A survey of toothbrushing sequence in children and young adults

The Efficacy of Populus euphratica and Myrtus communis Herbal Mouthwash on Gingivitis in Pediatric Patients Diagnosed Clinically and with Photometric CIELab Analysis: An In Vivo Randomized Double-blind Clinical Study

Background

Children are more prone to develop gingivitis as a result of deficient oral hygiene, morphological variance, and a diet that encourages the growth of pathogenic oral bacteria.

Aim

The purpose of this randomized, double-blind clinical study is to compare the therapeutic effect of an herbal mouthwash made of decoction and ethanolic extract of Populus euphratica and Myrtus communis to that of chlorhexidine (CHX) mouthrinse.

Materials and methods

In this study, 60 patients aged between 8 and 10 years were divided into four groups, each with 15 patients. The first group was treated with a mouthwash made of ethanolic herbal extract, the second group was treated with a mouthwash made of herbal decoction, the third group was treated with CHX mouthwash (0.12%) (positive control), and the fourth group was treated with a placebo made with colored distilled water (negative control). Clinical parameters gingival index (GI) and plaque index (PI) were evaluated at the start, 1, and 2 weeks from ensuing the treatment. Preoperative and postoperative photographs of the maxillary anterior sextant were recorded to evaluate CIELab coordinates to monitor color changes.

Statistical analysis

One-way analysis of variance (ANOVA) with Tukey's honest significant difference (HSD) post hoc tests were used for data assessment.

Results

Significant reductions in GI and PI were found among the tested groups (p < 0.05). A significant reduction in a* value was observed, while L* value showed a significant increase between baseline and posttreatment (p < 0.05).

Conclusion

Herbal-based mouthwash of Populus euphratica and Myrtus communis, whether prepared by boiling or ethanolic extraction, reduced gingival inflammation significantly and has a lot of potential for treating and preventing periodontal disease in young children. Digital photography is a reliable supplementary approach for diagnosing and monitoring gingival inflammation in pediatric patients.

How to cite this article

Mohamed-Ali SF, Jasim AA, Mahmood MAK, et al. The Efficacy of Populus euphratica and Myrtus communis Herbal Mouthwash on Gingivitis in Pediatric Patients Diagnosed Clinically and with Photometric CIELab Analysis: An In Vivo Randomized Double-blind Clinical Study. Int J Clin Pediatr Dent 2024;17(8):918-924.

A randomised controlled trial evaluating the impact of oral health advice on gingival health using intra oral images combined with a gingivitis specific toothpaste

OBJECTIVES

Does a complex intervention of oral hygiene advice (OHA) delivered with intra-oral scanner images, anti-gingivitis toothpaste and motivational reminders, improve oral health more than a standard of care control arm of fluoride toothpaste, with OHA without scanner images?

METHODS

Adult participants with pre-existing gingivitis were randomised to intervention or control. Following enrolment, baseline and each subsequent visit (V) (3-weeks, V2; 3-months, V3; 6-months, V4) followed the same schedule. Bleeding on Probing (BOP) was assessed and Intra Oral Scan IOS(1) recorded. Plaque was disclosed, scored and re-scanned (IOS(2)). The intervention group received OHA with IOS images, control group receiving OHA without IOS images. Participants brushed with their allocated toothpaste (fluoride, control; anti-gingivitis, intervention), IOS(3) was recorded. Between visits participants brushed with their allocated toothpaste, intervention group received motivational reminders.

RESULTS

BOP scores from baseline were significantly improved in the intervention group compared to control at all visits for all surfaces (p<0.001); differences at V4 were 0.292 (all), 0.211 (buccal/labial) and 0.375 (lingual/palatal). Plaque scores from baseline pre-brushing to each visit pre- and post-brushing also favoured the intervention group, the difference always significant on lingual/palatal surfaces (p<0.05), significant for all but pre-brushing-V4 (p<0.05) on all surfaces, but only significant for pre-brushing-V3 (p<0.05) buccally/labially. Differences from baseline to post-brushing at V4 were: 0.200 (all), 0.098 (buccal/labial) and 0.291 (lingual/palatal).

CONCLUSION

A complex intervention comprising OHA delivered with IOS-images, anti-gingivitis toothpaste and motivational reminders improved gingival health more than existing standard of care-OHA together with a standard fluoride toothpaste over a 6-month period.

CLINICAL SIGNIFICANCE STATEMENT

Intra-oral scans (IOS) are now frequently used in general dental practice for a variety of purposes. IOS use, in combination with motivational texts and an anti-gingivitis toothpaste, could be further deployed to promote oral hygiene behaviour change in patients and improve gingival health, in a cost-effective manner.

Association Between Etiological Factors and Dentin Hypersensitivity: A Cross-Sectional Study in Turkey

Objective: This study purposed to estimate the prevalence of DH and how effective the etiological factors are in the development of DH in Turkey. Methods: Demographic features, hygiene habits, bruxism, beverage habits, parafunctional habits, smoking, and other medical problems were asked. Air was blasted to the teeth via the air-water syringe for 3 seconds. The Visual Analogue Scale was used to measure DH sensitivity, and data were recorded in the 0-100 mm range, and 5 mm and higher were considered DH. The attrition, abrasion, erosion, abfraction per dental type (Incisal OR Canine OR Premolar OR Molar) were recorded. The same procedure was applied for abnormal tooth position and gingival recession. Results: A total of 4476 teeth and 236 individuals were evaluated. Significantly higher DH frequency was observed in females (p= .034), the 40- 55 age range (p= .009), and non-smokers (p= .016). Those who brushed their teeth three times a day or more (p< .001), preferred horizontal technique (p= .017), used toothbrushes with a hard bristle (p< .001) exhibited higher DH frequency. There was no significant difference in DH regarding bruxism, acidic beverage consumption, vomiting, and reflux (p> .05). Conclusion: DH is a multi-etiological symptom affected by demographic attributes, hygiene, and other habits. Clinicians should painstakingly distinguish the source of DH to gain the long-term success of DH treatment, which depends on many etiological factors.

Clinical Evaluation of Toothbrushes for Elderly Patients: A Crossover Study

OBJECTIVES

The aim of this study was to evaluate the efficacy of 2 newly designed toothbrushes used by elderly individuals based on plaque removal and gingival inflammation reduction compared with 2 commercially available toothbrushes.

MATERIALS AND METHODS

This was a randomised, controlled, single-blind, 4-period crossover clinical trial. Thirty elderly participants meeting the inclusion criteria were randomly allocated into 4 groups, which determined the sequence of the 4 toothbrushes: CUdent/extra soft, CUdent/soft, GoodAge, and Colgate. The participants' baseline bleeding on probing (BOP) and plaque index (PI) were assessed by one blinded calibrated examiner, then their teeth were professionally cleaned. The participants were assigned to use the tested toothbrush and were recalled for postbrushing examination 2 weeks later to evaluate their BOP and PI. At the end of each test period, the participants used their own toothbrush during the 2-week washout period before using the next tested toothbrush.

RESULTS

The mean age of the 30 participants was 63.2 years. The mean baseline BOP score was 44.4%, and mean baseline PI was 2.7. Three participants dropped out; thus, 27 participants (15 females and 12 males) provided data throughout the study period. The participant characteristics and baseline data between the groups were similar. CUdent/extra soft and CUdent/soft demonstrated significantly better PI scores at the buccal surfaces than GoodAge (P < .05). CUdent/soft had the lowest PI scores and Colgate presented the lowest BOP score in every comparison for other areas; however, the differences were not significant. No signs of tissue trauma or abrasion were observed.

CONCLUSIONS

The newly designed toothbrushes were comparable to the commercially available toothbrushes in plaque removal efficacy and reducing gingival inflammation. CUdent/extra soft and soft were significantly more effective in plaque removal in the buccal regions than GoodAge.

