International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Review Article

Powered Tooth Brush - A Review

Dr Aparna K S1, Dr Manjunath P Puranik2, Dr Sowmya K R3

1Post Graduate Student, 2Professor and Head of the Department, 3Assistant Professor, Government Dental College and Research Institute, Bangalore, India

Corresponding Author: Dr Aparna K S

ABSTRACT

Regular mechanical removal of bacterial plaque is essential to prevent the onset of dental diseases such as dental caries, gingivitis and periodontal disease. Oral practices involve the thorough daily removal of dental plaque and debris using intra oral cleaning devices. Tooth brushes are the most commonly used aids. As technology advanced, powered came into being as an alternative to manual tooth brushing. The powered was developed to aid people with manual dexterity problems or other physical limitations. They are available in many styles and modes of action. The early models had a simple back and forth action and were ineffective in plaque control. With the advent of newer models which incorporated the rotation oscillation action (ROA) and optional features like timer, pressure sensor and blue tooth, the popularity of powered toothbrushes increased. Nowadays, the use of powered toothbrush is indicated not only for the differently abled people but also for the general population. The superiority of powered tooth brush over manual brush in terms of plaque control and improving periodontal health is a topic of constant debate. Hence, the aim of this comprehensive review is to present an update about the current status of powered tooth brush in terms of its application in oral health and to compare with a manual tooth brush.

Keywords- oral health, oral hygiene, powered tooth brush, review, tooth brushing.

INTRODUCTION As many manual devices evolve into Tooth cleaning has been an integral their electric counterparts, electric version part of oral hygiene routine across many of toothbrush has also been developed. The cultures around the world from the times of device is intended to remove adherent antiquity. Oral hygiene practices involve the plaque and food debris from teeth to reduce thorough daily removal of dental plaque and or prevent dental disease. The very first debris by the tooth brush without injuring powered toothbrushes were introduced in the soft tissue. Tooth brushes are the most the 1940s. It took decades until the widely used oral hygiene aids. It is the advantages of powered toothbrushes were principal instrument in general use for accepted by the dental profession and accomplishing the goal of plaque control. consumers to be of considerable (clinically [1,2] relevant) benefit. [3] Dental plaque is the primary causal factor in dental caries, gingivitis, and HISTORY OF TOOTHBRUSH periodontitis. Good oral hygiene by A variety of cultures across the effective tooth brushing has a key role in world have used many different materials oral health with the prevention of from certain tree twigs like “Neem” and periodontal disease and caries. [1] “Miswak” to bird feathers and hog hair for

