Tooth Brushing for Oral Prophylaxis

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Japanese Dental Science Review (2014) 50, 69—77

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Tooth brushing for oral prophylaxis

a, a

Haruaki Hayasaki DDS, PhD *, Issei Saitoh DDS, PhD ,

a a

Kuniko Nakakura-Ohshima DDS, PhD , Mika Hanasaki DDS ,

a a

Yukiko Nogami DH , Tsutomu Nakajima DDS ,

b b

Emi Inada DDS, PhD , Tomonori Iwasaki DDS, PhD ,

a a

Yoko Iwase DDS, PhD , Tadashi Sawami DDS, PhD ,

a a

Katsushige Kawasaki DDS, PhD , Nozomi Murakami DDS ,

a a

Tomoya Murakami DDS , Mie Kurosawa DDS ,

a a

Masami Kimi DDS , Akiko Kagoshima DDS ,

a b

Miki Soda DDS , Youich Yamasaki DDS, PhD

Division of Pediatric Dentistry, Department of Oral Health Science, Course of Oral Life Science,

Graduate School of Medical and Dental Science Niigata University, 2-5274, Gakkocho-dori, Chuo-ku,

Niigata 951-8514, Japan

Department of Pediatric Dentistry, Graduate School of Medical and Dental Science, Kaghosima University,

8-35-1, Sakuragaoka, Kagoshima 890-8544, Japan

Received 23 November 2013; received in revised form 8 April 2014; accepted 25 April 2014

KEYWORDS Summary Control of plaque and debris is essential for the prevention of inﬂammatory

periodontal diseases and dental caries, because plaque is the primary etiological factor in the

Tooth brushing;

introduction and development of both of these infection-oriented diseases. Plaque removal with

Oral prophylaxis;

a toothbrush is the most frequently used method of oral hygiene. Powered toothbrushes were

Dental plaque;

Toothbrush developed beginning in the 1960s and are now widely used in developed countries. The bristles of

a toothbrush should be able to reach and clean efﬁciently most areas of the mouth, and recently

the design of both manual and powered toothbrushes has focused on the ability to reach and clean

interproximal tooth surfaces. An individual’s tooth brushing behavior, including force, duration,

motivation and motion, are also critical to tooth brushing efﬁcacy. Dental ﬂoss and the type of

toothpaste play additional important roles as auxiliary tools for oral prophylaxis. Dental profes-

sionals should help their care-receivers’ meet the requirements of oral hygiene to maintain their

QOL. This article reviews these topics.

# 2014 Japanese Association for Dental Science. Published by Elsevier Ltd.

Open access under CC BY-NC-ND license.

* Corresponding author. Tel.: +81 25 227 2908; fax: +81 25 227 2908.

E-mail address: [email protected] (H. Hayasakia).

http://dx.doi.org/10.1016/j.jdsr.2014.04.001

1882-7616/# 2014 Japanese Association for Dental Science. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.

70 H. Hayasaki et al.

of microorganisms not individual pathogens) in order to

1. Introduction

understand its biology and functional implications [7]. The

clinical presentation of these dental diseases is a net result of

Oral prophylaxis is the foundation of oral health, and daily

the cross-talk between the pathogenic dental plaque bioﬁlm

plaque removal is considered important for oral health.

and the host tissue response. In the healthy state, both

Speciﬁc oral bacteria, generically known as ‘‘dental plaque’’

plaque bioﬁlm and adjacent tissues maintain a delicate

are the primary cause of gingivitis (gum disease) and caries.

balance, establishing a harmonious relationship between

The removal of dental plaque is thought to play a key role in

the two. However, changes occur during the disease process

the maintenance of oral health. There is some evidence that

that transform this ‘healthy’ dental plaque into a ‘patho-

electric toothbrushes, other than those with a counter-rotat-

genic’ bioﬁlm. Recent advances in molecular microbiology

ing movement, are more effective than manual brushes for

have improved our understanding of dental plaque bioﬁlm,

tooth brushing [1]. One explanation might be the varying

producing numerous clinical beneﬁts.

