COMPARISON OF TOOTH ABRASION BETWEEN

TOOTH BRUSHES AND NATURALLY OCCURRING

AND COMMERCIALLY AVAILABLE TOOTH STICKS -
IN VITRO STUDY

A Dissertation submitted in
partial fulfilment of the requirements
for the degree of

MASTER OF DENTAL SURGERY

BRANCH - VII

PUBLIC HEALTH DENTISTRY

THE TAMILNADU DR. M. G. R. MEDICAL UNIVERSITY

CHENNAI – 600 032

2017-2020
 CERTIFICATE

This is to certify that this dissertation submitted

by Dr.S.Anupriya (2017 - 2020 Batch), Post graduate
student, Department of Public Health Dentistry, titled
“Comparison of Tooth Abrasion between Tooth Brushes
and Naturally Occurring and Commercially Available
Tooth Sticks - In Vitro Study” was carried out under my
guidance in partial fulfilment of the regulations laid down by
The Tamil Nadu Dr. M.G.R. Medical University, Chennai
for M.D.S in Public Health Dentistry (Branch VII) degree
examination.

Dr. M. B. Aswath Narayanan B.Sc., M.D.S.,

PROFESSOR & HEAD,
Department of Public Health Dentistry

Dr. G. Vimala. M.D.S.,

PRINCIPAL,
Tamil Nadu Government Dental College and Hospital,
Chennai-600 003.
 CERTIFICATE – II

This is to certify that this dissertation work titled “Comparison of Tooth Abrasion

between Tooth Brushes and Naturally Occurring and Commercially Available Tooth

Sticks - In Vitro Study” of the candidate Dr. S.Anupriya with registration number

241723001 for the award of M.D.S in the branch of Public Health Dentistry (Branch VII).

I personally verified the urkund.com website for the purpose of plagiarism check. I found that

the uploaded thesis file contains Introduction to Conclusion pages excluding Review of

Literature and References, and the result shows 1% of plagiarism in the dissertation.

Guide & Supervisor sign with seal

 DECLARATION

I, Dr. S. Anupriya, do hereby declare that the dissertation titled “Comparison of Tooth

Abrasion between Tooth Brushes and Naturally Occurring and Commercially Available

Tooth Sticks - In Vitro Study” was done in the department of Public Health Dentistry,

Tamil Nadu Government Dental College and Hospital, Chennai-600003. I have utilized the

facilities provided in the Tamil Nadu Government Dental College and Hospital for the study

in partial fulfilment of the requirements for the degree of Master of Dental Surgery in the

specialty of Public Health Dentistry (Branch VII) during the course period 2017-2020 under

the conceptualization in guidance of the dissertation guide Professor and Head,

Dr. M. B. Aswath Narayanan, B.Sc., MDS.

I declare that no part of the dissertation will be utilized for gaining financial assistance,

for research or other promotions without obtaining prior permission from the Tamil Nadu

Government Dental College and Hospital.

I also declare that no part of this work will be published either in the print or electronic

media except with those who have been actively involved in this dissertation work and I firmly

affirm that the right to preserve or publish this work rests solely with the permission of the

Principal, Tamil Nadu Government Dental College and Hospital, Chennai- 600003, but with

the vested right that I shall be cited as author(s).

Signature of the PG Student Signature of the HOD

Signature of the Head of the Institution

 TRIPARTITE AGREEMENT

This agreement herein after the “Agreement” is entered into on this day, January, 2020

between the Tamil Nadu Government Dental College and Hospital represented by its

Principal having address at Tamil Nadu Government Dental College and Hospital, Chennai-3,

(hereafter referred to as ‘the College’)

and

Dr. M.B. Aswath Narayanan B.Sc. MDS, aged 54 years working as Professor and Head

of the Department of Public Health Dentistry at the college, having residence address at

“Mathuram”, Plot No: 161, No: 5, Murugu Nagar, 5th street, Velachery, Chennai – 42 (herein

after referred to as the ‘Researcher and Principal investigator’)

and

Dr. S.Anupriya, aged 30 years currently studying as Post Graduate student in the

Department of Public Health Dentistry (herein after referred to as the ‘PG/Research student

and Co- investigator’).

Whereas the ‘PG/Research student as part of her curriculum undertakes to research on the

study titled “Comparison of Tooth Abrasion between Tooth Brushes and Naturally

Occurring and Commercially Available Tooth Sticks - In Vitro Study” for which purpose

the Researcher and Principal investigator shall act as Principal investigator and the College

shall provide the requisite infrastructure based on availability and also provide facility to the

PG/Research student as to the extent possible as a Co-investigator.

Whereas the parties, by this agreement have mutually agreed to the various issues including

in particular the copyright and confidentiality issues that arise in this regard.
Now this agreement witness as follows:

1. The parties agree that all the research material and ownership therein shall become the

vested right of the college, including in particular all the copyright in the literature including

the study, research and all other related papers.

2. To the extent that the College has legal right to do go, shall grant to licence or assign

the copyright do vested with it for medical and/or commercial usage of interested

persons/entities subject to a reasonable terms/conditions including royalty as deemed by the

college.

3. The royalty so received by the college shall be equally by all the parties.

4. The PG/Research student and PG/Principal Investigator shall under no circumstances

deal with the copyright, confidential information and know how generated during the course

of research/study in any manner whatsoever, while shall sole vest with the manner whatsoever

and for any purpose without the express written consent of the college.

5. All expenses pertaining to the research shall be decided upon by the Principal

investigator/Co-investigator or borne sole by the PG/Research student (Co-investigator).

6. The College shall provide all infrastructure and access facilities within and in other

institutes to the extent possible. This includes patient interactions, introductory letters

recommendation letters and such other acts required in this regard.

7. The principal investigator shall suitably guide the student research right from selection

of the research topic and area till its completion. However, the selection and conduct of

research, topic and area research by the student researcher under guidance from the principal

investigator shall be subject to the prior approval, recommendations and comments of the

Institutional Review Board of the college constituted for this purpose.

8. It is agreed that as regards other aspects not covered under this agreement, but which

pertain to the research undertaken by the Student Researcher, under guidance from the

Principal Investigator, the decision of the college shall be binding and final.

9. If any dispute arises as to the matters related or connected to this agreement herein, it

shall be referred to arbitration in accordance with the provisions of the Arbitration and

Conciliation Act, 1996.

In witness whereof the parties herein above mentioned have on this the day month and year

herein above mentioned set their hands to this agreement in the presence of the following two

witnesses.

College represented by its Principal Student Researcher

Witnesses Student Guide

1.

2.
 ACKNOWLEDGEMENT

I would like to express my sincere gratitude and indebtedness to my respected guide,

Dr. M. B. Aswath Narayanan B.Sc., MDS, Professor and Head of the Department, for his

constant support, continuous guidance, constructive suggestions and timely advice at every

stage of my preparation. It is an honour and privilege to add that it was my guide, who

encouraged me achieving my goal. I consider myself very fortunate to have been his student.

I am immensely grateful to Dr. G.Vimala, M.D.S., Principal, Tamil Nadu Government

Dental College and Hospital, Chennai, for her kind gesture in allowing me to proceed with my

study by using all the facilities in this prestigious institution.

It gives me immense pleasure to extend my heartfelt gratitude to Dr. S. G. Ramesh

Kumar, M.D.S., Dr. A. Leena Selvamary, M.D.S., and Dr. A. Sujatha, M.D.S., Assistant

Professors of the Department, for their continuous support rendered to me throughout my study.

I take this opportunity to thank my Post Graduate colleagues for their encouragement,

support and valuable feedback.

With profound gratitude I acknowledge from my heart, my Father, Mother and

Sisters for constantly supporting and encouraging me in every step that I take in my life. I am

forever indebted to the sacrifices made by them.

It would be impossible to name all the people who in one way or another contributed

like while conducting this scientific study, however I acknowledge my thanks to all of them.

Last but not the least; I am thankful to Almighty GOD without whose blessings nothing is
possible.
 ABSTRACT

Introduction: Various Oral hygiene measures are being practised around the world. Most

common method is using toothbrush and toothpaste. However, traditional method of using

chewing sticks are seen in several parts of the world. Nowadays, various types of commercial

chewing sticks are available in the market. Many studies have proven mechanical cleansing

action of chewing sticks is similar to tooth brush and additionally chewing sticks has

therapeutic effect. But there is limited evidence comparing the abrasion caused by the tooth

brushes and chewing sticks. So, this invitro study was conducted to assess and compare the

role of different types of commercial toothbrushes, natural chewing sticks and commercial

chewing sticks in causing abrasion.