International Journal of Health Sciences & Research (www.ijhsr.org) 299 Vol.8; Issue: 5; May 2018 Aparna K S et al. Powered Tooth Brush - A Review cleaning the teeth .Ancient people chewed  Shank-The section that connects head twigs from plants with high aromatic and handle. properties. Small twigs were eventually  Toe mashed at one end to increase their cleaning surface. Chewing these twigs freshened the FEATURES OF A TOOTHBRUSH [1] breath and spread out fibers at the tips of the  The stiffness of bristles vary based on twig for cleaning the tooth and gum diameter, length, number of filaments. surfaces. Chew sticks contain antibacterial  Diameter of bristles: For adults- soft oils and tannins that may help prevent or (0.007"), medium (0.012") and hard remove plaque. The Arabs before Islam (0.014") used a piece of the root of the Arrack tree  For Children -0.005" because its fibers stood out like bristles; this  Length of bristles :0.406" (adult), 0.344" device was called as siwak. In the seventh- (children) century, Prophet Mohammed made rules for  Number of filaments in a tuft : 80 - 86 oral hygiene, and so it became a religious per tuft obligation. To this day the siwak, composed ADA specification of a toothbrush [1] from aromatic types of wood, is still used. [1] Brushing surface: The Chinese are credited for  1-1.25 inches in length inventing the toothbrush comprising a handle with bristles during the Tang dynasty  2 to 4 rows of bristles  5/16 to 3/8 inches in width (618-907 A.D.). The bristle brush came to Europe during the 17th century and soon was  5-12 tufts/row widely used. French dentists advocated the use of toothbrushes in the 17th and early 18th POWERED TOOTHBRUSH centuries. At the same time, pre- A powered toothbrush is an AC- revolutionary American dentists were powered or battery-powered device that encouraging the use of bristle toothbrushes consists of a handle containing a motor that in America. Toothbrushes were first mass- provides mechanical movement to a brush produced by William Addis of Clerkenwald, head with filaments that move rapidly. The England. H.N.Wadsworth patented the first device is intended to remove adherent American toothbrush, and companies began plaque and food debris from teeth to reduce to mass produce toothbrushes in America or prevent dental disease. The powered around 1885.Natural bristles were obtained toothbrush was introduced to motivate patients to brush correctly in terms of proper from hair of Hog or Wild boar. These are [3] tubular in form and were more susceptible technique and duration. to fraying, breaking, contamination with [5] microbial debris, softening and loss of HISTORY elasticity. Nylon replaced the natural bristles 1886-Powered toothbrushes were first in modern brushes in 1938. These are advertised in Harper's Weekly. uniform in size and elasticity, resistant to 1939-The prototype of the first electric fracture. [1,4] toothbrush was developed in Switzerland by PARTS OF TOOTH BRUSH [1] Dr. Phillippe- Guy Woogin, but it wasn’t  Handle- The part grasped in the handle released until 1954. during tooth brushing. 1960- Squibb marketed the first American-  Head- The working end of a tooth brush made electric toothbrush called the that holds the bristles or filament. Broxodent. 1961-General Electric introduced a  Tufts- Clusters of bristles or filaments rechargeable cordless toothbrush secured into the head 1987-Interplak was the first rotary-action  Brushing plane-The surface formed by electric toothbrush for home use. This the free ends of the bristles or filament.

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"second generation" powered toothbrush strokes per minute) in the audible range. had a uniquely rotating head and was This vibrating motion creates turbulent fluid powered by long-life/ rechargeable dynamics that disrupts and removes dental batteries. Increased efficacy compared to plaque even beyond the point where the tips manual toothbrushes was consistently of the toothbrush's bristles actually touch. demonstrated in published studies. Most modern rechargeable electric 1992 - Sonic-powered toothbrushes were toothbrushes from brands such developed and were shown to remove more as Sonicare®, FOREO®, and Oral-B® fall plaque in comparison to manual into this category and typically have a toothbrushes, especially in long-term that range from 200 to 400 Hz, studies. that is 12,000-24,000 oscillations or 24,000- 48,000 movements per minute. Because GENERATIONS OF POWERED sonic toothbrushes rely on sweeping motion TOOTHBRUSH [1] alone to clean the teeth, the movement that they provide is often high in amplitude, meaning that the length of the sweeping movements that they make is large. [6] Ultrasonic-powered toothbrush It is the newest type of powered toothbrush which uses ultrasonic waves to clean the teeth. Ultrasonic toothbrushes emit vibrations that are very high in (minimum frequency of 20,000 Hz) but low in amplitude. These vibrations break up bacterial chains that make up dental plaque and remove their methods of attachment to First generation: The first generation of the tooth surface up to 5 mm below the gum power toothbrushes had a head resembling line. Some ultrasonic toothbrushes, such as manual toothbrushes, and moved back and the Emmi-Dent®, provide only ultrasonic forth to simulate manual brushing. The motion. Other ultrasonic toothbrushes, such problems encountered with these products as the Ultreo® and the Megasonex®, provide included short working time and mechanical [1] additional sonic vibration ranging from breakdown. 9,000 to 40,000 movements per minute, Second generation: The second generation comparable to a sonic toothbrush, in order had a uniquely rotating head and was to provide additional sweeping motion powered by long-life/rechargeable batteries. which facilitates removal of food particles It had increased efficacy compared to and bacterial chain remnants. [1,6] manual toothbrushes. The newer types Certain toothbrushes that offer both incorporated the vibrating and reciprocal ultrasonic and sonic motion allow for the motion and additional features like pressure [1] intensity of the sonic motion to be reduced, sensor and timer. or even for the sonic motion to be turned off Third generation: Sonic-powered entirely so that only ultrasound is emitted. toothbrushes and ultrasonic-powered Since ultrasound movements are very low in toothbrushes were introduced. They were amplitude, this setting may be indicated for shown to remove more plaque in patients who may not be suitable candidates comparison to manual toothbrushes, [1] for typical sonic or power toothbrush especially in long-term studies. vibration but need the additional cleaning Sonic-powered toothbrush power of an ultrasonic toothbrush, such as It has a conventionally shaped head patients who have recently undergone which vibrates in very high speed (>30.000 periodontal surgery. [2]

