Original Article

Sharma

Clinical Evaluation of the Plaque-removing Ability of Four

Different Toothbrushes in Visually Impaired Children
Asmita Sharmaa/Ruchi Arorab/Mallikarjun Kenchappac/
Deepak P. Bhayyad/Deepesh Singhe
Purpose: To evaluate the efficacy of plaque removal of four different toothbrushes in visually disabled children. Three
manual toothbrushes with different bristle designs (Oral-B CrossAction 40-regular, Oral-B ShinyClean 40-soft, Oral-B Advantage 40-soft) were compared with an electric toothbrush with an oscillating rotating head (Colgate Motion).
Materials and Methods: Forty visually impaired children in a professional education center participated in the study and
were divided into 4 groups of 10 participants each. To obtain a plaque-free condition at baseline, professional toothcleaning was performed on each participant. After instructions on how to use the toothbrushes, each group started the
experiment using a differently designed toothbrush. After 1 week of application, the Quigley Hein plaque index (QHI) was
used to assess the oral hygiene status of each participant. Students t-test was chosen for comparing brushes. P<0.01
was considered as the significance level. Results were presented as mean standard deviation.
Results: The QHI values obtained with the electric Colgate Motion brush were the lowest (0.0880.051) and Advantage (0.8010.132) the highest. Although the QHI values with the manual Oral-B CrossAction (0.4390.094) were
lower than those with the Oral-B shiny clean (0.5030.098), there was no statistical difference between the two.
Conclusion: The electric toothbrushes are still the most effective in the visually disabled group. However, because of
cheaper cost, easier availability and use, the Oral-B CrossAction toothbrush with criss-cross bristles could be a suitable
alternative.
Key words: plaque, toothbrush, visually impaired
Oral Health Prev Dent 2012;10: 1-6

oothbrushing and other mechanical measures

are the most practical and effective means of
achieving and maintaining adequate oral hygiene
(Audrey et al, 2001). Up to now, the toothbrush still
remains the most efficient of all cleaning devices
(Renton et al, 2001), and brush design and mechanisation of the brushing process have been the
subject of innumerable studies. Various toothbrush
a

Postgraduate Student, Department of Paedodontics and Preventive Dentistry, Darshan Dental College and Hospital, Udaipur, India.

Professor and Head of the Department, Department of Paedodontics and Preventive Dentistry, Darshan Dental College and Hospital, Loyara, Udaipur, India.

Professor, Department of Pedodontics and Preventive Dentistry,

Darshan Dental College and Hospital, Loyara, Udaipur, India.

Reader, Department of Pedodontics and Preventive Dentistry, Darshan Dental College and Hospital, Loyara, Udaipur, India.

Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Darshan Dental College and Hospital, Loyara, Udaipur, India.

Correspondence: Dr A. Sharma, Ranakpura Road, Loyara,

Udaipur-313011 Rajasthan, India. Tel: +91-946-857-9604. Email:
dr_asmitasharma@yahoo.com

Vol x, No x, 20xx

Submitted for publication: 13.7.11; accepted for publication: 21.12.11

designs have been recommended to enhance the

mechanical removal of dental plaque (Chava et al,
2000, Deery et al, 2004), with a number of studies
examining the efficacy of different toothbrushes
with different bristle designs in children (Bastiaan
et al, 1986, Sripriya et al, 2007), but there are few
studies about the efficacy of different toothbrushes
in disabled children. Effective toothbrushing depends on a technically correct toothbrush and on
patient compliance. Toothbrushing remains the
most efficient long-term means of removing the
dental plaque in children. Childrens ability to use
the toothbrush varies greatly not only according to
their age but also to their individual dexterity and
motivation (Unkel et al, 1995).
Effective mechanical plaque removal by means
of toothbrushing is an important oral health measure to prevent the initiation and progress of periodontal diseases (Audrey et al, 2001). However, the
high prevalence of periodontal disease in the general population indicates that individual tooth
brushing performance is often inadequate (Hunter