Materials and Methods: Eighty extracted sound human teeth were randomly selected and

prepared. Tooth samples were mounted in acrylic resin. The samples were randomly allocated

in 1:1:2 ratio into one of the three groups: Group A – Natural chewing sticks, Group B –

Commercial chewing sticks, Group C - Toothbrushes. These groups were further divided into

eight subgroups. Samples in subgroup 1, 2, 3, 4, 5, 6,7, 8 were brushed with natural neem

sticks, natural banyan sticks, commercial neem sticks, commercial miswak sticks, hard

toothbrush, medium tooth, soft brush, Ultrasoft brush respectively. The tooth samples were

brushed two minutes, twice daily for one month in unidirectional movement, under constant

force by using customised brushing machine. Water was used as control medium. Pre and post

brushing surface roughness were measured using noncontact profilometer. Change in surface

roughness (post minus pre) indicates the tooth abrasion. Wilcoxon Signed Rank test, Kruskal

Wallis test, post hoc- Scheffe, Tukey test were used for analysis.

Results: The results showed that there was statistically significant difference in change of

surface roughness produced by commercial chewing sticks and natural chewing sticks
(p═0.038). There is significant difference in tooth abrasion caused by hard toothbrush when

compared to natural sticks, medium, soft, Ultrasoft toothbrushes.

Conclusions: Hard toothbrush caused the most abrasion followed by commercial chewing

sticks (Neem, Miswak), natural neem sticks, other commonly used toothbrushes (Medium, soft,

Ultrasoft) and natural banyan sticks caused the least abrasion.

Key Words: Tooth Abrasion, Toothbrush, Chewing Sticks

 TABLE OF CONTENTS

S. NO. TOPICS PAGE NO.

1. INTRODUCTION 1

2. AIM AND OBJECTIVES 6

3. REVIEW OF LITERATURE 7

4. MATERIALS AND METHODS 13

5. RESULTS 26

6. DISCUSSION 42

7. SUMMARY AND CONCLUSION 51

8. REFERENCES 53

9. ANNEXURES 57
 LIST OF ABBREVIATIONS

WHO World Health Organisation

DCI Dental Council of India

RDA Relative Dentin Abrasivity

ANOVA Analysis of Variance

Ra value Average surface roughness

SPSS Statistical Package for Social Sciences

P value Probability Value

HSD Honest Significance Difference

nm Nanometre
 LIST OF TABLES

S. No. Tables Page

No.
1 Description of groups and subgroups 29

2 Normality test using Shapiro Wilk Test 30

3 Intragroup comparison of surface roughness (Ra) before and after 31

brushing using Wilcoxon signed rank test
4 Intergroup comparison of change in surface roughness between 32
Subgroups using Kruskal Wallis test
5 Intergroup comparison of change in surface roughness between Groups 33
using Kruskal Wallis test
6 Multiple pairwise comparison of groups using Scheffe test 34

7 Comparison of change in surface roughness caused by 35

Natural chewing sticks (Group A) with other subgroups using Tukey
HSD test
8 Comparison of change in surface roughness caused by 36
Commercial chewing sticks (Group B) with other subgroups using
Tukey HSD test
9 Comparison of change in surface roughness caused by 37
Toothbrushes (Group C) with other subgroups using Tukey HSD test
 LIST OF PHOTOGRAPHS

S. No. Photograph Page No.

1 Prepared tooth sample 20

2 Tooth brushes 21

3 Natural Chewing sticks 22

4 Commercial Chewing sticks 22

5 Customized brushing model with toothbrush 23

6 Customized brushing model with chewing stick 23

7 Surface Profilometer with mounted tooth sample 24

 LIST OF DIAGRAMS

S. No. DIAGRAM Page No.

1 Flow Chart 25
 LIST OF FIGURES

S. No. Diagram Page No.

1 Figure 1. Comparison of surface abrasion caused by 38
natural chewing sticks

2 Figure 2. Comparison of surface abrasion caused by 39

commercial chewing sticks

3 Figure 3. Comparison of surface abrasion caused by 40

various toothbrushes

4 Figure 4. Comparison of surface abrasion caused by 41

subgroups
 LIST OF ANNEXURES

S. No. Annexures Page no.

1 Annexure I: Master table containing all the data. 57

 Introduction

INTRODUCTION

Tooth wear is a non-carious destructive process which is a multifactorial

phenomenon. The term “tooth wear” defines the gradual loss of hard tissue through

processes of erosion, attrition, and abrasion. It is a cumulative lifetime process, which

subsequently leads to substantial tooth surface loss.1

Tooth wear can be localized or generalized. Localized tooth wear is commonly

associated with habits or occupation such as pipe smoking, nut and seed cracking, nail

biting, and hairpin holding. Generalized tooth wear is commonly related to oral hygiene

methods and products used, time and frequency of teeth cleaning, brush bristle design,

and abrasiveness of toothpaste. 2 Friction between a tooth and an exogenous agent causes

wear called “abrasion.”3

Abrasion of teeth was described first by Zsigmondy in 1894 as angular defects

and later by Miller in 1907 as a wasting of tooth structure. Abrasion along with erosion

and abfraction are termed as non-carious cervical lesions. Abrasion usually starts at

cementoenamel junction and then progresses rapidly as enamel and cementum are very

thin at this region. Abrasion process rapidly destroys the softer structures such as dentin

and cementum. Root caries and teeth sensitivity are two most common clinical

manifestations of this condition.4

Abrasion may occur as a result of improper toothbrushing, improper use of

dental floss and toothpicks or detrimental oral habits such as chewing tobacco; biting on

1
 Introduction

hard objects such as pens, pencils or pipe stems; opening hair pins with teeth; and biting

fingernails. Abrasion can also be produced by the clasps of partial dentures. Occupational

abrasion may occur among tailors who sever thread with their teeth, shoemakers and

upholsterers who hold nails between their teeth, glassblowers, and musicians who play

wind instruments.3

The appearance may vary depending on the etiology of abrasion, however most

commonly presents in a “ V ” shape caused by excessive lateral pressure while tooth-

brushing. The surface is shiny rather than carious, and sometimes the ridge is deep enough

to see the pulp chamber within the tooth itself.5

The maintenance of good oral health can be mainly achieved by the use of

mechanical and chemical plaque control methods. Most common mechanical method of

tooth cleaning is the use of a toothbrush with toothpaste.6 Various Oral hygiene measures

are being practised by different populations and cultures in a different way around the

world.7

In spite of the widespread use of toothbrushes and dentifrices, natural methods

of tooth cleaning using chewing sticks are seen in several parts of the world. The use of

herbal chewing sticks is common in many cultures, instead of using the toothbrush.

Chewing sticks are commonly taken from the plants, shrubs, or trees with anti-microbial

activity.6 Tripathi has documented various plants being used in oral health care as

chewing sticks (datun) by the rural population of India.4

2
 Introduction

According to World Health Organisation (WHO) 70% of Indian population,

rely on traditional medicine.8 According to the Dental Council of India (DCI) survey of

2003, almost 3.7% urban and 18.8% rural respondents age group 0f 35-44 years used

datun (chewing stick) for cleaning their teeth.2

The selection of chewing stick depends largely on traditional preference. It is

an affordable oral hygiene tool. Freshly cut sticks are always desirable because they are
4
more easily chewed into a brush. The use of chewing sticks also achieves the

fundamental requisite of primary health care and may be a proper substitute to the modern

manual toothbrush to accomplish the goal of prevention of oral diseases, especially in

countries with economic restraints and countries with limited oral health care services for

general population.9 Chewing sticks are easily available in majority of urban and rural

areas of developing countries. In India chewing sticks from Pilu (Salvadora persica),

neem, kicker, peepal tree, the Indian plum or ber fruit tree, the Java plum or jamun tree,

the gum arabic tree, safed babul, apamarga, bael tree, dhak, madarak, kamer, karanj,

vijayasar, arjun, gular, bargad, mulhatti, tejovati, mango are used.10

For abrasion, most attention has focused on toothpaste, and dentin loss appears

to correlate with its RDA value (Relative Dentin Abrasivity). In addition to the abrasivity

of the toothpaste, the type of brush and the applied brushing force are known to be

relevant factors for the loss of tooth surface. Furthermore, the filament diameter of the

toothbrush has also been suggested as an important co-factor for abrasion.11 If

toothbrushing is not done correctly, it could result in abrasion of the soft tissues as well

as hard tissues of the oral cavity.4

3
 Introduction

Nowadays, toothbrushes with various bristle diameter and more commercial

chewing sticks products are available. Hence, understanding the process of tooth abrasion

caused by various toothbrushes and chewing sticks is the need of the hour. There is

limited published evidence addressing this issue. Therefore, this study was undertaken to

compare the tooth abrasion caused by tooth brushes and naturally occurring and

commercially available tooth sticks.