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When consumers first purchase the efficacy of sonic technology in powered electric brush they tend to increase their toothbrushes for the removal of plaque has frequency of brushing. The effectiveness is not been substantiated by clinical data. [4] especially improved when the users are Teeth naturally have a negative ionic given instructions and controlled during the charge and, conversely, food particles first 6-month period. With the development naturally have a positive ionic charge. These of the second and third generation of opposite charges are attracted to each other powered toothbrushes, it appears that long- causing food particles to stick to the teeth. term use is increasing. [7] The ionic toothbrush temporarily changes the tooth’s negative ionic charge to a CLASSIFICATION OF POWERED positive charge. Then, another part of the TOOTHBRUSH toothbrush is positively charged, attracting Mode of action the plaque and food particles away from the Powered toothbrushes are divided into six tooth. The bristles brush the loosened groups [8] particles away. However, the effectiveness 1. Side to side action- brush head moves of this mechanism for the removal of plaque laterally. has not been substantiated by clinical data. 2. Counter oscillation- adjacent tufts of [4] bristles (usually six to 10 in number) rotate in one direction and then the DESIGN AND ACTIONS OF other, independently. POWERED TOOTHBRUSHES 3. Rotation oscillation- brush head rotates The heads of most powered or in one direction and then the other. mechanical toothbrushes are smaller than 4. Circular- brush head rotates in one manual toothbrushes and are usually direction. removable to allow for replacements. The 5. Ultrasonic- bristles vibrate at ultrasonic head follows three basic patterns when the frequencies (> 20 kHz). motor is started: (1) reciprocating, a back- 6. Ionic-impart an electrical charge to the and-forth movement; (2) arcuate, an up-and- tooth surface with the intent of down movement; and (3) elliptical, a disrupting the attachment of dental combination of the reciprocating and plaque. arcuate motions. The bundles of bristles are Mechanism of action arranged either in rows (as for a The mechanism of action of powered conventional toothbrush) or in a circular toothbrushes can be categorised as pattern mounted in a round head was more mechanical, sonic or ionic. compact, single tufts which facilitate The mechanical action powered interproximal cleaning and brushing in less toothbrush comes with rotating or accessible areas of the mouth. All brushes oscillating heads. The heads are self- rely primarily upon the abrasive, mechanical powered. As the bristles are pressed against contact between the bristles and the tooth teeth and gums, the rapid, constant surface to effect cleaning. [8] movement removes plaque and food particles. [9] The efficacy of mechanical OPTIONAL FEATURES OF action powered toothbrush for the removal POWERED TOOTHBRUSH [4] of plaque is superior when compared to A number of the new generation manual toothbrushes. [10] powered toothbrushes also incorporated The sonic toothbrush has a rotating design features which are aimed at head and bristles. But in addition, it emits improving the efficacy of cleaning and sound waves that create a vibration which reducing the likelihood of toothbrush helps in conjunction with the bristles to abrasion and gingival trauma in the long loosen plaque and food particles. The term. These features include:

