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Review Article

Toothbrush ‘A key to mechanical plaque control’
Deepak Grover, Ranjan Malhotra, Sumati J. Kaushal, Gurpreet Kaur
Department of Periodontics and Oral Implantology, National Dental College and Hospital, Derabassi, Punjab, India

ABSTRACT

Despite the wide range of methods available, mechanical plaque removal with a manual toothbrush remains the primary method of maintaining good oral hygiene for a majority of the population. Several different toothbrushing methods with manual brushes exist. The popularity of various techniques has waxed and waned over the twentieth century. However, no one method of brushing has been found superior to the other. However, plaque control by toothbrushing alone is not sufficient to control gingival and periodontal diseases because periodontal lesions are predominantly interdental. For years dental authorities have instructed their patients on how to brush their teeth correctly. However, many people lack the patience and do not follow dental instructions for more than a brief period. Therefore, studies were initiated in the belief that the introduction of power brushing would help the average person brush his teeth with greater efficiency. The purpose of this article is to update the available information on the toothbrush designs, tooth brushing methods, and the introduction of powered and ionic brushes.
Key words: Interdental contacts, plaque, toothbrush

Introduction
Dental plaque is established as the principle etiological agent of dental caries and periodontal disease. Recent investigations have stated that gingivitis may develop within two weeks without oral hygiene, and that early carious lesions may be detected after about four weeks, when the plaque is allowed to accumulate. Prevention of these two oral diseases in individuals is based, to a great extent, on the effective removal of plaque on a daily basis. Various authors have shown the effect of mouth cleaning in the healing and prevention of periodontal disease. Despite the wide range of methods available, mechanical plaque removal with a manual toothbrush remains the primary method of maintaining good oral hygiene for a majority of the population. When performed well, for an adequate duration of time, manual brushing is highly effective for most patients.

The Council of Dental Therapeutics has quoted, “In fact, the data from some studies emphasize the ability of persons to maintain good oral hygiene through effective use of a conventional toothbrush if they possess reasonable dexterity and have been trained adequately in the proper use of the brush”. Several different toothbrushing methods with manual brushes exist. The popularity of various techniques has waxed and waned over the twentieth century. However, no one method of brushing has been found superior to the other. Toothbrushing is a completely accepted part of daily life and good oral hygiene practice. However, plaque control by toothbrushing alone is not sufficient to control gingival and periodontal diseases because periodontal lesions are predominantly interdental. For years dental authorities have instructed their patients on how to brush their teeth correctly. However, many people lack the patience and do not follow dental instructions for more than a brief period.
Indian Journal of Oral Sciences  Vol. 3  Issue 2  May-Aug 2012

Address for Correspondence: Dr. Deepak Grover, Department of Periodontics and Oral Implantology, National Dental College and Hospital, Derabassi, Punjab, India. E‑mail: preet342@yahoo.com Date of Submission: 10-05-2012 Date of Acceptence: ???

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• Diameters of commonly used bristles range from: • 0. clinical trials over the last few years showed that in closely supervised trials electric toothbrushing appeared to be superior to manual brushing.007 inch (0. Bristle patterns. Kanchanakamol and Srisilapanan[3] evaluated a newly designed ‘Concept 45’ toothbrush for plaque removal in children and subsequently in adults. and claims of superiority for plaque removal by individual brands have been made in the past. with the test brushes. for efficacy and for possible influence of the toothpaste.Grover. and 60% after two minutes.009 inches in diameter 4. natural bristles are more susceptible to fraying.