dexterity of the participants in the different studies. Clear

deﬁciencies in manual tooth brushing have been recognized

both from epidemiological and clinical researches [2—5]. This 3. Toothbrushes

article reviews the contemporary literature to provide an

overview of present knowledge concerning tooth brushing. 3.1. Manual toothbrush design

2. Dental plaque

During the 18th century, the bristle toothbrush came into

use. Forerunners of today’s brushes were developed in the

A great diversity of microorganisms–—over 700 species–—has 1930s. These nylon toothbrushes with plastic handles were

been detected in the oral cavity [6], and evidence shows that easy to manufacture and therefore more affordable, making

the investigation of speciﬁc microorganisms or associations of tooth brushing a common practice in Western society. Ever

microorganisms as etiological agents of periodontal diseases since, much imagination and inventiveness has been applied

and caries is a simplistic approach. Instead, dental plaque to toothbrush design, and now numerous models of manual

must be studied as a bioﬁlm (i.e., as communities composed toothbrushes are available [8] (Fig. 1), with more than 450

Figure 1 Examples of typical bristle proﬁles [8].

Tooth brushing for oral prophylaxis 71

kinds in Japan. However, there is still insufﬁcient evidence bristles during brushing. Once independent motion is

that any speciﬁc toothbrush design is superior to another. achieved, the longer bristles can effectively reach farther

Modern toothbrushes have various bristle tuft arrange- between the teeth [16].

ments (e.g., ﬂat-trim, multilevel, angled) that are designed A recent systematic review [9] indicated that, depending

[9] to enhance plaque removal from hard-to-reach areas of on the plaque index used, a 7—9% improvement in efﬁcacy

the dentition, particularly from interproximal areas. The (with the Navy index and Q&H index, respectively) can be

degree of hardness and stiffness of a toothbrush depends achieved with a multilevel bristle tuft conﬁguration com-

on the ﬁlament characteristics such as its material, diameter pared to the traditional ﬂat trim. The most recent develop-

and length. Today many manufacturers vary the length or ment of angled (‘‘angle bristles’’ in Fig. 1) rather than

diameter of the ﬁlaments mounted in a single head. Tooth- vertical bristle tuft arrangements appears to have made a

brushes with thinner filaments are softer while thicker fila- significant contribution to interproximal plaque removal.

ment diameters are stiffer and less ﬂexible. The number of Clinical studies have consistently demonstrated that a brush

filaments per tuft also determines the hardness of a tooth- with an angled bristle tuft configuration is significantly more

brush, which in turn has an effect on the cleaning perfor- effective [8,17,18]. Slot’s review also showed that depending

mance. on the plaque index used, a 12—15% improvement in efﬁcacy

Robertson and Wade [10] showed that subjects cleaned (with the Q&H index and Navy index, respectively) can be

signiﬁcantly better with medium and hard brushes than with achieved with this particular bristle tuft conﬁguration com-

a soft-bristled brush. Berdon et al. [11] found that a tooth- pared to a ﬂat-trim design. Angulation appears to be an

brush with 0.18 mm diameter filaments was significantly less efficient innovation of brush head design, based on the

effective (P < 0.05) in cleaning than were ﬁve brushes with results of a review by Cronin et al. [19].

