

It is therefore important for oral healthcare professionals to emphasize that mechanical plaque removal remains the primary and most evidence-supported method for maintaining oral health. The adjunctive use of mouthrinse should be considered selectively, as effectiveness depends on the active ingredient. Therapeutic mouthrinses can be safely used for either short- or long-term purposes when clinically indicated. Evidence to date does not indicate an association between alcohol-containing mouthrinses and oral cancer [155]. It has also been suggested that the use of chlorhexidine-containing mouthrinses may alter the composition of the oral microbiota and theoretically could influence systemic parameters such as blood pressure. A recent systematic review suggests that any effect of chlorhexidine on blood pressure is minimal and unlikely to be clinically relevant [156].

3.7 Oral Health Behaviour

Oral hygiene practices vary across countries and populations. In general, populations in high-income regions have widely adopted regular toothbrushing using fluoridated toothpaste, often complemented by interdental cleaning devices such as dental floss or toothpicks [157]. Within countries, oral hygiene practices are influenced by socioeconomic factors such as income, education, and residence.

Recent professional consensus statements [158], developed through structured methodologies such as the Considered Judgement Form [159] and supported by the available scientific evidence, have led to clear, evidence-based recommendations for oral hygiene in both adults and children. Recommendations generally advise brushing at least twice daily, with one session preferably in the evening. Brushing duration should be sufficient to effectively clean all tooth surfaces, typically around two minutes, although this may vary depending on the number of teeth and an individual’s manual dexterity.

Regarding toothbrush selection, both manual and powered brushes are effective when used with proper technique. A small-headed brush with soft to medium bristles is generally advised, and brushes with adapted handles or specialized designs may be beneficial for individuals with physical or motor limitations. Interdental cleaning should be individualized based on interdental space size (see Table 1) and guided by professional advice.

Over the years, numerous toothbrushing techniques have been proposed, including rolling, vibrating, circular, vertical, and horizontal methods, but many have been abandoned as research emphasizes systematic and thorough plaque removal over any specific method. Currently, no consensus exists among dental care professionals or commercial entities regarding the most effective manual toothbrushing method [160]. Systematic reviews evaluating the evidence on different manual techniques reveal considerable heterogeneity in study designs, methodologies, and outcome measures, preventing definitive conclusions. Overall, there is insufficient evidence to recommend a single superior manual technique [160]. Some recent data from a network meta-analysis suggest that the Fones technique may slightly reduce plaque compared with no training, although its impact on gingivitis remains uncertain. The Bass technique appears to produce minimal differences in plaque removal, with limited evidence indicating it may slightly increase gingivitis [161]. Consequently, the prevailing recommendation remains to brush twice daily for approximately two minutes following a systematic pattern.

Observational studies indicate that actual brushing durations are often shorter than recommended for effective plaque removal. Over the past two decades, observed average brushing times have increased from roughly 20–30 s to 60 s, and more in uninstructed adults using a manual toothbrush for approximately 87 s [162]. This is below the recommended two minutes, although there is a trend toward longer durations in more recent studies. Reported brushing times often exceed observed durations, indicating a discrepancy between perception and practice [163]. In contrast, powered toothbrush users average approximately 151 s per session, suggesting that these devices may assist individuals in achieving brushing durations closer to recommended guidelines. A recent systematic review of single-brushing exercises found that brushing for 2 min significantly reduces plaque scores compared with 1 min, for both manual and powered toothbrushes [164]. The effect was moderate for manual brushes and small for powered brushes, supporting the recommendation of a 2-min brushing duration. Similarly, it was found that extending brushing from 2 to 3 min results in at most a very small additional reduction in dental plaque scores [165]. Brushing beyond 2 min may yield statistically detectable differences, but the clinical significance appears minimal.

4.1 Manual Toothbrush

Looking back through history, from the luxury toothbrushes of the 18th century to their mass adoption in the 1930s, and from early hard-bristled models to today’s ergonomic, multi-level, end-rounded designs, manual toothbrushes have undergone remarkable evolution. Despite historical and technological advances in toothbrush design, the fundamental principle remains unchanged: a toothbrush’s primary value is its capacity to remove plaque effectively without causing tissue damage, while supporting individuals in maintaining oral health through consistent, safe daily use. As simple as it may seem, the most effective toothbrush is the one that someone actually uses!

