| Abstract|| |
Aim: The aim of this 12 week, single-blind clinical trial was to compare the efficacy of Manual (Oral-B Pro Health Gum care®), Powered (Oral-B Cross action Power Dual®) and Charcoal (Colgate slim Soft Charcoal®) toothbrushes in plaque control. Materials and Methods: 60 systemically healthy students were selected at random among the students of a Dental College, living under similar environment and dietary conditions. Plaque and calculus were removed professionally and three varieties of toothbrush were distributed among them. Plaque index (PI), sulcus bleeding index (SBI) and gingival index (GI) were assessed at baseline, 3, 6 and 12 weeks. Assessment of colony forming units (CFU) was done at baseline and 12th week. The learning effect over a period of time was also assessed. Results: Over the 12-week period, PI reduced significantly (P < 0.001) with % reduction in plaque from 47% to 59%, 41% to 53% and 45% to 55% for manual, powered and charcoal brush. A significant reduction in GI and SBI was also seen with all the brushes. An insignificant difference in PI, GI and SBI was seen between the brushes. CFU count before and after brushing reduced gradually and statistically significantly (P < 0.001) for all the brushes; however, by end of 12th week period, there was no significant difference (P > 0.05). The learning effect increased from 35% to 60%, 24% to 56% and 31% to 58% for three brushes, respectively, but was more pronounced for powered brush. Conclusion: It can be concluded that all the three brushes (manual, powered and charcoal) are clinically effective in removing plaque, with learning effect more pronounced for powered brush and if proper technique is followed, no brush is superior to the other.
Keywords: Charcoal, manual, plaque, powered, toothbrush
|How to cite this article:|
Prusty AK, Sharma S, Malhotra S. Comparative efficacy of different varieties of toothbrushes in plaque control: A 12-week clinical trial. Indian J Dent Res 2021;32:372-9
|How to cite this URL:|
Prusty AK, Sharma S, Malhotra S. Comparative efficacy of different varieties of toothbrushes in plaque control: A 12-week clinical trial. Indian J Dent Res [serial online] 2021 [cited 2022 May 26];32:372-9. Available from: https://www.ijdr.in/text.asp?2021/32/3/372/338120
| Introduction|| |
Dental plaque is a soft deposit that forms a biofilm adhering to the tooth surface in the oral cavity, including removable and fixed restorations. It is a requisite etiologic factor in the inception and development of caries and periodontal diseases. Loe et al. showed the essential role of dental plaque in the etiology of gingivitis and also that the removal of plaque can reverse this process. Thus, effective plaque control is critical to improving health. However, controlling plaque accumulation effectively is influenced by a number of individual and material based factors. These main factors can be summarised as the design of the toothbrush, the skill of individual using the brush, tooth brushing frequency and duration of use.
Tooth brushing is the primary method used by people for plaque removal on day-to-day basis. Today, both manual and electric toothbrushes come in many shapes and sizes and are typically made of plastic moulded handles and nylon bristles. The first electric toothbrush, 'the Broxodent', was developed in Switzerland in 1954. The most recent toothbrush models include handles that are straight, angled, curved, contoured with grips and soft rubber areas to make them easier to hold and use. Also, the amount of time spent in each tooth brushing event has been positively correlated to efficiency of plaque removal, with a brushing time of at least two minutes being advocated.
An electric toothbrush performs oscillations or rotations of its bristles, driven by a motor. Any electric toothbrush is technically a powered toothbrush. Studies have shown that performance of both manual and electric toothbrush are equal and the electric version can be more comfortable with an additional timer and pressure sensors that can encourage a correct cleaning process. There are different forms of powered brushes, with mechanical movement of brush heads or with power delivered to brush heads (i.e., electric, electronic, sonic, ultrasonic, etc.). These brushes are grouped according to the mode of action as side to side action, counter oscillation, rotation-oscillation, circular, ultrasonic, ionic, multidimensional types. The first generation powered toothbrushes were commercially available as motorised oscillatory powered toothbrushes. Recently, newly experimental battery operated second generation toothbrushes have been developed with a dual moving head design, one oscillating and the other translating back forth.
