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90]

Review Article

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

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.
Key words: Interdental contacts, plaque, toothbrush

Introduction

Address for Correspondence:

Dr.Deepak Grover,
Department of Periodontics and Oral
Implantology, National Dental College
and Hospital, Derabassi, Punjab, India.
Email:preet342@yahoo.com
Date of Submission: 10-05-2012
Date of Acceptence: 25-08-2012

Access this article online

Website:
www.indjos.com
DOI:
10.4103/0976-6944.106456
Quick Response Code:

62

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

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 dexterity
2. Head size appropriate to the size of the patients mouth
3. Use of endrounded nylon or polyester filaments not
larger than 0.009 inches in diameter
4. 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 handles

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

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 etal.[6] found a conventional flat
multitufted brush significantly more effective than a
convexshaped brush.
Toothbrush bristles

Two kinds of bristle materials are used in toothbrushes:

Natural bristles from the hair of hog or wild boar.
A
 rtificial filaments made predominantly from
Nylon (0.006 to 0.4mm). In case of interdental
brush 0.075mm.
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 (0.2mm) for soft brushes.
0.012 inch (0.3mm) for medium brushes
0.014 inch (0.4mm) 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 (0.2mm) in diameter and
0.406 inch (10.3mm) 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 0.1mm) diameter
and shorter (0.344 inch or 8.7mm) 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 31.8mm)
long and 5/16 to 3/8 inch (7.9 to 9.5mm) wide, two
to four rows of bristles, and 5 to 12 tufts per row.
Atoothbrush should be able to reach and efficiently
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Grover, etal.: Toothbrush - A key to mechanical plaque control

clean most anxious of the teeth.[7]

In contrast, Pretaraspanedda etal.[8] demonstrated that
significantly more plaque was removed after a single
brushing when brushes with higher density were used.
Beatty etal.[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 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.
Twoheaded (double headed)

Bastiaan[10] compared the plaque removing effect of a

doubleheaded brush with that of a singleheaded flat
toothbrush (Oral B 35) in 39patients. The patients were
instructed in the Bass technique and brushes were used
for one week. The results indicated that lingually the
doubleheaded brush was superior to the singleheaded
brush, whereas, buccally no difference was found.
Agerholm[11] tested the plaque removing efficacy of
the new doubleheaded brush (Duodent 2000) in
comparison with a conventional brush (Oral B 32).
Twentyseven patients were attending the clinic for
an initial course of hygiene treatment and 23 were
recall patients with persistently inadequate plaque
control. The doubleheaded toothbrush helped achieve
significantly better lingual and palatal plaque control.
Tripleheaded

The tripleheaded toothbrush is intended to clear the buccal,

occlusal, and lingual or palatal surface of the teeth at one time.
Yankell etal.,[12] conducted a study to test a new
tripleheaded, 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 (OralB 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
flatheaded 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
64

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 etal. (1984[14]) compared a Vshaped

and control multitufted toothbrush in a superior
toothbrushing study and found significantly better
interproximal plaque removal with the Vshaped
brush. In 1984, same authors confirmed these
differences in comparison to spaced and multitufted
toothbrushes.
Bergenholtz etal.[14] could not find a difference in the
plaque removing ability of straight, multitufted, and
Vshaped brushes when they were used unsupervised.
When used professionally, the Vshaped toothbrush was
better at proximal plaque removal than the straight one.
Better interproximal access of Vshaped toothbrushes
was observed by Yankell etal.[15] These authors evaluated
different toothbrushing methods with six different
toothbrushes and observed that a hard toothbrush
with three rows, 12mm 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,
straighthandled, multitufted toothbrushes in plaque
removal efficiency.
In a fourweek crossover study on adult volunteers
(aged 19 to 64years) Wasserman (1985) compared a
newly developed Deepgrooved twolevel toothbrush
(Improve) with a conventional flat brush, with 48 tufts
and four rows. Significantly less plaque was found
lingually in the molar teeth (P < 0.001) and plaque
was also reduced significantly (P<0.03) on the buccal
interproximal surfaces (P<0.5) when the improve brush
(DeepGrooved twolevel) was used.
Curved: (collis curved brush)

