COMPARISON OF 2 TOOTHBRUSHINGMETHODS FOR EFFICACY INSUPRAGINGIVAL PLAQUE REMOVALTHE TOOTHPICK METHOD AND THEBASS METHODMorita M. Nishi K, Watanahe T : J Ciin Periodontol 1998: 25: 829-831.

Dr. Rupali DasFirst Year PG

Department of Periodontics

CONTENTSIntroduction

Definitions

Aids of plaque control

Toothbrushes

Types of toothbrushes

Brushing techniques

Various studies

Results

Advantages

Disadvantages

Conclusion

INTRODUCTION•The role of plaque in the etiology of gingivitis and periodontitis is well established.

•Gingival inflammation consistently follows the build-up of plaque, and conversely, removal of plaque can reverse this process.

Therefore, the regular use of oral hygiene practices is a requisite for proper supragingival plaque elimination.

DEFINITIONSPLAQUE : A structured, resilient, yellowish grayish substance, consisting mainly of microorganisms, that adheres tenaciously to intraoral hard surfaces, including removable and fixed restorations (Bowen WH) .

PLAQUE CONTROL :Removal of microbial plaque and prevention of its accumulation on teeth and adjacent gingival tissues.

AIDS OF PLAQUE CONTROLMECHANICAL CHEMICAL

TOOTHBRUSHESMANUAL ELECTRICAL

INTERDENTAL AIDSDENTAL FLOSSTOOTHPICS INTERDENTAL

BRUSHESAIDS FOR GINGIVAL

STIMULATIONRUBBER TIPBALSA WOOD EDGE

FIRST GENERATION ANTIBIOTICS PHENOLS

(TRICLOSAN) QUATERNATY AMM.

COMPOUNDS SANGUNARINE

SECOND GENERATION BISBIGUANIDES

(CHLORHEXIDINE)THIRD GENERATION

DELMOPINOL

TOOTH BRUSHESAccording to ADA “the toothbrush is designed primarily to promote cleanliness of teeth and oral cavity”.

First introduced in China in 1600 B.C.

Currently, the use of a toothbrush and fluoridated toothpastes is almost universal.

Parts of toothbrush:

Types of Toothbrushes

There are two main types of toothbrushes

1)The manual toothbrush.

2)Or the electric/battery operated toothbrush.

Different cleaning devices have been used in different cultures but the conventional toothbrush is most frequently used to remove dental plaque.

The efficacy of brushing is dictated by : (1) the design of the brush, (2) the skill of the individual using the brush(3) the frequency and duration of use

(Frandsen 1986)

BRUSHING TECHNIQUESThe Bass method (1948)

Modified Bass method

Modified stillman’s method (1932)

Charters method (1928)

Scrub method

Fones method (1934)

Leonard's method (1939)

Smith method (1940)

BASS METHOD/ SULCUS CLEANING METHOD

TECHNIQUEThe head of the brush is positioned in an oblique direction towards the apex, in order to introduce the bristles into the gingival sulcus.

The brush is then moved in an anterio-posterior direction using short strokes.

INDICATIONS:• For dental plaque removal adjacent to and directly beneath

the gingival margins.• Open interproximal areas, cervical areas beneath the height

of contour and exposed root surfaces.• Routine brushing for patients with or without periodontal

involvement.

ADVANTAGES :• Good gingival stimulation• Easy to learn

DISADVANTAGES :• Overzealous brushing may cause injury to gingival margin.• Time consuming• High dexterity requirement

MODIFIED BASS METHODTECHNIQUE:

Combines the vibratory and circular movements of Bass method with the sweeping motion of Roll method.

Toothbrush is held at 45O to the gingiva.

Bristles are gently vibrated by moving the brush handle in back and forth motion.

The bristles are then swept over the sides of the teeth towards the occlusal surfaces in a single motion.

