Toothbrushes and interdental cleaning aids

Resource faculty-Dr. Shiva Lal SharmaAdditional Professor and HODDepartment of Periodontology and Implantology Presenter-

Niraj Regmi (413)BDS 2009

CONTENTS1. Introduction2. Toothbrushes3. Dentrifrices4. Tooth brushing technique5. Interdental cleaning aids6. References

introductionDental plaque

Dental plaque is defined clinically as a structured, resilient, yellow-grayish substance that adheres tenaciously to the intraoral hard surfaces, including removable and fixed restorations.

Types of dental plaque- 1. Supragingival

2. Marginal

3. Subgingival

Plaque control

Plaque control is defined as removal of microbial plaque and the prevention of its accumulation on the teeth and adjacent gingival tissues. Besides, it also deals with the prevention of calculus formation.

Plaque control includes the usage of mechanical procedures as well as chemical agents, which retards plaque formation.

ToothbrushesHISTORY:- World’s first toothbrush was a just a stick

about the size of a pencil. One end was chewed into thus becoming softened and brush-like while the opposite end was pointed and used as a toothpick to clean food and debris from between the teeth. The twigs used were carefully chosen from aromatic trees such as neem, meswak, babool etc. that had the ability to clean and freshen the mouth.

The earliest literature showing the use of these twigs is found in Chinese literature at around 1600 BC.

The first toothbrush of a more modern design was made by William Addis in England around 1780 – the handle was carved from cattle bone and the brush portion was still made from swine bristles.

In 1844, the first 3-row bristle brush was designed. 

Natural bristles were the only source of bristles until Du Pont invented nylon. The invention of nylon started the development of the truly modern toothbrush in 1938, and by the 1950s softer nylon bristles were being made, as people preferred these.

The first electric toothbrush was made in 1939 by Fredrick Tornberg, a Swedish Watchmaker, and the first electric toothbrush in the US was the Broxodent in 1960.

Chinese in 3000 B.C. used gold toothpicks.

DEFINITION The toothbrush is an oral hygiene

instrument used to clean the teeth and gums that consists of a head of tightly clustered bristles mounted on a handle, which facilitate the cleansing of hard to reach areas of the mouth.

Tooth brushes are the most widely used oral hygiene aid. It is the principle instrument in general use for accomplishing the goals of plaque control.

According to American Dental Association Council on Dental Therapeutics ‘The toothbrush is designed primarily to promote cleanliness of teeth and oral cavity.

OBJECTIVES OF TOOTHBRUSHING:-1. To clean teeth and interdental spaces of food

remnants, debris, and stains.2. To prevent plaque formation.3. To disturb and remove plaque.4. To stimulate and massage gingival tissues.5. To clean the tongue.

TYPES OF TOOTHBRUSHES On the basis of manipulation a. Manual toothbrushes b. Powered toothbrushes c. Sonic and ultrasonic toothbrushes d. Ionic toothbrushes On the basis of sizes a. Large b. Medium c. Small On the basis of bristle diameter a. Soft bristle- 0.2mm (0.007inch) b. Medium bristle- 0.3mm (0.012 inch) c. Hard bristle- 0.4mm (0.014 inch)

MANUAL TOOTHBRUSHES

Ideal Characterstics1. It should confirm to individual patient requirement

in size, shape and texture.

2. It should be easily and effectively manipulated.

3. It should be readily cleaned and areated and should be impervious to moisture.

4. It should be durable and inexpensive.

5. It should be designed for utility, efficiently and cleanliness.

PARTS OF TOOTHBRUSH1. Handle- The part grasped in the hand during tooth brushing.

2. Head- The working end of a tooth brush that holds the bristle or filaments.

3. Tufts- Clusters of bristles or filaments secured into the head.

4. Brushing plane- The surface formed by the free ends of the bristles or filaments.

5. Shank- The section that connects head and handle.

ShankTufts

ADA SPECIFICATION OF A TOOTHBRUSH

Brushing Surface:- # 1 to 1.25 inches in length (25.4 to 31.6 mm long)

# 5/16 to 3/8 inches in width (7.9 to 9.5 mm wide)

# 2 to 4 rows of bristles

# 5 to 12 tufts per row

TOOTHBRUSH DESIGN:-# Two types of bristles material are

used-

1. Natural bristles from hogs

2. Artificial filaments made of nylon

# Bristle hardness is proportional to square of the diameter and inversely proportional to the square of bristle length.

# Amount of force used to brush is not critical for effective plaque removal.

# Tooth brush must also be replaced periodically, although the amount of visible bristle wear doesnot appear to affect plaque removal for upto 9 weeks.

