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ORIGINAL ARTICLE
Year : 2007  |  Volume : 25  |  Issue : 2  |  Page : 76-81
 

A comparative study of the efficacy of four different bristle designs of tooth brushes in plaque removal


Department of Preventive and Community Dentistry, MS Ramaiah Dental College, Bangalore - 560 054, India

Correspondence Address:
N Sripriya
Department of Preventive and Community Dentistry, MS Ramaiah Dental College, Bangalore - 560 054
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.33452

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   Abstract 

Background : The aim of the study was to compare the efficacy of four most commonly used bristle designs of toothbrushes in plaque removal.
Materials and Methods : The study was a randomized 4 cell, examiner blind cross-over design assessing the plaque removal efficacy of all four brushes on a single occasion. Sixteen subjects aged 14-15 years participated in the study. On day 1 of each test period, the subjects were rendered plaque free and were asked to suspend oral hygiene practices for 24 hours. On day 2, the subjects were scored for plaque prior to brushing using the Turesky-Gilmore modification of Quigley-Hein plaque index. The subjects then brushed with the allocated toothbrush for 2 minutes and the post-brushing plaque scores were assessed. A wash-out period of 4 days was allowed between the test periods.
Results : All the brushes showed a significant reduction in the post-brushing plaque scores ( p < 0.001). The mean reduction in the plaque scores for all the brushes was around 53%. The percentage plaque reduction was greater in the anterior surface than the posterior surface (59.6 7.45% vs. 49.83 4.35%). The percentage plaque reductions in the upper, lower, buccal and lingual surfaces were similar. No significant difference in the reduction of plaque scores between the four brushes was seen.
Conclusion : The data derived from the study supports the contention of many researchers that there is no single superior design of manual toothbrush. Though minor and some site differences in favor of the brushes were seen, they were not statistically significant.


Keywords: Bristle design, plaque removal, toothbrush


How to cite this article:
Sripriya N, Shaik Hyder Ali K H. A comparative study of the efficacy of four different bristle designs of tooth brushes in plaque removal. J Indian Soc Pedod Prev Dent 2007;25:76-81

How to cite this URL:
Sripriya N, Shaik Hyder Ali K H. A comparative study of the efficacy of four different bristle designs of tooth brushes in plaque removal. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2019 Jul 21];25:76-81. Available from: http://www.jisppd.com/text.asp?2007/25/2/76/33452



   Introduction Top


Dental caries and periodontal disease are the most commonly occurring diseases affecting mankind. Dental plaque is a very important factor in the causation of both these diseases. [1],[2],[3] Realistically, these diseases are kept at bay through personal and professional oral hygiene measures. Toothbrush is one of the most commonly used adjuncts for maintaining oral hygiene.

The toothbrush has undergone a great degree of sophistication [4] and is by far the most widely accepted and adopted tooth-cleaning tool. Since its introduction and particularly in the last decade, numerous designs of the manual toothbrush have emerged and the media abounds with claims of superiority in plaque removal by individual brands.

The role of toothbrushes in preventing the initiation and progression of periodontal diseases has been well documented. It has been adequately demonstrated that the accumulation of microbial plaque results in the development of gingival inflammation and daily removal of plaque leads to resolution of the gingival inflammation in just a few days. [5] Patients who have not received any professional advice regarding the type of brush to be used for cleaning, usually choose brushes based on cost, availability, advertising claims, family tradition or habit. The various designs of toothbrushes available in the market often put the common man in dilemma about the best design and they often seek professional advice on this matter. The bristles are perhaps the most important consideration in selecting a good toothbrush. The different bristle designs include flat trim, multilevel, wavy design, zigzag design and many more but no evidence of the superiority of one design over the other has been documented. [6],[7],[8] Because of the varieties of brushes currently available and the constant development of new brushes, the dental professional must maintain a high level of knowledge of these products and advice the patients appropriately.

