Journal September 2006

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CANAD IAN JOU RN AL OF DENTAL HYG IENE JOU RNAL CANAD IEN DE LH YGI N E DENTAI RE

SEPTEM BER OCTOBER 2006 , VO L. 40 , N O. 5

T H E O F FI C I A L JO U R N A L O F T H E C A N A D I A N D E N T A L H Y G I EN I S T S A SSO C I A T I O N


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Liste de souhaitspar Diane Thriault, RDH

IL EST DIFFICILE DE CROIRE QUE MON MANDATcomme prsidente de lACHD a pass sirapidement. Au dbut, j tais inquitelorsque jai accept ce poste m ais, m ainten ant,

je m e sen s u n peu triste q ue ce so it fin i. Ce tte exp rien ce at, pour moi, une vritable opportunit de croissancepersonn elle, elle ma permis de sortir de m a zone de con -fort. Au cours de 18 m ois o jai t prsidente, jai ren-contr plusieurs excellentes et excellents professionnelsqu e je respecte norm m en t et jai eu loccasion de travail-ler avec ces person n es. Cest dan s cet esprit qu e jaim eraisremercier mes collgues, membres du conseil dadministra-

tion, et le personn el de lACHD qui on t aid ce que m onmandat de prsidente soit une exprience rellement en-richissante. Ce fut un honneur de reprsenter et de servirno s mem bres au cours de la dernire ann e et demie et jecrois que notre prsidente lue, Bonnie Blank, apprcierason exprience autant que moi . Dans mon dern ier m essage de la prsident e , jaimerais partager avec vousm a liste de souhaits pour n otre association et n otre profes-sion.

Cest mon vu sin cre que toutes et tous les hyginistesdentaires de notre pays deviennent membres de lACHDainsi que de lassociation des hyginistes dentaires de leurprovince. Mais les non -mem bres ne sy joindron t pas justeparce qu e jaimerais q uils le fassent. Le dsir de se joind re un organisme profession nel doit venir de soi et rpon dre un besoin. Donc, je demande chacun et chacune devous dencourager vos collgues qui seraient peut-treprts ou p rtes faire le saut m ais qui ne son t pas certainsou certain es des raisons po ur lesquels ils ou elles devraient

le faire, ou qu i se dem and ent p ourqu oi il est si importan t,pour elles ou eux, dtre membres de leur association.Profitez de ch aqu e occasion pou r parler vos collgues desavantages dappartenir lACHD et son associationprovinciale des hyginistes dentaires. Amenez-les parlerdes changem ents qu i survienn ent et des dfis que lavenirnous rserve. Finalement, je vous demande de donnerlexemple et de montrer vos collgues que prendre desresponsabil i ts dans vos vies professionnelles peutconduire vers une carrire st imulante et pleinementsatisfaisante.

Wish Listby Diane Thriault, RDH

ITS HARD TO BELIEVE THAT MY TERM AS PRES-iden t of CDHA has gon e by so qu ickly. I wasapprehensive about taking on this role atfirst but n ow am a bit sad th at it is over. Thisexperience has been a real personal growth opportunityfor me, making me step out of my com fort zon e. In m y 18months as president, I have met and worked with manyexcellen t pro fessionals who m I respect greatly. In th is spir-it, I would like to th ank m y fellow CDHA board m emb ersand staff for helping make my tenure as president a trulyrewarding experience. It has been an honour to representand serve our membership over the past year and a half,

an d I believe our presiden t-elect, Bon n ie Blank, will enjoythe experience as much as I did. In my last PresidentsMessage, I would like to share with you my wish list forour association and profession .

It is my sincere hope that all dental hygienists acrossour coun try will become m emb ers of CDHA as well as the

dental hygienist association in their own province. Butno n-m emb ers will not join just because I would like th emto. The desire to join a professional organization mustcome from with in an d respond to a n eed. So I call upon allof you to encourage your colleagues who may be strad-dling the fence, not quite sure why they should getinvolved, or why it is so im portan t for them to be a mem -ber of th eir association. Take every opport un ity to tell yourcolleagues about the benefits of belonging to CDHA andtheir provincial dental hygienist association. Bring themup to speed about the changes that are occurring and thechallenges that lie ahead. Finally, I urge you to lead byexample and demonstrate to your colleagues that taking

responsibility for your professional lives can lead to a ful-filling an d ch allenging career.

If your passion has been stifled and you feel you havean 8-to-5 job rather than a career, then its time to reclaimyourself. Re-ignite your passion for your profession. Oneway to do this is by being proactive in your professionalassociation. CDHA and the provincial associations havemany opportunities for you to showcase your talents andshare your vision for our profession. Sign up for a councilor com m ittee, become a t rustee or an officer, and awaken

SEPTEM BER - O CTOBER 2006, VOL. 40, NO. 5 CANADIAN JOURNAL OF DENTAL HYGIENE (CJDH) 227

PRESID EN T S M ESSAGE DE LA PRSIDEN TE

Liste de souhaits suite page273

The desire to join a professionalorganization must come fromwithin and respond to a need.

Le dsir de se joindre unorganisme professionnel doit venir

de soi et rpondre un besoin.

Wish List continued on page271


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CONTENTSCDHA BOARD OF DIRECTORSDiane Thriault New Brunswick PresidentBonn ie Blank Den tal Hygien e Educat orsCana da; President Elect

Patty Wickstrom Alb erta Past PresidentLynn Smith British Colum biaSusan Vogt SaskatchewanCarol-Ann Yakiwchuk Man itob aEvie Jesin OntarioAnna Maria Cuzzolini QuebecAlison MacDougall Prince Edward IslandWanda Fedora Nov a Scot iaPalmer Nelson New found lan d and Labrador

RESEARCH ADVISORY COM M ITTEESusann e Sunell (Scientific Editor)Joan ne Clovis Dian ne Gallagh erSan dra Cobban Marilyn Gouldin gBon n ie Craig Salm e Lavign eSh afik Dh aram si Barbara Lon gIn du Dh ir Gladys Stewart

MANAGING EDITORPatricia Buchanan

ACQUISITIONS EDITORLaura Myers

TRANSLATION AND REVISIONJacyn th e Mo rin Lo uise Sain t-An dr

GRAPHIC DESIGN AND PRODUCTIONMike Donn elly

Published six times a year, January/February, March/April,May/June, July/August, September/October, No vember/

December, by the Canadian Dental Hygienists Association,96 Cent repoin te Drive, Ottaw a, ON K2G 6B1. Tel: (613)224-5515

Canada Post #40063062.

CANADI AN POSTM ASTERNotice of chan ge of address and un deliverables should b esent to:

Canadian Dental H ygienists Association96 Centrepointe Drive, Ottawa, ON K2G 6B1

ADVERTISINGKeith Health Care Inc.1599 H uron tario Street, Suite 104Mississauga, ON L5G 4S1(905) 278-6700 1 800 661-5004

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where. On e dollar per issue is allocated from m embershipfees for journal p roductions. All statements are th ose of theauth ors and d o n ot n ecessarily represent th e CDHA, itsboard, or its staff.

CDHA 20066176 CN ISSN 1712-171X (Print)

ISSN 1712-172 8 (Online)GST Registration No. R106845233

CDHA OFFICE STAFFExecut ive D irector: Susan A. ZiebarthHealt h Policy Com m un icati ons Specialis t: Judy LuxDirector of Strat egic Partn erships : Monica HelgothDirector of Educat ion: Laura MyersInform ati on Coordin ato r: Brenda LeggettExecut ive A ssist an t: Frances PattersonAdm ini strat ive A ssist an t: Lythecia Blanchard

CDH A CORPORATE SPON SORSOral-B Procter an d Gam ble

All CDHA members are invited to call the CDHAs Member/Library Line toll-free, with their questions/inquiriesMonday to Friday, 8:30 a.m. - 5:00 p.m. ET:

Toll free: 1 800 2 67-5235, Fax: (613) 224-728 3Internet: http://w ww.cdha.caE-mail: in fo@cdh a.ca

The Canad ian Dent al Hygienists Association journ al, theCanadian Journal of Dental Hygiene, is the official publicationof the CDHA. The CDHA invites subm issions of originalresearch, discussion pap ers, and statements of opin ion perti-nen t to th e dental h ygiene p rofession. All man uscripts arerefereed anonymously. Contributions to the journal do notnecessarily represent th e views of the CDHA, nor can t heCDHA guarantee th e authen ticity of the reported research.Copyright 2006 . All materials subject to th is copyright maybe photocopied or copied from the website for non-com-mercial purposes of scientific or educational advan cement.

