Comparison of Manual Toothbrushes with Different Bristle ...

Abstract

Objective:

The aim of the study was to compare the cleaning efficacy and plaque control of the straight and angled bristle design manual toothbrushes.

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Materials and Methods:

It was a pilot randomized trial comprising 30 dental students divided into 2 groups (group I flat bristle design toothbrush and group II zig-zag bristle design toothbrush) with 15 in each group. Prebrushing and postbrushing plaque scores were recorded at the baseline and at the end of 4 weeks using Turesky modification of Quigley and Hein plaque index.

Results:

Plaque and gingival scores were reduced significantly at 1 month in group II with P < 0.05 than compared to group I where P > 0.05. Mean GI and plaque scores of the criss-cross design were reduced significantly after 1 month (P < 0.05). Intergroup comparisons revealed that plaque and gingival scores significantly reduced (P < 0.05) at 1-month interval.

Conclusion:

Bristle design has significant impact on plaque removal capacity of a toothbrush. Toothbrush with zig-zag bristle design is efficient in removing plaque than the flat design of a toothbrush.

Keywords: Bristle design, manual toothbrush, plaque control, straight bristle design, zig-zag bristle design

I

NTRODUCTION

Dental plaque is the primary causative factor for the initiation and development of dental caries and periodontal disease.[1,2] Plaque as a biofilm gets attached to the teeth and on the denture surface, leading to the destruction of the supporting structures of the teeth, namely, the gingiva, cementum, periodontal ligament, and alveolar bone. Effective plaque control is essential for the removal of dental plaque and its accumulation on the teeth and adjacent gingival surface.[3] This facilitates the return of the health for patients with gingivitis and periodontitis. It is effectively influenced by a number of individual- and material-based factors. The factors are based on the design of the toothbrush, the skill of the individual using the brush, and toothbrushing frequency and duration of use.[4] The last two factors represent individual toothbrushing behaviors and are affected by learning experience, motivation, and manual capacity and can of course be improved with good cooperation established between dentists and patients. However, the first factor represents technology improvement and is affected by the physical and mechanical properties of the toothbrush bristles and the shape, size, and morphometry of the toothbrush heads and handles;[5] generally the use of a simple horizontal toothbrushing action and brush their teeth for the duration markedly shorter than optimal time.[6] Manufacturers of toothbrushes try for innovations in the brush head design that will help to compensate for nonideal toothbrushing technique and time.[7]

Many types of bristle designs are commercially available. They are toothbrushes with flat bristle, multilevel bristle, rippled (zig-zag) bristle, angled or crisscrossed bristle, V-shaped bristle, spiral filament bristle, and tapered filament design. The bristle designs play a role in removing plaque efficiently and so maintaining healthy gingival conditions. The more basic designs include toothbrushes with standard straight bristle toothbrushes or flat toothbrushes which are called old-fashioned classic manual toothbrushes. The more advanced models are angled (Zig-Zag) bristles especially aimed at helping to remove plaque from teeth and along the gum line.[8,9] First toothbrushes were developed solely to effectively remove plaque and they had hard and then medium bristle softness. The straight flat handles basic design is ergonomic free with more efficiency and comfort to the individuals. Recently, soft bristles were used in straight and criss-cross brushes as hard and medium bristle stiffness could have the potential for causing soft tissue damage. American Dental Association (ADA) has made a flat toothbrush design as the standard reference toothbrush for comparison with other toothbrushes. A toothbrush with a zigzag bristle design can reach interdental regions thereby effectively removing plaque.

To the best of our knowledge, there has been no clinical evidence that a toothbrush with zig-zag bristles does not cause soft tissue trauma after long-term usage. Therefore, the purpose of this single-blind, parallel-group clinical study was to compare the efficacy of plaque control based on the two different toothbrush models.

M

ATERIALS AND

M

ETHODS

A total of 30 healthy dental students (18 female and 12 male) who are of age 21&#;25 years were included in this pilot study This age group of individuals has a potential for manual dexterity while toothbrushing. The inclusion criteria are based on the following criteria: good oral health, six tooth excluding third molar in each quadrant with no crowns, orthodontic appliances, and no periodontal pocket &#;3 mm or attachment loss &#;2 mm. The exclusion criteria include any systemic illness, mucogingival problem, smoking habit, pregnancy, and fixed or removable prostheses. According to ADA specifications, the participants were given oral hygiene education to brush for two minutes twice daily with their allocated toothbrush with a gentle pressure of less than 3 N with sweeping movements. Stroski MC et al [21], proved that manual toothbrushes with three different bristle arrangements are equally effective in removing plaque and maintaining a healthy gingival condition.

