Primary Preventive Dentistry 6th Ed. (2004)
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At the end of this chapter it will be possible to The Manual Toothbrush Figure 5-5 Powered Toothbrushes Efficiency / Safety Evaluations The American Dental Association (ADA) Acceptance Program |
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Objectives ^ 1. Give a brief history of the toothbrush, describe its parts in detail, and explain why there is no one "ideal" brush. 2. Compare natural and nylon bristles for their uniformity of length, diameter, and durability. 3. Discuss the wide range of head and handle designs and explain why there are many "new" manual and powered toothbrush products being marketed. 4. Compare and contrast laboratory and clinical evaluations of toothbrush effectiveness. 5. Compare manual and powered toothbrushes for effectiveness and safety. 6. Compare the ADA process for evaluating "standard" and "new" manual toothbrushes. 7. Discuss modifications of toothbrushing methods applicable to special patient care, patients using prostheses, and those under orthodontic care. 8. Discuss interproximal access of different toothbrushes and their possible role in oral-disease treatment and prevention. Introduction After teeth have been completely cleaned by the dental professional or by the individual, soft microbial dental plaque continually reforms on the tooth surfaces. With time, plaque is the primary agent in the development of caries, periodontal disease, and calculusthe three conditions for which individuals most often seek professional services. If plaque, particularly at interproximal and gingival areas, is completely removed with home-care procedures, these dental-disease conditions can be prevented. Unfortunately, the majority of the population is unable, uninstructed, or unwilling or does not realize the need to spend the time to remove plaque from all tooth surfaces, and/or the product(s) used are not adequate to remove plaque at critical sites. Plaque deposits can be removed either mechanically or chemically. The focus of this chapter is the mechanical removal of plaque, using toothbrushes and toothbrushing techniques. The following two chapters emphasize the use of products and auxiliary aids with toothbrushes in removing plaque and the maintenance of healthy teeth and gingival tissues. ^ History Hirschfeld, in his 1939 landmark textbook on the toothbrush and oral care, included an in-depth review of the history of toothbrushing.1 The exact origin of mechanical devices for cleaning teeth is unknown. Ancient peoples chewed twigs from plants with high aromatic properties. Chewing these twigs freshened the breath and spread out fibers at the tips of the twig for cleaning the tooth and gum surfaces. The Arabs before Islam used a piece of the root of the arak tree because its fibers stood out like bristles; this device was called a siwak. After several uses, the bristle fibers became soft, and a new "brush" was created by stripping off the end and making new bristle fibers. In the seventh-century, Mohammed made rules for oral hygiene, and so it became a religious obligation. To this day the siwak, composed from aromatic types of wood, is still used. Chew sticks not only help to physically clean teeth but also, because they contain antibacterial oils and tannins, may help prevent or remove plaque.2 The Chinese are credited for inventing the toothbrush comprising a handle with bristles during the Tang dynasty (618-907 A.D.). They used hog bristles similar to those in some contemporary models. In 1780, in England, William Addis manufactured what was termed "the first modern toothbrush."3,4 This instrument had a bone handle and holes for placement of natural hog bristles, which were held in place by wire. In the early 1900s, celluloid began to replace the bone handle, a changeover that was hastened by World War I when bone and hog bristles were in short supply. As a result of the blockade of high-quality natural hog bristles from China and Russia during World War II, nylon bristles were used instead. Initially, nylon bristles were copies of natural bristles in length and thickness. They were stiffer than natural bristles of similar diameter. They did not have the hollow stem of natural bristles and, accordingly, did not absorb water. Compared to natural bristles, nylon filaments have the additional advantages that they can be prepared in various uniform diameters and shapes, and can be end-rounded to be more gentle on gingival tissues during the brushing procedure. In 1924, an American dentist reported on 37 different manual toothbrushes with regard to handle shape, head design, bristle type, length, and width. Individual dentists disagreed then, and still do today, on what type of toothbrush was best. The primary toothbrush shapes marketed in the 1940s through 1980s in the United States had flat, multitufted toothbrush-head shapes. Since the 1990s new manual toothbrushes have been introduced with new shapes, sizes, colors, and claimed advantages. By varying the length and the angle of the filaments in the brush head, brushing with these newly designed products has been documented to improve plaque removal