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Pesquisa Brasileira em Odontopediatria e Clínica Integrada 2019; 19:e4305

DOI: http://doi.org/10.4034/PBOCI.2019.191.05

ISSN 1519-0501

Association of Support to Oral Health Research - APESB

ORIGINAL ARTICLE

Efficacy of Two Different Toothbrushes on Plaque Control: A

Randomized Clinical Study

Márcia Aparecida Pampolin de Carvalho

, Flávia Martão Flório

, Silvio Antonio dos Santos Pereira

, Ana

Cristina Antunes Martin

, Elton José Cardoso Silveira

, Eduardo Saba-Chujfi

Post-Graduate Program, Department of Periodontology, São Leopoldo Mandic Research Institute, Campinas, SP, Brazil.

0000-0002-6014-2540

Department of Public Health Dentistry, São Leopoldo Mandic Research Institute, Campinas, SP, Brazil. 0000-0001-7742-0255

Department of Periodontology, São Leopoldo Mandic Research Institute, Campinas, SP, Brazil. 0000-0002-9868-9090

Post-Graduate Program, Department of Periodontology, São Leopoldo Mandic Research Institute, Campinas, SP, Brazil.

0000-0002-8132-2401

Post-Graduate Program, Department of Periodontology, São Leopoldo Mandic Research Institute, Campinas, SP, Brazil.

0000-0002-3669-7896

Department of Periodontology, São Leopoldo Mandic Research Institute, Campinas, SP, Brazil. 0000-0002-5596-8612

Author to whom correspondence should be addressed: Flávia Martão Flório, Rua José Rocha Junqueira, 13,

Ponte Preta, Campinas, São Paulo, Brazil. 13045-755. Phone: + 55 19 3211-3765. E-mail:

flaviaflorio@yahoo.com.

Academic Editors: Alessandro Leite Cavalcanti and Wilton Wilney Nascimento Padilha

Received: 21 August 2018 / Accepted: 27 November 2018 / Published: 05 December 2018

Abstract

Objective: This parallel, randomized, examiner-blind clinical trial aimed to evaluate the efficacy

of two different toothbrushes (manual and sonic) on plaque control in adolescents. Material and

Methods: This study enrolled 56 volunteers, randomly allocated to two different groups: group

A (n = 28) for the manual toothbrush (Curaprox 5460 Ultra Soft

) and group B (n = 28) for the

sonic toothbrush (Edel White

). Mean age was 17.2 ± 1.1 years. A calibrated periodontist

performed a periodontal evaluation to assess the presence of plaque with the Turesky

Modification of the Quigley Hein Plaque Index (PI) and the gingival inflammation with the

Silness & Löe Gingival Index (GI). Adolescents received instructions about the mechanical

control of plaque at baseline (T0), with a reexamination after 3 months (T1) and 6 months (T2).

Non-parametric Mann Whitney test was used to compare the differences between the two

toothbrush groups and the Friedman test was used for the comparisons between times. Results:

There has been PI reduction concerning the study times (T0, T1 and T2, p<0.05), but not

between the groups A and B (p>0.05). As for GI there has been no significant difference between

the groups and between the study times (p>0.05). Conclusion: Both toothbrushes were efficient

in the control of supragingival plaque (visible biofilm).

Keywords: Dental Plaque; Toothbrushing; Dental Devices, Home Care; Oral Health; Gingivitis.

Pesqui. Bras. Odontopediatria Clín. Integr. 2019; 19:e4305

Introduction

Periodontal disease is a plaque-dependent disease and its stagnation can lead to inflammatory

processes in the supporting tissue, triggering the destruction of protective tissue (gingivitis) and

supporting tissue (periodontitis) [1]. One of the most severe and advanced consequences of

periodontitis is the irreversible loss of the supporting tissues of the teeth, which can lead to loss of

teeth [2]. Periodontal disease is the second-leading cause of tooth loss [3] and, overall, it is thought

to account for up to 30-35% of all tooth extractions, and, because of cumulative effects or from the

disease itself, these losses increase with the individual's age [4]. Severe periodontitis affects from 5

to 20% of the adult population, and most children and adolescents present signs of gingivitis [5]. In

Brazil, gingival bleeding and calculus are more common in adolescents while the most severe forms

of periodontal disease have found to be prevalent in adults [6].

