A survey of toothbrushing sequence in children and young adults

Control of supragingival calculus. Scaling and polishing and anticalculus toothpastes: an opinion

The removal of supragingival calculus by scaling and polishing of the teeth is only one aspect of a dental prophylaxis. However in many countries, a large number of individuals only require and receive, at regular intervals, a supragingival scale and polish. The association of supragingival calculus to gingival and periodontal disease is unclear, however, it is logical to assume a plaque retention role. Moreover, for the individual, supragingival calculus may pose cosmetic problems. Regular calculus removal is both time consuming and exacting for dental professionals and has important financial implications to patients and/or health schemes. The benefits of regular supragingival calculus removal are not established, yet potential detrimental effects for the patient are known, and certain groups are susceptible to systemic disease consequent on scaling and polishing of the teeth. The oral hygiene habits of most individuals appear insufficient to prevent the reformation of supragingival calculus once removed and for this reason chemical inhibition is an attractive proposition. Most success to date has been with agents which inhibit crystal growth, notably pyrophosphates, and toothpaste products are available containing such agents. Clinical studies support efficacy for some products and indicate that the magnitude of calculus inhibition would reduce the need for or frequency of scaling and polishing of teeth in a proportion of individuals. Anticalculus toothpastes would appear to be proven worthy of recommendation for those individuals in whom supragingival calculus formation is a problem.

Aetiological, predisposing and environmental factors in dentine hypersensitivity

If the hydrodynamic theory of stimulus transmission across dentine is valid, sensitive dentine has tubules open at the surface and patent to the pulp. Direct and indirect evidence supports this supposition. Factors that result in dentine exposure remove the covering enamel or periodontal tissues (gingival recession). Epidemiological and clinical data for the distribution of exposed cervical dentine indicate that chronic trauma from physical and chemical factors is the most significant aetiological factor. Brushing with a toothpaste may not open dentinal tubules. It is more likely that toothpaste ingredients, when brushed on dentine, would create a smear layer. Exposure of tubules by erosion is probably the major initiator of sensitivity. An increase in our understanding of the aetiological factors involved in dentine hypersensitivity is essential if a sound approach to its management is to evolve. Such information could emanate from epidemiological studies, clinical investigations and laboratory experiments.

The plaque removal effects of single rinsings and brushings

Chemical plaque removal is one mechanism whereby an agent could improve oral hygiene and gingival health. As with toothpastes most agents, when delivered as rinses, would be considered adjunctive to mechanical tooth cleaning procedures. The aim of this study was to determine whether selected commercial rinses exhibited clinically significant plaque removal properties alone or when combined with toothbrushing with water or a toothpaste. A group of 12 volunteers took part in this single blind, randomized placebo-controlled, 12 cell cross-over study, employing 6 rinses. During each regimen subjects accumulated plaque from a zero baseline over 72 hours. Plaque removal was then measured by index and area after first a single rinse of product and second a subsequent brushing with water or toothpaste. Prebrushing rinsing removed less than 5% of the plaque with little difference between agents. No rinse was more adjunctive than water to postrinse brushings. Most statistically significant differences arose with the chlorhexidine rinse being apparently less effective. However, the possibility of a disclosing dye interaction cannot be discounted as explaining this anomalous result. This study could not support any claim of a direct prebrushing rinse benefit greater than that provided by water to mechanical plaque removal by any of the products tested.

Evaluation of a mouthrinse containing chlorhexidine and fluoride as an adjunct to oral hygiene

Chlorhexidine and fluoride have valuable preventive roles in dental and oral diseases. There is also evidence that in caries prevention, together, they provide additive benefits. However, combined chlorhexidine/fluoride formulations have rarely been evaluated. The aim of this study was to determine whether a 0.12% chlorhexidine, 100 ppm F- mouthrinse provided adjunctive oral hygiene benefits compared to a minus active control rinse. The study was a randomised double-blind parallel design involving 102 subjects of whom 99 completed the 6 week experimental period. Subjects rinsed 2x per day for 1 min with 15 ml of the allocated rinse. Normal toothbrushing procedures were maintained throughout the study. At 6 weeks, plaque and gingivitis scores were significantly lower and the incremental reduction significantly larger in the active rinse group. However, as expected, toothstaining was significantly increased with the active rinse. It is apparent that this chlorhexidine/fluoride rinse could be used in those regimens recommended for other chlorhexidine formulations. The value of the formulation in caries prevention would seem worthy of further investigation.