EVIDEN CE FOR PRACTICE

TOOTHBRUSHING:

CDHA Position Statementby CDHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

CDHA Position Paperby Joanna Asadoorian, AAS(DH), MSc . . . . . . . . . . . . . . . . . . . . . 232

The Chart Audit Process in a Clinical Teaching Environment:Fostering Excellence in Record Keeping

by Carmela Miliucci, BSc, RDH, and Lisa Rogers, RDH, BEd . . . . . 258

DEPARTM EN TS

Presidents Message de la prsidenteWish List / Liste de souhaits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Executive Directors Message de la directrice gnraleConnections / Les liens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

CDHA Conference 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

Crest Oral-B / CDHA Oral Health Promotion Awards . . . . . . . . . 257

Annual General M eeting Notice . . . . . . . . . . . . . . . . . . . . . . . . . . 271

The Library Column: On Our Bookshelf . . . . . . . . . . . . . . . . . . . . . . 275

Probing the Net: Latex Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277Classified Advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Advertisers Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278


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Les lienspar Susan Ziebarth, B.Sc., M.H.A., C.H.E.

Nous ne pouvons vivre seulem ent pour nous-

m mes. Un m illiers de fibres nous relient avec nos

semblables ; et, parmi ces fibres, com m e des fils de

com passion, nos actions agissent com m e causes et

elles nous revienn ent comm e effets . [Traduction] [Traduction] Herman Melville

LA CITATION DE MELVILLE NOUS RAPPELLE QUEL POINTno s contacts avec nos semblables sont forts et est un emtaphore approprie pour dcrire ce que nouspou von s faire au niveau p rofession n el. Notre bu t lACHDest de vous aider en vous donnant accs des ides, des

ressources et en vous permettant de communiquer entrevous pour suggrer une action positive dans lintrt de laprofession et de ltat de sant global des Canadiens et desCanadiennes. Dans cet article, je souligne deux desnombreux moyens par lesquels lACHD aide leshyginistes dentaires jouer un rle en tant que profes-sionnels et professionnelles de la sant.

LACHD t isse des liens en t re les m em bres, leu rs pa irs

professi onnels de la sa nt et le gouvernem ent

Notre adhsion aux coalitions nationales pour la santtire profit de la force du nombre pour tisser des lienssolides avec le gouvernement fdral et les autres profes-sionnels et professionnelles de la sant. Nous avonstrouv, cette anne, des points communs avec plusieurscoalitions nationales pour la sant sur un bon nombre dequestions touchant la sant. La participation au HEAL(Groupe dintervention action sant) nous a permis de

nous engager auprs de 31 organismes pour la sant,incluant des groupes comme lAssociation des infirmireset infirmiers du Canada, lAssociation mdicalecanadienn e et lAssociation canadienn e des soins de sant .Notre participation au sein de la Coalition canadiennepour la sant p ublique au XXIe sicle, un regroupem ent de37 organisations, nous aide galement nous exprimerdun e voix un ifie auprs du gouvernem ent con cernant lesdpen ses fdrales pou r la san t et les ressources hu m ainesdans le secteur de la sant. Notre partenariat avec ces

Connectionsby Susan Ziebarth, BSc, MHA, CHE

W e cannot live only for ourselves. A thousand

fibers connect us with our fellow m en; and

am ong those fibers, as sym pathetic threads, our

actions run as causes, and they come back to us

as effects.

Herman Melville

TH E Q UO TATIO N BY MELVILLE REM IN DS US H OWstrong our connections are with our fellow men andis an appropriate m etaphor for what you can do on aprofession al level. Our goal at CDHA is to help yo u by con -necting you with ideas, resources, and each oth er to evoke

positive action on behalf of the profession and Canadian soverall health. In this issue, I highlight two of the manyways in which CDHA is helping dent al hygienists connectas health professionals.

CDHA connects members to their health professional

peers and govern m entOur membership in national health coalitions capital-

izes on strength in numbers to create strong connectionswith th e federal governm ent an d oth er health care profes-sionals. We found common ground this year with severalnational health coalitions on a number of health issues.Participation in HEAL (Health Action Lobby) allows us toengage with 31 health organizations, including groupssuch as the Canadian Nurses Association, the CanadianMedical Association, and the Canadian HealthcareAssociation. Participation in the Canadian Coalition forPublic Health in th e 21st Century, a 27-m ember organiza-tion, also helps us speak to government with a unified

voice regarding federal spending on health and healthhuman resources. Connection with these groups lets usmonitor health issues, develop joint action plans, repre-sen t oral h ealth issues at the t able, and advocate for poli-cies th at strength en th e public health system an d prom oteand protect the health of all Canadians. As a member ofthese groups, CDHA has met with government officialssuch as th e Deputy Minister of Health an d th e Chief PublicHealth Officer to discuss health human resources issuesand fund ing for the h ealth services.

EXECUTIVE D IRECTOR S M ESSAGE DE LA D IRECTRICE GN RALE

We found common ground thisyear with several national

health coalitions on a numberof health issues.

Nous avons trouv, cette anne,des points communs avec plusieurscoalitions nationales pour la sant

sur un bon nombre de questionstouchant la sant.

Connectionscontinued on page 255 Les liens suite page 255


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232 JOURNAL CANADIEN DE LHYGINE DENTAIRE (JCHD) SEPTEMBRE - O CTOBRE 2006, VOL. 40, N O 5

EVIDEN CE FOR PRACTICE

CDHA Position Paper on Tooth Brushingby Joanna Asadoorian, AAS(DH), MSc

EXECUTIVE SUM MARYPurpose: Tooth brushing is the m ost comm only recom -

mended and performed oral hygiene behaviour by NorthAm ericans and is done ubiquitou sly in developed nation s.

It is the primary mechanical means for removing dentalplaque, th ereby assistin g in th e prevention of oral diseasesincluding gingivitis and dental caries. The aim of thispaper is to report on an investigation of the current stateof the science on t ooth brushing for the con trol of plaqueand periodontal diseases, particularly gingivitis, and inorder to d evelop a Canad ian Den tal Hygien ists Association(CDHA) position statemen t.

Methods: Using previously published reviews andanalyses as a departure poin t, a com prehen sive review andanalysis of the literature was conducted. The search wasguided by the development of several PICO questions ontooth brushing and included the following databases:

MedLine, CINAHL (Cumulative Index of Nursing a AlliedHealth Literature), and the Cochrane Controlled TrialsRegister. Salient websites were also exam ined . Subsequ entto the review and analysis, input was solicited from recog-nized experts and researchers in relevant fields of inquiry.

Results: A total of 238 papers were identified andretrieved in full text. Data on tooth-brushing frequencyand duration, ideal bristle stiffness, and tooth-brushingmethod were found to be equivocal. Worn toothbrusheswere not shown to be less effective than un worn bru shes,and no ideal toothbrush replacement interval is evident.

Re-chargeable power toothbrushes with an oscillating,rotating (with or without pulsating action) m ode of actionhave been sho wn to be mo re effective in rem oving plaque

and improving gingival outcomes than manual tooth-brushes. Ideal tooth-brushing force has yet to be deter-m ined , but excessive force m ay be associated with gingivaltrauma. While gingival recession and hard-tissue cervicalabrasion are recognized as having multi-factorial etiolo-gies, tooth brushing is considered contributory.Toothbrushes have been shown to support a variety ofmicro-organisms, but research showing a relationshipbetween a contaminated toothbrush and oral/systemicclinical man ifestations is n ot evident.