# Handle of toothbrush- slightly bent brush handles improve posterior access for plaque removal.

TOOTHBRUSH MODIFICATIONS (To achieve enhanced plaque removal)1. Long and contoured handle2. Double angulation of head and neck3. Concave surface of the brushing plane4. Special indicator bands

Recent advances in manual toothbrush

Colgate 360 Oral B

Colgate 360° is an advanced design manual toothbrush which includes the following bristle features: cleaning tips on the heel and toe of the brush for cleaning in hard to reach areas; polishing cups to hold toothpaste against the teeth; and vertical tapered bristles for interdental cleaning.

Oral-B Exceed toothbrush has a cris-cross configuration of the bristles angled in opposite directions to enhance penetration and cleaning between teeth relative to toothbrushes with the vertical bristle configuration.

Various products are made from these two basic design of modern toothbrushes .some examples are:Colgate 360° Optic White Toothbrushes, UP TOOTHBRSH 4CT CLN SOFT BRUSH, Reach REACH Adult Advance Design 2CT SOFT - 2 Ct.,

Oral-B Pro-Health For Me CrossAction Toothbrush, COLGATE TOTAL ADVANCE FLS TB FHS 1CT, Colgate 360 Sensitive Pro-Relief Toothbrush,etc.

RECOMMENDATIONS # Soft bristle toothbrushes clean

effectively, remain effective for a reasonable time and tend not to traumatize the gingiva or root surfaces.

# Toothbrushes need to be replaced about every 3 months.

# If patients perceive a benefit from a particular brush design, then they should use it.

POWERED TOOTHBRUSH

(AUTOMATIC OR MECHANICAL OR ELECTRIC TOOTHBRUSH)The heads of these toothbrushes oscillate in a side to side motion or in

rotary motion. The frequency of the oscillations is around 40Hz in an ordinary powered toothbrush.

ADVANTAGES1. It increases patient motivation resulting in better patient

compliance.

2. Increased accessibility in interproximal and lingual tooth surface

3. No specific brushing technique required

4. Uses less brushing force than manual toothbrushes

5. Brushing timer is incorporated in some brushes to help the patient in brushing for the required duration.

Recent advances in powered toothbrush Power toothbrush technologies can be grouped into four

general categories: rotating,counter rotational,side-to-side, andoscillating-rotating (Table 1).

With a rotating power toothbrush, the entire brushhead turns in a full circle, moving in one direction.

In contrast, a counter-rotational brush has tufts that rotate in different directions.

With oscillating-rotating technology,the brushhead oscillates from the center point but does not rotate in a full circle.

Recently a pulsating,or in-out movement, has been added to some oscillating-rotating power toothbrushes.

Sonic and oscillating-rotating technologies (with or without pulsation) are the most commonly used in power toothbrushes today.

Recent advances in Sonic Powered toothbrush

These types of toothbrushes produce high frequency vibrations (1.6MHz)which leads to the phenomenon of cavitation and acoustic microstreaming. This phenomenon aids in stain removal as well as disruption of the bacterial cell wall (bactericidal).

In recent times Philips company is the leading contender in advances in sonic toothbrushes.

Philips Sonicare is based on patented sonic technology. Sonicare achieves its bristle velocity--the movement of the brush head in your mouth--through a combination of high frequency and high amplitude bristle motions. These motions create dynamic cleaning action that drives fluids deep into the tight spaces between your teeth and along the gum line, which results in a cleaner, healthier mouth.

It comprises of contoured brush head to fit the natural shape of your teeth, creating a larger brushing surface on the brush head. Bristles are placed at precise angles to maximize coverage. Finally, it uses extremely soft bristles that are rounded at the top by a diamond grinding wheel, to create a safe and gentle brush head that effectively delivers a powerful clean.

These are the products that Philips have in the market :

DiamondClean (1) FlexCare+ (1) FlexCare (2)

HealthyWhite (2)

Sonicare for kids (1)

EasyClean (1)

Essence (2)

Removes up to 7X more plaque than a manual toothbrush

Improves gum health in only two weeks Whiten(s) teeth more than 2x better than a manual

toothbrush Sensitive Mode: Gentle teeth and gum cleaning Helps whiten teeth Provides a superior clean Dynamic cleaning action drives fluid between teeth Dual Charging System: Charging glass and travel case. Guides you to follow dental recommendations Quadpacer interval timer encourages thorough brushing Two-minute timer helps ensure recommended brushing

time

Features of Philips DiamondClean Sonic Brushes

Recent advances in Powered Toothbrush using Oscillating and Rotatory

TechnologyRegarding oscillating and rotatory technology

Oral B is the forerunner in developing advanced toothbrushes. There are two main product line by Oral B i.e.,

Professional andDeep sweep.

