For a routine that most of us have been doing since before we were tall enough to see ourselves in the bathroom mirror, we are exceptionally bad at brushing our teeth.
In Sweden, one study showed that only every tenth person applies the best tooth brushing technique.
British health insurer Bupa found that almost half of the respondents did not know how to brush their teeth properly in a survey of 2.000 people in Great Britain.
"It's very likely that anyone who hasn't received formal instructions from a dentist or hygienist is brushing incorrectly," says Josephine Hirschfield, associate professor and specialist in restorative dentistry at the University of Birmingham in the UK.
"In my experience, that's the vast majority of the population in every country."
This is perhaps not surprising, given the bombardment of various information about how you should brush your teeth.
One study found that there is at least 66 different, sometimes conflicting, expert advice.
"I think it's very confusing for the consumer," says Nigel Carter, chief executive of the Oral Health Foundation UK.
That confusion is compounded by the array of dental products available for purchase, from tongue scrapers to teeth and gum irrigators.
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So what are most of us doing wrong and how can we change our routine to make sure we're brushing effectively?
What is the best method?
"Most patients are aware that the most important thing is to remove leftover food," says Hirschfield.
"That is only partly true. It's much more important to get the bacteria off the teeth."
These bacteria and other microorganisms grow inside everyone's mouth and form a sticky biofilm known as dental plaque.
It consists of about 700 different types of bacteria, the second largest diversity in the human body after the intestine, as well as a handful of fungi and viruses.
"They live in the sticky plaque on the teeth as well as in the soft tissue," says Hirschfield.
"That sticky build-up doesn't wash off easily - it really has to be cleaned by hand."
The most important place from which it must be removed is actually not the teeth, but the joint of the gums.
This is where microbes can best infiltrate the gum tissue and cause inflammation, and ultimately conditions such as periodontitis.
Moreover, "brushing your teeth" is actually kind of a misnomer.
"Think about brushing your gum line instead of your teeth," says Hirschfield.
"The teeth will then be automatically brushed," she adds.
So what is the best way to do this?
One of the most effective ways to clear biofilm is known as the "modified Bass technique".
It requires much more manual dexterity than the vague "put the brush in your mouth and look like you're doing something" method that many people use, as I soon discovered.
In my own bathroom, armed with a hand brush with a bamboo handle and nylon bristles, I prepare to apply the modified Bass.
Taped to my mirror is my new miniature hourglass that measures two minutes (more on that later).
I turn it over and start.
The modified Bass technique involves placing the brush at a 45-degree angle to the front of the teeth (angled down for the lower jaw and up for the upper, as if you're trying to get the fibers under the gums).
Then make small vibrating movements back and forth at the junction with the gums.
After carefully studying several videos, I try the technique.
Moments later, my mirror is splattered with white paste and my brush is on the floor.
In my over-enthusiasm, I somehow tangled the brush, scraped my gums with the sturdy bamboo head, and dropped it.
Undeterred, I briskly rinse the brush under water and try again, this time more carefully.
The small, brisk but gentle movements that Hirschfield described to me in detail are surprisingly difficult to imitate.
As a right-handed person, I feel like I'm trying to write neat cursive with my left hand.
As I painstakingly went over the entire gums - upper, lower, inner, outer - with an attempt at modified Bass, I glance at my little green hourglass.
My two minutes went by in who knows how long and I still haven't even started flossing.
There are other techniques besides modified Bass that successfully remove biofilm.
On another occasion, I try a modified Stillman - it's similar to a modified Bass, with the addition of an occasional pleasant sweeping motion from the gums, during which I imagine the microbial fungal biofilm disappearing into frothy oblivion.
After a week of experimenting and getting less and less paste stains on the mirror as I feel like I'm getting the hang of the technique, my gums are starting to hurt a little.
It turns out that in my excessive enthusiasm I applied too much pressure.
The pressure applied should not be more than 150-400 grams, says Hirschfield, and the optimal pressure is still a matter of debate.
Rubbing too hard, especially with a brush with harder bristles, can damage the gums.
Small tears in soft tissue caused by overly dedicated brushing are an opportunity for bacteria to enter directly into the bloodstream.
And brushing too hard with the bristles of the brush over the enamel can wear away the tiny grooves in the tooth, leading to significant tooth erosion over time.
People who use a manual toothbrush often press harder than those who use an electric toothbrush, many of which have sensors that warn when the pressure is too strong.
For a few days, I try a different technique, intended for children and people with poor hand mobility.
Fons' method involves holding the brush at a 90-degree angle and making circular motions over the teeth, crossing the gum line.
It's definitely easier to apply as I experiment with trying the right pressure.
