Toothbrush Technology, Dentifrices and Dental Biofilm Removal a Peer-Reviewed Publication Written by Fiona M

Earn 2 CE credits This course was written for dentists, dental hygienists, and assistants.

Toothbrush technology, dentifrices and dental biofilm removal A Peer-Reviewed Publication Written by Fiona M. Collins, BDS, MBA, MA

PennWell designates this activity for 2 Continuing Educational Credits Publication date: July 2009 Go Green, Go Online to take your course Review date: April 2011 Expiry date: March 2014 This course has been made possible through an unrestricted educational grant. The cost of this CE course is $49.00 for 2 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives By the 1980s, it was known that dental plaque consisted of The overall goal of this course is to provide information on a complex environment containing both periodontopathic and the removal of plaque (dental biofilm) during home care oral cariogenic bacteria. The main cariogenic bacteria contained in hygiene with toothbrushes and dentifrices. dental biofilm are Streptococcus mutans, with lactobacilli and Upon completion of this course, the clinician will be able to minor bacteria also playing a role. The associations among, do the following: and proportions of, bacteria change over time as strains that 1. Decribe dental biofilm development and bacterial are more virulent are introduced. Supragingival plaque con- growth. tains more aerobic bacteria (e.g., Streptococcus mutans) and 2. Describe the attributes of ideal toothbrushes and acts as a bacterial reservoir for subgingival plaque. Subgin- dentifrices. gival plaque contains a high proportion of anaerobic bacteria 3. List and describe the considerations involved in selecting (periodontopathogens). Gram-negative anaerobic bacteria a manual, powered or sonic brush gradually increase in number and alter the nature of the bio- 4. List and describe the considerations involved in film. Socransky and Hafferjee discovered that dental biofilm dentifrice selection with respect to plaque removal. is made up of specific groupings of bacteria consisting of five complexes of varying pathogenicity and virulence.5,6,7 Three Abstract periodontopathogens in the red complex of bacteria — T. Dental plaque is a complex biofilm consisting of a polysac- forsythensis, P. gingivalis and T. denticola — are considered charide matrix containing bacteria, voids and nonvital mate- to be the most common bacteria associated with periodontal rial of bacterial origin. Both cariogenic and periodontopathic disease.8 In mature biofilm, the bacteria are enveloped by the bacteria reside in dental biofilm (plaque). While other factors biofilm structure, which consists mainly of a polysaccharide must also be present for caries or periodontal disease to exist matrix containing voids as well as nonvital material of bacte- in a patient, without these bacteria neither bacterial disease rial origin. It is important to note that periodontal disease will will occur. The primary goal of toothbrushing is to remove not result from the presence of a bacterial infection on its own, the dental biofilm present on and adjacent to the teeth, but involves local and systemic contributing factors and the thereby removing the bacteria associated with caries and host response.9 periodontal disease; use of a dentifrice while brushing helps Reducing, removing or changing the biofilm is carried remove plaque and will also deliver agents to the tooth sur- out to try to reduce the bacteria associated with caries and face. Manual, powered and sonic brushes have all been shown periodontal disease, to freshen the breath and for social ac- to be effective and safe for the removal of plaque, when used ceptance. A plethora of products is available for these indica- appropriately. Selecting or recommending oral hygiene aids tions, including toothbrushes, dentifrices, rinses, creams, and involves a number of considerations, including effectiveness, professional and prescription products. Agents that have an- cleaning ability, ease of use and likely compliance. tibacterial properties include triclosan/copolymer, essential oils, chlorhexidine, xylitol and cetylpyridinium chloride. The Introduction scope of this article is to address plaque removal. Since prehistoric times, man has devised a variety of methods to clean and whiten teeth. Some of the earliest devices used Ideal Toothbrush and Dentifrice Properties as “toothbrushes” were similar to some woodstick devices Toothbrushes are designed for dental plaque removal in as currently in use. It was not until the second half of the 20th efficacious a manner as possible, without damaging the hard century that first powered and later sonic toothbrushes were or soft tissues, and dentifrice slurry provides some cleaning introduced. Modern toothpaste precursors were developed ability with a toothbrush. starting in the early 1800s.1 The development of toothbrushes An ideal toothbrush should effectively and safely remove and dentifrices accelerated in the latter half of the 20th cen- plaque and deliver agents in the dentifrice to the tooth sur- tury, in the search for products ideally suited to their purpose. face. It should be easy to use, ergonomic and patient-friendly Early efforts at tooth cleaning were focused on making and be able to remove plaque from all surfaces of the tooth, teeth look cleaner and whiter and freshening breath. There including interstitially. For children, the toothbrush can in- was, however, no understanding of dental biofilm (plaque). corporate design features that help motivate them to brush. One of the first people to try to understand the oral ecology An ideal dentifrice should help prevent plaque formation, was Willoughby Miller, who believed that periodontal disease disrupt plaque and optimize plaque removal. It should also was caused by microbes, and who also published an article contain agents that help protect the dentition and periodontal identifying several acidogenic bacteria.2,3 Seminal research in tissues; these include agents that prevent demineralization and the 1960s and 1970s by Loe4 and others definitively demon- aid remineralization; prevent and reduce periodontal inflam- strated the role of plaque as a bacterial ecology involved in the mation and disease; help prevent oral ulcerations, irritations development of periodontal disease. Bacteria were also known and other oral conditions; and prevent or reduce halitosis. In to be associated with caries. addition, the toothbrush and dentifrice should be effective

