Reviews
Agnieszka Mielczarek
1, A, e, F, Teresa Bachanek
2, B, D, e, Tomasz Konopka
3, D–FAn Assessment of the Effect of Manual and Electric
Toothbrushes on Hard and Soft Oral Tissue
Ocena wpływu ręcznych i elektrycznych szczotek do zębów na stan
twardych i miękkich tkanek jamy ustnej
1 Department of Conservative Dentistry, Medical University of warsaw, Poland
2 Department of Conservative Dentistry and endodontics, Medical University of Lublin, Poland 3 Department of Periodontology, wroclaw Medical University, wroclaw, Poland
A – concept, B – data collection, C – statistics, D – data interpretation, E – writing/editing the text, F – compiling the bibliography
Abstract
in recent years a higher prevalence of gingival recession and dental abrasion has observed in the world popula-tion. The etiology of these pathological processes has a complex, multifactorial nature, but in many cases incorrect brushing techniques are recognized as one of the reasons for oral tissue destruction. Regular tooth brushing is the most important method of good oral care maintenance, but sometimes harmful effects to the dental and oral soft tissue structures are observed after forceful brushing procedures. Recently many new models of manual and electric toothbrushes are available on the market. The aim of this review is to present the current scientific views on the safety of soft and hard tissue with the use of various manual and electric toothbrushes (Dent. Med. Probl.
2013, 50, 4, 472–475).
Key words: gingival recession, dental abrasion, manual toothbrush, electric toothbrush.
Streszczenie
w ostatnich latach w populacji światowej obserwuje się zwiększenie występowania recesji dziąsłowych i abrazji. etiologia tych procesów chorobowych ma złożony, wielokierunkowy charakter. Jednym z czynników uznawanych za przyczynę uszkodzenia tkanek jamy ustnej jest niewłaściwe szczotkowanie zębów. Regularne szczotkowanie zębów jest najistotniejszym elementem utrzymania zdrowia jamy ustnej. Nieodpowiednia technika szczotkowania i użycie zbyt dużej siły nacisku może powodować destrukcję tkanek jamy ustnej. Obecnie na rynku jest dostępnych wiele modeli ręcznych i elektrycznych szczotek do zębów. w pracy zaprezentowano przegląd współczesnych poglą-dów na temat wpływu stosowania szczoteczek ręcznych i elektrycznych na stan twardych i miękkich tkanek jamy ustnej (Dent. Med. Probl. 2013, 50, 4, 472–475).
Słowa kluczowe: recesja dziąseł, abrazje zębowe, szczoteczka ręczna, szczoteczka elektryczna.
Dent. Med. Probl. 2013, 50, 4, 472–475
issN 1644-387X © Copyright by wroclaw Medical University and Polish Dental society
Mechanical control of bacterial plaque is re-garded as the key method of eliminating the in-fective agents responsible for the development of caries and gingivitis. A prerequisite for plaque re-moval is exerting enough energy on the biofilm. The energy generated has to overcome adhesion (adherence to the substrate) and cohesion (inte-gration of the biofilm structure) [1]. in the case of manual toothbrushes this energy comes from
the flexible bending and deflecting of the fibers, i.e. from physical abrasion. electric toothbrush usage ensures an additional source of energy from hydrodynamic action and the generation of sound wave pressure. At present there are many models of mechanical toothbrush on the market, including oscillating-rotating toothbrushes (OR) and oscillating-rotating-pulsating toothbrushes (ORP).
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it is assumed that efficient bacterial plaque re-moval can be accomplished by brushing the teeth for two minutes twice a day, using a fluoridated toothpaste [2]. However, patients tend to overesti-mate the time they spend on oral hygiene: Tooth-brushing times below the recommended 2 minutes are observed, especially when no time control is conducted [3]. The pressure of the toothbrush head during toothbrushing seems to significantly affect the condition of the tissue in the oral cavity. Ac-cording to some authors, manual toothbrushing en-tails the application of much higher pressure than the use of power brushes [4]. Toothbrushing tech-niques also affect the safety of oral cavity tissues to a significant extent. The horizontal scrub tooth-brushing technique is still very popular in Poland, although it has been associated with an increased risk of inducing abrasive defects in oral cavity tis-sues, as compared to the rotary technique. Abra-sivity also depends on toothpaste retention on the brush bristles. it is well recognized that toothpaste, which delivers many chemical agents, is an impor-tant factor in the prophylaxis of caries and gingivitis, but it also has some potential to do harm, connected with its abrasivity when the brush moves the paste over the tooth surface [5]. some data indicate that soft-bristle brushes have more abrasive potential, be-cause of better toothpaste retention on a smaller di-ameter, and due to flexible filaments that have better contact with dental tissue [5, 6]. On the other hand, when a proper toothbrushing technique is used, the type of toothpaste and its relative dentin abrasivity (RDA) value affect the abrasive potential more than the toothbrush bristle characteristics [7, 8].