In certain South-East Asian countries, charcoal has been added to the bristles of toothbrushes, the bristles of which are black in colour. Manufacturers of these toothbrushes claim that the blending of charcoal into nylon bristles can reduce halitosis (as charcoal absorbs any bad odour), reduce plaque and also kill bacteria that may develop in the bristles during storage, thus reducing the bacterial contamination of toothbrushes.
Though there are many published studies comparing efficacy of manual and powered toothbrushes, to the best of our knowledge, this is the first study that compares the efficacy of a relatively newer form of manual brush (charcoal brush) with the conventional manual and the powered toothbrush. Further, this study is also substantiated with the microbiological assessment for accuracy. Thus, the aim of this 12 week, single-blind clinical trial was to compare the efficacy of three different toothbrushes, Manual-(Oral-B Pro Health Gum care®), Powered-(Oral-B Cross action Power Dual®) and Charcoal-(Colgate slim Soft Charcoal®), in reducing plaque, gingivitis, sulcular bleeding along with reduction in colony forming units (CFU) and to analyse the learning effect in handling efficacy of these three toothbrushes.
| Materials and Methods|| |
This randomised, parallel single blind clinical study [Figure 1] was conducted in the Department of Periodontology and Implantology of the institution. The study protocol was in accordance with the ethical standard outlines given in 1964, Declaration of Helinski as revised in 2008 and was approved by Institutional Ethical Committee. Of the total of 92 dental students living under similar environment and dietary conditions in the dental hostel, 78 subjects fulfilled the inclusion criteria, but only 72 submitted written informed consent for the study. 60 systemically healthy dental student volunteers (25 males and 35 females), mean age-20.6 ± 1.48 years, were selected from these 72 subjects at random using lottery method, to avoid any sample variations. The sample size was calculated using G*power software (Heinrich-Heine-university Dusseldorf) to obtain 80% of statistical power.
|Figure 1: Consort Flowchart representing the study population: n- number of samples|
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They were selected according to the following criteria: presence of a minimum of 20 natural teeth and no removable partial dentures, had never used a powered brush before, had a full complement of teeth (3rd molar excluded), no caries or filling on the tooth surfaces for which plaque scoring was done, normal occlusion, good gingival, periodontal and general health, without any systemic disease, and had not taken any antibiotics or antiseptic mouthwashes since last one month prior to study.
Exclusion criteria consisted of subjects undergoing orthodontic treatment, root canal treatment, under medical treatment especially antibiotics, with <16 teeth, partial dentures, or fixed prosthodontic appliances, teeth with mobility, smokers, drug users, individuals who consumed alcohol and those who did not sign the informed consent form.
For this study, three different varieties of toothbrushes were randomly selected, based on their local availability at the time of the study. The study was carried out with Manual-(Oral-B Pro Health Gum care®), Powered-(Oral-B Cross action Power Dual®) and Charcoal-(Colgate slim Soft Charcoal®). No financial assistance was taken from the respective companies for the conduct of the study. The subjects were also provided with sufficient toothpaste (Colgate sensitive toothpaste) and plain distilled water for cleaning of toothbrushes during the whole test period. Plaque was stained with two-tone disclosing agent (Alpha Plac) and periodontal assessment was performed with University of Michigan 'O' probe with William's marking.