But I am determined to master the modified Bass once my gums have recovered from my over-commitment.
"Bas' modified technique is one of the best. It cleans the teeth in the best possible way, without damaging the teeth and gums along the way," says Hirschfield.
But Nigel Carter of the Oral Health Foundation points out, reassuringly, that getting the textbook version right isn't always the most important thing.
"What dentists and hygienists usually recommend today is to look at what the person normally does and make modifications to their existing technique to improve it," he says.
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How long?
Brushing for at least two minutes, twice a day, is recommended by the American Dental Association, the NHS, the Indian Dental Association and the Australian Dental Association, as well as many other national health organizations.
The problem is that most of us are very bad at judging how long two minutes really is.
The average time we actually brush our teeth varies greatly, from 33 seconds, 45 seconds, 46 seconds, to 97 seconds, according to different studies.
Only about 25 percent of people brush their teeth long enough, with proper pressure and movements, according to a study led by Karolina Gans, professor of the Department of Conservative and Preventive Dentistry at the Justus-Liebig University of Gesse, Germany.
Luckily, there are easy solutions like using an app on your phone, a miniature hourglass attached to your bathroom wall (like I chose), or an electric toothbrush that already has a built-in timer.
In general, the longer you brush, the more biofilm you'll remove, Carter says, but about two minutes is thought to be the time it takes to get over all the tooth surfaces and gum line.
For people with diseased gums or other oral health problems, however, it may take more time to make sure the biofilm is thoroughly removed.
"Furthermore, the optimal washing time is extremely dependent on the individual situation," says Hirschfield.
"In fact, it is not defined and cannot be defined, because everyone's dental and oral situation is different. It's important that all teeth are cleaned, all surfaces of each tooth, including the hard-to-reach parts - and that can easily take more than two minutes."
How often?
The advice in countries like the US, UK and Australia is to do a carefully timed, dedicated brushing technique twice a day.
The Indian Dental Association, however, advises that it can be useful up to three times (including brushing after lunch).
For most people without major oral health problems, there is no benefit to exceeding this recommendation.
"More time is not necessary to remove bacteria from the teeth, and it can even be harmful to brush more than twice a day," because excessive scrubbing risks tooth abrasion, Hirschfield says.
Although, once again, there are exceptions.
"If you think about people who wear dentures, where food gets stuck easily, those patients are often advised to brush their teeth after every meal," she adds.
Brushing your teeth twice a day also helps to insure against imperfect technique.
"Strictly speaking, if you brushed perfectly once a day, that would probably be enough, because it's actually the older plaque on your teeth that's causing the problems, both in terms of tooth decay and in terms of gum disease," says Carter.
"But none of us do it 100 percent successfully. And so the idea is that by doing it twice a day, you're cleaning up the bits that you missed before, so that every day you'll be able to clean everything."
Before or after food?
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Is it better to brush your teeth before or after breakfast?
From toothpaste manufacturers to dental clinics, many advocate that it is better to brush your teeth before breakfast than after.
But spears are still breaking over this.
"There's no specific, explicit recommendation," says Hirschfield.
"However, many dentists will recommend that you brush your teeth after breakfast, as this will not only remove plaque, but also the food residue from breakfast itself."
Whether it will work better for you before or after breakfast depends on what you eat and when.
This is because two things need to be present for a biofilm to form: the microbes and the food they will eat.
"Without bacteria or without food, you can't get cavities," says Hirschfield.
"If you wash the bacteria really thoroughly before breakfast, then in theory it shouldn't matter how much sugar you eat. And if there are no bacteria to ferment it, then everything is fine."
But removing 100 percent of biofilm with one brushing before breakfast is by no means guaranteed, especially considering the questionable habits of most people when it comes to just brushing their teeth.
Also, washing after breakfast can be effective.
"If you have sugars over the existing bacteria and then you wash them anyway, that should be fine as well," Hirschild says.
One of the biggest downsides to brushing after breakfast, however, is that you have to leave a decent gap between eating and brushing—the American Dental Association suggests waiting 60 minutes.
The reason for this is that the acid in food and the by-product of microbial digestion of carbohydrates temporarily makes teeth vulnerable.
"The acid attacks the tooth enamel and makes it smile for a period of time," says Hirschfield.
This strips away some of the key enamel elements - calcium and phosphate - although these are replaced within hours by minerals in the saliva.
"That process itself is, therefore, recovery by itself. But if you don't wait for that self-healing, then that eroded surface will become very susceptible to blistering."
Carter agrees that the question of before or after breakfast is complex and depends on what you ate.
Acidic foods and drinks - such as citrus fruits, fruit juice and coffee - would be a reason to wash before rather than after breakfast, so you don't have to worry about the remineralization process.