Visualization of dental plaque with a 3D-intraoral-scanner-A tool for whole mouth planimetry

Planimetry is a reliable method for detecting and monitoring plaque. Until now, this method has mainly been applied to conventional-camera images, which is difficult and time-consuming in relation to the entire dentition. Today, 3D-intraoral-scans are well suited for imaging the entire dentition and are therefore an efficient and feasible alternative. 3D-intraoral-scans have already proven successful for the quantification of plaque based on a plaque index. Therefore, aim of this study was to investigate whether images from 3D-intraoral-scans are also suitable for valid planimetric plaque measurements and monitoring; intraoral-camera images served as a reference. Twenty subjects (27.5±1.2 years) were included. Plaque was disclosed at three different time points: habitual plaque (T1), after 72 h without oral hygiene (T2) and after subsequent tooth brushing (T3) and quantified using 3D-intraoral-scans and intraoral-camera images (intraoral-camera CS 1500, intraoral-scanner CS 3600; Carestream Dental, Germany). The percentage of the plaque-covered surface of the total surface area (P%) was determined with a software specially programmed for this purpose using images from 3D-intraoral-scans of the oral and vestibular surfaces of the Ramfjord teeth (16, 21, 24, 36, 41, and 44); the intraoral-camera images of the vestibular surfaces of 16 and 36 served as reference. P% from images of the 3D-intraoral-scan and the intraoral-camera revealed a very good correlation (r = 0.876; p ≤ 0.001); the Bland-Altmann analysis showed a good agreement with no proportional and a very minor systematic bias with slightly higher values from images of the 3D-intraoral-scan. Further, P% measurements of the images of the 3D-intraoral-scan were able to detect changes in plaque levels, showing a 47% (p ≤ 0.001) increase in P% from T1 to T2 and a 43% (p ≤ 0.001) decrease after toothbrushing (T3). Planimetry using images of the 3D-intraoral-scan seems to be a suitable tool for whole mouth planimetry to record and monitor dental plaque.

Efficacy of a sonic toothbrush on plaque removal-A video-controlled explorative clinical trial

Clinical studies on the efficacy of sonic toothbrushes show inconsistent results, most studies have been conducted without sufficient supervision of appropriate toothbrush usage. Aims of the explorative clinical trial were therefore to investigate whether the usage of an activated sonic toothbrush reduces plaque more effectively than an inactivated one used as a manual toothbrush, and to which extent the correct use of such toothbrush plays a role in its efficacy. The clinical trial was designed as a video-controlled interventional study. Thirty participants (mean (±SD) age 22.9 (±2.5) years) were included, areas of interest were the buccal surfaces of the upper premolars and the first molar (partial mouth recording). Toothbrushing was performed without toothpaste in a single brushing exercise under four different conditions: switched off, habitually used as manual toothbrush, no instruction; switched on, habitually used as powered toothbrush, no instruction; switched off, used as manual toothbrush, instruction in the Modified Bass Technique; switched on, used as powered toothbrush, instruction in a specific technique for sonic toothbrushes. Brushing performance was controlled by videotaping, plaque was assessed at baseline (after 4 days without toothbrushing) using the Rustogi modified Navy-Plaque-Index and planimetry. Main study results were that plaque decreased distinctly after habitual brushing regardless of using the sonic brush in ON or OFF mode (p for all comparisons < 0.001). After instruction, participants were able to use the sonic brush in ON mode as intended, with only minor impact on efficacy. Using the toothbrush in OFF mode with the Modified Bass Technique was significantly less effective than all other conditions (p for all comparisons < 0.001). Under the conditions used, the sonic toothbrush was not more effective when switched on than when switched off, and there was no evidence that the correct use of the toothbrush was more effective than the habitual use.

Validation of motion tracking as tool for observational toothbrushing studies

Video observation (VO) is an established tool for observing toothbrushing behaviour, however, it is a subjective method requiring thorough calibration and training, and the toothbrush position is not always clearly visible. As automated tracking of motions may overcome these disadvantages, the study aimed to compare observational data of habitual toothbrushing as well as of post-instruction toothbrushing obtained from motion tracking (MT) to observational data obtained from VO. One-hundred-three subjects (37.4±14.7 years) were included and brushed their teeth with a manual (MB; n = 51) or a powered toothbrush (PB; n = 52) while being simultaneously video-filmed and tracked. Forty-six subjects were then instructed how to brush their teeth systematically and were filmed/tracked for a second time. Videos were analysed with INTERACT (Mangold, Germany); parameters of interest were toothbrush position, brushing time, changes between areas (events) and the Toothbrushing Systematic Index (TSI). Overall, the median proportion (min; max) of identically classified toothbrush positions (both sextant/surface correct) in a brushing session was 87.8% (50.0; 96.9), which was slightly higher for MB compared to PB (90.3 (50.0; 96.9) vs 86.5 (63.7; 96.5) resp.; p = 0.005). The number of events obtained from MT was higher than from VO (p < 0.001) with a moderate to high correlation between them (MB: ρ = 0.52, p < 0.001; PB: ρ = 0.87; p < 0.001). After instruction, both methods revealed a significant increase of the TSI regardless of the toothbrush type (p < 0.001 each). Motion tracking is a suitable tool for observing toothbrushing behaviour, is able to measure improvements after instruction, and can be used with both manual and powered toothbrushes.

Data on toothbrushing study comparing infrared-based motion tracking versus video observation

Investigations of toothbrushing habits are an important vector to understand their influence on brushing effectiveness. User compliance in toothbrushing is known to deviate from professional recommendations in brushing time, evenness across all areas of the dentition, and brushing force [1,2]. Despite the recent development of tools designed to guide users to optimised brushing habits [3,4], research on habit evaluation and tracking is limited and typically relies on labour-intensive video observation (VO) [5]. Here we present raw data on toothbrush position as determined by an automated motion tracking (MT) capability and by human VO and provide a technical description of the MT capability. The MT system described in this article was developed in collaboration with Soft2Tec GmbH (Rüsselsheim, Germany) as a potential substitute for the VO tool. The MT system consists of a monocular vision module and a target module with active infrared LED trackers. The MT system determined the position and orientation of a toothbrush relative to the jaw while subjects brushed under realistic conditions. For VO, a trained assessor coded video recording data from toothbrushing sessions. The data presented here describes a clinical study (103 subjects; 46 completed two sessions, 57 completed one session, altogether 149 events) comparing toothbrushing behaviour recorded with the MT system and with VO simultaneously. The raw data was deposited in Mendeley Data, under data identification number doi:10.17632/4f384xrbhm.1 [https://data.mendeley.com/datasets/4f384xrbhm/1].

Randomized controlled trial assessing plaque removal of an oscillating-rotating electric toothbrush with micro-vibrations

OBJECTIVE

The objective was to assess plaque removal potential of a newly designed oscillating-rotating (O-R) electric rechargeable toothbrush with micro-vibrations compared to a manual toothbrush.

METHODS

This was a randomized single-brushing, two-treatment, examiner-blind, replicate-use, four-period crossover design study, conducted with three cohorts of nine subjects each, with all subjects using each toothbrush twice. Test toothbrushes included a new O-R rechargeable electric toothbrush with micro-vibrations (Oral-B iO prototype) and a manual American Dental Association (ADA) reference toothbrush. On each of the four study visits, subjects refrained from oral hygiene for 12 hours prior. At each visit, subjects received a pre-brushing plaque examination, brushed with their assigned toothbrush and a marketed fluoride dentifrice and then received a post-brushing plaque examination. Plaque was assessed using the expanded Turesky Modified Quigley-Hein Plaque Index. Treatment comparison analyses were two-sided and carried out at the 5% significance level.

RESULTS

All 27 randomized subjects (mean age = 42.0 years) completed the trial. Both brushes produced significant plaque reductions versus baseline (P < 0.001). The O-R electric brush provided statistically significantly greater plaque reductions in all regions compared to the regular manual toothbrush, with a between-treatment difference of 0.929 for whole mouth plaque, 0.965 for proximal plaque, 1.029 for lingual plaque and 0.815 for facial plaque (P < 0.001 for all comparisons). Additionally, use of the novel O-R brush yielded greater brushing evenness/consistency when comparing the facial and lingual mean plaque removal differences relative to manual brushing (P = 0.001). Both brushes were well-tolerated.