2 www.ineedce.com without damaging the tooth surface or gingivae. Finally, in propriate use of toothbrushes varies15, and other factors may our esthetically conscious society, a toothpaste that improves impact the amount of plaque removed with a given effort. esthetics by whitening the teeth through stain removal, or that gives the appearance of whiter teeth, is desirable. When used appropriately, manual, powered and sonic brushes can all be effective for dental biofilm removal. Table 1. Ideal Properties Historically, for manual brushing patients have been Disrupt and remove plaque effectively taught the Bass technique and to angle the brush so that the Reduce plaque bristles will be at 45 degrees to the sulcus. The Bass technique Prevent and remove stain requires dexterity, patience and knowledge in order to perform Deliver agents to the tooth surface satisfactorily. More recent manual brushes have been designed Prevent demineralization with the bristles configured at varying angles and lengths to Aid remineralization overcome the requirement to perform the Bass technique, or Prevent and reduce periodontal inflammation with handles and grips that result in the bristles being in a Prevent oral irritations and ulcerations tilted 45 degree angle and help patients brush. Prevent and reduce halitosis Patient-friendly and ergonomic Figure 1. Manual brushes

Toothbrushes The primary objective of toothbrushing is to safely and effectively remove dental biofilm from all surfaces of the dentition. While patients tend to focus on the buccal and labial aspects of the teeth, particularly the upper anterior teeth, since these are the areas that are visible and easy-to-reach, plaque removal from the lingual and interdental plaque is key; failure to regu- larly remove dental plaque will result in the development of a mature biofilm. Typically, brushing and interdental cleaning with the adjunctive use of floss or other interdental devices to remove plaque interdentally (where a toothbrush cannot reach Powered brushes also require patients to master an appropri- or only partially reaches) are recommended for oral hygiene. ate technique; however, one advantage of powered brushes in general is their ability to remove a greater amount of plaque in The primary objective of toothbrushing is the safe a given period of time than manual brushes. One study found and effective removal of dental biofilm from all that 75% of dental biofilm was removed in 15 seconds with surfaces of the dentition. a rotation-oscillation powered brush; the same amount of plaque removal required twice as long with a manual brush.16 Brushing can be achieved using a manual, powered or sonic Sonic and powered rotation and rotation-oscillation brushes brush. Manual, powered and sonic brushes are all effective at have been found in other studies to also offer superior plaque removing dental biofilm provided they are used appropri- removal compared to manual brushes. ately and are well-designed.10,11,12 Robinson et al. conducted Figure 2. Powered and sonic brushes a meta-analysis of manual and powered toothbrushes catego- rized by mode of action, finding that the rotation-oscillation brushes reduced plaque and gingivitis more than the manual brushes, with a 7% reduction in plaque (Quigley-Hein index) and a 17% reduction in bleeding-upon-probing (Ainamo Bay index) after more than three months. It should be noted that one of the criteria was for studies to be 28 days or longer; all studies shorter than this or not meeting other criteria were ex- cluded.13 A small cross-over study submitted in 2006 involved 30 days use of each brush (manual, powered or ultrasonic) in orthodontic patients and a 15-day washout period between use of the different test brushes. Plaque scores were lower on the buccal surfaces with brackets when using the ultrasonic brush. Strep. Mutans levels were lower using the powered or ultrasonic brushes.14 Compliance with oral hygiene and ap- www.ineedce.com 3 Figure 3. Interdental aids One advantage of powered brushes in general is their potential to remove a greater amount of plaque in a given time.