‑ Toothbrush head The Manual Toothbrush There are numerous manual toothbrush designs. Plaque removal was 39% after 0. Toothbrush handles • Barnarius et al. with rounded ends. 3  Issue 2  May-Aug 2012 1 2 3 4 5 6 7 8 9 AQ3 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 . 40% after one minute.006 to 0.: Kindly provide running tittle??? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 Therefore. • Two kinds of bristle materials are used in toothbrushes: • Natural bristles from the hair of hog or wild boar.5 minutes of brushing. • Nylon bristles vastly predominate in the market. for age and dexterity 2. • This is because of their tubular form. • 0.5. et al. • Soft bristle brushes of the type described by Bass have gained wide acceptance • Bass (1948) recommended a straight handle and nylon bristles of 0. It permits each patient to assure responsibility for his or her own health on a daily basis.406 inch (10. Kieser and Groeneveld [4] evaluated another novel toothbrush design (Snake brush) that was characterized by double angulations of handle and neck. and repulsion of water and debris. Without it.012 inch (0. • In contrast. uniformity of bristle size. The recent introduction of some ionic toothbrushes seems all set to revolutionize home care maintenance by all people. contamination with diluted microbial debris. with a brushing time of 0. and 2 minutes. Indian Journal of Oral Sciences  Vol. resistance to fracture. The handle was designed to facilitate the Bass toothbrushing technique and it was shown that this toothbrush could remove significantly more plaque than a conventional toothbrush with a standard handle. • The short‑headed toothbrush was significantly most effective. Handle size appropriate to use. breaking. In a 30‑day parallel design study this toothbrush showed significantly higher levels of plaque removal than two control brushes. Brushes with modest angulations between the head and the handle are available. with greatest reduction of plaque in the lingual areas. softening. Thevissen et al. However.3 mm) for medium brushes • 0. • Rounded bristle ends cause fewer scratches on the gingiva than flat bristles with sharp ends. Use of end‑rounded nylon or polyester filaments not larger than 0. • Bristles hardness is proportional to the square of the diameter and inversely proportional to the square of the bristle’s length.[6] found a conventional flat multi‑tufted brush significantly more effective than a convex‑shaped brush. and loss of elasticity. Although earlier studies did not conclusively prove any differences in the efficiency of plaque removal between electric and manual toothbrushing. • rtificial filaments made predominantly from A Nylon (0. Use of soft bristle configuration. (1967) compared brush sizes (Long head 51 mm and short head 31 mm) on students and patients.4 mm). In case of interdental brush 0. as defined by the acceptable International Industry Standards (ISO) 5.4 mm) for hard brushes.3 mm) long. • Wasserman [5] observed a statistically significant reduction in plaque accumulation after use of a deep grooved design toothbrush. studies were initiated in the belief that the introduction of power brushing would help the average person brush his teeth with greater efficiency.014 inch (0. In terms of homogeneity of materials. which enhance plaque removal in the approximate spaces and along the gum line. The handle should fit comfortably in the palm of the hand.075 mm. The results were similar whether or not toothpaste was used. arranged 105 Toothbrush bristles The preference of handle characteristics is a nature of individual taste. thick or thin. it was agreed that the features of an ideal manual toothbrush should include: (Egelberg and Claffey[2]) 1.007 inch (0. At the European Workshop on mechanical plaque control. World Workshops on plaque control and oral hygiene practices have consistently concluded that there is insufficient evidence to prove that any one toothbrush design is superior to another (Frandson[1]).2 mm) for soft brushes. although perfection still remains an elusive goal. elasticity. Head size appropriate to the size of the patient’s mouth 3.2 mm) in diameter and 0. Plaque control is one of the key elements of the practice of dentistry. nylon filaments are clearly superior. optimal health through periodontal treatment cannot be attained or preserved. it may be straight or angled. 1.

