|Year : 2012 | Volume
| Issue : 2 | Page : 62-68
Toothbrush 'A key to mechanical plaque control'
Deepak Grover, Ranjan Malhotra, Sumati J Kaushal, Gurpreet Kaur
Department of Periodontics and Oral Implantology, National Dental College and Hospital, Dera Bassi, Mohali, India
|Date of Submission||10-May-2012|
|Date of Acceptance||25-Aug-2012|
|Date of Web Publication||24-Jan-2013|
Department of Periodontics and Oral Implantology, National Dental College and Hospital, Derabassi, Punjab
Source of Support: None, Conflict of Interest: None
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.
Keywords: Interdental contacts, plaque, toothbrush
|How to cite this article:|
Grover D, Malhotra R, Kaushal SJ, Kaur G. Toothbrush 'A key to mechanical plaque control'. Indian J Oral Sci 2012;3:62-8
| 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. 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  ).
At the European Workshop on mechanical plaque control, it was agreed that the features of an ideal manual toothbrush should include: (Egelberg and Claffey  )
- Handle size appropriate to use, for age and dexterity
- Head size appropriate to the size of the patient's mouth
- Use of end-rounded nylon or polyester filaments not larger than 0.009 inches in diameter
- Use of soft bristle configuration, as defined by the acceptable International Industry Standards (ISO)
- Bristle patterns, which enhance plaque removal in the approximate spaces and along the gum line.
The 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  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  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.-
- Wasserman  observed a statistically significant reduction in plaque accumulation after use of a deep grooved design toothbrush.
- In contrast, Thevissen et al.  found a conventional flat multi-tufted brush significantly more effective than a convex-shaped brush.
- 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 bristle's 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 clean most anxious of the teeth. 
- In contrast, Pretaraspanedda et al.  demonstrated that significantly more plaque was removed after a single brushing when brushes with higher density were used.
- Beatty et al.  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 designs
The 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.
Two-headed (double headed)
- Bastiaan  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  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.
The triple-headed toothbrush is intended to clear the buccal, occlusal, and lingual or palatal surface of the teeth at one time.
- Yankell et al.,  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 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).
- Bergenholtz et al. (1984  ) 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.  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 V-shaped toothbrushes was observed by Yankell et al.  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%).
- Finkelstein and Grossman  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 four-week cross-over 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 (P0 < 0.001) and plaque was also reduced significantly (P < 0.03) on the buccal interproximal surfaces (P0 < 0.5) when the improve brush (Deep-Grooved two-level) was used.
Curved: (collis curved brush)
The Collis curved brush, with two short middle rows and curved outer rows, was found by Shory et al.,  to be more effective on the interproximal and gingival, sulcular areas than a straight multi-tufted bristle brush. It also improved the gingival conditions and removed significantly more plaque than the regular toothbrush.
- Avery  confirmed these results and showed a significant, (P < 0.001) 50%, reduction of plaque in students using the Collies curved brush compared to a conventional brush.
- Williams and Schuman  found that handicapped children were able to remove more lingual plaque with a curved brush.
Circular and diamonds
- A circular toothbrush found a significant improvement in plaque removal compared to a conventional toothbrush.
- It was also found that the Oral B brush, with a flat surface was significantly more effective.
A major shortcoming of brushes has been the 'Blocking effect' of tight and dense brittle tufts, which prevents individual tufts from entering the interproximal areas.
Light energy conversion and Ionic manual toothbrush
Two recent studies introduced another novel approach in manual toothbrushing. Hoover et al.  investigated the plaque removing potential of a new light energy conversion toothbrush incorporated with a semiconductor of titanium dioxide (TiO2). A similar toothbrush without a semiconductor served as the control. After a period of three weeks the new toothbrush showed significantly more reduction of plaque on the buccal surfaces in a group of 73 school children. The authors speculated, 'As the buccal surfaces are more likely to allow light to reach the semiconductors during brushing than the lingual areas, it is possible that the reported photocatalytic property of the semiconductor may be involved in the observed radiation of the plaque'.
Van Swol et al.  evaluated the effect of a small, imperceptible electric current on the established dental plaque and gingivitis during manual toothbrushing in 64 adults over a period of six months. The result showed significantly more improvement from the baseline to six months of the test over the unchanged control brush.