4
 Introduction

Research Hypothesis

There is a significant difference in tooth abrasion caused by toothbrushes,

natural chewing sticks and commercial chewing sticks.

Null Hypothesis

There is no significant difference in tooth abrasion caused by toothbrushes,

natural chewing sticks and commercial chewing sticks.

5
 Aim and Objectives

AIM AND OBJECTIVES

AIM:

The aim of this study is to compare the tooth abrasion caused by tooth

brushes, natural chewing sticks and commercially available chewing sticks.

OBJECTIVES:

The objectives of the study are:

1. To measure the surface roughness of the teeth samples before and after

brushing with tooth brushes (Hard, Medium, Soft, Ultrasoft), natural chewing sticks

(Neem, Banyan) and commercially available chewing sticks (Neem, Miswak) by using

surface profilometer.

2. To compare the change in surface roughness caused by tooth brushes, natural

chewing sticks, commercially available chewing sticks.

6
 Review of Literature

REVIEW OF LITERATURE

AH AlShehab et al (2018) conducted an invitro study to compare the brushing

abrasion carried out by manual toothbrushes with different bristle types (hard and soft)

on normal and demineralized human enamel. Thirty enamel blocks were prepared and

the blocks were randomly divided into three main groups: A, teeth kept in artificial saliva

with no brushing (control, n = 2); B, teeth brushed with toothbrushes with hard bristles

(n = 14); and C, teeth brushed with toothbrushes with soft bristles (n = 14). Seven teeth

in groups B and C were brushed normally, and the remaining seven were demineralized

before brushing experiments with 6 wt.% citric acid (pH = 2.2) for 5 minutes. The

brushing experiments were carried out twice a day for 2 mins for 7 days by using

toothbrush simulation machine. The changes in the surface of enamel (pre -brushing and

post-brushing) were estimated using non-contact profilometry. Kruskal-Wallis test and

the Wilcoxon signed rank test were used for statistical analysis. The results revealed

significant differences (P = .055) in the surface roughness values between the four groups

pre-brushing. Within each group, the pre-brushing and post-brushing surface roughness

value differences were statistically significant (P < .05). It was concluded that soft bristles

caused more abrasion compared to the hard bristles.12

Naseem Shah et al (2018) conducted a cross‑sectional analytical study to

assess the plaque cleaning efficacy, gingival bleeding, recession and tooth wear of

different traditional oral hygiene methods as compared to use of toothpaste-toothbrush.

Total 1062 traditional oral hygiene method users (study group) were compared with same

number of toothpaste-brush users (control group). In study group 76% used tooth

7
 Review of Literature

powders, 20% used barks of trees and 4% used other methods such as charcoal/tobacco

powder, salt, and oil. The result showed that the plaque scores and gingival bleeding &

recession were found to be more in study group. There was only a small difference

between toothpowder users (47.08%) and other traditional method users (43.96%) in

severity of tooth wear. This study concludes that the traditional methods of oral hygiene

such as use of toothpowders and tree sticks caused excessive tooth wear, increased

gingival recession, and were also inferior in plaque control as compared to toothpaste and

toothbrush use.2

Chaitanya Pradeep Joshi et al (2017) conducted an in vitro study to

evaluate the abrasive effect of two different manual toothbrushes using predetermined

forces on cemental surfaces of the teeth. sixty extracted first molars were divided into six

experimental groups based on the three predetermined forces 1.5, 3, and 4.5 Newton and

two types of manual toothbrushes, i.e., soft and medium bristle hardness. Tooth samples

were brushed for 5000 cycles using specially designed toothbrushing machine. Type and

quantity of toothpaste used were kept constant throughout the study. Pre and post

brushing surface roughness were measured using profilometer and pre and post brushing

weight measured using digital weighing scale. Change in surface roughness and weight

shows loss of tooth substance during brushing. The results showed that the abrasion of

cementum is force dependent. Both soft and medium bristle toothbrushes cause

significant cemental abrasion at 3 and 4.5 N forces. They concluded that higher is the

force, more is the cemental surface abrasion. Soft bristled toothbrush causes more

cemental abrasion than medium bristled toothbrush at 3 and 4.5 N forces.4

8
 Review of Literature

Mozhgan Bizhang et al (2017) conducted an invitro study to evaluate the

susceptibility of dentin to brushing abrasion using four different toothbrushes (rotating-

oscillating, sonic and two types of manual toothbrushes) with the same brushing forces.

Dentin samples were selected from 72 impacted third molars. Half of the surface of dentin

samples were covered with an adhesive tape. Brushing was performed with either a: sonic

b: oscillating-rotating or two different manual toothbrushes c: flat trim brush head

toothbrush d: rippled-shaped brush head toothbrush using a custom-made automatic

brushing machine. The brushing force was set to 2 N and a whitening toothpaste was

used. The simulation period was performed over a calculated period to mimic a brushing

behaviour of two times a day brushing for eight years and six months. Dentin loss was

quantitatively determined by using profilometer. The results showed that highest dentin

abrasion was measured for sonic toothbrush and lowest for the rippled-shaped manual

toothbrush. It was concluded that using the same force and a highly abrasive toothpaste,

manual toothbrushes caused less abrasion compared to power toothbrushes for 8.5 years

simulation.13

Sandeep Kumar et al (2015) conducted an in vitro study to assess the role of

different types of toothbrushes (soft/ medium/hard) in abrasion process when used with

and without a dentifrice. Enamel specimens of forty-five extracted human incisor teeth

were prepared and mounted on acrylic bases. These specimens were divided into three

groups, 15 specimens in each group. Specimens in Group 1 were brushed with soft

toothbrush; Group 2 brushed with medium toothbrush and Group 3 with hard toothbrush.

First all the specimens were brushed using dentifrice and then the same procedure was

repeated with water as control. To give uniform force and uniform direction a customized

9
 Review of Literature

brushing model was used. Brushing was carried out for 2 minutes, twice a day, for 3

months on each specimen. Average surface roughness of the tooth samples before and

after brushing was recorded using profilometer. The differences between pre and post

readings were used as a proxy measure to assess surface abrasion. Kruskal Wallis and

Mann-Whitney U test were used for analysis. The results showed that brushing, with

water alone, caused less abrasion than brushing with toothpaste (p<0.008). When brushed

with water, the harder toothbrush caused more abrasion, but when toothpaste was added,

the softer toothbrush caused more abrasion (p<0.001). They concluded that a softer

toothbrush can cause more abrasion than harder when dentifrices used. The abrasivity of

dentifrice plays an important role in abrasion process.14

Aeeza S Malik et al (2014), compared the effectiveness of chewing stick and

manual toothbrush, for plaque removal and gingival health after one month. They

recruited the fifty dental students (age 18-22 years) of a public sector dental hospital for

the study. Participants were randomized into two groups and provided with either

chewing sticks or toothbrushes. Plaque and gingival indices were taken before and after

intervention by two calibrated examiners. Paired t-test, and two sample independent t-

tests were used for statistical analysis. The results showed that, except for the mean

plaque scores of toothbrush users, all other scores showed reduction. In contrast to the

final mean gingival scores, a significant difference (P = 0.0001) in the final mean plaque

score was observed for the two respective interventional groups. They concluded that

chewing stick has equal and at times greater mechanical and chemical cleansing of oral

tissues as compared to a toothbrush.9

10
 Review of Literature

Annette Wiegand et al (2013) conducted a study to determine and compare the

brushing forces applied during in vivo toothbrushing with manual and sonic toothbrushes

and to evaluate the effect of these brushing forces on abrasion of sound and eroded

enamel and dentin in vitro. Brushing forces of a manual and two sonic toothbrushes were

measured in 27 adults before and after instruction of the respective brushing technique.

In the invitro experiment, sound and eroded enamel and dentin of bovine incisor

specimens were brushed in an automatic brushing machine with the respective brushing

forces obtained in invivo experiment using a toothpaste slurry. Abrasion was determined

by using profilometer. The results showed that average brushing force of the manual

toothbrush (1.6±0.3 N) was higher than for the sonic toothbrushes (0.9±0.2 N) which

were not significantly different. Dentin abrasion is higher for manual than for power

toothbrushes. The lower abrasivity of the sonic toothbrushes is most likely due to the

lower brushing force.15

G Tellefsen et al (2011) conducted an invitro study to evaluate the relative

abrasion of ten different commercially available toothbrushes to find out the role of the

toothbrush in the abrasion process. Brushing was carried on acrylic plates using a

brushing machine with ten different toothbrushes with water alone and with a toothpaste.