Novel toothbrush designs • In this study. In 1984. Two‑level toothbrush 55 56 The triple‑headed toothbrush is intended to clear the buccal. et al. • Bergenholtz et al. Pretaraspanedda et al. • Better interproximal access of V‑shaped toothbrushes was observed by Yankell et al.[9] had conducted a comparative analysis of the plaque removal ability of 0.S. The ability of plaque reduction on the labial and lingual aspect was also compared. Two‑headed (double headed) • Bastiaan[10] compared the plaque removing effect of a double‑headed brush with that of a single‑headed flat toothbrush (Oral B 35) in 39 patients. lingual. The result showed that the super brush was more effective in the lingual aspect than in the labial aspect.9 to 9. two to four rows of bristles.[12] conducted a study to test a new triple‑headed.33 diameter removed most of the plaque (72%). and V‑shaped brushes when they were used unsupervised.[14] could not find a difference in the plaque removing ability of straight. Triple‑headed • Bergenholtz et al. The brushes were compared with a standard flat toothbrush (Oral‑B P35). The angled. • Agerholm[11] tested the plaque removing efficacy of the new double‑headed brush (Duodent 2000) in comparison with a conventional brush (Oral B 32).: Kindly provide running tittle??? in three rows of tufts. A toothbrush should be able to reach and efficiently clean most anxious of the teeth.25 inches (25. multi‑tufted.5) when the improve brush (Deep‑Grooved two‑level) was used. Jagadish Pai[13] conducted a study to evaluate the efficacy of the new‑triple‑headed toothbrush (Superbrush)TR and conventional (Plak‑off) toothbrush. • Yankell et al.02) between the baseline and one week.007 inch and 0.03) on the buccal interproximal surfaces (P < 0. • In a four‑week cross‑over study on adult volunteers (aged 19 to 64 years) Wasserman (1985) compared a newly developed ‘Deep‑grooved two‑level’ toothbrush (Improve) with a conventional flat brush.AQ1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 Grover. When used professionally.1 mm) diameter and shorter (0. 3  Issue 2  May-Aug 2012 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 AQ4 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 AQ3 39 40 41 42 43 44 45 46 47 48 49 AQ3 50 51 52 53 54 55 56 . • Dr..001) and plaque was also reduced significantly (P < 0.[8] demonstrated that significantly more plaque was removed after a single brushing when brushes with higher density were used. occlusal. in 5% increments.8 mm) long and 5/16 to 3/8 inch (7. the Dentrust toothbrush bristles were consistently superior to two manual toothbrushes in achieving proximal use. bileveled brush was significantly superior to the conventional. whereas. Significantly less plaque was found lingually in the molar teeth (P < 0. • Beatty et al. a Dentrust group removed a significant amount of tooth buccal and lingual plaque and the flat‑headed toothbrush removed a significant amount of buccal plaque only.4 to 31. and 5 to 12 tufts per row. Indian Journal of Oral Sciences  Vol. V‑shaped The new generation manual toothbrushes that have been tested in recent years exhibit better plaque removal ability than do the older brushes. B. straight‑handled.005 inch or 0. The differences are most significant when individuals have been instructed in the proper brushing technique.7 mm) diameter bristles. • Finkelstein and Grossman[16] evaluated its effectiveness on the lingual and facial surfaces in adult subjects by measuring the stained plaque on each facial and lingual surface.[7] • In contrast. The results indicated that lingually the double‑headed brush was superior to the single‑headed brush. and filament of 0. 106 • Guilfoyle in 1977 developed the ‘Two bristle level’ angulated handled toothbrush (Reach). with 48 tufts and four rows. These authors evaluated different toothbrushing methods with six different toothbrushes and observed that a hard toothbrush with three rows. and occlusal surfaces. The patients were instructed in the Bass technique and brushes were used for one week.344 inch or 8. [15]. multi‑tufted toothbrushes in plaque removal efficiency. toothbrush design (Dentrust) that claims to enable simultaneous plaque removal on the buccal. In a laboratory test.008 inch toothbrush bristles and demonstrated favorable results for the thinner bristles in school children. (1969. • The American Dental Association (ADA) has described the range of dimension of acceptable brushes. same authors confirmed these differences in comparison to spaced and multi‑tufted toothbrushes.5 mm) wide. There was a statistically significant difference in plaque index on the lingual aspect (P < 0. The double‑headed toothbrush helped achieve significantly better lingual and palatal plaque control. 1984[14]) compared a V‑shaped and control multi‑tufted toothbrush in a superior toothbrushing study and found significantly better interproximal plaque removal with the V‑shaped brush. buccally no difference was found. and lingual or palatal surface of the teeth at one time. the brush is smaller with thinner (0. a brushing surface 1 to 1. For children. Twenty‑seven patients were attending the clinic for an initial course of hygiene treatment and 23 were recall patients with persistently inadequate plaque control. 12 mm length. the V‑shaped toothbrush was better at proximal plaque removal than the straight one. six evenly spaced tufts per row with 80 to 86 bristles per tuft.

