1) Brush your teeth twice a day with a fluoride toothpaste While a seemingly simple statement, the guidance for brushing twice daily with a fluoride toothpaste weaves together a number of discrete components. Toothbrushing frequency Review of the scientific literature, along with guidance from governmental organizations and professional associations found sufficient evidence to support the contention that twice-daily brushing, when compared with lower frequencies, was optimal for reducing risk of caries,2-4 gingival recession or periodontitis.5-7 It is important to recognize that in these studies, it was the frequency of tooth-brushing with a fluoride toothpaste that was evaluated rather than tooth-brushing alone. Fluoride toothpaste Although the measures used to assess the benefit varied, studies examining the effect of over-the-counter (OTC) fluoride dentifrice on caries incidence in children and adolescents found the fraction of caries prevented ranged from 16% per tooth to 31% per surface versus placebo or no dentifrice, and concluded that fluoride-containing toothpaste was effective in caries control.4, 8, 9 In addition, high level evidence shows that 5,000 ppm fluoride (available with a prescription) results in significantly more arrest of root caries lesions than use of OTC levels of fluoride (1,000 - 1,500ppm).10 Toothbrushing duration Data examining the question of optimal duration of daily tooth-brushing encounters relies on plaque indices which are surrogate measures rather than direct measure of caries or gingivitis. Understanding that the use of surrogate measures decreases the certainty with which a recommendation can be made, the available systematic reviews found a brushing duration of two minutes was associated with bigger reduction in plaque than brushing for a single minute.11, 12 Two minutes per whole mouth can also be expressed as thirty seconds per quadrant or about four seconds per tooth. 2) Clean between your teeth daily While cleaning between teeth is important to maintaining oral health, it is a concept that must overcome several barriers to adoption. ”Flossing” is often used as a shorthand, common term for interdental cleaning, which can become problematic in the real world where many report a strong distaste for that particular activity.13 Some people presume flossing as ineffective or unnecessary, which can also make it harder for them to adopt the daily habit. Flossing is a technique-sensitive intervention14 as exemplified by the disparity in benefit observed when comparing study designs involving self-flossing and professional flossing.15 Where patients do not see positive results from flossing, they may not continue to do so. Using flossing as shorthand for interdental cleaning can also be problematic in that patients may be unaware of alternative devices that may be more pleasant or effective for them. A meta-review, which included the available devices developed for this purpose (i.e. dental floss, interdental brushes, oral irrigators, and woodsticks), addressed the question “What is the effect of mechanical inter-dental plaque removal in addition to tooth brushing on managing gingivitis in adults?” The strength of the evidence on the benefit ranged from weak to moderate depending on the device in question.16 Thus, there may not be one “best” interdental cleaning method; rather, the best method for any given patient may be one in which they will regularly perform. A guiding principle which is relevant to interdental cleaning is: “best care for each patient rests neither in clinician judgment nor scientific evidence but rather in the art of combining the two through interaction with the patient to find the best option for each individual.”17 3) Eat a healthy diet that limits sugary beverages and snacks While eating a healthy diet is important for overall health and well-being, a review of the literature found little in terms of the effects of micronutrients on the risk of caries or periodontal disease. However, the conclusion of numerous systematic reviews on the effect of the macronutrient content of the diet, specifically of sugar, is that there is an association between sugar intake and caries.18-20 A review of the evidence supporting nine international guidelines recommending decreased consumption of sugar found consistent recommendations from all the groups while noting that they relied on different data and rationales.18 4) See your dentist regularly for prevention and treatment of oral disease Viewed through the prism of the primary prevention of