Features of Professional:deep-cleaning, oscillating bristles cup each tooth

to get in hard-to-reach areasPressure sensor alerts you when you're brushing

too hardBristle tips have been rounded to be gentle while

reducing plaque and helping to prevent gingivitis

Features of Deep Sweep”the efficacy of Oral-B Power brushing combined

with the familiarity of a manual brush in look and technique

Unique bristles attack plaque and are gentle on teeth and gums

Triple cleaning action bristles clean hard-to-reach-areas

New brush head designs and filament technology have also been introduced, such as coextruded bifilaments that replaced crimped filaments to reduce axial stiffness and increase approximal penetration.In 2005, the Oral-B Triumph was developed combining the oscillating-rotating plus pulsation technology with Smart technology in the handle.

New brush head designs and filament technology have also been introduced, such as coextruded bifilaments that replaced crimped filaments to reduce axial stiffness and increase approximal penetration.

In 2005, the Oral-B Triumph was developed combining the oscillating-rotating plus pulsation technology with Smart technology in the handle.

Features of Oral B Triumph This onboard computer provides feedback to the

patient regarding brushing time, brushing mode, battery charge status, & brush head replacement. Two unique brush head designs were introduced with this model.

One has flexible MicroPulse™ bristles to enhance removal of plaque biofilm while the other has a polishing cup to facilitate stain removal.

Recently, further enhancements to the Triumph were revealed. A chip was added to the handle giving it the ability to send information wirelessly to a remote display, allowing patients to easily and continuously view brushing feedback.

• Timers - Research shows patientstypically spend about forty-sixseconds brushingtheirteeth, lessthan half the time recommendedby dental professionals.17 To helppatients meet the desired time,some models have a two-minutetimer. In addition, many powertoothbrushes are equipped witha professional timer that elicitsa sound or vibration everythirty seconds. This signals thepatient to move to the nextquadrant to ensure morethorough plaque removal acrossthe entire dentition.

Pressure Indicator - In addition toproviding feedback on brushingtime, some power toothbrusheshave pressure indicators. Thisfeature provides reassurancepatients will follow good brushingtechnique by alerting them if toomuch pressure is applied.Research shows patients actuallyuse less pressure with a powerbrush than a manual brush.18

Brushing Modes - Some power toothbrushes allow patients to customize their brushing mode. Examples of modes on various toothbrushes include clean, soft, massage, or polish. Patients can personalize their brushing experience based on their oral health needs and personal preferences.

Electric toothbrushes are both rechargeable and non rechargeable. Advances in power management has also been introduced in modern toothbrushes

Beside the basic technology, advances in brush head is a key factor. Different type of brush heads for Oral B products areas follows.

The new Oral-B Triumph with SmartGuide, an oscillating-rotating pulsating brush, is equipped with the features listed above, but it also offers a unique remote display technology (Figure 1.) The display can be placed on the counter, or anywhere within 10-15 feet of the patient, so the two-minute timer, brushing mode, and quadrant timer can be easily viewed during brushing. In addition, it also has a visual pressure signal that lights up if too much pressure should be applied, at which time pulsations are interrupted. This is the first power toothbrush that allows patients to visually follow feedback mechanisms continuously during brushing.

INDICATIONS OF POWERED TOOTHBRUSH

1. Young children

2. Handicapped patients

3. Individuals lacking manual dexterity

4. Patients with prosthodontic or endosseous implants

5. Orthodontic patients

6. Institutionalised patients including the elderly who are dependent on care providers

7. Patients on supportive periodontal therapy

TOOTHBRUSHING TECHNIQUES

Bass Technique (Vibratory/Sulcus Cleaning method)

Modified Stillman Technique (Roll method)

Fones Technique (Circular method)

Leonard Technique (Vertical method)

Scrub Technique (Horizontal method)

Modified Bass Technique

Physiologic method- Smith method

INTERDENTAL CLEANING AIDS

Dental Floss

Interdental Cleaners

# Wooden or plastic Tips

# Interdental Brushes

FACTORS DETERMINING THE SELECTION OF INTERDENTAL AIDS ARE THE TYPE OF EMBRASURES Type1: The interdental papilla fills up the embrasures.

Dental floss is advised. Type 2: In the moderately papillary recession

miniature interdental brushes and wooden tips are used.

Type 3: When there is completely loss of papilla and interdental gingiva is tightly bound to underlying bone (seen in diastema), unitufted brushes are used.

Dental flossMost widely recommended tool for

removing plaque from proximal tooth surfaces.

Dental floss may be available in various forms- # multifilament- Twisted / Non twisted # Bonded / Non bonded # Thick / Thin # Waxed / Non waxed #Monofilament – made of Teflon type material

FUNCTIONS OF DENTAL FLOSS1. Removal of adherent plaque and food debris from

interproximal embrasure and under the pontics of the fixed partial dentures.