Hoover et al. The Charters and Stillman techniques for gingival message were popular in the 1930s and 1960s. However. Physiological: Smith h. it is possible that the reported photocatalytic property of the semiconductor may be involved in the observed radiation of the plaque’. was found by Shory et al. Vibratory: Stillman. • Avery [18] confirmed these results and showed a significant. The popularity of various techniques have waxed and waned over the twentieth century. with a flat surface was significantly more effective. No one method of toothbrushing has been found to be superior to others. Japan. Bass described what is probably the most popular method taught today and his theories were popularized in the 1970s. (P < 0. Light energy conversion and Ionic manual toothbrush Two recent studies introduced another novel approach in manual toothbrushing. manual brushing is highly effective. modified Stillman c. Roll: Rolling stroke. The authors speculated. It merely applies the name to the typical uninstructed action of brushers. After a period of three weeks the new toothbrush showed significantly more reduction of plaque on the buccal surfaces in a group of 73 school children. Scrub‑brush method • A circular toothbrush found a significant improvement in plaque removal compared to a conventional toothbrush. Vertical: Leonard f. The scrub technique is probably the oldest. which prevents individual tufts from entering the interproximal areas. Most toothbrushing methods can be classified into one of the eight groups based on the motion and position of the brush. imperceptible electric current on the established dental plaque and gingivitis during manual toothbrushing in 64 adults over a period of six months. with two short middle rows and curved outer rows. • As early as 1855. One possible way to overcome their limitations associated with manual brushing is to develop a mechanical brushing device. A similar toothbrush without a semiconductor served as the control.: Kindly provide running tittle??? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 Curved: (collis curved brush) The Collis curved brush. There were many reports of the effectiveness of such devices. et al. ‘As the buccal surfaces are more likely to allow light to reach the semiconductors during brushing than the lingual areas.[20] investigated the plaque removing potential of a new light energy conversion toothbrush incorporated with a semiconductor of titanium dioxide (TiO2). for most patients neither of these criteria is fulfilled. • The first electric brushes mimicked the back‑and‑forth motion. More efficient plaque removal interproximally is claimed to be their main advantages.Grover. Horizontal g. when first introduced.. Sulcular: Bass b. It also improved the gingival conditions and removed significantly more plaque than the regular toothbrush. 3  Issue 2  May-Aug 2012 Powered Toothbrush Mechanical plaque removal with a manual toothbrush remains the primary method of maintaining good oral hygiene for a majority of the population. The lithium battery Indian Journal of Oral Sciences  Vol. commonly used with a manual toothbrush. However. Circular and diamonds contained in the handle of these toothbrushes tends to change the surface charges of the tooth by an influx of positively charged ions. a. A major shortcoming of brushes has been the ‘Blocking effect’ of tight and dense brittle tufts. reduction of plaque in students using the Collies curved brush compared to a conventional brush. has recently introduced a new generation of ‘hyG ionic toothbrushes’ that are based on the principle that plaque is positively charged and thus attach to the negatively charged tooth surfaces. The best method is the one that suits the individuals’ needs and abilities. • It was also found that the Oral B brush.[17] to be more effective on the interproximal and gingival. When performed well for an adequate duration of time. • The first electric toothbrush came much later and was first introduced in the 1960s. the Swedish watchmaker Frederick Wilhelm Tornberg patented a mechanical toothbrush. sulcular areas than a straight multi‑tufted bristle brush. The plaque with similar charges is then repelled and detached from ‘the tooth surfaces and is in turn attracted by the negatively charged bristles of the toothbrush. [21] evaluated the effect of a small. • Williams and Schuman[19] found that handicapped children were able to remove more lingual plaque with a curved brush. They provided a brush head capable of a variety of motions driven by a power source. Van Swol et al. Charters.001) 50%. Hukeeba dental. and the responsibility of the dentist is to instruct the patient on how to perform the task thoroughly. The result showed significantly more improvement from the baseline to six months of the test over the unchanged control brush. Bass d. Toothbrushing Methods There are several specific toothbrushing techniques. Circular: Fones e. an early 107 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 .