larger diameter ﬁlaments from the same manufacturer. Gib- Recently, Voelker et al. [20] compared various commercial

son and Wade [12] observed that a toothbrush with 0.2 mm manual toothbrush and powered heads to characterize the

diameter ﬁlaments tended to clean the marginal gingiva following: bristle size, shape, diameter, number of tufts,

more effectively than another with 0.18 mm diameter ﬁla- number of bristles per tuft and surface characteristics. There

ments. In a crossover study, Vowles and Wade [13] tested the were signiﬁcant differences for toothbrush bristle diameter

differences between 0.13 mm and 0.28 mm ﬁlament dia- and bristle shape. In contrast, there were no signiﬁcant

meters and found that plaque removal was signiﬁcantly differences between powered toothbrushes and manual

better (P < 0.001) with the thicker ﬁlaments when used with toothbrushes in bristle diameter, bristle count and tuft

the roll technique for brushing the facial and interproximal count. The results suggest that although there are wide

areas. It appears, therefore, that ﬁlaments must have a variations in toothbrush head designs, signiﬁcant differences

degree of stiffness to dislodge plaque deposits. are found only in bristle diameter and shape.

Designs are based on the premise that the majority of

persons in any population use a simple horizontal brushing 3.2. Powered toothbrushes

action. Over time, the design of the brush head has evolved

and multiple tufts of bristles, sometimes angled in different Powered toothbrushes were ﬁrst introduced commercially in

directions, are now used. Today, prospective users can read- the early 1960s [21,22] and have become established as an

ily ﬁnd a toothbrush with a handle size appropriate to their alternative to manual methods of tooth brushing. As a rule,

hand size, and much emphasis has been placed on new the advantage of the powered brush is both clinical and

ergonomic designs [14]. Toothbrush manufacturers have statistical improvements in overall plaque scores. Powered

made great effort in considering many different aspects toothbrushes offer an individual the ability to brush the teeth

when designing new models to meet the challenge of enhan- in a way that is optimal in terms of removing plaque and

cing plaque bioﬁlm removal through improved tooth brushing improving gingival health–—conferring good brushing techni-

efﬁcacy. A few toothbrush manufacturers have also made the que on all who use them, irrespective of manual dexterity or

effort to evaluate tooth brushing efﬁcacy. training [23]. Results showed that, powered brushes were

Product design changes can yield genuinely improved always better than manual brushes (Table 1).

performance characteristics [15]. A major shortcoming of There are two published Cochrane systematic reviews

conventional ﬂat-trim toothbrushes has been a ‘blocking comparing the efﬁcacy of powered toothbrushes and manual

effect’ of tight bristle tufts, preventing individual tufts from toothbrushes [5,24]. The ﬁrst suggested that the rotation/

reaching interproximal areas. Multilevel toothbrushes have oscillation type of powered tooth brushing is superior to

been developed with alternating rows of longer and shorter manual tooth brushing for the removal of plaque and reduc-

bristle tufts acting independently, uninﬂuenced by adjacent tion of gum inﬂammation. However, that review did not allow

Table 1 Reported comparisons of plaque removal efﬁciency between powered had manual toothbrushes.

Authors Year Manual brush (MB) Powered brush (PB) No. of subjects Differences

MB < PB (%)

Nathoo et al. 2003 Oral-B Cross Action Colgate Motion 126 42.1

Singh et al. 2005 Oral-B Indicator Colgate MicroSonic 39 52.9

Ghassemi et al. 2013 Oral-B Indicator 30 CS Spin brush GLOBRUSH 103 12.8

MB: manual toothbrush, PB: powered toothbrush.

72 H. Hayasaki et al.

direct comparison between different types of powered Hence, movements of the toothbrush during different brush-

toothbrushes, due to the small numbers of trials using other ing techniques could be characterized.

types of powered brushes. Therefore, no deﬁnitive conclu- The most recent study developed a toothbrush-monitoring

sions can be drawn regarding the superiority of one type of system that provided information concerning the orientation

powered toothbrush over another. Only minor and transient and linear displacement of the toothbrush actions [33].

side effects were reported, and cost and reliability of the Orientation and back-and-forth displacement of the tooth-

brushes were not reported. Further trials of good quality will brush were measured by a combined three-axis acceler-

be required to establish if other types of powered tooth- ometer.

brushes are better at reducing plaque and gingivitis. These Tooth brushing behavior is a daily habit, therefore, it is not

ﬁndings were not advanced much in the second review. easily altered, even after professional instruction in the

Another systematic review for powered toothbrushes pro- clinic. First, teaching brushing technique is a complex and

posed the necessity of methodological homogeneity in future time-consuming procedure. Second, from the perspective of

studies in this ﬁeld to enable quantitative comparison of movement sciences, skill training requires many repetitions

results [25]. of the same movements to incorporate them into an indivi-

dual’s habitual motor program.