2. Polishing of the tooth surface during removal of the plaque and debris.

3. Stimulating and massaging the interdental papillae.

4. Helping in locating the subgingival calculus deposits, overhanging margins of the restorations, proximal carious lesions.

5. Vehicle for application of polishing or therapeutic agents to interproximal and subgingival areas.

How to use dental floss?The floss must contact the proximal surface from

line angle to line angle to clean effectively. It must also clean the entire proximal surface, not just be slipped apical into the contact area.

The floss should be at least 12 to 18” long . It is wrapped around the fingers or the ends may be tied together in a loop.

After stretching the floss between thumb and forefinger, pass it gently through each contact area in a back and forth motion.

Once the floss is apical to the contact area, move it up

along the tooth till the contact area and down into the

sulcus again, this is repeated several times and the same is

repeated on the proximal surfaces of the other teeth.

Disadvantage of the dental floss

Using floss holder

Indication - low manual dexterity - handicapped - hospitalized patientsIdeally, floss holder should possess forks that are rigid enough to hold the floss firmly and mounting mechanism.Disadvantages:

- more time consuming- they must be rethreaded whenever

the floss becomes soiled or frayed.

Interdental cleaning devices Concave root surfaces and furcations that

are often present in periodental patients who have experienced significant attachment loss and recession are not as throughly cleaned with dental floss alone.

Commonly used interdental cleaning devices are:

Interdental brushesWooden or rubber tips

Interdental brushesThese are cone-shaped or

cylindrical brushes made of

bristles mounted on a handle,

single-tufted or small cylindrical

brushes.Indication : for cleaning large,

irregular, or concave tooth

surfaces adjacent to wide interdental spaces.

Technique These brushes of any style areinserted through interproximal spaces and moved back and forth between the teeth with short strokes. The diameter of brush should be slightly larger than the gingival embrasures to be cleaned. This size permits bristles to exert pressure

on bothproximal tooth surfaces, working their way

intoconcavities on the roots.

Single-tufted brushes They provide access to furcation areas, or

isolated areas of deep recession, and work

well on the lingual surfaces of mandibular

molars and premolars.

These areas are often missed when using

a toothbrush.

Wooden toothpicksThese are used either with or without

handle.Wooden toothpicks used on handles

improve access to all areas and have

been shown to be as effective as dental floss in reducing

plaque and bleeding scores in subjects with gingivitis

Triangular wooden tips These are most useful in

the anterior areas when used from the bucal surfaces of the teeth.

Wooden tips cannot be reused whereas rubber and plastic tips can be rinsed and reused.

Technique They can be used around all surfaces of

teeth when attached to the handles. The

tip of the toothpick is used to trace

along the gingival margin and into the

proximal areas from both facial and ling-

ual surface of each tooth.

Rubber tips

Rubber tips should be placed into the embrasure space and used in a circular motion. They can be applied to interproximal spaces and other defects throughout the mouth and are easily adaptable to lingual surfaces.

Gauze strips Teeth bordering edentulous areas may be cleansed with

the brush turned so that the bristles strike the proximal surfaces.

Four ply cotton yarn or gauze strips may be used when the tooth surfaces are not readily accessible to a brush

The gauze material for this technique may be 1-inch gauze bandage cut into strips 6 inches in length and folded down the center.

Place the fold on the tooth and carry the gauze as far gingivally ass possible even under the margin

Move the gauze in a shoeshine motion several times across the area

FLOSS THREADERSFloss or tape can be threaded through the embrasures,

and pontics and abutment teeth can be cleansed.

PIPE CLEANERS Are sometimes effective in cleansing inaccessible

interproximal areas and exposed bifurcations and trifurcations.

The cleansers are carefully teased b/w the exposed roots of the furcations and pulled through

Tooth abrasion in the furcation is common with this technique

PERIO AIDA device that is useful in reducing dental plaque

at gingival margins and interproximally This instrument consists of a plastic handle that

will receive round polished toothpicks and that permits the patient to cleanse the teeth at gingival margins where accessible and in arias of difficult access.

The tip can be dipped into the sulcus.

References… Carranza’s Clinical Periodontology- 10th edition

Essentials of clinical periodontology and periodontics-

Shantipriya Reddy

Essentials of Preventive and Community Dentistry – 4th

edition

Patricia A. Walters, MaryAnn Cugini, Aaron R. Biesbrock, Paul

R. Warren; A Novel Oscillating-Rotating Contemporary

Dental Practice Power Toothbrush with SmartGuide™:

Designed for Enhanced Performance & Compliance; Journal

of Contemporary Dental Practice

Internet resources

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