Effectiveness of Different Bristle Designs of Toothbrushes And

Sandhya P Naik et al 10.5005/jp-journals-10024-2229 ORIGINAL RESEARCH

Effectiveness of Different Bristle Designs of Toothbrushes and Periodontal Status among Fixed Orthodontic Patients: A Double-blind Crossover Design 1Sandhya P Naik, 2Sameer Punathil, 3Praveena Shetty, 4Ipsita Jayanti, 5Md Jalaluddin, 6Anisha Avijeeta

ABSTRACT Results: In both phase 1 and 2 of this RCT, toothbrush with crisscross bristles exhibited maximum plaque reduction among Aim: The aim of the present study was to evaluate the effec- the three different bristle design toothbrushes following 30 days tiveness of different bristle designs of toothbrushes and the (p = 0.312 ± 0.102 and 0.280 ± 0.110, respectively), which was periodontal status among patients undergoing fixed orthodontic statistically significant. treatment. Conclusion: It was concluded that all the three designs of This randomized controlled trial Materials and methods: toothbrushes were effective in removing plaque in patients (RCT) consisted of 45 adolescents (comprising 20 males and with fixed orthodontic appliances. But among the three different 25 females) undergoing fixed orthodontic treatment. The study toothbrushes, toothbrush with crisscross bristles showed the participants were randomly allocated to three groups, each highest mean plaque reduction. group being assigned a locally available toothbrush with a particular design of toothbrush bristle. In the first test phase, Clinical significance: Plaque accumulation around the orth- group I study participants were allocated to toothbrush with flat odontic brackets and gingival margins is quite common among bristles, group II study subjects were allocated to toothbrush with the fixed orthodontic patients, who encounter difficulty in main- zigzag bristles, and group III study participants were allocated to taining good oral hygiene. Specially designed toothbrushes are toothbrush with crisscross bristles. The study participants were very essential for effective plaque removal among the patients recalled after 4 weeks to check the effectiveness of the allocated undergoing fixed orthodontic treatment. toothbrushes. A washout period of 1 week was maintained to Keywords: Bristles, Crossover design, Fixed orthodontic appli- ensure that there was no carryover effect of the different bristle ances, Plaque. designs. In the second test phase, each patient used the oppo- site toothbrush bristle design (group I: toothbrush with zigzag How to cite this article: Naik SP, Punathil S, Shetty P, Jayanti I, bristles, group II: toothbrush with crisscross bristles, and group Jalaluddin M, Avijeeta A. Effectiveness of Different Bristle III: toothbrush with flat bristles). Plaque scores were measured Designs of Toothbrushes and Periodontal Status among using Turesky–Gilmore–Glickman modification of Quigley-Hein Fixed Orthodontic Patients: A Double-blind Crossover Design. plaque index (PI). J Contemp Dent Pract 2018;19(2):150-155.

Source of support: Nil

1Department of Public Health Dentistry, Government Dental Conflict of interest: None College and Hospital, Mumbai, Maharashtra, India 2Department of Pedodontics, Sree Anjaneya Institute of Dental INTRODUCTION Sciences, Kozhikode, Kerala, India The oral diseases most frequently occurring in human- 3Department of Orthodontics and Dentofacial Orthopedics Srinivas Institute of Dental Sciences, Mangaluru, Karnataka kind are dental caries and periodontal disease, and the India causative factor of both is dental plaque. Personal and 4-6Department of Periodontology, Kalinga Institute of Dental professional oral hygiene practices are the procedures Sciences, Bhubaneswar, Odisha, India directed at the removal of dental plaque. Toothbrush is Corresponding Author: Sandhya P Naik, Department of Public one of the most commonly used adjuncts for maintaining Health Dentistry, Government Dental College and Hospital oral hygiene.1 Mumbai, Maharashtra, India, Phone: +919156388888, e-mail: During orthodontic treatment, oral hygiene measures [email protected] that are directed toward the removal of dental plaque 150 JCDP