CONCLUSION

The novel O-R toothbrush with micro-vibrations produced significantly greater plaque reductions compared to the manual toothbrush.

Toothbrushing behavior in children - an observational study of toothbrushing performance in 12 year olds

Background

Many countries offer systematic group prevention programs in kindergarten and school in order to promote children’s oral health. Little is known, however, about the actual toothbrushing abilities of children when group prevention programs end.

Methods

In Germany, all children take advantage from a nationwide group prevention program (called “Gruppenprophylaxe”) lasting from kindergarten up to sixth grade (12 years of age). Standardized recommendations are given concerning brushing systematics and brushing movements. N = 174 children at the age of 12 were thus randomly selected from two German towns and were asked to perform toothbrushing to the best of their abilities in front of a mirror which also served as a camera. Brushing behavior was analyzed by video analysis.

Results

Children brushed their teeth for an average of 200 s ± 80.48 s (mean ± SD). Still, more than 55% missed at least one sextant when brushing inner surfaces, 16% missed them all. Only 7.5% of the children brushed both inner and outer surfaces by the intended movements (vertical movements on the inner surfaces and circular movements on the outer surfaces) for at least 90% of the respective brushing time. Instead, horizontal brushing was very common on the lateral surfaces.

Conclusions

The present analysis indicates that children have low efficiency to adopt the tooth-brushing recommendations given in prevention programs. This is surprising as great endeavors are made to help children internalize the recommendations. Future research is needed to better understand which factors impede adoption of toothbrushing recommendations in children and which efforts are necessary to improve their toothbrushing abilities.

Electronic supplementary material

The online version of this article (10.1186/s12903-019-0755-z) contains supplementary material, which is available to authorized users.

A new tooth brushing approach supported by an innovative hybrid toothbrush-compared reduction of dental plaque after a single use versus an oscillating-rotating powered toothbrush

Background

An innovative hybrid toothbrush was designed functioning either in manual mode, in powered mode (sonic) or in combined mode (manual and powered). The primary aim of this study was to evaluate and compare the clinical efficacy of this first hybrid toothbrush (Elgydium Clinic/Inava Hybrid) used in combined mode to a marketed oscillating-rotating powered toothbrush (Oral-B Vitality) in the reduction of dental plaque after a single use. The secondary aims were to evaluate the tolerance and acceptability of each device.

Methods

It was a randomized, examiner-blind, single-center study performed on two parallel groups: hybrid toothbrush (n = 33) versus oscillating-rotating toothbrush (n = 33). A brushing exercise was conducted for two minutes on subjects presenting a “Silness and Löe Plaque Index” (PI) between 1.0 and 2.0 and a “Modified Gingival Index” between 1.0 and 2.0. They were not to have ever used an electric toothbrush. To assess the device effect after brushing, a paired t-test was applied on the change outcome (After-Before brushing). An unpaired t-test was used to compare the efficacy of both devices. A global tolerance assessment of each powered toothbrush was done on all the subjects. The number and percentage of reactions related to each toothbrush was collected and the final tolerance assessment was estimated.

Results

After a single use, the hybrid toothbrush used in combined mode presented a global anti-plaque efficacy characterized by a significant decrease of the global PI of 45% on average (p < 0.0001; paired t-test). It was as effective as the oscillating rotating toothbrush in plaque removal (p > 0.05; unpaired t-test). The global tolerance of both toothbrushes was judged as “Good” and they were equally appreciated by the users.

Conclusion

The results of this one-time use trial demonstrate the efficacy of the hybrid toothbrush used in combined mode for plaque removal. The hybrid toothbrush design allows each user to adapt tooth brushing to his preference (manual / sonic / combined), his skills or his mouth condition. We hypothesize that such an individualized approach can favor long term compliance with oral health recommendations and improve global oral wellness.

Trial Registration

ISRCTN12394494, 20/02/2018 - Retrospectively registered.

Toothbrushing Systematics Index (TSI) - A new tool for quantifying systematics in toothbrushing behaviour

Systematics is considered important for effective toothbrushing. A theoretical concept of systematics in toothbrushing and a validated index to quantify it using observational data is suggested. The index consists of three components: completeness (all areas of the dentition reached), isochronicity (all areas brushed equally long) and consistency (avoiding frequent alternations between areas). Toothbrushing should take a sufficient length of time; therefore, this parameter is part of the index value calculation. Quantitative data from video observations were used including the number of changes between areas, number of areas reached, absolute brushing time and brushing time per area. These data were fed into two algorithms that converted the behaviour into two index values (each with values between 0 and 1) and were summed as the Toothbrushing Systematics Index (TSI) value; 0 indicates completely unsystematic and 2 indicates perfectly systematic brushing. The index was developed using theoretical data. The data matrices revealed the highest values when all areas are reached and brushed equally long. Few changes occurred between the areas when the brushing duration was ≥90 s; the lowest values occurred under opposite conditions. Clinical applicability was tested with data from re-analysed videos from an earlier intervention study aiming to establish a pre-defined toothbrushing sequence. Subjects who fully adopted this sequence had a baseline TSI of 1.30±0.26, which increased to 1.74±0.09 after the intervention (p≤0.001). When the participants who only partially adopted the sequence were included, the respective values were 1.25±0.27 and 1.69±0.14 (p≤0.001). The suggested new TS-index can cover a variety of clinically meaningful variations of systematic brushing, validly quantifies the changes in toothbrushing systematics and has discriminative power.

Finding an upper limit of what might be achievable by patients: oral cleanliness in dental professionals after self-performed manual oral hygiene

AIMS

Though patients have been shown to have difficulties in achieving oral cleanliness after self-performed oral hygiene, scientifically and empirically justified standards for the degree of oral cleanliness they should achieve are lacking. Oral cleanliness of dental staff was therefore assessed as an indicator of what might be an upper limit of what can be expected by patients.

MATERIALS AND METHODS

In a multicentre study, N = 64 university dentists, N = 33 dental students and N = 30 dental assistants were asked to perform manual oral hygiene to the best of their abilities. The presence or absence of dental plaque adjacent to gingival margins was assessed by the marginal plaque index (MPI). As full-crown index, the Turesky modification of the Quigley and Hein Index (QHIm) was applied.

RESULTS

Only three participants showed papillary bleeding and only one a clinical pocket depth of more than 3.5 mm. After self-performed oral hygiene, no differences between groups were observed with respect to plaque nor did results differ between those who habitually used a powered toothbrush only and those who did not. Most participants (96%) achieved oral cleanliness at more than 70% of their gingival margins and QHIm levels below .63. Half of the participants showed QHIm levels below .17 and oral cleanliness at 96% of gingival margins.

CONCLUSIONS AND CLINICAL RELEVANCE

Considering that half of the dental professionals achieved oral cleanliness at 96% of gingival margins and QHIm levels below .17 after thorough oral hygiene, this might reflect an upper limit of what can be expected by patients.

Tooth brushing motion patterns with manual and powered toothbrushes-a randomised video observation study

INTRODUCTION

Systematic reviews have shown that powered toothbrushes (PTs) are more effective than manual toothbrushes (MTs), but with only minor effect sizes. Whether PTs are used adequately, however, has not been investigated so far. The aim of the present study was therefore to analyse motion habits with PT in comparison to MT toothbrushes by video observation.

MATERIALS AND METHODS

One hundred subjects were enrolled in this observational trial and brushed their teeth in randomised order with a MT and PT while being video-filmed, resulting in 95 analysable sets of recordings. Parameters of interest were brushing duration (s; median (min;max)), type of brushing strokes, area of brushing, changes between areas (n; median (min;max)) and brushing sequence.