Conclusions: Seven recomm end ations were developedrepresent ing the current unders tanding surroundingtoothbrush use, based on the best available evidence.

Wh ile considerable research into t ooth brushing h as beencondu cted, it was foun d th at th ere is a pau city of researchon several aspects of tooth brushing; thu s man y firm con -clusions could not made. This lack of conclusive data inseveral areas about tooth brushing limits den tal hygienistsability to provide evidence-based recommendations fortheir clients. In these cases, dental hygienists will need torely on their clinical experience along with the specificcondition s of th eir clients. It is apparent th at m any opp or-tunities exist for future dental hygiene research in severalareas of tooth brushing.

Canadian Dental Hygienists Association Position StatementResearch is scarce on several aspects of tooth brushin g, disallowing firm con clusions an d p rovidin g m any opportu ni-

ties for future d ental h ygiene research. Frequency an d d uration data are equ ivocal, and neith er ideal bristle stiffness nortooth-brushing method has been determined. Re-chargeable toothbrushes with oscillating, rotating (with or withoutpulsatin g action) m ode of action have been sho wn t o be m ore effective in removin g plaque and im proving gingival out-comes than manual toothbrushes currently available. Due to the length of the clinical trials that assessed mode ofaction, on ly the clinical significance of plaque and gingivitis reduction could be assessed, no t th e imp act on reductionof periodontal destruction. While the ideal force of tooth brushing has not been determined, excessive force may belinked with gingival trauma. Gingival recession and hard-tissue cervical abrasion have multi-factorial etiologies andtooth brushing is considered contributory. Worn toothbrushes have not been shown to be less effective than unwornbrushes; therefore, n o ideal replacem ent interval is evident. Toothbrush es support a variety of m icro-organisms, butresearch is lacking th at shows a relation ship between a cont am inated to oth brush an d oral/system ic clinical man ifesta-tions.

Keywords: Dental devices, home care; dental plaque; gingival recession; gingivitis; health behavior; periodontitis;toothbrushing

TOOTH BRUSHING


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Dclaration de LACHD sur le brossage des dentsIl y a un m anq ue dtudes sur plusieurs aspects du brossage des dents, ce qui emp che de tirer des conclusion s fermeset offre de no m breuses possibilits pour la recherche future en h ygine d entaire. Les donn es sur la frquence et la duresont quivoques. Ni la rigidit des soies ni la mthode de brossage idales nont t dtermines. Toutefois, il y aquelques tudes qui indiquent quune technique de frottage est moins efficace pour lenlvement de la plaque quedautres techniques ou mthodes. Il a t dmontr que les brosses dents piles rechargeables oscillantes, rotatives

(avec ou sans action pulsatoire) taient plus efficaces pour lenlvement de la plaque et lamlioration de ltat gingivalque les brosses dents manuelles actuellement offertes. tant donn la dure des essais cliniques valuant le modedaction, seule la porte clinique de la rduction de la plaque et de la gingivite pouvait tre mesure. Leffet sur larduction de la destruction parodontale na donc pas t mesur. Bien que la force idale de brossage nait pas tdterm ine, un e force excessive peut causer un trau m atisme gin gival. La rcession gingivale et labrasion d es tissus durscervicaux ont d es tiologies m ultifactorielles et le brossage de dents est considr com m e un facteur con tribut oire. Il napas t dmontr que les brosses dents uses taient moins efficaces que les brosses qui ne ltaient pas ; parconsquent, aucun intervalle de remplacement idal nest vident. Les brosses dents favorisent le dveloppementdune multitude de microorganismes, mais peu dtudes dmontrent quil y a une relation entre une brosse dentscontam ine et les man ifestations cliniques systm iques et bu ccales.

RECOMMANDATIONS1. Les brosses dents manuelles sont une opt ion viable pour le contrle de la plaque.2. Il a t dmont r que le seul type de brosse dents lectrique tre cliniquement suprieur aux brosses dents manuelles

en ce qui concerne llimination accrue de la plaque dentaire et la rduction des risques de gingivite est celui quiincorpore une action oscillante, rotative (avec ou sans action pulsatoire) dans un modle pile rechargeable ; les autrestypes de brosses dents lectriques se sont rvls aussi efficaces que les brosses dents manuelles.

RSUM

Le but : Le brossage des dents est le comportementdhygine buccale le plus couramment recommand etadopt par les Nord-Amricains et est fait de faonsystmatique dans les nations dveloppes. Cest leprincipal moyen mcanique denlever la plaque dentaire,aidant ainsi prvenir les affections buccales, incluant lagingivite et la carie dentaire. Le but de cet article est defaire rapport sur un e investigation de la po sition actuellede la science sur le brossage des dents comme moyen decontrle de la plaque et des affections parodontales,particulirement la gingivite et den arriver formuler unedclaration de lAssociation canadienne des hyginistesden taires (ACHD).

Les mthodes : En utilisant les tudes et analysespublies antrieurement comme point de dpart, unetude et une analyse approfondie de la littrature a tfaite. La recherche tait guide par le dveloppement deplusieurs questions PICO sur le brossage des dents etincluaient lutilisation des bases de donn es suivant es :MedLine, CINAHL (Cumulative Index of Nursing a AlliedHealth Literature) et le Cochrane Controlled TrialsRegister. Des sites Web srieux ont galement t vrifis. la suite de ltude et de lanalyse, des commentaires ontt sollicits auprs dexperts et de chercheurs reconnusoeuvrant d ans des dom aines pertinen ts dinvestigation s.

Les rsultats : Au to tal, 238 articles on t t iden tifis et

rcuprs en text e intgral. Les don n es sur la frquen ce etla dure d u b rossage des dents, sur la rigidit des soies et lam th ode d e brossage idales se son t rvles qu ivoques. Ilna pas t dmontr que les brosses dents uses taientm oins efficaces et aucun intervalle de rem placem ent idal

nest vident. Il a t dmontr que les brosses dents

piles rech argeables avec action oscillant e, rotative (avec ousans action pulsatoire) sont plus efficaces pourlenlvement de la plaque et lamlioration de ltatgingival que les brosses dents manuelles. La force idalede brossage na pas encore t dtermine, mais la forceexcessive peut tre associe un traumatisme gingival.Bien qu e la rcession gingivale et labrasion des tissus durscervicaux sont reconnues comme ayant des tiologiesm ultifactorielles, le brossage de dent s est con sidr com m eun facteur con tributoire. Il a t dm on tr que les brosses dents favorisent le dveloppement dune multitude demicroorganismes, mais les tudes montrant une relationentre un e brosse dents contam ine et les man ifestations

cliniques systmatiques et buccales ne sont pas videntes.Les conclusions : Bases sur les meilleures donnes

probantes disponibles, sept recommandations, reprsen-tant la vision commune actuelle concernant lutilisationde la brosse dents, ont t dveloppes. Bien quunerecherche considrable ait t ralise sur le brossage dedents, il a t dmontr quil y a un manque dtudes surplusieurs aspects du brossage de dents ; par consquent, ilna pas t possible de tirer plusieurs conclusions fermes.Ce man que de don nes concluantes dans plusieurs aspectsdu brossage de dents limite la capacit des hyginistesdentaires de faire des recommandations bases sur desdonnes probantes leurs clients. Dans ces cas, les

hyginistes dentaires devront sen remettre leurexprience clin ique en tenan t com pte de ltat spcifiquede leurs clients. Il est vident que de nombreuses pos-sibilits existent pour la recherche future en hyginedentaire dans plusieurs aspects du brossage des dents.