The results were evaluated using a profilometer after one and 6 h of brushing. A surface

roughness value and volume loss were calculated. The results showed that brushing with

water alone caused less abrasion than when a toothpaste was added. Six-hour brushing

with water caused less abrasion than one hour with a toothpaste. When brushing with

water, the harder toothbrush caused more abrasion, but when adding the toothpaste, the

11
 Review of Literature

softer toothbrush caused more abrasion. They concluded that a softer toothbrush can

cause more abrasion than harder ones with toothpaste.16

Ajay Bhambal et al (2011) conducted a single blind, randomized cross-over

study to compare the effect of neem stick and toothbrush on plaque removal and gingival

health. Thirty participants were selected for the study. Quigley- Hein plaque and Loe

Silness gingival index were taken at baseline and after 3 weeks use of either neem stick

or toothbrush. Oral prophylaxis was done one week before the start of the study and it

was repeated after 3 weeks. All participants were instructed to use either neem stick or

the toothbrush in a cross-over manner for a period of 3 weeks and after that participants

were instructed to continue their regular oral hygiene practice for the following week.

Paired t- tests, Unpaired t test and ANOVA was used for statistical analysis. They

concluded that neem stick is equally effective as toothbrush in reducing plaque and

gingival inflammation.7

Alessandra Miranda de Azevedo et al (2008) conducted an invitro study to

assess the influence of brushing on non-carious cervical lesions formation. Fifteen human

premolars were brushed in the cementoenamel junction region, using hard, medium and

soft-bristled toothbrushes with a toothpaste of medium abrasiveness under a 200 g load,

at a speed of 356 rpm for 100 minutes. The surface structure of the region was analysed

before and after brushing, by using laser interferometer. Based on the results, they

concluded that soft, medium and hard brushes are not capable of abrading enamel,

whereas in dentin medium and hard bristled toothbrushes caused increased surface

roughness.17

12
 Materials and Methods

MATERIALS AND METHODS

Study Design

It is an invitro study conducted to compare the tooth abrasion caused by tooth

brushes, natural chewing sticks and commercially available chewing sticks.

Study Setting

The study was conducted at Department of Public Health Dentistry, Tamil Nadu

Government Dental College and Hospital, Chennai.

Study Sample

Extracted Human Teeth

Inclusion criteria

1. Extracted permanent teeth with intact facial surface.

Exclusion criteria

1. Tooth with Dental caries

2. Tooth with non-carious cervical lesions

3. Tooth with any restorations

4. Fractured tooth

5.Teeth with developmental abnormalities

13
 Materials and Methods

Sample size

Sample size was calculated using G power software.

F tests - ANOVA: Fixed effects, omnibus, one-way

Analysis: A priori: Compute required sample size

Input:

Effect size f = 0.4931797

α err prob = 0.05

Power (1-β err prob) = 0.80

Number of subgroups = 8

Output:

Noncentrality parameter λ = 17.5122876

Critical F = 2.1564240

Numerator df = 7

Denominator df = 64

Total sample size = 72

Actual power = 0.8414842

Thus, the final sample for the study was decided to be a minimum of 72 samples,

each subgroup having a minimum of 9 samples. However, the samples were

approximated to 10 per subgroup, a total of 80 samples.

Sampling procedure:

Simple random sampling

14
 Materials and Methods

Study Groups

Naturally Available Tooth Commercially Available Tooth Brush

Sticks (Group A) Tooth Sticks (Group B) (Group C)

1. Neem 3. Neem 5. Hard

2. Banyan 4. Miswak 6. Medium

7. Soft

8.Ultrasoft

Data Collection

Armamentarium:

The following armamentarium were used during the study.

1. Instruments for tooth sectioning (Diamond Disc)

2. Acrylic resin for embedding tooth

3. Toothbrushes

4. Various chewing sticks

5. Distilled water

6. Customized brushing model

7. Non – Contact Surface Profiler

Methodology for the study:

Ethical Clearance

Ethical approval for the study was obtained from Institutional Review Board of

Tamil Nadu Government Dental College and Hospital, Chennai (IRB Reference

No:7/IRB/2017).

15
 Materials and Methods

Preparation of tooth specimens

Each extracted tooth was rinsed in saline to remove all loose debris. Ultrasonic

scaling was performed with ultrasonic scaler unit (Woodpecker Ultrasonic Scaler) to

remove any remaining flecks of calculus. Teeth were then preserved in 10% formalin

until further experimental procedure.

Teeth were sectioned and then mounted on acrylic bases with buccal/labial

surface facing upward. A total of eighty mounted samples were prepared.

Construction of customized brushing model

In order to deliver uniform force and unidirectional movement a brushing model

was constructed under expert guidance. This customized brushing model was electrically

operated. This apparatus was designed to facilitate easy replacement of toothbrushes and

sticks. The brushing model was customized to perform the following functions:

1. To clamp and hold the tooth samples

2. To exert a constant force throughout the procedure

3. To hold the toothbrush and chewing sticks and give strokes unidirectionally.

Parts of the customized brushing model

1. Motor - A motor converts energy into torque which then moves or controls a

mechanism or a system into which it has been incorporated. It can introduce motion

as well as prevent it.

2. Arduino - Arduino is one of the microcontrollers. It generates pulse to activate the

working process

16
 Materials and Methods

3. Transformer - A transformer is a static device which transfers electrical energy from

one circuit to another through the process of electromagnetic induction. Stepdown

transformer was used.

The toothbrushes from same manufacturer was used to eliminate bias. The

chewing sticks were tampered at one end until it become frayed into a brush before using

them. Chewing sticks were renewed every day.

Brushing duration and frequency

The constant force of 200grams was maintained throughout the procedure.

Brushing was carried out on each mounted specimen for the duration of 2 minutes (100

strokes /min), twice a day, for 1 month. Water was used as a control medium while

brushing with toothbrushes and chewing sticks.

Test Procedure

All eighty mounted tooth samples were numbered from 1–80 using permanent

marker pen. Premeasurement of surface roughness of each samples was measured using

profilometer. The teeth samples were randomly assigned to one of the three groups

(Group A, B, C) with 1:1:2 allocation ratio using table of random numbers. These groups

were further divided into eight subgroups (Subgroup1,2,3,4,5, 6,7,8). Ten mounted tooth

samples were assigned to each subgroup.

All samples of Subgroup 1 were brushed using natural neem sticks; teeth samples

in Subgroup 2 were brushed using natural banyan sticks, teeth samples in Subgroup 3

were brushed using commercially available neem sticks, samples in Subgroup 4 were

brushed using commercially available miswak sticks, samples in Subgroup 5 were

17
 Materials and Methods

brushed using hard tooth brush, samples in Subgroup 6 were brushed using medium tooth

brush, samples in Subgroup 7 were brushed with soft tooth brush, and samples in

Subgroup 8 were brushed with ultra-soft toothbrush. While brushing with tooth brush the

tooth sample holder was placed in horizontal direction and while using chewing sticks it

was placed in vertical direction. After brushing procedure, post surface roughness was

measured.

Profilometry

Surface profilometry quantifies the loss of dental tissue in relation to a non-treated

reference area. It also provides information on surface roughness. In profilometry, the

surface of a sample is scanned to produce a two-dimensional or three-dimensional profile,

using either a contact or a non-contact measuring device. In contact profilometry, the

surface is scanned using a stylus with a diamond or steel tip. Noncontact profilometry

uses a laser light probe with its calibration based on the optical triangulation principle

and the vertical array varies from 300μm to 10mm. 18

The mean surface roughness of the tooth samples before and after brushing was

measured using a non-contact profilometer (Bruker, Contour Gt). It provides Ra value

(average surface roughness). Difference between Ra value before and after tooth brushing

indicates the surface loss and it represents the tooth abrasion.

Outcomes:

The primary outcome of this invitro study was the change in surface roughness

caused by toothbrushes with various bristle diameter, natural and commercially available

chewing sticks while brushing using customized brushing model.

18
 Materials and Methods

Statistical Analysis:

The results were analysed statistically using Statistical Package for the Social

Sciences (SPSS) software (version 20.0; SPSS Inc., Chicago, IL, USA). Shapiro Wilks

test used to check the normality. Wilcoxon signed rank test was done to compare the

surface roughness values before and after brushing. Kruskal Wallis test and Scheffe post

hoc test, Tukey post hoc test were used to compare the changes in surface roughness

between groups and subgroups. The level of significant was set at p value <0.05.

Bias:

Extracted tooth samples were randomly selected and same brand tooth brushes

were used to minimize the selection bias.