Zimmer et al. compared two sonic brushes with a manual toothbrush in a single-blinded crossover study on 36 teenagers and adults. Each participant sequentially used each type of toothbrush for two weeks, with a two-week washout period between brush types. Both sonic brushes were found to result in superior plaque removal and pre- vention of gingivitis compared to the manual toothbrush.18 In a six-month, single-blinded study comparing use of a sonic or powered brush by 66 patients, 54 of whom completed the study, it was found that supragingival plaque removal was greater with the sonic brush. In addition, by six months, the reduction in gingival inflammation reached 31.9% for the sonic brush and 18.1% for the powered brush, and probing depth reductions were 15.8% and 7.2%, re- spectively.19 Bader and Boyd found a rotary powered brush to be more effective than a sonic brush.20 A recent in vivo single-blinded, randomized crossover study with a sonic showed that in the majority of the studies, no additional brush found 88.9% whole-mouth plaque reduction com- benefit was seen with the use of floss, and the investiga- pared to the control.21 tors concluded that dental professionals should determine One study compared the volume of dental biofilm and for individual patients whether recommending floss is fluoride retention following brushing with a rotation-oscil- useful and if patients can floss adequately. For interdental lation, sonic or manual brush or a manual brush plus floss- brushes, nine publications were found to meet all inclusion ing. Forty-seven subjects were randomized to a sequence of criteria, with use of interdental brushes shown to remove trials with each method and used fluoride or fluoride-free more interdental plaque than brushing alone, resulting dentifrice with a washout of seven days between tests. Sonic in improvements in plaque and bleeding-upon-probing brushing resulted in the least remaining plaque, with a 43% scores and probing pocket depth.25,26 For woodsticks, seven to 65% reduction compared to all other treatments. With publications met all inclusion criteria. It was concluded that respect to fluoride retention, use of a sonic brush resulted woodsticks did not reduce the level of interdental plaque in greater fluoride retention from the first day, and after a or improve gingival indices. They were, however, found to week resulted in 40% greater fluoride concentration than any reduce bleeding.27 Finally, a separate publication analysis on other treatment, the least effective being manual brushing oral irrigation found seven publications that met all inclu- and flossing (which demonstrated a reduction in fluoride sion criteria. It was found that oral irrigation did not reduce retention on day 1).22 visible plaque compared to brushing alone. Nonetheless, the researchers were able to conclude from the publications Interdental plaque removal that the trend was positive for improvements in gingival Interdental cleaning is associated with lack of compli- health with oral irrigation compared to brushing only (Table ance23,24 and has been reported to have relatively poor ef- 2).28 The American Dental Association recommends using ficacy with a number of methods used. Interdental cleaning either floss or an interdental cleaner daily.29 aids include floss as well as interdental brushes, picks, A sonic subgingival cleaner (soniPick Sonic Inter- woodsticks and irrigators. dental Plaque Remover) with three bristle lengths was Floss is known to be difficult for patients to use, which introduced as an adjunct to improve plaque removal. In can result in inadequate plaque removal even with compli- vitro testing found that this device resulted in greater sub- ance. Some studies have found the efficacy of floss to be gingival plaque removal with any of the bristle tip lengths, negligible. as measured by removal of artificial plaque from pressure- Separate literature reviews using MEDLINE-PubMed sensitive paper inserted 3 mm under mock gingivae, and Cochrane database–sourced publications have been compared to use of a manual, multi-tufted, flat toothbrush conducted to determine the effectiveness of interdental aids with the bristle tips at a 45 degree angle at the gingival as adjuncts for interproximal plaque removal. For flossing, margin.30 Irrespective of efficacy, each of these techniques eleven publications met all eligibility criteria. Analysis requires an additional step.

4 www.ineedce.com Table 2. Literature review of interdental plaque removal aids effects was use of a sonic toothbrush and an electric interdental flosser, mainly attributable to the flosser, and only in Flossing 11 studies No additional benefit in majority 35 of studies patients with poor oral hygiene. In another study, use of a Interdental 9 studies Remove more plaque than brush- sonic toothbrush resulted in a 57% reduction of supragingival brushes ing alone plaque in orthodontic patients who had gingivitis, versus 10% 36 Improvements in plaque, for manual brushing. Costa et al. also studied plaque and bleeding-upon-probing scores gingival indices for reductions with either manual or sonic/ and probing pocket depth ultrasonic brushes. Both types were found to provide reduc- Woodsticks 7 studies Reduced bleeding tions; however, for orthodontic and dental implant patients, a Oral irrigation 7 studies Positive trends in gingival health greater reduction was found with sonic brushes.37 For children, the more attractive and easier a brush is Compared to manual brushes, powered and sonic brushes to use, the more, in principle, they will be motivated to use have been found to offer superior interdental plaque removal the brush. For this reason, children’s manual and powered in a number of studies (with the only extra step being a simple toothbrush designs have incorporated pop culture characters change of the brush head to an interdental brush head, for and names, flashing lights, tunes, and other visual and aural some models). One study found that use of such a brush head displays aimed at attracting children. in a powered rotation-oscillation brush resulted in superior plaque removal and control of gingivitis compared to man- Figure 4. Pediatric manual brushes ual brushing plus flossing and use of interdental toothpicks (woodsticks).31 Yankell et al. found in in vitro testing that a sonic brush demonstrated greater ability to access interproximal areas compared to either a powered brush or a manual brush.32 A recent single-blinded, randomized crossover in vivo study with a sonic brush (Spinbrush Sonic) found that its use resulted in plaque reduction in hard-to-reach areas ranging from 69% to almost 98%. The greatest reductions were found in lingual interproximal areas.33 These results are significant given the inability of patients to reach difficult-to- access areas of the dentition.

Compared to manual brushes, powered and sonic brushes Figure 5. Pediatric powered brushes have been found to offer superior interdental plaque removal.