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INTRODUCTION

INADEQUATE PLAQUE CONTROL CAN LEAD TO AN INCREASEin pathogenic microflora, which is considered the pri-mary cause of gingivitis and is certainly implicated inthe progression of periodontitis although its relationshipto th e latter is m ore complex.1,2

Tooth brushing is the most commonly recommendedand performed oral hygiene behaviour in North America

and is don e ubiquitously in developed nation s.3-5 It is con -sidered a primary m echan ical mean s of removing substan-tial amounts of plaque in order to prevent oral disease,including gingivitis and den tal caries, wh ile also m aintain-ing den tal aesth etics and preventing h alitosis.2 While theprimary mechanism of action of tooth brushing is them echan ical removal of plaque, it is also used as a m eans ofdelivering ch emot h erapeutic agents via toothp aste.6

Though most people in developed countries use toothbrushing as part of their routine oral health in terventions,the adequacy in controlling plaque through this means isconsidered sub-optimal, particularly in the gingival area,which is critical in preventing inflammation.5,7,8 In an

early review, it was reported that the average daily tooth-brush cleanin g of two m inutes would remove on ly 50% ofall plaqu e.5 Factors affecting th e efficacy of too th brush inginclude the technique, frequency, duration, brush typeand design, and th e dentifrice used.5,6

Dental clients look to oral health professionals, particu-larly dental hygienists, for current and accurate informa-tion abo ut o ral health care behaviours. The in flux of oralhealth care aids, including new designs of both manualand power toothbrushes, has contributed to m uch con fu-sion for consum ers surroun ding th e efficacy and safety ofnew models.9 It is therefore critical that dental hygienistsbe knowledgeable about toothbrushes and tooth brushing

in order to make evidence-based recommendations totheir clients.10 This task is equally confusing for oralhealth care professionals in that there have been interna-tional workshops and abundant research studies, some-times presenting con tradictory findin gs.10

The aim of this paper is to report on an investigationinto the current state of the science on tooth brushing forth e control of p laque an d p eriodon tal diseases, particular-ly gingivitis. This review will en com pass tradition al tooth -brushes, both m anu al and power, but will exclude special-ized toothbrushes designed for specific areas of the denti-tion . Th e outcom e of th e investigation is th is position paper

and accompanying position statement that will providedental hygienists with a current knowledge base on thetopic in o rder to p rovide eviden ce-based client edu cation.

BACKGROUNDThe tooth brush has been reported to have been invent-

ed in China in approximately 1000 AD.11 This early con-figuration is reported to have had an ivory or oxen bone

handle with either horse mane or hog bristles.10,11 It wasnot unti l the 17th century that the toothbrush made i tsway to Europe, and it was the latter part of that centurybefore Am erican d entists were recomm endin g its use.11 In1885, it is reported toothbrushes were being mass pro-duced11 and, as a result, were more commonly in use,albeit often shared among family members due to theexpense.6 In the late 1930s, nylon bristles had largelyreplaced n atural on es.6,11,12 Improvements in m anufactur-ing also allowed for the development of plastic handlesand a subsequent decrease in price, making toothbrushesmore readily accessible.6 Interestingly, it was a result of am and atory tooth -brushin g protocol for Am erican soldiers

in the Second World War and subsequent bringing thehabit back hom e that gave the im petus for widespread useof tooth brushing.11

Powered toothbrushes were first developed in

Switzerland after th e Secon d World War and were poweredby electricity.11 Introdu ced to th e United States market in1960, powered toothbrushes were an immediate success,but these early versions were not superior to manualtoothbrushes and suffered from mechanical failure.11

These first p owered tooth brushes were designed sim ply tom imic the m anual tooth-brushing motions, some up anddown and oth ers side to side.13 Continuous developm entshave o ccurred since th ese initial m odels.14,15 However, thesecond generation of powered toothbrushes did notemerge unt il th e 1990s and th ey have increasingly becomea h ousehold item ever since.1,6,11


3. Lutil isation dune brosse dents lectrique nest pas plus dommageable pour les tissus buccaux que lutil isation d unebrosse dents manuelle et peut tre moins dommageable.

4. En ce qui concerne lefficacit d une technique de brossage de dents, aucune mthode ne sest rvle clairementsuprieure. Cependant la technique de frottage peut tre moins efficace que les autres mthodes.

5. Il ny a pas dlments probants quune brosse dent aux soies uses est moins efficace quune brosse dents aux soiesnon uses. Par consquent, aucun intervalle de remplacement idal na encore t dtermin.

6. Les clients montrant une rcession gingivale et/ ou des lsions des tissus durs cervicaux non carieuses devraient tre conseil-ls, sur une base individuelle, concernant les interventions et les recommandations devraient inclure de linformation sur

ltiologie multifactorielle de ces manifestations.7. Bien que la recherche dmont re que les brosses dents favorisent le dveloppement dune mult itude de microorganismes,

il n a pas t dmont r que cela se traduisait en manifestations cliniques systmiques et buccales.

It is therefore critical that dentalhygienists be knowledgeable abouttoothbrushes and tooth brushing in

order to make evidence-basedrecommendations to their clients.


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MATERIALS AND M ETHODSThis position paper, commissioned by the Canadian

Dental Hygienists Association (CDHA), represents a com-prehensive review of the literature on tooth brushing inorder to develop a position statem ent abo ut th e practice oftooth brushing as a preventive oral health behaviour. Thefirst step in the investigation was to develop several PICOquestions that subsequently guided the literature search

and th is report. In th is case, more th an o ne PICO questionwas deemed essent ial due to th e m ulti-dimen sion al facetsof tooth brushing. The following questions were devel-oped:1. For an adult cl ient with p laque and/or gingivit is

(Population), will powered tooth brushing (Intervention)as compared to manual tooth brushing (Comparison)better reduce plaque and /or reduce bleeding and /or gin-gival and/ or p eriodon tal related scores (Outcome)?

2. For an adult cl ient with p laque and/or gingivit is(Population), will man ual tooth brushing using a specif-ic technique, dura t ion , force and/or frequency(Intervention) as compared to normal manual tooth

brushing (Comparison) better reduce plaque, and/orreduce bleeding and/or gingival and/or periodontalrelated scores (Outcom e)?

3. For an adult cl ient with p laque and/or gingivit is(Population), wil l tooth brushing with unworn tooth-brush bristles (Intervention) as com pared to tooth brush-ing with worn toothbrush bristles (Comparison) betterreduce plaque, and/or reduce bleeding and/or gingivaland /or periodon tal related scores (Outcome)?

4. For an adult cl ient with p laque and/or gingivit is(Population), will specified toothbrush storage and/orcleanin g procedures (Intervention) as compared to nor-mal toothbrush storage and/or no cleaning procedures

(Comparison) better reduce microbial contamination,cross-contam ination and /or re-infection (Outcom e)?A state-of-the-science workshop was held in 1985 to

examin e the status of dent al plaque cont rol measures andoral hygiene procedures.5 A year later, the proceedings,which included both state-of-the-science and reactionpapers plus reports of the working groups and workshopparticipant discussions, were published and included achapter by Frandsen on mechanical oral hygiene prac-tices.5 Frandsen reported th at th e investigation was basedon available research a n d several previous worksho ps: An nArbor (1966), Malm (1971), Chicago (1977), and SantaMonica (1980).5 Brothwell et al. later conducted a review,

which in volved a search from 1984 to 1995, thus proceed-ing from the 1986 workshop.3 This subsequent reviewfocused only on studies that examined disease outcomes,recogn izing th at a certain am oun t of plaque is comp atiblewith a healthy periodontium.3 In 2003, the CochraneCollaboration conducted a systematic review and meta-analysis on manual tooth brushing versus powered toothbrushing, and that review was subsequently updated in2005.1,16 This present position paper uses these previousreviews as a departure point for its literature search andfindings.

The literature search for the present investigation wasconducted in stages beginning in April 2006 through toMay 25, 2006. The search included the following databas-es: MedLine, CINAHL (Cumulative Index of Nursing andAllied Health Literature), and the Cochrane ControlledTrials Register. Th e search focused o n th ose pap ers report-ing on both in vitro an d in vivo rando m ized controlled tri-als (RCT) but also included other relevant papers such as

systematic or unsystematic reviews and various othersources in cludin g websites.