19
 Materials and Methods

Photograph 1. Prepared tooth sample

20
 Materials and Methods

Photograph 2. Tooth brushes

Hard Medium Soft Ultrasoft

Toothbrush Toothbrush Toothbrush Toothbrush

21
 Materials and Methods

Photograph 3. Natural Chewing sticks

Neem Banyan

Photograph 4. Commercial Chewing sticks

Neem Miswak

22
 Materials and Methods

Photograph 5. Customized brushing model with toothbrush

Photograph 6. Customized brushing model with chewing stick

23
 Materials and Methods

Photograph 7. Surface Profilometer with mounted tooth sample

24
 Materials and Methods

Diagram 1. Flowchart

Assessed for eligibility

(n=100)

Excluded (n=20)

Randomization
(n=80)

Pre-measurement of Ra
Allocation ration 1:1:2

Group A Group B Group C

Natural Chewing sticks Commercial Chewing Commercial tooth

(n=20) sticks (n=20) brushes (n=40)

Subgroups (n=10 in each)

Subgroups (n=10 in each) Subgroups (n=10 in each) 5.Hard
1. Natural Neem 3. Commercial Neem 6. Medium
2. Natural Banyan 4. Commercial Miswak 7. Soft
8. Ultrasoft

Samples brushed using customized brushing

model for two minutes, twice daily, for one month.

Post measurement of Ra and analyzed

25
 Results

RESULTS

Table 1. showed the description of groups and subgroups.

Table 2. demonstrates the results of Shapiro Wilks test. It reveals that the data

was in non-normal distribution. We decided to perform the non-parametric test.

Table 3. shows the results of Wilcoxon signed rank test which was performed to

compare the surface roughness before and after brushing. It revealed that there was

statistically significant difference between before and after brushing using chewing sticks

and toothbrushes (p ═ 0.005). The surface roughness was increased after brushing with

toothbrush and chewing sticks. It indicates that there was surface loss after brushing in

all subgroups. This surface loss represents the surface abrasion.

Table 4. demonstrates the Kruskal Wallis test results for comparison between

subgroups. It reveals statistically significant difference in surface abrasion caused by

subgroups (p=0.000). The mean difference in surface roughness by hard toothbrush

(641.20±176.72) was higher than other subgroups. The natural banyan sticks

(193.54±81.22) caused lesser abrasion. It was lesser than surface roughness caused by

Ultrasoft toothbrush (193.56±115.50). The mean difference in surface roughness for

other subgroups: Natural Neem (403.62±171.50), Commercial Neem (460.22±130.46),

Commercial Miswak (479.89±196.87), Medium Toothbrush (275.05±230.24), Soft

Toothbrush (234.80±113.91).

26
 Results

Table 5. showed the results of Kruskal Wallis test which was done to compare

the surface abrasion between groups. It demonstrates that there was statistically

significant difference in surface abrasion caused by groups (p=0.005). The mean

difference in Group B (470.06±162.86) was higher than mean difference of Group A

(298.58±169.32) and Group C (336.15±241.20).

Table 6. demonstrates the results of Scheffe post hoc test. It was done to compare

the difference in surface abrasion caused by Group A, Group B, Group C. It revealed that

there was statistically significant difference between Group A and Group B (p=0.038).

Although there was difference in mean surface loss of Group A, Group B when compare

to Group C, it was statistically insignificant.

Table 7, 8, 9 showed the results of Tukey’s post hoc test. It was done to compare

the surface abrasion caused by subgroups. It was showed that there was statistically

significant difference in surface abrasion caused by natural neem stick verses hard brush

(Table 7). Surface abrasion caused by natural banyan sticks shows statistically significant

with commercial chewing sticks and hard toothbrush (Table 7).

Surface abrasion caused by commercial chewing sticks (neem and miswak)

showed statistically significant difference with natural banyan sticks, soft toothbrush and

Ultrasoft toothbrush (Table 8).

While comparing the surface abrasion caused by hard toothbrush with other

subgroups, it was observed that there was statistically significant difference in surface

abrasion caused by hard toothbrush verses natural neem sticks, natural banyan, medium

toothbrush, soft tooth brush and Ultrasoft toothbrush (Table 9).

27
 Results

Figure.1 showed the comparison of change in surface roughness produced by

natural chewing sticks. It reveals natural banyan cause less abrasion than natural neem

sticks.

Figure.2 showed the comparison of change in surface roughness produced by

commercial chewing sticks. It shows that commercial miswak cause more abrasion than

commercial neem sticks.

Figure.3 showed the comparison of surface abrasion caused by tooth brushes. It

shows that hard toothbrush causes more abrasion and Ultrasoft toothbrush causes less

abrasion.

Figure.4 showed the change in surface roughness produced by subgroups in

ascending order.

28
 Results

Table 1. Description of Groups and Subgroups

Groups Subgroups Material Used No. of Samples

Subgroups 1 Natural Neem sticks 10

Group A
Subgroups 2 Natural Banyan sticks 10

Subgroups 3 Commercial Neem Sticks 10

Group B
Subgroups 4 Commercial Banyan Sticks 10

Subgroups 5 Hard Toothbrush 10

Subgroups 6 Medium Toothbrush 10

Group C
Subgroups 7 Soft Toothbrush 10

Subgroups 8 Ultra Soft brush 10

29
 Results

Table 2. Normality test using Shapiro Wilk Test

Variable Statistic Sig.

Pre 0.694 0.000

Post 0.908 0.000

Post minus Pre 0.942 0.001

30
 Results

Table 3. Intragroup comparison of surface roughness (Ra) before and after

brushing using Wilcoxon signed rank test

Group Sub group Mean Ra (nm) Std. Deviation P Value

Pre 161.74 59.69
Group A Natural Neem 0.005
Post 565.36 152.07
Pre 274.04 232.12
Natural Banyan 0.005
Post 467.59 243.81
Pre 312.77 231.90
Group B Commercial Neem 0.005
Post 773.08 204.99
Pre 357.76 413.83
Commercial Miswak 0.005
Post 837.66 444.84
Pre 355.81 355.39
Hard Toothbrush 0.005
Post 997.02 342.54
Group C
Pre 206.02 96.31
Medium Toothbrush 0.005
Post 481.08 260.41
Pre 424.27 308.50
Soft Toothbrush 0.005
Post 659.07 285.04
Pre 320.76 169.89
Ultrasoft Toothbrush 0.005
Post 514.32 245.91

31
 Results

Table 4. Intergroup comparison of change in surface roughness between

Subgroups using Kruskal Wallis test

Subgroup Mean Difference (nm) Std. Deviation P value

Natural Neem 403.62 171.50

Natural Banyan 193.54 81.22

Commercial Neem 460.22 130.46

Commercial
479.89 196.87
Miswak
0.000
Hard Toothbrush 641.20 176.72

Medium Toothbrush 275.05 230.24

Soft Toothbrush 234.80 113.91

Ultrasoft
193.56 115.50
Toothbrush

32
 Results

Table 5. Intergroup comparison of change in surface roughness between Groups

using Kruskal Wallis test

Group Mean difference (nm) Std. Deviation P Value

Group A 298.58 169.32

Group B 470.06 162.86 0.005

Group C 336.15 241.20

33
 Results

Table 6. Multiple pairwise comparison of groups using Scheffe test

Group Comparison Group Mean Difference (nm) P value

Group B -171.47* 0.038

Group A
Group C -37.57 0.804

Group A 171.47* 0.038

Group B
Group C 133.90 0.069

Group A 37.57 0.804

Group C
Group B -133.90 0.069

*. The mean difference is significant at the 0.05 level.

Negative (-) values shows the less abrasion.

34
 Results

Table 7. Comparison of change in surface roughness caused by

Natural chewing sticks (Group A) with other subgroups using Tukey HSD test

Comparison
Subgroup Mean Difference (nm) P value
Subgroup
Natural Banyan 210.07 0.077
Commercial Neem -56.60 0.993
Commercial Miswak -76.27 0.961
Natural Neem Hard Toothbrush -237.58* 0.028
Medium Toothbrush 128.57 0.617
Soft Toothbrush 168.82 0.270
Ultrasoft Toothbrush 210.06 0.077
Natural Neem -210.07 0.077
Commercial Neem -266.68* 0.008
Commercial Miswak -286.35* 0.003
Natural
Hard Toothbrush -447.65* 0.000
Banyan
Medium Toothbrush -81.50 0.944
Soft Toothbrush -41.25 0.999
Ultrasoft Toothbrush -0.01 1.000

*. The mean difference is significant at the 0.05 level.

Negative (-) values shows the less abrasion.