More important than the question of breakfast is brushing your teeth in the evening, which also has a simple answer: it should always happen just before going to bed.
"Your saliva is your natural defense mechanism," says Carter, which stops bacteria from spreading and tooth decay.
"Saliva flow decreases during the night, so it's very important to wash away all the plaque before you go to sleep."
What should you use to brush your teeth?
There are some confusing brushes and pastes on the market that will literally "wash your teeth by making them disappear," says Hirschfield.
Highly abrasive pastes, often labeled as "whitening" and brushes with hard bristles are notorious for this, especially when used together.
"It's a very slow process that happens over years and decades," she says.
"But over time, the teeth wear down and can become very sensitive to temperature or get cavities."
Brushes with medium bristles are best for adults, as is toothpaste that does not contain small abrasive particles.
A brush with a smaller head—which allows for more movement around individual teeth—is also more recommended, Hirschfield says, as is making sure to replace a worn-out brush before its bristles become too twisted.
TOOTHBRUSH FROM NATURE
Toothbrush wood, Salvadora persica, has played an important role in dental hygiene for around 7.000 years.
This small tree grows throughout most of Africa, the Middle East, India and Pakistan.
In mature trees, the twisted trunk with pale bark leads to a dense crown rich in the green of small leaves.
Ever since the Babylonian times, smaller tree branches were removed and the leaves were stripped from them, so they were cut into smaller pieces that are easy to hold in the hand.
At one end the twig is peeled and scattered, creating a bushy fibrous tip, which practically doubles as a toothbrush known as a miswak.
In addition to mechanically helping to remove biofilm, this wood produces antimicrobial compounds that stop the growth of pathogens that cause periodontitis and caries, and naturally contains a lot of fluoride.
Traditional toothbrushes or chewing sticks such as miswak from the toothbrush tree, which are widely used throughout Africa, the Middle East and South Asia, are also effective in removing plaque and preventing tooth decay.
But they come with a higher risk of gum abrasion if not used properly. (See the natural toothbrush box).
Even more effective than manual options, although much more expensive, is an electric toothbrush.
After many years of studies showing no significant difference between the two types, a large number of meta-analyses have produced a moderate amount of evidence that electric toothbrushes are more effective at removing plaque. (The authors of these meta-analyses point out that they have received money from electric toothbrush manufacturers in the past.)
Part of the reason is that the vibration movements are automatic and rely on less manual skill, but another important factor is the size of the brush head.
Many also have pressure sensors that light up when the user presses too hard, risking damage to the enamel.
"But if you're using a manual toothbrush and you're using it absolutely correctly in terms of the rubbing method, the pressure and everything else, then you're going to get just as good a result," says Hirschfield.
Should you floss?
Despite occasional controversy over the paucity of research on flossing, many dental health organizations remain staunch supporters of the practice.
"If you think of each tooth as a cube with five surfaces exposed to the oral environment, all of those areas have biofilm growing over them, and there's really no reason why half of them should be left out," says Hirschfield.
In Great Britain, Carter estimates that a very small percentage of people - perhaps one in XNUMX people - floss occasionally.
A 2019 survey found that one-third of British adults have never flossed.
Flossing is not the only way to remove biofilm between teeth.
The characteristics of your teeth—closely packed or widely spaced, for example—will determine what will work best, a small brush or a thin piece of floss.
For those with gum or tooth problems, brushing between teeth is an opportunity to loosen up.
"Many of our patients use a wide variety of interdental cleaning devices, so they have maybe five or six different brushes of different sizes, floss, and other brushes," says Hirschfield.
Time spent flossing should be considered part of your two-minute cleanse, she adds, and there's no need to do it more than once a day.
This is contrary to a 2011 review of randomized controlled trials that claimed there was "only weak, unreliable evidence that flossing plus toothbrushing may be associated with a small reduction in plaque at one month or three months", but most the study contained methodological errors.
However, that review was later withdrawn, after remarks that "absence of evidence is not evidence of absence".
A later update showed that flossing was significantly better than brushing alone when it came to gingivitis (a superficial gum disease that can later lead to deep gum disease or periodontitis), although the evidence that it reduced plaque was still "weak". and "very unreliable".
"It's very difficult to do these types of studies," says Hirschfield.
It is difficult to obtain a large enough corpus that reflects the general population and not simply dental students who are easy to recruit for such studies and to circumvent factors such as the unreliability of self-reports in studies.
Another big change is conducting studies long enough to see how the occurrence of teeth and gum problems changes, which takes decades.
"That is difficult to achieve, if not impossible. That's why the evidence is so weak."