Its negative effects on the quality of life of the population are known [7] and functional

aspects of the stomatognathic system, such as chewing, swallowing and speaking, can be

compromised by periodontal disease, as well as smile aesthetic and personal self-esteem [3,8,9].

Disease prevention is closely linked to simple routine actions, and it has been proved that the

disorganization and constant removal of the biofilm is capable of influencing disease onset and

progress [10,11]. Then, more broadly, there is health promotion, which involves empowering people

and communities to make healthy choices to improve their health [12], highlighting the importance

of oral-health education in this process [11,13]. Instructions with audiovisual resources considerably

improve the information assimilation by patients [14]. Educational actions lead to an improvement

in oral health, as well as promoting changes in knowledge and attitudes [11].

Regular removal of plaque with a manual toothbrush is the method most commonly used for

oral hygiene - when correctly and enough performed, can remove properly the supragingival plaque

[15]. However, in the case of routine procedures, current statistical data suggest that a

simplification of oral hygiene procedures at home could be useful [16].

In this context, power toothbrushes were introduced in the 1960s and continued to evolve in

terms of performance and design, and many of the models currently available on the market

incorporated a timer to automatically track brushing time and turn the toothbrush off after two full

minutes of brushing and contributing to proper removal of plaque [17]. Although some promising

studies show sonic toothbrushes to be comparable or more effective than manual toothbrushes [18-

21], there are not yet enough studies available on sonic toothbrushes and the outcomes do not show

significant differences between manual and sonic devices on plaque reduction [22]. The scientific

literature does not present enough evidence on the joint effects of oral hygiene motivation and type

of toothbrush and there is no consensus on the effectiveness of manual toothbrushes compared to

electrical ones in terms of reduction of dental plaque [23].

The objective of this study was to evaluate the clinical performance of two different

toothbrushes (manual and sonic) on plaque control and their effects on periodontal health.

Pesqui. Bras. Odontopediatria Clín. Integr. 2019; 19:e4305

Material and Methods

Study Design

This randomized masked clinical trial analyzed two types of toothbrushes: manual and sonic.

Outcome measures were Gingival (GI) and Plaque (PI) indexes.

Sampling Selection

Volunteers, students from Centro de Formação e Integração Social (CAMP), São Bernardo do

Campo, SP, Brazil, were invited by the investigators to take part in the research, informed of the

procedures to which they underwent and about their benefits. They were informed about the follow-

up procedures, being free to leave the experiment at any time, if they wished so. Volunteers decided

freely whether to join the research. In positive case, their participation began only after the signature

of a written informed consent and an assent form.

The calculation of the sample size of 28 students for each group was based on literature

[23,24]. This sample size provided minimum 0.80 power and 5% significance and minimum 0.77

effect [25,26]. The sample size was run in the G*Power software (Heinrich-Heine-Universität

Düsseldorf, Germany).

After agreeing to take part in the research, the volunteers were individually taken into a

private room, where a thorough clinical examination was performed, following a well-founded

history taking, allowing their selection. A questionnaire survey supported the history taking for

everyone. Parents or legal guardians signed the questionnaires for participants under 18 years of

age.

Clinical examination was performed through visual examination and palpation to detect soft-

tissue lesions. Dental explorer No. 5 and oral mirror were used for caries evaluation, and CPI probe

and oral mirror for periodontal status.

Volunteers should be in (1) good general health, (2) having a minimum of twenty permanent

natural teeth, excluding third molars. Subjects were excluded if they presented (1) advanced

periodontal disease, with oral lesions or periodontal pockets ≥ 3mm, periodontal insertion loss or

gingival recession ≥ 2mm, (2) limited manual dexterity, (3) active caries, (4) medical conditions

limiting their salivary function or immunological condition, and if they were (5) fixed orthodontic

appliances users, (6) pregnant women or (7) smokers.

