Download Toothbrush technology, dentifrices and dental biofilm removal

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This course was
written for dentists,
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and assistants.
Toothbrush technology,
dentifrices and dental
biofilm removal
A Peer-Reviewed Publication
Written by Fiona M. Collins, BDS, MBA, MA
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Educational Objectives
The overall goal of this course is to provide information on
the removal of plaque (dental biofilm) during home care oral
hygiene with toothbrushes and dentifrices.
Upon completion of this course, the clinician will be able to
do the following:
1. Provide a brief overview of dental biofilm development
and bacterial growth.
2. Describe the attributes of ideal toothbrushes and
dentifrices.
3. Know the considerations involved in selecting a manual,
powered or sonic brush
4. Understand the considerations involved in dentifrice
selection with respect to plaque removal.
Abstract
Dental plaque is a complex biofilm consisting of a polysaccharide matrix containing bacteria, voids and nonvital material of bacterial origin. Both cariogenic and periodontopathic
bacteria reside in dental biofilm (plaque). While other factors
must also be present for caries or periodontal disease to exist
in a patient, without these bacteria neither bacterial disease
will occur. The primary goal of toothbrushing is to remove
the dental biofilm present on and adjacent to the teeth,
thereby removing the bacteria associated with caries and
periodontal disease; use of a dentifrice while brushing helps
remove plaque and will also deliver agents to the tooth surface. Manual, powered and sonic brushes have all been shown
to be effective and safe for the removal of plaque, when used
appropriately. Selecting or recommending oral hygiene aids
involves a number of considerations, including effectiveness,
cleaning ability, ease of use and likely compliance.
Introduction
Since prehistoric times, man has devised a variety of methods
to clean and whiten teeth. Some of the earliest devices used
as “toothbrushes” were similar to some woodstick devices
currently in use. It was not until the second half of the 20th
century that first powered and later sonic toothbrushes were
introduced. Modern toothpaste precursors were developed
starting in the early 1800s.1 The development of toothbrushes
and dentifrices accelerated in the latter half of the 20th century,
in the search for products ideally suited to their purpose.
Early efforts at tooth cleaning were focused on making
teeth look cleaner and whiter and freshening breath. There
was, however, no understanding of dental biofilm (plaque).
One of the first people to try to understand the oral ecology
was Willoughby Miller, who believed that periodontal disease
was caused by microbes, and who also published an article
identifying several acidogenic bacteria.2,3 Seminal research in
the 1960s and 1970s by Loe4 and others definitively demonstrated the role of plaque as a bacterial ecology involved in the
development of periodontal disease. Bacteria were also known
to be associated with caries.
2
By the 1980s, it was known that dental plaque consisted of
a complex environment containing both periodontopathic and
cariogenic bacteria. The main cariogenic bacteria contained in
dental biofilm are Streptococcus mutans, with lactobacilli and
minor bacteria also playing a role. The associations among,
and proportions of, bacteria change over time as strains that
are more virulent are introduced. Supragingival plaque contains more aerobic bacteria (e.g., Streptococcus mutans) and
acts as a bacterial reservoir for subgingival plaque. Subgingival plaque contains a high proportion of anaerobic bacteria
(periodontopathogens). Gram-negative anaerobic bacteria
gradually increase in number and alter the nature of the biofilm. Socransky and Hafferjee discovered that dental biofilm
is made up of specific groupings of bacteria consisting of five
complexes of varying pathogenicity and virulence.5,6,7 Three
periodontopathogens in the red complex of bacteria — T.
forsythensis, P. gingivalis and T. denticola — are considered
to be the most common bacteria associated with periodontal
disease.8 In mature biofilm, the bacteria are enveloped by the
biofilm structure, which consists mainly of a polysaccharide
matrix containing voids as well as nonvital material of bacterial origin. It is important to note that periodontal disease will
not result from the presence of a bacterial infection on its own,
but involves local and systemic contributing factors and the
host response.9
Reducing, removing or changing the biofilm is carried
out to try to reduce the bacteria associated with caries and
periodontal disease, to freshen the breath and for social acceptance. A plethora of products is available for these indications, including toothbrushes, dentifrices, rinses, creams, and
professional and prescription products. Agents that have antibacterial properties include triclosan/copolymer, essential
oils, chlorhexidine, xylitol and cetylpyridinium chloride. The
scope of this article is to address plaque removal.
Ideal Toothbrush and Dentifrice Properties
Toothbrushes are designed for dental plaque removal in as
efficacious a manner as possible, without damaging the hard
or soft tissues, and dentifrice slurry provides some cleaning
ability with a toothbrush.
An ideal toothbrush should effectively and safely remove
plaque and deliver agents in the dentifrice to the tooth surface. It should be easy to use, ergonomic and patient-friendly
and be able to remove plaque from all surfaces of the tooth,
including interstitially. For children, the toothbrush can incorporate design features that help motivate them to brush.