caries and/or gingivitis, a systematic review of the literature failed to arrive at consensus regarding optimal recall frequency to minimize either caries21, 22 or periodontal disease risk23 in part due to limited availability of studies addressing this topic. Nonetheless, in terms of the balance between resource allocation and risk reduction, it can be concluded that there is merit in tailoring a patient’s recall interval to individual need based on assessed risk of disease.21, 24 Previously, the ADA Healthy Smile Tips advised people to “Visit your dentist regularly.” However, dentists are doctors of oral health, which encompasses both the prevention and treatment of oral disease. The current recommendation goes a step further than its predecessor in articulating the duality of the dental visits. Dental care includes actions to reduce disease risk, as well as the formulation and execution of a treatment plan when disease is present. While generalized recommendations for home oral care may be appropriate to help optimize oral wellness for many patients, those found to be at elevated risk of caries and/or gingivitis, may ask their dentists to provide guidance on additional action steps that they can take to reduce their risk of oral disease.25 To help address this reality, the ADA recommends that dentists: Design a home care regimen with specific recommendations for oral hygiene. This may involve consideration of not only the person’s individual oral disease risk, but the needs and wants of the patient. Offer direction concerning lifestyle changes. This is addressed in the next section, entitled “Lifestyle Considerations.” Provide guidance on dental products and mechanical devices. This includes detailed suggestions that can help patients make decisions about dental hygiene practices and products. Patients may look to their dentists for guidance and recommendations to help discern among the plethora of home oral care products and mechanical devices that lay claim to oral health benefit. Dentists and patients can look to the ADA Seal of Acceptance program as a source of validated information regarding the safety and efficacy of many home oral care products. After careful review of the available evidence, the Council on Scientific Affairs provides the following rationale to inform decision-making between dentists and patients on products and mechanical devices that can be considered as adjunct therapies and modalities for the prevention of caries and/or gingivitis: 1) Antimicrobials For individuals with increased risk for gingivitis or periodontal disease, there is evidence that over-the-counter oral care products containing specific antimicrobial active ingredients can decrease risk of gingivitis. Systematic reviews found that mouthrinses containing an antimicrobial effective amount of a fixed combination of four essential oils (eucalyptol, menthol, methyl salicylate, and thymol) or cetylpyridinium chloride,26-28 and toothpastes containing Triclosan or stannous fluoride,29-31 were associated with decreased risk of gingivitis and periodontal disease. 2) Fluoride Mouthrinses With regards to caries risk reduction, there is strong evidence supporting the use of fluoride-containing mouthrinses by children at elevated caries risk;32 and low level evidence on the benefit of adults using fluoride mouthrinse to decrease their risk of root caries.10 However, all of the products available in the market that contain the ADA Seal of Acceptance have shown to have fluoride levels that are safe and effective. 3) Powered Toothbrushes Like their manual counterparts, powered toothbrushes provide effective removal of dental plaque and reduction in gingival inflammation when used appropriately.11, 12, 33-37 Some patients may find powered toothbrushes easier to use.38-43 4) Interdental Cleaning Devices Recent analysis using NHANES data found that adults who more frequently reported using floss or other devices to clean between their teeth were found less likely to have periodontitis.44 Because of the barriers to interdental cleaning, it may not be effective to tell patients that they must floss and expect it to become a regular part of their oral home care routine. Instead, dentists can support effective home oral care by gauging their patient’s level of understanding, learning about their motivation, and then serving as a “coach” by communicating and promoting daily cleaning between their teeth.45 Discussing the various interdental cleaning devices can help educate patients on available options and provide