Ideal characteristics of a powered toothbrush: (Heasman[22]) • An active brush tip to facilitate plaque control around posterior teeth and at interdental sites • An orthodontic head for brushing around and beneath the components of fixed orthodontic appliances • Rotating/spiraling filaments for interproximal cleaning • An audible clicking mechanism to warm the brusher when a pre‑set brushing force has been searched • Timers Brush movement Design and Mode of Action Generally. • This streaming is accompanied by large hydrodynamic shear stresses. This may be a simple electric motor driving an eccentric cam as a series of gears for rotary action. The traditional designs of the head. The bundles of bristles are arranged either in rows or in a circular pattern mounted on a round head.AQ1 1 2 3 AQ3 4 5 6 7 8 9 10 11 12 13 14 15 AQ3 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 Grover. but they are not strong enough to disrupt the biological cells or tissues that require hydrodynamic shear stresses of the order of 1 × 103 Nm−2. also incorporate design features that are aimed at improving 108 Electric toothbrushes may have a potentially improved action due to rapid vibration of the buccal head in a liquid medium. The rechargeable battery types operate at approximately 2000 complete strokes/minute. Since then. • Often if an antiplaque agent (irrigant) is incorporated into the liquid. Types of motion • Oscillation of the brush head is powered by a battery pack in the handle of the brush. • Acoustic microstreaming will occur around the bristles of an electric toothbrush. manual brushes. Biophysical action • Reciprocating — more back and forth in a line • Arcuate — filament ends follow an arc as they move up and down • Orbital — circular • Vibratory • Elliptical — oval • Dual motion — more than one of the previous motions mentioned Speed Speed varies from low to high among the different models. This may result in both cavitations and acoustic microstreaming. powered toothbrushes fell out of favor and during the mid 1960s they gradually disappeared from the market. • Cavitational activity encompasses a wide variety of bubble behaviors. Electric toothbrushes operate at relatively low frequencies and are unlikely to generate the destructive transient form of cavitation. then a synergistic effect may be used (i. ranging from the relatively gentle linear pulsation of gas‑filled bodies (Stable cavitation) to the violent and highly destructive formation and collapse of vapor‑filled voids and cavities (Transient cavitation). Due to lack of clear superiority and many problems of mechanical breakdown. the brush heads of powered toothbrushes tend to be more compact than those of conventional.: Kindly provide running tittle??? authoritative report reviewed such research and stated that both manual and electric toothbrushes were equally effective in removing plaque (Ash 1983). A number of new generation powered toothbrushes. et al. as well as those who had difficulty in mastering a suitable hand brushing technique. which facilitate interproximal cleaning and brushing in less accessible areas of the mouth. • Another method of generation is by magnetostriction. • At the World Workshop in Periodontics 1966. the mechanical and chemical effects work Indian Journal of Oral Sciences  Vol. ‘the use of an electric brush with its standard movement might result in more frequent and better cleansing of the teeth’ (Greene 1966. research and development have continued and many modifications have been made to the electric toothbrush design[22]. The number of strokes/minute varies from 1000 cycles/minute for a replaceable battery type to about 3600 oscillations/minute for an arcuate model. The bristles are also arranged as more compact single tufts. or counter‑rotational movements. even though the actual streaming velocities that produce them are relatively low. whereas.e. Such forces will occur readily at ultra sonic frequencies of 25 Hz. operate with a conventional side‑to‑side. Their frequency of oscillation varies from 40 Hz (cycle/second) for battery‑powered brushes to 250 Hz for magnetostrictive devices. WWP).. 3  Issue 2  May-Aug 2012 55 56 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 . circular brush heads have oscillating. the efficacy of cleaning and reducing the likelihood of toothbrush abrasion and gingival trauma in the long term (Heasman[22]). the consensus was that in non‑dentally oriented persons and persons not highly motivated to oral healthcare. which is similar to that employed by ultrasonic scalers and results in a higher mode of oscillation. or back‑and‑forth motions. rotational. arcuate. These shear forces may dislodge the plaque.