An ideal dentifrice should help prevent plaque formation,
disrupt plaque and optimize plaque removal. It should also
contain agents that help protect the dentition and periodontal
tissues; these include agents that prevent demineralization and
aid remineralization; prevent and reduce periodontal inflammation and disease; help prevent oral ulcerations, irritations
and other oral conditions; and prevent or reduce halitosis. In
addition, the toothbrush and dentifrice should be effective
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without damaging the tooth surface or gingivae. Finally, in
our esthetically conscious society, a toothpaste that improves
esthetics by whitening the teeth through stain removal, or
that gives the appearance of whiter teeth, is desirable.
Table 1. Ideal Properties
Disrupt and remove plaque effectively
Reduce plaque
Prevent and remove stain
Deliver agents to the tooth surface
Prevent demineralization
Aid remineralization
Prevent and reduce periodontal inflammation
Prevent oral irritations and ulcerations
Prevent and reduce halitosis
Patient-friendly and ergonomic
propriate use of toothbrushes varies15, and other factors may
impact the amount of plaque removed with a given effort.
When used appropriately, manual, powered and sonic
brushes can all be effective for dental biofilm removal.
Historically, for manual brushing patients have been
taught the Bass technique and to angle the brush so that the
bristles will be at 45 degrees to the sulcus. The Bass technique
requires dexterity, patience and knowledge in order to perform
satisfactorily. More recent manual brushes have been designed
with the bristles configured at varying angles and lengths to
overcome the requirement to perform the Bass technique, or
with handles and grips that result in the bristles being in a
tilted 45 degree angle and help patients brush.
Figure 1. Manual brushes
Toothbrushes
The primary objective of toothbrushing is to safely and effectively remove dental biofilm from all surfaces of the dentition.
While patients tend to focus on the buccal and labial aspects
of the teeth, particularly the upper anterior teeth, since these
are the areas that are visible and easy-to-reach, plaque removal
from the lingual and interdental plaque is key; failure to regularly remove dental plaque will result in the development of a
mature biofilm. Typically, brushing and interdental cleaning
with the adjunctive use of floss or other interdental devices to
remove plaque interdentally (where a toothbrush cannot reach
or only partially reaches) are recommended for oral hygiene.
The primary objective of toothbrushing is the safe
and effective removal of dental biofilm from all
surfaces of the dentition.
Brushing can be achieved using a manual, powered or sonic
brush. Manual, powered and sonic brushes are all effective
at removing dental biofilm provided they are used appropriately and are well-designed.10,11,12 Robinson et al. conducted a
meta-analysis of manual and powered toothbrushes categorized by mode of action, finding that the rotation-oscillation
brushes reduced plaque and gingivitis more than the manual
brushes, with a 7% reduction in plaque (Quigley-Hein index)
and a 17% reduction in bleeding-upon-probing (Ainamo Bay
index) after more than three months. It should be noted that
one of the criteria was for studies to be 28 days or longer; all
studies shorter than this or not meeting other criteria were excluded.13 A small cross-over study submitted in 2006 involved
30 days use of each brush (manual, powered or ultrasonic) in
orthodontic patients and a 15-day washout period between
use of the different test brushes. Plaque scores were lower on
the buccal surfaces with brackets when using the ultrasonic
brush. Strep. Mutans levels were lower using the powered or
ultrasonic brushes.14 Compliance with oral hygiene and apwww.ineedce.com
Powered brushes also require patients to master an appropriate technique; however, one advantage of powered brushes in
general is their ability to remove a greater amount of plaque in
a given period of time than manual brushes. One study found
that 75% of dental biofilm was removed in 15 seconds with
a rotation-oscillation powered brush; the same amount of
plaque removal required twice as long with a manual brush.16
Sonic and powered rotation and rotation-oscillation brushes
have been found in other studies to also offer superior plaque
removal compared to manual brushes.
Figure 2. Powered and sonic brushes
3
One advantage of powered brushes in general
is their potential to remove a greater amount of
plaque in a given time.
Zimmer et al. compared two sonic brushes (Sonicare and
WaterPik Sonic Speed) with a manual toothbrush in a singleblinded crossover study on 36 teenagers and adults. Each
participant sequentially used each type of toothbrush for
two weeks, with a two-week washout period between brush
types. Both sonic brushes were found to result in superior
plaque removal and prevention of gingivitis compared to the
manual toothbrush.18 In a six-month, single-blinded study
comparing use of a sonic or powered brush (Sonicare and
Braun Oral-B) by 66 patients, 54 of whom completed the
study, it was found that supragingival plaque removal was
greater with the sonic brush. In addition, by six months, the
reduction in gingival inflammation reached 31.9% for the
sonic brush and 18.1% for the powered brush, and probing
depth reductions were 15.8% and 7.2%, respectively.19 Bader
and Boyd found a rotary powered brush to be more effective than a sonic brush.20 A recent in vivo single-blinded,
randomized crossover study with a sonic brush (Spinbrush
Sonic) found 88.9% whole-mouth plaque reduction compared to the control.21
One study compared the volume of dental biofilm and
fluoride retention following brushing with a rotation-oscillation, sonic or manual brush or a manual brush plus flossing. Forty-seven subjects were randomized to a sequence of
trials with each method and used fluoride or fluoride-free
dentifrice with a washout of seven days between tests. Sonic
brushing resulted in the least remaining plaque, with a 43%
to 65% reduction compared to all other treatments. With
respect to fluoride retention, use of a sonic brush resulted
in greater fluoride retention from the first day, and after a
week resulted in 40% greater fluoride concentration than any
other treatment, the least effective being manual brushing
and flossing (which demonstrated a reduction in fluoride
retention on day 1).22
Interdental plaque removal
Interdental cleaning is associated with lack of compliance23,24
and has been reported to have relatively poor efficacy with a
number of methods used. Interdental cleaning aids include
floss as well as interdental brushes, picks, woodsticks and
irrigators.