The first stage of the review was of the three databasesand included combinations of the following keywords:tooth brush(ing), power, electric, manual, soft, medium,hard, bristles, filaments, method, Bass, Stillmans, Fones,Charters, Roll, frequency, storage, replacement, contami-nation and th e outcom e m easures, plaque, gingivitis, gin-gival bleeding. The search was limited to the English lan-guage from 1996 to 2006 for all search terms (or com bina-tions) with the exception of tooth brushing, power toothbrushing and manual tooth brushing. In these cases, thesearch was limited to th e period 2000 to 2006. This initial

search o f the th ree databases, usin g titles, abstracts and fulltext, resulted in 872 articles. Papers were retrieved if theyexamined any of the tooth-brushing variables in relationto an outcom e m easure. Other relevant literature was sim-ilarly retrieved at this point if deemed to provide back-ground in formation . A total of 209 papers were identifiedand subsequen tly retrieved in full text.

The secon d stage of the search used all papers th roughthe initial search and involved manually checking bibli-ographies and references for additional salient materials.This stage resulted in an additional 29 papers beingretrieved in full text. Websites were also subsequentlyexamined including those of the Canadian Denta l

Association (CDA) and the American Dental HygienistsAssociation (ADHA).

A unique element of a position paper is the solicitedinput from recognized experts and researchers. For thispaper, input was sought from experts within preventiveoral health care, periodontology, and community oralhealth and epidemiology. The rationale for this combina-tion was to provide expertise in th is rath er broad scient ificth eme of inquiry.

RESULTSPart I: The Instrument

At th e time of th e Fran dsen review (1986), it was report -

ed th at n o evidence was yet available to show th e superi-ority of any one specific toothbrush type or design inremoving p laque, and research into th e field was scanty.5

It was reported th at, in general, the available tooth brusheswere satisfactory in aiding in plaque removal, providingth at th e individuals using them were sufficiently m otivat-ed and edu cated in t heir use.5 At the time, it was also con-cluded, con sistent with th e Ann Arbor and Chicago work-shops, that neither power nor manual toothbrushes hadbeen shown to be superior to the oth er.5 It was believed atthe time of Frandsens report that if plaque removal fails,improvem ents were more likely by altering the con ditions



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determining toothbrush use, such as tooth-brushing tech-nique, frequency and duration, rather than the tooth brushitself.5

Due to technological advances, the findings from theBroth well et al. review cont rasted with th e Frand sen reportin that oscillating/rotating action power brushes werefound to be more effective in reducing gingivitis thanm anu al tooth brushes and less likely to cause gingival dam-

age.3 Furthermore, it was concluded that other designs ofpower toothbrushes had n o advantage over man ual tooth-brushes.3 While the Brothwell paper was published severalyears prior to the Cochrane review, these findings were inagreemen t with each oth er.

Commonly agreed-upon features for manual tooth-brushes included a large, comfortable han dle with a goodgrip and a small-to-moderate-sized contoured brush headset on an an gle.5,6,17

Manual versus manual toothbrushesThe abundant research and development surrounding

m anu al toothb rush designs h ave not reinforced Frand sen s

assertion that improvements in plaque control will resultfrom users technique rather than from the instrumentitself. However, despite contin uous tooth brush m odifica-tions, compelling evidence is yet to emerge that demon-strates one toothbrush design to be consistently superiorin plaque rem oval and to im prove gingival outcom es.

Recent short-term trials evaluating manual toothbrushdesigns h ave shown some designs to be significant ly supe-rior in plaque rem oval.7,18,19 For example, toothbru sh pro-totypes with m ulti-level bristle trim patterns o r th ose withtightly packed an d tap ered bristles have dem on strated sig-nificant reductions in plaque scores over a conventionaltoothbrush design.7,18 However, other studies with vari-

ously designed manual toothbrushes have shown no sig-nificant differences in plaque rem oval.10,20-22

A relatively n ewly design ed m anu al tooth brush (Oral-BCrossAction) has undergone considerable study. Thistoothbrush has angled filaments in opposing directions(criss-cross) alon g the h orizon tal axis of th e brush an d fea-tures elliptical-shaped tufts of bristles and a large mono-tuft at the tip containing more than 700 filaments. Thismanual brush has shown significant improvements inplaque removal in laboratory studies23 and in several invivo studies,24-28 which have also shown gingivitis reduc-tions.26 However, conflicting results have also emerged:other studies show other manual designs to significantly

reduce plaque19,29 and gingivitis29 scores more effectively,while yet oth er studies have dem on strated n o difference.22

The successor to this manual toothbrush (Oral-BCrossAction Vitalizer) has been modified with two lateralrows of non-latex rubber nubs; it has been shown to bemore effective than its predecessor and another conven-tional manual toothbrush.30 Some authors are still inagreemen t with th e Frandsen and Broth well reviews, con-cluding that the technique employed may be a moreimportant variable than the toothbrush design wherem anu al brushes are concerned.20

Powered versus manual toothbrushesA Cochrane systematic review and meta-analysis pub-

lished in 2003 compared tooth brushing with poweredtoothbrushes to various manual toothbrushes .16

Systematic reviews of randomized controlled trials (RCTs)are considered t h e gold standard for assessing h ealth careintervention effectiveness. By using explicit and stringentscientific methods, they provide objective and compre-

hensive reviews of the available literature.31 The literaturesearch for th e Cochran e system atic review was con ductedfrom 1966 to 2002 with 354 articles being identified.Using strin gent exclusion criteria (RCT, 28 d ays, clinicaletc.), 29 trials were included in th e final an alysis. The p ri-m ary reason for excluding a study from th e m eta-analysiswas tha t the s tudy was too short in dura t ion .31

Approxim ately 25 powered tooth brushes were clusteredinto six modes of action: side-to-side (moves laterally),coun ter oscillation (adjacent tu fts ind ependen tly rotate inon e direction , then th e other, and in o pposite direction t oadjacen t tu fts), rotation oscillation (brush h ead rotates inone direction and then the other), circular (brush head

rotates in one direction), ultrasonic (bristles vibrate atultrason ic frequencies [> 20 kHz]), and un known .16

The primary outcom e measures used in th e studies thatwere included in the meta-analysis and its subsequent

update were quantified levels of plaque and/or gingivi-tis.1,16,31 When possible, gingivitis values were recorded atthe time of arrival for assessment. But, where necessary,values were taken after tooth brushing was conducted atthe assessment visit as it was assumed that a single toothbrushing would not influence the gingival outcomescores.1,16 However, only those plaque values taken beforebrushing at the assessment visit were included in thereviews because these scores were believed to be morereflective of actual home use.1,16

The only cluster that removed more plaque (7%) andreduced gingivitis more effectively (17%) than manualtooth brushing in both the short ( 28 days an d long term

( 3 mo nt hs) was th e rotational oscillation powered tooth -brush cluster. The authors concluded that both manualand powered tooth brushes were effective in reducing gin-givitis, possibly preven ting p eriodon titis, an d preventingtooth decay if using fluoridated tooth paste.16

The Cochrane review is significant to this body of liter-ature because it is the most comprehensive independentreview of power tooth brushing ever conducted.11 Th ereview was updated in 2005 with the search extendinginto 2004 but it still confined studies to those comparingvarious manual toothbrushes with powered brushes.1

However, the clustering was somewhat different in that


Compelling evidence is yet to emergethat demonstrates one [manual]

toothbrush design to be consistentlysuperior in plaque removal and to

improve gingival outcomes.


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there were seven groups, with the ionic group beingadded: side-to-side laterally, counter oscillation, rotationoscillation , circular, ultrason ic, ion ic (brush aim s to imp artan electrical charge to tooth surface) and, finally,unknown mot ion .1

In the update, results and conclusions were similar tothe previous Cochrane review. The rotation oscillationbrushes removed m ore plaque and reduced gingivitis more

effectively than manual brushes in the short term (11%plaque reduction s and 6% gingival indices reductions) andreduced gingivitis over three months (17% Bleeding onProbing reductions).1 It was concluded that individualswho prefer to use a power toothbru sh can be assured th atpowered tooth brushing is at least as effective as manualtooth brushing, and there is no evidence that poweredtooth brushing will cause any more injuries to the gumsthan with m anual.1 Thus, Frand sens and Broth wells con -clusions that use of a manual toothbrush is worthwhilewere reaffirmed .