Various studies have been conducted regarding the efficacy of manual toothbrushes. Needless to say, the results are conflicting, with some studies reporting some designs of toothbrushes to be superior, [9] but the general consensus in most of the studies has been that there is no one superior design of toothbrush for plaque removal. [10]

There are very few studies conducted in India on the efficacy of manual toothbrushes in plaque removal and their results have been contradictory. Hence this study has been undertaken to compare the plaque-removing efficacy of four different designs of toothbrushes and to recommend the best manual brush of the four based on the findings of the clinical study.


   Materials and Methods Top


The present clinical study was conducted on 14 to 15 year old school children in a higher secondary school. Before starting the study, necessary permission from the concerned authorities was obtained and the study protocols followed, were in accordance with the ethical standards of the committee on human experimentation (of the institution involved in the study) and with the principles and guidelines of the Helsinki Declaration.

Four different types of commercially available manual toothbrushes were selected for the study [Figure - 1]. These brushes differed in their pattern of bristle arrangement. The four different designs of brushes were -

A. Toothbrush with a flat-trim bristle arrangement

B. Toothbrush with bi-level bristles arrangement

C. Toothbrush with wavy bristle arrangement

D. Toothbrush with zigzag bristle arrangement

The bristles of all the toothbrushes were of "soft" type.

Male and female children aged 14-15 years with good general health and with a minimum of 25 intact teeth were included in the study, while subjects undergoing orthodontic treatment, with excessive dental caries (more than four unrestored carious teeth) advanced periodontal disease, with a history of antibiotic usage at least 2 weeks prior to the study, and who may require antibiotics during the course of the study were excluded.

The study was a randomized 4 cell, examiner blind cross-over clinical study to evaluate the efficacy of four designs of toothbrushes in single use plaque removal. The subjects were allocated toothbrushes based on the random list prepared. A nonparticipating dentist was requested to carry out the randomization procedure. Each of the toothbrushes was given a code. The codes were decoded only at the end of the study.

Before the start of the actual study, calibration of the examiner was done by examining a few subjects who were not included in the study. The subjects in the study were taught the roll method of brushing before the start of the study. On the first day of each test period, the subjects were rendered plaque free and were then asked to refrain from oral hygiene practices for 24 hours. On day two, the subjects were assessed for plaque prior to brushing according to the criteria of Turesky and Gilmore modification of Quigley-Hein plaque index. [11] Plaque was assessed on the buccal and lingual surfaces of all teeth except the third molars using the erythrosine disclosing solution. The subjects were then allocated the toothbrushes and were asked to brush for 2 minutes, following which they were rescored for plaque using the same index. The same procedure was followed during test periods 3, 4 and 5. A wash-out period of 4 days was allowed between the study periods, during which the subjects returned to normal oral hygiene practices. Mean plaque index for each subject was determined by adding all the individual plaque scores (two per tooth) and dividing the sum by the total number of surfaces examined.


   Results Top


Of the 16 subjects included in the study there were no dropouts. The codes given to the four brushes were as follows:

BRUSH A = flat-trim bristle design

BRUSH B = bi-level bristle design

BRUSH C = wavy bristle design

BRUSH D = zigzag bristle design

The results of the study were as follows:

Equal number of male and female subjects participated in the clinical study. There were 8 males (50%) and 8 females (50%). Distribution of prebrushing plaque scores among the four brushes showed that the plaque accumulation during all four test periods were to a similar degree (3.49 0.16, 3.36 0.15, 3.36 0.08, 3.35 0.11 for brushes A, B, C and D respectively). Though "Brush A" group showed greater accumulation of plaque, it was not statistically significant. Comparison of the prebrushing plaque scores among the four test periods on the upper surfaces showed that the plaque accumulation were similar during all four test periods (3.46 0.19, 3.32 0.16, 3.36 0.13, 3.31 0.11 for brushes A, B, C and D respectively). Though the plaque accumulation in the "Brush A" group was slightly higher on the upper surfaces, it was not statistically significant. Comparison of the prebrushing plaque scores among the four test periods on the lower surfaces showed that the plaque accumulation were similar during all four test periods (3.52 0.17, 3.41 0.16, 3.39 0.13, 3.35 0.12 for brushes A, B, C and D respectively). Though the "Brush A" group showed greater accumulation of plaque on the lower surfaces, it was not statistically significant.