Floss is known to be difficult for patients to use, which can
result in inadequate plaque removal even with compliance.
Some studies have found the efficacy of floss to be negligible.
Separate literature reviews using MEDLINE-PubMed
and Cochrane database–sourced publications have been
conducted to determine the effectiveness of interdental
aids as adjuncts for interproximal plaque removal. For
flossing, eleven publications met all eligibility criteria.
4
Figure 3. Interdental aids
Analysis showed that in the majority of the studies, no
additional benefit was seen with the use of floss, and the
investigators concluded that dental professionals should
determine for individual patients whether recommending floss is useful and if patients can floss adequately.
For interdental brushes, nine publications were found to
meet all inclusion criteria, with use of interdental brushes
shown to remove more interdental plaque than brushing
alone, resulting in improvements in plaque and bleedingupon-probing scores and probing pocket depth.25,26 For
woodsticks, seven publications met all inclusion criteria. It
was concluded that woodsticks did not reduce the level of
interdental plaque or improve gingival indices. They were,
however, found to reduce bleeding.27 Finally, a separate
publication analysis on oral irrigation found seven publications that met all inclusion criteria. It was found that
oral irrigation did not reduce visible plaque compared to
brushing alone. Nonetheless, the researchers were able to
conclude from the publications that the trend was positive
for improvements in gingival health with oral irrigation
compared to brushing only (Table 2).28 The American
Dental Association recommends using either floss or an
interdental cleaner daily.29
A sonic subgingival cleaner (soniPick Sonic Interdental
Plaque Remover) with three bristle lengths was introduced as
an adjunct to improve plaque removal. In vitro testing found
that this device resulted in greater subgingival plaque removal
with any of the bristle tip lengths, as measured by removal of
artificial plaque from pressure-sensitive paper inserted 3 mm
under mock gingivae, compared to use of a manual, multitufted, flat toothbrush with the bristle tips at a 45 degree angle
at the gingival margin.30 Irrespective of efficacy, each of these
techniques requires an additional step.
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Table 2. Literature review of interdental plaque removal aids
Flossing
Interdental
brushes
Woodsticks
Oral irrigation
11 studies No additional benefit in majority
of studies
9 studies Remove more plaque than brushing alone
Improvements in plaque,
bleeding-upon-probing scores
and probing pocket depth
7 studies Reduced bleeding
7 studies Positive trends in gingival health
Compared to manual brushes, powered and sonic brushes
have been found to offer superior interdental plaque removal
in a number of studies (with the only extra step being a simple
change of the brush head to an interdental brush head, for
some models). One study found that use of such a brush head
in a powered rotation-oscillation brush resulted in superior
plaque removal and control of gingivitis compared to manual brushing plus flossing and use of interdental toothpicks
(woodsticks).31 Yankell et al. found in in vitro testing that
a sonic brush (Sonicare) demonstrated greater ability to access interproximal areas compared to either a powered brush
(Braun Oral B) or a manual brush.32 A recent single-blinded,
randomized crossover in vivo study with a sonic brush (Spinbrush Sonic) found that its use resulted in plaque reduction
in hard-to-reach areas ranging from 69% to almost 98%.
The greatest reductions were found in lingual interproximal
areas.33 These results are significant given the inability of patients to reach difficult-to-access areas of the dentition.
Compared to manual brushes, powered and sonic brushes
have been found to offer superior interdental
plaque removal.
Orthodontic patients and children
Powered and sonic brushes may offer help to orthodontic
patients and children who do not brush for long enough or
may have difficulty brushing manually. Comparative studies have been conducted in vitro, in situ and in vivo with
orthodontic patients on the use of manual, powered and
sonic brushes as well as interdental aids. Sander et al. assessed
the ability of sonic and rotating brushes to remove artificial
plaque in vitro from plastic surfaces simulating teeth with
multibracket appliances. The reduction in plaque was determined using before and after photo analysis. In this study, it
was found that brushing efficacy, defined as plaque removal,
was dependent not on the type of brush but on the individual
brush. The investigators also concluded that longer brushing
times and mastery of a proper brushing technique were still
required.34 In orthodontic patients, a comparison of manual
and sonic toothbrushes, sonic toothbrush plus an electronic
interdental flosser, and sonic toothbrush plus manual flossing
was documented; while improvements occurred in the first
four weeks, the only treatment regimen offering longer-term
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effects was use of a sonic toothbrush and an electric interdental flosser, mainly attributable to the flosser, and only in
patients with poor oral hygiene.35 In another study, use of a
sonic toothbrush resulted in a 57% reduction of supragingival
plaque in orthodontic patients who had gingivitis, versus 10%
for manual brushing.36 Costa et al. also studied plaque and
gingival indices for reductions with either manual or sonic/
ultrasonic brushes. Both types were found to provide reductions; however, for orthodontic and dental implant patients, a
greater reduction was found with sonic brushes.37
For children, the more attractive and easier a brush is
to use, the more, in principle, they will be motivated to use
the brush. For this reason, children’s manual and powered
toothbrush designs have incorporated pop culture characters
and names, flashing lights, tunes, and other visual and aural
displays aimed at attracting children.
