Week 2 – Toothbrushes & Tooth-Brushing Methods

Objectives of Toothbrushing

  • Remove dental biofilm (plaque) and inhibit/slow its re-formation.
  • Clean teeth of food debris, stains, and acquired pellicle.
  • Stimulate gingival tissues to help prevent or control gingival/periodontal disease.
  • Serve as a vehicle for dentifrice ingredients that protect against dental caries, periodontal diseases, and oral malodor/hypersensitivity.

Historical Overview

  • Pre-history: chewing aromatic twigs; fibres fan out to clean teeth.
  • 3500\text{–}3000\,\text{B.C.} Babylonians & Egyptians – “tooth sticks.”
  • Arabic world – siwak (arak tree roots); natural antibacterial oils & tannins.
  • Tang Dynasty (China) 618\text{–}907\,\text{A.D.} – first handled toothbrush with bristles.
  • 1780 (England) – William Addis manufactures bone-handled, hog-bristle brush.
  • Early 1900\text{s} – celluloid replaces bone; WW I introduces nylon bristles.
  • 1939 (Switzerland) – first power toothbrush.

Characteristics of an Effective Toothbrush

  • Conforms to individual needs in size, shape, texture.
  • Easily manipulated; lightweight, balanced grip.
  • Impervious to moisture; readily cleaned & aerated.
  • Durable yet inexpensive.
  • Optimal flexibility, softness & diameter of filaments; strong but light handle.
  • End-rounded filaments (“end-rounding” reduces trauma).
  • Overall design promotes utility, efficiency, cleanliness.

Toothbrush Anatomy & Dimensions

  • Handle – grasp area.
  • Shank – connects handle to head.
  • Head – working end; tufts of filaments fixed in the stock.
    • Typical head length 25.4\text{–}31.8\,\text{mm}\,(1\text{–}1.25\,\text{in}).
    • Width 7.9\text{–}9.5\,\text{mm}\,(5/16\text{–}3/8\,\text{in}).
    • Filament height ≈11\,\text{mm}.
  • Total brush length ≈15\text{–}19\,\text{cm}\,(6\text{–}7.5\,\text{in}) (junior/child shorter).
  • Brushing plane, heel (proximal end of head), toe (distal end).

Filament Materials Comparison

  • Nylon (synthetic)
    • Uniform diameter; can be fabricated extra-soft → hard.
    • End-rounded; least trauma; repels water/debris; dries quickly.
    • Maintains form longer; more resistant to bacterial contamination.
  • Natural bristle (hog/boar, horse)
    • Irregular/open ends; absorb water; texture varies with animal, origin, season.
    • Wear rapidly; inconsistent diameter; more bacterial retention.

Brush Head Design & Replacement

  • Traditional heads: 10\text{–}12\,\text{mm} long; 3\text{–}4 rows wide.
  • Wide tuft spacing = easier brush cleaning; close spacing = smoother plane & mutual filament support.
  • Angled tuft arrangements improve plaque removal.
  • Soft brushes are least traumatic; recommend for most clients.
  • Replace brush every 2–3 months or sooner when filaments appear splayed/worn.

Bristle Texture & Stiffness

  • Texture = resistance to pressure (firmness/stiffness/hardness).
  • Determined by:
    • Diameter – thinner ⇒ softer (e.g., 0.15\,\text{mm} extra-soft, 0.23\,\text{mm} medium).
    • Length – shorter ⇒ stiffer.
    • Filament density per tuft – more filaments ⇒ stiffer feel.
    • Filament angle – angled filaments offer more flexibility than straight ones of equal size.

Advantages of Soft Nylon Brushes

  • Superior plaque removal in cervical, proximal, and marginal areas.
  • Minimal gingival trauma; can safely access sulcus.
  • Ideal around fixed orthodontics or maxillomandibular fixation.
  • Reduce risk of toothbrush abrasion & recession for vigorous brushers.
  • Beneficial for sensitive/inflamed gingiva (e.g., NUG), post-surgery, or healing sites.
  • Suitable first brush for children; available in many shapes & diameters; solid (non-hollow) filaments.

Toothbrush Abrasion

  • Etiology: hard bristles, improper methods, excessive pressure, abrasive pastes.
  • Common on facial & cervical surfaces of exposed roots.

Factors Influencing Brush Selection

  • Client: oral/systemic health, manual dexterity, motivation.
  • Gingival status & anatomy.
  • Tooth position (crowding, open contacts) & shape/exposed roots.
  • Personal preference & willingness to change.
  • Chosen brushing method’s ease/effectiveness.

Manual Toothbrushing Guidelines

  • Grasp: palm-thumb or modified pen for control.
  • Sequence: begin molar region → opposite side → lingual/facial; overlapping placements.
  • Posterior teeth: head parallel to arch; anterior lingual: handle vertical.
  • Occlusal: filaments pressed into pits/fissures.
  • Encourage patient to start in areas disclosed as most missed.
  • Duration: ≈2\,\text{min} (many people only 45\text{–}60\,\text{sec}).
    • Count system: 5 or 10 strokes / 10-second vibration per site.
    • Clock/egg-timer or built-in timers on power brushes (30-s quadrants).
  • Frequency: minimum 2× daily with interdental care; strongly emphasize night-time cleaning.
  • Include tongue cleaning & evaluation of adverse effects.