Comparison of the prebrushing plaque scores among the four test periods on the buccal surfaces showed that the plaque accumulation were similar during all four test periods (3.40 0.16, 3.28 0.14, 3.31 0.17, 3.29 0.12 for brushes A, B, C and D respectively). Though the "Brush A" group showed greater accumulation of plaque on the buccal surfaces, it was not statistically significant. Comparison of the prebrushing plaque scores among the four test periods on the lingual surfaces showed that the plaque accumulation were similar during all four test periods (3.58 0.18, 3.451 0.19, 3.45 0.25, 3.37 0.12 for brushes A, B, C and D respectively). Though the "Brush A" group showed greater accumulation of plaque on the lingual surfaces, it was not statistically significant.

Comparison of the prebrushing plaque scores among the four test periods on the anterior surfaces showed that the plaque accumulation was similar during all four test periods. Though the "Brush A" group showed greater accumulation of plaque on the anterior surfaces, it was not statistically significant. The anterior surfaces showed lesser plaque accumulation when compared to the other surfaces (3.17 0.32, 2.99 0.22, 3.04 0.17, 2.90 0.21 for brushes A, B, C and D respectively). Comparison of the prebrushing plaque scores among the four test periods on the posterior surfaces showed that the plaque accumulation was similar during all four test periods. Though the "Brush A" group showed greater accumulation of plaque on the posterior surfaces, it was not statistically significant. The posterior surfaces showed greater plaque accumulation when compared to the other surfaces (3.75 0.21, 3.60 0.24, 3.58 0.16, 3.62 0.17 for brushes A, B, C and D respectively). The anterior surfaces showed lesser accumulation and the posterior surfaces showed greater accumulation than the other surfaces.

Distribution of postbrushing plaque scores among the four brushes showed that the amount of residual plaque was similar for all four brushes (1.68 0.10, 1.55 0.16, 1.57 0.09, 1.49 0.05 for brushes A, B, C and D respectively) [Graph 1] . Though "Brush A" group showed greater postbrushing out residual plaque when compared to the other three groups, it was not statistically significant [Graph 2].

Comparison of the postbrushing plaque scores among the four brushes on the upper surfaces showed that the residual plaque accumulation was similar for all four brushes (1.66 0.12, 1.54 0.16, 1.54 0.12, 1.48 0.08 for brushes A, B, C and D respectively). Though the "Brush A" group showed greater residual accumulation of plaque on the upper surfaces, it was not statistically significant. Comparison of the postbrushing plaque scores among the four brushes on the lower surfaces showed that the residual plaque accumulation was similar for all four brushes (1.69 0.08, 1.56 0.18, 1.6 0.09, 1.53 0.04 for brushes A, B, C and D respectively). Though the "Brush A" group showed greater accumulation of plaque on the lower surfaces, it was not statistically significant [Graph 3].

Comparison of the postbrushing plaque scores among the four brushes on the buccal surfaces showed that the residual plaque accumulation was similar for all four brushes (1.65 0.11, 1.53 0.17, 1.54 0.1, 1.48 0.06 for brushes A, B, C and D respectively). Though the "Brush A" group showed greater residual accumulation of plaque on the buccal surfaces, it was not statistically significant. Comparison of the postbrushing plaque scores among the four brushes on the lingual surfaces showed that the residual plaque accumulation was similar for all four brushes (1.70 0.08, 1.58 0.16, 1.60 0.1, 1.52 0.05 for brushes A, B, C and D respectively). Though the "Brush A" group showed greater accumulation of plaque on the lingual surfaces, it was not statistically significant. Comparison of the plaque scores between the buccal and lingual surfaces showed no significant differences between the two surfaces [Graph 4].