Figure 4. Pediatric manual brushes
Figure 5. Pediatric powered brushes
One concern with powered and sonic brushes has been their
effect on the shear bond strength of orthodontic brackets. A
number of in vitro studies has been conducted concluding
that use of powered and sonic brushes did not negatively
influence the shear-bond strength of orthodontic brackets.
Garcia-Godoy and de Jager, in an in vitro study using orthodontic brackets bonded to the enamel surface of extracted
teeth, determined that the shear bond strengths were the
same whether manual, sonic or powered brushes were used in
a method equivalent to two years of regular use.38 Ultrasound
5
toothbrushes and rotation-oscillation toothbrushes were also
found in in vitro studies to be safe for orthodontic brackets
and dental restorations. No significant effect was found on
orthodontic brackets with any of the brushes tested.39
Sonic toothbrushes and mechanism of action
Sonic toothbrushes utilize the principles of fluid dynamics
to accomplish dental biofilm removal. A study assessing the
ability of fluid pressure and dynamic shear forces to remove
dental biofilm was conducted by Stanford et al. In situ samples were allowed to develop dental biofilm for 16 hours, then
removed and tested in vitro for 5, 10 or 15 seconds with the
bristles held 2 mm or 3 mm from the surface. After brushing,
the residual bacterial count was assessed. Similar testing was
performed with another electric toothbrush (Interplak) held
3 mm from the surface of similar samples. Plaque reduction
using the sonic brush was 56% to 78% compared to control
samples, and no reduction was found using the electric
toothbrush 3 mm from the tooth surface. (It should be noted
that powered brushes are not intended for use 3 mm from
the tooth surface.) The investigators also assessed the results
using scanning electron microscopy and concluded that sonic
toothbrushes could remove dental biofilm through fluid dynamics when held up to 3 mm from the tooth surface.40
Another study confirmed that using airy bubbles against
mature dental biofilm on a solid surface resulted in removal
of the biofilm where the bubbles collided with it. The amount
removed in a given time was found to vary with the rate of
collision of the bubbles against the biofilm and the surface
area of the bubbles. The investigators attributed the biofilm
removal to fluid dynamic shear forces and determined that a
fast bubbly flow could be expected to remove biofilm.41 Parini
et al. found that low-velocity flowing bubbles in fluid could
remove a film of Streptococcus mutans from a glass surface
better than fluid in the absence of bubbles.42
Sonic toothbrushes can remove dental biofilm
through fluid dynamics when held up to 3 mm from
the tooth surface.
It has been hypothesized that sonic brush-head motion
would generate bubbles in a dentifrice so that ultrasound
beamed into the slurry would cause the bubbles to expand and
contract in a manner that would dislodge the plaque bacteria
adherent to the tooth surface. Pitt conducted an experiment
in which a submerged biofilm of Streptococcus mutans was
subjected to sonic energy between 80 and 1000 Hertz. It was
found that the intensity of the acoustics influenced biofilm
removal when convective fluid flow was present, but that
removal was negligible without this fluid flow (up to 2% over
10 minutes). Introducing gas bubbles into the fluid resulted
in almost 100% biofilm removal with intensive sonic activity.43 Pitt et al. concluded from their in vitro study on dental
biofilm and sonic acoustic waves that the dynamics of fluid
6
flow with bubbles can be expected to remove dental biofilm in
vivo and recommended maximum fluid velocity.44 It has also
been found that bubbles are most effective when they collide
with the biofilm at an angle of between 5 and 45 degrees.45
Busscher et al. concluded that a high percentage of bacterial pairs that were adherent to each other were removed by
noncontact sonic brushing at a distance of up to 6 mm from
the surface on which the bacteria had colonized.46 In a similar
study, electric, manual and sonic brushes were compared for
their ability to remove adhering and nonadhering streptococci
and actinomyces. It was found that sonic brushes removed almost all adhering bacterial pairs, while manual and powered
brushes did not and removed less of the coadhering than the
nonadhering bacteria. It was also found that the presence of
fluoride was immaterial to the amount of bacteria removed by
any of the tested brushing methods.47
Increasing the rate of flow in a fluid overlying biofilm has
been found to result in increased delivery of the agent to
penetrate and cross the layer of biofilm.
A recent literature review by Stoodley et al. on the mass
transport of agents to the biofilm and teeth found that dental
biofilm influences the delivery of caries preventives, specifically fluoride. It was found that increasing the rate of flow in
a fluid overlying biofilm resulted in increased delivery of the
agent to penetrate and cross the layer of biofilm.48
Figure 6. Action of sonic toothbrushes
Mechanical – Brush contact
Fluid Dynamics
Bubbles
Biofilm Removal
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Dentifrices
Plaque reduction can be achieved by the mechanical activity
of toothpaste slurry in combination with a toothbrush and/
or by using chemotherapeutic agents to reduce the volume
of plaque. Soft or ultra-soft toothbrush bristles are recommended. Studies have variously demonstrated greater or
lesser abrasivity with manual or powered brushes, notably
on eroded (demineralized) dental hard tissue.49,50 However, it
was found that, specifically with regard to erosion, the abrasiveness of toothpaste slurry was more predictive of abrasion
than the stiffness of the filaments of manual brushes.51 The
abrasives in modern dentifrices consist of fine, rounded
particles that gently help remove dental biofilm and stain.
Frequently used cleaning agents in dentifrices include baking
soda (sodium bicarbonate), calcium carbonate and calcium
phosphate. The radioactive dentin abrasivity (RDA) of current dentifrices is typically in the range of 70 to 100 RDA,
with baking soda offering a lower RDA of 30 to 40. Nonbaking soda dentifrices with an RDA of 70 to 110 are safe and
effective for dental biofilm and stain removal when used appropriately with a toothbrush, as are baking soda dentifrices
with a lower RDA of 30 to 40. While it has low abrasivity,
baking soda has excellent cleaning ability even when compared to higher-RDA agents.52 Clinical trials with use of a
manual brush with baking soda dentifrices at concentrations
ranging from 20% to 65% demonstrated baking soda’s ability
to remove plaque. Increased plaque reduction was found with
baking soda dentifrice, with higher concentration of baking
soda resulting in more plaque reduction. In addition, for all
concentrations of baking soda, incremental plaque reduction
was found on the harder-to-reach-and-brush proximal and
lingual surfaces. It is believed that cleaning power rather than
abrasivity is an important factor in the effectiveness of baking
soda. Baking soda readily dissolves intraorally and is known
to impart a “clean” feeling. The investigators suggested that
the large, soft crystals of baking soda, with a lower RDA than
a typical fluoride dentifrice, may displace plaque more than
other dentifrices or may affect the biofilm’s polysaccharide
matrix, or the baking soda may disrupt bacterial adhesion by
blocking calcium bonds involved in co-adhesion and simultaneously release calcium dioxide gas.53
The inclusion of baking soda in dentifrices has been
found to benefit plaque removal, especially
in hard-to-reach areas.
Another option that has been investigated is intraoral
recharging with liquid toothpaste onto the brush head during brushing (the IntelliClean System). This was found in a
small, single-blinded, randomized crossover study to result
in a greater reduction of colony-forming bacteria and gramnegative anaerobes compared to conventional brushing without redosing, and also an increase in the amount of surfactant
present in the gingival crevicular fluid.54 Interestingly, Lea
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et al. found that the load (0, 1 or 2 Newtons) and toothpaste
used for powered toothbrushing significantly influenced the
bristle vibration of the brush. The study used scanning laser
vibrometry to determine the effects of sonic and other powered
brushes (Oral-B Sonic Complete; Oral-B Professional Care
8000 Series; Sonicare Elite and Ultrasonex). For all brushes except the Sonicare, the displacement amplitudes of the bristles
were affected by a load of 1 Newton without use of toothpaste;
with toothpaste, all brushes were affected. This could be expected to influence the performance of powered brushes.55
Education
It is not uncommon for patients to attempt to use powered and
sonic brushes similarly to the way they use manual brushes,
moving them in a horizontal manner across the teeth and
disregarding the movement generated by power, and applying too much load (which would typically result in stalling).
Patients may say “ I didn’t like the electric toothbrush and
couldn’t get used to it” for that very reason. The importance
of educating patients on the use of any type of toothbrush, not
just manual brushes, was underscored in a study by RentonHarper et al. They found that uninstructed de novo use of two
different rotation-oscillation brushes and one manual brush
resulted in no difference in plaque reduction during the early
period of usage.56 Whether a manual, powered or sonic brush
is recommended for a given patient, oral hygiene instruction
and instructions on use of the toothbrush are required.
Summary
Since prehistoric times, man has devised a variety of methods
to clean and whiten the teeth. Toothbrushes are designed for
dental plaque (biofilm) removal in as efficacious and safe a
manner as possible, with dentifrices offering cleaning ability
when used with toothbrushes, as well as delivery of preventives and other agents. When used appropriately, manual,
powered and sonic brushes can all be effective for dental biofilm removal. One advantage of powered and sonic brushes in
general is their ability to remove a greater amount of plaque
in a given period of time and to aid interdental cleaning. Sonic
brushes have been shown to have the ability to also remove
dental biofilm when held a slight distance from the tooth
surface and to help in the delivery of dentifrice agents.
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Clin Dent. 1997;8(1 Spec No):4–9.