INDICATIONS:• As a routine oral hygiene measure• Intrasulcular cleansing

ADVANTAGES:• Excellent sulcus cleansing• Good interproximal and gingival cleaning• Good gingival stimulation

DISADVANTAGES:• Moderate dexterity of wrist required

MODIFIED STILLMANS METHOD

TECHNIQUEThe head of the brush is positioned in an oblique direction toward the apex, with the bristles placed partly in the gingival margin and partly on the tooth surface. Light pressure together with a vibratory movement is then applied to the handle, and the head of the brush moves in an occlusal direction.

INDICATIONS:• Plaque removal from cervical areas below height of

contour.• Recommended for cleaning in areas with progressing

gingival recession and root exposure to prevent abrasive tissue destruction.

DISADVANTAGES:• Time consuming• Improper brushing can damage the epithelial

attachment.

CHARTERS METHOD(1928)TECHNIQUEA soft /medium multitufted toothbrush is indicated.Bristles are placed at an angle of 45* to the gingiva with bristles directed coronally. T he bristles are activated by mild vibratory strokes with the bristle ends lying interproximally.

INDICATIONS•Open interdental spaces with missing papilla and exposed root surfaces.•Those wearing FPD or orthodontic appliances•Those who had periodontal surgery•Patients with recession mainly interproximally.•For massage and stimulation of marginal and interdental gingiva.

DISADVANTAGES•Brush ends do not engage the gingival sulcus to remove sub gingival plaque.•In some areas, correct brush placement is limited•Requires high digital dexterity.

ROLL STROKE/ ADA METHOD/ SWEEP METHOD

It works fairly well for patients with anatomically normal gingival tissues.

The bristles are placed at 45* angle and slightly rolled across the tooth surface towards the occlusal surfaces.

This technique requires some dexterity around the wrists.

INDICATIONS•Children and adults with limited dexterity.•Patients requiring gingival massage and stimulation.•Cleaning debris from teeth without emphasis on gingival sulcus.•Useful for first lesson for modified stillman technique since the initial brush placement is same.

DISADVANTAGES•Brushing too high during initial placement can lacerate alveolar mucosa.•Quick sweeping strokes result in no brushing from cervical third of tooth.•Brushing with filament tips directed into gingiva may produce punctuate lesions.

FONES/ CIRCULAR SCRUB METHOD( 1934)

Child is asked to make big circles in the air using whole of the arm.

The circles are reduced in diameter until very small circles are made in front of the mouth.

The child is ready to make circles on the teeth with toothbrush, making sure that teeth and gums are covered.

INDICATIONSYoung children who want to do their own brushing but do not have muscle development for more coordination.

ADVANTAGES•Equal or better potential than Bass method.•Easy to learn.•Physically or emotionally handicapped individuals.•Patients who lack dexterity for a more technical brushing method.•Gingiva is provided with good stimulation.

DISADVANTAGES•Possible trauma to gingiva.•Interdental areas are not properly cleaned.•Detrimental for adults who use the brush vigorously.

LEONARDS/ VERTICAL METHOD( 1939)

TECHNIQUEThe bristles are placed at 90*angle to the facial surface of teeth.The motion is up and down on the facial surface of clenched anterior and posterior teeth.

ADVANTAGESMost convenient and effective for small children and deciduous teeth.

DISADVANTAGESInterdental spaces of permanent teeth of adults are not properly cleaned.

SMITH/ PHYSIOLOGIC METHOD (1940)

Described by Smith and later advocated by Bell.It is an attempt to duplicate natures self cleansing and gingival stimulation mechanism during mastication of food.

TECHNIQUEThe bristles of toothbrush are pointed incisally or occlusally and then along and over the tooth surfaces and gingiva.

The motion is gentle sweeping from incisal/occlusal surface over to facial surfaces and progressing toward and over the gingiva

ADVANTAGES:•Natural self cleansing mechanism.•Supragingival cleaning is good.

DISADVANTAGES:•Interdental spaces and sulcus areas of teeth are not properly cleaned.

