Received: 12 January 2023 | Revised: 4 April 2023 | Accepted: 30 July 2023

DOI: 10.1111/idh.12732

ORIGINAL ARTICLE

Description of a new laboratory evaluation method of

interdental brush abrasion as a clinical hazard

Patrick R. Schmidlin | Tim M. Schmidlin | Andrea Gubler | Stephan Brändli |

Thomas Attin

Clinic of Conservative and Preventive

Dentistry, Center of Dental Medicine,
University of Zurich, Zurich, Switzerland
Correspondence
Patrick R. Schmidlin, Clinic of
Conservative and Preventive Dentistry,
Center of Dental Medicine, University of
Zurich, Plattenstrasse 11, Zurich 8032,
Switzerland.
Email: patrick.schmidlin@zzm.uzh.ch
Abstract
Objectives: To simulate the abrasive potential of an interdental brush when applied
with toothpastes and prophylactic gels/solutions in a novel laboratory brushing simu-
lation set-­up.
Methods: A brushing device was customized to treat dentin samples mimicking a sim-
plified interdental space with an interdental brush (ISO 2). The brushing, that is, 7200
strokes for 1 h, was performed with artificial saliva (control), a povidone-­iodine solu-
tion, and slurries of chlorhexidine and fluoride gels as well as three toothpastes with
different RDA values ranging from 29 to 100, respectively. The loss of dentin was
profilometrically assessed and compared with ANOVA and Fishers LSD.
Results: While artificial saliva as control, the solution and the gel slurries showed no
measurable dentin loss, toothpastes resulted in a measurable linear surface dam-
age with respect to the actual intrinsic RDA values and ranged from 12.6 to 26.5 μm
(p < 0.001).
Conclusions: Any interdental cleaning product should be tailored and carefully in-
structed. Any over-­and misuse should be avoided, which applies especially to the use
of interdental brushes in combination with abrasive toothpastes.

KEYWORDS
dental prophylaxis, in vitro techniques, tooth abrasion, tooth erosion, tooth wear, toothpastes

1 | I NTRO D U C TI O N
In the past years, the prevalence and severity of caries has de-
creased worldwide, being lower in high-­income countries; the num-
ber of retained teeth has increased at the same time around the
1
globe in a continuously aging population. In this context, dental
hard substance loss and damage not necessarily related to bacte-
rial influences are becoming more relevant and will gain a greater
health-­economic impact in the future. 2 Several non-­carious tooth
structure loss patterns are known like abrasion, erosion, attrition,
and abfraction. The overall aetiology must be considered in most
cases as multifactorial, with fundamental combinations of mechani-
cal and chemical actions like friction, biocorrosion, and occlusal load.
The prevalence of these non-­carious lesions, predominantly at ex-
posed cervical tooth areas buccally, reaches almost 50% and seems
even higher in older populations.3
Abrasion can actually occur on all dental surfaces, but the
most common site of abrasion remains the bucco-­cervical area of

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© 2023 The Authors. International Journal of Dental Hygiene published by John Wiley & Sons Ltd.