35
 Results

Table 8. Comparison of change in surface roughness caused by

Commercial chewing sticks (Group B) with other subgroups using Tukey HSD test

Comparison
Subgroup Mean Difference (nm) P value
Subgroup
Natural Neem 56.60 0.993
Natural Banyan 266.68* 0.008
Commercial Miswak -19.67 1.000
Commercial
Hard Toothbrush -180.97 0.194
Neem
Medium Toothbrush 185.17 0.172
Soft Toothbrush 225.42* 0.044
Ultrasoft Toothbrush 266.66* 0.008
Natural Neem 76.27 0.961
Natural Banyan 286.35* 0.003
Commercial Neem 19.67 1.000
Commercial
Hard Toothbrush -161.30 0.325
Miswak
Medium Toothbrush 204.84 0.092
Soft Toothbrush 245.09* 0.020
Ultrasoft Toothbrush 286.33* 0.003

*. The mean difference is significant at the 0.05 level.

Negative (-) values shows the less abrasion.

36
 Results

Table 9. Comparison of change in surface roughness caused by

Toothbrushes (Group C) with other subgroups using Tukey HSD test

Comparison
Subgroup Mean Difference (nm) P value
Subgroup
Natural Neem 237.58* 0.028
Natural Banyan 447.65* 0.000
Commercial Neem 180.97 0.194
Hard
Commercial Miswak 161.30 0.325
Toothbrush
Medium Toothbrush 366.15* 0.000
Soft Toothbrush 406.40* 0.000
Ultrasoft Toothbrush 447.64* 0.000
Natural Neem -128.57 0.617
Natural Banyan 81.50 0.944
Commercial Neem -185.17 0.172
Medium
Commercial Miswak -204.84 0.092
Toothbrush
Hard Toothbrush -366.15* 0.000
Soft Toothbrush 40.25 0.999
Ultrasoft Toothbrush 81.48 0.944
Natural Neem -168.82 0.270
Natural Banyan 41.25 0.999
Commercial Neem -225.42* 0.044
Soft
Commercial Miswak -245.09* 0.020
Toothbrush
Hard Toothbrush -406.40* 0.000
Medium Toothbrush -40.25 0.999
Ultrasoft Toothbrush 41.23 0.999
Natural Neem -210.06 0.077
Natural Banyan 0.01 1.000
Commercial Neem -266.66* 0.008
Ultrasoft
Commercial Miswak -286.33* 0.003
Toothbrush
Hard Toothbrush -447.64* 0.000
Medium Toothbrush -81.48 0.944
Soft Toothbrush -41.23 0.999
*. The mean difference is significant at the 0.05 level.

Negative (-) values shows the less abrasion.

37
 Results

Figure 1. Comparison of surface abrasion caused by natural chewing sticks

Comparison of change in surface roughness in natural chewing

sticks
500
Mean surface Roughness (nm)

400

300

200

100

0
Natural Banyan Natural Neem

38
 Results

Figure 2. Comparison of surface abrasion caused by commercial chewing sticks

Comparison of change in surface roughness in Commercial

chewing sticks
500
Mean surface Roughness (nm)

400

300

200

100

0
Commercial Neem Commercial Miswak

39
 Results

Figure 3. Comparison of surface abrasion caused by various toothbrushes

Comparison of change in surface roughness in Toothbrushes

700

600
Mean surface Roughness (nm)

500

400

300

200

100

0
Hard Medium Soft Ultrasoft

40
 Results

Figure 4. Comparison of surface abrasion caused by subgroups

Comparison of change in surface roughness in subgroups

700

600
Mean change in surface roughness (nm)

500

400

300

200

100

0
Natural Ultrasoft Soft Medium Natural Commercial Commercial Hard
Banyan Toothbrush Toothbrush Toothbrush Neem Neem Miswak Toothbrush

41
 Discussion

DISCUSSION

Dental plaque is an important etiological factor for the initiation of dental caries,

periodontal disease. The effective removal of plaque can significantly reduce oral

diseases. Various Oral hygiene methods are being used for plaque control.2

Chewing sticks are the commonly used indigenous Oral hygiene aid across the

globe. India has an ancient history of using traditional Oral hygiene methods. History

suggests that Babylonians used chewing sticks 7000 years ago. 19

Datun is a term used for any branch or twig that is used for oral hygiene. It is a

most hygienic toothbrush as it is used only once and thrown away. The chewing sticks

are chewed or tapered in one end until it become frayed into a brush. 20 Conventionally

used chewing sticks are obtained from babul, guava, neem, mango, and miswak trees.

These sticks are thought to be effective in increasing the salivation and helps in the

removal of oral microorganisms.19 The chewing sticks contain natural ingredients, which

are beneficial for Oral health. It has been shown that it contains ascorbic acid, tri-

methylamine, chloride, fluoride, silica, resins. These ingredients have potency to heal the

inflamed gums, stimulatory effect on gingiva, remove tartar, re-mineralize dental hard

tissue, whitens teeth, provide enamel barrier, and increase salivary flow. Chewing sticks

also contains volatile oils, tannic acid, sulphur and sterols which contribute to anti-septic,

astringent and bactericidal properties. It helps in reducing plaque formation, provides

anti-carious effects, eliminates bad odour, improves taste sensation.9

42
 Discussion

According to the Dental Council of India survey of 2003, approximately 3.7%

urban and 18.8% rural respondents used datun (chewing stick) for cleaning their teeth.2

Use of chewing sticks is common in the rural areas and among tribal communities in

India.19 The World Health Organization (WHO) has recommended and encouraged the

use of chewing sticks as an effective tool for Oral hygiene, since it is available locally in

most rural areas.20

In modern civilization, use of toothbrush and toothpaste is considered an effective

method of plaque removal. The use of toothbrush and tooth paste helps in plaque removal

and improving oral health. However, injudicious use of toothpaste and toothbrush may

cause injuries to dental hard and soft tissues which has been documented in the previous

literature. The most common hard tissue injury is tooth abrasion.14

The most common reason attributed for dental abrasion is usage of dentifrice. The

tooth surface loss appears to correlate with RDA value (Relative Dentin Abrasivity) of

toothpaste. In addition to RDA value of toothpaste, the type of brush, brushing force,

filament diameter of toothbrush is known to be relevant factors for the loss of tooth

surface.11

Recently, various authors have concluded that chewing sticks or its extract has

therapeutic effect on Oral diseases. Various studies showed that chewing sticks has

equivalent and at times greater mechanical and chemical cleansing of Oral tissues as

compared to a toothbrush.9,21 As a result, this natural product have become popular in

Oral healthcare in the last decades in many countries.22

43
 Discussion

Various types of commercial toothbrushes and commercial chewing sticks are

available in the market, which makes it difficult for the consumer to choose the Oral

hygiene aid, due to lack of information about its quality. There is limited evidence

comparing the abrasion caused by the tooth brushes and chewing sticks. So, this invitro

study was conducted to assess and compare the role of different types of commercial

toothbrushes, natural chewing sticks and commercial chewing sticks in causing abrasion.

The present study worked with the hypothesis that there is significant difference

in tooth abrasion caused by using natural chewing sticks, commercial chewing sticks and

commercial toothbrushes for brushing.

As we already know that brushing method23 and brushing force influences the

abrasion.11 The dissimilar designs of chewing sticks and toothbrush suggest that each

may be used with varying force, method under in vivo conditions. Therefore, an in vitro

design was chosen in order to eliminate the individual variations in toothbrush and

chewing sticks use. Previous studies recommended the higher level of standardisation in

research for better comparison of outcomes.24 In the present study, both chewing sticks

and toothbrushes are fixed to holder of customised brushing machines which ensure a

unidirectional brushing movement as well as a constant brushing force while brushing.

In the present study, brushing force of 200 g was used which is close to the brushing force

used by most people and used in previous studies.15,12,14 The toothbrushing was carried

out for one month, twice a day for 2 minutes (100 strokes/min).

44
 Discussion

A variety of local trees and shrubs have been used for the preparation of chewing

sticks in different parts of the world in various local names. Neem (Azadirachtha Indica),

Banyan (Ficus Religiosa) is widely used chewing sticks in the Indian subcontinent.25 The

aerial roots of the banyan were commonly used for brushing. Neem and Banyan twigs

are commonly used in the rural areas of Tamil Nadu. so, in present study we have chosen

neem sticks and banyan sticks in Group A.

Miswak (Salvadora Persica) grows in the region extending from north western

India to Africa.25 The twigs, roots and stems of miswak tree have been used for oral

hygiene practice by Muslims in the Middle East, Asian and various African countries.26

During each namaz, as part of the ritual, Muslims use miswak stick for gum massaging.21

Nowadays, neem sticks and miswak sticks in various brand names are available in the

market. In this study neem sticks and miswak sticks were selected for Group B.