4. Tooth brushing behavior

4.2. Toothbrush force and pressure

4.1. Techniques for manual toothbrushes

The choice of toothbrush is usually a matter of individual

To identify the most effective methods of tooth brushing in preference rather than a demonstrated superiority of any one

children, Muller-Bolla and Courson [26] carried out a sys- type [42]. The enthusiastic use of a toothbrush is, however,

tematic review to evaluate the children’s ability to remove not synonymous with a high standard of oral hygiene. Adults,

dental plaque. The horizontal technique was found to be the despite their apparent efforts, appear not to be as effective

most effective up to 6—7 years of age [27—29]. Advantages of in their plaque removal as might be expected. Most indivi-

the horizontal Scrub are that it is easy to learn and practice duals reduce plaque scores by approximately 50% during

and is effective at plaque removal [30,31]. However, this tooth brushing. A 1-min brushing exercise in participants

tooth brushing method is less effective for cleaning in the adhering to their customary brushing method, but all using

proximal and gingival sulci of permanent teeth and may the same type of toothbrush, observed a plaque score reduc-

results in gingival recession and tooth abrasion [32]. For tion of approximately 39% [42]. These results indicate that

older children, there was no statistical difference between most people are not effective brushers and probably live with

the Bass and Fones techniques. Bergstrom et al. suggested considerable amounts of plaque on their teeth, despite

that the horizontal technique should be advised in younger brushing at least once a day. What currently is lacking is a

children. For adults, the modiﬁed Bass technique is often systematic review that provides a reliable overview of tooth

recommended by dentists and in textbooks and used in brushing efﬁcacy through the process of systematically locat-

clinical studies [33—35]. However, the Fones technique is ing, appraising and synthesizing evidence from individual

often recommended in patient brochures in Germany, and its trials [9].

efﬁciency recently was proved by Harnacke et al. [36]. In Professional recommendations for individual oral hygiene

general, these brochures, recommendations and instructions mostly include tooth brushing at least twice daily [43,44] for

of tooth brushing technique are very helpful for improving 2—3 min with gentle force [39] using the Bass technique or

oral hygiene. However, for serious improvement in a patient’s modiﬁcations of it [33,45] as suggested by American Dental

oral hygiene, the dentist should ﬁrst evaluate the patient’s Association. However, ‘‘gentle force’’ is not deﬁned clearly

hand-skill motion before giving instructions. Each individual enough to be used in the clinical situation.

has poor (or weak) or favorite (or strong) hand-skill motion When brushing force is increased, more plaque is removed

for each of the brushing techniques. From this point of view, [46]. Numerous studies have reported brushing forces. Some

toothbrushing technique is still an open question. of these previously reported tooth brushing forces were

As for the effectiveness of tooth brushing instruction along 2.95 N [47], 2.61 N [46], 2.96 N [48], 3.23. N [42], 2.3 N

with practicing a particular tooth brushing method, Slot et al. [39]. Force discrepancies might have been due to random

[9] summarized in their systematic review that tooth brush- effects from using different measuring systems and tooth-

ing practice reduces plaque from baseline plaque scores by brushes, and different gender, age and dental characteristics

42% on average, with a variation of 30—53%, dependent on of the study groups. Burgett and Ash discussed the signiﬁcant

the plaque index used. In addition, they suggested that variation in the magnitude of brushing force (from 1.04 N g to

bristle tuft arrangement (ﬂat-trim, multilevel, angled) and 11.3 N) when using different measuring systems, toothbrush

brushing duration were factors that contribute to the varia- grips, toothbrushes and techniques [49]. In addition, no

tion in observed efﬁcacy. systematic review or evaluation of brushing forces has so

