The Journal of EVIDENCE-BASED DENTAL PRACTICE

ORIGINAL ARTICLE

THE EFFECT OF THE BASS

INTRASULCULAR TOOTHBRUSHING
TECHNIQUE ON THE REDUCTION
OF GINGIVAL INFLAMMATION:
A RANDOMIZED CLINICAL TRIAL

FEDERICO AUSENDA, DDS, MSa, NATALIE JEONG, DMD, MAa,

PETER ARSENAULT, DMDb, ROBERT GYURKO, DMD, PhDa,
MATTHEW FINKELMAN, PhDc, IRINA F. DRAGAN, DDS, MSa, AND PAUL A. LEVI JR., DMDa
a
Department of Periodontology at Tufts University School of Dental Medicine, Boston, MA, USA
b
Department of Comprehensive Care at Tufts University School of Dental Medicine, Boston, MA, USA
c
Division of Biostatistics and Experimental Design at Tufts University School of Dental Medicine, Boston, MA, USA

CORRESPONDING AUTHOR:
Irina F. Dragan, DDS, MS, Tufts University School of
Dental Medicine, Department of Periodontology, 1 ABSTRACT
Kneeland st, Boston, MA 02111.
Objectives
E-mail: irina.dragan@tufts.edu
The primary objective of this randomized controlled clinical trial was to investi-
KEYWORDS gate the effect of the Bass Intrasulcular Technique (BIT) on reducing gingival
Toothbrushing technique, Bass technique, inflammation at 4 and 12 weeks compared with the toothbrushing techniques
Toothbrush wear, Gingival inflammation
commonly used.
Compliance with ethical standards: This study
complies with the ethical standards. Methods and Materials
Source of Funding: This study was partially After receiving ethical approval from the Tufts Health Sciences Institutional Review
funded by Procter and Gamble (P&G) through a
Board, 55 subjects were invited to participate in the study. Only the subjects who
donation to the Department of Periodontology at
Tufts University School of Dental Medicine and
presented with bleeding on probing (BoP) were enrolled. The test group (BT) was
donation of oral hygiene tools. instructed on how to use the BIT, and the control group (NI) received no brushing
Conflict of Interest: The authors have no actual technique instructions. Clinical measurements (probing depth, plaque score, BoP)
or potential conflicts of interest. of each tooth were recorded at 4 and 12 weeks. The toothbrushes of all partici-
Ethical Approval: All procedures performed in the pants were photographed and assessed by two blinded examiners using the
study involving human participants were in
ImageJ software. The statistical significance between the cohorts’ BoP and their
accordance with the ethical standards of the
institutional and/or national research committee
plaque score results was assessed via hierarchical logistic regression. The analyses
and with the 1964 Helsinki declaration and its later were performed using the SAS software (version 9.4; SAS Institute, Cary, NC).
amendments or comparable ethical standards.
Informed Consent: Informed consent was obtained Results
from all individual participants included in the study. Forty-eight participants were eligible to participate and were randomly assigned
to one of the two groups (N 5 24). The BT group showed significantly smaller
percentages of BoP than the NI group at 4 (BT 5 12.4% and NI 5 31.4%) and 12
(BT 5 11.6% and NI 5 43.8%) weeks. The difference in plaque scores at 12 weeks
Received 23 October 2018; revised 12
was statistically significant (P 5 .0003) between the two groups. At 12 weeks, the
January 2019; accepted 16 January 2019
Mann-Whitney U Test indicated that the difference between the groups in terms
J Evid Base Dent Pract 2019: [106-114]
of toothbrush area was statistically significant (P 5 .043).
1532-3382/$36.00
ª 2019 Elsevier Inc. All Conclusions
rights reserved.
Within the limitations of this randomized controlled clinical trial, the BIT used by
doi: https://doi.org/10.1016/
j.jebdp.2019.01.004 participants in the BT group was significantly more effective in reducing gingival