The investigators of both t he Coch rane review and t heupdate identified several possible weaknesses of the study

and its update, including the grouping of the brushes bytheir modes of action.1,16 While these groupings allowedfor a more powerful meta-analysis, subtle differencesbetween brushes could not be assessed.1,16 For example,isolated, individual toothbrush design features such astoothbrush head size and design and filament size andarrangement could not be analyzed.1,16 This limitationmay in turn imply that while some oscillating, rotationaltoothbrushes are more effective than manual toothbrush-es, some indeed may not be. Furthermore, the effective-ness of some individual designs may have been maskeddue to clustering with less effective designs. For example,some much earlier designs were grouped together with

later version s with similar mo des of action . Furth ermore,because of the length of the trials included in the review(typically less th an th ree mo nt hs), only th e clinical signif-icance of plaque and gingivitis reductions could beassessed and not the impact on reductions of periodontaldestruction.16

Wh ile studies of fewer than 28 days were excluded fromth e Cochran e review, several recent single-use an d sho rter-term studies have been conducted comparing powertoothbrushes with various manual toothbrushes, andsince th e Cochran e update, 28-day or longer studies havebeen published. Results from these studies have demon-

strated that various powered designsincluding hybridpower designs (mean ing a com bination of design features,for example a power rotational head and a m anu al comp o-nen t), battery-operated an d rech argeable rotational oscil-lating designs and sonic re-chargeable designshave beenshown to be significantly more effective in reducingplaque than con ventional manual toothbrushes.2,13,21,32-37

Similarly, findings were reported, demonstrating hybrid

power designs (Crest SpinBrush Pro) to be superior inplaque reduction to non-conventional manual tooth-brushes (Oral-B CrossAction).27

However, other studies produced conflicting results andhave revealed manual toothbrushes to be more effectivethan powered tooth brushes,31,33,38,39 or o f equal effective-ness.40 A more recent manual toothbrush design (dis-cussed previously), distinct in th at it h as a brush h ead withtufts of brist les angled from the vert ical (Oral-BCrossAction), has been shown to be more effective inplaque removal than two different battery-powereddesigns: one a oscil lat ing rotat ing design (ColgateActibrush) an d th e other a h ybrid design t hat com bines an

oscillating rotational head with an un-powered compo-nent (Dr. Johns Spin Brush Classic).38,39 These plaquereductions were confirmed in longer-term studies, but nosign ifican t differences were show n in gingivitis scores.39 Ina single-use study, a recent modification of this particularmanual toothbrush design (Oral-B CrossAction Vitalizer)has also been shown to be superior in plaque rem oval thana battery-operated h ybrid design.30

Powered versus powered toothbrushesSeveral studies have been conducted that compare

oscillating rotating, and no w pulsatin g, power toothbrush -es with high-frequency/sonic tooth brushes.37,41,42 Some

of these studies have been consistent with the Cochranefind ings in th at th e oscillating rotational brush es had sig-nificantly greater reductions in plaque on all surfaces,9,41-44 and in oth er studies, on som e surfaces.37 Som e of th esesame trials were also able to show reductions in gingivalparameters, including gingival bleeding.9,37 In addit ion,some of these same studies conducted surveys of studyparticipants and showed significantly greater preferencefor the oscillating, rotational design.9,42

Interestingly, results of other studies conflict with thepreceding findings. While the oscillating, rotating, pulsat-ing power toothbrush has demonstrated greater reduc-tions in plaque an d bleeding in dices over th e sonic brush,

these differences were not found to be statistically signifi-cant .45 The efficacy of sonic brushes is claimed to be theresult of micro-streaming of the saliva-toothpaste slurrycaused by t he high-frequen cy bristle m ovemen t, resultingin a beyond the bristle efficacy.37,42 This effect isdescribed as generating localized hydrodynamic shearforces in the fluids that surround the brush head. 46 In anuncontrolled study comparing two sonic toothbrusheswith oval heads in reversing experimental gingivitis, nodifference between th e two brush es could be detected.47 Inan in vitro study comp aring a sonic brush with an oscillat-ing, rotating, pulsating power toothbrush, it was shown


Individuals who prefer to use apower toothbrush can be assuredthat powered tooth brushing is atleast as effective as manual toothbrushing, and there is no evidencethat powered tooth brushing will

cause any more injuries to thegums than with manual.


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th at th e sonic brush was capable of rem oving significantlymore plaque bacteria beyond its bristles than the other.46

The authors concluded that this would result in moreeffective plaque control in vivo,46 although this was notdemonstrated.

Of the increasing number of powered toothbrushesbecoming available, many are low-cost battery-operateddesigns, but there is a lack of published clinical data to

support th eir use.38 A laboratory study com paring battery-operated oscillating, rotating power toothbrushes witheach other has shown significant differences betweenbrushes in removing artificial plaque.48 In single-use stud-ies comparing a battery-operated oscillating, rotatingpower toothbrush (Colgate Actibrush) with a hybriddesign (Crest SpinBrush), the latter significantly outper-formed th e form er in p laque reduction. 49,50 A th ree-m on thin vivo study com paring two battery-operated oscillatin g,rotating power toothbrushes (Braun Oral-B [D4], ColgateActibrush) showed that one (D4) was superior to theother.51 A single-use cross-over study compared a re-chargeable oscillating, rotating, pulsating power tooth-

brush (Braun Oral-B 3D Excel [D17]) with a batt ery-operat-ed oscillating, rotating brush (Colgate Actibrush). Resultsshowed the re-chargeable design to affect significantlygreater plaque removal.52

Oth er sin gle-use studies have com pared different pow-ered hybrid designs with subtle design modifications toeach other (Crest SpinBrush flat bristle profile, CrestSpinBrush rippled bristle profile). In some cases, the stud-ies found significant improvements in plaque removalscores;53 in o th er cases, no sign ificant differen ces were evi-dent (Crest SpinBrush Pro, re-designed Crest SpinBrushPro).54

Bristle designFor most of the previous century, manual toothbrush

designs h ave had flat bristle trim pattern s and rectangularheads.35 More recently, brush heads have been modifiedinto more tapered, oval and diamond shapes with bristletrim patterns evolving into bi-leveled, multi-leveled andrippled trim s, an d som e designs h aving criss-cross an gulat-ed bristle tufts.35

Based on available evidence at the time, Frandsen rec-ommended that a manual toothbrush have soft nylonend-rounded bristles with a diameter of approximately0 .2 mm and a length of 10 mm with a m ul ti -tuftedstraight trimmed brush head design.5 According to the

Brothwell review, more recent studies suggested serratedtufts, raised toe bristles, and an angled head may presentadvantages.3 It was concluded in that latter review thatmost commercially available manual brushes could beused effectively with th e exception o f foam brushes, whichhad been shown to be less effective.3

Toothbrush design is believed to have an impact ontooth-brushing efficacy, particularly in areas that have tra-ditionally been m ore difficult to clean, such as the lingual,interproximal, and posterior surfaces.18 Design modifica-tions can include improvements to the handle, brushhead, and bristles. However, some reports are more in

alignm ent with Frandsens assertion in th at th ey claim th edesign features of a toothbrush have little to do withplaque removal efficacy,20 and poor technique combinedwith insufficient brushing duration lead to inadequateplaque removal.26

Of toothbrush com ponen ts, perhaps the m ost studied isthe bristle design. It is believed that the bristle design con-tributes to the plaque removal efficacy of the toothbrush,

and m ore tapered bristles have been shown in vitro to haveimproved access to the sub-gingival region.55 Other in vitrostudies have shown modified filaments to be superior inplaque removal to end-rounded designs. For example,feath ered filam ents, when comp ared with end-roun ded fil-aments, removed significantly more artificial plaque belowthe gingival margin than the control.56 In a recent RCT,conical shaped filam ents with m icrofin e tips that im m e-diately bend when pressure is applied were evaluatedagainst an American Dental Association (ADA) referencetooth brush, using several outcom e m easures.8 However, n osign ificant d ifference was detected between t h e two designs.8