Recommendations on how long a toothbrush should be used vary internationally. Most national dental associations advise replacement after approximately three months, with some suggesting slightly shorter or longer intervals [168]. Although this guidance appears reasonable, evidence is limited regarding whether replacing a toothbrush every three months produces measurable improvements in plaque control. Most in-vivo studies have not demonstrated statistically significant improvements in whole-mouth plaque scores when an old brush is replaced with a new one [169, 170]. The primary factor affecting reduced cleaning performance was the degree of wear, rather than the age of the brush [171]. Severely worn brushes were found to be less effective than those with no or minimal wear [64]. Bristle splaying beyond the base of the head can serve as a practical signal that a brush should be replaced. Therefore, a schematic illustrating the effective brushing area of a toothbrush may assist consumers in assessing brush wear more consistently. A study was conducted to develop and validate such a drawing to support adults in determining when to replace a manual toothbrush [168]. Based on their findings, the authors envisage creating separate wear-assessment schematics for right-handed and left-handed users.

Ensuring equitable access to effective oral hygiene requires consideration of both traditional and conventional approaches. In this context, alternative practices are particularly relevant in countries with limited resources or restricted access to oral health services, where chewing sticks are affordable and widely available in both urban and rural settings. Evidence suggests that chewing sticks can contribute to plaque removal and may serve as a viable adjunct or alternative to the modern manual toothbrush for the prevention of oral diseases [172]. At the same time, continued access to modern oral hygiene products remains essential. Addressing disparities in oral health requires not only evidence-informed selection of oral hygiene methods but also sustained policy and industry commitment to ensuring that effective preventive tools are accessible to all populations, regardless of socioeconomic status [173, 174].

4.2 Powered Toothbrush

Current evidence suggests that some technological approaches in powered toothbrush development may have limited clinical benefit. Battery-powered brushes remain a budget-friendly option, but systematic reviews have shown that rechargeable powered toothbrushes consistently outperform disposable battery models in reducing plaque during single brushing sessions [175]. Ultrasonic-powered toothbrushes, which theoretically disrupt bacterial chains using high-frequency vibrations, have not consistently demonstrated increased plaque removal or improvements in gingival health compared with conventional sonic or manual toothbrushes [176, 177]. Similarly, ionic toothbrushes, designed to temporarily reverse the tooth’s natural negative charge to repel plaque and food particles, remain largely unsupported by clinical evidence, with studies failing to confirm significant improvements in plaque control or gingival outcomes [178, 179].

Current innovations in powered toothbrushes have transformed the toothbrush from a simple cleaning tool into a sophisticated device that actively enhances oral hygiene [180]. Modern powered toothbrushes are increasingly equipped with features designed to improve cleaning efficacy, personalize the brushing experience, and reduce the risk of gingival trauma or enamel abrasion. Among the most common features is the built-in timer, which signals the end of the recommended two-minute brushing period, helping users maintain adequate duration and thoroughness. Some models include display screens showing elapsed time, technique prompts, or motivational icons such as smiley faces, supporting habit formation and consistency. To prevent forceful brushing, many premium brushes incorporate pressure sensors, which promote safer daily hygiene particularly in individuals prone to abrasion or recession. Bluetooth connectivity allows toothbrushes to communicate with smartphone apps, creating a feedback loop in which brushing data is transmitted to the phone and personalized guidance is returned to the user. Real-time feedback and coaching may support improved brushing technique and adherence to recommended oral hygiene practices [181].

Future developments in sensors, connectivity, and data processing may lead to AI-enhanced powered toothbrushes capable of detecting biofilm in real time, automatically adjusting brushing patterns, identifying early signs of gingival inflammation, and providing personalized oral health coaching based on long-term behavioral data. Integration with home health systems, dental practices, and electronic health records could enable systematic monitoring and guidance of oral hygiene practices.