The nature of the study was explained and patient informed consent was obtained prior to the study. The study was approved by Institutional Ethical Board, &#;Institutional Scientific Review Committee,&#; Asan Memorial Dental College.

Toothbrush design

Two manual toothbrushes with different bristle designs were used: standard flat bristles and zig-zag bristles.

Study procedures

According to Melanie L Bell ,[11] a sample size of 30 trial participants with 15 in each group was taken for this pilot study. Study subjects received no oral prophylaxis and were individually instructed to brush using the modified bass technique[12,13] and were given the toothbrush of study randomly using tossing of coin method at baseline by the person who was not doing the clinical examination. The participants were instructed to brush their teeth twice daily using the toothbrush given for the study purpose. Also, they were instructed to refrain from oral hygiene procedures and chewing gum for 12 h prior to the appointment of clinical examination. The toothbrush of flat and zig-zag bristle design toothbrush and identical toothpaste with no antiplaque agents was given as shown in Figures 1 and 2.

Figure 1.

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Flat bristle design toothbrush

Figure 2.

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Zigzag bristle design toothbrush

All the periodontal parameters were recorded by another investigator who was blinded to randomization. Plaque index (PI) by Quigley and Hein,[14] modified by Turesky et al.,[15] was recorded: Score 0: no plaque, Score 1: separate flecks of plaque at gingival margin of the crown, Score 2: a thin continuous band of plaque at the gingival margin of the crown, Score 3: a band of plaque wider than 1 mm but covering less than one-third of the crown of tooth, and Score 5: plaque covering more than two-thirds of the crown of the tooth. The dental plaque on the teeth was disclosed by 2-tone disclosing solution. The gingival index (GI) was scored according to Loe and Silness:[16] Score 0: absence of inflammation, Score 1: a slight change in the color and texture, Score 2: a moderate redness, edema, and hypertrophy and bleeding on probing, and Score 3: A moderate redness, hypertrophy, and tendency to bleed spontaneously. The oral hygiene index according to Kokoceva-Ivanovska Olga[17] was scored: Score 0: no debris or stain, Score 1: soft debris covering not more than one-third but more than two-thirds of the exposed tooth surface or the presence of extrinsic stains, Score 2: soft debris covering more than one-third but more than two-thirds of the exposed tooth surface, and Score 3: soft debris covering more two-thirds of the exposed tooth surface. Criteria for classifying calculus: Score 0: no calculus present, Score 1: supragingival calculus covering not more than one-third of the tooth surface, Score 2: supragingival calculus covering more than one-third but not more than two-thirds of the tooth surfaces, and Score 3: supragingival calculus covering more than two-thirds of the exposed tooth surface or a continuous heavy band of subgingival calculus around the cervical portion of the tooth/both. The average of individual or group debris or calculus score are combined to obtain simplified oral hygiene index. The presence of bleeding on probing was recorded almost 10 s after probing. All the measurements were recorded at the baseline and repeated after 1 month period by the same single examiner blinded to randomization. It was instructed to avoid the use of gels or mouth rinses.

Statistical analysis

Statistical analyses were performed with a software program IBM SPSS Statistics 23 (SPSS version 24 IBM, India). The collected data within the groups were analyzed using paired T-test. Intragroup assessment of PI, GI, and oral hygiene index simplified of the standard bristle design after 1 month was not found to be statistically significant, P > 0.05. PI, GI, and oral hygiene index simplified of the zig-zag bristle design after 1 month were found to be statistically significant, P < 0.05. Also, intergroup comparisons reveal that there was significant reduction in plaque and gingival score after a period of 1 month, P < 0.05.

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R

ESULTS

The demographic findings of the study subjects are shown in Table 1. There was no statistical difference in age (22.45 ± 0.35, 22.76 ± 0.67), respectively, between the groups. All subjects were dental students and there were no smokers in both the groups comprising 30 dental students recruited into the study. Plaque and gingival scores were reduced significantly at 1 month and 3 months in group II with P < 0.05 than compared to group I where P > 0.05. Mean GI and plaque scores of the criss-cross design were reduced significantly at 1-month interval (P < 0.05). Intergroup comparisons revealed that plaque and gingival scores significantly reduced (P < 0.05) at 1-month interval as shown in Tables 2&#;4.

Table 1.

Demographic values

Parameters Standard design ZIG-ZAG design Mean age±SD 22.45±0.35 22.76±0.67 Range 22-24 22-25 Gender male/female 13/30 17/30 Smoker None None Open in a new tab

Table 2.