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Timer assist the user in creating better brushing Many modern electric toothbrushes technique and habits. Electric toothbrush have a timer which buzzes, or briefly models that currently utilise Bluetooth interrupts power, typically after two include the Oral-B Pro 6000, Pro 6500, Pro minutes, and sometimes every 30 seconds. 7000 and Genius 9000. This is associated with a customary Cleaning modes recommendation to brush for two minutes, Most sonic toothbrushes come with 30 seconds for each of the four quadrants of different cleaning modes and intensity the mouth. levels. Cleaning modes are designed for Display special types of cleaning efficiency. Some Some electric toothbrushes of the most well known are Sensitive, Daily have LCD screens which show brushing care, Whitening and Tongue cleaning. time and sometimes smiley face icons or other images to encourage optimal brushing. RECOMMENDED POWERED These features could encourage people to TOOTHBRUSHING METHODS [11] brush more accurately. Most powered toothbrush manufacturers do Pressure sensor not recommend a specific brushing method; Brushing teeth too hard cause however, the electric brushes should be used enamel and gum damage. Most modern top- in a specified manner. The Swiss Dental end sonic toothbrushes come with a pressure Society, in 2001 developed an instruction sensor, which prevents users from brushing manual. Instructions for brushes with a too aggressively. There are two types of sweeping and /or oscillating rotary motion pressure sensors. Some sensors produce a are as follows: sound warning and some immediately stop  The brushes are positioned on the tooth movements of the sonic toothbrush when it surfaces in a 45- or 90-degree angle to is used too aggressively. the incisal plane. Ultrasound indicator  Only when positioned should the brush Because of the fact that ultrasonic be switched to "on." frequencies are beyond the audible  The mouth should be almost closed. range and the amplitude of movement  The brush should be moved slowly over emitted by an ultrasonic toothbrush is and around each tooth for 3 to 5 typically too small to be perceived, the seconds, making sure that the bristles ultrasound is imperceptible to humans and it clean the crevices between the teeth. may not be apparent that a brush running in  The brush head can be lifted distally and pure ultrasound is turned on. Ultrasonic mesially into the interproximal areas to toothbrushes may include an indicator to reach the interdental area; the brush notify the patient that ultrasound is being always remains on a single tooth. emitted.  After a period of approximately 5 Bluetooth seconds, the brush is moved to the next Bluetooth connectivity enables data tooth surface and repositioned. to be transmitted from an electric toothbrush to another Bluetooth device, such as a smart Experienced individuals can use the phone. The brush can send data to an app, brush also in a perpendicular angle to the such as how long it has been brushing for teeth and gums, but the applied force has to and if too much pressure has been applied be gentle. In this way, each tooth in the when brushing. The app can in turn send upper and lower arch is cleaned on the data back to the brush such as changing the buccal and lingual surfaces. It is best to cleaning modes available, and cleaning divide the mouth into four quadrants and time. The sharing of data between start brushing on a tooth in the upper rear toothbrush and smart phone is intended to and then clean one surface after the other

International Journal of Health Sciences & Research (www.ijhsr.org) 303 Vol.8; Issue: 5; May 2018 Aparna K S et al. Powered Tooth Brush - A Review very systematically. It is an easy way, gives available for many years, it was not until the good control for the individual, and does not 1990s that they became a common omit any tooth surface. This method takes household item for dental hygiene self-care more time, because at a single time interval, and a primary preventive tool. By 2001, only one tooth surface can be cleaned. powered toothbrushes accounted for 7% of all toothbrushes sold, compared to just 2% INDICATIONS [4] in 1999. In 1980s, battery-powered or  For orthodontic patients disposable after "running down," powered  Those who are on supportive toothbrushes were introduced. In most periodontal therapy developed countries, the number of powered  Patients with prosthodontic or toothbrush products sold has increased endosseous implants. dramatically in recent years. In Switzerland,  For hospitalized patients the regular use of powered toothbrushes increased from 10 to 30% in the last decade.  Individuals with low manual dexterity, [4] such as children and the handicapped POWERED TOOTHBRUSHES - CONTRAINDICATIONS [4] INDIAN SCENARIO  Hypersensitivity- The vibration of In India, a variety of powered powered toothbrushes can aggravate the toothbrushes are available which differ in sensitivity issues. their mechanism of action, mode and price  Patients with cardiac pacemakers -As range. Some of them have incorporated optional features like pressure-sensor and they can result in electrical interference with the normal functioning of timer which makes them expensive. The leading brands in powered toothbrush implantable cardiac devices. category include Colgate, Oral-B, Philips, JSB, Trisa and Dento Shine. [12] ADVANTAGES [2] The different types of powered  Powered toothbrush increases patient toothbrushes available under the Colgate motivation resulting in better patient brand include Colgate® 360° Charcoal compliance and increase accessibility in Battery Operated Toothbrush, interproximal and lingual tooth surfaces. Colgate® 360° Total Advanced Floss Tip  It uses less brushing force than manual Battery- operated toothbrush and toothbrushes. Colgate® 360° Surround Toothbrush with  Brushing timer is incorporated in some Vibrating Bristles. For the pediatric brushes. population, Colgate® Kids Spiderman