since the bristle filaments can be directed into the sulcus or interproximal areas.3-12 New unconventional toothbrushes with two or more heads or segments of filaments in angular relation- ship have shown improved plaque removal. One new brush with three heads can be used to simultaneously clean the buccal, occlusal, and lingual surfaces.13-15 The proliferation of brushes can be attributed, in part, to advances in manufacturing, for example, the attachment of bristles into the handle using molding techniques rather than stapling to allow a wider flexibility in toothbrush designs and bristle angulations. In addition, toothbrush bristles are now available in a variety of colors, textures and shapes. There also has been an increase in both the quality and number of laboratory and clinical research studies on toothbrushes. The International Association of Dental Research and American Association of Dental Research are major meetings for both academic and industry scientists to present their latest research. In the 1991 and 1992 key-word indexes of the abstracts accepted for presentation at these meetings, toothbrushes were not included as a topic. In 1993 the number of abstracts were ranked as dentifrices mouthrinses toothbrushes. Since then, through 2001, the number of dentifrice abstracts has shown marked increases or decreases, with a peak of over 90 abstracts in 1998. Mouthrinse abstracts have shown essentially a leveling-off or a slight decrease in number since 1991. Toothbrush abstracts have continued to demonstrate a consistent increase, and at the 2001 AADR meeting, exceeded dentifrices and mouthrinses. With the scientific reports about toothbrush contamination after oral or medical bacterial/ viral infections, dental professionals recommend replacing toothbrushes at 3- to 4-month intervals, so repeat purchasing of toothbrush products is done more frequently. The increase in toothbrush sales may be an additional driving force for the marketing of new designs and variety of toothbrushes. Toothbrush pricing has reached new highs with the introduction of "high-tech" manual toothbrush designs and stronger claims, yet the cost per individual product is generally less than the cost for a "family-size" tube of toothpaste or mouthrinse. Toothbrush shipping costs are less, breakage is minimal and the shelf-life (stability) is longer than for other product categories thus, the potential profitability of toothbrushes to the manufacturers may be greater than for dentifrice or mouthrinse products. Question 1 Which of the following statements, if any, are correct? A. The toothbrush became commercially available in the United States just before the Civil War; the celluloid handle became popular during World War I; and nylon bristles appeared just before World War I. B. While toothbrush-head designs have changed considerably in the past decade, toothbrush bristles shapes have remained essentially the same. C. The cross section of the average toothbrush in the United States, prior to the 1990s, had a flat head and a flat bristle profile. D. Nylon bristles are more firm or stiffer than natural bristles with the same diameter. E. In the 1990s toothbrushes have been the subject of a steadily increasing number of laboratory and clinical research studies. Manual Toothbrush Designs Manual toothbrushes vary in size, shape, texture, and design more than any other category of dental products.5 A manual toothbrush consists of a head with bristles and a handle (Figure 5-1). When the bristles are bunched together, they are known as tufts. The head is arbitrarily divided into the toe, which is at the extreme end of the head, and the heel, which is closest to the handle. A constriction, termed the shank, usually occurs between the handle and the head. Many toothbrushes are manufactured in different sizeslarge, medium, and small (or compact)to adapt better to the oral anatomy of different individuals.5,7 Toothbrushes also differ in their defined hardness or texture, usually being classified as hard, medium, soft or extra soft. Descriptions and measurements of selected U.S. toothbrushes are shown in Table 5-1. Much of the early data comparing the efficacy of various toothbrush designs is contradictory because of (1) the lack of quantitative methods used to measure cleaning (plaque removal), (2) the many sizes and shapes of toothbrushes used, and (3) the lack of standardized toothbrushing procedures used in the studies. More recently, toothbrush heads have been altered to vary bristle lengths and placement in attempts to better reach interproximal areas. Handles have also been ergonomically designed to accommodate multiple dexterity levels. As described in the introduction, the change from the old flat toothbrush to multilevel designs was possible because of new bristle technology and manufacturing procedures. Profiles When viewed from the side, toothbrushes have four basic lateral profiles: concave, convex, flat, and multileveled (rippled or scalloped). The concave shape can be useful for improved cleaning of facial surfaces, whereas convex shapes appear more useful for improved cleaning of lingual surfaces.5 Lateral and cross-section profiles and the overhead appearance of selected toothbrushes commercially available in the United States are shown in Figures 5-2, 5-3, and 5-4. In laboratory and clinical studies, toothbrushes with multilevel profiles were consistently more effective than flat toothbrushes, especially when interproximal efficacy was monitored.6,8,11,16,17 Bristle Shapes Recently, new toothbrush bristle shapes and textures have been fabricated, as shown in ^ . Toothbrush products utilizing these bristles in multiple diameters, textures, and bristle trims have been developed, and laboratory studies have documented improved efficacy of toothbrushes with tapered, feathered and diamond-shaped bristles, compared to toothbrushes with standard round bristles. 