them with some of the skills necessary to be effective stewards of their own oral health. Dentists can provide, promote or direct patients to information about lifestyle behaviors and/or services that can aid in reducing the risk of problems and improving overall oral health. Beyond the general and personalized recommendations above, there are specific ADA policies that address lifestyle considerations to help reduce risks to oral health. Four policies are discussed below: 1) At-Home Orthodontic Treatments At-home orthodontic treatments, such as direct-to-consumer (DTC) and do-it-yourself (DIY) orthodontia are both forms of orthodontic treatment discouraged by the ADA due to patient safety concerns. DTC orthodontic treatment services allow consumers to order teeth straightening kits directly from a supplier and often rely on patient-supplied impressions or photographs. Unlike impressions and radiographs taken by an experienced, licensed dental professional, patient-supplied impressions may be more likely to result in user error, which can ultimately lead to an improper fit of orthodontic appliances. A poor fit can cause the gum tissue to be impinged or stripped, and may also increase the chances of tooth loss or misalignment; or problems with the temporomandibular joint (TMJ). In addition to assuring proper fit, dental professionals can provide pre-treatment dental evaluations and take radiographs. These play an important role in planning treatment, and identifying underlying problems, such as periodontal disease, which can impact both oral health and orthodontic results.46 For example, while patients who undergo orthodontic treatment are more likely to experience root resorption than those who do not,47 the process may be exacerbated by periodontal disease.48 The importance of regular dental visits is greater during orthodontic treatment to ensure the well- being of the teeth being treated. Regular dental visits, including radiographs, as part of the orthodontic treatment plan can help identify tooth structure loss or other problems as they occur, and address the problem in real time. The use of rubber bands and paper clips to adjust teeth is ill advised. DIY orthodontia commonly involves using household items and can result in permanent damage and/or require corrective measures to avoid adverse results, such as tooth loss or misalignment.49 Citing concern about patient harm, and the importance of dental oversight throughout orthodontic treatment, the ADA passed a resolution discouraging the use of DIY orthodontic treatment in 2017 (Do-It-Yourself Teeth Straightening (Trans.2017:XXX)).50 2) Consumption of Fluoridated Water Much of the literature evaluated in systematic reviews examining the association between consumption of fluoridated water and reduced levels of caries in primary and permanent dentition derives from studies conducted before the 1980’s.51 One experiment, in which a Canadian community discontinued its community water fluoridation to allow for the comparison of caries rates within a socioeconomically similar, adjacent community which maintained its water fluoridation demonstrated a significant increase in primary tooth decay and an increasing trend for increased decay in permanent dentition 2.5 – 3 years post cessation among residents who reported usually drinking tap water.52 In 2016, the U.S. Surgeon General expressed the view that community water fluoridation was an important component for developing a culture of disease prevention and helping to ensure health equity for all.53 The ADA’s most recent resolution supporting community water fluoridation was passed in 2015 (Operational Policies and Recommendations Regarding Community Water Fluoridation (Trans.1997:673; 2015:273).50 3) Use of Tobacco Products While the various forms of tobacco have a variety of health consequences, the oral consequences of cigarette smoking54 and smokeless tobacco products55 can include adverse effects on gingival health, enamel discoloration and erosion, and oral cancer. For these reasons, the ADA has long advocated for smoking and tobacco cessation initiatives both at the policy (Policies and Recommendations on Tobacco Use (Trans.2016:323))50 and practice levels. 