One week before the start of the trial, plaque and supra-gingival calculus were removed professionally. All the participants were demonstrated and taught Modified Bass technique before the start of the study and were asked to brush in front of the examiner to assess the brushing technique. At baseline (week 0), the brushing technique was again demonstrated and the subjects were divided into three groups by an independent examiner not taking part in further clinical assessment. Thereafter, subjects in Group 1 (manual toothbrush) and Group 3 (charcoal toothbrush) were instructed to brush using the modified Bass technique and Group 2 (powered brush) were instructed to brush according to the manufacturer's instructions, twice daily for 2 min. A leaflet along with verbal instructions mentioning not to use any other inter-dental cleaning aids, medicated mouthwash, tooth powder, toothpaste, quantity of toothpaste and the use of distilled water to clean the toothbrushes were given to subjects. In addition, each visit at baseline, 3, 6 and 12 weeks consisted of two plaque assessments, before and after brushing, using the Turesky-Gilmore-Glickman modification of the Quigley–Hein plaque index at six sites per tooth, to check the efficacy in plaque removal over time and for monitoring the change in efficacy in plaque removal (learning effect) over time. The day before examination, subjects were asked to brush once in morning only. The brushing was carried out by all the subjects in front of the examiner and leaflet instructions were reinforced and repeated to them at every visit. Also, sulcus bleeding index (SBI) was used to assess the gingival bleeding health and gingival index (GI) was assessed before and after brushing. Follow up was done at 3, 6 and 12 weeks and the subjects resumed their normal brushing habits for the next experimental period.
For each subject, microbial assessment was done for the detection of CFU from the plaque samples which were collected at baseline and 12th week both before brushing and after brushing. The samples were suspended in 0.3 ml of 0.9% sterile sodium chloride solution and in order to minimise dumping of samples they were processed within one hour of collection and immediately transported to laboratory for further analysis. Plaque samples were transferred to culture media (mitis salivarius bacitracin, MSB agar) with the help of sterile platinum loop in a streaky manner and incubated at 37°C temperature which was maintained from 48 to 72 hours for bacterial growth in an electric balance machine, following which the colonies of bacteria (Streptococcus sanguis, Streptococcus mutans and Actinomyces viscosus) were counted using a manual method and were identified following the standards described for the MSB agar.
Intra-group comparisons were analysed by paired t-test. Inter-group comparisons of reductions in various clinical parameters between the groups were analysed by one-way ANOVA test. P value <0.05 was considered statistically significant. In order to appreciate the ability to learn an efficient manipulation of the new brush, the percentage of plaque reduction by supervised brushing was taken as a measure of the learning effect in time.
| Results|| |
Mean reduction in plaque scores [Table 1] and [Graph 1] was statistically significant for all the three brushes, i.e., Manual, Powered and Charcoal from BL to 3 weeks (P = 0.017, 0.019, 0.018), BL to 6 weeks (P = 0.010, 0.014, 0.016) and BL to 12 weeks (P = 0.009, 0.007, 0.008), respectively. Intergroup comparison with P values (P = 0.776, 0.122, 0.052) was found to be statistically non-significant.
|Table 1: Comparison of reduction in plaque index at different time intervals|
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Mean reduction in gingival scores [Table 2] and [Graph 2] was statistically significant for all the three brushes, i.e., Manual, Powered and Charcoal from BL to 3 weeks (P = 0.024, 0.044, 0.021), BL to 6 weeks (P = 0.014, 0.020, 0.013) and BL to 12 weeks (P = 0.019, 0.01, 0.015), respectively. Intergroup comparison with P values (P = 0.065, 0.172, 0.058) was found to be statistically non-significant at all the recall intervals.
|Table 2: Comparison of reduction in gingival index at different time intervals|
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Sulcus bleeding index
Mean reduction in sulcus bleeding scores [Table 3] and [Graph 3] was statistically significant for all the three brushes, i.e., Manual, Powered and Charcoal from BL to 3 weeks (P = 0.029, 0.049, 0.031), BL to 6 weeks (P = 0.002, 0.007, 0.004) and BL to 12 weeks (P = 0.001, 0.005, 0.003) respectively. Intergroup comparison with P values (P = 0.070, 0.115, 0.063) was found to be statistically non- significant.