After the selection, numbers associated to each volunteer were put into an urn, allowing a

draw to compose the study groups. 56 participants, of both genders, aged between 15 and 20 years,

were split into two groups (A and B): Group A (n = 28) – manual toothbrush (Curaprox 5460 Ultra

Soft

, Curaden Swiss do Brasil Imp. Exp. LTDA, São Caetano do Sul, Brazil) and Group B (n = 28) –

sonic toothbrush (Edel White

, Scanderra GmbH, Zürich, Switzerland).

For randomization, as per Figure 1, each volunteer removed from an urn a paper with his or

her respective group. This urn had 28 papers for each one of the two groups. Another dentist

performed the randomization, which did not involve trial investigators.

Pesqui. Bras. Odontopediatria Clín. Integr. 2019; 19:e4305

Figure 1. Flow diagram of study design showing the randomization of participants.

Experimental Procedures

After the randomization, volunteers were taken to a room corresponding to their groups,

where they received, from a periodontist with no clinical involvement in the trial, the kit with

manual toothbrushes or sonic toothbrushes respectively, dentifrice (Colgate 1450ppm fluoride –

basic dentifrice with no antiplaque agent, Colgate-Palmolive Company, São Paulo, Brazil) and

Colgate dental floss (Colgate-Palmolive Company, São Paulo, Brazil). Each group of participants (A

or B) was instructed on its tooth brushing technique, through a tutorial video session, with

complimentary instructions being given thereafter by the same periodontist. Study participants

agreed to refrain from the use of all oral hygiene procedures, including chewing gum, for 12 hours

prior to each evaluation. Study participants also agreed to refrain from the use of mouthwashes and

gels during the trial period.

Group (A) instructions (T0):

Bass technique for manual toothbrush (Curaprox 5460 Ultra Soft

! Place the head of the toothbrush against the teeth, then tilt the bristle tips to a 45-degree

angle against the gum line (cervical margin of the tooth);

! Press the bristle tips slightly to penetrate the gingival sulcus, as well as the interdental niches.

Vibrate the brush back and forth with short strokes without moving the bristle tips far from

Pesqui. Bras. Odontopediatria Clín. Integr. 2019; 19:e4305

their original positions. Consistently advance in sets of two teeth, spending approximately

four seconds by each set, until two minutes are reached for both dental arches;

! Clean either the vestibular region (external – between the teeth, lips and cheeks), as the

palatine and lingual regions (internal), twice a day;

! In the occlusal region, press the bristles lightly against the occlusal surface, on the cusps and

occlusal fissure sites, vibrating the brush back and forth with short strokes, advancing by

dental groups (molars, premolars, canines e incisors) thoroughly, until the whole arch is

covered.

Group (B) instructions (T0):

Manufacturer’s instructions for the sonic toothbrush:

! Edel White Sonic Generation

is a rechargeable hydro-active toothbrush. The sonic waves

that move with a speed of up to 45.000 strokes per minute allow the bristle tips to vibrate

gently and penetrate even the smallest dental spaces. Edel White Sonic Generation

has

different brushing modes, which can be selected by repeatedly pushing the MODE

SELECTION button. The toothbrush remembers the last chosen mode so that it does not

have to be selected the next time the device is activated (Memory function). The selected mode

for this trial was the Intensive mode;

! When selecting the Intensive mode, the upper two Led-lights glow;

! Gently place the brush against the teeth at a slight angle (approximately 45o) towards the

gum line (cervical margin of the tooth);

! Consistently advance in sets of two teeth, spending approximately four seconds by each set,

until two minutes are reached for both dental arches;

! Clean either the vestibular region (external – between the teeth, lips and cheeks), as the

palatine and lingual regions (internal), twice a day;