RESULTS

Brushing duration was 145 s (60;354) and 135 s (48;271) for PT and MT, respectively (p ≤ 0.001). Subjects brushed vestibular surfaces completely, but reached oral surfaces to a much lesser extent, regardless of the toothbrush type. With both toothbrushes, subjects moved frequently between areas (MT 35 (14;79); PT 33 (14;85); n.s.) and brushed predominantly with circling and horizontal strokes; with the PT, 50.5% of the subjects spent only <10% of the brushing duration with passive brushing (positioning the brush head on the teeth with ≤2 movements/s).

CONCLUSIONS

Intra-individual motion patterns were similar with both MT and PT, and most subjects persisted in their habitual motion patterns regardless of the toothbrush type.

CLINICAL RELEVANCE

The use of PT and MT may need intensive training and supervision from oral hygiene educators in order to help subjects taking full advantage from these devices.

A specific brushing sequence and plaque removal efficacy: a randomized split-mouth design

AIM

It has been propagated by the dental care professionals to start toothbrushing the lingual aspect of teeth first. In general, it is assumed that these surfaces of teeth are more difficult to clean. The evidence to support this recommendation is sparse.

METHOD

In this randomized controlled clinical trial using a split-mouth design, 46 students were included. Before the visit, the participants were requested to refrain from any oral hygiene procedure for 48 h. First, the plaque index (PI) score was assessed full mouth. Two randomly chosen contra-lateral quadrants were used to start brushing from the lingual aspect first. The opposing two quadrants were used to start brushing from the buccal aspect. After the brushing exercise was completed, full-mouth PI was scored again. Subanalyses were performed for the buccal, lingual and approximal surfaces.

RESULTS

At baseline, there was no statistically significant difference between the two sets of contra-lateral quadrants (P = 0.770). Starting at the lingual aspect of the lower jaw resulted in a 55% reduction of plaque scores in comparison with 58% when the brushing exercise was started buccally. [Correction added on 16 January 2017, after first online publication: In the preceding sentence, the percentage reduction of plaque scores when the brushing exercise was started buccally, was previously wrong and has been corrected to 58% throughout this article.] The difference in mean plaque scores between brushing orders was 0.04, which was not significant (P = 0.219). None of the subanalyses revealed any significant differences for the isolated surfaces.

CONCLUSION

Using a manual toothbrush reduced the plaque scores between 55 and 58% with no difference between brushing from either the lingual or buccal aspect first. Within the limitations of this study, a recommendation to start toothbrushing the lingual aspect is not supported by the outcome in this young student population.

What is the best predictor for oral cleanliness after brushing? Results from an observational cohort study

BACKGROUND

Brushing performance is an important factor for brushing success. Thus, observing brushing performance might help to explain deficits in oral hygiene. However, it is unknown how brushing behavior observed at one time relates to brushing capabilities observed at another time. The authors assessed the predictive validity of video-observed habitual brushing behavior for the capability to achieve oral cleanliness several weeks later.

METHODS

Study participants (N = 101) were video-recorded while cleaning their teeth. Two independent, calibrated examiners assessed brushing duration, evenness of distribution of brushing time across areas of the mouth as one indicator of brushing systematics, and duration of specific brushing movements. Weeks later (mean: 6.4 weeks; range: 1 to 24 weeks), 70 participants were asked to remove plaque to the best of their ability, and degree of oral cleanliness was assessed immediately afterward. A forward regression analysis was performed to assess the predictive values of brushing parameters.

RESULTS

Regression analysis revealed that evenness of distribution of brushing time and duration of circling movements explained 20.8% of variance of oral cleanliness (P < 0.001).

CONCLUSION

Evenness of distribution of brushing time and duration of circling movements are aspects of observed habitual brushing behavior that predict brushing capabilities in terms of oral cleanliness.

Evaluation of holy basil mouthwash as an adjunctive plaque control agent in a four day plaque regrowth model

Objectives: Various antibacterial and antiplaque agents are used in chemical plaque control but none are without their shortcomings. Chlorhexidine considered a gold standard, also has an array of side effects. To overcome these, numerous herbal extracts have been tried and tested and one among them is holy basil. The present study evaluated the antibacterial efficacy of holy basil in vitro against some periodontopathogens and its antiplaque effect in vivo. Study Design: Thirty periodontally healthy volunteers were randomly divided into three groups and refrained from all mechanical oral hygiene measures for 4 days and used one of the randomly assigned mouthwash (1- chlorhexidine; 2- holy basil; and 3- sterile water [placebo]) twice daily. The Plaque Index (PI) was assessed at days 0 and 5. Aqueous extract of holy basil was tested against Prevotella intermedia (P. intermedia) and Fusobacterium nucleatum (F.nucleatum). Results: Holy basil extract showed inhibition of both the tested periodontopathogens (P.intermedia and F.nucleatum) at various concentrations. In all groups, the PI increased from baseline to day 5. There was a statistically significant difference (p < .05) between the chlorhexidine and placebo rinse and the holy basil and placebo rinse, but no statistically significant difference was found between the chlorhexidine and holy basil rinse with respect to PI. Conclusions: These results indicate that the holy basil mouthwash has an antiplaque effect and is efficacious against P. intermedia and F. nucleatum strains in vitro. Hence holy basil mouthwash may have potential as an antiplaque mouthwash with prophylactic benefits.

Key words:Antibacterial agent, basil, Fusobacterium nucleatum, mouthwashes, Prevotella intermedia.

Effect of two herbal mouthwashes on gingival health of school children

This study aimed at determining the effect of indigenously prepared neem and mango chewing stick mouthwashes on plaque and gingival indices. A sample of 105 children aged 12-15 years was randomized into three groups, namely neem, mango, and chlorhexidine mouthwash groups. All the children were examined at baseline and gingival and plaque indices were recorded. Baseline scores for plaque and gingivitis were fair and moderate, respectively, in all the three groups and there existed no statistically significant difference among them. Ten millilitres each of herbal and chlorhexidine mouthwashes (0.2%) were administered according to the group allocation twice daily for 21 days. Indices were reassessed at 21 days (immediately after intervention) and at 1 month, 2 months, and 3 months after discontinuing the mouthwashes. Statistically significant reduction (P < 0.001) in plaque index was found in all the three mouthwash groups at 21 days and at 1 month from discontinuing the mouthwash. Chlorhexidine additionally showed statistically significant reduction in plaque index at 2 months from discontinuing the mouthwash. Statistically significant reduction (P < 0.001) in gingival index was found in all the three mouthwash groups at 21 days (immediately after discontinuing the mouthwash) and at 1 and 2 months from discontinuing the mouthwash. To conclude, all the three mouthwashes were effective antiplaque and antigingivitis agents. Chlorhexidine and neem possess equivalent efficacy in reducing plaque, while chlorhexidine has superior antigingivitis properties.

Toothbrushing and flossing behaviour in young adults--a video observation

OBJECTIVES

Video observation studies of habitual oral hygiene from the 1970s revealed a striking neglect of brushing oral surfaces and unsystematic brushing patterns with frequent movements between areas. These findings were not systematically followed up; furthermore, nothing is known about whether subjects are able to floss sufficiently. Therefore, the aim of this video study was to analyse the performance of habitual toothbrushing and flossing.

METHODS

A random sample of 101 18-year-olds was included. Toothbrush and floss were provided; habitual brushing/flossing was videotaped in a standardised setting and analysed with the video coding software INTERACT. Parameters of interest were toothbrushing duration, type of brushing strokes, brushing patterns, flossed interproximal spaces and flossing technique.

RESULTS

The mean brushing duration was 156.0 ± 71.1 s; duration differed only slightly between the upper and lower jaw as well as between the right, left and anterior areas. However, oral surfaces were brushed distinctly shorter than vestibular surfaces (27.1 ± 27.8 s versus 72.1 ± 31.8 s; p ≤ 0.001). Participants brushed different areas of the mouth with different types of strokes, predominantly with horizontal and circular strokes. Brushing movements frequently alternated between areas (45.1 ± 22.4) not randomly but accumulated within a jaw with a tendency to move from the right to the left. Half of the participants flossed, but only one performed sufficiently.