however. sonicare was found to be up to 11 times more effective than the manual brush in removing lingual and interproximal plaque. who are dependent on others • Interestingly. In: Loe H. in adults. which are compared in the literature. Rotadent. This electric toothbrush was the next innovative toothbrush design and was introduced into the market in the mid 1980s. and had a small circular brush head. The side‑to‑side movement of the sonicare was operated at a high frequency of 260 Hz.Grover. with a view to enhance an interest in oral hygiene practices. and sonex. 109 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 AQ5 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 AQ6 54 55 56 . editors. but was effective in stain removal. are the Braun Oral B‑plaque removers (D5. Rotadent This electric brush was the first clinically investigated powered brush. the approximal plaque index (API). 93-116. with small bristles that reached one surface per tooth. Such effects could prove useful with the electric toothbrush. • Zimmer S. Frandsen A. and hollow‑cup brush tip). The interplak toothbrush had a rectangular brush with six to eight bristle tufts. The authors concluded that the Ultra Sonex Ultima may be more efficacious than manual toothbrushes in removing plaque and preventing gingivitis in patients without severe periodontal disease. Ultrasonic toothbrush Sonicare (sonic toothbrush) The main electric toothbrushes. • A new toothbrush introduced in 1993. elongated. and for patients with chronic adult periodontitis. patients were not aware of any ultrasonic effect. Kleinman DV. In addition. which made an oscillating/rotating movement. the frequency of the Braun Oral‑B electric toothbrush was increased from 47 Hz to 63 Hz (Model D9). during a 30‑day trial. if the associated toothpaste has an antiplaque agent incorporated within it. it was seen that sonicare damaged the adherence properties of the oral bacteria.[28] compared the ultrasonic toothbrush to the oral‑B 40 toothbrush in 54 subjects. 1994[25]). • The safety of this brush was demonstrated by Donly KJ[26] who concluded that Sonicare had no potential for destruction of restoration. This is used around endodontic files. D7. It had a rotary action and was a single‑tuft brush. Actinomyces viscosus. • Patients with fixed orthodontic appliances • Those for whom there is also evidence that powered toothbr ushes are more effective in reducing decalcifications • Children and adolescents • Handicapped and severely retarded children • Institutionalized patients. After four weeks of use. and D9) — Interplak. plaque removal with sonicare was compared with a manual brush Oral‑B 30. Efficacy studies This electric brush was first launched in 1991. Dental plaque control measures and oral hygiene practices. had a rectangular brush head with bristles arranged in a saw tooth design. In 1996. powered toothbrushes have been shown to be of no significant benefit for patients with Rheumatoid arthritis. and D9) There is considerable evidence that powered toothbrushes are beneficial in achieving improved plaque control in specific patient groups. 3  Issue 2  May-Aug 2012 References 1. by destroying the fimbriae of the organization.: Kindly provide running tittle??? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 together). but the ultrasonic brush produced slightly improved plaque removal. which individually counter rotated. Indications for the use of powered toothbrushes Braun Oral‑B plaque control (D5. The Turesky modification of the Quigley‑Hein plaque index (PI). et al. Oxford: IRL Press.[29] evaluated the efficacy of the Ultra Sonex Ultima (R) in comparison with a conventional manual toothbrush in 64 healthy volunteers. Indian Journal of Oral Sciences  Vol. and the PBI were recorded at baseline. 1993. a ‘Special group’ alone does not constitute a sufficiently wide market and powered toothbrushes are now recommended on a community‑wide basis. It came with three brush head designs (Short‑pointed. Mechanical oral hygiene practices: State‑of‑the science review. 1986. Clearly.[23] tested sonicare and found that 60% of the plaque on a titanium surface could be disrupted at a distance of 2 mm away from the object. p. from the industrial point. Four and 8 weeks after baseline. the indices were recorded again. which turned away from the conventional design of electric toothbrushes. however. • In a study by Johnson and McInnes[24]. the angle of rotation was decreased from 70° to 60°. • Wu‑Yuan et al. • In two other studies (McInnes et al. for children who are well‑motivated brushers. These electric toothbrushes have been studied in relation to their ability to remove plaque and improve the gingival condition in comparison with either manual toothbrushes or electric toothbrushes from different manufactures. The ultrasonic toothbrush was significantly more potential in plaque removal. where the associated irrigant is sodium hypochlorite. • Terezhalmy et al. Interplak • When a prototype of an ultrasonic brush was compared with a manual brush by Goldman[27]. including the elderly. D7. Sonicare.