4) Oral Piercings The literature on the oral consequences of oral piercings show tooth fracture, tooth wear and gingival recession among the commonly reported adverse events, and the ADA established policy discouraging oral piercing in 1998 ( Policy Statement on Intraoral/Perioral Piercing and Tongue Splitting (Trans.1998:743; 2000:481; 2004:309; 2012:469; 2016:300).50 ADA article and recommendations References Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J 2009;26(2):91-108. Cooper AM, O'Malley LA, Elison SN, et al. Primary school-based behavioural interventions for preventing caries. Cochrane Database Syst Rev 2013(5):Cd009378. Kumar S, Tadakamadla J, Johnson NW. Effect of toothbrushing frequency on incidence and increment of dental caries: A systematic review and meta-analysis. J Dent Res 2016;95(11):1230-6. Twetman S. Caries prevention with fluoride toothpaste in children: an update. Eur Arch Paediatr Dent 2009;10(3):162-7. Heasman PA, Holliday R, Bryant A, Preshaw PM. Evidence for the occurrence of gingival recession and non-carious cervical lesions as a consequence of traumatic toothbrushing. J Clin Periodontol 2015;42 Suppl 16:S237-55. Rajapakse PS, McCracken GI, Gwynnett E, et al. Does tooth brushing influence the development and progression of non-inflammatory gingival recession? A systematic review. J Clin Periodontol 2007;34(12):1046-61. Zimmermann H, Zimmermann N, Hagenfeld D, et al. Is frequency of tooth brushing a risk factor for periodontitis? A systematic review and meta-analysis. Community Dent Oral Epidemiol 2015;43(2):116-27. Santos AP, Oliveira BH, Nadanovsky P. Effects of low and standard fluoride toothpastes on caries and fluorosis: systematic review and meta-analysis. Caries Res 2013;47(5):382-90. Wright JT, Hanson N, Ristic H, et al. Fluoride toothpaste efficacy and safety in children younger than 6 years: a systematic review. J Am Dent Assoc 2014;145(2):182-9. Wierichs RJ, Meyer-Lueckel H. Systematic review on noninvasive treatment of root caries lesions. J Dent Res 2015;94(2):261-71. Rosema N, Slot DE, van Palenstein Helderman WH, Wiggelinkhuizen L, Van der Weijden GA. The efficacy of powered toothbrushes following a brushing exercise: a systematic review. Int J Dent Hyg 2016;14(1):29-41. Slot DE, Wiggelinkhuizen L, Rosema NA, Van der Weijden GA. The efficacy of manual toothbrushes following a brushing exercise: a systematic review. Int J Dent Hyg 2012;10(3):187-97. American Academy of Periodontology. More Than a Quarter of U.S. Adults are Dishonest with Dentists About How Often They Floss Their Teeth. 2015. Wilder RS, Bray KS. Improving periodontal outcomes: merging clinical and behavioral science. Periodontol 2000 2016;71(1):65-81. Hujoel PP, Cunha-Cruz J, Banting DW, Loesche WJ. Dental flossing and interproximal caries: a systematic review. J Dent Res 2006;85(4):298-305. Salzer S, Slot DE, Van der Weijden FA, Dorfer CE. Efficacy of inter-dental mechanical plaque control in managing gingivitis--a meta-review. J Clin Periodontol 2015;42 Suppl 16:S92-105. Suvan JE, D'Aiuto F. Progressive, paralyzed, protected, perplexed? What are we doing? Int J Dent Hyg 2008;6(4):251-2. Erickson J, Sadeghirad B, Lytvyn L, Slavin J, Johnston BC. The scientific basis of guideline recommendations on sugar intake: A systematic review. Ann Intern Med 2017;166(4):257-67. Moynihan P. Sugars and dental caries: evidence for setting a recommended threshold for intake. Adv Nutr 2016;7(1):149-56. Moynihan PJ, Kelly SA. Effect on caries of restricting sugars intake: Systematic review to inform WHO guidelines. J Dent Res 2014;93(1):8-18. Patel S, Bay RC, Glick M. A systematic review of dental recall intervals and incidence of dental caries. J Am Dent Assoc 2010;141(5):527-39. Riley P, Worthington HV, Clarkson JE, Beirne PV. Recall intervals for oral health in primary care patients. Cochrane Database Syst Rev 2013(12):Cd004346. Azarpazhooh A, Main PA. Efficacy of dental prophylaxis (rubber cup) for the prevention of caries and gingivitis: a systematic review of literature. Br Dent J 2009;207(7):E14; discussion 328-9. Twetman S. Caries risk assessment in children: how accurate are we? Eur Arch Paediatr Dent 2016;17(1):27-32. Chapple IL, Van der Weijden F, Doerfer C, et al. Primary prevention of periodontitis: managing gingivitis. J Clin Periodontol 2015;42 Suppl 16:S71-6. Serrano J, Escribano M, Roldan S, Martin C, Herrera D. Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: a systematic review and meta-analysis. J Clin Periodontol 2015;42 Suppl 16:S106-38. Van der Weijden FA, Van der Sluijs E, Ciancio SG, Slot DE. Can chemical mouthwash agents achieve plaque/gingivitis control? Dent Clin North Am 2015;59(4):799-829. Araujo MW, Charles CA, Weinstein RB, et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. J Am Dent Assoc 2015;146(8):610-22. Paraskevas S, van der Weijden GA. A review of the effects of stannous fluoride on gingivitis. J Clin Periodontol 2006;33(1):1-13. Riley P, Lamont T. Triclosan/copolymer containing toothpastes for oral health. Cochrane Database Syst Rev 2013(12):Cd010514. Salzer S, Slot DE, Dorfer CE, Van der Weijden GA. Comparison of triclosan and stannous fluoride dentifrices on parameters of gingival inflammation and plaque scores: a systematic review and meta-analysis. Int J Dent Hyg 2015;13(1):1-17. Marinho VC, Chong LY, Worthington HV, Walsh T. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2016;7:Cd002284. Petker W, Weik U, Margraf-Stiksrud J, Deinzer R. Oral cleanliness in daily users of powered vs. manual toothbrushes - a cross-sectional study. BMC Oral Health 2019;19(1):96. Vibhute A, Vandana KL. The effectiveness of manual versus powered toothbrushes for plaque removal and gingival health: A meta-analysis. J Indian Soc Periodontol 2012;16(2):156-60. Neelima M, Chandrashekar BR, Goel S, Sushma R, Srilatha Y. "Is powered toothbrush better than manual toothbrush in removing dental plaque?" - A crossover randomized double-blind study among differently abled, India. J Indian Soc Periodontol 2017;21(2):138-43. Kakar AM, Nair SK, Saraf S. A 12-week, multicenter, normal-use evaluation of a manual toothbrush with angled bristle design. J Indian Soc Periodontol 2019;23(5):469-74. Yaacob M, Worthington HV, Deacon SA, et al. Powered versus manual toothbrushing for oral health. Cochrane Database Syst Rev 2014(6):Cd002281. Wolff L, Kim A, Nunn M, Bakdash B, Hinrichs J. Effectiveness of a sonic toothbrush in maintenance of dental implants. A prospective study. J Clin Periodontol 1998;25(10):821-8. Swierkot K, Brusius M, Leismann D, et al. Manual versus sonic-powered toothbrushing for plaque reduction in patients with dental implants: an explanatory randomised controlled trial. Eur J Oral Implantol 2013;6(2):133-44. Elkerbout TA, Slot DE, Rosema NAM, Van der Weijden GA. How effective is a powered toothbrush as compared to a manual toothbrush? A systematic review and meta-analysis of single brushing exercises. Int J Dent Hyg 2020;18(1):17-26. Pitchika V, Pink C, Volzke H, et al. Long-term impact of powered toothbrush on oral health: 11-year cohort study. J Clin Periodontol 2019;46(7):713-22. Erbe C, Klukowska M, Tsaknaki I, et al. Efficacy of 3 toothbrush treatments on plaque removal in orthodontic patients assessed with digital plaque imaging: a randomized controlled trial. Am J Orthod Dentofacial Orthop 2013;143(6):760-6. Allocca G, Pudylyk D, Signorino F, Grossi GB, Maiorana C. Effectiveness and compliance of an oscillating-rotating toothbrush in patients with dental implants: a randomized clinical trial. Int J Implant Dent 2018;4(1):38. Cepeda MS, Weinstein R, Blacketer C, Lynch MC. Association of flossing/inter-dental cleaning and periodontitis in adults. J Clin Periodontol 2017;44(9):866-71. Vernon LT, Howard AR. Advancing Health Promotion in Dentistry: Articulating an Integrative Approach to Coaching Oral Health Behavior Change in the Dental Setting. Curr Oral Health Rep 2015;2(3):111-22. Meeran NA. Iatrogenic possibilities of orthodontic treatment and modalities of prevention. Journal of Orthodontic Science 2013;2(3):73-86. Gay G, Ravera S, Castroflorio T, et al. Root resorption during orthodontic treatment with Invisalign®: a radiometric study. Progress in Orthodontics 2017;18:12. Alfuriji S, Alhazmi N, Alhamlan N, et al. The effect of orthodontic therapy on periodontal health: a review of the literature. Int J Dent 2014;2014:585048. American Association of Orthodontists. Orthodontists Report Uptick in Number of Patients Attempting DIY Teeth Straightening: American Association of Orthodontists; 2017. American Dental Association. Current Policies, Adopted 1954–2017. Chicago, IL: American Dental Association; 2018. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev 2015(6):CD010856. McLaren L, Singhal S. Does cessation of community water fluoridation lead to an increase in tooth decay? A systematic review of published studies. J Epidemiol Community Health 2016;70(9):934-40. Centers for Disease and Prevention. Surgeon General's Statements on Community Water Fluoridation. 2016. Accessed September 14, 2017. U.S. Centers for Disease Control and Prevention (CDC). The health consequences of smoking – 50 years of progress: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General 2014. Accessed February 17, 2016. Couch ET, Chaffee BW, Gansky SA, Walsh MM. The changing tobacco landscape: What dental professionals need to know. J Am Dent Assoc 2016;147(7):561-9.