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Toothbrushing in relation to meal consumption.

During my studies as a dental hygiene student and current practice as a licensed dental hygienist, patients have asked me, "When is the best time to brush?" Though limited evidence is available regarding the ideal time to brush, the majority of patients I have treated have previously been instructed to brush immediately after meals. Aside from instructing them to brush before bedtime, I have been suggesting that they consider brushing before meals. Since this suggestion is just the opposite of what they have heard in the past, they are usually surprised, prompting a discussion and explanation for this alternative viewpoint. One question often asked is, "Why brush before eating, when there is no food to remove?" Toothbrushing before meals may not make sense if brushing is being performed to remove food debris; however, when the purpose is to remove dental biofilm, there may be some logic and limited evidence to support brushing before meal consumption.

A large-scale study of European adults (N=3,187) spanning seven countries found no benefits in waiting to toothbrush until after eating breakfast. (1) In fact, toothbrushing less than 1.41 hours after breakfast was related to increased tooth wear. Though the timing of brushing in relation to tooth wear remains controversial, and more research directly targeting an acidic diet and toothbrushing is needed, this study's findings support the suggestion to brush before breakfast.

Enamel and dentin erosion following acid exposure in relation to toothbrushing has been studied. In a two-period crossover design in situ study, toothbrush abrasion was observed to occur more often when toothbrushing took place after exposure to an acidic beverage than it did when toothbrushing was performed before. (2) To examine the effects of erosion on enamel and dentin in relation to toothbrushing, three enamel and dentin specimens were fixed in an intraoral appliance in 10 volunteers. Specimens in volunteer groups A and B were exposed to extraoral erosion for 40 seconds, three times a day for 14 days, with a minimum of four hours between exposures. In addition, the enamel and dentin specimens worn by group A were subjected to 20 seconds of brushing treatment in an automatic brushing machine before the erosive challenge took place. Group B's specimens were exposed immediately, and then received the automated brushing treatment after five minutes. For each of the 10 volunteers, mean enamel and dentin wear was significantly lower when brushing treatment was performed before an erosive challenge than when brushing was applied after.

Another study assessed the effect of toothbrushing on previously demineralized enamel following different remineralization periods. (3) During the 21-day evaluation, eight panelists wore a human enamel specimen on the buccal aspect of an intraoral appliance. Demineralization was performed by exposing the specimens extraorally to Sprite Zero--a low-calorie, carbonated lemon-lime flavored soft drink --for 90 seconds twice a day. The specimens were brushed immediately after the erosive challenge, at 10-minute intervals up to 30 minutes, after 60 minutes, or not at all. Abrasion resistance of "softened" enamel was found to increase with the remineralization period; however, even after 60 minutes, the wear from brushing was significantly higher than that in control specimens, which were demineralized but not brushed. Prospective longitudinal clinical trials are needed to strengthen the evidence produced by these two in situ pilot studies.

In a related study, the effect of dental plaque on oral sugar clearance and salivary pH was examined. (4) In this in-vivo study, 60 12-year-olds (33 males and 27 females) were assigned to one of two groups based on the presence or absence of biofilm. Plaque scores were assigned using the Plaque Index by Silness and Loe. (5) The control group had a mean plaque score <1.0 (little to no plaque); the plaque group had a plaque score equal to 1.0 (biofilm present on the free gingival margin and adjacent area of the tooth that is detectable only after the use of a disclosing agent or probe). Each group abstained from eating or drinking one hour before their saliva was collected in the morning. The children were instructed to rinse thoroughly with water 10 minutes before collection to avoid contamination of food debris. Saliva was collected after a one-minute exposure to 10 ml of a 25 percent sucrose-containing solution. For approximately one hour afterward, non-stimulated saliva was collected at two-minute intervals starting at zero and up to 10 minutes, then at 10-minute intervals up to 60 minutes. The non-stimulated saliva samples were then analyzed for salivary sucrose concentrations and salivary pH. It was determined that the sucrose cleared significantly faster in the control group than in the plaque group. The amount of sugar in the saliva was also significantly higher in the plaque group at various time intervals. The researchers came to the conclusion that, "Plaque may act as a reservoir in the saliva at a later stage. This may be due to the structure of plaque." (4) Additionally, the salivary pH was significantly lower in the plaque group at various time intervals compared to the control group. It was stated that the lower pH, representing greater acidity, in the plaque group was thought to have resulted from the cariogenic bacteria's presence in oral biofilm, which may have metabolized the sucrose, forming acid and thus lowering the oral cavity's pH. These findings raise a logical question about the effect on salivary pH from tooth-brushing for biofilm removal prior to meals containing cariogenic foods.

Despite this information, there might be reasons that patients would resist brushing their teeth before eating, such as altered taste of food. Toothbrushing without the use of a dentifrice is an option; though it may not be the best one for all patients, especially individuals who are at high risk for caries and would greatly benefit from the use of fluoridated dentifrice, as many studies have suggested. (6) Also, patients who are willing to forego brushing after eating might still desire to remove food particles. I have found that use of an oral irrigator, floss, soft interdental picks or mouth-rinse and even vigorously rinsing with water are all good options to help clear the oral cavity of food debris.

As oral care providers, it is important that we continually emphasize the value of dental biofilm removal and control to reduce pathogenic bacteria in the oral cavity. It is also important to keep in mind that while dental biofilm plays a significant role in the caries process, it is not the only contributing factor. We must stress other caries risk factors for our patients such as frequent cariogenic food exposures and poor nutrition, as well as protective factors such as fluoride and remineralizing and other caries-preventive agents.

Overall, my patients have accepted these recommendations and report having implemented them in their daily self-care routine. Although the recommendation to brush before eating is supported by limited emerging evidence as well as my own experiences as a clinician, further research is indicated to assess brushing time in relation to both patient acceptance and to tooth erosion and demineralization.

Jodie Nathan, RDH, graduated from New York City College of Technology in May 2014 with a Associate in Applied Science in Dental Hygiene. She currently works as a registered dental hygienist in Manhattan.

The faculty mentor for this edition of Student Focus is Susan H. Davide, RDH, MS, MSEd, assistant professor, dental hygiene, New York City College of Technology, Brooklyn, N. Y.


(1.) Bartlett DW, Lussi A, West NX, et al. Prevalence of tooth wear on buccal and lingual surfaces and possible risk factors in young European adults. J Dent. 2013 Nov;41(11): 1007-13.

(2.) Wiegand A, Egret S, Attin T. Toothbrushing before or after an acidic challenge to minimize tooth wear? an in situ/ex vivo study. Am J Denr. 2008;21(1):13-6,

(3.) Attin T, Knofel S, Buchalla W. Tiitiincu R. In situ evaluation of different remineralization periods to decrease brushing abrasion of demineralized enamel. Caries Res. 2001 ;35(3):216-22.

(4.) Pradhan D, Jain D, Gulati A, et al. Effect of the presence of dental plaque on oral sugar clearance and salivary pH: an in vivo study. J Contemp Dent Pract. 2012;13(6):753-5.

(5.) Wilkins EM. Clinical practice of the dental hygienist. Philadelphia: Wolrers Kluwer Health/Lippincott Williams & Wilkins, 2013.

(6.) Rugg-Gunn A. Dental caries: strategies to control this preventable disease. Acta Med Acad. 2013;42(2):117-30.

By Jodie Nathan, RDH
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Title Annotation:STUDENT FOCUS
Author:Nathan, Jodie
Date:Sep 1, 2015
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