Indian Journal of Oral Sciences Vol. 3 Issue 2 May-Aug 201262

Introduction

Dental plaque is established as the principle etiological agent of dental caries and periodontal disease. Recent investigations have stated that gingivitis may develop within two weeks without oral hygiene, and that early carious lesions may be detected after about four weeks, when the plaque is allowed to accumulate.

Prevention of these two oral diseases in individuals is based, to a great extent, on the effective removal of plaque on a daily basis. Various authors have shown the effect of mouth cleaning in the healing and prevention of periodontal disease.

Despite the wide range of methods available, mechanical plaque removal with a manual toothbrush remains the primary method of maintaining good oral hygiene for a majority of the population. When performed well, for an adequate duration of time, manual brushing is highly effective for most patients.

The Council of Dental Therapeutics has quoted, In fact, the data from some studies emphasize the ability of persons to maintain good oral hygiene through effective use of a conventional toothbrush if they possess reasonable dexterity and have been trained adequately in the proper use of the brush.

Several different toothbrushing methods with manual brushes exist. The popularity of various techniques has waxed and waned over the twentieth century. However, no one method of brushing has been found superior to the other.

Toothbrushing is a completely accepted part of daily life and good oral hygiene practice. However, plaque control by toothbrushing alone is not sufficient to control gingival and periodontal diseases because periodontal lesions are predominantly interdental.

For years dental authorities have instructed their patients on how to brush their teeth correctly. However, many people lack the patience and do not follow dental instructions for more than a brief period.

Date of Submission: 10-05-2012Date of Acceptence: 25-08-2012

Address for Correspondence: Dr. Deepak Grover, Department of Periodontics and Oral Implantology, National Dental College and Hospital, Derabassi, Punjab, India. E-mail: preet342@yahoo.com

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DOI: 10.4103/0976-6944.106456

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ABSTRACT

Despite the wide range of methods available, mechanical plaque removal with a manual toothbrush remains the primary method of maintaining good oral hygiene for a majority of the population. Several different toothbrushing methods with manual brushes exist. The popularity of various techniques has waxed and waned over the twentieth century. However, no one method of brushing has been found superior to the other. However, plaque control by toothbrushing alone is not sufficient to control gingival and periodontal diseases because periodontal lesions are predominantly interdental. For years dental authorities have instructed their patients on how to brush their teeth correctly. However, many people lack the patience and do not follow dental instructions for more than a brief period. Therefore, studies were initiated in the belief that the introduction of power brushing would help the average person brush his teeth with greater efficiency. The purpose of this article is to update the available information on the toothbrush designs, tooth brushing methods, and the introduction of powered and ionic brushes.

Toothbrush A key to mechanical plaque controlDeepak Grover, Ranjan Malhotra, Sumati J Kaushal, Gurpreet Kaur

Department of Periodontics and Oral Implantology, National Dental College and Hospital, Dera Bassi, Mohali

Key words: Interdental contacts, plaque, toothbrush

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Grover, et al.: Toothbrush - A key to mechanical plaque control

Indian Journal of Oral Sciences Vol. 3 Issue 2 May-Aug 2012 63

Therefore, studies were initiated in the belief that the introduction of power brushing would help the average person brush his teeth with greater efficiency. Although earlier studies did not conclusively prove any differences in the efficiency of plaque removal between electric and manual toothbrushing, clinical trials over the last few years showed that in closely supervised trials electric toothbrushing appeared to be superior to manual brushing.

The recent introduction of some ionic toothbrushes seems all set to revolutionize home care maintenance by all people, although perfection still remains an elusive goal. Plaque control is one of the key elements of the practice of dentistry. It permits each patient to assure responsibility for his or her own health on a daily basis. Without it, optimal health through periodontal treatment cannot be attained or preserved.

The Manual Toothbrush

There are numerous manual toothbrush designs, and claims of superiority for plaque removal by individual brands have been made in the past. However, World Workshops on plaque control and oral hygiene practices have consistently concluded that there is insufficient evidence to prove that any one toothbrush design is superior to another (Frandson[1]).

At the European Workshop on mechanical plaque control, it was agreed that the features of an ideal manual toothbrush should include: (Egelberg and Claffey[2])1. Handle size appropriate to use, for age and dexterity2. Head size appropriate to the size of the patients mouth3. Use of end-rounded nylon or polyester filaments not

larger than 0.009 inches in diameter4. Use of soft bristle configuration, as defined by the

acceptable International Industry Standards (ISO)5. Bristle patterns, which enhance plaque removal in the

approximate spaces and along the gum line.

Toothbrush handlesThe preference of handle characteristics is a nature of individual taste. The handle should fit comfortably in the palm of the hand; it may be straight or angled, thick or thin. Brushes with modest angulations between the head and the handle are available.

Kanchanakamol and Srisilapanan[3] evaluated a newly designed Concept 45 toothbrush for plaque removal in children and subsequently in adults. The handle was designed to facilitate the Bass toothbrushing technique and it was shown that this toothbrush could remove significantly more plaque than a conventional toothbrush with a standard handle.

Kieser and Groeneveld[4] evaluated another novel toothbrush design (Snake brush) that was characterized by double angulations of handle and neck. In a 30-day parallel design study this toothbrush showed significantly higher levels of plaque removal than two control brushes, with greatest reduction of plaque in the lingual areas.-

Toothbrush head Wasserman [5] observed a statistically significant

reduction in plaque accumulation after use of a deep grooved design toothbrush.

In contrast, Thevissen et al.[6] found a conventional flat multitufted brush significantly more effective than a convex-shaped brush.