It is believed that filament stiffness can contribute tothe traumatic potential of a toothbrush, but the influenceof th is factor is n ot clear.6,17 The m ajority of com m erciallyavailable toot hbru shes today are m arketed as being soft,meaning that they have thinner diameter bristles andsome degree of polishing applied to the cut ends. 12

However, hard-bristled brushes have been shown to bem ore effective in p laque removal th an m edium bristles in

one study that employed several tooth-brushing tech-niques.57 While conventional brushes typically incorpo-rate cylindrical filaments with end-rounded tips,8 fila-ments can be of different materials, lengths, thicknesses,and tip geometries and be situated within the brush headwith varying comp actness and an gulation s to the head.58

Brist le t ips have received much attention fromresearchers. Contemporary understanding favours end-roun ded filam ent tips as they are believed to be less abra-sive to soft tissue; however, their clinical value is lessdefined.12,17,59 Despite many toothbrush designs claimingto have end-rounded bristles, studies have shown thatcommercially available toothbrushes demonstrate non-

uniform filam ent m orphology and th at m any brushes donot present with an acceptable level of quality.12,17,60

While the proportion of acceptable tips may be increas-ing,17 regardless of the original geometry of bristle tip,roun ding of sharp-edged filamen ts occurs when th e brushis being used by the client.12,17 It has been shown that ,when less than 10% of the expected toothbrush life haselapsed, bristle tips of various geom etries will display a flat-tened shape.12 This ch ange in bristle tip geometry has n otbeen shown to significantly affect th e abrasiveness of thebrush.12 Despite this, it is asserted that filaments shouldbegin with an acceptable level of quality.60


Toothbrush design is believedto have an impact on

tooth-brushing efficacy.


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PART II: THE USERTooth-brushing duration

Frandsen and later Brothwell et al. did not make con-clusions regarding the opt imal duration of tooth brushing.Recent reports have concluded that tooth-brushing dura-tion is an im portan t variable in plaque rem oval efficacy.18

However, scientific investigations into the ideal brushingtime have been problematic.6 While it is believed thatincreased brushing time does result in more plaqueremoval, th e brush ing techn ique used can confoun d studycomparisons.6 Some h ave recomm ended th ree minutes asideal for man ual brushing.6

It has been shown that individuals typically brush for

about on e min ute or less but th at m ost people sign ificant -ly overestimate tooth-brushing duration.18 Studies haveshown ranges of brushing tim es from 56.7 to 83.5 seconds,whereas estimated brushing t imes by th ese subjects rangefrom 134.1 to 154.6 seconds.4,10 These differen ces betweenactual and estimated brushing times have been found tobe statistically significant .

Recent studies have shown that a significant relation-ship exists between recession and tooth-brushing dura-t ion.61 In a study using a powered toothb rush, both bru sh-ing force and duration significantly affected the level ofplaque removed, but these outcomes were not uniform.62

The auth ors con cluded t hat little advantage could be real-

ized when brushing for more than two minutes at a forceof 150 grams (g).62 Powered toothbrush designs haveincorporated this understanding by incorporating timers,typically set for two minutes, to enable the user to accu-rately assess their brushing time. However, the efficacy ofth is feature h as not been evaluated.63

Tooth-brushing frequencyIn th e state-of-th e-science workshop, Frandsen reported

that confusion surrounded op timum brushing frequency.5

He reiterated th at th e quality of brushing is likely a m oreimportant factor than the frequency.5 Frandsen concludedthat findings from the previous workshops, which had

identified a brush ing frequen cy up to two tim es a day, wasstill substantiated and that no significant gains could beachieved by increasing this frequency.5 The Brothwellupd ate, while concluding th at studies h ave suggested th atincreased brushin g frequen cy is indeed related to im prove-ments in periodontal health, asserted that no optimumfrequen cy had yet been established.3

Since th ese reviews, few studies have been pu blished ontooth-brushing frequency, and those that have been pub-lished also found frequen cy data to be equivocal.61 Recentresearch conducted on dogs reinforced tooth brushingon ce a day as being n ecessary to m aintain gin gival fibrob-

last activity and proliferation of the junctional epitheli-um .64 However, a study conducted in 2001 assessed therelationship among several variables, including frequencyof tooth brushing, on recession and found that a signifi-cant positive relationsh ip did exist.61

Tooth-brushing forceMost of the literature surroun ding toot h-brushin g force

has examined its impact on gingival abrasions9 0 reces-02


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Recent studies h ave recognized the role th at techn ique,frequency, and duration of tooth brushing has on reces-sion, showing significant relationships between recessionand th ese variables.61 In one study, the greatest recessionwas found to be associated with a horizontal scrubbingtechnique, and recession increased with increased dura-tion and frequency of brushing.61 Other studies haveshown that tooth-brushing technique and brushing fre-

quen cy were both associated with recession.75 In a un iver-sity dental program population, those who were in firstyear and used more simple brushing techniques (i.e.,scrubbing) were found to have less recession, whereasth ose in fifth year who em ployed mo re soph isticated tech-n iques demon strated more recession.75 Age was not foundto be associated with increased recession. The somewhatcontradictory results were explain ed by t h e very small pro-portion of the fifth-year students who had maintainedsimple brushing methods and who accounted for theincreased recession.75 Other studies have shown that thebristle hardness of the toothbrush was correlated withrecession whereas brushing technique was not.82

Furthermore, end-rounding of toothbrush bristles hasbeen shown to affect th e incidence of gingival abrasions.79

A review conducted in 2003 concluded that gingivalrecession has a multi-factorial etiology: anatomical factors(tooth m alposit ion, path of tooth eruption, tooth shape,profile and position in th e arch, alveolar bone deh iscence,muscle attachment, and frenal pull), pathological factors(periodon tal disease and treatmen t an d iatrogenic restora-tive and operative treatment), along with improper oralhygiene methods and self-inflicted injuries were all con-tributory.76 Other reports are in agreement that factorsbeyond tooth -brushin g force are more influential in gingi-val recession .14 The premise exists that tooth brush traum a

causes gingival abrasion leading to recession.76 Whilethere is evidence that gingival trauma and abrasion dooccur in the short term, their consequences in regard torecession are still un clear.76 While it is believed that abra-sion plays a major role in the etiology of gingival reces-sion, causal relationships have not been established.76

Finally, the combined benefit of soft toothbrushes, low-abrasive toothpastes, and better patient education aboutless aggressive brushing techniques has contributed to lessconcern about gingival lesions.12

Hard-tissue lesionsWh ile th e term abrasion h as been defin ed as a loss of

hard tissue due to mechanical process involving foreignobjects or substances, the term abfraction was tradition-ally associated with a pathologic loss of tooth structurecaused by biom echan ical loading forces, which resulted intooth flexure.83-86 Available data surrou n din g loss of cervi-cal hard tissue are scant.15,84 The process by which abfrac-tions occur has n ot been supp orted by th e data. Therefore,the term non-carious cervical lesion has been morerecent ly accepted as it im plies a mu lti-factorial etiology forthese lesions.15,83,84

Studies have linked hard-tissue wear to incorrect andover-vigorous tooth brushing, in particular brushin g with

increased frequency, longer duration, and a scrubbingtechnique.15 Additionally, intra-oral chemical forces havealso been identified as contributory.86 Frandsen reportedthat the exact causal mechanisms for abrasions had notyet been established.5 However, tooth brushing was imp li-cated in th e process and m ore so with im proper or overly-vigorous technique.5 Even at the time of Frandsensreview, it was recognized that the etiology of hard-tissue

abrasions was likely multi-factorial and that enamel abra-sions were not a clinical problem although cervical onesm ay be for some client s.5

In vitro studies have shown that toothbrush abrasioncan induce cervical lesions of a variety of defect shapes.83