Comparison of the postbrushing plaque scores among the four brushes on the anterior surfaces showed that the plaque accumulation was similar for all four brushes (1.29 0.19, 1.17 0.29, 1.22 0.15, 1.17 0.13 for brushes A, B, C and D respectively). Though the "Brush A" group showed greater accumulation of residual plaque on the anterior surfaces, it was not statistically significant. The anterior surfaces showed lesser plaque accumulation when compared to the other surfaces. Comparison of the postbrushing plaque scores among the four brushes on the posterior surfaces showed that the plaque accumulation was similar during all four test periods (1.92 0.11, 1.84 0.11, 1.79 0.14, 1.73 0.14 for brushes A, B, C and D respectively) [Graph 5].

A comparison of percentage reduction on the mean plaque scores between the four brushes showed no significant differences between the four brushes (51.82, 53.53, 54.09 and 55.41 for brushes A, B, C and D respectively). All the brushes reduced plaque to a similar degree on all surfaces. Though the "Brush D" group showed greater reduction in the plaque scores, it was not statistically significant ( p = 0.11) [Graph 2]. Paired comparisons of percentage reductions in the plaque scores between the upper and lower surfaces of all four brushes showed no significant differences between the two surfaces. Paired comparison of the percentage reduction in plaque scores between the buccal and lingual surfaces of all four brushes also showed no significant differences between the two surfaces. Paired comparison of the percentage reduction in plaque scores between anterior and posterior surfaces of all four brushes showed that there was a significant reduction in plaque scores on the anterior surfaces when compared to the posterior surfaces ( p < 0.001) [Graph 5].


   Discussion Top


There is a general agreement that a positive correlation exists between bacterial plaque on the tooth surfaces and gingival inflammation. The strong association of plaque with gingivitis was revealed in several epidemiological surveys. [2] Mechanical plaque control is the most important strategy to prevent periodontal disease and manual toothbrushes are the most frequently used devices. Tooth brushing plays a pivotal role in the defense against plaque and gingivitis.

The paucity of studies on the effects of plaque removal is largely due to the biomechanical complexity imposed by the teeth and the oral cavity that houses them. The clinical evaluation of tooth-brushing efficiency is constrained by a number of factors such as time devoted to brushing, hand pressure, manual dexterity, patient motivation, brushing technique and also by the criteria used to measure plaque. [12] Although several workshops and reviews have consistently concluded that there is no superior design of manual toothbrush, [6],[7],[12] yet different companies are coming out with different designs, each claiming superiority, backed by the results of their own clinical research teams. Therefore, the present clinical study was undertaken to find out if any significant differences exist between four different bristle designs of toothbrushes.

Different studies have been conducted for different time periods and no fixed duration has been agreed upon. Studies ranging from single use to 1 month to 6 months have been conducted. In this study, a cross-over design assessing the efficacy of four different bristle designs of toothbrushes in single-use plaque removal was employed. Single-use plaque removal studies are considered to be as accurate as conventional plaque removal studies in assessing the efficacy of brushes. [10],[12],[13],[14],[15],[16],[17],[18]

The choice of the index was based on the fact that with this index all natural teeth (except third molars) can be assessed for plaque and it provides more sensitive and accurate evaluation of brushing effectiveness compared to other indices used in other studies [11],[17] where only certain designated teeth were assessed. Moreover, the index is simple, reliable and reproducible and facilitates comparison with other studies.