Recently, several studies have tried to evaluate brushing far been performed that compares different sextants and

techniques in terms of brushing motion, brushing action or tooth sites or of the effect of instruction on brushing tech-

both [33,37—40]. One study developed and evaluated the nique.

efﬁciency of a smart digital toothbrush monitoring and train- Very few studies have investigated the association

ing system in terms of correct brushing motion and grip axis between brushing force and gingival recession. The available

orientation in the at-home environment [41]. Their analyzing evidence suggests that tooth brushing force should not

software allowed calibration of all parameters individually. exceed 3 N to avoid gingival recession [50]. Tooth brushing

Tooth brushing for oral prophylaxis 73

abrasion is one factor in the multi-factorial process of tooth efﬁcacy and effectiveness of various types of clinical inter-

wear. While tooth brushing is considered to be of minor vention. Indices for the clinical evaluation of dental plaque

importance for abrasion of sound enamel and dentin [51], have been developed and are listed in Table 3. Each index has

it was shown to be a signiﬁcant risk factor for the etiology of its own characteristics, and each study selects the index best

erosive lesions [52—54], especially on eroded enamel and suited for its purpose. However, this variety of indices makes it

dentin. Tooth-brushing abrasion is determined by the abra- difﬁcult to compare them directly for a systematic review. In

sive properties [55,56] and concentration [57] of the tooth- addition, studies using these indices typically rely on clinical

paste, and is also modiﬁed by the kind of toothbrush [58] and examiners to assign index values as a means of determining

the brushing force [59,60]. outcomes or for performing group comparisons. The quality of

Comparison of the brushing forces applied during in vivo the assigned values is dependent, to a large extent, on the

tooth brushing with manual and sonic toothbrushes and the skills of the examiners and on the validity of the assessment

average brushing force of manual toothbrushes (1.6 Æ 0.3 N) methods that are used. Therefore, much attention has to be

was signiﬁcantly higher than for sonic toothbrushes paid to the common sources of error and bias that can lead to

(0.9 Æ 0.2 N) [54]. These different brushing forces affect difﬁculties in standardizing examiners [68].

the abrasive capacity of manual and sonic toothbrushes. Personal oral hygiene is often combined with therapeutics

Recent systematic reviews also suggest that power tooth- such as ﬂuoride or xylitol, which have an effect on dental

brushes produce less clinically relevant damage potential to diseases and possibly tooth loss, making the evaluation of the

soft and hard tissues than manual toothbrushes [61,62]. pure effects of oral hygiene behavior difﬁcult. Because the

Patients with clinically signiﬁcant severe tooth wear and evidence for the effectiveness of these chemo-therapeuti-

exposed or eroded dentin surfaces should use sonic tooth- cals is sufﬁciently convincing that withholding them may be

brushes to reduce abrasion, while patients without tooth considered unethical. However, alternative delivery mechan-

wear or with erosive lesions conﬁned to the enamel do not isms, such as chewing gum, may be viable, more practical,

beneﬁt from reduced abrasion from sonic toothbrushes [54]. and more reliable than personal oral hygiene tools. Another

possibility is to evaluate variations in the level of personal

oral hygiene (much like studying varying levels of fat intake,

4.3. Duration of manual tooth brushing

physical activity, etc.).