Future developments should also support dependent populations, such as nursing home residents with cognitive or physical limitations [182]. Telemonitoring-enabled powered toothbrushes offer a practical method for compliance tracking, allowing caregivers to supervise and guide oral care. Early findings suggest that such interventions can improve plaque control and reduce gingival bleeding, although benefits may diminish once monitoring is removed. Evidence from a study in elderly individuals with mild cognitive impairment illustrates this potential [183]. Objective measurements of powered toothbrush use, including frequency and duration, were compared with self-reported brushing habits and their impact on plaque index, bleeding on probing, and periodontal pocket depth (PPD ??4?mm). Despite participants brushing less often and for shorter durations than recommended, adherence to guidance with powered toothbrushes led to measurable clinical improvements. Importantly, self-reported use correlated poorly with actual brushing behavior, highlighting the value of objective data that may inform the evaluation of oral hygiene interventions. Such data-driven approaches could become a cornerstone in strategies to preserve and improve oral health in older adults with cognitive impairment.

4.3 Interdental Cleaning

ISO 16409:2016 provides a size classification system for the qualitative assessment of manual IDBs [184]. Selecting an appropriately sized interdental brush supports safe and effective interproximal cleaning. Brushes that are too small may fail to remove plaque effectively, whereas oversized brushes can damage the papilla or cause discomfort, potentially reducing user compliance. The passage hole diameter (PHD) of commercially available IDBs ranges from 0.6 to 5.2?mm, with roughly 90% measuring ??2.0?mm [22, 118]. This distribution results in fewer larger-size brushes, which may be relevant for older adults or patients with periodontal diseases. Implementing standardized and clearly labeled brush sizes could improve patient education, communication, and adherence to recommended oral hygiene practices. A comprehensive, standardized set of IDBs accommodating both healthy individuals and patients with oral conditions could improve patient care and adherence [4].

Future design considerations should also focus on the brush filaments themselves. By carefully engineering filament characteristics such as diameter, length, taper, and stiffness, brushes could more effectively reach narrow and complex interdental spaces without causing trauma. Filament designs that match interdental contours and maintain adequate mechanical strength could improve plaque removal efficiency and user comfort.

Research indicates that both oral irrigators [185] and non-wired interdental cleaning devices [127] can serve as effective alternatives to traditional IDBs in individuals without periodontitis. Interdental cleaning should be applied cautiously in healthy sites without attachment loss or demineralization as inappropriate use may cause tissue trauma [4]. Although oral irrigators have a lower risk of tissue injury, their cost-effectiveness should be assessed before recommendation of routine use.

4.4 Dentifrice

Toothpaste has evolved from early formulations in ancient Egypt to modern scientifically validated products, reflecting developments in oral health knowledge and technology. As scientific knowledge and medical technologies advance, toothpaste is expected to continue evolving, yet its purpose to maintain healthy teeth and gums remains unchanged.

Given the extensive variety of products available, dental care professionals must carefully select appropriate formulations, understanding the specific benefits and limitations of each in order to provide evidence-based guidance during oral hygiene instruction. A controlled study examined how variations in toothbrushing behavior influence fluoride availability in the interproximal region [186]. Interproximal saliva fluoride concentrations were found to be significantly affected by the amount of toothpaste used, brushing duration, and the volume of water used for rinsing. Specifically, doubling the toothpaste length from 1 to 2?cm increased interproximal fluoride concentration by approximately 47%, extending brushing time from one to two minutes raised fluoride levels by about 27%, and reducing rinsing water from 20 to 10?mL enhanced fluoride retention by roughly 41% after brushing. These findings indicate that modifications in brushing routines, including toothpaste amount, duration, and rinsing volume, can affect fluoride retention in interdental areas.

Current research is focused on innovations aimed at improving the efficacy of dentifrices. Advances in biotechnology and artificial intelligence hold the potential to enable personalized toothpaste formulations. By integrating genetic analysis with AI-driven health assessments, toothpaste could be tailored to an individual’s oral health profile, optimizing ingredients to target issues such as dental sensitivity, caries, or periodontal conditions [187]. However, the clinical relevance, feasibility and cost-effectiveness of highly personalized dentifrices remain uncertain, and there is currently limited evidence that they provide meaningful advantages over well-formulated conventional products.

Material-based innovations are also under investigation. Nanotechnology, including the use of nanohydroxyapatite, has shown promise in enamel remineralization and surface repair, although robust clinical evidence demonstrating superiority over existing, more affordable alternatives is still limited [188]. More recently, bio-inspired approaches such as water-based keratin films have been explored for enamel regeneration by guiding the growth of aligned apatite nanocrystals [189]. These approaches are still experimental, and further research is needed to determine biological safety, clinical effectiveness, and economic feasibility.