18-20 End-rounding Originally, individual toothbrush bristles were cut bluntly and often had sharp end configurations. In 1948, Bass reported that these bristle tips could damage the soft tissues and that rounded, tapered, or smooth bristle tips were less abrasive.21 Although Bass's research was not performed according to strict research protocol, his findings have remained undisputed for more than 40 years. Indeed, advertisers still recommend end-rounded tips for safety and to promote toothbrush sales. When toothbrushes are examined under low magnification, most bristles labeled as "rounded" do in fact appear smooth or end-rounded. However, at higher magnification, as shown in Figure 5-6, many of these "rounded" bristles take on different configurations.5 During use, bristles become smoother and more end-rounded. With continued use, the bristles of the tuft expand and spread out.22 Bristle wear has been shown to vary directly with the toothbrushing load and amount of dentifrice and inversely with bristle diameter.23 In a recent study, there were no significant differences in plaque or gingivitis indices in a group in which toothbrushes were replaced on a monthly basis compared to the second group using their same toothbrush over the 3 month period. The toothbrushes used for 3 months exhibited a significant increase in the wear index compared to the baseline values.24 A 1988 scanning-electron microscope study25 compared end-rounding of bristles from eight marketed types. Based on statistical analysis of 30 toothbrushes of each type, acceptability varied from 22 to 88%, indicating to these authors that some brushes are not sufficiently rounded and are likely to produce gingival damage. In addition, they have abrasive potential on dentin and cementum. A 1992 study26 compared a ripple design with a flat-profile brush using a stereoscopic microscope with fiberoptic lighting. Close to 90% of the bristles of the ripple brush were end-rounded, whereas the flat brush had an average of 52% rounded bristles. Apparently, the degree of end-rounding depends on a manufacturer's specifications and not on toothbrush design. In a study conducted in 2001 on 31 different toothbrushes, only 4 products had more than 50% of the filaments rounded; in 19 products, end-rounding was 12 to 40% and only 0 to 7% in 8 brands. The authors concluded that a large percentage of marketed toothbrushes do not meet acceptable end-rounding criteria.27 If bristles are cut, frayed, or are hollow they can harbor bacteria, viruses, and other potential periopathogens, especially if no dentifrice is used, and they can transfer these into and around the mouth.28 Handle Designs Many of the new toothbrushes in the United States have a styled-handle design. Modifications, such as triangular extrusions or indentations along the sides for a better grasp, a "thumb position" on the back of the handle for more comfort, and various angle bends to permit better access into and around the mouth, have been introduced. Four toothbrush-handle designs are shown in Figure 5-7. Several brushes have recently been marketed with an "angled" design, stated to be like a dental instrument. As shown in Figure 5-8, these toothbrushes are similar to a dental professional's mirror. Brushes are also available, as depicted in Figure 5-9, with a handle on the same plane as the bristle tips, as are dental instruments used for caries evaluations and prophylaxes. With both the offset and angled-offset designs, points of bristle contact are in line with the longitudinal axis of the handle during brushing. Handle design and length may provide comfort and compliance during toothbrush use and these factors have recently been documented to improve the quality of tooth brushing. This is particularly true of toothbrushes for children, whose dexterity may not be highly developed.8,9 Texture Nylon bristles have a uniform diameter and a wide range of predictable textures. Texture is defined as bristle resistance to pressure and is also referred to as firmness, stiffness, and hardness. The firmness or texture of a bristle is related to its (1) composition, (2) diameter, (3) length, and (4) number of individual bristles per tuft. In the manufacturing process, the diameter of nylon bristles can be well controlled. Because the majority of toothbrushes contain bristles 10- to 12-millimeters long, the diameter of the bristle becomes the critical determinant of texture. The usual range of diameters for adult toothbrush