Duration is one of the critical factors affecting the efﬁcacy of

6. Toothpaste and/or dentifrice

tooth brushing for dental plaque removal [63]. It has been

proposed that the main cause of insufﬁcient oral hygiene in

Advances in toothbrush technology are associated with more

the general population is too short a brushing time [64].

effective plaque removal, but excessive plaque regrowth can

However, changing this seems to be very difﬁcult [65].

also be a problem for individuals. Therefore, there is a need

Reported tooth brushing durations for children and adults

for products that not only help users achieve optimal plaque

are shown in Table 2. Brushing’s major effect on plaque

removal, but also ensure that plaque levels remain controlled

reduction is reached after 30—45 s of brushing per quadrant;

overnight and throughout the day, thereby reducing the risk

accordingly, the commonly recommended tooth brushing

of oral hygiene becoming suboptimal. The choice of denti-

times vary between 120 s (USA) and 180 s (Europe) [66].

frice had a signiﬁcant effect on the inhibition of plaque

Manual brushing for additional time did not lead to any

regrowth in a study with manual toothbrushes and may also

signiﬁcant improvement [66], and a brushing duration of

play an important role in optimizing the level of plaque

more than 3 min is usually not achieved [67]. On the other

control achieved with power brushing.

hand, Schlueter et al. [41] reported that repeat motivation at

The systematic review of the Cochrane database by Walsh

each recall, using leaﬂets, instructions and demonstrations,

et al. [69] confirmed the benefits of using fluoride toothpaste

were statistically effective in prolonging tooth brushing

to prevent caries in children and adolescents, but only for

duration and improving tooth brushing technique.

ﬂuoride concentrations of 1000 ppm and above. The relative

caries preventive effect of ﬂuoride toothpastes increases

5. Clinical research for plaque removal

with higher ﬂuoride concentration. However, the choice of

efﬁcacy

ﬂuoride level to use for children under 6 years should be

balanced with the risk of ﬂuorosis. Haftenberger et al. [70]

The gold standard for clinical research is a randomized con- reported that most 1—3-year-old children in Brazil are

trolled trial with large numbers of participants to test the exposed to a daily ﬂuoride intake above the suggested

Table 2 Reported toothbrushing durations.

Authors Year Age (mean age or range) Mean Duration (sec)

Tesini and Perlman 1994 8.4 57.8

Das and Singhal 2009 9—11 76.2

Sharma et al. 2012 8—12 85.8

Macgregor and Rugg-Gunn 1979 11—13 78.0

Macgregor and Rugg-Gunn 1985 18—22 33.0

Dentino et al. 2002 Adults 14 out of 81 spent 120 or more

74 H. Hayasaki et al.

Table 3 Indices for the clinical evaluation of dental plaque.

Authors Year Method

Quigley and Hein 1962 Quigley and Hein (Q&H) plaque index

Silness and Loe 1964 Silness and Lo¨e plaque index

Turesky et al. 1970 Turesky modiﬁcation of the Q&H plaque index

Elliott et al. 1972 Navy plaque index

O’Leary et al. 1972 O’Leary plaque control record

Lobene et al. 1982 Lobene modiﬁcation of the Q&H plaque index

Rustogi et al. 1992 Rustogi modiﬁed Navy plaque index

threshold for dental ﬂuorosis. The dentifrice alone was good oral health. Medications can induce hyposalivation,

responsible for an average of 81.5% of the daily ﬂuoride which in turn, increases the risk of tooth decay and other

intake, while the diet, water and milk were the other most dental diseases [85,86]. Without support for regular oral

important contributors. Although the efﬁcacy of ﬂuoride hygiene habits there is a risk that dependent residents will

paste has been conﬁrmed, information about its risks should develop oral diseases. Care involves not only caring for the

be given more emphasis. Accordingly, detailed longitudinal sick but also taking preventive measures to preserve good

studies of ﬂuoride intake during tooth brushing with tooth- overall health.

paste in large populations are still needed, especially of very For individuals with disabilities, the dental health is gen-

young children in various countries and areas. erally worse than that of normal people of the same age

There is evidence that casein phosphopeptide-amorphous because their medical, physical, social, or psychological

calcium phosphate, CPP-ACP, can bolster the effects of disabilities limit their access to oral health care, including

ﬂuoridated toothpaste alone to prevent caries. The localized diagnostic, preventive, interceptive and treatment services