The most frequent morphology reported was v/wedged,followed by a mixed appearance; the least encounteredwas u/rounded.83 Furth ermore, the m orph ology of defectschanged over time and increased recession was associatedwith cervical lesions that t ended t o be roun der and broad-er in con trast to sharper an d an gled lesions with d ecreasedrecession.83 On e in vitro study showed similar progressionof lesions to that seen in vivo, and the authors surmised

that the position of the gingival margin may also play arole in abrasion shape.83 Prevalence data has also shownthat tooth brushing is a contributing factor for wedge-shaped lesions.84

Anecdotal reports and in vitro studies have supportedthe contribution of tooth brushing with toothpaste as aconsistent factor in hard-tissue non-carious lesions.58,87 Itis well recognized t hat tooth paste is im portan t for deliver-ing fluoride for p revent ing caries. Frandsen reported th atdentifrice use has been associated with increased plaquereductions over brushin g with water alon e.5 Interestingly,the tooth brush on i ts own is currently understood to havenegligible effects on dentin and enamel.58 It has become

evident that abrasion is considered to be a result of thebrush m oving the paste over the tooth structure.58,87 Mostsurprising are th e accumu lated data showin g that soft-bris-tled brushes have the most influence on abrasion.58 It isbelieved that th e smaller diam eter filamen ts of soft too th -brushes hold the toothpaste better than do the hard fila-ments, and the greater flexion of soft bristles increases thecontact area of the filam ents with th e tooth surface.58,87,88

In lab studies, it has been demonstrated that brushingwith water resulted in no abrasion of hard surfaces.58

Interestingly, in vivo studies have shown that th e amoun tof tooth paste used with power brushes is directly related toth e size of th e head.81

While studies have demonstrated that different brush-ing motions result in significant differences in hard-tissueabrasion, especially with increasing numbers of brushstrokes, the resulting abrasions were considered small.87

Authors have concluded that brushing with toothpasteover many years would produce minimal damage todent in, an d to oth brushing with differing b ristle stiffnesslikely has little clinical significance.58,87 However, onecaveat to th is is in th e case of abrasion in th e presence ofdental hard tissues that have already been demineralizedby erosion, where a synergistic effect is suggested, andhard-tissue loss may have more clinical significance.88 In



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laboratory studies using previously chemically erodedbovine enam el sam ples, it was revealed th at wh ile m anu al,inactivated power and even some activated power tooth-brushes ind uced no m ore loss of hard tooth structure thanth e erosion alone, som e other activated power tooth brush-es produced significantly greater abrasion.88 It was con-cluded that power toothbrushes differ in their transporta-tion of toothpaste and subsequent abrasion.88 It was sur-

m ised that th e frequency, m ovemen t, and filamen t config-uration m ay influen ce the loss of h ard tissue.88

A recent review concluded th at it is now accepted th atabrasion of hard tissues is alm ost ent irely related to tooth -paste, little, if any, damage occurring with a toothbrushalone with other tooth-brushing variables such asmethod, force, time, frequency, type of brush, filamentstiffness, filament end-rounding influencing abrasionoverall.15 The reviewers did assert that conclusions wereformulated based p rimarily on in vitro studies and logicalassumptions.15 The aut h ors also state th at difficulties ariseunder conditions of over- or misuse of tooth brushing,but, even then, the clinical manifestations would be evi-

dent in dentin and not enam el.15

Tooth-brush contaminationThe typical storage conditions of tooth brushes m ay act

as a reservoir for the re-introduction of potentialpathogens to the oral cavity and for the introduction of

other potential pathogens from the bathroom environ-men t .89-92 These micro-organisms have the potential tocolonize the oral cavity due to the micro-trauma thattooth brushin g can cause.93 However, stud ies investigatingth e im plications of tooth brush storage and contam inationhave been intermittent with varying methodologies,89,90

making it difficult to reach definite conclusions. NeitherFrandsen nor Brothwell made comments surrounding this

matter.Studies that h ave been con ducted are in agreemen t th at

toothbrushes do support a wide variety of micro-organ-isms.89-92In v itro research h as shown th e viability of m icro-organisms varies depending on the aerobicity of them icro-organism (the susceptibility of th e m icrobe to oxy-gen) and the design of the brush, specifically whether ithad a hollow area that was accessible to the bacteria.91

Aerobes survived best as did anaerobes on hollowdesigns.91 These authors recommended solid toothbrushdesigns and th orough rinsin g and sh aking of brushes afteruse.91

Studies examining the association of filament-anchor-

ing methods and microbial contamination showed thatbristles having what is described as individual in-moldplacement (where each filament, rather than the entiretuft, is placed individually into the toothbrush head), incontrast to in-mold tufting and staple set tufting, maderetention of micro-organisms significantly more diffi-



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cult .93 Indiv idual in-mold p lacement e l iminates thebundling of filaments and associated gaps and spaceswithin th e anch or but provides greater space between fila-m ents an d allows for m ore effective rinsin g.93

Other studies have recommended antimicrobial (i.e.,chlorhexidine) post-brush ing sprays as a m etho d of disin -fection for preventing cross-infection or re-infection, find-ing that rinsing with water was ineffective in reducing

contamination.94 Interestingly, the routine use of a pre-brushing mouth rinse has been shown to be associatedwith the least amount of toothbrush contamination. 89,90

Toothpastes with a strong surfactant or with amine andstannous fluoride have also been shown to significantlyreduce the amount of contamination of toothbrushes.92

Antiseptic coatings placed during the manufacturingprocess exert contact an tibacterial activity over 45 days,but investigation s into th e efficacy of reducing contam ina-tion h ave not sho wn p ositive results.92

In a study examin ing th e viability of m icro-organisms,specifically Streptococcus mut ans, on tooth brushes made ofopaque versus transparent brush head materials, it was

demonstrated that transparent materials more effectivelyinhibited the retention of micro-organisms. This was dueto th e ability of ligh t to pen etrate more transparent m ate-rials, thus impeding the proliferation of micro-organ-

isms.95 However, th e differences were n ot sh own to be sta-tistically significant and micro-organisms decreased withtime, regardless of brush head materials.95

Oth er researchers have con cluded th at intra-in dividualspread does n ot occur read ily.96 The implication s of tooth -brush contamination may be more of an issue for at-riskclients, such as m edically com prom ised in dividuals.91

CONCLUSIONSSince the publication of the state-of-the-science work-

shop in 1986 an d th e 1998 update condu cted by Broth wellet al., con siderable research in to to oth brushin g has beenconducted. This body of literature has helped to clarifysome critical issues surrounding this commonly recom-mended and performed oral health care intervention,which has subsequently permitted researchersand inturn , oral health care providersto m ake definitive state-ments about these practices. However, several issues sur-rounding toothbrush use remain unclear and definitiveconclusion s still cann ot be m ade, thus limiting the den talhygienists capacity to m ake evidence-based recom m enda-

tions to their clients. In these cases, dental hygienists willneed to rely on their clinical experience along with thespecific condition s of their clien ts.


RECOMMENDATIONSThe following seven recommendations represent the current understanding surrounding toothbrush use and are

based on the best available evidence:1. Manual toothbrushes are a viable opt ion for plaque control.2. The only power toothbrush designs that have been shown to be clinically superior to manual toothbrush designs in

removing more plaque and reducing gingivitis are those that incorporate oscillating, rotating (with or without pulsat-ing) action in a re-chargeable design; other designs of power t oothbrushes have been shown to be as effective as man-

ual toothbrushes.3. Use of a power toothbrush is no more damaging than a manual toothbrush to oral tissues and may be less damaging.4. Regarding the efficacy of toot h-brushing technique, no method has been shown to be clearly superior.5. There is inconclusive evidence that worn t oothbrush br istles are less effective than unworn bristles. Therefore, an ideal

re-placement interval has yet to be identified.6. Clients demonstrating gingival recession and/or non-carious hard-t issue cervical lesions should be advised on an indi-

vidual basis regarding interventions, and recommendations should incorporate the multi-factorial etiology of thesemanifestations.

7. While research shows toothbrushes support a variety of micro-organisms, this has not been shown to t ranslate intooral/ systemic clinical manifestations.

ACKNOWLEDGEMENTS

An unrestricted educational grant from Crest Oral-Bprovided partial fun ding for th is paper.

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