bristles is from 0.007 to 0.015 inches. Factors such as temperature, uptake of water (hydration), and toothbrush-use frequency affect texture. Texture labeling is not standardized. Individual manufacturers label their brushes according to their testing criteria. Thus one manufacturer's "soft" grade may be stiffer than another manufacturer's "medium" grade. The International Organization for Standardization (ISO) has formulated testing procedures that permit manufacturers to label their brushes in a consistent manner.29 The American Dental Association is a member of ISO. Nylon Versus Natural Bristles The nylon bristle is superior to the natural (hog) bristle in several aspects. Nylon bristles flex as many as 10 times more often than natural bristles before breaking; they do not split or abrade and are easier to clean. The configurations and hardness of nylon bristles can be standardized within specified and reproducible tolerances. Natural bristle diameters, since they are tapered, vary greatly in each filament. This can lead to wide variations in the resulting texture of the marketed toothbrush. As a result of the advantages of nylon, as well as its ease and economy of production, relatively few natural bristle toothbrushes are marketed. Actions Bristle actions caused by different brushing motions are illustrated in a 1992 publication7 that measured and quantified three-dimensional individual movements during brushing. Data frames were filmed to create a computer-generated reanimation of brushing motions in order to design new toothbrush bristle conformations. These authors concluded that an individual's brushing techniques do not vary and are inadequate; therefore bristle configurations in newly designed toothbrushes could be developed to be adaptable to any brushing style
^ Introduction Powered toothbrushes were first advertised in Harper's Weekly in February 1886,30 but only became a factor in the U.S. marketplace beginning in the 1960s with the introduction of Broxadent. With the commercial success of this product, battery-powered products were introduced with the advantage of being portable and available at a lower cost. Unfortunately, problems with these battery-powered products included short "working times" and mechanical breakdowns. The enthusiasm for the powered toothbrush declined and was recommended mainly for the handicapped. In the 1980s, the category of powered toothbrushes was revitalized with the introduction of the InterPlak product. This "second generation" powered toothbrush had a uniquely rotating head and was powered by long-life/ rechargeable batteries. Increased efficacy compared to manual toothbrushes was consistently demonstrated in published studies.4,8,9, 31-33 Since then, sonic-powered toothbrushes of a "third" generation have been developed and shown to remove more plaque in comparison to manual toothbrushes, especially in long-term studies. Two primary types of head designs are now used: the rotating, oscillating type with a small, round molar-crown-size brush head and three oscillating brushes with either vibrating or rotational sonic movements.34-37 Plaque removal by these brushes appears equally effective; periodontal therapeutic effects were demonstrated in pockets of 5 mm. "Generations" of powered toothbrushes are presented in Table 5-2. Most recently, powered toothbrushes have been introduced that are battery-powered or disposable after "running down," and are priced, in the United States below $20.00. Published studies have been found on two of these brushes.38-39 In most developed countries, the number of powered toothbrush products sold has increased dramatically in recent years. In Switzerland, the regular use of powered toothbrushes increased from 10 to 30% in the last decade. In epidemiological studies, it has been documented that populations are exhibiting increased gingival abrasion and recession. This has been associated with the increased use of oscillating powered toothbrushes. In comparison to these oscillating toothbrushes, sonic toothbrushes have been shown to do little harm to the gingiva. Also sonic brushes of this type can be used up to 6 or 12 months because the bristles show minimal overt signs of use and do not splay.40-44 Bristle/Designs The heads of most powered or mechanical toothbrushes are smaller than manual toothbrushes and are usually removable to allow for replacements (Figure 5-10). The head follows three basic patterns when the motor is started: (1) reciprocating, a back-and-forth movement; (2) arcuate, an up-and-down movement; and (3) elliptical, a combination of the reciprocating and arcuate motions. Powered toothbrushes are consistently superior to manual toothbrushes in plaque removal and gingivitis efficacy.9,31,45 Differences are most significant when tested against manual toothbrushes. Motivation Motivation to improve oral hygiene appears to be a key factor for patients to purchase powered toothbrushes.31,46 In a survey by the ADA, of the 139 respondents who owned powered toothbrushes, 21.6% used them regularly, and 25.2% used them occasionally.47 This survey does not indicate the toothbrushing frequency of the remaining 53%. A published study on the