Sharma

et al, 1994, Vander et al, 2004). Children are no

exception in this case (Nandini, 2003; Chang et al,
2005).
Little data is available on the prevalence of dental and periodontal conditions among visually impaired children (Chang et al, 2005). Many studies
agree that these children have poor oral hygiene
compared to the general population due to limited
dental services targeting this group of children (Joseph, 1979; Bhavsagar et al, 1995; Ahmed et al,
2009; Miliani et al, 2009; Shetty et al, 2010). Visually disabled children are generally incapable of obtaining an adequate oral hygiene level by manual
brushing because of their limited skills, limited intellectual capacity in some children, other disorders and health problems, their lack of knowledge
about oral hygiene and effective brushing and the
reduced amount of time spent brushing their teeth
(Martens et al, 2000; Sebnem et al, 2006; Azrina
et al, 2007). It has been estimated that two-thirds
of people with a visual impairment have other disabilities and health problems (Mahoney et al,
2008). Thus, it has been suggested that complete
plaque removal with a conventional toothbrush is
not realistic for this group. For this reason, studies
were directed at developing new toothbrushes to
improve effective plaque removal.
According to some authors, electric toothbrushes are especially suited for people with disabilities
(Ross, 1986; Vander et al, 1993; Deery et al, 2004;
Dogan et al, 2004; Penick, 2004). Hence, the aim
of this study was to compare the plaque-removing
capability of four different toothbrushes (3 manual,
1 electric) with different bristle designs in visually
impaired children.

MATERIALS AND METHODS

Forty visually impaired children aged 614 years in
an orphanage/professional education center for
visually impaired children participated in this crosssectional double blind study. All the participants
were males, as the orphanage was only for boys.
Permission for carrying out this study was given by
the Superintendent of the institution. The ethical
approval for the project was obtained from Darshan
Dental College and Hospital, Udaipur, Rajasthan,
India.
Children were randomly divided into four groups according to the toothbrushes used (Fig1): Oral-B
Shiny Clean (zig-zag bristle design), Oral-B CrossAction (criss-cross bristle design), Oral-B Advantage
2

Fig 1From left to right: OralB Shiny Clean, OralB CrossAction, OralB Advantage, Colgate Motion electric toothbrush
with rotating, oscillating head.

(flat-trim bristle design) (Oral-B; Cincinnati, OH, USA)

and Colgate Motion electric toothbrush with oscillating rotating head (Colgate; New York, NY, USA).
All the subjects who were selected fulfilled the
following modified criteria of Chava (Chava, 2000):
1) no history of receiving antibiotic and/or antiseptic therapy; 2) no use of supplemental plaque control aids over the previous 5 months; 3) children
with ability to brush their own teeth.
Baseline scores were rendered zero as each participant went through professional prophylaxis done
by the first examiner in the Department of Paedodontics and Preventive Dentistry, Darshan Dental
College and Hospital to ensure a plaque-free starting point. Before the experiment, the children were
randomly assigned to 4 groups with 10 participants
each. All the groups were compared amongst each
other. The examiner taught every child individually
how to hold the brush handle and position the
brush in all areas of the mouth. After instructions
on how to use the tooth brushes, each group started the study with a different type of toothbrush.
Most of the subjects were currently cleaning their
mouths only in the morning with a conventional
manual toothbrush and toothpaste.
The horizontal scrub technique, which is scrubbing in anterio-posterior direction keeping the brush
horizontal, was used by all participants brushing
their teeth with the manual toothbrushes (Wilkens,
2005; Davies et al, 2009). Instructions on how to
use the electric toothbrushes were given to the children of that group.
Brushing time was 3 min, performed twice a day
(Jonathan, 2009). The children were given toothpaste by the examiner and were instructed to use a
pea-sized amount of it (Colgate) during the entire
Oral Health & Preventive Dentistry

Sharma
Table 1 Means and standard deviations (SD) of the QHI
(n = 40)
Toothbrushes

Mean

SD

Oral-B Advantage

0.801

0.132

Oral-B ShinyClean

0.503

0.098

Oral-B CrossAction

0.439

0.094

Colgate Motion

0.088

0.051

Table 2 Level of significance between different toothbrushes

P-value

Significance

Zig-zag (Shiny Clean) vs

Criss-cross (CrossAction)

> 0.05

Nonsignificant

Zig-zag vs
flat trim (Advantage)