|Table 3: Comparison of reduction in sulcus bleeding index at different time intervals|
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[Table 4] shows a statistically significant reduction in % of CFU count for all the three brushes before and after brushing at BL for manual brush as 55.46% (P = 0.027), powered brush as 40.36% (P = 0.043) and charcoal brush as 49.18% (P = 0.038). At 12 weeks, % reduction in CFU count for all the three brushes before and after brushing, i.e., manual brush as 35.06% (P = 0.059), powered brush as 15.78% (P = 0.206) and charcoal brush as 20.23% (P = 0.121) was statistically non-significant.
|Table 4: Comparison of CFU between three groups at different time intervals|
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The learning effect [Table 5] and [Graph 4] was expressed as the change in percentage of plaque reduction after 2 min of supervised brushing over time. At 12 weeks, the cleaning ability increased significantly from 35% to 60% for cross action manual, from 31% to 58% for charcoal brush and from 24% to 56% for powered brush from baseline.
| Discussion|| |
Plaque is the primary etiologic agent in the initiation and mediation of both dental caries and periodontal infections. Tooth brushing is an essential part of an oral hygiene routine. The powered toothbrush was introduced as an alternative to manual tooth brushing. Charcoal toothbrush is a newer variety of toothbrush which is currently being assessed for its efficiency in plaque removal, due to addition of charcoal to it and it may provide additional benefits.
This 12-week single-blind clinical trial was conducted to compare the efficacy of three different types of toothbrush in plaque control. Findings of this study showed a statistically significant reduction of plaque scores over a 12 week period which is in accordance with other studies.,,,, The plaque reduction in this study can be attributed to the mechanism of action of brushes, for criss-cross action manual brush; mechanical cleansing effect, for charcoal brush; mechanical action along with the natural cleansing effect of charcoal, for powered toothbrush; oscillating and rotating motion which work through mechanical contact between bristles and tooth to remove plaque bio-film in addition to the biophysical action of cavitations and acoustic micro-streaming effect.
The results of this study are in agreement with the study conducted by Ainamo et al., who evaluated and compared the efficacy of plaque removal with powered and manual toothbrush over a period of 12 months and concluded that there was no statistical difference in plaque removal between the two brushes. Similar results were also seen with other studies.,,, However, the results were contrary to the study conducted by Warren et al., who compared a powered brush with a manual brush in terms of plaque control and reported that powered brush was more efficient than the manual toothbrush, and the reason cited for the same was due to higher motivation in powered toothbrush users (P < 0.05). In this study, there was an insignificant difference between manual and powered brushes as this study comprised of dental students who were equally motivated for using all the brushes and brushing techniques.
This study showed an insignificant difference in plaque reduction between cross action manual and charcoal brushes which could be due to the synergistic effect of charcoal added to the bristles of the straight handle brush which had a natural cleaning effect along with mechanical cleaning to pull away plaque from tooth surfaces. This is in contrast with the study of Biesbrock et al., who evaluated a new manual toothbrush in terms of plaque removal efficacy and reported that Oral-B Exceed was significantly more efficacious in overall plaque removal than Asian Colgate (P < 0.001).
A statistically significant reduction in percentage of plaque scores was seen from baseline to 12 weeks in the three groups. The results of this study were in accordance with the study by Sharma et al., where they concluded that each of the toothbrushes (powered, manual and sonic) provided a significant reduction in plaque score after single brushing. In our study, this probably can be attributed to a better understanding of the hygiene requirement by the patient, the use of better brushes than those used previously, Hawthorne effect, and active participation in the study till 6 weeks. Thereafter, as the subjects were dental students, they became competent with the use of the three brushes and thus there was an insignificant difference between pre brushing and post brushing plaque scores.