Effectiveness of Different Bristle Designs of Toothbrushes around the brackets and orthodontic appliances need to The participants using chemical plaque control measures become more effective. Plaque accumulation around the and those taking drugs that could affect the state of gin- fixed orthodontic appliances can be challenging for effec- gival tissues, including corticosteroids and nonsteroidal tive toothbrushing and can interfere with the mechanical antiinflammatory drugs, were excluded from the study. cleaning action of mastication. As the duration of orthodontic treatment is long, routine oral hygiene measures Sample Size Determination for the orthodontic patient including professional tooth The formula used to calculate sample size was: cleaning and home care instructions must be given with 2 2 a lot of consideration. Z12−α / n= 2 Effective home-plaque-control measures are very con- d n is the required sample size; Z is a constant; its ducive for maintaining a functional dentition throughout 1–α/2 value for a two-sided test is 1.96 for 95%; d is absolute life. These include toothbrushing by manual or electric precision 20% = 0.2. toothbrush combined with interdental cleaning. It is well As calculated from the above formula, 45 participants known that there is a positive correlation between the were randomly allocated to three different types of locally degree of plaque accumulation and gingival disease. The available toothbrushes with varied toothbrush bristle role of plaque as a causative factor in the development designs groups (Flow Chart 1). of chronic inflammatory disease has been routinely con- 3 firmed in the scientific literature. Dental plaque causes Study Groups inflammatory process in the supporting structures of the teeth, which, if progressed, results in tooth loss.4 First test phase The most effective method of achieving good oral • Group I: Toothbrush with flat bristles health in most of the population is the daily usage of • Group II: Toothbrush with zigzag bristles 5 manual toothbrush. Since their first use by the Chinese • Group III: Toothbrush with crisscross bristles (Figs 1 in the late 16th century, toothbrushes have gone through and 2). changes in their basic structure. Various aspects, such as size, shape, bristle arrangement, texture and stiffness, Second test phase head design, angulations between head, shaft and handle • Group I: Toothbrush with zigzag bristles along with other features, as well as many other modifica- • Group II: Toothbrush with crisscross bristles tions have been made. • Group III: Toothbrush with flat bristles. In the present day, a very wide variety of toothbrushes are available in the market. This has led to a dilemma Methodology in the consumer’s mind with respect to efficacy of each This was a double-blind crossover study, where a 1-week toothbrush. In addition, factors such as cost, availability, washout period was given between the crossover phases advertising claims, family tradition, or personal habits to evaluate the effectiveness of the three bristle designs decide the type of toothbrush going to be used by a par- of toothbrushes among patients undergoing fixed orth- ticular person.6 Thus, the aim of the present study was odontic treatment. to evaluate the effectiveness of different bristle designs The examiner was trained and calibrated before the of toothbrushes and the periodontal status among fixed start of the study. Intraexaminer agreement for PI was orthodontic patients. calculated by repeat measurements that were done on 10 patients not participating in the study, within an inter- MATERIALS AND METHODS val of 1 hour. The Kappa coefficient for PI was found to This RCT was conducted on 45 adolescent participants be 0.7. All the participants were given a similar type of (20 males and 25 females) undergoing fixed orthodontic toothpaste. Toothbrushing technique instructions were treatment, whose ages varied between 15 and 18 years. given to the participants for the purpose of standardiza- Ethical approval along with informed consent was tion. Furthermore, instructions to brush twice daily for obtained from the participants before the study. Detailed 2 minutes (morning just after waking up and in the night information about the study design and procedure was before going to bed) were given to the participants, along explained to the participants. with directions to use the same toothbrush and toothpaste Patients with fully bonded fixed orthodontic appli- given to them. ances and without any systemic diseases, patients who Lottery method was used to randomly allocate all the had not taken any antibiotics or antiseptic mouthwashes patients to the study groups according to the different for 1 month before the study were included in the study. bristle designs of toothbrushes. Coding was done for The Journal of Contemporary Dental Practice, February 2018;19(2):150-155 151 Sandhya P Naik et al