The effectiveness of toothbrushing depends on: – the frequency and duration of toothbrushing, – the toothbrushing technique,
– the pressure applied to the tissue by means of a toothbrush,
– toothbrush bristle wear,
– manual dexterity and embedded habits, – patient motivation to maintain optimal oral hygiene, and
– dental arch anatomy.
The authors of papers concerning the safety of different toothbrush types most often focus on a cou-ple of aspects of this problem. They usually consider the toothbrushes’ efficiency in dental plaque remov-al, the effect that specific types of toothbrushes have on tooth hard tissue, and/or their potential to initiate abrasive damage and gingival recession.
The effect of the force used during toothbrush-ing on the efficiency of dental plaque removal was assessed in 1996 by van der veijden et al. [9]. The authors compared the efficiency of toothbrushing by means of a manual brush and the oscillatory-rotary power brush Braun Oral-B Plak Control®.
They also measured the habitual pressure
generat-ed during toothbrushing by means of manual and electric toothbrushes, using brushes with appro-priate sensors. An analysis of the results allowed the authors to conclude that when using both man-ual toothbrushes and the power brush, increasing pressure by 100–250 g improves effectiveness of dental plaque removal. This effect was comparable on both buccal and lingual tooth surfaces. Howev-er, the percentage of plaque reduction, which cor-responds to the effectiveness of oral hygiene pro-cedures, was higher in the group using the Braun Oral-B Plak Control brush. Ultimate cleaning effi-ciency was achieved using a pressure of 300 g. ex-ceeding this threshold caused pain and gingival bleeding. The patients automatically applied low-er pressure when using a powlow-er brush. Moreovlow-er, the force exerted on the lingual surfaces was high-er than on the buccal surfaces.
subsequent studies performed by van der vei-jden’s group [10] complemented the previous find-ings. The authors documented a decrease in plaque removal efficiency from 60% to 56% when the pres-sure exerted by an electric toothbrush was increased from 1.5 to 3.5 N. An analysis of these results justifies the conclusion that an increase in pressure can fa-vorably affect the efficiency of toothbrushing only to a certain extent. exceeding the threshold of 300 g is not recommended due to the risk of tissue damage and a decrease in dental plaque elimination.
One of the parameters used to assess the in-fluence of toothbrushing on tooth hard tissue is dentin abrasivity. schemehorn et al. [11] have per-formed an experimental study to compare the RDA of manual and electric toothbrushes (the Braun Oral B Plaque Remover®) on neutron
irra-diated dentin. The study results showed that den-tin abrasivity while using the electric toothbrush was very low (about 16 RDA) and that differed sig-nificantly from the abrasivity of a manual tooth-brush (100 RDA). since the electric toothtooth-brush was proved not to increase dentin abrasivity it was determined to be safer for tooth hard tissue than manual toothbrushes.
Dörfer et al. [12] also affirmed the safety of electric brushes for tooth hard tissue in a long term study. The authors assessed the tooth sur-face profile by means of digital subtraction, using a 3D-Laser scan Profiler after 35 months of brush-ing with oscillatbrush-ing-rotatbrush-ing-pulsatbrush-ing or manual toothbrushes. No statistically significant differ-ences between the toothbrushes were observed in terms of the initiation of abrasive lesions within the enamel and dentin.
Danser et al. [13] assessed the development of gingival recession as a result of toothbrushing. The analysis they performed included the effects of the type of toothbrush, pressure, the frequen-cy of head rotations and bristle shape on dental
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plaque reduction and the risk of gingival recession. The authors observed no differences between manu-al and electric toothbrushes in the clinicmanu-al parameters under investigation. Toothbrushes with sharp bristle ends increased the risk of potential gingival lesions as compared to the rounded ones. No correlation was found between gingival abrasion and the pressure ex-erted by the toothbrush head or the rotation speed.
Further studies in this area revealed that the addi-tional option of pulsating movements utilized in oscil-lating-rotating-pulsating electric brushes, does not in-crease the risk of traumatic gingival injuries [14].