Orthodontic patients and children Powered and sonic brushes may offer help to orthodontic patients and children who do not brush for long enough or may have difficulty brushing manually. Comparative studies have been conducted in vitro, in situ and in vivo with orthodontic patients on the use of manual, powered and sonic brushes as well as interdental aids. Sander et al. assessed the ability of sonic and rotating brushes to remove artificial plaque in vitro from plastic surfaces simulating teeth with multibracket appliances. The reduction in plaque was determined using before and after photo analysis. In this study, it One concern with powered and sonic brushes has been their was found that brushing efficacy, defined as plaque removal, effect on the shear bond strength of orthodontic brackets. A was dependent not on the type of brush but on the individual number of in vitro studies has been conducted concluding brush. The investigators also concluded that longer brushing that use of powered and sonic brushes did not negatively times and mastery of a proper brushing technique were still influence the shear-bond strength of orthodontic brackets. required.34 In orthodontic patients, a comparison of manual Garcia-Godoy and de Jager, in an in vitro study using orth- and sonic toothbrushes, sonic toothbrush plus an electronic odontic brackets bonded to the enamel surface of extracted interdental flosser, and sonic toothbrush plus manual flossing teeth, determined that the shear bond strengths were the was documented; while improvements occurred in the first same whether manual, sonic or powered brushes were used in four weeks, the only treatment regimen offering longer-term a method equivalent to two years of regular use.38 Ultrasound www.ineedce.com 5 toothbrushes and rotation-oscillation toothbrushes were also flow with bubbles can be expected to remove dental biofilm in found in in vitro studies to be safe for orthodontic brackets vivo and recommended maximum fluid velocity.44 It has also and dental restorations. No significant effect was found on been found that bubbles are most effective when they collide orthodontic brackets with any of the brushes tested.39 with the biofilm at an angle of between 5 and 45 degrees.45 Busscher et al. concluded that a high percentage of bacte- Sonic toothbrushes and mechanism of action rial pairs that were adherent to each other were removed by Sonic toothbrushes utilize the principles of fluid dynamics noncontact sonic brushing at a distance of up to 6 mm from to accomplish dental biofilm removal. A study assessing the surface on which the bacteria had colonized.46 In a similar the ability of fluid pressure and dynamic shear forces to re- study, electric, manual and sonic brushes were compared for move dental biofilm was conducted by Stanford et al. In situ their ability to remove adhering and nonadhering streptococci samples were allowed to develop dental biofilm for 16 hours, and actinomyces. It was found that sonic brushes removed al- then removed and tested in vitro for 5, 10 or 15 seconds with most all adhering bacterial pairs, while manual and powered the bristles held 2 mm or 3 mm from the surface. After brush- brushes did not and removed less of the coadhering than the ing, the residual bacterial count was assessed. Similar testing nonadhering bacteria. It was also found that the presence of was performed with another electric toothbrush held 3 mm fluoride was immaterial to the amount of bacteria removed by from the surface of similar samples. Plaque reduction using any of the tested brushing methods.47 the sonic brush was 56% to 78% compared to control samples, and no reduction was found using the electric toothbrush 3 Increasing the rate of flow in a fluid overlying biofilm has mm from the tooth surface. (It should be noted that powered been found to result in increased delivery of the agent to brushes are not intended for use 3 mm from the tooth surface.) penetrate and cross the layer of biofilm. The investigators also assessed the results using scanning electron microscopy and concluded that sonic toothbrushes A recent literature review by Stoodley et al. on the mass could remove dental biofilm through fluid dynamics when transport of agents to the biofilm and teeth found that dental held up to 3 mm from the tooth surface.40 Another study biofilm influences the delivery of caries preventives, specifi- confirmed that using airy bubbles against mature dental cally fluoride. It was found that increasing the rate of flow in biofilm on a solid surface resulted in removal of the biofilm a fluid overlying biofilm resulted in increased delivery of the where the bubbles collided with it. The amount removed in agent to penetrate and cross the layer of biofilm.48 a given time was found to vary with the rate of collision of the bubbles against the biofilm and the surface area of the Figure 6. Action of sonic toothbrushes bubbles. The investigators attributed the biofilm removal to fluid dynamic shear forces and determined that a fast bubbly flow could be expected to remove biofilm.41 Parini et al. found that low-velocity flowing bubbles in fluid could remove a film of Streptococcus mutans from a glass surface better than fluid in the absence of bubbles.42 Mechanical – Brush contact Sonic toothbrushes can remove dental biofilm through fluid dynamics when held up to 3 mm from the tooth surface. Fluid Dynamics

It has been hypothesized that sonic brush-head motion Bubbles would generate bubbles in a dentifrice so that ultrasound beamed into the slurry would cause the bubbles to expand and contract in a manner that would dislodge the plaque bacteria adherent to the tooth surface. Pitt conducted an experiment Bioﬁlm Removal in which a submerged biofilm of Streptococcus mutans was subjected to sonic energy between 80 and 1000 Hertz. It was found that the intensity of the acoustics influenced biofilm removal when convective fluid flow was present, but that removal was negligible without this fluid flow (up to 2% over 10 minutes). Introducing gas bubbles into the fluid resulted in almost 100% biofilm removal with intensive sonic activity.43 Pitt et al. concluded from their in vitro study on dental biofilm and sonic acoustic waves that the dynamics of fluid