[2] Battery Operated Toothbrush and DISADVANTAGES Colgate® Kids Barbie Battery Operated  The cost and maintenance of powered Toothbrush are available. All of them brushes is more than manual belong to second generation powered tooth toothbrushes. brush with rotation oscillation action (ROA)  It also results in noise and discomfort except Colgate® 360° Surround Toothbrush due to vibration with Vibrating Bristles which belongs to the third generation. [13] TRENDS IN POWERED Colgate® 360° Charcoal incorporates TOOTHBRUSH long, thin bristles infused with specially Powered toothbrushes have selected charcoal to provide better cleansing undergone many technological advances in action and Colgate® 360° Total Advanced design and bristle motion, including Floss Tip facilitates interdental cleaning rotation, oscillation and sonic vibration. with the help of floss tips. Colgate® 360° Even though these products had been Surround Toothbrush with Vibrating

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Bristles is a sonic tooth brush with a sonic populations with diminished manual cleaning power of 20000 strokes/ minute. dexterity and cognition problems. [4] [13] Safety Oral-B® brand offers a wide range of Powered toothbrushes are powered toothbrushes with cross action considered to be as safe as manual power. They include Oral-B ® Pro 600 toothbrushes. They employ mechanical CrossAction Power Electric Rechargeable action instead of a manual action, reduces Toothbrush, Oral-B® Pro 2000 Cross Action brushing force and the incidence of gingival Electric Rechargeable Toothbrush. Oral-B® bleeding because of gum damage. Powered CrossAction Power is a battery-powered toothbrushes are used with about one-third toothbrush that uses a rotating PowerHead the force of manual toothbrushes. In with CrissCross bristles for more cleaning epidemiological studies, it has been action in every stroke than a regular manual documented that populations are exhibiting toothbrush. It belong to second generation increased gingival abrasion and recession. powered tooth brush with rotation This has been associated with the increased oscillation action (ROA). [13] use of oscillating powered toothbrushes. In Philips® brand provides a variety of comparison to these oscillating sonic tooth brushes (third generation) which toothbrushes, sonic toothbrushes have been include Sonicare DiamondClean®, Sonicare shown to do little harm to the gingiva. Also Flex Care Platinum®, Sonicare EasyClean® sonic brushes of this type can be used up to for the adults and Sonicare For Kids® for the 6 or 12 months because the bristles show pediatric population. They incorporate minimal overt signs of use and do not splay. additional features such as pressure sensor, [4] Gingival abrasion is not influenced by timer and Bluetooth technology. [14] brushing force, but is affected by the filament end-rounding of the brush. When PRICE RANGE OF POWERED compared to manual toothbrushes, powered TOOTH BRUSH IN INDIAN MARKET toothbrushes do not cause greater gingival (AS OF 2018) [12-14] abrasion. [4] BRAND PRICE RANGE Effectiveness (Indian Rupee, ₹) Colgate: Powered toothbrushes are as Colgate® 360° Charcoal ₹ 650-700 effective as traditional brushes. They not Colgate® 360° Total Advanced Floss Tip ₹ 600-650 Colgate® 360° Surround Toothbrush ₹750-850 only move bristles at a much faster speed with Vibrating Bristles than the manual toothbrushes, but they also Colgate® Kids Spiderman and Barbie ₹550-650 Oral- B: remove plaque more evenly in hard-to-reach Oral-B ® Pro 600 CrossAction ₹5800-6000 places, such as inter proximal areas and on Oral-B ® Pro 2000 CrossAction ₹3800-4000 back molars. Powered brushes simulate the Philips: DiamondClean® ₹11500-12000 manual motion of toothbrushes with lateral Flex Care Platinum® ₹8500-9000 and rotary movements of the brush head. EasyClean® ₹4500-5000 Sonicare For Kids® ₹5500-6000 Powered brushes with a rotation oscillation mode of action are more effective at MANUAL VERSUS POWERED reducing plaque and gingivitis when TOOTHBRUSHES compared to manual brushes. No other Early commercially available powered brushes show consistent reductions powered toothbrushes lacked superiority in plaque and gingivitis in comparison with [15] compared with manual toothbrushes, and manual brushes. problems with mechanical breakdown caused their sales to decrease significantly. CONCLUSION Despite this, dentists continued to Tooth brushing is generally accepted recommend them for use in special as the most efficient oral hygiene method of cleaning teeth. Powered toothbrushes have