Flow Chart 1: Distribution of study participants

Fig. 1: Front view of all the three toothbrushes Fig. 2: Side view of all the three toothbrushes each one of the toothbrushes. It was only at the end of the The second test phase was carried out in a similar way, study that the codes were decoded. In the first test phase, after a 1-week washout period to negate the carryover the toothbrushes that were allocated were in the order: effects of the different bristle designs. Toothbrush bristle • Group I: Toothbrush with flat bristles designs were alternated in the order: • Group II: Toothbrush with zigzag bristles • Group I: Toothbrush with zigzag bristles • Group III: Toothbrush with crisscross bristles • Group II: Toothbrush with crisscross bristles On the first day of each phase, all the patients were • Group III: Toothbrush with flat bristles asked to refrain from any oral hygiene practices for 24 hours. Data regarding plaque scores were collected Statistical Analysis by assessing plaque using Turesky–Gilmore–Glickman Statistical analysis was done using the Statistical Package Modification of Quigley-Hein PI.7 Two-tone disclosing for the Social Sciences software (version 20.0). Mean and solution was used to evaluate plaque on the buccal and standard deviations (SDs) of the clinically examined lingual surfaces of all teeth except the third molars. The scores were calculated. Analysis of variance and post hoc participants were recalled following 4 weeks to assess the paired t-tests were applied to analyze differences between effectiveness of the toothbrushes allocated to the three the three different bristle designs. A p = 5% significance study groups. level was maintained for all the analysis. 152 JCDP

Effectiveness of Different Bristle Designs of Toothbrushes

RESULTS DISCUSSION Overall, 45 patients (20 males and 25 females) were This was a double-blind crossover trial with a washout included in the present study. Table 1 shows the com- period, conducted to evaluate the effectiveness of dif- parison between the pre- and postbrushing scores for PI ferent toothbrush bristle designs in patients undergo- in phase 1. Among all the three different bristle design ing fixed orthodontic treatment. It is well known that toothbrushes, group III (toothbrush with crisscross bris- the presence of orthodontic brackets and appliances tles) shows the maximum plaque reduction after 30 days makes the patients vulnerable to plaque accumulation (0.312 ± 0.102), following which group II (toothbrush with around these sites. The advantages of using the cross- zigzag bristles) 0.344 ± 0.012 and group I (toothbrush with over design are many; here the effects of the different flat bristles) 0.516 ± 0.212 show plaque reduction respec- types of toothbrushes were measured in the same tively. There was a statistically significant difference in person. The other advantages included lower number the reduction of plaque scores between groups II and III. of participants required for the study and confound- Table 2 shows the comparison between pre- and ing factors within the participants (e.g., age, gender, postbrushing PI scores in phase 2. Following crossover, and hand skills). However, to minimize the carryover among three different bristle design toothbrushes, effect, which is the main concern during the use of a group II (toothbrush with crisscross bristles) is found crossover design, we allowed for a 7 days washout to have the maximum plaque reduction after 30 days period, during which the patients went back to using (0.280 ± 0.110), followed by group I (toothbrush with their normal toothbrushes.8,9 zigzag bristles) 0.310 ± 0.142 and group III (toothbrush The manual toothbrush that we use in our daily life with flat bristles) 0.390 ± 0.148 respectively. All the three was introduced in the 1920s; it has since then become groups show a statistically significant difference in the an affordable oral hygiene device for the population at reduction of plaque scores. large. The most common oral hygiene habit in the last Table 3 depicts Scheffe post hoc analysis, which indi- decade is toothbrushing using toothbrush and tooth- cated that the average number of plaque removed is paste. Numerous innovative design improvements have significantly higher in group III than in groups II and I. facilitated to increase the efficacy of a toothbrush. Most of In phase 2, the post hoc analysis shows that the average the variations/innovations that have been observed are number of plaque removed is higher in group II than in majorly pertaining to the design of the brush head and groups I and III, as observed from Table 4. configuration of the filaments.4