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Which toothpaste is the best?
Although there are many different toothpastes, from those that prevent cavities to those that whiten teeth to those that reduce tooth sensitivity, expensive brands are not necessary to achieve the basics, both Hirschfield and Carter agree.
"I've looked at the ingredients list of some very cheap confusion pastes I've seen, sometimes costing as little as 40p, and I don't see anything wrong with them," says Hirschfield.
From the long list of ingredients on the back of every average toothpaste box, there is one ingredient to look for in particular.
"The fluoride content," says Hirschfield.
"That's definitely a key factor," she adds.
It should have at least 1.350 parts per million (ppm) for adults, and 1.000 ppm for children to protect enamel from acids.
Tooth enamel is the hardest tissue in the human body and one of the hardest that can be found in nature.
"It's almost as hard as a diamond," says Hirschfield.
It is mainly composed of a mineral called hydroxyapatite (a type of calcium phosphate) arranged in a complex crystal structure, which varies in different forms and arrangements throughout the tooth to enhance its hardness and durability.
But despite its resistance to mechanical force, enamel is easily dissolved in acid.
Microbes present in biofilm release lactic acid as a byproduct of digesting sugars and carbohydrates, and they can easily get stuck between our teeth.
This lactic acid gradually removes calcium and phosphate from the enamel, which then begins to crown over time and caries occurs.
Compounds naturally present in saliva can greatly replace lost minerals.
Especially if fluoride is present (as it is naturally present in soil and water in many parts of the world), then the enamel is restored as fluorapatite, which is more resistant to acids than hydroxyapatite.
Spitting out the toothpaste when you're done brushing, but not rinsing it off, helps to keep the fluoride around the teeth longer, as an extra protection.
"Since fluoride was introduced into toothpastes, the incidence of tooth decay has declined everywhere fluoride toothpastes are used," says Hirschfield.
However, some modern ingredients should be treated with caution.
Charcoal, which has been used to clean teeth for millennia and has become increasingly popular in commercial toothpastes, has less research to support its use.
There is little evidence that charcoal whitens teeth and may even increase the risk of tooth erosion and other problems.
Claims regarding the antibacterial, antifungal and antiviral properties of charcoal in toothpastes cannot be proven, according to one review, which concluded that dentists should “advise patients to be cautious when using charcoal and charcoal-based dental products with unproven claims of efficiency and safety".
Many charcoal toothpastes do not contain fluoride and therefore offer less protection against tooth decay.
However, if someone uses toothpaste without added fluoride, they will still get some benefits from brushing alone.
"They can still get mechanical plaque removal," says Carter.
"But it won't have the benefit of preventing decay, which fluoride in toothpaste does."
Some other popular toothpaste additives are less controversial.
Toothpastes containing baking soda (small crystals of sodium bicarbonate) have been shown to remove plaque better than those without, according to the authors of a meta-analysis, although they noted that more follow-up studies are needed (the authors of that study noted that in the past received funds from toothbrush and toothpaste manufacturers).
The same analysis showed that toothpastes with baking soda can slightly reduce bleeding from gingivitis.
Should I use mouthwash?
Mouthwash is less effective at removing plaque than brushing, Carter says, but when combined, the two can remove slightly more plaque than brushing alone.
"I would say that it is a very useful additional element, which should not replace brushing, but should serve as a supplement."
It may, however, be useful in the treatment of gingivitis, according to a recent consensus statement.
To be useful, it should contain at least 100 ppm fluoride and be clinically proven to reduce plaque.
And it's best to use it only if your gums are already bleeding, rather than as a preventative measure.
For lack of a better term, there is probably a "sweet spot" for effective brushing.
If you do not brush enough, biofilm will accumulate and there will be a risk of caries and periodontitis.
If you wash too much and too hard, the enamel can easily peel over time.
Although getting into the ideal routine - with floss or brushes between your teeth, and maybe mouthwash if you have gingivitis - can be difficult, it's worth it for the benefits to your overall health.
Effective brushing is proving to be an increasingly influential way to reduce our risk not only of bad breath, yellow teeth and tooth decay, but also of conditions such as type 2 diabetes, cardiovascular disease and cognitive decline.
"A growing body of evidence points to a link between periodontal disease and cognitive impairment through inflammation," says Bei Wu, professor of global health at New York University's Rory Meyers College of Nursing.
"Good oral hygiene practices, such as effective brushing, can reduce plaque and reduce the risk of gingivitis."
With that as motivation, my now growing collection of brushes, interdental cleaners, floss and a new bathroom timer doesn't seem like an exaggeration at all.
Marta Enriques is the editor of BBC Planet of the Future, tweeting from @Martha_Rosamund
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