CONCLUSIONS

There was a significant neglect of brushing oral surfaces and insufficient use of floss. Brushing patterns were similar to those observed in the 1970s.

CLINICAL RELEVANCE

Understanding habitual oral hygiene behaviour is essential for improving oral hygiene instruction strategies.

Scaffold-free microtissues: differences from monolayer cultures and their potential in bone tissue engineering

OBJECTIVES

Cell-based therapies for bone augmentation after tooth loss and for the treatment of periodontal defects improve healing defects. Usually, osteogenic cells or stem cells are cultivated in 2D primary cultures, before they are combined with scaffold materials, even though this means a loss of the endogenous 3D microenvironment for the cells. Moreover, the use of single-cell suspensions for the inoculation of scaffolds or for the direct application into an area of interest has the disadvantages of low initial cell numbers and susceptibility to unwanted cellular distribution, respectively.

MATERIALS AND METHODS

We addressed the question whether an alternative to monolayer cultures, namely 3D microtissues, has the potential to improve osteogenic tissue engineering and its clinical outcome.

RESULTS

By contrast, to monolayer cultures, osteogenic differentiation of 3D microtissues is enhanced by mimicking in vivo conditions. It seems that the osteogenic differentiation in microtissues is enhanced by strong integrin-extracellular matrix interaction and by stronger autocrine BMP2 signaling. Moreover, microtissues are less prone to wash out by body fluids and allow the precise administration of large cell numbers.

CONCLUSION

Microtissue cultures have closer characteristics with cells in vivo and their enhanced osteogenic differentiation makes scaffold-free microtissues a promising concept in osteogenic tissue engineering.

CLINICAL RELEVANCE

Microtissues are particularly suitable for tissue engineering because they improve seeding efficiency of biomaterials by increasing the cell load of a scaffold. This results in accelerated osteogenic tissue formation and could contribute to earlier implant stability in mandibular bone augmentation.

Scaffold-free microtissues: differences from monolayer cultures and their potential in bone tissue engineering

Objectives

The paper’s aim is to review dentin hypersensitivity (DHS), discussing pain mechanisms and aetiology.

Materials and methods

Literature was reviewed using search engines with MESH terms, DH pain mechanisms and aetiology (including abrasion, erosion and periodontal disease).

Results

The many hypotheses proposed for DHS attest to our lack of knowledge in understanding neurophysiologic mechanisms, the most widely accepted being the hydrodynamic theory. Dentin tubules must be patent from the oral environment to the pulp. Dentin exposure, usually at the cervical margin, is due to a variety of processes involving gingival recession or loss of enamel, predisposing factors being periodontal disease and treatment, limited alveolar bone, thin biotype, erosion and abrasion.

Conclusions

The current pain mechanism of DHS is thought to be the hydrodynamic theory. The initiation and progression of DHS are influenced by characteristics of the teeth and periodontium as well as the oral environment and external influences. Risk factors are numerous often acting synergistically and always influenced by individual susceptibility.

Clinical relevance

Whilst the pain mechanism of DHS is not well understood, clinicians need to be mindful of the aetiology and risk factors in order to manage patients’ pain and expectations and prevent further dentin exposure with subsequent sensitivity.

Interactive toothbrushing education by a smart toothbrush system via 3D visualization

The very first step for keeping good dental hygiene is to employ the correct toothbrushing style. Due to the possible occurrence of periodontal disease at an early age, it is critical to begin correct toothbrushing patterns as early as possible. With this aim, we proposed a novel toothbrush monitoring and training system to interactively educate on toothbrushing behavior in terms of the correct brushing motion and grip axis orientation. Our intelligent toothbrush monitoring system first senses a user's brushing pattern by analyzing the waveforms acquired from a built-in accelerometer and magnetic sensor. To discern the inappropriate toothbrushing style, a real-time interactive three dimensional display system, based on an OpenGL 3D surface rendering scheme, is applied to visualize a subject's brushing patterns and subsequently advise on the correct brushing method.

The Bass technique using a specially designed toothbrush

BACKGROUND

Reducing the plaque index (PI) is still the main objective in the prevention of gingivitis and periodontitis.

AIM

This experiment evaluated the efficiency of a new manual toothbrush shape from two perspectives: allowing the maximum exploitation of the bristle surface in all directions of the dental arches and simplifying the Bass technique handling and movements in domestic oral care.

PATIENTS AND METHOD

The distinct shape was obtained by distancing the bristle surface from the surface of the toothbrush handle in the direction of the bristles, maintaining the two surfaces on parallel planes. This modification facilitates brushing with the Bass technique, since rotation of the new toothbrush handle on its axis allows the bristle surface to cover a greater area. Sixteen patients between the ages of 23 and 49 years with at least 28 dental elements were divided randomly into two groups. On the first day, they underwent professional plaque removal and were provided with pairs of toothbrushes to test. They were evaluated 30 days later using the Full Mouth Plaque Score determined by two dental hygienists who were unaware of the instructions given concerning the method, quadrants and toothbrushes used for the experiment.

RESULTS

The results showed that the modifications to the manual toothbrushes produced greater PI control compared with the traditionally shaped toothbrushes.

CONCLUSION

Although oral hygiene testing at home usually provides subjective information, in this experiment, the data provided a positive, objective result.

A study in vitro of the combined effects of soft drinks and tooth brushing with fluoride toothpaste on the wear of dentine

The aim of this study was to measure loss of dentine produced by soft drinks alone and combined with tooth brushing with and without toothpastes. Groups of flat human dentine specimens were exposed for 10 min and then 30 min to orange juice (OJ), carbonated cola (CC) or modified blackcurrant (MB) drinks alone or after the exposures brushed with a fluoride toothpaste for 10 s. Further groups were exposed to OJ as before but brushed with water or non-fluoride toothpaste or placed in slurries of fluoride paste. Five cycles of each regimen were carried out. Tissue loss was determined by profilometry. Water immersion/brushing and brushing controls were included. OJ and CC produced similar erosion and significantly more than MB. Compared with drinks alone, dentine loss was reduced by fluoride toothpaste brushing but increased by water and non-fluoride toothpaste brushing. Fluoride toothpaste slurry had no significant effect on soft drink erosion. Very little abrasion with brushing alone was recorded over the time frame of these experiments. It is concluded that fluoride toothpaste could provide protection, albeit small, against erosion. The data again support the concept of brushing before meals.

Tooth-brushing practices of parents and toddlers: a study of home-based videotaped sessions

The aim of this pilot study was to investigate the tooth-brushing behaviour of parents and toddlers, by analysis of tooth-brushing sessions videotaped in families' homes. Eighteen families (self-selected from an ongoing preventive-intervention study) videotaped all home tooth-brushing sessions involving their toddler (average age 2.5 years) over a 24-hour period. The vast majority of families (89%) engaged in at least two sessions per day, usually supervised by mothers. The average length of the sessions was 142 s, although the brush tended to be in the child's mouth for less than half of that time. On average, only 10 s were spent brushing the front teeth, 13 s the back teeth, and 29 s spent on non-brushing activities (e.g., biting brush, sucking water). Three styles of brushing were identified, and families tended to be consistent in their use of these styles: exclusively parent-led (least common), exclusively child-led, and shared between parent and child (most common). In contrast with these poor behavioural outcomes, feedback from parents indicated that they were generally confident that the sessions had been effective in achieving clean teeth. These findings suggest that home-based tooth-brushing activity falls far short of professional expectations. Tooth-brushing, even with fluoride toothpaste, may be seriously compromised as a method of reducing caries in toddlers because teeth are being brushed too briefly.