Kindly provide author first name and also provide rest of authors. Goldman HM. Pucher JJ. 3  Issue 2  May-Aug 2012 . Comparative evaluation plaque removing capacity of a new triple headed tooth brush and a conventional brush. Plaque removing effect of a convex‑shaped brush compared with a conventional flat brush. In‑vitro comparison of restoration wear and tensile strength following extended brushing with sonicare and a manual toothbrush.5:89-93. 23. Johnson B. 7. 1998. Clinical and computer‑assisted evaluations of stain removal ability of the Sonicare electronic toothbrush. How to cite this article: ???. Int Dent J 1992. In: Proceedings of the European Workshop on Mechanical Plaque Control. 1969 Kindly provide reference details for author McInnes et al. Yankell SL. J Dent Child 1988. Scand J Dent Res 1984. J Clin Dent 1994. Thevissen E.45:84-7. Toothbrush bristle density: Relationship to plaque removal. J Am Dent Assoc 1987.8:30-5. A  clinical evaluation. J Clin Periodontol 1984.19:434-6. 13. J Clin Periodontol 1997. Seemann R. A six‑month clinical evaluation of the Dentrust toothbrush. p. Pahwa P. Donly KJ. Kindly provide date of Acceptance. Greco PM. Wasserman BH. 007 and. 9.7:7-11. Curro FA. Quintessence Int 1996. Finkelstein P. Br Dent J 1991. Bizhang M.92:344-51. Stoller NH. 20. J Prosthet Dent 1995.55:291-3. Effectiveness of an ultrasonic toothbrush in a group of uninstructed subjects.29:496-500. 26. McInnes C. Kugel G. 5.11:331-9.73:97-103.65:692-7. Zimmer S. Barthel C. Komiyama K.26:407-20. A study of the effectiveness of two types of toothbrushes for 18. Singer DL. Clinical evaluation of an ionic toothbrush in the removal of established plaque and reduction of gingivitis. 11.170:411-3. 14. Beatty ???. Kindly confirm highlighted author and provide rest of author name. Clin Prev Dent 1990. A  new deep‑grooved design toothbrush. Emling RC. J Periodontol 1987. Nezhat V. Terezhalmy GT. Kieser J. Source of Support: Nil. Pai BS. Quintessence Books. Clin Prev Dent 1984.12:22-7. Meckes M.27:389-94. Grossman E.5:13-8. Give your teeth a hug: A simplilied brushing technique for children. Johnson B. Yankell SL. Avery KD. Grossman E. Test procedures and scoring criteria to evaluate toothbrush effectiveness. Clin Prev Dent 1985. 28. Clin Prev Dent 1990. Carranza’s Clinical Periodontology – 9th Edition. Few References cross cited and few References have not present. 008 toothbrush bristles. A comparison of the clinical effectiveness of a single and double‑headed toothbrush. Sharma A. Kidnly confirm author Pai BS name and also provide rest of author name and provide page number. 1993. 3.12:8-11. Perez B. Clinical evaluation of the efficacy and safety of a new sonic toothbrush. The curved – bristle toothbrush: An aid for the handicapped population. removal of oral accumulations.115:717-20. Segerlund N. 25. 10. Hoover JN. 27. J Clin Periodontol 1999. Groeneveld H. Conflict of Interest: None declared 17. Hurley E. Author Queries??? AQ1: AQ2: AQ3: AQ4: AQ5: AQ6: Kindly provide Running Title. 8. Ability of the Sonicare Electronic Toothbrush to Generate Dynamic Fluid Activity that Removes Bacteria.2:345-8. J Dent Child 1984. Claffey N. The effectiveness of the newly designed ‘Concept 45 degrees’ toothbrush for removal of dental plaque in primary schoolchildren. Yankell SL. Generallo C. 21. Clinical evaluation of the effect of an ultrasonic toothbrush on plaque. Role of brushing technique and toothbrush design in plaque removal. Kindly provide reference details Kindly provide reference citation for author Bergenholtz. 6. Bastiaan RJ. JISP 2003. Srisilapanan P. Williams NJ.58:861-7. Iffland H. A comparative analysis of the plaque removal ability of. Heasman PA. Miller MF. Dentino AR. Vargas M. gingivitis and gingival bleeding: A six month study. 22. Van Swol RL. Hagberg C.51:371-3. et  al. Van Scotter DE. J Clin Dent 1996. Jelepis C. Clinical efficacy of a new sonic/ultrasonic toothbrush. 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