106 Volume 19, Number 2


inflammation as determined by BoP than the techniques
used by participants who had no instructions on brushing
techniques; at 12 weeks, the BT group experienced less
toothbrush deformation than the control group.
Clinical Relevance
BIT should be recommended particularly to patients exhib-
iting BoP and periodontal diseases.
INTRODUCTION
A ccumulation of bacterial biofilm increases the proba-
bility of caries, periodontal diseases, and peri-implant
diseases.1,2 These inflammatory conditions have been
shown to negatively affect systemic health.3 Effective use of
the toothbrush is fundamental to prevent the occurrence of
these diseases. Over the years, there have been various
toothbrushing techniques recommended; however, to the
authors’ knowledge, there is limited evidence reporting on
the use of bleeding on probing (BoP) as the criterion for
measuring effectiveness. The Stillman, the Charter, and
the Fones techniques were proposed in the early 1900s,
whereas the Bass Intrasulcular Technique (BIT) and the
modified BT (MBT) were described in the mid to late
1900s. C. C. Bass was the first to emphasize the insertion
of the toothbrush bristle tips into the gingival crevice,
using a short (3-5 mm) back-and-forth motion.4,5 The BIT
and MBT are sulcular techniques, whereas the Stillman,
Charter, and Fones methods use a sweep or scrub tech-
nique. Most commonly, when using a toothbrush, in-
dividuals scrub the occlusal, facial, and lingual surfaces of
the teeth for less than 120 seconds twice a day.6 There are
conflicting reports in the literature regarding toothbrushing
techniques. Numerous authors7–9 report the BIT method4 as
effective in plaque removal, whereas others recommend the
Fones method. Thus, it is fundamental for preventive
dentistry to determine the most effective method of
toothbrushing.
BoP is evidence of a bacterial infection due to the presence
of toxins from bacteria elaborated subgingivally.10–12
Although supragingival plaque is important in the devel-
opment of caries, it is the subgingival flora that is critical in
the development of gingivitis and periodontitis.10–12 If
gingival inflammation is reduced or eliminated with sulcular
plaque removal, supragingival plaque must also be
removed in the process. The theory of plaque removal is
displacement, not abrasion.13 In addition, the efficacy of
plaque removal may depend not only on the technique
used but also on the deformation of the toothbrush
bristles through use.
The American Dental Association advocates brushing by a
method similar to the MBT and supports replacing a
toothbrush every 3-4 months.14 It is well documented that
toothbrush bristles become permanently bent (deformed)
The Journal of EVIDENCE-BASED DENTAL PRACTICE
over time.15–17 However, there is no consensus on how
many uses or which technique causes a toothbrush to
become ineffective in removing plaque.18–27 Some
authors15,20,21 have concluded that deformed bristles are
as effective as new ones in plaque removal, whereas
others16,17,22,23,28 have stated that there are differences. In
these studies, a variety of techniques were used. Some
used the BIT or MBT,14,22,24 and others instructed the
participants to use short horizontal strokes20; there were
some who did not control for the brushing technique.23,28
To date, there is little evidence to discern the
effectiveness of brushing techniques and toothbrush wear
in reducing or preventing gingival inflammation.29
Objectives
The primary aim of the study was to determine the effect of
the BIT (test group, BT) in reducing gingival inflammation at
4 and 12 weeks compared with the toothbrushing tech-
niques most commonly used by the control group (NI). The
secondary aim was to determine the amount of toothbrush
bristle deformation at 4 and 12 weeks for both groups,
evaluated by macroscopic photographs.
Hypotheses
We hypothesized that there would be a higher reduction in
gingival inflammation while using BIT than while using the
most common toothbrushing techniques by the NI group
subjects at 4 and 12 weeks. We additionally hypothesized
that a greater bristle deformation would increase the
gingival inflammation compared with reduced bristle
deformation at 4 and 12 weeks.
MATERIAL AND METHODS
Study Design
This study was a double-armed randomized clinical trial
conducted in the Department of Periodontology of the Tufts
University School of Dental Medicine, Boston, MA, USA,
and consisted of two groups: BT (test) and NI (control). The
subjects were randomized into two groups and assigned to
either the BT or the NI group following a printout of a
randomization scheme that was created using the statistical
software package R (version 3.1.2) before the outset of the
study. The study was approved by the Tufts Health Sciences
Institutional Review Board and registered on Clinical-
Trials.gov #NCT03158350. Throughout the study, the prin-
ciples of the Declaration of Helsinki were followed and the
Consolidated Standards of Reporting Trials guidelines were
applied.30
Study Participants
Respecting the approved protocol, subjects were invited to
participate if they fulfilled the following inclusion criteria:
aged 18 years, had a minimum of 20 teeth, had a
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 The Journal of EVIDENCE-BASED DENTAL PRACTICE