< 0.001

Highly
significant

Zig-zag vs
electric toothbrush

< 0.001

Highly
significant

Criss-cross vs
flat trim

< 0.001

Highly
significant

Criss-cross vs
electric toothbrush

< 0.001

Highly
significant

Flat-trim vs
electric toothbrush

< 0.001

Highly
significant

1
0.8
0.6
0.4
0.2

we
r
po

im

cr

fla

t-t
r

ss
cr
o

-za

zig

All the participants completed the study. There was

a statistically significant difference between the
Colgate Motion electric toothbrush and the other
toothbrushes (P<0.001). There was also a statistically significant difference (P<0.001) between
the manual Oral-B CrossAction, Oral-B Shiny Clean
and Oral-B Advantage. The QHI values of the electric Colgate Motion were the lowest (0.088 0.051),
followed by the Oral-B manual CrossAction
(0.4390.094) and Shiny Clean (0.5030.098),
with Advantage showing the highest values
(0.8010.132). Although the QHI values of the
manual Oral-B CrossAction were lower than that of
the Oral-B Shiny Clean, there was no statistical difference (P>0.05) between the two (Tables1 and
2, Fig2).

Mean Plaque Score

RESULTS

Bristle design
(toothbrush brand)

is
s-

study (Pang et al, 1992; AAPD, 2009; Scottish Intercollegiate Guideline Network, 2009; AAPD,
2009). The caretakers and teachers were instructed to check that the children brushed twice daily;
they were also asked to monitor and make sure
that the children brushed for 3 min using same
amount of toothpaste. The plaque-removal effectiveness of the four brushes was evaluated at the
end of the week using the modified Quigley-Hein
Plaque index (QHI). On the day of examination, data
were collected in morning immediately after toothbrushing. The scores were verified by plaque disclosing erythrosine chewable tablets. The QHI was
registered on both the buccal and lingual sides of
all the teeth (Fischman, 1986; Turesky et al, 2006).
All the measurements were performed by the
second examiner, also from the Department of
Pedodontics and Preventive Dentistry, Darshan
Dental College and Hospital, who was trained and
calibrated to assess the index. Students t-test was
chosen for comparing brushes. P<0.01 was set
as the significance level. Results were given as
meanstandard deviation.

Type of Bristles

Fig 2Different types of toothbrushes with different bristle

design and their mean Quigley-Hein plaque index score.

DISCUSSION
The number of blind people in the world is not accurately known, but it has been estimated various
times by the World Health Organization. Blindness
affects over 180 million people today and worldwide it is estimated that 45 million people are totally visually impaired. In India, sensory impairment

Vol x, No x, 20xx

(visual and hearing) accounts for the largest percentage of disability. The number of visual impaired
persons in India is 10,634,881 and accounts for
48.55% of total disability (Kishor, 2006). Almost
half of these have additional disabilities, such as
deafness, physical handicaps or learning difficulties, which complicate their needs.
3

Sharma

Blindness is one disorder that may result in frequent hospitalisations, separation from family and
slow social development. Since a blind childs abilities are difficult to assess, often such a child may
be considered to be a late developer. Sensory defects often mask a childs intellectual capacity because responses cannot be the same as in other
children (Sebnem et al, 2006). Visually impaired
children may learn to speak later than sighted children and may start school when they are a year or
more older. In addition, they are deprived of the opportunity to learn by imitation. Since the families of
visually disabled children tend to focus on the problems related to their blindness, they neglect their
oral hygiene. This is the reason for which the study
was conducted in visually disabled children.
It is of great importance to establish good oral
hygiene routines and knowledge early in life, particularly in disabled patients. Fortunately, for children with sensory disabilities affecting sight and
hearing, a variety of innovative teaching methods
and mechanical aids are available to enhance their
development towards a meaningful and productive
life. These techniques are most effective when introduced early. They may need special instructions
and approaches, since loss of sight is a major physical deprivation.
Dental and periodontal problems are more prevalent in visually disabled patients, although the etiology is similar to that of healthy children (Joseph,
1979; Bhavsagar et al, 1995; Ahmed et al, 2009;
Milliani et al, 2009; Shetty et al, 2010). However, it
is of utmost importance to control and treat oral
and dental diseases at an early stage of development, especially for this group. Only limited studies
worldwide have specifically assessed these parameters among visually impaired children (Chang et al,
2005).
It is known that effective toothbrushing depends
on the toothbrush, brushing time, manual dexterity,
motivation and ability to follow instructions (Martens et al, 2000). The development of manual dexterity is related to chronological age, so it is thought
that a child of 6 years is capable of independent
brushing (Unkel et al, 2000; Choo et al, 2001). For
this reason, children under 6 years old were not included in this study. Moreover, it is believed that
the shape of the toothbrush might increase the
brushing effectiveness for this group of patients
(Dogan et al, 2004). The importance of toothbrushing techniques and the relative effectiveness of different types of toothbrush have been the focus of
many studies in this research area (Ross, 1986;
4