Dentine hypersensitivity--the effect of toothbrushing and dietary compounds on dentine in vitro: an SEM study

Dentine hypersensitivity occurs when dentinal tubules are open on the dentine surface and patent to a vital pulp. There has been limited interest in the aetiology of dentine hypersensitivity. In particular, little is known about agents that remove the dentine smear layer to expose tubules. Toothbrushing certainly may expose dentine, but whether a toothbrush per se has the effect of opening tubules has not been established. The aim of this study in vitro was to determine whether a toothbrush could remove or create a smear layer. In addition, the combined effects of toothbrushing with dietary fluids on dentine was assessed. Toothbrushing was observed, by scanning electron microscopy, both to remove and to recreate a smear layer on dentine specimens. However, the processes took a considerable time, and under conditions of normal toothbrushing it is unlikely that the latter plays a direct aetiological role in opening tubules. Indeed, together with toothpaste it is more likely that brushing has a therapeutic action by mechanically forming a smear layer. Conversely, and importantly, toothbrushing in the presence of dietary acids enhanced smear layer removal. This finding raises the question of whether the dental profession should be advising that teeth be brushed before meals rather than after, as is often the case.

Using a "lifestyle" perspective to understand toothbrushing behaviour in Scottish schoolchildren

Using data from a wider survey of health related behaviour in 4,935 Lothian schoolchildren, 11, 13, and 15 yr old, this paper analysed toothbrushing frequency and its relation to "lifestyle" factors. Analysis of the results showed that girls brush more frequently than boys and that children with higher social class background brushed more frequently than children with low social class background. Further toothbrushing frequency was significantly related to the subjects' health perception, smoking and drinking habits, eating habits, bedtimes, and video-watching. Moreover, all these lifestyle factors were inter-related. The paper reinforced the concept of lifestyle as a meaningful descriptive term. The results demonstrated that the bivariate associations are pieces in a more complex mosaic. Toothbrushing thus seems to be an integrated part of a child's lifestyle and should be regarded as such in future health promotion efforts.

The distribution of plaque and gingivitis and the influence of toothbrushing hand in a group of South Wales 11-12 year-old children

Numerous factors may affect the distribution of plaque and gingivitis in any individuals mouth. Of considerable importance must be the oral hygiene habits of each person, which will be influenced by compliance and dexterity with tooth cleaning methods. The pattern of gingivitis seen at a young age may, with time, reflect the eventual distribution of attachment loss. This in part, could explain the considerable variation in chronic periodontal disease seen between individuals and at different sites within the same mouth. This study reports the baseline data for the distribution of plaque and gingivitis in 1105, 11-12-year-old children in South Wales. The children were selected by disproportionate stratified random sampling and examined by a multidisciplinary group with the long-term aim of evaluating the importance of malocclusion to dental health and psychosocial variables. Toothbrushing frequency had a very low but significant correlation with the distribution of plaque and gingivitis, accounting therefore for only a small % of the variance in the group. For the total group and right-handed toothbrushers, buccal plaque and gingivitis was significantly increased on right contralateral teeth. No specific pattern for plaque and gingivitis distribution by side was seen for 100 left-handed toothbrushers. Plaque and gingivitis also showed significant differences dependent upon arch, tooth number, and surface. The population is being followed at 4-year intervals to monitor the pattern of periodontal disease with time and correlate changes with these baseline findings.