Common Brushing Methods

  • Fones (Circular / Rotary)
    • Teeth together; large gentle circles on facial surfaces.
    • Lingual/palatal: in-and-out strokes; occlusal: back-and-forth.
    • Easy for children; risk of trauma if too vigorous.

  • Horizontal/Scrub
    • Vigorous cross-wise motion; generally NOT recommended (abrasion, missed proximal/cervical areas).

  • Bass (Sulcular) & Modified Bass
    • Filaments 45^{\circ} apically into sulcus; small vibratory jiggle.
    • Indicated for periodontal clients without recession.
    • Modified version adds coronal “roll/sweep.”
    • No tissue blanching required.

  • Stillman’s & Modified Stillman’s
    • Filaments partly on gingiva & tooth; slight blanching then vibrate/coronal roll.
    • Designed for gingival massage; useful with recession.

  • Charters & Modified Charters
    • Filaments 45^{\circ} toward occlusal/incisal (away from gingiva); short vibratory strokes.
    • Helpful around ortho brackets, fixed prostheses; modified adds a rolling stroke.

  • Rolling Stroke (vertical sweep) – filaments start apically, roll occlusally; often taught to children.

Supplemental Brushing & Special Considerations

  • Address problem sites (malpositioned teeth, edentulous spaces, occlusal pits).
  • Acute lesions: continue brushing other areas; saline rinses promote healing.
  • Post-periodontal surgery: gentle brushing over dressing & occlusals with soft brush.
  • NUG/Severe inflammation: ultra-soft brush; stress thoroughness.
  • Post-extraction/restoration: avoid surgical site but clean adjacent teeth.

Care & Maintenance of Toothbrushes

  • Keep two brushes (home + travel).
  • Replace every 2\text{–}3 months or when filaments splay.
  • Immunocompromised/infected/surgical patients: disinfect or use disposables.
  • Cleaning: rinse under strong warm water; tap excess.
  • Storage: upright, open air, not touching other brushes; travel cases need vent holes.

Power Toothbrushes

  • Brands/examples: Oral-B, Philips Sonicare, Waterpik Sensonic, Rotadent, Emmi-dent.
  • Beneficial for: ortho appliances, decalcification, periodontal maintenance, gingivitis/periodontitis, elderly, dexterity issues, recession/abrasion lesions, extensive prosthodontics/implants, caregivers, poor motivation.

Modes of Action

  • Rotational – 360° circular (Oral-B early models).
  • Counter-rotational – adjacent tufts rotate opposite directions.
  • Oscillating-rotating – rotates left/right 20^{\circ}\text{–}55^{\circ}, may pulsate.
  • Pulsating – in-out toward tooth (Sonicare).
  • Side-to-side / Cradle / Twist / Translating / Combination – various lateral or vertical vibrations.
  • Sonic – high-frequency, high-amplitude bristle movement; creates hydrodynamic fluid motion.
  • Ultrasonic – >20\,\text{kHz} vibration; cavitational cleaning effect.

Powered Brush Technique

  1. Place bristles on tooth at 45^{\circ}\text{–}90^{\circ} to incisal/occlusal; then switch “on.”
  2. Mouth nearly closed; light, steady pressure.
  3. Keep on each surface 3\text{–}5\,\text{s}; lift to interproximal if needed.
  4. Systematically progress tooth-by-tooth; divide mouth into four quadrants.
  5. Experienced users may angle perpendicular, but pressure must remain gentle.

Tongue Cleaning

  • Papillary dorsum harbors bacteria → malodor & plaque reservoir.
  • Benefits: reduces halitosis, removes debris & bacteria, lessens coated appearance (esp. xerostomia, deep fissures, smokers).
  • Tools: toothbrush (sideways sweep) or dedicated scraper (plastic, stainless steel).
  • Procedure: place scraper arch posteriorly, press lightly, pull forward; rinse & repeat; avoid back-and-forth pushing bacteria posteriorly.

Disclosing Agents

  • Liquid or chewable tablet; erythrosine dye commonly used.
  • Application: swab or dilute rinse 15\text{–}30\,\text{s} then expectorate.
  • Protect lips/restorations with non-petroleum lubricant.
  • Self-evaluation tool; record initial plaque index (PI) & post-instruction PI to gauge improvement.
  • Listerine Agent Cool Blue – pre-brush tinting rinse for children \geq6 yrs; stains plaque blue to guide brushing.

Client Education & Motivation

  • Show specific problem areas with mirror & disclosing agent.
  • Tailor recommendations to client’s abilities, health status, preferences; involve caregivers as needed.
  • Offer alternatives to foster ownership.
  • Demonstrate intra-orally; require client “show-back.”
  • Use positive reinforcement: Educate → Congratulate → Motivate.

References

  • Harris, N.O. & Garcia-Godoy, F. “Primary Preventive Dentistry”, 8th ed., Pearson, 2014.
  • Bowen, D.M. & Pieren, J. “Darby & Walsh: Dental Hygiene – Theory & Practice”, 5th ed., Elsevier, 2020.
  • Evolve Elsevier online resources.