Dentine hypersensitivity: a randomised, double-blind placebo-controlled study of the efficacy of a fluoride-sensitive teeth mouthrinse

OBJECTIVES

Potassium and fluoride salts have been used in the treatment of dentine hypersensitivity (DH). The primary aim of this study was to compare a fluoride-containing mouthrinse product with a placebo rinse for the treatment of DH. A secondary aim was to compare effects on plaque index (PI) and gingivitis index (GI).

MATERIAL AND METHODS

The study was a double-blind, randomised, two-treatment parallel design involving 91 subjects with DH. At screening, an air evaporative stimulus (AES) was used for selection. Approximately 4 weeks later, at the baseline visit, DH was recorded, using a response-based visual analogue scale (VAS) from upper and lower incisors, canines, premolars and first molars in response to AES and from two to six teeth in response to a cold water stimulus (CWS). PI and GI were also recorded. Subjects were then allocated the test or placebo rinse. On days 28 and 56, VAS scores were again recorded for AES and CWS, with PI and GI recorded at day 56.

RESULTS

Both groups improved symptoms to day 28 and again to day 56. The majority of the data favoured the test rinse as more effective but there was no clear evidence for a statistically significant difference between test and placebo. PI at lingual sites approached significance for the test rinse.

CONCLUSIONS

The placebo response has again been shown to play a significant role in DH clinical trials and narrows the range over which to detect treatment differences. Study designs to minimise or prevent the placebo response in DH seem worthy of consideration.

Clinical development and evolution in plaque removal performance of a battery powered toothbrush

BACKGROUND AND AIM

There is growing evidence that the new generation of electric toothbrushes are more effective than manual toothbrushes. The primary aim of these studies was to compare, as an indication of the stage of development, the plaque removal properties of a prototype battery powered toothbrush with an established product. A secondary aim was to utilise the data to appraise plaque accumulation together with the patterns of removal.

METHOD

The three studies presented used the same, single-examiner, randomised, single-blind cross-over design involving up to 24 healthy volunteers. The prototype brushes, E6500 versions s1, s2 and s3 and E8000 with head speeds of 6500 and 8000 oscillations/min were compared with a similar design marketed product (MP) with a head speed of 8800 oscillations/min. All brushes had circular brush heads with oscillating rotating actions. Subjects accumulated plaque over a 4-day period during which no oral hygiene measures were performed. On day 4, the plaque accumulation was scored by index. Subjects then used the allocated toothbrush for 2 min. This was followed by a re-scoring of the remaining plaque.

RESULTS

Studies 1 and 2 showed significantly less plaque removed by prototype E6500 (s1) and prototype E6500 (s2), respectively, than by MP. In study 3, prototype E8000 removed similar quantities of plaque to MP (approximately 65%). In contrast prototype E6500 (s3) only removed 60% of accrued plaque. Differences, however, did not reach statistical significance.

CONCLUSIONS

The study methodology was appropriate to distinguish between the study toothbrushes and was furthermore able to establish a level of comparability for one of the prototype modifications with a similar MP.

Periodontal diseases: current and future indications for local antimicrobial therapy

The microbial etiology of gingivitis and periodontitis provides the rationale for use of adjunctive antimicrobial agents in the prevention and treatment of periodontal diseases. Although mechanical removal of supra- and subgingival calcified and non-calcified plaque deposits has been proved effective to control the gingival inflammatory lesions as well as to halt the progression of periodontal attachment loss, some patients may experience additional benefits from the use of systemic or topical antimicrobial agents. Such agents are able to significantly affect supra- and subgingival plaque accumulation and/or suppress or eradicate periodontal pathogenic microflora. Currently, properly selected local antiseptic and systemic antibiotic therapies can provide periodontal treatment that is generally effective, low-risk and affordable. This paper will briefly review the host-related conditions in which the periodontal preventive and therapeutic approaches may be effectively assisted by a local antimicrobial regimen. Potential future indications for adjunctive local antimicrobial therapy will also be discussed.

Can tooth brushing damage your health? Effects on oral and dental tissues

Circumstantial evidence based on anecdote, case reports, epidemiological data and studies in vitro and in situ implicate tooth brushing with toothpaste with tooth wear, gingival recession and dentine hypersensitivity. This review attempts to assess the clinical significance of the potential harm produced by this most common oral hygiene habit. The toothbrush alone appears to have no effect on enamel and very little on dentine. Most toothpaste also has very little effect on enamel and in normal use would not cause significant wear of dentine in a lifetime of use. Wear of enamel and dentine can be dramatically increased if tooth brushing follows an erosive challenge. Gingival recession has a multi-factorial aetiology and certain individuals and specific teeth may be predisposed to trauma from tooth brushing. Tooth brushing is known to cause gingival abrasions but how these relate to gingival recession is not known. The role of toothpaste in gingival abrasion and recession surprisingly has received little if any attention. Gingival recession most commonly exposes dentine and localises sites for dentine hypersensitivity. Some toothpaste products can expose dentinal tubules but erosion is probably the more dominant factor in dentine hypersensitivity. There is no evidence to indicate that electric and manual toothbrushes differ in effects on soft and hard tissues. It is only under, over or abusive use or when combined with erosion that significant harm may be thus caused. In normal use it must be concluded that the benefits of tooth brushing far out-way the potential harm.

A modification to the experimental gingivitis protocol to compare the antiplaque properties of two toothpastes

BACKGROUND AND AIMS

Randomised, blind, controlled experimental gingivitis and home-use study protocols are used to evaluate the efficacy of oral hygiene products. The present methodological study combined the two clinical trial designs to compare the preventive and therapeutic potentials of two toothpastes.

MATERIAL AND METHODS

The study was a parallel group, randomised, double-blind design, initially involving 73 healthy dentate subjects. A 21-day experimental gingivitis protocol was combined with a 6-week (42 days) home-use protocol. At baseline, modified gingival index (MGI), gingival index (GI) and gingival bleeding (GB) were recorded. A dental prophylaxis was then performed. Subjects were allocated to either control fluoride or stannous fluoride toothpaste based on gender and GI. During the first 21-day period, subjects applied the allocated toothpaste, for 1 min twice a day, to a group of teeth in a plastic shield and brushed the remaining teeth with the same paste. From day 21 the shield was not placed, and subjects brushed all teeth with the toothpaste for 1 min twice per day up to day 42. MGI, GB and a plaque index (PI) were recorded on days 21 and 42.

RESULTS

Sixty-nine and 67 subjects completed to days 21 and 42, respectively. For shielded teeth, PI, MGI and GB increased to day 21 and then after ceasing the use of the shield decreased to day 42. At day 21, PI favoured the stannous fluoride toothpaste, but differences did not achieve statistical significance for any parameter at days 21 or 42. For unshielded teeth, there were no significant differences between the toothpastes for any parameter at either time point.

CONCLUSION

: The feasibility of combining two gingivitis clinical trial methodologies appears proven, and data on both the preventive and therapeutic chemical and mechanical efficacy of toothpastes can be obtained through such protocols. Specifically from the present study and consistent with some other reports, the plaque inhibitory properties of the stannous fluoride product are limited and do not always translate into an antiplaque/antigingivitis effect.

Comparative professional plaque removal study using 8 branded toothbrushes

BACKGROUND AND AIM

Considerable interest has been shown in the plaque removal properties of modern toothbrush designs. The primary aim of the study was to compare the plaque removal properties of 8 relatively recent designs of manual toothbrush using a professional tooth brusher and within a commonly used time frame. A secondary aim was established to utilise the data to observationally appraise plaque accumulation together with the patterns of removal as a consequence of using the timed professional tooth brusher.

METHOD

The method was an 8-period, single-examiner, randomized, blind cross-over study involving 24 healthy volunteers, balanced for residual effects. Subjects accumulated plaque over a 4 day no oral hygiene period. On day 4, the accumulated plaque was scored by plaque index at the mesial, mid and distal sites of each of the buccal and lingual surfaces of the assessed teeth. Subjects were then removed from the assessment area where they received a professional brushing timed to last 48 s. Brushing was completed according to pre-study training without toothpaste and was followed by a re-scoring of the remaining plaque. A washout period of 3 days was then allowed prior to the next period during which normal oral hygiene was resumed.