Int J Dent Hygiene. 2023;00:1–7.  wileyonlinelibrary.com/journal/idh | 1

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2 SCHMIDLIN et al.
teeth.4 Especially, excessive and inadequate use of oral hygiene
tools cause accentuated tooth substance loss and the main mecha-
nisms and aetiologic factors involved in this process are the physi-
cal quality of the hygiene tools, as well as the frequency, duration,
and mode of application. 5 A pivotal aspect remains the role of
toothpastes, since mechanical cleaning without does little, if any,
damage. 6 The relative dentin abrasiveness (RDA) value thereby in-
dicates the scalable degree of abrasiveness of a respective tooth-
paste.7 In general, toothpastes with an RDA value up to a maximum
of 80 are recommended, while values between 30 and 50 repre-
sent a good compromise between a balanced cleaning efficacy and
abrasiveness.
While occlusal and smooth surfaces can be quite adequately
mechanically accessed and cleared from biofilms with conven-
tional brush heads, the interproximal areas remain difficult to reach.
Therefore, interproximal root areas require additional tools and spe-
cial attention in dental prophylaxis and therapy; the focus lays on
interdental aids especially with interdental brushes playing a central
role.8,9 Recently, unusual proximal and lingual-­cervical lesions as a
result of bizarre interdental cleaning habits have also been eluci-
dated as being relevant in daily practice.10
Besides fluoride-­containing toothpastes, the use of remineraliz-
ing and disinfecting solutions, gels and unguents offer the chance for
prophylactic adjunct effects, but may theoretically open the door
for additional abrasion or erosion of tooth substance, since they may
also remove the pellicle and may render teeth more susceptible to
erosion.11 Any incorrect use, for example, cleaning the interdental
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spaces with IDBs dipped in toothpaste, can potentially have disas-
trous consequences in the form of accentuated hard tissue dam-
age.12 Two illustrative exemplary cases of massive interproximal
abrasion are shortly presented in order to elucidate this problem:
The first example shows a case, which was anamnestically under-
pinned of being caused by regular interdental brushing in combina-
tion with medium to high abrasive toothpastes three times per day
(Figure 1). A 66-­year old male patient (healthy, no medication, non-­
smoker) under regular supportive periodontal therapy alio loco (2–­3
times per year) presented for a second opinion regarding the buccal
and interproximal tooth substance loss. All teeth displayed –­espe-
cially in the posterior area –­severe signs of interproximal abrasion
and erosion with typical signs of a brush influence as elucidated by
typically visible striations and wear of the root surface. Some fill-
ings have already been placed before to restore the most advances
lesions, especially in the upper front. In a first step, the patient was
thoroughly informed regarding the potential etiologic influence of
his previous exaggerated brushing habits and the negative impact
of using additional tooth paste. It has been agreed to monitor the
affected areas and to restore them step by step with adhesive res-
torations if progressing.
A second case illustrates radiographically another form of mas-
sive approximal hard substance damage, which was also caused by
inappropriate and exaggerated use of interdental brushes and es-
pecially the contact of the wire due to angulation problems during
application; in addition, a floss/tape mis-­and abuse was probably
also causative (Figure 2).
F I G U R E 1 Clinical case of a
66-­years old male patient (healthy, no
medication, non-­smoker) under regular
supportive periodontal therapy alio loco
(2–­3 times per year). Panels A/C show
representatively the first and fourth
quadrants, whereas panels B and D are
the enlarged aspects indicated by the
white arrow.