! In the occlusal region, press the bristles lightly against the occlusal surface, on the cusps and

occlusal fissure sites, keeping the brush in position, advancing by dental groups (molars,

premolars, canines e incisors) thoroughly, until the whole arch is covered;

! Quadrant Timer – the quadrant timer is a 30-second interval timer that briefly interrupts the

brushing to signal the recommended change to the next quadrant. It reminds the user to brush

the four-quadrants or his mouth equally and thoroughly, for a better overall cleaning;

Participants received instructions for proper floss use, also through video tutorials:

! Be sure to wash the hands before reaching for the floss;

! Break off a piece about 45 centimeters long. Wrap most of the floss around either the middle

finger or the index finger of one hand, and a small amount onto the middle or index finger of

the other hand;

Pesqui. Bras. Odontopediatria Clín. Integr. 2019; 19:e4305

! Gently slide the floss between the teeth in a zigzag motion and be careful not to let the floss

snap or “pop” between teeth;

! Make a C shape with the floss as it is wrapped around the tooth. Then carefully pull the floss

upward from the gum line to the top of the tooth;

! As the floss is moved from one tooth to the next, unroll a fresh section of floss from the finger

of one hand while rolling the used floss onto the finger of the other hand, using the thumb as a

guide;

! Floss each tooth front and back sides.

Manual toothbrush and sonic toothbrushes refills were replaced in T1, and dentifrice and

floss were replenished as well. A calibrated examiner, blinded to the patients’ group allocation,

evaluated them at T0 = baseline, T1 = 3 months and T2 = 6 months [24] according to the

following criteria - Clinical examination: (1) A new clinical examination was conducted after

participants’ enrollment in study groups, this time to assess Gingival and Plaque indexes (with the

use of a CPI probe and oral mirror for periodontal status); (2) All teeth were evaluated, excluding

third molars. When a tooth was missing, the adjacent tooth was evaluated; and (3) The gingival

sulcus surrounding each tooth was probed and measured at 6 locations (3 buccal = MB, B, DB e 3

lingual or palatal = ML/MP, L/P, DL/DP).

Gingival Index (GI)

Silness & Löe Gingival Index (1963) [27]: Score 0 = Normal gingiva. Score 1 = Mild

inflammation - slight change in color, slight edema. No bleeding on probing. Score 2 = Moderate

inflammation - redness, edema and glazing; bleeding on probing. Score 3 = Severe inflammation -

marked redness and edema. Ulceration. Tendency to spontaneous bleeding. Probing depth (PD –

distance from the gingival margin to the bottom of the sulcus) and clinical attachment level (CAL –

distance between cemento-enamel junction and bottom of the sulcus) were also measured. All

measurements were taken at six sites around all teeth, excluding the third molars. The presence of

bleeding on probing (BoP) was recorded almost 10s after each PD measurement.

Plaque Index (PI)

The dental plaque on the teeth was disclosed with a 0.5% basic fuchsin mouthwash. The

crown surfaces of the anterior and posterior teeth were divided into 3 thirds: (1) Cervical third: the

vestibular, lingual or palatal surface closest to the cervix; (2) Middle third: closest to the center of the

tooth; and (3) Incisal or occlusal third: the third of an anterior tooth closest to incisal edge or the

third of a posterior tooth closest to the occlusal surface.

Turesky Modification of the Quigley Hein Plaque Index (1970) [28]: PI was represented as:

Score 0 = No plaque. Score 1 = Separate flecks of plaque at the cervical margin of the tooth. Score 2

= A thin continuous band of plaque (up to one mm) at the cervical margin of the tooth. Score 3 = A

Pesqui. Bras. Odontopediatria Clín. Integr. 2019; 19:e4305

band of plaque wider than one mm but covering less than one third of the crown of the tooth. Score 4

= Plaque covering at least one-third but less than two-thirds of the crown of the tooth. Score 5 =

Plaque covering two-thirds or more of the crown of the tooth. PI for the tooth surfaces stained by

the disclosing agent was scored. The trial ended after 6 months, when it reached the length of

follow-up goal.