6 www.ineedce.com Dentifrices toothbrushing significantly influenced the bristle vibration Plaque reduction can be achieved by the mechanical activity of the brush. The study used scanning laser vibrometry to of toothpaste slurry in combination with a toothbrush and/ determine the effects of sonic and other powered brushes. For or by using chemotherapeutic agents to reduce the volume all brushes except the Sonicare, the displacement amplitudes of plaque. Soft or ultra-soft toothbrush bristles are recom- of the bristles were affected by a load of 1 Newton without mended. Studies have variously demonstrated greater or use of toothpaste; with toothpaste, all brushes were affected. lesser abrasivity with manual or powered brushes, notably This could be expected to influence the performance of pow- on eroded (demineralized) dental hard tissue.49,50 However, ered brushes.55 it was found that, specifically with regard to erosion, the abrasiveness of toothpaste slurry was more predictive of Education abrasion than the stiffness of the filaments of manual brush- It is not uncommon for patients to attempt to use powered es.51 The abrasives in modern dentifrices consist of fine, and sonic brushes similarly to the way they use manual rounded particles that gently help remove dental biofilm brushes, moving them in a horizontal manner across the and stain. Frequently used cleaning agents in dentifrices in- teeth and disregarding the movement generated by power, clude baking soda (sodium bicarbonate), calcium carbonate and applying too much load (which would typically result in and calcium phosphate. The radioactive dentin abrasivity stalling). Patients may say “ I didn’t like the electric tooth- (RDA) of current dentifrices is typically in the range of 70 brush and couldn’t get used to it” for that very reason. The to 100 RDA, Dentifrices with an RDA of 70 to 110 are safe importance of educating patients on the use of any type of and effective for dental biofilm and stain removal when used toothbrush, not just manual brushes, was underscored in a appropriately with a toothbrush, as are baking soda denti- study by Renton-Harper et al. They found that uninstruct- frices with a lower RDA. While it has low abrasivity, baking ed de novo use of two different rotation-oscillation brushes soda has excellent cleaning ability even when compared to and one manual brush resulted in no difference in plaque higher-RDA agents.52 Clinical trials with use of a manual reduction during the early period of usage.56 Whether a brush with baking soda dentifrices at concentrations rang- manual, powered or sonic brush is recommended for a given ing from 20% to 65% demonstrated baking soda’s ability to patient, oral hygiene instruction and instructions on use of remove plaque. Increased plaque reduction was found with the toothbrush are required. baking soda dentifrice, with higher concentration of baking soda resulting in more plaque reduction. In addition, Summary for all concentrations of baking soda, incremental plaque Since prehistoric times, man has devised a variety of meth- reduction was found on the harder-to-reach-and-brush ods to clean and whiten the teeth. Toothbrushes are designed proximal and lingual surfaces. It is believed that cleaning for dental plaque (biofilm) removal in as efficacious and safe power rather than abrasivity is an important factor in the a manner as possible, with dentifrices offering cleaning effectiveness of baking soda. Baking soda readily dissolves ability when used with toothbrushes, as well as delivery intraorally and is known to impart a “clean” feeling. The of preventives and other agents. When used appropriately, investigators suggested that the large, soft crystals of bak- manual, powered and sonic brushes can all be effective for ing soda may displace plaque more than other dentifrices or dental biofilm removal. One advantage of powered and may affect the biofilm’s polysaccharide matrix, or the bak- sonic brushes in general is their ability to remove a greater ing soda may disrupt bacterial adhesion by blocking calcium amount of plaque in a given period of time and to aid in- bonds involved in co-adhesion and simultaneously release terdental cleaning. Sonic brushes have been shown to have calcium dioxide gas.53 the ability to also remove dental biofilm when held a slight distance from the tooth surface and to help in the delivery of The inclusion of baking soda in dentifrices has been dentifrice agents. found to benefit plaque removal, especially in hard-to-reach areas. References 1 A brief history of your toothbrush, toothpaste and oral Another option that has been investigated is intraoral hygiene. Available at: www.associated content.com/ recharging with liquid toothpaste onto the brush head dur- article/164851/a_brief_history_of_your_toothbrush. ing brushing. This was found in a small, single-blinded, html. Accessed May 10, 2009. randomized crossover study to result in a greater reduction 2 Miller WD. The human mouth as a focus of infection. of colony-forming bacteria and gram-negative anaerobes Dent Cosmos. 1891;33:689,789,913. compared to conventional brushing without redosing, and 3 Miller WD. The microorganisms of the human also an increase in the amount of surfactant present in the mouth: The local and general which are caused by gingival crevicular fluid.54 Interestingly, Lea et al. found that them. The SS White Dental Manufacturing Company, the load (0, 1 or 2 Newtons) and toothpaste used for powered Philadelphia, 1890. www.ineedce.com 7 4 Löe H, Theilade E, Jensen SB. Experimental gingivitis the Braun Oral-B electric toothbrushes on improving in man. J Periodontol. 1965;36:177–87. periodontal health in adult periodontitis patients. J 5 American Academy of Periodontology Research, Clin Dent. 1997;8(1 Spec No):4–9. 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Int J Dent Hyg. 14 Costa MR, Silva VC, Miqui MN, et al. Efficacy of 2008;6(4):304–14. Ultrasonic, Electric and Manual Toothbrushes in 29 American Dental Association. Oral health topics A-Z. Patients with Fixed Orthodontic Appliances. Angle Cleaning your teeth and gums. Available at: http:// Orthod. 2007;77(2):361-366. www.ada.org/public/topics/cleaning.asp 15 McCracken G, Janssen J, Heasman L, et al. Assessing 30 Yankell SL, Shi X, Emling RC, Bock RT. Subgingival adherence with toothbrushing instructions using a access and artificial plaque removal by a sonic cleaning data logger toothbrush. Br Dent J. 2005;198(1):29-32. device. J Clin Dent. 1999;10(4):139–42. 16 Preber H, Ylipaa V, Bergstrom J, Ryden H. A 31 Murray PA, Boyd RL, Robertson PB. Effect on comparative study of plaque removing efficiency periodontal status of rotary electric toothbrushes using rotary electric and manual toothbrushes. Swed vs. manual toothbrushes during periodontal Dent J. 1991;15:229–234. maintenance. II, Microbiological results. J 17 Tritten CB, Armitage GC. Comparison of a sonic Periodontol. 1989;60(7):396–401. and a manual toothbrush for efficacy in supragingival 32 Yankell SL, Emling RC, Shi X. Interproximal access plaque removal and reduction of gingivitis. J Clin efficacy of Sonicare Plus and Braun Oral-B Ultra Periodontol. 1996;23(7):641–648. compared to a manual toothbrush. J Clin Dent. 18 Zimmer S, Fosca M, Roulet JF. Clinical study of the 1997;8(1 Spec No):26–9. effectiveness of two sonic toothbrushes. J Clin Dent. 33 Data on file. 2000;11(1):24–7. 34 Sander FM, Sander C, Toth M, Sander FG. Dental 19 Robinson PJ, Maddalozzo D, Breslin S. A six-month care during orthodontic treatment with electric clinical comparison of the efficacy of the Sonicare and toothbrushes. J Orofac Orthop. 2006;67(5):337–45.