use of powered toothbrushes found that when consumers first purchased the electric brush they increased their frequency of brushing. The effectiveness is especially improved when the users are given instructions and controlled during the first 6-month period. More recently,48 a survey conducted 6 months after subjects completed a clinical efficacy study indicated that most subjects were not using their powered device twice a day. With the development of the second and third generation of powered toothbrushes, it appears that long-term use is increasing; however, recent publications on this have not been definitive. Weinstein et al.49 analyzed the failures of motivation. One of the important aspects is to accept each patient as an individual, and the dental hygienist and dentist should be able to listen to the patient. Oral hygiene can be instructed only when we are informed about a patient's attitudes, and he or she has to demonstrate their oral hygiene. The procedure in brushing for any method used should have a definite sequence. Health professionals should take time and not expect the patient to change more than one thing from session to session. It is important to have a preventive program for each patient, and this starts with the charting. After the first steps we should follow the program to obtain the goals with the patient. The patients' progress should be evaluated from session to session and from year to year. Dental professionals should also accept failures and have an alternative plan to implement in case of failure.
^ Toothbrushing devices have been developed that accurately standardize all of the above factors, in addition to length and number of toothbrushing strokes over simulated anterior or posterior teeth. Published testing methods are now available to evaluate both safety and efficacy of manual and powered toothbrushes (Table 5-3). Differences between products can be determined and, in several areas, are predictive of clinical results. For example, three laboratory methods have been predictive of clinical plaque removal when plaque assessments focusing on interproximal areas were used. Significant clinical differences between toothbrush designs have also been documented.8,9,17 Interproximal access efficacy has been directly related to increasing brushing pressures and inversely correlated with bristle texture (the "softer" the texture, the higher the interproximal efficacy).50,51 Clinical advantages of various toothbrush-head configurations for removing dental plaque and debris (cleaning efficacy) have been difficult to substantiate. This is attributed to the wide variations among individuals in toothbrushing times, motions, pressures, and in the shape and number of teeth present. Published studies on the clinical superiority of one newly designed manual or powered toothbrush versus another have been inconsistent. It is clear, however, that these new products are more effective than standard manual brushes.8,9 ^ The American Dental Association (ADA) has established guidelines to enable manufacturers to obtain an acceptable rating and use the ADA Seal of Acceptance. In 1996, the Council on Scientific Affairs of the American Dental Association proposed new guidelines for the Seal of Acceptance.52 These guidelines require laboratory documentation of acceptable end-roundedness, good manufacturing procedures (GMPs), and equivalency in clinical plaque and gingivitis efficacy compared with a control toothbrush provided by the ADA. Manual toothbrushes with a standard design, acceptable laboratory data, and GMPs do not require clinical testing. For manual toothbrushes with new designs and for mechanical brushes, the guidelines require only equivalency in plaque and gingivitis reduction compared with a toothbrush provided by the ADA. The clinical protocol is summarized in Table 5-4. The statement to be used in the labeling of products accepted by the ADA is: "(Product Name) is accepted as an effective cleansing device that has been shown to remove plaque and reduce gingivitis when used as directed in a program of good oral hygiene to supplement regular professional care." As listed on the American Dental Association's website (www.ADA.org), more than 140 manual toothbrushes have been awarded the ADA Seal of Approval (August 2001). The ADA has developed criteria for acceptance of powered toothbrushes based on both safety and efficacy. These are: (1) laboratory evidence of electric safety, that is, no electric shock hazard; (2) clinical evidence of both hard- and soft-tissue safety under unsupervised conditions; (3) clinical evidence of plaque and gingivitis efficacy compared to a toothbrush already accepted and provided by the ADA; and (4) evidence of proper labeling and advertising claims that may mention plaque reduction but not improvement of any existing oral disease.52 The required statement for labeling and commercial claims on powered toothbrushes accepted by the ADA is the same as for manual toothbrushes. As of August 2001, 10 powered toothbrushes have been awarded the ADA Seal of Acceptance. Five of these products are distributed by Water Pik Technologies. |
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