Table 1: Comparison of pre- and postbrushing PI scores in phase 1 Table 2: Comparison of pre- and postbrushing PI scores in phase 2 Groups Mean ± SD t-value Significance Groups Mean ± SD t-value Significance Group I Group I Prebrushing 0.824 ± 0.192 10.24 0.08 Prebrushing 0.882 ± 0.186 9.74 0.001 Postbrushing 0.516 ± 0.212 Postbrushing 0.310 ± 0.142 Group II Group II Prebrushing 0.868 ± 0.164 9.62 0.02 Prebrushing 0.844 ± 0.130 8.36 0.001 Postbrushing 0.344 ± 0.012 Postbrushing 0.280 ± 0.110 Group III Group III Prebrushing 0.782 ± 0.126 8.14 0.001 Prebrushing 0.712 ± 0.012 8.96 0.02 Postbrushing 0.312 ± 0.102 Postbrushing 0.390 ± 0.148

Table 3: Multiple comparison of all the toothbrushes using post Table 4: Multiple comparison of all the toothbrushes using hoc Tukey’s test in phase 1 post hoc Tukey’s test in phase 2 Groups Mean difference Standard error Significance Groups Mean difference Standard error Significance Group I Group I Group II –0.216 0.062 0.82 Group II 0.008 0.004 0.14 Group III –0.162 0.081 0.01 Group III 0.250 0.062 0.02 Group II Group II Group I 0.216 0.066 0.22 Group I –0.008 0.004 0.26 Group III 0.054 0.082 0.10 Group III 0.242 0.050 0.01 Group III Group III Group I 0.162 0.084 0.01 Group I –0.250 0.094 0.02 Group II –0.054 0.090 0.12 Group II –0.242 0.050 0.01

The Journal of Contemporary Dental Practice, February 2018;19(2):150-155 153 Sandhya P Naik et al

The present study was conducted for 30 days (4 weeks) Sharma et al20 compared five toothbrushes having flat- for each of the test phases. According to a study by trimmed bristles, multilevel straight bristles with three Cohen,10 trial periods of 3 weeks are advisable if a tooth- advanced crisscross bristles, concluding that crisscross brush needs to be tested accurately. We found that the bristles were superior, which was similar to our results. findings of this study were in accordance with Cohen10 Another study conducted by Kakar et al21 revealed that depicting the trend toward progressive reduction in zigzag bristles showed increase in percentage reduction plaque scores among all the types of study brushes used of PI scores, which are in contradiction to the present during the 4 weeks of the trial. In a trial conducted by study results. Scopp et al,11 the experimental toothbrush was found However, the efficacy and relative effectiveness of to produce lowest plaque scores in the 1st week, which various types and designs of toothbrushes should be was in contrast with our findings. One possible explana- confirmed through long-term studies with larger sample tion could be that patients tend to revert to the same old size, with the further assessment of the plaque removal technique they are most comfortable with. efficacy along with a long-term follow-up throughout the At baseline, the plaque scores were almost similar orthodontic treatment. in all the groups during each test phase. The results Fixed orthodontic treatment makes the patients vul- showed statistically significant differences between the nerable to plaque accumulation around the orthodontic three toothbrushes. This is in contrast to the findings of brackets and gingival margins, complicating mainte- the study done by Bergenholtz et al,12 who compared a nance of good oral hygiene. Hence, it is suggested to use flat-trim toothbrush with V-shaped bristles and found specially designed toothbrushes for easy and effective no significant differences between the toothbrushes. In toothbrushing. another study, Staudt et al13 compared the efficacy of three different toothbrushes, which were convex bristle, CONCLUSION multilevel bristle, and flat-trim bristle. This study used All the three designs of toothbrush bristles were effec- a computer-based planimetric PI, which is considered tive in removing plaque among the patients undergoing to be superior in terms of sensitivity, objectivity, and fixed orthodontic treatment. Out of the three different reliability. 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