Comparison of PI, GI, OHI-S among study subjects using standard bristles

Criteria Baseline (Mean±SD) Follow-up (Mean±SD) t df P Plaque index 0.99±0.11 0.77±0.45 1.823 14 0.09 Gingival index 0.73±0.21 0.7±0.44 0.236 14 0.817 Oral hygiene index-simplified 1.2±0.52 1.1±0.89 0.483 14 0.751 Open in a new tab

Table 4.

Comparison of PI, GI, OHI-S at baseline and follow-up among standard and zigzag bristle designs

Paramerts t df P PI baseline SB Vs PI baseline ZB 0.975 14 0.346 PI followup SB Vs PI followup ZB 2.735 14 0.016 GI baseline SB Vs GI followup ZB 1.071 14 0.302 GI followup SB Vs GI followup ZB 2.427 14 0.029 OHI-S baseline SB Vs OHI-S followup 0.801 14 0.436 OHI-S followup SB Vs OHI-S followup 2.016 14 0.063 Open in a new tab

Table 3.

Comparison OF PI, GI, and OHI-S at baseline and follow-up among standard and zigzag bristle designs

Paramerts t df P PI baseline (SB) vs PI baseline (ZB) 0.975 14 0.346 PI follow-up (SB) vs PI follow-up (ZB) 2.735 14 0.016 GI baseline (SB) vs GI baseline (ZB) 1.071 14 0.302 GI follow-up (SB) vs GI follow-up (ZB 2.427 14 0.029 OHI-S baseline (SB) vs OHI-S baseline (ZB) 0.801 14 0.436 OHI-S follow-up (SB) vs OHI-S follow-up (ZB) 2 14 0.063 Open in a new tab

D

ISCUSSION

This study was designed to assess the presence of dental plaque, materia alba, food residues, and plaque removal efficiency by two different bristle design toothbrushes, standard bristle design, and zig-zag bristle design, thereby evaluating the plaque removal efficiency, and to improve the oral hygiene performance as shown in the bar diagram.

Many studies have been done using different bristle design toothbrushes on plaque removal efficiency. These studies emphasize the benefits on gingival health. Sharma et al.[8] have reported that criss-cross bristle design promotes the plaque removal efficiency from hard to reach areas and have advantages over straight bristle configuration. Studies have concluded that advances in toothbrush design can present great plaque removal outcome. A clinical study was done using three manual toothbrushes on dental plaque and gingival inflammation. The PI and GI scores were statistically significant in subjects using tapered and cross-angled soft bristle design toothbrushes. In another clinical study done by Nathoo et al.,[18] it is found that criss-cross bristle design is significant in effectively reducing gingivitis. Studies done by Sripriya et al.[19] evaluated the efficacy of the four most commonly used bristle design of toothbrushes in plaque removal. The results showed that toothbrushes reduced plaque scores significantly compared to baseline scores but no superior design of manual toothbrush was found.

In a single-blinded cross-over study,[20] performance of different toothbrush models for controlling plaque was compared. It was found that all three brushes were capable of removing plaque effectively and the different bristle designs had little effect over plaque removal. Manual toothbrushes with hard bristles may cause more soft tissue trauma compared to brushes with softer bristles as reported in a recent study.[21]

A randomized methodology development study by Roberta Grimaldi [22], assess the efficacy of plaque removal from manual toothbrushes and showed significant plaque reduction by flat round end bristle design compared to tapered bristle design thereby providing different study design on bristle design influence the plaque removal efficacy as shown in [Figure 3].

Figure 3.

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Comparision of PI, GI, OHI-S among study subjects using standard and zig-zag bristles

The findings of our study demonstrated that zig-zag bristle design was superior and effective in plaque removal efficiency with minimal plaque deposition, preventing gingival inflammation. Overall the results of our study showed additive benefit in using zig-zag bristle design was in reducing gingivitis than compared to standard flat bristle design tooth design.

Our randomized pilot study provides information on the feasibility and reliability of the present study design that needs to be implemented in the main study.

The limitations of the study are the small sample size. Though the outcome of the study has potential benefits and efficacy towards zig-zag bristle design than flat bristle design toothbrush, it needs to be confirmed by the study including a larger sample size. We, advise individuals, to replace the toothbrush when the bristles are flared up.

C

ONCLUSION

It can be concluded that the presence of plaque and material alba was minimal in using zig-zag bristle design compared to standard flat bristle design toothbrush. Also, the plaque removal efficiency is effective in zig-zag bristle design compared to flat brush design toothbrush. On comparing the two different bristle design toothbrushes, it can be concluded that zig-zag bristle design is superior than standard flat design toothbrush in reducing gingivitis and better oral hygiene performance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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