The effects of a 0.2% chlorhexidine gluconate mouthrinse on plaque, toothstaining and candida in aphthous ulcer patients. A double-blind placebo-controlled cross-over study

Despite the known effectiveness of 0.2% chlorhexidine gluconate mouthwash in preventing plaque formation, relatively few studies have assessed adjunctive benefit to normal unsupervised oral hygiene measures. Furthermore, there have been few accurate measurements of toothstaining in the presence of normal oral hygiene and little data of effects on oral candidal carriage. This study was a double-blind placebo-controlled cross-over study of a 0.2% chlorhexidine gluconate mouthwash used 3 times daily on plaque, staining and candidal carriage in a group of recurrent aphthous ulcer suffers who maintained normal oral hygiene measures. At the end of 2 6-week treatment periods, baseline plaque scores were reduced by active and placebo mouthwashes. Chlorhexidine significantly reduced plaque compared to the placebo. Staining has markedly and significantly increased during chlorhexidine rinsing. Candidal carriage was present in 22.2% of this group and there was no significant effect of chlorhexidine on the mean number of candidal colonies. The distribution of plaque and staining by tooth was plotted and observationally studied. Baseline and placebo treatment plaque distributions indicated the considerable relevance of toothbrushing behaviour for plaque distribution. The effects of toothbrushing on plaque distribution were minimised during the use of chlorhexidine. Staining associated with chlorhexidine showed a distribution again suggesting the influence of toothbrushing. In conclusion, chlorhexidine has significant adjunctive effects on plaque inhibition in the presence of normal unsupervised oral hygiene, but toothbrushing did not prevent toothstaining.

The cleaning efficiency of different toothbrushes in children

A 2-way, blind, cross-over study was carried out to compare the plaque-removing effects of a double-headed toothbrush with a popular single-headed flat toothbrush in 34, 11- to 13-year-old boys. Both brushes were used with a modified Bass technique for 3 weeks each. The results of the study indicated that lingually, the double-headed brush was superior to the single-headed brush whilst bucally no difference was found. Although the overall plaque-removing effect of both brushes was similar, 95% of the children preferred the single-headed brush to the double-headed brush.

Effectiveness of children's habitual toothbrushing

Individual toothbrushing habits are usually consistent. Frequency, pattern and duration are different aspects of the toothbrushing habit. The aim of this study was to analyze the effect of habitual toothbrushing in children. The schoolchildren (n = 110) aged 13, were examined clinically before and after brushing their teeth in the habitual way; the brushing procedure was filmed without the children's knowledge. From the film, the pattern of brushing was assessed by three dentists, and the duration measured in seconds. Frequency of toothbrushing was assessed by postal questionnaire 2 months after the clinical examination. The examination included both photographed plaque and disclosed plaque diagnosed clinically. From the photographs, plaque was measured by computer planimeter as a % of plaque area and clinically by the oral debris index recommended by WHO. Subjects who had little plaque before toothbrushing were excluded from the analyses. Frequency seemed to affect plaque removal only in boys and only in the maxillary teeth. The pattern affected plaque removal in girls, but for boys, this aspect of toothbrushing affected only the left side of the jaws. Duration had produced the strongest effect on plaque removal. Therefore, duration of toothbrushing should be emphasized more in dental health education.

Duration and pattern of toothbrushing in children using a gel or paste dentifrice

This study investigated the brushing times and patterns of two groups of children who used either a translucent gel dentifrice or a conventional paste dentifrice during a one month period. The children brushed without supervision and were examined without their knowledge. Examinations after the initial use and after a month of use of the two dentifrices showed no significant differences in toothbrushing times or patterns. Also, there were no significant deviations from the baseline scores. The study further demonstrated that uninstructed children in this age category brushed their teeth for approximately one minute per brushing, but failed to brush 38% of the tooth surfaces. The lingual surfaces were the areas most often missed, whereas the buccal, labial, and mandibular occlusal surfaces were the areas brushed most thoroughly.