TOOTHPICK METHODThe tips of the bristles are placed on the gingival margin toward the crown at a 30 degree angle to the long axis of the teeth, as in the Charters' method (Rylander et al, 1985).The bristles are pressed into interdental spaces and pulled out, just like a “toothpick", from the buccal and the lingual aspects .Piston motion is repeated 8-9 times in one region(Watanabe et al,1984)

ADVANTAGES:Removal of inter-proximal plaque is possible without the need for dental floss or an interdental brush. The number of toothbrush bristles inserted depends on the inter-proximal space. .A small number of bristles can be inserted in a small inter-dental space, whereas 1 or 2 tufts are applicable in wide interdental spaces.

NO.1Comparison of 2 toothbrushing

methods for efficacy insupragingival plaque removal

The Toothpick method and theBass method

Morita M. Nishi K, Watanahe T : J Clin Periodontol 1998: 25: 829-831.

AIM The present study is based on a previously reported design (Van der Weijden et al, 1995). The purpose of the professional brushing part of the study was to assess the efficacy of the 2 tooth brushing methods without individual variation

Material and MethodsSUBJECT SELECTION

20 male dental students from Okayama University Dental School, Okayama, Japan were selected and included in the study after having signed an informed consent.

1. Number of subjects - 202. Age range – 24 to 26years (mean age,

25+-2yrs)

Criteria for subject selection

They were screened to exclude those having: (a) orthodontic banding;(b) crowding: (c) fewer than 6 natural teeth in each quadrant; (d) Periodontal pockets 3-4 mm.(e) No students was taking antibiotics during the study.(f) all the subjects received professional tooth cleaning and scaling.

STUDY DESIGNEXPERIMENT I: PROFESSIONAL TOOTHBRUSHING

All subjects were asked to abstain from oral hygiene procedures for 48 h.

Subsequently, 1 examiner (KN) evaluated the amount of dental plaque using a modification of the Quigley & Hein Index(Turesky. et al. 1970).

Plaque was stained with erythrosine. 6 surfaces of each tooth were scored; mesial, middle and distal examined from both the buccal and lingual aspect.

Each participant's mouth was brushed in a split-mouth order by a 2nd examiner (MM) using the 2 brushing methods in the absence of the 1st examiner (KN),

In random order, either the 1st and 3rd quadrants or the 2nd and4th quadrants were brushed using the Toothpick method.

The 2 remaining quadrants were brushed professionallyusing the Bass method.

Toothpickmethod

Bass method

Bass method

Toothpick method

CONTROL

• The toothbrush had 2 rows of nylon bristles, 6 tufts per row, 50 filaments (0=0.2 mm) per tuft.

• The time available for brushing was standardized to 30 s per quadrant and was monitored using a stopwatch (2 min for a whole mouth), because comparison of plaque removing efficacy after 2-min tooth brushing is clinically practical.

• No toothpaste was used in the experiment.

• The 1st examiner (KN) who had no prior knowledge of the assignation of the quadrants, then re-evaluated the amount of dental plaque remaining

EXPERIMENT II: Tooth brushing by the participants after tooth brushing instruction

The same 20 subjects were instructed to brush their teeth using the Bass and the Toothpick methods, and then asked toabstain from oral hygiene procedures for 48 h prior to this experiment.

After plaque accumulation, supervised tooth brushing was performed by the participants according to the split-mouth design, and using the same tooth brushing method as in Experiment I.

The time available for tooth brushing was 30 s per quadrant.

DATA ANALYSISThe mean plaque index was calculated separately for the buccal/lingual surfaces and for the proximal surfaces for each set of quadrants for all individuals.

The differences between the end of trial scores of the 2 tooth brushing methods were assessed using the analysis of covariance (ANCOVA)

The baseline score (48-h plaque accumulation) was used as a covariate.

Comparison of the % reduction between the two Tooth brushing methods was performed using a Wilcoxon test for matched pairs.

Statistical significance was established at the p>0.05 level.

