Toothbrushing: review finds association between infrequent brushing and periodontitis


A number of studies have suggested a relationship between periodontal disease and oral hygiene.

The aim of this review was to assess the relationship between toothbrushing and periodontitis.


Searches were conducted in PubMed a range of other databases (not indicated) and the reference lists of included articles. Studies reporting association between periodontitis or alveolar bone loss with oral hygiene and toothbrushing frequency were considered.   Two reviewers independently conducted study selection. Study quality was assessed using the Health Evidence Bulletin (HEB) Wales checklist.

The association between toothbrushing and periodontitis was presented as an odds ratio (OR) with corresponding 95% Confidence interval (CI).


  • 14 studies were included (12 cross-sectional, 2 case-controlled)
  • Sample size ranged from 44-9203
  • Meta-analysis for infrequent compared to frequent tooth brushing.
    • 12 cross sectional studies, OR=1.41 (95%CI: 1.25-1.58, P < 0.0001)
    • All 14 studies, OR=1.44 (95%CI: 1.21-1.71, P < 0.0001).


The authors concluded

There are relatively few studies evaluating the association between tooth brushing frequency and periodontitis. A clear effect was observed, indicating that infrequent tooth brushing was associated with severe forms of periodontal disease. Further epidemiological studies are needed to precisely estimate the effect of key risk factors for periodontitis and their interaction effects.


The authors highlight that there were no consistent clinical measurements across the included studies. There is also limited agreement on a case definition for periodontitis and terms for severity of periodontitis. The authors also highlight that in many of the included studies only partial mouth recording of periodontal status was undertaken. Tooth brushing behaviour is also self-reported in many studies and frequency does not necessarily equate with efficiency of brushing.

The abstract indicted that 7 databases were searched although only information about PubMed was included in the text so we are unclear as to what other databases were searched. The HEB Wales assessment tool for assessing study quality is an interesting choice as the Newcastle Ottawa Scale increasingly commonly used for cohort and cross-sectional studies.

The Cochrane Collaboration has not considered toothbrushing for the prevention and control of periodontal disease but it has reviewed interdental brushing (Poklepovic et al, 2013) and flossing (Sambunjak et al, 2011). Both found evidence to suggest a reduction in gingivitis compared with toothbrushing alone.


Zimmermann H, Zimmermann N, Hagenfeld D, Veile A, Kim TS, Becher H. Is frequency of tooth brushing a risk factor for periodontitis? A systematic review and meta-analysis. Community Dent Oral Epidemiol. 2014 Sep 26. doi: 10.1111/cdoe.12126. [Epub ahead of print] PubMed PMID: 25255820.

Poklepovic T, Worthington HV, Johnson TM, Sambunjak D, Imai P, Clarkson JE, Tugwell P. Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD009857. DOI: 10.1002/14651858.CD009857.pub2.

Dental Elf 6th Jan 2014 – Only low quality evidence available for effectiveness of interdental toothbrushes

Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM, Imai P, Tugwell P, Worthington HV. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD008829. DOI: 10.1002/14651858.CD008829.pub2.

Dental Elf 12th Dec 2011 – People who brush and floss regularly have less gum bleeding compared to toothbrushing alone

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