The results of the study showed equal plaque accumulation on all surfaces, although the posterior surfaces showed greater accumulation when compared to the other surfaces. This is in agreement with most of the previous studies. [14],[19] The plaque scores were similar during all the four test periods. The results of the study showed no statistically significant differences between the four brushes. This is in line with the study by Bergenholtz et al., [18] who conducted a similar study comparing the toothbrush having v-shaped bristles with a flat-trim toothbrush and concluded no significant differences between the toothbrushes. It is also similar to the studies by Staudt, [20] who conducted a study to compare the efficacy of three toothbrushes - namely, convex bristle, multilevel bristle and flat-trim bristle. This study used a computer-based planimetric plaque index, which is considered to be superior in terms of sensitivity, objectivity and reliability. The results of their study were similar to that of the present study in that no toothbrush could prove significant superiority over the other brushes. However, this study is in contradiction to the study by Kieser and Groenveld, [21] where all brushes reduced plaque to a similar degree. The positive results in the Kieser and Groenveld [21] study can be attributed to the use of Silness and Loe plaque index, which scores plaque on six teeth and does not take the plaque scores on the remaining teeth into consideration.

In the present study, the reduction of the mean plaque scores reached approximately 52% compared to the baseline plaque scores. This is in line with the study by Claydon and Addy, [19] who conducted a single-use plaque removal study to compare the efficacy of four different bristle designs of toothbrushes and concluded that all the subjects removed approximately 60% of the accumulated plaque with different designs of brushes and whatever minute differences were observed were of little clinical significance. The results of the present study are also similar to the study by Claydon and Leech, [22] who conducted a single-use study to compare the efficacy of a double-textured prototype manual toothbrush with three branded products and found that all four brushes removed about 50% of the accumulated plaque and there was no significant superiority of one toothbrush design over the other.

The V-trim toothbrush (zigzag) is equally effective as the flat-trim toothbrush and no significant differences were observed between the two brushes (i.e., 55 and 52%), but a similar comparison study by Turner et al . [23] and Kakar et al . [24] showed that the zigzag toothbrush removed more plaque compared to the flat-trim toothbrush.

The results of the present clinical study indicated that all the toothbrushes reduced plaque scores significantly compared to the baseline scores and yet no significant differences were observed between the four brushes. This is in contradiction to the study by Cohen, [14] who compared a newly introduced brush with bristles inclined upward and outward and a flat-trim toothbrush and concluded that the new brush was superior. A comparison of the percentage plaque reduction on all surfaces showed that the anterior surface showed greater reduction and the posterior surface least reduction than the other surfaces. This is in agreement with the study by Claydon, [19] who showed greater postbrushing residual plaque on the posterior surface.

In the present study, though the Brush D showed a slightly greater reduction when compared to the other three brushes, it was not statistically significant. Overall, the results of the present study showed that all four brushes were equally effective in reducing the plaque scores and there was no superior design of manual toothbrush. Finally, it is apparent that single-use brushing studies are merely screening experiments and should not be considered definitive. This is particularly important since they provide no data on gingival health status.


   Conclusion Top


Tooth brushing continues to be the most widely used form of oral hygiene practice the world over, but majority of the population does less than an optimal job of plaque removal. Of the many factors that influence plaque removal by a toothbrush, bristle design has been a widely studied aspect. Marked changes in the design of toothbrushes have occurred in the last decade but still no data demonstrates unequivocally that one toothbrush design is better than the other.

In conclusion, the present study showed no significant differences between the four toothbrushes. The data derived from the study supports the contention of many researchers that there is no one superior design of manual toothbrush. This leads to a uncontested conclusion that the user is by far the most significant variable affecting the tooth-brushing efficacy.