Statistical Analysis

Data did not meet the assumptions of a parametric test. Hence, Mann Whitney

nonparametric analysis was used for comparing the two toothbrushes, and Friedman test to compare

the times. R* software (The R Foundation) with a significance level of 5% was used in the analyses.

Ethical Aspects

The present randomized experimental study was approved by the Research Ethics

Committee of the São Leopoldo Mandic School of Dentistry and Research Center (CAAE

56711116.1.0000.5374), according to the Resolution No. 466/12 of the National Council of Health,

which defines guidelines for researches involving human beings. This trial is registered at

ClinicalTrials.gov, number NCT03099551.

Results

Fifty-six adolescents, mean age 17.2 ± 1.1 years, volunteered for this study, 54% female. Of

the total Group A sample, 5 volunteers left the study in T1. From Group B, 4 volunteers left in T1

and 1, prescribed with corticosteroid, was excluded. After T1, new sample size was n = 23 for each

study group. Table 1 presents the demographic information for both groups.

Table 1. Distribution according to gender and age.

Groups

Variables

Manual Toothbrush (N = 28)

Sonic Toothbrush (N = 28)

p-value

Gender

Male

39.3

53.6

0.284

Female

60.

46.4

Age (Mean and SD)

17.34 ± 1.07

17.18 ± 1.16

0.4783

Table 2 shows GI and PI results. No statistically significant difference was observed in GI

between the two toothbrush groups and the visits (p>0.05). Both groups showed a significant

reduction in PI, after 3 months (p<0.05), sustained after 6 months (p>0.05). At 3 months (T1), PI

was significantly lower for the sonic toothbrush group (p< 0.05).

Table 3 presents the results excluding the volunteers with zero scores at baseline (T0). Each

index presents a different volunteer number, as the calculation excluded the volunteers with zero

scores for that index. As for GI, there was a significant reduction after 3 months, for both toothbrush

groups (p<0.05), sustained after 6 months (p>0.05). At baseline, the manual toothbrush group

Pesqui. Bras. Odontopediatria Clín. Integr. 2019; 19:e4305

presented GI greater than the sonic toothbrush (p<0.05), but after 3 months no significant difference

was observed (p>0.05). There were no volunteers with a PI zero score at baseline.

Table 2. Median (minimum value; maximum value) for GI and PI according to the toothbrush used at

all study time points.

Groups

Time

Manual Toothbrush

Sonic Toothbrush

0.07 (0.00; 1.23)

1.50 (0.25; 2,61)

0.00 (0.00; 0.32)

1.30 (0.50; 2.41)

0.00 (0.00; 1.36)

*0.68 (0.11; 1,86)

0.00 (0.00; 0.25)

0.34 (0.00; 2.27)

0.00 (0.00; 1.43)

0.38 (0.00; 2.59)

0.00 (0.00; 0.14)

0.57 (0.00; 1.52)

*Differs from sonic toothbrush at the same study time point (p≤ 0.05). Medians in a column followed by different letters are significantly

different (p≤0.05).

Table 3. Median (minimum value; maximum value) for GI and PI according to toothbrush used at all

study time points, excluding volunteers with zero scores at baseline for each index.

Groups

Manual Toothbrush

Sonic Toothbrush

Time

GI (N=12)

PI (N=23)

GI (N=11)

PI (N=23)

0.36 (0.07; 1.23)

1.50 (0.25; 2,61)

0.18 (0.02; 0.32)

1.30 (0.50; 2.41)

0.06 (0.00; 1.36)

*0.68 (0.11; 1,86)

0.00 (0.00; 0.25)

0.34 (0.00; 2.27)

0.05 (0.00; 1.43)

0.38 (0.00; 2.59)

0.04 (0.00; 0.14)

0.57 (0.00; 1.52)

*Differs from sonic toothbrush at the same study time point (p≤0.05). Medians in a column followed by different letters are significantly

different (p≤0.05).