RESULTSThe Toothpick method removed significantly more plaque than the Bass method after 30 s of tooth brushing per quadrantIn the professional tooth brushing experiment:xp

In the participant tooth brushing experiments :

DISCUSSIONPlaque removal from buccal/lingual sites did not differ in either experiment between the 2 brushing methods.

The mean reductions in the plaque scores interproximally were significantly higher at the sites brushed using the Toothpick method than those brushed using the Bass method.

Studies comparing interproximal plaque-removing efficacy of differentmanual tooth brushing methods have concluded that the interproximal areas are inaccessible to the toothbrush (Hansen & Gjermo 1971, Bergenholtz et al. 1984).

ADVANTAGES

The present study is based on a previously reported design (Van der Weijden et al, 1995).

The purpose of the professional brushing part of the study was to assess the efficacy of the 2 tooth brushing methods without individual variation.

DISADVANTAGES•The mean interproximal plaque score at the sites brushed using the Bass method was lower than the result obtained by Tritten etal, (1996), who used the same plaque assessment technique and brushing time.

•This difference may be due to the disparity between the ages of the 2 study groups, as Tritten et al, (1996) recruited older subjects (mean age ; 32 years).

•Since the Quigley & Hein index is based on vision, some problems do arise when assessing low plaque accumulation.

•Specifically, wider interproximal sites are clearly visible, whereas Interproximal spaces with papilla are inaccessible to the eyes

•The toothpick method is more difficult to master than the Bass method, and it should be borne in mind that the results showing increased efficacy of the Toothpick method in plaque removalwere obtained using Senior Dental Students with high levels of manual dexterity.

CONCLUSION

The Bass method of tooth brushing (Bass 1954) is one of the most commonly recommended techniques in dental practice (Rylander et al. 1985).

The Toothpick method was developed (Watanabe et al, 1984) to remove interdental plaque using only an ordinary toothbrush.

NO.2 A comparison of the effectiveness of the

Charters', scrub, and roll methods of toothbrushing in removing plaque

ASGER M. FRANDSEN, JOSEPH P. BARBANO, JOHN D. SUOMI, JAQUELINE J GHANG , ROBERT

HOUSTON

AIMThe effectiveness of the Charters', scrub, and roll methods of tooth brushing in removing plaque was studied in 182 college students.

RESULTSThe Charters' and scrub methods of brushing appeared to be more effective in removing plaque.

All methods of brushing were relatively ineffective in removing proximal plaque

NO. 3A Comparative Evaluation of the Scrub

and Bass Methodsof Toothbrushing with Flossing as an

Adjunct

EMERSON ROBINSON

Am J. Public Health 66:1078-1081, 1976

AIMThe Scrub and Bass Methods of tooth brushing with flossing as an adjunct was evaluated to determine which is most effective in eliminating or reducing plaque and gingivitis.

METHODThree hundred and eleven children were randomly selected and placed in five groups (Scrub, Scrub-Floss, Bass, Bass-Floss, Comparison).Four Method groups went through four weeks of daily supervised tooth brushing with four dental hygienists, while the Comparison group received no supervised instructions.

RESULTSNo one method is superior to another.The duration of the improvement in oral hygiene is a subject forfurther study.

NO. 4The comparison between the

effectiveness of six different tooth brushing methods on removing dental

bacterial plaque

Saghazadeh M, Ashayeri N. Journal of Dentistry Vol. 17; No2; 2004

AIMThe aim of this research was to compare the effectiveness of six different accepted tooth brushing methods on total and specific teeth, as well as on special tooth surfaces. The research also compared the time needed for instruction, learning and using the methods.

RESULTThe tooth brushing methods of Charters’ and a kind of Modified Bass method (in which Bass and Roll methods are used separately and consequently) were evaluated as the most effective methods.

CONCLUSIONAlthough the Bass method is more effective on lingual axial surfaces than the Roll, the Circular Scrub and Horizontal Scrub methods, none of these brushing methods was superior to the others in interproximal plaque-removing efficacy (Bergenholtz et al. 1984).

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