Hukeeba dental, Japan, has recently introduced a new generation of 'hy Gionic toothbrushes' that are based on the principle that plaque is positively charged and thus attach to the negatively charged tooth surfaces. The lithium battery contained in the handle of these toothbrushes tends to change the surface charges of the tooth by an influx of positively charged ions. The plaque with similar charges is then repelled and detached from 'the tooth surfaces and is in turn attracted by the negatively charged bristles of the toothbrush. More efficient plaque removal interproximally is claimed to be their main advantages.
| Toothbrushing Methods|| |
There are several specific toothbrushing techniques. The popularity of various techniques have waxed and waned over the twentieth century. The scrub technique is probably the oldest. It merely applies the name to the typical uninstructed action of brushers. The Charters and Stillman techniques for gingival message were popular in the 1930s and 1960s. Bass described what is probably the most popular method taught today and his theories were popularized in the 1970s.
No one method of toothbrushing has been found to be superior to others. The best method is the one that suits the individuals' needs and abilities, and the responsibility of the dentist is to instruct the patient on how to perform the task thoroughly. Most toothbrushing methods can be classified into one of the eight groups based on the motion and position of the brush.
- Sulcular: Bass
- Roll: Rolling stroke, modified Stillman
- Vibratory: Stillman, Charters, Bass
- Circular: Fones
- Vertical: Leonard
- Physiological: Smith
- Scrub-brush method
| Powered Toothbrush|| |
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. However, for most patients neither of these criteria is fulfilled. One possible way to overcome their limitations associated with manual brushing is to develop a mechanical brushing device.
- As early as 1855, the Swedish watchmaker Frederick Wilhelm Tornberg patented a mechanical toothbrush.
- The first electric toothbrush came much later and was first introduced in the 1960s. They provided a brush head capable of a variety of motions driven by a power source.
- The first electric brushes mimicked the back-and-forth motion, commonly used with a manual toothbrush, when first introduced. There were many reports of the effectiveness of such devices. However, an early authoritative report reviewed such research and stated that both manual and electric toothbrushes were equally effective in removing plaque. Due to lack of clear superiority and many problems of mechanical breakdown, powered toothbrushes fell out of favor and during the mid 1960s they gradually disappeared from the market.
- At the World Workshop in Periodontics 1966, the consensus was that in non-dentally oriented persons and persons not highly motivated to oral healthcare, as well as those who had difficulty in mastering a suitable hand brushing technique, 'the use of an electric brush with its standard movement might result in more frequent and better cleansing of the teeth'. Since then, research and development have continued and many modifications have been made to the electric toothbrush design  .
| Design and Mode of Action|| |
Generally, the brush heads of powered toothbrushes tend to be more compact than those of conventional, manual brushes. The bundles of bristles are arranged either in rows or in a circular pattern mounted on a round head. The bristles are also arranged as more compact single tufts, which facilitate interproximal cleaning and brushing in less accessible areas of the mouth.
The traditional designs of the head, operate with a conventional side-to-side, arcuate, or back-and-forth motions, whereas, circular brush heads have oscillating, rotational, or counter-rotational movements.
Types of motion
- Reciprocating - more back and forth in a line
- Arcuate - filament ends follow an arc as they move up and down
- Orbital - circular
- Elliptical - oval
- Dual motion - more than one of the previous motions mentioned
Speed varies from low to high among the different models. The number of strokes/minute varies from 1000 cycles/minute for a replaceable battery type to about 3600 oscillations/minute for an arcuate model. The rechargeable battery types operate at approximately 2000 complete strokes/minute.
A number of new generation powered toothbrushes, also incorporate design features that are aimed at improving the efficacy of cleaning and reducing the likelihood of toothbrush abrasion and gingival trauma in the long term (Heasman  ).
Ideal characteristics of a powered toothbrush: (Heasman  )
- An active brush tip to facilitate plaque control around posterior teeth and at interdental sites
- An orthodontic head for brushing around and beneath the components of fixed orthodontic appliances
- Rotating/spiraling filaments for interproximal cleaning
- An audible clicking mechanism to warm the brusher when a pre-set brushing force has been searched
- Oscillation of the brush head is powered by a battery pack in the handle of the brush. This may be a simple electric motor driving an eccentric cam as a series of gears for rotary action.
- Another method of generation is by magnetostriction , which is similar to that employed by ultrasonic scalers and results in a higher mode of oscillation. Their frequency of oscillation varies from 40 Hz (cycle/second) for battery-powered brushes to 250 Hz for magnetostrictive devices.
Electric toothbrushes may have a potentially improved action due to rapid vibration of the buccal head in a liquid medium. This may result in both cavitations and acoustic microstreaming.
- Cavitational activity encompasses a wide variety of bubble behaviors, ranging from the relatively gentle linear pulsation of gas-filled bodies (Stable cavitation) to the violent and highly destructive formation and collapse of vapor-filled voids and cavities (Transient cavitation). Electric toothbrushes operate at relatively low frequencies and are unlikely to generate the destructive transient form of cavitation.