The safety of electric toothbrushes was also ex-amined by Mantokoudis et al. [15]. They observed a group of 26 participants (dental students) who had received professional oral hygiene instruc-tions for using both manual and electric tooth-brushes. The effects of two different electric brush-es (namely the Braun Oral-B Plak Control Ultra®
and Braun Oral-B Plak Control 3D®) and a
conven-tional manual toothbrush on plaque retention (Q-H plaque index), gingivitis (BOP index) and develop-ment or progression of gingival recessions was ob-served. The results demonstrated comparable effi-ciency of plaque removal by all the toothbrushes. No increased risk of gingival recession development was observed for electric toothbrushes.
in 2007 a new product was introduced to the market: a toothbrush that was developed to en-able conscious control of toothbrushing. it creat-ed hope for an eventual increase in the efficien-cy of mechanical plaque control. This new type of toothbrush uses ORP technology and has also been equipped with an integrated wireless smart Guide® display. it enables full control and
moni-toring of toothbrushing, including brushing time for each quadrant and toothbrush pressure on oral tissue. Too much pressure – exceeding 2N – is sig-nalized by sensor excitation.
A 30-day comparative study was performed to compare the efficiency and safety of the new generation of toothbrush used with or with-out the smart Guide® system [16]. in the group
equipped with a display, the pressure sensor was excited 85% less often. in the group deprived of the possibility of monitoring their toothbrushing this reduction was only 53.4%. Using the smart Guide® system also enabled participants to
even-ly allocate the time spent brushing each quadrant and specific tooth surfaces. A lack of brushing time control led to inadequate cleaning of lingual surfaces [16].
A systematic review was published in 2011 by van der veijden et al. [17] concerning the safety of different toothbrushes in respect to soft and hard oral cavity tissue. Thirty five published re-ports from in vitro and in vivo studies culled from a number of databases were included in the
re-port. Their analysis of the collected evidence en-abled the authors to conclude that OR toothbrush-es are safe and their usage dotoothbrush-es not lead to hard or soft tissue destruction.
An additional problem discussed as a result of incorrect toothbrushing techniques is the oc-currence of tooth sensitivity [18]. Hypersensitivi-ty can cause sharp temporary pain during hygiene procedures, eating or drinking. some cases of hy-persensitivity can be observed as a result of the caries process, or as a side effect of restoration or tooth bleaching. This pathology occur when a loss of enamel or dentine, abraded by strong brushing force or eroded by highly acidic products, is ob-served. The exposure of dentinal tubules to the oral cavity environment causes a painful response to all kinds of stimuli. The most common surface for dentine hypersensitivity is the buccal-cervical area. From this point of view tooth sensitivity may be an indirect effect of an incorrect brushing tech-nique, leading to gingival recession and dental tis-sue destruction. This damaging method of den-tal plaque elimination is frequent among manual toothbrush users. Power toothbrushes, especially working in OR mode, require less force for plaque removal than manual brushes [4]. some in vitro studies have also indicated that brushing with low force could occlude patent dentin tubules through the formation of a smear layer [19]. Therefore, for tooth sensitivity prevention, a vigorous, excessive scrubbing technique with highly abrasive tooth-paste should be avoided, especially immediately after drinking or eating acidic products. The ap-plication of desensitizing toothpaste and a prop-er toothbrushing technique with controlled tooth-brush pressure is highly recommended as an im-portant element in the treatment and prevention of hypersensitivity [20, 21]. The hypersensitivity mode available in modern type of electric tooth-brush and appropriate tooth-brush heads with soft bris-tles make it possible to effectively eliminate hyper-sensitivity symptoms. To date, no studies have re-ported any increase in the risk of tooth sensitivity after using electric toothbrushes [22].
The results outlined above suggest that the proper use of power toothbrushes is safe for hard and soft oral tissues. electric brushes do not in-crease gingival abrasion in comparison to manual toothbrushes. Dentin abrasivity was not found to be higher when using power brushes – conversely, they proved to be less abrasive than manual brush-es. Taking into account the advantages of electric toothbrushes over manual ones in terms of dental plaque removal and the reduction of gingival in-flammation, the use of electric brushes should be promoted in everyday oral hygiene routine as an important and effective way to prevent and treat many oral pathologies.
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Address for correspondence:
Agnieszka Mielczarek
Department of Conservative Dentistry Medical University of warsaw Miodowa 18 00-246 warszawa Poland Tel.: +48 22 502 20 32 e-mail: agnieszka.mielczarek@wum.edu.pl Received: 23.10.2013 Revised: 12.11.2013 Accepted: 18.12.2013
Praca wpłynęła do Redakcji: 23.10.2013 r. Po recenzji: 12.11.2013 r.