Selecting the Right Toothbrush for Optimal Patient Care

David C. Alexander, BDS, MSc, DDPH

Toothbrushing is the major behavior performed by patients to fulfill their needs to feel clean and fresh and to avoid dental problems. It is also considered by the dentist–dental hygienist team to be the major tool in the removal and control of dental biofilm and the prevention of periodontal diseases and dental caries. While patients depend on their dental team to protect their oral health, they spend far more time brushing their teeth than they do receiving care in the dental office.

For these reasons, the dental professional should be prepared to provide comprehensive advice not only on the most effective brushing techniques, but also on the design and selection of the brushes their patients use. Unfortunately, there is a considerable amount of confusing information. As not all brushes are the same in their effectiveness,¹ patients should be advised on the selection of a toothbrush that can meet their everyday personal hygiene and grooming needs while also best maintaining their oral hygiene status between visits. By using the appropriate brush and technique together, patients can maximize their daily oral hygiene efforts.

Biofilm Removal

Why must plaque biofilm be removed? When the biofilm matures, the microbial ecology changes and becomes pathogenic due to the different microorganisms, their by-products, and—in the case of periodontal diseases—the inflammatory response provoked in the host.²

For periodontal health, biofilm must be removed from:
• the healthy sulcus or shallow pocket—the ideal anaerobic breeding ground
• the gingival margin—where maturing and growing supragingival plaque deposits are in contact with the marginal gingivae and can alter the subgingival environment
• the interproximal areas, which are hard to reach

Failure to remove the biofilm enables plaque to mature and to comprise more pathogenic organisms; this leads to an inflammatory and potentially destructive challenge to the healthy tissues.

For caries prevention, biofilm must be removed from areas most prone to caries—the cervical areas, pits and fissures, and interproximal sites. Routine disruption of the biofilm will help minimize the establishment of cariogenic organisms and the ability to produce demineralizing acids.

Biofilm Removal Challenges

Toothbrushing is the principal weapon in the armamentarium for oral hygiene for nearly all adults.¹ However, as studies confirm, few adults are able to achieve the level of biofilm removal desired by their dental professional. After 2 minutes of unsupervised brushing, it was shown in one study that plaque was still evident on 50% of surfaces³; in another study, plaque was still evident on 90% of surfaces in over one-third of patients.⁴ Given that most patients brush for less than 1 minute, these findings suggest that an effective brush is critical for maximum plaque removal. Plaque remains in the hard-to-reach areas where many toothbrushes do not have the design attributes to clean thoroughly. Toothbrushes come in a myriad of designs intended to overcome the challenge of these hard-to-reach areas, and dental professionals invariably recommend the adjunctive use of a between-the-teeth or proximal mechanical cleaning aid, such as an interproximal brush or floss. However, flossing on a routine basis is only carried out by less than 30% of the population,⁵ so its beneficial effect is limited. Maximizing the effectiveness of toothbrushing is clearly the first choice, as the daily habit is already well instilled in most people.

In terms of personalized dental care, each patient may need slight modifications of a well-established technique and will certainly need guidance in the selection of the most appropriate brush and adjunctive cleaning aids. Understanding the design elements of the toothbrush will help in the selection of the best cleaning aids. Patients look to their dental professionals as experts with respect to their self-care, as well as providing in-office care, so the dentist–dental hygienist team should be prepared to respond to patients’ questions about the many conflicting advertising claims encountered.

Toothbrushes

Understanding the different elements of brush design will help guide clinicians in making the correct selection and recommendation for each patient. The main anatomical areas of the typical toothbrush are the head, bristles, and handle.

Head and Bristles

The toothbrush head is an extension of the handle and is contoured to position the bristles. Bristles are typically round nylon filaments. The degree of hardness or stiffness of the brush is determined by the filament characteristics—especially diameter—and length as well as elasticity. Because larger diameters are stiffer, they do not bend and, therefore, exert greater pressure on the soft tissues and do not extend as easily into hard-to-reach areas. Round-ending of bristle tips was introduced in the 1940s after it was reported that trauma could occur from sharp bristle tips. The end-rounded bristle was the standard for the remainder of the 20th century. Brushes with round-ended bristles were tested in many studies, which demonstrated they were not able to penetrate much beyond 1 mm into the gingival sulcus.⁶

In the quest to clean hard-to-reach areas, innovation in bristle technology and design introduced fine-diameter bristles, which taper to a very narrow, rounded end. In these extremely tapered bristles, the diameter of the base of the bristle is 0.2 mm, and the tapering commences at 6 mm from the bristle tip and reduces smoothly to a diameter of 0.01 mm at the tip (Figure 1). The tapering of the bristle allows greater flexibility and slenderness to reach deep into the sulcus. In comparison, the end of a traditional and most commonly encountered round-ended bristle is tapered only for 0.5 mm of the upper part, and the smallest diameter of the bristle is 0.02 mm. This is a significant contrast in size (double) and shape (tapered). The extremely tapered end-rounded bristles not only reach into the depth of the sulcus but penetrate more deeply into the interproximal spaces. In commonly accepted laboratory tests, these extremely tapered bristles have been shown to reach as deeply as 2.75 mm into the sulcus (Figure 2 and Figure 3). Also, they have been shown in the same studies to reach further into the interproximal areas than regular bristles (1.43 mm versus 0.85 mm).⁵ Another recently introduced bristle has a feathered tip, where the single filament splits into five to seven much finer endings, providing up to 70% more surface contact with the tooth and thus yielding greater cleaning power. Configuration of the bristles is also important. Positioning tufts to be 10 degrees to 20 degrees away from the vertical axis increases interproximal penetration. A dome-shaped head of bristles, where the bristles in the center of the head are raised, enhances the Bass technique and has been shown to increase plaque removal and clinical indices^7,8 (Figure 4).