SCHMIDLIN et al.
F I G U R E 2 Radiographic images of
a case with severe interproximal root
damage (A/B) most probably caused by
inadequate abuse of interdental brushes
with the metal wire and dental floss/
tape over years as determined and
demonstrated by the medical history and
anamnesis (courtesy Dr. G. Sirtes, Zurich).
Both examples illustrate the importance of early and critical
evaluation of clinical signs and possible etiologic factors and accen-
tuated research on that topic. To date, mainly toothbrush-­induced
abrasion has been studied. Although the work on the use of inter-
dental brushes and sticks is gaining growing attention in research,
data on interproximal abrasion is still scarce.13,14
In this work, we introduce a novel in vitro model for especially
the standardized evaluation of dentin abrasion using interdental
brushes in combination with various agents. In the latter regard, we
hypothesized that adjunct cleaning, disinfecting and gliding materi-
als may significantly increase the abrasivity of interdental brushes
on dentin in vitro.
2 | M ATE R I A L S A N D M E TH O DS
2.1 | Tooth sample preparation
Freshly extracted mandibular lower anterior bovine teeth were used
for this study. The animals of this study were raised and slaughtered
for food production according to the Swiss standards for animal wel-
fare and the study protocol did not influence in any way the pre-
mortal fate of the animals or the slaughtering process. Therefore,
this investigation was not classified as a classical animal study, and
the institutional ethics committee did not have any objections to the
protocol.
After extraction and cleaning, teeth were cut at the enamel-­
dentin interface and the pulp tissue was removed with endodon-
tic needles. After removal of the root cementum with discs under
water cooling, 84 round dentin samples with a diameter of 4 mm
were drilled out of the root with a trephine drill. Dentin samples
were then stored in tap water at 4°C until further processing. Sub-
sequently, samples were embedded in acrylic resin (Paladur, Her-
aeus Kulzer) using a silicone template with a diameter of 6 mm.
The acrylic resin was polymerized at 55°C and 2 bar for 10 min in a
laboratory polymerization unit (Palamat elite, Heraeus Kulzer). To
completely remove the cementum layer of the roots and to create
a standardized dentin surface among all samples, a standardized
polishing was performed in an automatic grinding machine using
|
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3
2000-­ and 4000-­grit carborundum papers (Tegramin-­3 0, Stru-
ers) at a pressure of 1 N for 30 s under constant water cooling,
respectively.
2.2 | Test set-­up and preparation of the
media and slurries
For this study, a custom-­made brushing device (Clinic of Conserva-
tive and Preventive Dentistry, Center of Dental Medicine, University
of Zurich; Zurich, Switzerland) was modified to carry and treat six
samples in a 3D-­printed plastic mould with an opposing and clos-
ing screw-­retained counterpart (Figure 3). In this way, specimens fit-
ted in one reproducible position and a resulting interdental space
and access hole with size ISO 2 (0.9 mm) was formed, closed and
tightly secured with screws. The carrier was mounted in the brush-
ing machine with an axially aligned brush holder allowing placing and
passing interdental brushes through the centre of the access hole.
In the following tests steps, all groups were mechanically treated
with the same interdental brush (TePe red ISO 2, D-­A-­CH GmbH,
Art. 132430).
Twelve samples were treated for each group, that is, two runs
of six embedded samples each were performed. The samples were
treated for 1 h with 120 vertical brush strokes per minute resulting
in 7200 strokes in total. The samples were continuously treated
with the respective solution, slurry or gel. For this purpose, the
medium was placed in the carrier tub, which was connected via
two tubes to a peristaltic squeeze pump (ISM834C, Ismatec SA)
and the brushing machine. The resulting volume for each trial in
this pump circuit corresponded to a final volume of 60 mL. The
slurry was composed of one part of test agent and two parts of
artificial saliva according to a modified recipe of Klimek and co-­
workers (Caries Res 1982;16:156-­161).15 The artificial slurry in
this study contained no ascorbic acid and D(1)-­glucose. Besides
the control group, only the povidone-­iodine group was not treated
with a slurry, but consisted of the original solution only. The test
products in combination with the interdental brush were com-
monly used to prevent gingival inflammation and caries, especially
in patients with recessions and a history of periodontitis. The
 |
4 SCHMIDLIN et al.
mould with six samples each per run was randomly allocated in to
the following groups (A.G.):
• Artificial saliva
• Povidone-­iodine gargle solution (Mundipharma)
• Chlorhexidine gel (Plak-­out, KerrHawe)
• Elmex Gelée (Colgate-­Palmolive)
• Elmex Sensitive Professional (Colgate-­Palmolive)
• Elmex Kariesschutz (Colgate-­Palmolive)
• Colgate total original (Colgate-­Palmolive)
2.3 | Profilometric analysis
A profilometer (MFW-­250, Perthometer S2; Mahr) was used to
measure the surface profile of the samples. For this purpose, the
specimens were individually mounted on a holder and reproduc-
ibly positioned in the measuring device. All samples were coded
and analysed by a single trained assessor (T.M.S.) in a blind man-
ner. A fine needle moved over the specimens and recorded the
profiles. Five parallel profiles at a distance of 250 μm from each
other were registered. From each sample, a baseline measure-
ment was taken before the start of the experiment and a second
measurement after treatment as described above. The obtained
corresponding profiles were then superimposed in the computer
and the substance removal was calculated in micrometres. The
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F I G U R E 3 Test set-­up representing
the brushing device connected to a
an external tank and peristaltic pump
for brushing simulation (A) including a
magnified image section representing
again the connected holding apparatus (B).
The plastic sample holder for placement
of the embedded samples (C) and the
mounted counterpart (D), which could be
placed on the brushing device and allowed
for straight and repetitive insertion of the
interdental brushes in a guiding hole.
accuracy of the measurements in this study was 0.2 μm with a
lower measurement limit set at 0.5 μm.
2.4 | Statistical analyses and data evaluation
Measured values were coded in Excel and analysed in DATAtab
Team (2022; DATAtab: Online Statistics Calculator. DATAtab e.U.
Graz, Austria. URL https://datat​ab.net). The assumption of normal
distribution was tested with Kolmogorov–­
Smirnov and Shapiro–­
Wilk tests. The results between the treatment groups were analysed
using a simple analysis of variance (ANOVA) and Fisher's Least Sig-
nificant difference test was applied. Results of statistical analyses
with a p-­value <0.05 were interpreted as statistically significant.
3 | R E S U LT S
The control group with saliva did not show any dentin substance
removal, which means that mechanical cleaning alone did not lead
to any measurable defect creation in our set-­up. Only cleaning using
IDB in combination with the toothpastes revealed a measurable den-
tin loss (Figure 4), which followed the order of the actual intrinsic
RDA values of the respective toothpastes and decreased statisti-
cally significantly with decreasing values (p > 0.001). All other tested
materials showed no measurable loss of dental hard tissue, which
 |