At the same time, consumer preferences and social media increasingly influence toothpaste development, particularly the demand for “natural” formulations. Although consumer trends may stimulate innovation, they may also lead to products with unverified efficacy or potential risks. Examples include self-prepared or commercially promoted charcoal-based toothpastes, which may exhibit excessive abrasivity and pose a risk to dental hard tissues [190, 191]. Overall, future dentifrice development should be guided by robust evidence of clinical benefit, safety, affordability, and broad applicability in everyday oral healthcare.

4.5 Oral Health Behavior

Sustained oral hygiene behaviors are essential for maintaining long-term oral health, and interventions should support this goal. Many behavior-change strategies demonstrate only short-term effects, with adherence often declining when motivation decreases [192]. Research should therefore focus on sustaining behaviors and preventing relapse [193]. A key target is habit formation. Repeated performance in stable contexts creates automatic, low-effort behaviors, enabling consistent oral hygiene even when motivation or attention is limited. Future studies should clarify how habit functions: whether to promote habitual initiation of brushing for frequency or habitual execution for technique quality [194].

Oral hygiene behaviors, such as twice daily toothbrushing and regular interdental cleaning, are no exception. Their effectiveness depends on long-term, consistent performance. Understanding how to help individuals develop strong oral hygiene habits embedded within daily routines and sustained with minimal effort is therefore necessary for improving and maintaining oral health across the lifespan [195]. Integrating habit formation principles into interventions, education, and digital tools may promote consistent oral hygiene routines and support improvements in individual and population oral health.

4.6 Environmental Impact

Environmental sustainability is a significant global public health issue with current and future implications. The planet and its population face multiple interconnected challenges, including climate change, biodiversity loss, air and water pollution, and ozone depletion. The healthcare sector is a notable contributor, accounting for roughly 5% of carbon dioxide emissions on average [196]. Over 3.5 billion toothbrushes are purchased annually [197]. Growing awareness of the environmental impact of disposable toothbrushes has led major manufacturers to develop “eco-friendly” products, which rely on three main strategies: the use of biopolymers, natural materials such as bamboo, or replaceable heads.

In a comparative life cycle assessment study, four types of toothbrushes were compared. These included conventional plastic manual toothbrushes with fixed heads, bamboo manual toothbrushes with fixed heads, and plastic manual toothbrushes with replaceable heads featuring a reusable bioplastic handle. Powered toothbrushes were also included, consisting of a handle with a charging unit and replaceable heads [198]. Results showed that plastic manual toothbrushes with replaceable heads and bamboo manual toothbrushes had lower environmental impacts than both traditional plastic manual and powered toothbrushes across all environmental impact measures evaluated. Powered toothbrushes have a higher environmental footprint than manual brushes due to their batteries and electronic components, which are difficult to recycle and often end up in landfill or incineration [198].

Although toothpaste and mouthrinses support oral health, some formulations may also have environmental impact [3]. Multilayer packaging, commonly used in toothpaste tubes, combines materials such as plastic and aluminum, creating significant recycling challenges that require advanced and economically demanding separation technologies.

Microplastics also appear in toothpaste. In a systematic review on “Microplastic content of over-the-counter toothpastes,” the proportion of microplastics per tube ranged from 0.4% to 7.24%, with the shape of the microplastics being inconsistent [199]. Traditional wastewater treatment plants are not built to eliminate these smaller particles from the water. These microplastics can enter open water sources, where they can persist for decades or even longer due to their non-biodegradable nature [200].

Additionally, antimicrobial agents present in personal care products can enter aquatic ecosystems through municipal wastewater [201]. Many of these compounds persist in the environment while retaining biological activity, potentially affecting non-target microorganisms in naturally occurring microbial biofilms [202]. For example, triclosan, introduced as a pesticide in the 1960s and incorporated into hospital and consumer products, including toothpaste, since the 1970s, has raised concerns over its potential health and environmental effects, leading to its removal from many formulations by the late 2010s [203, 204]. Although toothpaste tablets are marketed as environmentally friendly alternatives, studies suggest that they may have a higher environmental impact than conventional toothpaste [204].