professional prophylaxis done within 3 months before the

beginning of the study, exhibited BoP . 20% on examina-
tion in the cervical areas, and had cervical gingival probing
depths (PD) between 1 and 3 mm. Subjects were not
enrolled if they had fixed orthodontic appliances (including
lingual retainers or clear incremental aligners), were smok-
ing, received antibiotic treatment 1 month before or during
the study, or self-reported pregnancy.
Figure 1. Examples of standardized pictures of
toothbrushes. These images were selected by the
authors to highlight the standardized technique used
for the photography. They also were chosen to show
that there was less toothbrush deformation in the BT
(test) group versus the NI (control) group.

Study Interventions
The study consisted of one baseline examination and two
follow-up evaluations. At the baseline examination, the in-
vestigators observed and recorded the subjects’ habitual
brushing techniques. All subjects were instructed to brush
their teeth twice a day for 2 min each time and to use an
amount of toothpaste covering the area of noncolored bris-
tles at the end of the toothbrush. All subjects in both groups
were asked to use only their assigned toothbrush and
toothpaste throughout the duration of the study. There were
no restrictions regarding interproximal plaque removal. Using
a periodontal probe (UNC 1-15; Hu-Friedy), the examiners
recorded the cervical PD on the buccal and lingual surfaces of
each tooth (excluding third molars). The subjects returned
4 weeks (65 days) after their baseline examination, at which
time their eligibility was reviewed. The subjects’ toothbrushes
were photographed, and the BoP and PD were recorded.
The subjects were again asked to demonstrate their tooth-
brushing techniques, which were observed and recorded. For
the subjects in the BT group, toothbrushing technique in-
structions were reviewed. At the third visit, 12 weeks
(65 days) after the baseline examination, all measurements
and procedures carried out at the second visit were repeated.

Study Outcomes
Bleeding on Probing
A complete mouth BoP score was recorded. The presence
of BoP and plaque was documented as a binary variable
(present or absent) for two surfaces on each tooth (buccal
and lingual or palatal). Interproximal bleeding and plaque
accumulation were not recorded because the toothbrush
primarily removes plaque cervically. Bleeding was assessed
by sliding the probe horizontally with the tip at the most
apical portion of the gingival crevice from line angle to line
angle on the facial and lingual surfaces of all teeth. After
observing the areas for 20 seconds, the examiner assessed
BoP. Subjects were then asked to chew a Sunstar-Butler
GUM disclosing tablet for 30 seconds, swish it throughout
their mouth, expectorate, and rinse with water. The pres-
ence of plaque on the buccal and lingual tooth surfaces was
recorded as a binary variable.
Toothbrush deformation
At baseline, each toothbrush was photographed using a
fixed macro lens camera (Nikon D90; Nikon Corporation,
Tokyo, Japan) to visualize the tip ends of the bristles (axial
view). The camera settings were maintained, and each
toothbrush was placed in the same standard preformed
toothbrush holder, which was covered by a disposable
plastic shield to ensure infection control. For the purposes
of calibration and standardization of the pictures, a 5.5 3 2-
mm rectangular aluminum foil was applied on each tooth-
brush when photographed (Figure 1).
Sample size calculation
A calculation was performed to determine the sample size
required to obtain adequate power for the primary aim of
the study. The calculation assumed that the average num-
ber of sites evaluated per subject would be 48 (two sites
per tooth with an average of 24 teeth per subject). It was
assumed that the intracluster correlation coefficient (r)
would be equal to 0.02 based on the study by Killip et al.31
Finally, based on the results of the study by Harnacke