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SCHMIDLIN et al. 5

F I G U R E 4 Box-­plot illustration showing the dentin loss in μm of the IDB with and without a toothpaste with different RDA according to
Imfeld et al.6 (respective RDA ranges in brackets; exact RDA values are presented in Table 1) after 1 h brushing, that is, 7200 strokes (the
negative values correspond to the material loss). Different capitals represent statistically significant differences between the groups (ANOVA
and Fisher's LSD; p < 0.05). The dashed and continuous lines in the box-­plot illustration represent the mean and median values, respectively.

TA B L E 1 Data from the profilometric analysis in μm (N = 12 In our set-­up, samples were continuously cleaned for 1 h with-
per group). Abbreviations: PVP-­polyvinylpyrrolidone; CHX-­ out exchange of the brushing media and the brushes. Therefore, the
chlorhexidine; different RDA ranges (Imfeld et al.5) and exact RDA model certainly has its limitations and represents a simplistic worst
values (Hamza et al.,16 in brackets), respectively.
case scenario, since no remineralization phases were encompassed.
Mean Standard However, the model follows other laboratory approaches like the
value deviation 95%-­CI evaluation of abrasion in old-­fashioned chewing machine set-­ups.17
Artificial saliva 0 0 0; 0 The actual number of strokes used in the model and the translation
PVP-­iodine solution 0 0 0; 0 to the clinic reality also remains a matter of assumptions. A set of
CHX gel 0 0 0; 0 7200 brush strokes was selected, which corresponds –­depending

Fluoride gel 0 0 0; 0 on the insertion frequency per application, that is, one, five or 10
strokes18 -­to cumulative overall time periods of 20, 4 and 2 years. An
Toothpaste RDA 20–­4 0 −12.6 2.2 −13.9; −11.4
(29) extrapolation of the results in this study in combination with tooth-