Vander et al, 1993; Zimmer et al, 1999; Deery et

al, 2004; Dogan et al, 2004; Penick, 2004; Camela
et al, 2006). Different shapes and locations for the
handle and bristles have been designed to increase
plaque-removing efficacy in hard to reach places.
Evidently, the effectiveness of a toothbrush is dependent on the user in both guiding the head to all
accessible surfaces of the teeth and providing the
appropriate mechanical action to enable the filaments to remove surface deposits. For electric
toothbrushes, the user need only guide the head of
the brush around the dentition (Penick, 2004). Various studies have stated that electric toothbrushes
remove significantly more plaque than manual
toothbrushes (Deery et al, 2004; Dogan et al,
2004), as was also shown in the present study.
Contradictory results have been reported in studies evaluating the plaque removing efficacy of toothbrushes (Ainimo et al, 1997). The contradictions
arise mainly from the differences in design and duration of the studies (long- vs short-term). Although
long-term studies yield more reliable results, the
results suggest that patients lose motivation in the
course study. On the other hand, significant clinical
differences arise based on different motivation levels of the patients, as proved by earlier long-term
and short-term studies done by various authors
mentioned in this study. This is known as the Hawthorne effect (Haesman et al, 1999). Zimmer et al
(1999) argue that one week is enough to assess
the plaque-removal efficacy, because it is a matter
of only hours before visible plaque reappears even
on professionally cleaned teeth (Zimmer et al,
1999; Wolff et al, 2005). In terms of motivation
levels, the results presented here are in accordance with the previous short-term findings, as the
children did not lose motivation over the course of
study, unlike in long-term studies. In terms of evaluating the plaque-removing capability of different
toothbrushes with different bristle designs used by
visually impaired children, the results are in accordance with both long-term and short-term studies,
as the electric toothbrush proved to be the best,
especially in the disabled group.
Electric toothbrushes have been used by the disabled over the years owing to their advantage of not
requiring much manual dexterity. Although it has
long been argued by researchers that electric toothbrushes can be used to advantage also by healthy
individuals, it was only confirmed at the end of the
1990s by U.S. and European Periodontologists that
electric toothbrushes perform better in plaque removal compared to manual toothbrushes (Renton
Oral Health & Preventive Dentistry

Sharma

et al, 2001). Studies conducted to investigate the

reasons for the lack of popularity of electric toothbrushes have found that these brushes were not
adequately recommended by dentists and the patients were not adequately informed. Other disadvantages of the equipment are the higher cost and
maintenance (Saxer et al, 1997).

CONCLUSION
The current study showed that electric toothbrushes are the most effective type of toothbrush in visually disabled groups, better than the manual toothbrushes. The required manual dexterity for
toothbrushing was present among the younger children examined here, and our results affirm the
need for toothbrushing instructions in young children appropriate to their manual skills. Instructions
should be given according to the childrens degree
of readiness for toothbrushing and their stage of
psychological development, and should include systematic training and reinforcement. Intensive individual training is essential; each person with visual
impairment must be considered in relation to individual aptitudes, interests, abilities and potential,
with sight as one factor involved.
Oral health can have a significant impact on overall well-being. Oral health education gives the individual accurate information with which to take actions for the benefit of their health. Thus, it is
important to maintain and improve existing oral
health education programmes to better reach the
targeted children.

ACKNOWLEDGEMENT
This study would not have been completed without the help of Dr.
Parvind Gumber, post-graduate student, Department of Oral Pathology, who helped in data collection. My heartfelt thanks go to Mr.
Virendra, superintendent of the School for the Blind, Udaipur, Rajasthan, who was kind enough to permit us to carry out this study in
his institution.

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