Handle

The design of the handle is also critical to effectiveness and patient compliance. The ideal handle grip should aid the patient in holding the brush at the correct angle so that the bristles are presented at 45 degrees to the long-axis of the tooth, as required for the modified Bass technique.⁹ Some handle designs are available to support the patient in this endeavor and to comply with some of the most commonly recommended oral hygiene techniques (Figure 5 through Figure 7). The length of the handle is also important. It should be long enough to provide adequate grip to give full control, and the distance between the grip area and the head should enable easy access to the most posterior teeth.

Adjunctive Cleaning Aids

Toothbrushes alone may not lead to adequate levels of plaque removal between the teeth. Although there is a clear need for between-the-teeth cleaning, for a variety of reasons, the vast majority of the population does not comply with their dental professional’s recommendation that they use dental floss on a consistent basis. Highly effective alternatives to flossing include interproximal brushes.¹⁰ These are available in a wide variety of designs, and a high level of customization is available. Many dental professionals report greater success in between-the-teeth-cleaning if they can select and recommend the most appropriate interproximal brush for their specific patient’s needs. A recently introduced interproximal brush features an innovative triangular-shaped bristle whereby the angled edges have been shown to remove up to 25% more plaque (Figure 8). Interproximal brushes when used as an adjunct to toothbrushing have been shown to be more effective than floss in removing plaque.¹¹

Optimizing Professional Recommendations to the Patient

Many offices—typically through the expertise of the dental hygienist—provide patients with advice for their use of oral hygiene products and techniques to benefit oral health. Additionally, many offices offer hygiene products to their patients to reinforce education and oral hygiene instruction reflecting the quality of the office. Attention to this detail is critical, as it helps the patient remember the advice given and the specific oral hygiene aids recommended. The dentist and dental hygienist should have a clear understanding of the benefits of the products provided to their patients, which are also widely perceived as an endorsement of the specific items. While fluoride toothpastes are very similar in their preventive efficacy, this is not the case with mechanical aids; therefore, products should be selected to ensure that patients derive the benefits of maximum plaque removal.

Factors to consider in selection of toothbrushes for patients include:

• The bristles must be effective in cleaning the hard-to-reach areas—extremely tapered bristles have demonstrated superiority.
• The handles should have a grip designed to automatically position the brush to achieve the correct angle of the bristles as required by the modified Bass technique.
• The brush is one element of a plaque-removal system that includes between-the-teeth cleaning devices.
• The brush should be readily available commercially so the patient can easily replace the provided brush at ideal intervals between office visits.
• The brush head must be compact to reach to the back of the mouth, and have soft bristles designed to minimize soft- and hard-tissue trauma and sensitivity, while maximizing cleaning.
• The brushes should be designed and manufactured by a long-established supplier of scientifically tested toothbrushes and interproximal cleaning aids in keeping with high-quality dental care.

Patients depend on their dentist–dental hygienist team to help them make informed choices for oral health. As toothbrushing is the single most time-intensive oral healthcare activity, offices that recommend and provide effective mechanical devices for plaque removal can greatly enhance their patients’ oral health. Dental professionals who support their patients’ home care with the selection of well-designed, high-quality products supported by science and deployed with optimal techniques stand to improve their patients’ oral healthcare outcomes and the reputation of their practices.

Acknowledgment

The figures for this article were provided by Sunstar Americas, Inc.

References

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2. Socransky SS, Haffajee AD, Cugini MA, et al. Microbial complexes in subgingival plaque. J Clin Periodontol. 1998;25(2):134-144.

3. De la Rosa MR, Zacarias GJ, Johnston DA, Radike AW. Plaque growth and removal with daily toothbrushing. J Periodontol. 1979;50(12):661-664.

4. Christersson LA, Grossi SG, Dunford RG, et al. Dental plaque and calculus: risk indicators for their formation. J Dent Res. 1992;71(7):1425-1430.

5. Bauroth K, Charles CH, Mankodi SM, et al. The efficacy of an essential oil antiseptic mouthrinse vs. dental floss in controlling interproximal gingivitis: a comparative study. J Am Dent Assoc. 2003;134(3):359-365.

6. Yankell SL, Barnes CM, Xiuren S, Cwik J. Laboratory efficacy of three compact toothbrushes to reduce artificial plaque in hard to reach areas. Am J Dent. 2011; 24:195-199.

7. Bass CC. The optimum characteristics of toothbrushes for personal oral hygiene. Dental Items of Interest. 1948;70:696.

8. Reynolds HS, Zambon JJ. Microbiological and clinical alterations from using Butler GUM toothbrushes [abstract]. J Dent Res. 1997;76(special iss). IADR Abstract 1753.

9. Poyato-Ferrera M, Segura-Egea JJ, Bullón-Fernández P. Comparison of modified Bass technique with normal toothbrushing practices for efficacy in supragingival plaque removal. Int J Dent Hyg. 2003;1(2):110-114.

10. Bergenholtz A, Olsson A. Efficacy of plaque removal using interproximal brushes and waxed dental floss. Scand J Dent Res. 1984;92(3):198-203.

11. Rasines G. The use of interproximal brushes along with toothbrushing removes most plaque. Evid Based Dent. 2009;10(3):74

About the Author

David C. Alexander, BDS, MSc, DDPH
President
Dental Learning Systems, LLC