Toothpaste RDA 60–­8 0 −18.5 2.1 −19.7; −17.3 paste therefore correspond over 20 years to 12.6–­26.5 μm (with one
(69) stroke per day) up to 126–­265 μm (10 strokes per day), respectively.
Toothpaste RDA > 80 −26.5 4.0 −28.8; −24.2 Notably, in this context, slurries were used in our study, while under
(100) a clinical misuse, patients apply the agents directly to the brush and
teeth, that is, without additional dilutive effect of saliva. Under this
was above the threshold value for a potential measurement error premise, the values obtained in this study even rather under-­than
(Table 1). overestimate the actual damage potential. Unfortunately, data on
Figure 5 presents the details of an interdental brush before and interproximal cleaning and its qualitative or quantitative analysis are
after its use in the experimental set-­up. The images reveal minimal still scarce or even non-­existent. Therefore, the authors cannot ade-
wear on the bristle ends. quately discuss the actual results of this study with other data sets in
this specific regard. This novel device allows instrumentation under
standardized and adjustable conditions at exact distances.
4 | DISCUSSION So-­
called interdental ‘grooving’ in teeth seems a well-­
known
problem. It has been even historically described as a specific type
This work addressed the rare but real problem of approximal abra- of interproximal tooth wear.19 While it was originally postulated
sion due to excessive prophylactic cleaning efforts. As the cases when investigating human fossils and skulls of indigenous people
impressively show, it is important to establish methods to measure that these defects were primarily caused by secreted acid of the
and screen the overall damage potential in this context. The labora- gums, 20,21 later hypotheses assumed that food residues as well as
tory study has shown for the first time –­according to the author's sand and soil from the food and drinking water were responsible for
knowledge –­that toothpastes when used as an additive to cleaning the tooth damage by flushing the interdental spaces during swal-
with interdental space brushes indeed have the clear potential for lowing. 21 More recent studies emphasize again the etiologic cause
root damage like in ordinary toothbrushing, while the solutions and in toothpick furrows and therefore underpin and demonstrate early
gels, however, did not. forms of mouth care habits of the early hominids. 22 But again, a
 |
6 SCHMIDLIN et al.
multifactorial aetiology with a mix of erosive and abrasive influences
should be highlighted.
Regarding the influence of lubrification, one laboratory study as-
sessed experimentally the cleaning forces (ECF) with rubber sticks
with and without artificial saliva also in a 3D-­printed interdental
space model resembling human teeth with three different morphol-
ogies (isosceles triangle, convex, and concave). 23 This study found
that artificial saliva reduced the cleaning force by half and there-
fore potentially allowed for using even larger brush diameters. The
authors associated their results with a potentially resulting higher
cleaning effectiveness and a higher patient acceptance, especially
in patients with dry mouth. Since our data showed that prophylactic
and disinfecting gels did not lead to a measurable tooth loss, the use
of biologically active substances should maybe also be taken into
consideration and strategically investigated in risk groups for car-
ies and gingivitis or periodontitis. However, the potential of greater
damage potential in general should also be always discussed as com-
peting aspects and goals in future studies. Larger brush diameters
and application forces could notably also lead –­depending on the
brush hardness as such –­to a greater damage potential.
5 | CO N C LU S I O N
In summary, this study showed that interdental cleaning should be care-
fully instructed and any over-­and misuse must be avoided. Interdental
brushes should not be used neither under direct toothpaste application
nor without rinsing immediately after brushing, since remaining abra-
sives of the toothpaste in the saliva may lead to accentuated abrasion.
Since the removal of (eroded) dentin depends not only on the RDA
value of toothpaste slurry but also on the hardness and stiffness of the
toothbrush. The influence of these latter aspects should be carefully
addressed for interdental brush designs in future studies.
6 | C LI N I C A L R E LE VA N C E
6.1 | Scientific rationale for the study
Exposed root surfaces may be subject to mechanical and chemical
wear. Unfortunately, there is a lack of data regarding the abrasion
caused by interdental brushes in combination with toothpastes.
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F I G U R E 5 Representative SEM images
taken at 75-­fold magnification show a
brush before (A) and after (B) laboratory
testing. The bristle ends exhibit minimal
wear, while some debris from toothpaste
with an RDA of 100 is visible on the wire
and around a few bristles.
6.2 | Principal findings
Abrasive ingredients in toothpastes can also influence the abrasive
behaviour of interdental brushes, which seems to be correlated to
the intrinsic RDA values.
6.3 | Practical implications
Interdental cleaning products and especially interdental brushes
should be tailored and carefully instructed. Any over-­and misuse,
which applies especially to the combination with abrasive tooth-
pastes, should be avoided.
AU T H O R C O N T R I B U T I O N S
P.R.S. conceived the idea; T.S., A.G. and S.B. collected the data; S.B.
designed the testing device; T.S. and A.G. analysed the data; and
P.R.S., T.S. and T.A. led the writing; all authors have read and cor-
rected the manuscript.
AC K N O​W L E D
​ G E ​M E N T S
The help of Priska Irenen during data acquisition was greatly appre-
ciated. Open access funding provided by Universitat Zurich.
F U N D I N G I N FO R M AT I O N
The study was funded solely by the authors’ institution.
C O N FL I C T O F I N T E R E S T S TAT E M E N T
All authors have completed the ICMJE uniform disclosure form.
The authors have no conflicts of interest to declare, no sources of
funding.
DATA AVA I L A B I L I T Y S TAT E M E N T
Data is available upon request from the corresponding author.
ORCID
Patrick R. Schmidlin https://orcid.org/0000-0002-1377-0325
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How to cite this article: Schmidlin PR, Schmidlin TM,
Gubler A, Brändli S, Attin T. Description of a new laboratory
evaluation method of interdental brush abrasion as a clinical
hazard. Int J Dent Hygiene. 2023;00:1-7.
doi:10.1111/idh.12732