However, the results are in contrast with the study of Terézhalmy et al. who showed contradictory findings on testing the ability of two powered toothbrushes with a manual toothbrush to remove plaque and concluded that there was statistically significant greater reduction in plaque for the powered toothbrush as compared to ADA reference manual toothbrush (P < 0.001). Also, the powered toothbrush was found to deliver greater plaque removal by 42.4% and 28.2% compared to the control manual toothbrushes. The reason for this disagreement may be due to inaccessibility of powered toothbrushes in posterior areas leading to higher plaque scores in these areas and difficulty to maintain efficacy with brushing for powered toothbrush.
Our results also confirm the findings of previous studies of Weijden et al., Checchi et al. and Haffajee et al. who reported a significant reduction in gingival indices using manual and powered toothbrushes. In a study, Niederman concluded that only one type of powered toothbrush with rotation and oscillation action achieved a significant but modest reduction in plaque and gingivitis as compared with manual toothbrushes. However, most of the comparison studies,, i.e., manual vs powered, showed no significant difference between the two types of toothbrushes, which are in accordance with our study.
In our study, a significant reduction in bleeding scores for all the brushes is in accordance with Haffajee et al. and Glavind and Zeuner. Short-term results of insignificant difference in reduction of bleeding scores between manual and powered brushes till 6 weeks are in accordance with the study of Lazarescu et al. However, they are in contrast to the long-term study of McCracken et al., who showed gingival bleeding reduction in favour of manual brushing over a period of 16 months.
Deshmukh et al. found a statistically significant difference in the number of CFU count assessed before and after brushing using active ionic toothbrush, which is in accordance with the results of our study. However, in this study, no statistically significant difference was found in CFU count at 12 weeks in all the groups, pre and post brushing. The reason for the same could be familiarisation and equal motivation of all the dental subjects with the brushing techniques and the brushes they were using in this study.
In the present study, we tested how fast subjects learned to handle the two brushes correctly. It is obvious that manual dexterity, ability and motivation of individual patients are of paramount importance to oral hygiene. Subjects need individual instructions to ensure correct use and to achieve a fast 'learning curve' in effective handling of the oral hygiene instruments, i.e., their toothbrush. In this study, subjects received repeated instructions on how to use the manual and the powered toothbrushes. It has been shown that without re-instruction and positive reinforcement, the novelty of the instrument and the compliance to the brushing instructions and protocol diminish rapidly. Thus, all subjects had learned to use their brushes more efficiently by the end of 12 weeks. The learning effect, however, was significantly more important for the powered brush: it showed a more pronounced and more rapid increase in plaque removal efficacy than the manual brush. This phenomenon was in agreement with the study of Lazarescu et al. and Walmsley where they stated that correct use of an electric brush seems to be more difficult in the beginning as compared to a manual brush. In our study, the dental subjects learned to use powered brushes more efficiently by the end of 12 weeks.
| Conclusion|| |
This randomised, parallel, single-blinded clinical study demonstrated that repeated hygiene instruction and the introduction of an electric toothbrush or a new manual brush enhanced plaque control significantly, as evidenced by the steady improvements in habitual plaque reduction and gingivitis scores over the 12-week period. It can therefore be concluded that all three brushes, manual, powered and charcoal, are clinically effective in removing plaque, and its clinical implication points to the fact that no brush is superior to the other if proper brushing technique is followed.
A similar study with a larger sample size and longer duration is recommended to obtain more accurate results. There is a need of further in vitro or in vivo studies on charcoal brushes to understand the abrasive capacity of charcoal brushes as abrasive capacity of charcoal has long been proven. Further, there is a need of studies in general population, who are familiar with the use of all the three brushes/have extensive familiarisation period, as this study was specific to dental students only. Also, gingival traumas following manual and powered tooth brushing also need to be investigated in future studies.
Declaration of patient consent
The authors certify that they have obtained all appropriate participant consent forms. In the form, the participants have given their consent for their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to acknowledge the Management of Kalka Group of Institutions, Meerut, for their constant support, in providing us the infrastructure and basic amenities to conduct this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Shivani Sharma
Department of Periodontics, Kalka Dental College, NH-58, Partapur Bye-Pass, Meerut - 250 006, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]