RESULTS

Similar quantities of plaque accumulated in each arch, although the difference between the buccal and lingual surfaces was of the order of 30%. The professional toothbrusher removed approximately 40% of the accumulated plaque in the 48 s allocated. The buccal surfaces were most effectively cleaned (approximately 45%) compared with the lingual (approximately 25%), with the plaque removal in the mesial and mid sections approaching 40% and 60% respectively. The difference in performance between the test brushes corresponded to 5% of the residual plaque values with none being significantly more efficient overall. Pair wise site comparisons did produce differences of the order of 10% (p=0.004) at the mesio-buccal, and 8% (p=0.030) at the mid-buccal sites respectively in favour of 2 brushes compared to one other brush.

CONCLUSIONS

These data derived from a standardized brushing method support the contention of many researchers that there is no one superior design of manual toothbrush. The minor and few site differences in favour of some brushes are unlikely to be of clinical significance to gingival health. This leaves uncontested the conclusion that the user is by far the most significant variable. Perhaps methods such as used in the present study could be more gainly employed to set a minimum standard of toothbrush efficacy.

Video instruction to establish a panel of experts to compare tooth cleaning by 4 electric toothbrushes

BACKGROUND AND AIMS

Laboratory robots can reveal differences in the cleaning of artificial tooth surfaces by different electric toothbrushes. The primary aim of this study was to establish, through video instruction, a panel of experts in tooth cleaning with an oscillating rotating electric toothbrush in an attempt to mimic the highly reproducible laboratory robot. A secondary aim was to use the "expert" panel, in an attempt to distinguish between tooth cleaning efficacy of 4 head/model combinations of the oscillating rotating electric brush.

METHOD

A 24-subject panel, after video training and home habituation for up to 12 weeks with the basic model of electric brush, participated in a single examiner blind, 4-cell, randomised, cross-over study balanced for residual effects. In each period, subjects suspended tooth cleaning for 4 days. Plaque was then scored by area before and after tooth brushing for 2 min in tandem with the instructional video with the allocated brush head/model combination.

RESULTS

Differences between subjects was significant, but overall plaque removal with all brushes was of the order of 85% with one subject achieving >97% plaque removal. There were significant differences between the brushes with the oscillating rotating brush with the faster head movement, in most analyses, significantly more effective than the slower oscillating rotating brush with 2 head combinations. The faster oscillating rotating brush was also significantly more effective than the most recently introduced oscillating rotating reciprocating model.

CONCLUSIONS

Previous studies have shown that single uses of watch-and-follow video instruction significantly improve toothcleaning with electric toothbrushes. The present study shows that extended training using these videos results in almost complete plaque removal even when prebrushing plaque levels have been enhanced by a 4-day period of no oral hygiene. Furthermore, the establishment of an "expert" panel can distinguish between brushes of different cleaning efficiencies. However, given the level of achievement of all panel members with all brushes, the absolute differences observed are of doubtful clinical significance for gingival health. Finally, the slightly-reduced plaque removal by the 3 directional head action brush can be explained by the inability within the present protocol to habituate the subjects in its use.

Computer-based intraoral image analysis of the clinical plaque removing capacity of 3 manual toothbrushes

BACKGROUND

(I) Introducing an intraoral camera system with a special positioner to allow computer-based analysis of reproducible images on lingual tooth surfaces and (II) comparing plaque removal by three manual toothbrushes with different brushhead designs (convex, multilevel and flat trimmed) on lingual mandibular tooth surfaces.

METHOD

In a clinical single-blind, crossover, 24-h plaque-regrowth study on 25 subjects, a computer-based index (PPI) was used to evaluate pre- and postbrushing plaque on lingual surfaces of mandibular premolars and molars. Subjects brushed their teeth under standardized conditions at three visits, each time with a different, randomly assigned toothbrush.

RESULTS

The intraoral camera system allowed a reproducible and relatively convenient access to the lingual surfaces of the mandibular teeth and provided an increase in objectivity. Overall, each brush achieved statistically significant plaque removal, however, none reached clinical relevance. The multilevel brush was superior at specific sites, but failed to show statistically significant superiority in terms of overall plaque reduction. Without regard of the toothbrush used, the right handed subjects were less efficient in removing plaque from the right side compared to the left.

CONCLUSIONS

The method is able to detect even small differences in plaque reduction. None of the different brushhead designs was able to compensate an insufficient brushing techniques.

Plaque removal with the uninstructed use of electric toothbrushes: comparison with a manual brush and toothpaste slurry

BACKGROUND

Individuals purchasing electric toothbrushes for the 1st time will mostly only have the manufacturer's instructional leaflet for information of usage.

AIMS

This study was designed to simulate the 1st-time purchase and early use of an electric toothbrush with the aim of comparing plaque removal with a manual toothbrush. Secondary aims were to assess chemical plaque removal effects of a toothpaste slurry and to compare between 2 electric brushes which differed only in head speed.

METHODS

A group of 16 dentate subjects participated in this single-examiner blind, randomised, crossover design balanced for residual effects. Subjects had "average" oral hygiene and had never used an electric toothbrush previously. 7 days prior to the study, all subjects received the slower oscillating rotating toothbrush under test to use at home as they wished. The test treatments were brushing with 2 oscillating rotating electric toothbrushes, a manual toothbrush and a rinse with a toothpaste slurry (3 g/10 ml water). On day 1 of each study period, subjects were rendered plaque-free, suspended oral hygiene and returned on day 5. Plaque was scored at baseline by index and area and after 30 s, 30 s (total 60 s) and 60 s (total 120 s) of the cleaning treatments. Washout periods were at least 2 1/2 days.

RESULTS

Highly significant treatment differences were found between the 4 treatments because the toothpaste slurry was totally without effect. Analyses between the 3 brush treatments overall revealed no consistent significant differences. The data suggest that in the early days of electric toothbrush use, subjects perform no better than using a manual brush.

CONCLUSIONS

The present study, taken with results from others showing greater benefits from the use of electric brushes, supports the idea that dental professionals should, where possible, provide advice and instruction in the use of such devices.

Home use oral hygiene product trials; timing of the last brushing before scoring; an assessment of variation

Home use studies to evaluate oral hygiene products often standardise the time lag between plaque scoring and the previous toothbrushing. Most protocols have favoured an evening before brushing regimen, but the rationale and even the validity of this approach has not been evaluated. In this study, a group of 30 adult subjects participated in a 4-period randomised single-blind crossover evaluation of within-subjects and between-subjects variation in plaque levels after two different brushing times. Thus, on 2 occasions, plaque was scored after an "evening before" brushing and on the other 2 occasions plaque was scored after a "morning before" brushing. As expected, mean plaque levels were lower after morning brushing, but only by 11%. There was little difference for lingual plaque (4%) but a greater difference for buccal plaque (18%). Comparisons for within-subjects variation, which ideally should be low, favoured morning brushing but differences were small and not significant. Comparisons for between subjects variation, which ideally should be high to permit discrimination between high and low plaque formers, also favoured morning brushing but were only significant for lingual plaque. Intraclass correlation coefficients of reliability revealed that overall repeatability was high for both morning and evening regimens; marginally favouring morning brushing. Analyses using all four scores per subject disregarding timing of brushing increased within subjects variation and decreased repeatability, particularly for buccal plaque. In conclusion, the data support the concept of standardising the time between plaque scoring and the previous tooth-brushing. There were no clear statistically significant grounds for preferring one brushing regimen to the other, however the data favoured the morning brushing.