CPP-ACP nanocomplexes in plaque and on tooth surfaces can [87,88]. Anders and Davis [89] concluded that patients with

buffer the free calcium and phosphate ion activities, main- intellectual disabilities have poorer oral hygiene than the

tain a state of supersaturation with respect to tooth enamel, general population [90—95]. The above listed disadvantages

prevent enamel demineralization, and promote reminerali- lead to poorer oral health, more untreated decayed teeth

zation [71]. Several studies have shown a synergistic effect of and severe periodontal status [96—99]. However, some stu-

CPP-ACP and ﬂuoride in reducing caries [72,73]. Almost all dies [100,101] have reported that the oral health of children

clinical trials have investigated the effectiveness of CPP- with disabilities can be improved to a similar or even better

ACP-containing products in caries prevention and enhancing status than that of normal children at the same age in spite of

remineralization of initial caries lesions in the permanent their disadvantages. The main reasons for improvement can

dentition of young adolescents [74—76]. be accredited to the practice of daily tooth brushing by

Specially formulated oral care products containing stan- themselves or by their caregivers, and diet control by insti-

nous salts (e.g., chloride, ﬂuoride) have shown to effectively tutes and schools [100].

protect enamel and dentin from erosive and abrasive wear in Dental care has been found to be the most common cate-

vitro [77—79] and in situ [77,80,81]. It has been suggested gory of unmet healthcare services for individuals with special

that the stannous ion can act either by precipitation on healthcare needs [102,103]. These individuals are at a higher

dental surfaces forming a relatively acid-resistant mineral risk for more untreated caries, gingivitis and other periodontal

layer or by incorporation into the eroded surface in a complex diseases, malocclusions secondary to abnormal development

demineralization and remineralization process [79]. While and muscle function, problems related to poor oral hygiene

these data are encouraging, it must be borne in mind that and dental/orofacial trauma, as well as inadequate access to

erosion is highly inﬂuenced by biological factors, especially care. [102] More importantly, if adequate oral hygiene and oral

those imposed by the acquired dental pellicle [82]. health care are not addressed the sequelae can be detrimental

to the overall health of the individual. The role of caregivers

7. Oral care for elderly persons and persons and dental health professionals’ instructions to caregivers are

with disabilities crucial for these disable persons.

8. Conclusion

Good oral health is an important aspect of quality of life,

even for the elderly [83]. Teeth are important for chewing,

speech and appearance [84]. In recent years, people’s overall In this paper we have discussed various aspects of oral

health has improved, as is reﬂected in an increase in the prophylaxis, especially, tooth brushing. This is a basic and

average life expectancy in developed countries. Today, the fundamental daily custom for almost all people, even in

elderly remain dentate to a greater extent than just a few developing countries, and its aim is to remove dental plaque.

decades ago and have more teeth, often with extensive However, more than 40% of plaque will not be removed, even

repairs, crown and bridge work and implants. This places by a well-trained person. Because of the importance of

high demands on satisfactory oral care for the elderly to prevention of dental caries and periodontal disease,

remain in good oral health. improvement of the quality of daily brushing is indispensable.

Oral health is also affected by a number of general health In addition, combining more effective brushing with dental

factors. Dementia and various mental and physical disabil- ﬂoss, inter-dental brush and oral rinses, will provide better

ities, for example, can result in difﬁculties in maintaining oral health for all.

Tooth brushing for oral prophylaxis 75

[21] Chilton NW, Didio A, Rothner JT. Comparison of the

Conﬂict of interest statement

clinical effectiveness of an electric and a standard toothbrush

in normal individuals. J Am Dent Assoc 1962;64:777—82.

The authors declare no conﬂict of interest.

[22] Hoover DR, Robinson HB. Effect of automatic and hand tooth-

brushing on gingivitis. J Am Dent Assoc 1962;65:361—7.

[23] Jain Y. A comparison of the efﬁcacy of powered and manual

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