The Collis curved brush, with two short middle rows and
curved outer rows, was found by Shory etal.,[17] to be more
effective on the interproximal and gingival, sulcular areas
than a straight multitufted bristle brush. It also improved
the gingival conditions and removed significantly more
plaque than the regular toothbrush.
Avery [18] 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.
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Grover, etal.: Toothbrush - A key to mechanical plaque control

Williams and Schuman[19] 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 etal.[20] investigated
the plaque removing potential of a new light energy
conversion toothbrush incorporated with a semiconductor
of titanium dioxide (TiO2). Asimilar 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 etal. [21] 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
Indian Journal of Oral Sciences Vol. 3 Issue 2 May-Aug 2012

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.
a. Sulcular: Bass
b. Roll: Rolling stroke, modified Stillman
c. Vibratory: Stillman, Charters, Bass
d. Circular: Fones
e. Vertical: Leonard
f. Horizontal
g. Physiological: Smith
h. Scrubbrush 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 backandforth
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 problemsof 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
consensuswas that in nondentally 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 withits
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Grover, etal.: Toothbrush - A key to mechanical plaque control

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[22].

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 sidetoside, arcuate, or backandforth
motions, whereas, circular brush heads have oscillating,
rotational, or counterrotational 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
Vibratory
Elliptical oval
Dual motion more than one of the previous motions
mentioned
Speed

Speed varies from low to high among the different

models. The number of strokes/minute varies from
1000cycles/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[22]).
Ideal characteristics of a powered toothbrush:
(Heasman[22])

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 preset brushing force has been searched
Timers
66

Brush movement

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 40Hz
(cycle/second) for batterypowered brushes to 250Hz
for magnetostrictive devices.
Biophysical action

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 gasfilled bodies (Stable cavitation)
to the violent and highly destructive formation and
collapse of vaporfilled 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 1 103 Nm2. Such forces will occur readily at ultra
sonic frequencies of 25Hz.
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
toothbr ushes are more effective in reducing
decalcifications
Children and adolescents
Handicapped and severely retarded children
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Grover, etal.: Toothbrush - A key to mechanical plaque control

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
wellmotivated 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
communitywide basis, with a view to enhance an interest
in oral hygiene practices.
Efficacy studies

The main electric toothbrushes, which are compared in

the literature, are the Braun Oral Bplaque removers (D5,
D7, and D9) 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.
Rotadent

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 singletuft brush, with small bristles that
reached one surface per tooth. It came with three brush
head designs (Shortpointed, elongated, and hollowcup
brush tip).
Interplak

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 OralB plaque control (D5, D7, and D9)

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 OralB
electric toothbrush was increased from 47Hz to 63Hz
(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 sidetoside movement of the sonicare was
operated at a high frequency of 260Hz.
WuYuan etal.[23] tested sonicare and found that 60%
of the plaque on a titanium surface could be disrupted
at a distance of 2mm away from the object.
Indian Journal of Oral Sciences Vol. 3 Issue 2 May-Aug 2012

In a study by Johnson and McInnes,[24] in adults, plaque

removal with sonicare was compared with a manual brush
OralB 30. After four weeks of use, sonicare was found to
be up to 11times more effective than the manual brush
in removing lingual and interproximal plaque.
In two other studies (McInnes etal., 1994[25]), 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[26] who concluded that Sonicare had no
potential for destruction of restoration, but was
effective in stain removal.
Ultrasonic toothbrush

When a prototype of an ultrasonic brush was compared

with a manual brush by Goldman,[27] patients were not
aware of any ultrasonic effect, but the ultrasonic brush
produced slightly improved plaque removal.
Terezhalmy etal.[28] compared the ultrasonic toothbrush
to the oralB 40 toothbrush in 54 subjects, during a
30day trial. The ultrasonic toothbrush was significantly
more potential in plaque removal.
Zimmer S,[29] 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 QuigleyHein plaque index (PI),
the approximal plaque index (API), and the PBI were
recorded at baseline. Four and 8weeks 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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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.
Source of Support: Nil, Conflict of Interest: None declared

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