International Journal of Health Sciences & Research (www.ijhsr.org) 305 Vol.8; Issue: 5; May 2018 Aparna K S et al. Powered Tooth Brush - A Review been developed to improve and facilitate http://www.yourdentistryguide.com: oral hygiene. Currently, various types of Accessed on 1/10/17 at 10.30 am powered toothbrushes with different power 7. Schmidt JC, Zaugg C, Weiger R, Walter C. supplies and different modes of action are Brushing without brushing?-a review of the available. Power toothbrushes are effective efficacy of powered toothbrushes in noncontact biofilm removal. Clin Oral in removing plaque and reducing gingivitis. Investig 2013;17(3):687-09. They are as safe as manual toothbrushes and 8. Yaacob M, Worthington HV, Deacon SA, have good compliance. Motivation to Deery C, Walmsley AD, Robinson PG et al. improve oral hygiene appears to be a key Powered versus manual toothbrushing for factor for patients to purchase powered oral health. Cochrane Libr 2014;(6). toothbrushes. 9. Niederman R. Moderate quality evidence finds statistical benefit in oral health for REFERENCES powered over manual toothbrushes. Evid 1. Harris NO, Garcia-Godoy F. Primary Based Dent 2014;15(3):77-78. Preventive Dentistry. 6th ed. Upper Saddle 10. Robinson P, Deacon SA, Deery C, Heanue River, NJ: Pearson Education; 2004. M, Walmsley AD, Worthington HV, Glenny 2. Kumar G, Jalaluddin M, Singh DK. Tooth AM, Shaw BC. Manual versus powered Brush and Brushing Technique. J Adv Med toothbrushing for oral health. Cochrane Libr Med Res 2015;2(1):65-76. 2005;(2). 3. Rosema NA, Slot DE, Palenstein 11. Heasman PA, McCraken GI. Powered Helderman WH, Wiggelinkhuizen L, toothbrushes: a review of clinical trials. J Weijden GA. The efficacy of powered Clin Periodontol 1999;26:407-20. toothbrushes following a brushing exercise: 12. Oral-B launches rechargeable electric tooth a systematic review. Int J Dent Hyg brush in India. http://www.gadgetsnow.com 2014;14(1):29-41. : Accessed on 26/1/18 at 1.30 pm. 4. Penick C. Power toothbrushes: a critical 13. Tooth brushes. http://www.colgate.co.in: review. Int J Dent Hyg. 2004;2(1):40-44. Accessed on 26/1/18 at 1.30 pm. 5. Tadinada A, Kilham J, Bysani P, 14. Electric tooth brushes. Gopalakrishna A. The evolution of a tooth http://www.philips.co.in: Accessed on brush: from antiquity to present-a mini- 26/1/18 at 1.30 pm. review. J Dent Health Oral Disord Ther 15. Deacon SA, Glenny AM, Deery C, 2015;2(4):157-64. Robinson PG, Heanue M, Walmsley AD et 6. Rondon N. Mechanical toothbrushes- al. Different powered toothbrushes for features and considerations. Consumer plaque control and gingival health. Aust guide to dentistry. Dent J 2011;56(2):231-33.

How to cite this article: Aparna KS, Puranik MP, Sowmya KR. Powered tooth brush- a review. Int J Health Sci Res. 2018; 8(5):299-306.

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International Journal of Health Sciences & Research (www.ijhsr.org) 306 Vol.8; Issue: 5; May 2018