Discussion

Literature shows controversy about the efficacy of toothbrushes in plaque control. Some

researches proved power toothbrushes are superior relative to manual toothbrushes [15,18,19,29-

31]. Others reported that there is no significant difference between them [20,22,32-34]. In the

present study, even PI reduced over time for both study groups, there was no significant difference

between toothbrushes concerning plaque removal.

Some authors have evaluated the reduction of plaque index and gingival index for only a few

weeks [18-20,35] or a few months [21]. And in some cases, even in a single-session [36], making

difficult the comparison of results, as the methodologies differ. In this study, the interval between

visits followed evaluation parameters previously defined [24], allowing no direct interference of the

oral hygiene instructions and motivation performed in T0 in the PI reduction seen at the following

visits [23].

Regarding the assessment of the effect of supragingival plaque control on inflammatory

status, even with the PI reduction (visible plaque) between visits, there has been no GI reduction, as

also observed in previous studies [34,37]. Some studies showed the association between gingivitis

and PI [17,20,21,35,36,38-40]. As for the studies in which the volunteers did not present gingivitis

reduction after using the toothbrushes [37], possibly this effect was due to lack of the oral

hygiene instructions and motivation at T1, what would cause more false-positive results in PI

reduction [23].

Pesqui. Bras. Odontopediatria Clín. Integr. 2019; 19:e4305

Low GI at baseline can result from the volunteers belonging to a differentiated group,

receiving dietary follow up (from a nutritionist), behavioral coaching and professional psychological

support from the institution as part of their educational activities. This situation illustrates how the

multidisciplinary care focused on oral health became a supporting factor for the plaque reduction in

those studies [41,42].

Although an association between PI and GI exists [22], the present study demonstrated that

the significant reduction in PI observed for both groups did not repeat in GI. This shows that when

dental plaque, as a single sub and supragingival film, is not properly removed from sulcus according

to the recommended brushing technique (Bass), mild or moderate gingival inflammation may occur,

even if the visible plaque around the crown of the tooth is low.

Toothbrush utilization time and inadequate removal of plaque seems to influence plaque

control, interfering with its amount after toothbrushing. This represents an observation from the

present study, which demonstrated a reduction in PI (visible plaque) after oral hygiene instructions

and toothbrushing motivation [23,38,43]. However, it cannot be said that the non-visible plaque

[subgingival] was reduced, what may have kept the gingival inflammation levels. According to the

findings in this study, there has been no significant reduction in GI for both groups after 3 and 6

months, as previously observed [34].

However, more than the device used (manual of sonic), the toothbrushing technique, the

dental material used and the dexterity with which the individual cleans his teeth and oral soft tissues

(clearly linked to his ability and to the level of oral hygiene instructions received) are the

determinant factors for plaque removal and consequently for health promotion. In addition, plaque

control to prevent gingivitis and/or periodontitis is influenced by several individual and material

factors [14].

There are few limitations associated with the present study. One of the potential limitations

is that the investigation was carried out on two small and highly selected sample groups. The same

study, conducted on larger and less favored sample groups would perhaps show conflicting results.

The behavioral modifications of the volunteers caused by the participation in the study and the

institution’s discipline are other possible limitations and may have positively influenced the outcomes

(Hawthorne effect).

The results of the present study were consistent with the literature, although the importance

of the prevention and continuous oral hygiene instructions, independently from the results observed

in the sample evaluated and from the device used, have to be considered. Reference studies highlight

that these resources effectively stimulate the individuals for the daily plaque control and reduction

practices, hence preventing early onset of oral diseases as caries and periodontal disease.

Conclusion

This study did not observe differences between manual and sonic toothbrushes for plaque

control and the effects of plaque reduction on periodontal health were achieved mainly by oral

hygiene instructions and motivation.

Pesqui. Bras. Odontopediatria Clín. Integr. 2019; 19:e4305

Financial Support: None.

Conflict of Interest: The authors declare no conflicts of interest.

Acknowledgments: We would like to thank the students from CAMP SBC who took part in this

study.

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