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Figure 2. CONSORT flow diagram. CONSORT, Consolidated Standards of Reporting Trials.
et al.,32 it was assumed that the percentage of BoP would
be 20% in the group without instructions. On the basis of
these assumptions, a simple size of 19 subjects per group
was found to be effective, yielding 470 sites (using the
formula of Killip et al.31 to account for intracluster
correlation within a subject). A calculation of power was
then performed using nQuery Advisor (version 7.0,
Statsols, CA, USA). Assuming an odds ratio of 0.60, which
was determined to be clinically significant, the
aforementioned sample size of 19 subjects per group was
adequate to obtain a two-sided hypothesis test with a
type I error rate of 5% and a power of 82%. To account for
approximately 20% attrition, a sample size of 24 subjects
per group was used.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Blinding
At the initial examination, the evaluators, P.A.L. and F.A.,
were calibrated and blinded as to which group the subject
would be assigned. Blinded evaluators, Dr Joshua Hall and
Dr Shivam Patel, independently measured the toothbrush
bristle area on the pictures using the ImageJ software. The
measurements were averaged and analyzed.
Statistical Methods
The statistical analyses were performed with the SAS soft-
ware (version 9.4; SAS Institute, Cary, NC). The percentage
of sites with BoP and the percentage of sites with plaque at
each time point were calculated by group. The experimental
units were defined as sites rather than patients because the
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 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Table 1. Subjects’ “natural” brushing technique at baseline.
Group Stillman’s Scrub nonsulculara
BT 1 (4.17%) 20 [10] (83.3%)
NI 0 (0%) 21 [9] (87.50%)
Total 1 (2.08%) 41 [19] (85.42%)
a
The number of subjects using a Scrub technique along with a Fones’ technique is given within square brackets.
Table 2. BoP over time.
Baseline
Group BoP No BoP Total
BT 320 (26.8%) 876 (73.2%) 1196 (100%) 148 (12.4%) 1048 (87.6%) 1196 (100%) 132 (11.6%) 1008 (88.4%) 1140 (100%)
NI 371 (28.1%) 949 (71.9%) 1320 (100%) 415 (31.4%)
patients had a varying number of teeth. The statistically
significant difference between the cohorts’ BoP and their
plaque score results was assessed via hierarchical logistic
regression. The mean, median, interquartile range (IQR),
and standard deviation (SD) of the deformation measure-
ments (areas) were calculated at each time point for each
group. Comparisons between the groups’ deformation
measurements were assessed via the Mann-Whitney U Test.
The two groups were compared with regard to gender
distribution via the chi-square test. P values less than 0.05
were considered statistically significant.
RESULTS
A total of 55 subjects were screened, and 48 subjects started
the study, with 24 participants assigned to each group
(Figure 2). The mean age of subjects in the BT group was
29.36 years, and the SD was 10.13, with a median of
26.00 and an IQR of 4.25. The mean age of subjects in
the NI group was 27.92, and the SD was 4.63, with a
median of 27.00 and an IQR of 4.00. The Mann-Whitney U
test showed no significant difference between groups in
regard to age (P 5 .641). The two groups were compared in
terms of gender distribution via the chi-square test, and
there was no statistically significant difference (P 5 .253). In
the BT group, at baseline, the “habitual brushing method”
of 83.3% of subjects was a nonsulcular brushing technique,
and 87.5% of NI subjects were using a nonsulcular tech-
nique (Table 1). At the 12-week follow-up, a total of 45
110 Volume 19, Number 2
Bass sulcular Stationary bristle technique sulcular Total
0 (0%) 3 (12.5%) 24 (100%)
1 (4.16%) 2 (8.33%) 24 (100%)
1 (2.08%) 5 (10.42%) 48 (100%)
One month Three months
BoP No BoP Total BoP No BoP Total
905 (68.6%) 1320 (100%) 578 (43.8%) 742 (56.2%) 1320 (100%)
subjects had completed the study: 24 belonged to the NI
group and 21 to the BT (Figure 2). In the BT group, three
subjects were lost to follow-up. One chose not to continue
after 10 days, and the other two lost their toothbrushes.
Bleeding on Probing
At baseline, the study population had a total of 2516 sites,
of which 27.5% showed BoP. The BT group exhibited 26.8%
BoP, and the NI group showed 28.1% BoP, with no signifi-
cant difference (P 5 .79). At 4 weeks, the BT group had
12.4% of sites showing BoP, whereas the NI group had
31.4% of sites exhibiting BoP; the difference was statistically
significant (P , .0001). At 12 weeks, 11.6% of sites in the BT
group exhibited BoP and 43.8% of sites in the NI group
showed BoP; the difference was statistically significant (P ,
.0001). When adjusting for baseline BoP, the differences in
BoP scores at 4 and 12 weeks were still statistically signifi-
cant (P , .0001) (Table 2).
Toothbrush Deformation
At baseline, in the BT group, the mean toothbrush area was
177.89 mm2 (SD, 6.73), with a median of 177.67 mm2 and
an IQR of 9.85. The mean toothbrush area in the NI group
was 179.48 mm2 (SD, 8.66), with a median of 177.16 mm2
and an IQR of 12.0. The Mann-Whitney U Test indicated no
significant difference between the groups in terms of
toothbrush area at baseline (P 5 .482). At 4 weeks, in the BT
group, the mean toothbrush area was 184.41 mm2 (SD,
21.15), with a median of 177.47 mm2 and an IQR of 7.37.