Bader HI, Boyd RL. Comparative efficacy of a rotary
and a sonic powered toothbrush on improving
gingival health in treated adult periodontitis patients.
Am J Dent. 1999;12(3):143–147.
Data on file.
Sjögren K, Lundberg AB, Birkhed D, Dudgeon
DJ, Johnson MR. Interproximal plaque mass and
fluoride retention after brushing and flossing: a
comparative study of powered toothbrushing, manual
toothbrushing and flossing. Oral Health Prev Dent.
2004;2(2):119–24.
w w w. d o c e r e . c o m / H y g i e n e t o w n / A r t i c l e .
HygieneTown Survey. July 2005.
Craig T, Montigue J. Family oral health survey. J Am
Dent Assoc. 1976;92:326–332.
Berchier CE, Slot DE, Haps S, Van der Weijden GA.
The efficacy of dental floss in addition to a toothbrush
on plaque and parameters of gingival inflammation: a
systematic review. Int J Dent Hyg. 2008;6(4):265–79.
Slot DE, Dörfer CE, Van der Weijden GA.The efficacy
of interdental brushes on plaque and parameters of
periodontal inflammation: a systematic review. Int J
Dent Hyg. 2008;6(4):253–64.
Hoenderdos NL, Slot DE, Paraskevas S, Van der
Weijden GA. The efficacy of woodsticks on plaque
and gingival inflammation: a systematic review. Int J
Dent Hyg. 2008;6(4):251–2.
Husseini A, Slot DE, Van der Weijden GA. The
efficacy of oral irrigation in addition to a toothbrush
on plaque and the clinical parameters of periodontal
inflammation: a systematic review. Int J Dent Hyg.
2008;6(4):304–14.
American Dental Association. Oral health topics A-Z.
Cleaning your teeth and gums. Available at: http://
www.ada.org/public/topics/cleaning.asp
Yankell SL, Shi X, Emling RC, Bock RT. Subgingival
access and artificial plaque removal by a sonic cleaning
device. J Clin Dent. 1999;10(4):139–42.
Murray PA, Boyd RL, Robertson PB. Effect on
periodontal status of rotary electric toothbrushes
vs. manual toothbrushes during periodontal
maintenance. II, Microbiological results. J Periodontol.
1989;60(7):396–401.
Yankell SL, Emling RC, Shi X. Interproximal access
efficacy of Sonicare Plus and Braun Oral-B Ultra
compared to a manual toothbrush. J Clin Dent.
1997;8(1 Spec No):26–9.
Data on file.
Sander FM, Sander C, Toth M, Sander FG. Dental
care during orthodontic treatment with electric
toothbrushes. J Orofac Orthop. 2006;67(5):337–45.
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35 Kossack C, Jost-Brinkmann PG. Plaque and gingivitis
reduction in patients undergoing orthodontic treatment
with fixed appliances: comparison of toothbrushes
and interdental cleaning aids, A 6-month clinical
single-blind trial. J Orofac Orthop. 2005;66(1):20–38.
36 Ho HP, Niederman R. Effectiveness of the Sonicare
sonic toothbrush on reduction of plaque, gingivitis,
probing pocket depth and subgingival bacteria in
adolescent orthodontic patients. J Clin Dent. 1997;8(1
Spec No):15–9.
37 Costa MR, Marcantonio RA, Cirelli JA. Comparison
of manual versus sonic and ultrasonic toothbrushes: a
review. Int J Dent Hyg. 2007;5(2):75–81.
38 García-Godoy F, de Jager M. Effect of manual and
powered toothbrushes on orthodontic bracket bond
strength. Am J Dent. 2007;20(2):90–2.
39 Sorensen JA, Pham MM, McInnes C. In vitro safety
evaluation of a new ultrasound power toothbrush. J
Clin Dent. 2008;19(1):28–32.
40 Stanford CM, Srikantha R, Wu CD. Efficacy of the
Sonicare toothbrush fluid dynamic action on removal
of human supragingival plaque. J Clin Dent. 1997;8(1
Spec No):10–4.
41 Parini MR, Pitt WG. Dynamic removal of oral
biofilms by bubbles. Colloids Surf B Biointerfaces.
2006;52(1):39–46.
42 Parini MR, Eggett DL, Pitt WG. Removal of
Streptococcus mutans biofilm by bubbles. J Clin
Periodontol. 2005;32(11):1151–6.
43 Pitt WG. Removal of oral biofilm by sonic phenomena.
Am J Dent. 2005;18(5):345–52.
44 Ibid.
45 Parini MR, Pitt WG. Removal of oral biofilms by
bubbles: the effect of bubble impingement angle and
sonic waves. J Am Dent Assoc. 2005;136(12):1688–
93.
46 Busscher HJ, Rustema-Abbing M, Bruinsma GM, de
Jager M, Gottenbos B, van der Mei HC. Non-contact
removal of coadhering and non-coadhering bacterial
pairs from pellicle surfaces by sonic brushing and de
novo adhesion. Eur 2003;111(6):459–64.