8 www.ineedce.com 35 Kossack C, Jost-Brinkmann PG. Plaque and gingivitis and sonic toothbrushes. Caries Res. 2006;40(1):60–5. reduction in patients undergoing orthodontic treatment 51 Wiegand A, Schwerzmann M, Sener B, Magalhaes with fixed appliances: comparison of toothbrushes AC, Roos M, et al. Impact of toothpaste slurry and interdental cleaning aids, A 6-month clinical abrasivity and toothbrush filament stiffness on single-blind trial. J Orofac Orthop. 2005;66(1):20–38. abrasion of eroded enamel: an in vitro study. Acta 36 Ho HP, Niederman R. Effectiveness of the Sonicare Odontol Scand. 2008;66(4):231–5. sonic toothbrush on reduction of plaque, gingivitis, 52 International Standards Organization 11609, 1995. probing pocket depth and subgingival bacteria in Dentistry: toothpaste—requirements, test methods adolescent orthodontic patients. J Clin Dent. 1997;8(1 and marking. Spec No):15–9. 53 Putt MS, Milleman KR, Ghassemi A, Vorwerk L, 37 Costa MR, Marcantonio RA, Cirelli JA. Comparison Hooper WJ, et al. Enhancement of plaque removal of manual versus sonic and ultrasonic toothbrushes: a efficacy by tooth brushing with baking soda review. Int J Dent Hyg. 2007;5(2):75–81. dentifrices: Results of five clinical studies. J Clin Dent. 38 García-Godoy F, de Jager M. Effect of manual and 2008;21(4):111–26. powered toothbrushes on orthodontic bracket bond 54 Barlow AP, Zhou X, Barnes JE, Hoke SH, Eichhold strength. Am J Dent. 2007;20(2):90–2. TH, et al. Pharmacodynamic and pharmacokinetic 39 Sorensen JA, Pham MM, McInnes C. In vitro safety effects in gingival crevicular fluid from re-dosing evaluation of a new ultrasound power toothbrush. J during brushing. Compend 2004;10 (Suppl 1):21–7. Clin Dent. 2008;19(1):28–32. 55 Lea SC, Khan A, Patanwala HS, Landini G, Walmsley 40 Stanford CM, Srikantha R, Wu CD. Efficacy of the AD. The effects of load and toothpaste on powered Sonicare toothbrush fluid dynamic action on removal toothbrush vibrations. J Dent. 2007;35(4):350–4. of human supragingival plaque. J Clin Dent. 1997;8(1 56 Renton-Harper P, Addy M, Newcombe RG. Spec No):10–4. Plaque removal with the uninstructed use of electric 41 Parini MR, Pitt WG. Dynamic removal of oral toothbrushes: comparison with a manual brush and biofilms by bubbles. Colloids Surf B Biointerfaces. toothpaste slurry. J Clin Periodontol. 2001;28(4): 2006;52(1):39–46. 325–30. 42 Parini MR, Eggett DL, Pitt WG. Removal of Streptococcus mutans biofilm by bubbles. J Clin Author Profile Periodontol. 2005;32(11):1151–6. 43 Pitt WG. Removal of oral biofilm by sonic phenomena. Fiona M. Collins, BDS, MBA, MA Am J Dent. 2005;18(5):345–52. Dr. Fiona M. Collins has authored 44 Ibid. and presented CE courses to den- 45 Parini MR, Pitt WG. Removal of oral biofilms by tal professionals and students in bubbles: the effect of bubble impingement angle and the US and internationally. She is sonic waves. J Am Dent Assoc. 2005;136(12):1688–93. a past-member of the Academy 46 Busscher HJ, Rustema-Abbing M, Bruinsma GM, de of General Dentistry Foundation Jager M, Gottenbos B, van der Mei HC. Non-contact Strategy Board, has been a member removal of coadhering and non-coadhering bacterial of the British Dental Association, pairs from pellicle surfaces by sonic brushing and de the Dutch Dental Association, the American Dental Asso- novo adhesion. Eur 2003;111(6):459–64. ciation, the International Association for Dental Research, 47 Yang J, Bos R, Belder GF, Busscher HJ. Co-adhesion and is a member of the Organization for Asepsis and Safety and removal of adhering bacteria from salivary Procedures. Dr. Collins earned her dental degree from pellicles by three different modes of brushing. Eur Glasgow University and holds an MBA and MA from 2001;109(5):325–9. Boston University. 48 Stoodley P, Wefel J, Gieseke A, Debeer D, von Ohle C. Biofilm plaque and hydrodynamic effects on mass Disclaimer transfer, fluoride delivery and caries. J Am Dent The author(s) of this course has/have no commercial ties with Assoc. 2008;139(9):1182–90. the sponsors or the providers of the unrestricted educational 49 Wiegand A, Lemmrich F, Attin T. Influence of grant for this course. rotating-oscillating, sonic and ultrasonic action of power toothbrushes on abrasion of sound and eroded Reader Feedback dentine. J Periodontal Res. 2006;41(3):221–7. We encourage your comments on this or any PennWell course. 50 Wiegand A, Begic M, Attin T. In vitro evaluation of For your convenience, an online feedback form is available at abrasion of eroded enamel by different manual, power www.ineedce.com. www.ineedce.com 9 Questions