Toothbrush bristles Two kinds of bristle materials are used in toothbrushes: Natural bristles from the hair of hog or wild boar. Artificial filaments made predominantly from

Nylon (0.006 to 0.4 mm). In case of interdental brush 0.075 mm.

Nylon bristles vastly predominate in the market. In terms of homogeneity of materials, uniformity of bristle size, elasticity, resistance to fracture, and repulsion of water and debris, nylon filaments are clearly superior.

This is because of their tubular form; natural bristles are more susceptible to fraying, breaking, contamination with diluted microbial debris, softening, and loss of elasticity.

Rounded bristle ends cause fewer scratches on the gingiva than flat bristles with sharp ends.

Bristles hardness is proportional to the square of the diameter and inversely proportional to the square of the bristles length.

Diameters of commonly used bristles range from: 0.007 inch (0.2 mm) for soft brushes. 0.012 inch (0.3 mm) for medium brushes 0.014 inch (0.4 mm) for hard brushes. Soft bristle brushes of the type described by Bass have

gained wide acceptance Bass (1948) recommended a straight handle and

nylon bristles of 0.007 inch (0.2 mm) in diameter and 0.406 inch (10.3 mm) long, with rounded ends, arranged in three rows of tufts, six evenly spaced tufts per row with 80 to 86 bristles per tuft. For children, the brush is smaller with thinner (0.005 inch or 0.1 mm) diameter and shorter (0.344 inch or 8.7 mm) diameter bristles.

The American Dental Association (ADA) has described the range of dimension of acceptable brushes; a brushing surface 1 to 1.25 inches (25.4 to 31.8 mm) long and 5/16 to 3/8 inch (7.9 to 9.5 mm) wide, two to four rows of bristles, and 5 to 12 tufts per row. A toothbrush should be able to reach and efficiently

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Indian Journal of Oral Sciences Vol. 3 Issue 2 May-Aug 201264

clean most anxious of the teeth.[7] In contrast, Pretaraspanedda et al.[8] demonstrated that

significantly more plaque was removed after a single brushing when brushes with higher density were used.

Beatty et al.[9] had conducted a comparative analysis of the plaque removal ability of 0.007 inch and 0.008 inch toothbrush bristles and demonstrated favorable results for the thinner bristles in school children.

Novel toothbrush designsThe new generation manual toothbrushes that have been tested in recent years exhibit better plaque removal ability than do the older brushes. The differences are most significant when individuals have been instructed in the proper brushing technique.

Twoheaded (double headed) Bastiaan[10] compared the plaque removing effect of a

double-headed brush with that of a single-headed flat toothbrush (Oral B 35) in 39 patients. The patients were instructed in the Bass technique and brushes were used for one week. The results indicated that lingually the double-headed brush was superior to the single-headed brush, whereas, buccally no difference was found.

Agerholm[11] tested the plaque removing efficacy of the new double-headed brush (Duodent 2000) in comparison with a conventional brush (Oral B 32). Twenty-seven patients were attending the clinic for an initial course of hygiene treatment and 23 were recall patients with persistently inadequate plaque control. The double-headed toothbrush helped achieve significantly better lingual and palatal plaque control.

TripleheadedThe triple-headed toothbrush is intended to clear the buccal, occlusal, and lingual or palatal surface of the teeth at one time. Yankell et al.,[12] conducted a study to test a new

triple-headed, toothbrush design (Dentrust) that claims to enable simultaneous plaque removal on the buccal, lingual, and occlusal surfaces. The brushes were compared with a standard flat toothbrush (Oral-B P35). In a laboratory test, the Dentrust toothbrush bristles were consistently superior to two manual toothbrushes in achieving proximal use.

In this study, a Dentrust group removed a significant amount of tooth buccal and lingual plaque and the flat-headed toothbrush removed a significant amount of buccal plaque only.

Zimmer et al[13] conducted a study to evaluate the plaque removing ability of a new triple-headed toothbrush (Superbrush), a conventional toothbrush and an electric toothbrush with a rotating head. In this single blind cross-over study, they found that the new triple headed toothbrush (Superbrush) was

more effective in removing plaque as compared to the conventional and powered toothbrush as observed using the Quigley-Hein Index (QHI) and proximal plaque index (API).

Vshaped Bergenholtz et al. (1984[14]) compared a V-shaped

and control multi-tufted toothbrush in a superior toothbrushing study and found significantly better interproximal plaque removal with the V-shaped brush. In 1984, same authors confirmed these differences in comparison to spaced and multi-tufted toothbrushes.

Bergenholtz et al.[14] could not find a difference in the plaque removing ability of straight, multi-tufted, and V-shaped brushes when they were used unsupervised. When used professionally, the V-shaped toothbrush was better at proximal plaque removal than the straight one.

Better interproximal access of Vshaped toothbrushes was observed by Yankell et al.[15] These authors evaluated different toothbrushing methods with six different toothbrushes and observed that a hard toothbrush with three rows, 12 mm length, and filament of 0.33 diameter removed most of the plaque (72%).

Twolevel toothbrush Finkelstein and Grossman[16] evaluated its effectiveness

on the lingual and facial surfaces in adult subjects by measuring the stained plaque on each facial and lingual surface, in 5% increments. The angled, bileveled brush was significantly superior to the conventional, straight-handled, multi-tufted toothbrushes in plaque removal efficiency.

In a fourweek crossover study on adult volunteers (aged 19 to 64 years) Wasserman (1985) compared a newly developed Deep-grooved two-level toothbrush (Improve) with a conventional flat brush, with 48 tufts and four rows. Significantly less plaque was found lingually in the molar teeth (P