47 Yang J, Bos R, Belder GF, Busscher HJ. Co-adhesion
and removal of adhering bacteria from salivary
pellicles by three different modes of brushing. Eur
2001;109(5):325–9.
48 Stoodley P, Wefel J, Gieseke A, Debeer D, von Ohle
C. Biofilm plaque and hydrodynamic effects on mass
transfer, fluoride delivery and caries. J Am Dent
Assoc. 2008;139(9):1182–90.
49 Wiegand A, Lemmrich F, Attin T. Influence of
rotating-oscillating, sonic and ultrasonic action of
power toothbrushes on abrasion of sound and eroded
dentine. J Periodontal Res. 2006;41(3):221–7.
50 Wiegand A, Begic M, Attin T. In vitro evaluation of
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52
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abrasion of eroded enamel by different manual, power
and sonic toothbrushes. Caries Res. 2006;40(1):60–5.
Wiegand A, Schwerzmann M, Sener B, Magalhaes
AC, Roos M, et al. Impact of toothpaste slurry
abrasivity and toothbrush filament stiffness on
abrasion of eroded enamel: an in vitro study. Acta
Odontol Scand. 2008;66(4):231–5.
International Standards Organization 11609, 1995.
Dentistry: toothpaste—requirements, test methods
and marking.
Putt MS, Milleman KR, Ghassemi A, Vorwerk L,
Hooper WJ, et al. Enhancement of plaque removal
efficacy by tooth brushing with baking soda
dentifrices: Results of five clinical studies. J Clin Dent.
2008;21(4):111–26.
Barlow AP, Zhou X, Barnes JE, Hoke SH, Eichhold
TH, et al. Pharmacodynamic and pharmacokinetic
effects in gingival crevicular fluid from re-dosing
during brushing. Compend 2004;10 (Suppl 1):21–7.
Lea SC, Khan A, Patanwala HS, Landini G, Walmsley
AD. The effects of load and toothpaste on powered
toothbrush vibrations. J Dent. 2007;35(4):350–4.
Renton-Harper P, Addy M, Newcombe RG.
Plaque removal with the uninstructed use of electric
toothbrushes: comparison with a manual brush and
toothpaste slurry. J Clin Periodontol. 2001;28(4):
325–30.
A uthor Profile
Fiona M. Collins, BDS, MBA, MA
Dr. Fiona M. Collins has authored
and presented CE courses to dental
professionals and students in the US
and internationally. She is a pastmember of the Academy of General
Dentistry Foundation Strategy Board,
has been a member of the British
Dental Association, the Dutch Dental
Association, the American Dental Association, the International Association for Dental Research, and is a member
of the Organization for Asepsis and Safety Procedures. Dr.
Collins earned her dental degree from Glasgow University
and holds an MBA and MA from Boston University.
Disclaimer
The author(s) of this course has/have no commercial ties with
the sponsors or the providers of the unrestricted educational
grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at
www.ineedce.com.
9
Questions
1. First powered and later sonic toothbrushes
were introduced in _________.
a.
b.
c.
d.
the second half of the 19th century
the first half of the 20th century
the second half of the 20th century
none of the above
2. Seminal research in the _________ by Loe
and others definitively demonstrated the
role of plaque as a bacterial ecology involved in the development of periodontal
disease.
a.
b.
c.
d.
1930s and 1940s
1940s and 1950s
1960s and 1970s
all of the above
3. Supragingival plaque contains more
aerobic bacteria and acts as a bacterial
reservoir for subgingival plaque.
a. True
b. False
4. In mature biofilm, _________.
a. the biofilm structure consists mainly of a polysaccharide matrix containing voids as well as nonvital
material of bacterial origin
b. the bacteria are enveloped by the biofilm structure
c. no aerobic bacteria are found
d. a and b
5. Agents that have antibacterial properties
include triclosan/copolymer, essential
oils, chlorhexidine, xylitol and cetylpyridinium chloride.
a. True
b. False
6. Reducing, removing or changing the
biofilm is carried out _________.
a. to try to reduce the bacteria associated with caries
and periodontal disease
b. to freshen the breath
c. for social acceptance
d. all of the above
7. An ideal dentifrice should help prevent
plaque formation, disrupt plaque and
optimize plaque removal.
a. True
b. False
8. An ideal toothbrush should _________.
a. effectively and safely remove plaque from all
surfaces of the tooth
b. be easy to use, ergonomic and patient-friendly
c. deliver agents in the dentifrice to the tooth surface
d. all of the above
9. Manual, powered and sonic brushes are
all effective at removing dental biofilm
provided they are used appropriately.
a. True
b. False
10. Historically, patients have been taught
the _________ and to angle the brush so
that the bristles will be at 45 degrees to
the sulcus.
a.
b.
c.
d.
Postillo technique
Bass technique
Base technique
Bassist technique
11. More recent manual brushes include
designs with handles and grips that result
in the bristles being in a tilted 45 degree
angle and help patients brush.
a. True
b. False
10
12. Robinson et al. found from their metaanalysis of studies longer than 28 days in
duration that rotation-oscillation brushes
reduced plaque and gingivitis more than
manual brushes.
a. True
b. False
13. One study found that _________ of
dental biofilm was removed in _________
seconds with a rotation-oscillation
powered brush; the same amount of
plaque removal required twice as long
with a manual brush.
a.
b.
c.
d.