Manual toothbrushes vary in size, shape, texture, and design more than any other

category of dental products. The diameter of the bristle is the critical determinant of

texture or stiffness.27 The commonly used brushes have bristles diameters ranges from

0.0071 inches (0.2 mm) for soft brushes to 0.012 inches (0.3 mm) for medium brushes

and 0.014 inches (0.4 mm) for hard brushes.28 There is controversial thoughts about

abrasion caused by hard and soft bristles and nowadays Ultrasoft/ Extra soft toothbrushes

are also available in the market. In the present study, hard, medium, Soft, Ultrasoft

toothbrush produced by the same brand was selected in Group C. Same brand

toothbrushes were used to reduce the selection bias.

45
 Discussion

The recommended brushing time was two minutes, twice daily for effective

plaque removal.29 In the present study the samples were brushed twice daily for two

minute using water as a control medium. In routine practices, dentifrice will not be used

with chewing sticks while brushing. So, water was selected as a control medium in

present study.

Evaluating tooth wear depends on the correct selection of a method to measure

the micromorphological alteration of the tooth structure. The determination of

micromorphological alteration in tooth surface caused by tooth abrasion can be assessed

using different methods, such as analyses of dental structure by surface hardness, atomic

force microscopy, microradiography, scanning electron microscopy, surface

profilometry, and other techniques.1

Profilometry was used to study enamel surface roughness in many previous

studies and recommended as a good measure to study the dental hard tissue loss. A

profilometer is considered as a good tool to quantitatively evaluate surface roughness.12

In contact profilometry the stylus penetrates the tooth surface. This can cause damage to

the surface and lead to overestimation of surface loss. Non-contact profilometry can

overcome these drawbacks as it does not involve direct contact of a stylus with the surface

being examined.1 So, in the present study the noncontact optical profilometer was used

to measure the changes in surface roughness quantitatively.

In the present study, normality test result revealed that the collected data was not

normally distributed. Nonparametric tests – Wilcoxon signed rank test, Kruskal Wallis

46
 Discussion

test was used for analysis. Post hoc Scheffe test was performed for multiple pairwise

comparison in between groups, because the sample size was unequal in Group A, Group

B, Group C.

In the present study we observed, the mean surface loss in Group B (commercial

chewing sticks) was higher than Group A (natural chewing sticks) and it was statically

significant (p=0.038) (Table.6). It indicates that the commercial chewing sticks cause

more tooth abrasion when compared to natural chewing sticks. The biological plausibility

for increased surface roughness caused by commercial chewing sticks could be dry and

stiff nature of these sticks when compared to fresh chewing sticks. In literatures, it was

stated that freshly cut sticks are always desirable because they are more easily chewed

into a brush.25

Comparison of mean changes of within groups reveals that in Group A natural

neem sticks caused more tooth abrasion than natural banyan sticks (Figure1). In Group

B, commercial miswak sticks produced more abrasion than commercial neem sticks

(Figure 2). It was observed that in Group C, hard toothbrush produced more abrasion than

medium, soft, Ultrasoft toothbrushes (Figure 3). Similar finding was reported by Kumar

S., et al14, Tellefsen G et al.16

We observed that there was no statistically significant difference in tooth abrasion

caused by Group A, Group B when compared to Group C. It may be explained by the

presence of various types of toothbrushes in Group C.

47
 Discussion

But, the pairwise comparison of subgroups revealed that mean of surface loss

caused by hard toothbrush was higher than other subgroups. This was statistically

significant with other subgroups except commercial neem and commercial miswak sticks.

In the present study, we observed that hard toothbrush produced more tooth abrasion

followed by commercial chewing sticks, natural neem sticks, toothbrush, medium, soft,

Ultrasoft toothbrushes, and natural banyan sticks. Natural banyan sticks caused lesser

abrasion (Figure 4).

The results of this study confirmed the invitro studies in which hard toothbrush

caused more surface abrasion than medium, soft toothbrush when using water as a

medium. Since, this study is the first invitro study to compare the tooth abrasion caused

by toothbrushes, natural chewing sticks and commercial chewing sticks, we are unable

to compare the results with previous studies. However, statistically significant difference

in tooth abrasion caused by commercial chewing sticks and natural chewing sticks

indicates that the commercial chewing sticks cause more abrasion than natural chewing

sticks. Statistically significant difference in between hard toothbrush and other subgroups

indicates that hard toothbrush produce more abrasion than natural chewing sticks,

medium toothbrush, soft tooth brush, ultra soft toothbrush.

48
 Discussion

Strength of the study:

The study had the following strengths;

(i) Tooth samples were randomly selected.

(ii) Mounted human enamel specimens were used to assess the abrasion instead of bovine

enamel, acrylic plates which was used in various previous studies.

(iii) Randomization was done using random table method for group allocation,

(iv) The change in surface roughness was assessed quantitatively by using noncontact

profilometer.

(v) In the present study the brushing technique, brushing force, duration and frequency

of brushing were kept constant and use of a customized brushing machine helped to

deliver uniform force, and unidirectional brushing movement.

Limitations:

The present in vitro study had certain limitations over in vivo studies. One such

limitation was methodological simulation was not attained. In real situation, there was of

continuous washing action of the saliva and its remineralising protective effects over the

worn surfaces of teeth will be present inside the mouth. Few previous invitro studies

assessed the role of saliva in abrasion and concluded that the abrasion was significantly

lowered if saliva was used as a medium. In the present study, the role of saliva and its

protective effect was not taken into consideration.

The other limitations are using the toothbrushes and commercial sticks from only

one brand, but it was needed to standardize the experiment. In present study the role of

dentifrices in abrasion process was not taken into consideration.

49
 Discussion

Previous studies which assessed the toothbrush abrasion has revealed that soft

toothbrush produces more surface abrasion when dentifrice used as a medium.

This study was performed for short duration, hence the role of chewing sticks in

abrasion in long term use cannot be documented.

Various types of plants and shrubs are being used as chewing sticks around

different parts of the world. In the present study, chewing sticks form few plants which

are locally available only used other plants are not considered.

50
 Summary and Conclusion

SUMMARY AND CONCLUSION

Various Oral hygiene measures are being practised by different populations and

cultures around the world to maintain good oral health. Most common method of Oral

hygiene measure is using toothbrush with toothpaste. However, their improper use may

cause injuries to dental hard and soft tissues. The common hard tissue injury is tooth

abrasion. The use of chewing sticks is practised in many rural areas. World Health

Organisation (WHO) also recommended and encouraged the use of chewing sticks as an

effective tool for oral hygiene in rural areas. Various authors concluded that chewing

sticks or its extract has therapeutic effect on Oral diseases and has equal cleansing action

as compared to a toothbrush. Nowadays, many types of commercial toothbrushes and

chewing sticks are available in the market which makes it difficult for the consumer to

choose the correct Oral hygiene aid. There is limited evidence comparing the abrasion

caused by the tooth brushes and chewing sticks. So, this invitro study was conducted to

assess and compare the role of different types of commercial toothbrushes, natural

chewing sticks and commercial chewing sticks in causing abrasion.

The results of the present study showed that hard toothbrush caused the most

abrasion followed by commercial chewing sticks (Neem, Miswak), natural neem sticks,

other commonly used toothbrushes (Medium, soft, Ultrasoft) and natural banyan sticks

caused the least abrasion.

51
 Summary and Conclusion

RECOMMENDATION

It is ideal to use the toothbrush and toothpaste for Oral hygiene practice. However,

in rural areas, where various factors may prevent the use of toothbrush and toothpaste,

the natural banyan sticks provide the best alternative with least abrasion.

52
 References

REFERENCES

1. Passos VF, Santiago SL. Methodologies to analyze the micromorphological

alterations of enamel subjected to abrasion/erosion. Dentistry. 2014 Jan 1;4(9):1.

http://dx.doi.org/10.4172/2161-1122.1000255

2. Shah N, Mathur VP, Jain V, Logani A. Association between traditional oral hygiene

methods with tooth wear, gingival bleeding, and recession: A descriptive cross-sectional

study. Indian J Dent Res 2018; 29:150-154.

3. Grippo JO, Simring M, Schreiner S. Attrition, abrasion, corrosion and abfraction

revisited: a new perspective on tooth surface lesions. The Journal of the American Dental

Association. 2004 Aug 1;135(8):1109-18.

4. Joshi CP, Patil AG, Karde PA, Mahale SA, Dani NH. Comparative evaluation of

cemental abrasion caused by soft and medium bristle hardness toothbrushes at three

predetermined toothbrushing forces: An in vitro study. Journal of Indian Society of

Periodontology. 2017 Jan;21(1):10-15.

5. Abrasion - Available at https://en.wikipedia.org/wiki/Abrasion_(dental) retrieved on

23/11/2019.

6. Haque MM, Alsareii SA. A review of the therapeutic effects of using miswak

(Salvadora Persica) on oral health. Saudi medical journal. 2015 May;36(5):530-543.

