Clinical studies have found little association between the amount of toothpaste used and anticaries efficacy; instead, as explained above, fluoride concentration is the important determinant of anticaries efficacy. Therefore, using more toothpaste than is recommended (such as a pea-sized amount for children) does not provide more caries protection.1
Brushing behavior is also important: Brushing twice a day is linked to a 20% to 30% lower likelihood of caries compared to brushing once or less daily.19 It should be noted that brushing frequency is linked to socioeconomic status, with children in poorer families brushing less, and this being one reason they experience more caries.20 While there has been much debate about whether it is better to brush before or after meals, there is little scientific evidence to indicate the better option. However, data do show that brushing immediately before bed plays an important role in reducing plaque load in the oral environment during sleep, when salivary flow and buffering capacity are naturally reduced. Therefore, the recommendation to brush just before going to bed and at least one other time during the day before or after a mealtime is appropriate for most patients.1 Fluoridated toothpaste can also be used therapeutically by asking the patient to apply a dab of paste with a finger or brush directly to a cleaned active lesion immediately before going to bed. This also allows an increased concentration of fluoride in the vicinity of the lesion at a time of day when salivary output is naturally low.
Rinsing behavior is another determinant of anticaries efficacy. Studies show that people who use a cup to rinse with water after brushing (and so put more water in their mouths) have approximately 20% more caries than those who use the toothbrush or hand to collect water. This is because more fluoride is washed away when rinsing with a cup of water after brushing.1
In summary, dental professionals should recommend to their patients: