In light of current knowledge and based on good clinical practice and teaching, I consider (yet) the mechanical methods (flossing, tongue cleaning, toothbrushing) still main methods to be taught and encouraged in schools of dentistry. The multiplier effect reaching public health services and dental offices should greatly improve the oral health status of the population. The mouthwash should be encouraged, yes, but as complementary oral hygiene respecting the age and specific indications.

Its a very good question and intrigued me to go to pubmed. I found two studies which are a bit relevant to the argument here.

The one I share here says that chlorhexidine does not work as efficient in the presence of the chemical environment of a toothpaste.

http://onlinelibrary.wiley.com/store/10.1111/j.1600-051X.1997.tb00190.x/asset/j.1600-051X.1997.tb00190.x.pdf?v=1&t=hnb0n8m2&s=3bc39c4fc41762e7d07502b14df3e8f73eb7728c

Another one says that mechanical and chemical ways both, are equal when it comes to plaque scores.

Please be a critique of the biases of the evidence here and add to my knowledge too. I wait for your views.

http://onlinelibrary.wiley.com/store/10.1111/j.1600-051X.1989.tb01632.x/asset/j.1600-051X.1989.tb01632.x.pdf?v=1&t=hnb0sm38&s=73ebff53446ffba6b2c0cf41b358e3f5827d3e28

Dear Matts thank u so much for the question. In my researchs after participation on ISBOR meeting in 2009 tongue cleaning beyond important (very important) to fight bad breath where about 60% of oral origin halitosis are from tongue coating biofilm there are also possible relationship to systemic disease like lung disse.

Dear Mats, you are always welcome. Regarding teeth-health, flossing and the couple toothbrush and toothpaste, employing after each meal and before the sleeping time. Sorry due my English. Mouthwashes are also good to complete the mechanical cleaning of mouth (full mouth concept of dental care). And additionaly, clean tongue dorsun provides the best flavor and taste of the meals. If you would check this it would be additional information:

http://www.ncbi.nlm.nih.gov/pubmed/23316683

http://www.ncbi.nlm.nih.gov/pubmed/21618654

http://www.ncbi.nlm.nih.gov/pubmed/18843727

http://www.ncbi.nlm.nih.gov/pubmed/15341360

Big hug, Vinícius.

Perfect... and of course, you must to search a girl (or girls) with very good oral care, rsrsrsrsrsrsrs. Big hug, ViP :-(!)

And here is the Cochrane SR on it! it says the same.

http://summaries.cochrane.org/CD008829/flossing-to-reduce-gum-disease-and-tooth-decay

Dear Zbys and Anirudha, thank you so much for the help... as Anirudha sent: "There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months. No studies reported the effectiveness of flossing plus toothbrushing for preventing dental caries.

Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD008829. DOI: 10.1002/14651858.CD008829.pub2

Perhaps education should be more close to oral care...

VP et al.. what is required to answer the question reliably is better quality research.. Historically RCTs in oral health have been largely of sub optimal quality and until we have some sold high quality trials/evidence... questions will remain... and largely unanswered. We as a profession should answer these questions but only by improving our research methods.

That's perfect, Z, many thanks!

What would be perfect is if we got onto these trials and did some to finally resolve the questions..

What a master class ... dear friend, education is behind all ... but we must first know how, where and when to do. We also must to believe in what we do and then try to convince in a suited way to the intellect of our customers. Many thanks for the excellent answer!

Guys its about the evidence... short simple and sweet.. the recommendations listed are NOT supported by reliable evidence.. and lest we forget absence of evidence isn't evidence of absence. So in short we dont know..even water fluoridation is under the spotlight and that ever since Fejerskovs seminal article.. Most of these recommendations are either unsupported, as with the fluoride drops saga or are dated and stating that they're current best practice doesn't do it for me.

Example: the Brit governments long standing recommendations( current best practice) for screening for Breast Cancer which cost them 58m sterling a year have been challenged and are under scrutiny with even the guy who recommended and set them up 15 years ago saying so.