65%; 15
75%; 10
75%; 15
85%; 15
14. Zimmer et al. compared two sonic
brushes with a manual toothbrush in
a single blinded crossover study on 36
teenagers and adults and found the sonic
brushes to remove more plaque compared
to the manual toothbrush.
a. True
b. False
15. With respect to fluoride retention, use
of a_________ brush resulted in greater
fluoride retention than use of a _________
brush in one study.
a.
b.
c.
d.
powered; sonic or manual
manual; powered or sonic
sonic; powered or manual
none of the above, all were equal
16. Berchier et al. found in a meta-analysis
that no additional benefit was seen with
the use of floss, and the investigators
concluded that dental professionals
should _________.
a. recommend the use of floss for all patients
b. determine for individual patients whether recommending floss is useful and if patients can floss
adequately
c. not recommend flossing
d. none of the above
21. Using scanning electron microscopy,
Stanford et al. concluded that sonic
toothbrushes could remove dental biofilm
through fluid dynamics __________.
a. only when in contact with the tooth surface
b. when held at a distance of up to 1 mm from the
tooth surface
c. when held at a distance of up to 2 mm from the
tooth surface
d. when held at a distance of up to 3 mm from the
tooth surface
22. Increasing the rate of flow in a fluid
overlying biofilm has been found to
result in increased delivery of the agent to
penetrate and cross the layer of biofilm.
a. True
b. False
23. Specifically with regard to erosion, the
abrasiveness of toothpaste slurry has
been found by investigators to be more
predictive of abrasion than the stiffness of
the filaments of brushes.
a. True
b. False
24. It is believed that cleaning power rather
than abrasivity is an important factor in
the effectiveness of baking soda.
a. True
b. False
25. Intraoral recharging with liquid
toothpaste onto the brush head during
brushing has been found to result in a
greater reduction of colony-forming
bacteria and an increase in the amount
of surfactant present in the gingival
crevicular fluid.
a. True
b. False
26. It has been hypothesized that baking
soda may affect the biofilm’s polysaccharide matrix, or may disrupt bacterial
adhesion by blocking calcium bonds.
a. True
b. False
17. Yankell et al. found in in vitro testing
that a sonic brush demonstrated greater
ability to access interproximal areas
compared to either a powered brush or a
manual brush.
27. Whether a manual, powered or sonic
brush is recommended for a given patient,
oral hygiene instruction should be
provided on use of the toothbrush.
18. Children’s manual and powered
toothbrush designs have incorporated pop
culture characters and names, flashing
lights, tunes, and other visual and aural
displays aimed at attracting children.
28. Uninstructed de novo use of rotationoscillation and manual brushes was found
in one study to result in no difference in
plaque reduction during the early period
of usage.
19. Powered brushes have been found to be
safe for orthodontic brackets.
29. Frequently used cleaning agents in
dentifrices include baking soda (sodium
bicarbonate), calcium carbonate and
calcium phosphate.
a. True
b. False
a. True
b. False
a. True
b. False
20. Sonic toothbrushes utilize the principles
of _________ to accomplish dental biofilm
removal.
a.
b.
c.
d.
hydrotherapy
fluid dynamics
electromagnetic forces
all of the above
a. True
b. False
a. True
b. False
a. True
b. False
30. The American Dental Association
recommends using either floss or an
interdental cleaner daily.
a. True
b. False
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ANSWER SHEET
Toothbrush technology, dentifrices and dental biofilm removal
Name:
Title:
Address:
E-mail:
City:
State:
Telephone: Home (
)
Office (
Specialty:
ZIP:
Country:
)
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
Mail completed answer sheet to
Educational Objectives
Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp.
1. Provide a brief overview of dental biofilm development and bacterial growth.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
2. Describe the attributes of ideal toothbrushes and dentifrices.
3. Know the considerations involved in selecting a manual, powered or sonic brush.
For immediate results,
go to www.ineedce.com to take tests online.
Answer sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
4. Understand the considerations involved in dentifrice selection with respect to plaque removal.
Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
1. Were the individual course objectives met?Objective #1: Yes No
Objective #3: Yes No
Objective #2: Yes No
Objective #4: Yes No
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3. Please rate your personal mastery of the course objectives.
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4. How would you rate the objectives and educational methods?
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5. How do you rate the author’s grasp of the topic?
5
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6. Please rate the instructor’s effectiveness.
5
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7. Was the overall administration of the course effective?
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8. Do you feel that the references were adequate?
Yes
No
9. Would you participate in a similar program on a different topic?
Yes
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Acct. Number: _______________________________
Exp. Date: _____________________
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10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
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___________________________________________________________________
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___________________________________________________________________
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AGD Code 017, 557
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER
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the unrestricted educational grant for this course.
SPONSOR/PROVIDER
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All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
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INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
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Completing a single continuing education course does not provide enough information
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COURSE CREDITS/COST
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