The IFDH White Paper “Sustainability in Oral Health and the Role of the Dental Hygienist” emphasizes that sustainable oral healthcare begins with prevention and informed daily oral hygiene practices [205]. Dental care professionals are encouraged to balance clinical effectiveness with environmental considerations when advising patients on oral hygiene tools and products. While bamboo or biodegradable toothbrushes may offer a lower environmental impact, their use should remain patient-focused and evidence-based, ensuring that oral health outcomes are not compromised. Similarly, the paper supports the use of interdental cleaning devices, preferably biodegradable options where feasible, while explicitly advising against disposal of dental floss in toilets due to environmental harm. Behavioral measures, such as turning off the tap during toothbrushing, can reduce water use. Maintaining effective daily oral hygiene may also reduce the need for complex treatments, limiting energy and material consumption, waste generation, and patient travel. Preventive oral hygiene can therefore contribute to environmental sustainability alongside its clinical benefits. In this way, effective preventive oral hygiene is positioned as a contributor to overall environmental sustainability, aligning clinical oral care with broader sustainability goals.

Environmental considerations may inform consumer choices, oral health recommendations, public health procurement, and product design by manufacturers [206]. Incorporating life cycle assessments into healthcare policies and recommendations may support the development of a more environmentally sustainable oral healthcare system.

4.7 The Central Role of Self-Performed Oral Hygiene

Achieving oral health involves a transition from gingival inflammation to stability and, ultimately, long-term periodontal health. The primary role of the dental care professional is to help prevent oral diseases and maintain the patient’s dentition for as long as possible. Although bleeding during toothbrushing is a characteristic sign of gingival inflammation, many individuals perceive it as benign or normal. In a multicenter adult population, over 80% of participants who reported gingival bleeding believed it was harmless, with only a small proportion regarding it as a serious symptom. This misperception accentuates the importance of patient education as a cornerstone of preventive care [207]. Dental care professionals should work with each patient to develop a personalized oral hygiene regimen, selecting appropriate brushes, toothpastes, and interdental cleaning aids, and provide regular reinforcement to support adherence.

Professional interventions to remove supragingival biofilms (plaque), calculus, and plaque retentive factors to ensure effective plaque control are a valuable component of preventive care. Yet, the effectiveness of professional care is limited without consistent self-performed oral hygiene. Routine professional prophylaxis provides only modest clinical benefits in adults without severe periodontitis [208], whereas patients with a history of periodontitis require tailored, risk-based maintenance [46]. Across all groups, however, the conclusion is clear: Professional care can support health, but it cannot substitute for daily plaque removal performed by the patient [209, 210]. Dental care professionals therefore must prioritize individualized instruction that accounts for the patient’s abilities, motivation, circumstances, and risk profile. Face-to-face coaching, complemented by self-instructional tools, enables patients to develop the skills necessary for thorough plaque control [211]. Shifting from fixed, uniform recall intervals toward evidence-based, personalized prevention aligns care with biological needs.

4.8 The Future of Research

Given the expanding number of systematic reviews, concerns have been raised regarding redundancy and diminishing returns from repeatedly synthesizing largely unchanged bodies of evidence. Meta-research has shown that many SRs address similar clinical questions without the inclusion of substantial new primary data, resulting in limited incremental knowledge and avoidable research waste [212, 213]. This issue is also evident in areas such as toothbrushing, interdental cleaning, and oral hygiene adjuncts, where multiple systematic reviews frequently include overlapping primary studies and report broadly comparable conclusions.

These observations have led to calls for a more strategic balance between evidence synthesis and primary research, with greater emphasis on generating high-quality, methodologically robust primary studies that address unresolved clinical questions and under-researched populations [214]. Nearing the end of this narrative review, it becomes apparent that oral hygiene research would benefit from well-designed randomized controlled trials comparing clinically relevant interventions under standardized conditions, using consistent outcome measures such as gingivitis resolution, reduction from generalised to localised gingivitis, and patient-reported outcomes. Such studies should also aim to address current gaps in evidence, including long-term effectiveness, adherence in real-world settings, and the performance of interventions in specific risk groups. Strengthening this primary evidence base would reduce reliance on repeated secondary analyses of largely unchanged datasets, minimizing unnecessary duplication in evidence synthesis [215].