1. First powered and later sonic toothbrushes 12. Robinson et al. found from their meta- toothbrushes could remove dental biofilm were introduced in ______. analysis that rotation-oscillation brushes through fluid dynamics ______. a. the second half of the 19th century reduced plaque and gingivitis ______a. only when in contact with the tooth surface b. the first half of the 20th century manual brushes. b. when held at a distance of up to 1 mm from the c. the second half of the 20th century a. less than tooth surface d. none of the above b. as much as c. when held at a distance of up to 2 mm from the 2. Seminal research in the ______by c. more than tooth surface Loe and others definitively demonstrated d. none of the above d. when held at a distance of up to 3 mm from the the role of plaque as a bacterial ecology 13. One study found that ______of tooth surface involved in the development of periodon- dental biofilm was removed in ______22. Increasing the rate of flow in a fluid tal disease. seconds with a rotation-oscillation overlying biofilm has been found to result a. 1930s and 1940s powered brush; the same amount of in ______delivery of the agent. b. 1940s and 1950s plaque removal required twice as long a. decreased c. 1960s and 1970s with a manual brush. b. regular d. all of the above a. 65%; 15 c. increased d. none of the above 3. Supragingival plaque ______b. 75%; 10 subgingival plaque. c. 75%; 15 23. Specifically with regard to erosion, the a. contains more aerobic bacteria than d. 85%; 15 abrasiveness of toothpaste slurry has been b. acts as a bacterial reservoir for 14. ______et al. compared two sonic found by investigators to be ______c. consists predominantly of periodontopathic brushes with a manual toothbrush in a predictive of abrasion than the stiffness of bacteria single blinded crossover study and found the filaments of brushes. d. a and b the sonic brushes to remove more plaque. a. less b. as 4. In mature biofilm, ______. a. Timmer b. Zimmer c. more a. the biofilm structure consists mainly of a polysac- d. none of the above charide matrix containing voids as well as nonvital c. Zimmerman material of bacterial origin d. Timmerman 24. It is believed that ______is an b. the bacteria are enveloped by the biofilm structure 15. With respect to fluoride retention, use important factor in the effectiveness of c. no aerobic bacteria are found of a______brush resulted in greater baking soda. d. a and b fluoride retention than use of a ______a. cleaning power b. abrasivity brush in one study. 5. ______has antibacterial properties. c. strength a. powered; sonic or manual a. Triclosan/copolymer d. none of the above b. Cetylpyridinium chloride b. manual; powered or sonic c. Chlorhexidine c. sonic; powered or manual 25. Intraoral recharging with liquid tooth- d. all of the above d. none of the above, all were equal paste onto the brush head during brushing has been found to result in ______. 16. Berchier et al. found in a meta-analysis 6. Reducing, removing or changing the a. a greater reduction of colony-forming bacteria biofilm is carried out ______. that no additional benefit was seen with b. an increase in the amount of surfactant present in a. to try to reduce the bacteria associated with caries the use of floss, and the investigators the gingival and periodontal disease concluded that dental professionals crevicular fluid b. to freshen the breath should ______. c. a lower reduction of colony-forming bacteria c. for social acceptance a. recommend the use of floss for all patients d. a and b d. all of the above b. determine for individual patients whether recom- 26. It has been hypothesized that baking 7. An ideal dentifrice should help ______. mending floss is useful and if patients can floss adequately soda may affect the biofilm’s ______. a. prevent plaque formation a. polysaccharide matrix b. disrupt plaque c. not recommend flossing d. none of the above b. polyol concentration c. optimize plaque removal c. polyol matrix d. all of the above 17. Yankell et al. found in in vitro testing that d. a and b 8. An ideal toothbrush should ______. a ______demonstrated the greatest access to interproximal areas. 27. If a ______brush is recommended for a. effectively and safely remove plaque from all a given patient, oral hygiene instruction surfaces of the tooth a. sonic brush b. powered brush should be provided on its use. b. be easy to use, ergonomic and patient-friendly a. manual c. deliver agents in the dentifrice to the tooth surface c. manual brush d. none of the above b. sonic d. all of the above c. powered 9. ______brushes are effective at remov- 18. Children’s manual and powered d. all of the above toothbrush designs have incorporated ing dental biofilm provided they are used 28. Uninstructed de novo use of rotation- ______. appropriately. oscillation and manual brushes was a. pop culture characters and names a. Manual found in one study to result in ______b. flashing lights b. Powered difference in plaque reduction during the c. Sonic c. tunes d. all of the above early period of usage. d. all of the above a. no 10. Historically, patients have been taught 19. Powered brushes have been found to be b. a barely significant the ______and to angle the brush so ______for orthodontic brackets. c. a very significant that the bristles will be at 45 degrees to a. unsafe d. none of the above the sulcus. b. safe 29. ______is a frequently used cleaning c. useless a. Postillo technique agent in dentifrices. d. none of the above b. Bass technique a. Calcium carbonate c. Base technique 20. Sonic toothbrushes utilize the principles b. Baking soda d. Bassist technique of ______to accomplish dental biofilm c. Calcium phosphate 11. More recent manual brushes include removal. d. all of the above designs with handles and grips that result a. hydrotherapy 30. The American Dental Association in the bristles being in a tilted ______. b. fluid dynamics recommends using ______daily. a. 15 degree angle c. electromagnetic forces a. floss b. 35 degree angle d. all of the above b. an interdental cleaner c. 45 degree angle 21. Using scanning electron microscopy, c. a brush d. 95 degree angle Stanford et al. concluded that sonic d. a or b