7. Bhambal A, Kothari S, Saxena S, Jain M. Comparative effect of neemstick and

toothbrush on plaque removal and gingival health—A clinical trial. Journal of Advanced

oral research. 2011 Oct;3(3):51-56.

8. Chandana K, Anjan SK, Kasturi S. Antibacterial property of few plants used as

chewing stick. IJHRMLP,2017;3 (1);9-11.

53
 References

9. Malik AS, Shaukat MS, Qureshi AA, Abdur R. Comparative effectiveness of

chewing stick and toothbrush: A randomized clinical trial. North American journal of

medical sciences. 2014 Jul;6(7):333-337.

10. Teeth cleaning twig – Wikipedia. Available at

https://en.wikipedia.org/wiki/Teeth_cleaning_twig retrieved on 22/11/2019.

11. Bizhang M, Riemer K, Arnold WH, Domin J, Zimmer S. Influence of bristle

stiffness of manual toothbrushes on eroded and sound human dentin–an in vitro study.

PloS one. 2016;11(4): e0153250. DOI: 10.1371/journal.pone.0153250.

12. Alshehab AH, Alhazoom AA, Alowa MH, Alali HA, Abdulmohsen AA, Farooq

I. Effect of bristle stiffness of manual toothbrushes on normal and demineralized human

enamel—An in vitro profilometric study. International journal of dental hygiene. 2018

May;16(2): e128-32.

13. Bizhang M, Schmidt I, Chun YH, Arnold WH, Zimmer S. Toothbrush abrasivity

in a long-term simulation on human dentin depends on brushing mode and bristle

arrangement. PloS one. 2017;12(2): e0172060.

14. Kumar S., Singh SK., Gupta A., Roy S., Sareen M., Khajuria S. A Profilometric

Study to Assess the Role of Toothbrush and Toothpaste in Abrasion Process. J Dent

Shiraz Univ Med Sci., 2015 September; 16(3 Suppl): 267-273.

15. Wiegand A, Burkhard JP, Eggmann F, Attin T. Brushing force of manual and

sonic toothbrushes affects dental hard tissue abrasion. Clinical oral investigations. 2013

Apr 1;17(3):815-22.

16. Tellefsen G, Liljeborg A, Johannsen A, Johannsen G. The role of the toothbrush

in the abrasion process. International journal of dental hygiene. 2011 Nov;9(4):284-90.

54
 References

17. Azevedo AM, Panzeri H, Prado CJ, De-Mello JD, Soares CJ, Fernandes-Neto

AJ. Assessment in vitro of brushing on dental surface roughness alteration by laser

interferometry. Brazilian oral research. 2008 Mar;22(1):11-7.

18. Joshi M, Joshi N, Kathariya R, Angadi P, Raikar S. Techniques to evaluate dental

erosion: a systematic review of literature. Journal of clinical and diagnostic research:

JCDR. 2016 Oct;10(10):ZE01.

19. Pachava S, Chandu VC, Yaddanapalli SC, Dasari AB, Assaf HM. Comparing

caries experience between Azadirachta indica chewing stick users and toothbrush users

among 35-44-year-old rural population of Southern India. Journal of International

Society of Preventive & Community Dentistry. 2019 Jul;9(4):417-422.

20. Kumar S. Indigenous Oral Hygiene Aids. Sch J App Med Sci, March, 2019; 7 (3):

1267-1269. DOI: 10.21276/sjams.2019.7.3.81

21. Al-Otabi.M, Al-Harthy M, Soder B, Gustafsson A, Angmar-Mansson.

Comparative effect of chewing sticks and toothbrushing on plaque removal and gingival

health. Oral Health Prev Dent. 2003; 1(4); 301-307.

22. Al-Hammadi AA, Al-Rabai NA, Togoo RA, Zakirulla M, Alshahrani I,

Alshahrani A. Knowledge, attitude, and behavior related to use of miswak (Chewing

Stick): A cross-sectional study from Aseer region, Saudi Arabia. Contemporary clinical

dentistry. 2018 Jun;9(Suppl 1): S64.

23. Wiegand A, Begic M, Attin T. In vitro evaluation of abrasion of eroded enamel by

different manual, power and sonic toothbrushes. Caries research. 2006;40(1):60-65.

24. Wiegand A, Attin T. Design of erosion/abrasion studies–insights and rational

concepts. Caries research. 2011;45(Suppl. 1):53-959.

25. Hooda A, Rathee M, Singh J. Chewing sticks in the era of toothbrush: A review.

The Internet Journal of Family Practice. 2010;9(2):12-8.

55
 References

26. Wu CD, Darout IA, Skaug N. Chewing sticks: timeless natural toothbrushes for oral

cleansing. Journal of periodontal research. 2001 Oct;36(5):275-284.

27. Baruah K, Thumpala VK, Khetani P, Baruah Q, Tiwari RV, Dixit H. A Review

on Toothbrushes and Tooth Brushing Methods. International Journal of Pharmaceutical

Science Invention.2017; 6( 5); 29-38

28. Dahiya P, Kamal R, Luthra RP, Mishra R, Saini G. Miswak: A periodontist's

perspective. Journal of Ayurveda and integrative medicine. 2012 Oct;3(4):184.

29. Gallagher A, Sowinski J, Bowman J, Barrett K, Lowe S, Patel K, Bosma ML,

Creeth JE. The effect of brushing time and dentifrice on dental plaque removal in vivo.

American Dental Hygienists' Association. 2009 Jun 1;83(3):111-6.

56
 Annexures

ANNEXURE -I

Master table containing all the data

Group A

NO. Subgroup Pre Ra Post Ra Difference

1 1 191.91 594.21 402.3
2 1 103.18 593.2 490.02
3 1 194.67 437.48 242.81
4 1 231.21 586.23 355.02
5 1 121 641 520
6 1 171.78 769.15 597.37
7 1 134 381 247
8 1 83.71 403.25 319.54
9 1 268 430 162
10 1 117.96 818.16 700.2
11 2 121.39 371.4 250.01
12 2 176.63 395.47 218.84
13 2 157.16 432.09 274.93
14 2 258.29 547.29 289
15 2 152.45 246.19 93.74
16 2 212.68 394.11 181.43
17 2 524.2 813.5 289.3
18 2 843.18 963.32 120.14
19 2 124.52 212.64 88.12
20 2 169.92 299.89 129.97

Group B

21 3 279.99 693.03 413.04

22 3 404.8 964.9 560.1
23 3 210.99 771.02 560.03
24 3 870.32 1249 378.68
25 3 151.71 601.9 450.19
26 3 293.8 547.2 253.4
27 3 501.34 781.9 280.56
28 3 140.47 700.5 560.03
29 3 141.34 797.42 656.08
30 3 133.43 623.6 490.17
31 4 366.92 727.16 360.24
32 4 119.41 799.45 680.04
33 4 324.98 780 455.02
34 4 208.42 463.17 254.75
35 4 314.32 693.2 378.88
36 4 250.91 1151 900.09
37 4 183.09 443.84 260.75

57
 Annexures

38 4 1510 1970 460

39 4 189.14 758.35 569.21
40 4 110.48 590.48 480

Group C

41 5 216.75 776.82 560.07

42 5 162.59 942.54 779.95
43 5 1310 1728 418
44 5 246.3 1116.42 870.12
45 5 261.32 719.94 458.62
46 5 227.43 877.63 650.2
47 5 566.72 1356 789.28
48 5 242.04 1117.2 875.16
49 5 157.27 717.54 560.27
50 5 167.77 618.16 450.39
51 6 128.4 232.13 103.73
52 6 166.82 505 338.18
53 6 223.99 311.23 87.24
54 6 153.2 273.38 120.18
55 6 278.25 717.2 438.95
56 6 189.98 1010 820.02
57 6 137.41 246.77 109.36
58 6 132.49 272.6 140.11
59 6 204.49 584.82 380.33
60 6 445.22 657.67 212.45
61 7 299.42 486.98 187.56
62 7 882.33 1159 276.67
63 7 875.55 1090.79 215.24
64 7 86.22 383.08 296.86
65 7 228.76 558.9 330.14
66 7 358.51 480.33 121.82
67 7 156.67 606.7 450.03
68 7 111.51 371.63 260.12
69 7 514.18 564.41 50.23
70 7 729.56 888.94 159.38
71 8 385.59 493.06 107.47
72 8 615.83 1000 384.17
73 8 438.76 809.14 370.38
74 8 400.96 631.34 230.38
75 8 235.43 331.5 96.07
76 8 174.93 392.14 217.21
77 8 161.78 316.01 154.23
78 8 177.43 412.5 235.07
79 8 116.75 188.37 71.62
80 8 500.15 569.21 69.06

58