My government here in Bahrain didnt follow them or not follow them.. They in fact made the right decision based on what we now know, and is evidence-based, by taking NO decision. As regards fluoridated toothpaste for which we do have evidence of benefit the pharma industry controls the price and this has an impact of availability if under/less well resourced countries. Cultural factors may also be deflected by some of these confounders.

What efervescense.... Mary thanks for the posts. I have a clear personnel evidence. Working in a city near ribeirão preto where my group of clinicians reach good results in a 12years prevention programm including supervised toothbrushing, mouthwashing with NaF 0,5% weekly and the essential teaching good practice in food and oral health. the DMS index were 12 at at 12 years old kids até school ano até the end we get 3.2

Published it? If not it should be and of course ....subjected to scrutiny/peer review.

I also have 'personal' evidence ie that neither of my kids have caries, they both received fluoride tabs, didn't live in a fluoridated area so .. was it the fluoride tabs? No because we now have evidence for their lack of effectiveness so what was it? Diet yes and adequate tooth-brushing.. Ah but all along i thought it was the Fl tabs.. But I was proved wrong.

VP I have no doubt your programme was highly successful publish it.

10.000 kids with more oral health keeping their teeth in their mouth with good conditons. And peace in my mind. Data already published but in brazilian health government .

Dear Mats very interesting points. Unfortunatelly I humble think this days only dental implants and whitening are important to teach in dental schools. Best Regards vip

GOHI... The best way . As I hear from a professor who passed away: one people without culture is a poor people.... One people who does not live culture is a people poor ....

UK dental situation less than satisfactory.. universal and often free access ready availability of flouride toothpaste some areas fluoridated BUT Im not totally in agreement that Brits have bad/worst teeth.. lets see the comparative evidence......Was in US recently.. extreme variability..

Its about effectiveness.. advocating the use of treatments which we were taught at dental school for which there is limited or no evidence of benefit is in part 'immoral'. I think this book is a great read I recommend it and its free to download.

http://www.testingtreatments.org/the-book/download-the-book/

Perfect ....... but the knowing when not shared, when it not reaches democratically whole society, is knowledge lost for no reason. Retain knowledge is a form of slavery too cruel.

Agreed. I ever practice and share this information: in practice, theory is not ever the same. Never ever it works. So, let's try to share and teach the best information on: flossing (first), toothbrushing (to complete flossing dua pharmacological process - like thickening agents) with a good ballanced dentifrice and, if mechanical oral care was done and the individual would like, moutrinses, mouthwashes, should be an alternative to complete the oral care. Thinking in social teach. Good discussion! Thanks to all! God bless you all.

We need to learn with the most graduate teacher: LIFE. She is very hard, but we learn from her, yes, we learn... so flossing, toothbrushing, drinking fluoridated water, eat (even as possible) according to food nutritional pyramid, avoiding sugar between meals, etc. etc. etc. but education in evidence. When did water fluoridation begin in the United States?

See...

http://www.cancer.gov/cancertopics/factsheet/Risk/fluoridated-water

In 1945, Grand Rapids, Michigan, adjusted the fluoride content of its water supply to 1.0 ppm and thus became the first city to implement community water fluoridation. By 2008, more than 72 percent of the U.S. population served by public water systems had access to fluoridated water (3).

The Centers for Disease Control and Prevention (CDC) considers fluoridation of water one of the greatest achievements in public health in the 20th century.

Dear Chris you are awesome. We are both professors with clinical profile and both Dentistry and comunity lovers. Godinho bless you and your Family. And we must keep our figth against caries, periodontal disease and of course, spraying health and happiness troughtout health smiles all overdose the world. Best regards, big hug your always friend and fan, Vinícius

Good toothbrushing and flossing still the best way to eliminate dental plaque and decrease the risk of dental caries, where toothbrushing eliminate the dental plaque occlusal, buccally and lingually, and the dental floss eliminate the dental plaque from the other 2 interproximal sides.

Mouthwashes are adjuvants.