 
   References Top

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2.Ash MM, Githin BN, Smith WA. Correlation between plaque and gingivitis. J Periodontol 1964;35:424-9.  Back to cited text no. 2    
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4.Wilkins EM. Clinical practice of the dental hygienist. 7 th ed. Lea and Fabriger: 1994. p. 333-7.  Back to cited text no. 4    
5.Loef H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol 1965;36:177-87.  Back to cited text no. 5    
6.Frandsen A. Mechanical oral hygiene practices. In: Loe H, Kleinman M, editors. Dental plaque control measures and oral hygiene practices. 1 st ed. DVIRL Press: Oxford; 1986. p. 93-116.  Back to cited text no. 6    
7.Jepsen S. Role of manual toothbrushes in effective plaque control: Advantages and limitations. In: Lang NP, Attstrom R, Loe H, editors. Proceedings of European workshop on Mechanical plaque control. 1 st ed. Quintessence Publishing: Illinois; 1983. p. 121-37.  Back to cited text no. 7    
8.Hancock EB. Periodontal diseases: Prevention. Ann Periodontol 1996;1:223-49.  Back to cited text no. 8    
9.Nygaard-Ostby P, Edvardsen S, Spydevold B. Access to interproximal tooth surfaces by different bristle designs and stiffnesses of toothbrushes. Scan J Dent Res 1979;87:424-30.  Back to cited text no. 9    
10.Claydon N, Leech K, Addy M, Newcombe RG, Ley F, Scratcher C. Comparison of a double-textured prototype manual toothbrush with 3 branded products. A professional brushing study. J Clin Periodontol 2000;27:744-8.  Back to cited text no. 10    
11.Bay I, Kardel KM, Skougaard MR. Quantitative evaluation of plaque removal ability of different types of toothbrushes. J Periodontol 1967;38:526-33.  Back to cited text no. 11    
12.Addy M. Measuring success in toothbrush design- An opinion and debate of concepts. Int Dent J 1998;48:509-18.  Back to cited text no. 12    
13.Suomi JD, Horowitz AM, Weiss RL, McClendon BJ, Driscoll WS. Comparison of the plaque removing ability of a standard and an unconventional toothbrush. J Dent Child 1972;39:35-9.  Back to cited text no. 13    
14.Cohen MM. A pilot study testing the plaque-removing ability of a newly invented toothbrush. J Periodontol 1973;44:183-7.  Back to cited text no. 14    
15.Horowitz AM, Suomi JD. A comparison of plaque removal with a standard or an unconventional toothbrush used by youngsters. J Periodontol 1974;45:760-4.  Back to cited text no. 15    
16.Berdon JK, Hornbrook RH, Hayduk SE. An evaluation of six manual toothbrushes by comparing their effectiveness in plaque removal. J Periodontol 1974;45:496-9.  Back to cited text no. 16    
17.Scopp IW, Cohen G, Cancro LP, Bolton S. Clinical evaluation of a newly designed contoured toothbrush. J Periodontol 1976;47:87-90.  Back to cited text no. 17    
18.Bergenholtz A, Gustafsson LB, Segerlund N, Hagberg C, Ostby N. Role of brushing technique and toothbrush design in plaque removal. Scan J Dent Res 1984;92:344-51.  Back to cited text no. 18    
19.Claydon N, Addy M. Comparative single use plaque removal study by toothbrushes of different designs. J Clin Periodontol 1996;23:1112-6.  Back to cited text no. 19    
20.Staudt CB, Kinzel S, Habfeld S, Stein W, Stachle HJ, Dorfer CE. Computer based intra-oral image analysis of the clinical plaque removing capacity of three manual toothbrushes. J Clin Periodontol 2001;28:746-52.  Back to cited text no. 20    
21.Keiser J, Groeneveld H. A clinical evaluation of a novel toothbrush design. J Clin Periodontol 1997;24:419-23.  Back to cited text no. 21    
22.Claydon N, Leech K, Addy M, Newcombe RG, Ley F, Scratcher C. Comparative professional plaque removal study using 8 branded toothbrushes. J Clin Periodontol 2002;29:310-6.  Back to cited text no. 22    
23.Turner PS, Surveyor AB, Turner FP. A clinical comparison of plaque removal of five manual toothbrushes. J Indian Dent Assc 1999;70:77-81.  Back to cited text no. 23    
24.Kakar A, Kakar RC, Kakar K, Kohli R, Rustogi KN. Plaque removing efficacy of a new design toothbrush with Zig-Zag bristle arrangement. J Indian Dent Assc 2002;73:29-34.  Back to cited text no. 24    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]


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