Figure 3. Comparison of clinical measurements
between BT (test) and NI (control) groups. (A) Bleeding
on probing. (B) Cervical plaque.
The mean toothbrush area in the NI group was 193.17 mm2
(SD, 28.65), with a median of 185.83 mm2 and an IQR of
38.99. The Mann-Whitney U Test indicated that there was
no significant difference between the groups in terms of
toothbrush area at 4 weeks (P 5 .218). At 12 weeks, the
mean toothbrush area for the BT group was 197.70 mm2
(SD, 40.83), with a median of 186.45 mm2 and an IQR of
22.02. The mean toothbrush area in the NI group was
216.55 mm2 (SD, 42.22), with a median of 234.38 mm2 and
an IQR of 46.81. The Mann-Whitney U Test indicated that
the difference between the groups in terms of toothbrush
area was statistically significant (P 5 .043).
Ancillary Analysis
At baseline, the total population of subjects had 2516 sur-
faces combined, 47.5% of which exhibited plaque. In the BT
group, 43.6% of surfaces had plaque, and in the NI group,
50.9% had plaque; the difference was not statistically sig-
nificant (P 5 .22). At 4 weeks, 27.2% of sites in the BT group
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 4. Toothbrush area change from baseline to
4 weeks.
Figure 5. Toothbrush area change from 4 to 12 weeks.
had plaque, and 39.2%, in the NI group; the difference was
statistically significant (P 5 .028). At 12 weeks, 26.3% of sites
in the BT group had plaque, and 45.1%, in the NI group; the
difference was statistically significant (P 5 .0003) (Table 2).
When adjusting for baseline plaque, the difference in
plaque scores at 4 weeks approached statistical significance
(P 5 .051); however, at 12 weeks, the difference was
statistically significant (P 5 .0003) (Figure 3).
Analysis of the toothbrush area change from baseline to
4 weeks showed that the BT group exhibited a mean tooth-
brush area increase of 6.52 mm2 (SD, 21.57), whereas the NI
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 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 6. Toothbrush area change from baseline to
12 weeks.
group had a mean increase of 14.28 mm2 (SD, 29.73) (Figure 4).
There was increased deformation in both groups from 4 to
12 weeks. The BT group exhibited a mean toothbrush area
increase of 12.76 mm2 (SD, 24.07) from 4 to 12 weeks
(Figure 5). The NI group had a mean increase of 22.78 mm2
(SD, 26.12). With regard to the deformation from baseline to
12 weeks, the BT group had a mean increase of 19.91 mm2
(SD, 41.75). The mean toothbrush area increase in the NI
group was 37.07 mm2 (SD, 43.51) (Figure 6).
Interreliability Measurements
One evaluator (Dr Shivam Patel) consistently showed
greater measurements than the other (Dr Joshua Hall). The
SD of the difference of the measurements between raters
was 20.45, and the mean was 10.47.
DISCUSSION
This 12-week prospective randomized clinical trial demon-
strates that the BT group was significantly more effective in
reducing BoP than the NI group. In comparing the BT group
with the NI group for plaque and BoP, the BT group
exhibited a statistically significant reduction of BoP and
plaque from baseline to 4 weeks and from baseline to
12 weeks when compared with the NI group, which showed
an increase in plaque and BoP values.
A reduction in plaque scores for both groups was expected
and occurred. However, with respect to the parameter BoP,