10 www.ineedce.com ANSWER SHEET Toothbrush technology, dentifrices and dental biofilm removal

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

Mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, 1. Describe dental biofilm development and bacterial growth. A Division of PennWell Corp. P.O. Box 116, Chesterland, OH 44026 2. Describe the attributes of ideal toothbrushes and dentifrices. or fax to: (440) 845-3447 3. List and describe the considerations involved in selecting a manual, powered or sonic brush. For immediate results, 4. List and describe the considerations involved in dentifrice selection with respect to plaque removal. go to www.ineedce.com to take tests online. Answer sheets can be faxed with credit card payment to Course Evaluation (440) 845-3447, (216) 398-7922, or (216) 255-6619. Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Payment of $49.00 is enclosed. (Checks and credit cards are accepted.) 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No If paying by credit card, please complete the Objective #2: Yes No Objective #4: Yes No following: MC Visa AmEx Discover Acct. Number: ______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Exp. Date: ______3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Charges on your statement will show up as PennWell 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

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AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST RECORD KEEPING The author(s) of this course has/have no commercial ties with the sponsors or the providers of All questions should have only one answer. Grading of this examination is done All participants scoring at least 70% on the examination will receive a verification PennWell maintains records of your successful completion of any exam. Please contact our the unrestricted educational grant for this course. manually. Participants will receive confirmation of passing by receipt of a verification form verifying 2 CE credits. The formal continuing education program of this sponsor offices for a copy of your continuing education credits report. This report, which will list form. Verification forms will be mailed within two weeks after taking an examination. is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for all credits earned to date, will be generated and mailed to you within five business days SPONSOR/PROVIDER current term of acceptance. Participants are urged to contact their state dental boards of receipt. This course was made possible through an unrestricted educational grant. No EDUCATIONAL DISCLAIMER for continuing education requirements. PennWell is a California Provider. The California manufacturer or third party has had any input into the development of course content. The opinions of efficacy or perceived value of any products or companies mentioned Provider number is 4527. The cost for courses ranges from $49.00 to $110.00. CANCELLATION/REFUND POLICY All content has been derived from references listed, and or the opinions of clinicians. in this course and expressed herein are those of the author(s) of the course and do not Any participant who is not 100% satisfied with this course can request a full refund by Please direct all questions pertaining to PennWell or the administration of this course to necessarily reflect those of PennWell. Many PennWell self-study courses have been approved by the Dental Assisting National contacting PennWell in writing. Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected]. Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet Completing a single continuing education course does not provide enough information DANB’s annual continuing education requirements. To find out if this course or any other © 2009 by the Academy of Dental Therapeutics and Stomatology, a division COURSE EVALUATION and PARTICIPANT FEEDBACK to give the participant the feeling that s/he is an expert in the field related to the course PennWell course has been approved by DANB, please contact DANB’s Recertification of PennWell We encourage participant feedback pertaining to all courses. Please be sure to complete the topic. It is a combination of many educational courses and clinical experience that Department at 1-800-FOR-DANB, ext. 445. survey included with the course. Please e-mail all questions to: [email protected]. allows the participant to develop skills and expertise.

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