- Acoustic microstreaming will occur around the bristles of an electric toothbrush.
- This streaming is accompanied by large hydrodynamic shear stresses, even though the actual streaming velocities that produce them are relatively low. These shear forces may dislodge the plaque, but they are not strong enough to disrupt the biological cells or tissues that require hydrodynamic shear stresses of the order of 1 × 10 3 Nm−2 . Such forces will occur readily at ultra sonic frequencies of 25 Hz.
- Often if an antiplaque agent (irrigant) is incorporated into the liquid, then a synergistic effect may be used (i.e., the mechanical and chemical effects work together). This is used around endodontic files, where the associated irrigant is sodium hypochlorite. Such effects could prove useful with the electric toothbrush, if the associated toothpaste has an antiplaque agent incorporated within it.
Indications for the use of powered toothbrushes
There is considerable evidence that powered toothbrushes are beneficial in achieving improved plaque control in specific patient groups.
- Patients with fixed orthodontic appliances
- Those for whom there is also evidence that powered toothbrushes are more effective in reducing decalcifications
- Children and adolescents
- Handicapped and severely retarded children
- Institutionalized patients, including the elderly, who are dependent on others
- Interestingly, however, powered toothbrushes have been shown to be of no significant benefit for patients with Rheumatoid arthritis, for children who are well-motivated brushers, and for patients with chronic adult periodontitis.
Clearly, however, from the industrial point, a 'Special group' alone does not constitute a sufficiently wide market and powered toothbrushes are now recommended on a community-wide basis, with a view to enhance an interest in oral hygiene practices.
The main electric toothbrushes, which are compared in the literature, are the Braun Oral B-plaque removers (D 5 , D 7 , and D 9 ) - Interplak, Rotadent, Sonicare, and sonex. These electric toothbrushes have been studied in relation to their ability to remove plaque and improve the gingival condition in comparison with either manual toothbrushes or electric toothbrushes from different manufactures.
This electric brush was the first clinically investigated powered brush, which turned away from the conventional design of electric toothbrushes. It had a rotary action and was a single-tuft brush, with small bristles that reached one surface per tooth. It came with three brush head designs (Short-pointed, elongated, and hollow-cup brush tip).
This electric toothbrush was the next innovative toothbrush design and was introduced into the market in the mid 1980s. The interplak toothbrush had a rectangular brush with six to eight bristle tufts, which individually counter rotated.
Braun Oral-B plaque control (D 5 , D 7 , and D 9)
This electric brush was first launched in 1991, and had a small circular brush head, which made an oscillating/rotating movement. In 1996, the frequency of the Braun Oral-B electric toothbrush was increased from 47 H z to 63 H z (Model D9). In addition, the angle of rotation was decreased from 70° to 60°.
Sonicare (sonic toothbrush)
- A new toothbrush introduced in 1993, had a rectangular brush head with bristles arranged in a saw tooth design. The side-to-side movement of the sonicare was operated at a high frequency of 260 Hz.
- Wu-Yuan et al.  tested sonicare and found that 60% of the plaque on a titanium surface could be disrupted at a distance of 2 mm away from the object.
- In a study by Johnson and McInnes,  in adults, plaque removal with sonicare was compared with a manual brush Oral-B 30. After four weeks of use, sonicare was found to be up to 11 times more effective than the manual brush in removing lingual and interproximal plaque.
- In two other studies (McInnes et al., 1994  ), it was seen that sonicare damaged the adherence properties of the oral bacteria, Actinomyces viscosus, by destroying the fimbriae of the organization.
- The safety of this brush was demonstrated by Donly KJ  who concluded that Sonicare had no potential for destruction of restoration, but was effective in stain removal.
- When a prototype of an ultrasonic brush was compared with a manual brush by Goldman,  patients were not aware of any ultrasonic effect, but the ultrasonic brush produced slightly improved plaque removal.
- Terezhalmy et al.  compared the ultrasonic toothbrush to the oral-B 40 toothbrush in 54 subjects, during a 30-day trial. The ultrasonic toothbrush was significantly more potential in plaque removal.
- Zimmer S,  evaluated the efficacy of the Ultra Sonex Ultima (R) in comparison with a conventional manual toothbrush in 64 healthy volunteers. The Turesky modification of the Quigley-Hein plaque index (PI), the approximal plaque index (API), and the PBI were recorded at baseline. Four and 8 weeks after baseline, the indices were recorded again. The authors concluded that the Ultra Sonex Ultima may be more efficacious than manual toothbrushes in removing plaque and preventing gingivitis in patients without severe periodontal disease.
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