the BT group showed a substantial decrease, whereas the
NI group showed a slight increase. The scrubbing tech-
nique4 seen at baseline for both groups, which presumably
112 Volume 19, Number 2
continued in the NI group, does not allow for sulcular
plaque removal. With the moving bristle tip technique,
there is little to no penetration of the gingival crevice. In
addition, the BT group received oral and written brushing
instructions at every follow-up visit and showed progres-
sive improvement of BoP and plaque scores; however, the
NI group received no brushing instructions. Considering
that 12.5% of the subjects in the NI group were already
using an intrasulcular technique at baseline, the difference
between the two groups over time is even more significant
than if those in the NI group were all using a nonsulcular
technique.
It might appear paradoxical that in both groups, the per-
centage of sites with plaque was greater than the percent-
age of sites with BoP. The fact that there was stainable
plaque on the teeth does not mean that the plaque was
mature enough to cause tissue breakdown, thus its presence
is not necessarily related to inflammation (BoP).33,34
Regarding toothbrush deformation, there were no statisti-
cally significant differences between groups when
measuring the change in area of the bristle tips. However,
the deformation in the NI group from baseline to 12 weeks
was greater than that observed in the BT group. One might
speculate that the deformation of the bristles in the NI
group hindered the bristles from entering into the gingival
crevice, which might in part account for the greater per-
centage of sites with BoP in the NI group than in the BT
group.
Despite the high level of evidence obtained from this single-
blinded, double-armed, randomized controlled trial, this
study has some limitations. The blinded evaluators who
measured the toothbrush deformation had to manually
trace the perimeter of the bristles, which could have led to
human error.
Within the limitations, this is the first study using BoP to
show a significant reduction in gingival inflammation with a
specific toothbrushing technique. Thus, BIT appears to be
an optimal technique, especially for patients with peri-
odontal diseases. Educating patients to use an appropriate
brushing technique will improve oral health and contribute
to systemic health. Future multicenter randomized,
controlled studies should include longer periods of follow-
up to fully confirm the current findings.
CONCLUSION
Based on the present study, BIT is more effective in reduc-
tion of BoP than the techniques used by individuals brush-
ing with no instructions. The deformation in the NI group
from baseline to 12 weeks was greater than that observed in
the BT group. Furthermore, this study illustrates the impor-
tance of motivational interviewing and consistent technique

instruction with an intrasulcular technique to patients.
Future multicenter studies with longer follow-up time are
recommended to confirm the current findings.
ACKNOWLEDGMENTS
The authors are grateful to the participants and the staff of
the Department of Periodontology at Tufts University School
of Dental Medicine who helped with the logistics. A special
thank you goes to Dr Joshua Hall and Dr Shivam Patel who
measured the toothbrush areas.
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