The comparative effect of acidified sodium chlorite and chlorhexidine mouthrinses on plaque regrowth and salivary bacterial counts

Acidified sodium chlorite (ASC) is recognised as a highly potent, broad spectrum antimicrobial system that has been successfully developed for uses in veterinary, food processing and medical device fields. The current studies aimed to investigate the persistence of antimicrobial action and plaque inhibitory properties of 3 ASC mouthrinses by comparison with positive control, chlorhexidine 0.12%, and placebo control, water, rinses. Both studies were randomised, double-blind, cross-over 5-cell designs balanced for carryover. The 1st study involved 15 healthy subjects who immediately before and at 30, 60, 180, 300 and 420 min after rinsing provided 2 ml saliva samples. The samples were immediately processed for total anaerobic bacterial counts recorded after 96 h incubation. Washout periods were a minimum of 3 days. The second study involved 20 healthy subjects who on day 1 of each study were rendered plaque free, suspended normal oral hygiene methods and commenced rinsing twice daily with the allocated rinse. On day 5, plaque was scored by index and area after disclosing with erythrosin. Washout periods were 2 1/2 days. The 3 ASC and chlorhexidine rinses produced similar reductions in salivary bacterial counts which remained significantly below the placebo control to 7 h. There were no significant differences between ASC and chlorhexidine rinses except at 30 and 60 min when significantly greater reductions were produced by 2 ASC rinses compared to the chlorhexidine rinse. Plaque indices and areas were considerably and significantly lower with the ASC and chlorhexidine rinses compared to the placebo rinse. There were no significant differences between plaque scores for the 3 ASC rinses and the chlorhexidine rinse, although for 2 ASC rinses plaque scores were lower than for the chlorhexidine rinse. The results indicate that the 3 ASC rinses have equivalent plaque inhibitory action to chlorhexidine as a rinse. Similar to chlorhexidine, the plaque inhibitory action of the rinses appears to be derived from a persistence of antimicrobial action in the mouth.

Comparative single-use plaque removal by toothbrushes of different designs

Overall literature reviews have concluded that no one design of the manual toothbrush is superior for plaque removal. More recently, a toothbrush with filaments angled away from the head was shown to be more effective in several single-use studies than conventional designs. The aim of this study was to compare plaque removal by this new toothbrush and 3 other toothbrushes which had more conventional filament arrangements. 36 volunteers participated in this single-blind, randomised, 4-cell, crossover single use toothbrushing study. On day 1 of each period, volunteers brushed with a standard toothbrush and toothpaste for 60 s and then suspended oral hygiene for 48 h. On day 3, volunteers were scored for plaque by area and then brushed with the allocated test toothbrush with toothpaste for 60 s and plaque area was rescored. A washout of 4 days was allowed between test periods. The plaque areas were used to record the binary scores of the Rustogi et al. modification of the modified Navy plaque index but away from the clinic employing the Claydon and Addy procedural method for the index. Plaque removal scored by area and site were not significantly different between the brushes. This study is at variance with previous similar investigations which suggested that the new design of toothbrush head was superior for plaque removal. It is concluded again that there are no data which demonstrate unequivocally that any one manual toothbrush design is superior to any other for plaque removal.

A 6-month home-usage trial of 0.1% and 0.2% delmopinol mouthwashes (I). Effects on plaque, gingivitis, supragingival calculus and tooth staining

Delmopinol is a morpholinoethanol derivative which, in mouthrinses used in the absence of normal oral hygiene, has been shown effective in the inhibition of plaque and gingivitis. The aim of this study was to determine the adjunctive oral hygiene benefits and safety of delmopinol rinses when used alongside normal toothcleaning. This 6-month home use study was a placebo-controlled, double-blind, randomised parallel design evaluating 0.1% and 0.2% delmopinol rinses and structured to conform with the ADA Council of Dental Therapeutics guidelines. A total of 450 dentate male and female subjects were recruited who had no relevant medical or pharmacotherapy histories determined from a full medical examination, including haematological and biochemical tests. Subjects had moderate levels of plaque and gingivitis. At baseline, 3 and 6 months subjects were scored for plaque, gingivitis, tooth stain and supragingival calculus, with plaque sampled for microbiological analysis. Additionally, oral mucosal examinations were performed and subjects questioned for adverse symptoms. Baseline special tests were repeated at the end of the study. After baseline examinations, the subjects received a professional prophylaxis, provided with the allocated mouthwash and instructed to use 10-ml volumes for 60 s 2 x daily and where appropriate after toothbrushing and meals. Demographic features of the 3 groups were similar and losses to trial were small. Adverse signs and symptoms included transitory numbness of the tongue, tooth and tongue staining, taste disturbance and rarely mucosal soreness and erosion. All local side-effects were less commonly reported at 6 compared to 3 months and only 6 subjects were withdrawn because of adverse event. No systemic effects attributable to the agent were observed and no significant shifts in haematological or biochemical parameters occurred. All groups showed considerable improvements in oral hygiene and gingival health with some significant differences in favour of 0.2% delmopinol compared to placebo for gingivitis and more particularly plaque. Staining was also significantly increased in the delmopinol groups but not calculus. In the present study, a considerable Hawthorne effect occurred, which must in part explain why only a modestly significant effect was achieved.

The comparative effects on plaque regrowth of phenolic chlorhexidine and anti-adhesive mouthrinses

The inhibition of bacterial attachment to the tooth surface is one possible approach to plaque control. This study evaluated in vivo the plaque inhibitory action of a novel copolymer reported to have considerable antiadhesive properties in vitro. The study was a single blind, 5-treatment, randomised Latin square crossover design, incorporating balance for carry-over effects. The rinses were the antiadhesive (1%), the antiadhesive with 0.02% chlorhexidine, a 0.2% chlorhexidine rinse product, an essential oil/phenolic rinse product and water. 15 volunteers participated and on day 1 of each study period were rendered plaque-free, ceased toothcleaning and rinsed 2 x daily, under supervision, with the allocated formulation. On day 5, plaque was scored by index and area. Washout periods were 2 1/2 days. Alone or combined with chlorhexidine, the antiadhesive agent showed no effects greater than water. The chlorhexidine rinse was significantly more effective than the essential oil/phenolic rinse which in turn was significantly more effective than the other rinses.

The use of planimetry to record and score the modified Navy index and other area-based plaque indices. A comparative toothbrush study

Many plaque-scoring methods are based on a subjective assessment of the amount of tooth surface covered by plaque or the presence or absence of plaque at specific sites. The 2x modified Navy plaque index is an example of the latter and requires chairside decisions from 9 zones of all buccal and lingual tooth surfaces, i.e., up to 576 for a complete dentition. The present study describes a procedural modification to the index, whereby plaque is recorded using an established planimetric plaque area method. Scoring is then performed using an overlay away from the clinic. To test the method, plaque-area measurements were made during a 30-subject, crossover study to compare plaque removal following single toothbrushings with 3 different types of manual toothbrush. Consistent with many such studies, no significant differences in plaque removal were noted between the brushes. The method was found quick and simple at the chairside, provided a permanent record of plaque distribution and could be analysed by clinical or nonclinical personnel under ideal conditions. The same method could be employed for other plaque indices based on area or site subjective decisions.

An 8-year study of changes in oral hygiene and periodontal health during adolescence

This study reports data collected from a cohort of 405 South Wales adolescents examined at the ages of 11-12, 15-16 and 19-20 years. Dental plaque and gingivitis scores decreased markedly between the ages of 11-12 and 15-16 years, and to a lesser extent between 15-16 and 19-20 years. There was a decrease in the mean depth of the gingival sulcus between the ages of 11-12 and 15-16 years, perhaps reflecting a decrease in false pocketing and gingival oedema associated with puberty and tooth eruption. Conversely, there was an increase in the mean depth of the gingival sulcus between the ages of 15-16 and 19-20 years, possibly indicating the initiation of periodontal breakdown and the appearance of true pocketing. Gender was found to be an important determinant of the level of oral hygiene practised, the boys having consistently poorer oral hygiene than did the girls. At the commencement of adolescence this was not reflected in higher gingivitis scores, but by the age of 15-16 years the boys exhibited significantly more gingivitis than did the girls.